Lymphatic Obstruction Related to Small Bowel Obstruction With Chylous Ascites in Prior Roux En Y Gastric Bypass Patient Case Report

Patient: Male, 51-year-oldFinal Diagnosis: Congenial dual internal hernia with small bowel obstructionSymptoms: Abdominal pain • vomiting • constipationMedication: —Clinical Procedure: —Specialty: SurgeryObjective:Rare diseaseBackground:Internal hernias involve protrusion of the small bowel through a peritoneal or mesenteric space in the abdominal or pelvic cavity. Congenital internal small bowel hernias are rare and patients with them usually present with small bowel obstruction (SBO) at a young age, whereas in older patients, internal small bowel hernias usually are acquired secondary to previous surgery. The present report is of a rare case of SBO due to dual congenital internal small bowel hernias in a 51-year-old man with no history of abdominal surgery.Case Report:We report a case of dual congenital internal hernias of the small bowel in a patient who presented with symptoms and signs of SBO. He had no history of abdominal trauma, surgery, or comorbid conditions. His abdomen was mildly distended with minimal tenderness in the upper left quadrant but there was no guarding or rebound tenderness. Abdominal X-rays confirmed the SBO. A contrast-enhanced computed tomography scan of the patient’s abdomen revealed SBO with transition at 2 points, suggestive of a closed-loop obstruction. However, the exact cause of the SBO was confirmed at laparotomy, which revealed dual internal hernias (intramesosigmoid and paraduodenal). The hernias were managed individually and the patient had a successful outcome after surgery.Conclusions:Although the present report is of a rare presentation of internal small bowel hernia, the case underscores that patients with this condition may present with SBO. Successful surgical management requires knowledge of the intra-abdominal peritoneal spaces and management of the hernia sac.

Internal hernias (IH) are late complications of bariatric surgery, specifically gastric bypass and manifest with diffuse abdominal pain and/or intestinal obstruction. They have a low incidence, however, are increasingly common in patients undergoing laparoscopic gastric bypass (LGBP). Petersen's internal hernia is one of the most frequent internal hernias following Bariatric surgery. We describe our experience at a third-level surgical center using a prophylactic Petersen's space herniorrhaphy immediately following LGBP as a preventative strategy for post-bariatric internal hernias. In addition, we perform a retrospective descriptive study with 667 patients undergoing LGBP under which we divided into two groups. In the first group, the Petersen's space was not closed, and in the second group, the Petersen´s space closure was performed using non-absorbable polypropylene non-interrupted sutures. 667 patients were taken to LGBP, and of which 5 presented internal hernias. From the 346 patients who had Petersen´s herniorrhaphy performed, one developed signs of an internal hernia at 22 months follow-up and was subsequently confirmed later with laparoscopy (0.02%). Of the 321 patients not having had Petersen's space closure, 4 developed Petersen's internal hernia at an average of 22-month post-op, incidence of 0.1%. We analyzed and compared our results with those reported in the literature. Petersen's space closure immediately after a LGBP with an alimentary loop in the anterior colic position (prophylactic herniorrhaphy) with non-interrupted non-absorbable suture is a useful, safe, and effective technique to prevent the development of Petersen's IH during the post-operative period following LGBP.

Torsion of the small bowel around its mesenteric axis can lead to small bowel volvulus (SBV) and subsequent small bowel necrosis. Chylous ascites (CA) is attributed to lymphatic damage and compression/obstruction of lymphatic vessels. There are few case reports of SBV with CA. A 70-year-old man, who had a history of laparoscopic total gastrectomy 10 years ago, presented to our emergency department with acute abdominal pain that lasted for 1 hour after eating dinner. The patient was diagnosed with acute small bowel obstruction secondary to SBV based on curved planar reconstruction (CPR) and underwent emergency surgery. The abdominal cavity had CA, the small bowel and mesentery showed overall white edematous changes, and the small bowel mesentery was twisted 360 degrees, but there was no small bowel ischemia or necrosis. After detorsion, surgery was completed. The postoperative course was uneventful, and the patient was discharged on postoperative day 9. CPR is useful for diagnosing SBV in cases without typical CT findings. SBV with CA may not require small bowel resection due to necrosis, because occluded lymphatic vessels lead to small bowel and mesenteric edema, which inhibits further twisting. Additionally, surgical intervention is performed because of acute abdominal pain. We assume that dietary guidance is important because dietary factors may also be involved in SBV.

