Complications in Bariatric Surgery

Bariatric surgery represents the most valid option to treat the chronic disease of morbid obesity and all its related comorbid conditions with the purpose to increase life expectancy.^1,2 Despite multiple recommendations of the different scientific societies,^3–5 bariatric surgery remains worldwide largely underused. Considering only a 16% rate of obesity disease, ⁶ with the largest number of bariatric surgeries performed in Europe of 50k procedures a year, France should need more than 200 years to surgically approach all morbid obese patients. Similarly, in the United States, obesity is a chronic condition that affects more than 1 in 3 adults, with a mean number of 250k bariatric procedures a year, ⁷ hence they would need 437 years to manage this population. Definitely, the bariatric surgery is very poorly used and there are several factors to explain it. Inadequate access to medical care and insufficient information provided by the general practitioner are frequently encountered in our practice. But the main limitation for the bariatric treatment remains the patients' “fear” of a surgical complication. Over the past decade, the bariatric surgery has known important progress in the prevention and treatment of early and late complications after different surgical procedures, among which laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are the most exploited. It was proved that increasing surgical experience can decrease up to 10 times the incidence of the most dreaded complication, the gastric leak after LSG. ⁸ We always need to consider two learning curves. The first one is related to the ability to perform the procedure and the second learning curve (more important) is related to significantly decreasing the complication rate. Independently of the surgical technique, awareness for tobacco use in patients proposed for bariatric surgery represents another major factor involved in the effort to decrease long-term complications after LRYGB. ⁹ The purpose of this special number focused on complications after bariatric surgery was to present several mechanisms and treatments for the complications after different bariatric procedures.

In the first article, the authors have very well summarized all benefits of image-guided endovascular surgery for hemorrhagic complications after bariatric surgery. It is necessary to know what the benefits of endovascular treatment would be in this eventuality. It is a minimally invasive procedure and does not require re-entry into the abdominal cavity to perform revision surgery with all that entails. For active bleeding, the embolization is performed by physical (coils) or chemical means and in case of pseudoaneurysm, the stent deployment is necessary.

Cirera de Tudela et al. ¹⁰ have presented different approaches for the treatment of leaks after single anastomosis duodenoileal switch (SADIS). We commend the authors for presenting us also their experience with this relatively new bariatric procedure with an important benefit for patients with important metabolic syndrome or for patients with weight regain after LSG.

ReSleeve gastrectomy has always been presented as a very safe procedure. Still, Coste et al. ¹¹ noticed a high index of complications. This can be explained by stapling near the angulus, on scar rigid tissues resulting from the previous LSG, which can lead to a too tight gastric tube with even higher intraluminal pressure and important risk of complications. Consecutively, nowadays, rigorous selection criteria are applied when proposing this procedure as revisional surgery after sleeve.

Acute gastric dilatation, a rare complication after LRYGB, can be treated even less invasive than using the laparoscopic approach, by percutaneous drainage. Davrieux et al. presented their experience with 2 cases, when this less invasive approach allowed them to avoid or to perform the definitive surgery in better conditions. They have emphasized on having a high suspicion to obtain an early diagnosis and that percutaneous gastrostomy is an image-guided procedure that can solve the problem temporarily or permanently.

For a long period of time, the principal endoscopic approach for acute leak after LSG was the stent. Despite the poor quality of life and associated complications with stent use (high rate of migration), it is still present in the algorithm of treatment of many bariatric departments. In the current literature review, the authors have highlighted an extremely rare complication, but still present: the aortoesophageal fistula.

Regarding the lithiasis of common bile duct there are several approaches, of which the most used are endoscopic, laparoscopic, and percutaneous. Owing to the anatomical modification after LRYGB, direct endoscopic access is not possible without surgical assistance (laparoscopic gastrostomy). The preferred approach is the percutaneous and Gimenez et al. ¹² reported a multicentric experience of 18 patients with no complications.

Nissen Sleeve gastrectomy, a new procedure in the bariatric armamentarium, was proposed to minimize the rate of postoperative gastro esophageal reflux disease (GERD), to protect the staple line of the angle of His, and finally to provide a safe and effective alternative for patients with contraindication to LRYGB because of GERD. As all new bariatric procedures, Nissen Sleeve gastrectomy has its learning curve, and the evaluation of the initial experience is very important for any team that is considering this new approach for reflux and obesity. Carandina et al. reported their experience with this technique, addressing particularly the early postoperative complications (<30 days).