Strangulation of upper jejunum in subsequent pregnancy following gastric bypass surgery

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.

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

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Internal hernias after RYGB are more common in pregnant women.

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

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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.

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.

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.

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.

Reconstruction of short bowel syndrome after internal hernia in a pregnant woman with previous bariatric surgery

INTRODUCTION

Bariatric surgery is most often performed with the laparoscopic Roux-en-Y gastric bypass. A complication to the laparoscopic Roux-en-Y gastric bypass is internal hernia, which occurs in up to 16% of the patients. Since the laparoscopic Roux-en-Y gastric bypass is performed in women of fertile age, internal hernia may occur during pregnancy.

PRESENTATION OF CASE

A 22-year old woman with a history of laparoscopic Roux-en-Y gastric bypass suffered from massive internal hernia during pregnancy with widespread bowel necrosis. Extensive surgery was performed leaving the patient with an intact duodenum, 15 cm of jejunum, 35 cm of ileum and colon. Parenteral nutrition was initiated and ten months after the internal hernia, intestinal continuity was re-established. Ten weeks later the patient reached parenteral nutrition independence.

DISCUSSION

Internal hernia after laparoscopic Roux-en-Y gastric bypass can be difficult to diagnose, especially during pregnancy and might be severe and life threatening for both mother and child.

CONCLUSION

Obstetricians and abdominal surgeons must be aware of this condition. Surgery should be performed on a wide indication. When bowel necrosis is found it should be resected and in case of extensive bowel resection the patient should be evaluated in centres specialized in intestinal failure.

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.

Pregnancy and foetal outcome after bariatric surgery: a review of recent studies

It is well known that maternal obesity has adverse effects on the health of offspring, causing immediate and long-term morbidities. The various types of procedure coming under the heading of bariatric surgery have proved effective in preventing some maternal and foetal complications in morbidly obese pregnant women. This review aims to assess the role, the risks and the benefits of bariatric surgery for mothers and offspring. According to recent findings, pregnancy and neonatal outcomes in morbidly obese women who have undergone bariatric surgery depend to some extent on the type of surgery used. Maternal complications, nutritional defects and intestinal obstruction are more frequently reported after Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD) than after laparoscopic adjustable gastric banding (LAGB) procedures, whereas caesarean section, preterm delivery and neonatal death are more commonly reported after RYGB than after LAGB. The authors of the only long-term follow-up study conducted on this subject reported that the rate of obesity in the children dropped by 52% after bariatric surgery for the mother, and the cases of severe obesity decreased by 45%. Data on pregnancy and bariatric surgery confirm that the procedure is more effective than dietary measures alone in morbidly obese women, and that pregnancy outcome is generally favorable after surgery. Some studies have indicated, nonetheless, that pregnancies after bariatric surgery are at higher risk: the women affected require special medical attention, particularly as concerns gastrointestinal symptoms and vitamin deficiencies, warranting nutritional/dietary counselling by a multidisciplinary team before, during and after pregnancy.

Obstetrical and neonatal outcomes of pregnancies following gastric bypass surgery: a retrospective cohort study in a French referral centre

BACKGROUND

The objective of this study was to analyze obstetrical and neonatal outcomes following Roux en Y Gastric Bypass procedures (RYGBP).

METHODS

A retrospective cohort study was conducted in a single French tertiary perinatal care and bariatric center. The study involved 24 pregnancies, following RYGBP (exposed group) and two different control groups (non-exposed groups). A body mass index (BMI)-matched control group included 120 pregnancies matched for age, parity, and pregnancy BMI. A normal BMI control group included 120 pregnancies with normal BMI (18.5-24.9 kg/m(2)), matched for age and parity. Hospital data were reviewed from all groups in the same 6-year period. Obstetrical and neonatal outcomes after RYGB were compared, separately, to the two different-matched control groups.

RESULTS

The median interval from RYGBP to conception was 26.6 (range: 3-74) months. Rates of perinatal complications did not differ significantly between the RYGBP group and normal BMI and BMI-matched controls groups. The rate of Cesarean section before labor was higher in the RYGBP patients than in the normal BMI control group (25% vs. 9.3% respectively, p = 0.04). Weight gain was lower in the RYGBP patients than normal BMI control group (5.8 kg vs. 13.2 kg respectively, p < 0.0001). Birthweight was also lower in the RYGBP group than those in normal BMI and BMI-matched controls groups (2,948.2 g vs. 3,368.2 g and 3,441.8 g, respectively, p < 0.0001).

CONCLUSIONS

RYGBP surgery was associated with reduced birthweight, suggesting a possible role of nutritional growth restriction in pregnancy.

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

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