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Internal herniation after LRYGB

Reoperation for suspected IH is recommended after LRYGB

A total of 193 reoperations were performed for (suspected) IH from 6,896 LRYGB, an estimated incidence of 2.8%
In a multivariate analysis, a positive CT scan for IH was the only independent predictor for pain relief

Reoperation for suspected internal herniation (IH) is recommended after laparoscopic Roux-en-Y gastric bypass (LRYGB) if no marginal ulcer is found during gastroscopy because many patients benefit from closure of the mesenteric defects irrespective of perioperative presence of IH, according to researchers from the Netherlands. They added that pain relief after closure of the mesenteric defects for (suspected) IH “remains unpredictable” with a swirl sign on computed tomography (CT) the only significant predictor of pain relief after reoperation for (suspected) IH after delayed closure of mesenteric defects of LRYGB. The paper, ‘Predicting Symptom Relief After Reoperation for Suspected Internal Herniation After Laparoscopic Roux-en-Y Gastric Bypass’, was published in Obesity Surgery by researchers from Maasstad Hospital, Rotterdam, the Rode Kruis Hospital, Beverwijk and the OLVG, Amsterdam, in The Netherlands

The authors note that IH is one of the most common long-term complications after LRYGB and diagnosis of IH is difficult and not all patients with suspected IH have full relief of symptoms after closure of both mesenteric defects. Therefore, they decided to investigate patient-related factors and intraoperative findings in patients with delayed closure of mesenteric defects, in order to predict postoperative symptom relief after reoperation in patients with suspected IH after LRYGB.

At the institutions involved in this study, LRYGB was performed without primary closure of the mesenteric defects. The reoperations were performed by an experienced bariatric surgeon using laparoscopy with inspection of the bowel anatomy of the alimentary limb, the biliopancreatic limb and the common limb. The authors note that if IH in Petersen’s space or through the defect of the jejunojejunostomy was identified, they repositioned the bowel and the mesenteric defects were either closed with running, non-absorbable sutures or with non-absorbable staples (EndoHernia, Medtronic) depending on the surgeon’s preference.

For this study, all patient records who underwent reoperation after LRYGB for suspected acute or chronic IH from June 2009 until December 2016 at the three bariatric institutions, were retrospectively reviewed. Computed tomography scans (interpreted both by a radiologist and an experienced bariatric surgeon) were defined as ‘positive’ if a swirl sign with an estimated amount of swirl of at least 180° was seen. Pain relief was scored ‘positive’ if the patient did not have postprandial, upper abdominal pain three months after reoperation.

Outcomes

A total of 193 reoperations were performed for (suspected) IH from 6,896 LRYGB, an estimated incidence of 2.8%. The mean age of patients at reoperation was 41.5±9.6 years and 171 (88.6%) patients were female. The median interval between gastric bypass and reoperation was 18.3±19.0 months. Laparoscopic cholecystectomy was performed between LRYGB and reoperation for suspected IH in 16.0% of patients, in 35.2% of patients a gastroscopy was performed before reoperation for suspected IH and in 28 (14.5%) patients gastroscopy was performed after reoperation; in four cases a marginal ulcer was found.

Seventy-two procedures (37.3%) were performed in an acute setting and pre-operative abdominal CT was performed in 144 patients, and in 56 patients (38.9%) signs of internal herniation were found. The sensitivity of the swirl sign found on CT for suspected IH was 50.0% and the specificity was 83.0%.

An IH was found intraoperatively in 118 (61.1%) patients, in 75 (38.9%) patients no abnormalities were found intraoperatively and there were no cases of intestinal ischaemia. Mesenteric defects were closed in these patients in order to prevent future IH and absorbable sutures were used more frequently than staples to close the mesenteric defects (164 vs. 22) and in the remaining seven patients, absorbable sutures were used.

A total of 37 patients underwent reoperation for recurrence of the postprandial, upper abdominal complaints; four had recurrence of IH after previous closure with absorbable sutures, 14 had previous closure with non-absorbable sutures and one had a recurrence after closure with staples. In 18 patients with symptom recurrence, there was no perioperative sign of IH. Three had a marginal ulcer during gastroscopy.

Complete postoperative symptom relief was observed in 146 patients (77.2%). For patients in which IH was present during surgery, 82.8% had relief of pain post-operatively vs 68.5% for those procedures in which no IH was found.

There was no significant difference in the presence of IH between females and males (p=0.107) and when internal herniation was visible on CT, IH was found present perioperative in 82.8% of procedures. In patients with normal abdominal CT, internal herniation was found in 47.3% of procedures. In acute surgery, perioperative IH was seen more frequently than in elective surgery.

A predictive factor for pain relief after delayed closure of mesenteric defects was IH on CT (OR 4.24, 95%CI 1.63–11.05) and the presence of IH perioperatively affected post-operative pain relief (OR 2.21, 95%CI 1.11–4.40). The authors report that in a multivariate analysis, a positive CT scan for IH was the only independent predictor for pain relief. The time from initial LRYGB to reoperation, the location of IH and the closure technique did not seem to affect postoperative pain relief, the authors report, and there was no significant correlation between smoking status and postoperative pain relief.

The authors recommend that all patients with chronic and/or intermittent postprandial, upper abdominal pain, a treatment with PPI and mucosal protective drugs should be instigated. If this does not give pain relief, the presence of cholecystolithiasis should be excluded by ultrasound and if there are no gallstones detected or if the patient does not have a gall bladder anymore, they advise a CT scan in order to rule out IH. If there is no swirl sign, they state that gastroscopy should be performed to exclude the presence of a marginal ulcer. If this is negative and symptoms persist, they advise diagnostic laparoscopy to close the mesenteric defects. The recommended treatment algorithm for chronic and/or intermittent complaints can be found in Figure 1.

Figure 1: Treatment algorithm for patients with chronic and/or intermittent postprandial upper abdominal pain. (1) Treatment with PPI (proton-pump inhibitor) and MPD (mucosal protective drugs) for gastric irritation, gastritis, or marginal ulcer. (2) If a marginal ulcer is not found during gastroscopy and a CT scan has not been performed yet, a CT scan prior to diagnostic laparoscopy is recommended to exclude other abdominal pathologies.

“Closure of mesenteric defects with sutures or with staples during initial LRYGB appears to result in lower incidence of IH as compared to no closure. In the present study, there is no significant difference in the odds of symptom relief after closure of mesenteric defects with sutures as compared to staples,” the authors write. “A limitation of this study is the small number of patients in whom staples were used to close the mesenteric defects. Further research to the difference in the use of staples versus non-absorbable sutures is recommended.”

To access this paper, please click here

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