Does the closure of mesenteric defects during laparoscopic gastric bypass surgery cause complications?

doi:10.1016/j.soard.2014.10.013

Surgery for Obesity and Related Diseases

Volume 11, Issue 2, March–April 2015, Pages 459-464

https://doi.org/10.1016/j.soard.2014.10.013 Get rights and content

Abstract

Background

A well-known complication of laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) is bowel obstruction due to internal herniation (IH). Evidence suggests that mesenteric defects should be closed during LRYGB to reduce the risk of IH. Therefore, surgeons are now closing mesenteric defects during LRYGB using sutures, clips, or fibrin glue. However, it has been reported that complications may arise due to the closure of mesenteric defects. The aim of this review was to summarize the reported possible complications associated with the closure of mesenteric defects during LRYGB.

Methods

A literature search of PubMed and EMBASE was performed to identify studies related to the closure of mesenteric defects during LRYGB. The studies were screened for the listing of possible complications associated with the closure of mesenteric defects. This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations.

Results

Thirty studies complied with the inclusion criteria for our analysis, which included 21,789 patients. Reported complications related to closure of the mesenteric defects were: small bowel obstruction because of IH, kinking, and adhesions. IH occurred because of incomplete closure of the mesenteric defects in 1.4% of all patients, 1.2% by the antecolic approach, and 1.9% by the retrocolic approach, respectively. Kinking of the small bowel occurred in .2% of 1630 patients after closure of the mesenteric defects with clips and adhesion formation was found among 4.6% of 152 patients after closure of the mesenteric defects with nonabsorbable sutures.

Conclusions

The reported risk of complications caused by closure of the mesenteric defects during LRYGB seems low.

Section snippets

Methods

This systematic review was conducted according to the PRISMA guidelines and MOOSE guidelines [11], [12]. A literature search of PubMed (2003–2013, restrictions: English language, humans) and EMBASE (2003–2013, restrictions: English language, humans, and full text) was performed in October 2013 to identify studies related to the closure of mesenteric defects during LRYGB. The studies were screened for the listing of possible complications associated with the closure of mesenteric defects.

Studies

Results

Thirty studies examining a total of 21,789 patients were included (Table 1). Out of the 30 studies, 26 studies (16,541 patients) described in detail the risk of IH after the closure of mesenteric defects.

The following complications related to the closure of mesenteric defects were reported:

Discussion

In most of the reviewed studies, the indication for closure of mesenteric defects was the prevention of later IH (Table 1). However, only a few studies have focused on possible complications due to the closure of mesenteric defects during LRYGB. Therefore, the present review attempted to identify possible risks related to the closure of mesenteric defects.

There seems to be a low rate of IH due to incomplete closure of the mesenteric defects. Twenty-six of the 30 reviewed studies addressed this

Conclusion

The present review describes the reported possible complications associated with the closure of mesenteric defects in LRYGB; the overall risk of such complications seems low.

Disclosures

The authors have no commercial associations that might be a conflict of interest in relation to this article.

References (40)

J.-P. Marmuse et al.
Gastric bypass. Principles, complications, and results
J Visc Surg
(2010)
L. Sjöström et al.
Effects of bariatric surgery on cancer incidence in obese patients in Sweden (Swedish Obese Subjects Study): a prospective, controlled intervention trial
Lancet Oncol
(2009)
K. Higa et al.
Laparoscopic Roux-en-Y gastric bypass: 10-year follow-up
Surg Obes Relat Dis
(2011)
E. Aghajani et al.
Internal hernia after gastric bypass: a new and simplified technique for laparoscopic primary closure of the mesenteric defects
J Gastrointest Surg
(2012)
D. Moher et al.
Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement
J Clin Epidemiol
(2009)
R.W. Bauman et al.
Internal hernia at Petersen׳s space after laparoscopic Roux-en-Y gastric bypass: 6.2% incidence without closure--a single surgeon series of 1047 cases
Surg Obes Relat Dis
(2009)
L.A. Miyashiro et al.
Favorable internal hernia rate achieved using retrocolic, retrogastric alimentary limb in laparoscopic Roux-en-Y gastric bypass
Surg Obes Relat Dis
(2010)
J. Felsher et al.
Small bowel obstruction after laparoscopic Roux-en-Y gastric bypass
Surgery
(2003)
K.C.K. Nandipati et al.
Counterclockwise rotation of Roux-en-Y limb significantly reduces internal herniation in laparoscopic Roux-en-Y gastric bypass (LRYGB)
J Gastrointest Surg
(2012)
J.S. Koppman et al.
Small bowel obstruction after laparoscopic Roux-en-Y gastric bypass: a review of 9,527 patients
J Am Coll Surg
(2008)

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Among the medium-term complications (i.e. > 12 months) of RYGB, small bowel obstruction due to internal hernia (IH) is one of the most redoubtable because diagnosis is often difficult, and its consequences are potentially lethal [3]. The occurrence of IH is favored by non-closure or incomplete closure of mesenteric defects at the initial surgery [4], by pregnancy [5], and by major weight loss (> 50 % loss of excess weight) [3]. To reduce the chances of developing IH, it is essential to systematically close all such mesenteric defects [3,6].
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Internal hernias (IH) are a recognized problem in laparoscopic Roux-en-Y gastric bypass (LRYGB) that can cause intestinal obstruction. The routine closure of the mesenteric defects (MDs) to prevent IH in the LRYGB remains controversial.
The main objective of our study was to evaluate the risk of reopening at the level of both MDs, the Petersen space, and the intermesenteric gap.
University hospital.
Prospective cohort of patients with a history of LRYGB, all with closure of both MDs, and in whom another intra-abdominal surgery was performed after the LRYGB, between January 2013 and December 2018. The status of both MDs was recorded. All analyses were performed with Stata version 15 software with a level of significance of .05.
A total of 76 patients were included. The average time that elapsed between the LRYGB and the surgery that evaluated the state of the MDs was 22.8 months. The patients lost on average 34.7 kg, with a minimum of 8 kg and a maximum of 76 kg. The indications for the interventions were cholelithiasis (68.3%), recurrent abdominal pain (13.2%), intestinal obstruction (11.8%), malabsorption syndrome (7.3%), and bilateral inguinal hernia (2.4%). At the time of surgery, 52 patients (68.4%) had a completely closed Petersen space; 58 patients (76.3%) had a completely closed intermesenteric defect. Both MDs were closed in 36 patients (47.4%), and 33 patients (43.4%) had at least 1 of the MDs open.
The closure of MDs eliminated the risk of IH in half of the operated patients of LRYGB in this series.

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Review articleDoes the closure of mesenteric defects during laparoscopic gastric bypass surgery cause complications?

Abstract

Background

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Conclusion

Disclosures

J Visc Surg

Lancet Oncol

Surg Obes Relat Dis

J Gastrointest Surg

J Clin Epidemiol

Surg Obes Relat Dis

Surg Obes Relat Dis

Surgery

J Gastrointest Surg

J Am Coll Surg

Surg Obes Relat Dis

Surg Obes Relat Dis

Surg Obes Relat Dis

Surg Obes Relat Dis

Effects of bariatric surgery on mortality in Swedish obese subjects

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Review article
Does the closure of mesenteric defects during laparoscopic gastric bypass surgery cause complications?