BTK Bariatric Clinical Scenario 1.12.24

All right. Hello, everyone. This is Matt Martin with the Behind the Knife Bariatric Surgery team. I'm a bariatric surgeon at University of Southern California and Los Angeles General Medical Center. I'm also the Chief of Emergency General Surgery. And today's topic, I think, is a nice interaction between Emergency General Surgery and bariatric surgery.

I'm here with my partners, Dr. Adrian Dan. Thank you, Matt. My name is Adrian Dan, and I am a bariatric MIS and foregut surgeon, as well as the director of the MIS bariatric and foregut fellowship at Summa Health System. And we have a new member joining us. Paul, you want to introduce yourself? Thank you, Dr.

Martin. I'm a USC general surgery resident. I'm in my fourth year of training now, and I am interested in foregut and bariatric surgery. I will be starting off this podcast, we're going to be doing a clinical scenarios in bariatric surgery. And to start us off, we have a 42 year old

female that presents with a 12 hour history of worsening abdominal pain and nausea.

She has a surgical history that's significant for a gastric bypass that was done two years ago, and she's had 70 percent excess weight loss with a current BMI of 28. Her weight is 170 pounds with 100 pound weight loss over that two year period. Her temperature is 37 degrees centigrade. Her blood pressure is 124 over 70.

Her heart rate's 100 and she's sat in 99 percent on room air. Dr. Martin, how do you start your evaluation? What are some of the pertinent findings or red flags that will lead you to suspect any kind of intradermal pathology or internal hernia in this case? Sure, you could always start off with the oral board answer of, I would do a detailed history and physical, and I'll just say in these cases, you will do a good focused history and physical exam.

And the big things you're going to focus on, in addition to just the current complaints and what brought the patient in, is you really want to know about that bariatric

history. Because one thing I have found is you'll often get reported patient had a gastric bypass. When they actually did not have a gastric bypass, just in some people's minds, every bariatric surgery is a gastric bypass.

So it's very important. You actually ask the patient. They're often very well educated about their procedures and know what they had done. If you can get their operative report, I would review that in detail, but I would say most often it was done somewhere else and you probably don't have access to the operative report.

And then there's a couple of questions. You can ask them very quickly. That will kind of summarize. Did they have a straightforward course? Did they have an odd course? So, how long were you in the hospital after your bariatric surgery? Did you have to get readmitted back to the hospital ever? Did you ever have to undergo another surgery?

And then it's really just focusing on their complaints and the abdominal exam. And trying to figure which route I'm going. But I would say in these patients, be a constant pessimist. And I always think of what's the worst or most life threatening thing first.

rule those out. Then you can get to the more common things.

Imaging and some blood work would also help in these cases. Certainly agree with operative before you got to look at that. But in a patient with a history of gastric bypass, diffuse abdominal pain and bloating are suggestive of an internal hernia until proven otherwise. The presentation may consist of nonspecific and vague symptoms which are chronic and worsening due to a closed loop obstruction leading to the acute presentation.

The patient that presents with severe abdominal pain would raise my suspicion for mesenteric ischemia of the small intestine. And as you guys know, that's a whole different ballgame and something that you have to address. Got it. So a lot of these times I know people present sometimes with vague abdominal pain.

Are there other kind of symptoms that you look for that would raise your index of suspicion for an internal hernia? Well, I think in general you're looking for abdominal complaints. The problem is they can run the gamut

from acute and severe to low grade and chronic. There was a study from the Netherlands that actually looked at all the presenting symptoms of these patients who did have an internal hernia and some of the symptoms other than just abdominal pain they found were pain that radiates to the back postprandial pain that's reproducible after eating and then goes away.

And localized peritonitis all increase the odds of having a diagnosis of an internal hernia. But regardless, I think any patient who has a history of a bariatric procedure that involved the small bowel anastomosis and comes in with abdominal pain complaints, it's important to keep an internal hernia high on your deferential.

