Obstruction After Laparoscopic Roux-en-Y Gastric Bypass: Roux Obstruction and Biliopancreatic Gangrene up to Ligament of
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MULTIMEDIA ARTICLE
Obstruction After Laparoscopic Roux-en-Y Gastric Bypass: Roux Obstruction and Biliopancreatic Gangrene up to Ligament of Treitz Ahmad Bashir 1 & Ashraf Haddad 1
# Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Obstruction after laparoscopic Roux-en-Y gastric bypass (LRYGB) is a known complication. We present a video of a patient who suffered both early Roux limb obstruction, and late Petersen’s hernia with proximal biliopancreatic limb volvulus and gangrene up to the ligament of Treitz, and how both were managed. Keywords Gastric bypass . Internal hernia . Obstruction . Brolin's anti-obstruction stitch . Volvulus . Small bowel resection
Introduction Obstruction after laparoscopic Roux-en-Y gastric bypass (LRYGB) is a known complication. Isolated limb obstruction is more common in Roux limb compared with biliopancreatic limb (BPL) [1, 2]. We review a patient who suffered from both.
Methods We retrospectively reviewed this patient’s electronic record, imaging studies, and video recordings.
Petersen’s defects. Patient was discharged on postoperative day (POD) 3. He returned on POD 6 with recurrent nonbilious vomiting due to kink in Roux before jejunojejunostomy (JJA), fixed successfully by removing the anti-obstruction (Brolin) suture, and stricturoplasty (HeinekeM i k u l i c z ) , g u i d e d b y in tr a o p e r a t i v e e n d o s c o p y. Unfortunately, the patient presented again 8 months later with acute onset abdominal pain without vomiting. His BMI was 33.2 kg/m2. Upon workup and laparoscopy, volvulus of the BPL through the Petersen’s defect caused closed loop obstruction and gangrene of the proximal 30 cm of the BPL. After resection, the proximal segment was not long enough to anastomose to, so a duodenojejunostomy with the third part of the duodenum, inframesocolic, was done. A protective gastrostomy tube in the remnant was placed.
Results A 33-year-old male with a body mass index (BMI) of 49 kg/ m2 underwent LRYGB antecolic, antegastric, with Roux and BPL lengths of 1 m each, and with closure of mesenteric and Electronic supplementary material The online version of this article (https://doi.org/10.1007/s11695-020-04575-4) contains supplementary material, which is available to authorized users. * Ahmad Bashir [email protected] * Ashraf Haddad [email protected] 1
Gastrointestinal, Bariatric & Metabolic Center at Jordan Hospital, Amman, Jordan
Conclusion This video illustrates management and review of technical flaws that potentially contributed to the patient’s complications. Video archiving is essential. Obstruction after LRYGB requires early surgical intervention almost always. Endoscopy and gastrostomy tube placement in the blind remnant are tools for surgeons in managing obstruction after LRYGB.
Compliance with Ethical Standards Informed consent was obtained from the patient in this review. All procedures performed in this review involving this patient were in accordance with the ethical standards of the institutional research committee
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