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Wu QL, Liu QZ, Xi YY, Deng XQ, Xu TS, Xie ZC, Chen JA, Yuan Y. Closed or Unclosed Mesentery? A Meta-analysis of Internal Herniation After Laparoscopic Roux-en-Y Gastric Bypass. Obes Surg 2023:10.1007/s11695-023-06594-3. [PMID: 37081253 DOI: 10.1007/s11695-023-06594-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 04/06/2023] [Accepted: 04/10/2023] [Indexed: 04/22/2023]
Abstract
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.
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Affiliation(s)
- Qian-Long Wu
- Guangzhou Medical University, Guangzhou, 510180, China.
| | - Quan-Zhen Liu
- Guangzhou Medical University, Guangzhou, 510180, China
| | - Ying-Yun Xi
- Guangzhou Medical University, Guangzhou, 510180, China
| | | | - Tong-Shan Xu
- Guangzhou Medical University, Guangzhou, 510180, China
| | - Zi-Chun Xie
- Guangzhou Medical University, Guangzhou, 510180, China
| | - Jin-An Chen
- Guangzhou Medical University, Guangzhou, 510180, China
| | - Yi Yuan
- Guangzhou Medical University, Guangzhou, 510180, China
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Povoas HP, Vilas-Bôas ML. Retrocolic retrogastric ROUX-EN-Y gastric bypass: how I do it. Langenbecks Arch Surg 2021; 406:2059-2065. [PMID: 34023942 DOI: 10.1007/s00423-021-02187-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 05/03/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Technical variations of the laparoscopic Roux-en-Y gastric bypass may influence the incidence of complications such as fistulas, marginal ulcers, stenosis, and internal hernias. METHODS We described the technical aspects of a retrocolic, retrogastric, laparoscopic gastric bypass procedure with manual gastrojejunostomy and the closure technique for the three mesenteric defects generated by the Roux-en-Y limb reconstruction. RESULTS We summarized the data from 587 patients concerning complications directly related to the surgical technique. There were no internal hernias in patients followed, and in only 2 cases, small bowel obstruction related to defect closure occurred. CONCLUSIONS The retrocolic, retrogastric gastric bypass performed with a meticulous closure of all three mesenteric defects reflects a low incidence of internal hernias and low complication rates related to the closure itself. The technique also allows less tension at the gastrojejunostomy.
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Affiliation(s)
- Heitor P Povoas
- BAROS - Cirurgia Bariátrica e Metabólica, Av. Prof. Magalhães Neto, 1541, sala 4012/13, Salvador, BA, 41810-011, Brazil.
| | - Marcos Leão Vilas-Bôas
- BAROS - Cirurgia Bariátrica e Metabólica, Av. Prof. Magalhães Neto, 1541, sala 4012/13, Salvador, BA, 41810-011, Brazil
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Torensma B, Kooiman L, Liem R, Monpellier VM, Swank DJ, Tseng L. Internal Herniation Incidence After RYGB and the Predictive Ability of a CT Scan as a Diagnostic Tool. Obes Surg 2021; 31:127-132. [PMID: 32748202 PMCID: PMC7808966 DOI: 10.1007/s11695-020-04892-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 07/24/2020] [Accepted: 07/28/2020] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Bart Torensma
- Department of Anaesthesiology, Leiden University Medical Center, Leiden, The Netherlands.
- Department of Surgery, Dutch Obesity Clinic West & LUMC, The Hague, The Netherlands.
