Blood clot obstruction of the jejunojejunostomy after laparoscopic gastric bypass

Endoscopic management of postoperative bleeding

Postoperative gastrointestinal bleeding is a rare but serious complication that can lead to prolonged hospitalization and significant morbidity and mortality. It can be managed by reoperation, endoscopy, or radiological intervention. Although reoperation carries risks, particularly in critically ill postoperative patients, minimally invasive interventions, such as endoscopy or radiological intervention, confer advantages. Endoscopy allows localization of the bleeding focus and hemostatic management at the same time. Although there have been concerns regarding the potential risk of creating an anastomotic disruption or perforation during early postoperative endoscopy, endoscopic management has become more popular over time. However, there is currently no consensus on the best endoscopic management for postoperative gastrointestinal bleeding because most practices are based on retrospective case series. Furthermore, there is a wide range of individual complexities in anatomical and clinical settings after surgery. This review focused on the safety and effectiveness of endoscopic management in various surgical settings.

The Jejunojejunostomy: an Achilles Heel of the Roux-en-Y Gastric Bypass Construction

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (RYGB) has for long been the gold standard technique in bariatric surgery, especially in the Scandinavian countries. In a tertiary hospital setting, we observed an increasing number of patients with postprandial abdominal pain and nausea, often associated with complex hypoglycemia.

OBJECTIVES

The present study aimed to characterize the clinical patterns, patient characteristics, and clinical outcomes after surgical revision of dysfunctional RYGB at Sahlgrenska University Hospital in Gothenburg, Sweden.

METHODS

This cohort study included patients with RYGB who underwent revision of the jejunojejunostomy (JJ) after 2013. Information was obtained by reviewing medical records and performing complementary interviews.

RESULTS

Laparoscopic revisional surgery was performed in 115 cases with either adhesiolysis or total revision of the JJ (mean age 41 years, range 19-67 years; 90% women). The median time to assessment after the last revision was 33 months (range 12-75 months). Forty-four (38%) patients reported that they were symptom-free long-term after the intervention, and 32 (28%) patients experienced an improvement in the symptoms that were the indication for revision. However, 31 (27%) patients reported no long-term improvement, and half of them (n = 16) subsequently had a reversal of the anatomy. Eight (7%) patients were lost to follow-up.

CONCLUSIONS

Dysfunction of the JJ appears to be a relatively common cause of postprandial pain and nausea after ante-colic/ante-gastric RYGB. Most patients with symptoms of dysfunction experienced partial or total relief following revisional surgery, but a substantial minority had persistent problems, with one in five eventually undergoing reversal of the anatomy.

Small Bowel Obstruction After Laparoscopic Roux-en-Y Gastric Bypass Caused by Hemobezoar: A Case Series and Review of Literature

BACKGROUND

The development of an intraluminal blood clot (hemobezoar), represents a rare cause (0.05% to 1.9%) of small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass (LRYGB). We present a case series of 6 cases of SBO caused by hemobezoar.

METHODS

A retrospective analysis of a prospective database including patients who underwent LRYGB from January 2010 to December 2019 has been performed. All the patients who underwent reoperation because of an SBO caused by an intraluminal blood clot were included in the present study.

RESULTS

Six of 843 LRYGB patients developed an hemobezoar (0.71%). Primary LRYGB was uneventful in all cases. SBO symptoms developed after a mean interval of 26.6 hours from the primary procedure. All reoperations were performed with the laparoscopic approach. In all cases, the hemobezoar was located at the level of the jejunojejunal anastomosis (JJA) and was removed through an enterotomy performed at the distal end of the biliopancreatic stump. Three postoperative complications occurred: 1 ab-ingestis pneumonia, 1 leak of the JJA requiring further reoperation, and 1 pelvic abscess treated with radiologic drainage. The mean hospital stay was 11 days.

DISCUSSION

SBO due to hemobezoar is a rare but worrisome early complication after LRYGB. It almost always affects the JJA and requires a prompt diagnosis to avoid dreadful sequelae. In the absence of anastomotic leak or stenosis, surgical management may consist of the removal of the blood clot without refashioning the anastomosis and it may be accomplished with the laparoscopic approach.

Surgical management of obstructing clot at the jejunojejunostomy after gastric bypass: a single center experience and literature review

BACKGROUND

Roux-en-Y gastric bypass is a proven treatment for morbid obesity and its sequelae. Gastric bypass has a safe risk profile, but postoperative complications can be seen. We report on 10 cases of postoperative bleeding causing an obstructing clot at the jejunojejunostomy (JJ) occurring over a 9-year period.

OBJECTIVES

The aim was to document presenting symptoms of obstructing clots at the JJ and to suggest a treatment approach to minimize complications.

SETTING

University Hospital, United States METHODS: The local Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was queried for all patients undergoing reoperation after Roux-en-Y gastric bypass, from July 2009 until December 2019. All patients who were found to have postoperative bleeding causing an obstructing clot at the JJ were selected for retrospective medical-record review.

