Management of suture dehiscence, bile reflux, and diarrhea after RYGB surgery

Another less common cause of stricture is gastrointestinal ulcers.

Ulcers occur when: the proximal gastric pouch contains parietal cells, the closure mechanism is destroyed, or a fistula between the gastric pouch and the remnant stomach allows gastric acid to reflux from the distal stomach into the proximal gastric pouch.

Gastroesophageal reflux after RYGB surgery is a controversial issue, and most experts recommend reducing the size of the large gastric sac or re-stapled to cure the fistula between the gastric sac and the residual stomach.

Cracked stitching

The incidence of stitch cracking is 5% to 10%.

Most commonly, the staples may break, leading to weight rebound and reflux symptoms and ulcers at the Roux loop or anastomosis.

A fistula between the gastric sac and the residual stomach may cause a gastric fistula, and the fistula area may increase, thereby offsetting the effect of RYGB surgery in restricting food intake.

Bile reflux esophagitis

In theory, this complication should not occur; however, in reality, bile reflux esophagitis can occur due to suture rupture or a Roux loop that is too short.

We recommend that the Roux loop for the first surgery should not be less than 100 cm, while for corrective surgery, the Roux loop should be at least 150 cm long, especially when the weight loss effect of the first surgery is not ideal.

Diarrhea/steatorrhea

After distal RYGB surgery, chronic diarrhea or steatorrhea can lead to severe malabsorption of protein and fat.

These patients need to receive parenteral nutrition as soon as possible to ensure their nutritional supply.

The common passage of the ileum is then extended through surgery.

It is often necessary to insert a gastrostomy tube or jejunostomy tube to meet the future needs of enteral nutrition.

Intergastric fistula between gastric sac and distal gastric remnant

Less than 1% of patients will develop a fistula between the gastric sac and the distal gastric remnant due to leakage of the suture thread used to divide the gastric sac.

There are also very few reports of surgical treatment for gastric pouch and distal gastric fistula due to unsatisfactory weight loss or incurable anastomotic ulcers.

Unsatisfactory weight loss results

Patients who are not satisfied with their weight loss without mechanical or anatomical reasons need intensive psychological counseling to break their harmful and unhelpful eating habits.

Once all other potential anatomical causes have been identified or eliminated, the patient should be evaluated by a multidisciplinary medical team.

We have observed many patients who did not achieve their desired weight loss. The surgery went very well, but they could not control their appetite and kept eating high-energy foods.

In some cases, performing an additional surgery primarily for malabsorption, such as a gastric bypass with an extra-long Roux loop, is more effective than performing a bandage surgery to restrict food intake, but there is limited clinical evidence to support this treatment strategy.

For patients whose weight loss is not satisfactory, distal RYGB surgery is performed, but whether or not steatorrhea will occur, this question remains unanswered.

Surgical techniques

When the proximal gastric pouch is too large, the gastrojejunostomy should be disassembled and opened, and the original gastric fundus should be removed using a linear cutting closure device to greatly reduce the volume of the gastric pouch.

When the stapled suture breaks, a straight cutting closure device is needed to insert the omentum or a ring of jejunum to separate the distal gastric remnant and gastric pouch.

Stenosis of the anastomosis caused by inflammation of the gastric serosa and surrounding tissues is difficult to repair, and sometimes even requires esophagojejunostomy.

Prognosis of re-correction surgery after RYGB

The proposed corrective surgery to address the unsatisfactory weight loss results after RYGB surgery did not achieve the desired outcome.

However, when corrective surgery is used to address complications related to RYGB surgery and anatomical changes, these complications can be resolved simultaneously while maintaining the weight loss effect.