Obstruction of Defunctionalized Small Bowel Its Occurrence After

Bypass Surgery

for Morbid

Delmar R. Aitken, MD; Clifton Reeves, MD; M. C. Theodore

Obesity

Mackett, MD; Bruce

W.

Branson,

MD

\s=b\ Complications associated with jejunoileal bypass for morbid obesity are being recognized more frequently. A variety of

such

mechanical obstructions in the defunctionalized small-bowel segment have recently been corrected in seven surgical patients. Volvulus of the defunctional limb was the most frequent cause of obstruction. Intussusception, bypass enteritis, fascial hernia, and adhesive bands were also causes of obstruction. Radiographic contrast studies were valuable in establishing the preoperative diagnosis. The altered small-intestinal anatomy predisposed these patients to a uniquely subtle and dangerous form of closed-loop obstruction. Prompt recognition was based on patient history and physical findings. Characteristic roentgenographic findings often confirmed the diagnosis. Clinical suspicion of these small-bowel obstructive syndromes may lead to early surgical treatment.

recognized surgical complications such as wound dehis¬ cence,4 upper gastrointestinal (GI) bleeding,4 acute chole¬ cystitis,'8 and acute and chronic dilation.7" An additional complication for concern is bowel obstruction. This report reviews seven cases that represent the speetrum of obstruction involving the defunctionalized bypass limb of

(Arch Surg 115:1031-1036, 1980)

the introduction of any

surgical procedure, recognized and will enthusiasm for the procedure. With the temper the increasing frequency of treating morbid obesity by jejuno¬ ileal bypass, the complications associated with this proce¬ dure are also becoming more frequent. Much attention has been given to the metabolic sequelae and complications

Withunanticipated complications early

new

are

Accepted

for publication May 7, 1980. From the Department of Surgery, Loma Linda University Medical Center, Loma Linda, Calif. Read before the annual meeting of the Southern California Chapter of the American College of Surgeons, Rancho Mirage, Calif, Jan 20, 1980. Reprint requests to Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA 92350 (Dr Aitken).

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as

stones,

diarrhea, electrolyte depletion, liver changes, renal etc.1

**

Less attention has been directed to the 5

the small intestine.

REPORT OF CASES was the complication in this 39-year-old who had done well for three years after jejunoileal bypass until she was hospitalized with right upper quadrant pain, nausea, and vomiting; she continued to have loose bowel movements. Her workup included a normal intravenous pyelogram and oral chole¬ cystogram. Plain abdominal x-ray films showed multiple air-fluid levels. A GI roentgenographic series showed a short segment of small bowel with rapid passage of contrast material into the rectum. A barium enema roentgenogram revealed no obstructing lesion. A psychiatric examination attributed the patient's com¬ plaints to her immature, dependent personality. After 11 days of nonoperative management, she was trans¬ ferred to our medical center. Our findings included a markedly distended, diffusely tender abdomen with a WBC count of less than 10,000/cu mm. Dilated loops of small intestine with air-fluid levels were seen on the upright abdominal roentgenograms. Upper Gì (UGI) roent¬ genographic series with small-bowel follow-through showed pas¬ sage of barium to the rectum within ten minutes. Of note were dilated bowel loops outside of the contrast-filled bowel, suggesting obstruction of the defunctionalized small-bowel segment (Fig 1).

Case 1.—Volvulus

woman

Attempted colonoscopic evaluation of the ileosigmoid anastomo¬ sis was unsuccessful. At exploration, markedly dilated loops of defunctionalized small bowel were found. A 360° volvulus of gangrenous, perforated ileum based at the ileosigmoid anastomo¬ sis was present (Fig 2). This gangrenous segment of ileum was resected with revision of the ileosigmoid colostomy. Case 2.—Double volvulus was the complication in a 29-year-old woman who had had intestinal bypass surgery for obesity four years prior to the development of epigastric pain. A UGI roent¬ genographic series, barium enema roentgenogram, and oral chole¬ cystogram were all normal. The patient was admitted after an exacerbation of her epigastric pain that was associated with a burgundy-colored bowel movement. Abdominal rebound tender¬ ness with guarding and a guaiac-positive stool test were the important findings, along with a WBC count of 25,000/cu mm. Friable, bleeding rectosigmoid mucosa was found at 10 cm by