And anybody who comes in with a true small bowel obstruction, internal hernia is your diagnosis until proven otherwise in these patients. Dr. Dan, I think earlier we mentioned imaging as part of the initial evaluation. What kind of imaging study would you order? Well, I think it would be fair to start with a CT scan of the abdomen and

pelvis with PLN IV contrast, but it does have a good specificity and sensitivity for picking up the signs of an internal hernia.

Plus, it can also help you work your way and rule out Other common causes and things that may be in your differential diagnosis for abdominal pain, such as diverticulitis, pancreatitis, intussusception, rather than an internal hernia, perforated marginal ulcerations, and, of course, gallbladder problems.

Let me ask you this. You said oral contrast. Do you always get oral contrast? Not always, but if they can tolerate it, I think that it would be a nice way to to delineate if they're obstructed Yeah, I agree. I'd say usually the CAT scan's been ordered by the ER. It's usually an IV contrast only or sometimes a non con, which is not very helpful.

But one thing though is don't do the full three doses of giant jug of contrast in these gastric bypass patients. You only need a little bit of contrast if you are going to give it. But I think

90 percent of your diagnostic utility you can actually get probably with just an IV contrast scan. Dr.

Dan, you mentioned some some findings on the CT scan. Dr. Martin, I was just wondering if you, can you go over some of the things that you specifically look for on the CT scan, and what is the sensitivity specificity of some of these findings? Yeah and Adrienne already mentioned a couple of them. I think The mesenteric swirl sign, which is just a sign that you have volvulus has been shown to really be probably the most specific sign.

There's a whole bunch of other signs that are relatively non specific. So, clustered loops of small bowel in the left upper quadrant. The bird's beak, which just means your bowel comes to a tapered end, if you've given contrast. Dilation of the roo or the biliopancreatic limb is another clue.

SMV narrowing or even SMA SMV twisting where they're in their opposite relationship to each other. And another one is displacement of the jejunal jejunal anastomosis

into the right upper quadrant. All of those raise red flags, but I think it's critical to remember you can help make the diagnosis with a CAT scan.

You cannot 100 percent rule out an internal hernia. Yeah, and I think it's also important that a radiologist familiar with gastric bypass anatomy and bariatric surgery reads the studies. And these studies have been shown to have a positive predictive value of 81%, negative predictive value of 96%. I will tell you, they probably have an even better predictive value when you, as the treating surgeon, learns how to read them and becomes familiar with the presentations on the imaging.

Okay, so now that we have the patient's clinical history and our imaging findings, the patient has their operative report or they had their operation done at this hospital, and you go through and read that the operating surgeon had closed the defects, potential defects during the index operation. Would that decrease your suspicion of possible internal herniation?

iT doesn't matter. I'd say it does not matter what they did with them in the initial operation. One, you know, never trust anyone except for yourself, but two, and I ask this on almost every bypass case. I always ask the resident or med student about this of, you know, we're closing this perfectly. Could this patient possibly come back with an attorney or right here?

And they often say no, or they say, yeah, it's a technical error. So they insult us that we don't know what we're doing. But I tell them, look at that tissue. That's fat. We're sewing to fat. This patient's going to lose a lot of fat, especially in that first year. So even the most perfectly closed defect.

Can and will open up. There was actually a study on that published in 2019 that looked at the post op mesenteric defect integrity in patients who had a bypass who underwent later intra abdominal surgical intervention, and they found that the, rate of defects were up to 40 to 60 percent even in patients who had their residential

defects closed at the initial gastric bypass surgery.

So, so 40 to 60 percent of those were found to have defects. So that is no guarantee that they don't have an internal hernia. And I remember that study quite well, Matt. You know, that number seems to be recurrent in the literature. And as our closure techniques have improved, as our instrumentation has improved and our understanding of the defects and their geometry, I think we may be reducing those rates.

And part of that is because we are seeing the data and starting to close these routinely. And when you do something routinely, you just get better at it. Yeah, and let me ask you this, Adrian, so you're taking a bypass patient back a year later and you're doing a lap coli. Are you routinely always looking at your mesenteric defects?

