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1:04

right. Hello, everyone. This is

1:06

Matt Martin with the Behind the

1:08

Knife bariatric surgery team. I'm

1:10

a bariatric surgeon at

1:12

University of Southern California and Los

1:15

Angeles General Medical Center. I'm

1:17

also the chief of emergency general surgery. And today's

1:20

topic, I think, is a

1:22

nice interaction between emergency general surgery

1:24

and bariatric surgery. I'm

1:26

here with my partners, Dr. Adrian Dan.

1:30

Thank you, ma'am. My name is Adrian

1:32

Dan, and I am a bariatric MIS

1:34

and foregut surgeon, as well

1:36

as the director of the MIS

1:38

bariatric and foregut fellowship at Sumo

1:41

Health System. And we have

1:43

a new member joining us. Paul, you want to introduce

1:45

yourself? Thank you, Dr. Martin. I'm

1:47

a USC general surgery resident. I'm in

1:49

my fourth year of training now, and

1:52

I am interested in foregut and bariatric

1:54

surgery. I will be starting

1:56

off this podcast. We're going to be doing a

1:58

clinical scenarios and bariatric surgery. surgery and

2:00

to start us off we have a 42 year

2:03

old female that presents with a 12-hour history

2:05

of worsening abdominal pain and nausea. She has

2:07

a surgical history that's significant for a gastric

2:10

bypass that was done two years ago and

2:12

she's had 70% excess weight loss with a

2:14

current BMI of 28. Her weight is 170

2:18

pounds with 100 pound weight

2:20

loss over that two-year period. Her

2:23

temperature is 37

2:25

degrees centigrade. Her blood pressure is 124 over 70. Her heart rate

2:27

is 100 and she's

2:30

sat in 99% on room air. Dr.

2:33

Martin, how do you start your evaluation? What are

2:36

some of the pertinent findings or red flags that

2:38

will lead you to suspect any

2:40

kind of intra-dial pathology or internal hernia in

2:42

this case? Sure, you can

2:44

always start off with the oral board answer

2:46

of I would do a detailed history and

2:48

physical and I'll just say

2:51

in these cases you will do

2:53

a good focused history and physical

2:55

exam and the big things you're going

2:57

to focus on in addition to just the current

2:59

complaints and what brought the patient in, you

3:01

really want to know about that bariatric history because

3:04

one thing I have found is

3:06

you'll often get reported patient had

3:08

a gastric bypass when they

3:10

actually did not have a gastric bypass just in

3:13

some people's minds every bariatric surgery

3:15

is a gastric bypass so it's

3:17

very important you actually ask the patient they're

3:19

often very well educated about their procedures and

3:21

know what they had done. If you can

3:23

get their operative report I would review that

3:25

in detail but I would

3:27

say most often it was done somewhere else

3:29

and you probably don't have access to the

3:31

operative report and then there's a

3:34

couple questions you can ask them very quickly

3:36

that will kind of summarize did they have

3:38

a straightforward course did they have a an

3:40

odd course so how long are you in

3:42

the hospital after your bariatric surgery did you

3:44

have to get readmitted back to the hospital

3:46

ever did you ever have to go undergo

3:48

another surgery and then it's

3:50

really just focusing on their complaints and

3:53

the abdominal exam And trying to

3:55

figure which route I'm going but I would say

3:57

in these patients be it be a constant pessimist.

4:00

And I always think of what's the worst are

4:02

most life certainly think first. Rule. Is

4:04

out. Then you can get some more common things. I.

4:06

Imaging and some bloodwork would also help in these

4:09

cases. Certainly. Agree with them.

4:11

Operative. The forty got to look at that. But.

4:14

In a patient with a history of

4:16

gastric bypass, diffuse abdominal pain of bloating

4:18

are suggestive of an internal hernia until

4:20

proven on. The. Presentation: The

4:22

ecosystem nonspecific and vague symptoms

4:24

which are chronic in worsening.

4:27

Due. To closed loop obstruction leading to

4:29

be a kid presentation. The

4:32

patient that presents with severe abdominal

4:34

pains would raise my suspicion for

4:36

mesenteric best or occlusion scheme yelled

4:38

the small doesn't. In. As

4:41

he has no, that's a whole different ballgame

4:43

something least you have to address. Got.

4:46

It so are a lot of he signs

4:48

that old people present sometimes with a bag

4:50

abdominal pain are there other kind of symptoms

4:52

that you look for of that were raise

4:54

index of suspicion for an internal hernia. At

4:57

why Adding in general you're looking for

5:00

abdominal complaints as a promise. They can

5:02

run the gamut. From. A

5:04

cute and severe too low grade in

5:06

chronic. There was a study from the

5:08

Netherlands that actually looked at all the

5:10

presenting symptoms of these patients who did

5:12

have an inch Ah, Hernia. And

5:14

as some of the sentence other than just abdominal

5:16

pain they sam were paying the really adds to

5:19

the back. Post. Brand your pain

5:21

that's reproducible after eating and then goes away.

