Surgery for Obesity and Related Diseases 9 (2013) 874–878
Original article
Late perforation at the jejuno-jejunal anastomosis after laparoscopic gastric bypass for morbid obesity Ramya Kalaiselvan, M.R.C.S., M.Phil.a, Mahmoud Abu Dakka, M.R.C.S., M.B.Ch.B.b, Basil J. Ammori, M.B.Ch.B., F.R.C.S., M.D.a,b,c,* a Salford Royal Hospital, Manchester, United Kingdom Manchester Royal Infirmary, Manchester, United Kingdom c The University of Manchester, Manchester, United Kingdom Received December 27, 2012; accepted April 24, 2013 b
Abstract
Background: Although marginal ulceration and perforation at the gastrojejunal anastomosis is an established, albeit rare, risk after laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity, little is known about the risk of late perforation at the jejuno-jejunal (J-J) anastomosis. The objective of this study was to identify the incidence of J-J perforation and describe management options and sequelae. Methods: This is a retrospective review of the database of all patients who underwent LRYGB. The results are presented as mean (range) where appropriate. Results: Between April 2002 and April 2012, 1652 patients underwent LRYGB (1577 primary and 75 revision procedures). The operative mortality was .18%. Three patients developed late perforation of the J-J anastomosis (.18%) at 7, 9, and 18 weeks, respectively. Two patients were managed with resection and reanastomosis of the perforation by laparotomy, and a third patient was managed laparoscopically with peritoneal lavage and transcutaneous tube jejunostomy of the perforation. All patients recovered well postoperatively. However, the third patient represented 42 days later with sepsis and died secondary to recurrent J-J ulcer perforation. Conclusion: Perforation of the J-J anastomosis is a rare and life-threatening delayed complication after LRYGB and usually presents within 2–8 months postoperatively. It poses difficulties with diagnosis and management and should be dealt with judiciously. (Surg Obes Relat Dis 2013;9:874–878.) r 2013 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Laparoscopic; Jejuno-jejunal perforation; Marginal ulcer; Gastric bypass; Perforation; Bariatric surgery
The prevalence of obesity has been increasing [1] leading to an increase in the number of bariatric procedures performed worldwide and in their associated complications.
Presented at the International Federation for the Surgery of Obesity & Metabolic Disorders, 2012, India and awarded “Best Oral Presentation.” * Correspondence: Basil J. Ammori, M.D, The University of Manchester, Salford Royal NHS Foundation Trust, Stott Lane, Salford, Manchester, M6 8HD, United Kingdom. E-mail: [email protected]
Laparoscopic Roux-en-Y gastric bypass (LRYGB) is, by far, the most common antiobesity procedure performed [2]. Although marginal ulceration and perforation at the gastrojejunal anastomosis is an established [3], albeit rare, risk after LRYGB for morbid obesity, little is known about the risk of late perforation at the jejuno-jejunal (J-J) anastomosis. This report aims to evaluate the incidence of late J-J anastomotic perforation after LRYGB, identify potential risk factors, and describe the management options and their outcomes.
1550-7289/13/$ – see front matter r 2013 American Society for Metabolic and Bariatric Surgery. All rights reserved. http://dx.doi.org/10.1016/j.soard.2013.04.020
Jejuno-Jejunal Anastomosis Perforation / Surgery for Obesity and Related Diseases 9 (2013) 874–878
Methods Patients A retrospective review of the electronic records of patients who underwent LRYGB by the senior author or under his direct supervision between April 2002 and April 2012 was carried out. A detailed analysis of the patients who developed perforation of J-J anastomosis was conducted. Details of patients’ demographic characteristics, past history (including relevant data from the primary bariatric surgery), and co-morbidities, as well as mode of presentation of perforation, management, and outcomes were established. As this retrospective study did not influence patient management, it did not warrant ethics committee approval. Operative technique of J-J anastomosis Of the 1652 patients, the initial 982 J-J anastomoses were stapled, and the subsequent 670 J-J anastomoses were completely hand-sewn using 2 layers of Vicryl 3-0 (Johnson & Johnson Int., St. Stevens-Woluws, Belgium) posteriorly and one layer anteriorly in a continuous fashion. Postoperative care after management of perforation of the J-J anastomosis. Patients received intravenous antibiotic therapy postoperatively. Any ulcerogenic drugs were discontinued. Investigations were carried out to detect the presence of Helicobacter pylori. Patients were advised against smoking and the use of alcohol, and proton pump inhibitor (PPI) therapy was resumed if patients had discontinued it after the LRYGB. Results Between April 2002 and April 2012, 1754 patients underwent LRYGB. LRYGB was performed in 1652 patients, of which 1577 were primary and 75 were revision procedures; 102 patients underwent mini-gastric bypass.
