Prevalence of vitamin D depletion among morbidly obese patients seeking gastric bypass surgery

BACKGROUND: Abnormalities in calcium and vitamin D metabolism have been reported after bariatric surgery. The purpose of this study was to evaluate vitamin D nutritional status among morbidly obese patients before gastric bypass surgery. METHODS: We prospectively studied 279 morbidly obese patients seeking gastric bypass surgery for vitamin D nutritional status as assessed by serum 25-hydroxyvitamin D level. In addition, serum samples were analyzed for calcium, alkaline phosphatase (AP), intact parathyroid hormone (PTH), and 1,25-dihydroxyvitamin D. RESULTS: Mean patient age was 43 +/- 9 years; 87% of the study patients were women, and 72% were white. Serum calcium and AP levels were normal in 88% and 89% of the patients, respectively. Vitamin D depletion, defined as serum 25-hydroxyvitamin D level 相似文献   

Effect of gastric bypass surgery on vitamin D nutritional status

BACKGROUND: We previously reported a 60% prevalence of vitamin D (VitD) depletion, defined as a 25-hydroxyvitamin D (25-OHD) level of < or =20 ng/mL, in morbidly obese patients preoperatively. We now report the effect of gastric bypass (GB) on the VitD nutritional status in these patients. METHODS: We prospectively studied 108 morbidly obese patients who had undergone GB. Routine postoperative supplementation consisted of 800 IU VitD and 1500 mg calcium daily. Serum calcium, parathyroid hormone, and 25-OHD were measured before and 1 year after GB. RESULTS: The mean patient age was 46 +/- 9 years, 93% were women, and 72% were white. Preoperatively and at 1 year postoperatively, the prevalence of VitD depletion and hyperparathyroidism (HPT) and the mean 25-OHD level was 53% and 44%, 47% and 39%, and 20 and 24 ng/mL, respectively. One year after GB, the percentage of excess weight loss was 67% and demonstrated significant correlations both positively with 25-OHD and inversely with parathyroid hormone. At both intervals, blacks had a greater incidence of VitD depletion than did whites, and, at 1 year after GB, HPT was more common in patients with VitD depletion (55% versus 26%, P = .002). CONCLUSION: With customary supplementation, VitD nutrition is improved after GB, but VitD depletion persists in almost one half of patients, and blacks are at a significantly greater risk than whites. HPT did not improve, and those with VitD depletion had a significantly greater rate of HPT. Additional prospective studies are needed to determine how to optimize VitD nutrition and avoid potential long-term skeletal complications after GB.     

Secondary hyperparathyroidism and osteopenia in women following gastric exclusion surgery for obesity

Gastric exclusion has been introduced as a surgical treatment for morbid obesity. We describe two women who had undergone gastric bypass for obesity with metabolic bone disease and secondaryhyperparathyroidism. In one patient transiliac bone biopsy after double tetracycline labelling demonstrated histologic evidence of hyperparathyroidism with osteitis fibrosa cystica. Six additional women who had undergone gastric exclusion were evaluated. Serum phosphorus, calcium, and creatinine were normal in all but one patient who had hypocalcemia. Serum immunoreactive parathyroid hormone was elevated in seven of eight patients and urinary calcium was 2 mmol/d (80 mg/24 h) in 6 patients. Lumbar spine bone mineral density was 86±7 (mean±SE) per cent of predicted and femoral neck bone mineral density was 89±6 per cent of predicted. Women who have had gastric exclusion for obesity may develop secondary hyperparathyroidism which could result in loss of bone mass.Deceased     

Conversion of laparoscopic Roux-en-Y gastric bypass

BACKGROUND: To determine the incidence and causes of conversion from a laparoscopic to an open gastric bypass for morbid obesity, we reviewed the experience of our bariatric center. METHODS: We performed a retrospective review of the records of consecutive patients undergoing laparoscopic Roux-en-Y gastric bypass at our center. RESULTS: In all, 1,236 consecutive patients with body mass indes (BMI) from 35 to 82 were approached laparoscopically. In 97%, bypasses were completed laparoscopically and in 3% (40 patients), a conversion was required to complete the procedure. Older age and male sex were greater in the converted group, whereas BMI was not different nor was the proportion of super obese patients. The cause of conversion was technical in 80%, bleeding in 10%, and a massive liver in 10%. CONCLUSIONS: Our risk of conversion was generally low, but increased in older patients and males. In 33% of patients, conversions could have been avoided with technical lessons learned by experience.     

Percutaneous transhepatic cholangiography for choledocholithiasis after laparoscopic gastric bypass surgery

INTRODUCTIONGallstones are a common condition in bariatric patients after a laparoscopic Roux-en-Y gastric bypass (LRYGB). The management of ductal stones is challenging due to the altered gastrointestinal anatomy. Various techniques have been reported to manage bile duct stones.PRESENTATION OF CASEWe present the successful percutaneous trans hepatic management of common bile duct stones after LRYGB.One year after a LRYGB for morbid obesity, a 59-year-old female presented with acute cholecystitis. One month after laparoscopic cholecystectomy a 1 cm calculus was found within the distal CBD and patient underwent a percutaneous trans hepatic cholangiography under local anesthetic. This involved a right sided anterior segmental duct puncture. With the sphincter dilated to 10 mm, a balloon catheter was used to push the stone into the duodenum leaving an internal- external drain. Patient recovered completely at follow up.DISCUSSIONPatients with morbid obesity have a higher incidence of gallstones. After LRYGB, the altered anatomy does not allow the conventional endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis.Various techniques have been reported as means of managing bile duct stones in LRYGB patients. These include a double balloon enteroscope-assisted ERCP, laparoscopic transgastric ERCP, laparoscopic or open biliary surgery and interventional radiology. We report a non-surgical approach using percutaneous transhepatic technique under local anesthetic that resulted effective and could be applied more extensively.CONCLUSIONDue to the increase of global obesity, bariatric centers need to strategically plan resources such as interventional radiology in order to manage post LRYGB choledocholithiasis safely, efficiently and in a cost effective manner.     

Nephrolithiasis after bariatric surgery: A comparison of laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy

IntroductionLaparoscopic Roux-en-Y gastric bypass (LRYGB) is known to increase risk for calcium oxalate nephrolithiasis due to hyperoxaluria; however, nephrolithiasis rates after laparoscopic sleeve gastrectomy (LSG) are not well described. Our objective was to determine the rate of nephrolithiasis after LRYGB versus LSG.MethodsThe electronic medical records of patients who underwent LRYGB or LSG between 2001 and 2017 were retrospectively reviewed.Results1,802 patients were included. Postoperative nephrolithiasis was observed in 133 (7.4%) patients, overall, and 8.12% of LRYGB (122/1503) vs. 3.68% of LSG (11/299) patients (P < 0.001). Mean time to stone formation was 2.97 ± 2.96 years. Patients with a history of UTI (OR = 2.12, 95%CI 1.41–3.18; P < 0.001) or nephrolithiasis (OR = 8.81, 95%CI 4.93–15.72; P < 0.001) were more likely to have postoperative nephrolithiasis.ConclusionThe overall incidence of symptomatic nephrolithiasis after bariatric surgery was 7.4%. Patients who underwent LRYGB had a higher incidence of nephrolithiasis versus LSG. Patients with a history of stones had the highest risk of postoperative nephrolithiasis.     

Early postoperative complications after gastric bypass revisional surgery in patients with previous sleeve gastrectomy versus primary gastric bypass