5:23

And localized paired night as all increase

5:26

the odds of having a diagnosis of

5:28

an inch or hernia but regardless adding

5:30

any patients who has a history of

5:32

a. Barrier. Utrecht procedure that about

5:35

the small bow on asked to moses.

5:37

And. Comes in with abdominal pain complaints.

5:39

It's important to keep it into a

5:41

hernia. Hire you deferential. And

5:44

anybody who comes in with us too

5:46

small bowel obstruction. Internal. Hernia

5:48

is your diagnosis until proven otherwise

5:50

in these stations. Doctor.

5:52

dan i think earlier we mentioned emerging

5:54

as part of the initial valuation what

5:57

what kind of our imaging study would

5:59

you order I think it would

6:01

be fair to start with the CT scan

6:03

of the abdomen and pelvis with a pylonid

6:05

contrast but it does have

6:07

a good specificity and sensitivity for picking

6:09

up the signs of an internal hernia.

6:12

Plus, it can also help you work

6:14

your way and rule out other

6:16

common causes and things that may

6:18

indeed be in your differential diagnosis

6:20

for abdominal pain such as diverticulitis,

6:22

pancreatitis, and to suception

6:24

rather than an internal hernia or

6:27

for rated marginal ulcerations and

6:29

of course all bladder problems. Let

6:32

me ask you this, you said oral contrast.

6:34

Do you always get oral contrast? Not

6:37

always but if they can tolerate it, I think

6:39

that it would be a nice way to deal

6:41

the need if they're obstructed. Yeah,

6:43

I agree. I'd say usually the CT scan

6:46

has been ordered by the ER. It's usually

6:48

an IV contrast only or sometimes a non-con

6:50

which is not very helpful. But

6:52

one thing though is don't do

6:54

the full three doses of giant

6:56

jugular contrast in these gastric bypass

6:59

patients. You only need a little bit of

7:01

contrast if you are going to give it but I think 90% of

7:04

your diagnostic utility you can actually get probably

7:07

with just an IV contrast scan. Dr.

7:09

Dan, you mentioned some findings on the CT

7:11

scan. Dr. Martin, I was just wondering if

7:14

you could you go over some of the

7:16

things that you specifically look for on the

7:18

CT scan and what is the sensitivity specificity

7:20

of some of these findings? Yeah,

7:22

Adrian already mentioned a couple of them.

7:24

I think the mesenteric swirl sign which

7:26

is just a sign that you have

7:29

volvulus has been shown to

7:31

really be probably the most specific

7:33

sign. There's a whole

7:35

bunch of other signs that are relatively

7:37

non-specific. So clustered loops of

7:39

small bowel in the left upper quadrant. The

7:42

bird's beak which just means your bowel comes

7:44

to a tapered end if you've given contrast. Dilation

7:48

of the rue or the bileopancreatic

7:50

limb is another clue. SM

7:52

and ASMV narrowing or even SM and

7:55

ASMV twisting where they are in their

7:57

opposite relationship to each other. One

8:00

is displacement of the jejunol anastomosis

8:02

into the right upper quadrant. All

8:04

of those raise red flags, but

8:06

I think it's critical to remember

8:08

you can help make the diagnosis

8:10

with a CAT scan. You cannot

8:12

100% rule out an

8:14

intramarine. Yeah, and I think

8:17

it's also important that a radiologist familiar

8:19

with gastric bypass anatomy and

8:21

bariatric surgery reads the studies. And these

8:23

studies have been shown to have a

8:25

positive prediction value of 81%, negative predictive

8:29

value of 96%. I

8:31

will tell you that the even better predictive

8:33

value when you as a treating surgeon learns

8:36

how to read them and becomes familiar

8:38

with the presentations on the imaging.

8:42

Okay, so now that we have

8:44

the patient's clinical history and our

8:46

imaging findings, the patient has their

8:48

operative report or they had their

8:50

operation done at this hospital and

8:52

you go through and read that

8:55

the operating surgeon had closed the

8:57

defects, potential defects during the index

8:59

operation. Would that decrease your suspicion

9:01

of possible internal herniation? It

9:03

doesn't matter. I'd say it does not matter what

9:06

they did with them in the initial operation. One,

9:09

never trust anyone except for yourself. But two,

9:11

and I ask this

9:14

on almost every bypass case, I always

9:16

ask the resident or med student about this of,

9:19

we're closing this perfectly. Could this patient

9:21

possibly come back with an intranet or

9:23

right here? And they

9:25

often say no or they say, yeah, it's a

9:27

technical error. So they insult us, so we don't

9:29

know what we're doing. But I tell them, look

9:31

at that tissue, that's fat we're selling to fat.

