Overview
Definition:
Revision bariatric surgery refers to operative procedures performed after an initial bariatric surgery, often to address complications, inadequate weight loss, or weight regain
Leaks and strictures are among the most serious early and late complications, respectively
Leaks typically occur at staple lines, anastomoses, or port sites, leading to peritonitis or abscess formation
Strictures, usually fibrotic, cause luminal narrowing and obstructive symptoms.
Epidemiology:
Leaks occur in approximately 0.5-5% of primary bariatric procedures, with revisional surgery potentially carrying a higher risk
Strictures are more common late complications, reported in 1-10% of patients, particularly after sleeve gastrectomy and gastric bypass.
Clinical Significance:
Leaks are life-threatening emergencies requiring prompt diagnosis and management to prevent sepsis and mortality
Strictures lead to significant morbidity, including malnutrition, dehydration, and impaired quality of life, necessitating timely intervention to restore gastrointestinal patency and function.
Clinical Presentation
Symptoms:
Leak: Severe abdominal pain, often diffuse
Fever, tachycardia, and hypotension (septic shock)
Vomiting and inability to tolerate oral intake
Shoulder tip pain (diaphragmatic irritation)
Signs of peritonitis: abdominal guarding and rigidity
Stricture: Dysphagia, initially for solids, progressing to liquids
Nausea and vomiting, especially postprandial
Abdominal pain
Weight loss and malnutrition
Belching and regurgitation.
Signs:
Leak: Signs of peritonitis, distended and tender abdomen, decreased bowel sounds, fever, tachycardia, tachypnea, hypotension
Stricture: Epigastric tenderness, possible palpable mass if contained fluid collection, dehydration, weight loss, malnutrition signs.
Diagnostic Criteria:
No single strict diagnostic criterion
diagnosis is based on a combination of clinical suspicion, imaging findings, and sometimes fluid analysis
Leaks are often suspected with persistent tachycardia, fever, and abdominal pain postoperatively
Strictures are suspected with progressive dysphagia and vomiting without other obvious cause.
Diagnostic Approach
History Taking:
Detailed history of the primary bariatric procedure
Onset and progression of symptoms
Tolerance of oral intake
Presence of fever, pain, vomiting
Previous interventions or medical history relevant to GI issues
Red flags for leaks: acute onset of severe pain, fever, tachycardia post-operatively
Red flags for strictures: insidious onset of dysphagia, progressive weight loss.
Physical Examination:
Complete abdominal examination focusing on tenderness, guarding, rigidity, rebound tenderness, bowel sounds, and presence of masses
Assessment of hydration status, vital signs (temperature, heart rate, blood pressure, respiratory rate).
Investigations:
Imaging: Water-soluble contrast swallow study (gastrografin or iohexol) is the gold standard for leak detection
it is safe even if a leak is present
CT scan of the abdomen and pelvis with oral and IV contrast can identify leaks, abscesses, and free fluid
Endoscopy (gastroscopy) can visualize anastomotic sites and strictures
it can also be used for intraluminal pressure measurements and biopsies if indicated
Laboratory tests: Complete blood count (leukocytosis), liver function tests, renal function tests, electrolytes, amylase, lipase, CRP
Blood cultures if sepsis is suspected
Fluid analysis from drains or suspected abscesses.
Differential Diagnosis:
For leaks: intra-abdominal abscess, anastomotic dehiscence (non-septic), pancreatitis, perforated ulcer, cholecystitis, bowel obstruction
For strictures: marginal ulcers, anastomotic edema, internal hernia, adhesions, peptic stricture, malignancy.
Management
Initial Management:
Leak: Immediate NPO status
IV fluid resuscitation
Broad-spectrum IV antibiotics
Nasogastric decompression
Urgent surgical consultation
Stricture: NPO status or clear liquids
IV fluids
Nutritional support (parenteral or enteral feeding if indicated)
Analgesia.
