Editing RYGB (section)

== '''Complications''' ==

* Early (<30 days)
** Leak - see 'sleeve      gastrectomy'
*** Common at gastric pouch or       gastroenterostomy, uncommon at enteroenterostomy
** Obstruction
*** Internal hernia

* Peterson's space is between     an antecolic Roux limb and the transverse colon
* Mesojejunal ('Brolin's')     space occurs under the distal part of the BP limb, where it has been     detached and brought down to the J-J anastomosis
* The transverse mesocolic     space occurs in retrocolic Roux limbs
* 'Classic bypass torsion'     occurs when the entero-enterostomy prolapses through Petersen's space and     creates a torsion in the mesentery, which can be symptomatic for weeks     prior to presentation
* CT with PO contrast is the     best study
* Any dilated loops of bowel on     the right are concerning. Look particularly for a mesenteric twist or     volvulus of the Roux limb. The danger is that proximal distension of the     stomach can rupture the staple line.
* Generally, most patients with     SBO after RYGB need a re-operation
* Diagnostic laparoscopy - run     bowel from proximal to distal or vice versa. Reduce torsion either by     pushing/pulling back through from right to left. Remember to close     mesenteric defect with non-absorbable suture.

* Adhesive
* E-E anastomosis
* Obstructed BP limb
** Closed loop obstruction      between the obstructing point and duodenal stump
** High intra-luminal pressures      can cause elevated LFTs/lipase, and eventually necrosis of the loop
** Can see epigastric pain,      upper abdominal mass and high lipase

* PE 1%
* Pneumonia
* Bleeding
* Acute distal gastric     dilatation
* Infection

* '''Late'''
** Marginal ulcer (2-10%)
*** Not related to acid       according to AC - related to ischaemia - although UTD just says caused       by acid injuring jejunum
*** Risk factors - H pylori,       larger pouch size (presumably leaves more parietal cells secreting       acid), smoking, tenuous blood supply of g-j, excess acid production in       gastric pouch due to gastro-gastric fistula, NSAID use, diabetes
*** Occurs on jejunal side of       anastomosis
*** Presentation
**** Commonly continuous        'boring' epigastric pain
**** Can also present with        perforation or chronic bleeding
**** Complication - fistula to        lower part of stomach, which provides more acid and thus exacerbates        the ulcer
**** Also leads to structure at        G-J
*** Management
**** Medical is usually        successful - PPI sulfate (for minimum three months), avoid NSAIDs - for        3-6 months
**** If bleeding - usual        endoscopic treatment. UTD says consider embolization - I'm not sure if        this is a good idea
**** Exclude gastro-gastric        fistula
**** Operation for complication        - options are gastrojejunostomy revision, vagotomy, subtotal/total        gastrectomy, and reversal to normal anatomy
**** QUIT SMOKING
**** Consider revision of limb        if resistant to medical treatment
** Stomal stenosis
*** Occurs at the       gastrojejunostomy
*** More common after stapled       join
*** More common with NSAID use       and smoking
*** Usually manifests at 4-6       weeks post-op as progressive intolerance to solids and then liquids
*** Usually treated       successfully with balloon dilation. Doesn't require a reoperation unless       there is a marginal ulcer.
** Dumping syndrome
*** See 'gastrectomy'       complications
** Obstruction - see above
*** Internal hernia
** Incisional hernia
** Cholecystitis
** Vitamin and mineral      deficiencies
*** Wernicke's encephalopathy -       particularly seen with severe vomiting - vitamin B1 (thiamine)       deficiency
*** Iron deficiency (since iron       is absorbed in duodenum and proximal jejunum). Usually managed with oral       iron (the gluconate form is best absorbed in a non-acid environment).
*** B12 deficiency (15-20%).       Rarely causes anaemia. Inefficient absorption due to delayed mixing with       intrinsic factor, so can develop despite oral supplementation. Need to       use a route other than oral.
** Weight regain
*** Can try endoscopic suturing       of the gastroenterostomy, to deliberately reduce it in size
** Hypoglycaemia

[[Category:Bariatrics]]