Surgical management of early small bowel obstruction after laparoscopic Roux-en-Y gastric bypass

Rare events model of the MBSAQIP database: risk of early bowel obstruction following metabolic surgery

BACKGROUND

Early small bowel obstruction (eSBO) (within 30-days) is a rare but important complication that is associated with high rates of morbidity, including readmission, reintervention, and reoperation.

OBJECTIVES

To identify patient-specific and operation-specific characteristics that predispose patients to eSBO and to identify at-risk individuals preoperatively.

SETTING

2015-2021 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).

METHODS

Utilizing the 2015-2021 MBSAQIP PUF, 1,016,484 records were analyzed. Pediatric, revisional, open-conversion, and cases with incomplete data in sex, body mass index, operative-time, 30-day-follow-up variables were excluded. Case details were compared using Fisher's exact & Wilcoxon -Mann -Whitney tests to identify at-risk patients. The likelihood of eSBO was modeled with rare event logistic regression.

RESULTS

Incidence of eSBO was .40%. Of the 4103 occurrences of eSBO, RYGB (Roux-en-Y gastric bypass), SG (sleeve gastrectomy), and DS (duodenal switch) accounted for 79.4%, 19.3%, and 1.3%, respectively. Many patient-specific characteristics were significantly associated with eSBO. History of prior foregut surgery, a non-metabolic surgery trained operator, and longer operative times were all associated with increased eSBO (P < .0001). While simultaneously controlling for these factors, eSBO remained higher in DS (OR 9.55, P < .0001) and RYGB (OR 5.18, P < .0001) compared to SG. Increased length of operation (OR 1.03, P < .0001) and non -MS-trained operators (OR 1.33, P < .0001) remained highly significant. Male-sex (OR .70, P < .0001) and diabetes (OR .78, P < .0001) were both protective.

CONCLUSIONS

In the largest analysis to date, eSBO remains a rare event. RYGB accounts for the largest proportion of eSBO, however, DS has a higher risk adjusted rate of eSBO.

Bariatric Surgery Emergencies in Acute Care Surgery

Patients who have undergone bariatric surgery present unique challenges in the acute care surgery setting. This review includes the presentation, workup, and management of most common bariatric surgery emergencies encountered by acute care surgery.

Early Bowel Obstruction after Bariatric Surgery: An Analysis of the 2020-2021 MBSAQIP Database

BACKGROUND

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program evaluates 30-day outcomes of bariatric cases performed in the United States. The Participant Use File in 2020 introduced bowel obstruction (BO). We compared the rates of BO, risk factors, and postoperative outcomes after laparoscopic Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and duodenal switch (DS).

METHODS

Retrospective analysis of patients who underwent laparoscopic RYGB, SG, or DS obtained from the 2020-2021 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. Patients who underwent either as a primary procedure with a body mass index >35 kg/m 2 were selected. Baseline characteristics, operative details, and postoperative complications were collected. The outcome of interest was BO occurring within 30 days.

RESULTS

A total of 205,533 cases of which 148,944 were SG (72.4%), 54,606 were RYGB (26.5%), and 1983 were DS (1%). BO occurred in 0.74%, 0.4%, and 0.03% of patients who underwent an RYGB, DS, or SG, respectively. Patients with a BO in the RYGB group were more likely to be on immunosuppressive therapy (5.4% vs. 1.9%, P <0.001) with longer operative time (136.2 min±58.0 min vs. 117.4 min±53.6 min, P <0.001). SG patients with a BO were older (47.5±13.6 vs. 41.9±11.6, P =0.011) with longer operating times (98.6±63.8 vs. 68.9±33.4, P =0.002). Patients in the RYGB group with a BO had the highest rates of readmissions (71.9%) and reoperations (58.4%).

CONCLUSIONS

Early bowel obstruction is rare after bariatric surgery. It is more common after RYGB and least common after SG. Readmission and reoperation rates were highest in patients with BO in the RYGB group.

