Managing Bariatric Surgery Complications at a Third Level Public Hospital in Panamá

Abstract

Background: Surgical complications are devastating both for patients and treating surgeons. When complications occur after bariatric procedures, due to specific characteristics of this population, management, although multidisciplinary, should always be led by a surgical team. Methods: We present major complications treated at our general surgery service over a seven-year period. Case series: We present five cases that were treated at our service after a bariatric procedure was performed. Two patients were operated on in another country and two more at another service. Three patients showed perforation and leak-related complications. One patient died due to refeeding syndrome complications after revisional surgery. Conclusions: Optimal preoperative evaluations and surgical planning are mandatory for any type of surgery including bariatric procedures, and attempting adequate and well-established surgical techniques extensively described in the medical literature is associated with better outcomes. It is also our understanding that easy channels of communication between patients and treating surgeons could avoid delays in detecting and treating life-threatening conditions.

1. Introduction

General surgery is a broad discipline, covering a significant proportion of medical conditions that lead patients to the hospital. It encompasses emergency surgical conditions that entail immediate evaluation and management to prevent worsening of the patient’s clinical status and progression to multi-organ failure. Seven percent of the world’s population lives in Latin America, where life-threatening conditions—such as those requiring surgical management—are frequently treated at public hospitals [1]. Despite the predominance of public hospitals, the volumes of patients in their emergency departments are relatively low [2]. Nevertheless, this setting helps train surgical residents and includes trained staff who can identify and manage surgical complications. On the other hand, public hospitals resources are limited and undertrained [3].

Using the database of a general surgery emergency department’s surgical complications over the past seven years, the most common complications were evaluated by a group of surgeons. The time of presentation, quality of the diagnosis, cause of the complication, and patient outcome after the complication, among other variables, were evaluated and discussed. The resulting manuscript aimed to show the influence of a public hospital setting on the management of surgical complications, present the most common surgical complications causing severe complications and an increased length of hospital stay in each surgical subspecialty, and discuss practices that could be implemented in low-resource hospitals to provide high-quality medical care to surgical patients.

2. Case Series Presentation

This case series retrospectively presents bariatric surgery complications treated at our hospital by the bariatric surgery team over a seven-year period (2017 to 2023). Major complications were recorded in detail, while minor complications, such as postoperative nausea, vomiting after surgery, intraoperative bleeding, adverse events requiring a change of strategy, and phlebitis cases, were excluded. All patients (67) who submitted to bariatric procedures were recorded during the seven-year period; this case series includes one patient from our program (case 2), two referred to us from private hospitals, and two more from another country (Colombia). Due to a lack of surgical details, no intraoperative adverse events were reported, as per the ICARUS classification [4].

Demographics and preoperative Body Mass Indexes (BMIs) of patients that presented with complications after bariatric surgery are shown in

Table 1. Complications cases demographic data.

Complications Cases	Gender/Age	Comorbidities	Pre-OP BMI *
Case 1		Hypertension
	Female/42	Dyslipidemia	56.8 kg/m2
		Hypothyroidism
Case 2	Female/44	None	44 kg/m2
Case 3		Hypertension
	Female/43	Diabetes	54.6 kg/m2
		Asthma
Case 4	Female/50	Knee arthropathy	29 kg/m2
Case 5	Male/48	None	43.9 kg/m2

* Preoperative Body Mass Index—BMI.

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2.1. Case 1

The patient arrived at the emergency room 48 h after a laparoscopic sleeve gastrectomy (LSG) in a private hospital; she was admitted for abdominal pain referred to the left shoulder. Computer tomography (CT) was performed with evidence of leakage at the gastroesophageal junction, a left subphrenic collection, and pleural effusion with left predominance (Figure 1). She was taken to the operation theatre and laparoscopic lavage and drainage was performed (Figure 2). Treatment continued with IV antibiotics and parenteral nutrition. Although both mechanical and pharmacological DVP prophylaxis were administered, thirteen days after re-intervention the patient presented with deep venous thrombosis (DVP) of the right lower limb and pulmonary thromboembolism of a segmental branch of the left lower lobe; she was managed with full anticoagulation and high flow cannula. She was admitted to the intensive care unit (ICU) for 72 h for observation. After stabilization was carried out, endoscopic management of the leak site with an over-the-scope clip (OVESCO) was performed, mixed nutrition was installed, and outpatient management was provided with enteral nutrition for 4 weeks. However, the leak persisted, so after placement of a vena cava filter, the patient was submitted for a revisional Roux-en-Y gastric bypass (Figure 3). The patient was discharged 72 h postoperatively with complete resolution of the fistula, and follow-up at 4 months was uneventful.

