P2000 - Caught up in You: A Rare Complication of Roux-en-Y Gastric Bypass Surgery

Randy Leibowitz, DO¹, Erica Park, MD², Priya Simoes, MD^1
1Mount Sinai St. Luke's and Mount Sinai Roosevelt, New York, NY; ²Mount Sinai West, Mount Sinai Morningside and Mount Sinai Beth Israel Hospitals, New York, NY

Introduction: Internal hernias are the most common complication of Roux-en-Y gastric bypass surgery. A large percentage are through Petersen’s space: a potential space between the transverse mesocolon and retroperitoneum. If present, internal hernias can cause significant morbidity due to small bowel obstruction and mesenteric or bowel ischemia.

Case Description/Methods: A morbidly obese 72 year old woman with a history of Roux-en-Y gastric bypass surgery 7 years ago, atrial fibrillation, COPD, cirrhosis, and treated hepatitis C, presented with acute post-prandial epigastric abdominal pain radiating retrosternally with nausea and vomiting. Patient was hemodynamically stable but uncomfortable. Her abdomen was diffusely tender with guarding. Upon admission, she was febrile (38.4°C). She also developed large volume hematochezia with an acute drop in hemoglobin from 12.3 to 9.3g/dl.

Abdominal CT angiography revealed a superior mesenteric artery occlusion, extensive small bowel ischemia of the jejunum and ileum, and changes consistent with a post-bariatric internal hernia. Exploratory laparotomy revealed herniation of the distal Roux limb through Petersen’s space with ischemic bowel segments; 42cm of ischemic bowel proximal to the jejunojejunal junction was resected.

Post-operative course was complicated by prolonged intubation and ventilator associated pneumonia. She expired after 30 days in the intensive care unit.

Discussion: This is one of the first recorded cases of SMA occlusion due to an internal hernia following a Roux-en-Y gastric bypass procedure. The retrocolic Roux limb approach taken during her bypass and the absence of mesenteric defect closure attributed to this complication.

Meta-analysis shows the incidence of internal hernia nearly doubles in patients who undergo the retrocolic Roux limb approach in contrast to antecolic. In a retrospective study, the incidence of internal hernias nearly doubled when the mesenteric defects were not sutured closed intra-operatively. Our case emphasizes the need to consider small bowel ischemia in patients with a history of Roux-en-Y gastric bypass presenting with abdominal pain and hematochezia.

Al Harakeh et. al. Bowel obstruction rates in antecolic/antegastric versus retrocolic/retrogastric Roux limb gastric bypass: a meta-analysis Surg Obes Relat Dis. 2016 12 (1):194-198

Chowby et. al. Mesenteric Defect Closure Decreases the Incidence of Internal Hernias Following Laparoscopic Roux-En-Y Gastric Bypass: a Retrospective Cohort Study Obes Surg. 2016 25:2029-2034


Figure: Superior Mesenteric Artery within the Petersen's space internal hernia causing obstruction


Disclosures:
Randy Leibowitz indicated no relevant financial relationships.
Erica Park indicated no relevant financial relationships.
Priya Simoes indicated no relevant financial relationships.


Randy Leibowitz, DO¹, Erica Park, MD², Priya Simoes, MD¹. P2000 - Caught up in You: A Rare Complication of Roux-en-Y Gastric Bypass Surgery, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.