American Journal of Gastroenterology ISSN 0002-9270


C 2007 by Am. Coll. of Gastroenterology doi: 10.1111/j.1572-0241.2007.01421.x
Published by Blackwell Publishing

CLINICAL REVIEWS CME

Gastrointestinal and Nutritional Complications

After Bariatric Surgery
G. Anton Decker, M.B.B.Ch., M.R.C.P.,1 James M. Swain, M.D.,2 Michael D. Crowell, Ph.D.,1
and James S. Scolapio, M.D.3
1
Division of Gastroenterology and Hepatology, 2 Department of Surgery, Mayo Clinic, Scottsdale, Arizona; and
3
Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida

The prevalence of obesity has increased to epidemic proportions, making obesity and its comorbid conditions a
major public health concern. Bariatric surgery is the most effective treatment, but it carries substantial morbidity.
The subsequent gastrointestinal and nutritional complications are often not recognized or properly managed. As
part of the multidisciplinary team taking care of obese patients, gastroenterologists should be familiar with the
types of bariatric surgery and their associated complications. We review the most common gastrointestinal and
nutritional complications after bariatric procedures and examine how gastroenterologists may best prevent,
investigate, and treat them.
(Am J Gastroenterol 2007;102:2571–2580)

INTRODUCTION
Obesity has increased in prevalence to the extent that it has
reached epidemic proportions and become a major public
health concern. This stigmatizing disease is more than just
a cosmetic issue; it is a form of malnutrition resulting in
considerable morbidity and mortality.
Nearly two-thirds of adults in the United States are over-
weight (body mass index [BMI] ≥25 [kg/m2 ]), and one-third
are obese (BMI ≥ 30) (1). The comorbid conditions asso-
ciated with obesity include coronary artery disease, diabetes
mellitus, obstructive sleep apnea, hypertension, nonalcoholic
fatty liver disease, cholelithiasis, and several types of cancer.
The relationship between excess body weight and mortality
from all causes is well established (2, 3).
Faced with the obesity epidemic, clinicians are limited by
ineffective treatment options. Dietary and behavioral modifi-
cation, exercise, and pharmacotherapy all have relatively poor
long-term results (4). Although gastrointestinal surgery is a
drastic approach, it is the most effective way for many patients
to achieve long-term consistent weight loss and improved or
resolved comorbid conditions (5). The National Institutes of
Health (6) have established guidelines for bariatric surgery.
Patients may be bariatric candidates if they have a BMI of
40 or more or a BMI of 35 or more with one or more co-
morbid conditions and have failed conservative weight-loss
strategies such as diet and exercise (7).
Bariatric surgery carries considerable risk of complica-
tions. Herein, we discuss the types of procedures and their
associated gastrointestinal and nutritional complications.
METHODS
Ovid MEDLINE (1966-March 2007) and PubMed (no time
limit) databases were searched to identify the published litera-
ture in the English language. An initial search was performed
using the terms bariatric surgery, gastric bypass, obesity
surgery, Roux-en-Y, gastric band, lapband, laparoscopic ad-
justable gastric band (LAGB), gastroplasty, biliopancreatic
diversion, and vertical banded gastroplasty. These terms were
then coupled with secondary search terms: complications,
anastomosis, leak, staple line, dehiscence, dumping, nutri-
tion, malnutrition, anemia, vitamin B12 , calcium, vitamin de-
ficiency, vitamin C, vitamin D, vitamin B1 , diet, weight loss,
liver, nonalcoholic fatty liver disease, hepatitis, gallstones,
cholecystectomy, ursodeoxycholic acid, abdominal pain, gas-
trointestinal hemorrhage, obstruction, hernia, stenosis, ulcer,
band erosion, bacterial overgrowth, bloating, diarrhea, vom-
iting, gastroesophageal reflux disease (GERD), bile reflux,
excluded stomach, Roux limb, endoscopy, small-bowel en-
teroscopy, double-balloon enteroscopy, computed tomogra-
phy, barium radiograph, morbidity, and mortality. Both ab-
stracts and published papers were reviewed, but only pub-
lished papers were referenced in this manuscript. Because
of the heterogeneity of the patient population and the proce-
dures performed, this field of medicine does not easily lend
itself to randomized control trials. All levels of evidence were
therefore considered, but more emphasis was placed on larger
randomized trials in this review. Where evidence is lacking,
it is stated as such.

