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Phytobezoar causing small bowel obstruction seven years after laparoscopic Roux-en-Y gastric bypass
Surgery for Obesity and Related Diseases 7 (2011) e3– e5
Case report
Phytobezoar causing small bowel obstruction seven years after laparoscopic Roux-en-Y gastric bypass William F. Powers, IV, M.D., David R. Miles, M.D.* Department of Surgery, South East Area Health Education Center, New Hanover Regional Medical Center, Wilmington, North Carolina Received July 8, 2010; accepted July 20, 2010
Keywords:
Bezoar; Small bowel obstruction; Endoscopy; Gastric bypass
With more than one third of the U.S. adult population now obese, obesity surgery is at the forefront of weight loss management [1]. With the advent of laparoscopic Rouxen-Y gastric bypass (RYGB) and its subsequent refinements, weight loss surgery is an ever-present procedure in many institutions across the United States. A number of postoperative complications have been well described. Early complications have included deep venous thrombosis with or without pulmonary embolus, anastomotic leak, obstruction, and bleeding, and late complications have included anastomotic stricture, ulcer formation, small bowel obstruction of varying etiologies, cholelithiasis, and nutritional deficiencies [1,2]. Bezoars are a less common complication that, to our knowledge, have continued to be described only in case reports. Of the case reports reviewed, all discovered bezoars as a cause of small bowel obstruction occurred in the early or intermediate postoperative period (2-24 months postoperatively; Table 1 [2-7]). The present report describes a patient who presented with a small bowel obstruction 7 years after laparoscopic RYGB. Case report A 57-year-old woman with a body mass index of 44 kg/m2 and concurrent hypertension and osteoarthritis had undergone laparoscopic RYGB in 2003. The patient had a history of open cholecystectomy, hysterectomy, and bilateral tubal ligation before the initial bariatric procedure. A *Correspondence: David R. Miles, M.D., Department of Surgery, Miles Surgical, PLLC, 1717 Shipyard Boulevard, Wilmington, NC, 28403. E-mail: [email protected]
30-cm3 pouch was constructed using an endo-GIA stapler (Ethicon-Endosurgery, Cincinnati, OH). The enteroenterostomy was constructed using a linear stapler, and a retrocolic retrogastric gastrojejunostomy was created. The Roux limb was sutured to the transverse mesocolon with a single nonabsorbable stitch. All potential spaces were closed with nonabsorbable suture. The patient was discharged home on postoperative day 1 without complications. The patient did well postoperatively, with no signs of any complication until 7 years later when she presented to the emergency department with an acute onset of epigastric abdominal pain scoring 8 on a scale of 10, nausea, and vomiting after eating at work. The patient related a history of taking nonsteroidal anti-inflammatory drugs for her arthritis. She was given narcotics and antiemetics in the emergency department after plain films of the abdomen failed to show a cause for her abdominal pain. Her vital signs revealed no fever or tachycardia. The patient’s body mass index had decreased to 32 kg/m2. Her abdomen was noted to have minimal epigastric distension and no peritoneal signs. A complete blood count and basic metabolic profile were normal. On repeat examination, the patient’s clinical status was unchanged. She had developed emesis that was strongly hemoccult positive. A nasogastric tube was placed and immediately returned 600 mL of feculent gastric contents. On a computed tomography scan, the patient was noted to have a small bowel “fecal sign,” consistent with a distal intestinal obstruction (Fig. 1) [1]. Given these findings, the general surgery staff was consulted, and the patient was taken to the operating room, where upper endoscopy revealed a widely patent gastrojejunostomy anastomosis that was free of ulceration. A large collection of food debris was
1550-7289/11/$ – see front matter © 2011 American Society for Metabolic and Bariatric Surgery. All rights reserved. doi:10.1016/j.soard.2010.07.008
e4
W. F. Powers & D. R. Miles / Surgery for Obesity and Related Diseases 7 (2011) e3– e5
Table 1 Data from previous studies Investigator
Postoperative interval
Bezoar location
Operative repair
Jejunojejunal anastomosis
Open exploration with extraction of bezoar and closure of perforation with absorbable suture EGD, cut suture endoscopically releasing bezoar EGD, endoscopic fragmentation EGD, cut suture endoscopically releasing bezoar
Goiten et al. [2]
2 mo
Pratt et al. [3] Ionescu et al. [4] Payman et al. [5] Pinto et al. [6] Case 1 Case 2
15 mo 14 mo 11 mo
Roux limb (stitch from gastrojejunal anastomosis) Gastrojejunal anastomosis Jejunal limb
2 mo 24 mo
Gastrojejunal anastomosis Gastric pouch
6 wk
Gastrojejunal anastomosis
Steele et al. [7]
EGD, endoscopic EGD, endoscopic fragments with EGD, endoscopic
fragmentation fragmentation and extraction of endoscopic net scissors
EGD ⫽ Esophagogastroduodenoscopy.
