Internal hernia with Roux loop obstruction during pregnancy after gastric bypass surgery

Successful pregnancy and weight loss management in a woman unknowingly pregnant at the time of bariatric surgery: a case report

BACKGROUND

Preventing unintended pregnancy is an important issue for women undergoing bariatric surgery, not only to avoid an adverse fetal outcome but to also ensure maximum weight loss for mother. Current guidelines strongly advise to use a reliable method of contraception following surgery and to delay pregnancy for 12-18 months after surgery.

CASE PRESENTATION

We present the case of a woman who underwent laparoscopic sleeve gastrectomy while she was unknowingly pregnant. She was monitored closely throughout her pregnancy for maternal-fetal wellbeing and delivered a healthy full-term girl. At her last follow-up visit 6 months post-delivery, both mother and infant were in good general condition and the mother achieved 94.4% excess weight loss.

CONCLUSIONS

In all-female patients of childbearing age planning to undergo bariatric surgery, pregnancy should be avoided by using a reliable method of contraception well before surgery. Pregnancy should also be excluded on the day of surgery.

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.

Petersen's Hernia after Esophagectomy With Antesternal Jejunal Reconstruction: Case Report

Petersen's hernia after esophagectomy is quite rare. The patient was a 75-year-old man who had undergone esophagectomy via right thoracotomy and reconstruction with a jejunal loop by the antesternal route in 2014. In March 2015, severe acute abdominal pain occurred the next day. A contrast-enhanced abdominal computed tomography scan revealed a diffuse low density area in the abdominal cavity and partial dilatation of the small intestine with torsion of the superior mesenteric artery. The patient underwent emergency laparotomy, revealing chyle-like ascites and pallor of almost the entire small intestine due to circulatory impairment because of strangulation after herniation through Petersen's defect. After strangulation was relieved, the color and motility of the small intestine recovered rapidly. Then we closed the defect between the jejunal pedicle and the transverse mesocolon. This is the first English report showing Petersen's hernia after esophagectomy.

Internal hernias in pregnant females with Roux-en-Y gastric bypass: a systematic review

Improved fertility following a Roux-en-Y gastric bypass (RYGB) can lead to pregnancy and increase the risk of internal herniation. A developing fetus and symptoms of pregnancy can mask the diagnosis and delay intervention, leading to deleterious maternal and fetal consequences. The aim of this systematic review is to summarize the literature regarding internal hernias during pregnancy, their management, and patient outcomes. A comprehensive literature search was undertaken on PubMed and Google Scholar to identify cases of internal hernias presenting during pregnancy after RYGB. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for eligibility and inclusion of articles. Twenty-seven articles, with a total of 59 patients, regarding internal herniation during pregnancy after RYGB were identified. Epigastric pain and nausea and vomiting was the most common presentation. Regardless of orientation of the Roux limb and despite previous closure of mesenteric defects, internal herniation can still occur. A triad of epigastric pain, pregnancy, and a history of RYGB should be a red flag for clinicians to consider internal hernias as a top differential diagnosis. Prompt bariatric consultation and rapid intervention will improve maternal and fetal outcomes.

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

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

Internal Hernia in Pregnant Women After Gastric Bypass: a Retrospective Register-Based Cohort Study

BACKGROUND AND AIMS

Pregnant women who have previously had laparoscopic Roux-en-Y gastric bypass surgery are increasingly seen in the acute surgical care setting with abdominal pain due to internal hernia. With this study, we want to contribute with our experience and to present our local surgical guidelines concerning this particularly vulnerable patient group.

MATERIALS AND METHOD

This article is a retrospective study on prospectively collected data. Using data from the Danish National Health Register, we identified 23 women who had bariatric surgery previously and who were admitted to our surgical department and operated on for suspicion of internal hernia. Additional data was collected from patient files and surgical files.

RESULTS

We identified 23 women who all during pregnancy underwent surgery on suspicion of internal hernia; in 17 patients, the diagnosis was confirmed. We found that laparoscopic approach in our sample was performed as late as the 31st gestational week. All women and foetuses survived this dangerous condition, and none suffered from serious complications, nor did any of the patients have a bowel resection due to small bowel strangulation.

CONCLUSION

In skilled clinical hands, internal hernia has a good prognosis in pregnant patients. Surgery may be performed subacutely or even electively, depending on the condition of patient and foetus, and straightforward clinical assessment is adequate, and imaging studies, e.g. CT, are not necessary.