Re-pancreaticojejunostomy for Necrosis of the Roux-en-Y Limb Tip 14 Years After Partington-Rochelle Procedure

Longitudinal pancreaticojejunostomy for chronic pancreatitis, the Partington-Rochelle (PR) procedure, is a good option to control pain caused by dilation of the main pancreatic duct. However, long-term complications related to anastomosis are still unclear. Here, we present a case of a 78-year-old patient with sudden necrosis of the Roux-en-Y limb tip in a PR procedure performed 14 years ago. During emergent laparotomy, we resected the necrotic limb and re-anastomosed the remaining Roux-en-Y limb to the main pancreatic duct. Postoperatively, we managed the inflammation caused by the pancreatic fistula and successfully saved the patient by long-term drainage. Although the cause of necrosis is still unclear, mild kinking and stenosis of the Roux-en-Y limb might be associated with this situation.

Small Bowel Obstruction After Laparoscopic Roux-en-Y Gastric Bypass Caused by Hemobezoar: A Case Series and Review of Literature

BACKGROUND

The development of an intraluminal blood clot (hemobezoar), represents a rare cause (0.05% to 1.9%) of small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass (LRYGB). We present a case series of 6 cases of SBO caused by hemobezoar.

METHODS

A retrospective analysis of a prospective database including patients who underwent LRYGB from January 2010 to December 2019 has been performed. All the patients who underwent reoperation because of an SBO caused by an intraluminal blood clot were included in the present study.

RESULTS

Six of 843 LRYGB patients developed an hemobezoar (0.71%). Primary LRYGB was uneventful in all cases. SBO symptoms developed after a mean interval of 26.6 hours from the primary procedure. All reoperations were performed with the laparoscopic approach. In all cases, the hemobezoar was located at the level of the jejunojejunal anastomosis (JJA) and was removed through an enterotomy performed at the distal end of the biliopancreatic stump. Three postoperative complications occurred: 1 ab-ingestis pneumonia, 1 leak of the JJA requiring further reoperation, and 1 pelvic abscess treated with radiologic drainage. The mean hospital stay was 11 days.

DISCUSSION

SBO due to hemobezoar is a rare but worrisome early complication after LRYGB. It almost always affects the JJA and requires a prompt diagnosis to avoid dreadful sequelae. In the absence of anastomotic leak or stenosis, surgical management may consist of the removal of the blood clot without refashioning the anastomosis and it may be accomplished with the laparoscopic approach.

Laparoscopic Gastric Bypass: Still the Gold Standard?

Roux-en-Y gastric bypass has been considered the gold standard bariatric procedure for decades. The surgical technique for Roux-en-Y gastric bypass and perioperative management for patients who undergo the procedure are still being improved for better clinical outcomes, shorter hospitalization, and faster return to normal activity. In the past 15 years there have been similar improvements and further development of novel surgical weight loss procedures. As data on other surgical alternatives emerge, the data need to be compared with Roux-en-Y gastric bypass to determine noninferiority. Further long-term investigations are needed to determine superiority of one bariatric procedure over another.

Risk factors for readmission for early small bowel obstruction following laparoscopic Roux-en-Y gastric bypass: an MBSAQIP analysis

BACKGROUND

Small bowel obstruction (SBO) following laparoscopic Roux-en-Y gastric bypass (LRYGB) is associated with significant morbidity.

OBJECTIVES

To evaluate the rate of and risk factors for readmission for SBO within 30 days of LRYGB.

SETTING

Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)-accredited centers.

METHODS

This is a retrospective study using the MBSAQIP database. A query was performed from 2015-2018 for patients who underwent LRYGB and required readmission for SBO. Those who had a reoperation, intervention, readmission, or expired from causes other than SBO were excluded. Descriptive, bivariate, and binary logistic regression analyses were performed.

RESULTS

Among 184,660 patients undergoing LRYGB, 1189 (.64%) required readmission due to SBO. Among the readmission cases, 978 (82.5%) were identified as having intestinal obstruction (unspecified), 108 (9.1%) incisional hernia, and 100 (8.4%) internal hernia. Among these cases, 69% had a reoperation and 1.3% expired during the 30-day period. From a logistic regression model, parameters independently associated with an increased risk for readmission for early SBO include being female (adjusted odds ratio [AOR], 1.53) or black (AOR, 1.41) and having gastroesophageal reflux (AOR, 1.35), a history of myocardial infarction (AOR, 1.76), a history of deep vein thrombosis (AOR, 1.73), previous obesity surgery/foregut surgery (AOR, 1.79), a robotic-assisted procedure (AOR, 1.23), concurrent hiatal hernia repair (AOR, 1.66) and adhesiolysis (AOR, 1.42).

