Small Bowel Obstruction Due to Retrograde Intussusception After Laparoscopic Roux-en-Y Gastric Bypass

A 39-year-old female presented 4 years after laparoscopic Roux-en-Y gastric bypass with colicky abdominal pain, vomiting and inability to pass flatus. She had lost 100% of her excess weight after surgery and her body mass index had dropped from 46 to 22 kg/m(2). At exploration, a retrograde intussusception of the small bowel was noted distally to the jejunojejunostomy causing obstruction of the alimentary and biliopancreatic limb and gastric remnant. The intussusception was irreducible with signs of bowel ischaemia and required excision. The patient made an uneventful recovery. Colicky abdominal pain in a bariatric patient persisting more than 4 h mandates urgent investigation with abdominal computed tomography. Emergency care doctors should be aware of this specific complication in bariatric patients and seek expert advice.     

Failure of Mesenteric Defect Closure After Roux-en-Y Gastric Bypass

Background and Objectives:

Bowel obstructions following Roux-en-Y gastric bypass (RYGB) are a significant issue often caused by internal herniation. Controversy continues as to whether mesenteric defect closure is necessary to decrease the incidence of internal hernias after RYGB. Our purpose was to evaluate the effectiveness of closing the mesenteric defect at the jejunojejunostomy in patients who underwent RYGB by examining this potential space at reoperation for any reason.

Methods:

We retrospectively reviewed medical records of patients undergoing surgery after RYGB from August 1999 to October 2008 to determine the status of the mesentery at the jejunojejunostomy.

Results:

Eighteen patients underwent surgery 2 to 19 months after open (n=8) or laparoscopic (n=10) RYGB. All patients had documented suture closure of their jejunojejunostomy at the time of RYGB. Permanent (n=12) or absorbable (n=6) sutures were used for closures. Patients lost 23.6kg to 62.1kg before a reoperation was required for a ventral hernia (n=8), cholecystectomy (n=4), abdominal pain (n=4), or small bowel obstruction (n=2). Fifteen of the 18 patients had open mesenteric defects at the jejunojejunostomy despite previous closure; none were the cause for reoperation.

Conclusion:

Routine suture closure of mesenteric defects after RYGB may not be an effective permanent closure likely due to the extensive fat loss and weight loss within the mesentery.     

Small Bowel Obstruction After Laparoscopic Gastric Bypass with Nonclosure of Mesenteric Defects

Methods:This is a retrospective review of a series of consecutive LGBs over a 3-year period. All procedures were performed by the same surgeon using the same technique. In no case was the mesenteric defect closed. A prospectively maintained database was used for data collection. Patients who returned with an SBO were the study group, and those who underwent revisional bariatric surgery or conversion to open operation were excluded.Results:There were 249 primary LGBs performed during the study period; 15 of the operations were followed by SBO, for an incidence of 6.0%. Four cases were caused by an internal hernia (IH), for an incidence of 1.6%, and 11 were caused by adhesions, which accounted for 73% of the SBOs.Conclusions:SBO after LGB is a relatively common complication. The incidence of SBO from IH with nonclosure of the mesenteric defect is similar to that in other series where the defect is closed. Regardless of the cause of the SBO, operative treatment of the patient who has a gastric bypass remains the definitive standard and should not be delayed.     

Bowel Obstruction after Laparoscopic Roux-en-Y Gastric Bypass

Background: Bowel obstruction has been frequently reported after laparoscopic Roux-en-Y gastric bypass (LRYGBP). The aim of this study was to review our experience with bowel obstruction following LRYGBP, specifically examining its etiology and management and to strategize maneuvers to minimize this complication. Methods: We retrospectively reviewed the charts of 9 patients who developed postoperative bowel obstruction after LRYGBP. Each chart was reviewed for demographics, timing of bowel obstruction from the primary operation, etiology of obstruction, and management. Results: 9 of our initial 225 patients (4%) who underwent LRYGBP developed postoperative bowel obstruction. The mean age was 46 ± 12 years, with mean BMI 47 ± 9 kg/m². 6 patients developed early bowel obstruction, and 3 patients developed late bowel obstruction. The mean time interval for development of early bowel obstruction was 16 ±16 days. The causes for early bowel obstruction included narrowing of the jejunojenunostomy anastomosis (n=3), angulation of the Roux limb (n=2), and obstruction of the Roux limb at the level of the transverse mesocolon (n=1). The mean time interval for development of late bowel obstruction was 7.4 ± 0.5 months. The causes for late bowel obstruction included internal herniation (n=2) and adhesions (n=1). 6 of 9 bowel obstructions (66%) were considered technically related to the learning curve of the laparoscopic approach. Eight of the 9 patients required operative intervention, and 6 of the 8 reoperations were managed laparoscopically. Management included laparoscopic bypass of the jejunojejunostomy obstruction site (n=5), open reduction of internal hernia (n=2), and laparoscopic lysis of adhesion (n=1). Conclusions: Bowel obstruction is a frequent complication after LRYGBP, particularly during the learn ing curve of the laparoscopic approach. Specific measures should be instituted to minimize bowel obstruction after LRYGBP as most of these complications are considered technically preventable.     

