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     

Laparoscopic antecolic Roux-En-Y gastric bypass with closure of internal defects leads to fewer internal hernias than the retrocolic approach

Background  Laparoscopic Roux-en-Y gastric bypass surgery reportedly has a higher rate of postoperative internal hernias than open bypass surgery. Even with closure of mesenteric defects, hernias occur in up to 9% of cases. To minimize this complication, an antecolic antegastric approach to anastomosis of the Roux limb and gastric pouch has been used. Whereas the retrocolic retrogastric technique creates three mesenteric defects, the antecolic approach produces only two: Petersen’s defect and the jejunojejunostomy. The rate of internal hernias was compared among patients undergoing laparoscopic Roux-en-Y gastric bypass surgery using the retrocolic and antecolic approaches. Methods  The experience of a single surgeon from August 2001 to September 2005 was reviewed. Only Roux-en-Y gastric bypass procedures were included. Patients were followed for a minimum of 18 months postoperatively. The retrocolic approach was used for 274 patients and the antecolic approach for 205 patients. All defects were closed at the time of surgery. With the antecolic approach, Petersen’s defect was closed from the root of the mesentery of the Roux limb and the transverse colon mesentery up to the transverse colon. Results  Of the 274 patients, 7 (2.6%) experienced a symptomatic internal hernia with the retrocolic retrogastric technique. No internal hernias were reported among the 205 patients treated with the antecolic antegastric method. Chi-square analysis showed that an antecolic approach was associated with a decreased rate of internal hernias (p < 0.025). Of 479 patients, 35 (7%) underwent diagnostic laparoscopy without any internal hernia found. Of these patients, 15 were found to have cholelithiasis and subjected to laparoscopic cholecystectomy. Conclusions  The antecolic antegastric approach to laparoscopic Roux-en-Y gastric bypass is associated with fewer postoperative hernias than the retrocolic retrogastric approach. The frequency of hernias using either technique is low if meticulous attention is paid to closure of all mesenteric defects. Presented at the 2007 Society of American Endoscopic Surgeons (SAGES) meeting in Las Vegas, SS16: Outcomes, Presentation: S097, Sunday 22 April 2007     

Spectrum and treatment of small bowel obstruction after Roux-en-Y gastric bypass.

BACKGROUND: Small bowel obstruction (SBO) is a well-recognized complication of bariatric surgery. Many factors that play a role in the etiology of SBO affect the presentation, timing, and treatment after Roux-en-Y gastric bypass (RYGB). We reviewed our experience with SBO after open and laparoscopic RYGB. METHODS: We reviewed prospectively collected data from 784 consecutive patients who had undergone RYGB (458 open and 326 laparoscopic) from July 1998 to March 2005. The operative techniques were standardized, including closure of the mesenteric defects. The follow-up data were taken from clinic visit records and follow-up questionnaires. The mean follow-up period was 16 +/- 1 months (range 1-75). The data presented are the mean +/- SEM. RESULTS: The overall incidence of SBO after RYGB was 3.2%. Thirteen patients developed SBO after laparoscopic RYGB (4%) and 12 patients did so after open RYGB (2.6%, P = NS). Obstruction at the jejunojejunostomy was more common after laparoscopic RYGB (77%, P <.05), and adhesive SBO was more common after open RYGB (50%, P <.05). The incidence of SBO from internal hernia was low, regardless of the operative approach (open 0.7% versus laparoscopic 0.3%). Early SBO resolved with nonoperative treatment in 30% of patients. CONCLUSION: Understanding the anatomic considerations of RYGB in the development of SBO after open and laparoscopic approach is essential to timely and effective treatment.     

Diagnosis and management of partial small bowel obstruction after laparoscopic antecolic antegastric Roux-en-Y gastric bypass for morbid obesity

