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Michael Schweitzer, M.D., F.A.C.S |
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Risks and
Complications of Bariatric Surgery
The
purpose of bariatric (morbid obesity) surgery is prevent,
alleviate or cure obesity related medical problems. The individual patient must weigh the risk of
staying morbidly obese versus the risk of morbid obesity surgery. It is a choice made by each patient. It is
very important that each patient has a support system of family or friends to
help him or her after the surgery. A good support system is needed for
physical limitations right after the surgery and also psychological changes
that most patients will experience.
Your support person(s) should understand the surgery, why you are
doing it (for your health!), and the risks involved. It must be understood that even if the
surgery is done through tiny incisions it is still major abdominal
surgery. It must also be understood
that all patients may need another laparoscopic or open surgery in the
future. All
major surgeries have a long list of complications that can take a full
textbook to explain each one. The list
below is for educational purposes only to help you understand the possible
complications that could happen. It is
important to ask your surgeon about any part of the operation or possible complication
that you do not understand. It may
help to go to support group meetings where you can meet people and discuss
these issues from postoperative patient's perspective. I
have a very low rate of complications and will be more than happy to discuss
this with you in the office. I have
even published my results! The
list below is for all 4 operations; Duodenal Switch, Gastric Bypass, Lap
Band, Sleeve Gastrectomy. It is also for those patients who need to
undergo a revision operation. Each
operation has its own set of complications that are more or less risk than
the other operations. This is
complicated and again another reason why you should come to the consultation
ready to ask us questions. Bleeding: Stomach and intestinal surgery involves cutting
and closing blood vessels. Blood vessels can spasm after being cut only to
open up hours later. This may lead to
major bleeding that can require a blood transfusion(s) and/or a re-operation. Transfusions carry the risk of infection
(HIV, AIDS, Hepatitis, etc) or reaction.
Some patients donate their blood before the operation, take iron
supplements and then have it in case they need it. You will have to arrange this donation
yourself. You may become anemic and
need to cancel surgery, or after surgery need a transfusion due to
anemia. Please be aware that most
patients will get a blood thinner before the start of the operation to
prevent blood clots. This can cause or
accentuate a bleeding problem. Most
bariatric surgeons agree that the risk of preventing blood clots out weighs
the risks of bleeding but there is no perfect balance to ensure 100%
prevention of both. Blood Clots: These usually form in the
legs and pelvis (they can form elsewhere) and the ones that are dangerous
form in the deep veins. The blood clots can break off and go to your heart
and lungs (Pulmonary Embolism) and cause no symptoms, minor shortness of
breath, or even death. They may cause the leg to swell, so if you notice one
leg is swollen more than the other please bring it to the attention of the
nurse or doctor since you may need to get an ultrasound. Most patients get some swelling after
surgery due to fluids given through your veins. Many patients already have swelling. This is why we give most patients blood
thinners, squeezing devices on the legs (or feet) if they fit, and get them
walking as soon as they are able to. Leaks: Any part of the operation that involves dividing
or adjoining the stomach or intestines can leak at the suture or stapling
line. This can lead to a life
threatening infection with septic shock and death. You should ask your surgeon about their
leak rate and the number of surgeries done.
Lungs: Pneumonia after general anesthesia combined with
an upper abdominal surgery is one of the risks. After surgery it is important for you to do
deep breathing exercise and ambulate (with assistance at first). Some patients have severe lung disease that
might require a tracheostomy. This can also happen with any severe
complication. It is usually temporary. Anesthesia: General anesthesia is safer than it’s ever
been. Morbid obese patients can at
times be difficult to intubate (place the breathing
tube down your throat) due to a narrow airway. This could lead to an emergency tracheostomy ,
brain damage and/ or death. Please
discuss this with your anesthesia team since there are different methods used
for patients with known difficult airways. Allergies: This could be anything
from a minor rash to shock and death. Heart: If you are over 40, family
history of heart attacks, diabetes, high blood pressure the please ask your
primary care doctor to assess your risk.