Small Bowel Obstruction and Internal Hernias after Laparoscopic Roux-en-Y Gastric Bypass

Background: Small bowel obstruction (SBO) is a recognized complication of open bariatric surgery; however, the incidence after laparoscopic procedures is not clearly established. This paper reviews our experience with small bowel obstruction after laparoscopic Roux-en-Y gastric bypass. Methods: Between 1995 and 2001, 711 (246 antecolic, 465 retrocolic) patients underwent a laparoscopic proximal divided Roux-en-Y gastric bypass via the linear endostapler technique. 13 patients (1.8%) developed SBO requiring surgical intervention.There were 11 females and 2 males, ages 29-60 (mean 38), with mean weight 126 kg (range 105-188), and mean BMI 50 (range 41-59). 7 obstructive patients (55%) had undergone previous open abdominal surgery. Median time to obstruction was 21 days (range 5-1095). Mean follow-up of all patients is 43 months (range 3-79). Results: Etiology of obstruction was internal hernia - 6, adhesive bands - 5 (only 2 were related to prior open surgery), mesocolon window scarring - 1, and incarcerated ventral hernia - 1. The incidence of SBO was 4.5% (11/246) in the retrocolic group, and 0.43% (2/465) in the antecolic group, which was highly significant (P=.006). 1 adhesive patient required an open bowel resection for ischemia. There was 1 death. Conclusion: SBO occurred with an overall incidence of 1.8% in a large series of laparoscopic gastric bypass patients, and was associated with a high morbidity. A significant decrease in occurrence was found after adoption of antecolic placement of the Roux limb.     

Jejunojejunal Anastomotic Obstruction Following Laparoscopic Roux-en-Y Gastric Bypass Due to Non-Absorbable Suture: A Report of Seven Cases

Introduction: Small bowel obstruction (SBO) is a well-known complication of laparoscopic Roux-en-Y gastric bypass (LRYGBP). We describe 7 cases of jejunojejunal anastomotic obstruction related to adhesion formation after closure of the mesenteric "leaves" defect with non-absorbable suture. Methods: All patients undergoing LRYGBP from October 2002 until February 2005 were entered into a prospective, longitudinal database. All patients who subsequently presented with SBO were analyzed. Results: Jejunojejunal anastomotic obstruction occurred in 7 out of 152 patients (4.6%) in whom LRYGBP was performed from October 2002 to February 2004. Since February 2004, the suture used to close the jejunojejunal mesenteric leaves defect was changed from non-absorbable Dacron (Surgidac^™) to absorbable suture material. The mean interval between initial LRYGBP and subsequent SBO was 153 days. Operative findings common to all 7 cases were dilated loops of proximal small bowel, and a single adhesion just distal to the Roux-Y anastomosis. Following adhesiolysis, each patient had prompt return of bowel function without recurrence of obstruction. Of the 156 patients who have since undergone LRYGBP, none have presented with SBO, and this difference is statistically significant (P=0.008). Conclusions: The overall rate of SBO (2.3%) is consistent with the previous literature, although the incidence of adhesions specifically at the jejunojejunal anastomosis is higher than that previously encountered. It appears that the incidence of postoperative SBO at the jejunojejunal anastomosis is directly linked to the choice of suture material intraoperatively. As such, absorbable suture should be used to close the jejunojejunal mesenteric leaves defect.     

