Laparoscopic sleeve gastrectomy is an effective weight loss operation. It is quickly becoming the most commonly performed weight loss operation. Understanding the possible complications that can arise is important.
Nausea and Vomiting
There is a chance of nausea and vomiting for the first 24-48 hours after general anesthesia and gastric sleeve surgery. Nausea can be a side effect of the general anasethsia and the pain killers used after surgery. In addition, the stomach will be smaller with a long staple line that has been reinforced with sutures and with tissue glue. All these contribute to the nausea. Nausea will settle by the second or third postoperative day. It is not usual for nausea or vomiting to continue past the first few days.
Blood Clots (Venous Thrombo-Embolism)
Blood clotting in the legs or the lungs are complications that can come from any surgery and obesity itself is a risk factor for blood clots. The risk of clotting will continue for up to 3 months after surgery, but most cases will appear within 30 days. That being said, an aggressive thrombo-prophylactic plan reduces the risk of clotting to less than 1%. We take the prevention of blood clots very seriously with the following:
- An injection of a blood thinner called heparin three times a day starting before the surgery.
- Thrombo-Embolic Detereant (TED) Stockings worn by all patients before, during and after surgery for two weeks.
- Intermittent pneumatic compression devices around the claves during the operation and continued till the following morning after the operation.
- Deep breathing exercises using the Triflow device after surgery for two weeks. This encourages the expansion of the lungs and increases the blood return from the lower limbs.
- Early mobilization out of the bed within few hours after the operation.
- Prevention of Dehydration.
- Some higher risk patients will be given self-administered low molecular weight heparin injections (called Clexane) to use for the first two weeks after going home.
Bleeding from the Staple Line
Within the first few days of surgery bleeding may occur along the staple line of the stomach. The risk is around 0.5% of sleeve patients. On rare occasions a blood transfusion will be needed. Our technique of reinforcing the entire staple line with suture and the application of dissolving glue makes this very rare. There is also a risk of bleeding from the spleen, the liver, and the abdominal wall at the site of trocar entry. In rare circumstances re-operation may be needed.
Staple line Leak
Leakage of stomach juice through a hole in the staple line is the most serious complication of the sleeve operation. Leak occurs in around 1% of patients having the sleeve gastrectomy as their first operation and around 3% in patients having the sleeve gastrectomy after a failed gastric band. The majority of leaks occur early while the patient is in the hospital or shortly after going home. Leak is rare to occur 6 weeks after the operation. Leaks can occur due to staple malfunction, technical error, stomach ischemia ( not enough blood to the stomach), thermal injury, or obstruction resulting from a kink in the stomach tube. Leaks can also be related to patient factors such as the use of steroids and anti-inflammatory medications, smoking and eating solids too early. Leakage of stomach juice into the abdomen triggers a severe inflammatory reaction that if not managed properly can result in death. The management of leaks often requires a long stay in hospital, re-operations, intravenous nutrition, endoscopy and stenting of the sleeve. The key to managing gastric leakage is prevention with proper surgical technique, prevention of kinks and the reinforcement of the entire staple line with a long continuous suture reattaching the omentum to the new stapled border of the stomach.
Stricture (narrowing) of the gastric tube
Stricture formation (narrowing) can occur in sleeve patients, and most commonly presents itself in a later phase after the surgery. Common symptoms include food intolerance, or nausea and vomiting. Narrowing can occur due to removing too much of the stomach, twisting or kinking at the angle of the stomach (incisura) or scarring related to inflammation. Endoscopic dilation of the narrowing with a balloon tend to help the patients however, this often need to be repeated. In extreme cases reoperation is needed often involving performing a gastric bypass operation. Prevention is the key to eliminate this problem with proper surgical technique, leaving ample of room near the angle of the stomach, proper use of the sizing tube, and the prevention of kinks or twist in the gastric sleeve by suturing the omentum back to the entire staple line.
Acid reflux is common in obese patients due to the increased abdominal pressure as well as the higher incidence of hiatus hernia. Following sleeve gastrectomy some patients develop new onset acid reflux. This is related to the small capacity of the new stomach and the increased pressure inside the gastric tube. In the majority of patients the reflux is easily controlled with medications (e.g. Nexium) and the reflux settles when patients lose enough weight. We routinely check for presence of a hiatus hernia before the operation using Barium swallow or gastroscopy. If a hiatus hernia is present we repair it at the same time as the sleeve operation to reduce the chance of reflux after the surgery.