875
The operative mortality for the whole series was .17% (.18% after LRYGB). Three patients developed late perforation of the J-J anastomosis at 7, 9, and 18 weeks, respectively, after LRYGB with an antecolic Roux limb. Therefore the incidence of J-J anastomotic perforation in our series of 1652 LRYGB was .18%. Table 1 describes the patients’ demographic details and body mass index (BMI) at time of LRYGB, co-morbidities, and drug history. Table 2 lists the interval between LRYGB, presentation with perforation, a brief description of its management, and outcome. Patient I A 25-year-old morbidly obese woman with a BMI of 56.3 kg/m2 underwent a LRYGB with a hand-sewn J-J anastomosis, made an uneventful recovery, and was discharged on the next postoperative day. She was reviewed at 6 weeks and had an uneventful course with 39 kg weight loss and BMI reduced to 42.2 kg/m2. She then underwent an uneventful laparoscopic cholecystectomy 16 weeks postLRYGB at another hospital. Two weeks later, she presented to a nonbariatric surgeon at another hospital with acute abdominal pain, and a computed tomography (CT) scan with oral Gastrografin found a gastrointestinal perforation. She underwent laparotomy, excision of a perforated J-J anastomosis, and reanastomosis with reinforcement using an omental patch. She spent 7 days in the intensive care unit and 3 weeks on the ward. She developed wound infection that was treated with regular dressing and made remarkable recovery. She was followed up with for 6 months postoperatively and continued to do well. Patient II A 44-year-old lady with a BMI of 45 kg/m2 underwent a LRYGB with a hand-sewn J-J anastomosis, made an
Table 1 Details of patients presenting with perforation at jejuno-jejunal anastomosis post-LRYGB EWL No. Age at Sex BMI (kg/m2) (%) LRYGB (yr) PrePreperforation LRYGB
Co-morbidities
1
25
F
56.3
42.2
27.8
2
44
F
50.4
45
6.9
Asthma, depression, gastrooesophageal Negative reflux disease, vertebral disc disease Hypertension, polycystic ovary Negative syndrome
3
47
F
52
48
7.2
Potential risk factors for ulcer
J-J anastomosis
H. pylori Others status
Hypertension, osteoarthritis, osteoporosis, epilepsy, obstructive sleep apnea, depression
Nonsmoker, not taking PPI or Hand-sewn H2 blocker, recent surgery Nonsmoker; not taking PPI or Hand-sewn H2 blocker; aspirin, NSAID as needed; stress Not done Nonsmoker, NSAID Hand-sewn
BMI ¼ body mass index; EWL ¼ excess weight loss; J-J anastomosis ¼ jejuno-jejunal anastomosis; LRYGB ¼ laparoscopic Roux-en-Y gastric bypass; PPI ¼ proton pump inhibitor.
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R. Kalaiselvan et al. / Surgery for Obesity and Related Diseases 9 (2013) 874–878
Table 2 Operative management and outcomes of patients with perforation at jejuno-jejunal anastomosis No. Interval between Investigation LRYGB and perforation (wk)
Operative findings
Procedure
1
18
CT: perforation
Laparotomy: J-J perforation
2
7
CT: leak at J-J
Laparotomy: J-J perforation
3
9
CT: free fluid and Laparoscopy: enteric J-J perforation contents, 3-mm posterior J-J anastomotic perforation with clean margins
33 Excision of a perforated J-J anastomosis, primary anastomosis, omental patch End stoma of J-J anastomosis of 18 bilioenteric limb, loop stoma of Roux limb Restoration of intestinal continuity after 16.5 mo on TPN Catheterization of the 8 perforation to create a controlled fistula
Postoperative Morbidity hospital stay (d)
Mortality/cause of death
Wound infection; Nil chest infection None
Nil
Port site wound infection
Yes, recurrence of perforation
BMI ¼ body mass index; CT ¼ computed tomography; J-J ¼ jejuno-jejunal; LRYGB ¼ laparoscopic Roux-en-Y gastric bypass.
uneventful recovery, and was discharged on the second postoperative day. After 7 weeks of uneventful discharge from the hospital, she sought treatment at her local hospital for acute abdominal pain, signs of peritonism, and rapid deterioration of her clinical state. CT scan with oral Gastrografin showed free fluid in the abdomen and evidence of contrast extravasations into the peritoneal cavity. She underwent emergency laparotomy at her local hospital and was found to have 5-mm posterior perforation of the J-J anastomosis and free enteric contents in the peritoneal cavity. The gastrojejunal anastomosis was intact and no other pathology was detected. The J-J anastomosis was disconnected, the distal end of the bilioenteric limb was brought out as an end-jejunostomy, and the side-enterotomy of the Roux limb (site of the J-J anastomosis) was brought out as a loop jejunostomy. She was then transferred to our unit for further specialist input. She was maintained with intravenous nutrition as well as enteral tube feeding through the loop jejunostomy under the joint care of the intestinal failure unit. She underwent intestinal reconstruction with hand-sewn J-J re-anastomosis after 16.5 months of nutritional rehabilitation. A tube gastrostomy into the excluded stomach was placed. She made a rather slow but uneventful recovery and was discharged from the hospital on the 18th postoperative day with a BMI of 26.9 kg/m2. She remains well at 11 months after her last surgery.