Jejunal Bezoar Causing Obstruction After Laparoscopic Roux-en-Y Gastric Bypass

Bowel obstruction is a known complication of Roux-en-Y gastric bypass. It can be caused by adhesions, internal hernia, incarcerated ventral hernia, or intussusception. Sometimes the underlying cause may be unusual. These 2 case reports describe patients who underwent laparoscopic Roux-en-Y gastric bypass and whose postoperative courses were complicated by small-bowel obstruction due to phytobezoars in the ileum, distal to the jejunojejunal anastomosis. We reviewed the literature by using PubMed and Medline for causes, pathogenesis, classifications, diagnosis, and management.     

Small Bowel Obstruction after Laparoscopic Roux-en-Y Gastric Bypass Caused by an Intraluminal Blood Clot

We report a rare case of acute early postoperative small bowel obstruction after laparoscopic Roux-en-Y gastric bypass due to an intraluminal blood clot at the site of the jejuno-jejunostomy. Patient was treated successfully with enterotomy and removal of the clot. A review of literature showed three similar publications. There has been absolutely no interference of any commercial interest or financial support creating this article.     

Small Bowel Obstruction After Antecolic Antegastric Laparoscopic Roux-en-Y Gastric Bypass Without Division of Small Bowel Mesentery: A Single-Centre, 7-Year Review

Reported incidence of small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass varies between 1.5% and 3.5%. It has been suggested that the antecolic antegastric laparoscopic Roux-en-Y gastric bypass (AA-LRYGB) is associated with a low incidence of internal herniation (IH). Therefore we routinely did not close mesenteric defects. The records of 652 consecutive patients undergoing primary AA-LRYGB from January 2003 to December 2009 in a single institution were retrospectively reviewed to determine the incidence, etiology, clinical symptoms, radiologic diagnostic accuracy and operative outcomes of SBO. Of the 652 patients, 63 (9.6%) developed SBO. The majority (6.9%, 45 patients) had a SBO due to IH. In 41 (91%) cases, the IH was at the jejunojejunostomy (JJ), four cases had an IH at Petersen’s space. Adhesions and ventral hernia were found in 14 (2.1%) and four (0.6%) cases, respectively. Twenty-nine out of 63 cases had negative computed tomography (CT) findings and IH was diagnosed on CT in only 33% (14/45) of patients with IH. All patients underwent diagnostic laparoscopy. No bowel resections had to be performed. In contrast to previous reports, a high incidence of SBO with a high rate of IH at the JJ site was found in our series. Accuracy of CT is low and diagnostic laparoscopy is mandatory when SBO is suspected. Since 2010 we have started closing the JJ site, and data on SBO are collected prospectively. We believe that closing of the mesenteric defects is a mandatory step, even in an AA-LRYGB.     

Anatomical Basis for the Low Incidence of Internal Hernia After a Laparoscopic Roux-en-Y Gastric Bypass Without Mesenteric Closure

Background

Different techniques have been designed to reduce the rate of internal hernia (IH) after laparoscopic bariatric surgery, and mesenteric closure is possibly the most controversial. We propose a laparoscopic Roux-en-Y gastric bypass (LRYGB) procedure without mesenteric closure with several specific technical details to avoid IH. To support this view, we have reviewed the outcome of our LRYGB patients and have carried out an anatomical study on cadavers.

Methods

A retrospective observational study was carried out using the Unit’s prospective database. The patients selected were those who were operated on for morbid obesity using LRYGB and who presented to the Emergency Unit with symptoms of intestinal obstruction (IO). Data concerning demographics, weight progress, technical details of the surgery, follow-up percentage, morbidity, and mortality were collected. Furthermore, an anatomical model was made in order to recreate the surgery on cadavers.

Results

Only 1.6 % of postoperative IO and very few (0.3 %) of IH cases were associated with our technique of LRYGB without mesenteric closure. The anatomical model showed two large potential hernia spaces, but their supramesocolic situation, the orientation of the bowel loops, leaving the mesentery and omentum undivided and the antecolic passage of the alimentary limb made intestinal herniation difficult even though the mesenteric spaces were not closed.

Conclusions

With a proper technique, the closure of mesenteric spaces after a LRYGB is not essential to avoid postoperative IH in bariatric patients, as evidenced in an anatomical model.     

