Surgical management of obstructing clot at the jejunojejunostomy after gastric bypass: a single center experience and literature review

Abstract Background Roux-en-Y gastric bypass is a proven treatment for morbid obesity and its sequelae. Gastric bypass has a safe risk profile, but post-operative complications can be seen. We report on 10 cases of post-operative bleeding causing an obstructing clot at the jejunojejunostomy (JJ) occurring over a nine-year period. Objectives The aim was to document presenting symptoms of obstructing clots at the JJ and to suggest a treatment approach to minimize complications. Setting University Hospital, United States Methods The local Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was queried for all patients undergoing re-operation after Roux-en-Y gastric bypass, from July 2009 until December 2019. All patients who were found to have post-op bleeding causing an obstructing clot at the JJ were selected for retrospective chart review. Results The most common presenting symptoms were Hematocrit drop (10/10), nausea (9/10), abdominal pain (7/10), and hematemesis (4/10). There were 12 reoperations in the 10 patients, 10 of which were completed laparoscopically. Infectious complications were the most frequent morbidity in our patients; four patients developed abscesses. In all of these, the operative notes described gross spillage into the peritoneal cavity. In later cases, the remnant stomach was decompressed before re-operation, reducing spillage. Conclusions Despite the low rate of obstructing clots at the JJ, without rapid recognition and re-operation, there is a risk for serious complications. Typical presenting symptoms include nausea and abdominal pain, which help differentiate it from other causes of decreased hematocrit. Diagnosis is commonly made with computerized tomographic (CT) scan. Decompression of a dilated remnant stomach before addressing the clot can prevent intraperitoneal spillage and subsequent abscess formation. Enterotomy creation and removal of clot is recommended, without fear of continued bleeding.