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El Nogoomi I, Nouh AK, Jaber AA, Toubah AM, Alkaram SS. Petersen's Hernia After Roux-en-Y Gastric Bypass: A Case Report. Cureus 2023; 15:e50757. [PMID: 38239520 PMCID: PMC10796129 DOI: 10.7759/cureus.50757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2023] [Indexed: 01/22/2024] Open
Abstract
Internal hernia (IH) is the protrusion of abdominal contents, mostly small bowel loops, through a defect in the peritoneum or mesentery. Petersen's hernia is a type of internal hernia, in which part of the intestinal loop protrudes through a defect between small bowel limbs, transverse mesocolon, and retroperitoneum. It has been reported in individuals undergoing gastrojejunostomy (GJ), especially following bariatric surgeries. Because of the expanding popularity of these surgical treatments, the total incidence of internal hernias has recently increased. The laparoscopic Roux-en-Y gastric bypass (RYGB) has been proven to be a safe and successful alternative to the classic open RYGB. Although the absence of postoperative adhesions is one advantage of minimally invasive surgery, it facilitates the occurrence of internal hernia with reported rates of 5% three months to three years following surgery. Clinical findings are vague and can vary from mild to severe abdominal pain that can be accompanied by vomiting, nausea, and abdominal distention.
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Affiliation(s)
| | | | | | | | - Sana S Alkaram
- Department of General Surgery, Al Kuwait Hospital, Sharjah, ARE
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2
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Apostolou KG, Lazaridis II, Kanavidis P, Triantafyllou M, Gkiala A, Alexandrou A, Ntourakis D, Delko T, Schizas D. Incidence and risk factors of symptomatic Petersen's hernias in bariatric and upper gastrointestinal surgery: a systematic review and meta-analysis. Langenbecks Arch Surg 2023; 408:49. [PMID: 36662172 DOI: 10.1007/s00423-023-02798-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 11/29/2022] [Indexed: 01/21/2023]
Abstract
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.
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Affiliation(s)
- Konstantinos G Apostolou
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, 17 Agiou Thoma Str, 11527, Athens, Greece.
| | - Ioannis I Lazaridis
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Basel, Switzerland
| | - Prodromos Kanavidis
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, 17 Agiou Thoma Str, 11527, Athens, Greece
| | - Margarita Triantafyllou
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, 17 Agiou Thoma Str, 11527, Athens, Greece
| | - Anastasia Gkiala
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, 17 Agiou Thoma Str, 11527, Athens, Greece
| | - Andreas Alexandrou
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, 17 Agiou Thoma Str, 11527, Athens, Greece
| | | | - Tarik Delko
- Chirurgie Zentrum St. Anna, St. Anna-Strasse 32, 6006, Lucerne, Switzerland
| | - Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, 17 Agiou Thoma Str, 11527, Athens, Greece
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Diab ARF, Oviedo RJ, Nazir S, Sujka JA, DuCoin CG. RYGB-Induced Gut Dysmotility and Retrograde Intussusception: an Unusual Phenomenon. A Narrative Literature Review. Obes Surg 2022; 32:3452-3457. [PMID: 35947330 DOI: 10.1007/s11695-022-06236-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 07/27/2022] [Accepted: 08/04/2022] [Indexed: 11/25/2022]
Abstract
Intussusception following Roux-en-Y gastric bypass (RYGB) is a rare complication of bariatric surgery with an unclear etiology. The pathogenesis underlying intussusception after gastric bypass is likely different from that in the general population. Post-RYGB intussusception might be related to motility issues in the divided small bowel, thinning of the mesentery following rapid weight loss, or anastomotic sutures/staple line acting as the lead point. This condition can cause obstruction with subsequent strangulation and bowel necrosis if not recognized and treated promptly. Clinical presentation is vague and nonspecific, and computerized tomography scan represents the diagnostic test of choice. Surgical treatment consists of reduction with or without anastomosis resection and reconstruction. This literature review provides an extensive overview of this condition, based on multiple studies involving 120 patients.
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Affiliation(s)
- Abdul-Rahman F Diab
- Division of Gastrointestinal Surgery, Department of Surgery, University of South Florida, Morsani College of Medicine, 5 Tampa General Circle, Tampa, FL, 33606, USA.
| | - Rodolfo J Oviedo
- Department of Surgery, Houston Methodist, 6550 Fannin St., Houston, TX, 77030, USA
| | - Sharique Nazir
- Department of Surgery, NYU Grossman School of Medicine, 8714 Fifth Avenue, Brooklyn, NY, 11209, USA
| | - Joseph A Sujka
- Division of Gastrointestinal Surgery, Department of Surgery, University of South Florida, Morsani College of Medicine, 5 Tampa General Circle, Tampa, FL, 33606, USA
| | - Christopher G DuCoin
- Division of Gastrointestinal Surgery, Department of Surgery, University of South Florida, Morsani College of Medicine, 5 Tampa General Circle, Tampa, FL, 33606, USA
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4
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Torensma B, Kooiman L, Liem R, Monpellier VM, Swank DJ, Tseng L. Internal Herniation Incidence After RYGB and the Predictive Ability of a CT Scan as a Diagnostic Tool. Obes Surg 2021; 31:127-132. [PMID: 32748202 PMCID: PMC7808966 DOI: 10.1007/s11695-020-04892-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 07/24/2020] [Accepted: 07/28/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE The clinical diagnosis of an internal herniation (IH) after a Roux-en-Y Gastric Bypass (RYGB) remains difficult; therefore, performing a CT scan is usually part of the diagnostic process. The goal of this study was to assess the incidence of IH in patients with open and closed MD (mesenteric defect) and to study if the ability to diagnose an IH with a CT scan is different between these groups. MATERIALS AND METHODS IH was defined as a visible intestine through the mesenteric defect underneath the jejunojejunostomy and/or in the Petersen's space. CT scan outcomes were compared with the clinical diagnosis of an IH. Until 31 June 2013, standard care was to leave mesenteric defects (MDs) open; after this date, they were always closed. RESULTS The incidence of IH in the primarily non-closed group was 3.9%, and in the primarily closed group, this was 1.3% (p = 0.001). In group A (non-closed MD and CT), the sensitivity of the CT scan was 80%, and specificity was 0%. In group C (closed MD and CT), the sensitivity was 64.7%, and specificity was 89.5%. In group B (non-closed, no CT), an IH was visible in 58.7% of the cases and not in 41.3%. In group D (only a re-laparoscopy), an IH was visible in 34.3% of the cases and not in 65.7%. CONCLUSIONS Using the CT scan in suspected IH is not useful in if the MDs were not closed. If the MDs were closed, then a CT scan is predictive for the diagnosis IH.
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Affiliation(s)
- Bart Torensma
- Department of Anaesthesiology, Leiden University Medical Center, Leiden, The Netherlands.