TYPES OF SURGICAL PROCEDURES

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In 1991, the National Institutes of Health (6) consensus state-
www.acg.gi.org/journalcme. ment identified bariatric surgery as the only long-term, con-
2571
2572 Decker et al.
Figure 1. Vertical banded gastroplasty (used with permission of
Mayo Foundation for Medical Education and Research).
sistent way for morbidly obese patients (BMI >40) to lose
substantial weight and achieve lasting improvement in comor-
bid conditions. Bariatric surgical procedures have evolved
during the past 40 yr. Overall, there are many new techniques
and products (e.g., intragastric balloon or gastric stimulator)
to facilitate surgical weight loss, but most are investigational.
The two main categories of procedures are “restrictive” and
“restrictive with malabsorption.” Herein, we address the op-
erations in current use for each.
Restrictive Procedures
Gastroplasty, or stomach stapling, was first described in the
late 1970s (8) as a way to restrict the volume of oral intake by
creating an anatomically smaller proximal stomach with less
reserve, thus resulting in earlier satiety. Various techniques
have subsequently been used to achieve this goal. Essentially,
there are two main types of restrictive procedures: the vertical
banded gastroplasty (Fig. 1) and the adjustable gastric band,
which is now routinely placed laparoscopically (Fig. 2). Both
procedures rely solely on the small pouch proximal to the
band to provide early satiety and thereby decrease overall
caloric intake. Both the vertical banded gastroplasty and the
LAGB rely on foreign material (e.g., silicone or mesh) to
maintain a narrow stomal size that slows the passage of food
into the distal stomach. The popularity of the vertical banded
gastroplasty has greatly declined because reports show poor
long-term results (9).
Conversely, the use of the LAGB has increased tremen-
dously (10, 11). It offers the advantages of simplicity of tech-
nique, it maintains intestinal continuity, and it is reversible.
The data on weight loss are promising (12–14). Early weight
loss is greater after Roux-en-Y gastric bypass (RYGB), but
the difference starts to diminish after 2 yr (15, 16). Jan et al.
(17) reported similar weight loss compared with RYGB at
5 yr. Because of its lower complication rate, LAGB has be-
Figure 2. Laparoscopic adjustable gastric band (used with permis-
sion of the American Society for Bariatric Surgery).
come a particularly attractive option for patients with mild to
moderate obesity (BMI ≤35) (18). Disadvantages of LAGB
include increased reoperative rate, slower initial weight loss,
and lifelong issues of an implanted foreign body in the gas-
trointestinal tract.
Restrictive With Malabsorption Procedures
The restrictive with malabsorption bariatric procedures en-
compass techniques that vary gastric restriction and intestinal
bypass. Biliopancreatic diversion (BPD) (Fig. 3) produces
relatively minor gastric restriction (about 200–300 mL) with
considerable intestinal bypass. This leads to an almost purely
malabsorptive operation.
A more recent modification is the duodenal switch (Fig. 4),
which preserves the distal stomach and pylorus while main-
taining malabsorption. Its advantage is long-term weight loss.
Its disadvantage is a resulting increase in the incidence of nu-
tritional deficiencies. It is therefore generally reserved for the
super-obese patient (BMI >50).
First described in the 1960s, gastric bypass with a loop
gastrojejunostomy was complicated by bile reflux (19). This
led to the development of the RYGB (20) (Fig. 5). RYGB
consists of creating a small gastric pouch from the cardia of
the stomach. The distal stomach and proximal small bowel
are bypassed by attaching the distal end of the mid jejunum
to the proximal gastric pouch, then reattaching the biliary
and pancreatic limb a specific distance along the length of
the small intestine that is attached to the proximal stomach.
This is the Roux limb. Its length is usually determined by the
patient’s BMI. Advantages include excellent short- and long-
term weight loss with relatively few nutritional complica-
tions. Disadvantages include disruption of normal intestinal
continuity and anastomotic complications.
 Complications of Bariatric Surgery 2573