9:34

This patient's going to lose a lot of fat,

9:37

especially in that first year. So

9:39

even the most perfectly closed defect can

9:41

and will open up. There

9:44

was actually a study on the publish

9:46

in 2019 that looked at

9:48

the post-op mesenteric defect integrity in

9:51

patients who had a bypass,

9:53

who underwent later intravital ulcerative

9:55

intervention. And They found that

9:58

the rate of defects were up to... Forty

10:00

to sixty percent even. And patients

10:02

who had a rather defects close

10:04

at the initial gastric bypass surgery.

10:07

So. So forty to sixty percent of

10:09

those were found to have defect, so

10:11

that is no guarantee that they don't.

10:13

Evidence are near. Now.

10:15

Remember that study played well met your

10:18

that number seems to be with current

10:20

in the literature. And as

10:22

are closer, techniques have improved as

10:24

are instrumentation has improved. In

10:27

our understanding of the defects and their geometry

10:29

I think we may beat. we do symbols

10:31

rates of part of as because we are

10:33

seeing the data in. starting to close is

10:36

routinely and we do something were teenagers get

10:38

better at it. Yet.

10:40

And let me ask you this

10:42

Adrian so you're taken a bypass

10:44

tasted back a year later. you

10:46

didn't a lot coli or you

10:48

routinely always looking at your mesenteric

10:50

defects. Matter. Wish I

10:52

would say yes to that, but the truth

10:54

is that we don't. End.

10:56

Of the gentleman who did the studies we

10:58

just mentioned did exactly that. He

11:01

looked at every patient a went

11:03

back for every reason proactively rather

11:05

than waiting for a patient to

11:08

the to develop symptoms and problems

11:10

and therefore was able to discern

11:12

exactly. rate of open defects was

11:15

whether the recent mad or not.

11:18

If. Somebody has and the kid cause status and

11:20

them tick the gallbladder out. Over.

11:22

I have seen situations where we've worked a

11:24

patient top. Four. Gallbladder disease

11:26

just to the center, the abdomen some

11:28

and you know, the milky. Societies

11:31

in that situation again have two hours

11:33

a day. We had Sergeant A a

11:35

gallbladder. smart problem. They're. Probably having.

11:38

Been. symptoms that are associated

11:41

with internal hernia and the incidence

11:43

of internal hernias even after gastric

11:45

bypass impatience that had defect closure

11:47

is about zero eight percent scrolling

11:50

to what the previous study said

11:52

with forty to sixty percent of

11:54

defects opening at the time of

11:56

any intra abdominal surgery and ford

11:59

at eighteen for of patients develop

12:01

internal hernia where the defect is

12:03

not closed. So evidence does

12:05

seem to support loathing those mesentery

12:07

defects during the initial operation. However,

12:09

back to our patient, the ED.

12:11

So say we are suspicious of

12:13

an internal hernia at this time.

12:16

Dr. Martin, how do you determine

12:18

how quickly they need to go

12:20

back to the operating room? Is

12:22

there any role for preoperative resuscitation

12:24

or even waiting till the

12:26

morning for an operation instead of say you know bring

12:28

the team in if there's no one available at two

12:30

or three o'clock in the morning? Yeah

12:32

and I would say I pretty

12:35

much 100% just base that on symptomatology.

12:39

So the patient that's still having

12:41

pain, they should be going

12:44

to the operating room. It doesn't matter if it's

12:46

day or night because that is potentially

12:50

non-viable bowel or development of non-viable

12:52

bowel and these patients can lose

12:54

most or even all their small

12:57

intestine in a missed internal

12:59

hernia or one where there's a delay to the

13:01

OR. Now do

13:03

I rush every patient off at 3 a.m. you

13:05

know if they came in with some vague abdominal

13:07

pain and the you know the CAT scan shows

13:10

maybe some signs of a possible internal hernia but

13:12

their pain is gone. You don't need to take

13:14

that in the middle of the night. You can

13:16

put it on for the next day or the

13:18

next several days but anybody with ongoing

13:20

pain or other symptoms I

13:22

believe at least you really should be taken into

13:25

the operating room as soon as possible. Yeah

13:28

and similarly I try to be very

13:30

judicious about it also. I think patients with internal

13:33

hernias fall to two main

13:35

categories. Those with the vague

13:37

abdominal discomfort and symptoms

13:39

and can be resuscitated and temporized

13:41

until the morning and those

13:44

who show clear signs of bowel ischemia.

13:46

I've had come in and found

13:48

patients just sitting up in bed playing on their phone

13:50

and I knew that I

13:52

would take care of it because I came in for it

13:54

but it may have been okay to do it in the

13:56

morning and I've seen patients

13:58

come in by squat and the

14:01

fetal position. But any sign

14:03

of symptom which suggests ischemia should

14:05

warrant an emergent intervention is. Every

14:08

single minute counts in such a situation.

