Internal Hernia in Pregnant Women After Gastric Bypass: a Retrospective Register-Based Cohort Study

Can small bowel obstruction during pregnancy be treated with conservative management? A review

BACKGROUND

Small bowel obstruction can occur during pregnancy, which, if missed, can lead to dire consequences for both the mother and foetus. Management of this condition usually requires surgical intervention. However, only a small number of patients are treated conservatively.

OBJECTIVE

The objective was to review the literature to determine the feasibility of conservative management for small bowel obstruction.

METHODS

A systematic search of the PubMed and Embase databases was performed using the keywords [small bowel obstruction AND pregnancy]. All original articles were then reviewed and included in this review if deemed suitable.

CONCLUSION

Conservative management of small bowel obstruction in pregnant women is feasible if the patient is clinically stable and after ruling out bowel ischaemia and closed-loop obstruction.

Management of small bowel obstruction in the third trimester

Small bowel obstruction (SBO) in pregnancy is exceedingly rare. Management of SBO in the third trimester may pose particular challenges, as clinicians must determine whether or not the delivery of the fetus is indicated. In this report, we review the case of a patient in her mid-20's with no prior surgical history who presented with nausea and vomiting at 34 weeks of gestation and was ultimately diagnosed with an SBO. Following expectant management during the initial 4 days of inpatient admission, the patient subsequently underwent an exploratory laparotomy at 35 weeks without concurrent delivery. She was monitored for the remainder of her pregnancy with non-stress tests to evaluate fetal status and eventually underwent induction of labour at 39 weeks, resulting in a successful vaginal delivery. Herein, we review the challenges related to the diagnosis and management of SBO in pregnancy, as well as the maternal-fetal outcomes in the setting of SBO in the third trimester.

The Impact of Pregnancy on Outcomes After Bariatric Surgery

BACKGROUND

Bariatric surgery is performed mostly on obese women of reproductive age. Many studies have analyzed pregnancy outcomes after bariatric surgery, but only a small number have studied the impact of pregnancy on the postoperative outcomes.

PURPOSE

To study the effect of pregnancy on outcomes after bariatric surgery in women of childbearing age.

METHODS

From January 2010 to October 2017, a retrospective study of a prospectively maintained database was conducted at the University Hospital of Geneva (HUG), where 287 women between the ages of 18 and 45 years had undergone Roux-en-Y gastric bypass (RYGB). A comparison of the results during a 5-year follow-up was performed between women who became pregnant after their bariatric surgery (pregnancy group, n = 40) and postoperative non-pregnant women (non-pregnancy group, n = 247). The two groups were compared for weight loss, complications, and nutritional deficiencies.

RESULTS

The pregnancy group was significantly younger (29.2 ± 5.5 vs. 36.4± 6.3 years, p < 0.001) and heavier (124.0 ± 18.0 kg vs. 114.7 ± 17.1, p < 0.001) compared with the non-pregnancy group at the time of surgery. The percentage of excess BMI loss (%EBMI loss) was similar in both groups during the 5-year follow-up. Complications after RYGB and nutritional deficiencies were nearly identical in the two groups. The interval of time between bariatric surgery and first pregnancy was a median of 20.8 months. Out of 40 first pregnancies, 28 women completed pregnancy successfully with live birth.

CONCLUSION

Pregnancy after bariatric surgery is safe and does not adversely affect outcomes after RYGB.

Pregnant patients with internal hernia after gastric bypass: a single-center experience

BACKGROUND

Bariatric surgery has been a popular way for many women to reach a healthy body mass index, and as a consequence, a decreased body mass, which causes a greater chance of fertility, with improved pregnancy and better maternal outcomes.

OBJECTIVE

Describe a single-center experience of pregnancies complicated by internal hernias after gastric bypass.

SETTING

Academic Medical Center.

METHODS

During 2011 and 2019 a series of patients were treated for internal hernia after gastric bypass at our teaching hospital. The hospital records were retrospectively reviewed.