Objective To summarize the clinical features and therapeutic experiences of pediatric internal hernia. Methods From January 2007 to March 2016, 72 children with an intraoperative diagnosis of internal hernia were recruited. General profiles, symptoms, signs, auxiliary examinations, surgical procedures and prognosis were retrospectively analyzed. The male-to-female ratio was 2.43: 1 and the median onset age 41 months (2 days-171 months). Internal hernia occurred most frequently in children aged under 2 years (especially <1 year). The interval between onset to clinical presentation was 47 (5-312) hours. The common clinical symptoms included abdominal pain (crying) with emesis (94.4%), fever (55.6%) and shock (30.6%). Bloody ascites was confirmed by abdominal puncture in 59.7% patients. The mean WBC count was (15.95±8.36)×109/L and neutrophil (73.2±15.8)%. Half of them had a mean value of C-reactive protein (87.22 59.30) mg/dl. Abdominal ultrasonography revealed intestinal obstruction (77.8%), ascites (68.1%), internal hernia (59.7%) and intestinal necrosis (9.7%). Results Laparotomy confirmed congenital internal hernia in 93.1% patients (congenital mesenteric hernia, Meckel's diverticulum with congenital cord, simple congenital cord, left paraduodenal hernia) and acquired internal hernia in 6.9% (postoperative adhesion cord, Roux-Y ascending loop mesenteric hernia & traumatic mesenteric hernia). Intestinal necrosis was detected in 77.8% and the median length of resected intestine was 80 (10-300) cm. χ2 test revealed that shock (P=0.001), bloody ascites (P=0.000) and elevated CRP level (P=0.009) could effectively predicate intestinal necrosis. Among them, 62 were cured by one single surgery and 6/10 were cured by staged intestinal enterostomy or exteriorization. Two were re-hospitalized because of adhesive ileus and became cured conservatively. One was re-operated for postoperative intestinal perforation and another for postoperative intestinal volvulus. There was no case of mortality. Conclusions The most frequent onset age of pediatric internal hernia is under 1 year and the most common symptom remains abdominal pain (crying) with emesis. The major causes are congenital with congenital mesenteric hernia ranking first. Abdominal ultrasonography has certain diagnostic values and bloody ascites indicates immediate laparotomy. Shock, bloody ascites and elevated CRP level can effectively predicate intestinal necrosis. The surgical approaches of internal hernia are to resect necrotic intestine and/or Meckel's diverticulum/cord and repair hernia ring with or without intestinal enterostomy or exteriorization. The general prognosis of pediatric internal hernia is excellent after timely surgery. Key words: Internal abdominal hernia; Intestinal obstruction; Prognosis

Introduction Small bowel obstruction (SBO) in pregnancy is rare and is most commonly caused by adhesions from previous abdominal surgery. Previous literature reviews have emphasised the need for prompt laparotomy in all cases of SBO because of the significant risks of foetal loss and maternal mortality. Since the last review, magnetic resonance imaging (MRI) and computed tomography (CT) scans have become more widely available and can determine the exact aetiology of SBO in pregnancy. We undertook a systematic review of the contemporary literature to determine if immediate laparotomy is still always necessary with the advent of these improved imaging modalities. Method The Medline and PubMed databases were searched for cases of SBO in pregnancy between 1992 and 2014. Two cases from our own institution were also reviewed. Results Forty-six cases of SBO in pregnancy were identified, with adhesions being the most common aetiology (50%), followed by small bowel volvulus (15%) and internal hernia (13%). The overall risk of foetal loss was 17% and maternal mortality was 2%. In cases of adhesional SBO, 91% of cases were managed surgically, with 14% foetal loss. Two cases (9%) were managed conservatively with no complications. MRI scan was used to diagnose SBO in 11% of cases and CT scan in 13% of cases. Conclusion Based on our experience, and the contemporary literature, we recommend that if available, an urgent MRI of the abdomen should be undertaken to diagnose the aetiology of SBO in pregnancy. In cases of adhesional SBO, conservative treatment may be safely commenced, with a low threshold for laparotomy. In other causes, such as volvulus or internal hernia, prompt laparotomy remains the treatment of choice. Disclosure of interest None Declared.