noted in the proximal Roux limb that had completely obstructed the jejunum. Diagnostic laparoscopy was performed to rule out bowel ischemia. Minor lysis of adhesions was performed, but no obvious bowel obstruction was discovered. The enteroenterostomy appeared normal. The transverse mesocolon was widely patent, and no Petersen’s hernia was present. The distal bowel was decompressed and healthy appearing. Attention was returned to the phytobezoar, which was disimpacted internally using biopsy forceps to create a patent lumen (Fig. 2). Once a patent lumen had been established, a bowel clamp was placed on the jejunum to prevent insufflation of the small bowel, and the lumen was irrigated to further break up the debris. Bowel distension was carefully monitored laparoscopically. Once the phytobezoar had been successfully fragmented in this
fashion, the bowel clamp was removed, and the debris was flushed well past the proximal jejunum, with no further areas of obstruction identified. In a postoperative discussion with the family, it was discovered that the patient had recently consumed a large serving of blueberries. The patient began a liquid diet in the morning, which she tolerated without issue, and she was discharged home later that same day. Discussion Gastric bypass patients undergo specific diet counseling in the immediate preoperative and postoperative periods to ensure their nutrition is correct and to help reduce postoperative complications. Ingested materials high in cellulose, delayed gastric emptying, and anastomotic stricture seem to
Fig. 1. Computed tomography scans showing (a) 9.8 cm jejunum with air-fluid level, (b) small bowel fecal sign, (c) questionable internal hernia versus stricture causing obstruction, and (d) distal small bowel of normal diameter and normal-appearing enteroenterostomy site.
W. F. Powers & D. R. Miles / Surgery for Obesity and Related Diseases 7 (2011) e3– e5
a
b
c
d
e5
Fig. 2. (a) Phytobezoar distal to gastrojejunal anastomosis. (b) Patent mesocolic window. (c) Endoscopy showing endoscopic fragmentation of bezoar using biopsy forceps. (d) Patent Roux limb after endoscopic fragmentation of bezoar.
play a key role in bezoar formation [6]. The overall volume and frequency of intake can also play a role in the development of a bezoar, especially in the RYGB patient with the anatomic limitation imposed by the gastric pouch [4]. To our knowledge, this is the first report of a phytobezoar causing small bowel obstruction in a RYGB patient 7 years after surgery. A patient with these symptoms would usually be taken to the operating room for diagnostic laparoscopy or, perhaps, laparotomy, only to find no extrinsic cause of obstruction. Therefore, it is important for the surgeon and radiologist to identify a phytobezoar using routine imaging studies. An ovoid or round, encapsulated intraluminal mass with a mottled gas pattern is suggestive of a phytobezoar [1,8]. If a phytobezoar is identified or suspected from the preoperative imaging studies, upper endoscopy should be used to rule out intraluminal obstruction and might obviate the need for additional operative intervention. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article.
References [1] Sunnapwar A, Sandrasegaran K, Menias CO, Lockhart M, Chintapalli KN, Prasad SR. Taxonomy and imaging spectrum of small bowel obstruction after Roux-en-Y gastric bypass surgery. AJR Am J Roentgenol 2010;194:120 – 8. [2] Goitein D, Papasavas PK, Gagné DJ, Caushaj PF. Late perforation of the jejuno-jejunal anastomosis after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2005;15:880 –2. [3] Pratt JSA, van Noord M, Christison-Lagay E. The tethered bezoar as a delayed complication of laparoscopic Roux-en-Y gastric bypass: a case report. J Gastrointest Surg 2007;11:690 –2. [4] Ionescu AM, Rogers AM, Pauli EM, Shope TR. An unusual suspect: coconut bezoar after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2008;18:756 – 8. [5] Payman G, Ahmad J. Jejunal food bolus obstruction. Gastrointest Endosc 2004:60:986. [6] Pinto D, Carrodeguas L, Soto F, et al. Gastric bezoar after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2006;16:365– 8. [7] Steele KE, Prokopowicz GP, Magnuson T, Lidor A, Schweitzer M. Unusual case of gastric bezoar causing obstruction after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2006;2:536 –7. [8] Patel RY, Baer JW, Texeira J, Frager D, Cooke K. Internal hernia complications of gastric bypass surgery in the acute setting: spectrum of imaging findings. Emerg Radiol 2009;16:283–9.