Figure 3. Biliopancreatic diversion (used with permission of Mayo

Foundation for Medical Education and Research).
Figure 4. Duodenal switch (used with permission of Mayo Founda-
tion for Medical Education and Research).
GASTROINTESTINAL AND NUTRITIONAL COMPLICATIONS
The obese patient is at increased risk for all postoperative complications are more likely after specific bariatric proce-
complications, and those related to the gastrointestinal tract dures (Table 1).
may be particularly difficult to diagnose and manage. Clas-
sic physical findings are often not appreciated during exam-
NUTRITIONAL COMPLICATIONS
ination of the obese abdomen, and diagnostic tests may be
difficult to perform and interpret. The medical team should Vitamin and Mineral Deficiencies
therefore be vigilant for postoperative complications. Long- Iron deficiency is common in RYGB patients, with an inci-
term complications may also be missed, particularly in pa- dence as great as 49% (22). The pathogenesis of iron de-
tients prone to functional gastrointestinal tract symptoms ficiency is multifactorial (23). Absorption of dietary iron
that elevate the physician’s threshold for ordering investi-
gations. Knowing exactly which bariatric surgery was per-
formed and having a good understanding of the normal post-
surgical anatomy facilitate the selection of the appropriate
test, procedure, or intervention.

Early Complications
Surgeons usually manage early (≤2 months) postoperative
complications. An anastomotic leak or intestinal obstruction
may not be easy to diagnose because of the patient’s large ab-
domen (21). Thus, there should be a low threshold for order-
ing a barium radiograph or computed tomogram. Endoscopy
is rarely indicated at this time.

Late Complications
The euphoria induced by weight loss in bariatric patients may
be replaced by disappointment and regret with the develop-
ment of new gastrointestinal tract symptoms and complica- Figure 5. Roux-en-Y gastric bypass (used with permission of Mayo
tions. Some nutritional, hepatobiliary, luminal, and functional Foundation for Medical Education and Research).
2574 Decker et al.

Table 1. Risk, Prevention, and Treatment of Postoperative Gastrointestinal and Nutritional Complications in Bariatric Patients
Risk by Procedure
BPD
Complication LAGB RYGB and DS Prevention Treatment
Nutritional
Vitamin deficiency
Iron 0 ++ ++ Multivitamin with iron and vitamin C Ferrous sulfate 300 mg/d with vitamin C
Vitamin B12 0 ++ + 1,000 µg/mo IM or 300–500 µg/d 1,000 µg/mo IM or 300–500 µg/d orally
orally or nasal spray 500 µg/wk or 500 µg/wk nasal spray
Folic acid 0 ++ ++ Folate 1 mg/d usually in multivitamin Folate 1 mg/d
Fat-soluble vitamins 0 + ++ Multivitamin, including at least 400 IU Replace vitamin as indicated
A, D, E, K vitamin D
Thiamine 0 + ++ Multivitamin with thiamine 50 mg IV
Mineral deficiency
Calcium 0 + ++ 1,500 mg/d elemental calcium 1,500 mg/d elemental calcium
Insufficient weight loss + 0 0 Obesity support group; dietary Consider alternative bariatric operation
education
Excessive weight loss 0 + ++ Dietary education; appropriate surgery Conduct dietary education; consider
surgical revision
Hepatobiliary
Gallstones and sludge + ++ ++ Ursodeoxycholic acid 300 mg twice Conduct cholecystectomy
daily for 6 mo; consider elective
cholecystectomy
Luminal
Stomal ulceration 0 + + Avoid NSAIDs; consider prophylactic Stop NSAIDs; prescribe PPI; conduct
PPI (pouch must not be too large) surgical revision
Stomal stenosis 0 + + Surgical technique; prevent ulcers; Conduct endoscopic dilation; remove
avoid silastic band silastic band; conduct surgical revision
Band erosion + 0 0 Surgical technique Conduct surgical revision
Staple line dehiscence 0 + 0 Surgical technique Conduct surgical revision
Fistula 0 + + Surgical technique; prevent ulcers Treat endoscopically; consider surgical
revision
Internal hernia 0 + + Surgical technique Treat as surgical emergency
Bile reflux 0 + 0 Roux limb must be long enough; rule Conduct surgical revision
out obstruction.
GI tract bleeding 0 + + Avoid NSAIDs Treat endoscopically; prescribe PPI
Dumping syndrome 0 + + Small meals; dietary education Conduct dietary education; consider
surgical reversal (rarely)
GERD + 0 0 Choose correct procedure Prescribe PPI; conduct surgical revision
Functional
Vomiting ++ + + Small meals; prevent ulceration and Dilate stenosis endoscopically; conduct
stenosis surgical revision; conduct dietary
education
Diarrhea 0 + ++ Appropriate diet Treat infection; rule out bacterial
overgrowth; administer loperamide;
consider surgical revision
Bloating and flatulence 0 + ++ Consider small-bowel bacterial Exclude and treat bacterial overgrowth;
overgrowth conduct dietary education
BPD = biliopancreatic diversion; DS = duodenal switch; GERD = gastroesophageal reflux disease; GI = gastrointestinal; IM = intramuscular; IU = international units; IV =
intravenous; LAGB = laparoscopic adjustable gastric band; NSAIDs = nonsteroidal anti-inflammatory drugs; PPI = proton pump inhibitor; RYGB = Roux-en-Y gastric bypass.
0, rare; +, occasional; ++, frequent.