Patient III A 47-year-old woman with a BMI of 52 kg/m2 underwent LRYGB with a hand-sewn J-J anastomosis, made an uneventful recovery, and was discharged on the second postoperative day. She was reviewed by the
multidisciplinary bariatric team in clinic at 6 weeks, had an uneventful course, and lost 6 kg (BMI 50.4 kg/m2). She presented acutely 9 weeks after surgery with sudden severe central abdominal pain and clinical features of peritonitis. CT with oral Gastrografin showed free fluid in the abdomen and evidence of contrast extravasation at the JJ anastomosis. A laparoscopy was carried out by the senior author within 27 hours of onset of symptoms and within 21 hours of admission to hospital, and this showed free enteric contents in the peritoneal cavity. A 3-mm posterior J-J anastomotic defect with clean margins and with no evidence of a localized chronic inflammatory response or abscess was detected and had the appearances of an acute ulcer perforation quite similar to those that rarely occur at the gastrojejunal anastomosis. A thorough peritoneal lavage was carried out. Although we contemplated primary closure of the ulcer, we elected to avoid the risk of failure of healing and percutaneously placed an 8F Foley catheter into the perforation to create a controlled fistula and secured the catheter into the bowel with a purse-string Vicryl 2-0 suture. The intestine at the site of perforation was also secured to the abdominal wall with interrupted Vicryl 2-0 sutures to ensure a short tract between the skin and the site of perforation. Her recovery was uneventful, and she was discharged on the 8th postoperative day on PPI prophylaxis. The Foley catheter was removed 4 weeks after surgery in the office, and at that visit, the patient had attained a BMI of 43.8 kg/m2. She represented 42 days later with septic shock. A CT scan and relaparoscopy showed no evidence of perforation or collection. A repeat CT scan 4 days later once again showed no evidence of a perforation but a small amount of free fluid in the pelvis. Despite intravenous antibiotics and inotropes, the patient died a few hours after the CT scan. However, postmortem examination revealed a perforation at
Jejuno-Jejunal Anastomosis Perforation / Surgery for Obesity and Related Diseases 9 (2013) 874–878
the J-J anastomosis with approximately 2 liters of enteric fluid in the abdomen. The authors can only assume that the reperforation must have reoccurred just before this presentation. Discussion Complications at the site of the J-J anastomosis after LRYGB are recognized and may include postoperative anastomotic leak, staple-line bleeding, and obstruction [4]. Obstruction at the J-J anastomotic site is the most frequently reported late complication [2]. Late perforation at the J-J anastomosis is extremely rare [4,5]. The incidence of J-J anastomotic perforation in our series of 1652 LRYGB was .18%. Goitein et al. [4] described 3 patients with late J-J anastomotic perforation 7–8 weeks after LRYGB, with an incidence of .42% among 717 patients in their series. Gonzalez-Pezzat et al. [5] reported 1 patient who suffered ulcer perforation at the J-J anastomosis complicated with abscess formation 24 weeks after LRYGB. Table 3 summarizes the details of these 4 patients. Many authors have described and attempted to define anastomotic leak [6]. The 30-day cut-off is often used to describe incidence of anastomotic leak, whereas anastomotic perforation can present late. Both surgical complications can present as grade III/IV as per Clavien-Dindo definitions and require operative with or without radiologic intervention. The presentation of J-J perforation is typically that of an acute abdomen with sudden severe abdominal pain. Although features of generalized peritonitis are likely to ensue, it is important to remember that obese patients might not present in the usual manner because of their large size
877
and their diminished physiologic reserve [2]. Fever or abdominal signs of peritonitis might be lacking, and tachycardia (pulse 120 beats per minute or more) has been described as the most reliable physical finding [7]. Goitein et al. [4] managed 2 of their patients laparoscopically and the third by open surgery. Gonzales et al. [5] attempted laparoscopic repair but converted to open procedure because of technical difficulties. The details of those patients are summarized in Table 3. Primary suturing is an option in selected patients, such as in young patients with healthy tissues, early presentation, and no serious comorbidities. The patients in the literature (Table 3) have been managed with interrupted absorbable sutures [4], except 1 for whom resection and reanastomosis was performed [5]. In a large study of 5387 intestinal resections (3501 colectomies and 1886 small bowel resections) in which there were 100 anastomotic leaks, Telem et al. [8] performed proximal diversion of enteric flow in 92% (n ¼ 81) and considered this approach the safest option. Although the exact etiology is unclear, anastomotic ischemia is thought to be the most likely cause for ulcer formation, followed by perforation at a later stage [2]. Potential risk factors such as H. pylori, NSAIDs, smoking, and stress could have led to the perforation in these patients; in our series, 1 patient had undergone laparoscopic cholecystectomy 2 weeks before the perforation, another reported undue emotional stress, and the third patient continued NSAIDs despite advice. Distal obstruction and, thereby, increased intraluminal pressure has been hypothesized to lead to anastomotic weakness and suture degradation [4,5]. This applies to anastomotic leaks rather than delayed perforation. Product literature quotes an absorption profile of 56–70 days for
Table 3 Literature review No. [Ref]
Age (yr)
Sex
PreLRYGB BMI
J-J anastomosis
Interval between LRYGB and perforation (wk)
Investigation
Operative findings and management
Follow-up (mo)
1 [4]
45
F
40
Stapled 60-mm linear, continuous 2-0 absorbable
8
Normal x-ray and water-soluble contrast study
42
2 [4]
44
F
47
Stapled 60-mm linear, continuous 2-0 absorbable
8
X-ray: free air
3 [4]
51
F
48
Stapled 60-mm linear, continuous 2-0 absorbable suture
7
X-ray: free air
4 [5]
24
M
38
Stapler and 3-0 absorbable suture
24
CT: abscess in the left upper abdomen
Pinhole perforation; laparoscopic approach; closed with interrupted absorbable sutures 2-mm perforation; laparoscopic approach; closed with interrupted absorbable sutures Converted because of limited pneumoperitoneum; obstruction caused by phytobezoar, closed with absorbable sutures Converted because of limited pneumoperitoneum and abscess formation; resection of J-J and reanastomosis
BMI ¼ body mass index; CT ¼ computed tomography; J-J ¼ jejuno-jejunal; LRYGB ¼ laparoscopic Roux-en-Y gastric bypass.
