Abstract
Purpose
Weight loss is one of the desired outcomes after a gastric bypass, in order to reduce co-morbidity, and even mortality. However, weight loss might contribute to a serious complication: internal herniation (IH). Pre-operative diagnosis of IH is demanding. This study was conducted to investigate if percentage total weight loss (%TWL) is clinically usable in recognizing patients with IH.
Materials and Methods
Patients who had undergone a gastric bypass between 2011 and 2014 were included retrospectively if a CT scan or reoperation was performed for suspected IH between 2011 and 2016. Differences in %TWL were calculated in patients with IH and without (NO-IH). A sub analysis was done in patients with complaints. A multivariate analysis to identify risk factors for IH was performed.
Results
Out of 1007 patients, 31 patients were diagnosed with an IH (3.1%) after a median time of 16.5 months (range 6.5–46.1). The %TWL was higher in patients with an IH (34.2% ± 12.7) vs. NO-IH (30.8% ± 9.6). This result was also seen in patients presenting with symptoms (IH 34.2% ± 12.7 vs. NO-IH 27.0% ± 14.8). If %TWL is above 30%, IH is significantly more diagnosed in patients presenting with symptoms. A multivariate logistic model for IH in patients presenting with symptoms identified both ≥ 30%TWL (adjusted OR 3.1, 95% CI 1.1–8.8, p = 0.036) and abdominal cramping (adjusted OR 3.2, 95% CI 1.2–8.5, p = 0.0021) as risk factors.
Conclusion
Our study showed significant more %TWL in patients with an IH. Both ≥ 30%TWL and cramping abdominal pain result in a threefold higher risk of presence of IH.
Similar content being viewed by others
References
Spivak H, Abdelmelek MF, Beltran OR, et al. Long-term outcomes of laparoscopic adjustable gastric banding and laparoscopic Roux-en-Y gastric bypass in the United States. Surg Endosc. 2012;26:1909–19.
Colquitt JL, Pickett K, Loveman E, et al. Surgery for weight loss in adults. Cochrane.Database.Syst Rev. 2014;CD003641.
Courcoulas AP, Goodpaster BH, Eagleton JK, et al. Surgical vs medical treatments for type 2 diabetes mellitus: a randomized clinical trial. JAMA Surg. 2014;149:707–15.
Sjostrom L. Bariatric surgery and reduction in morbidity and mortality: experiences from the SOS study. Int J Obes. 2008;32(Suppl 7):S93–7.
Iannelli A, Buratti MS, Novellas S, et al. Internal hernia as a complication of laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2007;17:1283–6.
Aghajani E, Jacobsen HJ, Nergaard BJ, et al. Internal hernia after gastric bypass: a new and simplified technique for laparoscopic primary closure of the mesenteric defects. J Gastrointest Surg. 2012;16:641–5.
Quezada N, Leon F, Jones A, et al. High frequency of internal hernias after Roux-en-Y gastric bypass. Obes Surg. 2015;25:615–21.
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.
Garrard CL, Clements RH, Nanney L, et al. Adhesion formation is reduced after laparoscopic surgery. Surg Endosc. 1999;13:10–3.
Blachar A, Federle MP. Gastrointestinal complications of laparoscopic roux-en-Y gastric bypass surgery in patients who are morbidly obese: findings on radiography and CT. AJR Am J Roentgenol. 2002;179:1437–42.
Champion JK, Williams M. Small bowel obstruction and internal hernias after laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2003;13:596–600.
Ahmed AR, Rickards G, Husain S, et al. Trends in internal hernia incidence after laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2007;17:1563–6.
Scheirey CD, Scholz FJ, Shah PC, et al. Radiology of the laparoscopic Roux-en-Y gastric bypass procedure: conceptualization and precise interpretation of results. Radiographics. 2006;26:1355–71.
Hamdan K, Somers S, Chand M. Management of late postoperative complications of bariatric surgery. Br.J.Surg. 2011;98:1345–55.
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.
Rogula T, Yenumula PR, Schauer PR. A complication of Roux-en-Y gastric bypass: intestinal obstruction. Surg Endosc. 2007;21:1914–8.
Quebbemann BB, Dallal RM. The orientation of the antecolic Roux limb markedly affects the incidence of internal hernias after laparoscopic gastric bypass. Obes Surg. 2005;15:766–70.
Merkle EM, Hallowell PT, Crouse C, et al. Roux-en-Y gastric bypass for clinically severe obesity: normal appearance and spectrum of complications at imaging. Radiology. 2005;234:674–83.
Schneider C, Cobb W, Scott J, et al. Rapid excess weight loss following laparoscopic gastric bypass leads to increased risk of internal hernia. Surg Endosc. 2011;25:1594–8.
Geubbels N, Roell EA, Acherman YI, et al. Internal herniation after laparoscopic Roux-en-Y gastric bypass surgery: pitfalls in diagnosing and the introduction of the AMSTERDAM classification. Obes Surg. 2016;26:1859–66.
Stenberg E, Szabo E, Agren G, et al. Closure of mesenteric defects in laparoscopic gastric bypass: a multicentre, randomised, parallel, open-label trial. Lancet. 2016;387:1397–404.
