Ernia interna ed angina abdominis dopo bypass gastrico laparoscopico : la complessa gestione di un problema sottostimato

ABSTRACT The pandemic explosion of severe obesity and refinement of minimally invasive surgical techniques have led, starting in 2000, to a rapid spread of bariatric surgery. Gastric bypass is a bariatric surgery procedure with better results on weight loss, providing an excellent quality of life for patients when compared with extremely low morbidity and mortality. Among late complications, particular attention has recently been placed with regard to internal hernias, rare phenomenon (3%) but become more common with the spread of minimally invasive procedures (and less formation of adhesions). The clinical expression of internal hernias is highly variable, having as common denominator the abdominal pain. Faced with a small percentage of acute frameworks, for which the diagnosis is easy and therapy immmediate, numerous are cases of relapsing not complicated internal hernia , the clinical expression of which is typical of angina abdominis. For these cases, the diagnostic and therapeutic management is undoubtly the most intriguing and complex. In the series of gastric bypasses carried out at the Surgical Clinic and Surgical Therapy of the University of Parma, 4 patients (5.4%) were submitted to laparoscopy for suspected internal hernia : in all cases these were patients who had shown a rapid and significant weight loss. The clinical presentation, although variable, was coupled by the onset of recurrent and worsening addominalgia, in epigastric or left upper quadrant location , resistant to antispasmodics, postprandial tardive or not associated with meals. Under laparoscopic examination it was diagnosed in all 4 cases, a not strangulated Petersen's herina, which was reduced by suturing the breach. The postoperative course was uneventful, with a mean hospital stay of 1.7 days. The data of our series confirm that the laparoscopic exploration is intended as a safe and effective tool in the management of cases of internal hernia. The high incidence of faded symptoms cases suggests to undergo all patients with relapsing addominalgia to accurate diagnostic procedures (Rx of first digestive tract, CT scan), considering laparoscopy surgery not only as a therapeutic, but also as a complete diagnostic tool in cases of more difficult classification.