ArticlePublisher preview available

Internal Hernia After Laparoscopic One-Anastomosis (Mini) Gastric Bypass: Video Case Series of a Single-Center Experience

June 2021
Obesity Surgery 31(5)

DOI:10.1007/s11695-021-05362-5

Authors:

Andrei Ilczyszyn

University College London Hospitals NHS Foundation Trust

Mohamed Elkalaawy

Internal hernia (IH) after one-anastomosis gastric bypass (OAGB) was thought to have an extremely low incidence. In this video, we report three cases of post-OAGB symptomatic internal herniation. The first case is a 45-year-old female who presented 4 months after her OAGB with crampy abdominal pain and reflux symptoms. An exploratory laparoscopy showed Petersen’s hernia; the hernia was reduced with no ischemia and the defect was closed. The second case is a 40-year-old male who presented 7 months after his surgery with abdominal pain and reflux. An exploratory laparoscopy showed Petersen’s hernia; bowel was reduced and defect was closed through a laparotomy. The third case is a 64-year-old male who presented with refractory biliary reflux after OAGB. An elective diagnostic laparoscopy showed Petersen’s hernia; the hernia was reduced and defect was closed. All patients recovered well with no recurrence of symptoms on follow-up. Internal hernia after OAGB is more common than the reported incidence. The threshold for diagnostic laparoscopy should be lowered for a OAGB patient with symptoms suggestive of IH.

A preview of this full-text is provided by Springer Nature.
Learn more

Preview content only

Content available from Obesity Surgery

This content is subject to copyright. Terms and conditions apply.

MULTIMEDIA ARTICLE

Internal Hernia After Laparoscopic One-Anastomosis (Mini) Gastric

Bypass: Video Case Series of a Single-Center Experience

Alwahhaj Khogeer

1,2

&Andrei Ilczyszyn

&Marco Adamo

&Mohamed Elkalaawy

Received: 21 December 2020 /Revised: 4 March 2021 /Accepted: 16 March 2021

#Crown 2021

Abstract

Internal hernia (IH) after one-anastomosis gastric bypass (OAGB) was thought to have an extremely low incidence. In this video,

we report three cases of post-OAGB symptomatic internal herniation. The first case is a 45-year-old female who presented 4

months after her OAGB with crampy abdominal pain and reflux symptoms. An exploratory laparoscopy showed Petersen’s

hernia; the hernia was reduced with no ischemia and the defect was closed. The second case is a 40-year-old male who presented

7 months after his surgery with abdominal pain and reflux. An exploratory laparoscopy showed Petersen’s hernia; bowel was

reduced and defect was closed through a laparotomy. The third case is a 64-year-old male who presented with refractory biliary

reflux after OAGB. An elective diagnostic laparoscopy showed Petersen’s hernia; the hernia was reduced and defect was closed.

All patients recovered well with no recurrence of symptoms on follow-up. Internal hernia after OAGB is more common than the

reported incidence. The threshold for diagnostic laparoscopy should be lowered for a OAGB patient with symptoms suggestive

of IH.

Keywords Bariatric surgery complications .One-anastomosis gastric bypass .Mini-gastric bypass .Internal hernia .Petersen’s

hernia .Case report .Case series

Introduction

One-anastomosis gastric bypass (OAGB) has been recognized

as one of the standard bariatric procedures due to its efficacy

and safety [1,2]. It was believed that the incidence of internal

hernia (IH) after OAGB is extremely rare compared to the

Roux-en-Y gastric bypass (RYGB) [3–5], with only 5 cases

reported in literature [6–10]; however, this may have been

under-reported [11]. We present a video case series from a

single center with the operative management.

Case Series

Seventy-one OAGB cases have been performed in our center.

Three patients developed IH after OAGB. The first is a 45-

year-old female who had undergone a laparoscopic conver-

sion of sleeve gastrectomy (SG) to OAGB for weight regain.

She presented to the Emergency Department (ED) 4 months

later with left-sided abdominal pain and reflux symptoms. An

abdominal CT scan showed clustering of bowel loops in the

left upper quadrant with a suspicion of internal hernia through

Petersen’s defect without ischemia. An endoscopy showed

evidence of bile gastritis. The patient was taken for a diagnos-

tic laparoscopy. Intraoperatively, the efferent limb was found

dilated and herniated through Petersen’s defect with twisting

of the anastomosis. The bowel was reduced successfully. The

defect was closed with continuous non-absorbable sutures.

The patient recovered well. She was followed up to 2 years

post-op with no reoccurrence of pain or reflux.