sigmoidoscopy. Radiographie findings

included dilated loops of small bowel on abdominal films. A diatrizoate meglumine (Gastrografin) enema roentgenogram showed an abrupt, beaked termination of the sigmoid colon (Fig 3), and then the contrast material transversed a segment of small bowel with "thumbprinting" (Fig 4). A diatri¬ zoate meglumine UGI roentgenographic series revealed a short¬ ened small bowel, no filling beyond the transverse colon, and again small-bowel loops outside of the contrast-filled bowel (Fig 5). At exploration, a 180° volvulus of the distal defunctionalized small bowel was found centered at the ileosigmoid colostomy. Redundant sigmoid colon was also involved in the volvulus (Fig 6). Arterial pulsations were present, and the dusky serosal color disappeared after detorsión. The mesenteric defect between the distal bypass ileum and the sigmoid mesentery was closed. Case 3.-Volvulus with pneumatosis intestinalis occurred in a woman who, at 21 years of age, had undergone jejunoileal bypass surgery for morbid obesity. She had had a satisfactory weight loss and had been asymptomatic for eight years except for chronic diarrhea. Abdominal distention and pain, as well as small amounts of rectal bleeding, were present for the week prior to admission. There were no signs of peritoneal irritation; only marked tympanites, distention, and hyperactive bowel sounds were pres¬ ent. The abdominal roentgenograms showed obvious pneumoperi¬ toneum with pneumatosis cystoides intestinalis and distended loops of air-filled small bowel and colon (Fig 7). Pertinent findings at laparotomy included a markedly dilated, defunctionalized small-bowel segment with numerous subserosal air-filled blebs. A volvulus of the ileum proximal to the sigmoid anastomosis had herniated through a mesenteric defect, thus causing the obstruction. There was no evidence of intestinal compromise after needle decompression of the obstructed smallbowel segment, detorsión of the volvulus, and repair of the mesenteric defect. Case 4.—Adhesion caused obstruction in a 25-year-old man who had had a small-bowel bypass three years before coming to us after three days of progressive abdominal pain, distention, and vomiting. Abdominal distention, percussion tympanites, and obstructive bowel sounds were present. Rectal examination and a sigmoidoscopy were unremarkable. The WBC count was 14,500/cu mm with a shift to the left. Dilated small-bowel air-fluid loops were seen on the upright abdominal roentgenogram. A barium enema roentgenogram was normal. Diatrizoate meglumine flowed to the colon. Extrinsic dilated small-bowel loops were seen, sug¬ gesting an obstruction of the defunctionalized small-bowel seg¬ ments (Fig 8). The obstruction was secondary to a dense band adhesion that was lysed. Case 5.—Bypass enteritis was the complication in a 59-year-old woman who had had a jejunoileal bypass one year before being

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Fig 1 .—Barium-filled colon with extrinsic indentations from dilated small bowel. admitted for dehydration secondary to 40 diarrheal stools per day. A UGI roentgenographic series and barium enema roentgeno¬ gram were normal. Over the next several days, her persistent abdominal pain localized to the left lower quadrant along with an increase in abdominal distention. Serial abdominal x-ray films showed air-fluid levels with a vague, soft-tissue-mass-like effect pressing on the descending colon (Fig 9). Surgical exploration revealed multiple adhesions around the dilated small-bowel loops. An inflammatory tumor-like mass with an adjacent thin-walled pseudocyst was encountered near the descending colon and the left ovary. Approximately 30 cm from the ileal ascending colostomy, the defunctionalized small-bowel limb was intimately incorporated in the tumor-like mass. Frozen section biopsy specimens failed to reveal small-bowel or ovarian malignant neoplasms. The mass was excised, and the ileoascending colostomy was revised to an ileotransversostomy. Micro¬ scopic examination showed muscularis disruption with inflamma¬ tion, fibrosis, and areas of old-fat necrosis. No granulomas or malignant neoplasms were found. The pathologic diagnosis was sclerosing mesenteritis. Case 6.—Intussusception was the complication in a 40-year-old woman who, 20 months prior to admission, had had a small-bowel bypass procedure performed with drainage of the defunctionalized limb into the transverse colon. Subsequently, she had lost 60.75 kg. During this time, she had had frequent abdominal pain, 12 stools per day, and progressive evidence of malabsorption with hepatic failure. Direct epigastric tenderness and the previous surgical scar were the only notable findings on examination of the abdomen. Contrast GI studies were considered normal for a small-intestinal

bypass patient.

