© 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_22
22. Roux-en-Y Gastric Bypass: Recognizing and Treating Complications
Department of General Surgery, Rowan University, Stratford, NJ, USA
Postoperative complications following laparoscopic Roux-en-Y gastric bypass (LRYGB) can be broadly grouped into early and late complications. Complications that occur within the 2-week postoperative period are considered an early complication. Complications after the second postoperative week are considered late complications.
Like any surgery, the common complications of the bypass include bleeding and infection. With morbid obesity comes other comorbid conditions such as diabetes, coronary artery disease, and hypertension. These conditions place the patients at higher risk for infections – both intra-abdominal and wound, myocardial infarctions, and DVT/PE. Important cues to be aware of are tachycardia, tachypnea, fever, low urine output, and low blood pressure. Additionally, nausea, vomiting, swelling in lower extremities, and leukocytosis may point to larger underlying issues.
22.1 Early Complications
22.1.1 Anastomotic Leaks
One of the most dreaded and quite possibly devastating complications of this procedure, with a mortality rate of nearly 50 %, is an anastomotic leak. A multivariate study of 3000 patients who underwent LRYGB concluded that an anastomotic leak was one of the strongest independent risk factors for postoperative death. The incidence of leak is relatively low at 0.4–5.2 % .
The most common site for a leak is at the gastrojejunal anastomosis. Generally, clinical signs such as tachycardia, fevers, nausea/vomiting, and abdominal pain are indicators of a leak. A recent study concluded that sustained tachycardia with a heart rate in excess of 120 beats per minute was a good indicator . Early operative management is typically the treatment for leaks following LRYGB. The goal of the operation is to find and repair the leak, remove gastric contents from the abdomen, and place drains . Patients are then treated with IV antibiotics and fluids. They are also maintained NPO until their symptoms improve.
22.1.2 Postoperative Bleeding
There are two types of postoperative hemorrhage that can occur. The first is intra-abdominal where the bleeding occurs along the staple lines, at the anastomoses, or the gastric pouch. The second site of bleeding can occur within the bowel at the previously mentioned sites. Once again clinical signs and laboratory results may be the initial indicators of a bleed. Tachycardia, drop in the hemoglobin level and/or urine output, and excessive bloody output from the drain or the incisions are a few such signs and symptoms. Surgical intervention is prudent at this point. The source of the bleed is identified and controlled, and the abdominal cavity is evacuated of any clots that may have developed.
22.1.3 Dumping Syndrome
As mentioned earlier, dumping syndrome occurs when a large bolus of food enters the stomach and small intestines too rapidly. It can be divided into both early and late stages. The early stage occurs within 15–30 min after eating. The late stage occurs hours after a meal. In the early stage, the large fluid bolus causes hyperosmolar shifts in the small intestines. This is in turn draws large amounts of fluids into the gut lumen and causes overdistention. This causes symptoms such as nausea, vomiting, bloating, diarrhea, and fatigue. The symptoms of the late stage of dumping occur due to hypoglycemia. In reaction to the large hyperosmotic load and fluid shifts, the pancreas releases a large amount of insulin into the bloodstream. These symptoms include diaphoresis, weakness, and fatigue. The simple solution to this is to eat smaller portions .
Deep vein thrombosis (DVT) with resultant pulmonary embolism is the most common cause of death after bariatric surgery. Although the incidence of such an event is only 2 %, the mortality associated with it is around 20–30 % . In order to avoid such a complication, patients are given chemoprophylaxis in the form of subcutaneous heparin or Lovenox. Perhaps the most important intervention is to encourage early ambulation including postoperative day 0. Sequential compression devices are applied to allow constant circulation of blood in the lower extremities.