What is the best initial approach for a patient with a history of sleeve gastrectomy (bariatric surgery) presenting with weight loss, signs of intestinal obstruction, and radiating pain to the right thigh and knee?

Management of Intestinal Obstruction in a Post-Sleeve Gastrectomy Patient

Laparoscopic exploration is strongly recommended as the initial approach for this patient with a history of sleeve gastrectomy presenting with weight loss, intestinal obstruction, and radiating pain to the right thigh and knee. 1

Initial Assessment and Rationale

• In patients with a history of bariatric surgery presenting with persistent abdominal pain, weight loss, and features of intestinal obstruction, exploratory laparoscopy should be performed within 12-24 hours, especially when clinical and radiological findings are inconclusive 1
• The radiating pain to the right thigh and knee suggests possible involvement of internal hernia with nerve compression, which requires urgent surgical evaluation 1
• While both exploration (open surgery) and laparoscopy are options, the laparoscopic approach is preferred due to decreased operative time, blood loss, and length of hospital stay 1, 2

Surgical Approach

• The laparoscopic exploration should begin systematically from the ileocecal junction (distal to the obstruction) and proceed proximally 1

• The surgeon should inspect for potential causes of obstruction including:

  • Internal hernias (a possible complication even after sleeve gastrectomy) 2
  • Adhesions (particularly if there was a previous leak from the sleeve) 2
  • Intussusception 1
  • Volvulus 1
  • Stenosis at the incisura angularis of the sleeve 1

• If an internal hernia is found, assessment of intestinal viability is mandatory 1

• Any mesenteric defects should be closed with non-absorbable suture material 1

Management Based on Intraoperative Findings

• If intestinal ischemia is present, perform limited intestinal resection and anastomosis in hemodynamically stable patients 1
• For extensive intestinal ischemia or peritonitis in unstable patients, damage control surgery with open abdomen approach should be considered 1
• In case of intussusception, reduction may be sufficient if the bowel is viable, but resection of the affected segment is recommended to prevent recurrence 1
• If no obvious cause is found, the entire small intestine must be thoroughly assessed 1

Special Considerations

• Indocyanine green (ICG) fluorescence angiography can be used to evaluate bowel perfusion when available 1
• The pain radiating to the right thigh and knee may indicate nerve compression from an internal hernia, which requires careful exploration of all potential hernia sites 1
• If the patient has a history of previous leak after sleeve gastrectomy, adhesive bands from the leak site may have created defects through which bowel loops can herniate 2

Potential Pitfalls and Caveats

• Delay in surgical intervention increases the risk of bowel ischemia and need for extensive resection 1
• Late presentation (10+ years post-surgery) may be associated with complex adhesions or chronic internal hernias that have intermittently caused symptoms 2
• Weight loss in this patient could be due to both the intestinal obstruction and possible malnutrition, which should be addressed postoperatively 3
• If GERD symptoms are also present, this may need to be addressed in future management, potentially with conversion to Roux-en-Y gastric bypass if severe 4, 5