A complication of Roux-en-Y gastric bypass: intestinal obstruction

Background Intestinal obstruction is a significant and increasingly recognized complication after laparoscopic and open gastric bypass. Materials and methods The medical records of 3,463 patients who had gastric bypass during the study period from July 1997 to December 2004 at a single bariatric center were evaluated. 1,120 patients had retrocolic, retrogastric Roux limb placement and 2,343 patients had antecolic, antegastric. Results 40 patients had 44 intestinal obstructions (1.27%). The onset ranged from 1 day to 7 years postoperatively (mean 16.9 months). Internal hernia at the transverse mesocolon defect was the most common cause. 36 (3.2%) obstructions were observed in retrocolic, retrogastric vs. 8 (0.3%) in antecolic, antegastric approach. Internal hernia repair at mesocolinic effect (n = 11), jejunojejunostomy mesenteric defect repair (n = 7), lysis of adhesions (n = 16) were the most common procedures. A total of 70.5% were done laparoscopically. Conclusions A high index of suspicion is needed to diagnose bowel obstruction after gastric bypass. Radiological imaging of the abdomen has significant limitations. Surgical exploration should be performed without delay. Diagnostic laparoscopy is a safe and effective therapy. We recommend closing all mesenteric defects to prevent internal hernias. The antecolic, antegastric technique reduces the incidence of internal hernias.     

Frequency and management of internal hernias after laparoscopic antecolic antegastric Roux-en-Y gastric bypass without division of the small bowel mesentery or closure of mesenteric defects: review of 1400 consecutive cases

BACKGROUND: It is common practice to close mesenteric defects in abdominal surgery to prevent postoperative herniation and subsequent closed-loop obstruction. The aim of this study was to review our experience with antecolic antegastric laparoscopic Roux-en-Y gastric bypass (AA-LRYGBP) without division of the small bowel mesentery or closure of potential mesenteric defects. METHODS: Data for 1400 patients who underwent AA-LRYGBP between January 2001 and December 2004 was prospectively collected and retrospectively analyzed for the incidence of internal hernias. In all cases, an antecolic antegastric approach was performed without division of the small bowel mesentery or closure of potential hernia defects. RESULTS: Three patients (0.2%) developed a symptomatic internal hernia. Two of these patients had a 200-cm-long Roux limb, and the other had a 100-cm-long Roux limb. All three patients exhibited mild symptoms of partial small bowel obstruction. In all three cases the internal hernia was clinically manifested more than 10 months after the original AA- LRYGBP. Exploration revealed that the hernia site was between the transverse colon and the mesentery of the alimentary limb at the level of the jejunojejunostomy (Petersen's defect) in all three cases. All three patients underwent successful laparoscopic revision, hernia reduction, and mesenteric defect closure. CONCLUSIONS: AA-LRYGBP without division of the small bowel mesentery or closure of mesenteric defects does not result in an increased incidence of internal hernias. The laparoscopic approach for reexploration appears to be an effective and safe option.     

Trends in Internal Hernia Incidence After Laparoscopic Roux-en-Y Gastric Bypass

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.     

