Internal Hernia After Gastric Bypass: Sensitivity and Specificity of Seven CT Signs with Surgical Correlation and Controls

Internal herniation is a well-described complication after a gastric bypass, particularly when performed laparoscopically, although it is rarely described following a total gastrectomy.A 55-year-old lady presented with a 24-hour history of vomiting and rigors 10 months after a radical total gastrectomy with Roux-en-Y reconstruction for a gastric adenocarcinoma. Computed tomography (CT) showed a complete small bowel obstruction and a mesenteric swirl sign, indicating a possible internal hernia. The entire small bowel was found at laparotomy to have migrated through the mesenteric defect adjacent to the site of the previous jejunojejunostomy and was dark purple and aperistaltic. The small bowel was reduced through the defect. At a second laparotomy, the small bowel looked healthy and the defect was repaired. Postoperative recovery was unremarkable.Of numerous signs described, the mesenteric swirl sign is considered the best indicator on CT of an internal hernia following Roux-en-Y reconstruction in gastric bypass surgery. A swirl sign on CT in a patient with abdominal pain should always raise the suspicion of an internal hernia.Ann R Coll Surg Engl 2011; 93: e71-e73 doi 10.1308/147870811X590333 Although a well-described complication after a gastric bypass, particularly a laparoscopic gastric bypass, internal hernias are rarely described following a total gastrectomy. We present a rare case of herniation of the entire small bowel through the mesenteric defect adjacent to the jejunojejunostomy of the Roux-en-Y reconstruction. The ischaemia noted at the laparotomy was reversible upon reduction of the internal hernia. Recognition of the mesenteric swirl sign on computed tomography (CT) and a high degree of clinical suspicion with early operative intervention are critical to pre-empt ischaemic necrosis. case historyA 55-year-old woman presented with a 24-hour history of vomiting and rigors. She had been complaining of lowgrade central abdominal pain for about a month and her appetite had been poor. She was hypotensive and the abdomen was diffusely tender without signs of peritonism. Ten months previously she had undergone a radical total gastrectomy with Roux-en-Y reconstruction for a T2 proximal gastric adenocarcinoma. On histopathological analysis, the resection margins were clear. Three of twenty-four regional lymph nodes contained metastatic adenocarcinoma so she was then treated with an adjuvant course of chemotherapy that was completed six months after the surgery. She had previously had a hysterectomy and a bilateral salpingooophorectomy for a cervical carcinoma.Following initial fluid resuscitation, CT of the abdomen and pelvis was performed, which showed moderate volume ascites, a complete small bowel obstruction with a transition point in the distal ileum and a collapsed colon but no evidence of recurrent or metastatic malignant disease. A mesenteric swirl sign was noted, indicating a possible internal hernia.At emergency laparotomy it was discovered that the entire small bowel had migrated through th...

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“…2,3 A swirl sign on CT in a patient with abdominal pain should always raise the suspicion of an internal hernia. …”

Section: Discussionmentioning

confidence: 99%

Internal hernia following total gastrectomy with Roux-en-Y reconstruction

Larkin

Cooke

Ravi

et al. 2011

annals

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“…According to Lockhart et al 10 , the laparoscopic Roux-en-Y gastric bypass resulted in reduction of perioperative complications, but the internal hernia remains a problem. The studies of Blachar et al 12 , who found 2.8% of internal hernias, and of Higa et al7, with 2.5%, corroborate this opinion.…”

Section: Ribas Ribas Ribasmentioning

confidence: 99%

Achados tomográficos das alterações abdominais pós-operatórias dos pacientes submetidos ao derivação gastrojejunal em Y-de-Roux sem anel

Ribas

Nassif

Ribas

et al. 2012

Rev. Col. Bras. Cir.

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CT CT CT CT findings in patients submitted to findings in patients submitted to findings in patients submitted to findings in patients submitted to findings in patients submitted to Roux-en-y gastric bypass without ring Roux-en-y gastric bypass without ring Roux-en-y gastric bypass without ring Roux-en-y gastric bypass without ring Roux-en-y gastric bypass without ring Achados tomográficos das alterações abdominais pós-operatórias dos pacientes Achados tomográficos das alterações abdominais pós-operatórias dos pacientes Achados tomográficos das alterações abdominais pós-operatórias dos pacientes Achados tomográficos das alterações abdominais pós-operatórias dos pacientes Achados tomográficos das alterações abdominais pós-operatórias dos pacientes submetidos ao derivação gastrojejunal em Y-de-Roux sem anel submetidos ao derivação gastrojejunal em Y-de-Roux sem anel submetidos ao derivação gastrojejunal em Y-de-Roux sem anel submetidos ao derivação gastrojejunal em Y-de-Roux sem anel submetidos ao derivação gastrojejunal em Y-de-Roux sem anel FERNANDA We studied 40 CT exams from patients attended at the radiology service with the intention to clarify abdominal complains. The patients were in post-bariatric surgical follow-up and were operated in the same hospital. We excluded patients who had undergone bariatric surgery by other surgical techniques, operated by another surgical team and the ones who did not agree with the administration of oral or intravenous iodinated contrast media and exceeding the weight limit of the examination table. Results Results ResultsResults Results: The patients were aged from 23 to 70 years, 11 male and 29 female. There were no extra-abdominal changes, and 30 of the 40 patients had CT findings within normal limits. The presence of stenosis at the gastrojejunal anastomosis was found in one patient, internal hernias occurred in five, anastomotic leak in one and the presence of abscess occurred in three of patients. ConclusionConclusion Conclusion Conclusion Conclusion: Total abdominal CT failed to inform the cause of the symptoms in 87.5% of patients seeking medical re-evaluation for symptoms of post-operative bariatric surgery. Due to the need for more effective intervention in the clinical management of severe obesity, the indications for bariatric operations have been growing 5 . The surgical treatment for severe obesity has been employed for nearly half a century. It began in the 1950s with operations that caused malabsorption, abandoned in the late 1970s due to their serious side effects. From then on, procedures that limit food intake began to dominate, either by simply restricting the capacity of the stomach, or by its division and anastomosis to the proximal jejunum 6 . Among the surgical techniques currently considered for treatment of morbid obesity, Roux-en-Y gastric bypass is widely used 2,6,7 . With the increase in the frequency of bariatric operations, it is necessary that the radiologist must be aware The postoperative radiological study, the survey of complications an...

