In the name of GOD

Gastrointestinal Obstruction After Bariatric Surgery

understanding of the anatomy of RYGB Obstruction After Roux-En-Y Gastric Bypass understanding of the anatomy of RYGB

Roux-en Y gastric bypass

obstruction of the Roux limb or common channel nausea, vomiting, food intolerance, abdominal pain, distention.

Obstruction of the biliopancreatic limb abdominal fullness, bloating, hiccups, pain

( a ) This plain fi lm of a gastric bypass patient with obstruction of the biliopancreatic limb is not particularly revealing. ( b ) CT imaging of the same patient reveals a tremendously enlarged gastric remnant fi lled with fl uid. The antegastric Roux limb containing a small amount of contrast can be appreciated anteriorly

Gastrojejunal Stricture a significant majority of gastrojejunal strictures present within the first 90 days after surgery, Some patients may present much later, even a year or more postoperatively

etiology of gastrojejunal stricture switching from a 21 mm circular stapler to a 25 mm circular stapler reduced the rate of stricture by a factor of 3, from 27 to 9 % firm apposition or compression of the tissue edges may be helpful a circular stapler with 3.5 mm staple height resulted in a lower stricture rate than one with 4.5 mm staples The use of staple line reinforcement materials has also been shown to reduce stricture rate

Diagnosis : History Upper Endoscopy Radiographic Contrast

Treatment Balloon Dilation

Obstruction from Internal hernia the single most common cause of bowel obstruction in their gastric bypass patients, representing 41 % of all obstructions

ANTECOILC ROUX LIMB DISTAL ANASTOMOSIS MESENTERIC HERNIA PETERSEN HERNIA

Retrocolic gastric bypass Mesocolic Hernia

Sign and symptoms Severe abdominal pain far out of proportion to the physical exam findings Intense pain in the midepigastrium, often radiating to the back

Plain film of a patient with an incarcerated internal hernia, showing dilated small bowel loops. Bowel obstruction may or may not be present with internal hernia Petersen-type internal hernia after biliopancreatic diversionwith duodenal switch, resulting in irreversible small bowel ischemia

Small Bowel Obstruction from Scars and Adhesive Bands adhesions were the second most common source of obstruction (22 %) after internal hernia (42 %)

Incisional Hernia trocar site umbilical hernia site Previous open incision site

Intussusception

Obstruction from Intraluminal Blood Clot or Bezoar

General Approach to the Bypass Patient with Obstruction CT imaging with oral and IV contrast plain films and upper gastrointestinal (UGI) series Nasogastric tube

Obstruction in the Laparoscopic Adjustable Gastric Band Patient Early Postoperative Band Obstruction Late Postoperative Band Obstruction Unusual Types of Band Obstruction

Laparoscopic adjustable gastric band

( a ) Plain film of the abdomen showing normal positioning of a gastric band. An upward angulation of the left side of the band of 30–45° is normal. ( b ) Esophagram showing normal positioning of a gastric band. This band is not yet filled and causes minimal holdup of contrast through the band. The band is angulated with the left side up about 30°, which is normal

Esophagram showing a slipped band with posterior gastric prolapse Esophagram showing a slipped band with posterior gastric prolapse. Note the near- vertical orientation of the band and the excessively large stomach pouch

Obstruction After Sleeve Gastrectomy

Obstruction After Biliopancreatic Diversion with Duodenal Switch

The End