Matt, I wish I would say yes to that, but the truth is that we don't. And the gentleman who did the study that we just mentioned, did exactly that. He looked at every patient that went back

for every reason, proactively, rather than waiting for a patient to, to develop symptoms and problems, and therefore was able to discern exactly rate of open defects was whether they were symptomatic or not.

If somebody has an acute cholecystitis, I'm just going to take the gallbladder out. However, I have seen situations where we've worked a patient up for gallbladder disease just to enter the abdomen and find, you know, the milky chylosocytes. And in that situation, you have to know as a bariatric surgeon that your gallbladder is not the problem.

They're probably having vague symptoms that are associated with an internal hernia. And the incidence of internal hernias even after gastric bypass in patients that had defect closure is about 0 8 percent relating to what the previous study said with 40 60 percent of defects opening at the time of any intra abdominal surgery and 4 18 percent of patients develop internal hernia where the defect is

not closed.

So, evidence does seem to to support closing those mesenteric defects during the initial operation. However, back to our patient, the ED. So say we're, we are suspicious of an internal hernia at this time, Dr. Martin, how do you determine how quickly they need to go back to the operating room? Is there any role for preoperative resuscitation or even waiting till the morning for an operation instead of say, you know, bring the team in if there's no one available at two or three o'clock in the morning?

Yeah. And I would say I, I pretty much 100 percent just base that on symptomatology. So, the patient that's still having pain, they should be going to the operating room. It doesn't matter if it's day or night, because that, that is potentially non viable bowel or development of non viable bowel. And these patients can lose most or even all their small intestine in a missed internal hernia or one where there's a delay to the OR.

Now,

do I rush every patient off at 3 a. m.? You know, if they came in with some vague abdominal pain and, you know, the CAT scan shows maybe some signs of a possible internal hernia, but their pain's gone, you don't need to take that in the middle of the night. You can put it on for the next day or the next several days.

But anybody with ongoing pain or other symptoms I believe at least you really should be taking them to the operating room as soon as possible. Yeah. And similarly, I try to be very judicious about it also. I think patients with internal hernias fall into two main categories. Those with the vague abdominal discomfort and symptoms and can be resuscitated and temporized until the morning and those who show clear signs of bowel ischemia.

I've had come in and found patients just sitting up in bed playing on their phone and I knew that. I would take care of it because I came in for it, but it may have been okay to do it in the morning. And I've seen patients come in by squat in the fetal position. But any

sign and symptom which suggests ischemia should warrant an emergent intervention as every single minute counts in such a situation.

I've seen that situation, and thankfully it wasn't one of the patient that I had performed the operation on, but. Someone who had gastric bypass about two decades ago who came in with essentially their entire small bowel ischemic. I see. That is that's never a position that you want to be in.

So it sounds like it's all based on the symptoms, but generally we will proceed to the operating room. more urgently. Is there any benefit for this patient as they're waiting to go back for a nasogastric tube for decompression? And if so, any tips and tricks on how to place it, just given their anatomy with a smaller gastric pouch?

Sometimes people can be hesitant in placing the nasogastric tube in those scenarios. Yeah, I'll just say generally I don't. If I need one, I'll place it in the OR usually when I'm looking at the gastric pouch. You have to remember it's a very small

gastric pouch. It can't hold that much fluid or food contents.

And if they're vomiting, it's mostly actually small bowel contents. It's reflexing up. And there are some risks, obviously, of iatrogenic injuries with the NG tube, so, so it's pretty rare that I would preoperatively place an NG tube in these patients. And also remember that a nasal esophageal tube is an option.

It's an option which will not affect or damage the pouch, but may decrease the possibility of aspiration at the time of intubation if there's a high grade obstruction. Okay, so for our patient, because she has worsening pain, we decide to take her back to the operating room for exploration. Dr. Dan, what is your approach to exploring the patient when they get in?