Heart evaluations appear to be less accurate at higher body weights. If you have heart disease then you will
need a cardiologist consultation. A heart attack during an operation or
postoperatively can lead to stroke or death. Bowel Obstructions: Any infection,
inflammation or surgery inside the abdomen can leave scar tissue. Even the laparoscopic approach has the
potential to leave scar tissue (usually much less than an open incision but
not always). Scar tissue can cause the
bowel to become obstructed (blocked) requiring another operation (open and/or
laparoscopic). The bowel could
perforate or become gangrene and need to be removed. If a significant amount of bowel becomes
gangrene then you could have chronic malabsorption
problems. Bowel Obstructions can be a
life threatening problem and need to be evaluated and possibly treated by an
abdominal surgeon (most cases a general surgeon). A hernia can cause bowel obstruction. Ulcer: The stomach or small
intestine may develop an ulcer after the operation. Most are simply treated by medication. An upper endoscopy
may be used to evaluate (it is similar to a colonoscopy except it is done up
above). An ulcer can bleed (in some
cases life threatening bleeding) and also perforate leading to a serious
infection. Smoking can cause or exacerbate an ulcer, and may also lead to
medication failure. Ibuprofin and asprin products may cause ulcers. The newer class of medications may be less
irritating but there is no good data to support this theory. Stricture: A narrowing in the bowel
can occur anywhere that the stomach or intestine was operated on. The most common place is at the hookup of the
gastric pouch and Roux limb (called the gastrojejunostomy
anastomosis or stoma). We make it small on purpose so that food
stays in your pouch longer. In some
cases this strictures and gets too small so that at
first solid food is difficult to keep down then eventually liquids. This is usually seen at 4 weeks after
surgery but can be earlier or later in some cases. It is almost always resolved with an upper endoscopy that can diagnose it and treat it by ballooning
the opening (small risk of perforation with infection and re-operation
exists). Occasionally more than one
ballooning by endoscopy is necessary and in a few
patients re-operation may be needed.
It can also happen in other parts of the esophagus, stomach, or
intestine. Strictures can develop in a
duodenal switch, sleeve gastrectomy or even an
adjustable gastric band. Dumping Syndrome: After gastric bypass the
small gastric pouch will be hooked directly up to Roux limb (small
intestine). High sugar foods can cause
a reaction that may lead to abdominal cramping/pain, fast heart rate, nausea,
and occasionally bowel movements. This
is why you should read the booklet and go over your diet with the
dietician. Many patients will get
dumping syndrome but not all, and it is common for it to dampen with time or
even try to beat it. This means that
it is still important to eat a healthy diet and avoid refined sugar products.
A few patients complain of felling very tired 1 hour after eating. This appears to be related to “late dumping
syndrome” which has to do with the glucose and insulin balance in your
body. In most cases by cutting back on
carbohydrates this will resolve. It
also appears to dampen with time in many cases. Again consult your bariatric surgeon for
more details. Gallstones: Gallstones may develop in-patients losing
weight. The gallbladder is left in
place with most cases of laparoscopic bariatric surgery. If you are having problems with your gallbladder
please discuss this with your surgeon at the time of consultation. The patient
may take a medication called atigall (ursodiol) for 6 months to lower the risks of gallstone
formation. Since most patients who
develop gallstones can have it remove laparoscopically
(unless very inflamed or adherent) we do not increase the complexity of the
operation at the time of the laparoscopic bariatric case unless the patient
and surgeon feel it should be removed.
Please discuss this with your surgeon.