*Mohamed Elkalaawy

Mohamed.elkalaawy@nhs.net

Alwahhaj Khogeer

alwahhaj.khogeer@nhs.net; khogeer.A2@kamc.med.sa

Andrei Ilczyszyn

Andrei.ilczyszyn@nhs.net

Marco Adamo

marco.adamo@nhs.net

Department of Bariatric and Metabolic Surgery, University College

London Hospitals, London, UK

Department of Bariatric Surgery, Specialized Surgery Center, King

Abdullah Medical City, Mecca, Saudi Arabia

https://doi.org/10.1007/s11695-021-05362-5

/ Published online: 31 March 2021

Obesity Surgery (2021) 31:2839–2840

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Prevention and management of internal hernias after bariatric surgery: an expert review

Article

Full-text available

Apr 2022

Internal hernia formation is a feared complication following bariatric surgery. Protrusion of the small bowel through mesenteric defects can result in volvulus presenting with symptoms of bowel obstruction. If left untreated, patients may go on to develop bowel ischemia with possible perforation or necrosis necessitating emergent surgical exploration with resection. In severe cases, extensive bowel resection is required, leading to short-gut syndrome, which can have devastating consequences for the already nutritionally vulnerable bariatric patient. This review presents a comprehensive summary of various surgical techniques and technical factors implicated in the formation of internal hernias. The clinical presentation of patients with internal hernias, appropriate diagnostic work-up, and effective management and treatment strategies are discussed based on the established literature.

Risk Factor and Surgical Outcome of Petersen’s Hernia After Gastrectomy in Gastric Cancer

Article

Full-text available

Nov 2021

Background Petersen’s hernia is a life-threatening complication after gastrectomy. This study is dedicated to identify risk factors for Petersen’s hernia and compare clinical outcomes between patients receiving early or delayed surgical interventions.Methods Data from all patients who received gastrectomy due to gastric cancer were collected. Clinical characteristics were compared between Petersen and non-Petersen groups, bowel necrosis and non-necrotic groups. Propensity score matching (PSM) was conducted to generate two comparative groups. Univariate analysis and multivariate logistic regression were performed for risk factor evaluation.ResultsA total of 24 cases of Petersen’s hernia were identified from 1,481 cases of gastrectomy. PSM demonstrated that lower body mass index [BMI; odds ratio (OR) = 0.2, p < 0.01] and distal gastrectomy (OR = 6.2, p = 0.011) were risk factors for Petersen’s hernia. Longer time interval from emergence visit to laparotomy (p = 0.042) and elevated preoperative procalcitonin (p = 0.033) and C-reactive protein (CRP; p = 0.012) were associated with higher risk of bowel necrosis in Petersen’s hernia. Early surgical intervention resulted in less bowel necrosis rate (p = 0.012) and shorter length of necrotic bowel (p = 0.0041).Conclusions Low BMI and distal gastrectomy are independent risk factor for Petersen’s hernia after gastrectomy. Curtailing observing time and executing prompt surgery are associated with bowel viability and better outcome in patients with Petersen’s hernia.

Braun Anastomosis: A Technique for Bile Reflux Improvement After Single Anastomosis Sleeve Ileal (SASI) Bypass; a Pilot Study

Article

Mar 2023
SURG INNOV

Background. Single anastomotic surgeries can increase the risk of reflux, marginal ulceration, and gastrointestinal complications. Braun anastomosis prevents bile reflux after gastric resection and gastrojejunal anastomosis surgeries. The present pilot study evaluated Braun’s efficacy in a single anastomosis sleeve ileal (SASI) bypass surgery. Methods. 28 patients with a history of SASI bypass surgery from October 2017 to September 2021 were included in the study. Patients were divided into 2 groups based on having Braun anastomosis to this surgical procedure; group A: underwent SASI bypass without Braun anastomosis; group B: underwent SASI bypass with Braun anastomosis. The surgical complications in terms of bile reflux, marginal ulcer, reflux esophagitis, and gastritis were evaluated and compared between the groups. Results. Bile reflux and reflux esophagitis were seen more in group A than in group B (37.5% vs 8.3% and 18.8% vs 8.3%, respectively). In contrast, 2 patients (16.7%) in group B had marginal ulcers compared to 1 (6.3%) in group A. Also, gastritis was seen in 1 patient in each group (6.3% in group A vs 8.3% in group B). However, the differences were not statistically different. Conclusions. Braun anastomosis is probably an effective procedure to reduce bile reflux, a concern of SASI bypass. Besides, further studies with a larger study population are needed.

