Problems after Gastric Bypass

There are numerous problems which can arise after gastric bypass surgery.

Staple line or anastomotic leak can occur after any stomach or bowel resectional surgery. If a section of the staple line or the joins don’t heal properly, it can break down resulting in a hole in the stomach or bowel much like a ruptured ulcer with leakage of stomach/intestinal contents into the abdominal cavity. This can be a life-threatening complication if not recognised early and appropriately managed.

The intestinal bypass is a low pressure system (compared to sleeve gastrectomy) which theoretically decreases the risk and can make them relatively easier to manage. However only the traditional Roux en Y bypass excludes bile refluxing and is thus much easier technically to manage a leak and the leak tends to be less hazardous though still serious. There is no single effective treatment for all leaks which may require a variety of endoscopic, surgical and radiological procedures to manage and may require prolonged hospitalisations, intensive care and repeat procedures. Prevention is always better than cure. In expert hands and with thorough assessment and preparation the risk of a leak should be under 1%. You should therefore choose your Surgeon wisely.

Difficulty swallowing or tolerating solid foods is not expected after the initial recovery transition diet and usually indicates a problem. This could include development of an internal hernia, twisting of the intestine, or a narrowing of the anastomosis (join between stomach pouch and intestine). Investigation may involve a gastroscopy, CT scan and/or contrast study to help diagnose the problem.

A stricture or narrowing can form at the anastomosis which is a result of inflammatory scarring during the healing process. A stricture may be amenable to stretching using a balloon (Endoscopic dilatation) which often needs to be repeated several times.

Marginal ulceration are ulcers that develop at the join between the stomach pouch and intestine due to the unopposed action of stomach acid on the intestine. They can be difficult to treat and may cause strictures or a perforation. Restarting smoking carries huge risk of marginal ulcer formation as is the use of anti-inflammatory medications (Aspirin, Naproxen, Ibuprofen etc.) which must also be avoided.

Dumping syndrome can occur due to rapid passage of food into the intestine. Symptoms can include abdominal pain, cramping, flushing and diarrhoea. Dumping can also cause low blood sugar levels.

Hypoglycaemia refers to low blood sugar levels. Although gastric bypass is effective at improving and resolving diabetes it can cause wide fluctuations in sugar levels especially after meals including potentially serious low blood sugar levels due to excessive hormonal response. Management usually involves the same dietary changes described above for dumping. Occasionally medication can be helpful. Revision or reversal surgery may be required for extreme cases.

Internal hernias and bowel obstruction can develop due to new spaces that are created and adhesions that form with rearranging the intestine. The risk is about 1-4% with Roux-en-Y Gastric Bypass. Bowel obstruction (blockage) can be life threatening after gastric bypass and doesn’t always reveal itself with vomiting. Severe abdominal pain or distention must be taken very seriously as emergency surgery may be required to prevent that section of bowel from dying. Patients should present to an emergency department, have a CT scan and be reviewed by an experienced Upper GI/Bariatric Surgeon to exclude this problem.

Bile reflux can be troublesome after the single anastomosis or mini gastric bypass. The Roux-en-Y gastric bypass prevents bile from reaching the stomach pouch and refluxing into the oesophagus. Bile may reflux into the bypassed section of stomach and cause pain. In such cases it may be better to remove the bypassed section of stomach. A single anastomosis gastric bypass can be converted to the traditional Roux-en-Y gastric bypass.

Obesity is a risk factor for Gallstones and Gallbladder disease. Gallstones will often form during periods of significant weight loss. Patients with gallstones often develop pain under the right ribs, around the right side or back and is often exacerbated by eating. Once gallstones start to cause symptoms the gallbladder should be removed or more serious complications can occur. Gallbladder removal can usually be done by keyhole surgery even after bariatric surgery. It usually requires an overnight stay in hospital.

Acid reflux is uncommon following Roux-en-Y Gastric bypass which is the most effective procedure for controlling reflux symptoms because most of the stomach is bypassed markedly reducing the amount of acid that can reach the oesophagus. Ongoing anti-acid medication may be required. Other causes should be excluded including stricture at the anastomosis and twisting or kinking of the small bowel.

A Hiatus Hernia can develop after surgery where the junction between the food pipe (oesophagus) and stomach slides up above the diaphragm into the chest. Small hiatus hernias are unlikely to cause a problem as reflux is usually well controlled by the gastric bypass.

Vitamin and mineral deficiencies can occur especially if you do not take the recommended daily supplements. After gastric bypass the commonest problems are low iron which can cause anaemia, low Calcium and vitamin D which are required for healthy bones and low vitamin B12 which can cause nerve damage. The best way to avoid potentially serious problems is to take the recommended supplements every day and to have blood tests performed annually.

Inadequate weight loss and/or weight regain can occur following any bariatric procedure. If the anastomosis is wide open or stretched, then it can be reduced by a minimally invasive endoscopic procedure with either suturing and/or thermal coagulation (APC – argon plasma coagulation) which have been shown to induce further weight loss. Surgical options for revision are limited and technically challenging after gastric bypass procedures but may include increasing the length of the bypassed intestine or conversion to another procedure such as SIPS surgery. Before undertaking further surgery it is important to address all issues that may have contributed including not following the recommending dietary and lifestyle changes and underlying psychological issues.

Diabetes usually improves with the metabolic and hormonal changes weight loss after gastric bypass but some patients may still need ongoing medications. There are operations with  stronger metabolic and hormonal effects such as SIPS surgery  that increases the chance of reversing diabetes without requiring ongoing anti-diabetic medications. Gastric Bypass can potentially be convered to SIPS if required.

Hair loss is not uncommon during the first 6 months after surgery and is a temporary phenomenon associated with rapid weight loss. Following the dietitian’s instructions to ensure adequate protein intake and taking the recommended vitamin and mineral supplements helps reduce hair loss and aids regrowth.

Excess skin can depend on many factors including the distribution of excess weight, amount of weight lost, age, elasticity of skin and muscle mass preservation with adequate protein in the diet and exercise. It does not depend on the rate of weight loss so faster and safe is better. Plastic Surgeons can offer removal of excess skin if required but it is recommended to wait for weight loss and body composition to completely stabilise before considering this option.