BackgroundRevisional bariatric surgery (RS) is indicated if there is weight regain or insufficient weight loss, no improvement or reappearance of co-morbidities, or previous bariatric surgery complications. It has been associated with higher postoperative morbidity.ObjectiveTo evaluate the early postoperative complications (<30 d) of Roux-en-Y gastric bypass RS (RYGB-RS) after primary sleeve gastrectomy (SG-1) compared with primary RYGB (RYGB-1) at a bariatric surgery referral center.SettingDepartment of General and Digestive Surgery of General Universitary Hospital of Alicante, Spain.MethodsRetrospective cohort study comparing RYGB-RS after SG-1 and RYGB-1 between January 2008 and March 2021. Postoperative complications, hospital stay, mortality, and readmissions were analyzed.ResultsSix hundred and twenty-eight RYGB surgeries (48 RYGB-RS, 580 RYGB-1) were studied. The mean age of patients undergoing RYGB-RS was 50 years, compared with 46 years in the RYGB-1 group (P = .017). Mean initial body mass index was 44.2 kg/m² (RYGB-RS) versus 47.6 kg/m² (RYGB-1; P = .004). Cardiovascular risk factors were higher in the RYGB-1 group (P < .05). Indications for RS were weight regain or insufficient weight loss (72.9%), weight regain or insufficient weight loss plus gastroesophageal reflux disease (14.6%), and gastroesophageal reflux disease (12.5%). There were no differences in the frequency of complications (RYGB-RS 22.9% vs RYGB-1 20.5%) or in their severity (Clavien–Dindo ≥IIIa; RYGB-RS 10.4% vs RYGB-1 6.4%; P > .05). There were no differences in emergency room visits (RYGB-RS at 12.5% vs RYGB-1 at 14.9%) or in readmissions (RYGB-RS at 12.5% vs RYGB-1 at 9.4%).ConclusionNo differences were observed between primary RYGB and revisional RYGB in early morbidity, mortality, emergencies, or readmissions. Revisional bariatric surgery is a safe procedure at referral centers and must be done by expert hands.     

Predictors of early quality-of-life improvement after laparoscopic gastric bypass surgery

BACKGROUND: Quality of life is getting more attention in the medical literature. Treatment outcomes are now gauged by their effect on quality of life (QOL), along with their direct effect on diseases they are targeting. Similarly, in obesity, consensus has been reached on the importance of QOL as an independent outcome measure for obesity surgery along with weight loss and comorbidity. Therefore, the aim of this study was to assess the impact of patient demographics and comorbidities on short-term QOL improvement after laparoscopic gastric bypass (LGB) surgery. METHODS: The change in QOL after LGB was assessed in 171 patients (147 women, 24 men; mean age, 43.1 y) using the Short-Form-36 (SF-36) questionnaire. Multivariate logistic regression analysis was used to identify patients' demographics and comorbidities predictive of major QOL improvement. RESULTS: Body mass index decreased significantly at 3 months (48.5 +/- 5.8 to 38.4 +/- 5.4 kg/m2; P < .001) with excess weight loss of 37.4% +/- 9.2%. The SF-36 follow-up evaluation showed significant improvement (44.2 +/- 15.7 to 78.6 +/- 15.5; P < .001). A significant inverse correlation was found between QOL (before and after bypass) and the number of comorbidities (r = .29, P = .001; R = .22, P = .005; respectively), but the magnitude of QOL change did not correlate with the number of comorbidities (P = .5). When the entire cohort of patients was dichotomized according to their magnitude of change in SF-36 scores, the univariate analysis showed that the group of patients with no improvement or minor improvement in their SF-36 was characterized by a higher percentage of male sex and a lower prevalence of diabetes. These 2 preoperative factors remained statistically significant in the multivariate analysis. Preoperative diagnosis of type 2 diabetes increased the likelihood of major improvement in QOL after LGB by 6.2 times, whereas being a woman increased this likelihood by 16.1 times. CONCLUSIONS: Significant weight loss was achieved as early as 3 months after LGB, causing substantial improvement in QOL in more than 95% of patients. Women with type 2 diabetes have the highest odds to achieve a major QOL improvement after LGB and therefore they should represent the ideal target population for surgical weight loss programs.     

Plasma homocysteine after laparoscopic Roux-en-Y gastric bypass increases in the early postoperative phase but decreases in the long-term follow-up. A retrospective analysis

