Closure Of Mesenteric Defects Research Articles

Retroperitoneal hernia following laparoscopic living-donor nephrectomy: a case report and review of literature

BackgroundThe laparoscopic approach is the standard of care for living-donor nephrectomy. A rare postoperative complication is small bowel obstruction due to a retroperitoneal hernia. We present a case of an incidental finding of a retroperitoneal hernia in a patient with a history of laparoscopic donor nephrectomy.Case presentationAn adult male presented with diffuse abdominal pain, vomiting, and obstipation for 12 h. He had undergone laparoscopic donor nephrectomy two months prior. Plain abdominal radiograph revealed a dilated small bowel with homogenous opacity in the left lumbar region. Due to worsening diffuse abdominal pain and a high clinical suspicion of intestinal strangulation and ischemia after conservative management, an exploratory laparotomy was performed. Intraoperatively, an incarcerated small bowel segment herniating through an 8 cm descending mesocolon defect into the retroperitoneal space was discovered, forming a closed-loop obstruction. The bowel segment was reduced, and the mesocolon defect was repaired. The patient was discharged five days postoperatively with good recovery.ConclusionRetroperitoneal hernia following laparoscopic living-donor nephrectomy is a rare but significant complication. Mitigation to prevent mesenteric defect creation, routine inspection, and closure of the defect can reduce the risk of hernia. Non-specific abdominal pain in patients with a history of laparoscopic donor nephrectomy prompts rapid imaging evaluation to aid in the early diagnosis of possible retroperitoneal hernia and its intervention.

Quality of stapled mesenteric defect closure influences the chance of reopening after laparoscopic Roux-en-Y gastric bypass surgery

AbstractInternal herniation (IH) is a common problem after laparoscopic Roux-en-Y gastric bypass surgery (RYGB). Routine closure of the mesenteric defects (MDs) reduces the risk of IH. Only very few articles report on risk factors for IH or describe detailed closing techniques. There is no consensus yet on the best closing method. The objective of this study is to determine the optimal stapling method for closure of MDs after RYGB. All performed RYGB procedures in our high-volume bariatric institute were included. Quality of the closure was scored in the categories poor, sub-optimal, and optimal, to see if the quality of the closure would predict the chance of reopening of the MDs and, therefore, the chance of IH. During any type of laparoscopy in the follow-up of the patient, the conditions of the MDs were stated, for example during diagnostic laparoscopy in symptomatic patients suspicious for IH or during laparoscopic cholecystectomy. Technically well-executed closure of Petersen’s space (PS) with two rows of staples had a greater chance of still being closed upon re-inspection compared to closure with one row (odds ratio = 8.1; 95% confidence interval [1.2–53.2], p = 0.029). Optimal closure of the MD at the jejuno-jejunostomy (JJ-space, JJS) resulted in more closed JJSs upon re-inspection compared to sub-optimal closure (odds ratio = 3.6 [CI 95% 0.8–16.1], p = 0.099). Non-optimally closed MDs had higher reopening rates and, therefore, pose an additional risk for IH. Our classification provides a quality assessment of MD closure during RYGB and gives insight into how to optimize surgical technique.

Very low risk of short bowel after Roux-en-Y gastric bypass – a large nationwide Swedish cohort study

BackgroundRoux-en-Y gastric bypass (RYGB) is one of the most common bariatric procedures. Internal herniation may lead to small bowel ischemia requiring small bowel resection, resulting in short bowel syndrome. ObjectiveTo determine the incidence of extensive small bowel resection in patients operated with RYGB. We also aimed to look for early clinical warning signs among patients requiring extensive small bowel resection. SettingCohort from national quality registers. MethodsAll patients having undergone RYGB between January 2007 to June 2019 were analyzed in the Scandinavian Obesity Surgery Registry (SOReg). We identified patients with small bowel obstruction (SBO) for whom small bowel resection was necessary. Additionally, we assessed clinical signs in these patients. ResultsThe study included 57,255 patients having undergone RYGB. Closure of the mesenteric openings was performed in 78%. Surgery for SBO was required in 3659 (6%) of patients, and small bowel resection in 188 (.3%). Extensive small bowel resection, resulting in less than 1.5 meters of remaining small bowel, was required in 7 patients (.01%). All patients with extensive small bowel resection presented with abdominal pain and had confirmed internal herniation as the cause of the small bowel resection, and 2 of 7 patients died. Closure of mesenteric defects was not associated with a reduction in overall small bowel resection rates (P = .89) ConclusionSurgery for SBO after RYGB was common (6%). The risk of extensive small bowel resection leading to short bowel was low (.01%). Patients with abdominal pain after RYGB should be assessed for internal hernia, as it can be devastating.

