https://orcid.org/0009-0007-3039-3190
Abstract
Hemobezoar is a rare cause of early postoperative small bowel obstruction after bariatric surgery, resulting from intraluminal clot formation and anastomotic impaction. Reports involve Roux-en-Y gastric bypass or one-anastomosis gastric bypass. Occurrence after Roux-en-Y transit bipartition remains poorly documented. We report a 40-year-old male with severe obesity, prior endoscopic sleeve gastroplasty, who underwent a laparoscopic Roux-en-Y transit bipartition without intraoperative complications. On postoperative day (POD) 1, abdominal pain, tachycardia, and bilious vomiting developed. Computed tomography demonstrated proximal small bowel dilation with distal collapse and hyperdense intraluminal material. Re-exploration revealed blood clots at the ileo-ileal anastomosis causing proximal obstruction. Enterotomy, clot evacuation, additional anastomosis, peritoneal lavage, and intraoperative endoscopy were performed; no anastomotic leak was identified. Self-limited melena was managed with anticoagulation withholding and tranexamic acid. The patient was discharged on POD 5. Hemobezoar should be considered in early obstruction after Roux-en-Y-type bariatric anatomy; low threshold for re-exploration and endoscopy are essential.
Introduction
Hemobezoar is a rare form of intraluminal bezoar composed of organized blood clots that can complicate bariatric procedures [1]. Unlike classic bezoars, it originates from gastrointestinal bleeding. Most available evidence comes from case series after Roux-en-Y gastric bypass (RYGB) and one-anastomosis gastric bypass, in which the staple line at the jejunojejunal anastomosis is proposed as the bleeding source [2–5]. However, hemobezoar-related obstructions after Roux-en-Y transit bipartition remain poorly described in the literature.
We present the case of early postoperative small bowel obstruction caused by a hemobezoar at the ileo-ileal anastomosis following laparoscopic sleeve gastrectomy with Roux-en-Y transit bipartition.
Case presentation
A 40-year-old male patient with persistent severe obesity (body mass index, 40.9 kg/m2), previous endoscopic sleeve gastroplasty performed in 2024, Hodgkin lymphoma in remission, fatty liver disease, and generalized anxiety disorder was admitted for elective bariatric surgery.
The patient underwent a laparoscopic sleeve gastrectomy with Roux-en-Y transit bipartition (Santoro procedure) under general anaesthesia. A vertical tubular gastric component was calibrated over a 36-Fr bougie. A side-to-side gastroileal anastomosis was fashioned 300 cm from the ileocecal valve, with a Roux-en-Y configuration 50 cm from the efferent limb. Mesenteric defects and Petersen’s space were closed. Methylene blue testing confirmed anastomotic patency with no leakage. Postoperative pharmacological management included intravenous crystalloids, acetaminophen, omeprazole, antiemetics, and thromboprophylaxis with enoxaparin 60 mg subcutaneously once daily.
On postoperative day (POD) 1, the patient developed progressive abdominal pain (7/10 visual analogue scale), tachycardia (102–110 bpm), and four episodes of bilious vomiting. Computed tomography (CT) imaging demonstrated proximal small bowel dilation (43.17 mm) with distal collapse (Fig. 1) and hyperdense intraluminal material at a transition segment consistent with blood clot (Fig. 2A–B). No anastomotic leak, abscess, pneumoperitoneum, or thrombosis were identified. Given clinical deterioration, emergency re-exploration was performed on POD 2.
Coronal contrast-enhanced abdominopelvic CT obtained after onset of abdominal pain, tachycardia, and bilious vomiting, demonstrating marked proximal small bowel dilation (approximately 43.17 mm) with distal collapse, consistent with early postoperative mechanical obstruction.
Coronal CT findings. (A) Hyperdense intraluminal material within a dilated small bowel loop, consistent with an intraluminal blood clot in the postoperative clinical context. (B) Transition zone with narrowing of the intestinal loop and distal collapse, supporting a mechanical obstructive pattern.