- Department of Surgery, Dutch Obesity Clinic West & LUMC, The Hague, The Netherlands.
| | - Laurens Kooiman
- Department of Surgery, Dutch Obesity Clinic West & LUMC, The Hague, The Netherlands
| | - Ronald Liem
- Department of Surgery, Dutch Obesity Clinic West & LUMC, The Hague, The Netherlands
| | - Valerie M Monpellier
- Department of Surgery, Dutch Obesity Clinic West & LUMC, The Hague, The Netherlands
| | - Dingeman J Swank
- Department of Surgery, Dutch Obesity Clinic West & LUMC, The Hague, The Netherlands
| | - Larissa Tseng
- Department of Surgery, Dutch Obesity Clinic West & LUMC, The Hague, The Netherlands
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Yang J, Guan B, Huang S, Peng J, Chong TH, Wang C, Mak TK. Different surgical techniques that influenced internal hernia prevalence rate after laparoscopic roux-en-Y gastric bypass: a retrospective analysis of 331 cases. BMC Surg 2020; 20:48. [PMID: 32178649 PMCID: PMC7077004 DOI: 10.1186/s12893-020-00713-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 03/06/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Internal hernia (IH) is a serious complication following laparoscopic Roux-en-Y gastric bypass (LRYGB), and closure of mesenteric defect has been recommended to reduce this complication. But what kind of material about suture and how to close the mesenteric defects were still controversial. The main aim of this study was to compare the incidence rate of internal hernia after LRYGB between patients with different surgical techniques. METHOD Three hundred and thirty-one patients underwent LRYGB between June 2004 and December 2017 in one single institute were retrospective analysed. The IH rate was evaluated according to different surgical methods and surgical materials before and 12 months after LRYGB. RESULTS All the cases were subdivided into three groups based on the suturing method, Roux limb position, and Suture material. The mean follow up time was 36 ± 12 months, and the total incident rate of IH was 1.8% (n = 6). In the six IH cases, the duration of IH occurred time ranged from 1 month to 36 months postoperatively, and for the IH sites, one for intestinal defect, three for transverse mesocolon defect and two Peterson defect respectively. There was a significant difference about IH rate between interrupted suture and running suture groups (p = 0.011), and there were no significant differences between the other two groups. CONCLUSION Compare with interrupted suture, running suture may prevent IH after LRYGB. Patient's gender, age, body mass index(BMI), glycometabolism condition, and Roux limb position and suture material had no effects on the IH prevalence after LRYGB.
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Affiliation(s)
- Jingge Yang
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Jinan University, Guangzhou, 510630 China
| | - Bingsheng Guan
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Jinan University, Guangzhou, 510630 China
| | - Shifang Huang
- Department of Intensive Care Unit, First Affiliated Hospital of Jinan University, Guangzhou, 510630 China
| | - Juzheng Peng
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Jinan University, Guangzhou, 510630 China
| | - Tsz Hong Chong
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Jinan University, Guangzhou, 510630 China
| | - Cunchuan Wang
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Jinan University, Guangzhou, 510630 China
| | - Tsz Kin Mak
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Jinan University, Guangzhou, 510630 China
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El Chaar M. Comment on: Effect of the closure of mesenteric defects in laparoscopic Roux-En-Y gastric bypass: a prospective study. Surg Obes Relat Dis 2019; 15:1909-1911. [PMID: 31551183 DOI: 10.1016/j.soard.2019.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 08/10/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Maher El Chaar
- Department of Bariatric Surgery, St. Luke's University Hospital and Health Network, Lewis Katz School of Medicine, Allentown, Pennsylvania
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7
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Santos EPRD, Santa Cruz F, Hinrichsen EA, Ferraz ÁAB, Campos JM. INTERNAL HERNIA FOLLOWING LAPAROSCOPIC ROUX-EN-Y GASTRIC BY-PASS: INDICATIVE FACTORS FOR EARLY REPAIR. ARQUIVOS DE GASTROENTEROLOGIA 2019; 56:160-164. [PMID: 31460580 DOI: 10.1590/s0004-2803.201900000-32] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 03/09/2019] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
| | | | - Eduarda Araújo Hinrichsen
- Curso de Medicina, Faculdade Pernambucana de Saúde, Instituto de Medicina Integral Prof. Fernando Figueira, Recife, PE, Brasil
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8
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Sharma N, Chau WY, Dobruskin L. An unusual case of perisplenic small bowel volvulus after laparoscopic Roux En Y gastric bypass. J Surg Case Rep 2019; 2019:rjz042. [PMID: 30800275 PMCID: PMC6380080 DOI: 10.1093/jscr/rjz042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 01/20/2019] [Accepted: 01/27/2019] [Indexed: 11/17/2022] Open
Abstract
Internal hernias (IH) are one of the dreadful complications of laparoscopic Roux En Y gastric bypass (LGBP). Commonly reported internal hernias (IH) following Roux En Y gastric bypass (LGBP) in the literature are meso-colic, meso jejunal and Peterson’s space hernias. These patients may not have any definitive symptoms. Findings are often missed on radiological studies and a high index of clinical suspicion is often necessary. If in doubt, a timely diagnostic laparoscopy is critical to decrease morbidity and mortality in these patients. We present a very unusual case of peri-splenic small bowel herniation with volvulus following LGBP with indeterminate radiological findings. Our case emphasizes that early laparoscopy is both diagnostic and therapeutic for desirable clinical outcomes.
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Affiliation(s)
- Nitin Sharma
- Penn Medicine Princeton Medical Centre, Bariatric and Metabolic Surgery, Suite 275, 5 Plainsboro road, Plainsboro, NJ 08536, USA
| | - Wai Yip Chau
- Penn Medicine Princeton Medical Centre, Bariatric and Metabolic Surgery, Suite 275, 5 Plainsboro road, Plainsboro, NJ 08536, USA
| | - Lisa Dobruskin
- Penn Medicine Princeton Medical Centre, Bariatric and Metabolic Surgery, Suite 275, 5 Plainsboro road, Plainsboro, NJ 08536, USA
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9
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Rosa SC, de Macedo JLS, Barbosa IM, Canedo LR, Casulari LA. Acute Intestinal Obstruction Due to Internal Hernia After Abdominal Dermolipectomy. Obes Surg 2018; 28:4046-4048. [PMID: 30232724 DOI: 10.1007/s11695-018-3504-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Simone Corrêa Rosa
- Post-Graduation Course in Health Sciences, University of Brasília, Brasília, DF, Brazil.,Department of Plastic and Reconstructive Surgery, Asa Norte Regional Hospital, Brasília, DF, Brazil
| | | | | | | | - Luiz Augusto Casulari
- Post-Graduation Course in Health Sciences, University of Brasília, Brasília, DF, Brazil
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10
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Ederveen JC, van Berckel MMG, Nienhuijs SW, Weber RJP, Nederend J. Predictive value of abdominal CT in evaluating internal herniation after bariatric laparoscopic Roux-en-Y gastric bypass. Br J Surg 2018; 105:1623-1629. [DOI: 10.1002/bjs.10886] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 12/29/2017] [Accepted: 04/04/2018] [Indexed: 12/11/2022]
Abstract
Abstract
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.
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Affiliation(s)
- J C Ederveen
- Department of Radiology, Catharina Hospital, Eindhoven, the Netherlands
| | - M M G van Berckel
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - S W Nienhuijs
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - R J P Weber
- Department of Radiology, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - J Nederend
- Department of Radiology, Catharina Hospital, Eindhoven, the Netherlands
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Kagoma YK, Gayer G. Computed Tomography of Internal Hernias Following Laparoscopic Roux-en-Y Gastric Bypass Surgery. Semin Ultrasound CT MR 2018; 39:145-150. [PMID: 29571551 DOI: 10.1053/j.sult.2017.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Internal hernia in the postoperative laparoscopic Roux-en-Y patient is a diagnosis associated with significant morbidity and risk of death. The radiologist plays an instrumental role in workup of this patient group; however, the imaging assessment of these patients is not straightforward given their complex postsurgical anatomy. Multiple radiologic signs of internal hernia have been studied in the literature. This review article presents these signs with representative cases as well as a summary of their diagnostic accuracy.
