Katherine H Yancey, MD1, Andrew M O’Neill, MD2. 1Mission Health, 2MAHEC
Introduction: Roux-en-Y gastric bypass (RYGB) is a frequently performed bariatric procedure, of which internal hernia (IH) is a known complication. We discuss a rare finding of occult gastric remnant perforation as a result of an obstructed IH in a post bypass patient.
Methods: We present a case report of a single bariatric surgeon’s experience at a tertiary care hospital. Literature review of PUBMED confirms the unique presentation and operative findings in our patient, as few similar cases have been published. A 59-year-old male s/p RYGB 12 years ago presented to the ED with right upper quadrant pain, nausea, vomiting, and a leukocytosis of 24,100. BMI was 31.7; weight was 254 lbs. Workup included an abdominal ultrasound showing gallbladder distention without signs of cholecystitis. Liver function tests were normal. Further imaging included a CT scan, remarkable for a paraesophageal hernia (PEH) containing the gastric pouch, and an elevated left hemidiaphragm. The scan showed no evidence of IH or bowel obstruction. An upper GI series was additionally obtained, which was also negative for small bowel obstruction. Due to unclear etiology for this patient’s symptoms or source of leukocytosis, diagnostic laparoscopy was planned.
Results: Intraoperative findings were significant for IH containing dilated small bowel with twisted and incarcerated omentum through the jejunojenunostomy site, as well as a distended gallbladder without acute inflammation. IH was reduced and closed without bowel resection. Cholecystectomy was completed. Subsequent inspection of the diaphragmatic hiatus revealed uncomplicated herniation of the gastric pouch. In attempts to dissect the left diaphragmatic crus, a large pocket of purulent material was encountered below the left diaphragm in the region of the remnant stomach fundus. Methylene blue test and intraoperative endoscopy did not demonstrate any connection to gastric pouch. The purulence was attributed to an occult remnant stomach perforation related to distal obstructed IH. A drain was left in the abscess and the PEH was not surgically addressed. Patient was discharged on postoperative day 5. He has not suffered any further complications or recurrent complaints.
Conclusion: Gastric perforation following RYGB is an uncommon complication resulting from IH. This diagnosis was missed by preoperative imaging and was only found after thorough laparoscopic investigation. Surgeons should maintain a high clinical suspicion of IH in post RYGB patients with otherwise unexplained abdominal symptoms, fever, and leukocytosis, even in the absence of confirmatory diagnostic testing. Threshold for operative exploration in this clinical setting should remain low.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 86687
Program Number: P171
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster