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Query: UMLS:C0021843 (bowel obstruction)
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Laparoscopic Roux-en-Y gastric bypass (LRYGB) is becoming a frequently performed procedure for the treatment of morbid obesity. It is important for all general surgeons to be able to diagnose correctly and treat its complications. It is the purpose of this study to determine whether computed tomography (CT) is useful in correctly diagnosing these complications. The medical records of all patients that underwent LRYGB between March 2000 and December 2002 (n = 574) at Huntington Memorial Hospital were reviewed. Major abdominal complications defined as anastomotic leaks or small bowel obstruction were noted. Results of CT scans in these patients were reviewed by both a radiologist and an attending surgeon. CT scan findings were then compared to intraoperative findings. Postoperatively, 18 patients were found to have small bowel obstruction/herniation and anastomotic leaks. CT scan correctly diagnosed anastomotic leaks and small bowel obstruction in 71 per cent and 100 per cent of patients, respectively. Complication following LRYGB are rare but potentially life-threatening. CT scans are helpful in predicting the pathology and directing the surgical management of these patients. CT scan findings, however, can be subtle and therefore be missed by those not intimately familiar with post gastric bypass anatomy.
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PMID:Use of computed tomography in diagnosis of major postoperative gastrointestinal complications of laparoscopic Roux-en-Y gastric bypass surgery. 1558 6

Surgery currently appears to be the most effective method to curtail the effects of morbid obesity and all of its comorbid conditions. Although the ideal procedure has yet to be devised, Roux-en-Y gastric bypass has proved to be successful for many morbidly obese patients pursuing weight loss and increased health. As the technical aspects of this procedure become less cumbersome and the patient population increases, it is vital for radiologists to be proficient in the specific evaluation of these patients, in order to provide optimal care. Complications can be minimized, managed more efficiently, or prevented with prompt evaluation by the radiologist. It is important to appreciate the patency of both the gastrojejunostomy and the jejunojejunostomy, as well as adequate progression of contrast material before the patient is discharged (preferably 24-72 hours after surgery). Follow-up complications include anastomotic leak, staple-line disruption, stomal stenosis, occlusion of the Roux limb, small-bowel obstruction due to adhesions or internal hernia, and obstruction of the enteroenterostomy leading to acute gastric distention. These complications may be life threatening, since clinical symptoms are often inconclusive. To achieve optimal outcome, therefore, conventional radiographic and computed tomographic studies should not be delayed.
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PMID:Roux-en-Y gastric bypass for clinically severe obesity: normal appearance and spectrum of complications at imaging. 1565 38

Severe or morbid obesity, with body mass indexes exceeding 35 to 40, are often refractory to all therapies other than surgery. The increasing number of patients undergoing bariatric surgery will result in increasing numbers of patients with gastrointestinal complications. The types of complications vary with type of surgery, whether restrictive, malabsorptive, or both, depending on what anatomical and physiologic changes occur postoperatively. One complication of bariatric surgery (gallstones) is due to weight loss after surgery, not the surgery itself. Based on previous meta-analyses, most of the top 10 complications from bariatric surgery are gastrointestinal: dumping, vitamin/mineral deficiencies, vomiting (and nausea), staple line failure, infection, stenosis (and bowel obstruction), ulceration, bleeding, splenic injury, and perioperative death. Two other gastrointestinal complications of bariatric surgery are indirect consequences of the surgery: bacterial overgrowth and diarrhea. Awareness of the types and frequency of gastrointestinal complications of bariatric surgery allows for timely diagnosis and appropriate therapy. As new surgical, and even endoscopic, procedures to treat obesity are developed, new gastrointestinal complications will need to be recognized.
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PMID:Gastrointestinal complications of bariatric surgery: diagnosis and therapy. 1661 37

