Large Hemobezoar Causing Acute Small Bowel Obstruction After Roux-en-Y Gastric Bypass: Laparoscopic Management

Abstract

The present video shows the laparoscopic management of an acute small bowel obstruction (ASBO) after a Roux-en-Y Gastric Bypass (RYGBP), due to the development of an intraluminal hemobezoar involving the jejuno-jejunostomy (j-j). On the first postoperative day (POD), the patient presented persistent abdominal pain, sense of fullness, nausea, and vomiting with traces of blood. The abdominal tube drained a small amount of serous fluid, while blood tests revealed a mild leukocytosis and a slight decrease of the hemoglobin. A CT scan showed the dilation of the excluded stomach, duodenum, and both the alimentary and biliopancreatic limbs. The transition point was located in the common limb, just beyond the j-j, which was dilated by a fluid collection with the radiological aspect of a blood clot. The patient underwent an emergency laparoscopy which confirmed the preoperative radiological findings. An enterotomy was performed at the biliopancreatic stump, and the blood clot was pulled out by suction. The enterotomy was then closed by means of a linear stapler. Postoperative course was uneventful, except for the development of low-grade pneumonia. The patient was discharged on POD 8. ASBO is a worrisome postoperative complication of RYGBP. Although rare, the development of intraluminal hemobezoar should always be considered as a possible cause of ASBO. Laparoscopic management is feasible and effective and does not necessarily entail the complete revision of the j-j.

Early Postoperative Anastomotic Obstruction Due to an Intraluminal Blood Clot After Laparoscopic Anterior Resection: A Case Report

“…Interestingly, all patients whose small bowels were obstructed by intraluminal blood clot after small intestinal surgery were female [4][5][6][7][8][9][10], and the patient in this case was also female. Men have higher risk of cardiovascular diseases, and it seems that sex hormones are associated with the development of cardiovascular diseases [12].…”

“…Nevertheless, postoperative bowel obstruction caused by blood clot is a rare event. There are a few published cases of postoperative small bowel obstruction caused by intraluminal blood clot after Roux-en-Y gastric bypass [4][5][6][7][8][9] and hepaticojejunostomy [10]. However, postoperative colonic obstruction caused by intraluminal blood clot is very rare.…”

“…Additionally, the blood in premenopausal women has less prothrombotic activity than postmenopausal women [12]. Indeed, the 10 patients who developed small bowel obstruction by intraluminal blood clot after gastric bypass had young age, and their mean age was 39.2 years (range, 27 to 53 years) [4][5][6][7][8][9].…”

“…Unlike small bowel obstruction, obstruction at the anastomosis site needs immediate management because it could lead to anastomosis leakage and perforation. In small bowel anastomosis, an endoscopic approach is usually difficult and most obstructions with intraluminal hematoma were managed with reoperation [4,[6][7][8][9][10]. However, the anastomosis site at the large bowel could be easily accessed with the endoscopic approach.…”

“…However, postoperative obstruction at the anastomosis site has been rarely reported [3]. Although several small bowel obstructions due to large blood clots have been reported after small intestinal anastomosis [4][5][6][7][8][9][10], to the best of our knowledge, there are no reports on colonic obstruction at the anastomosis site due to large blood clots. We encountered a patient who developed this rare complication and was managed by colonoscopic evacuation and herein present her case.…”