2.2. Case 2

An elective laparoscopic gastric sleeve procedure was performed at our service; ports were closed with trans facial stitches, as we usually do for all 10 mm ports. The patient was discharged at 48 h, and 12 h later she began bilious vomiting with pain in the left flank. Upon physical examination, we found tenderness and a palpable lump in the left flank 10 mm port site (extraction site) that could not be reduced upon manipulation. An acute abdomen X-ray series was ordered that showed evidence of an intestinal limb trapped at the site of the port in the left hypochondrium abdominal wall and intestinal obstruction (Figure 4 and Figure 5). The patient was taken to the operation theatre and a reduction of the incarcerated intestinal loop was performed; no ischemic damage to the bowel was detected, so closure of the port by means of laparoscopy was performed (Figure 6 and Figure 7).

The patient was discharged 24 h postoperatively and follow-up was uneventful at eleven months after surgery.

2.3. Case 3

The patient was admitted to our service nine days after an LSG (14 June 2023) operation abroad. She presented with a history of epigastric left hypochondrium pain associated with tachycardia and hyperlactatemia. A CT scan was performed, which showed free fluid and signs of peritonitis. The patient was taken to the operation theatre for a laparotomy; upon exploring the cavity, a contained bilious/purulent collection was evidenced, so lavage with 10 L of saline solution was performed. No evidence of a leak was found in the sleeved remnant stomach or small bowel.

In the postoperative period, the patient showed signs of sepsis, so a control CT scan was ordered; the findings showed residual collections that were managed by interventional radiology, after which she showed better general health conditions. However, one month after the laparotomy, at an outpatient consultation, the drain output had changed, with evident food remains in it. The patient also presented poor healing of the abdominal wound with partial dehiscence and food remains coming out of the cavity through the wound. Management was provided initially with nasoenteric tube feeding, but lack of positive results in decreasing fistula output led us to indicate OVESCO 10 mm clips at the fistula site (33 cm from the incisors) in the endoscopy suite. This measure did not show any improvement whatsoever, so a self-expandable metallic stent was placed to reduce the output of the fistula.

Despite adequate nutritional interventions and less invasive therapies, the gastrocutaneous fistula persisted, and healing of the operative wound was not satisfactory.

The patient was then admitted for preoperative optimization and revisional surgery to a laparoscopic Roux-en-Y gastric bypass with fistula takedown, which was performed with no intraoperative or immediate complications, approximately 21 weeks after the index surgery. Six days later, she was reoperated due to the dehiscence of the surgical wound; the wound was closed without any other injuries being found.

She had good oral tolerance and was discharged. At the control appointment in December 2024, partial dehiscence of the surgical wound was observed, which was managed non-operatively.

In follow-up appointments 4 months later, the patient reported poor food tolerance with hypersalivation and dysphagia. Laboratory results indicated severe hypoalbuminemia as well as microcytic anemia. She was then admitted for mixed nutrition in the surgical ward. During that hospitalization, she presented signs of severe disorientation, and refeeding syndrome was diagnosed.

The patient was given further nutritional therapy and her electrolytes were corrected; she was then discharged, and the time she was well oriented, with no signs of neurological impairment.

On 23 May 2024, while at home, the patient experienced a sudden deterioration of her mental status and was brought to the emergency room (ER) where she required mechanical ventilation; despite resuscitation maneuvers, she died from a severe electrolyte imbalance.