14:10

I've seen that situation and thankfully wasn't

14:13

one of the patient that

14:15

I had performed the operation on but so will

14:17

do it. Gastrobytes about

14:19

two decades ago came in

14:21

with essentially their entire small

14:23

bowel ischemic. I

14:26

see that is that's never position they want to be in.

14:29

So it sounds like it's all based on

14:31

the symptoms but generally we will proceed to

14:33

the operating room more urgently.

14:36

Is there any benefit for this patient as

14:38

they're waiting to go back for an anisogastric

14:41

tube for decompression and if so any tips

14:43

and tricks on how to place it just

14:45

given their anatomy with a smaller

14:47

gastric pouch sometimes people can be hesitant

14:50

in placing the anisogastric tube in those

14:52

scenarios. Yeah I'll

14:54

just say generally I don't if I

14:56

need one I'll place it in the

14:58

OR usually when I'm looking at the

15:00

gastric pouch. You have to remember it's

15:02

a very small gastric pouch it

15:05

can't hold that much fluid

15:07

or food contents. If

15:10

they're vomiting it's mostly actually small

15:12

bowel contents that's refluxing up and

15:14

there are some risks obviously of

15:16

iheogenic injuries with the NG tube.

15:18

So it's pretty rare that I

15:20

would preoperatively place an NG

15:22

tube in these patients. And

15:25

also remember that amazosophageal tube is an

15:27

option. It's an option which will not

15:29

affect or damage the pouch but may

15:32

decrease the possibility of aspiration at

15:34

the time of intubation if there's a high

15:36

grain obstruction. Okay so

15:38

for our patient because she has worsening

15:41

pain we decide to take her back

15:43

to the operating room for exploration. Dr.

15:46

Dan what is your approach to

15:48

exploring the patient when they get in? How do

15:50

you enter? Sometimes they could

15:52

have distended loops of bowel and

15:54

then what's your technique or process

15:56

for examining? Sure so

15:59

of course see you want to be very cautious when

16:01

you have 12

16:18

millimeter trocar at Palmer's Point, very close

16:20

to cost of large and to use as

16:22

a counterpoint and then I

16:25

do two to three five millimeter

16:27

ports in the midline and

16:29

left hemium to manmade the unassisted five

16:31

milliliter in the right upper clogger. At

16:34

this point you have to have some

16:36

kind of a plan. I start by

16:38

looking at the gastric pouch making sure

16:40

there's no perforation at the gastric geginostomy

16:42

and I evaluate the rulim and run

16:45

it towards the geginogiginostomy trying to evaluate

16:47

Peterson space and the mesogenal defect. The

16:49

biliary pancreatic limb usually lies to the

16:52

left and I follow that to the

16:54

ligament trutes then I come back and

16:56

around the common channel as far as

16:58

I can with internal

17:01

hernia sometimes that's not feasible. I

17:04

truly believe the greatest pearl in

17:06

in the situation is to start

17:09

running a common channel from the sail

17:11

of trev's retrograde toward the ligament of

17:13

trutes and many times this will reduce

17:16

the common channel that is incarcerated in one of

17:18

the hernia defects around but the sail of

17:20

trev's always going to be in the same

17:22

spot regardless of where the rest of the

17:24

bowel is but it's also

17:26

important to remember that that doesn't

17:28

work and can't make heads and tails out of

17:30

what's going on don't be afraid

17:32

to to proceed to an open approach. And

17:35

so Adrian you say you said at 12 millimeter

17:37

truck are initially do you mean OptiView entry or

17:40

you're doing a sign? OptiView entry.

17:43

I've got to be very careful more

17:45

twisting than pushing very gentle

17:47

counting every layer on the way in

17:49

and then we've had very few

17:52

issues with that technique. All

17:54

Right, we're in full agreement. I Hate

17:56

the Various needle I haven't hassoned in

17:59

15 years? Yeah, The I like I did he.

18:01

oh and I agree with everything he just said and

18:03

then again highlighting their most important point. Is

18:05

if there is a intra her near

18:07

the Jj. Necessary in and

18:10

tourist. Your. Run the rule him.

18:12

And as he gets the Jj it's a big not

18:14

and no matter how are you pull you can get

18:17

it to and twist and ass off. And when people

18:19

are an experience with this say I can't make this

18:21

out I'm going to compared to. And.

18:23

That's when I'll tell them

18:25

the resident or the seller

18:27

of assume appendectomy position. Go

18:30

stare at the Elysee, go bow than

18:32

and stuck writing that com and channel

18:34

backwards. Usually. What'll happen is.

18:36

They'll. Get to some dilate bow that they'll keep

18:39

running and all the sudden something will flop around

18:41

and will be at the Jj and it's now

18:43

or incorrectly. And. You have no idea

18:45

that you even. Reduce. This big

18:47

hernia. And. If it doesn't then at the

18:49

he I worry about. okay, do I have a

18:51

Peterson's defect? Where. Is it a retro

18:54

colleague? real? and I have a hernia through

18:56

that retro colic window? Emitter.