RESULTS

Seven women were treated. Median age was 33 years (range: 24-39 yr). Median gestational age was 25.6 weeks (range: 5-33 wk). Median time from Roux-en-Y gastric bypass to pregnancy was 4 years (range: 1-7 yr). Median body mass index was 24 kg/m² (range: 24-31 kg/m²). Five (71.4%) patients underwent an exploratory laparotomy, and 2 (28.5%) patients a diagnostic laparoscopy. In all patients, an internal hernia of the small bowel in the Petersen space was encountered. Median length of pregnancy was 38 weeks (range: 33.6-39.6 wk). Six (85.7%) patients underwent C-section, and 1 (14.2%) patient gave birth by vaginal delivery. There was only 1 maternal postoperative complication and no fetal postoperative complications. Median follow-up was 9 months (range: 2-20 mo).

CONCLUSION

The rapid growth in bariatric surgery on obese women of fertile age could result in more cases of internal herniation during pregnancy in the future. An internal hernia should be suspected when encountering a postgastric bypass pregnant patient with abdominal pain, nausea, and vomiting.

Internal herniation during pregnancy after banded Roux-en-Y gastric bypass: a unique location

A 26-year-old multigravida, 30⁺³ weeks pregnant woman, was referred to our tertiary referral centre with acute abdominal pain and vomiting suspected for internal herniation. She had a history of a primary banded Roux-en-Y gastric bypass (B-RYGB). The MRI scan showed a clustered small bowel package with possible mesenteric swirl diagnosed as internal herniation. A diagnostic laparoscopy was converted to laparotomy showing an internal herniation of the alimentary limb through the silicone ring. The internal herniation was reduced by cutting the silicone ring. Postoperative recovery, remaining pregnancy and labour were uneventful. During pregnancy after B-RYGB, small bowel obstruction can in rare cases occur due to internal herniation through the silicone ring. Education regarding this complication should be provided before bariatric surgery. Treatment of women, 24 to 32 weeks pregnant, in a specialised centre for bariatric complications with a neonatal intensive care unit is advised to improve maternal and neonatal outcome.

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.

The impact of pregnancy on postoperative outcomes among obese women who underwent bariatric surgery: A systematic review and meta-analysis

OBJECTIVES

Women who had a history of bariatric surgery are increasingly becoming pregnant. There is growing evidence showing that increased risk of postoperative complications may be associated with the gestation after bariatric surgery.The objective of this systematic review was to evaluate the potential impact of pregnancy on weight loss and postoperative complications in obese women after bariatric surgery.

STUDY DESIGN

PubMed, Embase, Medline and Cochrane Central Register of Controlled Trails were searched from inception through October 2018. Selection criteria included observational or randomized trial examining weight loss and medical complications in pregnant compared to non-pregnant women after bariatric surgery. Two reviewers extracted information and performed quality appraisal of eligible articles. Meta-analysis was performed to ascertain the certainty of the evidence when possible.

RESULTS

Seven observational cohort studies with a total of 27,369 obese women were included in the final analysis. The mean difference (95 % confidence interval) in percent excess weight loss between pregnant and non-pregnant subjects was -9.5 (-19.9, 0.9). The odds ratio (95 % confidence interval) for postoperative complications in pregnant relative to non-pregnant subjects was 0.85 (0.33, 2.18).

CONCLUSIONS

Pregnancy may have little or no effect on weight loss or postoperative complications in women who have undergone bariatric surgery.

