Alimentary Loop Obstruction Due To A Blood Clot After RYGB

Case

A 31-year-old morbidly obese female patient (BMI 47,3kg/m2) underwent an uncomplicated Laparoscopic Roux-en-Y Gastric Bypass. All the anastomoses were performed using a Covidien Vascular Medium Tri-Stapler (yellow), except for the gastro-enterostomy which was closed using a Covidien V-Lock 2/0 23cm length on a 27mm half-round tapered needle. A routine gastroscopic evaluation of the gastro-enterostomy and gastric pouch revealed no bleeding from the staple lines, however, eighteen hours post-surgery the patient complained of nausea, abdominal pain, and suddenly vomited 300ml of blood clots. Her pulse rate was 100 BPM, BP 120/85, the haemoglobin showed a decline from 14.2 to 13.9 mg/dL. A radio contrast CT scan with 25ml of gastrographin was performed and showed an alimentary loop obstruction due to a blood clot located at the entero-enterostomy site (FIG. 1). It is clear from this coronal view that the alimentary loop is distended, although some contrast did bypass the clot, as the contrast can be observed distal to the anastomosis. The CT confirmed no obstruction of the biliary loop, as the stomach remnant and duodenum were not distended. The bilirubin count was normal, indicating no re-absorption of bilirubin.

Treatment

Low molecular subcutaneous Heparin and NSAIDs were immediately withdrawn and she received Neostigmine 2.5mg/1ml/ 200ml of saline infused over one hour.

Outcome

Two and a half hours later, she passed 400ml of blood clots through the rectum, followed by normal liquid stools one hour later. Her nausea and abdominal pain subsided, the pulse returned to normal, and a standing abdominal x-ray showed gastrographin in the rectum, with minimal distention of the alimentary loop. The patient was prevented from receiving any oral intake for a further 24 hours, and then the normal post-operative dietary programme continued and he was discharged four days after the initial surgery, with no further indication of bleeding. The haemoglobin, pulse and BP remained normal, and the standard treatment of post-operative subcutaneous Clexane was resumed.