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Bruinsma FFE, van der Burg SJC, El Adel S, Schouten R, Smeets SJM. Quality of stapled mesenteric defect closure influences the chance of reopening after laparoscopic Roux-en-Y gastric bypass surgery. Updates Surg 2024:10.1007/s13304-024-01751-4. [PMID: 38332391 DOI: 10.1007/s13304-024-01751-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 12/31/2023] [Indexed: 02/10/2024]
Abstract
Internal herniation (IH) is a common problem after laparoscopic Roux-en-Y gastric bypass surgery (RYGB). Routine closure of the mesenteric defects (MDs) reduces the risk of IH. Only very few articles report on risk factors for IH or describe detailed closing techniques. There is no consensus yet on the best closing method. The objective of this study is to determine the optimal stapling method for closure of MDs after RYGB. All performed RYGB procedures in our high-volume bariatric institute were included. Quality of the closure was scored in the categories poor, sub-optimal, and optimal, to see if the quality of the closure would predict the chance of reopening of the MDs and, therefore, the chance of IH. During any type of laparoscopy in the follow-up of the patient, the conditions of the MDs were stated, for example during diagnostic laparoscopy in symptomatic patients suspicious for IH or during laparoscopic cholecystectomy. Technically well-executed closure of Petersen's space (PS) with two rows of staples had a greater chance of still being closed upon re-inspection compared to closure with one row (odds ratio = 8.1; 95% confidence interval [1.2-53.2], p = 0.029). Optimal closure of the MD at the jejuno-jejunostomy (JJ-space, JJS) resulted in more closed JJSs upon re-inspection compared to sub-optimal closure (odds ratio = 3.6 [CI 95% 0.8-16.1], p = 0.099). Non-optimally closed MDs had higher reopening rates and, therefore, pose an additional risk for IH. Our classification provides a quality assessment of MD closure during RYGB and gives insight into how to optimize surgical technique.
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Affiliation(s)
- F F E Bruinsma
- Department of Surgery, Flevoziekenhuis, Hospitaalweg 1, 1315 RA, Almere, The Netherlands.
| | - S J C van der Burg
- Department of Surgery, Flevoziekenhuis, Hospitaalweg 1, 1315 RA, Almere, The Netherlands
| | - S El Adel
- Department of Surgery, Flevoziekenhuis, Hospitaalweg 1, 1315 RA, Almere, The Netherlands
| | - R Schouten
- Department of Surgery, Flevoziekenhuis, Hospitaalweg 1, 1315 RA, Almere, The Netherlands
| | - S J M Smeets
- Department of Surgery, Flevoziekenhuis, Hospitaalweg 1, 1315 RA, Almere, The Netherlands
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2
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Muir D, Choi B, Clements C, Ratnasingham K, Irukulla S, Humadi S. Mesenteric Defect Closure and the Rate of Internal Hernia in Laparoscopic Roux-en-Y Gastric Bypass: A Systematic Review and Meta-analysis. Obes Surg 2023; 33:2229-2236. [PMID: 37162714 DOI: 10.1007/s11695-023-06597-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 04/06/2023] [Accepted: 04/10/2023] [Indexed: 05/11/2023]
Abstract
Internal hernias are a worrying complication from laparoscopic Roux-en-Y gastric bypass (LRGB), with potential small bowel necrosis and obstruction. An electronic database search of Medline, Embase, and Pubmed was performed. All studies investigating the internal hernia rates in patients whose mesenteric defects were closed vs. not closed during LRGB were analysed. Odds ratios were calculated to assess the difference in internal hernia rate. A total of 14 studies totalling 20,553 patients undergoing LRGB were included. Internal hernia rate (220/12,445 (2%) closure vs. 509/8108 (6%) non-closure) and re-operation for small bowel obstruction (86/5437 (2%) closed vs. 300/3132 (10%) non-closure) were reduced when defects were closed. There was no difference observed when sutures were used to close the defects compared to clips/staples.