A cognitive task analysis of expert surgeons performing the robotic roux-en-y gastric bypass.

The safe and effective performance of a robotic roux-en-y gastric bypass (RRNY) requires the application of a complex body of knowledge and skills. This qualitative study aims to: (1)define the tasks, subtasks, decision points, and pitfalls in a RRNY; (2)create a framework upon which training and objective evaluation of a RRNY can be based. Hierarchical and cognitive task analyses for a RRNY were performed using semi-structured interviews of expert bariatric surgeons to describe the thoughts and behaviors that exemplify optimal performance. Verbal data was recorded, transcribed verbatim, supplemented with literary and video resources, coded, and thematically analyzed. A conceptual framework was synthesized based on three book chapters, three articles, eight online videos, nine field observations, and interviews of four subject matter experts (SME). At the time of the interview, SME had practiced a median of 12.5years and had completed a median of 424 RRNY cases. They estimated the number of RRNY to achieve competence and expertise were 25 cases and 237.5 cases, respectively. After four rounds of inductive analysis, 83 subtasks, 75 potential errors, 60 technical tips, and 15 decision points were identified and categorized into eight major procedural steps (pre-procedure preparation, abdominal entry & port placement, gastric pouch creation, omega loop creation, gastrojejunal anastomosis, jejunojejunal anastomosis, closure of mesenteric defects, leak test & port closure). Nine cognitive behaviors were elucidated (respect for patient-specific factors, tactical modification, adherence to core surgical principles, task completion,judicious technique & instrument selection, visuospatial awareness, team-based communication, anticipation & forward planning, finessed tissue handling). This study defines the key elements that formed the basis of a conceptual framework used by expert bariatric surgeons to perform the RRNY safely and effectively. This framework has the potential to serve as foundational tool for training novices.

60 Mesenteric defect closure and the rate of internal hernia in laparoscopic Roux-en-Y gastric bypass: A systematic review and meta-analysis

Abstract Introduction Laparoscopic Roux-en-Y gastric bypass (LRGB) is an increasingly popular operation as rates of obesity rise. Internal hernias pose a worrying complication. This meta-analysis aimed to determine if internal hernia rates were reduced by closure of the mesenteric defects at primary operation. Method A systematic review was performed identifying all observational and randomised studies comparing internal hernia rates in patients whose mesenteric defects were closed vs not closed during LRGB. Results 14 studies were included, totalling 20,553 patients undergoing LRGB. There was a significant reduction in internal hernia rate at both Petersen’s and the Jejunojejunostomy (J-J) defect when closed at operation. The rate of re-operation for suspected small bowel obstruction was also lower in the closure cohort. There was no difference in anastomotic leak or perioperative bleeding between closure and non-closure patients. Similar efficiency was observed when sutures were used to close the defects compared to clips and staples. Conclusion Mesenteric defect closure is reducing internal hernia rate as well as re-operation for suspected small bowel obstruction. The closure method of choice remains debatable, and further studies are required to determine this.

The value of mesenteric closure after laparoscopic right hemicolectomy: a scoping review

ObjectiveTo evaluate the prognostic impact and describe suturing tools of mesenteric closure after laparoscopic right hemicolectomy (LRH).MethodsPubMed, Embase, Cochrane library, Web of Science, and Scopus databases, were searched and publications relating to mesenteric closure data and tools were extracted. Search terms: “Mesenteric Defects” and “Mesenteric Closure” were used, and manual searches of eligible articles from literature reference lists performed.ResultA total of 7 publications were identified. 5 focused on prognostic impact and 4 referred to tools for mesenteric closure, two of which concerned both prognostic data and tools. All studies related to prognostic impact were single center with “low” modified GRADE quality. A high degree of heterogeneous was found.ConclusionThe evidence from current research does not support routine closure of mesenteric defects. Use of a polymer ligation clip has produced favorable results in a small sample size trial and further investigation is merited. A large randomized controlled trial is still warranted.

