What is the management of post sleeve gastrectomy bleeding?

Management of Post Sleeve Gastrectomy Bleeding

Endoscopy is the first recommended diagnostic and therapeutic approach for hemodynamically stable patients with post sleeve gastrectomy bleeding, while immediate surgical exploration is mandatory for unstable patients not responding to resuscitation. 1

Initial Assessment and Resuscitation

• Perform rapid evaluation of airway, breathing, and circulation with hemodynamic stabilization as the primary goal 2
• Maintain systolic blood pressure 90-100 mmHg, normalize lactato and base deficit similar to trauma resuscitation protocols 2
• Implement restrictive transfusion strategy maintaining hemoglobin >7 g/dL, which has shown better outcomes than liberal strategies 2
• Correct or prevent coagulopathies that may worsen bleeding 2

Management Algorithm Based on Hemodynamic Status

For Hemodynamically Stable Patients:

1. First-line approach: Endoscopic assessment and treatment

   • Endoscopy should be performed by an expert endoscopist with CO2 insufflation to minimize risk of perforation 1
   • Endotracheal intubation is recommended before endoscopy to protect airways 1
   • Injection and mechanical techniques are preferred over thermal techniques to minimize risk of ischemia and anastomotic necrosis 1
   • Hemostatic powders can be effective for treating large bleeding areas 1

2. If endoscopic management fails:

   • Perform angio-CT and consider angioembolization when skills and equipment are available 1
   • Angioembolization is particularly useful for bleeding from vessels like the gastro-omental artery 3
   • The "sandwich technique" with detachable coils may be used for arterial embolization 3

3. If angioembolization fails or is unavailable:

   • Proceed to surgical exploration if there are signs of persistent bleeding 1
   • Consider intraoperative endoscopy to facilitate localization of the bleeding site 1
   • For RYGB patients, surgical gastrostomy may be needed to access the gastric remnant and duodenum 1

For Hemodynamically Unstable Patients:

• Immediate surgical exploration is mandatory for patients not responding to aggressive resuscitation 1
• Do not delay laparoscopy/laparotomy in patients with ongoing intraperitoneal bleeding, even after angioembolization 1
• Surgical hemostasis is the definitive treatment for these patients 1

Common Causes and Specific Management

• Staple line bleeding is the most common source (incidence 0.6-20%) 4

  • Staple line reinforcement techniques significantly reduce risk of postoperative bleeding 5
  • Waiting 30 seconds between compression and firing during stapling can reduce hemorrhagic complications from 6.21% to 1.11% 6

• Marginal ulcers (after RYGB) and gastric ulcers (after LSG) are common causes of late gastrointestinal bleeding 1

  • Biopsy of bleeding ulcers is recommended to exclude malignancy 1
  • Medical treatment with proton pump inhibitors for minimum 3-6 months is indicated 1

• Pseudo-aneurysms of visceral arteries (e.g., gastro-omental artery) are rare but serious causes of delayed bleeding 3

  • Angiographic embolization is the treatment of choice for these cases 3

Post-Treatment Monitoring

• Close monitoring for rebleeding is essential, as approximately 50% of conservatively managed patients may develop infected hematomas 4
• Infected hematomas may require CT-guided drainage or surgical intervention 4
• Monitor for late complications such as gastric leaks, which can develop in patients with conservatively managed bleeding 4

Prevention Strategies

• Implement intraoperative protocols for detecting silent bleeding 4
• Consider staple line reinforcement techniques, which independently predict lower risk of postoperative bleeding 5
• Proper stapling technique including waiting between compression and firing can reduce bleeding complications 6

Pitfalls and Caveats

• Conservative management of postoperative bleeding carries a high risk (50%) for late leakage and should be monitored closely 4
• Do not delay surgical exploration in unstable patients or when endoscopic and angiographic management fail 1
• Access to excluded segments (gastric remnant and duodenum) after RYGB is challenging and may require specialized techniques 1
• Bleeding after sleeve gastrectomy is associated with increased complications, readmission rates, reoperation rates, and mortality at 30 days 5