BACKGROUND: The resultant derangement of the normal gastrointestinal anatomy after a gastric bypass procedure increases the incidence of, and level of difficulty diagnosing, partial small bowel obstruction (SBO) in morbidly obese patients. We evaluated the diagnostic methods for partial SBO and the clinical characteristics according to the time after initial operation. STUDY DESIGN: Data of 1,400 consecutive patients who underwent antecolic antegastric laparoscopic Roux-en-Y gastric bypass between 2001 and 2004 were retrospectively analyzed. RESULTS: Partial SBO developed in 21 (1.5%) patients after laparoscopic Roux-en-Y gastric bypass. Five of 15 patients were preoperatively diagnosed with SBO by a gastrograffin study and CT scan diagnosed 17 of 19 patients (p = 0.002). Causes of SBO included jejunojejunostomy stenosis (n = 6), adhesions (n = 5), incarcerated ventral hernia (n = 5), internal hernia (n = 3), and other (n = 2). The majority of patients (n = 19) underwent surgical treatment. CONCLUSIONS: The most frequent cause of early SBO is jejunojejunal anastomotic stenosis. CT scan is a more accurate diagnostic tool for detecting partial SBO, compared with use of a gastrograffin study. Operation remains the most appropriate and definitive treatment for this complication and the laparoscopic approach is a feasible and safe surgical treatment option.     

Antecolic versus retrocolic alimentary limb in laparoscopic Roux-en-Y gastric bypass: a comparative study.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) has become the most common surgical treatment for morbid obesity. Intestinal obstruction and internal hernias are complications more commonly observed after LRYGB than after open RYGB. The aim of this study was to evaluate the incidence of these complications in patients who had undergone LRYGB using an antecolic versus a retrocolic technique. METHODS: From August 2001 to August 2005, LRYGB was performed in 754 patients. The retrocolic and antecolic technique was used in 300 and 454 consecutive patients, respectively. The mean patient age was 37 +/- 10 years, and 552 of the patients (73%) were women. The mean preoperative body mass index was 41.3 +/- 5 kg/m2. The median follow-up was 16 months. RESULTS: During follow-up, 36 patients (4.7%) underwent surgical exploration secondary to intestinal obstruction. This complication was observed in 28 (9.3%) and 8 (1.8%) patients in the retrocolic and antecolic technique groups, respectively (P <.001). In the retrocolic technique group, an internal hernia developed in 24 patients compared with 3 patients in the antecolic technique group. On multivariate analysis, the retrocolic technique was identified as a risk factor (P <.001). CONCLUSION: A greater incidence of intestinal obstruction and internal hernia was observed in the retrocolic technique group than in the antecolic technique group undergoing LRYGB. The results of our study have shown that the use of the retrocolic technique is a risk factor for intestinal obstruction after LRYGB.     

Small Bowel Obstruction and Internal Hernias during Pregnancy after Gastric Bypass Surgery

Small bowel obstruction (SBO) is a recognized complication of Roux-en-Y gastric bypass (RYGB) surgery. Internal hernia (IH) a potential problem associated with RYGB, can have severe consequences if not diagnosed. We present two cases of SBO due to IH during pregnancy after laparoscopic RYGB (LRYGB). Both patients underwent an antecolic, antegastric LRYGB. In both patients a Petersen’s type IH was found. We reviewed the cases reported in the literature of SBO during pregnancy after RYGB. IH should always be ruled out in pregnant patients with previous RYGB and abdominal pain. Prompt surgical intervention is mandatory for a good outcome.     

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.     

Small Bowel Obstruction After Antecolic Antegastric Laparoscopic Roux-en-Y Gastric Bypass Without Division of Small Bowel Mesentery: A Single-Centre, 7-Year Review

Reported incidence of small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass varies between 1.5% and 3.5%. It has been suggested that the antecolic antegastric laparoscopic Roux-en-Y gastric bypass (AA-LRYGB) is associated with a low incidence of internal herniation (IH). Therefore we routinely did not close mesenteric defects. The records of 652 consecutive patients undergoing primary AA-LRYGB from January 2003 to December 2009 in a single institution were retrospectively reviewed to determine the incidence, etiology, clinical symptoms, radiologic diagnostic accuracy and operative outcomes of SBO. Of the 652 patients, 63 (9.6%) developed SBO. The majority (6.9%, 45 patients) had a SBO due to IH. In 41 (91%) cases, the IH was at the jejunojejunostomy (JJ), four cases had an IH at Petersen’s space. Adhesions and ventral hernia were found in 14 (2.1%) and four (0.6%) cases, respectively. Twenty-nine out of 63 cases had negative computed tomography (CT) findings and IH was diagnosed on CT in only 33% (14/45) of patients with IH. All patients underwent diagnostic laparoscopy. No bowel resections had to be performed. In contrast to previous reports, a high incidence of SBO with a high rate of IH at the JJ site was found in our series. Accuracy of CT is low and diagnostic laparoscopy is mandatory when SBO is suspected. Since 2010 we have started closing the JJ site, and data on SBO are collected prospectively. We believe that closing of the mesenteric defects is a mandatory step, even in an AA-LRYGB.     

