Bariatric Times - June 2008 - (Page 22)

22 Surgical Perspective Bariatric Times • June 2008 of security.3 A common credo is that the origin of GI hemorrhage after LRYGB is from a GI staple line until proven otherwise.2, 4, 11 There are four staple lines to consider when determining the site of postoperative bleeding: the gastrojejunostomy, gastric pouch, excluded remnant stomach, and jejunojejunostomy. One study found that the incidence of bleeding from a staple line was approximately 62 percent (21% each from the gastric pouch, GJ, or JJ) compared with a 14-percent incidence of intraluminal gastric remnant bleeding.13 Clinical manifestations often point to the offending staple line; for example, hematemesis suggests bleeding at the gastrojejunostomy or pouch, severe left upper quadrant pain, back and shoulder pain, intractable hiccups, or severe nausea with retching and melena suggests bleeding in the excluded remnant stomach, and bright red blood per rectum or melena suggests bleeding from the jejunojejunostomy.4 It is also possible to have a mixed clinical picture with multiple sites of bleeding. MANAGEMENT The initial management of acute hemorrhage following gastric bypass is guided by clinical parameters and consists of fluid resuscitation, discontinuation of all anticoagulation, evaluation of blood count and coagulation profile, and possible transfusion. The need for operative intervention depends on the clinical presentation and the timing of presentation.4 In the comprehensive review by Spaw, et al., of acute bleeding after LRYGB, 89 of 2,895 total patients had clinically significant postoperative hemorrhage, and only 20 percent required reoperation.3 The remainder of patients were successfully managed with observation, resuscitation with fluid and/or blood, and, in some cases, endoscopy. Of those patients who were managed nonoperatively, 20 percent were managed with observation alone, without the need for blood transfusion.3 These patients remained clinically stable, and the bleeding resolved spontaneously, though the source of bleeding in these patients could not be confirmed.3 Another 55 percent of patients required fluid and blood replacement, but did not undergo diagnostic or therapeutic interventions.3 The remaining 15 percent of patients presented with clinical evidence of severe bleeding that prompted urgent upper endoscopy which was diagnostic in five cases, therapeutic in six cases, and used to guide operative intervention in two cases.3 Endoscopy can be valuable in assessing the gastric and enteric anastomoses for evidence of active bleeding and can provide for less invasive treatment of the bleeding. A recent article by Fernandez reported successful early (within 24 hours of surgery) endoscopic identification of post-LRYGB bleeding and treatment by injection of epinephrine in all patients in the series. There were no complications, and patients were spared the need for reoperation.14 If the surgeon is not performing the endoscopy, he or she should be present or available nearby when bariatric patients undergo early postoperative endoscopy. Furthermore, it may be advisable for these patients to undergo endoscopy in the operating room in the event that surgical intervention to address the bleeding becomes necessary. Early reoperation should be performed for patients with hemodynamic instability and possibly patients with early onset of hemorrhage (12 hours) after surgery.11 Some authors propose initial laparoscopy to treat complications1, 15 with timely progression to laparotomy if laparoscopy fails. Others assert that urgent laparotomy is the safest option.3 Operative therapy is guided by the site of bleeding and may include oversewing of one or all staple lines, gastrotomy (for pouch or excluded stomach) or enterotomy with evacuation of clot, and revision of anastomotic sites. In the future, natural orifice transluminal endoscopic surgery (NOTES) may become another option for the treatment of postoperative bleeding. As with endoscopy, this procedure would allow for minimally invasive diagnosis and treatment of upper GI hemorrhage, but would also provide the advantage of extraluminal visualization and additional therapeutic capabilities. CONCLUSION Postoperative bleeding occurs in up to four percent of LRYGB cases and may be due in part to increased use of prophylactic anticoagulation and use of staplers for transection or anastamoses. Even when additional modalities are used or technical steps are taken to prevent postoperative bleeding, bariatric surgeons must maintain a high index of suspicion to identify postoperative bleeding in a timely fashion in order to take the appropriate action. With clinical vigilance and careful management, the majority of patients can be successfully treated without the need for reoperation. REFERENCES 1. Mehran A, Szomstein S, Zundel N, Rosenthal R. Management of acute bleeding after laparoscopic Roux-en-Y gastric bypass. Obes Surg http://www.synovissurgical.com http://www.synovissurgical.com

Table of Contents Feed for the Digital Edition of Bariatric Times - June 2008

Bariatric Times - June 2008 Endoluminal Treatment Options for Morbid Obesity: Devices and Techniques for Natural Orifice Approaches The Multidisciplinary Approach to Weight Loss: Defining the Roles of the Necessary Providers Acute Bleeding after Gastric Bypass Editorial Message Contents ASMBS: 25 Years Editorial Board Surgical Site Infection In The Morbidly Obese Patient: A Review Consultant's Corner The Link Between Sleep Loss and Obesity: Understanding the Mechanisms Responsible for Weight Gain with Sleep Deprivation Volume Matters Journal Watch Advertiser Index

Bariatric Times - June 2008

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