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

Management of small bowel obstruction in the third trimester

Small bowel obstruction (SBO) in pregnancy is exceedingly rare. Management of SBO in the third trimester may pose particular challenges, as clinicians must determine whether or not the delivery of the fetus is indicated. In this report, we review the case of a patient in her mid-20's with no prior surgical history who presented with nausea and vomiting at 34 weeks of gestation and was ultimately diagnosed with an SBO. Following expectant management during the initial 4 days of inpatient admission, the patient subsequently underwent an exploratory laparotomy at 35 weeks without concurrent delivery. She was monitored for the remainder of her pregnancy with non-stress tests to evaluate fetal status and eventually underwent induction of labour at 39 weeks, resulting in a successful vaginal delivery. Herein, we review the challenges related to the diagnosis and management of SBO in pregnancy, as well as the maternal-fetal outcomes in the setting of SBO in the third trimester.

Care of the Patient After Metabolic and Bariatric Surgery

Weight loss surgery, also known as metabolic and bariatric surgery (MBS), is an effective weight loss treatment and is associated with reduced mortality and improvements in obesity-related health conditions and quality of life. Postsurgical anatomical and physiologic changes include decreased absorption of micronutrients and alterations in gut-brain hormonal regulation that affect many aspects of health. Patients require ongoing monitoring of their physical and mental health for lasting success. Internists, particularly primary care clinicians, are in an ideal position to monitor for nonserious complications in the short and long term, adjust management of chronic diseases accordingly, and monitor for mental health changes. This article reviews key issues that internists should be aware of for supporting patients' health in the short and long term after MBS.

Internal Hernia in Pregnant Woman due to Congenital Transmesenteric Defect

Congenital transmesenteric hernias are uncommon and are a rare cause of bowel obstruction, which is even rarer in pregnant woman. Because of the lack of specific symptoms or reliable sensitive markers, it is difficult to diagnose internal hernia at early stage, therefore resulting in the delay of surgical intervention and a high mortality rate, especially in pregnant woman. We report a case in which a woman presenting at 16 weeks` gestation was admitted with symptoms of nausea, vomiting and left upper abdominal pain similar to her first-trimester morning sickness. Nephrolithiasis of the left kidney detected by ultrasound may lead to early incorrect diagnosis. Due to the patient`s concern about known adverse effects of ionizing radiation on the fetus, computed tomography was postponed until abdominal pain worsened, coffee color gastric contents vomited and anus stopped exhaust and defecation 12 hours later. Low dose CT plain scan showed features of small bowel obstruction by an internal hernia. Emergency exploratory laparotomy revealed a mesenteric defect of the left colon with a 30 cm long jejunal herniating distal to 10 cm of the ligament of Treitz. The involved small bowel was strangulated and gangrened, necrotic segmental resection and end to end anastomosis were performed subsequently, and the mesenteric defect was then successfully repaired with sutures.

How to Treat Hernias in Pregnant Women?

A hernia is a common surgical problem. Although hernias during pregnancy are uncommon, they can be challenging for both the surgeon and the patient if present. To date, there is no consensus in the medical community regarding the elective repair of hernias in pregnant women. The debate mainly concerns three areas: the timing, the approach, and the surgical technique. This study aims to offer a clear pathway in this field based on the best available data. In this study, we collected reviews written in English and published in PubMed from 2010 to 2020 (the exception being three articles that were published before 2010, which we retained since they contained relevant information). We used regular and Medical Subject Headings (MeSH) keywords. Two of the authors screened the collected studies to select the best articles that would fit our inclusion criteria for the review. The articles considered for this review can be classified into retrospective studies, case reports, and reviews. No randomized controlled trials were found. The lack of an agreement about the treatment of ventral hernias in fertile women makes the decision to treat and the process challenging. The treatment significantly depends on two factors: the symptoms and the pregnancy status at diagnosis. If the hernia is incarcerated or strangulated at presentation, an emergency repair is obligatory. If the hernia is symptomatic, but not complicated, elective surgery should be offered. The timing of repair will depend on whether the patient is already pregnant or non-pregnant. In pregnant patients, if the hernia is small and asymptomatic, it may be better to delay the surgery until after delivery or after the last pregnancy. If the hernia is symptomatic and seems to affect the patient's quality of life, it may be better to postpone the repair until the second trimester or after delivery if complications do not occur. Internal herniation (IH) should be suspected as a cause of the abdominal pain in pregnant women who have undergone laparoscopic Roux-en-Y gastric bypass (LRYGB). In pre-pregnancy patients, if the hernia is large and symptomatic, it may be better to do an elective repair and then wait for one or two years before the next pregnancy. However, if the hernia is small or minimally symptomatic, it may be better to hold the repair until after delivery or after the last pregnancy. Pregnancy may be considered a significant risk factor for hernia recurrence. The laparoscopic mesh repair should be offered whenever possible, whereas the open approach may be preferred in complicated cases. The suture repair may be suitable for both small hernias and in cases of gross contamination.