Elective laparoscopy for herald symptoms of mesenteric/internal hernia after laparoscopic Roux-en-Y gastric bypass

BackgroundMesenteric internal hernia (MIH) is the most common cause of small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass. Because MIH is a potentially life-threatening complication, we hypothesized that elective repair of MIH before developing acute SBO could decrease morbidity in this population.MethodsThe records of 702 consecutive patients undergoing primary laparoscopic Roux-en-Y gastric bypass from January 2002 and August 2007 were retrospectively reviewed to determine the incidence and etiology of SBO. During the last 9 months of the study, we offered elective laparoscopy to any patient who presented to us with symptoms of intermittent SBO.ResultsOf the 702 patients, 27 (3.8%) developed acute SBO. Of these 27 patients, 15 (55%) had obstruction related to an MIH. Nearly all patients had a typical history of intermittent abdominal pain, nausea, and bloating before developing acute SBO. Elective laparoscopy was offered to 11 patients with symptoms of intermittent SBO. Two patients who refused subsequently underwent operations for acute SBO. MIH was found at elective laparoscopic exploration in all cases. Of the 9 patients undergoing elective surgery, 3 (33%) had small bowel volvulus.ConclusionSBO due to MIH after laparoscopic Roux-en-Y gastric bypass is typically preceded by symptoms of intermittent obstruction. Patients who have these herald symptoms should promptly be offered elective laparoscopic exploration. Elective repair of MIH can be performed safely and expeditiously.     

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.     

Small-bowel obstruction after laparoscopic Roux-en-Y gastric bypass: etiology, diagnosis, and management

OBJECTIVE: To summarize our experience with small-bowel obstructions after laparoscopic Roux-en-Y gastric bypass. DESIGN: Retrospective record review. SETTING: University-affiliated hospital. PATIENTS: One hundred five consecutive patients undergoing surgery for intestinal obstruction after laparoscopic Roux-en-Y gastric bypass between May 24, 2001, and December 1, 2006. MAIN OUTCOME MEASURES: Common presenting symptoms, causes, yield of radiological studies, and types of surgical procedures performed for post-gastric bypass bowel obstruction. RESULTS: A total of 2325 laparoscopic Roux-en-Y gastric bypass procedures were performed during the study period. A total of 105 patients underwent 111 procedures. Bowel obstruction was confirmed in 102 patients, yielding an overall incidence of 4.4%. The most common presenting symptom was abdominal pain (82.0%), followed by nausea (48.6%) and vomiting (46.8%). Thirty-one patients (27.9%) presented with all of the 3 mentioned symptoms. The mean time to presentation was 313 days after bypass (range, 3-1215 days). Among the studies, results in 48.0% of computed tomographic scans, 55.4% of upper gastrointestinal studies, and 34.8% of plain abdominal radiography studies were positive for intestinal obstruction. In 15 patients (13.5%), all of the radiological study results were negative. The most common causes were internal hernias (53.9%), Roux compression due to mesocolon scarring (20.5%), and adhesions (13.7%). Laparoscopic explorations were carried out in 92 cases (82.9%). The incidences of bowel obstructions were 4.8% with retrocolic Roux placement and 1.8% with antecolic Roux placement. CONCLUSIONS: Altered gastrointestinal tract anatomy results in vague symptoms and a poor yield with imaging studies. A sound knowledge of altered anatomy is the key to correct interpretation of imaging studies and prompt diagnosis.     

Laparoscopic re-exploration in mechanical bowel obstruction after laparoscopic gastric bypass for morbid obesità

AIM: This study reports a series of 7 patients who experienced small-bowel obstruction (SBO) after laparoscopic gastric bypass (LGBP). METHODS: Between July 2001 and June 2004, 211 patients underwent surgery for morbid obesity in 2 different institutions and 7 of them required reoperative laparoscopic surgery or laparotomy for mechanical SBO. RESULTS: Seven patients in the series (3%) developed a postoperative bowel obstruction requiring operative management. Their mean body mass index was 49 (range: 38-65) and the average age was 48 years (range 29-60). Six (86%) had undergone an initial LGBP. One (14%) had been converted to open surgery because of the presence of thick adhesions. One percent of the patients (14%) had undergone abdominal surgery prior to gastric bypass. The most common cause of SBO was internal hernia through a mesenteric defect (57%), followed by adhesions (14%), obstruction at the entero-enterostomy (14%) and Petersen hernia (14%). The obstruction was managed laparoscopically. Small-bowel resection was required in 14% with no death encountered after the second revision of the entero-enterostomy. Recovery time was less than 72 h after laparoscopic approach and more than 92 h following the open procedure. CONCLUSIONS: Laparoscopic surgical correction of SBO following LGBP in morbidly obese patients is feasible. Reoperation of morbidly obese patients after LGBP can be achieved successfully through laparoscopic techniques.     