depends on various dietary and physiologic factors (24, 25).
To be absorbed, the ferric iron in foods must first be reduced
to the ferrous state. This reduction occurs in the stomach,
where it is facilitated by hydrochloric acid. Achlorhydria may
develop in RYGB patients, leading to a reduction in iron ab-
sorption. Gastric acid secretion from the proximal gastric
pouch may be absent after bariatric surgery (26). Postsurgi-
cal prophylactic use of histamine2 receptor antagonists (H2-
blockers) or proton pump inhibitors also reduces acid secre-
tion and subsequent iron absorption. The reduced intake of
iron-rich foods declines substantially after RYGB, both be-
cause of a decrease in total caloric intake and because of
frequent intolerance to iron-rich foods, particularly red meat
(27, 28).
Iron deficiency presents primarily as microcytic anemia.
Routine laboratory work (e.g., complete blood cell count,
serum iron, transferrin, and ferritin) should be performed
and monitored twice a year. Iron supplementation is rec-
ommended for all RYGB patients. In many cases, a stan-
dard multivitamin with iron is sufficient. However, when iron

deficiency is discovered, treatment may include the use of
additional oral iron given as ferrous sulfate 300 mg 3 times
daily (22). Iron supplements should be taken with vitamin
C between meals. Some patients will require IV iron infu-
sions because of gastrointestinal intolerance (dyspepsia and
constipation) to iron supplements or because of the inability
to correct anemia with oral supplements alone. Good food
sources of iron include red meat, fish, poultry, shellfish, eggs,
soybeans, and legumes.
The absorption of vitamin B12 begins in the stomach, where
both pepsin and hydrochloric acid cleave it from foods (pri-
marily meats). B12 deficiency occurs in 26–70% of gastric
bypass patients (28–30). Mechanisms include achlorhydria,
which prevents cleavage of B12 from foods, decreased B12
consumption because of intolerance to meat and milk (2 pri-
mary dietary sources), and inadequate secretion of intrinsic
factor after surgery.
Clinically significant B12 deficiency may lead to mega-
loblastic anemia, thrombocytopenia, leukopenia, and glossi-
tis, all reversible with replacement therapy. Despite the low
incidence of symptomatic B12 deficiency, the general con-
sensus (29, 30) is that most gastric bypass patients cannot
maintain adequate serum levels without supplementation. In-
tramuscular injections (1,000 µg/month) are recommended,
but several studies have shown that a 300- to 500-µg dose of
oral vitamin B12 is sufficient (29, 30). Other forms of sup-
plementation include sublingual (350 µg/d) and nasal spray
(500 µg/wk in 1 nostril).
Folic acid deficiency is another potential complication of
RYGB, affecting as many as 35% of patients. Folate absorp-
tion is facilitated by hydrochloric acid and occurs primarily in
the upper one-third of the small intestine (30). Additionally,
vitamin B12 acts as a coenzyme in converting methyltetrahy-
drofolate to tetrahydrofolate, so a vitamin B12 deficiency may
result in subsequent folate deficiency. Despite these apparent
mechanisms for folate deficiency, decreased folate consump-
tion from dietary sources may be the predominant cause (28,
31). Folate deficiency can present as megaloblastic anemia,
thrombocytopenia, leukopenia, or glossitis. Serum deficien-
cies are quite common (although symptoms are rare), and
they are easily corrected with vitamin supplementation. Fo-
late supplementation (1 mg/d) should correct deficiencies.
Folate deficiency is a serious threat for women who become
pregnant after gastric bypass, with neural tube defects re-
ported in infants. Women of reproductive age should there-
fore take folate supplementation.
Fat-soluble vitamin deficiency may also occur after RYGB
or BPD. Bypassing the duodenum results in delayed mix-
ing of dietary fat with pancreatic enzymes and bile salts,
which results in malabsorption of fat and fat-soluble vita-
mins. This complication occurs more commonly after BPD.
Halverson (22) reported vitamin A deficiency in 10% of gas-
tric bypass patients. The predominant symptom is visual dif-
ficulties at night. Oral replacement therapy is occasionally
needed.
Complications of Bariatric Surgery 2575
Vitamin D and calcium deficiencies are less likely because
they are absorbed preferentially in the jejunum and ileum.
Nonetheless, there have been reports of osteomalacia after
