Internal hernias in pregnant females with Roux-en-Y gastric bypass: a systematic review

Petersen's Hernia in a Pregnant Woman Following Roux-en-Y Gastric Bypass Surgery: The Importance of Emergency Surgical Treatment

Roux-en-Y gastric bypass (RYGB) patients are at risk of creating potential spaces for possible internal hernias during the procedure. During pregnancy, the pregnant uterus elevates the bowel, increasing intra-abdominal pressure. Cases reported to date have described mild abdominal pain and no evidence of peritoneal irritation, with inconclusive ultrasound and MRI findings for diagnosis of Petersen's hernia. We present the case of a 42-year-old female patient with a history of RYGB eight years earlier without complications, with a pregnancy of 34 weeks of gestation. Symptomatology began with colicky abdominal pain in the epigastric, with irradiation to the right upper quadrant. On physical examination, revealed a painful abdomen on the median and deep palpation in the epigastric and right upper quadrant, the rest of the studies were inconclusive. As there was no improvement of the symptoms in 12 hours, an emergency diagnostic laparoscopy was performed, finding a strangulated Petersen's hernia requiring resection, with the closure of the gastric pouch, intestinal anastomosis, and Stamm gastrostomy with closure of the mesenteric gap. Therefore, a pregnant patient presenting with upper quadrant abdominal pain with a history of RYGB, even one with normal labs and imaging, should be assumed to have an internal hernia until proven otherwise. The emergency surgical approach is associated with early resolution and prevents its progression with catastrophic results.

Surgical complications in pregnancy after bariatric surgery; a case series

BACKGROUND

Obesity is a rising world-wide problem and bariatric surgery, also in the reproductive age, is increasingly performed. Bariatric procedures are associated with surgical complications during pregnancy, such as internal herniation.

CASES

In this case series three cases with severe surgical complications after Roux-Y gastric bypass are described. In all three cases surgery was needed to prevent further complications. In one case subtotal bowel resection had to be performed because of extensive necrosis and intra-uterine fetal death was found.

CONCLUSION

Though surgical complications after Roux-Y gastric bypass are not very common, complications can be very serious and lead to severe morbidity and even mortality for mother and fetus. Because of the severity of complications, delaying bariatric surgery or considering alternative bariatric techniques with fewer (severe) complications should be considered in obese women in childbearing age.

Risk factors of lower birth weight, small-for-gestational-age infants, and preterm birth in pregnancies following bariatric surgery: a scoping review

PURPOSE

Bariatric surgery increases the risk of lower birth weight, small-for-gestational-age (SGA) infants, and preterm birth in a subsequent pregnancy. However, the factors that contribute to these adverse birth outcomes are unclear. This review aimed to collate available information about risk factors of lower birth weight, SGA, and preterm birth following bariatric surgery.

METHODS

A literature search was conducted using five databases (PubMed, PsycINFO, EMBASE, Web of Science, and Cochrane Library) to obtain relevant studies.

RESULTS

A total number of 85 studies were included. Studies generally excluded surgery-to-conception interval, pregnancy complications, cigarette use, and maternal age as influencing factors of birth weight, SGA, or preterm birth. In contrast, most studies found that malabsorptive procedures, lower gestational weight gain, lower glucose levels, abdominal pain, and insufficient prenatal care were associated with an elevated risk of adverse birth outcomes. Findings were mixed regarding the effects of surgery-to-conception weight loss, pre-pregnancy body mass index, micronutrient deficiency, and lipid levels on birth outcomes. The examination of maternal microbiome profiles, placental function, alcohol use, and exercise was limited to one study; therefore, no conclusions could be made.

CONCLUSION

This review identified factors that appear to be associated (e.g., surgery type) or not associated (e.g., surgery-to-conception interval) with birth outcomes following bariatric surgery. The mixed findings and the limited number of studies on several variables (e.g., micronutrients, exercise) highlight the need for further investigation. Additionally, future studies may benefit from exploring interactions among risk factors and expanding to assess additional exposures such as maternal mental health.

A Case of Late Dumping Syndrome in a Post-bariatric Pregnant Lady Seen in a Primary Care Clinic

Dumping syndrome is a common complication of bariatric surgery. A high clinical suspicion of hypoglycaemic events is required as the symptoms mimic early pregnancy complaints. Diagnosis and treatment of dumping syndrome remain a challenge in pregnancy. Thus, diet modification remains a mainstay of management. This case report discusses dumping syndrome in a post-bariatric surgery mother who presented hypoglycaemia symptoms in the primary care clinic.