Background Laparoscopically adjustable gastric bands (LAGB) have been widely employed as a means of weight loss in bariatric surgery over the past two decades. Although now largely superseded by other bariatric surgical techniques, complications from gastric bands continue to be encountered in surgical practice. We report an unusual case of small bowel obstruction due to an internal hernia caused by gastric band tubing resulting in closed loop small bowel obstruction. This is not commonly encountered and emergency general surgeons need to have a high index of suspicion for this condition as a possible cause for small bowel obstruction. Methods A 40 year old male presented with abdominal pain, vomiting and failure to open bowels or pass flatus for nine days. Twelve years previously (2008) he had had Roux n Y gastric bypass (RYGB), followed by by laparoscopic gastric banding of the RYGB about two years later (2010) also in the private sector. He had a soft but distended abdomen, and empty rectum on rectal examination. CT scan abdomen reported as: Multiple loops of distended small bowel demonstrated. No air seen in rectum, indicative of small bowel obstruction. No pneumoperitoneum. There is dilatation of the mid and distal small bowel seen to an apparent transition point in the mid abdomen where a loop is noted associated with the tubing for the inflation device for the gastric band. This appears to be centred on the cause of obstruction and appears tied around the base of mesentery and may be creating a closed loop obstruction, by having created an internal hernia. This patient had an internal hernia around loop of the gastric band tubing with resultant closed loop small bowel obstruction. The patient underwent diagnostic laparoscopy with ileo-caecal resection and primary anastomosis. He made successful recovery. Deflated gastric band remains in-situ. Results While small bowel obstruction is most commonly due to adhesions in individuals who have had previous laparotomy, it is important to bear in mind other causes such as internal hernias particularly in cases of those with history of previous gastric banding or Roux n Y gastric bypass. Early intervention may be necessary to reduce the likelihood of bowel ischaemia and bowel resection. Laparoscopy is a useful tool in the management of small bowel obstruction. Keywords: gastric band, small bowel obstruction, closed loop, emergency surgery, laparoscopy Conclusions Connection tubing causing small bowel obstruction and colonic erosion as a rare complication after laparoscopic gastric banding: a case report. Liza BK Tan, Jimmy BY So, and Asim Shabbir - J Med Case Reports. 2012; 6: 9. Acute small bowel obstruction due to the connecting tube of a gastric band. Federico Oppliger, M.D. Gonzalo Wiedmaier, M.D. Juan. Published April 07 2017. https://doi.org/10.1016/j.soard.2014.03.021 An unusual complication of gastric banding: recurrent small bowel obstruction caused by the connecting tube. M A Zappa, E Lattuada, E Mozzi, M Francese, I Antonini, S Radaelli, G Roviaro. Obes Surg . 2006 Jul;16(7):939-41. doi: 10.1381/096089206777822250 Total small bowel herniation through the space between the connecting tube of gastric band and abdominal wall: A case report of a surgical emergency. Tarek Hashem, Soliman M Soliman, Sherif Wagih 2. Int J Surg Case Rep. 2017;30:66-68. doi: 10.1016/j.ijscr.2016.11.021. Epub 2016 Nov 17

Petersen's hernia occurring through the epiploic foramen of the greater omentum, is an uncommon type of internal hernia. When it presents with complications such as chylous ascites, which is the lymphatic fluid accumulation in the abdominal cavity, it is particularly rare. Following laparoscopic total gastrectomy and Roux-en-Y anastomosis, the incidence of this condition is exceedingly low. A 62-year-old male patient developed Petersen's hernia following laparoscopic total gastrectomy (LTG) for gastric cancer, after Roux-en-Y anastomosis. Intestinal torsion and obstruction were experienced by the patient, along with a small amount of chylous ascites. Imaging studies and clinical assessment confirmed the diagnosis. Emergency surgery was performed promptly for the patient in the operating room. The twisted small intestine was reduced and the defect in Petersen's space was repaired. The procedure was successful in the correction of the intestinal torsion and approximation of the hernia without the need for bowel resection. The patient's condition significantly improved following the surgery. The ascites evolved from a milky white appearance to a pale yellow, with a substantial decrease in the triglyceride levels in the ascitic fluid, implying a favorable recovery trajectory. The patient was monitored closely and received appropriate care postoperatively, including nutritional support and fluid management. This report illustrates the significance of recognizing Petersen's hernia as a potential complication following gastrectomy for gastric cancer. It highlights the fundamental role of early surgical intervention in the effective management of such complications. The favorable outcome in this patient illustrates that prompt and appropriate surgical management can deter the necessity for more extensive procedures such as bowel resection.

BACKGROUNDSclerosing mesenteritis is a rare disorder involving inflammation of the mesentery. Its etiology remains unclear, but it is believed to be associated with previous abdominal surgery, trauma, autoimmune disorders, infection, or malignancy. Clinical manifestations of sclerosing mesenteritis are varied and include chronic abdominal pain, bloating, diarrhea, weight loss, formation of an intra-abdominal mass, bowel obstruction, and chylous ascites. Here, we present a case of idiopathic sclerosing mesenteritis with small bowel volvulus in a patient with antiphospholipid syndrome.CASE SUMMARYA 68-year-old female presented with recurrent small bowel obstruction. Imaging and pathological findings were consistent with sclerosing mesenteritis causing mesenteric and small bowel volvulus. Computed tomography scans also revealed pulmonary embolism, and the patient was started on a high dose of corticosteroid and a therapeutic dose of anticoagulants. The patient subsequently improved clinically and was discharged. The patient was also diagnosed with antiphospholipid syndrome after a hematological workup.CONCLUSIONSclerosing mesenteritis is a rare condition, and patients with no clear etiology should be considered for treatment with immunosuppressive therapy.