RYGB (32, 33). Daily supplementation of 400 IU of vitamin
D and 1,500 mg of elemental calcium is adequate.
Active absorption of thiamine (vitamin B1 ) occurs primar-
ily in the proximal small bowel. Humans cannot synthesize
thiamine, which is not stored in large quantities, so adequate
daily intake is essential. Dietary sources of thiamine include
cereals, grains, lean pork, and legumes. Thiamine deficiency
may lead to Wernicke-Korsakoff syndrome, which has been
described after gastric bypass surgery (22, 34). Symptom
onset is preceded by profuse vomiting along with the rapid
weight loss that occurs after bariatric surgery. The restrictive
diet after RYGB may lead to a drastic reduction in dietary
intake of thiamine. The redirection of the proximal small
bowel, where group B vitamins are preferentially absorbed,
coupled with persistent nausea and vomiting, increases the
risk for thiamine deficiency. A regimen of daily multivitamins
should prevent thiamine deficiency. When such deficiency is
suspected, a 50-mg intramuscular or IV injection of thiamine
should correct it.
Insufficient Weight Loss
The cardiac and metabolic consequences of obesity are im-
proved after just 5–10% weight loss (35), but patients under-
going bariatric procedures and the physicians taking care of
them generally strive for much greater weight loss. O’Brien
et al. (15) performed a systematic review of bariatric oper-
ations in which the pooled data showed that the percentage
of excess weight loss (the difference between presurgical and
ideal weight) was higher for RYGB compared with LAGB at
year 1 (67 vs 42) and year 2 (67 vs 53); however, no differ-
ences were noted at 3, 4, 5, 6, and 7 yr (62 vs 55, 58 vs 55, 58
vs 55, 53 vs 50, and 55 vs 51). After RYGB and LAGB, about
15–17% of patients are unable to lose more than 40–50% of
their excess weight (36–38), which is generally defined as
insufficient weight loss.
Inadequate weight loss may be due to the patient’s dietary
indiscretions or lack of exercise or to the surgical technique.
Patients may snack on high-calorie liquids or solids, thereby
overcoming the natural restriction caused by the smaller post-
surgical gastric pouch. Postoperative support groups are im-
portant in helping patients maintain long-term dietary com-
pliance and weight loss (39). In the case of RYGB, the surgeon
may have made the gastric pouch too large or the Roux limb
too short, or there could be dehiscence of the staple line in
the undivided stomach. An enlarged gastric pouch may be
revised, but revisional procedures carry an increased risk of
complications (40). After LAGB, the gastric pouch may di-
late in about 12% of patients due to proximal herniation of the
stomach (41). Deflation of the band resolved this problem in
77% of patients. Biertho et al. (36) reported that after LAGB,
1.2% of patients required repeat operation purely for insuffi-
cient weight loss and were converted to RYGB or PBD.
2576 Decker et al.
Excessive Weight Loss
The RYGB and the purely restrictive procedures rarely re-
sult in protein calorie malnutrition or excessive weight loss.
Such complications are more common after the BPD or the
duodenal switch, both of which result in a greater degree of
malabsorption. Undernutrition may not be obvious, because
patients are expected to lose weight and protein levels will
often remain normal initially (38).
The differential diagnosis includes eating disorders such
as anorexia nervosa or bulimia or postsurgical complications
(42). Stomal stenosis or ulceration may lead to vomiting and
inadequate caloric intake. Protracted diarrhea could be due to
an excessively long Roux limb or an enteric infection. Short-
ening the Roux limb after RYGB or lengthening the common
channel after BPD or duodenal switch may be necessary in
patients with severe fat and protein malabsorption (42).
Hepatobiliary Complications
Rapid weight loss predisposes bariatric patients to the for-
mation of cholesterol gallstones, irrespective of the type of
procedure performed (43–46). Within 6 months after surgery,
new gallstones develop in as many as 36% of patients and
sludge develops in as many as 13% (47, 48). Elective chole-
cystectomy during bariatric surgery appears to be safe (49,
50), but it increases the length of stay in the hospital and
adds considerably to cost (51). Routine intraoperative ul-
trasound with elective cholecystectomy has been advocated
