Abstract
Background
We evaluated the incidence and presentations of internal hernias (IH) after laparoscopic antecolic Roux-en-Y gastric bypass (RYGB) at our institution.
Methods
We retrospectively reviewed the records of 594 patients who underwent laparoscopic antecolic RYGB at our institution between December 2004 and December 2010.
Results
Five hundred ninety-four patients underwent laparoscopic antecolic RYGB with a mean follow-up of 50.5 months. Thirty-six patients developed 37 IH (6.2 %) requiring surgical intervention. Mean age of IH patients was 36.9 years. Thirty-one out of 36 were female. Mean preoperative BMI was 44.3 Kg/m2. The mean time of presentation after their RYGB was 25.9 months. The mean % excess body weight loss at time of presentation was 54.0 %. Twenty-five out of 37 of IH occurred at Petersen’s space; 9/37 IH occurred under the jejunojejunostomy; three patients had hernias at both locations. Mesenteric swirling was the most common CT scan finding in 20/36 (55.6 %). Six out of 36 CT were initially read as normal; however, on retrospective review by a radiologist, abnormalities indicating IH were found in 4/6. Patients presented with different degrees of acuity: 6/37 with chronic abdominal pain and 28/37 with acute abdominal pain. Bowel necrosis was found in 3/37.
Conclusion
IH is a serious and potentially fatal complication of RYGB. Presentation can vary from chronic abdominal pain to bowel necrosis. CT is helpful in providing diagnosis; however, careful attention to the specific signs of small bowel volvulus, such as mesenteric swirl sign, should be given. IH should be considered in RYGB patients who present with even vague symptoms.
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References
Sjöström L, Narbro K, Sjöström CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357:741–52.
Tice JA, Karliner L, Walsh J, et al. Gastric banding or bypass? A systematic review comparing the two most popular bariatric procedures. Am J Med. 2008;121:885–93.
Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292:1724–37.
DeMaria EJ. Bariatric surgery for morbid obesity. N Engl J Med. 2007;356:2176–83.
Smith SC, Edwards CB, Goodman GN, Halversen RC, Simper SC. Open vs laparoscopic Roux-en-Y gastric bypass: comparison of operative morbidity and mortality. [Internet]. Obesity surgery. 2004. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med4&NEWS=N&AN=14980037.
Luján JA, Frutos MD, Hernández Q, et al. Laparoscopic versus open gastric bypass in the treatment of morbid obesity: a randomized prospective study. Ann Surg. 2004;239:433–7.
Westling A, Gustavsson S. Laparoscopic vs open Roux-en-Y gastric bypass: a prospective, randomized trial. Obes Surg. 2001;11:284–92.
Capella RF, Iannace VA, Capella JF. Bowel obstruction after open and laparoscopic gastric bypass surgery for morbid obesity. J Am Coll Surg. 2006;203:328–35.
Higa KD, Ho T, Boone KB. Internal hernias after laparoscopic Roux-en-Y gastric bypass: incidence, treatment and prevention. Obes Surg. 2003;13:350–4.
Gunabushanam G, Shankar S, Czerniach DR, et al. Small-bowel obstruction after laparoscopic Roux-en-Y gastric bypass surgery. [Internet]. Journal of computer assisted tomography. 2009. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=19478629.
Husain S, Ahmed AR, Johnson J, et al. Small-bowel obstruction after laparoscopic Roux-en-Y gastric bypass: etiology, diagnosis, and management. [Internet]. Archives of surgery (Chicago, Ill.: 1960). 2007. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med4&NEWS=N&AN=17938313.
Champion JK, Williams M. Small bowel obstruction and internal hernias after laparoscopic Roux-en-Y gastric bypass. [Internet]. Obesity surgery. 2003. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med4&NEWS=N&AN=12935361.
Felsher J, Brodsky J, Brody F. Small bowel obstruction after laparoscopic Roux-en-Y gastric bypass. [Internet]. Surgery. 2003. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med4&NEWS=N&AN=14555940.
Carmody B, DeMaria EJ, Jamal M, et al. Internal hernia after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2005;1:543–8.
Cho M, Pinto D, Carrodeguas L, et al. Frequency and management of internal hernias after laparoscopic antecolic antegastric Rouxen-Y gastric bypass without division of the small bowel mesentery or closure of mesenteric defects: review of 1400 consecutive cases. Surg Obes Relat Dis. 2006;2(2):87-91.
Taylor JD, Leitman IM, Rosser JB, et al. Does the position of the alimentary limb in Roux-en-Y gastric bypass surgery make a difference?. [Internet]. Journal of gastrointestinal surgery: official journal of the Society for Surgery of the Alimentary Tract. 2006. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med4&NEWS=N&AN=17175460.