Long-term Safety and Efficacy of Closure of Mesenteric Defects in Laparoscopic Gastric Bypass Surgery

Short-term and midterm data suggest that mesenteric defects closure during laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery reduces the risk of internal herniation with small bowel obstruction (SBO) but may increase risk of kinking of the jejunojejunostomy in the early postoperative period. However, to our knowledge, there are no clinical trials reporting long-term results from this intervention in terms of risk for SBO or opioid use. To evaluate long-term safety and efficacy outcomes of closure of mesenteric defects during LRYGB. This randomized clinical trial with a 2-arm, parallel, open-label design included patients with severe obesity scheduled for LRYGB bariatric surgery at 12 centers in Sweden from May 1, 2010, through November 14, 2011, with 10 years of follow-up after the intervention. During the operation, patients were randomly assigned 1:1 to closure of mesenteric defects beneath the jejunojejunostomy and at the Petersen space using nonabsorbable running sutures during LRYGB or to nonclosure. The primary outcome was reoperation for SBO. New incident, chronic opioid use was a secondary end point as a measure of harm. A total of 2507 patients (mean [SD] age, 41.7 [10.7] years; 1863 female [74.3%]) were randomly assigned to closure of mesenteric defects (n = 1259) or nonclosure (n = 1248). After censoring for death and emigration, 1193 patients in the closure group (94.8%) and 1198 in the nonclosure group (96.0%) were followed up until the study closed. Over a median follow-up of 10 years (IQR, 10.0-10.0 years), a reoperation for SBO from day 31 to 10 years after surgery was performed in 185 patients with nonclosure (10-year cumulative incidence, 14.9%; 95% CI, 13.0%-16.9%) and in 98 patients with closure (10-year cumulative incidence, 7.8%; 95% CI, 6.4%-9.4%) (subhazard ratio [SHR], 0.42; 95% CI, 0.32-0.55). New incident chronic opioid use was seen among 175 of 863 opioid-naive patients with nonclosure (10-year cumulative incidence, 20.4%; 95% CI, 17.7%-23.0%) and 166 of 895 opioid-naive patients with closure (10-year cumulative incidence, 18.7%; 95% CI, 16.2%-21.3%) (SHR, 0.90; 95% CI, 0.73-1.11). This randomized clinical trial found long-term reduced risk of SBO after mesenteric defects closure in LRYGB. The findings suggest that routine use of this procedure during LRYGB should be considered. ClinicalTrials.gov Identifier: NCT01137201.

Closure of Mesenteric Defects During Gastric Bypass Reduces but Does Not Eliminate the Risk of Internal Hernia

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Mesenteric Defect Closure and the Rate of Internal Hernia in Laparoscopic Roux-en-Y Gastric Bypass: A Systematic Review and Meta-analysis.

Internal hernias are a worrying complication from laparoscopic Roux-en-Y gastric bypass (LRGB), with potential small bowel necrosis and obstruction. An electronic database search of Medline, Embase, and Pubmed was performed. All studies investigating the internal hernia rates in patients whose mesenteric defects were closed vs. not closed during LRGB were analysed. Odds ratios were calculated to assess the difference in internal hernia rate. A total of 14 studies totalling 20,553 patients undergoing LRGB were included. Internal hernia rate (220/12,445 (2%) closure vs. 509/8108 (6%) non-closure) and re-operation for small bowel obstruction (86/5437 (2%) closed vs. 300/3132 (10%) non-closure) were reduced when defects were closed. There was no difference observed when sutures were used to close the defects compared to clips/staples.

Closure of mesenteric defects for prevention of internal hernia after Roux-en-Y gastric bypass in bariatric surgery

Objectives This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the efficacy and safety of defect closure for prevention of internal hernia after Roux‐en Y gastric bypass (RYGB) in bariatric surgery.

Closed or Unclosed Mesentery? A Meta-analysis of Internal Herniation After Laparoscopic Roux-en-Y Gastric Bypass.