Fig 2.—Volvulus of defunctionalized small intestine at anastomosis.

ileosigmoid

Fig 4.—Barium-filled defunctionalized small intestine, strating ischemie mucosa "thumbprinting" (arrows).

demon¬

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3.—Beaked sigmoid colon suggesting sigmoid volvulus in patient with double volvulus, sigmoid volvulus, and defunctionalized small-intestine volvulus.

Fig

Fig 5.—Air-containing, defunctionalized small intestine extrinsic to contrast-material-filled functional small bowel and colon.

Defunctionalized eum volvulus

Sigmoid volvulus

Fig 6.—Defunctionalized ¡leal volvulus volvulus resulting in double volvulus.

contributing

to

sigmoid

Fig 7.—Mottled appearance of small intestine, suggesting pneu¬ matosis cystoides intestinalis. Free air above liver margin. small intestine and colon with air in obstructed, defunctionalized small intestine.

Fig 8.—Contrast-material-filled

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9.—Small arrows outline soft-tissue mass pressing on descending colon. Arrows point to area of colon obstruction secondary to soft-tissue

Fig

mass.

A 25-cm intussusception of the oversewn defunctional small bowel was found at the time of conversion of the bypass segment to normal anatomy. The intussusception was resected because of questionable viability after reduction. Microscopic examination revealed focal acute peritonitis. Postoperatively, the intermittent epigastric pain of the previous two months was relieved. Case 7.-Fascial hernia was the complication in a 48-year-old, obese woman who had had intestinal bypass surgery; on the 18th postoperative day, abdominal distention, vomiting, and obstruc¬ tive bowel sounds had developed. Dilated loops of small bowel were apparent on abdominal roentgenograms. Strangulated defunc¬ tionalized small bowel was found incarcerated in a partial fasciai separation. This nonviable bowel was resected with revision of the

ileoascending colostomy.

COMMENT

Surgeons must be aware of the various mechanical complications associated with the defunctionalized smallbowel loop after intestinal bypass surgery for obesity. With increasing frequency, reports are appearing that document a variety of syndromes that contribute to

obstruction of the defunctionalized small-bowel segment. Reported mechanical complications include volvulus,913 stornai obstruction,15,ls intussuscep¬ adhesions,14 and hernias of the internal type as well as tion,7,14,15,17*2" abdominal-wall hernias.911 Volvulus was seen in three cases. In all instances, the defunctionalized bowel was drained into the sigmoid colon. Case 2 involved an unusual form of volvulus in that a double volvulus was present. Volvulus of the redundant sigmoid colon was present and was believed to be second¬ ary to the volvulus of the defunctionalized small-bowel loop. Volvulus was suspected in this case when friable, bleeding mucosa was seen on sigmoidoscopy, and this suspicion was reinforced by the sharp, beaked cutoff of the sigmoid and the thumbprinting that was seen after the diatrizoate meglumine enema. Several articles are now available that report volvulus as a late complication of bypass surgery. Almost all cases have occurred when the sigmoid colon has been used to decom¬ press the isolated small bowel.911,13,16 Menguy reported a case of sigmoid volvulus that caused obstruction without volvulus of the small bowel itself.12 To our knowledge, only one case of ileal volvulus at a site other than the sigmoid colon has been reported, and it was believed to be due to an inadvertent technicality in suturing the ileum to the transverse colon.21 The incidence of this problem may be higher than was previously recognized. Gourlay and Evans found an ileal volvulus incidence of 17% in their series.21 The etiology of the sclerosing mesenteritis with fat necrosis, fibrosis, and inflammation in case 5 was never determined. No granulomatous lesions were seen on micro¬ scopic examination, and there was no history of pancreati¬ tis as a cause of the fat necrosis. An inflammatory process or a chronic ischemia secondary to the surgery may have been responsible. This case may be similar to cases of bypass enteritis reported by Passaro et al.22 Intussusception of the oversewn proximal jejunum has been reported as a frequent type of obstruction of the