Laparoscopic Management of Internal Hernia After One Anastomosis Gastric Bypass (OAGB)

Article

Full-text available

Oct 2020
OBES SURG

Among the advantages of the One Anastomosis Gastric Bypass (OAGB) are the lack of jejuno-jejunal anastomosis and a supposed lower incidence of internal hernia (IH), with only a few cases reported until now. However, the incidence of IH after OAGB is not null. We present a video of the laparoscopic management of an IH that occurred after an OAGB. The patient was a 49-year-old female who had undergone a laparoscopic revisional OAGB 2 years previously after a failed laparoscopic adjustable gastric banding. She was referred to our Unit for recurrent postprandial colicky pain. She lost a total of 50 kg and her body mass index (BMI) dropped from 38 to 19 kg/m2. A CT scan with intravenous contrast showed a swirl of the mesentery around the superior mesenteric artery, without small bowel obstruction. A laparoscopic exploration was performed, confirming the suspicion of IH at the Petersen’s space. An anticlockwise derotation of the whole common limb was performed, and the Petersen’s space was eventually closed with a running non-absorbable suture.

Another Petersen’s Space Hernia After One Anastomosis Gastric Bypass: a Video Case Report

Article

Full-text available

Nov 2019
OBES SURG

One anastomosisgastric bypass(OAGB) is currently known as a standard bariatric procedure worldwide. A rare event after OAGB is internal hernia throgh the Petersen’s defect.

Petersen’s Space Internal Hernia after Laparoscopic One Anastomosis (Mini) Gastric Bypass

Article

Full-text available

Apr 2018

Background One anastomosis gastric bypass (OAGB) is now considered as an appropriate alternative for Roux-en-Y gastric bypass (RYGB) with some advantages such as absence of risk for internal hernia (IH). But, is really the risk of IH equal zero after OAGB? Case Summary. A 37-year-old male was admitted due to severe abdominal crampy pain, nausea, vomiting, and obstipation. He had chronic and intermittent abdominal pain from 2 years after OAGB. With high suspicion of complete obstruction, the exploratory laparoscopy was performed. Intraoperative findings showed incarcerated bowel hernia from Petersen's defect. The incarcerated bowel was reduced, and the defect was repaired. The patient was discharged 2 days after operation. Conclusion The incidence of IH after OAGB is rare but not zero. In any suspicious signs and symptoms for IH, the early exploratory laparoscopy is mandatory to diagnose and treat.

Mini Gastric Bypass-One Anastomosis Gastric Bypass (MGB-OAGB)-IFSO Position Statement

Article

Full-text available

May 2018
OBES SURG

Preamble: The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) has played an integral role in educating both the metabolic surgical and the medical community at large about the role of innovative and new surgical and/or endoscopic interventions in treating adiposity-based chronic diseases.The mini gastric bypass is also known as the one anastomosis gastric bypass. The IFSO has agreed that the standard nomenclature should be the mini gastric bypass-one anastomosis gastric bypass (MGB-OAGB). The IFSO commissioned a task force (Appendix 1) to determine if MGB-OAGB is an effective and safe procedure and if it should be considered a surgical option for the treatment of obesity and metabolic diseases.The following position statement is issued by the IFSO MGB-OAGB task force and approved by the IFSO Scientific Committee and Executive Board. This statement is based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence. It will be reviewed in 2 years.

Efficacy and safety of one anastomosis gastric bypass versus Roux-en-Y gastric bypass for obesity (YOMEGA): a multicentre, randomised, open-label, non-inferiority trial

Article

Mar 2019

Background One anastomosis gastric bypass (OAGB) is increasingly used in the treatment of morbid obesity. However, the efficacy and safety outcomes of this procedure remain debated. We report the results of a randomised trial (YOMEGA) comparing the outcomes of OAGB versus standard Roux-en-Y gastric bypass (RYGB). Methods This prospective, multicentre, randomised non-inferiority trial, was held in nine obesity centres in France. Patients were eligible for inclusion if their body-mass index (BMI) was 40 kg/m² or higher, or 35 kg/m² or higher with the presence of at least one comorbidity (type 2 diabetes, high blood pressure, obstructive sleep apnoea, dyslipidaemia, or arthritis), and were aged 18–65 years. Key exclusion criteria were a history of oesophagitis, Barrett's oesophagus, severe gastro-oesophageal reflux disease resistant to proton-pump inhibitors, and previous bariatric surgery. Participants were randomly assigned (1:1) to OAGB or RYGB, stratified by centre with blocks of variable size; the study was open-label, with no masking required. RYGB consisted of a 150 cm alimentary limb and a 50 cm biliary limb and OAGB of a single gastrojejunal anastomosis with a 200 cm biliopancreatic limb. The primary endpoint was percentage excess BMI loss at 2 years. The primary endpoint was assessed in the per-protocol population and safety was assessed in all randomised participants. This study is registered with ClinicalTrials.gov, number NCT02139813, and is now completed. Findings From May 13, 2014, to March 2, 2016, of 261 patients screened for eligibility, 253 (97%) were randomly assigned to OAGB (n=129) or RYGB (n=124). Five patients did not undergo their assigned surgery, and after undergoing their surgery 14 were excluded from the per-protocol analysis (seven due to pregnancy, two deaths, one withdrawal, and four revisions from OAGB to RYGB) In the per-protocol population (n=117 OAGB, n=117 RYGB), mean age was 43·5 years (SD 10·8), mean BMI was 43·9 kg/m² (SD 5·6), 176 (75%) of 234 participants were female, and 58 (27%) of 211 with available data had type 2 diabetes. After 2 years, mean percentage excess BMI loss was −87·9% (SD 23·6) in the OAGB group and −85·8% (SD 23·1) in the RYGB group, confirming non-inferiority of OAGB (mean difference −3·3%, 95% CI −9·1 to 2·6). 66 serious adverse events associated with surgery were reported (24 in the RYGB group vs 42 in the OAGB group; p=0·042), of which nine (21·4%) in the OAGB group were nutritional complications versus none in the RYGB group (p=0·0034). Interpretation OAGB is not inferior to RYGB regarding weight loss and metabolic improvement at 2 years. Higher incidences of diarrhoea, steatorrhoea, and nutritional adverse events were observed with a 200 cm biliopancreatic limb OAGB, suggesting a malabsorptive effect. Funding French Ministry of Health.

