Internal Hernia and Biliary Tract Lithiasis after Rouxen- Y Gastric Bypass: the Diagnostic Dilemma and its Therapeutic Approach

Case Report

Ann Obes Disord. 2016; 1(2): 1009.

Internal Hernia and Biliary Tract Lithiasis after Rouxen- Y Gastric Bypass: the Diagnostic Dilemma and its Therapeutic Approach

Chiappetta S*, Khan MS and Stier C

Department of Obesity and Metabolic Surgery, Sana Klinikum Offenbach, Germany

*Corresponding author: Sonja Chiappetta, Department of Obesity and Metabolic Surgery, Sana Klinikum Offenbach, Starkenburgring 66, 63069 Offenbach am Main, Germany

Received: March 25, 2016; Accepted: July 01, 2016; Published: July 04, 2016

Abstract

Two of the most common surgical long-term complications after Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) are Small Bowel Obstruction (SBO) due to Internal Hernia (IH) and Biliary Tract Lithiasis (BTL). Due to elevated cholestatic and pancreatic enzymes in IH and BTL differential diagnoses can be difficult and IH has to be suspected in every acute or chronical abdominal pain after LRYGB.

We report a clinical case of IH mimicking BTL in a patient after LRYGB. In this clinical case exact diagnosis and treatment was performed using a standardized diagnostic flow chart. During diagnostic laparoscopy internal herniation of the entire common channel was seen through Peterson space. A chyloperitoneum is a typical sign for chronic herniation and can confirm IH.

Keywords: Roux-en-Y gastric bypass; Long term complications; Internal hernia; Biliary tract lithiasis; Chyloperitoneum

Abbreviations

LRYGB: Laparoscopic Roux-En-Y Gastric Bypass; SBO: Small Bowel Obstruction; BTL: Biliary Tract Lithiasis; IH: Internal Hernia; UDCA: Ursodeoxycholic Acid; MRCP: Magnetic Resonance Cholangiopancreatography

Introduction

Since its inception half a century ago, bariatric surgery has become the most rapidly increasing area of surgery almost worldwide and especially in the western countries. The most commonly performed procedures worldwide are Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) and sleeve gastrectomy.

In LRYGB stomach is reduced to a small gastric pouch with a capacity of 30 ml. Approximately 50 cm distal to ligament of Treitz, the jejunum is divided, and the bottom end of jejunum is anastomosed to this newly created gastric pouch (roux limb). The top end of divided jejunum (biliopancreatic limb) is anastomosed to jejunum at 150 cm distal to gastrojejunal anastomosis (Figure 1). LRYGB works by two principal mechanisms: restriction and malabsorption. Restriction is achieved by reducing the size of stomach and malabsorption results from bypassing part of jejunum.