An unusual case of early dysphagia post GBP: Dx & tx

Edward L Felix, MD, David Maccabee, MD, Carrie Smith, RN, MSN. Marian Regional Medical Center

The timing of the onset of dysphagia post Roux-en-Y gastric bypass usually helps determine the cause and therefore the treatment of the dysphagia. Dysphagia arising immediately after the procedure is usually due to edema and resolves spontaneously. When it begins 1-3 days after surgery, a mechanical reason should be suspected and treated. When the patient takes fluids for a week, is advanced to a soft diet but then develops dysphagia, the most common cause is stenosis. The dysphagia is diagnosed and treated with endoscopy and dilatation.

The patient in this video developed complete dysphagia after tolerating liquids and a puree diet. At 10 days post-op she was unable to tolerate even her own saliva. Endoscopy revealed a tight stenosis. The stenosis was dilated to 10mm and she again tolerated liquids for several days. Over the next four weeks the process was repeated several times, but within days after each dilatation the dysphagia recurred. She was hospitalized, started on hyperalimentation, and laparoscoped to determine if there was an extrinsic cause for the persistent dysphagia?

The laparoscopy revealed an anterior Peterson internal hernia with complete obstruction of the gastro-jejunostomy due to a corkscrew twisting of the anastomosis. The video demonstrates the surgical steps and technique required to release the obstruction. In this case a laparoscopic total revision of the gastro-jejunostomy was required because just untwisting the bowel did not release the obstruction. She was discharged home again tolerating her saliva and a liquid diet on the third post-op day.

In over 4000 laparoscopic bypass procedures completed before this patient, we have not seen an anterior Petersen hernia with or without dysphagia in the first month. This patient’s unusual complication therefore raises several important questions. Did this patient’s intial procedure differ in any way? Could this complication have been prevented and at what risk? Were there signs or symptoms that should have differentiated it from more common causes of early dysphagia? How should we select patients for earlier re-exploration if dysphagia persists?