Case Report
Ileal Bezoar after Roux-en-Y Gastric Bypass for Morbid Obesity: A Case Report
Dantas de Campos Martins MV*, Pantaleão Falcão JL, Cavaliere MB and Nunes LC
General Surgery Department, Barra D'or Hospital, Brazil
*Corresponding author: Marcus Vinicius Dantas de Campos Martins, General Surgery Department, Barra D'or Hospital, Rio de Janeiro, Brazil
Published: 31 May, 2016
Cite this article as: Dantas de Campos Martins MV,
Pantaleão Falcão JL, Cavaliere MB,
Nunes LC. Ileal Bezoar after Roux-en-Y
Gastric Bypass for Morbid Obesity: A
Case Report. Ann Clin Case Rep. 2016;
1: 1018.
Abstract
Bowel obstruction is a known complication of Roux-en-Y gastric bypass. Bezoar is an unsual cause. We report a case of a 53 year-old female who developed small bowel obstruction secondary to a phytobezoar at the distal ileum one year after the patient underwent a Roux-en-Y gastric bypass for morbid obesity. A computed tomography scan was a very useful method for making the diagnosis. The patient had successful minimally invasive surgical treatment.
Keywords: Bezoars; Intestinal obstruction; Bariatric surgery
Introduction
Bariatric Surgery is the most effective method for achieving persistent weight loss and reversing
obesity-related co morbidities in severe obese patients. Many bariatric procedures are available for
management of these high-risk patients and Roux-en-Y gastric (RYGB) by-pass is one of the most
commonly performed. In RYGB, the upper part of the stomach is transected; thus, a very small
gastric pouch is created. This gastric pouch is anastomosed to a Roux-en-Y jejunal limb, bypassing
the remaining stomach, duodenum and a small proximal jejunal segment. As a result, the RYGB
limits food intake and induces some nutrient malabsortion [1].
With the increasing frequency of bariatric surgery, we expect to be called upon more often to
deal with the complications of these procedures. Small bowel obstruction (SBO) is one of them. The
incidence of small bowel obstructions after RYGB ranges from 1% to 8% [2]. Phytobezoar is a rare
cause of SBO after RYGB but are the most common foreign bodies of the gastrointestinal tract [3].
More than one-half of the patients who develop phytobezoars had previous gastric surgery. Some
gastric and jejunal bezoars have already be reported in the literature [2,4,5] but a distal ileal bezoar
has not been described. We aimed to offer a rare case of intestinal obstruction caused by bezoar (in
terminal ileum), after Roux-en-Y gastric bypass surgery.
Case Report
A 53 year-old female presented with new onset of abdominal pain, nausea and vomiting for
the last 24 hours. One year ago, she was submited to a laparoscopic Roux-en-Y gastric bypass for
morbid obesity (BMI of 41Kg/m2). Her BMI decreased to 24Kg/m2 with a 100% excess weight loss.
Her vital signs were within normal limits and the laboratory investigations on admission were unremarkable. An abdominal computed tomography (CT) scan showed dilatation of the small
bowel with obstruction at distal ileum due to a intraluminal mottled mass (Figure 1). When her
alimentary history was questioned in detail, she declared that she ate some oranges one day before.
She was taken to the operating room for laparoscopic exploration. A solid obstructing
intraluminal mass was found close to the ileocecal valve suggesting a bezoar (Figure 2). In order
to avoid an enterotomy we decided to perform a 3 to 4 cm abdominal incision on the right lower
abdominal wall. We have introduced two fingers into the abdominal cavity and pushed the bezoar
through the ileocecal valve into the cecum.
The patint had an uneventful recovery. She tolerated liquids on postoperative day one and was
discharged home on postoperative day two. She went to the office nine days after surgery in very
good conditions.
Figure 1
Figure 2
Discussion
Bezoars are retained concretions of indigestible materials in the gastrointestinal tract. Bezoars
are typically grouped into 1 of 4 types according to their composition: phytobezoars (which are
composed of indigestible food particles that are found in vegetable or
fruit fibers), trichobezoars (which are composed of a conglomeration
of hair and food particles), lactobezoars (which are composed of milk
protein) and pharmacobezoars (which are concretions of various
medications) [6] Phytobezoars are the most common type of bezoars,
accounting for appoximately 40% of all reported cases.
The formation of bezoars can occur in individuals with normal
gastrointestinal (GI) physiology and anatomy. However, patients
with altered GI anatomy and/or motility are at an increased risk
for the development of bezoars. A total of 71 to 83% of bezoar cases
has a history of gastric surgery [4], including bariatric surgery. Poor
mastication and the passage of large-diameter solid matter from
the stomach into the small intestine can predispose to an intestinal
phytobezoars [5]. In addition, dietary factors including an excessive
consumption of oranges, persimmons and some vegetables may be
the cause of a bezoar formation [7].
The incidence of SBO after RYGB ranges from 1% to 8% [2].
Internal hernias are the most common cause followed by adhesions.
Intussusceptions and bezoars are rare etiologies cause <1% of SBO
[8]. Some articles suggest CT imaging is a useful method for making
the diagnosis of bezoar associated with small-bowel obstruction [9].
An intraluminal mass of a mottled appearance is usually seen at the transition zone between dilated and collapsed small-bowel loops. This
was the CT finding in our patient.
Gastric bezoars can be usually managed without surgery. Lavage
or dissolution, endoscopic fragmentation and/or retrieval are the
main techniques. Surgical removal should be considered in patients
who one or more of these methods have failed. Small-bowel bezoars
are usually not amenable to conservative or endoscopic treatments
and require a surgical intervention. Laparotomy is the traditional
approach but laparoscopic approach can be considered. Various
studies have reported laparoscopic management of intestinal
obstructions with the improvement of laparoscopic skills [10].
However, gentle manipulation of the distended intestine and open
technique to place the first trocar are some of the recommendations
to avoid damage to the distended bowel.
Enterotomy and bezoar removal is usually the choice. However,
fragmentation and flushing into the cecum can be alternative options.
In order to avoid peritoneal contamination and due to the position of
the bezoar close to the cecal valve, we have decided to push the bezoar
through the ileocecal valve into the cecum with good result.
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