Management of a Complicated Internal Herniation After Roux-en-YGastric Bypass in a 28-Week Pregnant Woman

Abstract

BackgroundSmall bowel obstruction (SBO) due to internal hernia (IH) is awell-known late complication after laparoscopic Roux-en-Y gastric bypass(LRYGB), with an incidence between 0.5 and 10% as reported by Iannelli et al.(Obes Surg. 17(10):1283–6, 2007). Itis reported most frequently 1–2 years after surgery because of the greaterweight loss at that time, with rapid loss of the mesenteric fat consequently asdiscussed by Stenberg et al. (Lancet. 387(10026):1397–404, 2016). Currently, women constitute more than50% of the patients undergoing bariatric surgery and most of them are ofchildbearing age as reported by the World Health Organization (2015). SBO, due to IH, is a rarecomplication during pregnancy, mostly occurring during the third trimester asdiscussed by Torres-Villalobos et al. (Obes Surg 19(7):944–50, 2009), and can result in fetal and maternalmorbidity and even mortality as reported by Vannevel et al. (Obstet Gynecol.127(6):1013–20, 2016). Moreover, thephysiologic changes of pregnancy can mask the symptoms of SBO after LRYGB,leading to significant diagnostic and therapeutic delays as detailed by Wax etal. (Am J Obstet Gynecol 208(4):265–71, 2013). Therefore, an early surgical exploration is necessaryin this particular and uncommon situation as discussed by Webster et al. (Ann RColl Surg Engl 97(5):339–44, 2015).MethodsA 32-year-old female patient, with Ehlers-Danlos syndrome andchronic pain, was in the 28th week of her first pregnancy after bariatricsurgery. She had had an antecolic LRYGB 6 years ago in another institution,resulting in a 35-kg weight loss. She presented to the emergency department withsevere and persistent epigastric pain associated with nausea and vomiting during24 h. On physical examination, her abdomen was painful and tender at theepigastrium and left hypochondrium, and her vital signs were normal. The bloodtests were in the normal range except the white blood cell count at 12′000 G/l.The obstetric and neonatal team was involved, and fetal heart monitoring wasnormal. Abdominal ultrasonography ruled out other causes of pain. An abdominalMRI was performed and displayed a distended proximal small bowel, free abdominalfluid, and bowel mesenteric edema in the left upper quadrant with compression ofthe superior mesenteric vein. Internal hernia with intestinal suffering wassuspected, and the patient consented for emergency laparoscopy.ResultsThe laparoscopic exploration, reduction of the internal hernia, andclosure of the mesenteric defects are demonstrated step-by-step in the presentedintraoperative video. The postoperative course was uncomplicated for bothpatient and fetus. Oral feeding was resumed at day 1, with no residual symptom,and the patient was discharged on postoperative day 3. At 1-month follow-up, shehad no complaint and her pregnancy had resumed a normal course. She delivered ahealthy baby at 36 weeks without any complication.ConclusionsInternal herniation after LRYGB represents a rare, high-riskcomplication during pregnancy. A low threshold for imaging, preferably byabdominal MRI, is recommended. Multidisciplinary management, includingobstetricians and bariatric surgeons, is necessary in order to avoid maternaland fetal adverse outcomes. During surgery, recognition of the anatomy is oftendifficult, and parts of the bowel are distended and fragile. Starting to run thebowel backwards from the ileocecal valve is a crucial surgical step for reducinginternal hernias during LRYGB, and reduces both the risk to worsen the situationand of bowel injury, making its management less hazardous.