How do you enter? Sometimes they could have distended loops of bowel, and then what's your technique or process for examining? Sure. So of course you want to be very cautious when you have dilated bowel and

you're accessing the abdomen for a liposcopy. I personally am not a fan of the varus needle. I don't use it in any situation, but I think it would be particularly dangerous in this situation.

I typically start by placing a 12 millimeter trocar at Palmer's point, very close to costal margin to use as a counterpoint. And then I do two to three, five millimeter ports. in the midline and left hemiabdomen, maybe an assistant 5mm in the right upper quadrant. At this point, you have to have some kind of a plan.

I start by looking at the gastric pouch, making sure there's no perforation at the gastrojejunostomy. And I evaluate the rulem and run it towards the jejunojynostomy. Trying to evaluate Peterson space and the mesogenital defect. The biliopancreatic limb usually lies to the left and I follow that to the ligamentotroits.

Then I come back and run the common channel as far as I can with internal hernia. Sometimes that's not feasible.

I truly believe the greatest pearl in, in this situation is to start running a common channel from the sale of Trev's. retrograde toward the ligament of trites. And many times this will reduce the common channel that is incarcerated in one of the hernia defects.

Remember the salotrebs is always going to be in the same spot regardless of where the rest of the bowel is. But it's also important to remember that if that doesn't work and you can't make heads and tails out of what's going on, don't be afraid to to proceed to an open approach. And so Adrian, you, so you said a 12 millimeter trocar initially, do you mean OptiView entry or you're doing Hassan?

Up to view entry, very careful, more twisting than pushing very gentle counting every layer on the way in and then we have had very few issues with that technique. All right, we're in full agreement. I hate the various needle. I haven't assigned in 15 years. Yeah I like to have to view and I agree with everything you just said.

And again,

highlighting that most important point, because if there is a intro hernia at the J. J. mesentery, and it's torched. You'll run the Roux limb, and as you get to the JJ, it's a big knot, and no matter how hard you pull, you can't get it to untwist, and that's often when people who aren't experienced with this say, I can't make this out, I'm going to convert to open, and that's when I'll tell them, the resident or the fellow, okay, assume appendectomy position, go stare at the illicical valve, and then start running that common channel backwards, and usually what will happen is, So, They'll get to some dilated bowel that they'll keep running and all of a sudden something will flop around and they'll be at the JJ and it's now oriented correctly and you have no idea that you even reduce this big hernia.

And if it doesn't, then I think you got to worry about, okay, do I have a Peterson's defect or is it a retrocolic brew and I have a hernia through that retrocolic window. And Matt, I have to say you described it so well, I almost saw it happening in front of my eyes as you were, as you were

saying it. Okay, so we discussed previously the sites of possible herniation.

From your guys experience, what's the most common site and do you close them when you find them, say even ones that are not involved? In terms of the most common site, it does vary a little bit in the literature, but most of the studies show the jejuno jejunostomy mesenteric defect is most common, followed by Peterson's.

And then again, if you have a retrocolic root limb you can also get an interhernia through that retrocolic window. But I think most of us now have gotten to anticolic root limbs, so that's less common. And I will close any and all defects if I'm taking someone back for an interhernia. So even if they have a JJ interhernia, I'll close that defect and Peterson's.

It's interesting that you ask that, Paul, because that's changed. A long time ago, we didn't close any of those, thinking that, you know, if our colorectal colleagues don't close them, then we don't need to close them there because they don't seem to be having problems.

But back then, when we closed neither, the jejunal dejunal defect was the most common.

And I remember it was about 2017 when we were having a a journal club. My fellow at the time said, no, Peterson's is the most common. I've seen four or five and they've all been Peterson's. And sure enough, we began seeing a lot more Peterson's defects. And the reason for that is because we have started closing our jejunal defects.

And that's why Peterson's became the most common. One of my fellows actually got me a bell of shame that I keep in my office. And if I hear that anybody has a closed one, I ring the bell of shame. Yeah, and I think it's also part of that too is closing the JJ defect is pretty straightforward and familiar to any surgeon who does a small bowel anastomosis closing Peterson's.