| | - Laurens Kooiman
- Department of Surgery, Dutch Obesity Clinic West & LUMC, The Hague, The Netherlands
| | - Ronald Liem
- Department of Surgery, Dutch Obesity Clinic West & LUMC, The Hague, The Netherlands
| | - Valerie M Monpellier
- Department of Surgery, Dutch Obesity Clinic West & LUMC, The Hague, The Netherlands
| | - Dingeman J Swank
- Department of Surgery, Dutch Obesity Clinic West & LUMC, The Hague, The Netherlands
| | - Larissa Tseng
- Department of Surgery, Dutch Obesity Clinic West & LUMC, The Hague, The Netherlands
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Ortega-Serrano J, Kraus-Fischer G, Alfonso-Ballester R, Cassinello-Fernández N. Shortening of the Common Channel as a Rescue Surgery After Gastric Bypass Failure. Obes Surg 2020; 30:4760-4767. [PMID: 32691399 DOI: 10.1007/s11695-020-04854-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/07/2020] [Accepted: 07/08/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND After Roux-en-Y gastric bypass (RYGB), up to 30% failures in weight loss have been reported. Among multiple solutions available, we report our experience with shortening of the common channel (SCC) by performing a limb distalization of the alimentary or the biliopancreatic limb. SETTINGS University Hospital. METHODS We reviewed data from 23 patients that underwent limb distalization between 2001 and 2019 due to inadequate weight loss after an initial RYGB in our center. All patients who failed to achieve an excess weight loss reduction of > 50% or maintained a body mass index (BMI) above 35 kg/m2 were included. Multiple variables were analyzed during the follow-up at five time points: initial, after RYGB, before SCC, after SCC, and current. RESULTS The mean BMI prior to the RYGB was 51.8 kg/m2, after RYGB was 37.6 kg/m2, before SCC was 43.6 kg/m2, after SCC was 36.1 kg/m2, and the final BMI was 36.3 kg/m2. No morbidity was seen after SCC. Long-term associated nutritional deficiencies were only identified in 3 patients which had iron deficiency and 1 patient with vitamin D deficiency. Patients with associated comorbidities significantly improved or were withdrawn from medications after the RYGB, with minor variations after SCC. CONCLUSIONS Limb distalization with SCC is a safe and effective technique for patients who failed to achieve an adequate weight loss after RYGB. There is a slight increase in excess of weight loss after the SCC compared with RYGB. In addition, no further weight regain was documented.
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Affiliation(s)
- Joaquin Ortega-Serrano
- Endocrine and Bariatric Surgery Unit, Hospital Clinico Universitario, Valencia, Spain. .,Department of Surgery, University of Valencia, Av. Blasco Ibanez, 17, 46010, Valencia, Spain.
| | - Gabriel Kraus-Fischer
- Endocrine and Bariatric Surgery Unit, Hospital Clinico Universitario, Valencia, Spain
| | - Raquel Alfonso-Ballester
- Endocrine and Bariatric Surgery Unit, Hospital Clinico Universitario, Valencia, Spain.,Department of Surgery, University of Valencia, Av. Blasco Ibanez, 17, 46010, Valencia, Spain
| | - Norberto Cassinello-Fernández
- Endocrine and Bariatric Surgery Unit, Hospital Clinico Universitario, Valencia, Spain.,Department of Surgery, University of Valencia, Av. Blasco Ibanez, 17, 46010, Valencia, Spain
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van Berckel MMG, Ederveen JC, Nederend J, Nienhuijs SW. Internal Herniation and Weight Loss in Patients after Roux-en-Y Gastric Bypass. Obes Surg 2020; 30:2652-2658. [DOI: 10.1007/s11695-020-04542-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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6
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Billroth-I reconstruction using an overlap method in totally laparoscopic distal gastrectomy: propensity score matched cohort study of short- and long-term outcomes compared with Roux-en-Y reconstruction. Surg Endosc 2019; 33:3990-4002. [DOI: 10.1007/s00464-019-06688-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 01/25/2019] [Indexed: 02/07/2023]
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Kannan U, Gupta R, Gilchrist BF, Kella VN. Laparoscopic management of an internal hernia in a pregnant woman with Roux-en-Y gastric bypass. BMJ Case Rep 2018; 2018:bcr-2017-221979. [PMID: 29674396 DOI: 10.1136/bcr-2017-221979] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Management of abdominal pain in a pregnant patient with a history of Roux-en-Y gastric bypass presents unique challenges. A misdiagnosis or delay in management can result in lethal maternal-fetal outcomes. We present a 30-year-old woman at 21 weeks of pregnancy presented with abdominal pain. She had a history of laparoscopic Roux-en-Y gastric bypass performed 3 years earlier. The clinical examination was remarkable for epigastric pain and tenderness. The vital signs and laboratory examinations were unremarkable. The CT scan was suggestive of an internal hernia. On an exploratory laparoscopy, the distal common small bowel was found to be herniating through the jejunojejunostomy mesenteric defect, causing intestinal obstruction with dilatation of the Roux limb and the biliopancreatic limb. The internal hernia was reduced, and no bowel resection was required. The mesenteric defect was closed with 3-0 silk sutures in a continuous fashion. The patient was discharged after 3 days and delivered a healthy baby at 40 weeks of gestation.
