bypass Blood obstruction bezoar causing after laparoscopic Roux-en-Ygastric International Journal of Surgery Case Reports CASE REPORT – OPEN ACCESS

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CASE REPORT – OPEN ACCESS

InternationalJournalofSurgeryCaseReports5(2014)183–185

ContentslistsavailableatScienceDirect

International Journal of Surgery Case Reports

j o u r n al ho m e p a g e :w w w . c a s e r e p o r t s . c o m

Blood bezoar causing obstruction after laparoscopic Roux-en-Y gastric bypass

Abdolreza Pazouki

^a

, Mohamadali pakaneh

^a

, Alireza Khalaj

^a,b,∗

, Zeinab Tamannaie

^a

, Ali Jangjoo

^c

, Parvin Shapoori

^a

, Mohsen Kalhor

^a

aMinimallyInvasiveSurgeryResearchCenter,Rasoul-e-AkramHospital,IranUniversityofMedicalSciences,Tehran,Iran

bShahedUniversity,FacultyofMedicine,Mostafa-KhomeiniHospital,Tehran,Iran

cSurgicalOncologyResearchCenter,ImamRezaHospital,FacultyofMedicine,MashhadUniversityofMedicalSciences,Mashhad,Iran

a r t i c l e i n f o

Articlehistory:

Received6January2013 Receivedinrevisedform 10September2013 Accepted17December2013 Availableonline24January2014

Keywords:

Bezoar

Roux-en-Ygastricbypass Bowelobstruction

a b s t r a c t

INTRODUCTION:BowelobstructionisaknowncomplicationafterbariatricsurgeryespeciallyRoux-en-Y gastricbypass.Theknownetiologiesincludeinternalhernia,jejunojejunostomystricture,ileus,intus- susceptions,superiormesentericarterysyndrome,incarceratedportsitehernia,andadhesions.Blood bezoarisararecauseofsmallintestinalobstructionafterRoux-en-Ygastricbypass.

PRESENTATIONOFCASE:WearegoingtopresenttwocasesofsmallbowelobstructionafterRoux-en-Y gastricbypassduetobloodbezoar.

DISCUSSION:BloodclotastheetiologyofsmallbowelobstructionafterRoux-en-Ygastricbypassisan unusualevent.Inthepresenceofpostoperativesmallintestinalobstructionanobstructivebloodbezoar shouldbeindifferentialdiagnosis.Asanyotheretiologyofpostoperativeobstructionitshouldbetreated immediatelytopreventitsadverselethalcomplications.

CONCLUSION:Thebestwayforpreventionofbloodbezoarispreventionofbleedingatstaplelineand doinghemostasisatstaplerline.

1. Introduction

Withincreasing thenumber of laparoscopic Roux-en-Ygas- tricbypasswemayincreasinglyfacewithitscomplications.One ofthesecomplicationsisgastricoutletandbowelobstruction.^1–4 Itusuallypresentwithepigastriccolickyabdominalpain,vomitingandobstipation.^5–7Inthissituationbowelobstructionshould beconsidered in differential diagnosis.The etiologies of bowel obstructionareadhesions,internalhernia,incarceratedportsite hernia,stenosisofanastomosis,intussuception,superiormesen- tericarterysyndromeandrarelybloodbezoarinthedistalofsmall intestine.^3,10,11 Itmaybecomplicatedwithdisruptionofanasto- moticlineandperitonitis.⁹

Wedescribetwocasesofsmallbowelobstructionafterlaparo- scopicRoux-en-Ygastricbypass.

∗Correspondingauthor.Tel.:+982166555448;fax:+982166555448.

E-mailaddresses:[email protected](A.Pazouki),[email protected] (M.pakaneh),[email protected](A.Khalaj),zeinab[email protected] (Z.Tamannaie),[email protected](A.Jangjoo),[email protected] (P.Shapoori),[email protected](M.Kalhor).

2. Presentationofcase

A34yearsoldwomanunderwentlaparoscopicantecolicante- gastricRoux-en-Ygastricbypass.HerBMIwas43kg/m² without comorbidities.Gastricpouchmadewith3bluecartridges.Gas- trojejunostomy were donewith blue 45mm endoGIA stapler.

