Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 674 - файл
.pdf
Nonspecic Abdominal Pain
https://t.me/medicina_free
Fig. 1 Flowchart for nonspecic acute abdominal pain
273
2 First Stage: Baseline Investigations
A thorough physical examination is recommended as the rst step in the diagnostic
assessment of acute abdominal pain. Traditionally, based on medical history, physical examination, and laboratory parameters, a physician would decide whether
additional investigations are necessary or not. However, it has been demonstrated
that clinical evaluation may not be highly accurate and specic in the diagnosis of
NSAP.Likewise, diagnostic adjuncts such as laboratory studies seem to not signicantly increase the diagnostic accuracy. The literature demonstrates how the diagnosis based on medical history and physical examination is correct in no more than
43–59% of patients with abdominal pain [18–20]), while the rate of correct diagnosis with the adjunct of laboratory parameters ranges between 46 and 48% [18, 21,
22]). The diagnostic accuracy increased when urgent and nonurgent conditions
were differentiated as primary outcome. A correct anamnesis, physical examination, and laboratory values showed high sensibility for urgent and nonurgent differentiation while low specicity for a specic diagnosis [21].
The diagnosis of acute NSAP has been highly discussed throughout the years,
and many suggestions have been formulated. In 1990, Lavelle and Kanagaratnam
introduced usefulness index test for the assessment of usefulness of clinical observations [23, 24]. DeDombal et al. have suggested that the proportion of correct
diagnoses can be greatly increased by the use of structured questionnaires and diagnostic programs on computer [25]. However, although computer-aided diagnosis
274
https://t.me/medicina_free
can improve diagnostic rates by at least 20%, these programs are unpopular. In addition, no scoring systems that increase diagnostic accuracy were found for patients
with acute abdominal pain. Several factors have been reported to possibly contribute to a low accuracy. First of all, performing a proper physical examination and
collecting sufcient information could be difcult in patients belonging to extreme
age groups (pediatric and elderly population). Furthermore, an interobserver difference in the diagnostic accuracy has been reported. In daily practice, the resident rst
examines the patient, while staff members will examine the patient afterward, usually when the imaging has been already done [18].
The agreement between residents and staff is generally moderate for several
aspects of medical history and physical examination (κ= 0.29–0.74) [9, 10]. The
agreement between residents and emergency physicians for additional diagnostic
imaging is sufcient (κ=0.6) [26].
Generally, residents and tutors are moderately in agreement regarding the anamnestic assessment of the patients as well as regarding the physical examination,
while the agreement on additional diagnostic imaging is considered to be sufcient.
Research of differences in diagnostic accuracy between residents and specialist
physicians is hampered by a methodological difculty. The presentation can change
over time, and so it can differ between the time of examination. This variability
could inuence the reliability of the comparison. For these reasons, some authors
have suggested the opportunity to have preliminary examinations carried out by two
different observers, ideally under the same circumstances. Outpatient reevaluation
of those ones suspected of nonurgent conditions led to a change in diagnosis in 35%
of patients after clinical reevaluation, a change in management in 19% of cases, and
a change from conservative to surgical treatment in 4.5% of patients [18, 27].
Moreover, outpatient reevaluation of patients suspected of nonurgent conditions
after clinical evaluation and the performance of ultrasound led to a change in diagnosis in 18% of cases, change in management in 13%, and a change from conservative to surgical treatment in 3% of patients [18, 27].