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Affiliation(s)
| | - Ranjan Gupta
- General Surgery, Bronx-Lebanon Hospital Center, Bronx, New York, USA
| | - Brian F Gilchrist
- General Surgery, Bronx-Lebanon Hospital Center, Bronx, New York, USA
| | - Venkata N Kella
- General Surgery, Bronx-Lebanon Hospital Center, Bronx, New York, USA
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Geubbels N, Röell EA, Acherman YIZ, Bruin SC, van de Laar AWJM, de Brauw LM. Internal Herniation After Laparoscopic Roux-en-Y Gastric Bypass Surgery: Pitfalls in Diagnosing and the Introduction of the AMSTERDAM Classification. Obes Surg 2018; 26:1859-66. [PMID: 26787196 DOI: 10.1007/s11695-015-2028-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Internal herniation (IH) probably is the most elusive complication of laparoscopic Roux- en-Y gastric bypass (LRYGB) surgery. This study provides a definition for IH, a diagnosing algorithm, and information on several factors influencing IH formation. METHOD Baseline characteristics, laboratory findings, imaging studies, operative findings, and follow up data of 1583 patients that underwent LRYGB at our bariatric facility between 2007 and 2013 were recorded. Follow up varied between 3 and 76 months, and 85 % of the data was available for analysis at 12 months. Our surgical technique was standardized. Intermesenteric spaces were not closed until July 2012, where after they were closed. To facilitate comparison, IH cases were matched with controls. RESULTS Forty patients (2.5 %) had an IH during re-laparoscopy. The modal clinical presentation is acute onset epigastric discomfort, often crampy/colicky in nature. Additional examinations included laboratory testing, abdominal X-ray, abdominal ultrasound, and abdominal CT scanning. Patients who developed an IH lost a significantly higher percentage of their total body weight than their matched controls at every time point. IH incidence was higher in the non-closure group than the closure group. CONCLUSION The large variation in reported IH incidence is due to the large variation in IH definition. To gain more uniformity in reporting IH prevalence, we propose the use of the AMSTERDAM classification. Post-LRYGB patients with acute onset crampy/colicky epigastric pain should undergo abdominal ultrasound to rule out gallbladder pathology and offered re-laparoscopy with a low threshold. IH incidence is highest among patients with rapid weight loss and non-closure of intermesenteric defects.
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Affiliation(s)
- Noëlle Geubbels
- Department of Metabolic and Bariatric Surgery, Slotervaart Hospital, Louwesweg 6, 1066 EC, Amsterdam, The Netherlands.
| | - Eveline A Röell
- Department of Metabolic and Bariatric Surgery, Slotervaart Hospital, Louwesweg 6, 1066 EC, Amsterdam, The Netherlands
| | - Yair I Z Acherman
- Department of Metabolic and Bariatric Surgery, Slotervaart Hospital, Louwesweg 6, 1066 EC, Amsterdam, The Netherlands
| | - Sjoerd C Bruin
- Department of Metabolic and Bariatric Surgery, Slotervaart Hospital, Louwesweg 6, 1066 EC, Amsterdam, The Netherlands
| | - Arnold W J M van de Laar
- Department of Metabolic and Bariatric Surgery, Slotervaart Hospital, Louwesweg 6, 1066 EC, Amsterdam, The Netherlands
| | - L Maurits de Brauw
- Department of Metabolic and Bariatric Surgery, Slotervaart Hospital, Louwesweg 6, 1066 EC, Amsterdam, The Netherlands
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Díaz-Tobarra M, Cassinello Fernández N, Jordá Gómez P, Nofal MN, Alfonso Ballester R, Ortega Serrano J. One-Stage vs Two-Stage Laparoscopic Roux-en-Y Gastric Bypass in Obese Patients with Body Mass Index >55 Kg/m 2; 5-YEAR FOLLOW UP. Obes Surg 2017; 27:955-960. [PMID: 27722822 DOI: 10.1007/s11695-016-2411-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Surgical strategies in patients with BMI > 55 kg/m2 are not well established. OBJECTIVES The objective of this study is to compare the long term results and complications of 1- vs. 2-stage laparoscopic "Roux-en-Y″ gastric bypass (LRYGB) for patients with BMI > 55 kg/m2. METHODS Retrospective review of the complications and outcomes, between January 2007 and January 2010, for patients with a BMI > 55 kg/m2 who underwent directly a LRYGB (1-stage) or a LRYGB as a 2nd stage of a laparoscopic sleeve gastrectomy (LSG). RESULTS Twenty-four patients were enrolled (no patient was lost during the 5-year follow-up). In the 1-stage LRYGB group, two patients had grade II complications according to Clavien-Dindo classification. In the 2-stage LRYGB group, complications of the first and the second surgery were summed. There were no differences between the two groups despite being heterogenous (more men with a higher BMI in the 2-stage group). There was a statistically significant difference in the final BMI in 1-stage LRYGB group compared to the 2-stage LRYGB group (34.46 ± 6.29 vs. 40.40 ± 3.47; p = 0.01, respectively) and in percentage of excess of BMI loss (%EBMIL; 69.80 ± 19.96 vs. 54.54 ± 13.93; p = 0.04, respectively). CONCLUSIONS In patients with a BMI > 55 kg/m2, both 1- and 2-stage LRYGB give good long-term results. If feasible, a 1-stage LRYGB obtains a better percentage of excess of BMI loss but if not possible, the strategy of initially performing a laparoscopic sleeve gastrectomy followed by a LRYGB is safe and there were no differences in complications.
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Affiliation(s)
- María Díaz-Tobarra
- Bariatric and Metabolic Surgery Unit, Hospital Clínico Universitario, Valencia, Spain
| | - Norberto Cassinello Fernández
- Bariatric and Metabolic Surgery Unit, Hospital Clínico Universitario, Valencia, Spain. .,Servicio Cirugía General y Aparato Digestivo, Hospital Clínico Universitario, Avda Blasco Ibañez, 17, 46010, Valencia, Spain.
| | - Pablo Jordá Gómez
- Bariatric and Metabolic Surgery Unit, Hospital Clínico Universitario, Valencia, Spain
| | - Mohammad Nebih Nofal
- Bariatric and Metabolic Surgery Unit, Hospital Clínico Universitario, Valencia, Spain
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Sabench Pereferrer F, Domínguez-Adame Lanuza E, Ibarzabal A, Socas Macias M, Valentí Azcárate V, García Ruiz de Gordejuela A, García-Moreno Nisa F, González Fernández J, Vilallonga Puy R, Vilarrasa García N, Sánchez Santos R. Quality Criteria in Bariatric Surgery: Consensus Review and Recommendations of the Spanish Association of Surgeons and the Spanish Society of Bariatric Surgery. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.cireng.2016.09.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Sabench Pereferrer F, Domínguez-Adame Lanuza E, Ibarzabal A, Socas Macias M, Valentí Azcárate V, García Ruiz de Gordejuela A, García-Moreno Nisa F, González Fernández J, Vilallonga Puy R, Vilarrasa García N, Sánchez Santos R. Quality criteria in bariatric surgery: Consensus review and recommendations of the Spanish Association of Surgeons and the Spanish Society of Bariatric Surgery. Cir Esp 2016; 95:4-16. [PMID: 27979315 DOI: 10.1016/j.ciresp.2016.09.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 09/16/2016] [Accepted: 09/22/2016] [Indexed: 12/19/2022]
Abstract
Bariatric surgery has proven to be highly effective in controlling obesity and metabolic syndrome; the results of this surgery are not only expressed in terms of weight loss, but also in terms of resolution of comorbidities, improved quality of life and complications. The different parameters used to measure these outcomes require uniformity and reference patterns. Therefore, it is essential to identify those indicators and quality criteria that are helpful in defining the «best practice» principles in bariatric surgery. In this regard, the Section of Obesity of the Spanish Association of Surgeons, in collaboration with the Spanish Society for Bariatric Surgery (SECO), present as an objective to identify the key points that define «quality» in this type of surgery. We describe the main indicators based on the published literature as well as the criteria for referral of the main comorbidities according to the evidence found and grades of recommendation.