20
4
Not mentioned
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R. Kalaiselvan et al. / Surgery for Obesity and Related Diseases 9 (2013) 874–878
coated polyglactin (Vicryl) sutures but the in vivo strength reduces from 75% in 2 weeks to 25% in 4 weeks [9]. Two of our patients presented at 7 and 9 weeks, well within the absorption time of Vicryl sutures. One could argue that these are delayed presentations of anastomotic leaks but leaks would have occurred earlier. Even in a very large series of 1223 patients studied for anastomotic leaks, none presented after 40 days of surgery [10]. Moreover, both of our patients recovered well before they presented with perforation. Although the 3 patients we reported with J-J perforation have had their anastomoses constructed with a hand-sewn technique using absorbable sutures at an incidence of .45% among all hand-sewn anastomoses, this complication is not unique to hand-sewn anastomoses. The 4 patients reported in the literature (Table 3) had in fact had stapled rather than hand-sewn anastomoses. Late presentation favors the perforated ulcer, as intestinal anastomoses are expected to heal within 2–3 weeks of surgery [11]. The 3 patients reported by Goitein et al. [4] presented 430 days after LRYGB, whereas the patient reported by Gonzalez-Pezzat et al. [5] presented 46 months after surgery. Our patients were reviewed in the outpatient department 6 weeks after LRYGB, at which point they were continuing to do well. They presented with acute onset of symptoms at 7, 9, and 18 weeks after LRYGB and had no features of chronic inflammation around the site of perforation to support a possible assumption of a delayed anastomotic leak. The macroscopic picture of the perforation was also in keeping with an acute ulcer perforation with clear margins and nonedematous surrounding bowel tissues. J-J anastomotic ulcer perforation is a serious late complication of LRYGB [12] and calls for prompt intervention. Various laparoscopic and open surgical management strategies have been described, such as temporary tube fistulization of the perforation, oversewing of the perforation with omental patch, and resection of J-J perforation with immediate or delayed reanastomosis. Proximal intestinal diversion has also been adopted in patients who had J-J perforation after intestinal resections. From our experience and literature review, suture closure is appropriate if performed early, and an alternative would be to redo the whole anastomosis. Disconnection of the anastomosis and temporary stomas is appropriate in delayed presentations and very septic and critically ill patients who would not tolerate a reperforation. At this point, we cannot recommend tube fistulization, as it failed to achieve the desired result in our patient. The appropriate management choice will depend on the patient’s physiologic status at the time of presentation and the expertise of the surgeon available.
Conclusion Perforation of the J-J anastomosis is a rare and lifethreatening delayed complication after LRYGB and usually presents within 2–8 months postoperatively. It poses difficulties with diagnosis and management and should be dealt with judiciously.
Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article.
