Chronic abdominal pain after RYGB

– A management guide

OBES21st October 2017

Dr Chun-Hai TanMBBS, Masters of Medicine (Surgery), FRCS (Edinburgh)

Consultant SurgeonMetabolic & Bariatric Surgery,

Minimally Invasive Upper GI Surgery

Department of General SurgeryKhoo 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

• 2nd 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

• Resection of this “candy cane” complete and immediate resolution of symptoms

Learning point

Minimize redundancy in the roux limb during RYGB

“Candy Cane” syndrome

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

• Long length of small bowel loop in Peterson’s space

• No evidence of IO

• Small bowel healthy

• Peterson’s space hernia reduced and closed

Discharged on POD1

Transverse colon

Alimentary Limb

Case presentation 2

BackgroundMdm JY57 Chinese Female

PMHxClass 1 ObesityBMI 31Poorly controlled T2DM

• HbA1C 10.3% • Insulin 60 units + SGLT2

HLD/HPTOSA

RYGB Oct 2015

3 months post surgeryCame 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 jejenumwithout 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 Bilio-pancreatic 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 retrocolicapproach)

B. Petersen’s spaceC. Jejuno-jejunal mesenteric defect

RecommendRoutine 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

open1

• 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

1Higa KD, Ho T, Boone KB. Internal hernias after laparoscopic Roux-en-Y gastric bypass: incidence, treatment and prevention. ObesSurg. 2003;13:350–4.2Schneider C, Cobb W, Scott J, et al. Rapid excess weight loss following laparoscopic gastric bypass leads to increased risk of internalhernia. 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

CT positive for etiology: Rx appropriately

CT negative but persistent symptomsConsider Diagnostic Laparoscopy

No specific etiology apparent, CT abdomen

Recurrent abdominal pain after RYGBDetailed history: maladaptive eating, biliary colic.

RF: Smoking, DM

Upper GI endoscopy: Marginal ulcersBarium Swallow: Candy cane

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 TanOBES 2017

Thank you

谢谢大家