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.     

Three-Year Follow-Up Study of Retrocolic versus Antecolic Laparoscopic Roux-en-Y Gastric Bypass

Background Since 1994, laparoscopic Roux-en-Y gastric bypass (LRYGBP) has gained popularity for the treatment of morbid obesity. In analogy to open surgery, the operation was initially performed in a retrocolic fashion. Later, an antecolic procedure was introduced. According to short-term studies, the antecolic technique is favorable. In this study, we compared the retrocolic vs the antecolic technique with 3 years of follow-up. We hypothesized that the antecolic technique is superior to the retrocolic in terms of operation time and morbidity. Methods 33 consecutive patients with retrocolic technique and 33 patients with antecolic technique of LRYGBP were compared, using a matched-pair analysis. Data were extracted from a prospectively collected database. The matching criteria were: BMI, age, gender and type of bypass (proximal or distal). The end-points of the study were: operation time, length of hospital stay, incidence of early and late complications, reoperation rates and weight loss in the followup over 36 months. Results In the retrocolic group, operation time was 219 min compared to 188 min in the antecolic group (P = 0.036). In the retrocolic group, 3 patients (9.1%) developed an internal hernia and 4 patients (12.1%) suffered from anastomotic strictures. In the antecolic group, 2 patients (6.1%) developed internal hernias and in 3 patients (9.1%) anastomotic strictures occurred. Median hospital stay in the retrocolic group was 8 days compared to 7 days in the antecolic group. In the antecolic group, the mean BMI dropped from 46 kg/m2 to 32 kg/m2 postoperatively after 36 months. This corresponds to an excess BMI loss of 66%. In the retrocolic group, we found a similar decrease in BMI from preoperative 45 kg/m2 to 34 kg/m2 after 36 months (P = 0.276). Conclusion The results of our study demonstrate a reduction of operation time and hospital stay in the antecolic group compared to the retrocolic group. No differences between the two groups were found regarding morbidity and weight loss. Taken together, the antecolic seems to be superior to the retrocolic technique.     

Impact of complete mesenteric closure on small bowel obstruction and internal mesenteric hernia after laparoscopic Roux-en-Y gastric bypass

BackgroundAlthough it is generally accepted that closure of mesenteric defects after laparoscopic Roux-en-Y gastric bypass (LRYGB) reduces the incidence of small bowel obstruction (SBO), data supporting this belief are inconsistent. After a spike in acute SBO cases in our LRYGB patients, we changed our technique of mesenteric closure. The objective of this study was to determine whether modification of our technique of mesenteric closure would decrease the incidence of SBO and internal hernia after LRYGB.MethodsThe records of 872 consecutive patients who had antecolic LRYGB by 1 surgeon over a 9-year interval were reviewed for acute SBO. The first 654 patients, mean follow up = 100±12 months, had incomplete mesenteric closure versus complete closure in 218 remaining patients, mean follow up = 40±14 months. Minimum follow up was 1 year.ResultsTotal incidence of acute SBO was 4.0% (35/872), including 4.4% (29/654) in the incomplete closure group versus 2.8% (6/218) in the complete closure patients. Seventeen (2.6%) of the incomplete closure patients with acute SBO had internal hernias versus 1 (.5%) in the complete closure group. Twenty-six patients with incomplete closure developed symptoms of SBO and subsequently had elective repair of mesenteric hernias versus none in complete closure group (P<.02). Postoperative morbidity and mortality rates after surgery for SBO were 30% and 7.4% in incomplete group versus zero in patients with complete closure.ConclusionComplete closure of mesenteric defects in antecolic LRYGB resulted in a significant reduction in internal mesenteric hernias. Complications were also reduced after operations for SBO in patients who had complete mesenteric closure.     