G. Gallo et al.
3 Second Stage: Imaging Studies
Since the rst step of examination is often insufcient to reach a diagnosis, additional imaging modalities could be used to increase diagnostic certainty. Several
imaging modalities such as conventional (plain) radiography, ultrasound, CT scan,
and magnetic resonance imaging (MRI) have been increasingly used over the years
[4, 18]. Plain abdominal radiographs have played fundamental, even though controversial, roles in the assessment of NSAP.Some institutions still propose the use of
a combination of plain chest radiography and the upright and supine plain abdominal radiographs as known as the acute abdominal series (AAS), as the rst radiological screening in all patients with abdominal pain [4, 18]. The purpose of
GAPEDES phase 1 study was to determine whether it was possible to derive a
sensitive, easy to run, and reproducible clinical guideline for the evaluation of
Nonspecic Abdominal Pain
https://t.me/medicina_free
275
NSAP using history, physical examination, commonly available laboratory studies,
AAS, and NHCT as potential inputs [6]. However, this guideline demonstrated low
sensitivity and accuracy, not higher than 56% [18, 21, 28]. Indeed, it could be misleading in the workup of acute abdominal pain [29, 30]. Concerning the ultrasound
(US) examination, the rate of correct diagnosis ranges from 53 to 83% of cases,
according to the literature [21, 31–33]. Not surprisingly, when compared with computed tomography, the sensitivity and specicity of ultrasound are denitely lower.
However, ultrasound is widely available, cheap, and easy to run; also, during on-call
hours, it carries no risk of ionizing radiation exposure or contrast-induced nephropathy, despite having a major drawback in the possibility of interobserver variability.
Previous studies have demonstrated how an early use of CT in the diagnostic
workup of acute abdominal pain has led to a correct diagnosis in 96.8% of cases [4,
34], when combined with the previous investigations. Ideally, except for few
patients, such as children or pregnant women, in which US or MRI should be considered the method of choice, CT should be considered the gold standard to guide
treatment and avoid harmful delays [21, 30].
It is important to remember that computed tomography has major downsides
such as the risk of contrast-induced nephropathy and exposure to ionizing radiation.
The steering group advises the use of intravenous contrast in preference to other
methods of contrast administration. Oral contrast administration delays computed
tomography for hours, and other methods of contrast administration provide little
additional information. However, the use of intravenous contrast media could lead
to contrast-induced nephropathy (CIN) even if this evidence is based on studies with
intra-arterial contrast administration. More recent studies have demonstrated that
the risk of CIN is minimal when the eGFR (glomerular ltration rate) is above
45mL/min/1.73m2 [35–37]. Preventive measures such as prehydration can decrease
the risk of CIN.In daily practice, this might not be possible for every patient. In
urgent situations, correctly diagnosing the underlying pathology (and subsequently
earlier start of treatment) is more important than the possible risk of CIN.Therefore,
computed tomography can be performed without preventive measures and without
prior ultrasound in critically ill patients [18].
Due to the downsides of CT, an ultrasound is still preferred as the rst imaging
modality. Only in critically ill patients, a computed tomography should be performed without a prior ultrasound; in other cases, a CT scan is recommended only
when the ultrasound is negative or inconclusive [18, 21].
No trials have been performed analyzing the diagnostic value of MRI in patients
with acute abdominal pain. Nowadays, some studies have demonstrated that MRI is
sufciently accurate to diagnose appendicitis and diverticulitis [18, 38, 39]. The
advantage of MRI over computed tomography is that no administration of contrast
media is necessary and that there is no ionizing radiation exposure. The downside is
that MRI scanners are not yet widely available and that the assessment of MRI
images needs specic training [40]. For pregnant women with a suspicion of an
urgent cause, an MRI should be contemplated, because of the serious consequences
of a missed diagnosis [18, 38, 39].
276
https://t.me/medicina_free
It has to be noted that, although the advanced utilization of modern imaging did
not decrease the rate of NSAP, the rate of emergency surgery in NSAP was greatly
decreased from 4% to 0.5% [15].
G. Gallo et al.
4 Wait andSee Policy
Hospitalization followed by active clinical observation, traditionally dened as
“wait and see,” has been the most widely used method in the clinical management
of patients with nontypical clinical signs. The predictive value of clinical diagnosis
reached with this method, which varies with the underlying cause, has been estimated between 68 and 92% [14].
Previous studies demonstrated how approximately half of the patients admitted
for observation is likely to undergo a surgical procedure during the rst admission.