18:58

Have see described it so I'll I'll

19:00

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19:02

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the ones who get it done. Okay,

19:35

so we discussed previously the site's a

19:37

possible herniate and from your guys experience,

19:39

what's the most common sight bend? Do

19:42

close them when you find them. Save

19:44

a ones that are not involves. Entered

19:47

the most common sight. It does vary

19:49

a little bit know literature but most

19:51

of the studies show that did you

19:53

know judge an ostomy mesenteric d the

19:56

act as most common, followed by Peterson's

19:58

and then again if you have. Retro

20:00

college rule limb you can. Also, they didn't

20:02

enter Honey A through that read your column

20:04

window, but I think most of us now

20:06

has gotten to anti colic. Rivlin says less

20:09

common. And. I was close.

20:11

Any and all the facts if I'm

20:13

taken someone back for going to Hernia.

20:15

So even if they have a Jj

20:17

and our hernia are close, that defect

20:19

and Peterson's. Interesting the

20:22

trust that paul because it's changed a

20:24

long time ago we didn't close any

20:26

of those speaking that you know before,

20:28

colorectal pods don't closer than we don't

20:30

need clothes on their because they don't

20:32

seem to be having problems. but back

20:34

then when we closed neither the judge

20:36

know digital defect was the most common

20:38

in I remember was about two thousand

20:40

and seventeen when we were having a

20:42

paternal club and. My. Fellow to

20:44

time said no Peter says is most

20:46

commonly seems four or five and have

20:48

all been Peterson's Im sure enough we

20:50

began seen a lot more Peter says

20:53

defects and the reason for that is

20:55

because we have started closing are judging

20:57

regional from gentle defects and that's why

20:59

Peterson's become the most common. I.

21:01

Want my cells actually got me a bell of

21:03

shame that a chip in my office and if

21:05

I show that anybody has closed one. A.

21:07

Ring the bell of shape. As. A

21:10

yeah anything. It's also part add

21:12

to his. Closing. The

21:14

Jj defect is pretty straightforward and familiar.

21:16

Them. For. Any any sergeant as

21:18

a small town as most is causing

21:21

Peterson's. It is a little more

21:23

complex and I have seen. Many.

21:25

Videos of our closing: Peterson's Alec The

21:27

The Long Bag. That was not

21:30

seeing Peterson's efficient. You really need to

21:32

slip. That transfers Cohen up. Get down

21:34

to the actual mesenteric. I mean I

21:36

see some people that the Weather Jonas

21:38

are tacking the Ruler military. To.

21:40

That. Transverse Cohen anti mesenteric

21:42

wall that's not closing beer since

21:44

the Spray Another reason why. That's

21:47

becoming a more common sight. and the

21:49

Jj. And I think the more you

21:51

do with the Boar Miller in of will you

21:53

get with it. And it's important to

21:55

keep in mind and when you do close to the

21:57

judge in a judge asked me to take that shit.

22:00

Your. Would kicking at the judge

22:02

noted. Lastly, Okay, So

22:05

all defects will be closed. Send a

22:07

thank you for the very descriptive technique

22:09

and how to do it. But.

22:11

He and to get into a little

22:13

bit more of the weeds. what type

22:15

of material do use for the closure

22:18

of these defects? Now I've read variety

22:20

of different methods, maybe some more exotic

22:22

than others, but. Running. Or

22:24

interrupted sutures absorb born on absorbable

22:26

I seen metal clips, glue even

22:28

some mess placement in some papers

22:31

that how to how you close

22:33

the defect. Yeah.

22:35

No say I have all the average time I

22:37

used to do a running. To.

22:39

Our Three Ozark. I. Have now

22:42

changed to Barb Suit. You're. Either.

22:45

Of the locker Strata fix. Am

22:47

I just think that makes it simpler

22:49

faster? I also think it's less likely.

22:52

To. Leading gaps are

22:54

loose areas. Because. The suit

22:56

your doesn't back up. Ah, and

22:58

I just think it holds his position better. Yeah.

23:01

I agree. My technique has evolved over

23:03

the years. Also used to do with

23:05

Trump did soaps and to intervene as

23:07

a Baden's. And now haven't

23:09

really intrigued by the know. Efficiency

23:12

in the effectiveness of that permanent

23:14

barb suitors he to set to

23:16

make sure the Good: friendly. On

23:19

a small so that it doesn't cause

23:21

other problems those have known to be

23:23

associated with bulbs. Trucks us when alone.

23:25

Tail. Is left to play So

23:27

there was also study with the

23:29

mean follow up with three Years

23:31

said look at some of the

23:34

differences in these materials and defect

23:36

Closer to it included the figures:

23:38

thirty one patients undergoing guessed by

23:40

Best Settlement fifty seven ago when

23:42

closer with interrupted suitors while hundred

23:44

seventy four underwent social with a

23:46

running censor. There was significant lower

23:48

rate of internal cronyism. Patients.

