EARLY SURGICAL COMPLICATIONS AFTER GASTRIC BY-PASS: A LITERATURE REVIEW (2024)

Anastomotic or staple line leaks

This complication can be defined as inadequate tissue healing allowing for exit ofgastrointestinal material through the staple or suture line. It remains as one of themost common causes of death after RYGB, leak-associated mortality can be up to37.5-50%^8,9,31 representingthe second cause of death and together with pulmonary embolism represent more than50% of the causes of death in patients undergoing bariatric surgery.

The incidence of this complication ranges from 0 to 5.6% in large series and does notdiffer significantly between laparoscopic and open RYGB⁸.

There are five potential sites of leaking after RYGB: gastrojejunostomy, gastricpouch staple line, roux limb staple line, jejunojejunostomy and gastric remnantstaple line. The frequency of these locations is shown in Table 1.

Different risk factors for developing a leak have been studied and it has been shownthat patients at higher risk are primarily those who are older super-obese, men, andthose with multiple co-morbidities and previous or revisional bariatricoperations^{8,14,27,28,31}.

In the other hand, operative technique can also be related with the leak rate:appropriate staple firing and its size, staple line reinforcement with biologicbuttress material¹¹, use of fibrinsealant^5,17, intraoperative leak testing, anastomosis undertension, and ischemia can affect the incidence of anastomotic leaks afterlaparoscopic RYGB¹⁷.

Although most anastomotic leaks occur five to seven days after surgery and arethought to be related to ischemia, 95% of anastomotic leaks that occur within twodays of surgery probably result from technical error²⁰. Regarding to the staple firing, one possible errorcan occur when the staples do not engage or do not completely close when theendoscopic stapler is fired. This may occur when the wrong-sized staple cartridge isselected. As a result, the staples appear to have fired and seated properly, but someor all of the staples may become dislodged and a leak occurs.

Another error can occur when a loose staple is retained at the apex of the previouslyfired staple line. Firing the device across the loose staple can damage subsequentstaples as they are deployed or the loose staple may damage the stapler firingmechanism leading to wedge-band bypass failure¹⁷. Wedge-band bypass failure occurs when the cutting blade ofthe stapler is pushed off its track as a free staple is dragged by the blade. As aresult, one side staples and seals while the other side cuts and opens. Because ofthese potential problems, every staple firing should be closely inspected on bothsides for the quality and integrity of the staple line and all free staples locatedin the apex of the staple line should be removed prior to the next firing².

Biologic buttress material like polyglycolide acid and trimethylene carbonate orbovine pericardial strips have been proposed as a reinforcement of the stapler linein order to reduce the leak rate (Figure 2).Results in terms of reducing the leak rate are not as conclusive as the decrease ofthe bleeding risk at the staple line^3,6,17. The polyglycolide acid and trimethylene carbonatestaple reinforcement material (polyglycolide 67%, trimethylene carbonate 33%) calledSeamguard - WL Gore & Associates) has an advantage over bovine pericardium whichis that the latter is nonabsorbable while the Seamguard is completely absorbed withinsix months and is therefore less likely to cause fistula or erode.

Fibrin sealants have been used with increasing frequency in a variety of surgicalfields for their unique hemostatic and adhesive abilities. Synthesized from pooledhuman fresh frozen plasma, they contain fibrinogen, factor XIII, thrombin, ionizedcalcium, and fibronectin. In the presence of calcium, thrombin facilitates theactivated factor XIII to polymerize fibrin monomer to form insoluble fibrin clot. Theprocess mimics the last step of the coagulation cascade. Fibrinogen gives the systemboth its adhesive and its hemostatic capabilities. Fibrin glue is solidified into afirm, white, rubberlike mass with strong adhesive properties within a few seconds ofbeing mixed. The application of this fibrin glue in the suture lines would reduce theincidence of leakage as some studies have shown¹⁶.

Like was said before, most anastomotic leaks occur at the gastrojejunostomy (Table 1); therefore, surgeons must use somemethod to intraoperatively test the integrity of this anastomosis, either viainstillation of methylene blue through an orogastric tube or air insufflation throughan orogastric tube or flexible gastroscope with the anastomosis submerged²⁸. Anastomotic tension has beenproposed as a risk factor for leaks after gastric bypass surgery because it mayresult in stress that exceeds the disruptive pressures of a stapled or suturedanastomosis. The main technical factor that has been studied and reported is the roleof Roux limb orientation in the development of anastomotic leaks after RYGB.

