title: Retrospective analysis of abdominal pain in postoperative laparoscopic Roux-en-Y gastric bypass patients: is a simple algorithm the answer?
abstract: BACKGROUND
  Patients who have undergone laparoscopic gastric bypass have a high risk of developing an internal hernia. Most patients present 9-18 months postoperatively with a weight loss of 75-120 lb and pain out of proportion to the physical findings. Given the risks of internal hernias and the difficulty in radiologic diagnosis, we have developed a single algorithm to avoid the triage complication of a "missed" diagnosis.
  
  
  METHODS
  A retrospective review was performed of 1500 bariatric procedures performed from 2001 to 2006, 33% (laparoscopic Roux-en-Y gastric bypass) of which were performed using an antecolic antegastric Roux limb, with all potential defects, including Peterson's, closed. Of these 1500 patients, 75 were evaluated for abdominal pain to rule out an internal hernia.
  
  
  RESULTS
  Of the 75 patients, 40 had signs of an internal hernia or abdominal obstruction on computed tomography and underwent laparoscopy. The operative time was 38-45 minutes, and the length of stay was 1.5 days. The remaining 35 patient's computed tomography scans were interpreted as "no evidence" of internal hernia or obstruction. Of the 35 patients, 29 underwent diagnostic laparoscopy and had either an internal hernia or critical adhesions. Thus, 69 patients (92%) underwent diagnostic laparoscopy. In 6 patients, the symptoms resolved completely without any surgical intervention.
  
  
  CONCLUSIONS
  At our institution, patients who undergo laparoscopic Roux-en-Y gastric bypass with a weight loss of 75-120 lb undergo computed tomography with contrast to rule out other potential nonoperative causes. Also, unless clinically stable or the patient has complete resolution of their pain, they then undergo laparoscopy for evaluation.
authors.affiliation: Department of Surgery, North Shore University Hospital, Manhasset, New York 11030, USA. eagaba@gmail.com
authors.forename: Emmanuel A
authors.initials: EA
authors.lastname: Agaba
authors.forename: Charmaine V
authors.initials: CV
authors.lastname: Gentles
authors.forename: Hazem
authors.initials: H
authors.lastname: Shamseddeen
authors.forename: Venketesh
authors.initials: V
authors.lastname: Sasthakonar
authors.forename: Anuj
authors.initials: A
authors.lastname: Kandel
authors.forename: Dominick
authors.initials: D
authors.lastname: Gadelata
authors.forename: Larry
authors.initials: L
authors.lastname: Gellman
mesh_terms: D015746:Abdominal Pain / Q000175:diagnosis / Q000209:etiology*; D000328:Adult; D000465:Algorithms; D016099:Endoscopy, Gastrointestinal; D005260:Female; D005500:Follow-Up Studies; D015390:Gastric Bypass / Q000009:adverse effects* / Q000379:methods; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009765:Obesity / Q000601:surgery; D010147:Pain Measurement; D010149:Postoperative Pain / Q000175:diagnosis / Q000209:etiology*; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome