Case Report
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World J Gastroenterol. Nov 21, 2014; 20(43): 16349-16354
Published online Nov 21, 2014. doi: 10.3748/wjg.v20.i43.16349
Intestinal infarction by internal hernia in Petersen’s space after laparoscopic gastric bypass
Massimiliano Fabozzi, Riccardo Brachet Contul, Paolo Millo, Rosaldo Allieta
Massimiliano Fabozzi, Riccardo Brachet Contul, Paolo Millo, Rosaldo Allieta, General and Laparoscopic Surgery Department, “Umberto Parini” Aosta Valley Regional Hospital, 11100 Aosta, Italy
Author contributions: All authors contributed to the manuscript.
Correspondence to: Massimiliano Fabozzi, MD, PhD, General and Laparoscopic Surgery Department, “Umberto Parini” Aosta Valley Regional Hospital, Viale Ginevra 3, 11100 Aosta, Italy. maxfabozzi@yahoo.fr
Telephone: +39-165-543284 Fax: +39-165-543635
Received: March 9, 2014
Revised: May 13, 2014
Accepted: July 15, 2014
Published online: November 21, 2014
Abstract

Intestinal occlusion by internal hernia is not a rare complication (0.2%-5%) after Laparoscopic Roux-en-Y-GBP (LGBP) with higher morbidity and mortality related to mesenteric vessels involvement. In our Center, from October 2009 to April 2013 we have had 17 pts treated for internal hernia on 412 LGBP (4.12%). Clinical case: 28-year-old woman, operated of LGBP (BMI = 49; co-morbidity: diabetes mellitus and arthropathy) about 10 mo before, was affected by recurrent abdominal pain with alvus alteration lasting for a week. After vomiting, she went to first aid Unit of a peripheric hospital where she made blood tests, RX and US of abdomen that resulted normal so she was discharged with flu like syndrome diagnosis. After 3 d the patient contacted our Center since her symptoms got worse and was hospitalized. Blood tests showed an alteration of hepatic enzymes and amylases. The abdominal computed tomography (CT) showed the presence of fluid in peri-splenic, peri-hepatic areas and in pelvis and a “target like imagine” of “clustered ileal loops” with a superior mesenteric vein (SMV) thrombosis involving the Portal Vein. During the operation, we found a necrosis of 80 cm of ileus (about 50 cm downstream the jejuno-jejunal anastomosis) due to an internal hernia through Petersen’s space causing a SMV thrombosis. The necrotic bowel was removed, the internal hernia was reduced and Petersen’ space was sutured by not-absorbable running suture. An anticoagulant therapy was begun in the post-operative time and the patient was discharged after 28 d. Conclusions: The internal hernia diagnosis is rarely confirmed by preoperative exams and it is obtained in most cases by laparoscopy but the improvement of technologies and the discover of “new” CT signs interpretation can address to an early laparoscopic treatment for high suspicion cases.

Keywords: Intestinal infarction, Internal hernia, Petersen’s hernia, Laparoscopic gastric bypass, Portomesenteric thrombosis

Core tip: We report a rare case of patients with a small bowel infarction due to Portomesenteric Vein thrombosis following an Internal Hernia through the Petersen’s space as a complication of Roux-en-Y laparoscopic gastric bypass and the different computed tomography physiological and pathological “uncommon signs” that must be searched and recognized. With the progressive diffusion of Bariatric Surgery, it is very important that all digestive surgeons and emergency physicians have knowledge of these rare but serious complication caused by internal hernia because these patients could be also hospitalized in urgency in whatever Surgery Unit that doesn’t commonly deal with obesity surgery.