Theoretically, compared with the antecolic route, the retrocolic Roux limb has a moredirect path to the gastric pouch and may be associated with lower gastrojejunalanastomotic tension. The studies presented until now have reported conflictingresults. Edwards et al.¹² reportedthat leaks may occur more commonly after antecolic (3%) versus retrocolic (0.5%)laparoscopic RYGB. However, Bertucci et al.⁵ reported no anastomotic leaks after 141 retrocolic and 200antecolic procedures, and Carrasquilla et al.¹⁰ reported an anastomotic leak rate of 0.1% after 1000 antecolicprocedures versus 1.85% after 108 retrocolic procedures. Therefore a prospectiverandomized study is still needed to prove this asseveration.

The diagnosis of leaks relies on clinical grounds, with or without the help ofradiographic¹⁹. A patient whodoes not progress favorably after the first postoperative day and experiencesincreasing abdominal pain, persistent tachycardia, fever, tachypnea, purulent drainoutput, oliguria or any combination of these symptoms requiresinvestigation^19,26,28. Some studies have shown that sustained tachycardia with a heartrate in excess of 120 beats per minute was a good indicator of a leak¹⁹.

Some groups have questioned the necessity of routine upper gastrointestinal contraststudies²⁷; however, suchroutine testing within the first 24-36 hours postoperatively is a standard practiceamong bariatric surgeons^17,19.

Some other methods that can be used to detect the leaks besides the uppergastrointestinal contrast, are computed tomography scan or oral administration ofmethylene blue and observation to see if it comes out through the drains²⁸.

If is decided to perform contrast studies, findings such as fluid collectionsadjacent to the pouch, diffuse abdominal fluid, free intraperitoneal air, and traceamount of oral contrast in the drain tract can confirm the diagnosis.

Early recognition and management is the mainstay of treatment of leaks followingRYGB. Depending on the patient's clinical condition and the magnitude of the leak,different treatments can be offered, from a minimal invasive treatment toreoperation.

Conservative management can be effective in non-septic, hemodynamically stablepatients with contained leaks. The mainstay of this treatment are intravenousantibiotics, monitoring of secretions through drains, nasoenteral nutrition or totalparenteral nutrition (depending on the case and the location of the leak), and if theleak is contained and accessible, a percutaneous treatment can be performed²⁸. This approach has been shown to besuccessful and lacks the morbidity associated with a reoperation²⁸.

But if the patient is hemodynamically unstable, has a complicated leak, or signs ofsepsis, an operative treatment is mandatory. The operative goals are: to confirm andrepair the leak, remove gastrointestinal contents from the abdominal cavity and placeclosed suction drains.

The repair of the leak would be the ideal situation, but often suturing the place ofthe leak can be challenging, as the acutely inflamed tissues might not be amenable tosuture placement. In such cases, the removal of gastrointestinal contents andplacement of drainage tubes may be the safest option. Depending on the surgical teamskills the approach could be laparoscopic or open.

Other options that have been described to control the leak are the omentalreinforcement of the area of the leak²⁴ and the endoscopic injection of fibrin sealant at the site of theleak¹⁸.

Maintain the nutrition is mandatory to allow healing the tissues in the place of theleak. In order to achieve this, the placement of a feeding gastrostomy into thegastric remnant or a feeding jejunostomy should be considered. This would allow forcontinued enteral nutrition while bowel rest is maintained at the site of theleak.

Anastomotic or staple line leaks are the main concern for bariatric surgeons whenperforming a RYGB, although its incidence is low its complications can bedevastating. Caution should be taken when firing the stapler, according theguidelines previously mentioned. If the leaks occurs, an early recognition isessential to avoid further complication and to reduce the morbidity and mortality.The line of treatment will vary according to the clinical status of the patient.

Gastrointestinal bleeding

Among the early complications, bleeding is one the most feared by surgeons. Theliterature reports an incidence between 1.9% and 4.4%^19,22and itsincidence can be higher in patients with previous abdominal surgery due to adhesionsrequiring adhesiolysis intraoperatively.