It is a little more complex and I have seen many videos of, oh, we're closing Peterson's and I looked at the video and I'm like, that was not closing Peterson's because you really need to flip that transverse

colon up, get down to the actual mesentery. I mean, I see some people that what they're doing is they're attacking their rule in mesentery to the transverse colon anti mesentery wall.

That's not closing Peterson's. So that's probably another reason why that's becoming a more common site than the JJ. And I think the more you do it, the more familiar and comfortable you get with it. And it's important to keep in mind that when you do close the jejunal jejunostomy defect that you you avoid kinking at the jejunal jejunostomy.

Okay, so all defects will be closed, and thank you for the very descriptive technique and how to do it. But, to get into a little bit more of the weeds, what type of material do you use for the closure of these defects? Now, I've read a variety of different methods, maybe some more exotic than others, but, running or interrupted sutures, absorbable or non absorbable.

I've seen metal clips, glue, even some mesh placement in some papers. But how do you close

these defects? Yeah, and I'll say I evolved over time. I used to do a running 2 silk. I've now changed to a barbed suture, either V lock or Stratafix. I just think that makes it simpler, faster. I also think it's less likely to leaving gaps or loose areas because the suture doesn't back up on.

I just think it holds his position better. Yeah, I agree. My technique has evolved over the years. Also, I used to do interrupted silks, interrupted filigree, ethebans, and now I'm really intrigued by the efficiency and the effectiveness of the permanent barbed sutures. You just have to make sure that you trim it small so that it doesn't cause other problems.

Those have been known to be associated with bowel obstructions when a long tail is left in place. So there was also a study with a mean follow up of three years that looked at some of the differences in these materials

and defect closure. It included 331 patients undergoing. Gastric bypass, 157 underwent closure with interrupted sutures, while 174 underwent closure with a running suture.

There was significant lower rate of internal hernias in patients with mesenteric defects closed with a running technique compared to the interrupted technique, but there was no difference when looking at the differences between suture materials. And another study from the Scandinavian Obesity Surgery Registry, also known as SOREG, looked at the use of metal clips and running non absorbable suture compared to non closure in over 34, 000 patients.

And over 19, 000 patients had mesenteric defects closed with metal clips and over 6, 000 with non absorbable sutures. Matt, are you familiar with that study? Oh, yeah. Their primary endpoints, they looked at 30 day complications and small bowel obstruction at five

years. And they actually found there was no difference in 30 day complications with closure versus non closure.

But both sutures and clips had lower rates of small bowel obstruction compared to non closure. And I think now that that's been pretty consistent in that, that literature and other studies. Yeah, and the authors concluded both clips and sutures were safe, and they were both effective, although sutures appear to be slightly more effective.

I Have seen some of those other unique methods. I think most people have abandoned those just for straight up suture, but things like fiber and glue Or to seal mesh and mesh reinforcement over a nonabsorbent suture closure. I had one partner who for a while was bovie pad scratching the mesentery at the site and counting on that to close the defect.

But, but I think now the evidence pretty much just support straightforward suture closure. Got it. So all defects for this lady were closed with, say with sutures and, you know, high fiving in the OR, none of

the bowels dead. We can, we close and she's going to the PACU now to the floor.

What are some of your post operative protocols for these patients? Do you leave a nasogastric tube in? Do you start them on clears? And is there any evidence for routine post op imaging? For the non complicated patient, meaning we, we didn't have to do a bowel resection, there wasn't a perforation, we found an internal hernia, it was the cause of their symptoms or their restructuring, we reduced it, we closed the defects, we pretty much treat all these.

With the standard ERAS protocol, they get multimodal pain medication. I would just start them on clears immediately, unless they had significantly dilated bowel and were worried about an ileus. We try to minimize narcotics in these patients and again, as long as we say laparoscopic, I think now that's, that's very possible and treat them really just like now we treat most of our primary bariatric patients.

