Ayman Obeid, MD, Matthew Breland, MS, Richard Stahl, MD, Ronald H Clements, MD, Jayleen Grams, MD, PhD
University of Alabama at Birmingham, Vanderbilt University
INTRODUCTION: Although laparoscopic Roux-en-Y gastric bypass (LRYGB) has decreased morbidity compared to the open approach, it was initially associated with a higher rate of internal hernia (IH). The aim of this study was to determine the impact of mesenteric defect closure on the rate and characteristics of IH after LRYGB.
METHODS AND PROCEDURES: Retrospective review was conducted on all patients undergoing LRYGB from 2001-2011. Only patients who had all defects closed (DC) or all defects not closed (DnC) were included. Patients who had an incidentally identified IH at the time of another operation were excluded. Data collected included demographics, clinical presentation, operative details, and postoperative course. Data were analyzed using SPSS (version 16) statistical software.
RESULTS: There were 1160 patients who underwent LRYGB from 2001-2011 and 914 met inclusion criteria [663 (72.5%) patients with DC and 251 (27.5%) with DnC]. Median follow-up time was 24.3 months (range, 0.5-93.3) vs 31.7 (range, 0.5-131) in DC vs DnC, respectively (p<0.0001). Forty-six patients (5%) developed a symptomatic IH, with 25 (3.8%) vs 21 (8.4%) in the DC vs DnC group, respectively (p=0.005). This remained statistically significant on multivariate analysis for the development of IH with DC vs DnC (p=0.0098, OR 0.44; 95% CI 0.24-0.82). Nineteen patients (42.2%) presented for emergent or urgent repair and 26 (57.8%) for elective repair. The most common symptom was chronic post-prandial abdominal pain (53.4%), followed by abdominal pain with nausea ± vomiting (35.6%), acute abdominal pain ± nausea and vomiting (8.8%), and an acute abdomen (2.2%). The median time to presentation from LRYGB was 16.6 (range, 3.1-71.9) vs 33.5 months (range, 10-103) in the DC vs DnC group, respectively (p<0.001). At the time of IH repair there was no significant difference in BMI or %EWL between the two groups. All patients underwent CT scan which was consistent with IH in 26 patients (57.5%), suggestive in 7 (15.6%), showed small bowel obstruction in 4 (8.9%), and was negative in 8 (17.8%). The majority of IH repairs were performed laparoscopically (86.7%) vs open (13.3%). Intra-operatively, 71 herniation sites were identified with 34 in the DC group vs 37 in the DnC. In the DC group, there were 23 (67.6%) pseudo-Peterson’s and 11 (32.4%) meso-mesoenteric defects. In the DnC group, there were 5 (13.5%) mesocolic, 15 (40.5%) Peterson’s, 2 (5.4%) pseudo-Peterson’s, and 15 (40.5%) meso-mesenteric defects. Two patients required small bowel resection. Median OR time was 104 minutes (range, 75-180). Median length of stay was one day (range, 0.5-32). There was one mortality in a patient who presented in extremis after being hospitalized elsewhere for 3 days with the incorrect diagnosis. One patient had recurrence of internal hernia 11.5 and 14.2 months after initial hernia repair.
CONCLUSIONS: Complications of IH can be devastating, and closure of the mesenteric defects during LRYGB results in a significantly lower IH rate. Furthermore, a high index of suspicion must be maintained since symptoms may be nonspecific and imaging may be negative in nearly 20% of patients. The majority of IH repairs may be performed laparoscopically.
Program Number: P009