Diagnosis and Management of Internal Hernias after Laparoscopic Gastric Bypass

[Value and Role of Obesity and Metabolic Surgery in the Study of Human Medicine, Academic Teaching and Advanced Training]

In teaching, obesity and metabolic surgery play only a limited role. However, due to the rapidly increasing number of surgical interventions, communication of knowledge in the study of human medicine as well as in gastroenterological and surgical residency (general and abdominal surgery) is required.Narrative review. · Currently, lectures on obesity and metabolic surgery do not belong to the current surgical curriculum of human medicine at all University Medical Schools, which needs to be absolutely established step by step - based on their topicality and importance in the clinical spectrum of clinical care.. · This rapidly developing special area of abdominal surgery is characterized by specific and diverse interdisciplinarity.. · Multimorbidity, changes in resorption mechanisms but also psychological changes have a substantial impact on the indication and patient outcome.. · The increase in endoscopic, surgical and also robotic interventions and surgical methods in this special field requires a broad knowledge of all surgical disciplines in intervention preparation, perioperative and follow-up management of obesity-associated basic diagnosis. This objective is important even in the study of human medicine and further advanced training.. The inclusion of such complex contents on obesity and metabolic surgery into surgical teaching and into residency of general and abdominal surgery is essential to be future-oriented and prepared for the development of the discipline.

Common postbariatric surgery emergencies for the acute care surgeon: What you need to know

ABSTRACT

The field of bariatric and metabolic surgery has changed rapidly over the past two decades, with an exponential increase in case volumes being performed because of its proven efficacy for morbid obesity and obesity-related comorbidities. Although this increased volume of procedures has been accompanied by significant decrease in postoperative complication rates, there are numerous potential complications after bariatric surgery that may require urgent or emergent surgical evaluation or interventions. Many of these risks extend well beyond the early postoperative period and can present months to years after the index procedure. Acute care surgeons are increasingly covering most or all of the emergency general surgery services at many centers and must be familiar with the numerous bariatric surgical procedures being performed and their individual complication profile to provide optimal care for these frequently challenging patients. This article provides a focused and concise review of the common bariatric procedures being performed, their early and late complication profiles, and a practical guide to the optimal diagnostic evaluations, surgical interventions, and perioperative management options. The author group includes both acute care surgeons and bariatric surgeons with significant experience in the emergency management of the complicated postbariatric surgical patient.

LEVEL OF EVIDENCE

Literature Synthesis and Expert Opinion; Level V.

Bariatric surgery and reproduction-implications for gynecology and obstetrics

As the rates of obesity continue to rise across the world, there has been an increasing resort to bariatric surgery amongst the options for treatment. Through the reproductive lifespan, between menarche and menopause, women might benefit from this surgical intervention, which may have a bearing on other aspects of their health. The consequences of bariatric surgery have been reported and evaluated from various perspectives in obstetrics and gynecology. Fertility and sexuality are enhanced, but not all gynecological diseases are ameliorated. There are also psychological and behavioral sequelae to be cognizant of. With multi-disciplinary and responsive care, most post-bariatric pregnancies have satisfactory outcomes. The effects of bariatric surgery on the babies conceived thereafter remains a subject of interest, whereas the possible effect on the climacteric is speculative.

The Diagnostic Accuracy of Abdominal Computed Tomography in Diagnosing Internal Herniation Following Roux-en-Y Gastric Bypass Surgery: A Systematic Review and Meta-analysis

OBJECTIVE

To analyze the diagnostic accuracy of abdominal computed tomography (CT) in diagnosing internal herniation (IH) following Rouxen-Y gastric bypass (RYGB) surgery.

SUMMARY OF BACKGROUND DATA

IH is one of the most important and challenging complications following RYGB. Therefore, early and adequate diagnosis of IH is necessary. Currently, exploratory surgery is considered the gold standard in diagnosing IH. Although CT scans are frequently being used, the true diagnostic accuracy in diagnosing IH remains unclear.

