Gastrointestinal Bleeding as a Late Complication After Gastric-Bypass: A Case Report as a Late Complication After Gastric-Bypass: A Case

Surgery is considered to be an effective and long-term treatment for individuals with severe obesity and over the past 20 years, bariatric surgery has gained immense popularity. Laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery as well as sleeve gastrectomy (SG), in particular, have become two of the most widely-performed bariatric procedures world-wide[1]. Whilst these operations are deemed safe in expert hands, severe and potentially life-threatening complications have been reported. Optimal management of these complications, however, usually poses a challenge for both general surgeons and gastroenterologists. Although the diagnosis and subsequent management of early complications including anastomotic leaks, venous thromboembolic events and intestinal obstruction are well documented, those for late complications, with the exception of internal hernias, are less well defined. We present a rare case of a late bleeding from the gastro-jejunal anastomosis 19 months following LRYGB surgery, including the successful treatment performed in a non- specialist center for bariatric surgery. Gastrointestinal Bleeding


Introduction
According to the World Health Organization (WHO), obesity is defined as a Body Mass Index (BMI) over 30 kg/m 2 . The treatment of obesity and adiposity-based chronic diseases has become a major health concern [2]. Organizations such as the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) play an integral role in educating both the metabolic surgical and the medical community about the best management of patients who have undergone bariatric surgery. Based on IFSO data, the two most common procedures for obesity are the LRYGB (35%) and the SG (47%) [3]. Although rare, post-operative complications can occur. These are defined as either early complications including bleeding, anastomotic leak, abscess, kinking and pulmonary thromboembolism, or late complications such as stenosis, anastomotic fistulas, dumping syndrome, marginal ulcers (MU) or internal hernia [4]. Management of early complications are well documented in the literature, however there are currently limited evidence-based guidelines on the treatment of late complications, perhaps due to their less common occurrence [5]. In the following case report, we present a rarely-reported late complication in the form of an acute bleeding anastomotic ulcer.

Discussion
Gastrointestinal (GI) bleeding often poses a challenge for gastroenterologists and general surgeons alike. This is often the case due to difficulties in identifying the source of bleeding, regardless of previous abdominal surgical history. In LRYGB performed for adiposity, the literature reports acute early GI bleeding as a common complication occurring between 2.6% to 11% [4,[7][8][9] of the cases, with the source usually occurring from the anastomosis or staple line. The incidence of bleeding as a late complication is estimated up to 5% [4,5,8,11], however data is limited and is only described in a few case reports. The main cause is believed to be due to bleeding marginal ulcers (MU). The characteristics of MU, its complications and management were analyzed in a systematic review from Coblijn et al. [12], involving 41 studies and a total of 16,987 patients. In symptomatic patients (n=777), epigastric burn was the most frequently reported symptom (56.8%) and of these patients, 117 (15.1%) were found to have bleeding. Furthermore, Coblijn and his colleagues reported that the incidence of MU was found to be underestimated and could be correlated to the preoperative presence of H. pylori, as was the case with our patient.
Whilst most would agree that endoscopy is clearly indicated as a part of the management pathway following bariatric surgery when patients are symptomatic, the role of routine surveillance endoscopy in LRYGB remains controversial.
IFSO recommends that postoperative endoscopy should be undertaken routinely for all patients at 1 year and then every 2 to 3 years for patients who have undergone SG or one anastomosis gastric bypass in order to improve early detection of other complications, but following LRYGB an endoscopy should be performed on the basis of upper GI symptoms [13]. Furthermore, while there are currently no evidence-based guidelines to help guide treatment in late complications following LRYGB, the authors feel endoscopic management of bleeding MU should be considered as first-line therapy. This can be safely performed by an experienced gastroenterologist at a non-specialist center for bariatric surgery.
The H. pylori should be tested when finding MU and eradication therapy should be performed. Of most importance, however is the critical role of interdisciplinary teamwork in the management of bariatric post-operative complications.