Internal hernias after laparoscopic Roux-en-Y gastric bypass

Petersen Hernia After Abdominoplasty: A Provocative Factor or a Coincidence?

Abdominal contouring procedures are frequently performed following massive weight loss after a Roux-en-Y gastric bypass. This last procedure can be associated with late complications like the development of internal hernias (e.g., Petersen hernia). The purpose of this article is to present a case of Petersen hernia after complete abdominoplasty. A 42-year-old female presented to the emergency department with acute abdominal pain three days after undergoing a complete abdominoplasty following massive weight loss post laparoscopic gastric bypass (Roux-en-Y). The patient was diagnosed with a mechanical small bowel obstruction, likely due to an internal hernia (Petersen hernia) and underwent surgical correction. Gastric bypass surgery may be associated with small bowel obstruction from internal herniation. A sudden rise in abdominal pressure, as occurs with abdominoplasty with rectus plication and subsequent use of compression garments, may result in strangulation and intestinal ischemia. A high degree of suspicion of intra-abdominal complications after abdominoplasty is essential, particularly in the setting of post-bariatric surgery.

Incidence and risk factors of symptomatic Petersen's hernias in bariatric and upper gastrointestinal surgery: a systematic review and meta-analysis

PURPOSE

The aim of this study was to investigate the actual incidence of symptomatic Petersen's hernias (PH) as well as identify risk factors for their occurrence.

METHODS

Search was performed in Medline (via PubMed), Web of Science, and Cochrane library, using the keywords "Petersen Or Petersen's AND hernia" and "Internal hernia." Only studies of symptomatic PH were eligible. Fifty-three studies matched our criteria and were included. Risk of bias for each study was independently assessed using the checklist modification by Hoy et al. Analysis was performed using random-effects models, with subsequent subgroup analyses.

RESULTS

A total of 81,701 patients were included. Mean time interval from index operation to PH diagnosis was 17.8 months. Total small bowel obstruction (SBO) events at Petersen's site were 737 (0.7%). SBO incidence was significantly higher in patients without defect closure (1.2% vs 0.3%, p < 0.01), but was not significantly affected by anastomosis fashion (retrocolic 0.7% vs antecolic 0.8%, p = 0.99). SBO incidence was also not significantly affected by the surgical approach (laparoscopic = 0.7% vs open = 0.1%, p = 0.18). However, retrocolic anastomosis was found to be associated with marginally, but not significantly, increased SBO rate in patients with Petersen's space closure, compared with the antecolic anastomosis (p = 0.09).

CONCLUSION

PH development may occur after any gastric operation with gastrojejunal anastomosis. Contrary to anastomosis fashion and surgical approach, defect closure was demonstrated to significantly reduce SBO incidence. Limitations of this study may include the high heterogeneity and the possible publication bias across the included studies.

Chronic abdominal pain after bariatric surgery: a narrative review

Objective: This paper reviews the prevalence, etiology, risk factors, diagnosis and prevention of chronic abdominal pain after bariatric surgery. Introduction: Chronic pain is a very common and complex problem that has serious consequences on individuals and society. It frequently presents as a result of a disease or an injury. Obesity and obesity-related comorbidities are a major health problem and are dramatically increasing year after year. Dieting and physical exercise show disappointing results in the treatment of obesity. Therefore, bariatric surgery is increasingly widely offered as a weight reducing strategy. In our pain clinic we see a lot of patients who suffer from chronic abdominal pain after bariatric surgery. This review aims to explore the link between chronic abdominal pain and bariatric surgery in this specific type of patients. Method: The review is based on searches in PubMed, Embase and Cochrane databases. Keywords are used in different combinations. We did a cross-reference of the articles included. Results: Chronic abdominal pain after bariatric surgery is very common. Around 30% of the bariatric patients experience persistent abdominal pain. An explanation for the abdominal pain is found in 2/3 of these patients. There is a wide variety of causes including behavioral and nutritional disorders, functional motility disorders, biliary disorders, marginal ulceration and internal hernia. Another, frequently overlooked, cause is abdominal wall pain. Unexplained abdominal pain after bariatric surgery is present in 1/3 of the patients with persistent abdominal pain. More studies are needed on the risk factors and prevention of unexplained abdominal pain in bariatric patients.

Operative management of acute abdomen after bariatric surgery in the emergency setting: the OBA guidelines

BACKGROUND

Patients presenting with acute abdominal pain that occurs after months or years following bariatric surgery may present for assessment and management in the local emergency units. Due to the large variety of surgical bariatric techniques, emergency surgeons have to be aware of the main functional outcomes and long-term surgical complications following the most performed bariatric surgical procedures. The purpose of these evidence-based guidelines is to present a consensus position from members of the WSES in collaboration with IFSO bariatric experienced surgeons, on the management of acute abdomen after bariatric surgery focusing on long-term complications in patients who have undergone laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

METHOD

A working group of experienced general, acute care, and bariatric surgeons was created to carry out a systematic review of the literature following the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) and to answer the PICO questions formulated after the Operative management in bariatric acute abdomen survey. The literature search was limited to late/long-term complications following laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

CONCLUSIONS

The acute abdomen after bariatric surgery is a common cause of admission in emergency departments. Knowledge of the most common late/long-term complications (&gt; 4 weeks after surgical procedure) following sleeve gastrectomy and Roux-en-Y gastric bypass and their anatomy leads to a focused management in the emergency setting with good outcomes and decreased morbidity and mortality rates. A close collaboration between emergency surgeons, radiologists, endoscopists, and anesthesiologists is mandatory in the management of this group of patients in the emergency setting.

