Does the non-absorbable suture closure of the jejunal mesenteric defect reduce the incidence and severity of internal hernias after laparoscopic Roux-en-Y gastric bypass?

Meticulous Closure of Mesenteric Defects Effectively Reduces the Incidence of Internal Hernia After Laparoscopic Roux-en-Y Gastric Bypass

INTRODUCTION

Internal hernia (IH) after Roux-Y gastric bypass (RYGB) can lead to extended small bowel ischemia if it not recognized and treated promptly. The aim of this study is to show whether improvement in mesenteric defect (MD) closure reduces the incidence of IH.

PATIENTS AND METHODS

Retrospective analysis of prospectively collected data from our database including all patients who underwent laparoscopic RYGB between 1999 and 2015. The usual technique was a retrocolic/retrogastric RYGB. We divided patients in four groups according to the closure technique for MD and compared incidences of IH between groups. All patients had at least 8 years of follow-up.

RESULTS

A total of 1927 patients (1497 females/460 males, mean age of 41.5 ± 11 years) were operated. A retrocolic/retrogastric RYGB was performed in 1747 (90.7%) and an antecolic RYGB in 180 patients. Mean duration of follow-up was 15 (8-24) years. 111 patients (5.8%) developed IH, the majority through the jejunojejunostomy (JJ, 3.7%) and Petersen (1.7%) defects. With improvement of closure technique, the incidence decreased over time, from 12.9% in the group with separate sutures to 1.05% in the most recent group with running non-absorbable sutures and an additional purse-string at the JJ defect (p < 0.0001).

CONCLUSION

Meticulous closure of MD during RYGB is a very important step that significantly reduces the IH risk after RYGB, even with a retrocolic/retrogastric anatomy. Using running non absorbable braided sutures and an additional purse-string suture at the JJ is the most effective technique, but a small IH risk persists. A high index of suspicion remains necessary in patients who present with acute abdominal pain after RYGB.

Comparative analysis of linear- and circular-stapled gastrojejunostomies in Roux-en-Y gastric bypass: a focus on postoperative morbidity using the comprehensive complication index

PURPOSE

The linear-stapled (LSA) and the circular-stapled anastomosis (CSA) are the two most commonly performed techniques for the gastrojejunostomy (GJ) during laparoscopic Roux-en-Y gastric bypass (RYGB). This study compared the outcome after both techniques with special focus on postoperative morbidity using the comprehensive complication index (CCI).

METHODS

Five hundred eighty-eight patients operated between 01/2010 and 12/2019 were included in the final analysis and divided in two cohorts according to the surgical technique of the GJ (LSA (n = 290) or CSA (n = 298)). Before 09/2016, the CSA was exclusively performed for the GJ, while after 09/2016, the LSA was solely used.

RESULTS

The mean CCI for patients with Clavien-Dindo complication grade ≥ 2 within the first 90 days after RYGB was 31 ± 9.1 in the CSA and 25.7 ± 6.8 in the LSA group (p < 0.001), both values still below the previously published benchmark cutoff (≤ 33.73). The C-reactive Protein (CRP)-levels on postoperative days (POD) 1 and 3 as well as the use of opioids on POD 1 were significantly higher in the CSA- than in the LSA-group (all p < 0.001). There were significantly more internal herniations in the CSA group during the first 24 postoperative months (p < 0.001).

CONCLUSION

Patients after RYGB with CSA were found to have higher CCI values during the first 90 PODs compared to patients in which the LSA was applied. To achieve optimal outcomes in terms of patient morbidity, the LSA seems to be the superior technique for GJ in RYGB.

Surgical treatment of internal hernia after Roux-en-Y gastric bypass - impact of institutional standards and surgical approach

INTRODUCTION

Internal hernia is one of the most frequent long-term complications after laparoscopic gastric bypass surgery (RYGB). Surgical treatment of an internal hernia itself has risks that can largely be avoided by the implementation of institutional standards and a structured approach.

