Dr. Roberto Rizzi and Team Surgery Complications

Dr. Roberto Rizzi - Surgery Risks Seminar

Complications with Obesity Surgery

Complications
Any major surgery involves the potential for complications - adverse events which increase risk, hospital stay, and mortality. Some complications are common to all abdominal operations, while some are specific to bariatric surgery. A person who chooses to undergo bariatric surgery should know about these risks.

But being Obese is also a risk. In two recent studies, researchers report that bariatric surgery can help obese people live longer. The two studies, published in the New England Journal of Medicine (NEJM 2007; 357:741, and NEJM 2007; 357:753), indicates that study has shown that gastric bypass surgery reduced all-cause mortality by 40% and bariatric surgery of any type reduced morality 29%!

Mortality & Complication Rates
Mortality is affected by complications, which in turn are affected by pre-existing risk factors such as degree of obesity, heart disease, obstructive sleep apnea, diabetes mellitus, and history of prior pulmonary embolism.

It is also affected by the experience of the operating surgeon: the "learning curve" for laparoscopic gastric bypass surgery is estimated to be about 100 cases, and inexperienced surgeons have been shown in several studies to have a significantly higher rate of complications and mortality. Unfortunately, the way a surgeon becomes experienced in dealing with problems is by encountering those problems over time.

A recent large multi-center study reported that, in experienced hands, the overall complication rate of this type of surgery ranges from 7% for laparoscopic procedures to 14.5% for operations through open incisions, during the 30 days following surgery. Mortality for this study was 0% in 401 laparoscopic cases, and 0.6% in 955 open procedures. Similar mortality rates – 30-day mortality of 0.11%, and 90-day mortality of 0.3% – have been recorded in the U.S. Centers of Excellence program, the results from 33,117 operations at 106 centers.

General Complications with Abdominal Surgery

Infection
Infection of the incisions, or of the inside of the abdomen (peritonitis, abscess) may occur, due to release of bacteria from the bowel during the operation. Nosocomial infection, such as pneumonia, bladder or kidney infections, and sepsis (bloodborne infection) are also possible. Effective short-term use of antibiotics, diligent respiratory therapy, and encouragement of activity within a few hours after surgery, can reduce the risks of infections.

Hemorrhage
Many blood vessels must be cut, to divide the stomach and to move the bowel. Any of these may later begin bleeding, either into the abdomen (intra-abdominal hemorrhage), or into the bowel itself (gastrointestinal hemorrhage). Transfusions may be needed, and re-operation is sometimes necessary. Use of blood thinners, to prevent venous thromboembolic disease, may actually increase the risk of hemorrhage slightly.

Hernia
A hernia is an abnormal opening, either within the abdomen, or through the abdominal wall muscles. An internal hernia may result from surgery, and re-arrangement of the bowel, and is mainly significant as a cause of bowel obstruction. An incisional hernia occurs when a surgical incision does not heal well; the muscles of the abdomen separate and allow protrusion of a sac-like membrane, which may contain bowel or other abdominal contents, and which can be painful and unsightly. The risk of abdominal wall hernia is markedly decreased in laparoscopic surgery.

Bowel obstruction
Abdominal surgery always results in some scarring of the bowel, called adhesions. A hernia, either internal or through the abdominal wall, may also result. When bowel becomes trapped by adhesions or a hernia, it may become kinked and obstructed, sometimes many years after the original procedure. Usually an operation is necessary, to correct this problem.

Venous thromboembolism
Any injury, such as a surgical operation, causes the body to increase the coagulation of the blood. Simultaneously, activity may be reduced. There is an increased probability of formation of clots in the veins of the legs, or sometimes the pelvis, particularly in the morbidly obese patient. A clot which breaks free and floats to the lungs is called a pulmonary embolus, a very dangerous occurrence. Commonly, blood thinners are administered before surgery, to reduce the probability of this type of complication.