Causes of small bowel obstruction after laparoscopic gastric bypass

Background Small bowel obstruction after laparoscopic Roux-en-Y gastric bypass is not a rare complication, occurring in approximately 3% of patients. The goal of this study was to review the causes and timing of small bowel obstruction as an aid to diagnosis, treatment, and prevention. Methods The records of consecutive patients who underwent laparoscopic Roux-en-Y gastric bypass at the authors' center from 4/99 to 7/03 were retrospectively reviewed. All the patients had a laparoscopic handsewn gastrojejunostomy and a stapled jejunojej-unostomy. The Roux limb was placed retrocolically in the first 405 patients and antecolically in the next 1,310 patients. Results Altogether, 1,715 patients underwent a total laparoscopic Roux-en-Y gastric bypass at the authors' bariatric center. In 51 patients, 55 small bowel obstructions occurred (3%) during a median follow-up period of 21 months (range 1–52 months). Small bowel obstruction developed in 27 (7%) of the retrocolic patients, as compared with 24 (2%) of the antecolic patients (p<0.001, chi-square). The cause of small bowel obstruction were adhesive bands (n=14), obstruction at the jejunojejunostomy from kinking or narrowing (n=13), internal hernia or external compression at the transverse mesocolon (n=11), internal hernia through the jejunal mesentery (n=8) incarcerated abdominal wall hernia (n=4), and other (n=5). For patients in whom small bowel obstruction developed in the first 3 weeks after their bypass surgery bowel resection was required in 19 of 24 patients, as compared with 6 of 31 patients in whom obstruction develop after 3 weeks (p<0.001, chi-square). Conclusions Early small bowel obstructions tend to result from technical problems with the Roux limb and require revision of the bypass or small bowel resection significantly more often than late obstructions. The latter group of obstructions usually result from adhesions or hernias, which could be handled laparoscopically without bowel resection. The position of the Roux limb (retrocolic vs antecolic) appeared to influence the incidence of small bowel obstruction. In the current series, changing the position of the jejunal bypass limb from retrocolic to antecolic significantly decreased the overall incidence of small bowel obstruction because it eliminated one of the most common sites for obstruction: the mesocolon. Online publication: 13 October 2004     

Root cause analysis of internal hernia and Roux limb compression after laparoscopic Roux-en-Y gastric bypass using observational clinical human reliability assessment

BackgroundInternal hernia (IH) and Roux limb compression (RC) are recognized complications after retrocolic laparoscopic Roux-en-Y gastric bypass for obesity. The aim of the present study was to systematically identify the surgical technical errors leading to these complications.MethodsAn observational clinical human reliability assessment approach was used to analyze the operating videos of 3 groups: an IH group (n = 12), a Roux compression group (n = 13), and a control group (no complications, n = 21). Two investigators, unaware of the outcomes, reviewed all videos, using special rating software. All errors were categorized using the external error mode system and further described if a direct consequential error (e.g., bleeding) was found.ResultsAn analysis of data showed that, on average, more errors occurred in the complication groups than in the control group (IH 5.85, Roux compression 3.54, control .90, P < .001). The strongest differences were found for missing intermesenteric stitches on both sides of the Roux limb. Logistic regression analysis showed that a missed stitch between the mesentery of the Roux limb and the transverse mesocolon was an independent predictor for IH (B = 1.727, P = .025). No technical or consequential errors could be identified as responsible for RC.ConclusionThe observational clinical human reliability analysis is a useful method to identify operative failure. For retrocolic, retrogastric laparoscopic Roux-en-Y gastric bypass, a systematic approach for the closure of the transverse mesenteric window might prevent IH complications.     

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

BackgroundRecent 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.MethodsThe 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.ResultsOf 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.ConclusionClosure of Petersen's space is important in preventing the morbidity of reoperation and the incidence of internal hernia.     

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.     

The Orientation of the Antecolic Roux Limb Markedly Affects the Incidence of Internal Hernias after Laparoscopic Gastric Bypass

Background: Internal herniation of the bowel may be a late complication after the laparoscopic Roux-en-Y gastric bypass (RYGBP). A seemingly minor change in technique is described that significantly prevents herniation behind the Roux limb mesentery. We hypothesized that internal hernias behind the Roux limb mesentery occur more frequently when the Roux limb is oriented such that the distal tip is toward the lesser curvature of the gastric pouch with the bowel then curving to the patient's left, compared with the opposite orientation. Methods: A retrospective chart review was performed of our prospectively collected database. A change in surgical technique occurred June 2003, in an attempt to reduce internal hernia formation. We compared 200 consecutive antecolic left-oriented RYGBP operations performed immediately previous to June 2003 (Group A) with 200 consecutive antecolic right-oriented RYGBP operations performed after June 2003 (Group B). Results: There was an 9.0% rate of internal hernia formation in Group A (18/200) and a 0.5% rate of internal hernia formation in Group B. Internal hernias were repaired an average of 1.2 years after surgery (range 4–30 months, median 14.3 months). The average length of follow-up was 2.1 and 1.6 years in Groups A and B, respectively. All herniations were behind the Roux limb mesentery. The difference in hernia formation after the change in technique was significant (P<0.005). Conclusions: With a simple change in technique, the incidence of internal herniation behind the Roux limb mesentery may be significantly reduced or eliminated.     

