OBES 21 st October 2017 Chronic abdominal pain after RYGB A management guide Dr Chun-Hai Tan MBBS, Masters of Medicine (Surgery), FRCS (Edinburgh) Consultant Surgeon Metabolic & Bariatric Surgery, Minimally Invasive Upper GI Surgery Department of General Surgery Khoo Teck Puat Hospital
Conflict of Interest No conflict of interest to declare
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
Khoo Teck Puat Hospital, Singapore
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 2 nd 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.
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
Candy Cane syndrome Symptoms Post-prandial abdominal pain Nausea Epigastric fullness Regurgitation of food, reflux? Related to Circular stapler used for construction of GJ
Candy Cane syndrome Resection of this candy cane complete and immediate resolution of symptoms Learning point Minimize redundancy in the roux limb during RYGB
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
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.
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.
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
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.
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.
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
Case Presentation 1
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
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
Diagnostic Laparoscopy Transverse colon Long length of small bowel loop in Peterson s space No evidence of IO Small bowel healthy Peterson s space hernia reduced and closed Alimentary Limb Discharged on POD1
Case presentation 2
Background Mdm JY 57 Chinese Female PMHx Class 1 Obesity BMI 31 Poorly controlled T2DM HbA1C 10.3% Insulin 60 units + SGLT2 HLD/HPT OSA RYGB Oct 2015 3 months post surgery Came 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 jejenum without ischemia or perforation
Transition point
Mushroom sign SMA Mesenteric vessels
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 Biliopancreatic 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.
CT Imaging in Internal Hernias
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.
Twisting of mesentery around mesenteric vessels
Clustering of normal looking small bowel in one corner
Dilated small bowel, normal large bowel
The mushroom sign: mushroom shape of the mesenteric root as it herniates through the J-J Mushroom sign
Hurricane Eye Sign: Tubular shape/column of mesenteric fat in corkscrew configuration
J-J anastomosis over the right side of abdomen
Internal herniation post RYGB Three potential location Type of herniation depends on configuration of Roux limb A. Transverse mesocolic defect (unique to the retrocolic approach) B. Petersen s space C. Jejuno-jejunal mesenteric defect Recommend Routine 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
Risk Factors for internal hernia Higher incidence of internal hernia after laparoscopic RYGB compared to open 1 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 1 Higa KD, Ho T, Boone KB. Internal hernias after laparoscopic Roux-en-Y gastric bypass: incidence, treatment and prevention. Obes Surg. 2003;13:350 4. 2 Schneider C, Cobb W, Scott J, et al. Rapid excess weight loss following laparoscopic gastric bypass leads to increased risk of internal hernia. Surg Endosc 2011;2013:1594 8
Treatment Principle Prevention Close all potential hernia sites Non-absorbable sutures Early surgical intervention Diagnostic Laparoscopy Hernia reduction Repair defects
Management Algorithms Recurrent abdominal pain after RYGB Detailed history: maladaptive eating, biliary colic. RF: Smoking, DM Upper GI endoscopy: Marginal ulcers Barium Swallow: Candy cane No specific etiology apparent, CT abdomen CT negative but persistent symptoms Consider Diagnostic Laparoscopy CT positive for etiology: Rx appropriately
Conclusion Abdominal pain is common post RYGB Diagnosis to entertain Maladaptive eating Candy cane syndrome Constipation Dumping Syndrome Gallstones Marginal Ulcers Internal Hernia **
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.
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 Tan OBES 2017
Thank you 谢谢大家