Iannelli A, Buratti MS, Novellas S, et al. Internal hernia as a complication of laparoscopic Roux-en-Y gastric bypass. [Internet]. Obesity surgery. 2007. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med4&NEWS=N&AN=18008110.
Bauman RW, Pirrello JR. Internal hernia at Petersen’s space after laparoscopic Roux-en-Y gastric bypass: 6.2 % incidence without closure—a single surgeon series of 1047 cases. Surg Obes Relat Dis. 2009; 5(5):565-70.
Comeau E, Gagner M, Inabnet WB, et al. Symptomatic internal hernias after laparoscopic bariatric surgery. Surg Endosc. 2005;19:34–9.
De la Cruz-Muñoz N, Cabrera JC, Cuesta M, et al. Closure of mesenteric defect can lead to decrease in internal hernias after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2011;7:176–80.
Filip JE, Mattar SG, Bowers SP, et al. Internal hernia formation after laparoscopic Roux-en-Y gastric bypass for morbid obesity. [Internet]. The American surgeon. 2002. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med4&NEWS=N&AN=12132750.
Finnell CW, Madan AK, Tichansky DS, et al. Non-closure of defects during laparoscopic Roux-en-Y gastric bypass. [Internet]. Obesity surgery. 2007. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med4&NEWS=N&AN=17476862.
Garza Jr E, Kuhn J, Arnold D, et al. Internal hernias after laparoscopic Roux-en-Y gastric bypass. Am J Surg. 2004;188:796–800.
Koppman JS, Li C, Gandsas A. Small bowel obstruction after laparoscopic Roux-en-Y gastric bypass: a review of 9,527 patients. [Internet]. Journal of the American College of Surgeons. 2008. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=18308230.
Miyashiro LA, Fuller WD, Ali MR. Favorable internal hernia rate achieved using retrocolic, retrogastric alimentary limb in laparoscopic Roux-en-Y gastric bypass. [Internet]. Surgery for obesity and related diseases: official journal of the American Society for Bariatric Surgery. 2010. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=20359667.
Nelson LG, Gonzalez R, Haines K, et al. Spectrum and treatment of small bowel obstruction after Roux-en-Y gastric bypass. [Internet]. Surgery for obesity and related diseases: official journal of the American Society for Bariatric Surgery. 2006. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med4&NEWS=N&AN=16925356.
Paroz A, Calmes JM, Giusti V, et al. Internal hernia after laparoscopic Roux-en-Y gastric bypass for morbid obesity: a continuous challenge in bariatric surgery. [Internet]. Obesity surgery. 2006. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med4&NEWS=N&AN=17132415.
Brolin RE, Kella VN. Impact of complete mesenteric closure on small bowel obstruction and internal mesenteric hernia after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2013; 9(6):850-4.
Abasbassi M, Pottel H, Deylgat B, et al. Small bowel obstruction after antecolic antegastric laparoscopic Roux-en-Y gastric bypass without division of small bowel mesentery: a single-centre, 7-year review. Obes Surg. 2011;21:1822–7.
Rodriguez A, Mosti M, Sierra M, et al. Small bowel obstruction after antecolic and antegastric laparoscopic Roux-en-Y gastric bypass: could the incidence be reduced?. [Internet]. Obesity surgery. 2010. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=20401758.
Madan AK, Lo Menzo E, Dhawan N, et al. Internal hernias and nonclosure of mesenteric defects during laparoscopic Roux-en-Y gastric bypass. [Internet]. Obesity surgery. 2009. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=18931883.
Obeid A, McNeal S, Breland M, et al. Internal hernia after laparoscopic Roux-en-Y gastric bypass. J Gastrointest Surg. 2014; 18(2):250-5. Discussion 255-6.
Lockhart ME, Tessler FN, Canon CL, et al. Internal hernia after gastric bypass: sensitivity and specificity of seven CT signs with surgical correlation and controls. [Internet]. AJR. American journal of roentgenology. 2007. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med4&NEWS=N&AN=17312063.
Acknowledgments
The authors thank Mr. Paul Visintainer, PhD for his assistance in performing the statistical analysis of the data.
Conflict of Interest
The authors declare that they have no conflict of interest
Ethical Approval Statement
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards
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For this type of study, formal consent is not required.
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Al-Mansour, M.R., Mundy, R., Canoy, J.M. et al. Internal Hernia After Laparoscopic Antecolic Roux-en-Y Gastric Bypass. OBES SURG 25, 2106–2111 (2015). https://doi.org/10.1007/s11695-015-1672-0
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DOI: https://doi.org/10.1007/s11695-015-1672-0