Strangulation of Upper Jejunum in Subsequent Pregnancy Following Gastric Bypass Surgery
Total Page：16
File Type：pdf, Size：1020Kb
■ 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 Taiwan JObstetGynecol Taiwan Table. Characteristics of patients with complicated subsequent pregnancies following gastric bypass surgery—review of the literature Gravidity First post- Age, GA, Bariatric Interval, Initial Case (G) and surgical Symptoms and signs Evaluation and survey Results Author yr wk surgical mo diagnosis • parity (P) pregnancy September 2007 1 41 31 G1P0 Open Roux- 18 Yes Mid-epigastric pain, WBC, 14500/mm; rise in Pancreatitis An emergency laparotomy was performed Moore en-Y bypass nausea, and vomiting amylase , 500 U/L; fever, after 48 hours. Gangrenous change of et al [5] surgery after fatty meals were 39°C; blood acidosis, small bowel 61 cm in length herniated by observed at 31 weeks. pH 7.13. a mesenteric defect was identified. A C/S • was performed to evacuate the nonviable Vol 46 Vol fetus. The patient died of ventricular fibrillatory arrest 3 hours after operation. • No 3 2 33 13 G3P1 Open Roux- 30 Yes At 6 weeks, periumbilical At 12 weeks, a CT scan Volvulus or A diagnostic laparoscopy was performed Kakarla en-Y bypass and left upper quadrant revealed a suspected internal after 1 week. A Petersen hernia was et al [6] surgery abdominal pain for volvulus or small bowel herniation observed and reduced. Her subsequent 6 weeks, exacerbated by herniation. Other workup pregnancy was uneventful, and she was eating and associated was negative. delivered of an infant at term. with nausea. 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 Roux-en-Y 2 days’ epigastric pain, suspected obstruction, herniation and C/S on day 2. An internal, mesenteric et al [6] bypass nausea, vomiting, and and distension of the loop hernia was repaired. A viable surgery decrease appetite. biliopancreatic limb, infant was delivered. Postoperative duodenum and stomach. complications were endometritis and Blood chemistry and liver deep vein thrombosis. function test results were normal. Gastric BypassandPregnancyComplication 4 23 25 G2P1 Open Roux- 6 Yes At 25 weeks, initially On day 1, laboratory Small bowel She underwent an exploratory laparotomy Charles en-Y bypass diffuse abdominal pain values, abdominal X-ray obstruction on day 6.