© Springer International Publishing Switzerland 2017Andrew Loveitt, Margaret M. Martin and Marc A. Neff (eds.)Passing the Certified Bariatric Nurses Exam10.1007/978-3-319-41703-5_18
18. Laparoscopic Sleeve Gastrectomy: Recognizing and Treating Complications
Department of General Surgery, Rowan University, Stratford, NJ, USA
The overall rate of serious morbidity from the laparoscopic sleeve gastrectomy (LSG) is 3.8 %, and 30-day mortality rate is 0.1 % . Complications unique to LSG include staple line leaks and stricture or obstruction of the gastric lumen. The bedside nurse must also be vigilant for complications that can present in all surgical patients including bleeding, DVT/PE, and infectious processes.
18.1 Staple Line Leaks
Inherent to LSG is the creation of a long staple line to form the gastric pouch. Gastric leakage from this staple line can be a life-threatening complication which occurs in 1–3 % of LSG and is the most common cause of major morbidity and mortality [2, 3]. To prevent this complication, surgeons have attempted to reinforce the staple line either through the use of a buttressing material, through application of sealants, or by oversewing. There is no consensus on the preferred technique, and this seems to have a larger effect on bleeding than leakage . Leaks can be classified as mechanical (stapler misfire, direct tissue injury) which present within 2 days of surgery or ischemic which appear 5–6 days postoperatively. Late leaks have been noted up to 16 months after surgery .
From a nursing perspective, the most important aspect is early recognition. Most agree that tachycardia, specifically a HR >120, is the most important and constant indication of a leak. This is often accompanied by acute (early) or more chronic (late) abdominal pain and fevers. Although an elevated WBC count or CRP may be present, this is difficult to interpret in the presence of a recent surgery . When a leak is suspected, CT scan with IV and PO water-soluble contrast is the best noninvasive test .
There is no consensus on the management of postoperative leaks. However, the first question that must be asked is if the patient is stable or unstable. If unstable, the answer is to return to the OR for washout and drainage. If stable, the management becomes more complicated. Typically conservative approaches are favored including IV hydration, NPO, PPIs, parenteral nutrition, percutaneous drainage, and broad-spectrum antibiotics and antifungals. If there is a persistent leak (2 weeks) despite conservative management, endoscopic therapies including clipping, application of fibrin glue, and stenting can be attempted. If all else fails, the patient will need a revisional surgery which could include conversion to a Roux-en-Y gastric bypass or even a total gastrectomy with esophageal-jejunal anastomosis [3, 4].
Bleeding requiring transfusion occurs in 0.65 % of patients following a LSG, and bleeding from the staple line itself is thought to occur in 1–2 % of patients [1, 2]. While a relatively uncommon complication, bleeding can present insidiously or as a major hemorrhage requiring rapid intervention. There are many potential bleeding sites after an LSG including the gastric staple line, gastric and omental vessels, lacerations to the liver or spleen, and trochar sites. The best treatment for bleeding is prevention through careful dissection and reinforcement of the staple line . Bleeding typically presents on postoperative day zero or one. It is detected clinically in the majority of cases by tachycardia, hypotension, and decreased urine output. Bloody vomiting or dark stools may occur . A drop in hemoglobin may also be present but should not be relied on for diagnosis.
Stable patients can be treated conservatively with cessation of blood thinners, transfusion, and close monitoring. Endoscopic evaluation may also be beneficial. If the patient is unstable or the bleeding is persistent, they should be taken back to the OR for exploration, washout, and control of bleeding which can typically be accomplished laparoscopically.
18.3 Venous Thromboembolism (VTE)
The risk of pulmonary embolism (PE) and deep vein thrombosis (DVT) after any bariatric surgery is less than 0.5 %. Procedure type does appear to significantly impact the incidence of VTE. Duodenal switch carries the highest risk, while LSG and laparoscopic adjustable band are safest . The majority of events occur after discharge from the hospital. While there is a low incidence of PE, this is a significant event resulting in 17–33 % of all postbariatric mortalities .
Wound infections, intra-abdominal abscess, and pneumonia all occur in less than 1 % of patients undergoing LSG . Careful clinical exam is paramount in the identification of these complications. Erythema or drainage from wounds should be noted and can be treated with incision and drainage. Intra-abdominal abscess presents with abdominal pain and persistent fevers. It is confirmed with CT scan and treated by percutaneous drainage and antibiotics . Attempts to prevent pneumonia include early ambulation and pulmonary toilet (incentive spirometer, deep breathing exercises). Once diagnosed, it should be treated with an appropriate course of antibiotics.
LSG is thought of as a less technically challenging procedure than other weight loss surgeries; however, the successful creation of the long gastric tube requires considerable expertise. Stricture can occur for a number of technical reasons including the use of small bougie sizes and asymmetrical lateral traction while creating the sleeve which results in twisting. Chronic inflammation from staple line leaks can also result in stricture. Overall stricture rate is approximately 2–3.5 % .
Most strictures are symptomatic within the first 6 weeks following surgery and often present when the patient is progressed to solid food . Occasionally they will present acutely due to tissue edema. Patients will complain of persistent reflux symptoms, often unrelated to oral intake. An upper gastrointestinal series or endoscopic evaluation is typically diagnostic .
Management consists of initial observation and multiple sessions of endoscopic balloon dilation. Injection of botulinum toxin into the pylorus has also been attempted . If these attempts fail, surgical intervention may be necessary including seromyotomy (cutting of the stomach muscle) and conversion to a Roux-en-Y gastric bypass .