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Affiliation(s)
- Duncan Muir
- Ashford and St Peter's Hospitals NHS Foundation Trust, Chertsey, UK.
| | - Byung Choi
- Ashford and St Peter's Hospitals NHS Foundation Trust, Chertsey, UK
| | | | | | - Shashi Irukulla
- Ashford and St Peter's Hospitals NHS Foundation Trust, Chertsey, UK
| | - Samer Humadi
- Ashford and St Peter's Hospitals NHS Foundation Trust, Chertsey, UK
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3
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Athanasiadis DI, Carr RA, Painter R, Selzer D, Lee NK, Banerjee A, Stefanidis D, Choi JN. Chylous ascites in the setting of internal hernia: a reassuring sign. Surg Endosc 2021; 36:2570-2573. [PMID: 33988770 DOI: 10.1007/s00464-021-08545-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 05/04/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Chylous ascites is often reported in cases with lymphatic obstruction or after lymphatic injuries such as intraabdominal malignancies or lymphadenectomies. However, chylous ascites is also frequently encountered in operations for internal hernias. We sought to characterize the frequency and conditions when chylous ascites is encountered in general surgery patients. METHODS Data from patients who underwent operations for CPT codes related to open and laparoscopic abdominal and gastrointestinal surgery in our tertiary hospital from 2010 to 2019 were reviewed. Patients with the postoperative diagnosis of internal hernia were identified and categorized into three groups: Internal Hernia with chylous ascites, non-chylous ascites, and no ascites. Demographics, prior surgical history, CT findings, source of internal hernia, open or laparoscopic surgery, and preoperative labs were recorded and compared. RESULTS Fifty-six patients were found to have internal hernias and were included in our study. 80.3% were female and 86% had a previous Roux-en-Y gastric bypass procedure (RYGBP). Laparoscopy was the main approach for all groups. Ascites was present in 46% of the cases. Specifically, chylous ascites was observed in 27% of the total operations and was exclusively (100%) found in patients with gastric-bypass history. Furthermore, it was more commonly associated with Petersen's defect (p < 0.001), while the non-chylous fluid group was associated with herniation through the mesenteric defect (p < 0.001). CONCLUSIONS Chylous ascites is a common finding during internal hernia operations. Unlike other more morbid conditions, identification of chylous ascites during an internal hernia operation appears innocuous. However, in the context of a patient with a history of RYGBP, the presence of chylous fluid signifies the associated small bowel obstruction is likely related to an internal hernia through a patent Petersen's defect.
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Affiliation(s)
- Dimitrios I Athanasiadis
- Section of Minimally Invasive and Bariatric Surgery, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr. EH 122, Indianapolis, IN, 46202, USA
| | - Rosalie A Carr
- Section of Minimally Invasive and Bariatric Surgery, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr. EH 122, Indianapolis, IN, 46202, USA
| | - Robert Painter
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Don Selzer
- Section of Minimally Invasive and Bariatric Surgery, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr. EH 122, Indianapolis, IN, 46202, USA
| | - Nicole Kissane Lee
- Section of Minimally Invasive and Bariatric Surgery, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr. EH 122, Indianapolis, IN, 46202, USA
| | - Ambar Banerjee
- Section of Minimally Invasive and Bariatric Surgery, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr. EH 122, Indianapolis, IN, 46202, USA
| | - Dimitrios Stefanidis
- Section of Minimally Invasive and Bariatric Surgery, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr. EH 122, Indianapolis, IN, 46202, USA
| | - Jennifer N Choi
- Section of Minimally Invasive and Bariatric Surgery, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr. EH 122, Indianapolis, IN, 46202, USA.
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4
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Collard MK, Torcivia A, Genser L. Descriptive anatomy and closure modalities of inter-mesenteric spaces in laparoscopic Roux-en-Y gastric bypass. J Visc Surg 2020; 157:418-422. [PMID: 32981885 DOI: 10.1016/j.jviscsurg.2020.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- M K Collard
- Sorbonne Université, Institut hospitalo-universitaire ICAN, Service de chirurgie digestive hépato-bilio-pancréatique, Hôpital Pitié Salpêtrière, Assistance publique-hôpitaux de Paris, AP-HP, 75013 Paris, France
| | - A Torcivia
- Sorbonne Université, Institut hospitalo-universitaire ICAN, Service de chirurgie digestive hépato-bilio-pancréatique, Hôpital Pitié Salpêtrière, Assistance publique-hôpitaux de Paris, AP-HP, 75013 Paris, France
| | - L Genser
- Sorbonne Université, Institut hospitalo-universitaire ICAN, Service de chirurgie digestive hépato-bilio-pancréatique, Hôpital Pitié Salpêtrière, Assistance publique-hôpitaux de Paris, AP-HP, 75013 Paris, France.
