Mount Sinai St. Luke's and Mount Sinai Roosevelt New York, NY, United States
Randy Leibowitz, DO1, Erica Park, MD2, Priya Simoes, MD1 1Mount Sinai St. Luke's and Mount Sinai Roosevelt, New York, NY; 2Mount Sinai West, Mount Sinai Morningside and Mount Sinai Beth Israel Hospitals, New York, NY
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.
Al Harakeh et. al. Bowel obstruction rates in antecolic/antegastric versus retrocolic/retrogastric Roux limb gastric bypass: a meta-analysis Surg Obes Relat Dis. 2016 12 (1):194-198
Chowby et. al. Mesenteric Defect Closure Decreases the Incidence of Internal Hernias Following Laparoscopic Roux-En-Y Gastric Bypass: a Retrospective Cohort Study Obes Surg. 2016 25:2029-2034
Figure: Superior Mesenteric Artery within the Petersen's space internal hernia causing obstruction
Disclosures: Randy Leibowitz indicated no relevant financial relationships. Erica Park indicated no relevant financial relationships. Priya Simoes indicated no relevant financial relationships.
Randy Leibowitz, DO1, Erica Park, MD2, Priya Simoes, MD1. P2000 - Caught up in You: A Rare Complication of Roux-en-Y Gastric Bypass Surgery, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.