Smoking Is Correlated to Internal Hernia After Gastric Bypass Surgery: a Post hoc Analysis of Data from a Randomized Clinical Trial.

PURPOSE: Internal herniation is a well-known complication of laparoscopic Roux-en-Y gastric bypass (L-RYGB). The aim of this study was to evaluate smoking as an independent risk factor for internal herniation after L-RYGB. MATERIALS AND METHODS: This study was performed as an exploratory post hoc analysis of data from a previous published randomized controlled trial (RCT) designed to compare closure and non-closure of mesenteric defects in patients undergoing L-RYGB. The primary outcome of this study was to assess the significance of smoking as a risk factor for internal herniation after L-RYGB. Secondary outcome was early postoperative complications defined as Clavien-Dindo grade ≥ 2. RESULTS: Four hundred one patients were available for post hoc analysis. The risk of internal herniation was significantly higher among patients who were smoking preoperatively (hazard ratio (HR) 2.4, 95% confidence interval (c.i.) 1.3 to 4.5; p = 0.005). This result persisted after adjusting for other patient characteristics (HR 2.2, 1.2 to 4.2; p = 0.016). 6.0% of the patients had postoperative complications within the first 30 days. 4.9% of these patients were smoking and 6.3% were not smoking, p = 0.657. 11.0% of the patients underwent surgery due to internal herniation by 5 years after the primary procedure. CONCLUSION: Smoking is a significant risk factor for internal herniation but did not increase risk for 30 days postoperative complications.

First Global Report of Catastrophic Results Due to Internal Herniation of Roux Limb in the Space Between the Gastric Pouch and Band: a Series of 3 Cases of Banded Roux-en-Y Gastric Bypass (BRYGB).

BACKGROUND: Banded Roux-en-Y gastric bypass (BRYGB) is associated with complications known with the bypass along with specific complications related to the band. Roux-limb gangrene, due to herniation between the gastric pouch and band, however, has no mention in literature. METHODS: We report this potentially fatal complication of BRYGB and its management in a series of 3 patients. RESULTS: All 3 patients were women, 35-45 years, with a BRYGB (roux limb-150 cm, biliopancreatic limb-100 cm) using a MiniMizer or a Fobi ring with 2-point fixation to the gastric pouch 2 cm above the gastrojejunostomy. All patients presented 3-4 years post-BRYGB, with an average total body weight loss (TWL%) of 41.28%. To discuss video of a single case, a 35-year-old female presented with abdominal pain, hematemesis and signs of abdominal tenderness and guarding. X-Ray abdomen showed distended small bowel loops and CT-scan revealed ischemic small bowel loops with free fluid. Diagnostic laparoscopy showed alimentary/roux limb (AL) gangrene, from the gastrojejunostomy to the jejunojejunostomy. The entire AL had herniated between the gastric pouch and band which had formed an obstructive ring around the herniated bowel loop and led to compromise of blood supply and gangrene. Resection of gangrenous bowel with reversal of BRYGB was done. CONCLUSION: Early diagnosis and timely management may save a patient from gangrene. It also raises questions: Is a 2-point fixation of the band to the gastric pouch insufficient? Does a longer roux limb make it prone to herniating in the space between the gastric pouch and band?

Midgut Volvulus on an Octogenarian Male: A Case Report.

Midgut volvulus is a rare incidence in adults, especially in octogenarians. More unlikely is to find a midgut volvulus without necrosis or the need to do bowel resection when the volvulus is found within an internal hernia due to a mesenteric defect. No case has been reported with our unusual presentation, making it a rare and challenging discovery. We describe the case of an 83-year-old male who presented with nonspecific symptoms and was found to have a midgut volvulus with an internal hernia through a mesenteric defect, which had a successful recovery at the end.

Mesenteric Defect Closure and the Rate of Internal Hernia in Laparoscopic Roux-en-Y Gastric Bypass: A Systematic Review and Meta-analysis.