Risks of gallbladder surgery are low but not zero and these include
bile duct injury, liver disease, bile leak, and re-operation. Incisional Hernia: A hernia is simply a hole and in this case it is a defect in the
fascia (not muscle, not ligament but holds the abdominal contents inside)
that intestines and other organs can either go in and out of or get
caught. If it gets caught it may cause
a blockage (obstruction) requiring surgery or in worst case block the
vascular supply and cause gangrene (life threatening). These hernia’s are
more common in patients with central obesity (a lot of fat inside the
abdomen). You may be able to wait and
have you hernia repaired (usually with mesh) after you have lost weight so
that it may be combined with a plastic surgery procedure to remove loose skin
and possible tighten your muscles. These type of hernia’s are infrequent in laparoscopic
surgery due to the smaller incisions (they can happen but even if they due
the repair is much simpler and infrequently requires mesh). If you are
experiencing pain then you should call your surgeon or go to the emergency
room. Internal Hernia: A hernia is a hole and in
the case of an internal hernia it is inside the abdomen where an organ, (ex:
small intestine) gets caught and can lead to strangulation and gangrene. The patient at first may only have an occasional
crampy abdominal pain that could be similar to
other benign sources (ex: an upset stomach from a spicy meal). If this mild
pain keeps reoccurring than you need to seek expert advice. If the pain is more than mild or last over
1 to 2 hours you need to get expert advice immediately. It is possible that your bowels will be
blocked and nausea and/or vomiting or abdominal distension will occur, again
seek expert advice immediately. Wound Infection: This can be a small minor outpatient infection to
a large necrotic one needing surgery (uncommon, but life threatening and
disfiguring). Laparoscopic appears to
greatly reduce this problem. Wound Seroma
or Drainage: This is much more common with open surgery than with laparoscopic.
The wound may drain for months and need dressing changes. It is possible that surgery on the wound
may be necessary. The laparoscopic
wounds are usually small so if they do drain it is almost always a minor
irritant compared to a larger open incision. Chronic Nausea: Nausea after surgery is
usually treated with medication and subsides in days to a couple weeks in
most patients. A few patients have
chronic nausea and despite medication it does not subside for months (it is
uncommon to have to reverse the operation due to chronic nausea). A patient who is not able to take in enough
calories/protein may need to go on gastrostomy tube
feeds (which may require re-operation or radiology procedure) or TPN which is
food through a catheter in your vein. Vomiting: Most common cause is overeating and this is why it
is very important you slow down, chew and eat slowly. Blockages of your bowels, stenosis, chronic
nausea and other reasons may cause continued vomiting and must be reported
immediately. Malabsorption: This
can happen after gastric bypass or duodenal switch. Duodenal switch is in most cases a much
more malabsorption procedure and therefore there is
more risk. Diarrhea and excessive
flatus can develop. Again this is more common after duodenal switch. Up to
5-10% of duodenal switch patients may need to have a revision surgery where
the common channel is lengthen to decrease the malabsorption
(this is less common in gastric bypass) Depression: Rapid weight loss, unable to enjoy certain foods or
large quantities of foods are just a couple reasons why you may get depressed
postoperative. It is very important
that you get immediate help from a mental health professional that in most
cases requires but not limited to medication.
Again get help and let our office know. Do not tough it out, it almost always gets
worse. If needed, you must be willing
to see a mental health professional! Vitamin & Mineral
Deficiencies: Certain vitamins and
minerals you will be required to take in the form of supplements for
life. It is also important that blood
levels (and possible other tests) be done in most cases on an annual basis
and in some cases more frequently. If
you do not understand what to do or take it is you should see our dietician
for more education. Duodenal switch
patients are more at risk due to more malabsorption. Kidney Stones: These may form and need treatment. Patients who never had them before may
develop them. It may be very
painful. An Urologist may need to be
consulted. It is important to stay hydrated to
help prevent stones but this alone sometimes is not enough. Taking too many of certain supplements also
may lead to stones in-patients who are predisposed to form them. Excessive Weight loss: Most patients level off
their weight loss after 1.5 to 2 years on average. It may be necessary to use TPN(food though a vein catheter) or gastrostomy
tube feeding if you are unable to get enough protein and
vitamins/minerals. In most cases this
is temporary. It is uncommon to have
to reverse the operation and with reversal weight regain is most likely since
morbid obesity is a chronic disease. Loose Redundant Skin: Weight loss can lead to sagging excess skin that
would need to be excised. Surgery to
remove this may not be paid for by insurance.