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“…Compared with the traditionally performed "open" surgery, the minimally invasive alternative, the laparoscopic Roux-en-Y gastric bypass (LRYGBP), has gained far wider acceptance because of fewer wound complications, shorter hospital stays, and better cosmetic results [7][8][9]. Likewise, postoperative intra-abdominal adhesions are less common.…”

Section: Introductionmentioning

confidence: 99%

“…The surgical defects leading to the prolapse of small bowel loops have been known to occur at four different sites: either at the incised transverse mesocolon; at the Petersen's space, which represents an opening between the mesocolon and the Roux limb mesentery; at the jejunojejunostomy mesenteric defect, known as mesojejunal hernia; or, finally, at the suture of the two jejunal loops, the biliopancreatic and the Roux limb, called jejunojejunal hernia [3,4,[6][7][8][9][10][11][12][16][17][18].…”

Section: Introductionmentioning

confidence: 99%

The Four Different Types of Internal Hernia Occurring After Laparascopic Roux-en-Y Gastric Bypass Performed for Morbid Obesity: Are There Any Multidetector Computed Tomography (MDCT) Features Permitting Their Distinction?

et al. 2011

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Background Four different types of internal hernias (IH) are known to occur after laparoscopic Roux-en-Y gastric bypass (LRYGBP) performed for morbid obesity. We evaluate multidetector row helical computed tomography (MDCT) features for their differentiation. Methods From a prospectively collected database including 349 patients with LRYGBP, 34 acutely symptomatic patients (28 women, mean age 32.6), operated on for IH immediately after undergoing MDCT, were selected. Surgery confirmed 4 (11.6%) patients with transmesocolic, 10 (29.4%) with Petersen's, 15 (44.2%) with mesojejunal, and 5 (14.8%) with jejunojejunal IH. In consensus, 2 radiologists analyzed 13 MDCT features to distinguish the four types of IH. Statistical significance was calculated (p< 0.05, Fisher's exact test, chi-square test). Results MDCT features of small bowel obstruction (SBO) (n=25, 73.5%), volvulus (n=22, 64.7%), or a cluster of small bowel loops (SBL) (n=27, 79.4%) were inconsistently present and overlapped between the four IH. The following features allowed for IH differentiation: left upper quadrant clustered small bowel loops (p<0.0001) and a mesocolic hernial orifice (p=0.0003) suggested transmesocolic IH. SBL abutting onto the left abdominal wall (p= 0.0021) and left abdominal shift of the superior mesenteric vessels (SMV) (p=0.0045) suggested Petersen's hernia. The SMV predominantly shifted towards the right anterior abdominal wall in mesojejunal hernia (p=0.0033). Location of the hernial orifice near the distal anastomosis (p=0.0431) and jejunojejunal suture widening (p=0.0005) indicated jejunojejunal hernia. Conclusions None of the four IH seems associated with a higher risk of SBO. Certain MDCT features, such as the position of clustered SBL and hernial orifice, help distinguish between the four IH and may permit straightforward surgery.

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Internal Hernia After Gastric Bypass: Sensitivity and Specificity of Seven CT Signs with Surgical Correlation and Controls

Abstract: Mesenteric swirl is the best indicator of internal hernia after laparoscopic Roux-en-Y gastric bypass, and even minor degrees of swirl should be considered suspicious.

Cited by 204 publications

References 18 publications

Internal hernia following total gastrectomy with Roux-en-Y reconstruction

Internal hernia following total gastrectomy with Roux-en-Y reconstruction

Achados tomográficos das alterações abdominais pós-operatórias dos pacientes submetidos ao derivação gastrojejunal em Y-de-Roux sem anel

The Four Different Types of Internal Hernia Occurring After Laparascopic Roux-en-Y Gastric Bypass Performed for Morbid Obesity: Are There Any Multidetector Computed Tomography (MDCT) Features Permitting Their Distinction?

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