During the laparoscopic Roux-en-Y gastric bypass procedure, closing mesentery or not was still controversial according to preexisted studies. So, the current meta-analysis aimed to compare the outcome of closure versus non-closure of mesenteric defects in laparoscopic Roux-en-Y gastric bypass. Fifteen studies were included, enrolling 53,488 patients. Based on the outcome of analysis, regarding internal hernia, Petersen space's IH, jejunal mesenteric's IH, hospital days, and reoperation, closure of the mesentery was better than non-closure. Besides, small bowel obstruction, anastomosis ulcer, stenosis, leakage, bleeding, gastrointestinal perforation, and postoperative BMI of patients show no difference between non-closure and closure.

Effect of Suture Used for Closure of Mesenteric Defects After Laparoscopic Roux-en-Y Gastric Bypass: Single-Center Study

Small bowel obstruction (SBO) due to internal herniation (IH) is a well-known complication of laparoscopic Roux-en-Y gastric bypass (LRYGBP). The objective of this study is to evaluate different types of non-absorbable sutures used for closure of the defects regarding the incidence of SBO due to IH/adhesions, adhesion formation in general, or reopening of the defects. A single-center retrospective study was performed. Patients who underwent LRYGBP were divided in 3 groups: group A closure of the defects with monofilament Polypropylene suture (Prolene®), group B with braided polyester suture(Ethibond®), group C with barbed knotless Polybutester suture (V-Loc®). Descriptive statistics were performed regarding SBO due to IH/adhesions, adhesion formation, and reopening of closed defects. From5145 patients, 224 patients underwent exploratory laparoscopy for suspicion of SBO. Mean time interval was 28.4months. IH orintermittent IHwas found in 1.94% in group A, 1.78% in group B, and 1.40% in group C. Obstruction due to adhesions was found in 0.70%, 0.36%, and 0.42% per group, respectively. Adhesions in general were observed in 1.47% in group A, 1.43% in group B, and 1.06% in group C. The incidence of reopening was higher in group A (2.24%) in comparison with group B (1.13%, P = 0.041) and group C (1.05%, P = 0.001). After descriptive analysis, these results can withhold no difference among the 3 non-absorbable sutures regarding incidence of SBO due to IH or SBO due to adhesions, yet tendency for higher reopening rates after closure with monofilament Polypropylene suture is observed.

BS O01 Closure of mesenteric defects during laparoscopic roux-en-y gastric bypass surgery and its effect on internal hernia rates and small bowel obstruction: A Meta- Analysis

Abstract Background Roux-en-Y gastric bypass surgery is an important treatment for obesity and it's related diseases, however internal herniation and small bowel obstruction from mesenteric defects can lead to reoperation in 10–16% of patients. This can be early (<30 days) or late. Routine closure of meso-jejunal defecfs and/or Petersens defect is still not adopted worldwide. Our objective was to systematically review and analyse pooled data from all studies, evaluating the impact of routine closure of mesenteric defects on the incidence of internal hernia in laparoscopic antecolic Roux-en-Y gastric bypass (RYGB) surgery for obesity. Secondary endpoints for analysis included the incidence of early and late small bowel obstruction (SBO), need for reoperation, bleeding, anastomotic leak, marginal ulceration and weight loss. Methods Ovid, MEDLINE, EMBASE and Cochrane databases were searched on 13 September 2021 using a combination of MeSH and non-MeSH terms, including ‘gastric bypass’, ‘mesenteric defect’, ‘hernia’, and ‘small bowel obstruction’. Studies comparing closure with non-closure of mesenteric defects were included. Two researchers independently examined titles, then abstracts, and finally, full text articles. Disagreements were arbitrated with the senior author. Fixed- or random-effect models were used, as appropriate. Results have been reported with 95% confidence intervals and I-squared indices to assess uniformity among results for each outcome measured. Results Seventeen studies met the criteria and were included, including two randomised trials. A total of 61,220 patients were included with follow-up ranging from 24–120 months. In the closure group the incidence of all types of internal hernia was lower (OR 0.22, 95% CI 0.19, 0.26), SBO beyond 30 days was less frequent (OR 0.47, 95% CI 0.44,0.52), and the reoperation rate was lower (OR 0.22, 95% CI 0.19,0.26). The incidence of SBO within 30 days was higher in the closure group (OR 1.34, CI 1.07,1.68). Conclusions This new pooled analysis updates previous meta-analyses, adding data from eight additional studies and almost 45,000 additional patients. This provides firm evidence that routine closure of mesenteric defects during laparoscopic gastric bypass reduces rates of internal herniation and SBO beyond the post-operative period. Closure of the mesenteric defects should be standard practice in RYGB. A higher incidence of early SBO was notable in the closure group, postulated by some studies as attributable to technical factors, including kinking of the jejunal anastomosis and bleeding. This must be considered when closing defects.