However, on the one hand, this method entails risks for the patients because of
possible complications such as peritonitis, hemorrhage, or infertility; on the other
hand, laparotomy might be unnecessarily performed [16, 41].
A recent RCT (randomized controlled trial) demonstrated how patients who
underwent delayed laparoscopy had a mean operative time equal to the mean operative time in early laparoscopy group, and there was no higher morbidity nor mortality. Therefore, the authors concluded that delaying surgery in NSAP patients does
not increase operative risks or jeopardize clinical results.
Furthermore, this kind of approach could help avoiding unnecessary surgical
procedures under general anesthesia [14, 45], and although patients treated by early
laparoscopy had a shorter hospital stay (3.7 vs. 4.7days) and more accurate diagnosis (83% vs. 45%), the greater accuracy did not show clear clinical benets (recurrent pain at 12months: 16% vs. 25%, not signicant) [42].
In other words, delaying the decision to submit patients with persistent symptoms and without a denite diagnosis to a laparoscopy of 24–72h from admissions
could reduce the number of unnecessary surgical operations.
5 Third Stage: Diagnostic Laparoscopy
So far, if the diagnosis remains uncertain or CT is not accessible, the next step in the
management of NSAP should be represented by diagnostic laparoscopy (DL).
The available studies on the value of diagnostic laparoscopy in case of NSAP
have enrolled patient samples not representative for the current clinical practice.
These studies have not included preoperative imaging in the diagnostic assessment.
Few RCTs compared the role of early laparoscopy with the traditional “wait and
see” approach in the management of NSAP [13, 14, 43].
Two of these studies presented at least one major limitation, such as the limited
number of patients, [13] insufcient preoperative evaluation, [43] and enrolling
both males and females. Furthermore, in these studies, the diagnostic laparoscopy
itself is used as reference diagnosis.
Nonspecic Abdominal Pain
https://t.me/medicina_free
Another RCT focused on acute right iliac fossa pain in young women and
concluded that, on the one hand, early laparoscopy results in a higher number of
denite diagnosis and in a shorter hospital stay when compared with active
observation. On the other hand, morbidity, mortality, and costs are similar [14].
In addition, in patients submitted to laparoscopy, the policy to remove the
appendix, if no other clear causes of pain were found, was adopted in accordance with the data showing that the external inspection of the appendix at laparoscopy is an unreliable nding for the presence of appendicitis [14, 44].
Greason etal. [44] showed that routine appendectomy during diagnostic laparoscopy does not increase morbidity and does not prolong hospital stay.
However, the study clearly showed that removing a “normal looking” appendix
has a limited clinical role when the follow-up is adequate.
The actual literature has demonstrated that, in selected patient populations where
no prior diagnostic imaging has been performed, a diagnostic laparoscopy can accurately diagnose the cause of the abdominal pain in 80–94% of patients [14, 18, 41,
43]. Postoperative complications have been reported in 3.5–25% of patients after
diagnostic laparoscopy [18, 41, 42, 44, 45].
Contraindications for DL do not differ from the ones for exploratory laparotomy,
except for patients unable to tolerate pneumoperitoneum and those with a tense and
distended abdomen (i.e., clinically suspected abdominal compartment syndrome)
[14, 46].
In the past few years, imaging modalities have signicantly improved in diagnostic accuracy. Treatment of the causes of acute abdominal pain has been modied thought the years and it does not always involve a surgical approach.
Compared with imaging modalities, diagnostic laparoscopy has a higher risk of
complications.
Reported complications range from severe complications such as septic shock
and enterocutaneous stula to wound infections.
Therefore, based on the current literature, no conclusions can be drawn on the
added value of a laparoscopy in the diagnostic pathway of patients with acute
abdominal pain. However, laparoscopy should not be used in the diagnostic pathway of patients when no sufcient prior imaging has been performed. Only in
patients with a high suspicion of an underlying life-threatening cause, with inconclusive imaging, a DL could be contemplated.