Abdominal Pain in the Emergency Department: How to Select the Correct Imaging for Diagnosis

Abdominal pain is a common presenting complaint in the emergency department, and utilization of diagnostic imaging is often a key tool in determining its etiology. Plain radiography has limited utility in this population. Computed tomography (CT) is the imaging modality of choice for undifferentiated abdominal pain. Ultrasound and magnetic resonance imaging may be helpful in specific scenarios, primarily in pediatrics and pregnancy, and offer the benefit of eliminating ionizing radiation risk of CT. Guidance for imaging selection is determined by location of pain, special patient considerations, and specific suspected etiologies. Expert guidance is offered by the American College of Radiology Appropriateness Criteria^® which outlines imaging options based on location of pain.

Mechanical ileus and mesenteric ischemia in a patient with simultaneous internal herniation through Petersen's and jejunojejunal spaces following laparoscopic Roux-en-Y gastric bypass: A case report

Introduction

Internal herniation (IH) of the small bowel after laparoscopic Roux-en-Y gastric bypass (LRYGB) is a well-known complication, with an incidence ranging from 1 to 5% depending on the route of the Roux limb and the closure of the mesenteric defects at the time of the initial operation. Simultaneous herniation of the biliopancreatic and Roux limbs through both Petersen's and jejunojejunal spaces with mesenteric torsion resulting in early small bowel ischemia has not been described earlier.

Presentation of case

A 63-year-old patient presented with mechanical small bowel ileus and early mesenteric ischemia due to simultaneous herniation of the alimentary and the biliopancreatic limb through the Petersen's and jejunojejunal spaces with subsequent rotation and torsion of the mesentery 33 months after LRYGB. The condition was managed by surgically reducing the hernias and closure of the mesenteric defects. Partial bowel resection was not performed. The patient's postoperative course was uneventful.

Discussion

Simultaneous herniation of the biliopancreatic and Roux limbs through both intermesenteric windows caused consequent life-threatening complications after LRYGB. Antecolic approach and closure of mesenteric defects with non-absorbable sutures are recommended when technically feasible. Proper history taking and clinical examination, as well as communication between surgeons and radiologists, are crucial in establishing a rapid diagnosis.

Conclusion

Internal hernia following LRYGB can be fatal. In cases of uncertainty, emergency exploratory laparoscopy or laparotomy should be performed. The open approach seems superior for recurrent small bowel obstruction (SBO) due to recurrent IH. High vigilance is necessary when IH is suspected, despite normal laboratory and radiological findings.

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Small bowel internal herniation (IH) is a serious complication occurring after LRYGBE.

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We treated simultaneous herniation of the biliopancreatic and Roux limbs.

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History taking, clinical examination, and interdisciplinary treatment are helpful.

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In cases of uncertainty, laparoscopy or in some cases laparotomy should be performed.

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The open approach seems superior for recurrent small bowel obstruction.

Closure of Petersen's Space Lowers the Incidence of Gastric Food Retention after Distal Gastrectomy with Gastrojejunostomy in Gastric Cancer Patients

Purpose

Delayed gastric emptying usually manifests as gastric food retention. This study aimed to evaluate the incidence of gastric food retention after distal gastrectomy with gastrojejunostomy in gastric cancer patients and identify the risk factors for its development.

Materials and Methods

We retrospectively enrolled 245 patients who underwent distal gastrectomy with gastrojejunostomy for gastric cancer at Boramae Medical Center between March 2017 and December 2019. We analyzed the presence of gastric food residue via computed tomography (CT) scans at 3 and 12 months postoperatively and analyzed the risk factors that may influence the development of gastric food retention.

Results

CT scans were performed on 235 patients at 3 months and on 217 patients at 12 months postoperatively. In the group that received closure of Petersen's space, the incidence of gastric food retention was significantly low as per the 3- and 12-month postoperative follow-up CT scans (P=0.028 and 0.003, respectively). In addition, hypertension was related to gastric food retention as per the 12-month postoperative follow-up CT scans (P=0.011). No other factors were related to the development of gastric food retention. In the multivariate analysis, non-closure of Petersen's space (hazard ratio [HR], 2.54; 95% confidence interval [CI], 1.20–5.38; P=0.010) was the only significant risk factor for gastric food retention at 3 months postoperatively, while non-closure of Petersen's space (HR, 2.81; 95% CI, 1.40-5.64; P=0.004) and hypertension (HR, 2.30; 95% CI, 1.14–4.63; P=0.020) were both significant risk factors for gastric food retention at 12 months postoperatively.

Conclusions

Closure of Petersen's space has an effect on decrease the incidence of gastric food retention after distal gastrectomy with gastrojejunostomy in gastric cancer patients.