Jejunojejunostomy was donewith white 60mm endo GIA stapler.Theoperationwaswithoutproblem.Thedayafteroperation patientunderwentupperGIgastrograﬁnstudy.Thedayafterthat shecomplicatedwithcolickyabdominalpain,vomitingandobstipation. Plain abdominal X-rays showed dilated small intestine withoutgasshadowinthelargebowel.Sheunderwentconserva- tivetreatment.Inthe6thdayafteroperationshebecamefebrileand complainedofabdominalpainandtenderness.Abdomenexplored throughamidlineincision.Onexplorationabdominalsecretions, small intestine dilatation and jejunojenunostomy leakage was determined.Atransitionalzonewithasolidmassincludingahard bloodbezoarwaspalpatedinthedistalofileum.Themassinclud- ingdriedclotextractedthroughanastomoticholeandanastomosis repaired(Fig.1).

Thesecondcasewasa45yearsoldwomanunderwentlaparo- scopicantecolicantegastricRoux-en-Ygastricbypass.Afterupper GIgastografﬁnstudyinthedayafteroperationshecomplained epigastriccolickyabdominal pain,vomitingandabdominal dis- tension.Aftersomewaterystoolpassageshebecameobstipated.

PlainabdominalX-raysshoweddistendedsmallbowelobstruction.

http://dx.doi.org/10.1016/j.ijscr.2013.12.022

Open access under CC BY-NC-ND license.

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Fig.1. Abdominalexploration:atransitionalzonewithasolidmassincludinga hardbloodbezoarinthedistalofileum.

In laparoscopic exploration in the 4th postoperative day dis- tendedbowelloopwasprominent.Withretrogradeexploration of collapsed small bowel fromileocecal area we sawa transi- tionzone,dilatedproximalbowelloopwithaﬁrmintraluminal mass.Bygraspingandpressingthemasswithbowelgrasperthe massdisruptedandpusheddistally.Patientdefecatedandbecame asymptomatic.Afterdefecationwesawsomepiecesofarelatively ﬁrmclot.

3. Discussion

Blood clot as the etiology of small bowel obstruction after antecolicantegastricRoux-en-Ygastricbypassisanunusualevent.

We usually use45–3.5 and 60–3.5 endoGIAstapler for pouch construction and gastrojejunostomy and 60–2.5 endo GIA stapler for jejunojejunostomy. Sometimes we see bleeding from stapleline. In obviousexternal bleeding weusually useenergy device,sutureor clipsforhemostasis.Bleedingfromstapleline in gastrojejunostomy or jejunojejunostomy is not visible. Peri- operativeadministrationofheparinmayaggravatebleeding.Our casestypicallybecamesymptomaticaftergastrografinstudy.We thinkhyperperistalticeffectofgastrografinonintraluminalblood accumulateand compressthem toform afirm to hard bezoar.

In ourseriesof more than 430LGB 2cases of bezoarobstruc- tion were detected. Other publications reported one in 796,¹ 5 in 825⁸ and one in 115 LGB.¹³ The symptoms are mechani- calobstructionofsmallbowelincludingcolickyabdominalpain, vomitingandobstipation.Inthecasesofclosedloopobstruction andgangrenefever,abdominaltendernessandleukocytosismay beadded.Bezoarobstructionandotheretiologiesofobstruction such as internal hernia, quinking of bowel at jejunojejunos- tomyand port sit incarcerated hernia predispose toclose loop obstruction.¹²

Quickdiagnosisand treatmentis necessary. Upper GIseries andCTscanarethebestdiagnosticmodalityfordetectingintra- luminalclot.¹⁴Althoughclinicalsignsareveryindicativeforclose loopobstruction,CTscanisalsoanimportanttoolfordetecting closeloopobstruction.Earlysurgicalinterventionisadvocatedin mostpublications.Completerevisionofanastomosis,longitudinal enterotomyandthrombectomyofintestinearevariouswaysfor thrombectomy.^8,13Ifthereisanobstructiveclotinthestomachit canberemovedwithendoscopy.^4,13

Abouttheeffectofgastrograﬁnonobstructionthereis some proved evidencesabout thetherapeutic role of gastrograﬁn on bowelobstruction.¹⁵

4. Conclusion

Bloodbezoarisarareetiologyforpostoperativesmallbowel obstruction afterlaparoscopic Roux-en-Y gastric bypass. In the presenceofpostoperativesmallintestinalobstructionanobstruc- tivebloodbezoarshouldbeindifferentialdiagnosis.Asanyother etiologyofpostoperativeobstructionitshouldbetreatedimmedi- atelytopreventitsadverselethalcomplications.NGtubewillonly decompressthealimentarylimbandthebiliopancreaticlimbwill notdecompress.