Management of surgical complications of previous bariatric surgery in pregnant women. A systematic review from the BARIA-MAT Study Group

Considering the large and increasing population of women of childbearing age with history of bariatric surgery, surgical complications of bariatric surgery during pregnancy may become more frequent in the future. The aim of this study was to analyze the clinical presentation, diagnostic procedures, and treatment of surgical complications of bariatric surgery during pregnancies. A systematic literature search was performed in accordance with the PRISMA (preferred reporting items for systematic review and meta-analysis) guidelines to identify all studies published up to and including December 2018 that included women with previous bariatric surgery undergoing emergency surgery during pregnancy. Sixty-eight studies were selected, including 120 women with previous bariatric surgery undergoing emergency surgery during pregnancy. Fifty cases were reported as case reports and 70 in case series. Included patients had previous history of Roux-en-Y gastric bypass (n = 99), laparoscopic adjustable gastric banding (n = 17), Scopinaro procedure (n = 2), vertical banded gastroplasty (n = 1), or one-anastomosis gastric bypass (n = 1). Final diagnosis in 50 case reports was internal hernia in 26 cases, bowel intussusception in 10, intestinal obstruction in 2, laparoscopic adjustable gastric banding slippage in 3, bowel volvulus in 3, gastric or jejunal perforation in 2, and other complications in 4 cases. Maternal and fetal death occurred in 3 (2.5%) and 9 cases (7.5%), respectively. In the case series, the majority of women were operated for internal hernia and laparoscopic adjustable gastric banding slippage. Surgical complications of previous bariatric surgery during pregnancy have potentially severe outcomes. Availability of multidisciplinary expertise, including bariatric/digestive surgeons, and education of healthcare providers and women on clinical signs that require urgent surgical examination are recommended in this setting. Prompt diagnosis is fundamental and based on clinical and laboratory findings and on radiologic examinations if needed, including computed tomography scan or magnetic resonance if available. Rapid surgical exploration is mandatory in case of high clinical and/or radiologic suspicion.

Internal hernias in pregnant females with Roux-en-Y gastric bypass: a systematic review

Improved fertility following a Roux-en-Y gastric bypass (RYGB) can lead to pregnancy and increase the risk of internal herniation. A developing fetus and symptoms of pregnancy can mask the diagnosis and delay intervention, leading to deleterious maternal and fetal consequences. The aim of this systematic review is to summarize the literature regarding internal hernias during pregnancy, their management, and patient outcomes. A comprehensive literature search was undertaken on PubMed and Google Scholar to identify cases of internal hernias presenting during pregnancy after RYGB. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for eligibility and inclusion of articles. Twenty-seven articles, with a total of 59 patients, regarding internal herniation during pregnancy after RYGB were identified. Epigastric pain and nausea and vomiting was the most common presentation. Regardless of orientation of the Roux limb and despite previous closure of mesenteric defects, internal herniation can still occur. A triad of epigastric pain, pregnancy, and a history of RYGB should be a red flag for clinicians to consider internal hernias as a top differential diagnosis. Prompt bariatric consultation and rapid intervention will improve maternal and fetal outcomes.

Pregnancy after bariatric surgery: a narrative literature review and discussion of impact on pregnancy management and outcome

Bariatric surgery (BS) is regarded to be the most effective treatment of obesity with long lasting beneficial effects including weight loss and improvement of metabolic disorders. A considerable number of women undergoing BS are at childbearing age.Although the surgery mediated weight loss has a positive effect on pregnancy outcome, the procedures might be associated with adverse outcomes as well, for example micronutrient deficiencies, iron or B12 deficiency anemia, dumping syndrome, surgical complications such as internal hernias, and small for gestational age (SGA) offspring, possibly due to maternal undernutrition. Also, there is no international consensus concerning the ideal time to conception after BS. Hence, the present narrative review intents to summarize the available literature concerning the most common challenges which arise before and during pregnancy after BS, such as fertility related considerations, vitamin and nutritional deficiencies and their adequate compensation through supplementation, altered glucose metabolism and its implications for gestational diabetes screening, the symptoms and treatment of dumping syndrome, surgical complications and the impact of BS on pregnancy outcome. The impact of different bariatric procedures on pregnancy and fetal outcome will also be discussed, as well as general considerations concerning the monitoring and management of pregnancies after BS.Whereas BS leads to the mitigation of many obesity-related pregnancy complications, such as gestational diabetes mellitus (GDM), pregnancy induced hypertension and fetal macrosomia; those procedures pose new risks which might lead to adverse outcomes for mothers and offspring, for example nutritional deficiencies, anemia, altered maternal glucose metabolism and small for gestational age children.