Late Perforation and Abscess Formation at the Site of the Jejunojejunal Anastomosis Following Laparoscopic Roux-en-Y Gastric Bypass Surgery

Late complications involving the site of the jejunojejunal (J-J) anastomosis are uncommon after laparoscopic Roux-en-Y gastric bypass. We present a case of a perforation at the J-J anastomosis complicated by the formation of an abscess 6 months after surgery. Following clinical and radiological evaluation, the patient underwent an exploratory laparoscopy which had to be converted to an open technique because of technical difficulties. The abscess was drained, the anastomosis was resected, and a new anastomosis was undertaken. When the surgical specimen was inspected, a perforation was found at the site of the previous J-J anastomosis. The patient had an uneventful recovery. To our knowledge, this is the first report of the formation of an abscess due to a perforation at the site of the J-J anastomosis after laparoscopic Roux-en-Y gastric bypass surgery. This complication, although rare, should be taken into account in patients with abdominal pain and systemic inflammatory response syndrome after bariatric surgery. No commercial interests to disclose.     

A Prospective Evaluation of Intracorporeal Laparoscopic Small Bowel Anastomosis during Gastric Bypass

Background: We evaluated the safety and feasibility of performing a laparoscopic intracorporeal end-toside small bowel anastomosis using a stapling technique as part of a Roux-en-Y gastric bypass operation (RYGBP). Methods: 80 consecutive patients who underwent RYGBP with laparoscopic jejunojejunostomy were evaluated. Operative time and intraoperative and postoperative complications directly related to the jejunojejunostomy anastomosis were recorded. Results: All 80 laparoscopic jejunojejunostomy procedures were successfully performed without conversion to laparotomy. Mean operative time was longer for the first 40 laparoscopic RYGBP than for the last 40 RYGBP (32±18 min vs 21±14 min, respectively, p<0.05). Intraoperative complications were staple-line bleeding (2 patients) and narrowing of the anastomosis (1 patient). Postoperative complications were four small bowel obstructions: technical narrowing at jejunojejunostomy site (2 patients), angulation of the afferent limb (1 patient), and food impaction at the jejunojejunostomy anastomosis (1 patient). These four patients underwent successful laparoscopic re-exploration and creation of another jejunojejunostomy proximal to the original anastomosis. There were no small bowel anastomotic leaks. The median time to resuming oral diet was 2 days. Conclusions: Laparoscopic jejunojejunostomy as part of the RYGBP operation is a safe and technically feasible procedure. Postoperative small bowel obstruction is a potential complication, which can be prevented by avoiding technical narrowing of the afferent limb.     

Small-Bowel Volvulus in Late Pregnancy Due to Internal Hernia After Laparoscopic Roux-en-Y Gastric Bypass

Internal hernias are a specific cause of acute abdominal pain and are a well-known complication after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Although internal hernias are a rare cause of intestinal obstruction, they may evolve towards serious complications, such as extensive bowel ischemia and gangrene, with the need for bowel resection and sometimes for a challenging reconstruction of intestinal continuity. The antecolic position of the Roux limb is associated with a decrease in the incidence of small-bowel obstruction and internal hernias. The best prevention of the formation of these hernias is probably by closure of potential mesenteric defects at the initial operation with a non-absorbable running suture. We present a patient in late pregnancy with a small-bowel volvulus following laparoscopic Roux-en-Y gastric bypass for morbid obesity and discuss the available literature. For a favorable obstetric and neonatal outcome, it is crucial not to delay surgical exploration and an emergency operation usually is mandatory.     

Late Sigmoid Colon Internal Herniation into the Jejuno-Jejunostomy Mesenteric Defect after Laparoscopic Roux-en-Y Gastric Bypass

A 49-year-old female with morbid obesity (BMI 42) underwent laparoscopic Roux-en-Y gastric bypass (LRYGBP). 10 months after the operation, she presented to the hospital with intermittent mid-abdominal pain. An internal hernia of the sigmoid colon through a mesenteric defect of the jejuno-jejunostomy was found. Although small bowel internal herniation has been widely documented, the finding of large bowel internal herniation has not been previously reported. Maintaining a high index of suspicion and a low threshold for urgent intervention are required when evaluating patients with vague abdominal complaints after LRYGBP.     

Abdominal Drain Causing Early Small Bowel Obstruction After Laparoscopic Colectomy

We report a rare drain-related complication leading to small bowel obstruction after laparoscopic colectomy. An 82-year-old man developed small bowel obstruction on the second day after laparoscopic anterior resection. Emergency relaparoscopy found herniation of the small bowel mesentery into the side holes of the silicon intra-abdominal drain, which led to a 90-degree acute turn of the small bowel and mechanical obstruction. The herniation was reduced, and the drain was removed laparoscopically.     

