What are the complications of sleeve gastrectomy (gastric sleeve surgery) that can cause nausea, vomiting, and epigastric pain 2 years post-operatively?

From the Guidelines

Gastric sleeve surgery complications that can cause nausea, vomiting, and epigastric pain after 2 years primarily include gastric obstruction, which occurs in 0.2-4% of cases, often due to mechanical narrowing or axial obstruction 1. These complications can significantly impact the patient's quality of life, morbidity, and mortality if not addressed promptly.

Common Causes of Complications

• Gastric obstruction: This can be caused by a mechanical narrowing, usually located at the incisura angularis or an axial obstruction due to rotation phenomenon secondary to incongruence between the anterior and posterior gastric wall 1.
• Strictures: Most of these are located in the proximal or distal third of the gastric sleeve, with the incisura angularis being the most prevalent location for obstruction 1.

Diagnosis and Treatment

Diagnosis of these complications typically requires endoscopy to assess the gastric sleeve and rule out other causes of symptoms.

• Endoscopic management of strictures with balloon dilatation or stent placement is reported to be successful in 88-94% of cases 1.
• When endoscopic methods are unsuccessful, conversion to Roux-en-Y gastric bypass (RYGB) should be considered 1.
• In the emergency setting, patients presenting with symptoms of obstruction may benefit from naso-gastric tube placement to decompress the stomach before assessing the gastric sleeve by endoscopy 1. It is essential for patients experiencing nausea, vomiting, and epigastric pain after gastric sleeve surgery to seek medical evaluation to determine the underlying cause and receive appropriate treatment, as delayed diagnosis can lead to increased morbidity and mortality 1.

From the Research

Complications of Gastric Sleeve Surgery

• Nausea and vomiting are common complications after gastric sleeve surgery, with a prevalence of 74.6% at 6 hours postoperative 2
• Epigastric pain can also occur, with severity of pain being an independent risk variable for the development of postoperative nausea and vomiting (PONV) 2
• Gastroesophageal reflux disease (GERD) is another potential complication, with some studies showing improvement or resolution of GERD symptoms after sleeve gastrectomy, while others develop or worsen symptoms 3

Risk Factors for Postoperative Nausea and Vomiting

• Female gender, smokers, preoperative GERD, gastropexy, and severity of pain are independent risk variables for the development of PONV 2
• Antral preservation, opioid-free analgesia, and intraoperative combined analgesia are independent protective variables against the development of PONV 2
• Helicobacter pylori status has no role in the development of PONV after laparoscopic sleeve gastrectomy 2

Management of Postoperative Nausea and Vomiting

• Combined intravenous ondansetron and metoclopramide can improve PONV, with a success rate of 92.6% 2
• Dexamethasone and antihistamines can be used for persistent PONV after using intravenous ondansetron and metoclopramide 2
• Opioid-free analgesia can help manage PONV postoperatively 2
• The use of metoclopramide, ondansetron, and granisetron as antiemetics can reduce the incidence of PONV, with the combination of metoclopramide and ondansetron being the most effective 4