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Affiliation(s)
- Yoan K Kagoma
- Division of Body Imaging-Department of Radiology, Stanford University Medical Center, Stanford, CA.
| | - Gabriela Gayer
- Division of Body Imaging-Department of Radiology, Stanford University Medical Center, Stanford, CA; Sheba Medical Center, affiliated to Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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12
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Dilauro M, McInnes MDF, Schieda N, Kielar AZ, Verma R, Walsh C, Vizhul A, Petrcich W, Mamazza J. Internal Hernia after Laparoscopic Roux-en-Y Gastric Bypass: Optimal CT Signs for Diagnosis and Clinical Decision Making. Radiology 2017; 282:752-760. [DOI: 10.1148/radiol.2016160956] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Marc Dilauro
- From the Departments of Radiology (M.D., M.D.F.M., N.S., A.Z.K., R.V., C.W., W.P.) and General Surgery (J.M.), Clinical Epidemiology Program, University of Ottawa Ottawa Hospital Research Institute, Room c159, Ottawa Hospital Civic Campus, 1053 Carling Ave, Ottawa, ON, Canada K1Y 4E9; and Department of Surgery, Pasqua South Medical Clinic, Regina, Sask, Canada (A.V.)
| | - Matthew D. F. McInnes
- From the Departments of Radiology (M.D., M.D.F.M., N.S., A.Z.K., R.V., C.W., W.P.) and General Surgery (J.M.), Clinical Epidemiology Program, University of Ottawa Ottawa Hospital Research Institute, Room c159, Ottawa Hospital Civic Campus, 1053 Carling Ave, Ottawa, ON, Canada K1Y 4E9; and Department of Surgery, Pasqua South Medical Clinic, Regina, Sask, Canada (A.V.)
| | - Nicola Schieda
- From the Departments of Radiology (M.D., M.D.F.M., N.S., A.Z.K., R.V., C.W., W.P.) and General Surgery (J.M.), Clinical Epidemiology Program, University of Ottawa Ottawa Hospital Research Institute, Room c159, Ottawa Hospital Civic Campus, 1053 Carling Ave, Ottawa, ON, Canada K1Y 4E9; and Department of Surgery, Pasqua South Medical Clinic, Regina, Sask, Canada (A.V.)
| | - Ania Z. Kielar
- From the Departments of Radiology (M.D., M.D.F.M., N.S., A.Z.K., R.V., C.W., W.P.) and General Surgery (J.M.), Clinical Epidemiology Program, University of Ottawa Ottawa Hospital Research Institute, Room c159, Ottawa Hospital Civic Campus, 1053 Carling Ave, Ottawa, ON, Canada K1Y 4E9; and Department of Surgery, Pasqua South Medical Clinic, Regina, Sask, Canada (A.V.)
| | - Raman Verma
- From the Departments of Radiology (M.D., M.D.F.M., N.S., A.Z.K., R.V., C.W., W.P.) and General Surgery (J.M.), Clinical Epidemiology Program, University of Ottawa Ottawa Hospital Research Institute, Room c159, Ottawa Hospital Civic Campus, 1053 Carling Ave, Ottawa, ON, Canada K1Y 4E9; and Department of Surgery, Pasqua South Medical Clinic, Regina, Sask, Canada (A.V.)
| | - Cynthia Walsh
- From the Departments of Radiology (M.D., M.D.F.M., N.S., A.Z.K., R.V., C.W., W.P.) and General Surgery (J.M.), Clinical Epidemiology Program, University of Ottawa Ottawa Hospital Research Institute, Room c159, Ottawa Hospital Civic Campus, 1053 Carling Ave, Ottawa, ON, Canada K1Y 4E9; and Department of Surgery, Pasqua South Medical Clinic, Regina, Sask, Canada (A.V.)
| | - Andrey Vizhul
- From the Departments of Radiology (M.D., M.D.F.M., N.S., A.Z.K., R.V., C.W., W.P.) and General Surgery (J.M.), Clinical Epidemiology Program, University of Ottawa Ottawa Hospital Research Institute, Room c159, Ottawa Hospital Civic Campus, 1053 Carling Ave, Ottawa, ON, Canada K1Y 4E9; and Department of Surgery, Pasqua South Medical Clinic, Regina, Sask, Canada (A.V.)
| | - William Petrcich
- From the Departments of Radiology (M.D., M.D.F.M., N.S., A.Z.K., R.V., C.W., W.P.) and General Surgery (J.M.), Clinical Epidemiology Program, University of Ottawa Ottawa Hospital Research Institute, Room c159, Ottawa Hospital Civic Campus, 1053 Carling Ave, Ottawa, ON, Canada K1Y 4E9; and Department of Surgery, Pasqua South Medical Clinic, Regina, Sask, Canada (A.V.)
| | - Joseph Mamazza
- From the Departments of Radiology (M.D., M.D.F.M., N.S., A.Z.K., R.V., C.W., W.P.) and General Surgery (J.M.), Clinical Epidemiology Program, University of Ottawa Ottawa Hospital Research Institute, Room c159, Ottawa Hospital Civic Campus, 1053 Carling Ave, Ottawa, ON, Canada K1Y 4E9; and Department of Surgery, Pasqua South Medical Clinic, Regina, Sask, Canada (A.V.)
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13
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Contribution of Computed Tomographic Imaging to the Management of Acute Abdominal Pain after Gastric Bypass: Correlation Between Radiological and Surgical Findings. Obes Surg 2017; 27:1961-1972. [DOI: 10.1007/s11695-017-2601-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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14
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Lee SY, Kim CH, Kim YJ, Kim HR. Internal hernia following laparoscopic colorectal surgery: a rare but fatal complication. Hernia 2016; 21:299-304. [DOI: 10.1007/s10029-016-1532-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Accepted: 08/26/2016] [Indexed: 12/19/2022]
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Danshøj Kristensen S, Naver L, Jess P, Floyd AK. Reoperation risk following the first operation for internal herniation in patients with laparoscopic Roux-en-Y gastric bypass. Br J Surg 2016; 103:1184-8. [DOI: 10.1002/bjs.10184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 03/02/2016] [Accepted: 03/07/2016] [Indexed: 11/11/2022]
Abstract
Abstract
Background
Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the most commonly used surgical procedure in the treatment of morbid obesity in Denmark. Internal herniation (IH) and intermittent internal herniation (IIH) are probably the most common late complications in patients with LRYGB. The aim of this study was to investigate a possible increased risk of subsequent operations after an initial IH or IIH event.
Methods
This long-term follow-up study of patients who had surgery for an initial IH or IIH event in 2006–2011, based on the Danish National Patient Registry (NPR), was performed to 2013. During this period, mesenteric defects were not closed routinely during LRYGB.
Results
Data were retrieved from 12 221 patients with LRYGB from the NPR. A total of 383 patients had surgery for an initial IH or IIH event. Some 102 patients (26·6 (95 per cent c.i. 22·5 to 31·3) per cent) had a second operation. Twenty-seven (26·5 (18·9 to 35·8) per cent) of these 102 patients had a third operation, and five (19 (8 to 37) per cent) of the 27 had a fourth operation. Of the 383 patients diagnosed with an initial IH or IIH event, 72 (18·8 per cent) had a second IH/IIH event, 14 (3·7 per cent) had a third event, and three (0·8 per cent) a fourth event requiring surgery.