Complications of Gastric Bypass Surgery

Anastamotic leakage
An anastamosis is a surgical connection, between the stomach and bowel, or between two parts of the bowel. The surgeon attempts to create a water-tight connection, by connecting the two organs with either staples or sutures, either of which actually makes a hole in the bowel wall. The surgeon will rely on the healing power of the body, and its ability to create a seal like a self-sealing tire, to succeed with the surgery. If that seal fails to form, for any reason, fluid from within the gastrointestinal tract can leak into the sterile abdominal cavity, and give rise to infection and abscess formation. Leakage of an anastamosis can occur in about 2% of gastric bypass procedures, usually at the stomach-bowel connection. Sometimes leakage can be treated with antibiotics, and sometimes it will require immediate re-operation. It is usually safer to re-operate, if an infection cannot be definitely controlled immediately. The use of a "fistula" for 30 days might give healing without need of re-surgery.

Anastamotic stricture
As the anastamosis heals, it forms scar tissue, which naturally tends to shrink ("contract") over time, making the opening smaller. This is called a "stricture". Usually, the passage of food through an anastamosis will keep it stretched open, but if the inflammation and healing process outpaces the stretching process, scarring may make the opening so small that even liquids can no longer pass through it. The solution is a procedure called gastroendoscopy, and stretching of the connection by inflating a balloon inside it. Sometimes this manipulation may have to be performed more than once, to achieve lasting correction.

Dumping syndrome
Normally, the pyloric valve at the lower end of the stomach regulates the release of food into the bowel. When the Gastric Bypass patient eats a sugary food, the sugar passes rapidly into the bowel, where it gives rise to a physiological reaction called dumping syndrome. An affected person feels his heart beating rapidly and forcefully, breaks into a cold sweat, gets a feeling of butterflies in the stomach, and has a "sky is falling" type of anxiety. He usually has to lie down, and is very uncomfortable for about 30 to 45 minutes. Diarrhea may then follow. The dumping syndrome is a response to a behavior which the patient should not be doing anyway: eating sugary foods. It is not life-threatening, and may assist one in making healthier food choices.

Cholecystectomy
One other risk factor of the Gastric Bypass surgery is related to rapid weight reduction, not the surgery itself. Any rapid weight reduction, regardless of the method used to lose weight, can lead to the increased formation of gallstones and possible gallbladder attack. For this reason, if you still have your gallbladder, an ultrasound of the gallbladder is automatically ordered. If you have gallstones, it will be recommended that the gallbladder be removed during or approximately 6 months after your bypass surgery. This is to prevent the need for an emergency cholecystectomy later. If the gallbladder shows no signs of gallstones, it will not be removed. To remove a healthy organ goes against good medical and ethical practice. This would then place you at a high risk of developing gallstones at a later date requiring gallbladder surgery.

Nutritional deficiencies
Hypoparathyroidism, due to inadequate absorption of calcium, may occur in over 30% of GBP patients. Calcium is primarily absorbed in the duodenum, which is bypassed by the surgery. Most patients can achieve adequate calcium absorption by supplementation with Vitamin D and Calcium Citrate (carbonate may not be absorbed - it requires an acidic stomach, which is bypassed).
Iron frequently is seriously deficient, particularly in menstruating females, and must be supplemented. Again, it is normally absorbed in the duodenum. Ferrous sulfate can cause considerable GI distress in normal doses; alternatives include Ferrous fumarate, or a chelated form of iron. Occasionally, a female patient develops severe anemia, even with supplements, and must be treated with parenteral iron.
Vitamin B-12 requires intrinsic factor from the gastric mucosa to be absorbed. In patients with a small gastric pouch, it may not be absorbed, even if supplemented orally, and deficiencies can result in pernicious anemia and neuropathies. Sub-lingual B-12 appears to be adequately absorbed.
Thiamine deficiency (also known as beriberi) will, rarely, occur as the result of its absorption site in the jejunum being bypassed. This deficiency can also result from inadequate nutritional supplements being taken post operatively.
Protein malnutrition is a real risk. Some patients suffer troublesome vomiting after surgery, until their GI tract adjusts to the changes, and cannot eat adequate amounts even with 6 meals a day. Many patients require protein supplementation during the early phases of rapid weight loss, to prevent excessive loss of muscle mass.

