What is the treatment for a partial volvulus of a gastric bypass?

Treatment for Partial Volvulus of Gastric Bypass

For a partial volvulus of gastric bypass, urgent surgical exploration via laparoscopy is mandatory within 12-24 hours in stable patients, with the goal of reducing the volvulus and preventing recurrence through fixation techniques. 1

Initial Assessment and Management

Stable Patients

• Obtain cross-sectional imaging (CT scan with oral and IV contrast) to confirm diagnosis
• Endoscopic decompression may be attempted if the patient is hemodynamically stable and there are no signs of ischemia or perforation 1
• Prepare for surgical intervention even if initial decompression is successful

Unstable Patients

• Immediate surgical exploration without delay in patients with signs of peritonitis, shock, or hemodynamic instability 1
• Fluid resuscitation and broad-spectrum antibiotics should be initiated immediately
• Consider damage control surgery in severely unstable patients 1

Surgical Approach

Laparoscopic Exploration

• Begin systematic exploration from the ileocecal junction, moving proximally to inspect:
  • Jejuno-jejunostomy
  • Petersen's space
  • Mesenteric defects
  • Remnant stomach 1
• Assess intestinal viability using visual inspection and/or indocyanine green (ICG) fluorescence angiography if available 1

Surgical Intervention Steps

1. Reduction of volvulus: Carefully untwist the involved segment
2. Viability assessment: Resect any non-viable bowel segments
3. Fixation procedure: Perform gastropexy or other appropriate fixation to prevent recurrence
4. Closure of mesenteric defects: Use non-absorbable suture material in running or interrupted fashion 1

Management Based on Findings

If Ischemia is Present

• Resect non-viable segments of bowel
• Consider temporary ostomy creation in unstable patients or those with significant contamination
• Close mesenteric defects to prevent future internal hernias 1

If No Ischemia is Present

• Reduce the volvulus and perform fixation to prevent recurrence
• Consider laparoscopic gastropexy for gastric volvulus components 2, 3
• For Roux limb volvulus, avoid stabilization sutures that may actually contribute to volvulus formation 4

Post-Operative Management

• Close monitoring for signs of leak or recurrent obstruction
• Early ambulation and respiratory care
• Gradual diet advancement based on clinical status
• Consider proton pump inhibitors to reduce risk of marginal ulcers 5

Prevention of Recurrence

• Fixation procedures are essential to prevent recurrence of volvulus
• Avoid placement of Roux limb stabilization sutures that may contribute to volvulus formation 4
• Consider conversion to a different bariatric procedure if anatomical factors predispose to recurrent volvulus 3

Pitfalls and Caveats

• Delayed diagnosis can lead to ischemia, perforation, and increased mortality
• Partial volvulus may progress to complete volvulus with closed-loop obstruction
• Afferent limb volvulus can present with back pain and anemetic nausea due to pancreatobiliary obstruction 6
• Perforation of the bypassed stomach is a rare but serious complication that requires aggressive surgical correction 6

Early surgical intervention is crucial to prevent progression to ischemia and perforation, which significantly increases morbidity and mortality. While endoscopic decompression may temporarily relieve symptoms, definitive surgical management with reduction and fixation is necessary to prevent recurrence.