Small Bowel Complication After Malabsorptive Procedures: Internal Hernias, Obstructions, and Intussusception

by Jesus E. Hidalgo, MD; Alexander Ramirez, MD; Raul Rosenthal, MD, FACS; and Samuel Szomstein, MD, FACS

The Bariatric Institute, Section of Minimally Invasive Surgery, Cleveland Clinic Florida, Weston, Florida

Introduction
Bariatric surgery is the only successful treatment option for maintained long-term weight loss in the morbidly obese, and the Roux-en-Y gastric bypass (RYGB) is the most common malabsortive procedure performed.[1–3] The laparoscopic approach to RYGB has been increasing in popularity, with demonstrated advantages over the traditional open technique in terms of fewer wound complications, better cosmesis, less postoperative pain, shorter length of hospital stay, faster recovery, and reduced incidence of incisional hernias.[4–7] However, complications including gastric outlet obstruction, anastomotic leaks, ulcers, and small bowel obstruction (SBO) are similar between the two techniques.[8–11] Some studies report a higher incidence of SBO after laparoscopic Roux-en-Y gastric bypass (LRYGB) when compared to the open approach.[3,12,13] Also, there are notable differences in the etiology, presentation, and management of SBO after LRYGB.[3,9,11,14–16]

Small Bowel Obstruction and Internal Hernia
The techniques of open and LRYGB are not standardized, and variations exist between centers. Several techniques are used, including antecolic antegastric, retrocolic antegastric, or retrocolic retrogastric approaches.[4,8,11,15,24]

The retrocolic defect can be closed in an interrupted fashion, a continuous fashion, or not at all.[8,14,15,24] Other mesenteric defects, including the jejunojejunal and Peterson’s space (retro-Roux loop), can be closed or left open.[4,11] Absorbable or nonabsorbable suturing can be used to close the mesenteric defects.[11,14] The length of the alimentary limb is also not standardized and varies from 75 to 200cm, according to individual patient’s body mass index (BMI) and surgeon preference.[4,24] The jejunal mesentery can be divided to lengthen the Roux limb or not.[4,8] An antikink suture, otherwise known as a Brolin stitch, can be routinely or selectively inserted after the completion of the jejunojejunostomy.[8,27] The Roux limb can be fixed or not when a retrocolic approach is used.[11,26] The greater omentum can be divided to reduce tension on the gastrojejunal anastomosis (GJA), not divided, or a window can be created in it for the Roux limb.[15] Circular staples, linear staplers, handsewn techniques, or a combination of these can be used to create and close the gastrojejunal and jejunojejunal anastomoses.[4,6,28] Finally, trocar sites may or may not be closed.[4]

Clinical evaluation
There are many causes of SBO after LRYGB (Table 1). The most common etiologies include iatrogenic causes of narrow anastomoses, overzealous closure of mesenteric defects, mesenteric or intramural hematoma, anastomotic leak, incarcerate ventral hernias, internal hernias, and adhesions.

Depending on the cause, patients develop symptoms in the immediate postoperative period, or in the weeks, months, or even years after surgery. Obstruction can involve the alimentary limb, biliopancreatic limb, common channel, or more distally if adhesive in nature. Because of the differences in surgical technique, the incidence of SBO varies from 0.4 to 7.45 percent.[3] With the adoption of the laparoscopic approach, there has been a reduction in postoperative SBO secondary to adhesions and incisional hernias; however, a higher incidence of SBO because of internal hernias is seen compared to the open procedure.[12,13] Early series of laparoscopic bypass reported an incidence of SBO of 1.5 to 3.5 percent, with most attributed to internal hernias, but with a short follow-up period of less than two years.[7] Internal herniation can occur at the jejunojejunostomy, Peterson’s space, or the transverse mesaconic defect after a retrocolic approach.

The incidence of internal hernias is higher after the retrocolic retrogastric approach and has been significantly reduced by adoption of the antecolic antegastric approach in reported series from 4.5 to 0.43 percent.[15] Patients can present acutely with the classical symptoms and signs of SBO or chronically with vague symptoms. Late SBO typically presents with intermittent, recurrent, cramping, periumbilical pain, which may be associated with intermittent nausea and vomiting. Not uncommonly, patients present to their local emergency room or primary care physician with recurrent vague symptoms; often their complaints are explained by failure to comply with diet, gastroesophageal reflux disease, postprandial pain, or marginal ulceration. Diagnosis is based on symptoms, clinical examination, and investigative tools, including blood test, plain abdominal radiographs, upper gastrointestinal (UGI) contrast studies, and abdominal computed tomography (CT) scans (Table 2 and Table 3). A methodical approach facilitates the identification of the site of obstruction in the majority of patients before surgery. Although symptoms are often similar, the presence of gastroesophageal reflux and significant vomiting is suggestive of an obstruction to the alimentary limb or common channel. Distention of the biliopancreatic limb and gastric remnant with elevated liver functions test and hyperamylasemia is suggestive of obstruction of the biliopancreatic limb or common channel (Table 3). Treatment is directed by the clinical condition of the patient and involves nasogastric decompression with early surgical intervention in the form of diagnostic laparoscopy.

