Reconstruction of short bowel syndrome after internal hernia in a pregnant woman with previous bariatric surgery

Abstract

Introduction: Bariatric surgery is most often performed with the laparoscopic Roux-en-Y gastric bypass. A complication to the laparoscopic Roux-en-Y gastric bypass is internal hernia, which occurs in up to 16% of the patients. Since the laparoscopic Roux-en-Y gastric bypass is performed in women of fertile age, internal hernia may occur during pregnancy.

Presentation of case: A 22-year old woman with a history of laparoscopic Roux-en-Y gastric bypass suffered from massive internal hernia during pregnancy with widespread bowel necrosis. Extensive surgery was performed leaving the patient with an intact duodenum, 15cm of jejunum, 35cm of ileum and colon. Parenteral nutrition was initiated and ten months after the internal hernia, intestinal continuity was re-established. Ten weeks later the patient reached parenteral nutrition independence.

Discussion: Internal hernia after laparoscopic Roux-en-Y gastric bypass can be difficult to diagnose, especially during pregnancy and might be severe and life threatening for both mother and child.

Conclusion: Obstetricians and abdominal surgeons must be aware of this condition. Surgery should be performed on a wide indication. When bowel necrosis is found it should be resected and in case of extensive bowel resection the patient should be evaluated in centres specialized in intestinal failure.

Keywords: Internal hernia; Laparoscopic gastric bypass; Pregnancy; Short bowel syndrome.

Fig. 1

The intestinal system of a 22-year old woman with previous gastric bypass operation after internal herniation with massive bowel necrosis. The patient ended up with a saliva fistula from the pouch-enteric anastomosis, a jejunostomy 15 cm from the ligament of Treitz, and a blind closed ileum 35 cm from the ileo-coecal valve (left). Ten months later the intestinal continuity was reestablished (right).