Case report
Phytobezoar causing small bowel obstruction seven years after laparoscopic Roux-en-Y gastric bypass William F. Powers, IV, M.D., David R. Miles, M.D.* Department of Surgery, South East Area Health Education Center, New Hanover Regional Medical Center, Wilmington, North Carolina Received July 8, 2010; accepted July 20, 2010
Keywords:
Bezoar; Small bowel obstruction; Endoscopy; Gastric bypass
With more than one third of the U.S. adult population now obese, obesity surgery is at the forefront of weight loss management [1]. With the advent of laparoscopic Rouxen-Y gastric bypass (RYGB) and its subsequent refinements, weight loss surgery is an ever-present procedure in many institutions across the United States. A number of postoperative complications have been well described. Early complications have included deep venous thrombosis with or without pulmonary embolus, anastomotic leak, obstruction, and bleeding, and late complications have included anastomotic stricture, ulcer formation, small bowel obstruction of varying etiologies, cholelithiasis, and nutritional deficiencies [1,2]. Bezoars are a less common complication that, to our knowledge, have continued to be described only in case reports. Of the case reports reviewed, all discovered bezoars as a cause of small bowel obstruction occurred in the early or intermediate postoperative period (2-24 months postoperatively; Table 1 [2-7]). The present report describes a patient who presented with a small bowel obstruction 7 years after laparoscopic RYGB. Case report A 57-year-old woman with a body mass index of 44 kg/m2 and concurrent hypertension and osteoarthritis had undergone laparoscopic RYGB in 2003. The patient had a history of open cholecystectomy, hysterectomy, and bilateral tubal ligation before the initial bariatric procedure. A *Correspondence: David R. Miles, M.D., Department of Surgery, Miles Surgical, PLLC, 1717 Shipyard Boulevard, Wilmington, NC, 28403. E-mail: [email protected]
30-cm3 pouch was constructed using an endo-GIA stapler (Ethicon-Endosurgery, Cincinnati, OH). The enteroenterostomy was constructed using a linear stapler, and a retrocolic retrogastric gastrojejunostomy was created. The Roux limb was sutured to the transverse mesocolon with a single nonabsorbable stitch. All potential spaces were closed with nonabsorbable suture. The patient was discharged home on postoperative day 1 without complications. The patient did well postoperatively, with no signs of any complication until 7 years later when she presented to the emergency department with an acute onset of epigastric abdominal pain scoring 8 on a scale of 10, nausea, and vomiting after eating at work. The patient related a history of taking nonsteroidal anti-inflammatory drugs for her arthritis. She was given narcotics and antiemetics in the emergency department after plain films of the abdomen failed to show a cause for her abdominal pain. Her vital signs revealed no fever or tachycardia. The patient’s body mass index had decreased to 32 kg/m2. Her abdomen was noted to have minimal epigastric distension and no peritoneal signs. A complete blood count and basic metabolic profile were normal. On repeat examination, the patient’s clinical status was unchanged. She had developed emesis that was strongly hemoccult positive. A nasogastric tube was placed and immediately returned 600 mL of feculent gastric contents. On a computed tomography scan, the patient was noted to have a small bowel “fecal sign,” consistent with a distal intestinal obstruction (Fig. 1) [1]. Given these findings, the general surgery staff was consulted, and the patient was taken to the operating room, where upper endoscopy revealed a widely patent gastrojejunostomy anastomosis that was free of ulceration. A large collection of food debris was
1550-7289/11/$ – see front matter © 2011 American Society for Metabolic and Bariatric Surgery. All rights reserved. doi:10.1016/j.soard.2010.07.008
e4
W. F. Powers & D. R. Miles / Surgery for Obesity and Related Diseases 7 (2011) e3– e5
Table 1 Data from previous studies Investigator
Postoperative interval
Bezoar location
Operative repair
Jejunojejunal anastomosis
Open exploration with extraction of bezoar and closure of perforation with absorbable suture EGD, cut suture endoscopically releasing bezoar EGD, endoscopic fragmentation EGD, cut suture endoscopically releasing bezoar
Goiten et al. [2]
2 mo
Pratt et al. [3] Ionescu et al. [4] Payman et al. [5] Pinto et al. [6] Case 1 Case 2
15 mo 14 mo 11 mo
Roux limb (stitch from gastrojejunal anastomosis) Gastrojejunal anastomosis Jejunal limb
2 mo 24 mo
Gastrojejunal anastomosis Gastric pouch
6 wk
Gastrojejunal anastomosis
Steele et al. [7]
EGD, endoscopic EGD, endoscopic fragments with EGD, endoscopic
fragmentation fragmentation and extraction of endoscopic net scissors
EGD ⫽ Esophagogastroduodenoscopy.
