Lemniscate intestinal loop through an internal hernia after Roux-en-Y gastric bypass cause of coecum mobile. A case report
DOI:
https://doi.org/10.30978/GS-2024-2-59Keywords:
internal hernia, Roux-en-Y gastric bypass, adipositas, bariatric surgery, mesenteric defect, mesenterial closure, Petersen pouch, Brolin pouch, coecum mobile, Lemniscate, BernoulliAbstract
The internal hernia is a typical complication after laparoscopic Roux‑en‑Y gastric bypass surgery. In most cases, there are chronic symptoms that only lead to a diagnostic laparoscopy during the diagnostic exclusion procedure. Less common is acute internal hernia with devastating pain, ileus symptoms and even the development of intestinal gangrene. Although this case describes a typical constellation, it posed a particular challenge because it resulted in mesenteric lemniscate‑like torsion through the Petersen pouch.
Case presentation. A 29‑year‑old patient presented to our emergency department with abdominal pain, complained of sudden epigastric pain that lasted overnight, and radiated into the back with a permanent belching every 10 seconds. Four weeks ago, the patient received an abdominoplasty, complaining of postprandial nausea, meterorism and constipation afterwards. 19 months ago, a Roux‑en‑Y gastric bypass with a weight of 109 kg and a body mass index of 42.6 kg/m2 was done. The current body weight was 60 kg and the body mass index was 23.4 kg/m2. After focused assessment with sonography for trauma and the detection of dilated intestinal loops, an abdominal computer tomography (CT) was performed. Radiologically, the suspicion of mesenteric malrotation was confirmed. The SWELL (CT‑graphic swirl sign, excess weight loss >95%, liquid in abdomen CT scan) score was positive with a CT‑graphic swirl sign and an excess weight loss of 108.9% (> 95%), no chylus or ascites. We discussed an immediate, necessary diagnostic laparoscopy. Based on the ileocoecalpol, it was not possible to establish a proper assignment of the detached gastrointestinal tract. The exploration of the sigmoid colon as the only fixed point revealed that this was a complete fixed twisting of the right intestinal part with a twist of the caecum into the right upper abdomen through the Petersen space. This necessitated a laparotomy to manually cancel Bernoulli’s lemniscate‑like loop and perform a mesenteric defect suture of the mesenteric space of Brolin and the Petersen space with a non‑absorbable suture. The intestinal loops and patient recovered quickly. The dismission was on the 4th post‑operative day.
Conclusions. The internal hernia after gastric bypass remains a diagnostic challenge despite advances in imaging. Due to the increasing number of patients undergoing bariatric surgery, this differential diagnosis must always be considered in the case of abdominal complaints. In addition to the excess weight loss of >95%, this case shows that a recent abdominoplasty can also provoke an internal hernia.
References
Aghajani E, Nergaard BJ, Leifson BG, Hedenbro J, Gislason H. The mesenteric defects in laparoscopic Roux-en-Y gastric bypass: 5 years follow-up of non-closure versus closure using the stapler technique. Surg Endosc. 2017;31(9):3743-8. http://doi.org/10.1007/s00464-017-5415-2.
Ahmed AR, Rickards G, Messing S, et al. Roux limb obstruction secondary to constriction at transverse mesocolon rent after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2009;5(2):194-8. http://doi.org/10.1016/j.soard.2008.02.004.
Altinoz A, Maasher A, Jouhar F, et al. Diagnostic laparoscopy is more accurate than Computerized Tomography for internal hernia after Roux-en-Y gastric bypass. Am J Surg. 2020;220(1):214-6. http://doi.org/10.1016/j.amjsurg.2019.10.034.
Athanasiadis DI, Carr RA, Painter R, et al. Chylous ascites in the setting of internal hernia: a reassuring sign. Surg Endosc. 2022;36(4):2570-3. http://doi.org/10.1007/s00464-021-08545-4.
Ballantyne GH. Review of sigmoid volvulus: history and results of treatment. Dis Colon Rectum. 1982;25(5):494-501. http://doi.org/10.1007/BF02553666.
Bossen MF, Gormsen J, Kristensen SD, Helgstrand F. Smoking Is correlated to internal hernia after gastric bypass surgery: a post hoc analysis of data from a randomized clinical trial. Obes Surg. 2024;34(4):1097-101. http://doi.org/10.1007/s11695-024-07097-5.
Cho M, Pinto D, Carrodeguas L, et al. Frequency and management of internal hernias after laparoscopic antecolic antegastric Roux-en-Y gastric bypass without division of the small bowel mesentery or closure of mesenteric defects: review of 1400 consecutive cases. Surg Obes Relat Dis. 2006;2(2):87-91. http://doi.org/10.1016/j.soard.2005.11.004.
Coecum mobile. Cal State J Med. 1911;9(8):310. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1893928/?page=1.