METHODS

PubMed, Embase, and Cochrane databases were systematically searched for relevant articles describing the diagnostic accuracy of abdominal CT in diagnosing IH after RYGB. Data were extracted, recalculated, and pooled to report on the overall diagnostic accuracy of CT in diagnosing IH, and the diagnostic accuracy of specific radiological signs.

RESULTS

A total of 20 studies describing 1637 patients were included. seventeen studies provided data regarding the overall diagnostic accuracy: pooled sensitivity of 82.0%, specificity of 84.8%, positive predictive value of 82.7%, and negative predictive value of 85.8% were calculated. Eleven studies reported on specific CT signs and their diagnostic accuracy. The radiological signs with the highest sensitivity were the signs of venous congestion, swirl, and mesenteric oedema (sensitivity of 78.7%, 77.8%, and 67.2%, respectively).

CONCLUSIONS

This meta-analysis demonstrates that CT is a reliable imaging modality for the detection of IH. Therefore, abdominal CT imaging should be added to the diagnostic work-up for RYGB patients who present themselves with abdominal pain suggestive of IH to improve patient selection for explorative surgery.

Value of contrast-enhanced multidetector computed tomography in imaging of symptomatic patients after laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy

Background

To assess the role of contrast-enhanced multidetector computed tomography (MDCT) in the assessment of symptomatic patients following laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy.

Results

We reviewed the studies of 129 cases and found complications in 113 patients: 55 early complications and 48 late complications. All of these complications were diagnosed with intravenous contrast-enhanced MDCT. Statistically significant difference was found between UGIS and MDCT in the diagnosis of many cases.

Conclusion

The rate of complications in bariatric surgery is high and the associated mortality is not negligible. The interpreting radiologists should know the normal postoperative findings and be aware of possible complications.

Internal hernia after gastrectomy for gastric cancer in minimally invasive surgery era

BACKGROUND

The incidence and clinical presentation of internal hernia after gastrectomy have been changing in the minimally invasive surgery era. This study aimed to analyze the clinical features and risk factors for internal hernia after gastrectomy for gastric cancer.

METHODS

We retrospectively analyzed internal hernia after gastrectomy for gastric cancer in 6474 patients between January 2003 and December 2016 at Seoul National University Bundang Hospital. Multivariable logistic regression was performed to evaluate risk factors.

RESULTS

Internal hernias identified by computed tomography or surgical exploration were 111/6474 (1.7%) and the median interval time was 450 days after gastrectomy. Fourteen (0.9%) of the 1510 patients who underwent open gastrectomy and 97 (2.0%) of the 4964 patients who underwent laparoscopic gastrectomy developed internal hernia. Of the 6474 patients, internal hernia developed in 0 (0%), 9 (1.1%), 40 (3.1%), 56 (3.3%), 6 (2.3%), and 0 (0%) patients who underwent Billroth I, Billroth II, Roux-en-Y, uncut Roux-en-Y, double tract, and esophagogastrostomy reconstructions, respectively. Fifty-nine (53.2%) of 111 patients with symptomatic hernia underwent surgery. Of the 59 internal hernias, treated surgically, 32 (53.2%), 27 (45.8%), and 0 (0%) were identified in jejunojejunostomy mesenteric, Petersen's, and transverse colon mesenteric defects, respectively. In multivariate analysis, non-closure of mesenteric defects (P < 0.01), laparoscopic approach (P < 0.01), and totally laparoscopic approach (P = 0.03) were independent risk factors for internal hernia.

CONCLUSIONS

The potential spaces such as Petersen's, jejunojejunostomy mesenteric, and transverse colon mesenteric defects should be closed to prevent internal hernia after gastrectomy for gastric cancer.

