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An estimated 5–25% of patients who undergo bariatric surgery will have complications. Most surgical complications will occur in the immediate postoperative period, perhaps while the patient is still in the hospital. These include anastamotic leak, pulmonary embolism, and bleeding. We will not discuss these complications in depth in this chapter.

Delayed complications occur in an estimated 10% of patients who undergo weight loss surgery. Patients may present to the emergency department (ED) with these delayed complications. Complications may be related to the device itself (if one is placed), to intermediate or late surgical complications (such as bowel obstruction), or they may relate to gastrointestinal (GI) symptoms that occur as a result of changing the GI tract anatomy (Table 3.1). Practitioners treating patients who have had bariatric surgery must be alert to the fact that these patients can have GI disorders that are not secondary to their weight loss surgeries as well. Any patient with significant abdominal symptoms who has had bariatric surgery in the past should be evaluated by a surgeon experienced with such patients. Such consultation may be helpful in directing the most appropriate workup and management, and early consultation is essential in those cases where a prompt return to the operating room is indicated. The main bariatric surgery complications with timing, symptoms, diagnostics and treatment are summarized in Table 3.2.

Table 3.1 GI symptoms and associated causes.

DiarrheaMalabsorptionBile saltsDumping syndromeFood intoleranceLactose intoleranceIrritable bowel syndromeBacterial overgrowthInfectionVomitingOvereatingNoncompliance with bariatric surgery dietObstructionMarginal ulcersStomal stenosisGastric band slippage with gastric prolapseRoux stasis syndromeExcessively tight gastric bandGallstonesGastroesophageal refluxConstipationDehydration due to decreased fluid intakeIron supplementationMultivitamin supplementation

All patients who present with abdominal pain, nausea, vomiting, or diarrhea after having weight loss surgery should have a full exam, with close attention to signs of dehydration and shock. Tachycardia is especially worrisome, as it may indicate dehydration, sepsis or infection (particularly in the setting of a postoperative leak), GI bleeding, pulmonary embolism, or even acute myocardial infarction. Intravenous access and full laboratory evaluation, including complete blood count, complete metabolic panel, and urinalysis, should be obtained. Blood gas, as well as stool hemoccult, may help acutely ill patient. The patient should be fluid resuscitated, antiemetics should be given for nausea and vomiting, and abdominal imaging should be considered. If there is concern for ileus or obstruction, abdominal radiographs should be performed. In a patient who is particularly toxic, or who has persistent abdominal tenderness, or nausea or vomiting after an antiemetic and fluids, abdominal CT or UGI study may need to be performed. This would help identify obstruction or staple line leak. Rapid weight loss can be a risk factor for development of gallstones. All bariatric surgery patients who have colicky abdominal pain and vomiting with no other identified cause should be evaluated for gallstones.

In the first month after surgery, patients who have undergone RYGB may present with nonspecific signs of infection: tachycardia, mental status changes, and dyspnea, with or without abdominal pain. This should immediately raise concern for anastomotic or staple line leak. Full labs, fluid resuscitation, and broad‐spectrum antibiotics should all be initiated, along with abdominal imaging via UGI or abdominal CT. Anastomotic leak is the most serious complication patients may develop after RYGB or sleeve gastrectomy and requires urgent surgical consultation and operative exploration.

Patients who have had RYGB are also particularly at risk for the development of marginal ulcers. These occur in 5–10% of patients and present several months after surgery. Patients classically present with epigastric abdominal pain, nausea and vomiting, dyspepsia, or signs of an upper GI bleed. Perforation may also occur, with signs and symptoms of infection and sepsis. Stable patients may respond to IV fluids, sucralfate, and a proton pump inhibitor, while more acutely ill or hemodynamically unstable patients will require aggressive fluid resuscitation and packed red blood cell transfusion, along with emergent endoscopy. RYGB patients may also develop stomal stenosis in the first months after surgery. This presents as epigastric pain after eating and may also be accompanied by vomiting, initially only of solids, and ultimately of all food and liquids. Stomal stenosis is identified via UGI or endoscopy and can be corrected with endoscopic balloon dilation the majority of the time.

LSG and LAGB are technically more simple surgical procedures than RYGB and are, therefore, associated with fewer complications than RYGB. Patients do not experience dumping syndrome, stomal ulceration, nutritional deficiencies, or small bowel obstruction in the way that they may after RYGB. LSG does carry the risk of leaking at the staple line. This occurs in less than 5% of patients, typically in the first month after the weight loss surgery. Patients may present with infection or abdominal pain and will have the staple line leak identified on UGI or abdominal CT.

Table 3.2 Bariatric surgery complications.

