Background

A 60-year-old male presented in delayed fashion to our ER with superior mesenteric artery embolus from atrial fibrillation. He was peritoneal on exam with CT findings consistent with dead bowel. The patient had laparoscopic duodenal switch 8 years prior with excellent weight loss results. The patient was taken emergently for exploratory laparotomy and required extensive resection. Vascular surgery was consulted. No embolectomy was performed given the degree of necrosis. After initial resection and takebacks, the BP limb was necrotic to around the D3/D4 junction, the roux limb was around 20 cm, and the terminal ileum around 25 cm. Anastomosis was performed between the alimentary limb and the terminal ileum. Biliopancreatic diversion was performed via foley catheter externalization. On final takeback, a portion of the cecum had become necrotic. We debrided and primarily repaired the cecum to preserve the ICV. To maximize length and preserve biliary drainage a side-to-side duodenoileostomy was performed in antecolic fashion. A side-to-side anastomosis was created between the duodenum of the BP limb and the ileal roux limb. This left our patient with 40 cm of continuous small bowel and intact ICV. The patient did well postoperatively and was discharged from the hospital around post op day 7 after his final operation. He is TPN dependent and is under evaluation now to start Teduglutide. Extensive small bowel loss post-bariatric surgery can pose a challenge during reconstruction. Treatment should maximize intestinal length with preservation of the ileocecal valve. Delay in diagnosis of intestinal ischemia is a catastrophic event.