■ CASE REPORT ■

STRANGULATION OF UPPER JEJUNUM IN SUBSEQUENT PREGNANCY FOLLOWING GASTRIC BYPASS SURGERY

Chen-Bin Wang*, Ching-Chuan Hsieh1, Chun-Hung Chen, Yu-Hsiang Lin, Chung-Yuan Lee, Chih-Jen Tseng Departments of Obstetrics and Gynecology and 1General Surgery, Chang Gung Memorial Hospital, Chia Yi, Taiwan.

SUMMARY Objective: Gastric bypass is a surgical procedure that is popularly used to treat morbid obesity. Herein, we report a woman who had a rare gastrointestinal complication during the subsequent antepartum period following a gastric bypass surgery. Case Report: After a Roux-en-Y gastric bypass surgery, a 32-year-old woman had unrelenting epigastria for one week at 36 weeks’ gestation. An emergency cesarean delivery, followed by laparotomy, was performed. A female neonate was delivered with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. Strangulation and gangrene of the upper jejunum caused by a fibrous band at the site of the Roux anastomosis were revealed. Segmental resection of the nonviable bowel was performed. The patient experienced a smooth postoperative course. Conclusion: The awareness of internal hernias and small bowel strangulation should be addressed when unre- lenting epigastric pain is present in women after Roux-en-Y gastric bypass surgery, during their first subsequent pregnancy. [Taiwan J Obstet Gynecol 2007;46(3):267–271]

Key Words: gastric bypass surgery, pregnancy complication, strangulation

Introduction at lowering body weight and raising pregnancy rate, it is associated with some morbidity and complications. The incidence of obesity is rising globally at an alarming This article reports on a young woman treated with rate [1]. Excess weight can negatively affect reproductive Roux-en-Y gastric bypass surgery, whose subsequent function among young women of reproductive age. In pregnancy was complicated by strangulation and gan- response to this spreading epidemic, bariatric surgery is grene of the upper jejunum caused by a fibrous band rapidly becoming widely accepted for obesity treatment. at the site of the Roux anastomosis. A MEDLINE search Bariatric surgery operations, such as Roux-en-Y gastric revealed four cases with the same subsequent com- bypass, adjustable gastric banding, and vertical banded plicated pregnancies following bypass surgeries. The gastroplasty, have been widely performed [2]. Roux-en-Y characteristics and outcomes of these four cases and gastric bypass is currently the standard and the most those of the present case are summarized and discussed popular procedure among the afore mentioned weight below. control surgeries [3]. Although this surgery is effective

Case Report

*Correspondence to: Dr Chen-Bin Wang, Department of A 32-year-old woman, gravida 1, para 0, was referred Obstetrics and Gynecology, Chang Gung Memorial Hospital, 6, to the emergency department at 37 weeks’ gestation Section West, Chia Pu Road, Pu Tz City, Chia Yi 613, Taiwan. E-mail: [email protected] because of persistent epigastria. She had undergone Accepted: November 22, 2006 a bariatric surgery (Roux-en-Y gastric bypass) at our