Variations on bowel obstruction after gastric bypass and management of the twisted Roux limb

Internal abdominal hernias in childhood.

Obesity is becoming more common in the United States, affecting > or = 30% of adults aged 20 years and older. Obesity (body mass index 30) is ranked second only to tobacco use as a preventable cause of death in the United States. Roux-en-Y gastric bypass (RYGBP) is being performed at a rapidly increasing rate, and laparoscopic Roux-en-Y gastric bypass (LRYGBP) surgery is frequently chosen rather than an open approach because of lower morbidity rates. One of the complications of LRYGBP includes small bowel obstruction (SBO) secondary to internal herniation. When RYGBP is performed through the open approach, SBO is most commonly caused by adhesions. The challenge with these patients is that the presenting signs, symptoms, and physical and radiological examinations may be vague, nonspecific, and/or nondiagnostic. Internal hernias that result as a complication of LRYGBP occur in 1 of 3 places. These locations include the transverse mesocolon, the jejunal mesenteric defect at the level of the jejunojejunostomy, and Petersen's space, which is the area between the mesentery of the Roux limb and the transverse mesocolon. We report the case of a 45-year-old woman who presented with SBO secondary to Petersen's hernia. The clinical presentation and radiologic studies are discussed.

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. 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). 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. 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.

It is difficult to make a diagnosis of internal hernia pre-operatively. However, intestinal strangulation occurs in many of these cases. The aim of this study was to review our clinical experience with internal hernias and compare patients with and without strangulation. We retrospectively reviewed the records of 25 patients with internal herniation seen between January 1991 and December 2001. Data analyzed included age, sex, signs and symptoms, previous history of surgery, operative findings, radiological findings, and laboratory data. Abdominal CT scans were retrospectively reviewed by a radiologist. A high percentage of patients (64%) had previous abdominal surgey, and 80% of the internal hernias were associated with adhesion ileus. Among the internal hernias, 40% were transmesenteric, 16% transomental, 12% transpelvic, 8% retroanastomotic, and 24% miscellaneous. Intestinal strangulation occurred in 52% of patients in our study and correlated with obstruction site of small bowel (P=0.041). Ascites was present in 9 of 13 patients with strangulation but in none without. There was no correlation between strangulation and age, sex, symptoms, peritoneal signs, leukocytosis, or the time elapsed between admission and surgery. No internal hernia was diagnosed pre-operatively. Internal hernia should be considered in the differential diagnosis of intestinal obstruction. Our experience suggests that the presence of ascites or distal small bowel obstruction should raise the index of suspicion for strangulation and indicate the need for urgent surgical intervention.

Internal hernia is the most common complication of Roux-en-Y gastric bypass. Although its incidence rate is low, hernias are becoming more common in patients undergoing bariatric surgery, with Petersen's hernia being one of the most frequent. The symptoms of internal hernia are variable, and the sensitivity of imaging methods is limited, resulting in a high rate of misdiagnosis of internal hernia by computed tomography. Surgery continues to be the first treatment option in patients presenting with clinical symptoms of obstruction after undergoing Roux-en-Y gastric bypass. Here, we present a case of intestinal obstruction secondary to Petersen's hernia after Roux-en-Y gastric bypass in the context of bariatric surgery.

Chylous ascites is often reported in cases with lymphatic obstruction or after lymphatic injuries such as intraabdominal malignancies or lymphadenectomies. However, chylous ascites is also frequently encountered in operations for internal hernias. We sought to characterize the frequency and conditions when chylous ascites is encountered in general surgery patients. Data from patients who underwent operations for CPT codes related to open and laparoscopic abdominal and gastrointestinal surgery in our tertiary hospital from 2010 to 2019 were reviewed. Patients with the postoperative diagnosis of internal hernia were identified and categorized into three groups: Internal Hernia with chylous ascites, non-chylous ascites, and no ascites. Demographics, prior surgical history, CT findings, source of internal hernia, open or laparoscopic surgery, and preoperative labs were recorded and compared. Fifty-six patients were found to have internal hernias and were included in our study. 80.3% were female and 86% had a previous Roux-en-Y gastric bypass procedure (RYGBP). Laparoscopy was the main approach for all groups. Ascites was present in 46% of the cases. Specifically, chylous ascites was observed in 27% of the total operations and was exclusively (100%) found in patients with gastric-bypass history. Furthermore, it was more commonly associated with Petersen's defect (p < 0.001), while the non-chylous fluid group was associated with herniation through the mesenteric defect (p < 0.001). Chylous ascites is a common finding during internal hernia operations. Unlike other more morbid conditions, identification of chylous ascites during an internal hernia operation appears innocuous. However, in the context of a patient with a history of RYGBP, the presence of chylous fluid signifies the associated small bowel obstruction is likely related to an internal hernia through a patent Petersen's defect.