BackgroundHomocysteine is an important independent risk factor for predicting cardiovascular disease (CVD). However, changes in the homocysteine levels after bariatric surgery remain controversial.ObjectivesModeling differences in homocysteine after bariatric surgery.SettingUniversity Hospital, Austria.MethodsSeven hundred eight consecutive bariatric surgery patients (78% female, 22% male, mean body mass index 41 kg/m² preoperatively) underwent laparoscopic long-limb Roux-en-Y gastric bypass in a 6-year period and were retrospectively evaluated for changes in their preoperative homocysteine levels, at 3, 6, 9, 12, 18, 24, 36, 48, 60, and 72 months postoperatively. Furthermore, a postal and telephone screening for postoperative CVD with a follow-up of 71% was conducted.ResultsHyperhomocysteinemia was present in 11.8% preoperatively (normal range: <15 μmol/L). The median plasma homocysteine level was 10.4 preoperatively, 12.1 at 3, 11.2 at 6, 10.0 at 9, 9.8 at 12, 8.9 at 18, 8.7 at 24, 8.6 at 36, 9.1 at 48, 9.8 at 60, and 10.0 μmol/L at 72 months postoperatively. After subdividing the study population in morbidly obese (n = 509, body mass index 40–50 kg/m²) and super-obese (n = 199, body mass index >50 kg/m²) patients, the short-term increase into homocysteine levels remained. Overall, newly onset CVD risk was 4.2%. After subdividing the CVD risk into risk for myocardial infarction, stroke, and risk for deep vein thrombosis/pulmonary embolism the distribution was as follows: .2% myocardial infarction, .59% stroke, and 2.97% deep vein thrombosis/pulmonary embolism (median 36 [interquartile range 36–48] mo postoperatively).ConclusionLaparoscopic Roux-en-Y gastric bypass leads to increased homocysteine levels in the early postoperative period. However, there was no relationship between increased homocysteine levels and CVD event onset.     

Socioeconomic predictors of weight loss after laparoscopic Roux-Y gastric bypass

Introduction  Successful weight loss after laparoscopic Roux-Y gastric bypass (LRYGB) hinges on many elements including neurohormonal, anatomical, and postoperative behavioral changes. To date, the effects of socioeconomic factors have been inadequately studied. We examine several components of socioeconomic status and its relationship to weight loss after LRYGB. Methods  Between August 2002 and July 2006, 405 LRYGB were performed by a single surgeon. Patient demographics were entered into a longitudinal, prospective database. At 1-year follow-up, 309 patients were available for analysis. Regional median household income (RMAHI) and primary insurance carrier were used as surrogates for preoperative socioeconomic status. Analysis of covariance (ANCOVA) test was used for statistical analysis. According to RMAHI, we divided the patients into three groups: US $20,001–40,000 (group A, n = 67), US $40,001–60,000 (group B, n = 153), and more than US $60,000 (group C, n = 89). Initial body mass index (BMI) was 52.76 ± 1.01, 51.28 ± 0.67, and 48.87 ± 0.94 kg/m², respectively. Additionally, patients were divided according to private insurance or state-based insurance. A total of 274 patients had private insurance, with an initial mean BMI of 50.6 kg/m², and 35 patients had state-based insurance, with an initial BMI of 53.0 kg/m². Results  After 1 year, weight loss in groups A, B and C was 110.6 ± 4.3, 110.0 ± 2.5, and 103.9 ± 3.6 lb with BMI decrease of 17.7 ± 0.6, 17.7 ± 0.4, and 16.9 ± 0.6 kg/m², respectively. Weight loss in the private insurance group was 49.2 ± 0.9 kg compared with 50.2 ± 2.3 kg in the state-based group with BMI decrease of 17.4 ± 0.3 and 18.4 ± 0.8 kg/m², respectively. There were no statistical significances in the effect of socioeconomic status, median household income, and insurance carrier on postoperative weight loss. Conclusion  With appropriate patient selection, the socioeconomic status of patients undergoing LRYGB does not affect postoperative weight loss.     

Technical considerations for transabdominal loading of the circular stapler in laparoscopic Roux-en-Y gastric bypass

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass is being undertaken with increasing frequency. We describe a technique for introducing the anvil of the circular stapler using a totally transabdominal approach. METHODS: One hundred consecutive patients underwent laparoscopic Roux-en-Y gastric bypass in a university-affiliated teaching hospital. RESULTS: The cardiojejunostomy was constructed in all 100 patients using the circular stapler with no complications. No anastomotic leaks were detected postoperatively. CONCLUSIONS: The totally transabdominal approach for introducing the anvil of the circular stapler into the gastric pouch is safe and feasible.     

