Mistakes in... 2022 - 25

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Mistakes in... 2022
a
Gastric
pouch
GastroBiliopancreatic
limb
Gastroenterostomy
enterostomy
Alimentary
limb
b
Gastric
pouch
Resected
stomach
Duodenoileostomy
Gastric
pouch
c
Duodenoileostomy
Alimentary
limb
Biliopancreatic
limb
Common
limb
Common
channel
Enteroenterostomy
Common
limb
Enteroenterostomy
Figure
3 | a | Standard biliopancreatic diversion. b | Biliopancreatic diversion with duodenal switch. c | Single-anastomosis duodeno-ileal bypass.
biliopancreatic diversion, and the related variants
(figure 2), intestinal obstruction has a different
presentation, with severe consequences if the
diagnosis and treatment are not timely. 19,28
Bowel obstruction after derivative bariatric
surgery can appear at any time after surgery
but usually appears months or years later,
following significant weight loss. The weight loss
can increase the diameter of the defects within
the mesenteries, thus facilitating internal
herniation of bowel loops. Internal hernias can
appear with both antecolic and retrocolic
gastro-enterostomies and less frequently in
one-anastomosis gastric bypass (figure 3).29
Typically, the internal hernia can be
transmesocolic, in Petersen's defect (between
the mesentery of the alimentary limb and the
transverse mesocolon), or at the level of the
entero-enterostomy (figure 4).30
In internal hernia, the dominant clinical
picture comprises abdominal pain, with a variable
degree of abdominal distension. Air-fluid levels
may be absent in traditional radiology because the
biliopancreatic limb and the excluded stomach do
generally not contain any air.
Obstruction of the biliopancreatic limb leads
to a closed-loop obstruction. In this scenario, the
evolution towards ischemia and necrosis is rapid
(figure 5).
The increase in intraluminal pressure is
transmitted to the bile duct and the pancreas, with
the onset of cholestasis and hyperamylasaemia,
which can be mistakenly confused with acute
pancreatitis.31
Biliopancreatic
limb
The progressive increase in pressure
cannot be relieved with vomiting, and ischemia
and perforation can occur rapidly.
Urgent abdominal CT scan is the most
reliable diagnostic investigation, and typical signs
comprise dilatation of the duodenum and gastric
remnant, bile duct dilatation, thickening of the
intestinal wall, clustering of jejunal loops in the
left upper quadrant, as well as distortion and
rotation of mesenteric vessels.32
In no case is a conservative treatment
advisable (infusion therapy and nasogastric
decompression). The patient should be surgically
explored: unless proven otherwise, an internal
hernia should be suspected in patients submitted
to derivative bariatric surgery with acute
abdominal pain.3
The herniated small bowel must be identified
at surgery, and the hernia reduced. The
mesenteric defect should be closed with a
non-absorbable suture.34
3
Mistake 6 Failing to identify invalidating or
potentially fatal nutritional deficiencies.
1
Petersen's
hernia
2
Hernia of the
alimentary
limb
Hernia of
the enteroenterostomy
Lorem
ipsum
Retrocolic
Figure 4 | Internal hernia after gastric bypass.
Antecolic
1
2
Despite the widespread acceptance of bariatric
surgery, diagnosis of long-term nutritional
complications is often elusive, and patients are
frequently referred to non-bariatric speciality
consultation by their treating physician.
Specific signs and symptoms of protein
deficiency include hair loss, fatigue, and lower
limbs oedema.35
Patients should be assessed
for adequate protein and calorie intake, and
diarrhoea should be ruled out. Serum total
protein albumin and transferrin are the most
used indicators of clinical nutrition. Anaemia of
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