Closure of Mesenteric Defects in Laparoscopic Gastric Bypass: a Meta-Analysis

INTRODUCTION

The purpose of the current study was to review the available literature on morbidly obese patients treated with laparoscopic Roux-en-Y gastric bypass (LRYGB) in order to assess the clinical outcomes of the routine closure of the mesenteric defects.

METHODS

A literature search was performed in PubMed, Cochrane library, and Scopus, in accordance with the PRISMA guidelines.

RESULTS

Nine studies met the inclusion criteria. A total of 16,520 patients were incorporated with a mean follow-up ranging from 34 to 120 months. The closure of the mesenteric defects was associated with a lower incidence of internal hernias (odds ratio, 0.25 [95% confidence interval 0.20, 0.31]; p < 0.01), small bowel obstruction (SBO) (0.30 [0.17, 0.52]; p < 0.0001) and reoperations (0.28 [0.15, 0.52]; p < 0.001). Both approaches presented similar complication rates and % excess weight loss (%EWL).

CONCLUSION

The present meta-analysis is the best currently available evidence on the topic and supports the routine closure of the mesenteric defects.

Imaging Postoperative Abdominal Hernias: A Review with a Clinical Perspective

Postoperative internal hernia is a challenging but critical diagnosis in postoperative patients presenting with acute abdomen. Postoperative internal hernias are increasingly being recognized after Roux-en-Y gastric bypass (RYGB) and bariatric surgeries. These internal hernias have a high risk of closed-loop obstruction and bowel ischemia; therefore, prompt recognition is necessary. Computed tomography (CT) is the imaging modality of choice in cases of postoperative acute abdomen. Understanding the types of postoperative internal hernia and their common imaging features on CT is crucial for the abdominal radiologist. Postoperative external hernias are usually a result of defect or weakness of the abdominal wall created because of the surgery. CT helps in the detection, delineation, diagnosis of complications, and surgical planning of an external hernia. In this article, the anatomy, pathophysiology, and CT features of common postoperative hernias are discussed. Afterreading this review, the readers should be able to (1) enumerate the common postoperative internal and external abdominal hernias, (2) explain the pathophysiology and surgical anatomy of Roux-en-Y gastric bypass-related hernia, (3) identify the common imaging features of postoperative hernia, and (4) diagnose the complications of postoperative hernias.

Laparoscopic Management of Internal Hernia After One Anastomosis Gastric Bypass (OAGB)

Among the advantages of the One Anastomosis Gastric Bypass (OAGB) are the lack of jejuno-jejunal anastomosis and a supposed lower incidence of internal hernia (IH), with only a few cases reported until now. However, the incidence of IH after OAGB is not null. We present a video of the laparoscopic management of an IH that occurred after an OAGB. The patient was a 49-year-old female who had undergone a laparoscopic revisional OAGB 2 years previously after a failed laparoscopic adjustable gastric banding. She was referred to our Unit for recurrent postprandial colicky pain. She lost a total of 50 kg and her body mass index (BMI) dropped from 38 to 19 kg/m². A CT scan with intravenous contrast showed a swirl of the mesentery around the superior mesenteric artery, without small bowel obstruction. A laparoscopic exploration was performed, confirming the suspicion of IH at the Petersen's space. An anticlockwise derotation of the whole common limb was performed, and the Petersen's space was eventually closed with a running non-absorbable suture.

Revisional Surgery: Aphagia After Gastric Bypass

Background: Gastric bypass is one of the most widely performed bariatric procedures worldwide and continues to be the gold standard in obese patients with metabolic disorders.¹ Regarding the complications, these can appear early or late, the most frequent of the latter being anastomosis stenosis, especially the gastrojejunal (G-J) stenosis. The first treatment option in stenosis is the endoscopic approach, but in cases wherein it fails or the diagnosis is kinking, revisional surgery should be performed. Methods: We describe the technique, step by step, we use to perform a very complex revisional surgery in a patient with aphagia after gastric bypass. Results: This is the case of a 38-year-old female patient who underwent laparoscopic adjustable gastric band in 2011; due to her poor tolerance, a laparoscopic gastric bypass was done. She began with vomiting and gastroesophageal reflux with remarkable symptoms. Diagnosis of stenosis of the jejunojejunal anastomosis of the Roux-en-Y was made and two surgeries were done to treat it. Later the patient referred aphagia and a kink of the gastrojejunal (G-J) anastomosis were observed in the gastrointestinal series. We decided to do a revisional surgery and we describe it step by step in this article. Conclusion: The G-J anastomosis stenosis is the most frequent late complication. Also kinking has to be considered strongly when aphagia or symptoms of obstruction are present. If endoscopic treatment for stenosis or cases of kinking is unsuccessful and fails, then revisional surgery should be considered.

Absorbable suture can be effectively and safely used to close the mesenteric defect in a gastric bypass Sprague-Dawley rat model

Background

To observe if closing the mesenteric defect with absorbable sutures creates a safe adhesion compared to non-absorbable suture after Roux-en-Y gastric bypass.

Methods

Rats were randomly assigned to 5 experimental groups according to the different suture materials used in closing the mesenteric defects (Peterson’s space) after Roux-en-Y gastric bypass. Group A (control group), Group B (non-absorbable suture, Prolene suture), Group C (biological glue), Group D (non-absorbable suture, polyester suture) and Group E (absorbable suture). All rats were followed up for 8 weeks postoperatively and underwent laparotomy to observe the degree of adhesion and closure of the mesenteric defect.