Conclusion
Patients who have surgery for IH or IIH have a substantial risk of needing further operations.
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Affiliation(s)
- S Danshøj Kristensen
- Department of Surgery, Koege Hospital, Koege, Denmark
- Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - L Naver
- Department of Surgery, Koege Hospital, Koege, Denmark
| | - P Jess
- Department of Surgery, Koege Hospital, Koege, Denmark
| | - A K Floyd
- Department of Surgery, Holbæk Hospital, Holbæk, Denmark
- Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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Baba A, Yamazoe S, Dogru M, Okuyama Y, Mogami T, Kobashi Y, Nozawa Y, Aoyagi Y, Fujisaki H, Ogura M, Matsui J. Petersen hernia after open gastrectomy with Roux-en-Y reconstruction: a report of two cases and literature review. SPRINGERPLUS 2015; 4:753. [PMID: 26693111 PMCID: PMC4666877 DOI: 10.1186/s40064-015-1556-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 11/24/2015] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Akira Baba
- Department of Radiology, Tokyo Dental College Ichikawa General Hospital, 5-11-13, Sugano, Ichikawa, Chiba 2728513 Japan
| | - Shinji Yamazoe
- Department of Radiology, Tokyo Dental College Ichikawa General Hospital, 5-11-13, Sugano, Ichikawa, Chiba 2728513 Japan
| | - Murat Dogru
- Department of Radiology, Tokyo Dental College Ichikawa General Hospital, 5-11-13, Sugano, Ichikawa, Chiba 2728513 Japan
| | - Yumi Okuyama
- Department of Radiology, Tokyo Dental College Ichikawa General Hospital, 5-11-13, Sugano, Ichikawa, Chiba 2728513 Japan
| | - Takuji Mogami
- Department of Radiology, Tokyo Dental College Ichikawa General Hospital, 5-11-13, Sugano, Ichikawa, Chiba 2728513 Japan
| | - Yuko Kobashi
- Department of Radiology, Tokyo Dental College Ichikawa General Hospital, 5-11-13, Sugano, Ichikawa, Chiba 2728513 Japan
| | - Yosuke Nozawa
- Department of Radiology, Tokyo Dental College Ichikawa General Hospital, 5-11-13, Sugano, Ichikawa, Chiba 2728513 Japan
| | - Yutaka Aoyagi
- Department of Radiology, Tokyo Dental College Ichikawa General Hospital, 5-11-13, Sugano, Ichikawa, Chiba 2728513 Japan
| | - Hiroto Fujisaki
- Department of Surgery, Tokyo Dental College Ichikawa General Hospital, 5-11-13, Sugano, Ichikawa, Chiba 2728513 Japan
| | - Masaharu Ogura
- Department of Surgery, Tokyo Dental College Ichikawa General Hospital, 5-11-13, Sugano, Ichikawa, Chiba 2728513 Japan
| | - Junichi Matsui
- Department of Surgery, Tokyo Dental College Ichikawa General Hospital, 5-11-13, Sugano, Ichikawa, Chiba 2728513 Japan
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Delko T, Kraljević M, Köstler T, Rothwell L, Droeser R, Potthast S, Oertli D, Zingg U. Primary non-closure of mesenteric defects in laparoscopic Roux-en-Y gastric bypass: reoperations and intraoperative findings in 146 patients. Surg Endosc 2015; 30:2367-73. [PMID: 26335072 DOI: 10.1007/s00464-015-4486-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Accepted: 08/01/2015] [Indexed: 01/02/2023]
Abstract
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.
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Affiliation(s)
- Tarik Delko
- Department of General Surgery, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
| | - Marko Kraljević
- Department of General Surgery, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Thomas Köstler
- Department of General Surgery, Limmattal Hospital, 8952, Schlieren, Switzerland
| | - Lincoln Rothwell
- Adelaide Bariatric Centre, Flinders Private Hospital, Bedford Park, 5042, Australia
| | - Raoul Droeser
- Department of General Surgery, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Silke Potthast
- Department of General Surgery, Limmattal Hospital, 8952, Schlieren, Switzerland
| | - Daniel Oertli
- Department of General Surgery, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Urs Zingg
- Department of General Surgery, Limmattal Hospital, 8952, Schlieren, Switzerland
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Nau P, Molina G, Shima A, Hani A, Meireles O. Roux-en-Y gastric bypass is associated with an increased exposure to ionizing radiation. Surg Obes Relat Dis 2015; 11:308-12. [DOI: 10.1016/j.soard.2014.07.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 07/10/2014] [Accepted: 07/16/2014] [Indexed: 12/28/2022]
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Geubbels N, Lijftogt N, Fiocco M, van Leersum NJ, Wouters MWJM, de Brauw LM. Meta-analysis of internal herniation after gastric bypass surgery. Br J Surg 2015; 102:451-60. [DOI: 10.1002/bjs.9738] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 09/24/2014] [Accepted: 11/10/2014] [Indexed: 12/18/2022]
Abstract
Abstract
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 < 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 < 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.
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Affiliation(s)
- N Geubbels
- Department of Metabolic and Bariatric Surgery, Slotervaart Hospital, Amsterdam, The Netherlands
| | - N Lijftogt
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - M Fiocco
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Centre, Leiden, The Netherlands
- Institute of Mathematics, Leiden University Medical Centre, Leiden, The Netherlands
| | - N J van Leersum
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - M W J M Wouters
- Department of Surgery, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - L M de Brauw
- Department of Metabolic and Bariatric Surgery, Slotervaart Hospital, Amsterdam, The Netherlands
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Kristensen SD, Floyd AK, Naver L, Jess P. Does the closure of mesenteric defects during laparoscopic gastric bypass surgery cause complications? Surg Obes Relat Dis 2014; 11:459-64. [PMID: 25813753 DOI: 10.1016/j.soard.2014.10.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 10/07/2014] [Accepted: 10/10/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND A well-known complication of laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) is bowel obstruction due to internal herniation (IH). Evidence suggests that mesenteric defects should be closed during LRYGB to reduce the risk of IH. Therefore, surgeons are now closing mesenteric defects during LRYGB using sutures, clips, or fibrin glue. However, it has been reported that complications may arise due to the closure of mesenteric defects. The aim of this review was to summarize the reported possible complications associated with the closure of mesenteric defects during LRYGB. METHODS A literature search of PubMed and EMBASE was performed to identify studies related to the closure of mesenteric defects during LRYGB. The studies were screened for the listing of possible complications associated with the closure of mesenteric defects. This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations. RESULTS Thirty studies complied with the inclusion criteria for our analysis, which included 21,789 patients. Reported complications related to closure of the mesenteric defects were: small bowel obstruction because of IH, kinking, and adhesions. IH occurred because of incomplete closure of the mesenteric defects in 1.4% of all patients, 1.2% by the antecolic approach, and 1.9% by the retrocolic approach, respectively. Kinking of the small bowel occurred in .2% of 1630 patients after closure of the mesenteric defects with clips and adhesion formation was found among 4.6% of 152 patients after closure of the mesenteric defects with nonabsorbable sutures. CONCLUSIONS The reported risk of complications caused by closure of the mesenteric defects during LRYGB seems low.
