- Case report
- Open Access
- Open Peer Review
A rare case of small bowel volvulus after jenjunoileal bariatric bypass requiring emergency surgery: a case report
© Patel et al; licensee BioMed Central Ltd. 2012
- Received: 25 August 2011
- Accepted: 7 March 2012
- Published: 7 March 2012
Bariatric surgery is on the increase throughout the world. Jejunoileal bypass bariatric procedures have fallen out of favor in western surgical centers due to the high rate of associated complications. They are, however, performed routinely in other centers and as a consequence of health tourism, management of complications related to these procedures may still be encountered.
We describe a rare case of small bowel obstruction in a 45-year-old British Caucasian woman, secondary to a volvulus of the jejunoileal anastomosis following bariatric bypass surgery. The pre-operative diagnosis was confirmed by radiology. We describe a successful surgical technique for this rare complication.
Bariatric surgery may be complicated by bowel obstruction. Early imaging is vital for diagnosis and effective management. The use of our surgical technique provides a simple and effective approach for the successful management of this bariatric complication.
- Small Bowel
- Small Bowel Obstruction
- Paralytic Ileus
- Jejunoileal Bypass
- Small Bowel Mesentery
Bariatric surgery has been used as a treatment for obesity since the early 1960s . Initial operations were malabsorptive bypass procedures, the most common being jejunoileal bypass surgery. This surgical intervention has fallen out of favor due to overriding hepatic and metabolic complications, with common procedures now being gastric banding or gastric bypass surgery . Despite this, jejunoileal bypass surgery remains a popular and routinely performed surgical procedure outside of North American and European surgical centers. We describe a case of small bowel obstruction following jejunoileal bypass surgery as well as a simple and effective surgical technique.
We report a rare case of a small bowel obstruction secondary to a volvulus of a side-to-side jejunoileal anastomosis for bariatric surgery. Between 1960 and 1980, when jejunoileal bypass surgery was common, the mainstay of delayed complications was related to malabsorption of vitamins, hepatic disease and nephrolithiasis . Small bowel obstruction secondary to jejunoileal bypass surgery has been reported but this is usually functional or secondary to adhesions [4, 5]. Our case is rare because the volvulus was secondary to the fashioning of a narrow side-to-side anastomosis at initial surgery, whereas all other reported cases have been as a result of a volvulus of an end-to-end or side-to-end anastomosis [5, 6]. As in our case, the clinical presentation of a small bowel obstruction following jejunoileal bypass surgery is usually non-specific and is delayed usually by 18 to 60 months [5, 6]. As seen in our case, the delay in presentation after the initial surgery can result in diagnostic difficulty. The inherent difficulty in the clinical cause of small bowel obstruction places a great onus on imaging to determine a diagnosis. The literature reports 71% to 92% specificity and 71% to 94% sensitivity of CT scanning in the diagnosis of small bowel obstruction [7, 8]. In closed loop obstruction, the specificity falls to 78% . In our case there was a delay in diagnosis due to intermittency of symptoms. A CT scan provided a diagnosis which was subsequently definitively made with an oral contrast swallow study. The importance of early imaging in such cases is crucial in instituting appropriate management. The placement of a proximal jejunal band is uncommon in typical jejunoileal bypass procedures. There are isolated case reports of band-related bowel obstruction; however these are a result of intraluminal band obstruction following erosion of the gastric band [10, 11]. Our case is interesting as our findings showed that the jejunal band had migrated into the small bowel mesentery. We describe an effective operating technique for the management of a volvulus secondary to a narrow side to side jejunoileal anastomosis. The fixation of the apex of the volvulus, by approximation of the adjacent bowel proximal and distal to the anastomosis avoided the need to re-fashion the anastomosis. The laparoscopic surgical options in our case were extremely limited by the emergency presentation as well as the previous open surgery. Adhesions post open-abdominal surgeries are well reported [12, 13]. They are associated with increased complications and re-hospitalization rates, making laparoscopic intervention difficult in an emergency setting . If such contraindications are not present our technique is quite amenable to a laparoscopic approach. Our case raises several important dilemmas with regard to health tourism. Jejunoileal bypass surgery for bariatric patients has fallen out of favor in European and North American surgical centers due to poor long term outcomes and delayed complications [3, 15]. As a result the complications are not commonly encountered and make diagnosis and management difficult. In addition, the surgical center was on another continent making communication and notes requesting challenging. We suggest that perhaps patients who undergo similar complex operations should be advised or provided with a detailed summary of their initial procedure if travelling abroad.
We describe a case with an important complication of bariatric jejunoileal bypass surgery, now uncommon in western centers. The management of our patient highlights the importance of early appropriate imaging in cases with subacute small bowel obstruction following complex obesity surgery. We describe a simple and effective surgical technique that secures and widens the anastomosis without having to contaminate the peritoneum by enterotomy.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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