Researchers from the Lausanne University Hospital (CHUV), Lausanne, Switzerland, have described their experience of managing early postoperative bleeding (POB) after 2,600+ laparoscopic Roux-en-Y gastric by-pass (RYGB) procedures. In the paper, ‘Early Bleeding After Laparoscopic Roux-en-Y Gastric Bypass: Incidence, Risk Factors, and Management — a 21-Year Experience’, published in Obesity Surgery, the authors outline the incidence, clinical presentation, risk factors and management of POB.
For this study, the authors reviewed all patients who underwent RYGB gastric bypass between 1999 and April 2020 in two bariatric centres. Patients with POB were divided into two groups: intraluminal bleeding (ILB) and extraluminal bleeding (ELB) following diagnostic tests according to their clinical condition (ie. clinical examination, CT scan, upper gastrointestinal endoscopy, laparoscopy, laparotomy etc).
From 2,639 patient, 253 (9.5%) presented at least one postoperative complication (the first 30 days) and the most common complications were POB (2.7%), leak (1.1%) and wound infection (1.1%) followed by intestinal obstruction without haemorrhage (0.8%), intra-abdominal infection (0.8%), and respiratory infection and/or pleural effusion (0.8%).
From the 72 (2.7%) patients with POB, 52 patients presented ILB (72%) and 20 presented ELB (28%). When the researcher compared patients with and without POB, POB was associated with male sex (37.5% vs 23.6%, p=0.01), older age (44.9 vs 42.1 years, p=0.04) and pre-existing high blood pressure (59.7% vs 46.9%, p=0.04). After multivariate analysis, only male sex (p = 0.01) remained an independent risk factor. Length of stay was significantly longer in patients who developed POB (8.3 vs 3.8 days, p<0.01).
A majority of patients (79.2%) presented POB within the first three postoperative days, whereas seven patients (10%) needed readmission for POB. Tachycardia was the most frequent symptom (45 patients, 63%) and abdominal pain was more frequent with ILB compared with ELB (50% vs. 20%, p=0.02).
Management
The source of bleeding was identified in 22 patients and originated from the GJ in six patients, the excluded stomach in four patients and from the JJ in the remaining 12. In total, 18 patients with ILB required urgent reoperation either because of haemodynamic instability or intestinal obstruction. In 14 of these patients, a tube gastrostomy was done initially to empty the stomach before intraluminal blood clots were evacuated via an enterotomy just distally to the jejuno-jejunostomy. In one patient with bleeding in the remnant but without distension, the distal gastric suture line was oversewn. In the last patient, the JJ was reopened to achieve haemostasis with cautery and the anastomosis was redone. Except for one patient who died, all patients fully recovered with no long-term sequela.
Twenty patients developed ELB and five required reoperations: two were reoperated on the day of surgery because of hemodynamic instability and three patients required re-laparoscopy because of progressive abdominal pain. In the remaining patients, bleeding stopped either spontaneously or after temporary withdrawal of prophylactic anticoagulation, and all the patients with ELB recovered completely.
The authors concluded that management of POB is most frequently achieved with conservative measures such as withdrawal of prophylactic anticoagulation, resuscitation and transfusion, however, treatment should be tailored depending on suspected location of bleeding and hemodynamic stability.
Further reading
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