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5
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Hajibandeh S, Hajibandeh S, Abdelkarim M, Shehadeh A, Mohsin MM, Khan KA, Morgan R. Closure versus non-closure of mesenteric defects in laparoscopic Roux-en-Y gastric bypass: a systematic review and meta-analysis. Surg Endosc 2020; 34:3306-20. [PMID: 32270276 DOI: 10.1007/s00464-020-07544-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 04/01/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The comparative evidence regarding the outcomes of closure versus non-closure of mesenteric defects in laparoscopic Roux-en-Y gastric bypass (LRYGB) is poorly understood. We aimed to compare the outcomes of closure versus non-closure of mesenteric defects in LRYGB for morbid obesity. METHODS We conducted a search of electronic information sources to identify all comparative studies investigating the outcomes of closure versus non-closure of mesenteric defects in patients undergoing LRYGB for morbid obesity. We used the Cochrane risk of bias tool and the ROBINS-I tool to assess the risk of bias of RCTs and observational studies, respectively. Random or fixed effects modelling was applied as appropriate. RESULTS We included 10,031 patients from six observational studies and 2609 patients from two RCTs. Analysis of observational studies showed closure defects resulted in lower risks of internal hernia (OR 0.28, 95% CI 0.15, 0.54) and reoperation for small bowel obstruction (SBO) (OR 0.30, 95% CI 0.10, 0.83); no difference was found between the two groups in terms of SBO not related to internal hernia (OR 1.19, 95% CI 0.47, 2.99), early SBO (OR 0.74, 95% CI 0.04, 14.38), anastomotic leak (OR 0.84, 95% CI 0.45, 1.57), bleeding (OR 1.08, 95% CI 0.62, 1.89), and anastomotic ulcer (OR 2.08, 95% CI 0.62, 6.94). Analysis of RCTs showed closure of defects resulted in lower risks of internal hernia (OR 0.29, 95% CI 0.19,0.45) and reoperation for SBO (OR 0.51, 95% CI 0.38, 0.69) but higher risks of SBO not related to internal hernia (OR 1.90, 95% CI 1.09, 3.34) and early SBO (OR 2.63, 95% CI 1.16, 5.96); no difference was found between the two groups in terms of anastomotic leak (OR 1.95, 95% CI 0.80, 4.72), bleeding (OR 0.67, 95% CI 0.38, 1.17), and anastomotic ulcer (OR 2.08, 95% CI 0.62, 6.94). CONCLUSIONS Our results suggest that closure of mesenteric defects in LRYGB may be associated with lower risks of internal herniation and reoperation for SBO compared with non-closure of the defects (moderate certainty). The available evidence is inconclusive regarding the risks of SBO not related to internal hernia and early SBO (low certainty). More RCTs are needed to improve the robustness of the available evidence.
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6
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Alkatary M. An invited commentary on "Closure of mesenteric defects is associated with a higher incidence of small bowel obstruction due to adhesions after laparoscopic antecolic Roux-en-Y gastric bypass: A retrospective cohort study" (Int J Surg 2019; 17:149-155). Int J Surg 2020; 77:119. [PMID: 32173610 DOI: 10.1016/j.ijsu.2020.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 03/05/2020] [Indexed: 11/26/2022]
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7
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Yao L, Dolo PR, Shao Y, Li C, Widjaja J, Hong J, Zhu X. Absorbable suture can be effectively and safely used to close the mesenteric defect in a gastric bypass Sprague-Dawley rat model. BMC Surg 2020; 20:8. [PMID: 31924213 PMCID: PMC6954620 DOI: 10.1186/s12893-019-0671-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 12/24/2019] [Indexed: 11/17/2022] Open
Abstract
Background To observe if closing the mesenteric defect with absorbable sutures creates a safe adhesion compared to non-absorbable suture after Roux-en-Y gastric bypass. Methods Rats were randomly assigned to 5 experimental groups according to the different suture materials used in closing the mesenteric defects (Peterson’s space) after Roux-en-Y gastric bypass. Group A (control group), Group B (non-absorbable suture, Prolene suture), Group C (biological glue), Group D (non-absorbable suture, polyester suture) and Group E (absorbable suture). All rats were followed up for 8 weeks postoperatively and underwent laparotomy to observe the degree of adhesion and closure of the mesenteric defect. Results No significant difference was found in the decrease in food intake and body weight among all groups. No internal hernia (IH) occurred in any group. The mesenteric defects of Group A remained completely visible without any closure or adhesion. Multiple gaps were found between the Prolene suture and the mesentery along the suture line in Group B. The mesenteric defects of Group C were complete closed with multiple adhesions of the small intestine and the greater omentum. The mesenteric defects in both Group D and Group E closed completely. The average adhesion scores in Group A and Group B were 0 and 0.33 ± 0.52 respectively. The average adhesion score in group C (3.83 ± 0.41) was higher than the other groups (p<0.05). The average adhesion scores in Group D and E were similar (3.17 ± 0.41 and 3.00 ± 0.00 respectively). Conclusion Absorbable suture created a safe adhesion score between the mesentery which was not inferior to non-absorbable sutures.
