Bowel Obstruction after Open and Laparoscopic Gastric Bypass Surgery
Bowel Obstruction after Open and Laparoscopic Gastric Bypass Surgery
Abstract & Commentary
By Helen Sohn, MD, Assistant Professor of Surgery, Department of Surgery, USC. Dr. Sohn reports no financial relationship relevant to this field of study.
This article was peer reviewed by Peter Crookes, MD, FACS
Synopsis: An unanticipated high incidence of bowel obstruction was found after laparoscopic gastric bypass surgery. An open approach may be a reasonable option for management of recurrent episodes of bowel obstruction after laparoscopy.
Source: Capella RF, et al. Bowel obstruction after open and laparoscopic gastric bypass surgery. JAm Coll Surg. 2006;203:328-335.
Bowel obstruction is increasingly recognized as an important complication after gastric bypass. This study analyzed late bowel obstruction after open and laparoscopic gastric bypass surgery. The medical records of 1378 patients who had proximal gastric bypass during the years 2002 and 2003 were evaluated at a large bariatric center for readmission with bowel obstruction requiring operations. In the study group, 697 patients underwent a laparoscopic approach and 735 had an open approach to gastric bypass. Patients had a minimum follow-up of 18 months.
In the laparoscopic group, 68 of the 697 patients were readmitted for bowel obstruction requiring operations, for an incidence of 9.7%. There were 14 additional recurrent obstructions, for a total of 82 operations. Of the 68 patients requiring reoperations, 8 (4.4%) required bowel resection and 8 (11.7%) had conversion to an open approach. Bowel resections were performed in 2 of the 3 patients with a second episode of bowel obstruction. The average time intervals between the primary operation in 2002 and 2003 and the first episode of obstruction were 511 and 385 days, respectively. There were no readmissions requiring operations for late bowel obstruction in the open gastric bypass group.
We found an unanticipated high incidence of bowel obstruction after laparoscopic gastric bypass surgery. There were no hospital admissions for bowel obstruction requiring operations in the open gastric bypass group. Lack of adhesions and the resulting free displacement of small bowel after laparoscopy appear to be the cause of this complication. Open gastric bypass surgery produces thin, diffuse upper abdominal adhesions that may then stabilize the bowel and prevent internal hernias and bowel obstruction. An open approach may be a reasonable option for management of recurrent episodes of bowel obstruction after laparoscopy. (J Am Coll Surg. 2006;203:328-335).
This is a retrospective review of all patients who underwent gastric bypass surgery for morbid obesity between 2002 and 2003 at a single institution to identify readmissions for bowel obstruction requiring operative therapy. This was done to study the incidence, timing, and presentation of operative bowel obstruction following open and laparoscopic gastric bypass surgery in order to better understand this common complication.
The surgery performed was Roux-en-Y gastric bypass, where the distal jejunal limb was brought up retrocolic, creating mesocolic, mesenteric, and Petersen defects. The laparoscopic surgeon chose to close the mesocolic defect alone, and the open surgeon chose to close the mesenteric defect alone.
Among the patients who underwent laparoscopic surgery, 9.7% were readmitted with bowel obstruction requiring operative therapy. Findings at operations were internal hernia (60%), adhesive band (21%), and incisional hernia (1.4%). Time interval between the primary operation and the obstruction ranged from 6 to 1180 days. There were no readmissions for operative bowel obstruction in the open group.
Commentary
This study suggests that in this series of gastric bypass patients, bowel obstruction requiring operative therapy occurs more frequently after laparoscopic surgery compared to open surgery. Capella and colleagues speculate that this is due to lack of adhesions formed during laparoscopic surgery, allowing free displacement of small bowel after surgery.
If what they say is true, it seems that what is considered a benefit of laparoscopic surgery, lack of adhesion formation, has an adverse affect, in this case, by promoting herniation of bowel through defects created as part of the operation. These defects that are usually closed off by adhesions in open cases stay open even with suture closure in laparoscopic cases. And bowel loops that normally adhese together loosely in open cases move freely after laparoscopic cases. Another contributing factor may be that the defects get larger as patients lose weight as a consequence of their operation, and this may promote easier herniation of bowel.
When considering all the possible explanations for the result of this study, we must take into consideration the limitation of this study. This is not a prospective study. Only patients that were admitted to the same institution with bowel obstruction requiring operative therapy were included in this study. There is no way of knowing how many more patients with bowel obstruction in either laparoscopic or open group presented to another institution.
Bowel obstruction after any abdominal operation is unavoidable. Adhesions are the main reason for development of bowel obstruction in most cases, but it seems that in this special growing population receiving laparoscopic gastric bypass, it is the opposite: the lack of adhesions coupled with iatrogenic internal defects may be more frequently associated with bowel obstruction, and more of these patients may need operative therapy. Does this mean that laparoscopic gastric bypass should be avoided? I think this is a small consequence compared to the numerous benefits afforded by laparoscopic surgery in these high-risk patients. As noted by Capella et al, this study raises more questions than there are answers for, and additional studies are necessary to continue to strive towards minimizing operative morbidities.
An unanticipated high incidence of bowel obstruction was found after laparoscopic gastric bypass surgery. An open approach may be a reasonable option for management of recurrent episodes of bowel obstruction after laparoscopy.Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.