Update for Long-Term WLS Post-Ops: Potential Issues To Watch ForSeptember 10, 2018
As our knowledge and understanding of obesity as a disease progresses, it’s becoming more evident that the disease process is chronic and relapsing. This is one of the main reasons for medical therapy failure in the intermediate and long run. Surgery affects multiple hormonal pathways and therefore allows for more consistent and successful weight-loss and maintenance for WLS post-ops in the long run.
However, just as with any intervention, be it medical or surgical, will have stimulated changes in the body to counteract the intervention. For example, when a gallbladder is removed due to gallstones, the short-term changes are diarrhea. This is due to an increase in bile production and/or malabsorption of fat in digested meals. Over time the body adapts to this new change and regulates the amount of bile being produced to help adequately with digestion.
Potential Issues for Long-Term WLS Post-Ops
The changes which occur after WLS depend on the procedure performed. For simplicity, we have divided WLS into restrictive and malabsorptive procedures.
The common procedures performed in the United States nowadays are:
- Laparoscopic Adjustable Gastric Band (LAGB)
- Laparoscopic Vertical Sleeve Gastrectomy (LVSG or VSG)
- Laparoscopic Roux-En-Y Gastric Bypass (LRYGB or RNY)
- Laparoscopic Biliopancreatic Diversion with Duodenal Switch (LVSG, BPD/DS).
There are other less frequently and/or older procedures which are not as common, we will not address these conditions now.
Laparoscopic Adjustable Gastric Band (LAGB)
In 2017, only 2.77% of cases were LAGB, this procedure has fallen out of favor with most bariatric surgeons and patients for several reasons.
Weight Regain. Weight recidivism, which is weight regain, is very common after 5+ years after the procedure. Sometimes we call this device or procedure failure so; despite compliance of the patient the device is no longer able to fulfill its role of weight loss maintenance.
Obstructions. Mechanical obstruction secondary to slippage, malrotation, over-inflation of the band all can cause uncomfortable symptoms of esophageal spasms which may be confused for cardiac ischemia and food getting stuck at the lower esophagus.
Many patients have learned to stay calm and slowly allow the food bolus to pass. However, this may require complete deflation of the band and endoscopic removal of the food bolus. If the band has slipped and is associated with epigastric pain it will require immediate evaluation by a bariatric surgeon. In rare occasions, the stomach slips through the rigid band and may cut its own blood supply. If this is the case immediate band deflation and surgical removal is warranted to avoid the stomach dying.
Erosion. If a patient experiences an erosion, this is one of the most serious complications of the LAGB. The gastroesophageal junction is a very active and dynamic region of the digestive tract, it has to constantly relax and contract to allow coordinated food movement from the mouth into the stomach. Having a mechanically stiff objected putting pressure on the site leads to the decreased blood supply to the site, along with long-term scarring, this may lead to slowly eroding into the stomach.
Slow erosion may be completely asymptomatic or associated with vague symptoms of heartburn, epigastric pain/discomfort and/or weight recidivism. Band erosion is usually diagnosed on endoscopy. The treatment depends on the extent of the problem. In occasions it may be removed endoscopically and if unsuccessful surgical exploration is required.
If you have any concerns about your band or have developed new symptoms, I strongly encourage you to see a bariatric surgeon for comprehensive evaluation.
Laparoscopic Vertical Sleeve Gastrectomy (LVSG)
This is the most common weight loss procedure performed in the United States with about 60% of all metabolic surgeries being LVSG (or VSG). It has many appeals for both patients and surgeons.
The long-term data for this procedure is lacking and there is a continual evaluation of the procedure. So far the results are very encouraging but, we need more long-term data to better evaluate the efficacy of this procedure in the long run. Some of the potential long-term issues to be mindful of including the following:
Nutritional Deficiency. Deficiencies may occur in the long run if patients don’t supplement their diets with vitamins and follow-up with their physicians routinely to evaluate their nutritional status. The symptoms for nutritional deficiencies are varied depending on what exactly is low in the body. For example, low iron and or vitamin B12 levels may lead to fatigue, malaise and being tired with minimal exertion. Whereas vitamin B1/thiamine deficiency may lead to neurological problems and, if serious, may need immediate attention. The treatment for this is fairly simple if the condition is diagnosed early. Essentially, you need to take high-quality supplementation to replenish the body’s low reserves.
Ulcers and/or Stricture of the Stomach. Because the stomach diameter is smaller after LVSG ulcers may lead to narrowing of the stomach, this will lead to intermittent blockage of food passage through the stomach. So, a patient may experience a sensation of food being stuck in the lower part of their breastbone or experience frequent vomiting with undigested food. Furthermore, if this condition persists, it may lead to nutritional deficiencies. The treatment for this condition depends on the exact problem. The stomach may need to be stretched via an endoscope or in rare occasions, surgical intervention may be warranted.
Reflux/Heartburn. We are seeing more frequent cases of heartburn and reflux after LVSG. In most cases, this is controlled with anti-acid medications but, if food regurgitation is severe and persistent, then full evaluation is needed to rule out a hiatal hernia, gastric narrowing (stricture), ulceration, possible tumors, and other serious conditions.