And I definitely don't do any routine post op imaging, you

know, to confirm what we actually saw with our own eyes. Yeah, I certainly agree with all that and our protocol is quite similar. In most patients, when surgical intervention has taken place prior to any ischemia of the bowel, reducing the hernia to relieve the obstruction and closure of that defect to prevent recurrence translate into a pretty fast recovery and a balanced post bariatric diet can be achieved pretty quickly.

If a post operative ileus is expected we may advance the diet in a stepwise manner, a slower manner as tolerated by the patient. And discharge criteria, I think, are probably pretty consistent between, you know, being able to eat. Have bowel movements, pass gas, walking around, pain is controlled.

Operate, standard for a typical post operative patient. But kind of turning a little bit, if I could introduce a different scenario, one that I think probably causes many residents and maybe a good number of attendings some concern. Say if our initial

patient who came in with abdominal pain was 20 weeks pregnant, would that change your management at all?

Absolutely. And this is one of those situations they usually get a call in the middle of the night, have a hard time sleeping the rest of the night, particularly with a patient that's at that point in pregnancy where the fetus may not be able to survive with a delivery. My management may include an evaluation of the fetus with ultrasound and fetal heart tones to confirm the viability, but otherwise I would continue the same workup and we'll try to expedite going to the operating room more urgently.

If there was any suspicion of internal hernia, is a delayed diagnosis that results in ischemia of the bowel can be detrimental to both the mother and the fetus? Yeah, I'd say this is consistent with, you know, most of the literature of any acute surgical issue in pregnant patients. Take them to the O. R.

Trimester generally doesn't matter. You're more at risk of

harm to the mother and the fetus by delaying your intervention for that acute process than any risk of surgery. These patients can be difficult. There's often a concern about imaging the, I'll tell you the worst small bowel loss. A case I actually saw was in a pregnant patient and there was a major delay because of concern of imaging because the patient was pregnant and ended up losing essentially their entire small bowel, lost the fetus because of the dead bowel and, you know, all because of a major delay in diagnosis.

The exposure at that point is minimal again, once the fetus, if they're past the first trimester, there's really no direct risk to the fetus. There is that small risk of future cancers, but again, I think that's significantly outweighed by your concern for missing something like an internal hernia. In this situation, the pathology is related to increased intra abdominal pressure from the growing uterus and the

fetus.

It's important to have a preoperative discussion with patients of childbearing age at the time of initial bariatric evaluation. Because if a patient is seeking a gastric bypass procedure and they're also intending to start a family or be pregnant It's important for them to understand that there's an increased risk for internal hernia not only with gastric bypass, but with gastric bypass and pregnancy.

Yeah and later in the course of the pregnancy, late second, third trimester, also, it also decreases the ability of your CAT scan to make that diagnosis, right? Because everything's displaced and compressed. So, so it also decreases your diagnostic yield of that study. Got it. Thank you. I know, I know every time I hear that, you know, patient is completely, you know, pregnant with complaints of abdominal pain, it always send shivers down my spine.

It's good to keep in mind, though, the appropriate courses are just standard evaluation

for. each patient. And to round out the management of this clinical scenario, so say you're seeing a post gastric bypass patient in your clinic that's having chronic abdominal pain with intermittent nausea. How do you differentiate this as a normal post operative course versus something that's pathologic?

And is there anything in their history that would lead you to pursue diagnostic imaging? Yeah. So, so again, I want here, I think their time course. So, how long has it been since the bariatric surgery? Because that also helps guide, you know, if it's the first couple months. After the bariatric surgery, you're worried about things like a, you know, a marginal ulcer that they could have a leak if it's in the first four weeks.

The internal hernia part usually will happen later, six months to many years later. And especially with a large amount of weight loss when those defects open back up. So that patient, that's where, again, a chronically incarcerating internal

hernia becomes higher on my diagnosis. So that patient, I would pretty rapidly work them up.

And really, I think the big differential, like we talked about, would be, is this an internal hernia? Could this be a peptic ulcer, marginal ulcer? Or could this be gallbladder symptoms? If all of that is suspicious, then you talk to the patient about taking him to the operating room and doing a diagnostic laparoscopy.

