Abstract
Purpose
A reliable and immediate diagnosis of internal hernia is important for optimal and timely management of patients with a history of gastric bypass surgery. The aims of this study were to evaluate the interrater agreement and diagnostic performance characteristics of seven predefined CT findings of internal herniation in patients admitted on clinical suspicion of internal herniation after laparoscopic Roux-en-Y gastric bypass (LRYGB).
Methods
Abdominal CT scans of 117 patients performed on clinical suspicion of internal hernia after LRYGB surgery were evaluated by three radiologists (two experts and one resident) for the following: (1) Swirl sign, (2) strangulation of superior mesenteric vein (SMV), (3) engorged mesenteric vessels and edema, (4) engorged lymph nodes, (5) ascites, (6) mushroom sign, (7) hurricane eye sign, and finally the overall conclusion. The CT findings were compared to the laparoscopic explorative findings.
Results
The highest interrater agreements were seen for the swirl sign, SMV strangulation, ascites, and overall conclusion (all Kappa 0.82–0.83). The presence of internal hernia was significantly and independently associated with SMV strangulation (OR 18.3; 95% CI 4.3–78.1; p < 0.001) and mesenteric edema (OR 5.2; 95% CI 1.4–19.6; p < 0.001) on multivariate analysis, while the other CT findings were not independently associated with herniation. The highest sensitivity was observed for mesenteric edema (85.0%), while SMV strangulation had the highest specificity (94.8%).
Conclusion
CT is an accurate diagnostic tool for detection of internal hernia after LRYGB. SMV strangulation and mesenteric edema are highly predictive and easily identified features of internal herniation.
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References
Higa KD, Ho T, Boone KB (2003) Internal hernias after laparoscopic Roux-en-Y gastric bypass: incidence, treatment and prevention. Obes Surg 13:350–354. https://doi.org/10.1381/096089203765887642
Garza E, Kuhn J, Arnold D, et al. (2004) Internal hernias after laparoscopic Roux-en-Y gastric bypass. Am J Surg 188:796–800. https://doi.org/10.1016/j.amjsurg.2004.08.049
Iannelli A, Facchiano E, Gugenheim J (2006) Internal hernia after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Obes Surg 16:1265–1271. https://doi.org/10.1381/096089206778663689
Dilauro M, Mcinnes MDF, Schieda N, et al. (2017) Internal hernia after laparoscopic roux-en-Y gastric bypass: optimal CT signs for diagnosis and clinical decision making. Radiology. https://doi.org/10.1148/radiol.2016160956
Iannuccilli JD, Grand D, Murphy BL, et al. (2009) Sensitivity and specificity of eight CT signs in the preoperative diagnosis of internal mesenteric hernia following Roux-en-Y gastric bypass surgery. Clin Radiol 64:373–380. https://doi.org/10.1016/j.crad.2008.10.008
Patel RY, Baer JW, Texeira J, Frager D, Cooke K (2009) Internal hernia complications of gastric bypass surgery in the acute setting: spectrum of imaging findings. Emerg Radiol 16:283–289. https://doi.org/10.1007/s10140-008-0781-7
Lockhart ME, Tessler FN, Canon CL, et al. (2007) Internal hernia after gastric bypass: sensitivity and specificity of seven CT signs with surgical correlation and controls. Am J Roentgenol 188:745–750. https://doi.org/10.2214/AJR.06.0541
Ximenes MAS, Baroni RH, Trindade RMC, et al. (2011) Petersen’s hernia as a complication of bariatric surgery: CT findings. Abdom Imaging 36:126–129. https://doi.org/10.1007/s00261-010-9626-4
Reddy SA, Yang C, McGinnis LA, et al. (2007) Diagnosis of transmesocolic internal hernia as a complication of retrocolic gastric bypass: CT imaging criteria. Am J Roentgenol 189:52–55. https://doi.org/10.2214/AJR.06.0898
Ahmed AR, Rickards G, Johnson J, Boss T, O’Malley W (2009) Radiological findings in symptomatic internal hernias after laparoscopic gastric bypass. Obes Surg 19:1530–1535. https://doi.org/10.1007/s11695-009-9956-x
Goudsmedt F, Deylgat B, Coenegrachts K, Van De Moortele K, Dillemans B (2015) Internal hernia after laparoscopic Roux-en-Y gastric bypass: a correlation between radiological and operative findings. Obes Surg 25:622–627. https://doi.org/10.1007/s11695-014-1433-5
Altieri MS, Pryor AD, Telem DA, et al. (2015) Algorithmic approach to utilization of CT scans for detection of internal hernia in the gastric bypass patient. Surg Obes Relat Dis 11:1207–1211. https://doi.org/10.1016/j.soard.2015.02.010
Karila-Cohen P, Cuccioli F, Tammaro P, et al. (2017) Contribution of computed tomographic imaging to the management of acute abdominal pain after gastric bypass: correlation between radiological and surgical findings. Obes Surg. https://doi.org/10.1007/s11695-017-2601-1
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All authors have no conflicts of interest. No funding was received for this study. The study involves humans and was approved by the Danish Data Protection Agency, and was conducted in accordance with the ethical standards of the institutional research committee and Helsinki Declaration.
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Frøkjær, J.B., Jensen, W.N., Holt, G. et al. The diagnostic performance and interrater agreement of seven CT findings in the diagnosis of internal hernia after gastric bypass operation. Abdom Radiol 43, 3220–3226 (2018). https://doi.org/10.1007/s00261-018-1640-y
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DOI: https://doi.org/10.1007/s00261-018-1640-y