Results

No significant difference was found in the decrease in food intake and body weight among all groups. No internal hernia (IH) occurred in any group. The mesenteric defects of Group A remained completely visible without any closure or adhesion. Multiple gaps were found between the Prolene suture and the mesentery along the suture line in Group B. The mesenteric defects of Group C were complete closed with multiple adhesions of the small intestine and the greater omentum. The mesenteric defects in both Group D and Group E closed completely. The average adhesion scores in Group A and Group B were 0 and 0.33 ± 0.52 respectively. The average adhesion score in group C (3.83 ± 0.41) was higher than the other groups (p<0.05). The average adhesion scores in Group D and E were similar (3.17 ± 0.41 and 3.00 ± 0.00 respectively).

Conclusion

Absorbable suture created a safe adhesion score between the mesentery which was not inferior to non-absorbable sutures.

Imaging of Abdominal Postoperative Complications

We present a case-based review of abdominal postoperative complications, organized by organ system affected, including wound/superficial, hepatobiliary, pancreatic, gastrointestinal, genitourinary, and vascular complications. Both general complications and specific considerations for certain types of operations are described, as well as potential pitfalls that can be confused with complications. Representative cases are shown using all relevant imaging modalities, including CT, fluoroscopy, ultrasound, MRI, and nuclear medicine. Management options are also described, highlighting those that require radiologist input or intervention.

INTERNAL HERNIA FOLLOWING LAPAROSCOPIC ROUX-EN-Y GASTRIC BY-PASS: INDICATIVE FACTORS FOR EARLY REPAIR

BACKGROUND

Internal hernia (IH) following laparoscopic Roux-en-Y gastric bypass (LRYGB) is a major complication that challenges the surgeon due to its non-specific presentation and necessity of early repair. Delayed diagnosis and surgical intervention of IH might lead to increased morbidity of patients and impairments in their quality of life.

OBJECTIVE

To evaluate the predictive factors for early diagnosis and surgical repair of IH after LRYGB.

METHODS

This study analyzed 38 patients during the postoperative period of LRYGB who presented clinical manifestations suggestive of IH after an average of 24 months following the bariatric procedure.

RESULTS

The sample consisted of 10 men and 28 women, with a mean age of 37.5 years and a mean body mass index (BMI) of 39.6 kg/m2 before LRYGB. All patients presented pain, 23 presented abdominal distension, 10 had nausea and 12 were vomiting; three of them had dysphagia, three had diarrhea and one had gastro-esophageal reflux. The patients presented symptoms for an average of 15 days, varying from 3 to 50 days. Seventeen (45.9%) patients were seen once, while the other 20 (54.1%) went to the emergency room twice or more times. Exploratory laparoscopy was performed on all patients, being converted to laparotomy in three cases. Petersen hernia was confirmed in 22 (57.9%). Petersen space was closed in all patients and the IH correction was performed in 20 (52.6%) cases. The herniated loop showed signs of vascular suffering in seven patients, and two (5.3%) had irreversible ischemia, requiring bowel resection.

CONCLUSION

The presence of recurrent abdominal pain is one of the main indicators for the diagnosis of IH after LRYGB. Patients operated at an early stage, even with negative imaging tests for this disease, benefited from rapid and simple procedures without major complications.

Intestinal failure after bariatric surgery: Treatment and outcome at a single-intestinal rehabilitation and transplant center

BACKGROUND

Though intestinal failure (IF) after bariatric surgery (BS) is uncommon, its prevalence is increasing. However, data on the outcomes for these patients are limited.

OBJECTIVES

To analyze the outcomes of treatment for patients with IF after BS.

SETTING

University hospital.

METHODS

A single-center analysis (1991-2016) of outcomes according to treatment arms established by a multidisciplinary team.

RESULTS

Twenty-five IF patients were identified (median age 45 yr). BS was 92% Roux-en-Y gastric bypass. The major cause of IF was volvulus/internal hernia (72%). Median time from BS to IF was 48 months. Treatment arms were intestinal rehabilitation (IR, n = 15), transplantation (TXP, n = 5), and parenteral nutrition (PN, n = 5). For IR, median bowel length was 60 cm. Forty-six percent ultimately discontinued PN. Twenty-seven percent were partially weaned PN and 27% failed IR. Common surgical rehabilitation was Roux-en-Y gastric bypass reversal and restoration of gastrointestinal continuity. The 5-year overall survival was 74%. For TXP, 7 patients were listed for TXP (5 initially and 2 after failed IR). Three underwent TXP, 2 isolated intestine and 1 isolated liver. Three were delisted (1 improvement and 2 death). For PN, 6 patients required long-term PN (5 initially and 1 after failed IR). Four patients are alive currently.

CONCLUSIONS

IF after BS is an increasing problem facing IR centers. Internal hernia is the major cause. Surgical IR is the first-line therapy and affords the best outcome. TXP is reserved for rescuing patients who failed IR or develop PN complications. Long-term PN is suitable for patients in whom IR or TXP is impractical.

