Small Bowel Ischemia after Roux-en-Y Gastric Bypass Complicated by Pregnancy: A Case Report

Abstract

Small bowel obstruction is an unusual complication of pregnancy. Its occurrence after Roux- en-Y gastric bypass (RYGB) for morbid obesity complicated by pregnancy is rare. Morbid obesity describes body weight at least 100 lb over the ideal weight, or a body mass index (BMI) ≥40. Surgery offers the only viable treatment option with long-term weight loss and maintenance. This case report involves a 23-year-old female at 25 weeks gestation with a 1-day history of diffuse abdominal pain and vomiting. She had a RYGB with a 15 cc micropouch 6 months prior to the commencement of this pregnancy. All radiologic investigations were normal. Esophagogastroscopy was performed revealing an ischemic Roux limb of the gastric bypass. At laparotomy, an internal hernia involving the afferent limb was identified at the site of the Roux anastomosis compromising portions of both the afferent and Roux limbs. Nonviable portions of both the afferent and Roux limbs were resected. Gastrointestinal continuity was achieved by fashioning a gastro-gastrostomy and a jejuno-jejunostomy, thus reversing the original gastric bypass procedure. The immediate postoperative period was complicated by fetal demise. With the increase in bariatric surgery, small bowel ischemia after Roux- en-Y gastric bypass will most likely become more prevalent, particularly in women of childbearing age.

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS, THE OBESITY SOCIETY, AND AMERICAN SOCIETY FOR METABOLIC & BARIATRIC SURGERY MEDICAL GUIDELINES FOR CLINICAL PRACTICE FOR THE PERIOPERATIVE NUTRITIONAL, METABOLIC, AND NONSURGICAL SUPPORT OF THE BARIATRIC SURGERY PATIENT

“…The symptom of cramping periumbilical pain should prompt strong consideration of reexploration by either the open or the laparoscopic technique because of the danger of bowel infarction, peritonitis, and death ( 330 (EL 4)) . This complication may be attributable to adhesions or to an incarcerated internal hernia through one of three potential mesenteric defects ( 639 , 640 , 641 (EL 3)) , especially during pregnancy ( 642 (EL 4), 643 (EL 3), 644 (EL 3)) .…”

“…Hyperhomocysteinemia can result from deficiencies in folic acid, vitamin B 12 , and other micronutrients, and in nonbariatric surgery patients, this condition is associated with placental vascular disease and recurrent early pregnancy loss and fetal neural tube defects ( 672 , 673 , 674 (EL 3)) . Obstetricians should monitor postbariatric surgery pregnant women for the potential development of internal hernias ( 644 (EL 3)) and small bowel ischemia ( 643 (EL 3)) .…”

Gastric bypass: a risk factor for neural tube defects?

“…Other authors have reported small bowel obstruction and ischemia in women during their first postgastric bypass pregnancy, and have suggested that the enlargement of the uterus, particularly during the second trimester, facilitates obstruction through an alteration in the intraabdominal pressure. 4 Bowel obstruction during pregnancy is associated with significant risk of death and complications for both the mother and fetus. 7 Likewise, folate deficiency as a consequence of gastric bypass surgery may even place these women at risk of giving birth to infants with NTDs.…”

Pregnancy and Fertility Following Bariatric Surgery

“…Maternal complications included 14 bowel obstructions (11 internal hernias), 1 gastric ulcer, 4 band events, and 1 staple-line stricture. 20,23,[69][70][71][72][73][74][75][76][77][78][79][80][81][82][83] Gestational age at adverse event ranged from 13 to 37 weeks (median, 26 weeks). Most women presented with nonspecific abdominal complaints and delays often occurred before therapeutic intervention.…”