Taiwan J Obstet Gynecol • September 2007 • Vol 46 • No 3 267 C.B. Wang, et al institution two months prior to her pregnancy. Her preoperative body weight was 90 kg with a body mass index (BMI) of 38 kg/m2. She had lost 18 kg before her pregnancy. Poor appetite, poor food intake, and no obvious weight gain were observed during her first and second trimesters. Her antenatal course had been uneventful other than those presentations. Amniocen- tesis at 18 gestational weeks demonstrated a normal female karyotype (46,XX). She began to suffer from mild mid-epigastric dis- comfort at 36 weeks of gestation. Pregnancy-induced gastro-esophageal reflux was suspected initially, and some antacids were prescribed. The discomfort became worse at 37 weeks of gestation. Nausea and vomiting Figure. After cesarean delivery, an exploratory laparotomy after meal were noted. She was sent to our emergency demonstrated gangrenous change of upper jejunum due to department for help. Initial evaluation revealed upper fibrous band involving the afferent limb near the site of the abdominal tenderness without rebound, hypoactive Roux anastomosis. Segmental resection of the nonviable bowel, about 20 cm in length, was performed. bowel sounds, and no palpable abdominal wall her- nias. The vital signs were unremarkable. The white cell count was 14,600/mm3. The lipase level was 71 U/L. Discussion Other laboratory values, including creatinine and liver function test, were all within normal limits. A sono- Pregnancy that is complicated by bowel strangulation graphic study of the right-upper quadrant was negative and ischemia following bypass surgery is extremely rare. for gallstones. An obstetric nonstress test exhibited However, in response to the rapid growth in bariatric a normal fetal heart rate (140–160 beats per minute) operations on obese women of childbearing age, such and no uterine contraction. Transabdominal sonogra- pregnancy complication seems likely to increase in the phy was also performed. The estimated fetal weight future. Adhesions secondary to gastroenteric and gyne- and biophysical profile were within the normal range. cologic surgeries are the predisposing factors for intes- No clinical evaluations, such as abdominal X-ray series, tine strangulation [4]. Bypass surgery is a crucial event in computed tomography scan, or esophagogastroscopy, the formation of an anatomic defect resulting in internal were performed in the emergency ward. herniation of the small intestine. Because of unrelenting symptoms, she agreed to The rarity of bowel obstruction during pregnancy undergo an emergent cesarean delivery after 12 hours’ following bypass surgery has led to a lack of agree- observation, and then a subsequent exploratory laparo- ment on the best method and clinical criteria for diag- tomy under a presumed diagnosis of peptic ulcer or nosis. Therefore, all reported cases in the literature were intestine perforation. Around 200 mL of bloody fluid explored. A comprehensive MEDLINE search of the lit- was found in the dependent area following a midline erature published from January 1966 to July 2006, longitudinal abdominal incision. A female baby weigh- using the search terms “gastric bypass” and “preg- ing 2,780 g was delivered by cesarean section, with Apgar nancy complications”, small bowel complications in scores of 8 and 9 at 1 and 5 minutes, respectively. This subsequent pregnancies after gastric bypass surgery was followed by exploratory laparotomy that extended have been documented in only three reports and the upper midline abdominal wound across the umbili- a total of four cases [5–7]. The Table summarizes cus after closure of the uterus. Strangulation and the clinical characteristics of the four cases and the gangrenous change of upper jejunum due to internal present case. herniation were identified at the afferent part under The maternal age was in the range of 23 to 41 years the Roux limb near the enteroenterostomy. Nonviable (mean, 32.8 years). The obstruction appeared in the alternation of the strangulated bowel occurred after third trimester in three cases and in the first and sec- the lysis of the fibrous band (Figure). Segmental resec- ond trimesters in one case each. The time interval from tion of the bowel was performed about 20 cm in bariatric surgery to complication presented in subse- length with end-to-end anastomosis. The operation quent pregnancy ranged between 6 and 30 months. All proceeded smoothly without major complication or five cases received open or laparoscopic Roux-en-Y gastric massive bleeding. The patient experienced a smooth bypass. Initial symptoms and signs in all cases were in postoperative course and was discharged 9 days later. a nonspecific pattern: epigastric or periumbilical pain,

