Roux-en-Y hepaticojejunostomy (RYHJ) is a commonly performed surgical procedure for various hepatobiliary and gastrointestinal operations. The success rate of RYHJ has been shown to be as high as 92%, and the reported complication rate is around 7% for benign disease. 1 Complications such as cholangitis, biliary calculi, pancreatitis, liver failure, and reflux-induced peptic ulcer disease have been described in literature.
We describe a recently encountered rare complication of RYHJ which to our knowledge has not been reported previously.
A 20-year-old male underwent choledochal cyst excision and RYHJ for choledochal cyst type 1 in 2008. His postoperative period was uneventful, and he was discharged after 5 days. He remained asymptomatic for 5 years doing normal routine work and reported routinely for follow-up. He now presented with complaints of progressively increasing, colicky abdominal pain in the central abdomen of mild to moderate intensity for 3 weeks. This was associated with abdominal distension and nonpassage of stool for 7 days. The patient also had episodes of cholangitis during the last 10 days. At the time of presentation, his bilirubin was 224 mmol/L (13.1 mg/dl) and total leukocyte count was 17,800 cells/cc with 89% polymorphs and 7% lymphocytes.
He was resuscitated with Ryle′s tube insertion, intravenous (IV) antibiotics, and IV fluids. Over the period of 4 days, the patient′s condition improved rapidly. He started tolerating oral feeds normally and was passing 1-2 stool/day. His abdominal X-ray had no air-fluid levels.
His abdomen continued to be soft but mildly distended with a 3 cm × 3 cm doughy, nonmobile lump to the right of the umbilicus. During further workup for etiology, ultrasound of the abdomen was performed which showed distended bowel loops with bilobar pneumobilia. The contrast-enhanced computed tomography (CECT) of the abdomen was done which indicated mildly dilated bilobar intrahepatic biliary radicles with pneumobilia and cuffing along the intrahepatic biliary radicles. No evidence of significant anastomotic bowel wall thickening was present. Subhepatic jejunal loop, possibly the Roux loop seemed distended Figure 1.
In view of persistent distension of the upper abdomen with a lump and generalized illness, this patient was readmitted for exploratory laparotomy. On admission, all his routine hematological and biochemical parameters were within normal limits. His bilirubin level had reduced to 11.97 mmol/L.
Intraoperatively, the Roux loop of the jejunum was densely, adherent to the omentum and distal bowel loops forming a lump. Proximal Roux loop was distended and the distal bowel loops were collapsed. Volvulus of Roux loop was present with a perforation of 2 cm × 1 cm. This was well-covered with omentum and bowel loops preventing free spillage. The volvulosed loop was derotated, and mesentery-sparing resection of the perforated segment was done without dismantling the previous jejunojejunostomy site Figure 2.
His postoperative period remained uneventful and he was allowed oral sips on post-operative day 3 which was gradually advanced from 4 thday onward and the patient was discharged with no complications.
RYHJ is a versatile surgical procedure which is commonly used for various hepatobiliary and gastrointestinal diseases. The complication associated with RYHJ can be divided into early and late. Early complications include biliary-enteric anastomosis dehiscence with biliary fistula, biloma or abscess formation, acute peritonitis, pancreatic leakage and fistula, acute cholangitis, acute pancreatitis, bowel obstruction due to kinking or adhesions, wound infection and dehiscence, gastrointestinal bleed, and hepatic failure. Long-term complications include biliary-enteric anastomotic stricture, peptic ulcer disease, cholangitis, biliary and intrahepatic stones, pancreatitis, liver failure, and biliary cancer.
There has been no literature on Roux limb volvulus leading to obstruction and perforation of jejunum as a complication of RYHJ. Two cases of volvulus of Roux-en-Y gastric bypass have been reported in literature. 2 , 3 Passage of Roux limb through the mesocolon effectively reduces the play in Roux limb, making this a rare event. In our case, the twisting of the Roux limb caused obstruction and cholangitis initially with perforation occurring subsequently. Perforation did not lead to peritonitis as it was effectively blocked by omentum and bowel loops. Easing of edema relieved the obstruction and led to improvement in cholangitis.
The chronology of clinical events and subsequent operative findings support this premise. Mesentery-sparing bowel resection allowed us to retain the same Roux loop without a fresh jejuno-jejunostomy.
Volvulus of Roux loop with cholangitis and perforation has not been reported previously. The importance of this review lies in the fact that despite being a rare complication, an index of suspicion and a low threshold for CECT allowed us to diagnose this condition. Early intervention is required to confirm this rare complication, which could otherwise be fatal.
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1. Tao KS, Lu YG, Wang T, Dou KF. Procedures for congenital choledochal cysts and curative effect analysis in adults Hepatobiliary Pancreat Dis Int. 2002;1:442–5
2. Fleser PS, Villalba M. Afferent limb volvulus and perforation of the bypassed stomach as a complication of Roux-en-Y gastric bypass Obes Surg. 2003;13:453–6
3. Keyser EJ, Ahmed NA, Mott BD, Tchervenkov J. Double closed loop obstruction and perforation in a previous Roux-en-Y gastric bypass Obes Surg. 1998;8:475–9