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Affiliation(s)
- Sara Danshøj Kristensen
- Department of Surgery, Koege Hospital, Denmark; Faculty of Health Sciences, University of Copenhagen, Denmark.
| | - Andrea Karen Floyd
- Department of Surgery, Koege Hospital, Denmark; Faculty of Health Sciences, University of Copenhagen, Denmark
| | - Lars Naver
- Department of Surgery, Koege Hospital, Denmark
| | - Per Jess
- Department of Surgery, Roskilde Hospital, Denmark
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Yoshikawa K, Shimada M, Kurita N, Sato H, Iwata T, Higashijima J, Chikakiyo M, Nishi M, Kashihara H, Takasu C, Matsumoto N, Eto S. Characteristics of internal hernia after gastrectomy with Roux-en-Y reconstruction for gastric cancer. Surg Endosc 2014; 28:1774-8. [DOI: 10.1007/s00464-013-3384-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2013] [Accepted: 12/09/2013] [Indexed: 01/30/2023]
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Ni Mhuircheartaigh J, Abedin S, Bennett AE, Tyagi G. Imaging Features of Bariatric Surgery and Its Complications. Semin Ultrasound CT MR 2013; 34:311-24. [DOI: 10.1053/j.sult.2013.04.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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24
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Acute complications after laparoscopic bariatric procedures: update for the general surgeon. Langenbecks Arch Surg 2013; 398:669-86. [DOI: 10.1007/s00423-013-1077-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2012] [Accepted: 03/05/2013] [Indexed: 12/24/2022]
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Shifting from normal to abnormal: transformation of clinical presentation of post-laparoscopic Roux-en-Y gastric bypass surgery complications. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2013; 27:69-71. [PMID: 23472239 DOI: 10.1155/2013/951469] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Kawkabani Marchini A, Denys A, Paroz A, Romy S, Suter M, Desmartines N, Meuli R, Schmidt S. The four different types of internal hernia occurring after laparascopic Roux-en-Y gastric bypass performed for morbid obesity: are there any multidetector computed tomography (MDCT) features permitting their distinction? Obes Surg 2011; 21:506-16. [PMID: 21318275 DOI: 10.1007/s11695-011-0364-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Four different types of internal hernias (IH) are known to occur after laparoscopic Roux-en-Y gastric bypass (LRYGBP) performed for morbid obesity. We evaluate multidetector row helical computed tomography (MDCT) features for their differentiation. METHODS From a prospectively collected database including 349 patients with LRYGBP, 34 acutely symptomatic patients (28 women, mean age 32.6), operated on for IH immediately after undergoing MDCT, were selected. Surgery confirmed 4 (11.6%) patients with transmesocolic, 10 (29.4%) with Petersen's, 15 (44.2%) with mesojejunal, and 5 (14.8%) with jejunojejunal IH. In consensus, 2 radiologists analyzed 13 MDCT features to distinguish the four types of IH. Statistical significance was calculated (p<0.05, Fisher's exact test, chi-square test). RESULTS MDCT features of small bowel obstruction (SBO) (n=25, 73.5%), volvulus (n=22, 64.7%), or a cluster of small bowel loops (SBL) (n=27, 79.4%) were inconsistently present and overlapped between the four IH. The following features allowed for IH differentiation: left upper quadrant clustered small bowel loops (p<0.0001) and a mesocolic hernial orifice (p=0.0003) suggested transmesocolic IH. SBL abutting onto the left abdominal wall (p=0.0021) and left abdominal shift of the superior mesenteric vessels (SMV) (p=0.0045) suggested Petersen's hernia. The SMV predominantly shifted towards the right anterior abdominal wall in mesojejunal hernia (p=0.0033). Location of the hernial orifice near the distal anastomosis (p=0.0431) and jejunojejunal suture widening (p=0.0005) indicated jejunojejunal hernia. CONCLUSIONS None of the four IH seems associated with a higher risk of SBO. Certain MDCT features, such as the position of clustered SBL and hernial orifice, help distinguish between the four IH and may permit straightforward surgery.
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Yamada H, Kojima K, Inokuchi M, Kato K, Otuki S, Hujimori Y, Kawano T, Sugihara K. Laparoscopic Internal Hernia Reposition after Laparoscopy-assisted Distal Gastrectomy with Roux-en-Y Reconstruction. ACTA ACUST UNITED AC 2010. [DOI: 10.5833/jjgs.43.912] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Varghese JC, Roy-Choudhury SH. Radiological imaging of the GI tract after bariatric surgery. Gastrointest Endosc 2009; 70:1176-81. [PMID: 19846080 DOI: 10.1016/j.gie.2009.06.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2009] [Accepted: 06/22/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Obesity is becoming epidemic in proportion and is leading to considerable morbidity and mortality in the community. Bariatric surgery offers one tested solution to sustained weight loss and comorbidity reduction. However, it is associated with a significant number of complications. OBJECTIVE The objective of this article is to review the utility of radiological techniques in the diagnosis of surgical complications after bariatric surgery. DESIGN Literature-based review and pictorial illustration in the use of imaging techniques in the diagnosis of complications after bariatric surgery. CONCLUSIONS Radiology plays a critical role in the diagnosis of complications after bariatric surgery. Upper GI contrast study and CT are the most commonly used imaging modalities in this regard. They are complementary in their diagnostic abilities and should be used in concert for the complete evaluation of symptomatic patients. All other radiological imaging modalities are also used in the diagnosis of complications after bariatric surgery, but much less commonly.
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Affiliation(s)
- Jose C Varghese
- Department of Radiology, Quincy Medical Center, Quincy, MA 02169, USA
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29
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Small-bowel obstruction after laparoscopic Roux-en-Y gastric bypass surgery. J Comput Assist Tomogr 2009; 33:369-75. [PMID: 19478629 DOI: 10.1097/rct.0b013e31818803ac] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE The purpose of this study was to review the etiology and computed tomography (CT) findings of small-bowel obstruction (SBO) in patients who have undergone bariatric laparoscopic Roux-en-Y gastric bypass (LGBP) surgery. MATERIALS AND METHODS Prospectively entered data from a surgical database of 835 consecutive patients who underwent antecolic-antegastric LGBP for morbid obesity from June 1999 to April 2005 in a single institution were retrospectively reviewed. A total of 42 cases of bowel obstruction were observed in 41 patients. Surgical proof was available in 38 cases, and 4 cases had characteristic imaging features and/or clinical follow-up. Seventeen CT scans were reviewed to determine cause and level of obstruction, and this was correlated with surgical findings and clinical follow-up. RESULTS Internal hernia was the most common (13 cases) and also the most frequently missed etiology of SBO on CT scans, with the diagnosis being made prospectively in only 2 of 6 cases, in which CT was done. Adhesions, ventral hernia, postoperative ileus, and jejunojejunal (JJ) anastomotic strictures, in that order, were the other commonly observed etiologies for SBO, with 11, 7, 5, and 4 cases, respectively. Some causes of SBO post-LGBP (JJ anastomotic stricture and postoperative ileus) developed relatively early, whereas others (internal hernia) tended to develop later or had a bimodal distribution (adhesions and ventral hernia). Fifteen (36%) of 42 cases had SBO at or near the level of jejunojejunostomy site; causes included internal hernia (5 cases), adhesions/kinking of small bowel (5 cases), JJ anastomotic stricture (4 cases), and JJ intussusception (1 case). CONCLUSION The time interval between LGBP and development of SBO might provide a useful clinical clue to its etiology. The JJ level is an important location for SBO post-LGBP because of a variety of causes, and special attention must be paid to this site at imaging of post-LGBP patients.
