Sensitivity and specificity of eight CT signs in the preoperative diagnosis of internal mesenteric hernia following Roux-en-Y gastric bypass surgery

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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“…The diagnosis is established through the clinical feature and radiological studies including abdominal x-ray, contrasted upper gastrointestinal series and CT scan. abdominal CT (Iannuccilli, 2009). A gastrographin upper gastrointestinal series may be used as an alternative (Fig 8).…”

Section: Clinical Presentationmentioning

confidence: 99%

Small Bowel Obstruction After Laparoscopic Roux – En - Y Gastric Bypass

Sánchez¹,

Herrera²

2011

Advanced Laparoscopy

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“…Das "Hurricane eye-sign" ist ebenso Folge der Konvergenz des torquierten, imbibierten analen Dünndarmmesenteriums zur Bruchpforte, wodurch sich in axialen Schichten durch den Mittelbzw. Unterbauch das Bild eines runden oder ovalen verdichteten Mesenteriums ergibt, das von Dünndarmschlingen umgeben ist [16,23].…”

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Bildgebung transmesokolischer innerer Hernien nach retrokolischer Roux-Y-Rekonstruktion: Tipps und Tricks für Radiologen

Meißnitzer¹,

Meissnitzer²,

Forstner³

et al. 2013

Fortschr Röntgenstr

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Zusammenfassung Intestinale Passagest?rungen werden zwar selten durch innere Hernien hervorgerufen, dennoch k?nnen nach retrokolischer Roux-y-Rekonstruktion im Rahmen onkologischer oder bariatrischer Magenoperationen transmesokolische innere Hernien auftreten. Beg?nstigend wirkt die postoperative Abnahme mesenteriellen Fettgewebes bei gleichzeitig erhaltener Lageverschieblichkeit des Darmes nach der heutzutage bevorzugten laparoskopischen Operationstechnik. In der Bildgebung postoperativer innerer Hernien finden sich die spezifischen CT-Befunde einer segmentalen intestinalen Obstruktion analog zu s?mtlichen differenzialdiagnostisch relevanten Entit?ten. Alleinig die exakte Analyse der pathognomonisch ver?nderten Topografie der Peritonealh?hle, die auch durch die Mesenterien definiert ist, gestattet dem Radiologen die Abgrenzung zu Briden als wichtigste Differenzialdiagnose. Basierend auf einfach und eindeutig aufzufindenden anatomischen Landmarken werden im Folgenden die diagnostischen Kriterien postoperativer transmesokolischer innerer Hernien in der Computertomografie herausgearbeitet. Besonderes Augenmerk wird auf das Mesocolon transversum und dessen Rolle als Kompartmentbegrenzung innerhalb der Peritonealh?hle gelegt. Zusammenfassend wird eine Checkliste f?r die t?gliche radiologische Praxis pr?sentiert.

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Sensitivity and specificity of eight CT signs in the preoperative diagnosis of internal mesenteric hernia following Roux-en-Y gastric bypass surgery

Cited by 100 publications

References 11 publications

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

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

Small Bowel Obstruction After Laparoscopic Roux – En - Y Gastric Bypass

Bildgebung transmesokolischer innerer Hernien nach retrokolischer Roux-Y-Rekonstruktion: Tipps und Tricks für Radiologen

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