腹腔镜胃旁路术结肠前与结肠后胃空肠吻合术的前瞻性比较研究

目的比较腹腔镜Roux-en—Y胃旁路术（LRYGB）治疗肥胖症术中结肠前与结肠后两种胃空肠吻合术式的疗效差异。方法前瞻性地将2008年3月至2010年7月暨南大学附属第一医院收治的40例肥胖症患者按随机数字表法分为结肠前组（20例）和结肠后组（20例）。比较两种术式术中、术后恢复情况及短期消化道症状。结果所有病例均顺利完成手术。两组术中失血量、术后排气时间、进食半流时间及术后住院时间方面的差异均无统计学意义（均P〉0．05）;但结肠后组手术时间明显长于结肠前组[（163．4±28．1）min比（131．8±22．7）min,P〈0．05]。两组均未出现腹内疝及吻合口瘘等并发症;术后3个月,两组患者消化道症状的差异亦无统计学意义（P〉0．05）。结论尽管LRYGB结肠后胃空肠吻合更加符合生理结构．但在术后短期疗效上结肠前与结肠后吻合术相当．其远期效果有待进一步研究证实。     

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.     

Internal Hernias after Laparoscopic Roux-en-Y Gastric Bypass: Incidence,Treatment and Prevention

Background: Laparoscopic Roux-en-Y gastric bypass (RYGBP) has been shown to be a safe and effective alternative to traditional "open" RYGBP. Although lack of postoperative adhesions is one advantage of minimally invasive surgery, this is also responsible for a higher incidence of internal hernias. These patients often present with intermittent abdominal pain or small bowel obstruction with completely normal contrast radiographs. Methods: Data was obtained concurrently on 2,000 consecutive patients from February 1998 to October 2001 and analyzed retrospectively. Radiographs, when available, were interpreted by both the operative surgeon and radiologist before intervention. Results: 66 internal hernias occurred in 63 patients, an incidence of 3.1%. 1 patient presented with a traditional adhesive band and small bowel obstruction. 20% of patients had normal preoperative small bowel series and/or CT scans. The site of internal hernias varied: 44 - mesocolon; 14 - jejunal mesentery; 5 - Petersen's space. Although most patients were symptomatic, 5% were incidental findings at the time of another surgical procedure. 5 patients required open repair. 6 patients presented with perforation either at the time of diagnosis or as a result of manipulation of the bowel. There was 1 death associated with complications of the internal hernia. The negative exploration rate was 2%. Conclusion: Internal hernias are more common following laparoscopic RYGBP than "open" RYGBP. Contrast radiographs alone are unreliable in ruling out this diagnosis. Early intervention is crucial; most repairs can be performed laparoscopically. This diagnosis should be entertained in all patients with unexplained abdominal pain following laparoscopic RYGBP. Meticulous closure of all potential internal hernia sites is essential to limit this potentially lethal complication.     

Computed Tomography Patterns in Small Bowel Obstruction after Open Distal Gastric Bypass

Background: Life-threatening small bowel obstruction (SBO) after Roux-en-Y gastric bypass can present with surprisingly minimal laboratory and plain x-ray findings. Based on a 10-year (1994-2003) experience of 1,409 open distal gastric bypasses, we present clinical and radiological findings in 29 patients with unusual forms of bowel obstruction. Methods: A retrospective chart review was conducted. A radiologist experienced in reviewing these in gastric bypass patients reviewed all computed tomography (CT) scans. Results: CT findings: The normal appearance and 7 recurring patterns of small bowel obstruction were identified. These include: 1) intussusception, 2) internal hernia through Petersen's space, 3) through Petersen's space and the mesenteric defect at enteroenterostomy, 4) through the mesenteric defect from the entero-enterostomy, 5) isolated biliary limb obstruction, 6) segmental non-anastomotic ischemia, and 7) internal hernia through bands. Clinical findings: 1 had peritonitis, and 1 had free air on plain film. WBC count was normal in 20/27 patients (74%) including 5/6 (83%) with dead bowel. 9/14 patients (62%) had "non-specific" findings on x-rays. 7 of these had an internal hernia (2 with volvulus and 2 with dead bowel), 1 had biliopancreatic limb obstruction, and 1 had peritonitis. Conclusion: Patients with SBO after distal gastric bypass may present with vague complaints and confusing laboratory and non-specific findings on x-rays. Delayed diagnosis can have catastrophic consequences. CT imaging with oral and intravenous contrast can be life-saving, and should be obtained in all gastric bypass patients with abdominal pain, particularly when all other parameters seem "normal". Unexplained abdominal pain should prompt exploration.