BS P05 Laparoscopic repair of internal hernia post Roux-en-Y Gastric Bypass: Our tricks and technique

Abstract Background The incidence of internal herniation (IH) post Roux-en-Y gastric bypass (RYGB) is variable across literature (0.5–11%). This may be partially related to the difference in the operative techniques of RYGB. Routine closure of mesenteric and Petersen's defects has shown noticeable decline in the incidence of IH over last few years. Nevertheless, it didn't prevent the development of IH at long-term follow up. Methods We describe a video of a case with a large non-obstructing mesenteric internal hernia post RYGB. A 33 years old female patient presented to our bariatric clinic with recurrent attacks of post-prandial abdominal pain over 6 months. She had RYGB 2.5 years before this presentation, with EWL of 65%. Of note, the mesenteric and Petersen's defects were closed in the original RYGB operation. CT scan showed suspicious findings of internal herniation without obstructing signs. Patient had a laparoscopic exploration which showed a large internal herniation through mesenteric defect containing more than two thirds of bowel length. Closure of the defect was done by a purse string technique using non-absorbable prolene 2/0 stitch after reduction of the bowel. Patient had an uneventful postoperative recovery. She denied any further attacks of abdominal pain at her follow up till 6 months postoperatively. Conclusions Diagnosis of non-obstructing internal herniation post RYGB is very challenging. Low threshold for laparoscopic exploration in suspicious cases of remittent abdominal pain is highly recommended. CT scan can't rule out IH completely due to its intermittent nature. Laparoscopic repair remains the optimal approach, even in the large IH, with favourable outcomes. Appropriate identification of the bowel configuration is the key step in such procedure.

SP6.1.10 Prevention of internal hernia by closure versus non-closure of the mesenteric defect in patients undergoing Roux-en-Y gastric bypass- a meta-analysis of published randomized controlled trials

Abstract Objective The objective of this article is to evaluate the prevention of internal hernia by mesenteric defect closure (MDC) versus non-closure of the mesenteric defect (MDNC) in patients undergoing Roux-en-Y gastric bypass. Method Standard medical electronic databases were searched, and relevant published randomized controlled trials (RCT) were shortlisted according to the inclusion criteria. Summated outcome of post-operative surgical variables including the incidence of internal hernia were analyzed using principles of meta-analysis on RevMan 5 statistical software. Result Five RCTs on 3285 patients undergoing Roux-en-Y gastric bypass operation for any indication or approach were found suitable for meta-analysis. There were 1635 patients in the MDC group and 1650 patients in the MDNC group. The duration of the operation was statistically longer in MDC [random effects model, standardized mean difference (SMD) 0.73, 95% CI (0.22–1.25), z=2.78, p=0.005]. There was no statistical difference related to length of hospital stay [random effects model, standardized mean difference (SMD) 0.15, 95% CI (-0.41, 0.44), z= 1.01; P= 0.31] between the two groups. The incidence of internal hernia was significantly reduced in MDC group. This difference was statistically significant [random effects model, odds ratio 0.36, 95% CI (0.19–0.66), z=3.27, p=0.001]. However, there was significant statistical heterogeneity (Chi2= 31.99, df = 4 (P < 0.00001) among included RCTs. Conclusion The routine closure of mesenteric defect in patients undergoing Roux-en-y bypass may be an effective approach to reduce the risk of internal hernia. However, more RCTs of robust quality recruiting higher number of patients are required to validate these findings.

Mechanical ileus and mesenteric ischemia in a patient with simultaneous internal herniation through Petersen's and jejunojejunal spaces following laparoscopic Roux-en-Y gastric bypass: A case report.