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Affiliation(s)
- Libin Yao
- Department of General Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221006, Jiangsu, People's Republic of China.,Institute of Digestive Diseases, Xuzhou Medical University, Xuzhou, 221006, Jiangsu, People's Republic of China
| | - Ponnie Robertlee Dolo
- Department of General Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221006, Jiangsu, People's Republic of China.,Institute of Digestive Diseases, Xuzhou Medical University, Xuzhou, 221006, Jiangsu, People's Republic of China
| | - Yong Shao
- Department of General Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221006, Jiangsu, People's Republic of China.,Institute of Digestive Diseases, Xuzhou Medical University, Xuzhou, 221006, Jiangsu, People's Republic of China
| | - Chao Li
- Department of General Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221006, Jiangsu, People's Republic of China.,Institute of Digestive Diseases, Xuzhou Medical University, Xuzhou, 221006, Jiangsu, People's Republic of China
| | - Jason Widjaja
- Department of General Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221006, Jiangsu, People's Republic of China.,Institute of Digestive Diseases, Xuzhou Medical University, Xuzhou, 221006, Jiangsu, People's Republic of China
| | - Jian Hong
- Department of General Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221006, Jiangsu, People's Republic of China.,Institute of Digestive Diseases, Xuzhou Medical University, Xuzhou, 221006, Jiangsu, People's Republic of China
| | - Xiaocheng Zhu
- Department of General Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221006, Jiangsu, People's Republic of China. .,Institute of Digestive Diseases, Xuzhou Medical University, Xuzhou, 221006, Jiangsu, People's Republic of China.
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8
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Koyama R, Maeda Y, Minagawa N, Shinohara T. Rapidly Growing Desmoid-Type Fibromatosis of the Mesentery of the Small Intestine after Distal Gastrectomy for Gastric Cancer. Case Rep Gastroenterol 2020; 14:197-205. [PMID: 32399003 PMCID: PMC7204778 DOI: 10.1159/000506926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/02/2020] [Indexed: 11/23/2022] Open
Abstract
We report the case of a 55-year-old man with a surgical history of distal gastrectomy with Roux-en-Y reconstruction performed 3 years prior to the present episode. During the follow-up, a newly developed, rapidly growing intraabdominal mass was detected in the mesentery of the small intestine. Although the patient had been asymptomatic, surgical resection was planned with the suspicion of malignancy, especially lymph node recurrence of the gastric cancer, owing to its rapid growth. Laparotomy showed that the tumor was located in the mesentery of the small intestine near the Roux-en-Y limb, and due to the involvement of the feeding vessels to the Roux-en-Y limb, the anastomotic site was resected en bloc with the tumor, and the whole Roux-en-Y limb was reconstructed. The histopathological finding was compatible with desmoid-type fibromatosis of the mesentery of the small intestine. Here we report our case and discuss the previously reported literature, especially related to gastric cancer.
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Affiliation(s)
- Ryota Koyama
- Department of Gastrointestinal Surgery, Hokkaido Cancer Center, Sapporo, Japan
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9
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Koyama R, Maeda Y, Minagawa N, Shinohara T, Hamada T. Chylous Ascites Accompanying Internal Hernia after Total Gastrectomy with Roux-en-Y Reconstruction. Case Rep Gastroenterol 2019; 13:481-486. [PMID: 31824237 DOI: 10.1159/000504565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 10/31/2019] [Indexed: 12/23/2022] Open
Abstract
We report the case of a 69-year-old man with a history of esophagogastric junction cancer (Barrett's esophageal cancer; pT1b [SM], N0, M0, pStage IA) that was surgically resected 2 years prior to the present episode. Recurrence was not observed during follow-up. Following complaints of dysphagia and abdominal pain, computed tomography revealed signs of internal hernia. Thus, laparoscopic exploration was performed. Intraoperatively, accumulation of chylous ascites accompanying the internal hernia through the jejunojejunostomy mesenteric defect was observed, which was successfully treated with laparoscopic hernia reduction and defect closure by sutures without intestinal resection. Here, we discuss the case and report that along with previous studies, our study suggests that chylous ascites might be a reliable sign of intestinal viability for herniated intestines.