Medical Management:
Antibiotics: Broad-spectrum coverage (e.g., cephalosporin + metronidazole or fluoroquinolone + clindamycin) for suspected leaks
Duration typically 7-14 days based on clinical response
Stricture: Medical management is usually adjunctive
focus is on decompression and nutritional support.
Surgical Management:
Leak: Management depends on size, location, and patient stability
Options include conservative management with drainage (percutaneous or surgical), endoscopic stenting, or reoperation (e.g., repair, diversion, resection with anastomosis)
Stricture: Endoscopic balloon dilation is the first-line treatment for most benign strictures
If dilation fails or stricture is severe/complex, surgical revision (e.g., revision of anastomosis, bypass, or conversion to another procedure) may be necessary
Revision bariatric surgery for leak management can involve jejunojejunostomy, Roux-en-Y conversion, or even reversal.
Supportive Care:
Aggressive fluid management
Nutritional support: high-protein diet, supplements, or parenteral/enteral nutrition as needed
Pain management
Monitoring of vital signs, urine output, abdominal girth, and laboratory parameters
Mobilization and respiratory physiotherapy.
Complications
Early Complications:
Leak: Sepsis, peritonitis, intra-abdominal abscess, fistula formation, prolonged ileus, wound infection
Stricture: Dehydration, malnutrition, electrolyte imbalances, aspiration pneumonia.
Late Complications:
Leak: Chronic fistula, incisional hernia at drain site, adhesions
Stricture: Chronic malnutrition, vitamin/mineral deficiencies, weight regain due to poor intake, need for further surgical intervention.
Prevention Strategies:
Meticulous surgical technique: careful handling of tissues, secure staple line reinforcement, appropriate use of drainage
Meticulous hemostasis
Adequate hydration and nutrition post-operatively
Early recognition and management of any signs of leak or obstruction
Careful patient selection and pre-operative optimization
Adherence to post-operative dietary guidelines.
Prognosis
Factors Affecting Prognosis:
For leaks: Promptness of diagnosis and intervention, hemodynamic stability, extent of contamination, patient comorbidities, surgical approach
For strictures: Degree of stenosis, length of stricture, etiology (benign vs
malignant), success of endoscopic dilation, patient nutritional status.
Outcomes:
With prompt and appropriate management, most leaks can be resolved with minimal long-term sequelae
However, delayed diagnosis or treatment can lead to significant morbidity and mortality
Successful endoscopic dilation for strictures often leads to good outcomes with restored oral intake
Surgical revision for refractory strictures also carries good prognosis but requires careful surgical planning.
Follow Up:
Long-term follow-up is crucial
Patients should be monitored for weight trends, nutritional status (including vitamin and mineral levels), and any recurrent symptoms of obstruction or malabsorption
Regular clinical assessment and dietary counseling are essential
In cases of strictures, occasional endoscopic evaluation may be needed.
Key Points
Exam Focus:
Remember the most common sites of leaks in different bariatric procedures (e.g., gastroesophageal junction in SG, gastrojejunal anastomosis in RYGB)
Contrast swallow study is the first-line imaging for suspected leaks
Endoscopic dilation is the mainstay for benign strictures
Be prepared to discuss surgical management options for both complications.
Clinical Pearls:
Always maintain a high index of suspicion for leaks in any bariatric patient presenting with new-onset tachycardia, fever, or abdominal pain, especially in the early postoperative period
For strictures, ask about the progression of dysphagia – solid only, then liquids
Consider underlying marginal ulcers as a cause of stricture, particularly post-RYGB.
Common Mistakes:
Delaying diagnosis of a leak due to underestimation of symptom severity or relying solely on a negative initial imaging study without considering the clinical picture
Over-reliance on antibiotics alone for leaks without surgical or endoscopic intervention
Aggressively dilating a stricture without adequate nutritional support or considering the possibility of a marginal ulcer.