277
6 Conclusions
Although attempts have been made toward developing consensus guidelines and
diagnostic algorithms, no prospective evidence-based clinical guidelines for the
exclusion of NSAP have been developed or validated to date [4, 14, 18]. The neces-
sity to achieve a correct diagnosis and a systematic approach to NSAP should be
useful in order to reduce the admission rate for NSAP because of the costs and
morbidity associated with this condition in terms of excessive hospital stay, multiple
investigations, and unnecessary surgical explorations [4, 14, 18]. In other words,
278
https://t.me/medicina_free
G. Gallo et al.
what Poulin etal. wrote still remains actual: “management of acute NSAP needs to
be periodically adjusted to get the best outcomes at the lowest costs and with the
least invasive and most appropriate diagnostic tools” [46].
Conict of Interest All authors declare no personal conict of interest.
Ethical Approval Not required.
References
1. Sheridan WG, White AT, Havard T, Crosby DL.Non-specic abdominal pain: the resource
implications. Ann R Coll Surg Engl. 1992;74(3):181–5.
2. Lewis FR, Holcroft JW, Boey J, Dunphy JE.Appendicitis: a critical review of diagnosis and
treatment in 1000 cases. Arch Surg. 1975;110:677–84.
3. Alvarado A.A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med.
1986;15:557–64.
4. Carlucci M, etal. Nonspecic abdominal pain. In: Emergency laparoscopy. Cham: Springer;
2016. p.73–8.
5. Cervellin G, Mora R, Ticinesi A, Meschi T, Comelli I, Catena F, Lippi G.Epidemiology and
outcomes of acute abdominal pain in a large urban emergency department: retrospective analysis of 5,340 cases. Ann Transl Med. 2016;4(19):362. https://doi.org/10.21037/atm.2016.09.10.
6. Gerhardt RT, Nelson BK, Keenan S, Kernan L, MacKersie A, Lane MS.Derivation of a clinical guideline for the assessment of nonspecic abdominal pain: the guideline for abdominal pain in the ED setting (GAPEDS) phase 1 study. Am J Emerg Med. 2005;23(6):709–17.
https://doi.org/10.1016/j.ajem.2005.01.010.
7. Irvin TT. Abdominal pain: a surgical audit of 1190 emergency admissions. Br J Surg.
1989;76(11):1121–5.
8. Brewer RJ, Golden GT, Hitch DC, etal. Abdominal pain—an analysis of 1000 consecutive
cases in a university hospital emergency room. Am J Surg. 1976;131:219–23.
9. Adams ID, Chan M, Clifford PC, etal. Computer aided diagnosis of acute abdominal pain: a
multicentre study. BMJ. 1986;293:800–4.
10. De Dombal FT.The OMGE acute abdominal pain survey. Progress report, 1986. Scand J
Gastroenterol. 1988;23:35–42.
11. American College of Emergency Physicians. Clinical policy for the initial approach to patients
presenting with a chief complaint of nontraumatic acute abdominal pain. Ann Emerg Med.
1994;23(4):906–22.
12. American College of Emergency Physicians. Clinical policy: critical issues for the initial evaluation and management of patients presenting with a chief complaint of nontraumatic acute
abdominal pain. Ann Emerg Med. 2000;36:406–15.
13. Decadt B, Sussman L, Lewis MP, etal. Randomized clinical trial of early laparoscopy in the
management of acute non-specic abdominal pain. Br J Surg. 1999;86:1383–6.
14. Morino M, Pellegrino L, Castagna E, Farinella E, Mao P.Acute nonspecic abdominal pain: a
randomized, controlled trial comparing early laparoscopy versus clinical observation. Ann Surg.
2006;244(6):881–6; discussion 886–8. https://doi.org/10.1097/01.sla.0000246886.80424.ad.
