Late Onset Abdominal Pain After Gastric Bypass Due to a Rare Diagnosis—Jejuno-Jejunostomy Volvulus

by 2nd LT Solomon Tong, MS; LCDR Jesse Bandle, MD; and CDR Gordon G. Wisbach, MD, MBA

AUTHOR AFFILIATION: 2nd LT Solomon Tong, MS, is from Uniformed Services University of Health Sciences, Bethesda Maryland. LCDR Jesse Bandle, MD, is Assistant Professor of Surgery, Uniformed Services University of the Health Sciences/F. Edward Hebert School of Medicine in Bethesda, Maryland. Dr. Bandle is also from U.S. Naval Hospital Okinawa, Japan. CDR Gordon G. Wisbach, MD, MBA, is Assistant Professor of Surgery, Uniformed Services University of the Health Sciences/F. Edward Hebert School of Medicine in Bethesda, Maryland. Dr. Wisbach is also from Naval Medical Center San Diego in San Diego, California.

FUNDING: No funding was provided.

DISCLOSURES: The authors report no conflicts relevant to the content of this article.

Bariatric Times. 2016;13(3):10–12.

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ABSTRACT
Bariatric surgery is the most effective therapy for obesity, with laparoscopic Roux-en-Y gastric bypass (RYGB) being one the most commonly performed operations. While late complications of RYGB are uncommon, they are difficult to diagnose accurately. We present a case of late abdominal pain following RYGB due to a jejuno-jejunostomy volvulus. We discuss the challenges of diagnosis and recommendations for treatment.

Introduction
Obesity is an epidemic with increasing prevalence worldwide. In the United States, over one-third of adults have obesity.[1] Bariatric surgery has been proven to be the most effective therapy for achieving clinically meaningful weight loss among the population with morbid obesity.[2] With over 460,000 procedures performed worldwide annually, gastric bypass still remains the one of the most common.[3]

Roux-en-Y gastric bypass (RYGB) is considered the bariatric operation to which other weight loss procedures are compared. The laparoscopic technique has become the dominant approach due to its shorter length of hospitalization, faster recovery, and reduction in wound complications.[4] Although laparoscopic RYGB can effectively combat obesity and associated comorbidities, it is not without complications.
As more weight loss operations are performed, more patients are likely to develop complications and, despite proper education, have urgent needs requiring evaluation in the emergency department. Late complications of RYGB are uncommon, but they can be life threatening. Late complications after RYGB include obstruction, internal and incisional hernia, marginal ulcer, anastomotic stenosis, intussusception, and intestinal volvulus.[5,6] These complications can be difficult to diagnose nonoperatively and challenging to differentiate from other gastrointestinal disorders.[7] The variation of intestinal volvulus with the jejuno-jejunostomy as the lead point is likely under-diagnosed. The following is a case report of a jejuno-jejunostomy volvulus after gastric bypass.

Case Report
After institutional review board (IRB)-approval, the following case report was performed.

A 34-year-old female who underwent RYGB in 2010 experienced 96% excess weight loss (EWL), with a body mass index (BMI) change of 44.3kg/m2 to 22.15kg/m2. She presented to the emergency department at our institution with a several day history of acute onset of central abdominal pain. She reported that the pain was burning in nature, radiated to her back and post-prandial. She admitted having similar intermittent abdominal pain for over a year, however, she said that pain was less intense and would resolve spontaneously. Possibly due to the uncertain etiology of her abdominal pain, the patient had undergone multiple procedures including laparoscopic cholecystectomy with concomitant internal hernia repair in December 2013 and exploratory laparoscopy with drainage of tubo-ovarian abscess in January 2014 followed by right salpingo-oopherectomy with left salpingectomy. While the pain would temporarily resolve following these procedures, her symptoms persistently recurred. We reviewed her symptoms and found that she reported nausea without emesis and intermittent intense central abdominal pain without obstipation.

On exam, her vital signs were within normal limits, however, she appeared uncomfortable. Her abdominal exam was notable for a soft, non-distended abdomen and tenderness to palpation predominately in her epigastric region with voluntary guarding. Her laboratory evaluation was unremarkable. A computerized tomography (CT) scan revealed a twisted segment of small bowel with no obvious signs of obstruction or necrosis (Figure 1). Since small bowel viability was a concern, the patient was offered a diagnostic laparoscopy. On exploration, a volvulus with a corkscrew appearance of the mesentery, twisted small bowel with a large dilated bulbous jejunojejunal anastomosis as the lead point was discovered (Figure 2). After reversal of the volvulus, a complete bowel exploration revealed viable, non-obstructed bowel in an antecolic- antegastric gastric bypass configuration. Resolution of the pathologic jejuno-jejunostomy volvulus was confirmed and the operation was complete. Postoperatively, her pain had resolved and she tolerated a regular diet. Unfortunately, two weeks later she presented with a recurrence of her complaint of central abdominal pain. She was admitted for bowel rest and rehydration due to suspicion of a recurrent volvulus. A CT scan was obtained with similar findings from the prior study of a volvulized segment of small bowel. The patient was taken back for laparoscopic re-exploratory, which confirmed a recurrent volvulus with the jejuno-jejunostomy again as the lead point and no internal hernia was present. The definitive treatment with resection of her jejuno-jejunostomy was performed with a reconstruction 10-12 cm distally using a stapled side-to-side functional end-to-end technique. Again, the patient had an uneventful recovery with good toleration of oral intake. She has experienced 12 months of resolution of her symptoms.