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Affiliation(s)
- Fátima Sabench Pereferrer
- General and Digestive Surgery Department, University Hospital of Sant Joan, Pere Virgili Health's Institute, Faculty of Medicine, Reus (Tarragona), España; Section of Morbid Obesity, Spanish Association of Surgeons
| | - Eduardo Domínguez-Adame Lanuza
- Metabolic and Gastroesophageal Surgery Unit, Virgen de la Macarena University Hospital, Sevilla, España; Section of Morbid Obesity, Spanish Association of Surgeons
| | - Ainitze Ibarzabal
- Clinical Institute of Digestive and Metabolic Diseases, Hospital Clínic de Barcelona, Barcelona, España; Section of Morbid Obesity, Spanish Association of Surgeons
| | - María Socas Macias
- General and Digestive Surgery Department, Bariatric and Gastroesophageal Surgery Innovation Unit, University Hospital Virgen del Rocío, Sevilla, España; Section of Morbid Obesity, Spanish Association of Surgeons
| | - Víctor Valentí Azcárate
- Department of Surgery, Bariatric and Metabolic Surgery, Clínica Universidad de Navarra, CIBER Pathophysiology of Obesity and Nutrition (CIBERobn), Carlos III Health's Institut, Health Research Institute of Navarra, Pamplona, España; Section of Morbid Obesity, Spanish Association of Surgeons
| | - Amador García Ruiz de Gordejuela
- Bariatric Surgery Unit, Surgery Department, Bellvitge University Hospital, L'Hospitalet de Llobregat (Barcelona), España; Section of Morbid Obesity, Spanish Association of Surgeons
| | - Francisca García-Moreno Nisa
- Surgery Department, Ramón y Cajal University Hospital, Madrid, España; Section of Morbid Obesity, Spanish Association of Surgeons
| | - Jesús González Fernández
- Metabolic, Bariatric and General Surgery Department, Asturias Medical Center, Oviedo, España; Section of Morbid Obesity, Spanish Association of Surgeons
| | - Ramón Vilallonga Puy
- Endocrine, Metabolic and Bariatric Surgery Unit, Center of Excellence for the EAC-BC, General Surgery Department, Vall d'Hebron University Hospital, Barcelona, España; Section of Morbid Obesity, Spanish Association of Surgeons
| | - Nuria Vilarrasa García
- Endocrinology and Nutrition Department, Bellvitge University Hospital, L'Hospitalet de Llobregat (Barcelona), España; Section of Morbid Obesity, Spanish Association of Surgeons
| | - Raquel Sánchez Santos
- General and Digestive Surgery Department, Complejo Hospitalario de Pontevedra, Pontevedra, España; Section of Morbid Obesity, Spanish Association of Surgeons.
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13
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Kimura H, Ishikawa M, Nabae T, Matsunaga T, Murakami S, Kawamoto M, Kamimura T, Uchiyama A. Internal hernia after laparoscopic gastrectomy with Roux-en-Y reconstruction for gastric cancer. Asian J Surg 2015; 40:203-209. [PMID: 26589299 DOI: 10.1016/j.asjsur.2015.09.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 09/25/2015] [Accepted: 09/30/2015] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Hideyo Kimura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Surgery, Japan Community Health care Organization, Kyushu Hospital, Fukuoka, Japan.
| | - Mikimasa Ishikawa
- Department of Surgery, Japan Community Health care Organization, Kyushu Hospital, Fukuoka, Japan
| | - Toshinaga Nabae
- Department of Surgery, Japan Community Health care Organization, Kyushu Hospital, Fukuoka, Japan
| | - Taketo Matsunaga
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Surgery, Japan Community Health care Organization, Kyushu Hospital, Fukuoka, Japan
| | - Soichiro Murakami
- Department of Surgery, Japan Community Health care Organization, Kyushu Hospital, Fukuoka, Japan
| | - Masahiko Kawamoto
- Department of Surgery, Japan Community Health care Organization, Kyushu Hospital, Fukuoka, Japan
| | - Tetsuro Kamimura
- Department of Surgery, Japan Community Health care Organization, Kyushu Hospital, Fukuoka, Japan
| | - Akihiko Uchiyama
- Department of Surgery, Japan Community Health care Organization, Kyushu Hospital, Fukuoka, Japan
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Rondelli F, Bugiantella W, Desio M, Vedovati MC, Boni M, Avenia N, Guerra A. Antecolic or Retrocolic Alimentary Limb in Laparoscopic Roux-en-Y Gastric Bypass? A Meta-Analysis. Obes Surg 2015; 26:182-95. [DOI: 10.1007/s11695-015-1918-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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15
