Long-Term Post-Operative Issues
The following complications are the most common problems encountered many months/years after bariatric surgery. If you suspect these problems, it is important to be in touch with the patient’s bariatric surgeon as soon as possible.
1. Marginal Ulceration (RYGB)
Marginal ulcers occur at the gastrojejunostomy site and result from acid exposure to the jejunum. It may happen any time after a gastric bypass operation. Helicobacter pylori infection, NSAID use, smoking, gastrogastric fistulas may predispose patients.
Patients may present with nausea, abdominal pain, UGI bleeding, or perforation. If you suspect marginal ulceration, prompt gastroscopy is required, and medical management should be started immediately. Patients who present acutely unwell with a known marginal ulcer may have obstruction, bleeding, or perforation and must be managed acutely in a tertiary hospital with an experienced bariatric surgeon.
2. Reflux (Sleeve Gastrectomy)
~20% of patients have worsening reflux after SG and 20% of patients have de novo reflux after SG. Barretts oesophagus is also relatively common after SG too. Treatment options may include conversion to RYGB or medical anti-reflux therapy. Prompt specialist review is required to help alleviate symptoms and to prevent complications.
3. Dumping syndrome (RYGB)
Dumping syndrome is a relatively common complication that occurs when undigested food is released rapidly into the intestine, triggering gastrointestinal (bloating, crampy abdominal pain, diarrhoea) and vasomotor symptoms (flushing, palpitations, tachycardia, sweating, hypotension). Around one-eighth of patients may experience moderate-severe symptoms. Some patients may experience significant delayed hypoglycaemia (late-dumping syndrome). Dumping syndrome may be beneficial for weight loss as it promotes modifying their eating habits.
4. Vitamin/Mineral Deficiencies
Vitamin/trace mineral deficiencies are more common than you expect. Common deficiencies may include vitamin D, B12, iron, and protein. Neurological complications can be devastating and irreversible – always think of vitamins/minerals when a bariatric patient presents with a new-onset neurological problem. B-group vitamins (thiamine, pyridoxine, niacin, B2, B12), copper, and vitamin E deficiencies usually are responsible for neurological complications. Always remind bariatric patients to take their multivitamins.
5. Gallstones
It is thought that up to 20% of bariatric patients with a wide range of procedures develop gallstones. Be highly suspicious of gallstones in a bariatric patient presenting with post-prandial abdominal pain.
6. Kidney Stones
Patients who have had bariatric surgery are at higher risk of new onset nephrolithiasis with calcium oxalate stones from hyperoxaluria and concomitant hypocitraturia. Calcium citrate supplementation, increased hydration, limiting dietary oxalate and a low-fat diet can help prevent gallstones. Calcium citrate supplementation helps bind intestinal oxalate and provides citrate for the urine, thus helping to prevent calcium oxalate stones.
7. Alcohol (RYGB)
There is an increased prevalence of alcohol and other substance abuse following bariatric surgery. Alcohol use disorder is particularly problematic, as it may contribute to weight regain and gastrointestinal complications. After a gastric bypass, patients may require fewer drinks to be intoxicated, and reach peak blood alcohol levels much more rapidly. Our advice is to avoid alcoholic beverages for as long as possible, only limiting it to very occasional use.
8. Bone Health
Bone demineralisation and fracture risk is increased after bariatric surgery. If your patient is post-menopausal after bariatric surgery, please ensure they have had a bone density scan after bariatric surgery if they have not had one. Adequate protein intake in combination with adequate physical activity/resistance training is important.