Dumping syndrome is marked by rapid movement of food from the stomach into the small intestine. This causes spikes in insulin production and subsequent reactionary drop in blood sugar. The results are nausea, vomiting, diarrhea and cramping tiredness and sweating. Dumping syndrome occurs mostly in patients who had gastric bypass however, some gastric sleeve patients experience the syndrome as well. A diet low in sugar and not drinking with meals help control the symptoms.
About one third of obese individuals being assessed for obesity surgery are found to have a nutritional deficiency. Nutritional deficiencies can also occur after any weight loss operation. This is much more common after a gastric bypass than after gastric sleeve. The following are some of the deficiencies that can occur after the sleeve operation.
This occurs following the sleeve gastrectomy due to:
1. Inadequate dietary intake (e.g. diet low in red meat)
2. Reduced acid secretion from the stomach. Acid is needed to convert iron to a form that is more easily absorbed in the intestine.
The deficiency is corrected with iron tablets three times a day or, rarely, iron injections.
Vitamin B12 Deficiency
Vitamin B12 is present if fish, red meat and dairy products. It play a vital role in DNA synthesis and in neurological functions. It is absorbed in the last part of the small intestine with the help of the intrinsic factor produced by the stomach. Because part of the stomach is resected in the sleeve gastrectomy, less intrinsic factor may be produced and deficiency may occur. Replacement can be in the form of tablets, mouth spray or injections.
Folate is present in lettuce and vegetables. Deficiency is present in about a quarter of patients before surgery. Folate deficiency often occurs with vitamin B12 deficiency and both can result in increased homocysteine level in the blood which is a risk factor for atherosclerosis. It is vital to correct the folate level before getting pregnant to reduce the risk of neural tube defects in the fetus.
Vitamin D and Calcium Deficiency
Vitamin D is absorbed from the diet and is also produces by the skin with exposure to sunlight. About one half of obese individuals have vitamin D deficiency. This occurs due to malnutrition, decreased outdoor activities and the storage of vitamin D in the fatty tissue. Low level of vitamin D results in the absorption of calcium from the bone and eventually osteoporosis. After weight loss surgery vitamin D level tend to improve due to the loss of fatty tissue, however, some patients develop deficiency due to decrease oral intake.
Obesity is a risk factor for development of stones in the gallbladder. Significant weight loss achievable by weight loss surgery increases that risk. The risk is more in patients who had the gastric bypass due to the reduced absorption of bile salts from the intestine. It can also occur in patients who had the sleeve operation due to the increase cholesterol excretion by the liver into the bile. This excess cholesterol precipitates into gallstones in the gallbladder. Patients who are known to have gallstones without symptoms may develop gallstones attacks due to the increase in the number and size of their gallstones.
We routinely check for gallstones before the operation (unless the gallbladder has already been removed). If gallstones are found then we recommend elective laparoscopic cholecystectomy (gallbladder removal) 3-6 months after the sleeve operation.
We recommend a repeat ultrasound 12 months after the sleeve gastrectomy for patients who do not have stones on their preoperative ultrasound scan.
Excess skin can result due to the significant weight loss in sleeve patients. The ability of the skin to mold is related to patient age, initial degree of obesity and genetic factors. Excess skin and skin folds can cause problems such as yeast infection, maceration, as well as challenges with hygiene. Patients who feel that the excess skin is limiting their physical activities can use body contour garments. In some patients (less than 10%) cosmetic surgery is needed.
Acute Gout Attack
The dietary changes that are needed before and after surgery in the form of a high protein diet as well as the stress of the surgery itself can bring an attack of gout in patients who are prone to it. Patients with history of gout or high preoperative uric acid level will be started on medications that prevent gout before the operation and continue with that for few months after the surgery.
Complications of any Surgical Procedure
All operations carry the risk of complications that range in severity. Some other examples include:
Hernia at the port sites
Collapsed lung or chest infection
Urinary tract infection
Myocardial infarction (heart attack)
Anaesthetic Risks and complications