Again, treatment depends on the exact cause of reflux. Some food reflux is normal but, persistent reflux may lead to other serious conditions such as esophageal cancer. In the majority of cases, the persistent reflux is due to the anatomical change created by surgery, having a tubular stomach may lead to increased reflux and inability of the gastro-esophageal junction in clearing regurgitated acid and food. The treatment depends on the exact pathophysiology. A thorough workup is necessary and it usually includes an upper GI study, endoscopy (EGD) and other specific testing if the first two tests are abnormal.
The common theme here is - continue to follow-up with a bariatric surgeon to make sure you are losing weight in a healthy manner.
Laparoscopic Roux-En-Y Gastric Bypass (LRYGB)
Laparoscopic Roux-En-Y Gastric Bypass (LRYGB) is the best and most comprehensively studied metabolic procedure by the virtue of it being one of the oldest and first metabolic procedures performed. This remains an excellent procedure for a well selected patient population, especially those suffering from diabetes and obesity.
Here are some of the potential long-term issues which one needs to be mindful of their potential occurrence.
Nutritional Deficiency. This is more common than the earlier two procedures mentioned. However, the symptoms and the workup is the same as above.
Marginal Ulcers. Ulceration and/or narrowing at the gastro-jejunal anastomosis known as marginal ulcers. There are multiple reasons for marginal ulcers. Some are related to the new anatomy and the ulcerogenic (ulcer causing tendency) nature of LRYGB, others are patient related. The patient influenced causes include dietary, medications and social habits.
Usually, the most common constellation of factors include analgesics such as NSAIDs, this is a class of medications including Ibuprofen, Aspirin, Motrin, Naproxen, etc) which are ulcerogenic and will lead to ulcers in a patient who has undergone LRYGB.
Smoking and alcohol consumption are two other factors which play an integral role in leading to ulcers formations and the complications associated with them. Also, poor dietary habits and lack of supplements may lead to abnormal healing and exacerbate the situation.
Ulcers can cause significant problems such as strictures (narrowing) leading to pain/nausea and vomiting. This may lead to severe nutritional deficiencies furthermore, if left untreated they may eventually perforate or cause life threatening bleeding.
Internal Hernia. An internal hernia is also a potential cause of abdominal pain. If the patient experiences abdominal pain which is not resolving despite taking over-the-counter analgesics and persists for over 30 minutes, they must seek medical attention as this may be a sign of an internal hernia.
An internal hernia is more common in laparoscopic/robotic RYGB versus open RYGB because of decreased scarring in laparoscopic/robotic surgery. The only way to confirm the diagnosis is by performing exploratory surgery, if your surgeon is experienced then they will perform the procedure laparoscopic/robotic but this will require an experienced surgeon.
It is very important to rule out an internal hernia as this may lead to small bowel ischemia (lack of oxygen and blood supply) which may lead to the devastating complication of large segments of small bowel dying.
Dumping Syndrome. This effect is a cause of altered anatomy loss of the pylorus which controls the size of the food bolus passing into the small intestine. Dumping syndrome usually occurs when the patient consumes large quantities of carbohydrates especially, in the form of refined sugars. Having said that, this is a desirable effect in bariatric patients as it will guide the patient to bad eating habits. Symptoms of dumping can be significantly improved by making simple dietary changes.
Laparoscopic Biliopancreatic Diversion with Duodenal Switch (LDS)
This procedure is only performed in <1% of patients, it is usually reserved for patients with super morbid-obesity which usually entails BMIs of greater than 50. It’s complex to perform and should only be done by experienced bariatric surgeons.
The long-term issues are very similar to that of LRYGB, with the exception of dumping syndrome which is very unlikely in LDS as the function of the pylorus is preserved.
Nutritional Deficiencies. Deficiencies are more common in LDS if the patient isn’t compliant with taking their supplements on daily basis. This may lead to fairly severe complications if the patient doesn’t follow-up with their physician on a routine basis.
- Since the anatomy is very similar to that of sleeve gastrectomy some of the potential complications of LVSG may also occur.
- Anastomotic ulceration/stricture (narrowing) is a potential long-term problem with LDS however because the anatomy of the anastomotic area is very close to normal this is not a common complication. Patients may complain of nausea and vomit undigested food.
- An internal hernia may also cause nausea and vomiting. So, if a patient starts complaining of nausea, vomiting and abdominal pain they must seek medical attention to be evaluated by a physician to rule out an internal hernia. The treatment for this problem is surgical exploration, which may be done in the form of diagnostic laparoscopy and it may also be repaired laparoscopically.
Weight recidivism is a potential long-term problem with any weight loss surgery but, it depends on the procedure performed. For example, weight regain after five years is around 85% with the adjustable gastric band whereas it’s around 2-5% with biliopancreatic diversion with duodenal switch. It makes sense though then the ‘more powerful’ the procedure the more likely the nutrition deficiencies, this is especially true in non-compliant patients.
ABOUT THE AUTHORDr. Husain Abbas of Memorial Advanced Surgery, is a Board Certified surgeon and fully trained in Minimally Invasive Surgery. After his surgical residency at St. Mary's, a Yale University affiliated hospital, Dr. Abbas completed a fellowship in Minimally Invasive Gastroesophageal and Bariatric Surgery at the University of Florida, Gainesville. Dr. Abbas' expertise extends to a wide array of gastroesophageal disorders, anti-reflux surgery, complex hernia repairs, endocrine, oncology and bariatric procedures.
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