腹腔镜下胃旁路手术应注意的关键技术问题

目的 探索腹腔镜下胃旁路手术术中意外情况发生的原因及处理方法,寻求术中关键技术,从而减少术后并发症的发生.方法 南京医科大学第一附属医院普外科自2010年6月至2013年6月完成腹腔镜下胃旁路术150例,按时间顺序分为三组,复习所有患者完整手术录像,记录术中并发症发生的类型,处理的方法,回顾患者的病历资料,统计术中并发症的相关因素.结果 149例胃旁路术患者均在腹腔镜下完成,1例中转开腹,无术中大出血,无术后死亡病例,无术后大出血及肠梗阻、吻合口梗阻等严重并发症,150例患者发生术中并发症17例（11.7％）23次,主要集中在损伤、错断胃囊两大类,三阶段中第三阶段并发症发生率明显低于其他两阶段（P＜0.01）.并发症的发生与体质量指数（BMI）呈正相关（P＜0.01）.结论 腹腔镜下胃旁路术术中并发症的发生与术者学习曲线相关,与患者的BMI相关.术中测漏以及可靠的缝合技术是发现和处理并发症的关键.     

Initial outcomes of laparoscopic Roux-en-Y gastric bypass in morbidly obese adolescents

BACKGROUND: Adolescent obesity is an epidemic in the United States, leading to significant morbidity. Because the impact of laparoscopic bariatric surgery in this population is not as well delineated as in adults, we examined the short-term outcome of adolescents undergoing laparoscopic Roux-en-Y gastric bypass at our institution. METHODS: The medical records of patients < or =18 years of age who had undergone laparoscopic Roux-en-Y gastric bypass for morbid obesity from 1999 to June 2005 were reviewed. The outcome variables examined included preoperative body mass index, percent of excess weight lost for those with at least 3 months of follow-up, length of hospital stay, postoperative morbidity and mortality, changes in comorbid conditions, and effects of surgical weight loss on quality of life. Data are presented as the mean +/- standard error of the mean. RESULTS: Eleven patients (seven girls and four boys) had undergone laparoscopic Roux-en-Y gastric bypass. The mean follow-up was 11.5 +/- 2.8 months (range 3-32). The average patient age was 16.5 +/- 0.2 years, and the average body mass index was 50.5 +/- 2.0 kg/m(2). The average number of comorbidities was 5.3, 70% of which improved or resolved postoperatively. No mortalities resulted. Of the 11 patients, 1 had early postoperative bleeding and 2 developed a marginal ulcer. The quality-of-life surveys obtained from 9 patients reflected an overall improvement in self-esteem, social functioning, and productivity in school or the workplace. CONCLUSIONS: The initial data suggest that laparoscopic gastric bypass is an effective weight loss treatment for morbidly obese adolescents.     

Late perforation at the jejuno-jejunal anastomosis after laparoscopic gastric bypass for morbid obesity

BackgroundAlthough marginal ulceration and perforation at the gastrojejunal anastomosis is an established, albeit rare, risk after laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity, little is known about the risk of late perforation at the jejuno-jejunal (J-J) anastomosis. The objective of this study was to identify the incidence of J-J perforation and describe management options and sequelae.MethodsThis is a retrospective review of the database of all patients who underwent LRYGB. The results are presented as mean (range) where appropriate.ResultsBetween April 2002 and April 2012, 1652 patients underwent LRYGB (1577 primary and 75 revision procedures). The operative mortality was .18%. Three patients developed late perforation of the J-J anastomosis (.18%) at 7, 9, and 18 weeks, respectively. Two patients were managed with resection and reanastomosis of the perforation by laparotomy, and a third patient was managed laparoscopically with peritoneal lavage and transcutaneous tube jejunostomy of the perforation. All patients recovered well postoperatively. However, the third patient represented 42 days later with sepsis and died secondary to recurrent J-J ulcer perforation.ConclusionPerforation of the J-J anastomosis is a rare and life-threatening delayed complication after LRYGB and usually presents within 2–8 months postoperatively. It poses difficulties with diagnosis and management and should be dealt with judiciously.     