CONCLUSION

The rate of readmission for early SBO following LRYGB was less than 1%. The majority of these cases required reoperation. The increased intraoperative complexity of LRYGB is associated with an increased risk of readmission due to early SBO.

Surgical management of obstructing clot at the jejunojejunostomy after gastric bypass: a single center experience and literature review

BACKGROUND

Roux-en-Y gastric bypass is a proven treatment for morbid obesity and its sequelae. Gastric bypass has a safe risk profile, but postoperative complications can be seen. We report on 10 cases of postoperative bleeding causing an obstructing clot at the jejunojejunostomy (JJ) occurring over a 9-year period.

OBJECTIVES

The aim was to document presenting symptoms of obstructing clots at the JJ and to suggest a treatment approach to minimize complications.

SETTING

University Hospital, United States METHODS: The local Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was queried for all patients undergoing reoperation after Roux-en-Y gastric bypass, from July 2009 until December 2019. All patients who were found to have postoperative bleeding causing an obstructing clot at the JJ were selected for retrospective medical-record review.

RESULTS

The most common presenting symptoms were Hematocrit drop (10 of 10), nausea (9 of 10), abdominal pain (7 of 10), and hematemesis (4 of 10). There were 12 reoperations in the 10 patients, 10 of which were completed laparoscopically. Infectious complications were the most frequent morbidity in our patients; 4 patients developed abscesses. In all of these, the operative notes described gross spillage into the peritoneal cavity. In later cases, the remnant stomach was decompressed before reoperation, reducing spillage.

CONCLUSIONS

Despite the low rate of obstructing clots at the JJ, without rapid recognition and reoperation, there is a risk for serious complications. Typical presenting symptoms include nausea and abdominal pain, which help differentiate it from other causes of decreased hematocrit. Diagnosis is commonly made with computerized tomographic (CT) scan. Decompression of a dilated remnant stomach before addressing the clot can prevent intraperitoneal spillage and subsequent abscess formation. Enterotomy creation and removal of clot is recommended, without fear of continued bleeding.

Small Bowel Obstruction

Identifying patients with small bowel obstruction who need operative intervention and those who will fail nonoperative management is a challenge. Without indications for urgent intervention, a computed tomography scan with/without intravenous contrast should be obtained to identify location, grade, and etiology of the obstruction. Most small bowel obstructions resolve with nonoperative management. Open and laparoscopic operative management are acceptable approaches. Malnutrition needs to be identified early and managed, especially if the patient is to undergo operative management. Confounding conditions include age greater than 65, post Roux-en-Y gastric bypass, inflammatory bowel disease, malignancy, virgin abdomen, pregnancy, hernia, and early postoperative state.

Early small bowel obstruction after laparoscopic gastric bypass: a surgical emergency

BACKGROUND

Early small bowel obstruction (ESBO; within 30 d of surgery) after laparoscopic gastric bypass (LRYGB) is reported in .5% to 5.2% of primary cases, but it is associated with significant morbidity, and the treatment is not standardized.

OBJECTIVES

To review prevalence, causes, management, and outcomes of patients treated for ESBO after LRYGB.

SETTING

Tertiary academic medical center.

METHODS

Retrospective review to identify consecutive patients who underwent primary LRYGB and those who developed ESBO from January 2000 through June 2017. Data included demographic characteristics, co-morbidities, LRYGB technical details, and ESBO clinical presentation, location, causes, treatment, and outcomes.

RESULTS

One thousand seven hundred seventeen patients (84.2% females) had LRYGB. Mean age and body mass index was 42.4 ± 11.1 years and 48.2 ± 7.3 kg/m², respectively. Twenty-nine patients (1.7%) had ESBO. All patients presented with symptoms, most commonly nausea and vomiting (n = 17), on average 4.1 ± 5.9 days postoperatively; most required reoperation (n = 23, 79.3%) and 5 required >1 reoperation. Location of the obstruction and treatment used were the following: (1) jejuno-jejunostomy (n = 17, 58.6%; narrowing or clot), treated with reoperation in 11; and (2) other than at the jejuno-jejunostomy (n = 12, 41.4%; trocar site, incisional or internal hernia, adhesions, mesenteric ischemia), treated with reoperation in all. All ESBO patients had additional complications, 6 (20.1%) developed an anastomotic leak, and 2 (6.9%) died.