Interestingly, a systematic review comparing open versus laparoscopic RYGB have notedthat the frequency of gastrointestinal tract bleeding was significantly higher in thelaparoscopic RYGB (LRYGB) series (1.9% vs 0.6%). Some hypothesis to explain thisincreased incidence of bleeding in the LRYGB in the minimally invasive surgery eraare the overuse of DVT chemoprophylaxis and the decreased of the practice ofoversewing the staple lines.

The bleeding after LRYGB can originate at one of five potential staple lines: thegastric pouch, excluded stomach, Roux limb staple line, gastrojejunostomy, andjejunojejunostomy. Staple-line bleeding occurs at the transected tissue edges or atthe sites of staple penetration of the tissue. In order of frequency, the sites ofstaple lines bleeding are: 40% were from the gastric remnant staple line, 30% fromthe gastrojejunal staple line, and 30% from the jejunojejunal staple line (Figure 3). Additional sites of bleeding includethe liver, spleen, and trocar sites.

There are two types of postoperative hemorrhage noted to occur following LRYGB:intraperitoneal or intraluminal. The first is bleeding into the abdominal cavity,possibly from staple lines at the gastrojejunostomy, the gastric pouch, thejejunojejunostomy or the excluded stomach²². The second, occurs into the lumen of the digestive tract atthe aforementioned sites. The latter usually occurs as a late bleeding while theintraperitoneal bleeding occurs as an early bleeding.

Like any bleeding associated with surgery, early recognition is essential. Theclinical signs and symptoms are crucial in determining the most appropriate steps formanaging this life-threatening complication. Some surgeons advocate the use of drainsfor the early recognition of bleeding. However, as in other areas of gastrointestinalsurgery, drains are not always a reliable indicator, particularly in the case ofintraluminal bleeding. Therefore, once again, a heavy reliance on clinical parametersand laboratory work-up become most important. The presence of pallor, dizziness,confusion, tachycardia, hypotension, hematemesis, bright red blood per rectum, dropin the hemoglobin level, large quantity of bloody fluid from the abdominal drains andlow urine output should alert the surgeon to ongoing postoperative bleeding¹⁹.

The treatment depends on the timing of onset and the clinical presentation. In casesof late presentation (>48 hours) of gastrointestinal bleeding after surgery, itcan be managed conservatively in most cases, especially when associated with no acuteclinical symptoms, and melena, which might indicate the passage of old blood andinactive bleeding. In these cases discontinuation of DVT chemoprophylaxis andwatchful waiting with supportive therapy can be successful.

In the other hand, early postoperative bleeding, occurring within a few hours afterthe surgery, manifested by hematemesis or bright red blood per rectum in the presenceof clinical signs of bleeding is a clear indication for urgent surgical intervention.Abdominal re-exploration using either a laparoscopic or open approach must beperformed. If the patient is hemodynamically unstable, laparoscopy is relativelycontraindicated because the increased intra-abdominal pressure duringpneumoperitoneum can result in worsening of the hemodynamics.

The goals are to evacuate the majority of the clots, attempt to identify and controlthe site of hemorrhage if it is readily apparent¹⁵ or to oversew all staple lines if the patient ishemodynamically unstable and does not have an obvious bleeding site²². Finding a dilated excluded stomachcan it be due to be filled with clots, and in these cases it is necessary to evacuatethe clots and place a gastric tube for continuous decompression. Not infrequently, noobvious source of bleeding can be determined during re-explorations, but the patientcan still benefit from the evacuation of intraperitoneal hematoma, which might speedthe recovery process through shortening the duration of postoperative ileus.

An important amount of blood can be lost with an acute postoperative gastrointestinalhemorrhage before overt clinical abdominal signs develop. If is suspectedintra-abdominal bleeding based on clinical signs - such as hypotension, tachycardia,or a falling hematocrit -, in the absence of any obvious gastrointestinal source,re-exploration should not be delayed.

Although hematemesis suggests a gastrojejunostomy origin, brisk, bright red blood perrectum might originate from the gastric remnant or jejunojejunostomy anastomosis.

If is suspected that the bleeding source is proximal intraluminal the best treatmentoption is an endoscopic intervention, which is invaluable in controlling bleedingfrom the gastric pouch or gastrojejunostomy. Thermal coagulation, injection ofvasoconstrictors, and clipping are all effective ways of controlling bleeding fromthese sites⁴.