IntroductionInternal herniation (IH) of the small bowel after laparoscopic Roux-en-Y gastric bypass (LRYGB) is a well-known complication, with an incidence ranging from 1 to 5% depending on the route of the Roux limb and the closure of the mesenteric defects at the time of the initial operation. Simultaneous herniation of the biliopancreatic and Roux limbs through both Petersen's and jejunojejunal spaces with mesenteric torsion resulting in early small bowel ischemia has not been described earlier.Presentation of caseA 63-year-old patient presented with mechanical small bowel ileus and early mesenteric ischemia due to simultaneous herniation of the alimentary and the biliopancreatic limb through the Petersen's and jejunojejunal spaces with subsequent rotation and torsion of the mesentery 33 months after LRYGB. The condition was managed by surgically reducing the hernias and closure of the mesenteric defects. Partial bowel resection was not performed. The patient's postoperative course was uneventful.DiscussionSimultaneous herniation of the biliopancreatic and Roux limbs through both intermesenteric windows caused consequent life-threatening complications after LRYGB. Antecolic approach and closure of mesenteric defects with non-absorbable sutures are recommended when technically feasible. Proper history taking and clinical examination, as well as communication between surgeons and radiologists, are crucial in establishing a rapid diagnosis.ConclusionInternal hernia following LRYGB can be fatal. In cases of uncertainty, emergency exploratory laparoscopy or laparotomy should be performed. The open approach seems superior for recurrent small bowel obstruction (SBO) due to recurrent IH. High vigilance is necessary when IH is suspected, despite normal laboratory and radiological findings.

The Influence of Mesenteric Defects Closure on the Use of Computed Tomography for Abdominal Pain 5 Years After Laparoscopic Gastric Bypass\u2014a Post Hoc Analysis of a Randomized Clinical Trial

BackgroundAbdominal pain after laparoscopic Roux-en-Y gastric bypass (LRYGB) is a common and unwanted complication that typically leads to further exploration through radiology. Concerns have been raised regarding the consequences of this radiation exposure and its correlation with the lifetime risk of cancer. The aim of this study was to evaluate the differences in computed tomography (CT) use between LRYGB patients with open and closed mesenteric defects and to assess the radiological findings and radiation doses.MethodsThis subgroup analysis included 300 patients randomized to either closure (n = 150) or nonclosure (n = 150) of mesenteric defects during LRYGB. The total number of CT scans performed due to abdominal pain in the first 5 postoperative years was recorded together with the radiological findings and radiation doses.ResultsA total of 132 patients (44%) underwent 281 abdominal CT scans, including 133 scans for 67 patients with open mesenteric defects (45%) and 148 scans for 65 patients with closed mesenteric defects (43%). Radiological findings consistent with small bowel obstruction or internal hernia were found in 31 (23%) of the scans for patients with open defects and in 18 (12%) of the scans for patients with closed defects (p = 0.014). The other pathological and radiological findings were infrequent and not significantly different between groups. At the 5-year follow-up, the total radiation dose was 82,400 mGy cm in the nonclosure group and 85,800 mGy cm in the closure group.ConclusionClosure of mesenteric defects did not influence the use of CT to assess abdominal pain.Graphical abstract

S3011 Caught up in You: A Rare Complication of Roux-en-Y Gastric Bypass Surgery

Introduction: Internal hernias are the most common complication of Roux-en-Y gastric bypass surgery. A large percentage are through Petersen’s space: a potential space between the transverse mesocolon and retroperitoneum. If present, internal hernias can cause significant morbidity due to small bowel obstruction and mesenteric or bowel ischemia. Case Description/Methods: A morbidly obese 72 year old woman with a history of Roux-en-Y gastric bypass surgery 7 years ago, atrial fibrillation, COPD, cirrhosis, and treated hepatitis C, presented with acute post-prandial epigastric abdominal pain radiating retrosternally with nausea and vomiting. Patient was hemodynamically stable but uncomfortable. Her abdomen was diffusely tender with guarding. Upon admission, she was febrile (38.4°C). She also developed large volume hematochezia with an acute drop in hemoglobin from 12.3 to 9.3g/dl. Abdominal CT angiography revealed a superior mesenteric artery occlusion, extensive small bowel ischemia of the jejunum and ileum, and changes consistent with a post-bariatric internal hernia. Exploratory laparotomy revealed herniation of the distal Roux limb through Petersen’s space with ischemic bowel segments; 42cm of ischemic bowel proximal to the jejunojejunal junction was resected. Post-operative course was complicated by prolonged intubation and ventilator associated pneumonia. She expired after 30 days in the intensive care unit. Discussion: This is one of the first recorded cases of SMA occlusion due to an internal hernia following a Roux-en-Y gastric bypass procedure. The retrocolic Roux limb approach taken during her bypass and the absence of mesenteric defect closure attributed to this complication. Meta-analysis shows the incidence of internal hernia nearly doubles in patients who undergo the retrocolic Roux limb approach in contrast to antecolic. In a retrospective study, the incidence of internal hernias nearly doubled when the mesenteric defects were not sutured closed intra-operatively. Our case emphasizes the need to consider small bowel ischemia in patients with a history of Roux-en-Y gastric bypass presenting with abdominal pain and hematochezia.Figure 1.: Superior Mesenteric Artery within the Petersen's space internal hernia causing obstruction

