Small Bowel Obstruction | Conditions Requiring Urgent Attention and What I Do FirstJul 14, 2023
Our next speaker will be dr. Israeli partner Benjamin Schneider of Dr. Dan Jones, who will be speaking to us about
obstruction, all of these important clinical issues in our daily bariatric practice, thank you for the opportunity to speak today. I have nothing to disclose, so
obstructionis an important topic to discuss some of the other speakers have not mentioned before, it is very common to occur in one to five percent of our gastric bypass population. The risk of small bowel obstruction in this population is that you cannot treat these patients the same way you do with their normal small bowel obstruction who come to the emergency room are at higher risk for closed loop obstructions. because of their changed anatomy they are at risk for gastric distension and perforation they are at risk for intestinal compromise unlike a typical small bowel obstruction that comes to the ER there really is no rule for simple nasal gastric decompression and watch and wait, that We were taught that early surgical consultation is of vital importance, that is something that we have to educate our doctors and that we would prefer to see these people early, it is also important that the findings of our physical examination laboratory with which we are accustomed to questioning these people are probably not that helpful, they may be negative, they may look good, and in fact they are also leading us down a wrong path. we are dealing with a sicker group of patients, some of the previous speakers have talked about their risk of sleep apnea, respiratory compromise, many of these patients are still obese or morbidly obese and I assume we would have heard about some of the deficiencies nutritional.
These people may be at risk, particularly if they have had vomiting and long-term illness, so you have to think about these patients a little differently than we normally would, so one of the most important things is the presentation of these gastric bypass patients. it may present with typically abdominal pain, now that is the main presentation, it is typically epigastric in nature up to the mid-abdomen, it is important to consider the chronicity of this, whether intermittent, acute or chronic, as again noted by a previous speaker , and patients may or may not actually present with nausea or vomiting depends on whether the common area where the pancreatic wound is obstructed billy-oh they may or may not have bile or vomiting if you have a patient who comes in with abdominal pain and vomiting, it is a surgical emergency until otherwise done. proven that it must have a very high index of suspicion, the reason is that patients who present with more than four hours of symptoms have a higher risk at six hours, the risk of intestinal compromise increases dramatically, so when thinking that saw, saw the previous slide.
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small bowel obstruction conditions requiring urgent attention and what i do first...
From the anatomy it is important to think about how the patient may present and why he or she may present with small bowel obstruction. Internal hernias are probably the leading cause of art obstruction in this patient population, followed by adhesions like every other patient since we've talked. Previously on the approach to anterior aunt colic versus retro colic, anticolic appears to have a lower incidence of obstruction from both the narrowing of the musical colic window and also from some of the internal hernias. You should also keep in mind that these patients are at higher risk for ventral hernias and port hernias, so obstruction is something to consider if that Jade jejunostomy you know may occur due to technical limitations, technical reasons or due to adhesions of those we talked about, the risk of ventral hernias is higher in this morbidly obese population. and consider other things like intussusception and bleeding, so starting with your internal hernia, there are usually three potential hernia sites in the knee, the Peterson defect, which is behind the roux limb, between the musical and the mesentery of the root tip with the anti-colic. approach, that's all, this obviously looks different, there is still a defect in this area with retrocolic, patients may have a Mesa colic defect in which the root may slide in a cephalad direction or, if it is a sufficiently large defect great, you can actually have other loops. of the small intestine slides upward, there is also a defect in the J gene or jejunostomy, which is also at risk when diagnosing an internal hernia.
You can see how this could happen on the slide above. See there is this. it's on JJA JJA's ostomy and underneath you can see the actual hernia defect, so this is
whatwe look for when we go to surgery in terms of diagnosis, this typical physical exam is obviously not helpful, flat x-rays probably Sean It won't be helpful. People have advocated for upper gastrointestinal tract radiography. I'll show you some examples that the feline scan is probably more sensitive and finally, as Dr. Shermer said earlier on laparoscopy, so this is a typical upper gastrointestinal tract in a patient who has had a gastric bypass and has a small intestine obstruction,
whatare we looking for?
Well, you see a dilated small intestine that is quite obvious in the upper left part of the abdomen. in the rule location, you expect most of the rule to be a book above the code below the colon. Here, what we're actually seeing are layers like coils of rope over the two intermediate points, so you're looking at a lot of rules. above the music: so this is a roux that actually slipped and caused a clog. Another thing we should look for is the gastric remnant. Do you see a bubble? You see an opacity because it may not have air, but you see an opacity. of fluid that is a distended gastric remnant that is suitable for perforation.
If we were to get a cat scan, there are a number of findings we should look for
firstand probably the most pathognomonic is a swirl sign and that's basically what you're doing. Looking inside, what the arrows indicate is the mesentery and vascularity of the small intestine, which causes the swirl, a sign of a hurricane, as again, this is more or less a pneumonic pathway and should prompt a call to the operating room. Secondly, we can look. for a small intestine obstruction, this is pretty obvious, you may not need a cat scan to diagnose this, but what the cat scan will allow you to do is get a better idea of where this is happening, you may be able to tell what a defect it is.
