Bariatric Times

MAR 2016

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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11 Case Report Bariatric Times • March 2016 c hallenge. Patients may present with intermittent, non-specific abdominal complaints along with nausea and vomiting. 6 Symptoms of obstruction may be reminiscent of cholelithiasis, i rritable bowel syndrome, or interpreted as patient non-adherence to dietary recommendations. Unless complete bowel obstruction is encountered, symptoms can be i nfrequently episodic, thus patients may not even disclose them to their physician. 8 Imaging modalities, while useful, are often vague and inconclusive. 9 Moreover, a long d ifferential can lead to a delay in proper diagnosis and treatment. Our case report involves a delay in diagnosis; the patient presented with abdominal pain that recurred intermittently following m ultiple exploratory laparoscopies that included a cholecystectomy and closure of internal hernia defect as well as gynecologic procedures. Bariatric patients presenting with l ate complications are associated with a lower overall incidence of major complications during hospitalizations when early operative management is pursued compared to those treated nonoperatively. 10 An obstruction after gastric bypass can result in a closed loop obstruction, which can be lethal; patient mortality is usually the result of a delay in treatment. 11 Patients with a more unclear presentation should undergo CT with oral contrast as the initial diagnostic study, which is found to be more accurate than a gastrografin upper gastrointestinal series in determining the presence of a small bowel obstruction. 12 Despite the altered bowel anatomy after RYGB, radiological imaging can be useful in diagnosing late complications of bariatric surgery, identifying the presence of hernia, obstructions, intussusceptions, and volvulus. 5 However, the sensitivity of radiological studies to diagnose bowel obstruction after gastric bypass is lower compared to the non-bariatric population. 4 While radiologic studies can be helpful, exploration may be the only effective way to diagnose and treat abdominal pathology in post-bariatric patients. Therefore, immediate exploratory surgery is warranted for subtle or overt signs of bowel obstruction in these patients. 10 A jejuno-jejunostomy volvulus is a rare complication following RYGB. The incidence of this complication is unknown likely because it is under- diagnosed and under-reported. A volvulus may be more common following a laparoscopic RYGBP compared with the open approach due to the lack of adhesion formation in the laparoscopic approach. 13 There have been several other reported cases of volvulus like presentation at the Roux limb following gastric bypass. One such case reported a volvulus in a pregnant patient with a previous laparoscopic RYGB. 14 Exploratory laparotomy revealed a Roux limb volvulus with approximately 150cm of necrotic bowel that was subsequently resected. This particular case was more consistent with an internal hernia. Another case described an intestinal volvulus with c oncurrent intussusception at the jejunojejunal anastomosis. 15 Other cases found in literature requiring resection of the jejunojejunal anastomosis include intussusception or obstruction at the anastomotic site, and perforation with abscess formation. 16,17 In the presented case, an intestinal volvulus was discovered with the jejuno-jejunostomy a s the lead point. This pathologic finding was definitively treated with a resection of the jejunojejunal anastomosis and small bowel anastomotic reconstruction distally. The clinical presentation of a jejuno- jejunostomy volvulus is not straightforward and can mimic that of an internal hernia or obstruction. S ymptoms, such as abdominal pain with or without nausea and vomiting, are typically vague. Contrast-enhanced CT may demonstrate a whirl sign indicating a twisting of the mesentery. The clinical presentation of a jejuno-jejunostomy volvulus is not straightforward and can m imic that of an internal hernia or obstruction. Symptoms, such as abdominal pain with or w ithout nausea and vomiting, are typically vague.

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