Practical Teaching Cases

Unraveling a patient’s post-op symptoms

Published previously in Gastroenterology (2016;151:250-1)

A 45-year-old female with history of morbid obesity who had undergone Roux-en-Y gastric bypass (RYGB) 6 months ago for weight loss presents to the emergency department with acute on chronic abdominal pain. She reports that these upper gastrointestinal symptoms have been occurring with increasing frequency over the past 2 months. Her pain is epigastric, postprandial, and without radiation.

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It is associated with nausea, vomiting, and early satiety. She denies fever, and reports that these intermittent obstructive symptoms occur after meals and only resolve after vomiting and regurgitation of the meal. She denies symptoms of hematemesis, constipation, odynophagia, or dysphagia. Physical examination reveals an obese woman in no acute distress. Her pulse is regular, abdomen is moderately distended with normal bowel sounds, and is non-tender. Blood chemistries and CBC are normal. An upper endoscopy is performed showing post-RYGB anatomy with a normal gastric pouch. The gastrojejunal anastomosis is patent and 12 mm in diameter with unraveled suture and staple material present (Figure A). The jejunum is otherwise normal and non-dilated to 60 cm beyond the anastomosis.

Dr. Storm and Dr. Thompson are in the department of medicine, division of gastroenterology, hepatology and endoscopy, Brigham and Women’s Hospital, Boston. Dr. Thompson is a consultant for Olympus, Cook, and Boston Scientific.

How should this patient be managed?

Symptomatic management with antiemetics and IV fluids

Endoscopic suture and staple removal

Referral for laparoscopic surgical revision

Upper GI series with gastrograffin

Balloon dilation of the gastrojejunal anastomosis

The correct answer is B: endoscopic suture removal. As the prevalence of bariatric surgery increases to address the obesity epidemic, endoscopists are increasingly called upon to evaluate postbariatric patients.1 In one case series of patients undergoing EGD for upper GI symptoms post-RYGB, normal postsurgical anatomy was found in 31.6%, anastomotic stricture in 52.6%, marginal ulcer in 15.8%, unraveled suture material causing functional obstruction in 4% and gastro-gastric fistula in 2.6% of cases.2 Another series reported unraveled suture material thought to be contributing to upper GI symptoms in up to 10% of cases.3 Suture material is found by a mean of 34 weeks after RYGB, and presenting symptoms include abdominal pain in 65%, nausea 52%, dysphagia 22%, and melena in 13%. Unraveled suture material may be associated with marginal ulceration, or may cause obstruction as it presents a mechanical obstruction to foodstuff as it passes through the gastrojejunal anastomosis. A series of 29 therapeutic endoscopic suture removal cases reported resolution or improvement of symptoms in 83% of patients and no complications or anastomotic leaks.3

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Tools available for suture removal are diverse and should be selected based on the appearance of the unraveled suture material (Figure B). First, when possible the suture material should be untangled to allow for examination of the number and location of sutures involved, as well to evaluate the underlying mucosa for defects or ulceration. In the best case, more sutures may be removed if a grasping tool like a biopsy forcep is used to grip the suture where it emanates from the mucosa, then the scope is driven onto this area and the tool is firmly and quickly pulled back into the biopsy channel to break the suture. Other techniques include use of endoscopic scissors and loop cutters to trim and remove the suture material, though loop cutters may jam on braided or silk suture and are generally reserved for cutting monofilament.
While symptomatic management with antiemetics and analgesics (answer A) is important in managing this patient, it will not lead to definitive management of her underlying condition. The patient may require laparosopic surgical revision (answer C) if her symptoms persist after endoscopic suture removal, but it is premature to recommend this. An upper GI series (answer D) would be helpful in diagnosing a gastro-gastric fistula in this patient population, but the endoscopic evaluation suggests suture material leading to food bolus impaction and gut irritation is the cause of her symptoms. Finally, while the patient’s symptoms of intermittent obstruction raises concerns for gastrojejunal stenosis, the endoscopic exam showed a normal-caliber stoma. Thus, stomal dilation (answer E) is incorrect.

References

1. ASGE Standards of Practice Committee, Evans J.A., Muthusamy V.R., et al. The role of endoscopy in the bariatric surgery patient. Gastrointest Endosc. 2015;8:1063-72.
2. Lee J.K., Van Dam J., Morton J.M., et al. Endoscopy is accurate, safe, and effective in the assessment and management of complications following gastric bypass surgery. Am J Gastroenterol. 2009;104:575-82.
3. Yu S., Jastrow K., Clapp B., et al. Foreign material erosion after laparoscopic Roux-en-Y gastric bypass: findings and treatment. Surg Endosc. 2007;21:1216-20.

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