Gastric sleeve complications: Causes, treatments and prevention

Gastric sleeve surgery does have a low complication rate. But, the seriousness of gastric sleeve complications should not be taken lightly. These complications can be acute or chronic. They may lead to longer recovery, another surgery to fix the occurring complication, and even (though rarely) death.

Complications of gastric sleeve surgery can be avoided by following and staying loyal to the instructions your surgeon gave you. That is why it is crucial to be consistent and absolutely determined about your new lifestyle.

The most common reason for these complications to occur is usually patients not following the instructions that are given to them. Other times, they can occur because of the surgery or the patient’s ongoing illnesses.

Let’s get into detail about these complications. We will talk about what they are, how they can be prevented; and if they occur, how they are treated.

Stomach-related complications

Let’s talk about the potential complications that occur inside the abdomen. These gastric sleeve complications need to be taken care of as soon as possible. If ignored or neglected, they can be even more dangerous.

Gastric sleeve long term complications can be manageable or can be treated. These can be done either via medicine or surgery. Whatever the treatment may be, the patient needs to have it in order to get rid of the complication before it gets worse, because the complications we are about to discuss concern the stomach. Especially after gastric sleeve surgery, the stomach should be protected at all costs.

Leakage after gastric sleeve

Staple line leaks are one of the most dreaded gastric sleeve complications. It can be seen in 5% of gastric sleeve patients. Leakage after gastric sleeve is a rare complication. But it is a serious one. Leakage is basically an opening on the staple line. The fluid in your stomach gets leaked into your abdomen. This can present itself with the following symptoms:

  • Severe abdominal pain
  • Dizziness
  • Fever
  • Difficulty breathing
  • Tachycardia (heart rate way over your resting heart rate, 100 for instance)

If you experience any of these symptoms, contact your bariatric surgeon immediately.

However, an early leakage may not show any of these symptoms. That is why gastric sleeve is an inpatient surgery, and that is why it is crucial for patients to stay 2-3 days in the hospital.

To prevent leakage from happening, your surgeon applies tissue glue on the staple line on your stomach. And right after the surgery, before you leave the operation room, the bariatric team will give you some blue water (methylthioninium chloride, commonly known as methylene blue). This blue water helps the surgeon see if there are any leaks on the staple line.

After your hospital stay and right before you get discharged, you will be given the same blue water. After that, you will be sent to get an X-Ray of your upper abdomen. If there are no leaks detected and other vitals are also in good shape, you will be sent home to rest.

There is also a chance for a delayed leak to occur. This happens usually 7-10 days after your surgery. People with diabetes or sleep apnea have a higher rate of experiencing leaks. Or, if the patient is not following the post-op instructions, leakage can occur. If the patient smokes, consumes alcohol, or eats solid food way before they should, they are taking a huge risk.

A postoperative leak can cause a serious infection. To fix a leak, you will be given antibiotics with an IV since it can be dangerous to take them orally. After that, the surgeon will drain the abdominal space. After the damage has been fixed, the surgeon will close the leak via endoscopy. A temporary stent is then planted on the leakage site in the stomach. The other method is for when things get more dangerous. This is when surgical repair is required.

After the anastomotic leak is repaired, you will stay in the hospital for a few more days. Even after being discharged, you won’t be able to eat through your mouth. You will be given a feeding tube. It takes about 6 weeks for a leak to heal.

So, if you do not wish for this to happen to you, please follow the instructions given to you. “Just a little won’t hurt” will NOT apply here.

Stricture

Stricture is basically the narrowing of the pylorus, the part where the stomach and small intestine are connected. It makes it hard for food to pass through. It can happen acutely or chronically. It will present itself with these symptoms:

  • Dysphagia (difficulty swallowing)
  • Nausea and vomiting
  • Food intolerance

The development of the stricture can be because of smoking and alcohol abuse, as well as edema or ischemia of the sleeve. Sometimes some surgeons may even narrow the pylorus more than they should to limit the food intake more, which should not be done.

Fixing a stricture is possible, though. If it is found early, it can be treated with bowel rest, meaning you will be fed and rehydrated through IV serums. If no other complications occur, such as a leak, the strictures will heal.

However, if the strictures are chronic and it is not detected early and/or neglected, endoscopic dilation might be needed.