The diagnostic performance and interrater agreement of seven CT findings in the diagnosis of internal hernia after gastric bypass operation

PURPOSE

A reliable and immediate diagnosis of internal hernia is important for optimal and timely management of patients with a history of gastric bypass surgery. The aims of this study were to evaluate the interrater agreement and diagnostic performance characteristics of seven predefined CT findings of internal herniation in patients admitted on clinical suspicion of internal herniation after laparoscopic Roux-en-Y gastric bypass (LRYGB).

METHODS

Abdominal CT scans of 117 patients performed on clinical suspicion of internal hernia after LRYGB surgery were evaluated by three radiologists (two experts and one resident) for the following: (1) Swirl sign, (2) strangulation of superior mesenteric vein (SMV), (3) engorged mesenteric vessels and edema, (4) engorged lymph nodes, (5) ascites, (6) mushroom sign, (7) hurricane eye sign, and finally the overall conclusion. The CT findings were compared to the laparoscopic explorative findings.

RESULTS

The highest interrater agreements were seen for the swirl sign, SMV strangulation, ascites, and overall conclusion (all Kappa 0.82-0.83). The presence of internal hernia was significantly and independently associated with SMV strangulation (OR 18.3; 95% CI 4.3-78.1; p < 0.001) and mesenteric edema (OR 5.2; 95% CI 1.4-19.6; p < 0.001) on multivariate analysis, while the other CT findings were not independently associated with herniation. The highest sensitivity was observed for mesenteric edema (85.0%), while SMV strangulation had the highest specificity (94.8%).

CONCLUSION

CT is an accurate diagnostic tool for detection of internal hernia after LRYGB. SMV strangulation and mesenteric edema are highly predictive and easily identified features of internal herniation.

Diagnostic Accuracy of MRI for Diagnosis of Internal Hernia in Pregnant Women With Prior Roux-en-Y Gastric Bypass

OBJECTIVE

The purpose of this study was to evaluate the accuracy of MRI for the diagnosis of internal hernia (IH) in pregnant women who have undergone Roux-en-Y gastric bypass (RYGB).

MATERIALS AND METHODS

Fifteen consecutively registered pregnant women (eight with surgically proven IH, seven without IH) who had previously undergone RYGB underwent MRI to rule out IH between July 2011 and July 2016. Two blinded radiologists retrospectively evaluated MRI examinations for the presence or absence of 13 established CT findings of IH. The final diagnosis of IH was evaluated subjectively and with two previously validated CT models (model 1, mesenteric swirl or small-bowel obstruction; model 2, beaking of the superior mesenteric vein or small-bowel obstruction). Diagnostic odds ratio (DOR) and interobserver agreement were calculated for each feature, and the subjective and model-based diagnoses of IH were compared by chi-square test.

RESULTS

There were no statistically significant differences in patient age (p = 0.68), gestational age (p = 0.35), or time since RYGB (p = 0.55) between patients with and those without IH. The findings with best DOR and interobserver agreement were beaking of the superior mesenteric vein (reader 1 DOR, 39; reader 2 DOR, 39; κ = 1.00), mesenteric swirl (reader 1 DOR, 11; reader 2 DOR, 39; κ = 0.86), engorgement of mesenteric vessels (reader 1 DOR, 24; reader 2 DOR, 15; κ = 0.84), and mesenteric edema (reader 1 DOR, 11; reader 2 DOR, 3; κ = 0.73). The other findings had either low accuracy, poor interobserver agreement, or both. The overall sensitivity and specificity of the diagnosis of IH ranged from 75% to 88% and 86% to 100% for the two readers. There was no difference in diagnostic accuracy between the three methods (p = 0.93).

CONCLUSION

MRI is useful in the diagnosis of IH in pregnant women who have undergone RYGB. The specificity is comparable to that of CT, and the sensitivity approaches that of CT.

Predicting Symptom Relief After Reoperation for Suspected Internal Herniation After Laparoscopic Roux-en-Y Gastric Bypass

Background

Internal herniation (IH) is one of the most common long-term complications after laparoscopic Roux-en-Y gastric bypass (LRYGB). Diagnosis of IH may be difficult, and not all patients with suspected IH will have full relief of symptoms after closure of both mesenteric defects.

Objectives

To investigate possible predictive factors for relief of symptoms in patients with suspected IH.

Methods

All patients that underwent reoperation for (suspected) IH after LRYGB from June 2009 to December 2016 were retrospectively evaluated in this multicentre cohort study. Logistic regression analysis was used to identify predictive factors for pain relief after closure of the mesenteric defects.

Results

A total of 193 patients underwent laparoscopy for (suspected) IH during the study period. The median interval between LRYGB and reoperation was 18.3 ± 19.0 months. In 40.2% of cases, IH was identified on computed tomography (CT), and IH was objectified during surgery in 61.1%. Postoperative symptom relief was observed in 146 patients (77.2%). For patients in which IH was present during surgery, 82.8% had relief of pain postoperatively, as compared to 68.5% for those procedures in which no IH was found. The only significant predictor for postoperative pain relief was a swirl sign on CT (OR 4.24, 95%CI 1.63–11.05).