Fertility, Pregnancy and Lactation After Bariatric Surgery - a Consensus Statement from the OEGGG

Bariatric surgery is recommended when other weight loss interventions, such as lifestyle modification or medications, have failed. A considerable number of women undergoing bariatric surgery are of childbearing age; hence, it is necessary to be aware of the effects of bariatric surgery on pregnancy for managing these patients. Although bariatric surgery is associated with positive effects on cardiovascular and metabolic parameters, side effects such as anaemia, the risk of developing internal hernia, altered glucose metabolism and the risk of small for gestational age offspring have to be considered. Pregnant women with a history of gastric bypass should not undergo the oral glucose tolerance test (OGTT) due to the high risk of hypoglycaemia. There are no contraindications for vaginal delivery and breastfeeding. This paper has been published as a consensus statement by the Austrian Society of Gynaecology and Obstetrics (OEGGG).

Management of Pregnant Women after Bariatric Surgery

The prevalence of obesity is growing worldwide, and strategies to overcome this epidemic need to be developed urgently. Bariatric surgery is a very effective treatment option to reduce excess weight and often performed in women of reproductive age. Weight loss influences fertility positively and can resolve hormonal imbalance. So far, guidelines suggest conceiving after losing maximum weight and thus recommend conception at least 12-24 months after surgery. As limited data of these suggestions exist, further evidence is urgently needed as well for weight gain in pregnancy. Oral glucose tolerance tests for the diagnosis of gestational diabetes mellitus (GDM) should not be performed after bariatric procedures due to potential hypoglycaemic adverse events and high variability of glucose levels after glucose load. This challenges the utility of the usual diagnostic criteria for GDM in accurate prediction of complications. Furthermore, recommendations on essential nutrient supplementation in pregnancy and lactation in women after bariatric surgery are scarce. In addition, nutritional deficiencies or daily intake recommendations in pregnant women after bariatric surgery are not well investigated. This review summarizes current evidence, proposes clinical recommendations in pregnant women after bariatric surgery, and highlights areas of lack of evidence and the resulting urgent need for more clinical investigations.

Laparoscopic management of an internal hernia in a pregnant woman with Roux-en-Y gastric bypass

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.

The Impact of Upper Abdominal Pain During Pregnancy Following a Gastric Bypass

OBJECTIVE

The aim of the present study was to describe the risk of internal herniation (IH) and the obstetric outcome in pregnant women with Roux-en-Y gastric bypass (RYGB) and episodes of upper abdominal pain.

METHODS

The cohort included 133 women with RYGB: 94 with 113 pregnancies, from the local area referred for routine antenatal care (local cohort) and 39 with 40 pregnancies referred from other hospitals for specialist consultation due to RYGB. RYGB was mainly performed without closure of the mesenteric defects. Data collected from medical records were episodes of upper abdominal pain, pregestational and gestational abdominal surgery and pregnancy outcome. The risk of upper abdominal pain was estimated in the local cohort. Surgical intervention, IH and obstetric outcome according to pain were evaluated for 139 pregnancies with delivery of a singleton after 24 weeks of gestation (birth cohort).

RESULTS

Upper abdominal pain complicated 42/113 (37.2 %) pregnancies in the local cohort and 11 women (9.7 %) had IH. In the birth cohort, upper abdominal pain complicated 64/139 (46.0 %) pregnancies; surgery was performed in 30/64 (46.9 %), and IH diagnosed in 21/64 (32.8 %). The median gestational age at onset of pain was 25 + 3 weeks. Women reporting abdominal pain had a higher risk of preterm birth (n = 14/64 vs. 1/75, p < 0.005), lower median gestational length (269 vs. 278 days, p < 0.005) and lower median birth weight (3018 vs. 3281 g, p = 0.002) compared to women without abdominal pain.

