Internal hernia, incision problems and thrombosis after laparoscopic gastric bypass

Internal hernias can occur in any mesenteric defect.

The most common internal hernias occur in mesenteric leaks caused by the Roux loop located behind the colon.

Hernias can also occur in weak areas of the jejunal mesentery or Peterson's space, but are less likely to cause obstruction. Twist can also occur in the Roux loop in the anterior colon.

Therefore, as long as the potential intestinal stenosis volvulus ring exists, the patient will face a lifelong risk of small bowel obstruction.

Most reports suggest that the low incidence rate in these cases is due to insufficient follow-up periods in studies.

Internal hernias may not present with symptoms of intestinal obstruction.

Patients who experience intermittent postprandial abdominal pain after gastric bypass surgery should have their underlying cause, such as biliary tract disease or anastomotic ulceration, ruled out.

Our retrospective study found that at least 20% of patients with internal hernias could not be diagnosed by imaging examinations.

In fact, more than half of symptomatic internal hernias are now treated by the patient experiencing intermittent pain, without needing to confirm intestinal obstruction.

Therefore, we conclude that if a patient presents with unexplained severe abdominal pain after gastric bypass surgery, laparoscopic exploration should be performed.

Regardless of whether the Roux loop is anterior or posterior to the colon during a gastrojejunostomy, the only way to prevent potential internal hernia risk is to carefully suture all mesenteric defects.

Incision problem

Serious surgical complications are rare and are usually caused by infection or hernia.

Incisions larger than 12 mm made by traditional blade-guided puncture cannulas should be sutured to prevent incisional hernias.

However, based on our experience, bladeless split-type trocars do not require suturing of the incision.

Infections at the incision site usually respond well to oral antibiotics, but are more likely to be caused by inadequate protection during transabdominal placement of a circular stapler into the intestine.

Although the bruising may affect appearance, bleeding from the puncture site usually heals on its own.

thrombosis

Although thrombosis is rare, it is the most common cause of perioperative death.

If a patient is found to be in a hypercoagulable state before the procedure, it is recommended to use antithrombotic drugs and instruments during the procedure to prevent thrombosis.

Inferior vena cava filters, preferably removable ones, should be used for patients with a history of pulmonary embolism or pulmonary hypertension.

Biliary tract diseases

It is clear that both surgery and medication for weight loss can increase the incidence of gallstones.

Shiffman et al. reported a postoperative morbidity rate of 36%.

Villegas et al. found that 6 months after laparoscopic gastric bypass surgery, 30% of patients had varying degrees of gallstones or biliary sludge symptoms, but only 7% of patients showed physical signs.

Although routine use of ursodeoxycholic acid after surgery can effectively reduce the incidence of gallstones, the side effects and high cost of this drug remain a problem.

Studies by Hamad et al. have shown that adding cholecystectomy during laparoscopic gastric bypass surgery increases hospital stay and operation time, but does not change the overall complication rate compared to performing gastric bypass surgery alone.

The technical challenges of performing cholecystectomy are due to the difficulty of endoscopic manipulation caused by the placement of the endoscope, as well as the changes in abdominal anatomy in obese patients.

Although gallstones are a common problem after rapid weight loss, the reduction in abdominal obesity makes subsequent gallbladder removal much easier. After laparoscopic gastric bypass surgery for weight loss, there are no large adhesions in the abdominal cavity that would affect the difficulty of the surgery, as is the case with traditional open surgery.

Occasionally, stones may form in the common bile duct after surgery.

Although experienced endoscopists may be able to perform endoscopic retrograde cholangiopancreatography (ERCP) after gastric bypass surgery, bariatric surgeons should also be proficient in laparoscopic or open common bile duct exploration.

Nutritional problems

Malnutrition caused by postoperative psychological problems and abnormal eating due to gastrointestinal anatomical reconstruction can manifest as acute symptoms, such as thiamine deficiency, or chronic symptoms, such as iron and calcium deficiency.

Regular oral vitamin and calcium supplements, along with educating patients about a balanced diet, can prevent most symptoms of malnutrition.

We still recommend regular monitoring of patients' nutritional status as part of postoperative nutritional health maintenance.

Excessive dieting

Excessive weight loss to a BMI below 18.5 or below ideal weight (ideal weight according to the New York Life Insurance Company analysis table) requires analysis of the patient's eating patterns and psychological problems.

Excessive weight loss may also indicate an addiction to alcohol or drugs.

To correct excessive weight loss, considerations could include reoperation to restore the gastrointestinal tract to its pre-operative state, establishing an enteral nutritional pathway, psychological counseling, or drug addiction treatment.

die

Although most patients with morbid obesity also suffer from multiple serious comorbidities, it is encouraging that the mortality rate of surgeries performed by most experienced surgeons is extremely low.

Although infection, suppuration, and gastrointestinal fistula can prolong the course of the disease and be contributing factors to death, the main cause of death is cardiopulmonary disease, such as pulmonary embolism.

Most literature reports a mortality rate of less than 0.5%, but this data does not include statistics from outside of some large centers.

Flum analyzed 30-day in-hospital mortality and post-discharge mortality in Washington state hospitals. The in-hospital mortality rate was 1.1%, and the overall mortality rate for obesity surgery was 1.9%.

Surgical mortality rates are related to the learning curve; surgeons with fewer than 25 cases of experience have an average surgical mortality rate of around 5%, while surgeons with more than 250 cases have a surgical mortality rate of almost 0%.

As with all treatments, prognosis is related to the doctor's experience, and surgical treatment of morbid obesity is no exception.

However, as this profession becomes more widely accepted, precise mortality rates, complication rates, and final weight loss will become important indicators for judging the maturity of a medical center.

summary

Because weight loss surgery is a selective elective procedure, the surgeon must ensure that all of the patient's surgical conditions are in optimal condition before performing the surgery.

The surgeon needs to control the patient's blood pressure and blood sugar within the optimal range, actively improve cardiac function, treat sleep apnea syndrome, and be mentally and psychologically prepared in order to minimize the possibility of complications.

Reducing the incidence and severity of complications requires not only a knowledgeable surgeon, but also the combined efforts of a well-trained professional team.

The hospital also needs to provide surgical instruments and medical services that meet the stringent requirements of the surgery.

The hospital should provide the team in this discipline with more than just professional operating rooms and efficient medical billing systems.

The bariatric surgeon is at the heart of the team, coordinating with cardiologists, pulmonologists, critical care specialists, radiologists, endocrinologists, psychologists, nutritionists, anesthesiologists, and the nursing team to work together to cure this multi-system disease.

Comprehensive bariatric surgery is the only hope for most patients with morbid obesity to achieve long-term weight control.

Although minimally invasive surgery typically has a longer learning curve, overall, the advantages of minimally invasive surgical methods over traditional open surgery are obvious.