Internal Herniation Incidence After RYGB and the Predictive Ability of a CT Scan as a Diagnostic Tool

Abstract

Purpose The clinical diagnosis of an internal herniation (IH) after a Roux-en-Y Gastric Bypass (RYGB) remains difficult; therefore, performing a CT scan is usually part of the diagnostic process. The goal of this study was to assess the incidence of IH in patients with open and closed MD (mesenteric defect) and to study if the ability to diagnose an IH with a CT scan is different between these groups. Materials and Methods IH was defined as a visible intestine through the mesenteric defect underneath the jejunojejunostomy and/or in the Petersen’s space. CT scan outcomes were compared with the clinical diagnosis of an IH. Until 31 June 2013, standard care was to leave mesenteric defects (MDs) open; after this date, they were always closed. Results The incidence of IH in the primarily non-closed group was 3.9%, and in the primarily closed group, this was 1.3% ( p = 0.001). In group A (non-closed MD and CT), the sensitivity of the CT scan was 80%, and specificity was 0%. In group C (closed MD and CT), the sensitivity was 64.7%, and specificity was 89.5%. In group B (non-closed, no CT), an IH was visible in 58.7% of the cases and not in 41.3%. In group D (only a re-laparoscopy), an IH was visible in 34.3% of the cases and not in 65.7%. Conclusions Using the CT scan in suspected IH is not useful in if the MDs were not closed. If the MDs were closed, then a CT scan is predictive for the diagnosis IH.

The Diagnostic Accuracy of Abdominal Computed Tomography in Diagnosing Internal Herniation Following Roux-en-Y Gastric Bypass Surgery

“…The number of radiologists analyzing CT scans variated from 1 to 3 radiologists. Exploratory surgery combined with a negative clinical follow-up following the CT scan was used as a reference standard in 5 studies, 10,22,33,36,40 whereas the remaining studies used exploratory surgery only 8,12,13,15,16,19,32,34,35,38,39,41–43 …”

“…Six of the included studies specifically reported on patients who presented with acute symptoms, 8,15,32,33,35,36 7 studies on patients with both acute and intermittent symptoms, 10,12,13,19,34,37,38,42 1 study specifically focused on patients with intermittent complaints suggestive of IH, 39 and 5 studies did not specify the duration or type of onset of symptoms 16,22,40,41,43 . A CT of the abdomen was performed in all patients with symptoms of IH.…”

“…Only 1 study evaluated the difference in diagnostic accuracy of CT comparing patients with open and closed mesenteric defects. Torensma et al 19 demonstrated a sensitivity of 80.0% (51.9%–95.7%) and specificity of 0% in the open group compared with a sensitivity of 64.7% (38.3%–85.8%) and specificity of 89.5% (66.9%–98.7%) in the closed mesentery group.…”

“…Except for 1 study, 32 the vast majority of the included patients was female (67%-100%). 8,10,12,13,15,16,19,22,[33][34][35][36][37][38][39][40][41] The mean index BMI ranged from 40.9 to 54.2 kg/m 2 . Weight loss at the time of presentation was reported in the majority of studies in terms of mean weight loss ranging from 34.5 to 63.0 kg, mean excess weight loss of 41.0% to 81.0%, and BMI loss of -2.1 to 17 kg/m 2 .…”

“…In the majority of the patients, an antecolic RYGB was performed. 10,13,16,19,22,35,40,41 In 4 studies, both antecolic and retrocolic gastrojejunostomies were created, 12,32-34 and a retrocolic RYGB was performed in 2 studies. 39,42 Routine primary closure of the mesenteric defects was reported in 1 study, 33 4 studies report the mesenteric defects to be left open, 10,15,35,40 in 6 studies primary mesenteric closure was performed variably, 13,19,22,34,41,42 with the remaining studies not specifying whether or not this was performed.…”