References [1] Lublin M, McCoy M, Waldrep DJ. Perforating marginal ulcers after laparoscopic gastric bypass. Surg Endosc 2006;20:51–4. [2] Livingston EH. Complications of bariatric surgery. Surg Clin North Am 2005;85:853–68. [3] Kalaiselvan R, Exarchos G, Hamza N, Ammori BJ. Incidence of perforated gastrojejunal anastomotic ulcers after laparoscopic gastric bypass for morbid obesity and role of laparoscopy in their management. Surg Obes Relat Dis 2012;8:423–8. [4] Goitein D, Papasavas PK, Gagné DJ, Caushaj PF. Late perforation of the jejuno-jejunal anastomosis after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2005;15:880–2. [5] Gonzalez-Pezzat I, Soto-Perez-de-Celis E, Pantoja-Millam JP. Late perforation and abscess formation at the site of the jejunojejunal anastomosis following laparoscopic Roux-en-Y gastric bypass surgery. Obes Surg 2009;19:661–3. [6] Bruce J, Krukowski ZH, Al-Khairy G, Russell EM, Park KG. Systematic review of the definition and measurement of anastomotic leak after gastrointestinal surgery. Br J Surg 2001;88:1157–68. [7] Buckwalter JA, Herbst CA Jr. Leaks occurring after gastric bariatric operations. Surgery 1988;103:156–60. [8] Telem DA, Sur M, Tabrizian P, et al. Diagnosis of gastrointestinal anastomotic dehiscence after hospital discharge: impact on patient management and outcome. Surgery 2009;147:127–33. [9] Ethicon. [homepage on the Internet]. Ethicon Endo-Surgery, Inc.; c2010–13 [updated 2012 June 12; cited 2011 De 15]. Available from: http://www.ethicon360.com/products/coated-vicryl-plus-antibacterialpolyglactin-910-suture. [10] Hyman N, Manchester TL, MD, Osler T, Burns B, Cataldo PA. Anastomotic leaks after intestinal anastomosis: it’s later than you think. Ann Surg 2007;245:254–8. [11] Hendriks T, Mastboom WJ. Healing of experimental intestinal anastomoses. Parameters for repair. Dis Colon Rectum 1990;33: 891–901. [12] Bramkamp M, Muller MK, Wildi S, Clavien PA, Weber M. Perforated ulcer at the gastrojejunostomy: laparoscopic repair after Roux-en-Y gastric bypass. Obes Surg 2006;16:1545–7.
Original article
Late perforation at the jejuno-jejunal anastomosis after laparoscopic gastric bypass for morbid obesity Ramya Kalaiselvan, M.R.C.S., M.Phil.a, Mahmoud Abu Dakka, M.R.C.S., M.B.Ch.B.b, Basil J. Ammori, M.B.Ch.B., F.R.C.S., M.D.a,b,c,* a Salford Royal Hospital, Manchester, United Kingdom Manchester Royal Infirmary, Manchester, United Kingdom c The University of Manchester, Manchester, United Kingdom Received December 27, 2012; accepted April 24, 2013 b
Abstract
Background: Although marginal ulceration and perforation at the gastrojejunal anastomosis is an established, albeit rare, risk after laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity, little is known about the risk of late perforation at the jejuno-jejunal (J-J) anastomosis. The objective of this study was to identify the incidence of J-J perforation and describe management options and sequelae. Methods: This is a retrospective review of the database of all patients who underwent LRYGB. The results are presented as mean (range) where appropriate. Results: Between April 2002 and April 2012, 1652 patients underwent LRYGB (1577 primary and 75 revision procedures). The operative mortality was .18%. Three patients developed late perforation of the J-J anastomosis (.18%) at 7, 9, and 18 weeks, respectively. Two patients were managed with resection and reanastomosis of the perforation by laparotomy, and a third patient was managed laparoscopically with peritoneal lavage and transcutaneous tube jejunostomy of the perforation. All patients recovered well postoperatively. However, the third patient represented 42 days later with sepsis and died secondary to recurrent J-J ulcer perforation. Conclusion: Perforation of the J-J anastomosis is a rare and life-threatening delayed complication after LRYGB and usually presents within 2–8 months postoperatively. It poses difficulties with diagnosis and management and should be dealt with judiciously. (Surg Obes Relat Dis 2013;9:874–878.) r 2013 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Laparoscopic; Jejuno-jejunal perforation; Marginal ulcer; Gastric bypass; Perforation; Bariatric surgery
The prevalence of obesity has been increasing [1] leading to an increase in the number of bariatric procedures performed worldwide and in their associated complications.
Presented at the International Federation for the Surgery of Obesity & Metabolic Disorders, 2012, India and awarded “Best Oral Presentation.” * Correspondence: Basil J. Ammori, M.D, The University of Manchester, Salford Royal NHS Foundation Trust, Stott Lane, Salford, Manchester, M6 8HD, United Kingdom. E-mail: [email protected]
Laparoscopic Roux-en-Y gastric bypass (LRYGB) is, by far, the most common antiobesity procedure performed [2]. Although marginal ulceration and perforation at the gastrojejunal anastomosis is an established [3], albeit rare, risk after LRYGB for morbid obesity, little is known about the risk of late perforation at the jejuno-jejunal (J-J) anastomosis. This report aims to evaluate the incidence of late J-J anastomotic perforation after LRYGB, identify potential risk factors, and describe the management options and their outcomes.