Conclusions

Pain relief after closure of the mesenteric defects for IH remains unpredictable. A positive CT for IH was a predictive factor for symptom relief after reoperation for (suspected) IH after LRYGB. However, many patients benefit from closure of the mesenteric defects, irrespective of perioperative presence of IH.

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.

Adult Intestinal Transplantation

Adult intestinal transplantation differs significantly from pediatric intestinal transplantation. While indications have remained largely consistent since 2000, indications for adults have expanded over the last two decades to include motility disorders and desmoid tumors. Graft type in adult recipients depends on the distinct anatomic characteristics of the adult recipient. Colonic inclusion, while initially speculated to portend unfavorable outcomes due to complex host-bacterial interactions has increased over the past two decades with superior graft survival and improved patient quality of life. Overall, outcomes have steadily improved. For adult intestinal transplant candidates, intestinal transplantation remains a mainstay therapy for complicated intestinal failure and is a promising option for other life threatening and debilitating conditions.

Internal Herniation After Laparoscopic Roux-en-Y Gastric Bypass Surgery: Pitfalls in Diagnosing and the Introduction of the AMSTERDAM Classification

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.

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.

Caecal herniation through the foramen of Winslow

Internal hernia is the protrusion of an abdominal viscus through the peritoneum or mesentery into a compartment within the abdominal cavity. We present a case of internal herniation through the foramen of Winslow that was identified by CT imaging. It was treated with reduction at laparotomy and subsequent right hemicolectomy.

Evaluating Patients with Left Upper Quadrant Pain

Imaging plays a major role in the evaluation of patients who present to the emergency department with acute left upper quadrant (LUQ) pain. Multidetector computed tomography is currently the primary modality used for imaging these patients. The peritoneal reflections, subperitoneal compartment, and peritoneal spaces of the LUQ are key anatomic features in understanding the imaging appearance of acute diseases in this area. Diseases of the stomach, spleen, pancreas, and splenic flexure are encountered in patients with acute LUQ pain. Optimization of the imaging protocol is vital for accurate diagnosis and characterization of these diseases in the acute setting.

Mechanism Underlying the Weight Loss and Complications of Roux-en-Y Gastric Bypass. Review

Various bariatric surgical procedures are effective at improving health in patients with obesity associated co-morbidities, but the aim of this review is to specifically describe the mechanisms through which Roux-en-Y gastric bypass (RYGB) surgery enables weight loss for obese patients using observations from both human and animal studies. Perhaps most but not all clinicians would agree that the beneficial effects outweigh the harm of RYGB; however, the mechanisms for both the beneficial and deleterious (for example postprandial hypoglycaemia, vitamin deficiency and bone loss) effects are ill understood. The exaggerated release of the satiety gut hormones, such as GLP-1 and PYY, with their central and peripheral effects on food intake has given new insight into the physiological changes that happen after surgery. The initial enthusiasm after the discovery of the role of the gut hormones following RYGB may need to be tempered as the magnitude of the effects of these hormonal responses on weight loss may have been overestimated. The physiological changes after RYGB are unlikely to be due to a single hormone, or single mechanism, but most likely involve complex gut-brain signalling. Understanding the mechanisms involved with the beneficial and deleterious effects of RYGB will speed up the development of effective, cheaper and safer surgical and non-surgical treatments for obesity.

Early surgical complications after gastric by-pass: a literature review

INTRODUCTION

Gastric bypass is today the most frequently performed bariatric procedure,but, despite of it, several complications can occur with varied morbimortality. Probably all bariatric surgeons know these complications, but, as bariatric surgery continues to spread, general surgeon must be familiarized to it and its management. Gastric bypass complications can be divided into two groups: early and late complications, taking into account the two weeks period after the surgery. This paper will focus the early ones.

METHOD

Literature review was carried out using Medline/PubMed, Cochrane Library, SciELO, and additional information on institutional sites of interest crossing the headings: gastric bypass AND complications; follow-up studies AND complications; postoperative complications AND anastomosis, Roux-en-Y; obesity AND postoperative complications. Search language was English.

RESULTS

There were selected 26 studies that matched the headings. Early complications included: anastomotic or staple line leaks, gastrointestinal bleeding, intestinal obstruction and incorrect Roux limb reconstruction.

CONCLUSION

Knowledge on strategies on how to reduce the risk and incidence of complications must be acquired, and every surgeon must be familiar with these complications in order to achieve an earlier recognition and perform the best intervention.

Petersen hernia after open gastrectomy with Roux-en-Y reconstruction: a report of two cases and literature review

Petersen hernia is a rare internal hernia that occurs after Roux-en-Y (R-Y) reconstruction. To our knowledge, there are a few reports on internal hernia, especially Petersen hernia after open gastrectomy for gastric cancer. Two rare cases of Petersen hernia are presented in this report. A man in his 70s was referred to our hospital due to a complaint of postprandial sudden abdominal pain. He had a history of open total gastrectomy with R-Y jejunal reconstruction through the antecolic route for gastric corpus cancer. On computed tomography (CT), bowel obstruction and strangulation of the small intestine were suspected. Emergency laparotomy was done, and an internal herniation of the small intestine through Petersen space was observed. A man in his 50s was referred to our hospital due to a complaint of severe sudden abdominal pain. He had a history of open gastrectomy and abdominal/lower intrathoracic esophageal resection with R-Y jejunal reconstruction of an antecolic jejunal limb for esophagogastric junction carcinoma. On CT, internal herniation of the small intestine was suspected. During emergency laparotomy, an internal herniation of the bowel through the Petersen space was observed. Though history of R-Y reconstruction surgery may be helpful, preoperative diagnosis of Petersen hernia is difficult to establish. Here we present two rare cases of this type of internal hernia.