23:50

with mesenteric defects closed with a

23:52

running technique compared to the interrupted technique

23:54

but. There. was no difference

23:56

when booking at the differences between

23:59

suture materials And

24:01

another study from the

24:03

Scandinavian obesity surgery registry, also

24:06

known as SORAG, looked

24:08

at the use of metal clips

24:10

and running non-absorbable suture compared to

24:12

non-closure in over 34,000 patients

24:16

and over 19,000 patients

24:18

had mesenteric defects closed with metal

24:20

clips and over 6,000 were

24:23

non-absorbable sutures. Man,

24:25

are you familiar with that study? Oh

24:28

yeah, their primary endpoints, they looked

24:30

at 30-day complications and small bowel

24:32

obstruction at five years. They actually

24:34

found there was no difference in

24:37

30-day complications with closure versus non-closure.

24:40

But both sutures and clips had lower

24:42

rates of small bowel obstruction compared to

24:44

non-closure. And I think now

24:46

that's been pretty consistent in that

24:49

literature and other studies. Yeah,

24:51

and the authors concluded both clips and

24:53

sutures were safe and they

24:55

were both effective. Although sutures appear to

24:58

be slightly more effective. I

25:00

have seen some of those other unique methods. I

25:03

think most people have abandoned those

25:05

just for straight up suture, but

25:07

things like fibrin glue or TISIL,

25:09

mesh reinforcement over a non-absorbable suture

25:11

closure. I had one partner who

25:13

for a while was bovipad

25:16

scratching the

25:18

mesenteric at the site and counting on that

25:20

to close the defect. But

25:23

I think now the evidence pretty much just

25:25

supports straightforward suture closure. Got

25:27

it. So all defects for this

25:29

lady were closed. We would say with

25:31

sutures and high-fiving in the OR, no,

25:33

the bowel is dead, we can reclose

25:35

and she's going to the pacuon out to

25:38

the floor. What are some

25:40

of your post-operative protocols for

25:42

these patients? Do you

25:44

leave a nasogastric tube in? Do you start them on

25:46

clears? But is there

25:48

any evidence for routine post-op

25:50

imaging? For the non-complicated

25:52

patient, meaning we didn't have to do

25:55

a bowel resection and if there wasn't

25:57

a perforation, we found an

25:59

internal hernia. It was the cause of

26:01

their symptoms or their obstruction. We reduced it.

26:03

We closed the defects. We pretty much treat

26:05

all of these with the standard e-RAS

26:08

protocol. They get

26:10

multimodal pain medication. I would just

26:12

start them on weird immediately unless

26:15

they had significantly dilated bowel and

26:17

were worried about an alias. We

26:20

try to minimize narcotics in these patients. And

26:22

again, as long as we say laparoscopic, I

26:24

think now that's very possible. We

26:26

treat them really just like now we treat most of

26:29

our primary or bariatric patients. And I

26:31

definitely don't do any routine post-subimaging

26:34

to confirm what we actually saw with our

26:36

own eyes. Yeah, I

26:38

certainly agree with all that. And our protocol

26:40

is quite similar. In most

26:42

patients, when surgical intervention has taken

26:44

place prior to any ischemia

26:46

of the bowel, reducing the

26:48

hernia to relieve the obstruction and closure of

26:51

that defect to prevent the recurrence

26:53

translated into a pretty fast

26:55

recovery, and a balanced post-bariatric

26:57

diet can be achieved pretty

26:59

quickly. If a post-operative

27:01

alias is expected, we may advance the

27:04

diet in a stepwise manner, in a

27:06

slower manner, as tolerated by the patient.