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30
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Carucci LR, Turner MA, Shaylor SD. Internal Hernia Following Roux-en-Y Gastric Bypass Surgery for Morbid Obesity: Evaluation of Radiographic Findings at Small-Bowel Examination. Radiology 2009; 251:762-70. [DOI: 10.1148/radiol.2513081544] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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31
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Meyer G, Stier C, Markovsky O. [Postoperative complications after laparoscopic Roux-en-Y gastric bypass in bariatric surgery]. Obes Facts 2009; 2 Suppl 1:41-8. [PMID: 20124778 PMCID: PMC6444587 DOI: 10.1159/000198259] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Der laparoskopische Roux-Y-Magenbypass weist eine Reihe charakteristischer chirurgischer KomplikationsmÖglichkeiten neben den in der bariatrischen Chirurgie generell vorhandenen Risiken auf. Durch die minimal-invasive Technik konnte das Risiko insgesamt vermindert werden. Die MortalitÄt betrÄgt 0–0,5%, das MorbiditÄtsrisiko betrÄgt zwischen 6 und 30%. Dabei erschweren die speziellen UmstÄnde des morbid adipÖsen Patienten hÄufig die Diagnosestellung, und insbesondere septische Komplikationen mit einem hohen MortalitÄtsrisiko stellen eine große Gefahr dar. GrÖßt mÖgliche Sicherheit und PrÄvention sind daher besonders wichtig. Die hÄufigsten Todesursachen sind Lungenembolie und Anastomoseninsuffizienz. Die hÄufigsten Komplikationen haben pulmonale und kardiale Ursachen. Wundkomplikationen werden als Folge des laparoskopischen Zugangssehrselten beobachtet. Chirurgische Komplikationen resultieren im Wesentlichen aus Blutungen, Problemen an den Anastomosen und NÄhten sowie dem DÜnndarm in Form von PassagestÖrungen unterschiedlicher Genese. Die chirurgischen wie bariatrischen Ergebnisse zeigen, dass das Ausmaß der FrÜh- und SpÄtkomplikationen im Vergleich zu den Folgeneiner fehlenden operativen Behandlung akzeptabel ist. Postoperative Complications after Laparoscopic Roux-en-Y Gastric Bypass in Bariatric Surgery The laparoscopic Roux-en-Y gastric bypass surgery involves some characteristic surgical complications besides the general risks associated with bariatric surgery. The overall risk could be effectively decreased due to the minimal invasive technique, though. The mortality is 0–0.5% and the risk ofmorbidity varies between 6 and 30%. However, the specific circumstances of morbidly obese patients make diagnostics difficult. Especially septic complications of any kind represent a high risk ofmortality. Therefore, maximal safety und prevention are very important issues to consider. The most common causes of death are pulmonary embolismand insufficiency of anastomosis. Due to the laparoscopic approach complications of wound healing are scarcely observed. The most frequent complications result from pulmonary and cardiac dysfunctions. Surgical complications mainly result from bleedings, problems with the anastomoses and sutures as well as from the small intestine showing any kind of passage malfunction. Overall, the surgical and bariatric results reveal that early postoperative and long-term complications remain within tolerable limits when compared toconsequences of a lack of surgery.
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Affiliation(s)
- Günther Meyer
- *Abteilung für Allgemein-, Viszeral- und Gefäßchirurgie, Chirurgische Klinik München-Bogenhausen, Denninger Straße 44, 81679 München, Germany, Tel. +49 8 99 27 94-16 00, Fax −16 03
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Bauman RW, Pirrello JR. Internal hernia at Petersen's space after laparoscopic Roux-en-Y gastric bypass: 6.2% incidence without closure--a single surgeon series of 1047 cases. Surg Obes Relat Dis 2008; 5:565-70. [PMID: 19342309 DOI: 10.1016/j.soard.2008.10.013] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2008] [Revised: 09/23/2008] [Accepted: 10/23/2008] [Indexed: 11/29/2022]
Abstract
BACKGROUND Recent reports describing a gastric bypass technique and the need for closure at Petersen's space using an antecolic antegastric laparoscopic method have differed in the incidence of internal hernia. We report a 6.2% incidence without closure of Petersen's space in a 1047-case, single-surgeon practice. METHODS The data from 1047 patients undergoing antecolic antegastric gastric bypass between January 2001 and December 2006 were prospectively collected and retrospectively evaluated for formation of an internal hernia at Petersen's space. All cases were performed by a single surgeon using an antecolic antegastric technique without closure of the mesenteric space and with division of 5 cm of small bowel mesentery. The biliopancreatic limb length was created at 50 cm during the first 2 years of the study and then at 50 or 100 cm depending on the patient's body mass index. RESULTS Of the 1047 patients, 73 underwent laparoscopic exploration for varying degrees of abdominal pain, unexplained nausea or vomiting, or radiographic evidence of an internal hernia. Of the 73 cases, 65 were Petersen's space hernias, for an incidence of 6.2%, 7 were mesenteric enteroenterostomy hernias, for an incidence of .7%, and 1 was negative for intra-abdominal pathologic findings. A direct relationship was found between the biliopancreatic limb length and the frequency of biliopancreatic internal hernia formation (P = .0194), and a high rate of false-negative radiographic reports were noted. Subsequent to these 1047 patients, we have had no internal hernias with space closure in 339 cases. CONCLUSION Closure of Petersen's space is important in preventing the morbidity of reoperation and the incidence of internal hernia.
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Affiliation(s)
- Roc W Bauman
- Carolina Weight Loss Surgery, Concord, North Carolina, USA.
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Internal Hernias and Nonclosure of Mesenteric Defects During Laparoscopic Roux-en-Y Gastric Bypass. Obes Surg 2008; 19:549-52. [PMID: 18931883 DOI: 10.1007/s11695-008-9722-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2008] [Accepted: 09/16/2008] [Indexed: 10/21/2022]
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Rogers AM, Ionescu AM, Pauli EM, Meier AH, Shope TR, Haluck RS. When Is a Petersen's Hernia Not a Petersen's Hernia. J Am Coll Surg 2008; 207:121-4. [DOI: 10.1016/j.jamcollsurg.2008.01.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2007] [Revised: 01/16/2008] [Accepted: 01/16/2008] [Indexed: 11/16/2022]
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Labrunie EM, Marchiori E, Tubiana JM. Fístulas de anastomose superior pós-gastroplastia redutora pela técnica de Higa para tratamento da obesidade mórbida: aspectos por imagem. Radiol Bras 2008. [DOI: 10.1590/s0100-39842008000200004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Descrever os principais aspectos radiológicos encontrados nas fístulas pós-operatórias de anastomose superior em pacientes submetidos a derivação gastrintestinal em Y de Roux pela técnica de Higa. MATERIAIS E MÉTODOS: Foram estudados 24 pacientes com fístula de anastomose no pós-operatório de gastroplastia redutora, avaliados por tomografias computadorizadas e/ou seriografias esofagogastrojejunais. RESULTADOS: As fístulas de anastomose superior ocorreram até o 30º dia de pós-operatório. Dezenove pacientes realizaram exame radiológico no momento do diagnóstico, sendo observado extravasamento de contraste, considerado sinal direto de fístula de anastomose, em dez pacientes. Dos nove restantes, em sete foi evidenciado extravasamento em exames subseqüentes, sendo ainda identificados sinais indiretos de fístula em seis destes. Sinais indiretos foram observados também em pacientes com extravasamento de contraste nos exames iniciais, sendo o pneumoperitônio o aspecto mais freqüente. Dos cinco pacientes sem exame radiológico no momento do diagnóstico, exames subseqüentes evidenciaram extravasamento de contraste em um e sinais indiretos em quatro pacientes. CONCLUSÃO: O achado radiológico mais comum foi o extravasamento de contraste (sinal direto de fístula). Os sinais indiretos foram: nível líquido bizarro, coleção intracavitária, pneumoperitônio desproporcional ao tempo pós-operatório, líquido na cavidade peritoneal, edema da anastomose inferior e distensão de delgado.