Internal hernia after laparoscopic Roux-en-Y gastric bypass

BACKGROUND: Internal hernia (IH) is a technical complication of laparoscopic Roux-en-Y gastric bypass (LRYGBP) that can have severe consequences. Little has been written on characterizing this complication. Antecolic Roux limb passage has been suggested to be safe without defect closure. METHODS: The records of 785 patients who underwent LRYGBP (136 antecolic, 649 retrocolic) between 1998 and 2003 were reviewed. In our early experience (n = 107), we used a retrocolic technique without defect closure. RESULTS: Twenty patients underwent surgical intervention for IH. The median interval between LRYGBP and symptom onset was 303 days (range, 25 to 1642 days). Abdominal pain was uniformly present, and 63% of patients developed nausea and/or vomiting. Exploratory laparoscopy was attempted in 94% of patients; conversion was necessary in 33%. A total of 21 IHs were identified (13 Petersen's, 5 mesocolic, 2 jejunojejunal, and 1 adhesion-related hernia). No nonviable bowel was identified, and no deaths occurred. A retrocolic technique involving closure of all defects resulted in the lowest rate of hernias (3/542; 0.55%) compared with the antecolic (12/136; 8.81%; P < .0001) and early retrocolic techniques (6/107; 5.6%; P < .0002). CONCLUSION: IH can occur long after gastric bypass surgery, and a low threshold for reoperation is crucial to avoid gut infarction. A retrocolic technique with defect closure appears to afford the lowest risk of IH. The lower incidence of IH in other series after antecolic technique likely results from a less aggressive detection and management approach, because our nonclosure technique could not differ from that of other authors. All defects must be closed to minimize the risk of hernia, whether antecolic or retrocolic.     

Internal Hernias and Nonclosure of Mesenteric Defects During Laparoscopic Roux-en-Y Gastric Bypass

Background  Internal hernias have been described after laparoscopic Roux-en-Y gastric bypass (LRYGB) as a major problem. Thus, many routinely close defects during LRYGB. In our technique, we do not close any defects. We hypothesize that not closing the defects would not cause a significant internal hernia rate diagnosed during reoperations. Methods  Patients who were reoperated after LRYGB were included in this study. Only patients who had a laparoscopic or open exploration focused on inspecting for internal hernias are reported here. The LRYGB technique that was utilized included an antecolic, antegastric gastrojejunostomy, minimal division of the small bowel mesentery, a long jejunojejunostomy performed with three staple lines, adequate division of the omentum, and placement of the jejunojejunostomy above the colon in the left upper quadrant. Results  There were a total of 387 patients who had LRYGB from 2002 to 2007 utilizing this particular technique. Fifty-four patients had a reoperation at an average of 24 (Range: 1–60) months postoperatively. The procedures were abdominoplasty, cholecystectomy, diagnostic laparoscopy, and lysis of adhesions. While two patients had a defect present, no patient had an internal hernia despite aggressive attempts to diagnose one. Conclusions  Internals hernias are not common after our particular method of LRYGB. Before adopting and advocating routine closure, surgeons should consider the surgical technique and the true associated incidence of internal hernias. We do not recommend routine closure of these defects with our technique. Presented in part at International Federation for the Surgery of Obesity annual meeting; August 2006; Sydney, Australia.