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Quezada N, León F, Jones A, Varas J, Funke R, Crovari F, Raddatz A, Pérez G, Escalona A, Boza C. High frequency of internal hernias after Roux-en-Y gastric bypass. Obes Surg 2015; 25:615-21. [PMID: 25638655 DOI: 10.1007/s11695-014-1302-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Internal hernias (IH) after Roux-en-Y gastric bypass (RYGB) are a serious concern among surgeons and are often under-diagnosed due to heterogeneity of clinical manifestations. Our aim is to assess the frequency of IH after a RYGB in symptomatic and asymptomatic patients. METHODS Retrospective analysis of our bariatric surgery unit's database between 2001 and 2013 is obtained. Patients are surgically explored after RYGB due to acute bowel obstruction (ABO), intermittent abdominal pain (IAP), or being asymptomatic (during an elective cholecystectomy) in whom anatomical presence of IH was established. Also, we compared patients with retrocolic and antecolic technique. Statistical analysis with non-parametric tests and chi-square are used. RESULTS Of the patients, 3,656 submitted to RYGB during this period, 81.9% (2,993) by laparoscopy and 26.3% (963) with retrocolic technique. Of the patients, 130 (3.5%) were surgically explored due to ABO, 27 patients (0.7%) due to IAP, and 93 patients (2.5%) submitted to an elective cholecystectomy with exploration for IH. IH was present in 75% of the obstructed patients, and in 69%, it was the cause of obstruction. Patients with IAP showed 59% of IH, but only 15% have herniated bowel. In asymptomatic patients, 25% showed IH and none of them have herniated bowel. Retrocolic technique showed a higher risk of whole causes of ABO and IH than the antecolic technique, with a relative risk of 1.53 (1.07-2.17) and 1.62 (1.06-2.47), respectively. CONCLUSIONS A high frequency of IH exists in all operated patients of this series. All members of the bariatric team should be aware of the symptoms related to IH and actively pursue it during follow-up.
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Affiliation(s)
- Nicolás Quezada
- Bariatric Surgery Unit, Digestive Surgery Department, School of Medicine, Pontificia Universidad Católica de Chile, Marcoleta 350, Patio Interior, Santiago, Chile,
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Delko T, Kraljević M, Köstler T, Rothwell L, Droeser R, Potthast S, Oertli D, Zingg U. Primary non-closure of mesenteric defects in laparoscopic Roux-en-Y gastric bypass: reoperations and intraoperative findings in 146 patients. Surg Endosc 2015; 30:2367-73. [PMID: 26335072 DOI: 10.1007/s00464-015-4486-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Accepted: 08/01/2015] [Indexed: 01/02/2023]
Abstract
BACKGROUND Internal hernias (IH) after laparoscopic Roux-en-Y gastric bypass (LRYGB) have been reported with an incidence of 11 %. IH can lead to bowel incarceration and potentially bowel necrosis. The aim of this study was to analyze reoperations and intraoperative findings in a cohort of patients with unclosed mesenteric defects. METHODS From a prospective database of patients with LRYGB, we selected as primary cohort patients with non-closure of mesenteric defects and abdominal reoperation for analysis. The data included pre-, intra- and post-operative findings, computed tomogram results and laboratory test results. This group underwent a very very long limb LRYGB, at that time the institutional standard technique. Additionally, a more recently operated cohort with primary closure of mesenteric defects was also analyzed. RESULTS We identified 146 patients with primary non-closure and reoperation, mean age of 43.8 years. The main indication for reoperation was unclear abdominal pain in 119 patients with 27 patients undergoing a reoperation for other reasons (weight regain, prophylactic surgical inspection of mesenteric defects). Median time and mean excess weight loss from RYGB to reoperation were 41.1 months and 62.7 %, respectively. The incidence of IH was 14.4 %, with all patients with an IH being symptomatic. Conversion rate from laparoscopic to open surgery was 5.5 %, mortality 0.7 % and morbidity 3.4 %. Thirty-one patients underwent a second re-look laparoscopy. Eleven patients had recurrent open mesenteric defects. Three hundred and sixteen patients who underwent primary closure of the mesenteric defects had a reoperation rate of 13.6 % and an IH rate of 0.6 %. CONCLUSION The incidence of IH in patients without closure of mesenteric defects and reoperation is high and substantially higher compared to patients with primary closure of mesenteric defects. Patients with or without closure of mesenteric defects following LRYGB with acute, chronic or recurrent pain should be referred to a bariatric surgeon for diagnostic laparoscopy.
