Re-do Roux-en-Y gastric bypass in a patient with known midgut malrotation

Abstract

A 40-year-old woman presented with small bowel obstruction caused by an internal hernia through Peterson's defect. The patient was known to have midgut malrotation (MM) and also had laparoscopic Roux-en-Y gastric bypass for morbid obesity 6 years prior. An open revision of Roux-en-Y gastric bypass was performed as a result of ischemia of alimentary limb. She made a slow but uneventful recovery and was discharged home. MM is a rare congenital anomaly that requires the surgeon to be well aware of the unique variation in anatomy to perform a mirror image of the routine Roux-en-Y gastric bypass. At the end of this case report, we present a short literature review of published data related to MM encountered during Roux-en-Y gastric bypass.

Figure 1.

Computed tomography scan showing evidence of small bowel obstruction (dilated stomach and small bowel loops) and MM (subhepatic cecum).

Figure 2.

Internal hernia through Peterson's defect (arrow).

Figure 3.

(A) Malrotated midgut with subhepatic location of the cecum, the course of internal hernia through the Peterson's defect, and the ischemic alimentary limb. It also shows the hepato-biliary limb of the gastric bypass. (B) Internal hernia reduced and the alimentary limb, which was disconnected at the gastro-jejunostomy and the entero-enterostomy. (C) Redo Roux-en-Y gastric bypass with the ischemic alimentary limb replaced and the gastro-jejunostomy and an entero-enterostomy refashioned.

Figure 3.

(A) Malrotated midgut with subhepatic location of the cecum, the course of internal hernia through the Peterson's defect, and the ischemic alimentary limb. It also shows the hepato-biliary limb of the gastric bypass. (B) Internal hernia reduced and the alimentary limb, which was disconnected at the gastro-jejunostomy and the entero-enterostomy. (C) Redo Roux-en-Y gastric bypass with the ischemic alimentary limb replaced and the gastro-jejunostomy and an entero-enterostomy refashioned.