Intraoperatively, turbid free fluid and fibrinopurulent exudate were identified throughout the peritoneal cavity. At the ileo-ileal anastomosis, proximal obstruction with distension of the alimentary and biliopancreatic limbs and collapse of the common channel was noted. Enterotomy revealed dark intraluminal blood clots consistent with hemobezoar (Fig. 3). Intraoperative endoscopy confirmed no leakage at any anastomotic site. An additional ileo-ileal anastomosis was completed, the abdominal cavity was lavaged, and two perigastric drains were placed. Post-reintervention arterial blood gas showed severe acidemia (pH 7.17, lactate 2.45 mmol/L).
Intraoperative laparoscopic finding. Laparoscopic view during re-exploration demonstrating enterotomy at the ileo-ileal anastomotic segment with evacuation of dark intraluminal blood clots consistent with hemobezoar. No anastomotic leak was identified.
On POD 4, the patient developed three episodes of melena without haemodynamic deterioration (blood pressure 125/80 mmHg, heart rate 91 bpm, hemoglobin 13.1 g/dl, hematocrit 37.8%). CT confirmed bilateral atelectasis. Anticoagulation was temporarily withheld, tranexamic acid was administered, and close haemoglobin surveillance was maintained. On POD 5, parameters normalized (hemoglobin 13.3 g/dl, lactate 1.8 mmol/L). Drains were removed, tranexamic acid was discontinued, and the patient was discharged with oral antibiotics, dietary instructions, and outpatient follow-up. Thromboprophylaxis was restarted 5 days after discharge.
Discussion
Small bowel obstruction after RYGB is commonly attributed to adhesions, internal hernia, stricture, or ileus; however, intraluminal blood clot is a rare etiology. Cases of hemobezoar obstruction at the jejunojejunostomy have been described after RYGB and mini/one-anastomosis gastric bypass [2–6]. The most plausible mechanism involves bleeding from a staple line or anastomosis, followed by intraluminal clot organization and impaction at an anastomotic or transitional segment [2, 6].
This mechanism is anatomically relevant to the present case. The ileo-ileal anastomosis in Roux-en-Y transit bipartition functions as the entero-enteric reconstruction analogous to the jejunojejunostomy in RYGB, creating alimentary, biliopancreatic, and common channels [7]. Previous reports describe obstruction at the entero-enteric anastomosis with proximal limb dilation [2–5], a pattern reproduced at the ileo-ileal anastomosis.
The clinical and radiologic presentation was consistent with prior literature. Awais et al. [2] reported five patients with early postoperative proximal small bowel obstruction after laparoscopic RYGB, with tachycardia present in 80% and symptoms emerging around POD2. CT findings in our case, proximal dilation with distal collapse and hyperdense intraluminal content, supported a mechanical obstructive pattern, confirmed at re-exploration.
The exact bleeding source was not directly visualized. The ileo-ileal anastomosis is the most probable source, supported by clot location and resulting limb distention. A proximally generated clot at the gastroileal anastomosis with distal migration, or bleeding from a Roux limb stump, are plausible alternatives. The gastric staple line is less likely given the distal clot location and negative intraoperative endoscopy.
Post-intervention melena on POD 4 is best interpreted as passage of residual intraluminal blood. Its self-limited course, hemodynamic stability, and absence of haemoglobin decline support a resolved bleeding episode. Temporary anticoagulation withholding, tranexamic acid, and hemoglobin surveillance were appropriate given the competing thromboprophylaxis needs in this patient [8].
Anastomotic leak was an important differential, given tachycardia, abdominal pain, turbid peritoneal fluid, and fibrinopurulent exudate. Intraoperative endoscopy excluded leakage at all anastomotic sites, with no collection or contrast extravasation on follow-up CT. This distinction was critical, as hemobezoar requires restoration of luminal patency, whereas anastomotic leak would demand a different source-control approach. Reported complications of sleeve gastrectomy with transit bipartition include anastomotic leak, postoperative bleeding, bowel obstruction, and anastomotic stricture, among others [9, 10].
This case expands the spectrum of early obstructive complications in Roux-en-Y-type bariatric anatomy. In patients undergoing Roux-en-Y transit bipartition, abdominal pain, tachycardia, and bilious vomiting should prompt urgent evaluation for mechanical obstruction and intraluminal bleeding. CT can identify obstruction and exclude other complications, but early laparoscopic re-exploration may be required for definitive diagnosis and management.
Conflicts of interest
The authors declare no conflict of interest.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Ethics statement
Written informed consent was obtained from the patient for publication of this case report and any accompanying images.
