Treatment Option in Patient Presenting with Small Bowel Obstruction from Bezoars in the Jejunojejunal Anastomosis after Roux-en-Y Gastric Bypass

Ask the Experts:
Dilemmas in Bariatric Surgery

This month’s dilemma:
Treatment Option in Patient Presenting with Small Bowel Obstruction from Bezoars in the Jejunojejunal Anastomosis after Roux-en-Y Gastric Bypass

This month’s expert:
Peter Benotti, MD, FACS

About the expert
Dr. Benotti is the Residency Program Director, Department of Surgery, St. Francis Medical Center, 601 Hamilton Ave., Trenton, NJ

Bariatric Times. 2010;7(4):26

The Dilemma
A 34-year-old man presented with new onset of epigastric pain, nausea, and vomiting for eight hours. He had laparoscopic Roux-en-Y gastric bypass (RYGB) for morbid obesity in this same institution five and a half years ago. He had two episodes of epigastric pain in the past. The first episode happened three years after the RYGB, during which he underwent a diagnostic laparoscopy to rule out an internal hernia. Although no true hernia was identified, the jejunojejunal mesenteric defect was suture closed. He presented with a similar episode of abdominal pain after a year, which was managed conservatively. His current abdominal pain was much more severe and the vomiting was more frequent than the previous episodes. A computed tomography (CT) scan of the abdomen showed dilatation of the alimentary limb and complete obstruction with food contents prior to the jejunojejunal anastomosis ( Figures 1A and 1B). Laparoscopic exploration was performed under general anesthesia with a four-trocar technique. The alimentary limb and the biliopancreatic limb were distended during the operation and an orogastric tube was inserted to decompress the alimentary limb. Solid mass was noted in the jejunojejunal anastomosis with complete obstruction. Attempts to move the mass with any maneuver outside the intestine was not successful. An enterotomy distal to the jejunojejunal anastomosis was performed, and a large amount of vegetables and debris was extracted using five specimen bags (Figure 2A). The enterotomy was closed with two layers of running suture with 2-0 vicryl (Figure 2B). The specimen was removed through the large supraumblical trocar site. The patient had an uneventful recovery and was discharged on Postoperative Day 4 on a soft diet. Food impaction is a rare cause of small bowel obstruction following RYGB. Complete impaction at the site of anastomosis may need surgical intervention and removal of impacted bezoars if it does not resolve with conservative management.

Expert Commentary
by Peter Benotti, MD, FACS
A bezoar is defined as a hard, indigestible mass of material, such as hair, vegetable fibers, or fruits found in the stomach and intestines of animals and humans. Trichobezoars, composed of hair, occur most commonly in young girls who swallow their hair. Phytobezoars are composed of vegetable matter and occur in the stomach in the setting of gastroparesis or gastric outlet obstruction. The clinical presentation usually involves obstructive symptoms, but bezoars can be associated with pain, ulceration, and gastrointestinal bleeding. Diagnosis is suggested by upper gastrointestinal (GI) fluoroscopy or CT scan and confirmed by endoscopy. Treatment options include chemical enzyme therapy, endoscopic dissolution and removal, or surgical removal.

Bezoar formation is also recognized as a rare late complication of gastric bypass surgery. In 1998, Fobi et al[1] reporteded 17 bezoars in 944 patients who underwent his modification of the open gastric bypass. Bezoar formation was recently reported after laparoscopic gastric bypass in several case reports. In all of the case reports reviewed, the bezoars occurred in the gastric pouch, usually in association with impaired emptying because of stricturing at the gastrojejunal anastomosis.[2,3] Bezoars have also been described as a complication of gastric banding, usually in a setting of poor pouch emptying and pouch stasis.[4,5]

In this particular case, the bezoar developed not in the gastric pouch as in previous case reports, but at the jejunojejunostomy. The bezoar apparently developed in the setting of recurring abdominal pain five years after gastric gastric bypass. Imaging suggests complete obstruction of the alimentary limb of the bypass. Successful treatment with laparoscopic enterotomy is documented.
This may be the first report of a bezoar forming at the jejunojejunostomy after successful gastric bypass surgery. Factors contributing to bezoar formation include stasis, poor emptying, bizarre eating behavior, anastomotic strictures, and gastrointestinal dysmotility.
The fact that intussusception involving the jejunojejunostomy has also been reported as an infrequent late complication after RYGB6 provides support for the assumption that dysmotility may play a role in these rare, late complications of gastric bypass.

The take-home message is that bezoar formation must be considered in the differential diagnosis when post-gastric bypass patients present with obstructive symptoms. In addition, since bezoars can be successfully treated by chemical/enzyme therapy or endoscopid removal, appropriate diagnostic studies should be obtained for patients presenting with obstructive foregut symptoms following bariatric surgery.

References
1.    Fobi M, Lee H, Holness R, et al.  Gastric bypass for obesity. World J Surg. 1998;22:925–935.
2.    Pinto D, Carrodeguas L, Soto F, et al. Gastric bezoar after laparoscopic Roux-en-y gastric bypass. Obes Surg. 2006;16:365–368.
3.    Ionescu A, Rogers A, Pauli E, et al.  An unusual suspect: coconut bezoar after laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2008;18:758.
4.    Parameswaran R, Ferrando J, Sigurdsson A. Gastric bezoar complicating laparoscopic adjustable gastric banding with band slippage. Obes Surg. 2006;16:1683–1684.
5.    Veronelli A, Ranieri R, Laneri M, et al.  Gastric bezoars after adjustable gastric banding. Obes Surg. 2004;14:796–797.
6.    Edwards M, Grinbaum R, Ellsmere J, et al. Intussusception after Roux-en-Y gastric bypass for morbid obesity:  case report and literature rewiew of a rare complication. Surg Obes Relat Dis. 2006;2:483–489.

Category: Ask the Experts, Past Articles