Complications of gastric bypass: avoiding the Roux-en-O configuration

Atypical complications of gastric bypass surgery include the Roux-en-O configuration: an improper connection of the bilio-pancreatic limb to the gastric pouch.

Four cases of Roux-en-O, which occurred at institutions not affiliated with the authors, were reviewed for issues related to causation and patient outcomes.

One case was diagnosed intraoperatively (patient 1), while the time of diagnosis in the remaining three patients was postoperative days 2, 52, and 230 (patients 2-4). The delay resulted in two computed tomography scans, two endoscopies, and four contrast studies per patient. These patients presented with protracted biliary emesis and a clinical picture of bowel obstruction. Irrespective of time to diagnosis, all patients endured significant postoperative sequelae-numerous surgeries (n=10, 3, 1, and 3, respectively) and increased length of stay (97, 86, 49, and 125 days, respectively). Patients 2 and 3 were diagnosed by repeat laparotomy, and patient 4 was diagnosed by HIDA scan.

Nevertheless, surgery remains the most effective means by which to diagnose the problem, as well as correct the complication. Maneuvers that should be employed to prevent this rare complication include keeping the bilio-pancreatic limb short, identifying the ligament of Treitz and marking the Roux limb shortly after jejunal transection.