Via endoscopy, the surgeon goes down to your stomach and locates the stricture. The surgeon will fix the stricture using esophagogastroduodenoscopy (yes, it is a word) balloon dilation. Basically, the surgeon will stretch the narrowing with a surgical balloon. The treatment and the recovery of the stricture may take 4-6 weeks.

If endoscopic balloon dilation does not work or is not done in time, surgical intervention might be needed. The surgical procedure can be one of the following:

  • Laparoscopic or open seromyotomy
  • Roux-en-Y gastric bypass surgery

Hiatal hernia

The diaphragm is not only the respiratory muscle, it also separates the upper body from the abdominal area. The esophagus, however, needs to pass through the diaphragm to reach the stomach. That is why there is a hole in the diaphragm that’s called esophageal hiatus.

A hiatal hernia happens when the stomach or intestine sticks out of the esophageal hiatus into the thoracic cavity. It will not be a pleasant experience for anyone. Besides hurting, it will bring great discomfort. The patient will experience heartburn, a sour taste of stomach acid, and constant burping. The patient can also experience difficulty swallowing, chest pain, intestinal obstruction, and difficulty breathing.

If the patient is suffering from GERD and it is not checked and treated, it can develop into a hiatal hernia. We will explain what GERD is right after this one.

GERD

Are you experiencing heartburn after gastric sleeve? If you do, it can be serious.

Gastroesophageal reflux disease (GERD) is another troublesome complication of gastric sleeve. The stomach acid goes up the esophagus constantly, also known as acid reflux. This irritates the esophagus over time. It can present itself with the following symptoms:

  • Heartburn
  • Regurgitation
  • Dysphagia (difficulty swallowing)

Some of the symptoms of heartburn are very similar to a heart attack, such as chest and arm pain. That is why if you are having any of these symptoms, you should get checked immediately.

If not treated, GERD can develop itself into a hiatal hernia. It can also lead to esophagitis, which later can cause ulcers. Experiencing an ulcer after gastric sleeve can cause bleeding in the stomach. All of these occurrences can mess with your recovery.

GERD can be treated via medications that are called proton pump inhibitors (PPI). This medicine reduces stomach acid. But if it is constant and if you use the medications more than once a week, you should consult your surgeon immediately. It may require surgical intervention.

To diagnose the issue, the surgeon needs to perform a gastroscopy. Antiacids –PPI and H2 blockers– are for long-term GERD management. No one wants to deal with the burning sensation in stomach after gastric sleeve all the time. If you do not want to deal with this constantly, there are surgical options to reduce GERD.

The most common procedure for the treatment of GERD is laparoscopic antireflux surgery, also known as fundoplication. In this procedure, the surgeon wraps and sews the upper part of the stomach (fundus) to the lower part of the esophagus. This alters the esophageal sphincter and helps prevent reflux.

If you're not keeping up with your post-operative routine

Of course, not all complications occur due to surgical reasons. The patient needs to stick to the strict instructions given to them. We did talk about leaks that may occur because of either staples opening or the patient not following the instructions. The complications we are about the talk about usually occur because of patient negligence. These are also considered to be short-term complications.

On the other hand, the patient may be having digestional discomfort that prevents them from following the instructions to their fullest. That is understandable. In cases such as where the patient is dehydrated but cannot drink water without feeling nauseous or vomiting, they can always consult their surgeon so that they can be given IV fluids.

Without further ado, let’s dive in.

Your wound might get infected

An infection can occur within 30 days after gastric sleeve surgery. The infection can be on the incision site, can be superficial, or can be on the stomach. If the infection is on the stomach, it can be life-threatening.

It presents itself as redness, fever, and stomach pain.

Since obese patients have a weak immune system, after the surgery they will be more defenseless against infections, and antibiotics are prescribed to them. Even before prescribing antibiotics, your bariatric surgeon gives them to you through IV fluids during your hospital stay to prevent infections.

To prevent infections, there are thorough pre-op preparations that your surgical team goes through. The surgical site of the patient’s body is cleaned before the surgery. Of course, it does not end there. The surgical tools, the operation table, the gown that the patient wears, and the sheets that are used during the operation are either disposable or cleaned thoroughly before the surgery by the surgical technologists.

The bariatric team that performs your surgery also gets prepared for your operation. They wash their hands and elbows with antiseptic soap, they wear disposable surgical gowns, bonnets, gloves, and masks.

