small bowel obstruction ( sbo ) is one of the most feared complications after a gastric bypass . it can be chronic or acute and can range from a nuisance to the patient to a life - threatening emergency
sbos related to adhesions occur after laparoscopic roux - en - y gastric bypass ( lgb ) , but ih formation , secondary to the reconstruction of the small intestine , is also of concern to bariatric surgeons .
multiple defects in the mesentery of the bowel can occur and may lead to ih and , in an antecolic bypass , a defect is associated with the roux limb passing over the transverse colon .
the reported incidence of sbo after lgb varies widely , perhaps because the technique used in the operation also varies widely , not only in placement of the roux limb , but regarding closure or nonclosure of the mesenteric defects .
the disparity in reports leads to confusion regarding the true incidence and even the causes of sbo after lgb .
in addition , the closure of mesenteric defects is questioned in a substantial body of literature .
the objective of this study was to examine the incidence and characteristics of sbo after antecolic antegastric bypass with nonclosure of the mesenteric defect of the jejunojejunal ( jj ) anastomosis .
following health insurance portability and accountability act guidelines , the author performed a retrospective chart review of a series of consecutive lgbs performed over a 3-year period and recorded in a prospectively maintained database .
the follow up of the patients included office visits at 1 week , 1 month , 3 months , 6 months , and then , yearly .
all procedures were performed by the same surgeon using the antecolic antegastric technique . in no case was the mesenteric defect closed .
any patients presenting with signs and symptoms of an sbo were emergently taken to the operating room .
the policy of our bariatric program has always been to explore aggressively any patient with suspicion of an sbo , whether based on physical examination , radiographic studies , or history .
patients with an sbo were usually taken to the operating room from the emergency department .
those who underwent revisional bariatric surgery or conversion to open operation during the primary surgery were excluded .
revisional procedures were not included because adhesions may have formed from the previous bariatric surgery that could have confounded the results .
all patients had given informed consent prior to surgery for their deidentified data to be used for study purposes .
the gastric pouch was sized to 20 ml with an orogastric balloon with 4 to 5 staple loads with seamguard ( w. l. gore , flagstaff , arizona ) staple - line reinforcement ( slr ) and the echelon 60-mm stapler ( ethicon endo - surgery , cincinnati , ohio ) .
the small bowel was divided 40 cm from the ligament of treitz , and the mesentery had minimal division .
the only division of the mesentery was from the same staple load that divided the small bowel .
the roux limb was measured to 100 to 120 cm , depending on the body mass index ( bmi ) of the patient .
the gastrojejunal anastomosis was hand sewn in 2 layers with absorbable sutures over a 34 french bougie .
the jejunojejunostomy was formed with a single firing of the same stapler , and the enteroenterostomy was closed with the stapler . in all cases ,
an intraoperative endoscopy was used to check the gastrojejunal anastomosis , and drains were used in all male patients because of higher technical difficulty and higher rates of mortality and morbidity ; in patients with a bmi over 50 , for the same reasons ; and in selected cases .
there was one conversion to an open operation for an incomplete malrotation ; there was no mortality .
the gastric pouch was sized to 20 ml with an orogastric balloon with 4 to 5 staple loads with seamguard ( w. l. gore , flagstaff , arizona ) staple - line reinforcement ( slr ) and the echelon 60-mm stapler ( ethicon endo - surgery , cincinnati , ohio ) .
the small bowel was divided 40 cm from the ligament of treitz , and the mesentery had minimal division .
the only division of the mesentery was from the same staple load that divided the small bowel .
the roux limb was measured to 100 to 120 cm , depending on the body mass index ( bmi ) of the patient .
the gastrojejunal anastomosis was hand sewn in 2 layers with absorbable sutures over a 34 french bougie .
the jejunojejunostomy was formed with a single firing of the same stapler , and the enteroenterostomy was closed with the stapler . in all cases ,
an intraoperative endoscopy was used to check the gastrojejunal anastomosis , and drains were used in all male patients because of higher technical difficulty and higher rates of mortality and morbidity ; in patients with a bmi over 50 , for the same reasons ; and in selected cases .
there was one conversion to an open operation for an incomplete malrotation ; there was no mortality .
there were 249 primary lgbs performed in the study period ( january 1 , 2011 , through december 31 , 2013 ) .
sbo in 4 cases was caused by ih ( incidence of 1.6% ) and by adhesions in 11 ( 73% ) ( figure 1 ) . in the cases with ih ,
the most common locations were from the jj to the roux limb ( n = 5 ) , followed by those forming from the jj to the abdominal wall ( n = 3 ) , and 1 each from the jj to the colon and from the jj to the common channel ( figure 2 ) . in all cases , the adhesions were treated with laparoscopic lysis .
the average time to sbo was 8.1 months ( range , 121 ) from the initial surgery .
sbo is common after lgb and can be easily managed or can just as easily lead to disaster if not recognized and treated promptly .
the surgical literature has many articles that discuss ih formation , and an area of contention has been closure versus nonclosure of the mesenteric defects .
most authors seem to agree that if a retrocolic gastric bypass is performed , the mesocolic defect must be closed , which can lead to a 0% rate of ih formation , although that number can climb as high as 15% .
elms et al showed that , in almost 2 400 patients who underwent antecolic antegastric bypass , ih formed in only 1.1% , primarily at the mesenteric defect . in those cases the defects had all been closed .
cho et al had a 0.2% ih formation rate in 1 400 patients who underwent antecolic antegastric bypasses with no mesenteric closure and no division of the mesentery .
rodriguez et al also reported that minimal division of the mesentery could lead to a decrease in ih formation .