Primary non-closure of mesenteric defects in laparoscopic Roux-en-Y gastric bypass: reoperations and intraoperative findings in 146 patients

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.

[Internal hernias after bariatric surgery]

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.

Modification of internal hernia classification system after laparoscopic Roux-en-Y bariatric surgery

INTRODUCTION

The occurrence of internal hernia is not an uncommon late complication following the laparoscopic bariatric Roux-en-Y gastric bypass procedure. In some instances, it can be life threatening if not treated in a timely manner. Although there are numerous publications in the literature addressing internal hernia, they are mostly retrospective, and focus mainly on describing the different reconstructive orientation as far as the bowel is concerned.

AIM

Our study aim is to address the relationship between the three basic elements of internal hernia, namely: intestinal mesentery defect, the involved intestine and herniated loop direction. Although a developed and widely accepted classification system of internal hernia has not been established yet, we hope this study can help the system to be established.

MATERIAL AND METHODS

We studied all patients who underwent revision bariatric operations in the Freiburg and Lübeck University Hospitals (2007-2013). A single surgeon performed and documented all revision procedures for internal hernia. The post-operative follow-up period is up to 6 years. All patients with internal hernias were included whether their primary surgery was performed in our center or performed in other institutions, being referred to our center for further management. The presence of hernia defect, the type of herniated intestinal loop and the direction by which the herniated intestinal loop migrated were analyzed.

RESULTS

Twenty-five patients with internal hernia were identified; in 2 patients more than one hernia type coexisted. The most frequent constellation of internal hernias was BP limb herniation into the Brolin space and migrating from left to right direction (28%). The highest incidence of internal hernia was found to be following Roux-en-Y gastric bypass (68%); the biliopancreatic limb (BP) limb was the most commonly involved intestine (51.9%). The incidence of Petersen hernia was the highest (59.3%), and left-right direction was more common. The most common hernia direction of the biliopancreatic limb was from left to right (92.6%), but alimentary limb (AL; 57.1%) and common channel (CC; 66.7%) often favor the other course.

CONCLUSIONS

There are existing different types of internal hernias after bariatric operations including separate mesenterial spaces, various intestine parts and herniation direction. Our SDL classification system may offer a useful pathway that facilitates the understanding, and systematic approach to internal hernia, which can be used by bariatric quality registers.

Late surgical complications after gastric by-pass: a literature review

INTRODUCTION

Gastric bypass is today the most frequently performed bariatric procedure, but, despite of it, several complications can occur with varied morbimortality. Probably all bariatric surgeons know these complications, but, as bariatric surgery continues to spread, general surgeon must be familiarized to it and its management. Gastric bypass complications can be divided into two groups: early and late complications, taking into account the two weeks period after the surgery. This paper will focus the late ones.

METHOD

Literature review was carried out using Medline/PubMed, Cochrane Library, SciELO, and additional information on institutional sites of interest crossing the headings: gastric bypass AND complications; follow-up studies AND complications; postoperative complications AND anastomosis, Roux-en-Y; obesity AND postoperative complications. Search language was English.

RESULTS

There were selected 35 studies that matched the headings. Late complications were considered as: anastomotic strictures, marginal ulceration and gastrogastric fistula.

CONCLUSION

Knowledge on strategies on how to reduce the risk and incidence of complications must be acquired, and every surgeon must be familiar with these complications in order to achieve an earlier recognition and perform the best intervention.

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.

Interventions to improve long-term weight loss in patients following bariatric surgery: challenges and solutions

Bariatric surgery aims to provide long-term weight loss and improvement in weight-related comorbidities. Unfortunately, some patients do not achieve predicted weight loss targets and many regain a portion of their lost weight within 2-10 years postsurgery. A review of the literature found that behavioral, dietary, psychological, physical, and medical considerations can all play a role in suboptimal long-term weight loss. Recommendations to optimize long-term weight loss include ensuring that the patient understands how the procedure works, preoperative and postoperative education sessions, tailored nutritional supplements, restraint with liquid kilojoules, pureed foods, grazing and eating out of the home, an average of 60 minutes of physical activity per day, and lifelong annual medical, psychological, and dietary assessments.

Internal hernia in late pregnancy after laparoscopic Roux-en-Y gastric bypass

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.