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Affiliation(s)
- Tarik Delko
- Department of General Surgery, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
| | - Marko Kraljević
- Department of General Surgery, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Thomas Köstler
- Department of General Surgery, Limmattal Hospital, 8952, Schlieren, Switzerland
| | - Lincoln Rothwell
- Adelaide Bariatric Centre, Flinders Private Hospital, Bedford Park, 5042, Australia
| | - Raoul Droeser
- Department of General Surgery, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Silke Potthast
- Department of General Surgery, Limmattal Hospital, 8952, Schlieren, Switzerland
| | - Daniel Oertli
- Department of General Surgery, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Urs Zingg
- Department of General Surgery, Limmattal Hospital, 8952, Schlieren, Switzerland
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Abstract
Hernias are among the most common long-term complications after bariatric surgery. Besides incisional hernias, which occur very often after conventional open bariatric surgery, internal hernias after bariatric surgery constitute a special challenge. The incidence of internal hernias after bariatric surgery is more common than for other upper gastrointestinal tract operations. Internal hernias are not limited to laparoscopic procedures but are also observed after conventional open gastric bypass surgery. As the incidence is significantly increased after laparoscopic interventions, there seems to be a close association with minimally invasive procedures. The clinical symptoms of internal hernias without complete obstruction are non-specific and the correct diagnosis is often not straightforward. In addition to the aspects of prevention of internal hernias in laparoscopic surgery, this article discusses the diagnosis and treatment, taking into account the various forms of internal hernia after bariatric operations.
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Affiliation(s)
- W K Karcz
- Bereich Metabolische und Adipositaschirurgie, Klinik für Allgemeine Chirurgie, Universitätsklinikum Schleswig Holstein - Campus Lübeck, Ratzeburger Allee 160, 23563, Lübeck, Deutschland,
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18
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Andreasen LA, Nilas L, Kjær MM. Operative complications during pregnancy after gastric bypass--a register-based cohort study. Obes Surg 2015; 24:1634-8. [PMID: 24659063 DOI: 10.1007/s11695-014-1232-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Late complications to bariatric surgery during pregnancy have become an area of concern. Expansion of the uterus and the following displacement of the small intestine may increase the risk of internal herniation. We wanted to estimate the risk and consequences of surgical complications during pregnancy in a national cohort of women with a history of gastric bypass surgery. METHODS A national, register-based cohort study of all Danish women with a history of gastric bypass surgery who had given birth from 2004 to 2010 was conducted. Surgical codes registered during pregnancy and until 120 days postpartum were identified in national registers, and the individual charts were reviewed in relevant cases. RESULTS Of 286 women giving birth, fourteen women underwent procedures that might be related to the earlier gastric bypass surgery. Three women were operated on suspicion of internal herniation. In all three cases, mesenteric defects were found, and herniation was still present in two women, one of which died postoperatively. Five women were investigated by gastroscopy or sigmoidoscopy either during or after the delivery, and in six women cholecystectomy was performed during the puerperium. CONCLUSIONS The incidence of internal herniation during pregnancy was 1 % in our study. Internal herniation may be a serious complication in pregnant women, and both the diagnosis and treatment requires handling by experienced obstetrical, radiological, and surgical staff.
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Geubbels N, Kappers I, van de Laar AWJM. Bridging the gap between gastric pouch and jejunum: a bariatric nightmare. BMC Surg 2015; 15:68. [PMID: 26025413 PMCID: PMC4458050 DOI: 10.1186/s12893-015-0043-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 02/25/2015] [Indexed: 11/10/2022] Open
Abstract
Background Even in a large volume bariatric centre, bariatric surgeons are sometimes confronted with intraoperative anatomical challenges which force even the most experienced surgeon into a pioneering position. In this video we present how a large gap of approximately 8 cm is bridged by applying several techniques that are not part of our standardized surgical procedure. Case presentation After creation of a 20 mL gastric pouch we discovered that the alimentary limb could not be advanced further cranially due to a very short a thick jejunal mesentery in a 49 year old male patient during laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery. By dissecting the gastro-oesophageal junction form the crus, stretching the gastric pouch, transecting the jejunal mesentery, using a retrocolic/retrogastric route, and creating a fully hand-sewn gastrojejunostomy we were able to safely complete the LRYGB. Drains were left near the gastrojejunostomy and the patient was kept nil by mouth for 5 days. On the 5th postoperative day radiographic swallow series were obtained which revealed no sign of leakage. The patient was discharged in good clinical condition on the 6th postoperative day. To date, no complications have occurred. Weight loss results are −31.5 % of the preoperative total body weight. Conclusions When confronted with a large distance between the gastric pouch and the alimentary limb, several techniques presented in this video may be of aid to the bariatric surgeon. We stress that only experienced bariatric surgeon should embark on these techniques. Inspecting the alimentary limb before the creation of the gastric pouch may prevent the need for such complex techniques. Electronic supplementary material The online version of this article (doi:10.1186/s12893-015-0043-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Noëlle Geubbels
- Department of Surgery, Slotervaart hospital, Amsterdam, The Netherlands.