Internal hernias are a worrying complication from laparoscopic Roux-en-Y gastric bypass (LRGB), with potential small bowel necrosis and obstruction. An electronic database search of Medline, Embase, and Pubmed was performed. All studies investigating the internal hernia rates in patients whose mesenteric defects were closed vs. not closed during LRGB were analysed. Odds ratios were calculated to assess the difference in internal hernia rate. A total of 14 studies totalling 20,553 patients undergoing LRGB were included. Internal hernia rate (220/12,445 (2%) closure vs. 509/8108 (6%) non-closure) and re-operation for small bowel obstruction (86/5437 (2%) closed vs. 300/3132 (10%) non-closure) were reduced when defects were closed. There was no difference observed when sutures were used to close the defects compared to clips/staples.

Closed or Unclosed Mesentery? A Meta-analysis of Internal Herniation After Laparoscopic Roux-en-Y Gastric Bypass.

During the laparoscopic Roux-en-Y gastric bypass procedure, closing mesentery or not was still controversial according to preexisted studies. So, the current meta-analysis aimed to compare the outcome of closure versus non-closure of mesenteric defects in laparoscopic Roux-en-Y gastric bypass. Fifteen studies were included, enrolling 53,488 patients. Based on the outcome of analysis, regarding internal hernia, Petersen space's IH, jejunal mesenteric's IH, hospital days, and reoperation, closure of the mesentery was better than non-closure. Besides, small bowel obstruction, anastomosis ulcer, stenosis, leakage, bleeding, gastrointestinal perforation, and postoperative BMI of patients show no difference between non-closure and closure.

Effect of Suture Used for Closure of Mesenteric Defects After Laparoscopic Roux-en-Y Gastric Bypass: Single-Center Study.

INTRODUCTION: Small bowel obstruction (SBO) due to internal herniation (IH) is a well-known complication of laparoscopic Roux-en-Y gastric bypass (LRYGBP). The objective of this study is to evaluate different types of non-absorbable sutures used for closure of the defects regarding the incidence of SBO due to IH/adhesions, adhesion formation in general, or reopening of the defects. METHODS: A single-center retrospective study was performed. Patients who underwent LRYGBP were divided in 3 groups: group A closure of the defects with monofilament Polypropylene suture (Prolene®), group B with braided polyester suture (Ethibond®), group C with barbed knotless Polybutester suture (V-Loc®). Descriptive statistics were performed regarding SBO due to IH/adhesions, adhesion formation, and reopening of closed defects. RESULTS: From 5145 patients, 224 patients underwent exploratory laparoscopy for suspicion of SBO. Mean time interval was 28.4 months. IH or intermittent IH was found in 1.94% in group A, 1.78% in group B, and 1.40% in group C. Obstruction due to adhesions was found in 0.70%, 0.36%, and 0.42% per group, respectively. Adhesions in general were observed in 1.47% in group A, 1.43% in group B, and 1.06% in group C. The incidence of reopening was higher in group A (2.24%) in comparison with group B (1.13%, P = 0.041) and group C (1.05%, P = 0.001). CONCLUSIONS: After descriptive analysis, these results can withhold no difference among the 3 non-absorbable sutures regarding incidence of SBO due to IH or SBO due to adhesions, yet tendency for higher reopening rates after closure with monofilament Polypropylene suture is observed.

Midgut Volvulus Evolving From Internal Herniation Following Roux-en-Y Gastric Bypass Surgery.

In the literature, midgut volvulus is a well-known surgical complication following gastric bypass surgery that is serious and necessitates an immediate intervention. Here, we report a case of internal herniation that was misdiagnosed twice but eventually managed appropriately. A 27-year-old male with a surgical history of Roux-en-Y gastric bypass came to the emergency department complaining of severe epigastric abdominal pain. Two months earlier, he had a similar pain which was treated with Helicobacter pylori eradication therapy. Despite completing the eradication therapy, the pain reoccurred. Computed tomography angiography showed a filling defect in the superior mesenteric artery that was followed by a diagnostic laparoscopy ending with internal hernia reduction. Physicians should consider internal herniation as a differential diagnosis for every patient with a history of gastric bypass surgery presenting with abdominal pain.