MATERIAL AND METHODS

From 2012 until 2022, we extracted all consecutive bariatric cases from the prospectively collected national database (StuDoQ). Data from all patients undergoing internal hernia repair were then collected from our hospital information management system and retrospectively analyzed. We compared patient characteristics and surgical outcome of patients before and after the implementation of standard operating procedures for institutional and perioperative aspects (first vs. second time span).

RESULTS

Overall, 37 patients were identified (median age 43 years, 86.5% female). Internal hernia was diagnosed after substantial weight loss (17.2 kg/m2) and on average about 34 months after RYGB. Baseline characteristics (age, sex, BMI, achieved total weight loss% and time interval to index surgery were comparable between the two groups). After local standardization, the conversion rate decreased from 52.6 to 5.6% (p = 0.007); duration of surgery from 92 to 39 min (p = 0.003), and length of stay from 7.7 to 2.8 days (p = 0.019).

CONCLUSION

In this study, we could demonstrate that the surgical therapy of internal hernia after gastric bypass can be significantly improved by implementing institutional and surgical standards. The details described (including a video) may provide valuable information for non-specialized surgeons to avoid pitfalls and improve surgical outcomes.

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.

The effect of routine division of the greater omentum on small bowel obstruction after Roux-en-Y gastric bypass

BACKGROUND

It remains unknown whether routine division of the greater omentum during laparoscopic Roux-en-Y gastric bypass (LRYGB) influences the risk for small bowel obstruction (SBO) after RYGB.

OBJECTIVE

To evaluate the effect of omental division on SBO after LRYGB stratified by handling of the mesenteric defects.

SETTING

Nationwide, registry-based.

METHODS

In this registry-based cohort study, 40,517 patients who underwent LRYGB in Sweden within the period from January 1, 2007, to December 31, 2019, with data from the Scandinavian Obesity Surgery Registry (SOReg) were included. The study was based on combined data from the SOReg, the National Patient Register, the Swedish Prescribed Drugs Register, and the Total Population Registry. The main outcome was reoperation for SBO.

RESULTS

During a follow-up period of 5.9 ± 2.6 years, the cumulative incidence of SBO was 11.2% in the nondivision group compared with 9.7% among patients with divided omentum (hazard ratio [HR] = .83, 95% confidence interval [CI]: .77-.89, P < .001). The association was seen in patients without mesenteric defects closure (HR = .69, 95% CI: .61-.78, P < .001) as well as patients with closed mesenteric defects (HR = .80, 95% CI: .74-.87, P < .001).

CONCLUSION

Division of the greater omentum is associated with reduced risk for SBO after antecolic, antegastric LRYGB and should be considered as a complement to mesenteric defects closure to further reduce the risk for SBO after LRYGB.

Risk Factor and Surgical Outcome of Petersen's Hernia After Gastrectomy in Gastric Cancer

Background

Petersen’s hernia is a life-threatening complication after gastrectomy. This study is dedicated to identify risk factors for Petersen’s hernia and compare clinical outcomes between patients receiving early or delayed surgical interventions.

Methods

Data from all patients who received gastrectomy due to gastric cancer were collected. Clinical characteristics were compared between Petersen and non-Petersen groups, bowel necrosis and non-necrotic groups. Propensity score matching (PSM) was conducted to generate two comparative groups. Univariate analysis and multivariate logistic regression were performed for risk factor evaluation.

Results

A total of 24 cases of Petersen’s hernia were identified from 1,481 cases of gastrectomy. PSM demonstrated that lower body mass index [BMI; odds ratio (OR) = 0.2, p < 0.01] and distal gastrectomy (OR = 6.2, p = 0.011) were risk factors for Petersen’s hernia. Longer time interval from emergence visit to laparotomy (p = 0.042) and elevated preoperative procalcitonin (p = 0.033) and C-reactive protein (CRP; p = 0.012) were associated with higher risk of bowel necrosis in Petersen’s hernia. Early surgical intervention resulted in less bowel necrosis rate (p = 0.012) and shorter length of necrotic bowel (p = 0.0041).

Conclusions

Low BMI and distal gastrectomy are independent risk factor for Petersen’s hernia after gastrectomy. Curtailing observing time and executing prompt surgery are associated with bowel viability and better outcome in patients with Petersen’s hernia.