Endoscopy has limited application for management of bleeding at the jejunojejunostomybecause of the long length of the Roux limb, particularly in patients with a 150-cmRoux limb, and the large amount of intraluminal clots prohibiting good visualization.Although, successful endoscopic management of bleeding at the jejunojejunostomy hasbeen described⁴, there is no rolefor endoscopic management of staple-line bleeding arising from the bypassed stomachwhich is inaccessible to the endoscope.

There are some potential methods for prevention of staple-line bleeding. One methodis to use a linear stapler with a shorter staple height. For example, using a whitelinear stapler load (2.5 mm) instead of a blue stapler load (3.5 mm) for the creationof the jejunojejunostomy or a blue stapler load instead of a green stapler load (4.8mm) for the creation of the gastric pouch. The shorter staple height provides morecompression of the tissues and hence results in better hemostasis. However, shorterstaple height does not completely prevent staple line bleeding and it can increasethe risk of leaking due to inadequate tissue approximation.

Another method for prevention of staple-line bleeding is the use of a staple-linereinforcement product. Peri-Strips Dry® (Synovis, Saint Paul, MN) are composedof two strips of biological tissue derived from bovine pericardium that are appliedto the linear stapler and act as a buttressing material at the staple-lines⁶. Seamguard® (W. L. Gore &Associates, Flagstaff, AZ) staple-line reinforcement works in a similar way usingePTFE instead of biologic tissue, but these products are nonabsorbable. The presenceof a foreign body next to the gastro intestinal tract could lead to infection of theforeign body and possible erosion. So, a bioabsorbable Seamguard® composed ofabsorbable Maxon® suture material which is degraded within six weeks aftersurgery could be a better option.

Another potential method for prevention of gastrointestinal bleeding performed bymany surgeons is to routinely oversewing of all staple-lines at the primaryoperation. However, this is a time-consuming task.

Bleeding is a potential complication after gastric bypass. Its incidence appears tobe higher in LRYGB than in open RYGB. Timing of intervention should be based on thepatient's clinical status, including vital signs, hematocrit, and other indicationsof ongoing hemorrhage. Endoscopic management of bleeding from the gastric pouch maybe successful. Laparoscopic exploration will be mandatory in case of intraperitonealbleeding and oversewing of all staple-lines should be performed. In some patients, agastric tube with clot evacuation will be necessary. Preventive measures include theuse of staples with shorter staple height, routine oversewing of staple-lines, and/orthe use of staple-line reinforcement products.

Intestinal obstruction

The most common causes of small bowel obstruction following LRYGB are related tointernal hernias which is a feared and well-recognized complication after RYGB. Aninternal hernia can be defined as a protrusion of intestine through a defect withinthe abdominal cavity. Most internal hernias present later in the postoperative periodrather than early.

Compared with the open approach, the incidence of internal hernia is greater afterLRYGB, estimated between 3-4.5%²⁵.Some hypotheses postulate that the laparoscopic approach reduce the bowelmanipulation and peritoneal irritation so it generates fewer postoperative adhesions,and therefore less fixation of small bowel to adjacent structures. In addition, rapidweight loss after LRYGB results in reduced intraperitoneal fat and larger mesentericdefects⁷.

Bowel obstruction secondary to internal hernias usually presents in the laterpostoperative period while early small bowel obstructions (in less than one month)usually result from technical problems with the Roux limb. Causes include completeblockage or partial narrowing of the gastrojejunostomy or jejunojejunostomy, acuteangulation of the Roux limb, and narrowing of the Roux limb at the level of thetransverse mesocolon. The latter obstruction also is seen as a late complication dueto scarring at the transverse mesocolon defect.

RYGB can be accomplished using either an antecolic or retrocolic approach. Dependingon the chosen approach a number of potential mesenteric defects are created (Figure 4). The retrocolic approach creates threedefects: one in the transverse mesocolon, one at the site of the jejunojejunostomyand a Petersen defect (a space created between the Roux limb and the transversemesocolon). While the antecolic approach creates only two mesenteric defects: one atthe jejunojejunostomy and another in the Petersen defect.