The role of citrulline, intestinal fatty acid-binding protein, and D-dimer as potential biomarkers in the diagnosis of internal herniation after Roux-en-Y gastric bypass.

BACKGROUND: Diagnosing internal herniation (IH) in Roux-en-Y gastric bypass (RYGB) patients with acute abdominal pain poses a diagnostic challenge. Diagnostic laparoscopy is often required for a definitive diagnosis. We hypothesized that intestinal ischemia biomarkers would aid in the diagnosing of IH. OBJECTIVES: To explore intestinal ischemia biomarkers in diagnosing IH. SETTING: University Hospital, Sweden. METHODS: Prospective inclusion of 46 RYGB patients admitted for acute abdominal pain between June 2015 and December 2017. Blood samples for analysis of citrulline, intestinal fatty acid-binding protein (I-FABP), and D-dimer were drawn <72 hours from admission and compared between patients with IH (n = 8), small bowel obstruction (SBO) (n = 5), other specified diagnoses (n = 12), or unspecified abdominal pain (n = 21). Levels of white blood cell count (WBC), C-reactive protein (CRP), and lactate at admission were compared. A prospective pain questionnaire for time of pain onset and level of pain at onset and at admission was analyzed. RESULTS: None of the investigated biomarkers differed significantly between diagnosis categories. Most patients with IH had normal CRP, WBC, and D-dimer levels while their lactate levels were significantly lower (P = .029) compared with the rest of the cohort. Neither pain level nor pain duration differed between the groups. CONCLUSION: This study shows that citrulline, I-FABP, and D-dimer cannot be used to diagnose IH and indicates that CRP, D-dimer, and lactate are rarely elevated by an IH. Furthermore, pain intensity and duration cannot differentiate patients with IH. A diagnostic laparoscopy remains the gold standard to diagnose and rule out an IH.

Retro-Ileal Conduit Small Bowel Internal Herniation After Radical Cystectomy: A Surgical Complication.

Intestinal obstruction is one of the most important cause of acute abdomen. An internal herniation is an uncommon yet relevant clinical entity causing an acute intestinal obstruction that can occur after major bowel surgery. Here, we describe a case of acute intestinal obstruction caused by internal herniation in a patient with muscle-invasive urinary bladder carcinoma who underwent robot-assisted radical cystectomy with an ileal conduit. We also discuss the management of adjuvant chemotherapy-induced leukopenia.

Internal Herniation Incidence After RYGB and the Predictive Ability of a CT Scan as a Diagnostic Tool.

PURPOSE: The clinical diagnosis of an internal herniation (IH) after a Roux-en-Y Gastric Bypass (RYGB) remains difficult; therefore, performing a CT scan is usually part of the diagnostic process. The goal of this study was to assess the incidence of IH in patients with open and closed MD (mesenteric defect) and to study if the ability to diagnose an IH with a CT scan is different between these groups. MATERIALS AND METHODS: IH was defined as a visible intestine through the mesenteric defect underneath the jejunojejunostomy and/or in the Petersen's space. CT scan outcomes were compared with the clinical diagnosis of an IH. Until 31 June 2013, standard care was to leave mesenteric defects (MDs) open; after this date, they were always closed. RESULTS: The incidence of IH in the primarily non-closed group was 3.9%, and in the primarily closed group, this was 1.3% (p = 0.001). In group A (non-closed MD and CT), the sensitivity of the CT scan was 80%, and specificity was 0%. In group C (closed MD and CT), the sensitivity was 64.7%, and specificity was 89.5%. In group B (non-closed, no CT), an IH was visible in 58.7% of the cases and not in 41.3%. In group D (only a re-laparoscopy), an IH was visible in 34.3% of the cases and not in 65.7%. CONCLUSIONS: Using the CT scan in suspected IH is not useful in if the MDs were not closed. If the MDs were closed, then a CT scan is predictive for the diagnosis IH.