CONCLUSION

ESBO infrequently occurs after LRYGB; many causes are technique related and possibly preventable. However, it is associated with significant morbidity and mortality. A high index of clinical suspicion, rapid and appropriate imaging, and prompt operative intervention are recommended.

Beyond the "B": a new concept of the surgical staple enabling miniature staplers

Background

Surgical staplers currently all rely on the same staple form—the “B” which necessitates a high delivery profile (12 mm). A novel “D” shape staple allows for an extremely low profile of the applicator. The acute and long-term efficacy of a D-shaped staple (Cardica, Redwood City, CA, USA) was compared to conventional B-form staples (Covidien, Norwalk, CN, USA) in an animal model for intestinal transections and anastomoses.

Methods

Jejunojejunal anastomoses (JJ) were performed via mini-laparotomy in a swine model. White & blue D- and B-shaped staples were studied in three groups (planned survival 14–84 days). Intraoperative assessment included completeness of staple line, hemostasis, and need for intervention. Postoperatively, animals were evaluated for complications. At the time of sacrifice, gross pathological and histological assessments were performed.

Results

Twenty-three animals had 40 anastomoses (23 “D” and 17 “B” staple anastomoses) with no intraoperative mortalities. One “D” staple application required a manual extension of the cut. Acute hemostasis was 100 %. Group 1 (n = 5) compared white staples in JJs (D staple n = 5; B staple n = 5; 14-day survival = 100 %). Group 2 (n = 12) compared white staples in JJs (D staple n = 12; B staple n = 6; 34-day survival = 92 %). One animal died on day 4 for a non-staple related cause. Group 3 (n = 6) compared blue staples in JJs (D staple n = 6; B staple n = 6; 84 day survival = 84 %). One animal died on day 18 due to an obstruction at the B staple JJ caused by stricture. There were no other bleeding, leaks or strictures in any of the groups. Gross pathology and histology were unremarkable in all JJs.

Conclusions

This study showed no difference in intraoperative performance and the chronic healing response in JJs between D- and B-shaped staples. Based on these findings, the D-shaped staple elicits a normal healing response in jejunostomies and offers the possibility of clinical use of this advance in staple design.

Early postoperative obstruction after Roux-en-Y gastric bypass

We report a case of early postoperative intestinal obstruction after gastric bypass. The most frequent radiologic presentation is one of gastric dilatation on the CT scan. It is a true surgical emergency.

Bariatric emergencies: current evidence and strategies of management

BACKGROUND

The demand for bariatric surgery is increasing and the postoperative complications are seen more frequently. The aim of this paper is to review the current outcomes of bariatric surgery emergencies and to formulate a pathway of safe management.

METHODS

The PubMed and Google search for English literatures relevant to emergencies of bariatric surgery was made, 6358 articles were found and 90 papers were selected based on relevance, power of the study, recent papers and laparoscopic workload. The pooled data was collected from these articles that were addressing the complications and emergency treatment of bariatric patients. 830,998 patients were included in this review.

RESULTS

Bariatric emergencies were increasingly seen in the Accident and Emergency departments, the serious outcomes were reported following complex operations like gastric bypass but also after gastric band and the causes were technical errors, suboptimal evaluation, failure of effective communication with bariatric teams who performed the initial operation, patients factors, and delay in the presentation. The mortality ranged from 0.14%-2.2% and increased for revisional surgery to 6.5% (p = 0.002). Inspite of this, mortality following bariatric surgery is still less than that of control group of obese patients (p = value 0.01).

CONCLUSIONS

Most mortality and catastrophic outcomes following bariatric surgery are preventable. The awareness of bariatric emergencies and its effective management are the gold standards for best outcomes. An algorithm is suggested and needs further evaluation.