Nutritional effects after Gastric Bypass Surgery

After surgery, patients feel fullness after ingesting only a small volume of food, followed soon thereafter by a sense of satiety and loss of appetite. Total food intake is markedly reduced. Due to the reduced size of the newly created stomach pouch, and reduced food intake, adequate nutrition demands that the patient follow the surgeon's instructions for food consumption, including the number of meals to be taken daily, adequate protein intake, and the use of vitamin and mineral supplements.

Protein nutrition
Proteins are essential food substances, contained in foods such as meat, fish and poultry, dairy products, soy, and eggs. With reduced ability to eat a large volume of food, gastric bypass patients must focus on eating their protein requirements first, and with each meal. Proximal GBP rarely leads to protein deficiency if this simple precaution is followed. Distal GBP is more likely to lead to protein deficiency, particularly if fat intake is excessive, and the position of the Y-connection is farther downstream. In some cases, surgeons may recommend use of a liquid protein supplement.

Calorie nutrition
The profound weight loss which occurs after bariatric surgery is due to taking in much less energy (calories) than the body needs to use every day. Fat tissue must be burned, to offset the deficit, and weight loss results. Eventually, as the body becomes smaller, its energy requirements are decreased, while the patient simultaneously finds it possible to eat somewhat more food. When the energy consumed is equal to the calories eaten, weight loss will stop. Proximal GBP typically results in loss of 60 to 80% of excess body weight, and very rarely leads to excessive weight loss. The risk of excessive weight loss is slightly greater with Distal GBP.

Vitamins
Vitamins are normally contained in the foods we eat, as well as any supplements we may choose to take. The amount of food which will be eaten after GBP is severely reduced, and vitamin content is correspondingly reduced. Supplements should therefore be taken, to completely cover minimum daily requirements of all vitamins and minerals. Absorption of most vitamins is not seriously affected, after Proximal GBP, although Vitamin B-12 may not be well-absorbed in some persons. Sub-lingual preparations of B-12 will provide adequate absorption. After the Distal GBP, fat-soluble vitamins A, D and E may not be well-absorbed, particularly if fat intake is large. Water-dispersed forms of these vitamins may be indicated, on specific physician recommendation.

Minerals
All versions of the GBP bypass the duodenum, which is the primary site of absorption of both Iron and Calcium. Iron replacement is essential in menstruating females, and supplementation of iron and calcium is preferable in all patients. Ferrous sulfate is poorly tolerated. Alternative forms of iron (fumarate, gluconate, chelates) are less irritating and probably better absorbed. Calcium carbonate preparations should also be avoided; calcium as citrate or gluconate, 1200 mg as calcium, has greater bioavailability independent of acid in the stomach, and will likely be better absorbed.

Health Benefits of Gastric Bypass Surgery

A recent study in a large comparative series of patients showed a 89% reduction in mortality over the 5 years following surgery, compared to a non-surgically treated group of patients. There were accompanying decreases in the incidence of cardiovascular disease, infections, and cancer.

Weight loss of 65 to 80% of excess body weight (the amount by which actual body weight exceeds actuarial ideal body weight) is typical of most large series of Gastric Bypass operations reported.

The medically more significant effects are a dramatic reduction in co-morbid conditions:

Hyperlipidemia is corrected in over 70% of patients.
Essential hypertension is relieved in over 70% of patients, and medication requirements are usually reduced in the remainder.
Obstructive sleep apnea is markedly improved with weight loss, so that most patients are asymptomatic, and often do not even snore, within one year.
Diabetes mellitus type 2 is reversed in up to 90% of patients, usually leading to a normal blood sugar without medication, sometimes within days of surgery.
Gastroesophageal reflux disease is relieved from the time of surgery in almost all patients.
Venous thromboembolic disease signs such as leg swelling are typically much improved.
Low back pain and joint pain are typically relieved or improved in nearly all patients.

Bariatric surgery is the most effective treatment for morbid obesity, and can markedly improve health and lifestyle.

Partial Resource: Wikapedia

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Cost of obesity surgery is significant lower in Brazil then in many other countries. Also the quality and reputation of surgeons in Brazil makes many foreigners decide to come to Brazil for this procedure.
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