Management of a Complicated Internal Herniation After Roux-en-Y Gastric Bypass in a 28-Week Pregnant Woman.

BACKGROUND: Small bowel obstruction (SBO) due to internal hernia (IH) is a well-known late complication after laparoscopic Roux-en-Y gastric bypass (LRYGB), with an incidence between 0.5 and 10% as reported by Iannelli et al. (Obes Surg. 17(10):1283-6, 2007). It is reported most frequently 1-2 years after surgery because of the greater weight loss at that time, with rapid loss of the mesenteric fat consequently as discussed by Stenberg et al. (Lancet. 387(10026):1397-404, 2016). Currently, women constitute more than 50% of the patients undergoing bariatric surgery and most of them are of childbearing age as reported by the World Health Organization (2015). SBO, due to IH, is a rare complication during pregnancy, mostly occurring during the third trimester as discussed by Torres-Villalobos et al. (Obes Surg 19(7):944-50, 2009), and can result in fetal and maternal morbidity and even mortality as reported by Vannevel et al. (Obstet Gynecol. 127(6):1013-20, 2016). Moreover, the physiologic changes of pregnancy can mask the symptoms of SBO after LRYGB, leading to significant diagnostic and therapeutic delays as detailed by Wax et al. (Am J Obstet Gynecol 208(4):265-71, 2013). Therefore, an early surgical exploration is necessary in this particular and uncommon situation as discussed by Webster et al. (Ann R Coll Surg Engl 97(5):339-44, 2015). METHODS: A 32-year-old female patient, with Ehlers-Danlos syndrome and chronic pain, was in the 28th week of her first pregnancy after bariatric surgery. She had had an antecolic LRYGB 6 years ago in another institution, resulting in a 35-kg weight loss. She presented to the emergency department with severe and persistent epigastric pain associated with nausea and vomiting during 24 h. On physical examination, her abdomen was painful and tender at the epigastrium and left hypochondrium, and her vital signs were normal. The blood tests were in the normal range except the white blood cell count at 12'000 G/l. The obstetric and neonatal team was involved, and fetal heart monitoring was normal. Abdominal ultrasonography ruled out other causes of pain. An abdominal MRI was performed and displayed a distended proximal small bowel, free abdominal fluid, and bowel mesenteric edema in the left upper quadrant with compression of the superior mesenteric vein. Internal hernia with intestinal suffering was suspected, and the patient consented for emergency laparoscopy. RESULTS: The laparoscopic exploration, reduction of the internal hernia, and closure of the mesenteric defects are demonstrated step-by-step in the presented intraoperative video. The postoperative course was uncomplicated for both patient and fetus. Oral feeding was resumed at day 1, with no residual symptom, and the patient was discharged on postoperative day 3. At 1-month follow-up, she had no complaint and her pregnancy had resumed a normal course. She delivered a healthy baby at 36 weeks without any complication. CONCLUSIONS: Internal herniation after LRYGB represents a rare, high-risk complication during pregnancy. A low threshold for imaging, preferably by abdominal MRI, is recommended. Multidisciplinary management, including obstetricians and bariatric surgeons, is necessary in order to avoid maternal and fetal adverse outcomes. During surgery, recognition of the anatomy is often difficult, and parts of the bowel are distended and fragile. Starting to run the bowel backwards from the ileocecal valve is a crucial surgical step for reducing internal hernias during LRYGB, and reduces both the risk to worsen the situation and of bowel injury, making its management less hazardous.

Abdominal pain after gastric bypass in the acute general surgical care setting.