CONCLUSIONS

Upper abdominal pain during pregnancy is frequent among women with Roux-en-Y gastric bypass, is often due to IH and is associated with adverse pregnancy outcome.

Pregnancy after bariatric surgery: improving outcomes for mother and child

The significant increase in the prevalence of obesity has led to an increase in the number of obese women who become pregnant. In this setting, in recent years, there has been an exponential rise in the number of bariatric procedures, with approximately half of them performed in women of childbearing age, and a remarkable surge in the number of women who become pregnant after having undergone bariatric surgery (BS). These procedures entail the risk of nutritional deficiencies, and nutrition is a crucial aspect during pregnancy. Therefore, knowledge and awareness of the consequences of these techniques on maternal and fetal outcomes is essential. Current evidence suggests a better overall obstetric outcome after BS, in comparison to morbid obese women managed conservatively, with a reduction in the prevalence of gestational diabetes mellitus, pregnancy-associated hypertensive disorders, macrosomia, and congenital defects. However, the risk of potential maternal nutritional deficiencies and newborns small for gestational age cannot be overlooked. Results concerning the incidence of preterm delivery and the number of C-sections are less consistent. In this paper, we review the updated evidence regarding the impact of BS on pregnancy.

FIXING JEJUNAL MANEUVER TO PREVENT PETERSEN HERNIA IN GASTRIC BYPASS

Background

: Among Roux-en-Y gastric bypass complications is the occurrence of intestinal obstruction by the appearance of internal hernias, which may occur in Petersen space or the opening in mesenteric enteroenteroanastomosis.

Aim

: To evaluate the efficiency and safety in performing a fixing jejunal maneuver in the transverse mesocolon to prevent internal hernia formation in Petersen space.

Method

: Two surgical points between the jejunum and the transverse mesocolon, being 5 cm and 10 cm from duodenojejunal angle are made. In all patients was left Petersen space open and closing the opening of the mesenteric enteroenteroanastomosis.

Results

: Among 52 operated patients, 35 were women (67.3%). The age ranged 18-63 years, mean 39.2 years. BMI ranged from 35 to 56 kg/m² (mean 40.5 kg/m²). Mean follow-up was 15.1 months (12-18 months). The operative time ranged from 68-138 min. There were no intraoperative complications, and there were no major postoperative complications and no reoperations. The hospital stay ranged from 2-3 days. During the follow-up, no one patient developed suspect clinical presentation of internal hernia. Follow-up in nine patients (17.3%) showed asymptomatic cholelithiasis and underwent elective laparoscopic cholecystectomy. During these procedures were verified the Petersen space and jejunal fixation. In all nine, there was no herniation of the jejunum to the right side in Petersen space.

Conclusion

: The fixation of the first part of the jejunum to left side of the transverse mesocolon is safe and effective to prevent internal Petersen hernia in RYGB postoperatively in the short and medium term. It may be interesting alternative to closing the Petersen space.

Complications of banded laparoscopic Roux-en-Y gastric bypass in a 33-week pregnant woman

Women desiring pregnancy might fail to conceive due to their obesity. Bariatric surgery has shown to reduce this infertility up to 58% and is therefore considered a successful strategy for morbidly obese infertile women. Nevertheless, when pregnancy has succeeded, surgery-related complications might occur.

Banded laparoscopic Roux-en-Y gastric bypass (B-LRYGB) is a relatively new technique in which a band is placed around the small gastric pouch. We report a case of a 30-year-old woman who succeeded to become pregnant after weight loss due to B-LRYGB, but presented with acute abdominal pain in Week 33 of her pregnancy.