title: Acute, complete proximal small bowel obstruction after laparoscopic gastric bypass due to intraluminal blood clot formation.
abstract: BACKGROUND
  To report the presentation and management of early complete proximal small bowel obstruction from intraluminal clot after laparoscopic Roux-en-Y gastric bypass.
  
  
  METHODS
  We performed a retrospective chart review of 5 female patients who developed small bowel obstruction at the jejunojejunostomy (JJ) secondary to intraluminal clot from January 2001 to January 2003. We analyzed the signs and symptoms, etiology of bowel obstruction, and operative treatment.
  
  
  RESULTS
  From January 2001 to January 2003, 5 patients who had undergone successful laparoscopic Roux-en-Y gastric bypass developed proximal small bowel obstruction from a solid intraluminal clot secondary to staple line bleeding. All patients were women, with an average age and body mass index of 37 years and 43.41 kg/m(2), respectively. All patients underwent an upper gastrointestinal series on postoperative day 1, which revealed no leak, and all became symptomatic on postoperative day 2. Tachycardia and a "sense of impending doom" were both observed in 80% of the patients with this clinical syndrome. The intraoperative findings consistently revealed intraluminal clot obstructing the JJ. After reexploration and anastomotic revision, all patients had an uneventful recovery, with an average hospital length of stay of 9.8 days (range 8-11).
  
  
  CONCLUSIONS
  Staple line bleeding potentially exacerbated by perioperative subcutaneous heparin use can cause proximal small bowel obstruction at the JJ after laparoscopic Roux-en-Y gastric bypass. It presents on postoperative day 2 most commonly as tachycardia and a "sense of impending doom." Prompt recognition and immediate reexploration will lead to an uneventful recovery. The need for complete anastomotic JJ revision is discussed.
authors.affiliation: Department of Surgery, Division of Thoracic and Foregut Surgery, University of Pittsburgh Medical Center, PA 15232, USA. awaiso@upmc.edu
authors.forename: Omar
authors.initials: O
authors.lastname: Awais
authors.forename: Ioannis
authors.initials: I
authors.lastname: Raftopoulos
authors.forename: James D
authors.initials: JD
authors.lastname: Luketich
authors.forename: Anita
authors.initials: A
authors.lastname: Courcoulas
mesh_terms: D000328:Adult; D005260:Female; D015390:Gastric Bypass / Q000009:adverse effects*; D006406:Hematoma / Q000209:etiology*; D006801:Humans; D007415:Intestinal Obstruction / Q000209:etiology*; D007421:Intestine, Small; D010535:Laparoscopy; D009767:Obesity, Morbid / Q000601:surgery*; D012189:Retrospective Studies