Thebestwayforpreventionofbloodbezoarispreventionof bleedingatstaplelineanddoinghemostasisatstaplerline.

Conﬂictofintereststatement Nonedeclared.

Funding

Nonedeclared.

Ethicalapproval

Writteninformedconsentwasobtainedfromthepatientfor publicationofthiscasereportandaccompanyingimages.Acopy ofthewrittenconsentisavailableforreviewbytheEditor-in-Chief ofthisjournalonrequest.

Authorcontributions

Dr.Jangjoo,Dr.Pazouki,Dr.Khalaj:studydesign.

Dr.Pakaneh,Dr.PazoukiDr.Jangjoo:datacollections.

Dr.Jangjoo,Dr.Tamannaie:writing.

References

1.PeetersG,GysT, LafullardeT.Smallbowelobstructionafter laparoscopic Roux-en-Ygastricbypasscaused byanintraluminal bloodclot.ObesSurg 2009;19:521–3.

2.MohammadSarhanMD,BhaktaShyamaliMD,AdesholaFakulujoMD,Leaque AhmedMD.JejunalBezoarcausingobstructionafterlaparoscopicRoux-en-Y gastricbypass.JSocLaparoendoscSurg2010;14:592–5.

3.BenjaminClappMD,BruceApplebaumMD.Superiormesentericarterysyn- drome after Roux-en-Y gastric bypass.J Soc Laparoendosc Surg 2010;14:

143–6.

4.LeungE,BarnesR,WongL.Bezoaringastro-jejunostomypresentingwithsymp- tomsofgastricoutletobstruction:acasereportandreviewoftheliterature.J MedCaseRep2008;2(October):323.

5.PeetersG,GysT, LafullardeT.Smallbowelobstructionafter laparoscopic Roux-en-Ygastricbypasscaused byanintraluminal bloodclot.ObesSurg 2009;19(April(4)):521–3.

6.AwaisO,RaftopoulosI,LuketichJD,CourcoulasA.Acute,completeproximal smallbowelobstructionafterlaparoscopicgastricbypassduetointraluminal bloodclotformation.ObesSurg2009;19(April(4)):521–3.

7.AyazVirjiMD,MichelM,MurrMD.Caringforpatientsafterbariatricsurgery.

AmFamilyPhysician2006;73(April(8))http://www.aafp.org/afp

8.AwaisO,RaftopoulosI,LuketichJD,CourcoulasA.Acute,completeproximal smallbowelobstructionafterlaparoscopicgastricbypassduetointraluminal bloodclotformation.SummSurgObesRelatDis2005;1(July–August(4)):418–22 (discussion422–3).

9.Spanager L, Sigild UH, Neuenschwander AU. Late perforation follow- ing laparoscopic gastricbypass. UgeskrLaeger 2010;172(September (36)):

2440–1.

10.HowardDD,DeShazoME,RichardsWO,RodningCB.retrogradejejunojeju- nalintussusceptionstatusfollowingRoux-en-Ygastrojejunostomy.IntSurg 2010;95(April–June(2)):177–82.

11.SarhanM,AhmedL,MieggeL.RetrogradeintussusceptionafterRoux-en-Ygas- tricbypass.AmSurg2010;76(April(4)):454–6.

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CASE REPORT – OPEN ACCESS

A.Pazoukietal./InternationalJournalofSurgeryCaseReports5(2014)183–185 185

12.GunabushanamG,ShankarS,CzerniachDR,KellyJJ,PeruginiRA.Small-bowel obstructionafterlaparoscopicRoux-en-Ygastricbypasssurgery.JComputAssist Tomogr2009;33(May–June(3)):369–75.

13.FelsherJ,BrodskyJ,BrodyF.SmallbowelobstructionafterlaparoscopicRoux-en Ygastricbypass.Surgery2003;134(September(3)):501–5.

14.RamanR,RamanB,RamanP,RossiterS,CuretMJ,MindelzunR,etal.Abnormal ﬁndingsonroutineupperGIseriesfollowinglaparoscopicRoux-en-Ygastric bypass.ObesSurg2007;17(March(3)):311–6.

15.SafamaneshS,PazoukiA,TamannaieZ,MohammadalipourB,RamezaniK, HajnasrollahE,etal.Evaluationofgastrograﬁntherapeuticroleontheman- agementofsmallbowelobstruction.JMinimInvasiveSurgSci2012;1(3):90–3, http://dx.doi.org/10.5812/jmiss.6996.

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