st october 2017 chronic abdominal pain after rygb a
TRANSCRIPT
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Chronic abdominal pain after RYGB
– A management guide
OBES21st October 2017
Dr Chun-Hai TanMBBS, Masters of Medicine (Surgery), FRCS (Edinburgh)
Consultant SurgeonMetabolic & Bariatric Surgery,
Minimally Invasive Upper GI Surgery
Department of General SurgeryKhoo Teck Puat Hospital
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Conflict of Interest
• No conflict of interest to declare
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Outline
• Abdominal pain is common after RYGB
• Causes• Maladaptive eating• Candy cane syndrome• Constipation• Dumping Syndrome• Gallstones• Marginal Ulcers• Internal Hernia **
• Management algorithm• Detailed history & Examination• Upper Endoscopy & Barium Swallow• CT Scan• Diagnostic Laparoscopy
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Khoo Teck Puat Hospital, Singapore
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Introduction
• Abdominal pain is one of the most common complaint after RYGB.
• 15 - 30% of patients will visit the emergency room or require admission within three years of gastric bypass• >50% Abdominal pain
• 2nd most common - Vomitting
Emergency room visits after laparoscopic Roux-en-Y gastric bypass for morbid obesity.Cho M, Kaidar-Person O, Szomstein S, Rosenthal RJ, SOARD 2008 4(2):104-9.
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Maladaptive eating
• Maladaptive eating behavior is a common cause of abdominal pain in the early post-operative period
• Gastric bypass alters satiety and patients may not perceive fullness until pouch distension to the point of pain.
• Modifying behavior to eat slowly and use defined portion sizes provides relief. • Small bites
• Chew over prolonged period of time
• Counseling together with Bariatric Dietician
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“Candy Cane” syndrome
• Symptoms• Post-prandial abdominal pain
• Nausea
• Epigastric fullness
• Regurgitation of food, reflux
• ? Related to Circular stapler used for construction of GJ
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• Resection of this “candy cane” complete and immediate resolution of symptoms
Learning point
Minimize redundancy in the roux limb during RYGB
“Candy Cane” syndrome
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Constipation
• Constipation is common in the early post-operative period and may be associated with abdominal pain
• Constipation may result from dehydration
• Laxatives and increased water intake provide simple solutions
• May worsen IBS and chronic abdominal pain after RYGB
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Dumping syndrome
• Dumping syndrome after gastric bypass surgery is when food gets “dumped” directly from your stomach pouch into your small intestine without being digested.
• 2 types of dumping: Early and Late.
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Early and late dumping
• Early dumping which occurs 30-60 minutes after eating and can last up to 60 minutes.
• Symptoms: Sweating, flushing, lightheadedness, tachycardia, palpitations, desire to lie down, upper abdominal fullness, nausea, diarrhea, cramping, and active audible bowels sounds.
• Late dumping which occurs 1-3 hours after eating.
• Symptoms are related to reactive hypoglycemia • Sweating, shakiness, loss of concentration, hunger, and fainting or passing
out.
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Dumping: what to do?
• Negative reinforcement.
• Patient is less likely to eat that food again.
• “I shouldn’t have eaten it the first time”
• “I definitely won’t eat it again.”
• Changes to diet
• Early dumping: Avoid refined sugars, high glycemic carbohydrates, or other foods that may be associated with the syndrome
• Late dumping: Half glass of orange juice about one hour after a meal may prevent the attack. Medications such as Acarbose or Somatostatin may be helpful if still symptomatic despite dietary changes
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Gallstones – Biliary colic
• Extreme weight loss → formation of gallstones
• Removal of gallbladder only for patients who are symptomatic
• Possible biliary colic as a cause of abdominal pain after RYGB.
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Marginal Ulcers
• One of the most common complications after RYGB• 0.6% - 16%
• Common Presentations:• Abdominal pain – 63%
• Bleeding – 24%
• Median 22months after surgery
• Risk Factors• DM
• Length of pouch
• Smokers
• HP infection
Rasmussen JJ et. al. Marginal ulceration after laparoscopic gastric bypass: an analysis of predisposing factors in 260 patients.Surg Endosc. 2007 Jul; 21(7):1090-4.