only in patients with existing gallstones, because new symp-
tomatic gallstones occur infrequently (7%) and cholecystec-
tomy is usually well tolerated (52). Only 30% of surgeons
performing standard RYGB remove normal-appearing gall-
bladders (53). The administration of ursodeoxycholic acid for
6 months after surgery reduces the incidence of postopera-
tively formed gallstones from 32% to 2% (54). Caruana et al.
(55) questioned the necessity of any form of prophylactic
treatment when they reported that only 10 of 125 patients
who received none after open RYGB ultimately required
cholecystectomy for symptomatic gallstones. Laparoscopic
bariatric surgery reduces adhesion formation and makes post-
surgical cholecystectomy more amenable to the laparoscopic
approach.
When cholelithiasis is suspected, alternatives to ultrasound
may be necessary because of poor image quality in the obese
abdomen (56). Computed tomography and magnetic reso-
nance cholangiopancreatography are good alternative diag-
nostic methods. Exploration of the common bile duct usually
must be done intraoperatively or else by a gastrostomy in the
excluded stomach because standard endoscopic retrograde
cholangiopancreatography is seldom feasible (21, 57).
Nonalcoholic fatty liver disease is a complication of obe-
sity with no effective medical therapy. In studies with small
numbers of patients, weight loss induced by bariatric surgery
has been shown to improve the histologic changes caused by
this condition (58–60).
LUMINAL COMPLICATIONS
Stomal and Marginal Ulceration
Ulceration occurs in as many as 20% of RYGB patients, usu-
ally within 3 months of surgery (61, 62). The ulcers are usu-
ally on the efferent side of the gastrojejunostomy, the marginal
ulcer (63). What causes these ulcers is much debatable. In-
creased rate of ulceration has been reported after undivided
gastric bypass (64). Local ischemia because of the surgical
technique and tension on the pouch may also predispose the
RYGB patient to ulceration (65). In 1976, Mason et al. (66)
reported that a larger gastric pouch led to an increased in-
cidence of ulceration, possibly because the larger pouch left
more parietal cells capable of producing more acid. The mod-
ern RYGB, however, leaves a tiny pouch (about 10–20 mL),
which may not contain parietal cells and hence would not
produce acid. Two recent studies challenge this theory. In
one study, parietal cells were found in the gastric pouch after
RYGB in all patients tested (67). Another study demonstrated
lower pH in the gastric pouch in patients with stomal ulcers
compared with asymptomatic patients after RYGB (68). It
would therefore seem logical that acid plays a role in some
ulcers after RYGB, particularly in patients with a larger gas-
tric pouch.
Patients with stomal or marginal ulceration may present
with abdominal pain, nausea, vomiting, or gastrointestinal
tract bleeding. Ulceration may also lead to stenosis, resulting
in symptoms similar to dysphagia or excessive weight loss.
In most cases, diagnosis can be made with an upper en-
doscopy. Biopsy specimens should be taken for Helicobacter
pylori, which should be treated when present. The role of He-
licobacter pylori in stomal and marginal ulceration, however,
has not been determined. Although candidates for bariatric
surgery are commonly tested for a treated ulceration before
surgery, this is not a routine or standard practice. Patients with
uncomplicated ulceration may be treated effectively with a
proton pump inhibitor (69), which again suggests that acid in-
fluences the pathogenesis of these ulcers. In many instances,
however, surgical technique varies and the gastric pouch is
larger than it should be. Patients with refractory nonhealing
ulcers may require surgical revision. Surreptitious ingestion
of nonsteroidal anti-inflammatory drugs must always be con-
sidered and investigated.
Stomal Stenosis
Stomal stenosis has been reported in as many as 27% of
bariatric patients (70). Some surgeons modify the RYGB
by applying a silastic ring around the proximal pouch
or the gastrojejunal anastomosis. This modification may
lead to a higher incidence of symptomatic stenosis. A
contrast-enhanced radiograph is often performed to inves-
tigate suspected stomal stenosis, but an upper gastrointesti-
nal endoscopy is the preferred procedure because it allows
therapeutic interventions (21). Knowing the diameter of the
normal anastomosis (10–12 mm) can help avoid unnecessary