Early and late complications of bariatric operation

Weight loss surgery is one of the fastest growing segments of the surgical discipline. As with all medical procedures, postoperative complications will occur. Acute care surgeons need to be familiar with the common problems and their management. Although general surgical principles generally apply, diagnoses specific to the various bariatric operations must be considered. There are anatomic considerations which alter management priorities and options for these patients in many instances. These problems present both early or late in the postoperative course. Bariatric operations, in many instances, result in permanent alteration of a patient’s anatomy, which can lead to complications at any time during the course of a patient’s life. Acute care surgeons diagnosing surgical emergencies in postbariatric operation patients must be familiar with the type of surgery performed, as well as the common postbariatric surgical emergencies. In addition, surgeons must not overlook the common causes of an acute surgical abdomen—acute appendicitis, acute diverticulitis, acute pancreatitis, and gallstone disease—for these are still among the most common etiologies of abdominal pathology in these patients.

Predictive value of abdominal CT in evaluating internal herniation after bariatric laparoscopic Roux-en-Y gastric bypass

Background

Internal herniation, a serious complication after bariatric surgery, is challenging to diagnose. The aim of this study was to determine the accuracy of abdominal CT in diagnosing internal herniation.

Methods

The study included consecutive patients who had undergone laparoscopic gastric bypass surgery between 1 January 2011 and 1 January 2015 at a bariatric centre of excellence. To select patients suspected of having internal herniation, reports of abdominal CT and reoperations up to 1 January 2017 were screened. CT was presumed negative for internal herniation if no follow-up CT or reoperation was performed within 90 days after the initial CT, or no internal herniation was found during reoperation. The accuracy of abdominal CT in diagnosing internal herniation was calculated using two-way contingency tables.

Results

A total of 1475 patients were included (84·7 per cent women, mean age 46·5 years, median initial BMI 41·8 kg/m2). CT and/or reoperation was performed in 192 patients (13·0 per cent) in whom internal herniation was suspected. Internal herniation was proven laparoscopically in 37 of these patients. The incidence of internal herniation was 2·5 per cent. An analysis by complaint included a total of 265 episodes, for which 247 CT scans were undertaken. CT was not used to investigate 18 episodes, but internal herniation was encountered in one-third of these during reoperation. Combining the follow-up and intraoperative findings, the accuracy of CT for internal herniation had a sensitivity of 83·8 (95 per cent c.i. 67·3 to 93·2) per cent, a specificity of 87·1 (81·7 to 91·2) per cent, a positive predictive value of 53·4 (40·0 to 66·5) per cent and a negative predictive value of 96·8 (92·9 to 98·7) per cent.

Conclusion

Abdominal CT is an important tool in diagnosing internal herniation, with a high specificity and a high negative predictive value.

Novel technique using a bioabsorbable prosthesis with fibrin glue fixation to prevent a Petersen's space hernia

INTRODUCTION

Laparoscopic Roux-en-Y gastric bypass is a bariatric operation that is effective for long-term weight loss. Although rare, one serious complication is an internal hernia through Petersen's space, which may result in bowel strangulation. Although the incidence of internal hernia can be reduced through closing the Petersen's defect, it does not eliminate the risk. This case describes a novel and reliable method to close Petersen's defect. We report the case of a 30-year-old female who underwent a laparoscopic Roux-en-Y gastric bypass for the management of morbid obesity. Following her Roux-en-Y reconstruction, a prosthetic bioabsorbable mesh was placed in Petersen's space and reinforced with fibrin glue to prevent internal herniation through Petersen's defect. The use of a bioabsorbable mesh in Petersen's space is a novel and easy technique that could be used to reduce the incidence of an internal hernia through Petersen's defect.