RESULTS

The most common presenting symptoms were Hematocrit drop (10 of 10), nausea (9 of 10), abdominal pain (7 of 10), and hematemesis (4 of 10). There were 12 reoperations in the 10 patients, 10 of which were completed laparoscopically. Infectious complications were the most frequent morbidity in our patients; 4 patients developed abscesses. In all of these, the operative notes described gross spillage into the peritoneal cavity. In later cases, the remnant stomach was decompressed before reoperation, reducing spillage.

CONCLUSIONS

Despite the low rate of obstructing clots at the JJ, without rapid recognition and reoperation, there is a risk for serious complications. Typical presenting symptoms include nausea and abdominal pain, which help differentiate it from other causes of decreased hematocrit. Diagnosis is commonly made with computerized tomographic (CT) scan. Decompression of a dilated remnant stomach before addressing the clot can prevent intraperitoneal spillage and subsequent abscess formation. Enterotomy creation and removal of clot is recommended, without fear of continued bleeding.

Acute bleeding obstruction pancreatitis after Roux-en-Y anastomosis in total gastrectomy: a single center experience

Anastomotic intraluminal bleeding is a well-known complication after total gastrectomy. Nevertheless, few data are published on acute bleeding obstruction pancreatitis (BOP) due to a bleeding from the jejunojejunostomy (JJ). In this paper we describe our experience. A total of 140 gastrectomies for EGJ cancer were performed in our Institute from January 2012 to January 2017. All reconstructions were performed with a Roux-en-Y anastomosis: a mechanical end-to-side esophago-jejunostomy and a mechanical end-to-side JJ. Three patients suffered from a bleeding at the JJ with a consequent BOP. We analyzed the time of diagnosis, the treatment and the outcomes. The three patients presented anemia at the laboratory findings on postoperative day (POD) 1. In patient I laboratory findings of acute pancreatitis were found in POD 2. CT scan was performed and showed signs of BOP. Endoscopic treatment was tried without success. Therefore, patient underwent surgery: JJ take down, bleeding control and anastomosis rebuild were performed. In spite of this the patient died of MOF in POD 4. Patient II had a persistent anemia treated with blood transfusions until POD 3, when laboratory tests showed increased lipase and bilirubin levels. Patient was successfully treated with endoscopy but several blood transfusions and a prolonged recovery were necessary. Patient III had laboratory findings of acute pancreatitis on POD 1. Immediate surgery was performed and patient was discharged on POD 9 without sequelae. BOP is a rare but deadly complication after Roux-en-Y anastomosis. An early diagnosis and an aggressive treatment seem to improve the outcome.

The Gastric Remnant in Roux-en-Y Gastric Bypass: Challenges and Possibilities

Laparoscopic Roux-en-Y gastric bypass (RYGB) is widely applied in the treatment of morbid obesity. Health personnel meeting these patients should thus be familiar with the potential clinical consequences of the modified anatomy induced by the surgery. After a RYGB, the stomach is left in situ after the closure of the upper part of the organ. This blind-ended gastric remnant may cause complications and surgical emergencies, but also opportunities for diagnostic and therapeutic intervention. The present review focuses on complications related to the gastric remnant including bleeding and acute dilatation in the early postoperative period and later adverse events such as gastroduodenal peptic disease, tumors, gastrogastric fistulas, and late dilatation. Opportunities offered by the remnant, including minimal invasive or open access for enteral nutrition, and therapeutic and diagnostic access to the bile ducts, the duodenum, and the gastric remnant, which is challenged by the modified anatomy, are discussed. Reversal of the gastric bypass and gastrointestinal reconstruction after esophageal resection have been commented on. The review aims to improve the awareness of issues related to the gastric remnant for physicians involved in the treatment and the follow-up of patients after a RYGB.

Bariatric emergencies: current evidence and strategies of management

BACKGROUND

The demand for bariatric surgery is increasing and the postoperative complications are seen more frequently. The aim of this paper is to review the current outcomes of bariatric surgery emergencies and to formulate a pathway of safe management.

METHODS

The PubMed and Google search for English literatures relevant to emergencies of bariatric surgery was made, 6358 articles were found and 90 papers were selected based on relevance, power of the study, recent papers and laparoscopic workload. The pooled data was collected from these articles that were addressing the complications and emergency treatment of bariatric patients. 830,998 patients were included in this review.

RESULTS

Bariatric emergencies were increasingly seen in the Accident and Emergency departments, the serious outcomes were reported following complex operations like gastric bypass but also after gastric band and the causes were technical errors, suboptimal evaluation, failure of effective communication with bariatric teams who performed the initial operation, patients factors, and delay in the presentation. The mortality ranged from 0.14%-2.2% and increased for revisional surgery to 6.5% (p = 0.002). Inspite of this, mortality following bariatric surgery is still less than that of control group of obese patients (p = value 0.01).

CONCLUSIONS

Most mortality and catastrophic outcomes following bariatric surgery are preventable. The awareness of bariatric emergencies and its effective management are the gold standards for best outcomes. An algorithm is suggested and needs further evaluation.