268 Taiwan J Obstet Gynecol • September 2007 • Vol 46 • No 3 Gastric Bypass and Pregnancy Complication arla (continued on next page) (continued on next day 6. An internal hernia involving et al [7] was performed to evacuate the nonviable fetus. The patient died of ventricular fibrillatory arrest 3 hours after operation. and C/S on day 2. An internal, mesenteric et al [6] obstruction on Initial diagnosis C; blood acidosis, small bowel 61 cm in length herniated by ° duodenum and stomach.Blood chemistry and liverfunction test results were complications were endometritis and deep vein thrombosis. normal. with diffuse ischemia andno motility. vaginal delivery of a nonviable fetus. herniation. Other workup pregnancy was uneventful, and she vomiting. Four days she had worsening later, esophagogastroscopy of abdominal pain. remarkable. On day 6, ischemia showed the small bowel anastomosis was identified. Fetal heart tones were absent after the operation. Then, she went into spontaneous observed at 31 weeks. pH 7.13. a mesenteric defect was identified. A C/S with nausea. 6 weeks, exacerbated by eating and associated was negative. delivered of an infant at term. First post- pregnancy en-Y bypass en-Y diffuse abdominal pain values, abdominal X-ray surgery and one episode of series, and a CT scan were and the afferent limb at the site of the Roux en-Y bypassen-Y surgery nausea, and vomiting amylase , 500 U/L; fever, after fatty meals were 39 bypass surgery after 48 hours. Gangrenous change of et al [5] nausea, vomiting, and decrease appetite. and distension of the biliopancreatic limb, loop hernia was repaired. A viable infant was delivered. Postoperative Roux-en-Y Roux-en-Y 2 days’ epigastric pain, suspected obstruction, herniation en-Y bypass en-Y surgery and left quadrant upper revealed a suspected abdominal pain for internal volvulus or small bowel after 1 week. A Petersen hernia was herniation observed and reduced. Her subsequent et al [6] Bariatric Interval, surgical mo Gravidity parity (P) Age, GA, yr wk Characteristics of patients with complicated subsequent pregnancies following gastric bypass surgery—review of the literature 4 23 25 G2P1 Open Roux- 6 Yes At 25 weeks, initially laboratory On day 1, Small bowel She underwent an exploratory laparotomy Charles Case1 41 (G) and 31 G1P0 Open Roux- 18 Yes surgical Symptoms and signs Mid-epigastric pain, Evaluation and survey WBC, 14500/mm; rise in Pancreatitis An emergency laparotomy was performed Moore Results Author 3 35 34 G3P2 Laparoscopic 9 Yes At 34 and 6/7 weeks, A CT scan indicated a Internal She underwent an exploratory laparotomy Kakarla Table. 2 33 13 G3P1 Open Roux- 30 Yes At 6 weeks, periumbilical At 12 weeks, a CT scan or Volvulus A diagnostic laparoscopy was performed Kak

Taiwan J Obstet Gynecol • September 2007 • Vol 46 • No 3 269 C.B. Wang, et al

decreased appetite, nausea, and vomiting after meals. Leukocytosis was present in some cases. Other labora- tory data, such as liver function tests, amylase, lipase, and electrolytes, were initially within normal limits. Only Case 1 had a raising amylase level, with misdiagnosis of acute pancreatitis. Three cases used computed tomog- raphy scans. Two cases revealed suspected bowel obstruction, and one had an unremarkable finding. Esophagogastroscopy was performed in one patient, and small intestine diffuse ischemia was discovered. Of the five women, one patient with a 61-cm gangrenous bowel died of ventricular fibrillation 3 hours after an emergency laparotomy. The maternal mortality rate was 20% (1/5). The neonatal mortality rate was 40% (2/5). Notably, those five patients suffered small bowel obstruction in their first pregnancies after bypass sur- gery, which seems to be consistent with the observation of Davis et al [4]. Because of the specific Roux-en-Y

Initial diagnosis anastomosis, internal defects are easily caused by post-

cesarean section. surgical adhesion at the transverse mesocolon and = small intestine mesentery [8], which would predispose ; Peptic An emergency C/S, followed by Present 3 to small bowel herniation. Another bariatric surgery, adjustable gastric banding, has been shown to have no obvious negative impact on subsequent pregnancies [9]. The increasing abdominal pressure and cephalic

within normal limits.intestinal anastomosis was performed. displacement in pregnant women associated computed tomography; C/S tomography; computed

= with the enlarging gravid uterus also contributes to small bowel strangulation and ischemia [10]. This review indi- cates the tendency, since in three of five cases, bowel ischemia happened in the third trimester of pregnancy. The symptoms in Case 2 occurred in the first white blood cell; CT

= trimester, and there was a 6-week history of periumbili- cal pain and 1 week of observation before a diagnostic the discomfort becameworse, and nausea Other laboratory values, vomiting were noted. including creatinine and liver function tests, were delivered. Gangrenous change of small bowel, 20 cm in length, was resected and end-to-end laparoscopy. The discomfort in Case 4 occurred in the second trimester, with a 4-day history of mid-epigastric pain, and it took 6 days to make a decision to perform