they showed that , with closure of the defect but with wide opening of the mesentery , there was a 14.4% ih rate ; if the defect was closed and the mesentery was not widely opened , the ih rate dropped to 1.1% .
abasbassi et al showed a lower ih formation rate with no division of the mesentery , but also no closure of the mesentery .
this cumulative experience could indicate that a way to decrease ih formation is to perform a minimal division of the mesentery .
obeid et al used mixed techniques in both retro- and antecolic bypasses , some with closure of defects , some without . in 679 patients with an antecolic roux limb , the majority of all the defects closed . in the retrocolic group ,
almost 4% of these had closure of the mesenteric defect , 8.4% had nonclosure ; 3.8% were in antecolic and 8.5% in retrocolic bypasses .
this wide range of techniques makes an overall analysis of the literature difficult . in 2010 in jsls , hope and colleagues examined the incidence of ih formation after documented closure of mesenteric defects .
permanent sutures were used to close these defects , but 15 of 18 patients in the series presented with open defects , causing ih .
these outcomes indicate that closure of the defects may not be as permanent as surgeons would like to believe , and indeed this very situation was the catalyst for this paper . in our lgbs , we were closing all defects , but our ih formation rate seemed to be climbing .
we noticed most of the mesenteric defects were open at reoperation , and so we switched to nonclosure .
as demonstrated here , the published papers on the subject have reported a wide range of ih incidence , from 0% to 15.5% .
another complicating factor may be that many of the papers published in this area are from surgical programs training fellows , and the association of postsurgical complications with performance of operations by fellows is not known . in this study , the author specifically examined the incidence and cause of sbo in antecolic antegastric bypasses . in no case was either the mesenteric or antecolic defect closed .
the interesting finding was that , of an overall incidence of sbo of 6% , only 1.6% of the total was caused by ih formation , all at the jj mesenteric defect .
this outcome compares favorably with the ih formation rate reported by other authors who did or did not close the defects . also , the incidence of sbo caused by adhesions is higher in the current study than in some others .
elms et al reported that 47.6% of the sbos in their series were secondary to adhesions , mostly at the jj , compared with our rate of 73% .
the opposing end of the adhesion had multiple locations , but the staple line of the jj was always at one end , perhaps because of the intense inflammatory reaction that it generates .
a hand - sewn technique could be used to close the common enterotomy and might reduce the incidence of sbo slightly , but the cut end of the biliopancreatic limb still has an exposed staple line .
the strength of this study is in the homogeneity of the technique used , as this was a single - surgeon series . however , its strength is also its chief weakness , as the results may not be reproducible by others .
the number of sbos is also small enough to raise the possibility of a type ii error .
the author lives in a geographically isolated part of the country , with no other surgeons who are willing to care for bariatric patients , and so it was more likely that all the sbos would be treated by the same bariatric surgeon .
another limitation of the study is that it was a small series with a short follow - up .
although only the years of 2011 through 2013 were examined , and the average time to sbo was 8.1 months , it is possible that the sbo rate will climb in these same patients as time passes , and some of the patients are likely to be lost to follow - up .
another confounding factor is that an slr was used early in the series at the jj , but not in later operations .
there may be an association of slr with adhesion formation , but the connection is not clear .
the most common location of adhesions was at the jj , were slr was used , but about half of the sbos caused solely by adhesions to the jj occurred after the use of slr was abandoned , so there are probably not enough cases to tell if the use of slr increases sbo .
the usual weaknesses of a retrospective study apply to this paper as they do to all other studies about ih formation .
surgeons should remember that the mainstay of treatment of sbo after lgb is an operation .
an isolated roux limb obstruction can be decompressed by vomiting , and the placement of an ngt involves risk of a perforation .
the surgeon should move the patient quickly to the operating room once an sbo is diagnosed or even suspected , as bowel ischemia can lead to extensive bowel resection and nutritional debility or even death .
these operations can often be performed laparoscopically , but laparotomy is also safe and effective .
the incidence of sbo caused by ih with nonclosure of the mesenteric defect is similar to that in other series where the defect was closed .
regardless of the cause of the sbo , operation remains the definitive treatment and should not be delayed in the gastric bypass patient .
 background and objectives : there is a wide variation of reported incidence of small bowel obstruction ( sbo ) after laparoscopic roux - en - y gastric bypass ( lgb ) . 
 there is also wide variation in technique , not only in placement of the roux limb , but also regarding closure or nonclosure of the mesenteric defects . 
 the objective of this study was to examine the incidence and characteristics of sbo after antecolic antegastric bypass with nonclosure of the mesenteric defect of the jejunojejunal anastomosis.methods:this is a retrospective review of a series of consecutive lgbs over a 3-year period . 
 all procedures were performed by the same surgeon using the same technique . in no case was the mesenteric defect closed . a prospectively maintained database 
 was used for data collection . 
 patients who returned with an sbo were the study group , and those who underwent revisional bariatric surgery or conversion to open operation were excluded.results:there were 249 primary lgbs performed during the study period ; 15 of the operations were followed by sbo , for an incidence of 6.0% . 
 four cases were caused by an internal hernia ( ih ) , for an incidence of 1.6% , and 11 were caused by adhesions , which accounted for 73% of the sbos.conclusions:sbo after lgb is a relatively common complication . 
 the incidence of sbo from ih with nonclosure of the mesenteric defect is similar to that in other series where the defect is closed . 
 regardless of the cause of the sbo , operative treatment of the patient who has a gastric bypass remains the definitive standard and should not be delayed . 
INTRODUCTION
METHODS
Surgical Technique
RESULTS
DISCUSSION
CONCLUSIONS