BACKGROUND: Managing acute abdominal pain in the large and growing population of Roux-en-Y gastric bypass (RYGB)-operated patients poses a challenge to general surgeons, because of diagnostic limitations and the risk of internal herniation. OBJECTIVE: To investigate the diagnoses, management, and outcome of RYGB patients admitted for acute abdominal pain. SETTING: University Hospital, Sweden. METHODS: Prospective inclusion of 280 consecutive RYGB patients admitted for acute abdominal pain between April 2012 and June 2015. Readmissions, surgical procedures, and overall mortality were recorded until October 2018. Medical records were retrospectively reviewed for anthropometric measures, medical history, time from RYGB surgery, and previous closure of mesenteric gaps. Admissions were separated into early (≤30 d) or late (>30 d) after RYGB. Procedures performed were categorized as follows: RYGB complication, other surgery, or unremarkable laparoscopy. Patients discharged with diagnosis of unspecified abdominal pain were separately analyzed. Diagnostic investigations, bariatric competency, on call surgery, surgical complications, and length of stay were registered. RESULTS: In late admissions, the cause of the abdominal complaints remained unexplained in 127 of 262 (48%) patients despite 95 abdominal computed tomographies and 28 diagnostic laparoscopies. Emergency surgery was performed in 128 of 262 (49%) patients. RYGB complications (n = 66), mainly internal herniation (n = 42), were >2 times more frequent than other surgical procedures (n = 32), such as cholecystectomies (n = 23). Internal herniation could occur at any time interval from RYGB surgery and regardless of previously closed mesenteric gaps. CONCLUSION: Better tools for evaluation of acute abdominal pain in RYGB patients are needed to reduce the number of unremarkable laparoscopies and admissions of patients with unspecified abdominal pain.

The Acute Abdomen in Pregnant Women After Roux-en-Y Gastric Bypass: Encouraging Results from a National Referral Centre.

BACKGROUND: Pregnant women with a history of bariatric surgery (BS) may develop acute abdominal pain related to this surgery, especially after Roux-en-Y gastric bypass. Studies showed alarming results regarding maternal and foetal morbidity and mortality. The aim of this study was to analyse these outcomes for pregnant women and their offspring. METHODS: Single-centre retrospective cohort study in a tertiary referral centre for bariatric complications during pregnancy. Pregnant women with a history of BS referred between September 2015 and November 2019 with acute abdominal pain suspected for a bariatric complication were included. Data were retrospectively collected from the patient files, and a questionnaire was sent regarding the postoperative course and childbirth. RESULTS: Fifty women were included. At presentation, mean maternal age was 31 (± 4) years, and median gestational age was 28+4 (25+4, 30+5) weeks. Thirteen women were treated conservatively. Thirty-seven women underwent surgery for, among others, internal herniation (n = 26) and intussusception (n = 6). Six women required small bowel resection. Two women underwent an emergency caesarean section shortly after the surgery due to foetal distress. Eight women delivered preterm of whom five infants required respiratory support. There was one intrauterine foetal death. Surgery > 48 h after the onset of the symptoms was not associated with an increase in small bowel resections or preterm birth. CONCLUSION: Acute abdominal pain in pregnant women may be related to a bariatric complication. Further awareness of bariatric complications within the obstetric care and transferal to specialized care to prevent diagnostic delay may improve maternal and neonatal outcome.

Internal Herniation and Weight Loss in Patients after Roux-en-Y Gastric Bypass.

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.

Intestinal obstruction caused by pericecal internal herniation.

Intestinal obstruction caused by pericecal internal herniation are rare and only described in a few cases. This case describes an 80-year-old man presented with acute abdominal pain, nausea and vomiting, with no prior surgical history. Computed tomography was performed and showed a closed loop short bowel obstruction in the right lower quadrant and ascites. Laparoscopy revealed pericecal internal hernia. This is a viscous protrusion through a defect in the peritoneal cavity. Current operative treatment modalities include minimally invasive surgery. Laparoscopic repair of internal herniation is possible and feasible in experienced hands. It must be included in the differential diagnoses of every patient who presents with abdominal pain. When diagnosed act quick and thorough and expeditiously. Treatment preference should be a laparoscopic procedure.

Chyloperitoneum secondary to internal herniation complicating omega-loop gastric bypass.

Chyloperitoneum is a potential complication of omega-loop gastric bypass caused by internal herniation. Chronic compression of the mesentery leads to chylous extravasation that can mimic peritonitis.

Closure of mesenteric defects during Roux-en-Y gastric bypass for obesity: A systematic review and meta-analysis protocol.

