Mechanical colon obstruction due to the alimentary limb after Roux-en-Y gastric bypass: a case report.

BACKGROUND: Small bowel obstruction is a known and potentially lethal complication after gastric bypass surgery, in both the early and the late postoperative course. Colon or large bowel obstruction, on the other hand, seems to be rare after gastric bypass surgery and thus is not routinely considered. CASE PRESENTATION: We present the case of a 21-year old morbidly obese caucasian patient who underwent laparoscopic Roux-en-Y gastric bypass surgery and developed an early severe transverse colon obstruction due to compression of the transverse colon by the antecolic alimentary limb. Emergency revisional surgery showed a short and tense alimentary limb mesentery and possibly tight closure of Petersen's space contributing to the compression. Through opening of Petersen's space and mobilization of alimentary limb mesentery, decompression was achieved, and the patient fully recovered. CONCLUSIONS: This is a rare case of colon obstruction caused by direct compression of the transverse colon by the antecolic alimentary limb. We propose that a combination of short tense alimentary limb mesentery and perhaps tight closure of Petersen's space was responsible for the obstruction in this case. Surgeons and treating physicians need to be aware of such rare causes of early postoperative bowel obstruction and take these into consideration when evaluating patients.

Delayed Diagnosis in Pulmonary Embolism: Frequency, Patient Characteristics, and Outcome.

BACKGROUND: The incidence and the outcomes of pulmonary embolism (PE) missed during emergency department (ED) workup are largely unknown. OBJECTIVES: To describe the frequency, demographics, and outcomes of patients with delayed diagnosis of PE. METHODS: We retrospectively compared patients diagnosed with PE during ED workup (early diagnosis) with patients diagnosed with PE thereafter (delayed diagnosis). Electronic health records (EHR) of 123,560 consecutive patients who attended a tertiary hospital ED were screened. Data were matched with radiology and pathology results from the EHR. RESULTS: Of 1,119 patients presenting to the ED with early workup for PE, PE was diagnosed in 182 patients (80.5%) as early diagnosis. Delayed diagnosis was established in 44 cases (19.5%) using radiology and/or autopsy data. Median age of patients with early diagnosis was significantly lower as compared to delayed diagnosis (67 vs. 77.5 years). Main symptoms were dyspnea (109 patients [59.9%] in early, 20 patients [45.5%] in delayed diagnosis), chest pain (90 patients [49.5%] in early, 8 patients [18.2%] in delayed diagnosis), and nonspecific complaints (16 patients [8.8%] in early, 13 patients [29.5%] in delayed diagnosis). In-hospital mortality was 1.6% in early diagnosis and 43.2% in delayed diagnosis. CONCLUSIONS: Delayed diagnosis of PE carries a worse prognosis than early diagnosis. This discrepancy may arise from either delayed therapy, confounding variables (e.g., older age), or both. Possible reasons for delayed diagnoses are nonspecific presentations and symptoms overlapping with preexisting conditions.