Essential bariatric emergencies for the acute care surgeon

Bariatric surgery is the most effective treatment for morbid obesity. Due to the high volume of weight loss procedures worldwide, the general surgeon will undoubtedly encounter bariatric patients in his or her practice. Liberal use of CT scans, upper endoscopy and barium swallow in this patient population is recommended. Some bariatric complications, such as marginal ulceration and dyspepsia, can be effectively treated non-operatively (e.g., proton pump inhibitors, dietary modification). Failure of conservative management is usually an indication for referral to a bariatric surgery specialist for operative re-intervention. More serious complications, such as perforated marginal ulcer, leak, or bowel obstruction, may require immediate surgical intervention. A high index of suspicion must be maintained for these complications despite "negative" radiographic studies, and diagnostic laparoscopy performed when symptoms fail to improve. Laparoscopic-assisted gastric band complications are usually approached with band deflation and referral to a bariatric surgeon. However, if acute slippage that results in gastric strangulation is suspected, the band should be removed immediately. This manuscript provides a high-level overview of all essential bariatric complications that may be encountered by the acute care surgeon.

Internal hernia after laparoscopic gastrectomy with Roux-en-Y reconstruction for gastric cancer

BACKGROUND/OBJECTIVE

Laparoscopic gastrectomy (LG) is increasingly used to treat gastric cancer. Simultaneously, internal hernia (IH) has been reported after LG with Roux-en-Y reconstruction (RY). The aim of this study was to investigate IH after LG with RY for gastric cancer.

METHODS

This study included 15 patients with IH from a database of 355 consecutive patients who underwent LG with RY for gastric cancers. We retrospectively analyzed IH incidence and clinical characteristics by operative procedures.

RESULTS

The total incidence of IH was 4.2%. The incidence of IH at Petersen's defect tended to decrease with modifications to the reconstruction methods, but not significantly so. The incidence of IH at jejunojejunostomy mesenteric defect significantly decreased with closure of this defect (p = 0.01). The incidence of IH at transverse mesocolic defect was 1.3% in patients who underwent retrocolic RY; emergent small-bowel resection was only required in two cases of herniation through this defect after laparoscopic total gastrectomy.

CONCLUSION

Retrocolic RY with appropriate closure of defects can reduce IH incidence at Petersen's defect and at jejunojejunostomy mesenteric defect. Although the IH incidence at the transverse mesocolic defect is not particularly high, the possibility of herniation through this defect should be kept in mind.

Meta-analysis of internal herniation after gastric bypass surgery

Background

The aim of this study was to provide a systematic and quantitative summary of the association between laparoscopic Roux-en-Y gastric bypass (LRYGB) and the reported incidence of internal herniation (IH). The route of the Roux limb and closure of mesenteric and/or mesocolonic defects are described as factors of influence.

Methods

MEDLINE, Embase, the Cochrane Library and Web of Science were searched for relevant literature, references and citations according to the PRISMA statement. Two independent reviewers selected studies that evaluated incidence of IH after LRYGB and possible techniques for prevention. Data were pooled by route of the Roux limb and closure/non-closure of the mesenteric and/or mesocolonic defects.

Results

Forty-five articles included data on 31 320 patients. Lowest IH incidence was in the antecolic group, with closure of all defects (1 per cent; P &lt; 0·001), followed by the antecolic group, with all defects left open and the retrocolic group with closure of the mesenteric and mesocolonic defect (both 2 per cent; P &lt; 0·001). The incidence of IH was highest in the antecolic group, with closure of the jejunal defect, and in the retrocolic group, with closure of all defects (both 3 per cent).

Conclusion

The present systematic review includes a random-effects meta-analysis. The antecolic procedure, with closure of both the mesenteric and Petersen defects, has the lowest internal herniation incidence following laparoscopic Roux-en-Y gastric bypass.

Systematic review on reoperative bariatric surgery: American Society for Metabolic and Bariatric Surgery Revision Task Force

BACKGROUND

Reoperative bariatric surgery has become a common practice in many bariatric surgery programs. There is currently little evidence-based guidance regarding specific indications and outcomes for reoperative bariatric surgery. A task force was convened to review the current evidence regarding reoperative bariatric surgery. The aim of the review was to identify procedure-specific indications and outcomes for reoperative procedures.

