Bariatric Times - February 2009 - (Page 26) 26 Surgical Perspective Bariatric Times • February 2009 Small Bowel Complication After Malabsorptive Procedures: Internal Hernias, Obstructions, and Intussusception by Jesus E. Hidalgo, MD; Alexander Ramirez, MD; Raul Rosenthal, MD, FACS; and Samuel Szomstein, MD, FACS The Bariatric Institute, Section of Minimally Invasive Surgery, Cleveland Clinic Florida, Weston, Florida Continued from Page 1 SMALL BOWEL OBSTRUCTION AND INTERNAL HERNIA The techniques of open and LRYGB are not standardized, and variations exist between centers. Several techniques are used, including antecolic antegastric, retrocolic antegastric, or retrocolic retrogastric approaches.4,8,11,15,24 The retrocolic defect can be closed in an interrupted fashion, a continuous fashion, or not at all.8,14,15,24 Other mesenteric defects, including the jejunojejunal and Peterson’s space (retro-Roux loop), can be closed or left open.4,11 Absorbable or nonabsorbable suturing can be used to close the mesenteric defects.11,14 The length of the alimentary limb is also not standardized and varies from 75 to 200cm, according to individual patient’s body mass index (BMI) and surgeon preference.4,24 The jejunal mesentery can be divided to lengthen the Roux limb or not.4,8 An antikink suture, otherwise known as a Brolin stitch, can be routinely or selectively inserted after the completion of the jejunojejunostomy.8,27 The Roux limb can be fixed or not when a retrocolic approach is used.11,26 The greater omentum can be divided to reduce tension on the gastrojejunal anastomosis (GJA), not divided, or a window can be created in it for the Roux limb.15 Circular staples, linear staplers, handsewn techniques, or a combination of these can be used to create and close the gastrojejunal and jejunojejunal anastomoses.4,6,28 Finally, trocar sites may or may not be closed.4 CLINICAL EVALUATION There are many causes of SBO after LRYGB (Table 1). The most common etiologies include iatrogenic causes of narrow anastomoses, overzealous closure of mesenteric defects, mesenteric or intramural hematoma, anastomotic leak, incarcerate ventral hernias, internal hernias, and adhesions. Depending on the cause, patients develop symptoms in the immediate postoperative period, or in the weeks, months, or even years after surgery. Obstruction can involve the alimentary limb, biliopancreatic limb, common channel, or more distally if adhesive in nature. Because of the differences in surgical technique, the incidence of SBO varies from 0.4 to 7.45 percent.3 With the adoption of the laparoscopic approach, there has been a reduction in postoperative SBO secondary to adhesions and incisional hernias; however, a higher incidence of SBO because of internal hernias is seen compared to the open procedure.12,13 Early series of laparoscopic bypass reported an incidence of SBO of 1.5 to 3.5 percent, with most attributed to TABLE 1. Etiology of small bowel obstruction after LRYGB Alimentary Limb: • Acute internal hernia through Peterson’s space • Jejunojejunostomy stenosis • Intussusception of Roux limb • Angulation of Roux limb at jejunojejunostomy • Torsion of Roux limb • Intraluminal hematoma • Intramural hematoma • Anastomotic leak • Tight mesocolic defect • Mesocolic hematoma • Angulation of Roux limb at fixation to mesocolic defect • Chronic internal hernia at fixation to mesocolic defect • Chronic internal hernia through Peterson’s space • Anastomotic stricture • Mesocolic fibrotic constriction of Roux limb Biliopancreatic Limb: • Acute jejunojejunostomy stenosis • Intraluminal hematoma • Intramural hematoma • Mesenteric hematoma • Intussusception of jejunojejunostomy • Kinking of jejunojejunostomy • Anastomotic leak • Volvulus • Chronic internal hernia • Anastomotic stricture Common Channel: • Acute anastomotic leak • Jejunojejunostomy stenosis • Intraluminal hematoma • Intramural hematoma • Mesenteric hematoma • Incarcerated abdominal wall hernia: Trocar site/previous surgical incision • Whole gut volvulus around Roux limb • Chronic internal hernia • Adhesion
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