© Springer Nature Singapore Pte Ltd. 2017
Saravana Kumar and Rachel Maria Gomes (eds.)Bariatric Surgical Practice Guide10.1007/978-981-10-2705-5_2828. Prevention and Management of Bleeding After Sleeve Gastrectomy and Gastric Bypass
(1)
Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
(2)
Bariatric Division, Upper Gastrointestinal Surgery and Minimal Access Surgery Unit, GEM Hospital and Research Centre, Coimbatore, India
28.1 Introduction
Bariatric Surgery has become one of the most successful and cost effective ways to manage the growing problem of obesity and its associated disorders. Today, close to 300 million adults worldwide are affected by obesity and the number is growing [1]. There are several options available in bariatric surgery and these are defined by certain principles. The procedures range from purely restrictive to purely malabsorptive, or a combination of both [2]. The most commonly performed bariatric procedures are the laparoscopic sleeve gastrectomy (LSG) and Laparoacopic roux en Y gastric bypass (LRYGB).
The aim of this chapter is to discuss the presentation, diagnosis, management and prevention of early bleeding following LSG and LRYGB.
28.2 Post-Operative Bleeding After Laparoscopic Sleeve Gastrectomy
Postsurgical complications after sleeve gastrectomy can be divided into acute and chronic. Hemorrhage, staple line leak and intra-abdominal abscess are considered acute complications [3]. Chronic complications include gastroesophageal reflux disease, nutritional deficiencies, bleeding etc [3]. Hemorrhage is one of the most common acute complications after sleeve gastrectomy as a result of the lengthy staple line and the change in intra-gastric pressure [4]. Another important risk factor for increased postoperative bleeding is preoperative low molecular weight heparins used for prevention of venous thromboembolism [5]. Chronic bleeding in LSG however is very uncommon and related to ulcers that may develop within the remnant stomach. Incidence of hemorrhage post LSG has been reported in 1.1–8.7 % of cases [3].
28.2.1 Presentation
Bleeding post LSG occurs, in the majority of cases, from the staple line, but may result from the resected greater omentum [6]. Some signs that aid in early recognition are hematemesis, blood loss through the nasogastric tube/drain (NG) and melena in stools[4] Clinical symptoms and signs of tachycardia (heart rate >100), pain, fever, hypotension (systolic blood pressure <100), mean hemoglobin count that has dropped at least 2 g/dl from what it was prior to the procedure should increase clinical suspicion of bleeding or staple line leak in the early post-operative period [4, 7].
Bleeding can be divided into intra-luminal and extra-luminal. Intraluminal bleeding presents as early hemorrhage, and it is the result of bleeding from the staple line, vessels nearby and gastric ulcers [8]. Early bleeding post-surgery is possibly due to technical failure in the operation [9]. Intraluminal bleeding from the staple line usually presents with an upper gastrointestinal bleed [9]. Extra-luminal hemorrhage presents in the abdominal cavity and early indication of extra-luminal bleeding will be through the abdominal drain [9]. Usual areas where extra-luminal bleeds occur are at the staple line, spleen, liver, or abdominal wall at trocar port sites [3]. As a result, there is an increased risk of developing hematoma and abscess formation. Early bleeding through drains or NG tube is called a sentinel bleed and it usually can occur within hours of surgery [9].
28.2.2 Diagnosis and Management
Acute management for hemorrhage involves fluid resuscitation, strict intake and output monitoring with Foley catheter [2]. Patient should receive adequate blood transfusion to stabilize hemoglobin level. Haemodynamically stable patients can be managed conservatively with serial hemoglobin monitoring and drain output. Majority of acute postoperative bleeds settle with conservative management. If there is clinical suspicion of an ongoing bleed, a Computed Tomography (CT) angiogram can demonstrate collections/hematomas and potentially identify the bleeding vessel. If active bleed is identified, angioembolization can be performed to control bleeding. If patient is unstable to proceed to radiology suite, then in the case of intraluminal bleeding the patient will need urgent endoscopic intervention – oesophagogastroduodenoscopy (OGD). Early endoscopic intervention has to be performed only by a trained bariatric endoscopist. Endoscopic evaluation allows for injection of adrenaline or insertion of clips to stop bleeding if detected. Endoscopic intervention should be attempted in the operating theatre in the event patient becomes unstable, and bleeding cannot be controlled endoscopically so that urgent surgery can be done.
In the case of intra-abdominal bleeding, hemodynamic instability warrants urgent re-operation. Diagnostic laparoscopy is an excellent option to allow direct visualization and to identify the bleeding source. It also allows evacuation of the hematoma and a thorough washout to prevent formation of an abscess. In some cases when no obvious source of bleeding is identified it may be advisable to oversew the entire staple line.
28.2.3 Intra-Operative Prevention of Bleeding
Several techniques have been established to control bleeding intraoperatively to identify the bleeder. One of the common methods used is intraoperative packing to help control bleeding and allow for hemostasis. Packing can be done with inserting a raytex gauze and helps to identify bleeding source. Another technique to help reduce bleeding is to increase abdominal pressure. Suction and irrigation can help to identify a source of bleeding, and allow for the application of a clip.
Various techniques have been developed when it comes to preventing bleeding from the staple line. Studies have shown 60 s of compression time instead of 20 s after closure of the stapler before firing has significantly reduced staple line bleeding [10]. It is extremely important to closely inspect the entire staple line after withdrawal of the bougie. Following these steps should significantly decrease the incidence of bleeding from the staple line. If any minor bleeding is detected in this area post-operatively, it can be easily controlled with small clips. However, post-operative bleeding may also be from the resected area of the omentum and the use of drains may aid in the detection of this type of intra-abdominal bleeding [4]. This will facilitate early treatment and the avoidance of the most serious consequences of bleeding [6].
Staple Line Reinforcement (SLR) is a routinely practiced technique today. Benefits of this has resulted in decreased bleeding and staple line leak postoperatively [3]. Concerns with SLR are that they can increase rate of stricture, increase operative time and costs for patients [3]. Different techniques are used for SLR:
- 1.
Oversewing the staple line with running suture,
- 2.
Buttressing it with specific material such as bovine pericardium strips, synthetic polyester, glycoside and trim ethylene carbonate copolymer, and applying glue/haemostatic agents.
- 3.
Covering the staple line with omentum or jejunum [3]. Some surgeons report a reduction in bleeding by reinforcing the staple line by over sewing or by using buttressing material.
However, caution should be used with over sewing since some studies have shown an increased risk of tearing and bleeding at the point of suture penetration when using this technique [8]. Intraoperative placement of drain will help to identify intra-abdominal bleeding. Added benefits of drain placement include identification of leak, may allow converting a leak to a controlled fistula and allows removal of contaminated fluid for prevention of abscess formation [4].
28.2.4 Conclusion
Haemorrhage after sleeve gastrectomy can be intra-luminal or extra-luminal. While bleeding at the site of stapling is best treated by prevention during the surgical procedure, management of upper gastrointestinal bleeding requires a close monitoring and multidisciplinary care. If bleeding is suspected, it can be confirmed by endoscopy or contrast enhanced CT angiogram. Management of bleeding may include surgery or more conservative techniques such as fluid resuscitation and/ or blood transfusion. With proper surgical techniques and through prompt detection and treatment, bleeding following bariatric surgery can be minimized or even avoided.