Mesenteric closure after laparoscopic total gastrectomy with Roux-en-Y reconstruction is effective for prevention of internal hernia: a multicenter retrospective study.

Internal hernia (IH) is one of the critical complications after gastrectomy with Roux-en-Y reconstruction, which can be prevented by closing mesenteric defects. However, only few studies have investigated the incidence of IH after laparoscopic total gastrectomy (LTG) with Roux-en-Y reconstruction for gastric cancer till date. This study aimed to assess the efficacy of defect closure for the prevention of IH after LTG. This multicenter, retrospective cohort study collected data from 714 gastric cancer patients who underwent LTG with Rou-en-Y reconstruction between 2010 and 2016 in 13 hospitals. We evaluated the incidence of postoperative IH by comparing closure and non-closure groups of Petersen's defect, jejunojejunostomy mesenteric defect, and transverse mesenteric defect. The closure group for Petersen's defect included 609 cases, while the non-closure group included 105 cases. The incidence of postoperative IH in the closure group for Petersen's defect was significantly lower than it was in the non-closure group (0.5% vs. 4.8%, p < 0.001). The closure group for jejunojejunostomy mesenteric defect included 641 cases, while the non-closure group included 73 cases. The incidence of postoperative IH in the closure group of jejunojejunostomy mesenteric defect was significantly lower than that in the non-closure group (0.8% vs. 4.1%, p = 0.004). Out of 714 patients, 41 underwent retro-colic reconstruction. No patients in the transverse mesenteric defect group developed IH. Mesenteric defect closure after LTG with Roux-en-Y reconstruction may reduce postoperative IH incidence. Endoscopic surgeons should take great care to prevent IH by closing mesenteric defects.

Small bowel obstruction following laparoscopic Roux-en-Y gastric bypass: is it always necessary to operate? A 5-year, high volume center experience.

This study aims to describe the incidence, associated factors, etiology, and management of small bowel obstructions following laparoscopic Roux-en-Y gastric bypass (LRYGB). A retrospective analysis was conducted between January 15 and December 19 using the surgery database of our hospital. Included LRYGB patients were those that evolved with a prolonged length of stay; readmission; emergency room consult; and re-intervention due to small bowel obstruction (SBO) related symptoms with compatible radiological or intraoperative findings. The LRYGB technique implied an antecolic alimentary limb reconstruction and systematic closure of mesenteric defects. Descriptive and analytical statistics were carried out, using a parametric or non-parametric approach as needed. Nine hundred forty-one LRYGB were performed. 9.9% were revisional surgeries of patients with a laparoscopic sleeve gastrectomy. During the study period, 36 SBOs occurred, representing 3.8% of operated patients, with no mortality. 58.3% had successful non-operative management, while 41.7% required surgical exploration, of which 73.3% were treated laparoscopically and 20% needed conversion to open surgery. Etiologies of SBO were jejuno-jejunostomy (JJO) related stenosis (22, 61.1%), internal hernias (6, 16.7%), adherences (3, 8.3%), and other diagnoses (5, 13.9%). Regarding JJO stenosis and internal hernias, median time to diagnosis was 8days (IQR 7-11) and 12months (IQR 8.7-16) respectively. Previous sleeve gastrectomy, age, or sex was not associated to the incidence of small bowel obstruction. LRYGB is safe when performed by experienced surgeons. SBO due to internal hernias were scarce in this series. JJO stenosis could explain most cases of SBO; under this diagnosis, non-surgical management was successful frequently.