1550-7289/13/$ – see front matter r 2013 American Society for Metabolic and Bariatric Surgery. All rights reserved. http://dx.doi.org/10.1016/j.soard.2013.04.020
Jejuno-Jejunal Anastomosis Perforation / Surgery for Obesity and Related Diseases 9 (2013) 874–878
Methods Patients A retrospective review of the electronic records of patients who underwent LRYGB by the senior author or under his direct supervision between April 2002 and April 2012 was carried out. A detailed analysis of the patients who developed perforation of J-J anastomosis was conducted. Details of patients’ demographic characteristics, past history (including relevant data from the primary bariatric surgery), and co-morbidities, as well as mode of presentation of perforation, management, and outcomes were established. As this retrospective study did not influence patient management, it did not warrant ethics committee approval. Operative technique of J-J anastomosis Of the 1652 patients, the initial 982 J-J anastomoses were stapled, and the subsequent 670 J-J anastomoses were completely hand-sewn using 2 layers of Vicryl 3-0 (Johnson & Johnson Int., St. Stevens-Woluws, Belgium) posteriorly and one layer anteriorly in a continuous fashion. Postoperative care after management of perforation of the J-J anastomosis. Patients received intravenous antibiotic therapy postoperatively. Any ulcerogenic drugs were discontinued. Investigations were carried out to detect the presence of Helicobacter pylori. Patients were advised against smoking and the use of alcohol, and proton pump inhibitor (PPI) therapy was resumed if patients had discontinued it after the LRYGB. Results Between April 2002 and April 2012, 1754 patients underwent LRYGB. LRYGB was performed in 1652 patients, of which 1577 were primary and 75 were revision procedures; 102 patients underwent mini-gastric bypass.
875
The operative mortality for the whole series was .17% (.18% after LRYGB). Three patients developed late perforation of the J-J anastomosis at 7, 9, and 18 weeks, respectively, after LRYGB with an antecolic Roux limb. Therefore the incidence of J-J anastomotic perforation in our series of 1652 LRYGB was .18%. Table 1 describes the patients’ demographic details and body mass index (BMI) at time of LRYGB, co-morbidities, and drug history. Table 2 lists the interval between LRYGB, presentation with perforation, a brief description of its management, and outcome. Patient I A 25-year-old morbidly obese woman with a BMI of 56.3 kg/m2 underwent a LRYGB with a hand-sewn J-J anastomosis, made an uneventful recovery, and was discharged on the next postoperative day. She was reviewed at 6 weeks and had an uneventful course with 39 kg weight loss and BMI reduced to 42.2 kg/m2. She then underwent an uneventful laparoscopic cholecystectomy 16 weeks postLRYGB at another hospital. Two weeks later, she presented to a nonbariatric surgeon at another hospital with acute abdominal pain, and a computed tomography (CT) scan with oral Gastrografin found a gastrointestinal perforation. She underwent laparotomy, excision of a perforated J-J anastomosis, and reanastomosis with reinforcement using an omental patch. She spent 7 days in the intensive care unit and 3 weeks on the ward. She developed wound infection that was treated with regular dressing and made remarkable recovery. She was followed up with for 6 months postoperatively and continued to do well. Patient II A 44-year-old lady with a BMI of 45 kg/m2 underwent a LRYGB with a hand-sewn J-J anastomosis, made an
Table 1 Details of patients presenting with perforation at jejuno-jejunal anastomosis post-LRYGB EWL No. Age at Sex BMI (kg/m2) (%) LRYGB (yr) PrePreperforation LRYGB
Co-morbidities
1
25
F
56.3
42.2
27.8
2
44
F
50.4
45
6.9
Asthma, depression, gastrooesophageal Negative reflux disease, vertebral disc disease Hypertension, polycystic ovary Negative syndrome
3
47
F
52
48
7.2
Potential risk factors for ulcer
J-J anastomosis
H. pylori Others status
Hypertension, osteoarthritis, osteoporosis, epilepsy, obstructive sleep apnea, depression
Nonsmoker, not taking PPI or Hand-sewn H2 blocker, recent surgery Nonsmoker; not taking PPI or Hand-sewn H2 blocker; aspirin, NSAID as needed; stress Not done Nonsmoker, NSAID Hand-sewn
BMI ¼ body mass index; EWL ¼ excess weight loss; J-J anastomosis ¼ jejuno-jejunal anastomosis; LRYGB ¼ laparoscopic Roux-en-Y gastric bypass; PPI ¼ proton pump inhibitor.
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Table 2 Operative management and outcomes of patients with perforation at jejuno-jejunal anastomosis No. Interval between Investigation LRYGB and perforation (wk)
Operative findings
Procedure
1
18
CT: perforation
Laparotomy: J-J perforation
2
7
CT: leak at J-J
Laparotomy: J-J perforation
3
9
CT: free fluid and Laparoscopy: enteric J-J perforation contents, 3-mm posterior J-J anastomotic perforation with clean margins
33 Excision of a perforated J-J anastomosis, primary anastomosis, omental patch End stoma of J-J anastomosis of 18 bilioenteric limb, loop stoma of Roux limb Restoration of intestinal continuity after 16.5 mo on TPN Catheterization of the 8 perforation to create a controlled fistula
Postoperative Morbidity hospital stay (d)
Mortality/cause of death
Wound infection; Nil chest infection None
Nil
Port site wound infection
Yes, recurrence of perforation
BMI ¼ body mass index; CT ¼ computed tomography; J-J ¼ jejuno-jejunal; LRYGB ¼ laparoscopic Roux-en-Y gastric bypass.