dilation. Balloon dilation is the preferred procedure. Al-
though multiple dilation sessions may be needed, patients
with a silastic ring may first require surgical removal of the
ring or revision of the anastomosis.
Band Erosion and Staple Line Dehiscence
The endoscopic appearance after staple line dehiscence, band
erosion, or fistula development may be confusing. Symptoms
are nonspecific and include abdominal pain, nausea, and vom-
iting. A contrast-enhanced radiograph is helpful and always
indicated in these patients. Although such complications usu-
ally require surgical correction, few fistulas are closed endo-
scopically. Endoscopic clipping and fibrin glue sealant may
be used to close fistula tracts (71).
Internal Hernias
Awareness of the possibility of internal hernias is important
because they may be difficult to diagnose. Internal hernias
do not occur in purely restrictive operations. Laparoscopic
surgery leads to fewer adhesions, which may increase small-
bowel mobility and the predisposition to internal hernias.
Symptoms are nonspecific but may include vomiting and ab-
dominal pain with or without nausea. A computed tomo-
gram or barium radiograph of the upper gastrointestinal tract
may not be confirmatory; thus, the decision to operate may
be based solely on clinical suspicion. Internal hernias occur
at three sites: (a) where the Roux limb passes through the
mesocolon, (b) at the jejunojejunostomy, and (c) between the
jejunal and colonic mesenteries (72).
Bile Reflux
After RYGB, bile reflux into the gastric pouch or proximal
Roux limb should not occur unless the Roux limb is inap-
propriately short. When bile is observed proximally during
upper endoscopy, it may indicate obstruction at, or distal to,
the jejunojejunostomy. A recent study of cholescintigraphy in
RYGB patients also suggests considerable duodenal gastric
bile reflux into the excluded stomach compared with con-
trols (73). The clinical significance of this complication has
not been established.
Gastrointestinal Tract Bleeding
Gastrointestinal tract hemorrhage after gastric bypass is rare
and is usually caused by stomal or marginal ulceration (74,
75). The initial investigation of choice is an esophagogastro-
duodenoscopy. Knowledge of the surgical anatomy (Figs. 1–
5) is a prerequisite to any endoscopic procedure on a bariatric
surgery patient. Bleeding may present a management chal-
lenge if the bleeding site is not found at esophagogastro-
duodonoscopy, because of the difficulty in accessing the dis-
tal roux limb, the biliary limb, and the excluded stomach.
If the patient had an RYGB or a BPD, a pediatric
colonosope may be required when a proximal source of bleed-
ing is not found with a standard upper endoscope. The Roux
limb should be inspected as far distally as possible. If no
source of bleeding is found, the diagnostic and therapeutic
Complications of Bariatric Surgery 2577
dilemma is how to reach the excluded stomach and the biliary
limb. Attempted retrograde passage of a pediatric colonosope
up the biliary limb (76) usually is not successful. A radiolog-
ically or laparoscopically placed percutaneous gastrostomy
may allow endoscopic access to the excluded stomach (77).
Rarely, intraoperative endoscopy is required. Double-balloon
enteroscopy is a new endoscopic technique that allows direct
visualization as well as diagnostic and therapeutic interven-
tion of the entire small bowel (78), and it has also been used
to access the biliary limb and excluded stomach after RYGB
(79).
Dumping Syndrome
Dumping syndrome is caused by the rapid emptying of a hy-