Obesity is an enduring chronic disease, with multifactorial etiology. Many procedures and solutions have been proposed in the last 25 years. If patients do not meet the criteria for bariatric surgery, intragastric balloons may be used to achieve weight reduction. Contraindications to balloon therapy are a large hiatal hernia, severe esophagitis, peptic ulceration and previous gastric surgery. Although intragastric balloons are advocated as safe devices, major complications such as intestinal obstruction, gastric perforation and gastric ulceration have been described. We report a case of esophageal rupture due to insertion of an intragastric balloon for the treatment of morbid obesity, for which no contraindication existed. When abnormal pain or discomfort arises, or esophageal damage is noted after insertion of an intragastric balloon, patients must be closely monitored to diagnose a possible esophageal rupture early and thereby prevent severe complications.
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PMID:Perforation of the esophagus caused by the insertion of an intragastric balloon for the treatment of obesity. 1668 40

Laparoscopic adjustable gastric banding (LAGB) is a widely performed surgical procedure for morbid obesity. The application of this mini-invasive approach has given the benefits of shorter hospital stay, less postoperative pain and quicker functional recovery. LAGB complications are related either to the access-port, such as port-site infection or tubing disconnection, or to the band, such as band slippage, pouch dilatation, or intragastric migration. We report a case of recurrent small bowel obstruction caused by the connecting tube around a jejunal loop, in a woman who had under-gone LAGB 3 years before. The diagnosis was difficult to establish because the clinical history and examination were non-specific. A 3-dimensional CT scan was needed to explain the cause of the recurrent abdominal pain, and the small bowel loop was freed from the connecting tube at laparoscopy.
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PMID:An unusual complication of gastric banding: recurrent small bowel obstruction caused by the connecting tube. 1683 99

In the United States, the most common surgical procedure for morbid obesity is the Roux-en-Y gastric bypass. Pulmonary embolism, leak, bowel obstruction, and gastrointestinal bleeding are among the potential early fatal complications. Early postoperative bleeding after laparoscopic gastric bypass, although uncommon, presents a dilemma because of the danger of perforation from postoperative endoscopy and the inability to access the gastric remnant easily. We describe a case of a Mallory-Weiss tear causing massive upper gastrointestinal hemorrhage 1 week after laparoscopic Roux-en-Y gastric bypass. Bariatric surgeons should consider this diagnosis, especially when encountering a patient with a history of significant retching postoperatively.
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PMID:Mallory-Weiss tear after laparoscopic Roux-en-Y gastric bypass. 1692 77

Intestinal obstruction and other complications have been reported following Roux-en-Y gastric bypass (RYGB) surgery. There is controversy of whether the alimentary limb should be placed in the retrocolic or antecolic position. A retrospective analysis was performed on 444 patients undergoing RYGB surgery for morbid obesity during a six year period. During operation, the surgeon chose the positioning of the 75-cm alimentary limb based upon technical consideration (the presence of adhesions from prior surgical procedures, thickness of the transverse mesocolon and mobility of the small bowel mesentery). Group A (216) patients had placement of the Roux limb anterior to the transverse colon, and group B (228) patients had placement of the limb through an opening created in the transverse mesocolon. The average age was 40 years (range 19-64) and the body mass index ranged from 40 to 75 kg/m2. Patients were followed for 24-86 months (mean 36 months). Any patients lost to follow-up were excluded. The average age of patients in the study was 40 years (range 19-64 years). Patients in both groups were similar in their body mass index and demographic characteristics. Group A had 16 patients (7.4%) that had early intolerance to enteral intake, compared to 13 patients in group B (5.7%, P>0.05). Thirteen patients required reoperation for intestinal obstruction (seven patients in group A and six patients in group B (P>0.05). Development of anastomotic stricture occurred in one patient (0.5%) in group A and three patients (1%, P>0.05) in group B. There were no differences in mean operating room times, hospital length of stay, and excess weight lost. No other complications during the follow-up period were attributed to the position of the alimentary limb. Placement of the Roux limb in the antecolic position is may be technically more feasible in some patients and does not appear to be associated with more complications. It avoids the risk of an internal hernia through the transverse and does not appear to be associated with feeding difficulties in the early or late postoperative period.
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PMID:Does the position of the alimentary limb in Roux-en-Y gastric bypass surgery make a difference? 1717 60