27:09

Discharge criteria, I think, are probably pretty

27:11

consistent between being able to eat, have

27:16

bowel movements, pass gas, walking around pain

27:18

is controlled, standard

27:21

for a typical post-operative patient. But

27:23

kind of turning a little bit, if

27:25

I could introduce a different scenario, one that

27:28

I think probably causes many residents and maybe

27:30

a good number of tending some concern. Say

27:32

if our initial patient who came in with

27:34

abdominal pain was 20 weeks pregnant, would that

27:38

change your management at all? Absolutely. And

27:40

this is one of those situations that you usually get

27:42

a call in the middle of the night, have

27:45

a hard time sleeping the rest of the night, particularly

27:48

with a patient that's at that point in

27:50

pregnancy where the fetus may not be

27:53

able to survive with a delivery. My

27:56

management may include an evaluation of the

27:58

fetus with ultrasound and fetal heart. hard

28:00

tones to confirm the viability. But

28:02

otherwise, I would continue the same workup and

28:05

will try to expedite going to

28:07

the operating room more urgently if there

28:09

was any suspicion of internal hernia

28:12

as delayed diagnosis that the results

28:15

in ischemia of the bowel can be detrimental

28:17

to both the mother and the

28:19

fetus. Yeah,

28:21

I'd say this is consistent with most

28:24

of the literature of any acute surgical

28:26

issue in pregnant patients. Take

28:28

them to the OR. Trimester generally

28:30

doesn't matter. You're more

28:32

at risk of harm to the mother

28:35

and the fetus by delaying your intervention

28:37

for that acute process than any risk

28:39

of surgery. These

28:41

patients can be difficult. There's often

28:43

a concern about imaging. I'll

28:46

tell you the worst, small bowel

28:48

loss. A case I actually

28:50

saw was in a pregnant patient and there

28:53

was a major delay because of concern of

28:55

imaging because the patient was pregnant and

28:58

ended up losing essentially their

29:00

entire small bowel, lost the

29:02

fetus because of the

29:04

dead bowel and all because of

29:06

a major delay in diagnosis. The

29:08

exposure at that point is minimal.

29:11

Again, once the fetus, if they're

29:13

past the first trimester, there's really

29:15

no direct risk to the fetus.

29:18

There is that small risk of future

29:20

cancers, but again, I think that's significantly

29:22

outweighed by your concern for missing something

29:24

like an interhearnia. In

29:27

this situation, the pathology is related to

29:29

increased intra-abdominal pressure from the growth of

29:32

the uterus and the fetus. It's

29:35

important to have preoperative discussion

29:37

with patients of childbearing age at the

29:39

time of initial

29:41

bariatric evaluation because

29:43

if a patient is seeking gastropiophase

29:46

procedure and they're also intending

29:48

to start a family or be

29:51

pregnant, it's important for them

29:53

to understand that there's an increased risk

29:55

for interhearnia not only with

29:57

gastropiophase but with gastropiophase and preeminent.

30:01

Yeah, and later in the course

30:03

of the pregnancy, late second, third

30:05

trimester, also it also decreases the

30:08

ability of your CAT scan to make

30:10

that diagnosis, right? Because everything's displaced

30:13

and compressed. So

30:15

it also decreases your diagnostic yield of

30:17

that study. Got it. Thank

30:19

you. I know every time I

30:21

hear that, you know, patient is completely

30:23

pregnant with complaints of abdominal pain, it

30:25

always sends shivers down my spine. Good

30:28

to keep in mind though, the

30:30

appropriate courses are just standard evaluation

30:33

for each patient.

30:35

And to round out the management

30:37

of this clinical scenario, so say

30:39

you're seeing a post-gastric bypass patient

30:41

in your clinic that's having chronic

30:43

abdominal pain with intermittent nausea, how

30:45

do you differentiate this as a

30:48

normal post-operative course versus something

30:50

that's pathologic? And is there anything in

30:52

their history that would lead you to

30:54

pursue diagnostic imaging? Yeah,

30:57

so again, here I

30:59

think their time course, so

31:02

how long has it been since their bariatric

31:04

surgery? Because that also helps guide, you know,

31:06

if it's the first couple months after

31:08

the bariatric surgery, you're worried about things like

31:11

a, you know, a marginal ulcer, that they

31:13

could have a leak if it's in the

31:15

first four weeks. The internal

31:17

hernia part usually will happen

31:19

later, six months to

31:22

many years later, and especially with

31:24

a large amount of weight loss when those

31:27

defects open back up. So that patient, that's

31:29

where again a chronically incarcerating

31:32

internal hernia becomes higher

31:34

on my diagnosis. So

31:36

that patient, I would pretty rapidly work

31:39

them up. And really, I think

31:41

the big differential like we've talked about would be, is

31:43

this an internal hernia? Could this

31:45

be a heptic ulcer, marginal ulcer,

31:47

or could this be gallbladder symptoms?

31:50

If all of that is suspicious, then you

31:52

talk to the patient about taking them to

31:54

the operating room and doing a diagnostic laparoscopy.