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Affiliation(s)
| | - Edson Marchiori
- Universidade Federal Fluminense; Universidade Federal do Rio de Janeiro, Brasil
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Agaba EA, Gentles CV, Shamseddeen H, Sasthakonar V, Kandel A, Gadelata D, Gellman L. Retrospective analysis of abdominal pain in postoperative laparoscopic Roux-en-Y gastric bypass patients: is a simple algorithm the answer? Surg Obes Relat Dis 2008; 4:587-93. [PMID: 18226974 DOI: 10.1016/j.soard.2007.10.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2007] [Revised: 09/03/2007] [Accepted: 10/19/2007] [Indexed: 01/29/2023]
Abstract
BACKGROUND Patients who have undergone laparoscopic gastric bypass have a high risk of developing an internal hernia. Most patients present 9-18 months postoperatively with a weight loss of 75-120 lb and pain out of proportion to the physical findings. Given the risks of internal hernias and the difficulty in radiologic diagnosis, we have developed a single algorithm to avoid the triage complication of a "missed" diagnosis. METHODS A retrospective review was performed of 1500 bariatric procedures performed from 2001 to 2006, 33% (laparoscopic Roux-en-Y gastric bypass) of which were performed using an antecolic antegastric Roux limb, with all potential defects, including Peterson's, closed. Of these 1500 patients, 75 were evaluated for abdominal pain to rule out an internal hernia. RESULTS Of the 75 patients, 40 had signs of an internal hernia or abdominal obstruction on computed tomography and underwent laparoscopy. The operative time was 38-45 minutes, and the length of stay was 1.5 days. The remaining 35 patient's computed tomography scans were interpreted as "no evidence" of internal hernia or obstruction. Of the 35 patients, 29 underwent diagnostic laparoscopy and had either an internal hernia or critical adhesions. Thus, 69 patients (92%) underwent diagnostic laparoscopy. In 6 patients, the symptoms resolved completely without any surgical intervention. CONCLUSION At our institution, patients who undergo laparoscopic Roux-en-Y gastric bypass with a weight loss of 75-120 lb undergo computed tomography with contrast to rule out other potential nonoperative causes. Also, unless clinically stable or the patient has complete resolution of their pain, they then undergo laparoscopy for evaluation.
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Affiliation(s)
- Emmanuel A Agaba
- Department of Surgery, North Shore University Hospital, Manhasset, New York 11030, USA.
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Higa K, Boone K, Arteaga González I, López-Tomassetti Fernández E. [Mesenteric closure in laparoscopic gastric bypass: surgical technique and literature review]. Cir Esp 2007; 82:77-88. [PMID: 17785141 DOI: 10.1016/s0009-739x(07)71673-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Despite the advantages offered by laparoscopy in bariatric surgery, the incidence of a new complication that was uncommon in the previous era of open surgery--internal hernias--has increased. Most publications in the literature dealing with internal hernia describe the incidence and form of presentation of this entity but few explain how these complications can be prevented. In this review article we describe a technique to close mesenteric defects in retrocolic Roux-en-Y laparoscopic gastric bypass with permanent, continuous running suture (ethibond). We also review the literature in MEDLINE (www.ncbi.nlm.nih.gov/entrez/ using the key words: obesity, laparoscopy, gastric bypass, internal hernia, Petersen hernia) and references from articles of interest to determine the real incidence of this complication. Our technique has proven to be safe, reliable and reproducible and has greatly diminished the incidence of internal hernias. However, our data need to be analyzed in the future to determine whether the technique described eliminates this complication. The optimal results achieved with complete closure of all mesenteric defects have also been observed by other authors.
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Affiliation(s)
- Kelvin Higa
- Bariatric Surgery, Advanced Laparoscopic Surgery Associates Medical Group, Fresno, CA, USA
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Trends in internal hernia incidence after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2007; 17:1563-6. [PMID: 18004631 DOI: 10.1007/s11695-007-9260-6] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2007] [Accepted: 07/09/2007] [Indexed: 12/30/2022]
Abstract
BACKGROUND Internal hernia is a known complication after gastric bypass, especially when performed laparoscopically. The aim of this study was to see when internal hernias occur in relation to weight loss and time course after surgery. Furthermore, we wish to examine the impact of Roux limb positioning ante- versus retrocolic and whether switching to running versus interrupted closure of the mesenteric defects created at surgery made any difference. METHODS A retrospective chart review was performed of all patients undergoing laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) who developed symptomatic internal hernia requiring operative intervention between January 1, 2000 and September 15, 2006. RESULTS Fifty-four internal hernias occurred in 2,572 patients, an incidence of 2.1%. The site of internal hernias varied: 25 (1%), transverse mesocolon; 22 (0.8%), enteroenterostomy; 7 (0.3%), Peterson's space. The mean time to intervention for an internal hernia repair was 413 +/- 46 days and average % excess body weight loss (%EBWL) in this period was 59 +/- 3.3. Subgroup analysis demonstrates internal hernia incidence to be 2 in 357 (0.6%) in antecolic Roux versus 52 in 2,215 (2.4%) in retrocolic Roux limb (odds ratio = 4, P < 0.05). Continuous closure versus interrupted stitching of mesenteric defects does not seem to alter the incidence of internal hernias. CONCLUSION This study demonstrates that the majority of internal hernias occur after a significant (>50%) EBWL. Furthermore, the antecolic approach is associated with a much reduced incidence of internal hernia.
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Coster DD, Sundberg SM, Kermode DS, Beitzel DT, Noun SH, Severidt M. Small bowel obstruction due to antegrade and retrograde intussusception after gastric bypass: three case reports in two patients, literature review, and recommendations for diagnosis and treatment. Surg Obes Relat Dis 2007; 4:69-72. [PMID: 17974496 DOI: 10.1016/j.soard.2007.08.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2007] [Revised: 07/15/2007] [Accepted: 08/24/2007] [Indexed: 11/18/2022]
Abstract
Intestinal obstruction due to intussusception, although rare, is a complication that can cause small bowel obstruction after Roux-en-Y gastric bypass. Possible causes include disordered intestinal motility, the presence of staple lines and other lead points in the intestinal wall, and the anatomic peculiarities of the enteroenterostomy. In the case of antegrade intussusception, the lead point is usually identifiable and can involve either limb. Retrograde intussusception is more common but usually has a featureless entry point beginning a few inches below the intestinal anastomosis, with the intussusceptum traversing the enteroenterostomy into either the biliary or Roux limb. Abdominal computed tomography scan is necessary for diagnosis, and early exploration is recommended to avoid ischemia and bowel resection.
