Bariatric Times - February 2009 - (Page 28) 28 Surgical Perspective Bariatric Times • February 2009 TABLE 2. Diagnosis of small bowel obstruction after LRYGB TABLE 3. Localization of site of small bowel obstruction after LRYGB Symptoms: • Intermittent/ persistent/recurrent • Acute/chronic Biliopancreatic Limb: • Tachycardia • Dehydration • Abdominal distension • Abdominal tenderness • Incarcerated ventral hernia • Sepsis • Peritonitis • White blood cell count • Liver function test • Alkaline phosphatase • Amylase • Imaging plain radiograph • Upper gastrointestinal contrast study • Abdominal computed tomography scan to the anatomical site of obstruction, we propose the following classification: type A— alimentary limb obstruction; type B—biliopancreatic limb obstruction; and type C—common channel obstruction (Figures 1 and 2). The time to SBO varies from zero to 1,414 days after LRYGB in reported series, with 44 to 48 percent occurring within the first month.8,14,15,24 In terms of the timing of onset of SBO after surgery, we propose the following additional classification system: acute early SBO, less than or equal to 30 days after LRYGB; acute late SBO, greater than or equal to 30 days and less than 12 months after LRYGB; and chronic SBO, greater than or equal to 12 months after LRYGB. Intussusception after RYGB. Intussusception after RYGB for morbid obesity has been reported infrequently and represents an additional complexity to the treatment of adult patients with intussusception. To date, nine cases have been reported in eight patients, three antegrade (isoperistaltic), four retrograde (antiperistaltic), and two not specified.8-12 No intussusceptions have been reported after LRYGB. Although this may represent a lead time bias, LRYGB has been reported for one decade, and intussusception after open RYGB has been described as occurring within 1 to 7 years postoperatively. The cause of intussusception after RYGB remains obscure but seems to be multifactorial, involving a lead point (suture lines, adhesions, and lymphoid hyperplasia), motility disturbances, and aberrant intestinal pacemakers. The clinical presentation of intussusception in adults is variable, Alimentary Limb: • Dilated alimentary limb Biliopancreatic Limb: • Dilated duodenum, biliopancreatic limb, and gastric remnant • Elevated liver function test • Elevated amylase Common Channel: • Dilated biliopancreatic limb, alimentary limb, and gastric remnant • Elevated liver function test • Elevated amylase TABLE 4. Published classification systems for small bowel obstruction after LRYGB Presentation: • Acute • Chronic Onset after Surgery:7,12,15 • Early • Late Extent:11 • Complete small bowel obstruction • Partial small bowel obstruction Anatomy: 11 • Type I: Roux limb • Type II: Biliopancreatic limb • Type III: Common channel uniform system of interpretation, understanding, and diagnosis of SBO after RYGB in the emergency room and also facilitate more effective communication between nonbariatric surgeons in the general community with specialists in bariatric centers. Our proposed classification system is based on the anatomical site of obstruction and onset of symptoms from the date of surgery. With regard making diagnosis on the basis of clinical assessment findings difficult. Symptoms tend to be chronic and intermittent, in contrast to the typical acute presentation in children. The most common presenting sign is vague abdominal pain.17,26 The presenting symptoms included abdominal pain (100%), nausea and vomiting (40%), and bloody stools (20%). The physical findings included abdominal tenderness (90%), abdominal mass (70%), and peritoneal irritation (20%). Only 10 percent presented with the classic triad of abdominal pain, red-currant jelly stools, and a palpable mass.17 The published data evaluating the radiologic diagnosis of intussusception in adults are limited. Options include CT, UGI radiocontrast studies, and ultrasonography. CT should be recommended for all bariatric patients presenting with abdominal symptoms (pain, nausea, vomiting). If patients present with peritoneal signs, additional radiologic evaluation should not delay emergent abdominal exploration. Conservative management of intussusception in children (reduction with contrast media, saline, or air) has a success rate of 90 percent17 and is appropriate because most cases have no identifiable pathologic lead point. Adult intussusception often has an identifiable lesion and requires surgical intervention. One controversy surrounds the issue of reduction before resection. The risk of reduction before resection includes perforation and emboli of malignant cells. The benefit of reduction before resection includes lengthening of the mesentery to avoid resection of healthy bowel.17 SBO after LRYGB is crucial to avoiding the development of catastrophic complications, including anastomotic dehiscence, staple-line disruption, small bowel ischemia, infarction, and gangrene. It is important to recognize that the most common cause of SBO after LRYGB is internal herniation, which will result in intestinal ischemia, perforation with peritonitis, sepsis, and death if not managed in a timely and appropriate fashion. Our proposed simplified classification system of SBO after LRYGB, based on the anatomical location of the obstruction and onset after surgery, will facilitate a better understanding of the underlying pathology and allow more effective communication between the nonbariatric patient and the surgical community to ultimately improve patient management and outcomes. REFERENCES 1. Anonymous. Gastrointestinal surgery for severe obesity. MIH consensus development conference, March 25-7, 1991. Nutrition. 1996;397–404. Maggard MA, Shugarman LR, Suttorp M, et al. Meta-analysis: surgical treatment of obesity. Ann Intern Med. 2005;142(7):547–559. Jones KB Jr, Afram JD, Benotti PN, et al. Open versus laparoscopic Roux-en-Y gastric bypass: a comparative study of over 25,000 open cases and the major laparoscopic bariatric reported series. Obes Surg. 2006;16(6):721–727. Rosenthal RJ, Szomstein S, Kennedy CI, et al. Laparoscopic surgery for morbid obesity: 1,001 consecutive bariatric operations performed at the Bariatric Institute, Cleveland Clinic Florida. Obes Surg. 2006;16(2):119–124. Nguyen NT, Goldman C, Rosenquist CJ, et al. Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs. Ann Surg. 2001;234(3):279–289. Higa KD, Boone KB, Ho T. Complications of the Laparoscopic Roux-en-Y gastric bypass: 1,040 patients– what have we learned? Obes Surg 200; 10(6): 509–513. Higa KD, Boone KB, Ho T, Davies OG. Laparoscopic Roux-en-Y gastric bypass for morbid obesity: technique and preliminary results of our first 400 patients. Arch Surg. 2000;135(9):1029–1033. Hwang RF, Swartz DE, Felix EL. Causes of small bowel obstruction after laparoscopic gastric bypass. Surg Endosc. 2004;18(11):1631–1635. Cho M, Carrodeguas L, Pinto D, et al. Diagnosis 2. 3. 4. 5. 6. 7. SUMMARY Early diagnosis and treatment of 8. 9.
For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.