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Page 2 of 8 Ardila-Gatas et al. Mini-invasive Surg 2020;4:16 I http://dx.doi.org/10.20517/2574-1225.2019.69

complications after weight loss surgery is esophagogastroduodenoscopy (EGD). Diagnostic and therapeutic
EGD should not be delayed for fear of disruption of a fresh anastomosis. Evidence has shown it is safe and
[8]
cost-effective to perform upper endoscopy in the early postoperative period .

BLEEDING
Acute or early gastrointestinal (GI) hemorrhage usually presents within the first hours to days after surgery
[9]
[2,3]
and it is often secondary to technical error . Its incidence is 1%-4% . Although bleeding usually occurs
from the submucosal vessels along the staple line at the gastrojejunostomy, jejunojejunostomy, or the sleeve
staple line, it can occur anywhere along the GI tract. Possible sites of bleeding include the gastric pouch
and the gastric remnant, as well as extraluminal, at trocar insertion sites, dissection planes, or mesenteric
or omental transection areas [2-4] . Late bleeding is usually caused by marginal ulceration or erosion
[5,9]
(discussed below) .
Signs and symptoms of early postoperative bleeding include tachycardia, hemoglobin level drop,
[9]
hematemesis, or hematochezia . Hemodynamically stable patients are initially treated non-operatively
with fluid resuscitation, close monitoring, proton pump inhibitors (PPIs), and blood transfusion as
needed [2-4,6,9] . For patients who present hemodynamically unstable, further operative or endoscopic
[2-4]
procedures are warranted .
Different endoscopic treatments are available to manage a bleed: injection of diluted epinephrine or
sclerosing agents, application of hemoclips or larger bear claw clips (Over-the-scope-clip, OTSC, Ovesco),
thermal therapies (heater probe, mono- and bipolar electrocoagulation, argon plasma coagulation, and
[2-6]
laser therapy), and application of hemostatic powder, fibrin, or thrombin glues . Standard endoscopes
can reach proximal bleeders in the gastric pouch or the sleeve staple line. For distal bleeders, balloon- or
spiral-assisted enteroscopy, or even surgical assistance, may be needed to reach the jejunojejunostomy or
[2,3]
the gastric remnant .

LEAKS AND FISTULAS
[2]
Leaks commonly occur at the anastomosis or staple line . After RYGB, leaks are usually seen at the
[2,5]
gastrojejunal (GJ) anastomosis, in up to 2%-5% of cases but can occur at any staple line or other location
on the GI tract. After LSG, leaks are most common near the angle of His, where the staple line meets the
[2,3]
gastroesophageal junction . This is attributed to distal stenosis, increased proximal pressure, thinner
[2,4]
tissue, and relative vascular watershed on angiographic studies, and occurs in 1%-9% of cases . After
duodenal switch, leaks may also be seen at the duodenojejunal (DJ) anastomosis.

Leaks are associated with significant morbidity and mortality. Although rare, with an incidence of 1%-6%,
[2-4]
several factors are believed to contribute in their development . Ischemia, technical error such as overlapping
[2]
staple lines, or anastomotic tension are suspected among the factors that leads to leaks . Fistulas are defined
as an abnormal communication between the GI tract and another organ (in the abdomen or thorax)
[7]
or surface [7,10] . Generally, fistulas are related to acute leaks that fail to close in more than 12 weeks .
Complications after RYGB are gastrogastric fistulas between the gastric pouch and remnant, fistulas to the
[10]
surrounding viscous organs, or fistulas to the skin .
[2]
Signs and symptoms of leaks include abdominal pain, fevers, and tachycardia . Suspicion of a leak requires
thorough work up to assess the location and size of the defect, infection control with antibiotics, nutritional
[2,4]
optimization, and appropriate therapeutic intervention . A CT scan is usually required to assess for intra-
abdominal fluid collections. If there is any surrounding fluid collection distant to the GI lumen, this needs
to be drained by interventional radiology, laparoscopically, or transluminal endoscopic debridement and