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Intestinal malrotations are rare and may be asymptomatic until adulthood. There are only a few descriptions of gastric bypass with intestinal malrotation. If the duodenojejunal angle is not correctly seen, as is generally the case, there is a risk of creating an antiperistaltic anastomosis.
We describe required attitude and cases of gastric bypass...
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... same way although the biliary-pancreatic loop comes from the patient's right (on the left on the screen) and the alimentary loop comes from the patient's left (on the right of the screen) (Fig. 5). If the angle of the Treitz ligament is not pinpointed accurately, as is always necessary, there is a risk of creating an antiperistaltic anastomosis (Fig. 6). With this anatomy, the position generally needs to be changed or trocars need to be added. It appears to us that Roux en Y gastric bypass is easier to perform if a rotation abnormality is discovered incidentally. The operation strategy can also be changed, either by not performing the intended procedure or by performing a sleeve ...Similar publications
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Citations
... Several studies show in accordance that routine upper GI series prior to bariatric surgery, and in particular before Roux-en-Y gastric bypass, have a low diagnostic yield. For this reason, it is not recommended as a routine examination in asymptomatic patients preoperatively [6][7][8][9]. This also applies to postoperative complications after gastric bypass surgery. ...
Unknown intestinal rotation anomaly poses a challenge in laparoscopic gastric bypass surgery. We present a case of a patient with intestinal non-rotation that stayed undetected throughout performing a laparoscopic Roux-en-Y gastric bypass. As a result, the alimentary limb was constructed in an anti-peristaltic way, and the whole gastric bypass was located far more distally than usual. Postoperatively, the patient presented with recurring nausea and vomiting. After several diagnostic steps, a computed tomography finally revealed the inadvertently reverse directed gastric bypass and the pre-existing condition of intestinal non-rotation. This was followed by a diagnostic laparoscopy and the reconstruction of the gastric bypass in “mirrored” technique.
... The perfect mastery of surgical techniques in bariatric surgery is essential, given the potential complications and their consequences on the patient's life. In some cases, in addition to the usual difficulties that the bariatric surgeon may encounter during standard bariatric procedures, anatomical anomalies such as situs inversus or intestinal malrotation can pose an additional technical challenge [1]. Situs inversus totalis is a rare autosomal recessive anatomical anomaly with incidences ranging between 1/10000 and 1/20000 births [2]. ...
In some cases, in addition to the usual difficulties that the bariatric surgeon may encounter during standard bariatric procedures, anatomical anomalies such as situs inversus can pose an additional technical challenge. A 58-year-old patient with total situs inversus underwent Roux-en-Y gastric bypass (RYGB) surgery in our department. The main difficulty was the realization of a mirrored RYGB. Laparoscopic RYGB in a patient with situs inversus totalis is feasible but requires significant concentration and three-dimensional coordination to perform the mirrored procedure.
... 5 Partial intestinal abnormal rotation occurs due to failure of embryonic midgut to complete the physiological 270°r otation during intrauterine gestational period. 6 It occasionally presents in adults who are symptomless, and diagnosed incidentally. 6 The typical features of midgut malrotation can be identified by sonography, CT or upper gastrointestinal contrast series. ...
... 6 It occasionally presents in adults who are symptomless, and diagnosed incidentally. 6 The typical features of midgut malrotation can be identified by sonography, CT or upper gastrointestinal contrast series. 7 Diagnostic imaging modality of choice in pediatric patients is the upper gastrointestinal contrast study. ...
In the embroyological development, any deviation from physiological midgutrotation results in intestinal malrotation, which may further cause midgutvolulus or intestinal obstruction. It is predominantly a pediatric diagnosis; however, it may occur in adolescent or adult life. A case is presented here of a 17-year boy who came in Accident and Emergency Department, Abbasi Shaheed Hospital with complaint of intermittent and severe intensity pain in left upper quadrant of abdomen. Screening ultrasound abdomen was done, which was unremarkable; then he underwent Doppler evaluation of upper abdomen. Doppler ultrasound depicted abnormal vertical orientation of superior mesenteric vessels. He underwent barium enema, which revealed features of intestinal malrotation. He was further investigated with contrast-enhanced CT abdomen for complications, which confirmed the aforementioned abnormal orientation of superior mesenteric vessels and diagnosis of intestinal malrotation without any complication. In summary, any non-specific abdominal complaint with or without intestinal obstruction in an adolescent or adult patient should be investigated for the possibility of intestinal malrotation.
... Anatomical abnormalities can pose a further technical challenge. Situs inversus or intestinal malrotations [1], which are not diagnosed preoperatively, can surprise the surgeon. The incidence of these abnormalities is reported to be in the range of 1/10,000 to 1/20,000 births, or even 1/8000 for some authors [2]. ...
... Prior studies have described laparoscopic gastrectomy and Roux-en-Y gastric bypass in the setting of IM [4][5][6]. In these studies, the authors emphasize that surgeons need to be aware of this anatomic variant in advance and know how to handle it intraoperatively [5] as the operation requires visualization of the duodenojejunal angle and identification of the ligament Treitz before dividing the stomach and performing the Roux-en-Y or other reconstruction. ...
... Prior studies have described laparoscopic gastrectomy and Roux-en-Y gastric bypass in the setting of IM [4][5][6]. In these studies, the authors emphasize that surgeons need to be aware of this anatomic variant in advance and know how to handle it intraoperatively [5] as the operation requires visualization of the duodenojejunal angle and identification of the ligament Treitz before dividing the stomach and performing the Roux-en-Y or other reconstruction. ...