Establishing Methods of Defect Closure in Roux-en-Y Gastric Bypass: an International Survey

INTRODUCTION

Internal herniation (IH) can be a life-threatening complication of Roux-en-Y gastric bypass (RYGB). Randomised controlled trials support the routine closure of mesenteric spaces at RYGB. However, there is currently no consensus on the method of closure in clinical practice. The purpose of this survey is to understand bariatric surgeons' practice in this regard.

METHODS

We conducted an international survey, whereby questions were created through collaboration of a consensus group of bariatric surgeons and hosted on the SurveyMonkey platform. The survey was distributed among British Obesity and Metabolic Surgery Society (BOMSS) members and international professional channels including The Upper Gastrointestinal Society (TUGS) and social media.

RESULTS

One hundred and thirty-six surgeons from 34 countries completed the survey. Of these, 49 respondents were UK-based surgeons with a cumulative experience of approximately 2500 RYGB per annum. Forty-five (91.8%) respondents reported always closing mesenteric defects, of whom 57.8% elected to use non-absorbable non-barbed sutures, followed by staples/clips in 28.9% and a selection of other methods. Most respondents used more than one method. A total of 2 UK and 14 non-UK participants reported never closing mesenteric spaces.

CONCLUSIONS

This survey has shown heterogeneity among defect closure and no consensus on preferred type. Additionally, there remains a practice of non-closure of mesenteric defects. We hope these findings help to inform further needed research and consensus building among experts.

Redo Gastric Bypass following internal herniation with gangrenous roux limb, in second trimester pregnancy: How safe?

Introduction and importance

Internal herniation following Gastric bypass is a serious life-threatening complication, needs prompt diagnosis and intervention. Internal herniation in later part of pregnancy can endanger life of both mother and fetus if not managed diligently.

Case presentation

30-year young lady with post gastric bypass status with 26 weeks of pregnancy presented with intestinal obstruction. Clinically she was suspected to have internal herniation. She was carrying a viable healthy intrauterine baby. Emergency laparotomy performed and the gangrenous roux limb was resected and Re-do gastric bypass was created. She delivered a healthy female baby at 37+ weeks.

Clinical discussion

Internal hernias after RYGB are more common in pregnant women due to cephalad displacement of intestines and creation of potential hernial spaces due to excess fat loss. Pregnancy with post RYGB status with intestinal obstruction, possibilities of internal hernia need to be excluded. In case non-viable intestinal loops, reconstruction of bypass possible. Post operatively cares with nutritional supplements play major role for fetal growth in advanced stage of pregnancy.

Conclusion

Internal hernia during pregnancy needs prompt intervention which can save of life mother as well as intrauterine baby.

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Internal hernia following gastric bypass is a serious life-threatening condition.

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Internal hernias after RYGB are more common in pregnant women.

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Patients with internal hernia usually presents with epigastric pain, nausea, and vomiting.

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Reconstruction of gastric bypass after resection of ischemic bowel following internal hernia

Operative management of acute abdomen after bariatric surgery in the emergency setting: the OBA guidelines

BACKGROUND

Patients presenting with acute abdominal pain that occurs after months or years following bariatric surgery may present for assessment and management in the local emergency units. Due to the large variety of surgical bariatric techniques, emergency surgeons have to be aware of the main functional outcomes and long-term surgical complications following the most performed bariatric surgical procedures. The purpose of these evidence-based guidelines is to present a consensus position from members of the WSES in collaboration with IFSO bariatric experienced surgeons, on the management of acute abdomen after bariatric surgery focusing on long-term complications in patients who have undergone laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

METHOD

A working group of experienced general, acute care, and bariatric surgeons was created to carry out a systematic review of the literature following the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) and to answer the PICO questions formulated after the Operative management in bariatric acute abdomen survey. The literature search was limited to late/long-term complications following laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

CONCLUSIONS

The acute abdomen after bariatric surgery is a common cause of admission in emergency departments. Knowledge of the most common late/long-term complications (> 4 weeks after surgical procedure) following sleeve gastrectomy and Roux-en-Y gastric bypass and their anatomy leads to a focused management in the emergency setting with good outcomes and decreased morbidity and mortality rates. A close collaboration between emergency surgeons, radiologists, endoscopists, and anesthesiologists is mandatory in the management of this group of patients in the emergency setting.