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bypass intestine.714,15,1719 It has been suggested that this complication can be recognized more readily if silver clips are used as references to mark the oversewn jejunum and the adjacent colon mesentery.19 The importance of the occurrence of pneumatosis cys¬ toides intestinalis after bypass surgery is unclear at pres¬ ent. It can definitely be a sign of other notable pathologic conditions such as bypass enteritis22 or obstruction second¬ ary to volvulus.12 Other reports suggest that in the majority of cases the pneumatosis will resolve without a need for surgical exploration.23 We have seen two other cases of pneumatosis, in which no exploration was performed. The only early postoperative obstructive complication 25

involved incarceration of the defunctionalized bowel in a fasciai separation, and this accounted for the only death. No umbilical hernia or stomai or jejunoileal anasto¬ motic obstructions were encountered. Closure of all mesenteric defects at the time of original bypass may stabilize the ileocolostomy pivot point, pre¬ venting the freedom of movement that probably contrib¬ utes to volvulus of the defunctionalized limb. Internal herniations as a cause of defunctionalized limb obstruction would also be prevented by closure of all mesenteric defects. Our three cases of the ileal volvulus were similar to other cases in which the defunctionalized ileum was anas¬ tomosed to the sigmoid colon.1"13 It appears that the problem would be avoided entirely if the sigmoid were not used for venting the defunctionalized small bowel. Recognition of any of the various forms of obstruction is frequently difficult because distention and cramping are frequently seen after jejunoileal bypass for morbid obesi¬ ty, and because the initial observations may confuse the problem with biliary- or urinary-tract symptoms. The defunctionalized limb of small bowel, when obstructed, becomes a unique form of closed-loop obstruc¬ tion. Recognition of this complication may be delayed because of the lack of substantial amounts of air in this isolated segment, which may be predominately fluid filled. This delay will allow progression of distention and an increase in intraluminal pressure, thus leading to vascular compromise with subsequent necrosis and perforation. Suspicion of this complication should be aroused if an intestinal bypass patient has high-pitched abdominal sounds, distention, and colicky abdominal pain suggestive of obstruction but continues to have recognized bowel function. This suspicion is confirmed when dilated loops of small bowel are seen in someone known to have only a short segment of functional bowel and when contrast GI roent¬ genograms fail to demonstrate an obstructing lesion but show dilated bowel loops extrinsic to contrast-filled bow¬ el.

partial

CONCLUSION With the extensive

for the increased incidence of closed-loop obstruction of the defunctionalized limb can be anticipated. Early recognition and surgical treatment of these obstructions will lead to decreased morbidity and treatment of morbid

mortality.

use

of

obesity,

jejunoileal bypass an

References 1. Baddeley M: Results of jejunoileostomy for gross refractory obesity. Br J Surg 63:801-806, 1976. 2. DeWind LT, Payne JH: Intestinal bypass surgery for morbid obesity: Long-term results. JAMA 236:2298-2301, 1976. 3. Starkloff GB, Donovan JF, Ramach KR, et al: Metabolic intestinal surgery: Its complications and management. Arch Surg 110:652-657, 1975. 4. Corso PH, Joseph WL: Intestinal bypass in morbid obesity. Surg Gynecol Obstet 138:1-5, 1974. 5. Payne JH, DeWind LT, Schwab CE, et al: Surgical treatment of morbid obesity: Sixteen years of experience. Arch Surg 106:432-437, 1973. 6. Neshat AA, Flye MW: Early formation of gallstones following jejunoileal bypass for treatment of morbid obesity. Am Surg 41:486-491, 1975. 7. Fikri E, Cassella RR: Jejunoileal bypass for massive obesity. Ann Surg 179:460-464, 1974. 8. Jewell WR, Hermreck AS, Hardin CA: Complications of jejunoileal bypass for morbid obesity. Arch Surg 110:1039-1042, 1975. 9. Moss AA, Goldberg HI, Koehler RE: Radiographic evaluation of complications after jejunoileal bypass surgery. AJR 127:737-741, 1976. 10. Harmon JW, Aliapoulos M, Braasch JW: The excluded small-bowel segment: A source of complications after small-bowel bypass. Arch Surg 111:953-954, 1976. 11. Rogers N, Carter P, Syphax B: Recurrent obstruction of bypass intestine in obesity surgery: A challenging late complication. Natl Med Assoc 68:28-30, 1976. 12. Menguy R: Pneumatosis intestinalis after jejunoileal bypass: Etiologic mechanism in one case. JAMA 236:1721-1723, 1976. 13. Ackerman NB, Abou-Mourad NN: Obstructive pseudo-obstructive, and enteropathic syndromes after jejunoileal bypass surgery. Surg Gynecol Obstet 148:168-174,1979. J