Geubbels N, Lijftogt N, Fiocco M, et al. Meta-analysis of internal herniation after gastric bypass surgery. Br J Surg. 2015;102:451–60.
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. AJR Am J Roentgenol. 2007;188:745–50.
Dilauro M, McInnes MD, Schieda N, et al. Internal hernia after laparoscopic Roux-en-Y gastric bypass: optimal CT signs for diagnosis and clinical decision making. Radiology. 2017;282:752–60.
Goudsmedt F, Deylgat B, Coenegrachts K, et al. Internal hernia after laparoscopic Roux-en-Y gastric bypass: a correlation between radiological and operative findings. Obes Surg. 2015;25:622–7.
Madan AK, Lo ME, Dhawan N, et al. Internal hernias and nonclosure of mesenteric defects during laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2009;19:549–52.
Cho M, Carrodeguas L, Pinto D, et al. Diagnosis and management of partial small bowel obstruction after laparoscopic antecolic antegastric Roux-en-Y gastric bypass for morbid obesity. J Am Coll Surg. 2006;202:262–8.
Finnell CW, Madan AK, Tichansky DS, et al. Non-closure of defects during laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2007;17:145–8.
Han SH, Gracia C, Mehran A, et al. Improved outcomes using a systematic and evidence-based approach to the laparoscopic Roux-en-Y gastric bypass in a single academic institution. Am Surg. 2007;73:955–8.
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.
Nelson LG, Gonzalez R, Haines K, et al. Spectrum and treatment of small bowel obstruction after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2006;2:377–83. discussion
Escalona A, Devaud N, Perez G, et al. Antecolic versus retrocolic alimentary limb in laparoscopic Roux-en-Y gastric bypass: a comparative study. Surg Obes Relat Dis. 2007;3:423–7.
Steele KE, Prokopowicz GP, Magnuson T, et al. Laparoscopic antecolic Roux-en-Y gastric bypass with closure of internal defects leads to fewer internal hernias than the retrocolic approach. Surg Endosc. 2008;22:2056–61.
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? Obes Surg. 2010;20:1380–4.
Himpens J, Verbrugghe A, Cadiere GB, et al. Long-term results of laparoscopic Roux-en-Y gastric bypass: evaluation after 9 years. Obes Surg. 2012;22:1586–93.
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;9:850–4.
Gandhi AD, Patel RA, Brolin RE. Elective laparoscopy for herald symptoms of mesenteric/internal hernia after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2009;5:144–9.
Ortega J, Cassinello N, Sanchez-Antunez D, et al. Anatomical basis for the low incidence of internal hernia after a laparoscopic Roux-en-Y gastric bypass without mesenteric closure. Obes Surg. 2013;23:1273–80.
Kristensen SD, Jess P, Floyd AK, et al. Internal herniation after laparoscopic antecolic Roux-en-Y gastric bypass: a nationwide Danish study based on the Danish National Patient Register. Surg Obes Relat Dis. 2016;12:297–303.
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;5:565–70.
Ederveen JC, van Berckel MMG, Jol S, et al. Diagnosing internal herniation after laparoscopic Roux-en-Y gastric bypass: usefulness of systematically reviewing CT scans using ten signs. Eur Radiol. 2018;28:3583–90.
Ederveen JC, van Berckel MMG, Nienhuijs SW, et al. Predictive value of abdominal CT in evaluating internal herniation after bariatric laparoscopic Roux-en-Y gastric bypass. Br J Surg. 2018;105:1623–9.
Pierik AS, Coblijn UK, de Raaff CAL, et al. Unexplained abdominal pain in morbidly obese patients after bariatric surgery. Surg Obes Relat Dis. 2017;13:1743–51.
Blom-Hogestol IK, Stubhaug A, Kristinsson JA, et al. Diagnosis and treatment of chronic abdominal pain 5 years after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2018;14:1544–51.
Nandipati KC, Lin E, Husain F, et al. Counterclockwise rotation of Roux-en-Y limb significantly reduces internal herniation in laparoscopic Roux-en-Y gastric bypass (LRYGB). J Gastrointest Surg. 2012;16:675–81.
Stenberg E, Ottosson J, Szabo E, et al. Comparing techniques for mesenteric defects closure in laparoscopic gastric bypass surgery-a register-based cohort study. Obes Surg. 2019;29:1229–35.
Aghajani E, Nergaard BJ, Leifson BG, et al. The mesenteric defects in laparoscopic Roux-en-Y gastric bypass: 5 years follow-up of non-closure versus closure using the stapler technique. Surg Endosc. 2017;31:3743–8.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
The authors declare that they have no conflict of interest.
Informed Consent
For this type of study, formal consent is not required.
Human and Animal Rights
This article does not contain any prospective studies with human participants or animals performed by any of the authors.
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
van Berckel, M.M.G., Ederveen, J.C., Nederend, J. et al. Internal Herniation and Weight Loss in Patients after Roux-en-Y Gastric Bypass. OBES SURG 30, 2652–2658 (2020). https://doi.org/10.1007/s11695-020-04542-z
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11695-020-04542-z