The most common location for internal hernias and its relation to Roux limbconfiguration has been a subject of debate. Understandably, mesocolic defect herniasare unique to a retrocolic approach and are not seen with an antecolic approach. Insome reports, mesocolic defects were the most common among all internalhernias³³. Some authorsreported that transverse mesocolic hernias were the most common, followed byjejunojejunostomy and Petersen's space hernias²⁵. In an antecolic approach, however, both Petersen's andjejunojejunostomy mesenteric defect hernias are reported, with hernias at thejejunojejunostomy defect being more common in some other series. Other investigatorsreport a higher incidence of Petersen's and jejunojejunostomy hernias with aretrocolic approach. A significant decrease in small bowel obstruction have beenreported by some authors after switching from a retrocolic to an antecolictechnique.

Dull abdominal pain with or without intestinal obstruction is the most commonpresentation of an internal hernia. Usually the presentation is delayed, occurringseveral months to years after the operation, but it can occur in the immediatepostoperative period (being more common in these cases the technical problems withthe Roux limb).

Some patients report previous episodes of undefined gastrointestinal upset andfrequent mild symptoms of intermittent obstruction before their main presentation.The small bowel may intermittently become trapped and then reduced at the site of theinternal hernia, causing this subtle presentation and atypical bowel obstructionfeatures. Nausea, emesis, and postprandial abdominal pain (usually in the left upperquadrant) are common complaints and because of change in the gastrointestinalanatomy, patients may not present with typical signs and symptoms of bowelobstruction.

A diagnosis of small bowel obstruction can be made by performing an uppergastrointestinal series. However, the specific cause may not be evident. Findingsthat favor a diagnosis of internal hernia include a cluster of dilated bowel segmentsin the left upper or middle abdomen, which remain relatively fixed in this highposition on views obtained with the patient in an erect position.

CT scans can be helpful in depicting signs of an internal hernia. In trans mesentericinternal hernia, when the Roux limb is herniated, CT scanning shows a cluster ofdilated bowel segments in the expected position of the Roux-en-Y loop. Other CTfindings suggestive of an internal hernia include small bowel mesentery traversingthe transverse colon mesentery and location of the jejunojejunostomy superior to thetransverse colon. In addition, crowding, stretching, and engorgement of the mainmesenteric trunk to the right and signs of small bowel obstruction may be seen. Aswirled appearance of mesenteric fat or vessels was found to be the best singlepredictor of hernia, with a sensitivity of approximately 80% and a specificity of90%.

However, CT scanning is not always diagnostic and the percentage of negative CTscanning in patients with internal hernias can be up to for 20%. Therefore anypatient with unexplained abdominal pain that does not correlate with physicalfindings should be considered to have an internal hernia. A high index of suspicionis crucial for early intervention and avoidance of an abdominal catastrophe, such aslong segment of small bowel ischemia.

To prevent bowel obstruction after gastric bypass, specific measures should be taken.Routine closure of the mesenteric defect at the jejunojejunostomy, transversemesocolon mesenteric defect, and the Petersen defect is recommended. Some authorsadvocate the placement of an ''anti-obstruction suture'' at the jejunojejunostomy toprevent bowel obstruction at the afferent limb²⁹. Other authors recommend placement of a suture on the proximalRoux limb that fixes it to the remnant stomach to prevent angulation of the Rouxlimb's proximal part in case of an antecolic, antegastric technique³³.

Whether to use absorbable or non-absorbable, running or interrupted suture have beenalso a matter of debate. Some authors who have modified their technique fromabsorbable to non-absorbable sutures and from an interrupted to a running techniquehave reported a reduction in the incidence of internal hernias.

Leaving aside the internal hernias, the second most common cause of small bowelobstruction after LRYGB is obstruction at the jejunojejunostomy, occurring inapproximately 1.8% of antecolic LRYGB procedures. It can also be a complication ofthe retrocolic approach. Early obstructions at the jejunojejunostomy can be caused bytechnical problems, such as bowel kinking, narrowing, or acute angulation of theanastomosis. Other causes include postsurgical anastomotic edema, stenosis, ischemia,and staple-line bleeding with intraluminal hematoma formation. Early obstructions atother locations usually result from edema or technical problems with the Roux limbposition, such as an extrinsic compression of the Roux limb as it traverses thetransverse mesocolic defect from thickened cicatrix formation in this area.

Other less-common causes of small bowel obstruction after LRYGB include trocar siteincisional hernias (port sites larger than 10 mm should be closed routinely toprevent port-site herniation), adhesive bands, bezoars, anastomotic strictures, andjejunojejunostomy intussusception. Rarely, superior mesenteric artery syndrome mightcomplicate the course of LRYGB secondary to rapid weight loss and cause gastricoutlet obstruction symptoms.

