Okay, welcome back to Behind the Knife. This is part two of bariatric emergencies for the general and acute care surgeon.

Again, I'm Jason Bingham, I'm a bariatric surgeon. I'm joined by John McClellan who is a trauma and critical care surgeon.

Behind the Knife, the surgery podcast where we take a behind the scenes intimate look at surgery from leaders in the field.

Now we're moving on to something that general surgeons are very well versed in is small bowel obstructions, specifically following gastric bypass. So in these patients, you'll see the incidence of these obstructions after bypass or perhaps shows you up to like five percent, they can be caused by a lot of different things, including internal hernia, which is predominantly the largest cause or the most scary cause. So it's about almost 50% of all

all the small bowel obstructions, adhesions, interception, these or an interim of blood clot, which actually is my favorite one. So Jason, tell me about internal hernia. So how do we how do we manage these patients?

Yeah, so this is why it's really important when I was said, you know, you got to understand the basic anatomy of the different bariatric procedures, you know, I've lost track of how many times I've gotten called from a, you know, an ER somewhere with like a sleeve patient who they're concerned about internal hernia.

And it just tells me we need to do a little bit of better job of educating our colleagues about some of the different complications after bariatric surgery.

Obviously with a sleeve, you don't have any Bessenteric defects, you know, they can have all the other reasons for a bowel obstruction and adhesions, a lot of those different things you mentioned, but internal hernia is not one of them. And even with a gastric bypass, there's different ways of constructing that, right?

So again, did they go retrocollect when they constructed it? They go antric collic. That's going to affect where your different mesenteric defects are. So, you know, we can, you can have your Peterson's defect, you can have your defect at your J or you can have your defect through your transverse musical and when you do your, you know, retrocollect, gastrogeogenoscomy, all those are potential spaces to form an internal hernia.

So I think we'll kind of address these kind of one by one. You mentioned a lot of different reasons why you can have internal hernia have the small bowel obstruction after gastric bypass.

For a hernia, you know, adhesions, interception, you know, phytobies or internal blood clot.

The key thing, the overarching thing to remember here, though, is, is what's different about a bypass patient versus any other patient that comes in with a small bowel obstruction is, is, you can't always decompress them with an NG tube.

So you need to look at that CT scan. You really need to look closely at that BP limonet remnants stomach because the risk is if you have a obstruction that's of that BP limb and their remnants of it is big and dilated.

Don't just put in it say don't manage these like you would a your standard small bowel obstruction where they're otherwise stable. You put in an NG tube and you decompress them. You can't access that that that bypass limb. So you're at risk for, you know, blowing out their remnants stomach.

Which is is really a disaster. So that's why we have to be very have a very low threshold for surgical exploring these patients, especially if they have dilation of their BP limb.

So is it safe to say that every single patient it comes in with, you know, dilation of the BP limb and a concern for small bowel obstruction should be explored.

I'm going to say yes. There's obviously some nuance to that.

Certainly on a board scenario, absolutely. You know, what are you doing with these things a lot, you know, there's, there's, you know, and you think you, it depends on what's going on, right?

Like so I had a patient a week ago that came in with some Epic gastric pain, had a little bit of a dilated of their gastric remnant, but it looked like they had a GG fish and that was the reason.

So, you know, you kind of have to be an expert in reviewing the CT scans. Nobody knows the anatomy better than the surgeon. So don't rely upon your radiologists.

Our radiologists are great, but they've never, you have to have been there a few times inside the admin to see this anatomy to really understand and be able to adequately interpret that CT scan.

So in answer to question, have a little threshold air on the side of going poppinscope in at the very least and taking a look around. Yes.

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