It is important to remember that at least half of patients who do have intrahernias present. in the outpatient setting. They don't all come to the ER with a small bowel obstruction. Yeah, the diagnostic acumen of an experienced clinician is very important and it will guide the workup. There's a lot of tests that are available to you, but you try not to take a shotgun approach.

Try to look at the timing after surgery. Internal hernias and obstructions from them are typically not seen in the immediate post op period, but you know, we have seen them. But you know, you've got a gamut of tests that you can get depending on what you're suspicious for. Of course, a

CT will tell you a lot about everything.

An upper GI with small bowel fault through an endoscopy, a ultrasound of the right upper quadrant, all those can be helpful. But if your entire workup is negative and all other culprits are excluded, we arrive at the same final common pathway of diagnostic laparoscopy. And if patient continues to have chronic pain unexplained, that's what I will resort to.

Yeah, and I'd say remember too, you can You can do more than one thing. I have seen these patients delayed of, Oh, we got to get them, we got to get a scope. And, you know, if we don't do our own scopes, GI's got to schedule them and then they got to get this. So remember, you can take them to the OR. You can do a diagnostic laparoscopy.

You can do an on table upper endoscopy. And then you're kind of prepared for everything. We'll often take these patients to the OR, diagnose laparoscopy, do an upper endoscopy to make sure it's not a marginal ulcer. And then we'll be prepared to do a cholecystectomy. Because if you go in there and you find no internal hernia, then

you got to start looking for other sources of their pain.

I don't know what your approach is, Adrian. You put scope in and there's no internal hernia. Yeah, so I'm not quite as liberal about the colicistectomy unless there's some kind of pathology, but a lot of times, you know, symptoms will get better. The changes, the physiological and anatomic changes could lead to symptoms also that will improve.

I think the main goal of my diagnostic laparoscopy is to rule out an internal hernia, which is potentially catastrophic. Yeah, and I'd say to keep in mind, if you do go in there and you don't find any internal hernia and you're looking for sources, look at your GJ, look at your JJ, see if you have a really long candy cane limb at either of those.

Those could be a potential cause. And then really look at your jejunot, jejunostomy for any signs of intussusception. That's probably the other mimic of an internal hernia that's easy to miss because they can have a chronic intermittent segment that's in a susception, in a suscepting and then

spontaneously reducing.

And one other thing in your differential diagnosis, especially years out especially with the triple staple jejunor jejunostomy technique there's a predisposition of that bowel to dilate because it's already dilated and given the law of Laplace, something that's dilated will continue to dilate and thin out.

And that jejunor jejunostomy in and of itself could intermittently torse and place a twist onto the mesentery and give those intermittent symptoms. But Dr. Dan, I think you hit the nail on the head. It's the good clinical exam by an experienced surgeon to evaluate the patient in both settings to allow for the appropriate and best outcome in these situations.

But to summarize some of the stuff that we had spoken about, I know we've touched on a variety of different things. If a patient comes in with a previous gastric bypass, you always need to maintain a high index of suspicion for an internal

hernia. A good history, labs, and CT scan are the best way to, to evaluate these patients.

But if you're suspicious, regardless of what those show, a diagnostic laparoscopy is going to be the preferred approach. And having a standardized approach to the intra abdominal evaluation is important. Patients that are pregnant, Have a standardized approach to the typical patient and having as well a low threshold for further evaluation of patients with this chronic abdominal pain in the outpatient setting is important as well.

Yeah, and one thing I'll add to, we talk about this with gastric bypass, but it's any anastomotic bariatric procedure that involved a small bowel anastomosis. Sleeves, you don't have to worry about interharnia, but the other ones, yes. All right, well that was a great discussion. I think the only thing we have left is who wants to say it?

We can have the listeners vote on who said it best. All right, so Paul. And don't forget to dominate the day.

Adrian. Dominate the day. All right, and this is the Bariatric team for Behind the Knife, and as Scott Steele would say, dominate the day.

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