Internal hernia in late pregnancy after laparoscopic Roux-en-Y gastric bypass

A 27-year-old patient in late pregnancy presented to the department of obstetrics with crampy abdominal pain located in the right flank, 3 years after a laparoscopic Roux-en-Y gastric bypass. Clinical investigation showed tenderness on palpation in the upper abdomen without signs of peritonitis. The cardiotocogram and blood tests were normal. The ultrasound showed a hydronephrosis on the right side, and a pigtail catheter was inserted. The abdominal symptoms did not abate and the abdominal surgeon was consulted 36 hours after admission. Diagnostic laparoscopy was performed promptly because of high suspicion of internal hernia (IH). Laparoscopy showed IH at the mesojejunal intermesenteric defect with a herniated common channel and volvulus of the anastomosis. Conversion to open reduction and complete closure with non-absorbable interrupted sutures was performed. Small bowel resection was avoided. The patient was discharged 10 days after the operation and a healthy boy was born 4 weeks later.

Perforation of the Pregnant Uterus during Laparoscopy for Suspected Internal Herniation after Gastric Bypass

We report perforations of a pregnant uterus during laparoscopy for suspected internal herniation after gastric bypass at 24 weeks of gestation. Abdominal access and gas insufflation were achieved by the use of a 12 mm optic trocar. An additional 5 mm trocar was positioned. The perforations were handled by suturing following laparotomy and mobilisation of the high located uterus. The uterine fundus was located in the subcostal area. Internal herniation was not verified. A cesarean section was made 6 weeks later due to acute low abdominal pain. During delivery the uterus was found normal. At 5 months of age the child has developed normal and seems healthy. Optical trocars should be used with caution for abdominal access during laparoscopy in pregnancy. Open access should probably be preferred in most cases. Accidental perforations of the uterine cavity may be handled in selected cases with simple closure even following the use of large trocars under close postoperative surveillance throughout the pregnancy.

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.

Internal hernias in pregnant women with history of gastric bypass surgery: Case series and review of literature

INTRODUCTION

Gastric bypass surgery is the most common obesity surgery procedure in women. Decreased weight loss favors fertility and leads to pregnancy sometimes just months after surgery, raising the risk of developing gastric bypass-related complications during pregnancy, including the formation of internal hernias.

PRESENTATION OF CASE

The first patient presented at 37 weeks of gestation with abdominal pain, nausea and vomiting. X-ray revealed multiple air-fluid levels and absence of gas in colon. She underwent a cesarean section and exploratory laparotomy without complications. A Petersen's space internal hernia was found. The second patient presented at 25 weeks of gestation with abdominal pain and nausea. X-ray revealed multiple air-fluid levels and a "U-shaped" intestinal loop. She underwent exploratory laparotomy with reduction of an internal hernia also in Petersen's space.

DISCUSSION

Pregnant patients with internal hernias after gastric bypass are usually of young age and with a several-day history of abdominal pain. Surgical exploration is safe and should not be delayed. The literature review showed that maternal death (9%) and fetal death (13.6%) rates are considerably high.

CONCLUSION

The possibility of an internal hernia should always be considered in pregnant women with history of gastric bypass who present with abdominal pain, in order to prevent catastrophic outcomes such as maternal and/or fetal death.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Complete small bowel obstruction secondary to transomental herniation in pregnancy

During pregnancy, abdominal pain can be caused by both obstetric and non-obstetric causes. Non-obstetric causes of severe abdominal pain during pregnancy must always be considered. Complete bowel obstruction caused by an internal hernia is rare in obstetric surgical patients. Delays in diagnosis can occur due to non-specific signs and symptoms which can be present in normal pregnancy, and a reluctance to operate on the pregnant patient. Prompt diagnosis and early surgical intervention is the cornerstone for a good outcome. Surgical intervention during pregnancy is associated with increased risk of foetal loss. The use of intra-operative cardiotocography for foetal monitoring in non-obstetric surgery remains controversial.

Abdominal pain after gastric bypass: labor, uterine rupture, or obstruction and internal hernia

Background. Although gastric bypass may reduce obesity-related complications of subsequent pregnancies, surgical complications requiring antenatal and postpartum interventions are not uncommon. Case. A 26-year-old G4P1112 status post-Roux-en-Y gastric bypass required multiple urgent antenatal evaluations due to frequent episodes of abdominal pain. At 35 + 4 weeks, she presented with severe abdominal pain; initial evaluation was negative for gastrointestinal pathology. The patient was found to be in preterm labor and underwent a repeat cesarean section. The postoperative course was complicated by bowel obstruction due to internal hernia resulting in an emergent laparotomy and a prolonged hospital course. Conclusion. As more reproductive-aged women opt for surgical treatment of obesity, it is essential that obstetricians recognize complications to be able to counsel and appropriately care for these patients.

