Discussing Surgical Complications: Bowel Obstructions among the Most Feared

| April 1, 2015

A Message from Dr. Raul J. Rosenthal

Raul J. Rosenthal, MD, FACS, FASMBS, Clinical Editor,
Bariatric Times; Chief of Staff, Professor of Surgery and Chairman, Department of General Surgery; Director of Minimally Invasive Surgery and The Bariatric and Metabolic Institute; General Surgery Residency Program Director; and Director, Fellowship in MIS and Bariatric Surgery, Cleveland Clinic Florida, Weston, Florida


Dear Friends and Readers:
Welcome to our April edition, which includes excellent surgical contributions.
Aman et al review the topic of intestinal complications in patients who have undergone gastric bypass for severe obesity. My colleagues and I had the privilege of publishing extensively on this subject, mainly attempting to classify bowel obstructions in order to better understand and treat these uncommon complications. Obstructions are among the most feared complications. Our group had an article published in The Journal of the American College of Surgeons on the ABC classification. Type A refers to the alimentary limb, B to the biliopancreatic limb, and C to the common channel. The B type is the most perplexing one since patients might have neither nausea nor vomiting at presentation. Instead, they may have left upper quadrant and back pain as well as elevated liver function test (LFT) levels. The A type is mainly due to jejunal-jejunal anastomosis strictures or obstructions and the C type is seen in patients with internal herniation. Although obstructions can present in a mixed fashion, it is still important to educate our colleagues in the emergency room to manage these accordingly.

Intussuceptions are more common than we may think. Recurrent and crampy abdominal pain with a target sign on computed tomography (CT) scans are their hallmark. We treat intussuceptions conservatively with observation and repeat the CT scan without contrast in 24 hours. Most cases (99%) show resolution after this. One of the most tricky intussuceptions we observed at my practice occured in the alimentary limb on the patient’s Postoperative Day 3. It did not resolve with observation and required reoperation. The patient developed aspiration pneumonia and required mechanical ventilation. This case still gets my heart rate up when I think of it.

How important is the size of the gastrojejunostomy in the mechanism of action of gastric bypass? Does it really help to maintain weight loss and prevent dumping syndrome? Severidt et al discuss a new product that can be injected into the tissue in order create restriction by narrowing the gastrojejunal anastomosis.

The most important question I ask patients that present with weight regain is, “Do you still have restriction?” The whole idea of asking this question is to understand if the pouch and/or anastomosis enlargement are present. It has been demonstrated that lengthening the alimentary limb beyond 150cm does not add much weight loss and increases the potential for complications instead. Based on this, either trimming the pouch and/or anastomosis is the only viable option. While the answer to the last question is most likely “yes,” we have likely all seen patients with large anastomosis that kept their weight down and others with small ones that regained their weight rapidly. Suturing, stapling, injecting, and burning the anastomosis in an attempt to reduce its size are some of the most popularized techniques.

In this month’s installment of “The Medical Student Notebook,” Jonnny Kim reviews a fascinating subject: the obesity epidemic. There are many contributors to the continuous increase in obesity rates. Mr. Kim explains that the dramatic increase in calorie intake due to poor choices has led to an inbalance between the food quality and population income. Technology and its conveniences may also contribute to the individual’s increased tendency to gain weight. Needless to say, transportation, communication, and storage have made food available to us 24 hours a day without the need to move, thus decreasing physical activity to a minimum. An increase in sedentary lifestyles is also a major contributor to the obesity epidemic. Don’t miss reading this outstanding report.
Drs. Michael Schwaitzberg and Allan Okraniek review the history and current status of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)/American College of Surgeons (ACS) Fundamentals of Laparoscopic Surgery (FLS). For decades, SAGES has been a worldwide leading society when it comes to research, education, and implementation of cutting-edge technology in general and endoscopic surgery. FLS and FES (Fundamentals of Endsoscopic Surgery) have become mandatory modules in the training of general surgeons in the United States. Thank you to Steve and Allan for providing insights into this successful program.

SAGES 2015 Surgical Spring Week will take place April 15 to 18, 2015, in Nashville, Tennessee. I look forward to seeing you there.

Sincerely,
Raul J. Rosenthal, MD, FACS, FASMBS

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