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Affiliation(s)
- Ryota Koyama
- Department of Gastrointestinal Surgery, Hokkaido Cancer Center, Sapporo, Japan
| | - Yoshiaki Maeda
- Department of Gastrointestinal Surgery, Hokkaido Cancer Center, Sapporo, Japan
| | - Nozomi Minagawa
- Department of Gastrointestinal Surgery, Hokkaido Cancer Center, Sapporo, Japan
| | - Toshiki Shinohara
- Department of Gastrointestinal Surgery, Hokkaido Cancer Center, Sapporo, Japan
| | - Tomonori Hamada
- Department of Gastrointestinal Surgery, Hokkaido Cancer Center, Sapporo, Japan
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10
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Al Motlaq AA, Al Saleh K. Commentary on: "Closure of mesenteric defects is associated with a higher incidence of small bowel obstruction due to adhesions after laparoscopic ante colic Roux-en-Y gastric bypass: A retrospective cohort study". Int J Surg 2019; 72:32-33. [PMID: 31639453 DOI: 10.1016/j.ijsu.2019.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 10/11/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Abdul Aziz Al Motlaq
- Laparoscopic and Bariatric Surgery Department, Salamat Medical Group, Hail, Saudi Arabia.
| | - Khaled Al Saleh
- Surgical Oncology Department, King Fahad Medical City, Riyadh, Saudi Arabia
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11
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Klop C, Deden LN, Aarts EO, Janssen IMC, Pijl MEJ, van den Ende A, Witteman BPL, de Jong GM, Aufenacker TJ, Slump CH, Berends FJ. Diagnosing Internal Herniation After Roux-en-Y Gastric Bypass Surgery: Literature Overview, Cadaver Study and the Added Value of 3D CT Angiography. Obes Surg 2019; 28:1822-1830. [PMID: 29404939 PMCID: PMC6107799 DOI: 10.1007/s11695-018-3121-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Purpose The purposes of the study are to outline the complexity of diagnosing internal herniation after Roux-en-Y gastric bypass (RYGB) surgery and to investigate the added value of computed tomography angiography (CTA) for diagnosing internal herniation. Materials and Methods A cadaver study was performed to investigate the manifestations of internal hernias and mesenteric vascularization. Furthermore, a prospective, ethics approved study with retrospective interpretation was conducted. Ten patients, clinically suspected for internal herniation, were prospectively included. After informed consent was obtained, these subjects underwent abdominal CT examination, including additional arterial phase CTA. All subjects underwent diagnostic laparoscopy for suspected internal herniation. The CTA was used to create a 3D reconstruction of the mesenteric arteries and surgical staples (3D CTA). The 3D CTA was interpreted, taking into account the presence and type of internal hernia that was found upon laparoscopy. Results Cadaveric analysis demonstrated the complexity of internal herniation. It also confirmed the expected changes in vascular structure and surgical staple arrangement in the presence of internal herniation. 3D CTA studies of the subjects with active internal hernias demonstrated remarkable differences when compared to control 3D CTA studies. The blood supply of herniated intestinal limbs in particular showed abnormal trajectories. Additionally, enteroenterostomy staple lines had migrated or altered orientation. Conclusion 3D CTA is a promising technique for diagnosing active internal hernias. Our findings suggest that for diagnosing internal hernias, focus should probably shift from routine abdominal CT examination towards the 3D assessment of the mesenteric vasculature and surgical staples. Electronic supplementary material The online version of this article (10.1007/s11695-018-3121-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Cornelis Klop
- MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands. .,Department of Bariatric Surgery, Rijnstate Hospital and Vitalys Clinic, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands.
