Presentation
Prior history of biliopancreatic diversion surgery years ago. Two days ago the patient underwent laparascopic entero-anastomosis procedure to proximalise the Roux limb because of short bowel syndrome. Now the patient is admitted to the emergency department with presentation of intestinal obstruction including vomiting, nausea and upper abdominal pain and distention. No passage of stool since the surgery 2 days ago.
Patient Data
During the most recent surgery somehow there was an accidental creation of 2 separate bowel circuits due to incorrect anastomosing of the bowel loops:
The Roux limb is anastomosed on itself (side-to-side anastomosis), creating a closed circuit, a so-called "Roux-en-O" loop. This results in an obstructed and dilated upper GI tract with small bowel feces sign all over this obstructed closed circuit, mostly in the right flank. No signs of mural ischemia.
The biliopancreatic loop is anastomosed on the ileum. The ileum and colon are mostly collapsed.
There is minor pneumoperitoneum, which is still a normal finding 2 days after surgery. Perforation of the closed-loop was thought to be less likely.
There is also a trace amount of fluid between the bowel loops, this can be due to the obstruction or because of the recent surgery.
Annotated paracoronal CT image showing the simplified trajectory (red) of the closed circuit in the Roux-en-O limb via the side-to-side anastomosis.
The bowel wall of the distal part of the Roux limb is annotated with a blue line.
Caudally from the blue line, there are ileal loops to which only the biliopancreatic loop is connected.
Laparoscopy confirmed the closed-loop circuit of the Roux limb and the anastomotic connections were corrected.
Case Discussion
A rare case of postsurgical small bowel obstruction where a closed intestinal circuit was accidentally created due to incorrect anastomosis of the bowel loops, with the Roux loop anastomosed on itself ("Roux-en-O" loop) and only the biliopancreatic loop anastomosed on the ileum.
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