2.4. Case 4

The patient came to our service with a diagnosis of gastric sleeve torsion and chronic malnutrition. She underwent an LSG five years ago in another country, two years later a laparoscopic gastric re-sleeve was performed, and 1 month later she had a gastric sleeve stenosis submitted for endoscopic dilation. As she was operated on abroad, we did not have intraoperative details or know why these surgeries were performed. She tolerated liquids and a soft diet, but persisted with vomiting and salivation upon solid food uptake. The patient lost weight until reaching a BMI of 29, with a significant loss of lean mass, a reduction in mobility, depressive symptoms, a reduction in quality of life, and hypophosphatemia. A tomography was performed, which showed gastric sleeve torsion. Hypophosphatemia was corrected parenterally, and mixed nutrition and physiotherapy were given for 1 month before surgery.

In May 2023, the patient underwent conversion to a laparoscopic gastric bypass with manual gastrojejunal anastomosis. One month later, she developed new episodes of salivation and poor tolerance to soft and solid diets. Two successful endoscopic dilations were performed (Figure 8), but the symptoms persisted, ranging from daily to three times a week. Supplementation with vitamins and protein were indicated. During this period, a conventional appendectomy was performed for acute inflammatory abdomen. A new endoscopic dilation was performed 10 months after surgery, with triamcinolone injection.

The patient developed adequate tolerance of a solid diet and normal hemoglobin values and nutritional parameters; she currently performs physical activity and weight workouts and has an improved quality of life. She had a BMI of 25 at a 6-month follow-up after the last dilation.

2.5. Case 5

The patient presented to the ER forty-eight hours after a one anastomosis gastric bypass (OAGB) was performed at a private hospital; he complained about abdominal pain, showed sepsis signs, and was tachycardic with elevated lactate and respiratory distress. After initial IV hydration and stabilization, he was taken to theatre for an exploratory laparoscopy; due to poor visualization, the surgery was converted and a punctiform perforation in the afferent loop approximately 3 m from the angle of Treitz was detected. An enterorrhaphy was performed and the patient went to the ICU for further management. On the seventh day after reoperation, he presented clinical decline in his general state with abdominal distention, fever, tachycardia, and worsening abdominal pain. A new abdominal CT scan showed perisplenic free fluid and purulent collection in the hepatic hilum, so the patient was taken to theatre where cavity lavage and drainage were performed, with no evidence of other lesions. He was managed with intravenous antibiotic therapy, and notable clinical improvement was observed, so he was discharged. In a follow-up visit one month after discharge, he showed no symptoms of dumping or sepsis, only referencing a few diarrheal stools.

At 4 months postoperative, the patient was in good shape and exercised regularly; on an outpatient visit an incisional hernia was detected.

3. Discussion

Bariatric surgery remains the pillar of obesity treatment nowadays [5]. Although it is considered an extremely safe procedure, complications related to it are in many cases difficult to manage and could even lead to potentially fatal outcomes [6].

When it comes to defining overweight and obesity, the World Health Organization relies on Body Mass Index (BMI) thresholds. However, the National Institute of Health (NIH) has pointed out that the risk of morbidity associated with obesity is directly linked to the degree of overweight. Despite these guidelines, BMI fails to take into account important factors such as sex, age, ethnicity, and fat distribution. This means that BMI is only an approximation of adiposity [7].

Thorough preoperative planning with complete internal medicine, psychology, nutritional status, and other medical specialties evaluations, according to the necessities of each case, is usually the first step to avoid serious complications whenever a patient could be excluded from the program when certain worrisome findings are detected [8].

Bariatric surgery, a highly effective treatment for morbid obesity, has gained significant traction in Latin America in recent years. However, the management of postoperative complications in this region presents unique challenges. Obesity remains a major public health concern, contributing to a significant burden of comorbidities, including cardiovascular disease, type 2 diabetes, and certain cancers [9]. Although bariatric surgery has been shown to produce substantial and sustained weight loss, as well as improvements in obesity-related comorbidities, it is not without risks [10].