Infections, irritation and pain may result. It is not possible to predict how much Pregnancy: Many female patients will
become more fertile as they lose weight and therefore, extra precaution is
advised. Remember no method of birth
control is 100% so discussion with your gynecologist is the best way to
plan. You should not get pregnant in
the first 1.5 to 2 years. It should be
a planned pregnancy and you must be taking all your vitamins and have your
blood levels checked before getting pregnant.
Most patients do not have a problem with their pregnancy but it is
very important to discuss this with your physicians. It is not risk free for the mother and the
fetus. It should be noted that a
morbid obese patient (who did not have gastric bypass) who gets pregnant has
an increase risk of complications (example: gestational diabetes). I can not stress again how important it is
to plan and see your doctors for advise. Stroke: Hardening of the arteries & hypertension are
examples of disease that could put you at higher risk for a stroke. Strokes can be mild to life threatening. Kidney Failure: Some patients may already
have kidney disease (for example: diabetes & hypertension are common
causes) and will be predispose to kidney failure after
surgery or due to intravenous contrast studies. If you develop a severe complication, for
example, life threatening infection your kidneys could fail and you may need
dialysis. Muscle & Fat Necrosis: Very rare but can lead to large areas of
skin and muscle removal, limb removal and death. Skin Ulcers: Breakdown of skin while under general anesthesia
or in the hospital bed is possible.
This is can be a concern in patients who are unable to ambulate after
surgery. It may require further
surgery. Nerve Damage: Pressure, retraction or lying under general
anesthesia with arms/shoulders extended; also mineral/vitamin deficiency, malabsorption, autoimmune diseases and other diseases may
cause temporary or permanent nerve damage and\or paralysis. Unfortunately some patients who get the
operation may also develop diseases unrelated to the operation. Paralysis: Nerve damage, muscle damage, vitamin & mineral
deficiencies, autoimmune disorders, represent possible reasons for this
uncommon complication. Back Pain: May occur due to lying on an OR table under
general anesthesia; with bed transfer, lying in a hospital bed, etc. Hair Loss: Rapid weight loss may lead to hair loss. In most
cases once weight loss slows or levels off then hair grows back if protein
and mineral/vitamin levels are adequate. Certainly if you had a problem with
this preoperatively than you are at higher risk after the operation and it
may not get better. Spleen: the spleen sits in the left upper part of you
abdomen, adjacent to your stomach where the operation is performed. If injured it can bleed and require repair
(most cases) or removal. If removed
you will need to get vaccines to prevent an increase risk of infection to
certain bacteria. Liver Damage: Morbid obesity cause a type of liver
damage called steatohepatitis. Gastric bypass, Duodenal Switch (and too a
lesser extent Lap-Band) surgery are an infrequent cause and in most cases
appear to resolve the liver problems by inducing weight loss. In some cases patients may go onto liver
damage or failure and death after surgery (most of these cases the patient
had damage to the liver before the operation) Please be aware that you can have
liver disease and no symptoms at all!!!!
We do not treat it if we see it at surgery but instead hope that
weight loss will improve or resolve it.
Older intestinal bypass surgeries caused liver damage and in some
cases death. Medications and
intravenous food through ones veins can cause liver damage. Erosion: The adjustable band may erode into the
stomach or esophagus. If this happens
you may not have any symptoms other than loss of restriction. We will have to remove your band. Esophageal dilation: The esophagus may dilate
after adjustable gastric band surgery and we may have to remove the
fluid. This usually resolves the
problem in most cases but the band may also need to be removed. Slip of the band: The stomach may slip through the band and
get caught. This can be chronic and
lead to weight loss failure problems eating or it can be acute with pain and
vomiting. Band or port
breakage: This is a device and it
can break. It will need to be
repaired. Trocar Injury: In laparoscopic surgery
small incisions are made and trocars are used to
access the abdomen so that carbon dioxide will stay inside. These trocars
could injury an organ, blood vessels nerves, etc. Fatal infection or life threatening
bleeding could occur. Pancreatitis: The pancreas sits under the stomach and may
be injured during the operation or may become inflamed due to a gallstone or
medication. Fistula: A communication from a part of the
intestine or stomach may develop to another part of the intestine or
skin. It may not close and in some
cases it may need a re-operation. Cancer: No evidence to date that these operations
lead to an increase risk of cancer (ex: stomach cancer). The hope is that by losing weight and by
preventing, alleviating or curing obesity related medical problems the
overall risk of cancer will decrease.