Pregnant Women After Bariatric Surgery: Diagnostic Accuracy of Magnetic Resonance Imaging for Small Bowel Obstruction

BACKGROUND

Small bowel obstruction (SBO) is a late complication of Roux-en-Y gastric bypass (RYGB). In non-pregnant patients, computed tomography (CT) is the first choice of imaging. During pregnancy, magnetic resonance imaging (MRI) is preferred to limit exposure to ionizing radiation. However, literature regarding the diagnostic accuracy of MRI for SBO is scarce.

OBJECTIVE

To describe the diagnostic accuracy of MRI for SBO during pregnancy.

METHODS

Pregnant women with RYGB suspected for SBO who presented at our center between September 2015 and April 2020 and who received an MRI scan (index) and underwent surgery (reference) were included. Original reports were retrospectively evaluated. Available MRI scans were structurally reinterpreted by two experienced radiologists. Statistical analysis included sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and Cohen's kappa.

RESULTS

Twenty-seven original MRI reports were included. Twenty-four (89%) MRIs were of good quality. Sensitivity was 67% (confidence interval (CI) 0.43-0.85), specificity 67% (CI 0.13-0.98), PPV 93% (CI 0.66-0.99), and NPV 22% (CI 0.04-0.60). MRI was unable to detect SBO in 1 out of 3 patients. The presence of swirl sign, SBO sign, or clustered loop sign increases the likelihood of SBO. The interobserver agreement was overall wide, with the highest score for swirl sign (κ 0.762).

DISCUSSION

MRI is a safe and feasible alternative for CT. The value is doubtful as diagnostic accuracy shows wide ranges with considerable variability in the interobserver agreement. We would cautiously advise to perform MRI in case of a mild clinical presentation, but in case of a severe clinic, the diagnostic laparoscopy should remain the gold standard.

Maternal and neonatal outcomes in women undergoing Roux-en-Y gastric bypass: A systematic review and meta-analysis

BACKGROUND

To summarize evidence of benefits and risks of maternal and neonatal outcomes among pregnant women after Roux-en-Y gastric bypass surgery.

METHODS

A systematic search was conducted in MEDLINE, EMBASE, Web of Science, Ovid and Cochrane Library until 24th May 2021. Inclusion criteria were randomized trails or observational studies including at least one of maternal or neonatal outcomes from pregnant women who had a history of Roux-en-Y gastric bypass surgery with a control group of pregnant women with no history of bariatric surgery. Non-English studies were excluded. Both fixed-effect and random-effect models were used in the meta-analyses. Newcastle-Ottawa Scale was used to assess quality of studies.

RESULTS

Nine retrospective articles were eligible including 13 848  pregnant women with a history of Roux-en-Y gastric bypass surgery and 255 008 pregnant women without a history of bariatric surgery. The results of meta-analysis showed a lower incidence of preterm premature rupture of membranes (OR 0.53, 95% CI [0.47, 0.60], p < 0.00001), large gestational age infants (OR 0.28, 95%CI [0.22, 0.37], p < 0.00001) or macrosomia (OR 0.26, 95%CI [0.23, 0.30], p < 0.00001) in women after Roux-en-Y gastric bypass surgery. On the other hand, infants born to mothers with a history of Roux-en-Y gastric bypass surgery had an increased risk of small gestational age (OR 2.24, 95% CI [1.55, 3.24], p ＜ 0.00001).

CONCLUSION

Roux-en-Y gastric bypass surgery reduces significantly of risks of preterm premature rupture of membranes and large for gestational age/ macrosomia, but increase the risk of small for gestational age.

Pregnant patients with internal hernia after gastric bypass: a single-center experience

BACKGROUND

Bariatric surgery has been a popular way for many women to reach a healthy body mass index, and as a consequence, a decreased body mass, which causes a greater chance of fertility, with improved pregnancy and better maternal outcomes.

OBJECTIVE

Describe a single-center experience of pregnancies complicated by internal hernias after gastric bypass.

SETTING

Academic Medical Center.

METHODS

During 2011 and 2019 a series of patients were treated for internal hernia after gastric bypass at our teaching hospital. The hospital records were retrospectively reviewed.

RESULTS

Seven women were treated. Median age was 33 years (range: 24-39 yr). Median gestational age was 25.6 weeks (range: 5-33 wk). Median time from Roux-en-Y gastric bypass to pregnancy was 4 years (range: 1-7 yr). Median body mass index was 24 kg/m² (range: 24-31 kg/m²). Five (71.4%) patients underwent an exploratory laparotomy, and 2 (28.5%) patients a diagnostic laparoscopy. In all patients, an internal hernia of the small bowel in the Petersen space was encountered. Median length of pregnancy was 38 weeks (range: 33.6-39.6 wk). Six (85.7%) patients underwent C-section, and 1 (14.2%) patient gave birth by vaginal delivery. There was only 1 maternal postoperative complication and no fetal postoperative complications. Median follow-up was 9 months (range: 2-20 mo).