15. Fagerström A, Paajanen P, Saarelainen H, Ahonen-Siirtola M, Ukkonen M, Miettinen
P, Paajanen H. Non-specic abdominal pain remains as the most common reason for
acute abdomen: 26-year retrospective audit in one emergency unit. Scand J Gastroenterol.
2017;52(10):1072–7. https://doi.org/10.1080/00365521.2017.1342140. Epub 2017 Jun 28.
16. Paterson-Brown S.Emergency laparoscopy surgery. Br J Surg. 1993;80(279–283):3.
Nonspecic Abdominal Pain
https://t.me/medicina_free
17. Ferlander P, Elfström C, Göransson K, von Rosen A, Djärv T.Nonspecic abdominal pain in
the Emergency Department: malignancy incidence in a nationwide Swedish cohort study. Eur
J Emerg Med. 2018;25(2):105–9. https://doi.org/10.1097/MEJ.0000000000000409.
18. Gans SL, Pols MA, Stoker J, Boermeester MA, Expert Steering Group. Guideline for the diagnostic pathway in patients with acute abdominal pain. Dig Surg. 2015;32(1):23–31. https://doi.
org/10.1159/000371583. Epub 2015 Jan 28.
19. Kraemer M, Yang Q, Ohmann C.Acute Abdominal Pain Study Group: classication of subpopulations with a minor and a major diagnostic problem in acute abdominal pain. Theor Surg.
1993;8:6–14.
20. Hancock DM, Heptinstall M, Old JM, Lobo FX.Computer aided diagnosis of acute abdominal
pain. The practical impact of a ‘theoretical exercise’. Theor Surg. 1987;2:99–105.
21. Lameris W, van Randen A, van Es HW, van Heesewijk JP, van Ramshorst B, Bouma WH, etal.
Imaging strategies for detection of urgent conditions in patients with acute abdominal pain:
diagnostic accuracy study. BMJ. 2009;338:b2431.
22. Laurell H, Hansson LE, Gunnarsson U.Diagnostic pitfalls and accuracy of diagnosis in acute
abdominal pain. Scand J Gastroenterol. 2006;41:1126–31.
23. Eskelinen M, Lipponen P. Usefulness index in nonspecic abdominal pain—an aid in the
diagnosis? Scand J Gastroenterol. 2012;47(12):1475–9. https://doi.org/10.3109/00365521.201
2.733951. Epub 2012 Oct 24.
24. Lavelle SM, Kanagaratnam B.The information value of clinical data. Int J Biomed Comput.
1990;26:203–9.
25. de Dombal FT, Leaper DJ, Staniland JR, McCann AP, Horrocks JC.Computer-aided diagnosis
of acute abdominal pain. Br Med J. 1972;2(5804):9–13. https://doi.org/10.1136/bmj.2.5804.9.
26. Pines J, Uscher Pines L, Hall A, Hunter J, Srinivasan R, Ghaemmaghami C.The interrater
variation of ED abdominal examination ndings in patients with acute abdominal pain. Am J
Emerg Med. 2005;23:483–7.
27. Toorenvliet BR, Bakker RF, Flu HC, Merkus JW, Hamming JF, Breslau PJ.Standard outpatient re-evaluation for patients not admitted to the hospital after emergency department evaluation for acute abdominal pain. World J Surg. 2010;34:480–6.
28. MacKersie AB, Lane MJ, Gerhardt RT, Claypool HA, Keenan S, Katz DS, etal. Nontraumatic
acute abdominal pain: unenhanced helical CT compared with three-view acute abdominal
series. Radiology. 2005;237:114–22.
29. Heesewijk JP, van Ramshorst B, Bouma WH, et al. Imaging strategies for detection
of urgent conditions in patients with acute abdominal pain: diagnostic accuracy study.
BMJ. 2009;339:b2431.
30. van Randen A, Lamris W, Luitse JS, Gorzeman M, Hesselink EJ, Dolmans DE, et al. The
role of plain radiographs in patients with acute abdominal pain at the ED.Am J Emerg Med.
2011;29:582–589.e2.