Internal hernia after omega loop gastric bypass: Beware of ischemic stenosis of small intestine!

Article

Feb 2019

Internal hernia after mini-gastric bypass: Myth or reality?

Article

Feb 2016

The mini-gastric bypass (MGBP) is becoming an increasingly popular procedure worldwide. It is based on an “omega” reconstruction, resulting in a single anastomosis and in potential shortening of operative time. Internal hernia represents a potentially life-threatening complication after laparoscopic Roux-en-Y gastric bypass, but it has not yet been reported after a mini-gastric bypass. We herein describe, for the first time, a case of internal hernia after this surgery.

Petersen’s internal hernia complicating a laparoscopic omega loop gastric bypass

Article

May 2015
SURG OBES RELAT DIS

The laparoscopic mini-gastric bypass: The Italian experience: Outcomes from 974 consecutive cases in a multicenter review

Article

Aug 2013
SURG ENDOSC

Due to the failure of the "old Mason loop," the mini-gastric bypass (MGB) has been viewed with skepticism. During the past 12 years, a growing number of authors from around the world have continued to report excellent short- and long-term results with MGB. One university center, three regional hospitals, and two private hospitals participated in this study. From July 2006 to December 2012, 475 men (48.8 %) and 499 women (51.2 %) underwent 974 laparoscopic MGBs. The mean age of these patients was 39.4, and their preoperative body mass index was 48 ± 4.58 kg/m(2). Type 2 diabetes mellitus (T2DM) affected 224 (22.9 %) of the 974 patients, whereas 291 of the 974 patients (29.8 %) presented with hypertension. The preoperative gastrointestinal status was explored in all the patients through esophagogastroduodenoscopia. The major end points of the study were definitions of both MGB safety and efficacy in the long term as well as the endoscopic changes in symptomatic patients eventually produced by surgery. The rate of conversion to open surgery was 1.2 % (12/974), and the mortality rate was 0.2 % (2/974). The perioperative morbidity rate was 5.5 % (54/974), with 20 (2 %) of the 974 patients requiring an early surgical revision. The mean hospital length of stay was 4.0 ± 1.7 days. At this writing, 818 patients are being followed up. Late complications have affected 74 (9 %) of the 818 patients. The majority of these complications (66/74, 89.1 %) have occurred within 1 year after surgery. Bile reflux gastritis was symptomatic, with endoscopic findings reported for 8 (0.9 %) and acid peptic ulcers for 14 (1.7 %) of the 818 patients. A late revision surgery was required for 7 (0.8 %) of the 818 patients. No patient required revision surgery due to biliary gastritis. At 60 months, the percentage of excess weight loss was 77 ± 5.1 %, the T2DM remission was 84.4 %, and the resolution of hypertension was 87.5 %. Despite initial skepticism, this study, together with many other large-scale, long-term similar studies from around the world (e.g., Taiwan, United States, France, Spain, India, Lebanon) demonstrated the MGB to be a short, simple, low-risk, effective, and durable bariatric procedure.

“Mini” Gastric Bypass: Systematic Review of a Controversial Procedure

Article

Aug 2013
OBES SURG

Mini gastric bypass is being explored by many bariatric surgeons as a standalone bariatric procedure. Several surgeons from different parts of the world have now published their extensive experience with this procedure. It appears to be an effective bariatric procedure with acceptable weight loss, co-morbidity resolution, and complication rates in the short and medium term. Its proponents claim that it is safer and easier than the gold standard Roux-en-Y gastric bypass. However, concerns with regard to symptomatic gastric or oesophageal biliary reflux requiring revisional surgery and long-term risk of gastric and oesophageal cancers persist. This paper reviews the published experience to date with this procedure and examines the surrounding controversy.