uneventful recovery, and was discharged on the second postoperative day. After 7 weeks of uneventful discharge from the hospital, she sought treatment at her local hospital for acute abdominal pain, signs of peritonism, and rapid deterioration of her clinical state. CT scan with oral Gastrografin showed free fluid in the abdomen and evidence of contrast extravasations into the peritoneal cavity. She underwent emergency laparotomy at her local hospital and was found to have 5-mm posterior perforation of the J-J anastomosis and free enteric contents in the peritoneal cavity. The gastrojejunal anastomosis was intact and no other pathology was detected. The J-J anastomosis was disconnected, the distal end of the bilioenteric limb was brought out as an end-jejunostomy, and the side-enterotomy of the Roux limb (site of the J-J anastomosis) was brought out as a loop jejunostomy. She was then transferred to our unit for further specialist input. She was maintained with intravenous nutrition as well as enteral tube feeding through the loop jejunostomy under the joint care of the intestinal failure unit. She underwent intestinal reconstruction with hand-sewn J-J re-anastomosis after 16.5 months of nutritional rehabilitation. A tube gastrostomy into the excluded stomach was placed. She made a rather slow but uneventful recovery and was discharged from the hospital on the 18th postoperative day with a BMI of 26.9 kg/m2. She remains well at 11 months after her last surgery.
Patient III A 47-year-old woman with a BMI of 52 kg/m2 underwent LRYGB with a hand-sewn J-J anastomosis, made an uneventful recovery, and was discharged on the second postoperative day. She was reviewed by the
multidisciplinary bariatric team in clinic at 6 weeks, had an uneventful course, and lost 6 kg (BMI 50.4 kg/m2). She presented acutely 9 weeks after surgery with sudden severe central abdominal pain and clinical features of peritonitis. CT with oral Gastrografin showed free fluid in the abdomen and evidence of contrast extravasation at the JJ anastomosis. A laparoscopy was carried out by the senior author within 27 hours of onset of symptoms and within 21 hours of admission to hospital, and this showed free enteric contents in the peritoneal cavity. A 3-mm posterior J-J anastomotic defect with clean margins and with no evidence of a localized chronic inflammatory response or abscess was detected and had the appearances of an acute ulcer perforation quite similar to those that rarely occur at the gastrojejunal anastomosis. A thorough peritoneal lavage was carried out. Although we contemplated primary closure of the ulcer, we elected to avoid the risk of failure of healing and percutaneously placed an 8F Foley catheter into the perforation to create a controlled fistula and secured the catheter into the bowel with a purse-string Vicryl 2-0 suture. The intestine at the site of perforation was also secured to the abdominal wall with interrupted Vicryl 2-0 sutures to ensure a short tract between the skin and the site of perforation. Her recovery was uneventful, and she was discharged on the 8th postoperative day on PPI prophylaxis. The Foley catheter was removed 4 weeks after surgery in the office, and at that visit, the patient had attained a BMI of 43.8 kg/m2. She represented 42 days later with septic shock. A CT scan and relaparoscopy showed no evidence of perforation or collection. A repeat CT scan 4 days later once again showed no evidence of a perforation but a small amount of free fluid in the pelvis. Despite intravenous antibiotics and inotropes, the patient died a few hours after the CT scan. However, postmortem examination revealed a perforation at
Jejuno-Jejunal Anastomosis Perforation / Surgery for Obesity and Related Diseases 9 (2013) 874–878
the J-J anastomosis with approximately 2 liters of enteric fluid in the abdomen. The authors can only assume that the reperforation must have reoccurred just before this presentation. Discussion Complications at the site of the J-J anastomosis after LRYGB are recognized and may include postoperative anastomotic leak, staple-line bleeding, and obstruction [4]. Obstruction at the J-J anastomotic site is the most frequently reported late complication [2]. Late perforation at the J-J anastomosis is extremely rare [4,5]. The incidence of J-J anastomotic perforation in our series of 1652 LRYGB was .18%. Goitein et al. [4] described 3 patients with late J-J anastomotic perforation 7–8 weeks after LRYGB, with an incidence of .42% among 717 patients in their series. Gonzalez-Pezzat et al. [5] reported 1 patient who suffered ulcer perforation at the J-J anastomosis complicated with abscess formation 24 weeks after LRYGB. Table 3 summarizes the details of these 4 patients. Many authors have described and attempted to define anastomotic leak [6]. The 30-day cut-off is often used to describe incidence of anastomotic leak, whereas anastomotic perforation can present late. Both surgical complications can present as grade III/IV as per Clavien-Dindo definitions and require operative with or without radiologic intervention. The presentation of J-J perforation is typically that of an acute abdomen with sudden severe abdominal pain. Although features of generalized peritonitis are likely to ensue, it is important to remember that obese patients might not present in the usual manner because of their large size
877
