Biliopancreatic Limb Obstruction Due to an Unexpected Variant of Internal Hernia After Roux-en-Y Gastric Bypass
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MULTIMEDIA ARTICLE
Biliopancreatic Limb Obstruction Due to an Unexpected Variant of Internal Hernia After Roux-en-Y Gastric Bypass Ron Dar 1,2 & Tamar Dola 1 & Nasser Sakran 1,2 Received: 16 July 2020 / Revised: 13 September 2020 / Accepted: 15 September 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Small bowel obstruction due to internal hernia (IH) is a well-known late complication of laparoscopic Roux-en-Y gastric bypass (LRYGB). A reliable and immediate diagnosis of IH is important for optimal and timely management of patients with a history of LRYGB. Mesenteric defects that are created during a LRYGB include the following: (1) through the transverse mesocolon defect, (2) through the entero-enterostomy mesenteric defect, and (3) through the space between the mesentery of Roux limb and transverse mesocolon (Petersen’s space). The aim of this case is to present an unusual variant of IH after LRYGB that was laparoscopically explored and treated. Keywords Biliopancreatic limb . Internal hernia . Laparoscopic Roux-en-Y gastric bypass . Morbid obesity . Small bowel obstruction
Background Laparoscopic Roux-en-Y gastric bypass (LRYGB) is currently the second most popular weight loss surgery [1]. This procedure withholds several complications, among them is the development of internal hernias (IH) with a reported incidence of 1– 5%, and a prevalence that varies up to 7.5% in the literature [2–5]. This complication may lead to small bowel obstruction (SBO) and can occur unexpectedly at any time post-surgery, making it a significant concern for surgeons and clinicians. Most common sites of IH post-LRYGB are through a transverse mesocolon defect followed by Petersen’s hernia and jejunojejunostomy (JJ) mesenteric space [5]. Electronic supplementary material The online version of this article (https://doi.org/10.1007/s11695-020-04992-5) contains supplementary material, which is available to authorized users. * Nasser Sakran [email protected]
Biliopancreatic limb (BPL) obstruction is an even more challenging diagnosis as the symptoms are very nonspecific. Patients with BPL obstruction can present acutely or subacutely with intestinal obstruction or intermittent, crampy, vague, and sharp abdominal pain, usually unrelated to eating. SBO, due to internal hernia, is commonly a closed-loop obstruction, which has a higher perforation risk. Symptomatic patients should undergo a prompt contrast-enhanced computed tomography (CT), and once diagnosed, the obstruction is treated by urgent surgical exploration in order to reduce the hernia. Early diagnosis and treatment are essential in reducing the morbidity and mortality associated with this condition. Uncorrected small bowel obstruction due to internal hernia could lead to bowel strangulation, which may necessitate extensive bowel resection and could result in short bowel syndrome. Here, we present a rare form of IH after LRYGB located between the jejunojejunostomy and the end of the biliopancreatic limb, directly between two jejunal limbs with
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