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

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

Best practice updates for multidisciplinary care in weight loss surgery

The objective of this study is to update evidence-based best practice guidelines for multidisciplinary care of weight loss surgery (WLS) patients. We performed systematic search of English-language literature on WLS, patient selection, and medical, multidisciplinary, and nutritional care published between April 2004 and May 2007 in MEDLINE and the Cochrane Library. Key words were used to narrow the search for a selective review of abstracts, retrieval of full articles, and grading of evidence according to systems used in established evidence-based models. A total of 150 papers were retrieved from the literature search and 112 were reviewed in detail. We made evidence-based best practice recommendations from the most recent literature on multidisciplinary care of WLS patients. New recommendations were developed in the areas of patient selection, medical evaluation, and treatment. Regular updates of evidence-based recommendations for best practices in multidisciplinary care are required to address changes in patient demographics and levels of obesity. Key factors in patient safety include comprehensive preoperative medical evaluation, patient education, appropriate perioperative care, and long-term follow-up.

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist health-care professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.

Reproductive outcome after bariatric surgery: a critical review

BACKGROUND

After many cycles of weight loss and weight gain, more and more morbidly obese patients undergo bariatric surgery, like gastric banding or gastric bypass, as the ultimate treatment for their obesity-problem. Since women of reproductive age are candidates for bariatric surgery, concerns arise regarding the potential impact on future pregnancy.

METHODS

English-language articles were identified in a PUBMED search from 1982 to January 2008 using the keywords for pregnancy and bariatric surgery or gastric bypass or gastric banding.

RESULTS

The few reported case-control and cohort studies clearly show improved fertility and a reduced risk in obstetrical complications, including gestational diabetes, macrosomia and hypertensive disorders of pregnancy, in women after operatively induced weight loss when compared with morbidly obesity women. The incidence of intrauterine growth restriction (IUGR) appears to be increased, however. No conclusions can be drawn concerning the risk for preterm labour and miscarriage, although these risks are probably increased compared with controls matched for body mass index. Operative complications are not uncommon with bariatric surgery and several cases have pointed to the increased risk for intestinal hernias and nutritional deficiencies in subsequent pregnancy. Deficiencies in iron, vitamin A, vitamin B(12), vitamin K, folate and calcium can result in both maternal complications, such as severe anaemia, and fetal complications, such as congenital abnormalities, IUGR and failure to thrive.

CONCLUSIONS

Close supervision before, during and after pregnancy following bariatric surgery and nutrient supplementation adapted to the patient's individual requirements can help to prevent nutrition-related complications and improve maternal and fetal health, in this high-risk obstetric population.

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist healthcare professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.

Female reproductive issues following bariatric surgery

One in 3 adult American women is obese. Almost half of the approximately 100,000 bariatric surgeries performed in 2004 were on reproductive-aged women. Anatomic and physiologic changes resulting from such surgery may have significant clinical implications for preconception, pregnancy, and postpartum care. This review summarizes these issues and the available related literature, and offers guidelines for care of these patients.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to recall that bariatric surgery has many anatomic and physiologic changes that potentially will affect future pregnancies, and state that attention to these physiologic changes and attention to potential nutritional deficiencies significantly improves the chances of a good pregnancy outcome.

Reproductive implications of bariatric surgery: pre- and postoperative considerations for extremely obese women of childbearing age

Extreme obesity remains a frustrating and formidable disease, with most sufferers requiring surgical intervention in order to achieve long-term, sustained weight loss. Most bariatric procedures today are performed on women, many of whom are of reproductive age; yet minimal evidence exists to guide clinicians in the care of such women before, during, and after pregnancy. This review outlines the fundamental nutritional and surgical alterations of the most commonly performed bariatric procedures with the aim to elucidate a physiologically sound approach to counseling and management of extremely obese women of childbearing age who are either contemplating or have already undergone bariatric surgery. Preconception, pregnancy, and lactation guidelines are offered based on available evidence. Outstanding questions are highlighted for further investigation.

Improvement in infertility and pregnancy outcomes after weight loss surgery

The majority of bariatric surgical procedures are performed in young women. There is a concern about safety and outcomes of pregnancies after weight loss surgery. Pregnancy after weight loss surgery is not only safe, but is associated with more favorable outcomes in comparison to obese populations who do not undergo weight loss surgery. An interval of 2 years is recommended from surgery to pregnancy. This delay helps avoid most of the potential nutritional complications. Optimal patient care is achieved in an experienced, multidisciplinary center. Early involvement of the bariatric surgeon in evaluating abdominal pain is critical because the underlying pathology may relate to the previous weight loss surgery. Although infertility is improved after weight loss surgery, reliable modes of contraception may be limited in this population.