Gastro-jejunal Obstruction Caused by Clotting after Gastric Bypass Surgery: A Case Series

Abstract

Purpose: One of the most frequent surgical modalities for the treatment of obesity is the Roux-en-Y gastric bypass (RYGB). Previously described complications of RYGB include stomal stenosis, gastric staple line dehiscence, leaks, jejunal and gastric wall necrosis, and loculated fluid collections. Another reported complication is post-operative intraluminal bleeding, which is usually self-limiting. However, it is uncommon to encounter early gastric outlet obstruction secondary to intraluminal blood clots. Intraluminal blood clot formation causing obstruction post RYGB has been reported in only a few case reports, where management predominantly included laparotomy and surgical revision. We report a case series of three patients who developed intraluminal blood clots at the gastro-jejunal anastomosis following robotically-assisted RYGB occurring within 72 hours of surgery. Our first case involves a 63-year-old woman with morbid obesity (BMI 42) who presented with persistent nausea and vomiting for 3 days after an elective, robotically-assisted RYGB and laparoscopic lysis of adhesions. After the procedure, the patient underwent a routine upper GI series without evidence of leakage from the visualized pouch; however, there was no evidence of emptying into the alimentary limb. Physical exam revealed a distended abdomen which was appropriately tender to palpation at the surgical site. EGD was performed and a large blood clot was visualized at the anastomotic site, causing a gastric outlet obstruction. After unsuccessful attempts at irrigation of the clot, biopsy forceps were utilized to fragment the clot. Thereafter, an 8-mm balloon was advanced twice through the clot and inflated to successfully create a lumen. Case 2 and Case 3 include a 53-year old woman (BMI 46) and a 29-year old woman (BMI 43), respectively, who were both admitted for elective RYGB. Both patients experienced persistent nausea for 3 days after surgery. Upper GI series revealed retention of contrast in the gastric pouch, concerning for a gastro-jejunal anastomotic stricture. A subsequent EGD revealed friable, ulcerated, and granulated clot tissue at the gastro-jejunal anastomosis. Thus, a 10-mm gastroscope was passed across the surgical anastomosis to break the clot and relieve the obstruction allowing for passage into the alimenatary limb. Endoscopic dilation has become the elected treatment for gastrojejunal anastomotic stricture after RYGB, due to the low morbidity of this procedure. We highlight three cases of obstructing blood clots at the gastro-jejunal anastomosis managed endoscopically. Endoscopic evaluation and evacuation of clot and fibrinous material should be pursued prior to proceeding straight to laparotomy.