| | - Laura N Deden
- Department of Bariatric Surgery, Rijnstate Hospital and Vitalys Clinic, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands
| | - Edo O Aarts
- Department of Bariatric Surgery, Rijnstate Hospital and Vitalys Clinic, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands
| | - Ignace M C Janssen
- Department of Bariatric Surgery, Rijnstate Hospital and Vitalys Clinic, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands
| | - Milan E J Pijl
- Department of Radiology, Rijnstate Hospital, Arnhem, The Netherlands
| | | | - Bart P L Witteman
- Department of Bariatric Surgery, Rijnstate Hospital and Vitalys Clinic, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands
| | - Gabie M de Jong
- Department of Bariatric Surgery, Rijnstate Hospital and Vitalys Clinic, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands
| | - Theo J Aufenacker
- Department of Bariatric Surgery, Rijnstate Hospital and Vitalys Clinic, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands
| | - Cornelis H Slump
- MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
| | - Frits J Berends
- Department of Bariatric Surgery, Rijnstate Hospital and Vitalys Clinic, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands
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12
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Thomas R, Olbers T, Barry JD, Beamish AJ. Closure of mesenteric defects during Roux-en-Y gastric bypass for obesity: A systematic review and meta-analysis protocol. Int J Surg Protoc 2019; 15:1-4. [PMID: 31851749 PMCID: PMC6913573 DOI: 10.1016/j.isjp.2019.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 02/20/2019] [Accepted: 02/21/2019] [Indexed: 01/08/2023] Open
Abstract
Roux-en-Y gastric bypass is an effective treatment for severe obesity and its comorbidities. Closure of mesenteric defects may reduce the overall incidence of internal herniation. Closure of mesenteric defects may also increase early small bowel obstruction and bleeding. This review is designed to establish the evidence for and against closure of mesenteric defects.
Introduction Closure of mesenteric defects during laparoscopic Roux-en-Y gastric bypass surgery (RYGB) has not been fully established as standard operative practice. However, in recent years a body of evidence has emerged suggesting that non-closure of defects leads to increased rates of internal herniation and its potential consequences, including the need for reoperation, along with an associated morbidity and mortality risk. Within the emerging literature there has also been some evidence of a greater risk of 30-day complications in closure groups. This systematic review and meta-analysis aims to look at the existing evidence and provide guidance on whether closure of mesenteric defects should be standard operative practice. Methods The systematic review and meta-analysis has been registered a priori. A literature search will be performed interrogating the Medline and Embase databases via Ovid, and also the Cochrane Controlled Register of Trials (CENTRAL), to identify randomised and non-randomised studies reporting comparative outcomes following closure vs. non-closure of mesenteric defects during RYGB. The primary outcome will be reoperation for small bowel obstruction, and secondary outcomes will include internal herniation, jejuno-jejunal anastomosis narrowing or kinking, adhesions, complications (<30 days and >30 days after surgery), 30-day mortality, reoperation, and any other outcome deemed relevant and reported in more than one study.
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Affiliation(s)
- Rhys Thomas
- Department of General Surgery, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | - Torsten Olbers
- Department of Gastrosurgical Research and Education, Institute of Clinical Sciences, Gothenburg University, Gothenburg, Sweden
| | - Jonathan D Barry
- Department of Surgery, Norrköping, Linköping University, Linköping, Sweden
| | - Andrew J Beamish
- Department of General Surgery, Abertawe Bro Morgannwg University Health Board, Swansea, UK.,Department of Surgery, Norrköping, Linköping University, Linköping, Sweden.,Welsh Institute of Metabolic and Bariatric Surgery, Swansea, UK
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13
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Abstract
BACKGROUND Roux-en-Y gastric bypass is the gold standard for weight loss surgery. This procedure creates two to three mesenteric defects, depending on ante-colic versus retro-colic technique. Current literature supports mesenteric defect closure, but there is no consensus on how to best close these defects. Described options include running separate suture lines for each defect, or employing endoscopic staplers for defect closure. METHODS This is a video/dynamic manuscript on operative technique. RESULTS We describe an alternative technique that does not require an extra laparoscopic instrument and is more efficient than traditional suture lines due to less suturing. CONCLUSIONS The technique maintains low gastric bypass complication rates by closing mesenteric defects, while keeping intra-operative costs low, and minimizing time spent on the defect closures.
