Intestinal Knot Formation after Total Gastrectomy Resulting in Strangulated Ileus and Acute Afferent Loop Obstruction

• Published in: Nippon Shokaki Geka Gakkai zasshi Vol. 44; no. 10; pp. 1256 - 1263
• Main Authors: Ohtsuka, Yasuhiro, Ogasawara, Takeshi, Nomura, Satoru, Shida, Takashi, Takahashi, Makoto
• Format: Journal Article
• Language: Japanese
• Published: The Japanese Society of Gastroenterological Surgery 2011
• Subjects: acute afferent loop obstruction; intestinal knot; strangulated ileus
• ISSN: 0386-9768; 1348-9372
• DOI: 10.5833/jjgs.44.1256

A 78-year-old woman was admitted to our hospital for abdominal pain and nausea at midnight. She had undergone total gastrectomy (antecolic Roux-en-Y reconstruction with splenectomy) for gastric cancer 9 years previously. Enhanced CT scan showed a severely dilated afferent loop with a beak sign and concentration of the mesentery, dilated intestinal loops without Kerckring folds, and a large amount of ascitic fluid. We made a diagnosis of strangulated ileus and acute afferent loop obstruction due to internal hernia involving the jejunojejunal end-to-side anastomosis created at total gastrectomy (Y anastomosis), and performed an emergency operation. At laparotomy, we found that the elongated reconstructed jejunum at total gastrectomy (Y arm) had adhered to the left diaphragm and formed an intestinal loop. A loop of the small intestine distal to the Y anastomosis had encircled the loop of the Y arm and formed a knot. The involvement of the Y anastomosis in this knot resulted in afferent loop obstruction. The operative diagnosis was an intestinal knot. After untwisting the knot, the blood supply to the congested Y arm and small intestine was improved, and a perforation at the posterior wall of the afferent loop was revealed. The perforated site was repaired, the adhesion of the Y arm to the diaphragm was dissected to straighten the Y arm, and a tube duodenostomy was created. Although minor leakage at the site of tube duodenostomy occurred, her postoperative clinical course was satisfactory, and she was discharged 27 days after surgery.