The other thing to look out for is the gastric remnant that you can see just above the period, it is dilated and again this is it, but the small intestine is not dilated enough, but a closed loop gastric remnant is really important for address early another finding to be aware of is an Aston, a somatic shift, usually the jejunum of the jejunostomy will be in the upper left abdomen for most of us and in this case you are actually looking at the jg2 staple line. jejunostomy in the upper right part of the abdomen, so this is what probably happened in this case: the small intestine is turned through the jejunum without jejunostomy defect, mesenteric defect, the final finding is small intestine bunched up, so no We only see a whirlpool or hurricane sign in this case, but we also see that most of the small intestine is displaced to the left side.
Now there is a relative lack of intestine in the rough small intestine on the right and this is again because most of the intestine slides up through which you slid. carpenter's jejunostomy moving it to the left in terms of how we dress this where we have identified this keep in mind that the caps can only identify is probably 70% so it has a sensitivity of 70% how do we approach this if you are very suspicious? that there is an internal hernia or if you have identified it, another study study For most of us it is reasonable to consider laparoscopy, but also if you are less expert in laparoscopy or have a very dilated intestine, the risk of perforation and leakage of the alveoli is high. so there really is no loss when converting to open in these cases, it can confuse the anatomy, although we don't see it, it can be very confusing, since you have the intestine herniated clockwise, counterclockwise clockwise, from left to right, sounds simple, but it's not always when you go into the operating room one of the key tips I learned years ago was to start in the cecum and run lilium backwards and in many cases, during that maneuver, in will actually reduce torque. and it will write itself without any confusion once you have achieved that it is important to close the mesenteric defect that may have been the problem in the beginning, it may not have closed or they may not have closed properly and there is evidence to suggest the use of a Permanent suture like silk and already in closure has a greater chance of repair.
Also consider placing a gastrostomy tube in the remaining stomach. There are several reasons for this, but isn't there really an easy way to decompress that stomach? and so later, even if you don't have a dilated remnant or billy, think critically, this patient may have a prolonged ileus after surgery and you may notice that you have gastric distension, eat them later, so it's better to just put a decompress the gastrostomy tube in those cases, another cause of obstruction is intestinal intussusception. This is a relatively uncommon cause of obstruction, but we see that intussusception is common, so if you do cat scans in patients who have had gastric bypass, you will often see asymptomatic intussusception that does not require treatment in The timing of surgery will often cause the small intestine to go into susceptibility spontaneously or, as I said, this is a relatively rare cause of actual obstruction, but when you have a patient who has had intermittent abdominal pain of unclear origin, this can Let this be something to consider apart from the internal hernia.
It is rare that we find a reference point. If we do, it's usually at the Juneau judge and a STEMI, and a lot of thought goes into why this might happen. Why would there be an interception? Could be. that there is a bleeding point, it could be due to changes in motility due to our anastomosis or it could be due to an overgrowth of bacteria, so there is a lot of theory and the cause is questioned. I got it a few years ago on a patient, you can actually see the emphasis septum in the Sicilians New Testament and it's a good slide anyway.
This is the same patient in whom the target sign of the intussusception treatment options scan is seen. and then the resection, so here we are a dentist who identifies the intussusception, we resect it and we do a template, you know, jejunostomy, in this case, as I said before, if my patients weigh more, they have a higher incidence of their Dias when you try to repair if with an open approach, you are likely to have a 20% incidence of postoperative hernia or if you place a port site with laparoscopy in the midline and patients will usually or often have a diastasis or at least attenuation of its shape, so I have heard that there is a very high risk for four ports and the typical risk of the laparoscopic population can be half of a person in our patients, it can be higher, so it is very important that bariatric surgeons close all your defects.
I advocate for anything. More than 10 millimeters of incisional hernia must be closed, as I said, 20% of patients with open surgery, the morbidly obese group, may have incisional hernia. A few years ago, a doctor presented an article saying that 8% of patients undergo weight loss. surgery actually occurs have terminal ventral hernias at the time of surgery, there is evidence to suggest that they should be repaired at the time of surgery to prevent postoperative complications of obstruction and in that case the recommendation was to use either a mesh biological or polypropylene coded Another cause of obstruction may be in the jjan of the jejunum and a stricture causes this may be too technical due to a short anastomosis or narrow anastomosis some techniques to avoid this are double shot or longer double staple lines The Stenosis can also occur due to ischemia or other factors.
You will also see here that there is an anti-obstruction stitch, but also something called a brolin or anti-obstruction stitch on the distal side of the anastomosis can prevent it from kinking at that point. obstruction also note that perioperative patients may have hemorrhage that dr. Wynn will probably cover the next talk, but if he has an intraluminal clock that obstructs at the anastomosis, later we talk about ulcers, if the patient has bleeding instead of perforation, that bleeding can also obstructthe ulcer and the diagnosis can be a CT scan and in this case we perform a revision of the anastomosis or an introduction to the ostomy.
Some typically anti-colic take home messages at the time of bariatric surgery to prevent obstruction. Anti-colic may have a benefit. Closure of closure defects. Closure of Peterson defects with permanent nonabsorbable sutures. laparoscopic operations tend to have a higher risk of internal hernia likely due to lack of adhesions advocate mesh repair of ventral hernias at the time of initial bariatric operation close port sites greater than one millimeter Milutin have a good knowledge of the anatomy and possible causes since obstruction is important remember that the symptoms can be vague and you have to have a high index of suspicion imaging studies can have a lower yield seventy percent for cat skin thank you very much
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