Roux-en-y gastric bypass reversal surgery because of massive ischemia in internal hernia

Abstract text (incl. references and figure legends)

Case history:45 year-old male with a past medical history of morbid obesity treated 15 years prior with RYGB, presented to our emergency department with severe abdominal pain and hemodynamic instability. Clinical findings were general tenderness to palpation and peritoneal irritation. Laboratory results showed leukocytosis, PCR 3,66 mg/dl and metabolic acidosis. A CT was performed which showed a massive small bowel ischemia. Therapy: A exploratory laparotomy was attempted emergently. A large mass of ischemic small bowel (5 meters biliopancreatic loop) was visualized with an internal herniation through jejunojejunal anastomosis. It was performed a demage control surgery: resection of ischemic bowel and abdominal vacuum therapy. At 48 postoperative hours, a second look surgery was performed objectifying no data of local ischemia. Bowel viability was: 50 cm biliopancreatic loop and 120 cm alimentary loop with high risk of short intestine syndrome. We decided an anatomic conversion of RYGB. He had an unremarkable post-operative course and he was discharge on the 6th postoperative day. Comments: Internal hernias are described as a complication of laparoscopic Roux-en-Y gastric bypass (RYGB), resulting in bowel obstruction in 5% and it may occur at Petersen"s space. Symptoms are nonspecific, so early diagnosis's important. Some patients with RYGB complications may be necessary reversal to normal anatomy. Most common indications are dumping syndrome, postpandrial hypoglycemia, malnutrition, among others. We performed a RYGB reversal to prevent malabsoptions consecuences given the small amount of viable bowel not resectioned. Otherwise, complications as small intestinal syndrome or several malnutrition could be happened. This procedure is safe with no reported mortality. However there is a high incidence of weight regain after RYGB reversal, so judicious patient selection must be considered. References:10.1016/j.soard.2016.02.023, 10.1007/s11695-016-2257-2.

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