However, there is to date no proof that your risks will drop and just
because you had surgery does not mean you can not get cancer. Death: This is major abdominal surgery and there is a
risk of death from any of the complications listed here or other possible
complications. Reversal of the Surgery: This is not common and
since morbid obesity is a chronic disease it is likely a patient reversed
will regain all there weight. Please
consult a bariatric surgeon before considering reversing since it may not
resolve your problem but some general surgeons do not believe in the surgery
and are glad to reverse it. Clearly if
there is an emergency, life threatening illness due to the surgery or all
efforts have been exhausted at a chronic problem then it may help to reverse
or convert to another type of morbid obesity surgery. Weight Regain: Patients on average stop
losing weight around 1.5 to 2 years.
Patients may regain weight. The
gastric pouch is made small in the beginning since it will dilate in most
cases but if too excessive (most common cause over eating) and/or the anstomosis of the pouch to the roux limb dilates and
empties too fast then some patients may regain too much weight. Under
a physicians care (primary care or gynecologist) you need to stop birth
control pills or estrogen products one month before to hopefully reduce your
risk of blood clots. If you are unable
to do this you should discuss it with us.
You must prevent from getting pregnant before and 1.5 to 2 years
after. Please
stop all herbal supplements (not taken under a physician’s care) at least one
month before surgery. We are now
learning that herbal medications can prolong anesthesia, interfere with
medications, and cause bleeding (all of these can lead to death). In most cases you should ask your physician
about stopping aspirin and blood thinning products before surgery. Please make us aware so we can tell you
how long before your date to stop them. Please
discuss and ask questions when you meet with us so you better understand your
risks. Patients who have previous
gastric surgery (for example: vertical banded gastroplasty)
are at higher risks for complications (ex: leak rate is higher than reported
for no previous gastric surgery patients).
Patients who are over 400 lbs (or higher body mass index is the more
accurate way to classify) may be at higher risks for complications. I will be happy to give you my current
percentages of risks as it pertains to you.
My complication rate is comparable to other published papers
(including my own). My leak rate is
well under 1% for the laparoscopic approach (and open approach,
most of my cases are done laparoscopcially). Remember that even if your risk is very
low, there is no perfect operation. Disclaimer: This buy no
means represents an entire list of complications, nor does it go into great
detail about each complication that could range from very minor to life
threatening in complexity. The purpose
is to help educate you on possible complications and for you to understand
that even if the incisions are small, morbid obesity surgery is a major
complex operation. It is important for
you to ask questions and to seek out professional advise about complications
that may occur with the type of morbid obesity surgery you are having done
(ex: surgeons due different types of gastric bypass which may have different
risks). This list is intended only for
Dr. Schweitzer’s patients who undergo surgery by him. |
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Michael Schweitzer, M.D., F.A.C.S. Associate Professor of
Surgery The Director of Minimally
Invasive Bariatric Surgery Department of Surgery 4940 Eastern Avenue Phone: 410-550-3345 email Schweitzer@doctor.com web site www.smallscar.com ©
The medical information provided in this
site is for education & information purposes only. The information
provided is not a substitute for a professional medical opinion. If you have
a medical problem, please contact your doctor or health care professional.
Content copyright © 2000 Michael Schweitzer, M.D. All Rights Reserved.
Republication or redistribution of any content is expressly prohibited
without the prior written consent of Michael Schweitzer, M.D.
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Johns Hopkins Bayview Medical
Center | Johns Hopkins Medicine |
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© The medical
information provided in this site is for education & information purposes only.
The information provided is not a substitute for a professional medical
opinion. If you have a medical problem, please contact your doctor or health
care professional. Content copyright © 2000 Michael
Schweitzer, M.D. All Rights Reserved. Republication or redistribution of
any content is expressly prohibited without the prior written consent of
Michael Schweitzer, M.D.