Classification system. Numerous descriptive terms have been employed in an attempt to classify SBO after LRYGB in reported series based on presentation, onset after bariatric surgery, extent of obstruction, or anatomical site (Table 4).[8,9,14,24] The most commonly used method has been onset of symptoms in relation to duration after surgery in terms of early or late presentation.[8,9,14,24] However, published classification systems of early presentation of SBO range from less than three weeks to less than three months, and similarly late presentation range from greater than three weeks to greater than three months. This would facilitate a uniform system of interpretation, understanding, and diagnosis of SBO after RYGB in the emergency room and also facilitate more effective communication between nonbariatric surgeons in the general community with specialists in bariatric centers. Our proposed classification system is based on the anatomical site of obstruction and onset of symptoms from the date of surgery. With regard to the anatomical site of obstruction, we propose the following classification: type A—alimentary limb obstruction; type B—biliopancreatic limb obstruction; and type C—common channel obstruction (Figure 1 and Figure 2).

The time to SBO varies from zero to 1,414 days after LRYGB in reported series, with 44 to 48 percent occurring within the first month.[8,14,15,24] In terms of the timing of onset of SBO after surgery, we propose the following additional classification system: acute early SBO, less than or equal to 30 days after LRYGB; acute late SBO, greater than or equal to 30 days and less than 12 months after LRYGB; and chronic SBO, greater than or equal to 12 months after LRYGB.

Intussusception after RYGB. Intussusception after RYGB for morbid obesity has been reported infrequently and represents an additional complexity to the treatment of adult patients with intussusception. To date, nine cases have been reported in eight patients, three antegrade (isoperistaltic), four retrograde (antiperistaltic), and two not specified.[8–12] No intussusceptions have been reported after LRYGB. Although this may represent a lead time bias, LRYGB has been reported for one decade, and intussusception after open RYGB has been described as occurring within 1 to 7 years postoperatively. The cause of intussusception after RYGB remains obscure but seems to be multifactorial, involving a lead point (suture lines, adhesions, and lymphoid hyperplasia), motility disturbances, and aberrant intestinal pacemakers. The clinical presentation of intussusception in adults is variable, making diagnosis on the basis of clinical assessment findings difficult.

Symptoms tend to be chronic and intermittent, in contrast to the typical acute presentation in children. The most common presenting sign is vague abdominal pain.[17,26] The presenting symptoms included abdominal pain (100%), nausea and vomiting (40%), and bloody stools (20%). The physical findings included abdominal tenderness (90%), abdominal mass (70%), and peritoneal irritation (20%). Only 10 percent presented with the classic triad of abdominal pain, red-currant jelly stools, and a palpable mass.[17] The published data evaluating the radiologic diagnosis of intussusception in adults are limited. Options include CT, UGI radiocontrast studies, and ultrasonography. CT should be recommended for all bariatric patients presenting with abdominal symptoms (pain, nausea, vomiting). If patients present with peritoneal signs, additional radiologic evaluation should not delay emergent abdominal exploration. Conservative management of intussusception in children (reduction with contrast media, saline, or air) has a success rate of 90 percent[17] and is appropriate because most cases have no identifiable pathologic lead point. Adult intussusception often has an identifiable lesion and requires surgical intervention. One controversy surrounds the issue of reduction before resection. The risk of reduction before resection includes perforation and emboli of malignant cells. The benefit of reduction before resection includes lengthening of the mesentery to avoid resection of healthy bowel.[17]

Summary
Early diagnosis and treatment of SBO after LRYGB is crucial to avoiding the development of catastrophic complications, including anastomotic dehiscence, staple-line disruption, small bowel ischemia, infarction, and gangrene. It is important to recognize that the most common cause of SBO after LRYGB is internal herniation, which will result in intestinal ischemia, perforation with peritonitis, sepsis, and death if not managed in a timely and appropriate fashion. Our proposed simplified classification system of SBO after LRYGB, based on the anatomical location of the obstruction and onset after surgery, will facilitate a better understanding of the underlying pathology and allow more effective communication between the nonbariatric patient and the surgical community to ultimately improve patient management and outcomes.

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Category: Past Articles, Review