noted in the proximal Roux limb that had completely obstructed the jejunum. Diagnostic laparoscopy was performed to rule out bowel ischemia. Minor lysis of adhesions was performed, but no obvious bowel obstruction was discovered. The enteroenterostomy appeared normal. The transverse mesocolon was widely patent, and no Petersen’s hernia was present. The distal bowel was decompressed and healthy appearing. Attention was returned to the phytobezoar, which was disimpacted internally using biopsy forceps to create a patent lumen (Fig. 2). Once a patent lumen had been established, a bowel clamp was placed on the jejunum to prevent insufflation of the small bowel, and the lumen was irrigated to further break up the debris. Bowel distension was carefully monitored laparoscopically. Once the phytobezoar had been successfully fragmented in this
fashion, the bowel clamp was removed, and the debris was flushed well past the proximal jejunum, with no further areas of obstruction identified. In a postoperative discussion with the family, it was discovered that the patient had recently consumed a large serving of blueberries. The patient began a liquid diet in the morning, which she tolerated without issue, and she was discharged home later that same day. Discussion Gastric bypass patients undergo specific diet counseling in the immediate preoperative and postoperative periods to ensure their nutrition is correct and to help reduce postoperative complications. Ingested materials high in cellulose, delayed gastric emptying, and anastomotic stricture seem to
Fig. 1. Computed tomography scans showing (a) 9.8 cm jejunum with air-fluid level, (b) small bowel fecal sign, (c) questionable internal hernia versus stricture causing obstruction, and (d) distal small bowel of normal diameter and normal-appearing enteroenterostomy site.
W. F. Powers & D. R. Miles / Surgery for Obesity and Related Diseases 7 (2011) e3– e5
a
b
c
d
e5
Fig. 2. (a) Phytobezoar distal to gastrojejunal anastomosis. (b) Patent mesocolic window. (c) Endoscopy showing endoscopic fragmentation of bezoar using biopsy forceps. (d) Patent Roux limb after endoscopic fragmentation of bezoar.
play a key role in bezoar formation [6]. The overall volume and frequency of intake can also play a role in the development of a bezoar, especially in the RYGB patient with the anatomic limitation imposed by the gastric pouch [4]. To our knowledge, this is the first report of a phytobezoar causing small bowel obstruction in a RYGB patient 7 years after surgery. A patient with these symptoms would usually be taken to the operating room for diagnostic laparoscopy or, perhaps, laparotomy, only to find no extrinsic cause of obstruction. Therefore, it is important for the surgeon and radiologist to identify a phytobezoar using routine imaging studies. An ovoid or round, encapsulated intraluminal mass with a mottled gas pattern is suggestive of a phytobezoar [1,8]. If a phytobezoar is identified or suspected from the preoperative imaging studies, upper endoscopy should be used to rule out intraluminal obstruction and might obviate the need for additional operative intervention. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article.
References [1] Sunnapwar A, Sandrasegaran K, Menias CO, Lockhart M, Chintapalli KN, Prasad SR. Taxonomy and imaging spectrum of small bowel obstruction after Roux-en-Y gastric bypass surgery. AJR Am J Roentgenol 2010;194:120 – 8. [2] Goitein D, Papasavas PK, Gagné DJ, Caushaj PF. Late perforation of the jejuno-jejunal anastomosis after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2005;15:880 –2. [3] Pratt JSA, van Noord M, Christison-Lagay E. The tethered bezoar as a delayed complication of laparoscopic Roux-en-Y gastric bypass: a case report. J Gastrointest Surg 2007;11:690 –2. [4] Ionescu AM, Rogers AM, Pauli EM, Shope TR. An unusual suspect: coconut bezoar after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2008;18:756 – 8. [5] Payman G, Ahmad J. Jejunal food bolus obstruction. Gastrointest Endosc 2004:60:986. [6] Pinto D, Carrodeguas L, Soto F, et al. Gastric bezoar after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2006;16:365– 8. [7] Steele KE, Prokopowicz GP, Magnuson T, Lidor A, Schweitzer M. Unusual case of gastric bezoar causing obstruction after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2006;2:536 –7. [8] Patel RY, Baer JW, Texeira J, Frager D, Cooke K. Internal hernia complications of gastric bypass surgery in the acute setting: spectrum of imaging findings. Emerg Radiol 2009;16:283–9.