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Image of the Month—Diagnosis
Arch Surg. 2003;138:456.
Answer: Biliopancreatic Limb Obstruction Resulting in Gastric Staple Line Dehiscence
Figure 1. Upper gastrointestinal series with oral contrast. The findings are normal, with no evidence of obstruction or extravasation of contrast.
Figure 2. Computed tomographic scan of the abdomen with oral and intravenous contrast. Free fluid is shown in the abdomen. There is no extravasation of contrast.
Laparoscopic reexploration of this patient revealed bilious free fluid in the abdomen. Examination of the gastrojejunostomy and enteroenterostomy revealed no leakage at these sites. However, the biliopancreatic limb was distended to twice the diameter of the alimentary limb, and fluid could not be passed manually from the biliopancreatic limb to the alimentary limb. The gastric remnant staple line was also found to be disrupted, apparently resulting from back-up pressure secondary to obstruction of the biliopancreatic limb. A new, more proximal side-to-side anastomosis between the gastrojejunal and biliopancreatic limbs was created after laparotomy to relieve the obstruction. The patient recovered without further complications and was discharged on postoperative day 6. She has done well since her operation in April 2002, losing 27.2 kg in the first 3 months.
In recent years, laparoscopic RYGBP has proven to be an increasingly popular, safe, and effective treatment for morbidly obese patients. However, one of the most-feared postoperative complications is anastomotic dehiscence, which occurs in approximately 3% to 5% of patients.1 On upper gastrointestinal series or computed tomographic scan, extravasation of contrast may be seen when there is leakage at the gastrojejunostomy or at the enteroenterostomy. On the other hand, leakage is far more difficult to detect when it occurs at the gastric remnant since it is not in continuity with the alimentary tract and thus does not fill with contrast during these studies.
A computed tomographic scan obtained prior to gastric remnant staple line disruption may reveal a definitive diagnosis of biliopancreatic limb obstruction when the dilated biliopancreatic limb and fluid-filled gastric remnant are visualized. However, in cases when the staple line has already disrupted (resulting in decompression of the biliopancreatic limb), free fluid in the abdomen may be the only subtle radiologic sign, and the diagnosis may be elusive. Rapid surgical intervention is imperative before peritonitis ensues.
In conclusion, this case demonstrates a rare but potentially fatal pitfall in the postoperative assessment of the RYGBP patient. Therefore, rather than relying on radiologic studies, the physician's clinical suspicion must be attuned to the signs and symptoms of anastomotic dehiscence, which may include tachycardia, hypotension, and/or oliguria.2 Persistent postoperative tachycardia and epigastric pain warrant laparoscopy or laparotomy to rule out an anastomotic dehiscence. As RYGBP is rapidly becoming the surgical gold standard of treatment for morbid obesity, all physicians should learn to recognize the signs and symptoms of this potentially fatal complication.
AUTHOR INFORMATION
Corresponding author: Arif Ahmad, MD, Department of Surgery, Stony Brook University Hospital, Health Sciences Center, Level 18, Room 60, Stony Brook, NY 11794-8191 (e-mail: ahmad{at}surg.som.sunysb.edu).
REFERENCES
1. Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic gastric bypass, Roux-en-Y: preliminary report of five cases. Obes Surg. 1994;4:353-357.
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2. Jones KB. Biliopancreatic limb obstruction in gastric bypass at or proximal to the jejunojejunostomy: a potentially deadly, catastrophic event. Obes Surg. 1996;6:485-493.
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SECTION EDITOR: GRACE S. ROZYCKI, MD
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