If the infection occurs after the patient is discharged, there are various reasons for it. If the patient does not take their antibiotics, if the wounds are not dressed for long enough and exposed too early, if the patient already had an infection in their body and did not lower their sugar and fat intake, there is a big possibility of an infection.

To treat the infection the patient should be given antibiotics. And let’s not forget, the patient must follow the instructions given to them postoperatively to avoid infections in the first place.

You might have abdominal abscess

An abdominal abscess is a very rare complication after a gastric sleeve procedure.

The infection we mentioned above can happen because of fluid buildup around the surgical site. If it meets with bacteria, it becomes infected. And that area creates an abscess. In other words, an abscess is a creation of infection.

The symptoms can be fever, redness and heat around the incisions, abdominal pain, and leukocytosis (a higher-than-normal amount of white blood cells, meaning the body is fighting an infection). It can be diagnosed via CT SCAN.

To treat an abdominal abscess, the surgeon will drain the infection. After that, the patient will be given antibiotics.

The abscess can also be splenic. If the draining and antibiotics do not work; and if the abscess relapses consistently and there are multiple of them, surgical intervention might be needed. The patient might need to have a splenectomy. With this surgery, your spleen is removed completely.

You may get blood clots

After your gastric sleeve surgery, your body will start the healing process. And that means your body will increase blood clotting to heal the injured tissue. However, if it is excess, blood clots can block the blood flow, causing an embolism. And that cuts the oxygen supply to different parts of your body.

It can present itself with various symptoms. Such as fever, shortness of breath, dizziness and fainting, chest pain, low blood pressure, discoloration of the lips, and tachycardia.

Severe blood clotting is a very rare occurrence. Because you will need to rest a few hours right after your gastric sleeve surgery, your surgeon will give you blood thinners pre and post-op to prevent clotting. And I actually prescribe my patients some blood thinner injections that they need to use for 10 days. It must not be neglected, since their mobility is limited during these first few weeks.

To prevent blood clotting better, the patient should walk around regularly. Sitting or laying will only increase the risk of clotting. Walking and climbing stairs for an hour a day will help you greatly. If the patient is a smoker, they should NOT be smoking for at least the first 3 months. Smoking also increases the chances of blood clots.

Last but not least, you should not wear anything that feels tight on you. This will disrupt the blood flow. Wear oversized clothing, or soft clothing that does not wrap your body tight, such as pajamas. If your doctor instructs you to wear specialized compression socks, follow their instruction to a T.

Remember that your bariatric team is always ready for any of these complications. So, have no fear. They will be dealt with immediately after diagnosis.

References:

(1) Chopra T, Zhao JJ, Alangaden G, Wood MH, Kaye KS. Preventing surgical site infections after bariatric surgery: value of perioperative antibiotic regimens. Expert Review of Pharmacoeconomics & Outcomes Research. 2010;10(3):317-328. doi:10.1586/erp.10.26

https://pubmed.ncbi.nlm.nih.gov/20545596/

(2) Sarkhosh K, Birch DW, Sharma A, Karmali S. Complications associated with laparoscopic sleeve gastrectomy for morbid obesity: a surgeon’s guide. Canadian Journal of Surgery. 2013;56(5):347-352. doi:10.1503/cjs.033511

https://pubmed.ncbi.nlm.nih.gov/24067520/

(3) Aoun R, Gabriel M, El Haddad E, Noun R, Chakhtoura G. Splenic Abscess after Sleeve Gastrectomy. Case Reports in Medicine. 2020;2020:1-4. doi:10.1155/2020/4850675

https://pubmed.ncbi.nlm.nih.gov/32328107/

(4) Mala T, Søvik TT, Schou CF, Kristinsson J. Blood clot obstruction of the jejunojejunostomy after laparoscopic gastric bypass. Surgery for Obesity and Related Diseases: Official Journal of the American Society for Bariatric Surgery. 2013;9(2):234-237. doi:10.1016/j.soard.2011.12.014

https://pubmed.ncbi.nlm.nih.gov/22421098/

(5) Froehling DA, Daniels PR, Mauck KF, et al. Incidence of Venous Thromboembolism After Bariatric Surgery: A Population-Based Cohort Study. Obesity Surgery. 2013;23(11):1874-1879. doi:10.1007/s11695-013-1073-1

https://pubmed.ncbi.nlm.nih.gov/24022324/

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