MRI appearance of internal hernia following Roux-en-Y gastric bypass surgery in the pregnant patient

Redo Gastric Bypass following internal herniation with gangrenous roux limb, in second trimester pregnancy: How safe?

Introduction and importance

Internal herniation following Gastric bypass is a serious life-threatening complication, needs prompt diagnosis and intervention. Internal herniation in later part of pregnancy can endanger life of both mother and fetus if not managed diligently.

Case presentation

30-year young lady with post gastric bypass status with 26 weeks of pregnancy presented with intestinal obstruction. Clinically she was suspected to have internal herniation. She was carrying a viable healthy intrauterine baby. Emergency laparotomy performed and the gangrenous roux limb was resected and Re-do gastric bypass was created. She delivered a healthy female baby at 37+ weeks.

Clinical discussion

Internal hernias after RYGB are more common in pregnant women due to cephalad displacement of intestines and creation of potential hernial spaces due to excess fat loss. Pregnancy with post RYGB status with intestinal obstruction, possibilities of internal hernia need to be excluded. In case non-viable intestinal loops, reconstruction of bypass possible. Post operatively cares with nutritional supplements play major role for fetal growth in advanced stage of pregnancy.

Conclusion

Internal hernia during pregnancy needs prompt intervention which can save of life mother as well as intrauterine baby.

•

Internal hernia following gastric bypass is a serious life-threatening condition.

•

Internal hernias after RYGB are more common in pregnant women.

•

Patients with internal hernia usually presents with epigastric pain, nausea, and vomiting.

•

Reconstruction of gastric bypass after resection of ischemic bowel following internal hernia

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.

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.

Internal Hernia in Pregnant Woman after Roux-en-Y Gastric Bypass Surgery

Laparoscopic Roux-en-Y gastric bypass has become the most common obesity surgery procedure worldwide over the last two decades. Many patients undergoing the procedure are women of reproductive age. This carries a risk for developing gastric bypass-related complications during pregnancy. One of the potentially serious risks is an internal hernia. We present a patient in the third trimester of pregnancy with an internal hernia following a laparoscopic Roux-en-Y gastric bypass for morbid obesity. We discuss the importance of computed tomography (CT) in the diagnosis of an internal hernia and review key CT findings including compression of the superior mesenteric vein, which proved to be crucial in diagnosing the internal hernia in this patient.

Operative complications during pregnancy after gastric bypass--a register-based cohort study

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.

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.

Roux-en-Y gastric bypass-associated bowel obstruction complicating pregnancy-an obstetrician's map to the clinical minefield

Over 80% of patients undergoing bariatric surgery are women, approximately half of whom are of reproductive age. The most common procedure in the United States is the Roux-en-Y gastric bypass. Small bowel obstruction is one of many recognized postoperative complications. For such a serious condition, this entity presents with remarkable subtlety and is easily misdiagnosed, particularly in pregnant women. The consequences of late recognition can be life-threatening to both mother and fetus. We aim to decrease preventable maternal and perinatal morbidity and mortality by revealing diagnostic and therapeutic missteps related to Roux-en-Y gastric bypass-associated small bowel obstruction.