Late Perforation of the Jejuno-Jejunal Anastomosis after Laparoscopic Roux-en-Y Gastric Bypass

Roux-en-Y gastric bypass (RYGBP) is the most commonly performed operation for the treatment of morbid obesity in the USA. Complications related to the jejuno-jejunal (J-J) anastomosis include postoperative leak, staple-line bleeding and obstruction. We present 3 cases of perforation at the J-J anastomosis occurring more than 30 days after surgery. 3 morbidly obese patients underwent laparoscopic RYGBP. The side-to-side J-J anastomosis was created with a linear stapler, and the anastomotic defect was closed with a running absorbable suture. All 3 patients had uneventful recoveries, but presented 7 to 8 weeks postoperatively with acute abdominal pain and peritoneal signs. Exploratory laparoscopy in these patients revealed a perforation at the J-J anastomosis. No apparent reason for the perforation was found in 2 patients. These perforations were repaired laparoscopically with absorbable suture. The third patient had an obstruction at the J-J anastomosis from an phytobezoar and required conversion to open technique due to limited pneumoperitoneum. All 3 patients recovered uneventfully. Late perforation of the J-J anastomosis is a very rare complication. Primary laparoscopic repair is a feasible and safe choice of treatment.     

Management of Anastomotic Leaks After Laparoscopic Roux-en-Y Gastric Bypass

Background Anastomotic leaks after bariatric surgery carry high morbidity and mortality. We aimed to describe our experience of the diagnosis and management of gastrointestinal anastomotic leaks in patients undergoing laparoscopic gastric bypass in a single institution. Methods Of 1,200 patients who underwent laparoscopic Roux-en-Y gastric bypass with manual gastrojejunal anastomosis for morbid obesity from January 2002 to January 2007, we retrospectively analyzed 59 patients with anastomotic leak. The location of the leak, day of diagnosis, diagnostic methods, clinical manifestations, treatment modalities, associated complications, and length of hospital stay were analyzed. Results Leaks were located as follows: 67.8% in the gastrojejunostomy, 10.2% in the gastric pouch, 3.4% in the excluded stomach, 5.1% in the jejunojejunal anastomosis, 3.4% in the gastrojejunostomy plus pouch, 3.4% in the pouch plus excluded stomach, and 6.8% in undetermined sites. Routine upper gastrointestinal series revealed contrast extravasation in nine patients (15.3%). Leaks were asymptomatic at diagnosis in 29 patients (49.2%). Surgical reintervention was carried out in 23 patients, and conservative treatment was provided in the remaining 36. Transfer to the intensive care unit was required in 11 patients, with five deaths (0.4%). Conclusion In our experience, most anastomotic leaks can be managed with conservative measures alone. In many patients, abdominal drains are effective in the management of leaks, obviating the need for reintervention. Nasoenteral nutrition was effective in the non-operative management of gastrojejunal leaks in patients without signs of systemic toxicity.     

Trends in Internal Hernia Incidence After Laparoscopic Roux-en-Y Gastric Bypass

Background Internal hernia is a known complication after gastric bypass, especially when performed laparoscopically. The aim of this study was to see when internal hernias occur in relation to weight loss and time course after surgery. Furthermore, we wish to examine the impact of Roux limb positioning ante- versus retrocolic and whether switching to running versus interrupted closure of the mesenteric defects created at surgery made any difference. Methods A retrospective chart review was performed of all patients undergoing laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) who developed symptomatic internal hernia requiring operative intervention between January 1, 2000 and September 15, 2006. Results Fifty-four internal hernias occurred in 2,572 patients, an incidence of 2.1%. The site of internal hernias varied: 25 (1%), transverse mesocolon; 22 (0.8%), enteroenterostomy; 7 (0.3%), Peterson’s space. The mean time to intervention for an internal hernia repair was 413 ± 46 days and average % excess body weight loss (%EBWL) in this period was 59 ± 3.3. Subgroup analysis demonstrates internal hernia incidence to be 2 in 357 (0.6%) in antecolic Roux versus 52 in 2,215 (2.4%) in retrocolic Roux limb (odds ratio = 4, P < 0.05). Continuous closure versus interrupted stitching of mesenteric defects does not seem to alter the incidence of internal hernias. Conclusion This study demonstrates that the majority of internal hernias occur after a significant (>50%) EBWL. Furthermore, the antecolic approach is associated with a much reduced incidence of internal hernia.