pertonic carbohydrate load into the small bowel. Patients may
present with abdominal pain, cramping, flushing, palpita-
tions, diaphoresis, tachycardia, or hypotension. Early dump-
ing syndrome occurs within the first hour after ingestion of
a meal and may be related to the sudden distension of the
jejunum by hypertonic solids or fluids. Late dumping occurs
1–3 h after eating and is most likely caused by the rapid ab-
sorption of glucose, with hyperglycemia triggering an exag-
gerated insulin release that results in rebound hypoglycemia.
Some surgeons look favorably on this complication, be-
cause it sensitizes patients to avoid high-calorie meals that
may lead to weight gain. In most patients, dumping syndrome
can be prevented and treated with dietary changes. To help
avoid rapid emptying of the gastric pouch, patients should eat
small meals, avoid carbohydrates at the beginning of a meal,
and consume food slowly.
Gastroesophageal Reflux Disease
GERD improves or disappears in most patients after RYGB
(80). The small remaining gastric pouch should not contain
parietal cells, which eliminates acid reflux. An added benefit
is the distal diversion of bile, which may contribute to reflux
symptoms. Conflicting results about the effect of LAGB on
GERD have been published. Some have reported a worsening
of symptoms (81), but a growing body of literature suggests
that symptoms and pH may improve after LAGB (82–84).
Overweight and obesity are risk factors for GERD, and weight
loss due to any intervention may reduce GERD (85–87).
Functional Symptoms
Little is known about changes in gastrointestinal tract symp-
toms after bariatric surgery. Foster et al. (88) compared symp-
toms before and 6 months after laparoscopic RYGB and found
improvement in functional symptoms, such as abdominal dis-
tension, abdominal pain, flatus, and fecal urgency. These pa-
tients had no worsening of symptoms.
Vomiting is frequently a long-term problem in as many as
69% of patients after gastric bypass surgery (89). Although
vomiting is usually caused by overeating, it also may indicate
stomal stenosis. If no abnormality is found on endoscopy or a
barium imaging study, the patient most likely is eating larger
meals than recommended. Binge-eating disorder is common
2578 Decker et al.
in obese patients (90), affecting as many as 49% of bariatric
patients before surgery (89). Patients who resume binge eat-
ing after surgery are more likely to regain weight (89). Band
slippage must also be considered in the patient with vomiting
after LAGB.
The true prevalence of functional symptoms (e.g., diarrhea,
constipation, abdominal pain, and bloating) after bariatric
surgical procedures has not been well studied.
CONCLUSION
Gastroenterologists are part of the multidisciplinary team tak-
ing care of obese patients. Their familiarity with the range
of bariatric procedures, the postsurgical anatomy, and the
gastroenterological and nutritional complications common in
these patients will facilitate their postsurgical care of bariatric
patients.
ACKNOWLEDGMENT
Editing, proofreading, and reference verification were pro-
vided by the Section of Scientific Publications, Mayo Clinic.
Reprint requests and correspondence: G. Anton Decker, M.D.,
Division of Gastroenterology and Hepatology, Mayo Clinic, 13400
East Shea Boulevard, Scottsdale, AZ 85259.
Received January 5, 2007; accepted May 15, 2007.
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CONFLICT OF INTEREST
All authors contributed equally to this manuscript. There was
no financial support. The authors do not have any competing
interests.