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14
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Han WH, Eom BW, Yoon HM, Kim YW, Ryu KW. Clinical characteristics and surgical outcomes of internal hernia after gastrectomy in gastric cancer patients: retrospective case control study. Surg Endosc 2018; 33:2873-2879. [PMID: 30421082 DOI: 10.1007/s00464-018-6584-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 11/07/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although the internal hernia is rare after gastric cancer surgery, it is a serious complication, and prompt surgical treatment is essential. However, internal hernia has not been studied because of low incidence and difficulty of diagnosis. This study investigated the clinical characteristics and proper management of internal hernia after gastrectomy. METHODS From June 2001 to June 2016, patients who underwent gastrectomy, either open or laparoscopic (robotic) surgery, with potential internal hernia defect were enrolled. The hernia defect was not closed in any of the enrolled patients. The clinicopathological data of internal hernia patients were compared to patients without internal hernia to identify risk factors. Surgical outcomes of internal hernia were compared between patients who underwent early and late intervention group according to time interval from symptom onset to operation. RESULTS Of 5777 patients who underwent gastrectomy with possible internal hernia, 24 (0.4%) underwent emergency or scheduled surgery for internal hernia. Internal hernia through the Petersen space was observed in 15 cases, and through the jejunojejunostomy mesenteric defect in 9 cases. Low body mass index (odds ratio [OR] 4.403, p = 0.003) and laparoscopic approach (OR 6.930 p < 0.001) were statistically significant factors in multivariate analysis. Postoperative complication rate (16.7% vs. 50% p = 0.083) and mortality rate (8.3% vs. 25.0% p = 0.273) were slightly higher in the late intervention group. CONCLUSIONS Although internal hernia is a rare complication, it is difficult to diagnose and cause serious complications. To prevent internal hernia, the necessity of hernia defect closure should be investigated in the further studies. Early surgical treatment is necessary when it is suspected.
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Affiliation(s)
- Won Ho Han
- Center for Gastric Cancer, National Cancer Center, Goyang, 410-769, Republic of Korea
| | - Bang Wool Eom
- Center for Gastric Cancer, National Cancer Center, Goyang, 410-769, Republic of Korea
| | - Hong Man Yoon
- Center for Gastric Cancer, National Cancer Center, Goyang, 410-769, Republic of Korea
| | - Young-Woo Kim
- Center for Gastric Cancer, National Cancer Center, Goyang, 410-769, Republic of Korea
| | - Keun Won Ryu
- Center for Gastric Cancer, National Cancer Center, Goyang, 410-769, Republic of Korea.
- Center for Gastric Cancer, Research Institute & Hospital, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang-si, 410-769, Republic of Korea.
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15
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Abstract
Background and Objectives: There is a wide variation of reported incidence of small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass (LGB). There is also wide variation in technique, not only in placement of the Roux limb, but also regarding closure or nonclosure of the mesenteric defects. The objective of this study was to examine the incidence and characteristics of SBO after antecolic antegastric bypass with nonclosure of the mesenteric defect of the jejunojejunal anastomosis. Methods: This is a retrospective review of a series of consecutive LGBs over a 3-year period. All procedures were performed by the same surgeon using the same technique. In no case was the mesenteric defect closed. A prospectively maintained database was used for data collection. Patients who returned with an SBO were the study group, and those who underwent revisional bariatric surgery or conversion to open operation were excluded. Results: There were 249 primary LGBs performed during the study period; 15 of the operations were followed by SBO, for an incidence of 6.0%. Four cases were caused by an internal hernia (IH), for an incidence of 1.6%, and 11 were caused by adhesions, which accounted for 73% of the SBOs. Conclusions: SBO after LGB is a relatively common complication. The incidence of SBO from IH with nonclosure of the mesenteric defect is similar to that in other series where the defect is closed. Regardless of the cause of the SBO, operative treatment of the patient who has a gastric bypass remains the definitive standard and should not be delayed.
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16
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Kim SH, Yoon KC, Lee W, Kim HY, Jung SE. Result of using a biologic collagen implant (Permacol) for mesenteric defect repair after excision of a huge mesenteric lymphangioma in a child. Ann Surg Treat Res 2015; 89:330-3. [PMID: 26665129 PMCID: PMC4672098 DOI: 10.4174/astr.2015.89.6.330] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 07/06/2015] [Accepted: 07/30/2015] [Indexed: 11/30/2022] Open
Abstract
Mesenteric lymphangiomas, which involve near total mesentery, are extremely rare. A mesenteric lymphangioma should be treated through excision because they can cause invasion of vital structures, bleeding, or infection. After excision of a huge mesenteric lymphangioma, internal herniation may occur through a large mesenteric defect leading to intestinal volvulus, obstruction, and other life-threatening circumstances. We report a case in which a biologic collagen implant (Permacol) was used for mesenteric defect repair after excision of a huge mesenteric lymphangioma. The implant did not cause any symptoms or complications during follow-up for 4 years. When encountering large defects of mesentery, closure with implant can be a feasible choice, and Permacol could be a possible implant for closing the defect.