INTRODUCTION: Closure of mesenteric defects during laparoscopic Roux-en-Y gastric bypass surgery (RYGB) has not been fully established as standard operative practice. However, in recent years a body of evidence has emerged suggesting that non-closure of defects leads to increased rates of internal herniation and its potential consequences, including the need for reoperation, along with an associated morbidity and mortality risk. Within the emerging literature there has also been some evidence of a greater risk of 30-day complications in closure groups. This systematic review and meta-analysis aims to look at the existing evidence and provide guidance on whether closure of mesenteric defects should be standard operative practice. METHODS: The systematic review and meta-analysis has been registered a priori. A literature search will be performed interrogating the Medline and Embase databases via Ovid, and also the Cochrane Controlled Register of Trials (CENTRAL), to identify randomised and non-randomised studies reporting comparative outcomes following closure vs. non-closure of mesenteric defects during RYGB. The primary outcome will be reoperation for small bowel obstruction, and secondary outcomes will include internal herniation, jejuno-jejunal anastomosis narrowing or kinking, adhesions, complications (<30 days and >30 days after surgery), 30-day mortality, reoperation, and any other outcome deemed relevant and reported in more than one study.

Closure of mesenteric defects is associated with a higher incidence of small bowel obstruction due to adhesions after laparoscopic antecolic Roux-en-y gastric bypass: A retrospective cohort study.

INTRODUCTION: Small bowel obstruction (SBO) is a frequent complication after laparoscopic Roux-en-y gastric bypass (LRYGB). OBJECTIVES: We wanted to evaluate the effect of closure of the mesenteric defects on the incidence of SBO and postoperative complications after LRYGB. Furthermore, we wanted to identify possible risk factors for SBO. METHODS: This study was a retrospective cohort study of 1364 patients who underwent a LRYGB between July 2003 and October 2015. Cohort 1 contained 724 patients in whom mesenteric defects were not closed. Cohort 2 contained 640 patients in whom mesenteric defects were closed. Main outcome parameters were the incidence of SBO and postoperative complications as well as potential risk factors for SBO. RESULTS: Closure of the mesenteric defects was associated with a reduction in the incidence of SBO due to internal herniation (4.8% vs. 5.5, p = 0.02) but resulted in a higher incidence of SBO due to postoperative adhesions (4.8% vs. 1.7%, p = 0.004). Multivariate analysis identified smoking as a risk factor for SBO (p = 0.0187). We observed a higher incidence of late postoperative pain in cohort 2 (5.3% vs. 2.1%, p = 0.007). CONCLUSION: Although closure of the mesenteric defects is associated with a lower incidence of SBO due to internal herniation, this effect is countered by a higher incidence of SBO due to postoperative adhesions. Smoking is an independent risk factor for SBO after LRYGB. Closure of the mesenteric defects is associated with a higher incidence of late postoperative pain.

Internal herniation through the falciform ligament of the liver: a case report.

Background: An internal abdominal hernia is defined as the protrusion of a viscus through a mesenteric or peritoneal aperture within the peritoneal cavity. A less common type of internal herniation is a small bowel herniation through a defect in the falciform ligament of the liver. This defect can be congenital or iatrogenic after penetration of the falciform ligament with a trocar during laparoscopic surgery. Methods: We present a case report illustrating an internal herniation through an iatrogenic defect in the falciform ligament of the liver. Results: A 78-year-old man comes to the emergency department with severe abdominal pain for several hours. Laparoscopic exploration shows a small bowel herniation through an iatrogenic defect of the falciform ligament after laparoscopic cholecystectomy. Reduction of the internal herniation is performed. Due to subsequently small bowel necrosis, a small bowel resection with primary anastomosis has to be performed too. Conclusion: Small bowel herniation through an iatrogenic defect in the falciform ligament is very rare. However, it can lead to severe complications such as small bowel necrosis. To prevent internal herniation, we strongly suggest immediate repair or division of the falciform ligament when an iatrogenic defect is created during laparoscopic procedures.