Comeau E, Gagner M, Inabnet WB, Herron DM, Quinn TM, Pomp A. Symptomatic internal hernias after laparoscopic bariatric surgery. Surg Endosc. 2005;19(1):34-9. http://doi.org/10.1007/s00464-003-8515-0.
Ederveen JC, Nienhuijs SW, Jol S, Robben SGF, Nederend J. Structured CT reporting improves accuracy in diagnosing internal herniation after laparoscopic Roux-en-Y gastric bypass. Eur Radiol. 2020;30(6):3448-54. http://doi.org/10.1007/s00330-020-06688-x.
Ende V, Devas N, Zhang X, Yang J, Pryor AD. Internal hernia trends following gastric bypass surgery. Surg Endosc. 2023;37(9):7183-91. http://doi.org/10.1007/s00464-023-10206-7.
Eunike K. Der Volvulus des aufsteigenden Dickdarms. Dtsch med Wochenschr. 1917;43(52):1619. http://doi.org/10.1055/s-0028-1144882.
Felsher J, Brodsky J, Brody F. Small bowel obstruction after laparoscopic Roux-en-Y gastric bypass. Surgery. 2003;134(3):501-5. http://doi.org/10.1067/s0039-6060(03)00251-4.
Francke, et al. Zur operativen Behandlung des Coecum mobile. Zentralblatt für Chirurgie. 1914;41(1):5-7.
Giudicelli G, Poletti P-A, Platon A, et al. Development and validation of a predictive model for internal hernia after Roux-en-Y gastric bypass in a multicentric retrospective cohort: The Swirl, Weight Excess Loss, Liquid Score. Ann Surg. 2022;275(6):1137-42. http://doi.org/10.1097/SLA.0000000000004370.
Gürleyik G, Kotan C, Dulundu E, Oztürk E, Sönmez R, Sağlam A. Van ve Istanbul illerinde cerrahi tedavi uygulanan akut kalin barsak tikanmali olgular arasindaki klinik farklar. Ulus Travma Derg. 2002;8(1):38-42.
Hajibandeh S, Hajibandeh S, Abdelkarim M, et al. Closure versus non-closure of mesenteric defects in laparoscopic Roux-en-Y gastric bypass: a systematic review and meta-analysis. Surg Endosc. 2020;34(8):3306-20. http://doi.org/10.1007/s00464-020-07544-1.
Hwang RF, Swartz DE, Felix EL. Causes of small bowel obstruction after laparoscopic gastric bypass. Surg Endosc. 2004;18(11):1631-5. http://doi.org/10.1007/s00464-004-8804-2.
Iannelli A, Buratti MS, Novellas S, et al. Internal hernia as a complication of laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2007;17(10):1283-6. http://doi.org/10.1007/s11695-007-9229-5.
Iannuccilli JD, Grand D, Murphy BL, Evangelista P, Roye GD, Mayo-Smith W. Sensitivity and specificity of eight CT signs in the preoperative diagnosis of internal mesenteric hernia following Roux-en-Y gastric bypass surgery. Clin Radiol. 2009;64(4):373-80. http://doi.org/10.1016/j.crad.2008.10.008.
Kamal FA, Fernet LY, Rodriguez M, et al. Nutritional Deficiencies Before and After Bariatric Surgery in Low- and High-Income Countries: Prevention and Treatment. Cureus. 2024;16(2):e55062. http://doi.org/10.7759/cureus.55062.
Karcz WK, Zhou C, Daoud M, et al. Modification of internal hernia classification system after laparoscopic Roux-en-Y bariatric surgery. Wideochir Inne Tech Maloinwazyjne. 2015;10(2):197-204. http://doi.org/10.5114/wiitm.2015.52160.
Kollmann L, Lock JF, Kollmann C, Vladimirov M, Germer C-T, Seyfried F. Surgical treatment of internal hernia after Roux-en-Y gastric bypass — impact of institutional standards and surgical approach. Langenbecks Arch Surg. 2023;408(1):318. http://doi.org/10.1007/s00423-023-03049-2.
Kristensen SD, Floyd AK, Naver L, Jess P. Does the closure of mesenteric defects during laparoscopic gastric bypass surgery cause complications? Surg Obes Relat Dis. 2015;11(2):459-64. http://doi.org/10.1016/j.soard.2014.10.013. .
Kristensen SD, Gormsen J, Naver L, Helgstrand F, Floyd AK. Randomized clinical trial on closure versus non-closure of mesenteric defects during laparoscopic gastric bypass surgery. Br J Surg. 2021;108(2):145-51. http://doi.org/10.1093/bjs/znaa055.
Li Y, Tian Z, Liu C, Li S, Bi W, Ji Q. A nomogram prediction model for internal hernia using clinical parameters and non-enhanced computed tomography imaging. J Gastrointest Surg. 2023;27(5):998-1000. http://doi.org/10.1007/s11605-022-05429-3.