Intestinal infarction by internal hernia in Petersen’s space after laparoscopic gastric bypass

Intestinal occlusion by internal hernia is not a rare complication (0.2%-5%) after Laparoscopic Roux-en-Y-GBP (LGBP) with higher morbidity and mortality related to mesenteric vessels involvement. In our Center, from October 2009 to April 2013 we have had 17 pts treated for internal hernia on 412 LGBP (4.12%). Clinical case: 28-year-old woman, operated of LGBP (BMI = 49; co-morbidity: diabetes mellitus and arthropathy) about 10 mo before, was affected by recurrent abdominal pain with alvus alteration lasting for a week. After vomiting, she went to first aid Unit of a peripheric hospital where she made blood tests, RX and US of abdomen that resulted normal so she was discharged with flu like syndrome diagnosis. After 3 d the patient contacted our Center since her symptoms got worse and was hospitalized. Blood tests showed an alteration of hepatic enzymes and amylases. The abdominal computed tomography (CT) showed the presence of fluid in peri-splenic, peri-hepatic areas and in pelvis and a “target like imagine” of “clustered ileal loops” with a superior mesenteric vein (SMV) thrombosis involving the Portal Vein. During the operation, we found a necrosis of 80 cm of ileus (about 50 cm downstream the jejuno-jejunal anastomosis) due to an internal hernia through Petersen’s space causing a SMV thrombosis. The necrotic bowel was removed, the internal hernia was reduced and Petersen’ space was sutured by not-absorbable running suture. An anticoagulant therapy was begun in the post-operative time and the patient was discharged after 28 d. Conclusions: The internal hernia diagnosis is rarely confirmed by preoperative exams and it is obtained in most cases by laparoscopy but the improvement of technologies and the discover of “new” CT signs interpretation can address to an early laparoscopic treatment for high suspicion cases.

Abdominal compartment syndrome following abdominoplasty: A case report and review

Abdominoplasty is among the most commonly performed aesthetic procedures in plastic surgery. Despite high complication rate, abdominal contouring procedures are expected to rise in popularity with the advent of bariatric surgery. Patients with a history of gastric bypass surgery have an elevated incidence of small bowel obstruction from internal herniation, which is associated with non-specific upper abdominal pain, nausea, and a decrease in appetite. Internal hernias, when subjected to elevated intra-abdominal pressures, have a high-risk of developing ischemic bowel. We present a case report of patient with previous laparoscopic Roux-en-y gastric bypass who developed acute ischemic bowel leading to abdominal compartment syndrome following abdominoplasty. To the best of our knowledge, this is the first reported case in the literature. We herein emphasise on the subtle symptoms and signs that warrant further investigations in prospective patients for an abdominal contouring procedure with a prior history of gastric bypass surgery.

Imaging of complications of common bariatric surgical procedures

Several techniques for the surgical management of obesity are available to bariatric surgeons. These interventions are performed more frequently with worsening of the obesity epidemic. Radiologists should be familiar with the surgical techniques, normal postoperative appearances, and potential complications for which imaging may be employed to establish a diagnosis to optimize patient care.

Roux-en-Y gastric bypass: hyperamylasemia is associated with small bowel obstruction

BACKGROUND

Small bowel obstruction after Roux-en-Y gastric bypass (RYGB) can be difficult to diagnose, but usually requires surgical treatment; clinical presentation may be nonspecific. Delay in diagnosis can result in catastrophic outcomes. Patients who present with small bowel obstruction after gastric bypass occasionally have pancreatic enzyme elevation and have been misdiagnosed as having acute pancreatitis. The objective of this study was to determine if there was an association between small bowel obstruction and an elevated amylase or lipase after RYGB.

METHODS

Ninety-nine cases of small bowel obstruction treated surgically were prospectively collected and retrospectively analyzed from a database of 4014 RYGB patients. Fifty-eight had a measurement of amylase or lipase at the time of operation.

RESULTS

An elevated amylase or lipase was found in 48% of all patients. These elevated rates were higher in an acute obstruction compared to those presenting with chronic symptoms (64% versus 28%; P=.007) and in obstruction involving the biliopancreatic limb compared to those that did not involve that limb (65% versus 21%; P<.001). These elevated rates were most notable in acute biliopancreatic limb obstruction compared to an acute obstruction not in the biliopancreatic limb (94% versus 27%; P<.001).

CONCLUSION

In RYGB patients, there is an association between small bowel obstruction and an elevated amylase or lipase. Acute obstruction of the biliopancreatic limb can be difficult to diagnose, and in these patients, the sensitivity of elevated amylase or lipase is very high. RYGB patients with abdominal pain should have their amylase and lipase measured. It is important to recognize that an elevation of these enzymes is not likely a result of acute pancreatitis.

Mesenteric irritation as a means to prevent internal hernia formation after laparoscopic gastric bypass surgery

INTRODUCTION

Internal hernias (IHs) occur more frequently in laparoscopic gastric bypass (LGB) surgery than in the classic open procedure. The incidence of small bowel obstruction after LGB ranges from 1.8% and 9.7%. Some have theorized that this occurs because of decreased adhesion formation.

METHODS

The mesenteric irritation technique is performed after closure of the jejunojejunal mesenteric defect with a running 2-0 silk suture. A sponge is then rubbed against the closed visceral peritoneal mesentery until petechiae are visualized on the surface of the mesentery.

RESULTS

In all, 338 LGBs were performed using the standard closure technique with an IH incidence of 5.3% (range 1.7% to 7.8%). When using the mesenteric irritation technique, 72 LGBs were performed with an IH rate of 1.4% (P = .13).

CONCLUSIONS

Mesenteric irritation is a novel technique performed with minimal additional time and no additional equipment. This technique may prove beneficial in reducing the incidence of IHs.

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.