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Affiliation(s)
- David D Coster
- Grinnell Bariatrics and Department of Surgery, Grinnell Regional Medical Center, Grinnell, Iowa, USA
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Labrunie EM, Marchiori E. Obstrução intestinal pós-gastroplastia redutora pela técnica de higa para tratamento da obesidade mórbida: aspectos por imagem. Radiol Bras 2007. [DOI: 10.1590/s0100-39842007000300006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: O objetivo deste estudo foi descrever os principais aspectos radiológicos encontrados nas obstruções intestinais pós-operatórias em pacientes submetidos a derivação gastrintestinal em Y de Roux pela técnica de Higa. MATERIAIS E MÉTODOS: Foram estudados 10 pacientes com obstrução intestinal no pós-operatório de gastroplastia redutora, examinados entre novembro de 2001 e abril de 2006. Os casos foram obtidos em sete instituições hospitalares distintas. RESULTADOS: Nos 10 pacientes, a obstrução ocorreu em alça de delgado, sendo cinco por hérnia interna, três por brida, um por hérnia umbilical e um por intussuscepção gástrica. Em quatro pacientes a obstrução ocorreu precocemente (até o sétimo dia de pós-operatório) e em seis aconteceu tardiamente (entre o terceiro mês e cinco anos de pós-operatório). CONCLUSÃO: Todos os casos de obstrução intestinal ocorreram ao nível do intestino delgado. A hérnia interna foi a causa mais freqüente, seguida de brida. Outras causas foram hérnia umbilical e intussuscepção gástrica.
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Affiliation(s)
| | - Edson Marchiori
- Universidade Federal do Rio de Janeiro, Brasil; Universidade Federal Fluminense
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Lockhart ME, Tessler FN, Canon CL, Smith JK, Larrison MC, Fineberg NS, Roy BP, Clements RH. Internal hernia after gastric bypass: sensitivity and specificity of seven CT signs with surgical correlation and controls. AJR Am J Roentgenol 2007; 188:745-50. [PMID: 17312063 DOI: 10.2214/ajr.06.0541] [Citation(s) in RCA: 134] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the sensitivity and specificity of seven CT signs in the diagnosis of internal hernia after laparoscopic Roux-en-Y gastric bypass. MATERIALS AND METHODS With institutional review board approval, the CT scans of 18 patients (17 women, one man) with surgically proven internal hernia after laparoscopic Roux-en-Y gastric bypass were retrieved, as were CT studies of a control group of 18 women who had undergone gastric bypass but did not have internal hernia at reoperation. The scans were reviewed by three radiologists for the presence of seven CT signs of internal hernia: swirled appearance of mesenteric fat or vessels, mushroom shape of hernia, tubular distal mesenteric fat surrounded by bowel loops, small-bowel obstruction, clustered loops of small bowel, small bowel other than duodenum posterior to the superior mesenteric artery, and right-sided location of the distal jejunal anastomosis. Sensitivity and specificity were calculated for each sign. Stepwise logistic regression was performed to ascertain an independent set of variables predictive of the presence of internal hernia. RESULTS Mesenteric swirl was the best single predictor of hernia; sensitivity was 61%, 78%, and 83%, and specificity was 94%, 89%, and 67% for the three reviewers. The combination of swirled mesentery and mushroom shape of the mesentery was better than swirled mesentery alone, sensitivity being 78%, 83%, and 83%, and specificity being 83%, 89%, and 67%, but the difference was not statistically significant. CONCLUSION Mesenteric swirl is the best indicator of internal hernia after laparoscopic Roux-en-Y gastric bypass, and even minor degrees of swirl should be considered suspicious.
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Affiliation(s)
- Mark E Lockhart
- Department of Radiology, University of Alabama at Birmingham, 619 19th St. S, Birmingham, AL 35249-6830, USA.
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Taylor JD, Leitman IM, Rosser JB, Davis B, Goodman E. Does the position of the alimentary limb in Roux-en-Y gastric bypass surgery make a difference? J Gastrointest Surg 2006; 10:1397-9. [PMID: 17175460 DOI: 10.1016/j.gassur.2006.09.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2006] [Revised: 08/24/2006] [Accepted: 09/05/2006] [Indexed: 01/31/2023]
Abstract
Intestinal obstruction and other complications have been reported following Roux-en-Y gastric bypass (RYGB) surgery. There is controversy of whether the alimentary limb should be placed in the retrocolic or antecolic position. A retrospective analysis was performed on 444 patients undergoing RYGB surgery for morbid obesity during a six year period. During operation, the surgeon chose the positioning of the 75-cm alimentary limb based upon technical consideration (the presence of adhesions from prior surgical procedures, thickness of the transverse mesocolon and mobility of the small bowel mesentery). Group A (216) patients had placement of the Roux limb anterior to the transverse colon, and group B (228) patients had placement of the limb through an opening created in the transverse mesocolon. The average age was 40 years (range 19-64) and the body mass index ranged from 40 to 75 kg/m2. Patients were followed for 24-86 months (mean 36 months). Any patients lost to follow-up were excluded. The average age of patients in the study was 40 years (range 19-64 years). Patients in both groups were similar in their body mass index and demographic characteristics. Group A had 16 patients (7.4%) that had early intolerance to enteral intake, compared to 13 patients in group B (5.7%, P>0.05). Thirteen patients required reoperation for intestinal obstruction (seven patients in group A and six patients in group B (P>0.05). Development of anastomotic stricture occurred in one patient (0.5%) in group A and three patients (1%, P>0.05) in group B. There were no differences in mean operating room times, hospital length of stay, and excess weight lost. No other complications during the follow-up period were attributed to the position of the alimentary limb. Placement of the Roux limb in the antecolic position is may be technically more feasible in some patients and does not appear to be associated with more complications. It avoids the risk of an internal hernia through the transverse and does not appear to be associated with feeding difficulties in the early or late postoperative period.
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Affiliation(s)
- Jerome D Taylor
- Department of Surgery, Beth Israel Medical Center, New York, New York 10003, USA
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Edwards MA, Grinbaum R, Ellsmere J, Jones DB, Schneider BE. Intussusception after Roux-en-Y gastric bypass for morbid obesity: case report and literature review of rare complication. Surg Obes Relat Dis 2006; 2:483-9. [PMID: 16925387 DOI: 10.1016/j.soard.2006.04.232] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2006] [Revised: 04/05/2006] [Accepted: 04/20/2006] [Indexed: 02/06/2023]
Abstract
Obstruction of the small intestine is a recognized complication after Roux-en-Y gastric bypass surgery for morbid obesity. Reported causes after bariatric surgery include volvulus, adhesion, internal hernia, hemorrhagic bezoar, incarcerated ventral hernia, and intussusception. Intussusception after Roux-en-Y gastric bypass for morbid obesity is rare. The etiology remains largely obscure. A delay in the diagnosis and management may result in catastrophic outcomes. Management should include the early involvement of a bariatric surgeon. We describe the clinical and radiologic presentation of a case of jejunojejunal intussusception 4 years after open Roux-en-Y gastric bypass.
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Affiliation(s)
- Michael A Edwards
- Department of Surgery, Harvard University Medical School, Boston, MA 02215, USA
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