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Internal hernia
• Internal hernia is an important cause of abdominal pain after gastric bypass with an incidence ranging from 1-9%
• Intermittent pain
• Severe consequences: bowel incarceration, bowel ischaemia
• Internal hernia is thought to occur most commonly within 2-3 years after RYGB, often with significant weight loss
Aghajani E et. al. Internal hernia after gastric bypass: A new and simplified technique for laparoscopic primary closure of the mesenteric defects. J Gastrointest Surg. 2012 Mar; 16(3): 641–645
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Case Presentation 1
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Case presentation 1
• 43yo Malay Female
• 132kg,BMI 48, OSA
• Sleeve 2009
• Lost 40kg, OSA resolved
• 3 years later after pregnancy, weight regain back to 105kg with severe reflux symptoms
• RYGB 2012
• Weight 87kg, OSA resolved, Reflux symptoms resolved
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13months after RYGB
Epigastric pain x 4/7
- Clenching
- Intermittent, colicky
- Worse after meals
- No vomiting
AXR: No obstruction
OGD: No anastomotic ulcer, No obstruction
CT Scan
Non specific changes. No sign of obstruction or internal herniation
No abnormal bowel thickening or dilatation
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Diagnostic Laparoscopy
• Long length of small bowel loop in Peterson’s space
• No evidence of IO
• Small bowel healthy
• Peterson’s space hernia reduced and closed
Discharged on POD1
Transverse colon
Alimentary Limb
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Case presentation 2
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BackgroundMdm JY57 Chinese Female
PMHxClass 1 ObesityBMI 31Poorly controlled T2DM
• HbA1C 10.3% • Insulin 60 units + SGLT2
HLD/HPTOSA
RYGB Oct 2015
3 months post surgeryCame in through A&E, Epigastric pain x 1/7
-Progressive and constant-Pain score 10/10-Radiating to the back-A/w nausea-AXR: non specific changes, one loop of mildly dilated small intestine
CT: closed loop obstruction of the jejenumwithout ischemia or perforation
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Transition point
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Mushroom sign
SMA Mesenteric vessels
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Diagnostic laparoscopy, laparotomy and resection of gangrenous bowel
Intra-op findings: • Loop of small bowel caught in small bowel
mesenteric defect causing gangrenous segment
• Gangrenous bowel was part of Bilio-pancreatic limb, from DJ flexure to JJ anastomosis.
• Mesenteric defect closed
Recovered well and was discharged on POD 6
Last review 11/10/16
Weight 57.8kg, BMI 23.2
Hba1c 10.7 -> 8.5 (11/2/16)
Insulin requirement decreased from 60 unit per day to 10 unit
HPT/HLD Rx also improved.
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CT Imaging in Internal Hernias
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Use of imaging• Liberal use of imaging to rule out major life threatening complications -
beware of false negatives
• Read the scans, not just the report• Face to face discussion with radiologist
• Do not assume concerning imaging findings in early postoperative period as normal postop variants.
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Twisting of mesentery around mesenteric vessels
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Clustering of normal looking small bowel in one corner
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Dilated small bowel, normal large bowel
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The mushroom sign: mushroom shape of the mesenteric root as it herniates through the J-J
Mushroom sign
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Hurricane Eye Sign: Tubular shape/column of mesenteric fat in corkscrew configuration
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J-J anastomosis over the right side of abdomen
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Internal herniation post RYGB
Three potential location
• Type of herniation depends on configuration of Roux limb
A. Transverse mesocolic defect (unique to the retrocolicapproach)
B. Petersen’s spaceC. Jejuno-jejunal mesenteric defect
RecommendRoutine closure of defects
Carmody B, DeMaria EJ, Jamal M, et al. Internal hernia after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2005;1:543–548
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Risk Factors for internal hernia• Higher incidence of internal hernia after laparoscopic RYGB compared to
open1
• Reduced bowel manipulation and peritoneal irritation →
• Fewer postoperative adhesions →
• Reduced fixation of the Roux limb and less scarring to help close mesenteric defects.
• Rapid weight loss leads to opening of more mesenteric spaces normally not open
1Higa KD, Ho T, Boone KB. Internal hernias after laparoscopic Roux-en-Y gastric bypass: incidence, treatment and prevention. ObesSurg. 2003;13:350–4.2Schneider C, Cobb W, Scott J, et al. Rapid excess weight loss following laparoscopic gastric bypass leads to increased risk of internalhernia. Surg Endosc 2011;2013:1594–8
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Treatment Principle
Prevention
• Close all potential hernia sites
• Non-absorbable sutures
Early surgical intervention
• Diagnostic Laparoscopy
• Hernia reduction
• Repair defects
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Management Algorithms
CT positive for etiology: Rx appropriately
CT negative but persistent symptomsConsider Diagnostic Laparoscopy
No specific etiology apparent, CT abdomen
Recurrent abdominal pain after RYGBDetailed history: maladaptive eating, biliary colic.
RF: Smoking, DM
Upper GI endoscopy: Marginal ulcersBarium Swallow: Candy cane
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Conclusion
• Abdominal pain is common post RYGB
• Diagnosis to entertain• Maladaptive eating
• Candy cane syndrome
• Constipation
• Dumping Syndrome
• Gallstones
• Marginal Ulcers
• Internal Hernia **
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Conclusion
• Detailed history and examination is important• Upper Endoscopy
• Barium swallow, contrast study
• CT Scan • Early diagnosis saves bowel
• There are many CT signs to suggest bowel compromise• Always go and talk to your radiologist (face to face consult, and review the scans
together)
• If symptoms persist, consider diagnostic laparoscopy.
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‘Better a negative laparotomy, than a positive post mortem’
‘Better a negative diagnostic laparoscopy, than a positive dead bowel and a very dead patient’
Chun-Hai TanOBES 2017
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Thank you
谢谢大家