METHODS

Literature search was conducted to identify studies reporting indications for and outcomes after reoperative bariatric surgery. Specifically, operations to treat complications, failed weight loss, and weight regain were evaluated. Abstract and manuscript reviews were completed by the task force members to identify, grade, and categorize relevant studies.

RESULTS

A total of 819 articles were identified in the initial search. After review for inclusion criteria and data quality, 175 articles were included in the systematic review and analysis. The majority of published studies are single center retrospective reviews. The evidence supporting reoperative surgery for acute and chronic complications is described. The evidence regarding reoperative surgery for failed weight loss and weight regain generally demonstrates improved weight loss and co-morbidity reduction after reintervention. Procedure-specific outcomes are described. Complication rates are generally reported to be higher after reoperative surgery compared to primary surgery.

CONCLUSION

The indications and outcomes for reoperative bariatric surgery are procedure-specific but the current evidence does support additional treatment for persistent obesity, co-morbid disease, and complications.

Achados tomográficos das alterações abdominais pós-operatórias dos pacientes submetidos ao derivação gastrojejunal em Y-de-Roux sem anel

OBJETIVO: Avaliar por exame de tomografia computadorizada de pacientes submetidos à derivação gastrojejunal em Y-de-Roux, sem anel, para tratamento de obesidade mórbida. MÉTODOS: Estudaram-se 40 pacientes, encaminhados ao serviço de tomografia do Hospital Universitário Evangélico de Curitiba para avaliação diagnóstica. Encontravam-se em pós-operatório de cirurgia bariátrica tendo sido operados no mesmo hospital. Foram incluídos pacientes submetidos à operação laparoscópica com sintomas que necessitavam de avaliação tomográfica diagnóstica. Excluíram-se pacientes que tinham sido submetidos à cirurgia bariátrica por outras técnicas cirúrgicas; que tinham sido operados por outra equipe; que não concordassem com a administração de contraste iodado por via oral ou endovenosa; e que excediam o limite de peso da mesa de exame. Para análise estatística utilizou-se a média das variáveis. RESULTADOS: Os pacientes apresentaram-se com idade entre 23 a 70 anos e eram 11 homens e 29 mulheres. Não houve alterações extra-abdominais detectáveis pela tomografia de abdômen total; dos 40 pacientes avaliados, 30 apresentavam achados tomográficos dentro do limite da normalidade. A presença de estenose na anastomose gastrojejunal foi encontrada em um paciente; hérnia interna ocorreu em cinco; fístula anastomótica em um e abcesso em três dos pacientes estudados. CONCLUSÃO: A tomografia de abdome total não conseguiu informar a causa dos sintomas dos pacientes operados em 87,5% dos pacientes que procuraram re-avaliação médica por sintomas pós-operatórios da cirurgia bariátrica.

Management of late postoperative complications of bariatric surgery

Background

The prevalence of obesity is increasing worldwide and the past decade has witnessed an exponential rise in the number of bariatric operations performed. As a consequence, an increasing number of patients are presenting to non-specialist units with complications following bariatric procedures. This article outlines the management of the most common late postoperative complications that are likely to present to the general surgeon.

Methods

A search was conducted for late postoperative complications after bariatric surgery using PubMed, Embase, OVID and Google search engines, and combinations of the terms bariatric surgery, gastric bypass, gastric banding or sleeve gastrectomy, and late or delayed complications. Only studies with follow-up longer than 6 months were included.

Results

The most common long-term complications after gastric banding include band slippage and erosion. Deflation or removal of the band is often required. Internal hernia, adhesions and anastomotic stenosis are common causes of intestinal obstruction after gastric bypass surgery. Hepatobiliary complications pose a particular challenge because of the altered anatomy. Functional disorders such as reflux and dumping, and nutritional deficiencies are common and should be differentiated from conditions that require urgent investigations and timely surgical intervention.

Conclusion

The immediate management of bariatric patients presenting with complications outside the immediate postoperative period requires adherence to basic surgical principles. Accurate diagnosis often relies on high-quality contrast and cross-sectional imaging, and effective surgical intervention necessitates a broad understanding of the altered anatomy, advanced surgical skills and liaison with specialists in the field when necessary.

