Clot busters! Relief of gastric outlet obstruction after Roux-en-Y gastric bypass

Roux-en-Y gastric bypass (RYGB) is a highly effective surgical approach for the treatment of morbid obesity [1]. Postsurgical bleeding leading to intraluminal blood clot formation causes gastric outlet obstruction (GOO) at the site of the anastomosis, and is typically managed by laparotomy or surgical revision [1] [2]. Gastrojejunal clots causing GOO following laparoscopic RYGB occur in 3 % – 27 % of patients [2]. Endoscopic dilation of gastrojejunal obstruction provides an alternative to surgical revision, but symptomatic relief may require up to three dilations [3] [4]. We present a case series of three patients who developed intraluminal blood clots at the gastrojejunal anastomosis (GJA) within 72 hours of robotically assisted RYGB surgery.

The first case was a 63-year-old woman with morbid obesity (body mass index [BMI] 42 kg/m²) who presented with persistent nausea and vomiting for 3 days after an elective RYGB. Routine upper gastrointestinal series revealed no evidence of emptying into the alimentary limb. Subsequent esophagogastroduodenoscopy revealed a large blood clot at the GJA ([Fig. 1]). After unsuccessful attempts to irrigate the clot, biopsy forceps were utilized to fragment it. In addition, an 8-mm balloon was advanced twice through the clot and inflated to successfully create a lumen ([Fig. 2]).

Fig. 1 Intraluminal blood clot at the gastrojejunal anastomosis.

Fig. 2 Endoscopic image showing balloon dilation of the stricture made by the clot.

The second and third cases were a 53-year-old woman (BMI 46 kg/m²) and a 29-year-old woman (BMI 43 kg/m²), respectively, who presented with nausea for 3 days after RYGB surgery. Upper gastrointestinal series revealed retention of contrast in the gastric pouch, suggesting stricture at the GJA. In both patients, a 10-mm gastroscope was used to break up the clot, and create a lumen through which passage into the alimentary limb was possible ([Fig. 3] and [Fig. 4]).

Fig. 3 Lumen created by the endoscope to relieve the obstruction.

Fig. 4 Passage of the endoscope into the rest of the alimentary limb after creation of the lumen.

All three patients experienced relief of GOO without undergoing surgical revision, resulting in a shorter hospital stay and lower morbidity [4] [5]. Moreover, these cases show that a single dilation may be sufficient to provide relief.

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• References

• 1 Santo MA, Pajecki D, Riccioppo D et al. Early complications in bariatric surgery: incidence, diagnosis and treatment. Arq Gastroenterol 2013; 50: 50-55
• 2 Goitein D, Papasavas PK, Gagné D et al. Gastrojejunal strictures following laparoscopic Roux-en-Y gastric bypass for morbid obesity. Surg Endosc 2005; 19: 628-632
• 3 Gill RS, Whitlock KA, Mohamed R et al. Endoscopic treatment options in patients with gastrojejunal anastomosis stricture following Roux-en-Y gastric bypass. Gastroenterol Res 2012; 5: 1-5
• 4 Da Costa M, Mata A, Espinos J et al. Endoscopic dilation of gastrojejunal anastomotic strictures after laparoscopic gastric bypass. Predictors of initial failure. Obes Surg 2011; 21: 36-41
• 5 Mala T, Søvik TT, Schou CF et al. Blood clot obstruction of the jejunojejunostomy after laparoscopic gastric bypass. Surg Obes Relat Dis 2013; 9: 234-237