CONCLUSION

The rapid growth in bariatric surgery on obese women of fertile age could result in more cases of internal herniation during pregnancy in the future. An internal hernia should be suspected when encountering a postgastric bypass pregnant patient with abdominal pain, nausea, and vomiting.

Internal herniation during pregnancy after banded Roux-en-Y gastric bypass: a unique location

A 26-year-old multigravida, 30⁺³ weeks pregnant woman, was referred to our tertiary referral centre with acute abdominal pain and vomiting suspected for internal herniation. She had a history of a primary banded Roux-en-Y gastric bypass (B-RYGB). The MRI scan showed a clustered small bowel package with possible mesenteric swirl diagnosed as internal herniation. A diagnostic laparoscopy was converted to laparotomy showing an internal herniation of the alimentary limb through the silicone ring. The internal herniation was reduced by cutting the silicone ring. Postoperative recovery, remaining pregnancy and labour were uneventful. During pregnancy after B-RYGB, small bowel obstruction can in rare cases occur due to internal herniation through the silicone ring. Education regarding this complication should be provided before bariatric surgery. Treatment of women, 24 to 32 weeks pregnant, in a specialised centre for bariatric complications with a neonatal intensive care unit is advised to improve maternal and neonatal outcome.

The Acute Abdomen in Pregnant Women After Roux-en-Y Gastric Bypass: Encouraging Results from a National Referral Centre

BACKGROUND

Pregnant women with a history of bariatric surgery (BS) may develop acute abdominal pain related to this surgery, especially after Roux-en-Y gastric bypass. Studies showed alarming results regarding maternal and foetal morbidity and mortality. The aim of this study was to analyse these outcomes for pregnant women and their offspring.

METHODS

Single-centre retrospective cohort study in a tertiary referral centre for bariatric complications during pregnancy. Pregnant women with a history of BS referred between September 2015 and November 2019 with acute abdominal pain suspected for a bariatric complication were included. Data were retrospectively collected from the patient files, and a questionnaire was sent regarding the postoperative course and childbirth.

RESULTS

Fifty women were included. At presentation, mean maternal age was 31 (± 4) years, and median gestational age was 28⁺⁴ (25⁺⁴, 30⁺⁵) weeks. Thirteen women were treated conservatively. Thirty-seven women underwent surgery for, among others, internal herniation (n = 26) and intussusception (n = 6). Six women required small bowel resection. Two women underwent an emergency caesarean section shortly after the surgery due to foetal distress. Eight women delivered preterm of whom five infants required respiratory support. There was one intrauterine foetal death. Surgery > 48 h after the onset of the symptoms was not associated with an increase in small bowel resections or preterm birth.

CONCLUSION

Acute abdominal pain in pregnant women may be related to a bariatric complication. Further awareness of bariatric complications within the obstetric care and transferal to specialized care to prevent diagnostic delay may improve maternal and neonatal outcome.

The impact of pregnancy on postoperative outcomes among obese women who underwent bariatric surgery: A systematic review and meta-analysis

OBJECTIVES

Women who had a history of bariatric surgery are increasingly becoming pregnant. There is growing evidence showing that increased risk of postoperative complications may be associated with the gestation after bariatric surgery.The objective of this systematic review was to evaluate the potential impact of pregnancy on weight loss and postoperative complications in obese women after bariatric surgery.

STUDY DESIGN

PubMed, Embase, Medline and Cochrane Central Register of Controlled Trails were searched from inception through October 2018. Selection criteria included observational or randomized trial examining weight loss and medical complications in pregnant compared to non-pregnant women after bariatric surgery. Two reviewers extracted information and performed quality appraisal of eligible articles. Meta-analysis was performed to ascertain the certainty of the evidence when possible.

RESULTS

Seven observational cohort studies with a total of 27,369 obese women were included in the final analysis. The mean difference (95 % confidence interval) in percent excess weight loss between pregnant and non-pregnant subjects was -9.5 (-19.9, 0.9). The odds ratio (95 % confidence interval) for postoperative complications in pregnant relative to non-pregnant subjects was 0.85 (0.33, 2.18).

CONCLUSIONS

Pregnancy may have little or no effect on weight loss or postoperative complications in women who have undergone bariatric surgery.