ORLANDO — Although internal hernias occur infrequently, they are a potentially serious complication that can develop long after gastric bypass surgery, according to a study presented by Brennan J. Carmody, M.D., at the annual meeting of the American Society for Bariatric Surgery.
“Internal hernia can be a devastating postoperative complication that leads to intestinal obstruction,” he said. With an overall incidence of 2.5%, clinical suspicion for internal hernia needs to be high.
Consider internal hernia when a bariatric surgery patient presents with abdominal pain, even if more than a year has passed since the procedure was done, Dr. Carmody suggested. In his study, all 20 patients who required surgery to correct an internal hernia initially presented with abdominal pain. Nausea, vomiting, and bowel obstruction are other clinical clues.
Dr. Carmody and his associates reviewed 785 laparoscopic gastric bypass procedures performed between 1998 and 2003 at Virginia Commonwealth University Medical Center in Richmond. The mean preoperative body mass index was 47 kg/m
The researchers identified different types of hernias, including Peterson's, mesocolic, jejunojejunal, and adhesion-related hernias. They used contrast radiography to assess 75% of patients. All findings were suspicious for internal hernia.
Surgical technique made a difference in the complication rate. In the first 107 patients, surgeons performed a retrocolic technique without defect closure. The internal hernia rate in this group was 6.5%. An antecolic technique was used with another 136 patients, and 4.4% developed a hernia. For the remaining 542 patients, surgeons performed a retrocolic technique with closure of all defects. Three developed an internal hernia, giving this group the lowest hernia rate—0.5%.
“We recommend routine closure of all mesenteric defects,” Dr. Carmody said.
“Patients, primary care physicians, radiologists, surgeons, and physician assistants may fail to recognize signs or symptoms.
Patients experiencing unexplained or intermittent abdominal pain should be considered for reexploration,” said Dr. Carmody, a laparoscopy Fellow with the Minimally Invasive Surgery Center at Virginia Commonwealth University.
There might be a reluctance to reexplore patients with vague symptomatology, Dr. Carmody said.
But that is not the only challenge. A mean of 303 days elapsed between bypass and development of symptoms in his study. The patient with a late complication may not see the same bariatric surgeon who performed the procedure, he said.
“Internal hernia can occur long after gastric bypass with variable presentation,” Dr. Carmody concluded.
“There is an underreporting of this complication. The true incidence is likely underestimated,” he said.