The bariatric surgery service at our hospital consists of one senior general surgeon, two bariatric surgeons, and one gastrointestinal surgeon. During this seven-year period, 70 elective procedures were performed, and considering this time span includes the COVID-19 pandemic, our service was considered a low volume bariatric service. We also must point to the fact that, like many public services in Latin America, we struggle with a lack of medical devices (laparoscopic staplers, surgical ports, and sometimes even sutures) and performing highly specialized procedures such as OVESCO in a timely manner.

Early complications related to LSGs are commonly leaks, portal venous thrombosis, intraluminal gastric bleeding, and stapler line hemorrhage. Moreover, late complications include gastroesophageal reflux, pouch dilation, gastric outlet obstruction due to stenosis, and nutrient deficits.

Intraoperative technical recommendations to avoid such events might be using the full angle of His dissection, left esophageal pillar exposure in every case, meticulous dissection of the larger curvature, and boogie-guided stapling of the pouch. For later complications, early gastroscopies might show early signs of reflux, and imaging could help detect a dilated pouch. Most stenosis symptoms tend to appear between the sixth and twenty-fourth month after surgery; diagnoses can be confirmed with a contrasted gastroduodenal study and endoscopy.

Gastric bypass (GB) complications could appear in the first 30 days after surgery, and include infections, peritonitis, hemorrhages, DVT, pulmonary embolism, portal vein thrombosis, food intake intolerance, marginal ulcers, and renal, cardiovascular, and pulmonary events. Leaks or dehiscence of stapler lines is the second cause of bariatric surgery-related deaths, so prevention and early intervention are important to prevent further morbidity. As GB is associated with higher morbimortality, many society committees recommend that only experienced laparoscopic surgeons should perform this surgery. Simple imaging such as X-rays and tomography scans might aid in the diagnosis of a GB complication; however, sometimes it is only confirmed at the time of reoperation.

Complications after bariatric surgery are not frequent, but surgeons and multidisciplinary teams in charge of morbidly obese patients should consider the possibility of complications and should adhere to the knowledge criteria to recognize them and perform suitable management. Some complications can be corrected or prevented. Generally, bariatric patients improve their quality of life by largely achieving their goal, which is to have an effective weight loss. More than weight loss, the biggest win is the improvement in systemic conditions. However, many patients are not informed about all the pros and cons of bariatric surgeries, and agree to an operation without knowing what to expect. It is essential to have a multidisciplinary team working for these patients to consider proper patient selection and an adequate preparation process.

Due to the small sample size of the bariatric surgery complication cases presented and the lack of information regarding some previous surgeries, because index procedures were performed outside our hospital in four of these cases (80%), our study had some limitations regarding intraoperative and preoperative strategies to mitigate or even avoid completely the occurrence of the presented complications. However, we presented them exactly the way they came to, and were managed in, our service to demonstrate how difficult it is to manage complex surgery complications in most public hospitals in Latin America.

4. Conclusions

Obesity is a chronic, complex, multifactorial, and unmanageable disease, highly prevalent globally, and considered a global health problem. Hence, bariatric surgeries, based on their effectiveness, are increasing. However, even if these surgeries are performed with all the current technical and scientific knowledge, by the most expert surgeons, and in the most advanced centers, there may be complications that, unlike in the past, are mostly not related to the surgeon or the technique itself. The clinical treatment of patients with morbid obesity is complex and multidisciplinary, and surgical procedures may lead to both primary and late complications, which require some knowledge to manage.

It is our understanding that adequate individualized preoperative planning with all clinic evaluations pertaining to each case might decrease the occurrence of complications related to the surgery itself. During the operation, always performing surgical steps according to the most recent data assures optimal results. The latest reports indicate that patients with BMIs greater than 50 are prone to more technical and hemodynamic complications. Finally, a relevant concept that could be useful after a surgical procedure has been performed is a dedicated hotline (call center) where patients can communicate in an expedited manner with the surgical team and get faster management; also, avoiding traveling to other countries/cities might decrease time lost detecting a potential life-threatening complication.