Surgical exploration of patients with suspected internal hernia should be performedwithout delay. A doubtful operative decision can result in the development of aclosed loop obstruction, a potentially devastating problem. Despite normalcomplementary studies, a diagnostic laparoscopy is recommended if the clinicalsymptoms suggest an internal hernia. The entire small bowel and all the potentialhernia defects should be carefully evaluated. If hernias are found, the repairinvolves reducing the hernia and closing defects. Remaining defects should be closedif they have not already been closed.

Lysis of adhesions should be performed if a strangulated band causes obstruction. Inpresence of a dilated gastric remnant decompression using a long needle or placementof a gastrostomy tube it's recommended.

Narrowing of the jejunojejunostomy due to incorrect stapling of the jejunojejunostomyusually requires creation of a new enteroenterostomy proximal to the obstructionsite. Angulation of the Roux limb at the jejunojejunostomy requires repositioning ofthe Roux limb and placement of an antiobstruction suture.

The possibility of performing a laparoscopic approach to manage a bowel obstructionwill depend on the extent of bowel dilation and the site of bowel obstruction. Incase of distal obstruction with concomitant severe bowel dilation often complicates asafe laparoscopic entry and may require laparotomy.

Roux limb obstruction due to edema of the jejunojejunostomy or gastrojejunostomyusually requires conservative treatment consisting of suspending the oral feeding andthe administration of intravenous fluids. Total parenteral nutrition is rarely neededbecause this problem usually resolves within a few days. Obstruction at thetransverse mesocolon is also typically managed conservatively.

Bowel obstruction is a relatively frequent complication after LRYGP. Closure of allmesenteric defects is highly recommended to prevent internal hernias. Theantegastric, antecolic approach could reduce the incidence of internal hernias at thetransmesocolon defect. Early diagnosis and surgical exploration in suspected cases isessential to a successful outcome.

Incorrect Roux limb reconstruction

This complication, although being rare, can be potentially devastating. Involves theinadvertent anastomosis of the proximal biliopancreatic limb of the jejunum to thegastric pouch in conjunction with a misplaced jejunojejunostomy. This so calledRoux-en-O construction gives rise to a blind loop (Figure 5). Although this seems to be an atypical complication infrequentlyreported in the literature, must be present in the surgeons mind because it can beeasily avoided, and if it does occur, it poses unique diagnostic challenges andprofoundly increases patient morbidity³.

Patients with the Roux-en-O configuration typically present with abdominal pain,biliary emesis, esophagitis and severe dehydration. This occurs promptly in thepostoperative period. Usually there is an important delay between the patient'sinitial symptoms presentation and the time at which the diagnosis is determined.During this period, physician usually request numerous contrast radiologic studiesand endoscopies, which commonly fail to highlight any important pathology.Ultimately, it seems as though only hepatobiliary iminodiacetic acid scanning is ableto facilitate the diagnosis of the complication accurately by revealing prompt refluxof radioactive tracer from the duodenum to the esophagus. In the reviewed publishedcase reports about this complication, patients had undergone repeated operativeinterventions, numerous complications, protracted hospital admissions and severedelay in the commencement of oral intake³.

The best management strategy for this problem is to avoid creating the Roux-en-Oanastomosis at the initial surgery. The lack of surgical experience with bariatrictechniques may be the most important predisposing factor to this complication. Sometechnical tips to avoid this complication are to make the biliopancreatic limb nolonger than 50 cm, thus precluding its easier anastomosis to the gastric pouch.Furthermore, the Roux limb should be marked with a suture, short segment Penrosedrain or Weck clip promptly after the jejunum is divided to facilitate easydifferentiation between itself and the biliopancreatic limb. Finally, beforefashioning the jejunojejunostomy, the biliopancreatic limb should be traced back tothe duodenojejunal ligament so that proper orientation is assured.

If intraoperative detection of a Roux-en-O was missed and a patient presentspostoperatively with suspicious symptoms and little radiographic evidence ofpathology, a hepatobiliary iminodiacetic acid scanning should be obtained beforesurgical intervention to help with diagnosis, as the aberrant construction issometimes hard to detect intraoperatively in a hostile abdomen.

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