A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional
Issue link: https://bariatrictimes.epubxp.com/i/651228
10 Case Report Bariatric Times • March 2016 INTRODUCTION Obesity is an epidemic with increasing prevalence worldwide. In the United States, over one-third of adults have obesity. 1 Bariatric surgery has been proven to be the most effective therapy for achieving clinically meaningful weight loss among the population with morbid obesity. 2 With over 460,000 procedures performed worldwide annually, gastric bypass still remains the one of the most common. 3 Roux-en-Y gastric bypass (RYGB) is considered the bariatric operation to which other weight loss procedures are compared. The laparoscopic technique has become the dominant approach due to its shorter length of hospitalization, faster recovery, and reduction in wound complications. 4 Although laparoscopic RYGB can effectively combat obesity and associated comorbidities, it is not without complications. As more weight loss operations are performed, more patients are likely to develop complications and, despite proper education, have urgent needs requiring evaluation in the emergency department. Late complications of RYGB are uncommon, but they can be life threatening. Late complications after RYGB include obstruction, internal and incisional hernia, marginal ulcer, anastomotic stenosis, intussusception, and intestinal volvulus. 5,6 These complications can be difficult to diagnose nonoperatively and challenging to differentiate from other gastrointestinal disorders. 7 The variation of intestinal volvulus with the jejuno-jejunostomy as the lead point is likely under-diagnosed. The following is a case report of a jejuno-jejunostomy volvulus after gastric bypass. CASE REPORT After institutional review board (IRB)-approval, the following case report was performed. A 34-year-old female who underwent RYGB in 2010 experienced 96% excess weight loss (EWL), with a body mass index (BMI) change of 44.3kg/m 2 to 22.15kg/m 2 . She presented to the emergency department at our institution with a several day history of acute onset of central abdominal pain. She reported that the pain was burning in nature, radiated to her back and post-prandial. She admitted having similar intermittent abdominal pain for over a year, however, she said that pain was less intense and would resolve spontaneously. Possibly due to the uncertain etiology of her abdominal pain, the patient had undergone multiple procedures including laparoscopic cholecystectomy with concomitant internal hernia repair in December 2013 and exploratory laparoscopy with drainage of tubo- ovarian abscess in January 2014 followed by right salpingo- oopherectomy with left salpingectomy. While the pain would temporarily resolve following these procedures, her symptoms persistently recurred. We reviewed her symptoms and found that she reported nausea without emesis and intermittent intense central abdominal pain without obstipation. On exam, her vital signs were within normal limits, however, she appeared uncomfortable. Her abdominal exam was notable for a soft, non-distended abdomen and tenderness to palpation predominately in her epigastric region with voluntary guarding. Her laboratory evaluation was unremarkable. A computerized tomography (CT) scan revealed a twisted segment of small bowel with no obvious signs of obstruction or necrosis (Figure 1). Since small bowel viability was a concern, the patient was offered a diagnostic laparoscopy. On exploration, a volvulus with a corkscrew appearance of the mesentery, twisted small bowel with a large dilated bulbous jejunojejunal anastomosis as the lead point was discovered (Figure 2). After reversal of the volvulus, a complete bowel exploration revealed viable, non- obstructed bowel in an antecolic- antegastric gastric bypass configuration. Resolution of the pathologic jejuno-jejunostomy volvulus was confirmed and the operation was complete. Postoperatively, her pain had resolved and she tolerated a regular diet. Unfortunately, two weeks later she presented with a recurrence of her complaint of central abdominal pain. She was admitted for bowel rest and rehydration due to suspicion of a recurrent volvulus. A CT scan was obtained with similar findings from the prior study of a volvulized segment of small bowel. The patient was taken back for laparoscopic re-exploratory, which confirmed a recurrent volvulus with the jejuno-jejunostomy again as the lead point and no internal hernia was present. The definitive treatment with resection of her jejuno- jejunostomy was performed with a reconstruction 10-12 cm distally using a stapled side-to-side functional end-to- end technique. Again, the patient had an uneventful recovery with good toleration of oral intake. She has experienced 12 months of resolution of her symptoms. DISCUSSION The cause of late abdominal pain after RYGB can be a diagnostic by 2 ND LT SOLOMON TONG, MS; LCDR JESSE BANDLE, MD; and CDR GORDON G. WISBACH, MD, MBA Bariatric Times. 2016;13(3):10–12. Late Onset Abdominal Pain After Gastric Bypass Due to a Rare Diagnosis—Jejuno- Jejunostomy Volvulus ABSTRACT Bariatric surgery is the most effective therapy for obesity, with laparoscopic Roux-en-Y gastric bypass (RYGB) being one the most commonly performed operations. While late complications of RYGB are uncommon, they are difficult to diagnose accurately. We p resent a case of late abdominal pain following RYGB due to a jejuno-jejunostomy volvulus. We discuss the challenges of diagnosis and recommendations for treatment. KEYWORDS Gastric bypass, bariatric surgery, intestinal volvulus, jejuno-jejunostomy, post-operative complications Figure 1. Transverse CT shows swirling mesentery around the superior mesenteric vessels. There is no proximal dilation to indicate active obstruction. Figure 2. Volvulized segment of bowel with corkscrew appearance