Complication	Timing	Weight loss procedure	Signs and symptoms	Diagnostic testing	Management
Small bowel obstruction	Within 1 month	RYGB	nausea/vomiting and abdominal pain	Abdominal Xray	Nasogastric decompression and fluids
Staple line leak	Within 1 month	RYGB and LSG	Abdominal pain, tachycardia, and sepsis	UGI abdominal CT	Fluids, antibiotics, and surgery
Marginal ulcers	2–4 months	RYGB	Epigastric abdominal pain, upper GI bleeding, and dyspepsia	N/V endoscopy	PPI, sucralfate, fluid, or PRBC resuscitation
Upper GI bleeding	First 6 months	RYGB and LSG	Hematemesis, melena, anemia, and hypotension	Bleeding scan, and endoscopy	acid blocker, packed red blood cells, and fluid resuscitation, and endoscopy
Dumping syndrome	Variable, typically first 6 months	RYGB	Diarrhea, abdominal cramping, flushing and sweating, N/V, palpitations, and hypotension	None	Supportive, small frequent meals and fluids
Cholelithiasis/cholecystitis	Anytime	RYGB, LSG, and LAGB	Colicky abdominal pain and N/V	Ultrasound	Supportive, cholecystectomy
GERD	Anytime	RYGB, LSG, and LAGB	Reflux, epigastric pain, and N/V	None	Acid blocker, small frequent meals
Gastric slippage	Anytime	LAGB	Epigastric pain, reflux, and food intolerance	AXR and UGI	Surgery
Gastric band erosion	Months to years	LAGB	Infected port site, weight gain, abdominal pain, and vomiting	UGI	Surgery for band removal
Gastric necrosis	Variable	LAGB	Acutely ill, abdominal pain, and N/V	UGI	Surgery

RYGB = Roux‐en‐y‐gastric bypass

LSG = laparoscopic sleeve gastrectomy

LAGB = laparoscopic adjustable gastric band

UGI=Upper GI radiography

AXR = abdominal xray

N/V=nausea/vomiting

CT=computerized tomography scan

PPI = proton pump inhibitor

PRBC = packed red blood cells

LAGB is the least complicated surgical procedure, but has not taken hold as a major bariatric surgery option because of the frequent band complications, and the significant segment of patients who do not achieve the weight loss results desired with this procedure. LAGB is considered reversible, though, after the band is removed, a significant amount of scar tissue will remain, complicating further surgical procedures. While the lap band is associated with fewer severe surgical complications such as leak and significant bleeding, the complication rate itself is higher. Complications include reflux symptoms, food intolerance, esophageal dilation, band slippage, gastric prolapse above the band, and erosion of the band, among others.

Gastric slippage, which occurs in 15–20% of LAGB patients, occurs when a part of the stomach becomes prolapsed above the gastric band and creates an unnecessarily large gastric pouch and potential obstruction. Patients will develop reflux symptoms and dysphagia and, in severe cases, can develop significant abdominal pain and vomiting. Abdominal upright radiographs or a UGI study will likely show the gastric slippage and dilation of the proximal gastric pouch. Even those patients who appear clinically well typically require surgery to correct the gastric slippage and should be aggressively fluid resuscitated and have electrolytes checked and corrected prior to surgery. Surgeons may attempt to deflate the gastric band by advancing a Huber needle into the port site at the skin until the needle hits the plate at the back of the port, and then withdrawing fluid to deflate the band completely. This should allow the stomach to return to its normal size and obviate the need for immediate surgery until a bariatric surgeon can evaluate the band. Nonsurgical practitioners are typically advised not to deflate the band themselves, though in EDs, where there is no timely access to a general or bariatric surgeon, ED physicians may do so.

Gastric band patients may also develop erosion of the band into the stomach. Band erosion may present subtly, with few abdominal complaints. Oftentimes, the presenting feature will be an infection at the band port site and can occur months or even years after the initial band placement. All patients with a port infection thus require evaluation for band erosion. Band erosion will require UGI or endoscopy to diagnose and will then require band removal. This is typically done surgically but endoscopic retrieval has been reported.

Finally, gastric band patients may also develop gastric necrosis. Gastric necrosis is typically a late complication of lap LAGB that occurs from a combination of pressure from the band and gastric prolapse. Patients will present acutely ill, with a surgical abdomen. UGI or abdominal CT studies demonstrate the gastric prolapse.

Though unlikely to cause someone to present to the ED, after LAGB, patients will sometimes present with weight gain, as the band is no longer functioning to restrict food intake or if patients themselves develop maladaptive eating strategies (ingesting high‐calorie liquids such as ice cream or milkshakes or foods that can easily pass through the small stoma, e.g. potato chips).