Pregnant woman with fatal complication after laparoscopic Roux-en-Y gastric bypass

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

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.

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.

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.

Risk of Abdominal Surgery in Pregnancy Among Women Who Have Undergone Bariatric Surgery

OBJECTIVE

To compare the rates of abdominal surgery during pregnancy among women with previous bariatric surgery (women in the case group) and women with first-trimester body mass index (BMI) greater than 35 and no previous bariatric surgery (women in the control group).

METHODS

We conducted a national cohort study, merging data from the Swedish Medical Birth Registry and the Swedish National Patient Registry, comparing women who had bariatric surgery from 1987 to 2011 with women in a control group with first-trimester BMI greater than 35 who had not had bariatric surgery. Primary outcome variables were diagnosis and surgical procedure codes grouped as five outcome categories: 1) intestinal obstruction, 2) gallbladder disease, 3) appendicitis, 4) hernia, and 5) diagnostic laparoscopy or laparotomy without the presence of a diagnosis or surgical code for outcomes in outcome categories 1-4. Odds ratios were computed using multivariate linear regression analysis for each separate pregnancy. For all pregnancies in a given woman, general estimating equations with robust variance estimation were used. Adjustment was made for smoking, year of delivery, maternal age, and previous abdominal surgery.

RESULTS

During the first pregnancy after bariatric surgery, the rate of surgery for intestinal obstruction was 1.5% (39/2,543; 95% confidence interval [CI] 1.1-2.0%) in women in the case group compared with 0.02% (4/21,909; 95% CI 0.0-0.04%) among women in the control group (adjusted odds ratio [OR] 34.3, 95% CI 11.9-98.7). Similarly, the rate of diagnostic laparoscopy or laparotomy was 1.5% (37/2,542; 95% CI 1.0-1.9%) among women in the case group compared with 0.1% (18/21,909; 95% CI 0.0-0.1%) among women in the control group (adjusted OR 11.3, 95% CI 6.9-18.5).

CONCLUSION

Bariatric surgery is associated with an increased risk of abdominal surgery during pregnancy.

A Large Refilling Cystic Lesion In A Gastric Bypass Patient

We describe a patient with a history of gastric bypass and chronic alcoholism suffering from a rare Peterson's hernia resulting from her surgery. There are a few case reports in which afferent loop obstruction was misdiagnosed as pancreatic pseudocyst after Billroth II gastrectomy. Ours is the first in which Peterson's hernia was initially misdiagnosed as a pancreatic pseudocyst in a gastric bypass 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.

Case review and consideration for imaging and work evaluation of the pregnant bariatric patient

BACKGROUND

There is an increasing trend toward morbid obesity in women of childbearing age and a subsequent increase in number of weight reduction surgeries in these individuals. As a result, special attention needs to be paid to potential postsurgical complications during pregnancy, particularly after Roux-en-Y gastric bypass (RYGB). We are presenting our small case series and our suggestions for management for the pregnant bariatric patient. The aim of this study is to review our institutional experience and present our algorithm to approach pregnant women presenting with abdominal pain and/or emesis after RYGB.

METHODS

After Institutional Review Board approval, a retrospective chart review was performed at a single center institution between 2010 and 2013. Data regarding clinical presentation, physical exam findings, laboratory values, radiographic studies, intraoperative findings, and clinical outcomes of both mother and fetus were collected and reviewed for pregnant patients with history of RYGB and abdominal distress.

RESULTS

Five patients were identified. Patient age ranged from 22-34 years (mean 28.4). Gestational age ranged from 9-31 months (mean 19.2). Average body mass index at presentation was 30.3 kg/m(2). Of the 5 patients, 4 presented with abdominal pain and one with intractable emesis. Four patients were taken to the operating room. One was successfully discharged. Two of the patients had an obstruction from adhesions, and the other 2 were found to have internal hernia. There was no mortality for either fetus or mother. One patient required premature delivery at 28 weeks.

CONCLUSIONS

Pregnant women with history of RYGB who present with abdominal pain should be evaluated urgently for internal hernia or obstruction. A systematic approach is needed to ensure prompt diagnosis.

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.

Acute fetal asphyxia after gastric rupture in a pregnant patient with a gastric band

We report a 37-year-old primigravida with a gastric band who developed the clinical picture of abdominal pain, vomiting and regurgitation coexistent with a cardiotocogram with severe variable decelerations with absent variability at 33 weeks' gestation. After partial improvement with gastric band enlargement, new aggravation of symptoms and recurrence of a pathological cardiotocogram led to an emergency cesarean section. Intraoperatively, hemoperitoneum from gastric rupture was verified and partial gastrectomy was performed. After bariatric surgery, pregnant women are at increased risk of gastrointestinal complications, which may need prompt and multidisciplinary diagnosis and management in order to avoid maternal-fetal morbidity and mortality.