Bariatric Times - February 2009 - (Page 27) Bariatric Times • February 2009 Surgical Perspective 27 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 internal hernias, but with a short follow-up period of less than two years.7 Internal herniation can occur at the jejunojejunostomy, Peterson’s space, or the transverse mesaconic defect after a retrocolic approach. The incidence of internal hernias is higher after the retrocolic retrogastric approach and has been significantly reduced by adoption of the antecolic antegastric approach in reported series from 4.5 to 0.43 percent.15 Patients can present acutely with the classical symptoms and signs of SBO or chronically with vague symptoms. Late SBO typically presents with intermittent, recurrent, cramping, periumbilical pain, which may be associated with intermittent nausea and vomiting. Not uncommonly, patients present to their local emergency room or primary care physician with recurrent vague symptoms; often their complaints are explained by failure to comply with diet, gastroesophageal reflux disease, postprandial pain, or marginal ulceration. Diagnosis is based on symptoms, clinical examination, and investigative tools, including blood test, plain abdominal radiographs, upper gastrointestinal (UGI) contrast studies, and abdominal computed tomography (CT) scans (Tables 2 and 3). A methodical approach facilitates the identification of the site of obstruction in the majority of patients before surgery. Although symptoms are often similar, the presence of gastroesophageal reflux and significant vomiting is suggestive of an obstruction to the alimentary limb or common channel. Distention of the biliopancreatic limb and gastric remnant with elevated liver functions test and hyperamylasemia is suggestive of obstruction of the biliopancreatic limb or common channel (Table 3). Treatment is directed by the clinical condition of the patient and involves nasogastric decompression with early surgical intervention in the form of diagnostic laparoscopy. Classification system. Numerous descriptive terms have been employed in an attempt to classify SBO after LRYGB in reported series based on presentation, onset after bariatric surgery, extent of obstruction, or anatomical site (Table 4).8,9,14,24 The most commonly used method has been onset of symptoms in relation to duration after surgery in terms of early or late presentation.8,9,14,24 However, published classification systems of early presentation of SBO range from less than three weeks to less than three months, and similarly late presentation range from greater than three weeks to greater than three months. This would facilitate a http://www.ironintern.com http://www.ironintern.com
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