14. Baber JC, Hayden WF, Thompson BW: Intestinal bypass operation for obesity. Am J Surg 126:769-772, 1973. 15. Gaspar MR, Movius HJ, Rosenthal JJ, et al: Comparison of Payne and Scott operations for morbid obesity. Ann Surg 184:507-515, 1976. 16. Sanders GB: Bypass enteritis or obstructive volvulus? Arch Surg 112:668, 1977. 17. Wise L, Boucher JK, Feutz E: Intussusception following jejunoileal bypass: Case report and review of the literature. Am Surg 42:346-349, 1976. 18. Kaufman JH, Welson HW: Intussusception: A late complication of small-bowel bypass for obesity. JAMA 202:1147-1148, 1967. 19. Starkloff GB, Shively PA, Gregory JG: Jejunal intussusception following small bowel bypass for morbid obesity. Ann Surg 185:386-390, 1977. 20. Backman L, Hallberg D: Some somatic complications after small intestinal bypass operations for obesity. Acta Chir Scand 141:790-800, 1975. 21. Gourlay RH, Evans KG: Jejunoileal bypass and the defunctioned bowel syndrome. Surg Gynecol Obstet 148:844-846, 1979. 22. Passaro E, Drenick E, Wilson SE: Bypass enteritis: A new complication of jejunoileal bypass for obesity. Am J Surg 131:169-174, 1976. 23. Prain GW, Buerk CA, Norton L, et al: Community experience with small bowel bypass for morbid obesity. Am J Surg 132:691-696, 1976. 24. Feinberg SB, Schwartz MZ, Clifford S, et al: Significance of pneumatosis cystoides intestinalis after jejunoileal bypass. Am J Surg 133:149-152, 1977. 25. Martyah SN, Curtis LE: Pneumatosis intestinalis: A complication of jejunoileal bypass. JAMA 235:1038-1039, 1976.

Editorial Comment As this article states, "Complications associated with jejunoileal bypass for morbid obesity are being recognized more frequently." This is very true, and the authors properly stress that obstruction of the defunctionalized small bowel may give subtle signs and symptoms that belie the serious nature of the evolving process. This, of course, can lead to unwarranted and sometimes fatal delay in surgical intervention. The authors also point out, quite correct¬ ly, that obstruction of the bypassed small bowel is more likely to occur when the sigmoid is used for the vent, because intraluminal pressures in that

segment and other factors make this a form of

closed-loop obstruction. Nevertheless, such obstruction has been reported when other areas of the colon are used for drainage. Obstruction is not the only recognized complication of jejuno¬ ileal bypass, and changing the drainage site of the defunctional-

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ized bowel will not reverse these sequelae. Such complications as liver disease, sometimes being fatal; renal disease, not just nephrolithiasis but a form of nephritis; electrolyte imbalances, sometimes requiring multiple hospital admissions; arthralgia and arthritis; gas and odor problems, even if the diarrhea is tolerable; easy fatigability, which is more than simple hypokalemia; and late weight gain as the small-bowel incontinuity regains its absorptive capacity have all been reported to occur in many patients who have had jejunoileal bypass. Isn't it time we surgeons called a morato¬ rium on this procedure for morbid obesity? Must we always wait for someone else to stay our hands?

Ward 0. Griffen, Jr, MD, PhD

Lexington, Ky