Effects of laparoscopic Roux-en-Y gastric bypass on bone mineral density and markers of bone turnover

BackgroundDespite multiple beneficial effects of weight loss after laparoscopic Roux-en-Y gastric bypass (LRYGB), the influence on bone mineral density (BMD) remains largely unknown. Our objective was to evaluate the changes in BMD and serum/urine bone markers after LRYGB.MethodsThirty-four women undergoing LRYGB were prospectively enrolled and underwent bone densitometry and serum/urine analysis preoperatively and 1 year postoperative. Changes≥.025 g/cm² in hip, femoral neck, and spine BMD and decreases>2% in total BMD were considered significant. Statistical analysis included paired t tests and McNemar’s test.ResultsMean age was 44.6 years. Body mass index at the preoperative and 1-year postoperative intervals were 46.7 and 29.6 kg/m², respectively. Mean hip, femoral neck, and spine (L1–L4) BMD was 1.191 versus 1.087 g/cm² (P< .001), 1.105 versus 1.032 g/cm² (P< .001), and 1.323 versus 1.277 g/cm² (P< .001) at the preoperative and 1 year postoperative intervals, respectively. Mean total BMD decreased from 1.328 preoperatively to 1.251 g/cm² at 1 year postoperative (P<.001). The decreases in BMD were 5.8%, 6.5%, 3.5%, and 8.8% for hip, femoral neck, spine (L1–L4) and total BMD from preoperative to 1 year postoperative. The proportion of patients with low vitamin D levels decreased from 55% preoperatively to 21% at 1 year postoperative (P = .004). Elevated osteocalcin and bone alkaline phosphatase was observed in 4% and 63% (P<.001), and 14% and 41% (P = .011) of patients preoperatively and at 1 year postoperative, respectively.ConclusionBMD and bone markers changed significantly after LRYGB. Current recommendations for supplementation in post-LRYGB women may need to be reevaluated.     

Assessment of comorbid conditions in veteran patients after Roux-en-Y gastric bypass

BACKGROUND: The present study assessed the degree to which comorbid conditions improved after bariatric surgery in veteran patients. METHODS: A retrospective review of 55 patients (age 49.1 +/- 1.2, body mass index 49.3 +/- 1.2 kg/m2; 62% male) who underwent open Roux-en-Y gastric bypass surgery at the Dallas Veterans Administration Medical Center was performed. Univariate and multivariate analyses were used to determine factors associated with outcomes. RESULTS: There were 17 minor (8 patients with anastomotic ulcer, 5 patients with hernia, 1 patients with cholecystitis, 1 patients with a wound infection, and 2 patients with seroma) and 4 major (3 patients with pulmonary embolism and 1 patients with gastrojejunostomy leak) complications. Univariate analysis demonstrated that body mass index was associated with increased length of hospital stay but not with morbidity. Age was not associated with length of hospital stay or morbidity. There was improvement in 91% of patients affected with diabetes mellitus, in 89% with hypertension, in 80% with dyslipidemia, and in 62% with obstructive sleep apnea. COMMENTS: Roux-en-Y gastric bypass results in a marked amelioration or elimination of obesity-related comorbid conditions in veteran patients. Morbidity and mortality are within acceptable rage for these patients with substantial comorbidities.     

Emergency room visits after laparoscopic Roux-en-Y gastric bypass for morbid obesity

BACKGROUND: Patients can be symptomatic after laparoscopic Roux-en-Y gastric bypass because of either surgical complications or physiologic changes and adjustment to the new anatomy. The aim of this study was to evaluate the factors that could influence the rate of postoperative emergency room admissions (ERAs) and the clinical implication of these visits for patients who have undergone laparoscopic Roux-en-Y gastric bypass. METHODS: The medical records of patients who underwent laparoscopic Roux-en-Y gastric bypass for morbid obesity from 2001 to 2004 were retrospectively reviewed. The data of patients with a history of an ERA after surgery was compared with the data of patients without a history of ERAs. The data collected included demographics, weight, body mass index, operative time, and more. The ERAs were subdivided into early ERAs and late ERAs, and the data were analyzed further. RESULTS: Of 733 patients, 228 (31.1%) had a history of ERAs. Patients with early postoperative complication (<7 days after the procedure) had a greater rate of ERAs (60.9% versus 30.1%, P <.05). The operative time was significantly longer in the ERA group (91.4 versus 86.5 min). The most frequent complaint in the emergency room was abdominal pain (61.4%) followed by vomiting (35.5%). Gastric outlet obstruction was the most frequent cause of an ERA within 2 weeks after surgery. Most patients were treated conservatively. CONCLUSION: Our results suggest that the rate of potential ERAs should not be disregarded. A prolonged operative time and early postoperative complications were significant predictors for late ERAs. Abdominal pain with or without vomiting was the most common presenting symptom. Most patients can be treated conservatively.