31:56

It is important to remember that

31:58

at least half of patients... patients who do

32:00

have inter-hurnias present in the outpatient

32:03

setting, they don't all come to the ER with

32:05

a small bowel obstruction. Yeah, the

32:07

diagnostic acumen of an experienced clinician is

32:09

very important and it will guide the

32:12

workup. There's a lot of tests that

32:14

are available to you but you try not to take a

32:16

shotgun approach, try to look at the timing

32:19

after surgery. Internal

32:21

hernias, obstructions from them are typically not seen

32:23

in the immediate post-op period but you know

32:25

we have seen them. But you know you've

32:27

got a gamut of tests

32:29

that you can get depending on what

32:31

you're suspicious for or SCCT will tell

32:33

you a lot about everything. An

32:36

upper GI with small bowel fall through

32:38

an endoscopy, an ultrasound with a right

32:40

upper quad and all those can be

32:42

helpful. But if your

32:44

entire workup is negative and all other

32:47

culprits are excluded, we arrive at the

32:49

same final common pathway of

32:51

diagnostic laparoscopy. And if patient continues

32:53

to have chronic pain, some explain,

32:56

that's what I will resort to. Yeah,

32:59

and I say remember too, you

33:01

can do more than one thing. I have

33:03

seen these patients delayed as though we got to

33:05

get a scope and you know if we don't

33:07

do it on scopes, GI has got to schedule

33:10

them and then they got to get this. So

33:12

remember you can take them to the OR, you

33:14

can do a diagnostic laparoscopy, you can do an

33:16

on-table upper endoscopy and then you're kind of prepared

33:18

for everything. People often take

33:21

these patients to the OR, diagnostic laparoscopy,

33:23

do an upper endoscopy to make sure

33:25

it's not a marginal ulcer and then

33:28

we'll be prepared to do a cholecystectomy

33:30

because if you go in there and you find no entera

33:32

hernia, then you got to start looking for other

33:34

sources of their pain. I don't know what

33:37

your approach is, Adrian, you put the scope in and there's

33:39

no entera hernia. Yeah, so I'm

33:41

not quite as liberal about the cholecystectomy

33:43

unless there's some kind of pathology but

33:45

a lot of times, you know, symptoms

33:48

will get better. The changes

33:50

of physiologic and atomic changes could lead

33:52

to symptoms also that will improve. I

33:54

think the main goal of my diagnostic

33:57

laparoscopy is to rule out an

33:59

internal hernia. Which is

34:01

potentially catastrophic. The.

34:03

And I did. I do you mind if you

34:05

do go in there and you don't find that

34:08

in any internal irony and you're looking for sources

34:10

luggage your Gj look at your jj see if

34:12

you have a real they won candy cane limb

34:14

and it either of those those kabir of potential

34:16

cause and then and really look at your judges

34:19

nos me for any signs of in a stepson.

34:21

At that price, the other. Mimic

34:23

of an entire hernia. Cz to

34:26

miss. Because they are, they can

34:28

have a chronic intermittent a segment

34:30

of the thinnest deception and intercepting

34:32

and and spontaneously reducing. In

34:35

one of the to new depressed diagnose

34:38

especially. Yours. Out, especially with

34:40

a fruitful staple judge noted last

34:42

me decade. There. Is predisposition

34:44

have been powered to dilate

34:46

because Saudi dilated. Given.

34:48

The laws or pass on minutes daily to

34:50

will continue to dilate and. Then.

34:53

Out and that judge noted last

34:55

be in and of itself could.

34:57

intermittently. Tours and place

34:59

a twist on to the

35:02

mesenteric and doesn't win symptoms.

35:06

But. That her dad that you hit

35:08

the nail on the head. It's

35:10

the good clinical exam by an

35:12

experienced surgeon to evaluate the pace

35:15

and and both settings to allow

35:17

for the appropriate him best outcome

35:19

in these situations. But. To

35:21

summarize some of the stuff that we had

35:23

spoken about know he touched on a variety

35:25

of different things. Efficient comes in

35:27

with their previous gastric bypass. He always

35:29

need to maintain a high index of

35:32

suspicion for an internal hernia. A.

35:34

Good history labs and C T scanner.

35:36

the best way to to evaluate these

35:38

patients. But. If you're suspicious regardless

35:40

of what the show and at

35:42

diagnostic Laparoscopy is going to be.

35:45

The. Preferred approach and how have a

35:47

good The standardized approach to the

35:49

and for abdominal valuation is important.

35:52

Patients. That are pregnant have a

35:54

standardized approach to the typical patients

35:56

as a having, as well as

35:58

a low threshold for. They're valuation

36:00

of patients with this chronic abdominal pain

36:02

The outpatient setting as important as well.

36:06

Get. And my in one thing I'll add

36:08

to we we talk about this the gastric

36:10

bypass but it's any and ask them on

36:12

a very uttered procedure. And above

36:14

the small bow and most. Sleeves.

36:17

You don't worry about internet by the

36:19

A Cs. Are. I what

36:21

out I was a great discussion. I think the only

36:23

thing we have left his who wants to say it.

36:26

Weekend. As a Listers vote on his cell a

36:28

best I'd so paul. That.

36:30

Don't forget to dominate the day. Adrian.

36:34

Dominate the day. Or rightness

36:36

of the bear at your team for behind the nice

36:38

and. As. Got still it's

36:40

a dominate the day. He

36:43

should check out our website www.behind and I've

36:45

got four for more. Great thought. It could

36:48

also follows or twitter as Behind the Knife

36:50

and Instagram has he has it I thought

36:52

cast like what here we stay committed to

36:54

leave us with you can't have produced by

36:56

the have a nice as intend for health

36:59

professionals and as for educational purposes only without

37:01

diagnose, treat or offer patient specific advice. Thank

37:03

you for listening. Into

37:05

next month nominee the Day.