Petersen's space hernia: A rare but expanding diagnosis

BACKGROUND

Petersen's space hernia is caused by the herniation of intestinal loops through the defect between the small bowel limbs, the transverse mesocolon and the retroperitoneum, after any type of gastrojejunostomy. The laparoscopic approach facilitates the occurrence of this type of hernia, due to the lack of post-operative adhesions which prevent bowel motility and hence, herniation.

CASE REPORT

We report the case of a 46 year-old male submitted to an open antrectomy and vagotomy with a Roux-en-Y reconstruction six-years before, for the treatment of bleeding gastric ulcer.He presented with epigastric abdominal pain radiating to the back and alimentary vomiting with a 3 days evolution, with an episode of hematemesis 2 h before admission. His abdomen was bloated and tender at the epigastric region. The laboratory exams revealed mild leucocytosis and CRP elevation with normal pancreatic tests. The abdominal CT scan revealed an intestinal occlusion. An exploratory laparotomy was performed, disclosing an incarcerated Petersen space hernia of the common limb, with obstruction and dilatation of the biliary limb.

CONCLUSION

The knowledge of this anatomic post-operative defect and a low threshold for diagnosis are crucial to its management, since its nonspecific clinical and laboratory findings. Early operative intervention is warranted in order to avoid the severe complications of bowel necrosis.

Small-bowel volvulus in late pregnancy due to internal hernia after laparoscopic Roux-en-Y gastric bypass

Internal hernias are a specific cause of acute abdominal pain and are a well-known complication after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Although internal hernias are a rare cause of intestinal obstruction, they may evolve towards serious complications, such as extensive bowel ischemia and gangrene, with the need for bowel resection and sometimes for a challenging reconstruction of intestinal continuity. The antecolic position of the Roux limb is associated with a decrease in the incidence of small-bowel obstruction and internal hernias. The best prevention of the formation of these hernias is probably by closure of potential mesenteric defects at the initial operation with a non-absorbable running suture. We present a patient in late pregnancy with a small-bowel volvulus following laparoscopic Roux-en-Y gastric bypass for morbid obesity and discuss the available literature. For a favorable obstetric and neonatal outcome, it is crucial not to delay surgical exploration and an emergency operation usually is mandatory.

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

BACKGROUND

Recent reports describing a gastric bypass technique and the need for closure at Petersen's space using an antecolic antegastric laparoscopic method have differed in the incidence of internal hernia. We report a 6.2% incidence without closure of Petersen's space in a 1047-case, single-surgeon practice.

METHODS

The data from 1047 patients undergoing antecolic antegastric gastric bypass between January 2001 and December 2006 were prospectively collected and retrospectively evaluated for formation of an internal hernia at Petersen's space. All cases were performed by a single surgeon using an antecolic antegastric technique without closure of the mesenteric space and with division of 5 cm of small bowel mesentery. The biliopancreatic limb length was created at 50 cm during the first 2 years of the study and then at 50 or 100 cm depending on the patient's body mass index.

RESULTS

Of the 1047 patients, 73 underwent laparoscopic exploration for varying degrees of abdominal pain, unexplained nausea or vomiting, or radiographic evidence of an internal hernia. Of the 73 cases, 65 were Petersen's space hernias, for an incidence of 6.2%, 7 were mesenteric enteroenterostomy hernias, for an incidence of .7%, and 1 was negative for intra-abdominal pathologic findings. A direct relationship was found between the biliopancreatic limb length and the frequency of biliopancreatic internal hernia formation (P = .0194), and a high rate of false-negative radiographic reports were noted. Subsequent to these 1047 patients, we have had no internal hernias with space closure in 339 cases.

CONCLUSION

Closure of Petersen's space is important in preventing the morbidity of reoperation and the incidence of internal hernia.