First post- pregnancy an exploratory laparotomy. Since the other three cases were diagnosed in the third trimester and had ex- ploratory surgeries performed within 2 days of admis- sion, the conclusion drawn is that the cases of the third trimester had serious bowel strangulation due to high

time between bypass and presentation; WBC time between pressure. Moreover, due to high fetal survival rate in = the third trimester, the decision to perform an explor- en-Y bypass en-Y surgery epigastric discomfort lipase, 71 U/L; was noted. At 37 week, hemoglobin, 13.6 g/dL. perforation ulcer and A viable infant 12 hours was later. was performed laparotomy, after case Bariatric Interval, surgical mo atory laparotomy is made more easily without hesitation than in other trimesters. Once internal hernias occur, the obstructed afferent

Gravidity parity (P) limb of duodenum presents no typical symptomatology suggestive of intestine obstruction [7]; thus, progres- sion from obstruction to strangulation and ischemia develop. Biochemistry tests provide no help in differ- Age, GA, yr wk (continued) entiation. Instead, the impression could initially be gestational age of final diagnosis; interval

= the diagnosis of conditions such as gastritis, perfora- Case5 32 (G) and 37 G1P0 Open Roux- 11 Yes surgical Symptoms and signs At 36 weeks, mild mid- WBC, 14,600/mm Evaluation and survey Results Author Table.

GA tion of peptic ulcer, or acute pancreatitis. Computed

270 Taiwan J Obstet Gynecol • September 2007 • Vol 46 • No 3 Gastric Bypass and Pregnancy Complication tomography examinations could give a hint of bowel 2. Steinbrook R. Surgery for severe obesity. N Engl J Med 2004; obstruction (in Case 2, 3) but may also be unremark- 350:1075–9. able (in Case 4). Esophagogastroscopy may provide 3. Hamilton EC, Sims TL, Hamilton TT, Mullican MA, Jones DB, Provost DA. Clinical predictors of leak after laparoscopic direct observation of small bowel ischemia and sus- Roux-en-Y gastric bypass for morbid obesity. Surg Endosc pected intestinal strangulation. 2003;17:679–84. This review indicates that the awareness of inter- 4. Davis MR, Bohon CJ. Intestinal obstruction in pregnancy. nal hernias and small bowel strangulation should be Clin Obstet Gynecol 1983;26:832–42. addressed when unrelenting epigastric pain is present 5. Moore KA, Ouyang DW, Whang EE. Maternal and fetal in women following Roux-en-Y gastric bypass surgery deaths after gastric bypass surgery for morbid obesity. N Engl and their first subsequent pregnancy. Symptoms and J Med 2004:351;721–2. signs tend to be nonspecific. Imaging studies might not 6. Kakarla N, Dailey C, Marino T, Shikora SA, Chelmow D. Pregnancy after gastric bypass surgery and internal hernia be diagnostic. Only a prompt exploratory laparotomy formation. Obstet Gynecol 2005;105:1195–8. or diagnostic laparoscopy can provide a final diagnosis 7. Charles A, Domingo S, Goldfadden A, Fader J, Lampmann R, and reduce both fetal and maternal mortality. Mazzeo R. Small bowel ischemia after Roux-en-Y gastric bypass complicated by pregnancy: a case report. Am Surgeon 2005;71:231–4. 8. Macgregor AM. Small bowel obstruction following gastric References bypass. Obes Surg 1992;2:333–9. 9. Martin LF, Finigan KM, Nolan TE. Pregnancy after adjustable 1. Liu JH, Zingmond D, Etzioni DA, et al. Characterizing the gastric banding. Obstet Gynecol 2000;95:927–30. performance and outcomes of obesity surgery in California. 10. Johnson BL, Lind JF, Ulich PJ. Transmesosigmoid hernia Am Surg 2003;69:823–8. during pregnancy. South Med J 1992;85:650–2.

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