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Affiliation(s)
- Soo-Hong Kim
- Department of Pediatric Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Kyung-Chul Yoon
- Department of Pediatric Surgery, Seoul National University Children's Hospital, Seoul, Korea
| | - Woohyung Lee
- Department of Pediatric Surgery, Seoul National University Children's Hospital, Seoul, Korea
| | - Hyun-Young Kim
- Department of Pediatric Surgery, Seoul National University Children's Hospital, Seoul, Korea
| | - Sung-Eun Jung
- Department of Pediatric Surgery, Seoul National University Children's Hospital, Seoul, Korea
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17
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Abstract
Small bowel volvulus is a rare and life threatening surgical emergency. Nearly 75% of volvulus occurs in colon and 25% occurs in small bowel. Small bowel volvulus is abnormal twisting of bowel loops around the axis of its own mesentry leading to twisting and occlusion of mesenteric vessels causing intestinal obstruction, venous engorgement, gangrene and perforation. Small bowel volvulus is more common in neonates and young adults and very rare in adults. We are reporting a first case of small bowel volvulus and gangrene caused by herniation of ovarian cyst through mesenteric defect and twisting of small bowel around the axis of ovarian cyst leading to closed loop obstruction, small bowel volvulus and gangrene. Outcome of the disease is mainly based on the early diagnosis and intervention. Mortality is about 5.8 - 8% in nongangrenous SBV which increases drastically to 20 - 100% in gangrenous bowel.
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Affiliation(s)
- Mano Ananth Arivazhagan Brinda
- Post Graduate Student, Department of General Surgery, Mysore Medical College and Research Institute , Mysore, Karnataka, India
| | - Srinidhi Manjunath
- Senior Resident, Department of General Surgery, Mysore Medical College and Research Institute , Mysore, Karnataka, India
| | | | - Basavaraju Nanjaiah
- Post Graduate, Department of General Surgery, Mysore Medical College and Research Institute , Mysore, Karnataka, India
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18
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Walker AS, Bingham JR, Causey MW, Sebesta JA. Mesenteric irritation as a means to prevent internal hernia formation after laparoscopic gastric bypass surgery. Am J Surg 2014; 207:739-41; discussion 741-2. [PMID: 24791637 DOI: 10.1016/j.amjsurg.2013.12.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 12/21/2013] [Accepted: 12/22/2013] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Internal hernias (IHs) occur more frequently in laparoscopic gastric bypass (LGB) surgery than in the classic open procedure. The incidence of small bowel obstruction after LGB ranges from 1.8% and 9.7%. Some have theorized that this occurs because of decreased adhesion formation. METHODS The mesenteric irritation technique is performed after closure of the jejunojejunal mesenteric defect with a running 2-0 silk suture. A sponge is then rubbed against the closed visceral peritoneal mesentery until petechiae are visualized on the surface of the mesentery. RESULTS In all, 338 LGBs were performed using the standard closure technique with an IH incidence of 5.3% (range 1.7% to 7.8%). When using the mesenteric irritation technique, 72 LGBs were performed with an IH rate of 1.4% (P = .13). CONCLUSIONS Mesenteric irritation is a novel technique performed with minimal additional time and no additional equipment. This technique may prove beneficial in reducing the incidence of IHs.
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19
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Vallumsetla R, Govind Rao N. Congenital transmesenteric internal hernia - A case report with literature review. Indian J Surg 2010; 72:268-70. [PMID: 23133264 DOI: 10.1007/s12262-010-0065-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Accepted: 02/03/2010] [Indexed: 11/25/2022] Open
Abstract
Congenital transmesenteric internal hernia is a rare condition presenting as recurrent pain abdomen or acute intestinal obstruction. Preoperative diagnosis of internal hernia is very rare. Early intervention and surgical correction goes a long way in preventing high morbidity and mortality associated with cases of internal hernia. We report a case of congenital transmesenteric intra-abdominal hernia presented as acute abdomen with timely surgical intervention in the form of emergency laparotomy with untwisting and reduction of small bowel herniated through large congenital terminal ileal mesenteric defect and repair of mesenteric defect.
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Affiliation(s)
- Ramesh Vallumsetla
- Department of General Surgery, ESI Hospital, Sanathnagar, Hyderabad, AP India
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