31. Lindelius A, Trngren S, Sondn A, Pettersson H, Adami J.Impact of surgeon-performed ultrasound on diagnosis of abdominal pain. Emerg Med J. 2008;25:486–91.
32. Allemann F, Cassina P, Rthlin M, Largiadr F.Ultrasound scans done by surgeons for patients
with acute abdominal pain: a prospective study. Eur J Surg. 1999;165:966–70.
33. Nural MS, Ceyhan M, Baydin A, Genc S, Bayrak IK, Elmali M.The role of ultrasonography
in the diagnosis and management of non-traumatic acute abdominal pain. Intern Emerg Med.
2008;3:349–54.
34. Wilson DH, Wilson PD, Walmsley RG, etal. Diagnosis of acute abdominal pain in the accident
and emergency department. Br J Surg. 1977;64:250–4.
35. Katzberg RW, Newhouse JH. Intravenous contrast medium-induced nephrotoxicity: is the
medical risk really as great as we have come to believe? Radiology. 2010;256:21–8.
36. Rudnick M, Feldman H. Contrast-induced nephropathy: what are the true clinical consequences? Clin J Am Soc Nephrol. 2008;3:263–72.
37. Rao QA, Newhouse JH. Risk of nephropathy after intravenous administration of contrast
material: a critical literature analysis. Radiology. 2006;239:392–7.
279
280
https://t.me/medicina_free
38. Heverhagen JT, Zielke A, Ishaque N, Bohrer T, El-Sheik M, Klose KJ.Acute colonic diverticulitis: visualization in magnetic resonance imaging. Magn Reson Imaging. 2001;19:1275–7.
39. Leeuwenburgh MM, Wiarda BM, Wiezer MJ, Vrouenraets BC, Gratama JW, Spilt A, et al.
Comparison of imaging strategies with conditional contrast-enhanced CT and unenhanced MR
imaging in patients suspected of having appendicitis: a multicenter diagnostic performance
study. Radiology. 2013;268:135–43.
40. Leeuwenburgh MM, Wiarda BM, Bipat S.Acute appendicitis on abdominal MR images: training readers to improve diagnostic accuracy. Radiology. 2012;264:455–63.
41. Gaita’n H, Angel E, Sa’nchez J, etal. Laparoscopic diagnosis of acute lower abdominal pain
in women of reproductive age. Int J Gynecol Obstet. 2002;76:149–58.
42. Champault G, Rizk N, Lauroy J, etal. Right iliac fosse in women: conventional diagnostic
approach versus primary laparoscopy. A controlled study (65 cases). Ann Chir. 1993;47:316–9.
43. Grunewald B, Keating J.Should the ‘normal’ appendix be removed at operation for appendicitis? J R Coll Surg Edinb. 1993;38:158–60.
44. Greason KL, Rappold JF, Liberman MA.Incidental laparoscopic appendectomy for acute right
lower quadrant abdominal pain. Surg Endosc. 1998;12:223–5.
45. Poulin EC, Schlachta CM, Mamazza J.Early laparoscopy to help diagnose acute non-specic
abdominal pain. Lancet. 2000;355:861–3.
46. Olsen JB, Myre’n CJ, Haahr PE.Randomized study of the value of laparoscopy before appendectomy. Br J Surg. 1993;80:922–3.
G. Gallo et al.
Management ofBariatric Surgery Early
https://t.me/medicina_free
andDelayed Complications
UriKaplan
1 Introduction
According to the World Health Organization (WHO), obesity rates have almost tripled in the last four decades [1]. It carries a signicant public health concern and is
associated with increased risk to develop chronic diseases such hypertension, diabetes mellitus, hyperlipidemia, and obstructive sleep apnea. Obesity negatively inuences patient’s morbidity and mortality.
Bariatric surgical procedures have been shown to be the best treatment option for
achieving sustained weight loss and remission of obesity-related comorbidities [2,
3]. Nowadays, most bariatric cases are performed in centers of excellence by trained
bariatric surgeons as part of multidisciplinary teams. These factors improve signicantly the outcome of bariatric surgery.
