Bowel gangrene from strangulated Petersen's space hernia after gastric bypass

BACKGROUND

Patients with internal herniation after Roux-en-Y gastric bypass might present with normal laboratory values, minimal physical examination findings, and nonspecific radiographic results, making early diagnosis difficult and resulting in catastrophic bowel necrosis.

OBJECTIVE

Our purpose is to increase awareness so physicians of all specialties caring for these patients have a heightened suspicion and low threshold to obtain early surgical consultation in bypass patients with unexplained abdominal pain.

CASE REPORT

A 36-year-old female had a delayed presentation of internal herniation 4 years after laparoscopic retrocolic Roux-en-Y gastric bypass for morbid obesity. Initially, she had unremarkable physical examination, laboratory results, and plain x-ray findings, which made diagnosis challenging. During emergent exploratory laparotomy, she was found to have a strangulated Petersen's space hernia with volvulus, necessitating extensive gastric, small bowel, and colonic resection. She was referred for small bowel transplantation and has survived more than 8 years.

CONCLUSIONS

The occurrence of Petersen's hernias has increased with laparoscopic Roux-en-Y gastric bypass due to less postoperative adhesions. Whether days or several years after gastric bypass, patients with intermittent abdominal pain, nausea, or vomiting need to be carefully evaluated. These herald signs of internal herniation should prompt early surgical consultation. Pain out of proportion to physical examination often indicates need for urgent surgical intervention. Physicians need to be educated about this potentially life-threatening complication so early diagnosis and treatment can avoid catastrophic bowel gangrene.

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.