and their diminished physiologic reserve [2]. Fever or abdominal signs of peritonitis might be lacking, and tachycardia (pulse 120 beats per minute or more) has been described as the most reliable physical finding [7]. Goitein et al. [4] managed 2 of their patients laparoscopically and the third by open surgery. Gonzales et al. [5] attempted laparoscopic repair but converted to open procedure because of technical difficulties. The details of those patients are summarized in Table 3. Primary suturing is an option in selected patients, such as in young patients with healthy tissues, early presentation, and no serious comorbidities. The patients in the literature (Table 3) have been managed with interrupted absorbable sutures [4], except 1 for whom resection and reanastomosis was performed [5]. In a large study of 5387 intestinal resections (3501 colectomies and 1886 small bowel resections) in which there were 100 anastomotic leaks, Telem et al. [8] performed proximal diversion of enteric flow in 92% (n ¼ 81) and considered this approach the safest option. Although the exact etiology is unclear, anastomotic ischemia is thought to be the most likely cause for ulcer formation, followed by perforation at a later stage [2]. Potential risk factors such as H. pylori, NSAIDs, smoking, and stress could have led to the perforation in these patients; in our series, 1 patient had undergone laparoscopic cholecystectomy 2 weeks before the perforation, another reported undue emotional stress, and the third patient continued NSAIDs despite advice. Distal obstruction and, thereby, increased intraluminal pressure has been hypothesized to lead to anastomotic weakness and suture degradation [4,5]. This applies to anastomotic leaks rather than delayed perforation. Product literature quotes an absorption profile of 56–70 days for
Table 3 Literature review No. [Ref]
Age (yr)
Sex
PreLRYGB BMI
J-J anastomosis
Interval between LRYGB and perforation (wk)
Investigation
Operative findings and management
Follow-up (mo)
1 [4]
45
F
40
Stapled 60-mm linear, continuous 2-0 absorbable
8
Normal x-ray and water-soluble contrast study
42
2 [4]
44
F
47
Stapled 60-mm linear, continuous 2-0 absorbable
8
X-ray: free air
3 [4]
51
F
48
Stapled 60-mm linear, continuous 2-0 absorbable suture
7
X-ray: free air
4 [5]
24
M
38
Stapler and 3-0 absorbable suture
24
CT: abscess in the left upper abdomen
Pinhole perforation; laparoscopic approach; closed with interrupted absorbable sutures 2-mm perforation; laparoscopic approach; closed with interrupted absorbable sutures Converted because of limited pneumoperitoneum; obstruction caused by phytobezoar, closed with absorbable sutures Converted because of limited pneumoperitoneum and abscess formation; resection of J-J and reanastomosis
BMI ¼ body mass index; CT ¼ computed tomography; J-J ¼ jejuno-jejunal; LRYGB ¼ laparoscopic Roux-en-Y gastric bypass.
20
4
Not mentioned
878
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coated polyglactin (Vicryl) sutures but the in vivo strength reduces from 75% in 2 weeks to 25% in 4 weeks [9]. Two of our patients presented at 7 and 9 weeks, well within the absorption time of Vicryl sutures. One could argue that these are delayed presentations of anastomotic leaks but leaks would have occurred earlier. Even in a very large series of 1223 patients studied for anastomotic leaks, none presented after 40 days of surgery [10]. Moreover, both of our patients recovered well before they presented with perforation. Although the 3 patients we reported with J-J perforation have had their anastomoses constructed with a hand-sewn technique using absorbable sutures at an incidence of .45% among all hand-sewn anastomoses, this complication is not unique to hand-sewn anastomoses. The 4 patients reported in the literature (Table 3) had in fact had stapled rather than hand-sewn anastomoses. Late presentation favors the perforated ulcer, as intestinal anastomoses are expected to heal within 2–3 weeks of surgery [11]. The 3 patients reported by Goitein et al. [4] presented 430 days after LRYGB, whereas the patient reported by Gonzalez-Pezzat et al. [5] presented 46 months after surgery. Our patients were reviewed in the outpatient department 6 weeks after LRYGB, at which point they were continuing to do well. They presented with acute onset of symptoms at 7, 9, and 18 weeks after LRYGB and had no features of chronic inflammation around the site of perforation to support a possible assumption of a delayed anastomotic leak. The macroscopic picture of the perforation was also in keeping with an acute ulcer perforation with clear margins and nonedematous surrounding bowel tissues. J-J anastomotic ulcer perforation is a serious late complication of LRYGB [12] and calls for prompt intervention. Various laparoscopic and open surgical management strategies have been described, such as temporary tube fistulization of the perforation, oversewing of the perforation with omental patch, and resection of J-J perforation with immediate or delayed reanastomosis. Proximal intestinal diversion has also been adopted in patients who had J-J perforation after intestinal resections. From our experience and literature review, suture closure is appropriate if performed early, and an alternative would be to redo the whole anastomosis. Disconnection of the anastomosis and temporary stomas is appropriate in delayed presentations and very septic and critically ill patients who would not tolerate a reperforation. At this point, we cannot recommend tube fistulization, as it failed to achieve the desired result in our patient. The appropriate management choice will depend on the patient’s physiologic status at the time of presentation and the expertise of the surgeon available.
Conclusion Perforation of the J-J anastomosis is a rare and lifethreatening delayed complication after LRYGB and usually presents within 2–8 months postoperatively. It poses difficulties with diagnosis and management and should be dealt with judiciously.
Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article.
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