... A minority of patients with IM will be asymptomatic until they have imaging for other conditions later in life. IM is a congenital anomaly of rotation of the mid-gut with the following anatomical findings: (1) the duodenal-jejunal junction and loops of small bowel are on the right side of the abdomen (the duodenum does not cross the midline); (2) the colon and 3) there is aplasia of the pancreatic uncinate process and absence of the transverse colon crossing the abdomen [5,8]. All these anatomical changes will affect surgical abdominal invasive procedures and surgeons are better prepared when they are aware of the condition before the planned procedure. ...
Bilateral adrenalectomy is the preferred surgical approach for patients with failed treatments for pituitary-based Cushing’s syndrome. Intestinal malrotation (IM) is a rare congenital anatomic variant that rarely affects adults. The abnormal abdominal anatomy is concerning to surgeons planning elective procedures in such patients. Here, we describe a bilateral robotic transabdominal adrenalectomy (RTA) in a patient with IM. A 29-year-old female presented with refractory pituitary-based Cushing’s syndrome and was found to have IM on preoperative CT scan. The RTA was performed using one 10–12 mm camera trocar, two 8 mm robotic trocars per side and two midline 5 mm assistant ports. The 8 mm robotic cardiere forceps and the 8 mm robotic cautery hook were used on the left and right ports, respectively. Total operation time was 165 min (62 min on the right, 93 min on the left and 21 min for re-positioning). Total console time was 114 min (45 min on the right and 69 min on the left). Blood loss was minimal and there were no complications. She was discharged on post-operative day one. Anatomic variations were noted and the procedure modified. To our knowledge, this is the first reported case of bilateral RTA in a patient with IM. Surgeons should always review the anatomy on preoperative imaging. During the procedure, care should be taken to avoid damage to the multiple loops of small bowel located in the right upper quadrant. On the left side, the colonic splenic flexure is not encountered making access to the underlying left adrenal and kidney easier. The vascular anatomy was normal.
... 1 Adults are often asymptomatic, and such cases are usually diagnosed as incidental findings when imaged for other conditions. 2 Ultrasound, CT or upper gastrointestinal studies may identify the typical characteristics. 3 As highlighted in this case, recognition of partial malrotation in symptomatic patients should therefore prompt a thorough search for additional intra-abdominal pathology. In addition, the anatomical variations exhibited in such cases may also be responsible for atypical presentations of common surgical pathology such as appendicitis. ...
... The strategy was to begin by measuring the common limb, which had not been measured at the time of OLGBP. If this limb had been shorter than 3 m, in order to avoid a common limb that was too short (risk of malnutrition) during conversion of the OLGBP to RYGBP, we would have had to completely Bundo^the OLGBP by resecting the gastro-jejunal anastomosis and then performing a classical RYGBP by measuring the small loops from the angle of Treitz [8,9]. In our patient, the common limb was long enough to allow us to convert the OLGBP to RYGBP by performing only the second step of the RYGPB according to the double omega technique [8,10]. ...
The omega loop gastric bypass (OLGB) has become a very commonly performed bariatric procedure because of the advantages it carries over the Roux en Y gastric bypass (RYGBP). However, mini gastric bypass is a misnomer, as this procedure is more malabsorptive than the RYGBP. Recently, it is called single or one anastomosis gastric bypass. The omega loop procedure is associated with a risk of afferent loop syndrome, a known complication of the Billroth II (Finsterer) operation. This rare complication of the OLGB can be debilitating, serious, and deadly. Afferent loop syndrome should be suspected in case of malabsorption syndrome with chronic diarrhea, steatorrhea, iron-deficiency anemia, edema, emaciation, and osteomalacia and also in case of simple biological anomalies such as macrocytosis or megaloblastic anemia. The diagnosis can be confirmed by measuring bacterial overgrowth, although this requires a jejunal aspirate performed during endoscopy with jejunal intubation. A microbial population of more than 106 organisms per milliliter of aspirate is pathological. Afferent loop syndrome is encountered less frequently now that the number of gastrectomies has dropped. Yet, with the omega loop bypass procedure becoming more common, surgeons must again be made aware of this potential complication.
... Surgical techniques have to adapt themselves to certain anatomical variations. 1 It is the case of intestinal malrotations that can influence (ouaffect) bariatric surgeries. These are often asymptomatic and are thus often underestimated preoperatively. ...
Congenital anomalies of midgut rotation are uncommon with a 0.2–0.5% incidence. Intestinal malrotation (IM) presents a unique challenge in bariatric surgery during laparoscopic gastric bypass (LRYGB), and familiarity with alternatives allows for safe laparoscopic intervention. IM was encountered in 5 of 1183 (0.4%) patients undergoing surgery. Once IM was suspected, a standardized approach was applied: rightward shift of ports, confirmation of IM by the absence of the ligament of Treitz, identification of the duodenojejunal junction, lysis of Ladd’s bands, mirror-image construction of the Roux limb and construction of the gastrojejunal anastomosis. Forty percent were male, age 33 ± 8 years, with body mass index 50 kg/m2 (37–75 kg/m2). IM was identified preoperatively in two patients (40%). All operations were completed laparoscopically. Despite the finding of IM, successful laparoscopic completion of gastric bypass can be anticipated if the surgeon has an understanding of the anatomic alterations and a strategy for intraoperative management.