Lockhart ME, Tessler FN, Canon CL, et al. Internal hernia after gastric bypass: sensitivity and specificity of seven CT signs with surgical correlation and controls. AJR Am J Roentgenol. 2007;188(3):745-50. http://doi.org/10.2214/AJR.06.0541.
Mason EE, Ito C. Gastric bypass in obesity. Surg Clin North Am. 1967;47(6):1345-51. http://doi.org/10.1016/S0039-6109(16)38384-0.
Nguyen NT, Huerta S, Gelfand D, Stevens CM, Jim J. Bowel obstruction after laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2004;14(2):190-6. http://doi.org/10.1381/096089204322857546.
Nimeri AA, Maasher A, Al Shaban T, Salim E, Gamaleldin MM. Internal hernia following laparoscopic Roux-en-Y gastric bypass: prevention and tips for intra-operative management. Obes Surg. 2016;26(9):2255-6. http://doi.org/10.1007/s11695-016-2267-0.
Orangio GR, Fazio VW, Winkelman E, McGonagle BA. The Chilaiditi syndrome and associated volvulus of the transverse colon. An indication for surgical therapy. Dis Colon Rectum. 1986;29(10):653-6. http://doi.org/10.1007/BF02560330.
Pfeifer J. Volvulus des DickdarmsJournal für Gastroenterologische und Hepatologische Erkrankungen 2003; 1(1):6-13.
Rabinovici R, Simansky DA, Kaplan O, Mavor E, Manny J. Cecal volvulus. Dis Colon Rectum. 1990;33(9):765-9. http://doi.org/10.1007/BF02052323.
Rogers AM, Ionescu AM, Pauli EM, Meier AH, Shope TR, Haluck RS. When is a Petersen’s hernia not a Petersen’s hernia. J Am Coll Surg. 2008;207(1):121-4. http://doi.org/10.1016/j.jamcollsurg.2008.01.019.
Rogers RL, Harford FJ. Mobile cecum syndrome. Dis Colon Rectum. 1984;27(6):399-402. http://doi.org/10.1007/BF02553011.
Rosas U, Ahmed S, Leva N, et al. Mesenteric defect closure in laparoscopic Roux-en-Y gastric bypass: a randomized controlled trial. Surg Endosc. 2015;29(9):2486-90. http://doi.org/10.1007/s00464-014-3970-3.
Sarmukh S, Lenny SS, Ramesh T, et al. The sigmoid volvulus: a surgical dilemma in adult patient. MOJ Surg. 2018;6(5):135-136. http://doi.org/10.15406/mojs.2018.06.00140
Schima W, Stübler J, Klaus A. Aktuelle Bilder: Innere Hernie nach laparoskopischer Magenbypass-Operation. Journal für Gastroenterologische und Hepatologische Erkrankungen. 2016; 4(1):22-23.
Schneider R, Schulenburg M, Kraljević M, et al. Does the non-absorbable suture closure of the jejunal mesenteric defect reduce the incidence and severity of internal hernias after laparoscopic Roux-en-Y gastric bypass? Langenbecks Arch Surg. 2021;406(6):1831-8. http://doi.org/10.1007/s00423-021-02180-2.
Stenberg E, Szabo E, Ågren G, et al. Closure of mesenteric defects in laparoscopic gastric bypass: a multicentre, randomised, parallel, open-label trial. The Lancet. 2016;387(10026):1397-404. http://doi.org/10.1016/S0140-6736(15)01126-5.
Tsushimi T, Kurazumi H, Takemoto Y, et al. Laparoscopic cecopexy for mobile cecum syndrome manifesting as cecal volvulus: report of a case. Surg Today. 2008;38(4):359-62. http://doi.org/10.1007/s00595-007-3620-7.
Tucker ON, Escalante-Tattersfield T, Szomstein S, Rosenthal RJ. The ABC System: a simplified classification system for small bowel obstruction after laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2007;17(12):1549-54. http://doi.org/10.1007/s11695-007-9273-1.
Wilms, et al. Das Coecum mobile als Ursache mancher Fälle von sogenannter chronischer Appendicitis. Dtsch med Wochenschr. 1908;34(41):1756-8. http://doi.org/10.1055/s-0028-1135773.
Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic Gastric Bypass, Roux-en-Y: Preliminary Report of Five Cases. Obes Surg. 1994;4(4):353-7. http://doi.org/10.1381/096089294765558331.
Yu J, Turner MA, Cho SR, et al. Normal anatomy and complications after gastric bypass surgery: helical CT findings. Radiology. 2004;231(3):753-60. http://doi.org/10.1148/radiol.2313030546.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2024 Authors
This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License.