Obesity has become a severe health problem in the Western world, and is rapidly becoming the most common disease of the 21st century. Morbid obesity is resistant to treatment and is accompanied by considerable morbidity. Some morbidly obese patients do not manage to reduce their weight by diet alone, yet are unsuitable or unwilling to undergo bariatric surgery. Lately, a new intragastric bioenteric balloonR (BIB) was developed to treat these patients. This article summarizes the current knowledge and experience with this balloon, and its advantages and disadvantages. There are very few placebo controlled studies regarding the BIB, and the results are controversial. One study shows the advantage of using the balloon compared with diet alone while another study showed no advantage of the balloon compared with a strict diet regimen. Uncontrolled studies show that balloon treatment combined with diet and physical activity had favorable results achieving both weight reduction and reduction in obesity associated morbidity. Those results were maintained a year after the balloon was removed. Mild and common side effects included vomiting and heartburn, but the balloon also caused severe complications including bowel obstruction, perforation and even death. The total rate of severe complications is estimated to be about 3%. We conclude that the intragastric balloon may be an appropriate addition to the treatment of morbid obesity, but only if combined with a proper diet, physical activity and psychological support. Patients should be carefully selected and monitored to avoid complications.
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PMID:[Intra gastric balloon for morbid obesity]. 1718 56

A rare complication of adjustable gastric banding is reported. A 65-year-old man developed recurrent vomiting, epigastric pain, and small-bowel obstruction 13 months after laparoscopic adjustable gastric banding for morbid obesity. Investigation revealed that the band had migrated completely into the gastric lumen and had passed far down the jejunum. The band was still connected by the tubing to the port chamber. By laparoscopy, the band was cut at the stomach, and removed via a jejunotomy. Postoperative course was uneventful. Complete band migration requires early removal of the band.
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PMID:Band erosion and passage, causing small bowel obstruction. 1721 47

Mortality has been reported to complicate gastric bypass, with common causes of death attributable to anastomotic leaks, sepsis, hemorrhage, and bowel obstruction. We evaluated autopsy reports from 10 patients having undergone gastric bypass. Medical records were reviewed to identify comorbidities. Data of interest included preoperative electrocardiogram (EKG) abnormalities, cause of death, body weight, anastamosis appearance, heart weight, extent of coronary artery disease, ventricular size, liver weight, and gall bladder status. A total of 7 men and 3 women were autopsied. Average age was 40 years (range, 30-49 years), and mean body mass index at autopsy was 60.3 kg/m(2) (range, 33.2-80.9 kg/m(2)). Evidence of anastomotic leaks was present in 7 cases, resulting in 4 deaths. Death was attributed to pulmonary embolism in one case. There were 5 cardiac-related deaths, all attributed to arrhythmias. Microscopic evidence of coronary artery disease was observed in 6. Cardiomegaly was seen in all patients, left ventricular hypertrophy in 8, right ventricular hypertrophy in 3, and hepatomegaly in all 10. Nine patients were status post cholecystectomy. Of the 8 preoperative EKG available, abnormalities were identified in 5. After gastric bypass, death was attributed to cardiac-related causes, pulmonary embolism, and operative complications. A significant proportion of cardiac-related deaths occured in the absence of atherosclerosis. Most patients had preoperative EKG abnormalities. As a high incidence of cardiomegaly was observed, operative stress associated with the procedure may increase the risk of arrhythmia in morbid obesity. Consequently, in morbidly obese patients, a detailed preoperative cardiovascular evaluation is warranted to reduce postoperative mortality.
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PMID:Postmortem findings in morbidly obese individuals dying after gastric bypass procedures. 1723 34


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