Discussion
The cause of late abdominal pain after RYGB can be a diagnostic challenge. Patients may present with intermittent, non-specific abdominal complaints along with nausea and vomiting.[6] Symptoms of obstruction may be reminiscent of cholelithiasis, irritable bowel syndrome, or interpreted as patient non-adherence to dietary recommendations. Unless complete bowel obstruction is encountered, symptoms can be infrequently 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 differential 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 multiple exploratory laparoscopies that included a cholecystectomy and closure of internal hernia defect as well as gynecologic procedures.

Bariatric patients presenting with late 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 concurrent 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 as 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.  Symptoms, 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. Surgical evaluation is essential as volvulus may lead to small bowel ischemia and subsequent necrosis if not treated. Definitive diagnosis must be determined intra-operatively. It is important to note that a volvulus may not be apparent at the time of operation; it may resolve and recur, thus leading to a delay in diagnosis. For this reason, we believe a jejuno-jejunostomy volvulus to be an under-diagnosed cause of abdominal pain following gastric bypass, even after exploration, and should be included on the differential of this patient population. If discovered or strongly suspected during exploration, resection of the jejuno-jejunostomy with small bowel reconstruction should be considered as the definitive treatment.

References
1.    Ogden CL, Carrol MD, Kit BK, Flegal K. Prevalence of childhood and adult obesity in the United States, 2011–2012. JAMA. 2014; 311(8):806–814.
2.    Mechanick JI, Youdim A, Jones DB, Garvey WT et al. Clinical Practice Guidelines for Perioperative Nutritional, Metabolic and Nonsurgical Support of the Bariatric Surgery Patient – 2013 Update. Obesity. 2013;21:/S1-S27.
3.    Angrisani L, Santonicola A, Lovino P, Formisano G, Buchwald H, Scopinaro N. Bariatric Surgery Worldwide 2013. Obes Surg. 2015;25(10):1822–1832.
4.    Podnos YD, Jimenez JC, Wilson SE, Stevens CM, Nguyen NT. Complications after laparoscopic gastric bypass. A review of 3464 cases. Arch Surg. 2003;138:957–961.
5.    Blachar A, Federle MP, Pealer KM, Ikramuddin S, Schauer PR. Gastrointestinal complications of laparoscopic Roux-en-Y gastric bypass surgery: clinical and imaging findings. Radiology. 2002;223(3):625–632.
6.    Abell TL, Minocha A. Gastrointestinal complications of bariatric surgery: diagnosis and therapy. Am J Med Sci. 2006;331:214–218.
7.    Griffith PS, Birch DW, Sharma AM, Karmali S. Managing complications associated with laparoscopic Roux-en-Y Gastric bypass for morbid obesity. Can J Surg. 2012;55(5):329–336.
8.    Higa K, Ho T, Boone KB. Internal hernias after laparoscopic Roux-en-Y gastric bypass: incidence, treatment, and prevention. Obes Surg. 2003;13:350–354.
9.    Husain S, Ahmed AR, Johnson J, Boss T, O’Malley W. Small-bowel obstruction after laparoscopic Roux-en-Y gastric bypass: etiology, diagnosis, and management. Arch Surg. 2007;142(10):988–993.
10.    Martin MJ, Beekley AC, Sebesta JA. Bowel obstruction in bariatric and nonbariatric patients: major differences in management strategies and outcome. Surg Obes Relat Dis. 2011;7:263–270.
11.    Champion JK, Williams M. Small bowel obstruction and internal hernias after laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2003;13:596–600.
12.    Cho M, Carrodeguas L, Pinto D, et al. Diagnosis and management of partial bowel obstruction after laparoscopic antecolic antegastric Roux-en-Y gastric bypass for morbid obesity. J Am Coll Surg. 2006;202(2);262–268.
13.    Garrard CL, Clements RH, Nanney L, Davidson JM, Richardson WO. Adhesion formation is reduced after laparoscopic surgery. Surg Endosc. 1999;13(1):10–13.
14.    Gazzalle A, Braun, D, Cavazzola LT, et al. Late intestinal obstruction due to an intestinal volvulus in a pregnant patient with a previous Roux-en-Y gastric bypass. Obes Surg. 2010;20:1740–1742.
15.    Ng M, Toribio R, Sugiyama, G. Rare case of concurrent intussusception and volvulus after Roux-en-Y gastric bypass for morbid obesity. J Sur Cas Rep. 2013;2013(1).
16.    Daellenbach L, Suter M. Jejunojejunal intussusception after Roux-en-Y gastric bypass: a review. Obes Surg. 2011;21:253–263.
17.    Gonzalez-Pezzat I, Soto-Perez-de-Celis E, Pantoja-Millan JP. Late perforation and abscess formation at the site of the jejunojejunal anastomosis following laparoscopic Roux-en-Y gastric bypass surgery. Obes Surg. 2009;19:661–663.
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Tags: gastric bypass

Category: Case Report, Past Articles