The rapid development of laparoscopic instrumentation in the early 1990s had
led to surge in bariatric procedures. Data comparing laparoscopic to open gastric
bypass found that laparoscopic approach was associated with less complications,
shorter hospital stay, and equivalent loss of excess weight [4]. In the last 20years,
with further advancement of laparoscopic bariatric surgery, this approach has
become the standard of care. Nowadays, postoperative admissions are short, and
some bariatric procedures are performed in outpatient clinics.
The aim of this chapter is to review both early and late bariatric procedure complications. We’ll provide diagnostic tools and treatment option for patients who
present to the emergency department.
U. Kaplan (*)
General Surgery B, Emek Medical Center, Afula, Israel
Rappaport Faculty of Medicine, Technion—Israel Institute of Technology, Haifa, Israel
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
F. Coccolini et al. (eds.), Mini-invasive Approach in Acute Care Surgery,
Hot Topics in Acute Care Surgery and Trauma,
https://doi.org/10.1007/978-3-031-39001-2_21
281
282
https://t.me/medicina_free
U. Kaplan
1.1 General
1.2 Epidemiology
Obesity has become a global epidemic and currently is one of the major public health
challenges. According to the WHO, in 2016, 39% of adults (more than 1.9billion) in
the world were overweight (dened as body mass index (BMI) ≥25kg/m2) and 13%
(over 650million) were obese (dened as BMI ≥30kg/m2) [1]. In 2014, the global
prevalence of morbid obesity (BMI ≥40 or BMI ≥35 with at least one obesity-related
comorbidity) was 0.64% in men and 1.6% in women [5]. There are disparities in the
prevalence of obesity across countries. This trend continues within the country
among sex, age, ethnic group, and socioeconomic status [6].
Commonly performed bariatric procedures have a morbidity rate between 5 and
10%. In 5% of them, the complications will happen at home [7]. With that being
said, the rate of emergency department (ED) visits of bariatric patients is much
higher. The rate of ED visits, within 30days of surgery, is around 11% of patients.
The readmission rate is between 4.4 and 5.5%. Around 50% of those visits and
readmissions occur in hospitals other than the one where the bariatric procedure was
performed [8, 9].
1.3 Types ofBariatric Surgery
Knowledge regarding the gastrointestinal tract anatomical changes post-bariatric surgery is a key factor in the management of patients with post-surgical complications.
Historically, bariatric procedures were classied as either restrictive, reducing
the volume of food patients can digest; malabsorptive, reducing the absorption of
food at the mucosal level; or both. However, it is reasonable to associate the benecial inuence of surgery on the body adipose system as the key factor for bariatric
surgery success [10]. The inuence of bariatric surgery on the adipose system is
beyond the scope of this chapter.
Clinical practice guidelines for bariatric surgery are well established [11, 12]. The
fth International Federation for the Surgery of Obesity and Metabolic Disorders
(IFSO) global registry report contains data from over 60 countries on over 833,000
operations [13]. According to it, in 2019, the four most common operations worldwide were sleeve gastrectomy (SG) (58.6%), Roux-en-Y gastric bypass (RYGB)
(31.2%), omega anastomosis gastric bypass/mini gastric bypass (OAGB/MGB)
(4.1%), and adjustable gastric band (AGB) (3.7%). Over the last decade, there is a
trend toward reduction in gastric banding and RYGB, while there is a rise in SG and
OAGB/MGB procedures. Nowadays, almost all bariatric procedures are performed
laparoscopically (99.1%) [13]. Currently, there is no evidence regarding which operation suits each patient, and that is the main reason for many operative options.
1.3.1 Sleeve Gastrectomy (SG)
The operation was developed as a rst stage for duodenal switch operation however,
due to comparable outcomes, became a stand-alone procedure. Most of the stomach
Соседние файлы в папке @xirurgi_2025