| | - Ingrid Kappers
- Department of Surgery, Slotervaart hospital, Amsterdam, The Netherlands
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20
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Geubbels N, Lijftogt N, Fiocco M, van Leersum NJ, Wouters MWJM, de Brauw LM. Meta-analysis of internal herniation after gastric bypass surgery. Br J Surg 2015; 102:451-60. [DOI: 10.1002/bjs.9738] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 09/24/2014] [Accepted: 11/10/2014] [Indexed: 12/18/2022]
Abstract
Abstract
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 < 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 < 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.
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Affiliation(s)
- N Geubbels
- Department of Metabolic and Bariatric Surgery, Slotervaart Hospital, Amsterdam, The Netherlands
| | - N Lijftogt
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - M Fiocco
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Centre, Leiden, The Netherlands
- Institute of Mathematics, Leiden University Medical Centre, Leiden, The Netherlands
| | - N J van Leersum
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - M W J M Wouters
- Department of Surgery, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - L M de Brauw
- Department of Metabolic and Bariatric Surgery, Slotervaart Hospital, Amsterdam, The Netherlands
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Gruetter F, Kraljević M, Nebiker CA, Delko T. Internal hernia in late pregnancy after laparoscopic Roux-en-Y gastric bypass. BMJ Case Rep 2014; 2014:bcr-2014-206770. [PMID: 25538214 DOI: 10.1136/bcr-2014-206770] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
A 27-year-old patient in late pregnancy presented to the department of obstetrics with crampy abdominal pain located in the right flank, 3 years after a laparoscopic Roux-en-Y gastric bypass. Clinical investigation showed tenderness on palpation in the upper abdomen without signs of peritonitis. The cardiotocogram and blood tests were normal. The ultrasound showed a hydronephrosis on the right side, and a pigtail catheter was inserted. The abdominal symptoms did not abate and the abdominal surgeon was consulted 36 hours after admission. Diagnostic laparoscopy was performed promptly because of high suspicion of internal hernia (IH). Laparoscopy showed IH at the mesojejunal intermesenteric defect with a herniated common channel and volvulus of the anastomosis. Conversion to open reduction and complete closure with non-absorbable interrupted sutures was performed. Small bowel resection was avoided. The patient was discharged 10 days after the operation and a healthy boy was born 4 weeks later.
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Affiliation(s)
- Florian Gruetter
- Deparment of Surgery, University Hospital of Basel, Basel, Switzerland
| | - Marko Kraljević
- Deparment of Surgery, University Hospital of Basel, Basel, Switzerland
| | | | - Tarik Delko
- Deparment of Surgery, University Hospital of Basel, Basel, Switzerland
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Goudsmedt F, Deylgat B, Coenegrachts K, Van De Moortele K, Dillemans B. Internal Hernia After Laparoscopic Roux-en-Y Gastric Bypass: a Correlation Between Radiological and Operative Findings. Obes Surg 2014; 25:622-7. [DOI: 10.1007/s11695-014-1433-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Ortega J. Author's response: Anatomical basis for the low incidence of internal hernia after a laparoscopic Roux-en-Y gastric bypass without mesenteric closure. Obes Surg 2013; 23:2112. [PMID: 24130042 DOI: 10.1007/s11695-013-1096-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Joaquin Ortega
- Unidad de Cirugía Endocrina y Bariátrica, Hospital Clínico Universitario, Avda. Blasco Ibáñez, 17, 46007, Valencia, Spain,
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Anatomical basis for the low incidence of internal hernia after a laparoscopic Roux-en-Y gastric bypass without mesenteric closure. Obes Surg 2013; 23:2110-1. [PMID: 24130041 DOI: 10.1007/s11695-013-1095-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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