Internal Herniation Incidence After RYGB and the Predictive Ability of a CT Scan as a Diagnostic Tool
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By
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Bart Torensma
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Laurens Kooiman
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Ronald Liem
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Valerie M. Monpellier
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Dingeman J. Swank
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Larissa Tseng
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August 3, 2020
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Clinical Scorecard: Incidence of Internal Herniation Following Roux-en-Y Gastric Bypass and the Role of CT Scans in Diagnosis
At a Glance
| Category | Detail |
|---|
| Condition | Internal herniation (IH) as a late complication of Roux-en-Y gastric bypass (RYGB) |
| Key Mechanisms | Herniation of small bowel through mesenteric defects (MD) underneath jejunojejunostomy and/or Petersen’s space |
| Target Population | Patients undergoing primary laparoscopic Roux-en-Y gastric bypass |
| Care Setting | Bariatric surgery centers with emergency and surgical re-laparoscopy capabilities |
Key Highlights
- Internal herniation is a recognized late complication of RYGB with challenging clinical diagnosis.
- Closure of mesenteric defects during RYGB surgery may influence the incidence of IH.
- CT scans are widely used for IH diagnosis but show variable sensitivity and specificity.
Guideline-Based Recommendations
Diagnosis
- Use CT scans as a diagnostic tool for suspected IH, interpreted by experienced radiologists.
- Confirm IH diagnosis via re-laparoscopy in symptomatic patients.
- Consider clinical suspicion and CT findings together, as intermittent IH may present with open MD but no herniated bowel.
Management
- Standardly close mesenteric defects during RYGB to potentially reduce IH incidence.
- Perform re-laparoscopy promptly in patients with clinical signs suggestive of IH.
Monitoring & Follow-up
- Monitor patients post-RYGB for intermittent upper abdominal pain, especially after meals.
- Use multidisciplinary follow-up programs focusing on long-term behavioral change.
Risks
- Risk of IH is associated with open mesenteric defects post-RYGB.
- CT scan may have limited sensitivity and specificity; negative CT does not fully exclude IH.
Patient & Prescribing Data
Patients undergoing primary laparoscopic RYGB between 2011 and 2016
Closure of mesenteric defects was introduced in 2013; CT scans used variably for diagnosis; re-laparoscopy performed in all suspected cases.
Clinical Best Practices
- Close mesenteric defects during RYGB surgery using standardized stapling techniques.
- Use CT scans as adjunctive diagnostic tools but rely on surgical findings for definitive diagnosis.
- Maintain high clinical suspicion for IH in patients with intermittent abdominal pain post-RYGB.
- Ensure experienced bariatric surgeons perform RYGB and manage IH complications.
- Implement multidisciplinary pre- and postoperative counseling with long-term follow-up.
References
