by Wasef Abu-Jaish, MD, FACS; Tristan McKnight, MS-III; Conor O’Neill, MD
Dr. Abu-Jaish is from The University of Vermont College of Medicine and The University of Vermont Medical Center. Mr. McKnight is a third-year medical student at The University of Vermont College of Medicine. Dr. O’Neill is a PGY III surgical resident at The University of Vermont Medical Center.
Bariatric Times. 2016;13(5):16–18.
Roux-en-Y gastric bypass (RYGB) was the most common bariatric procedure performed for obesity in the United States from 2004 to 2012, and complications are not uncommon. To our knowledge, diaphragmatic hernia is not a known complication after RYGB; however, it is a potentially fatal complication with increased risk for ischemia and perforation of the incarcerated contents.
Here, we present the case of a middle-aged women who presented years after RYGB surgery without the typical signs and symptoms of internal herniation or stricture. The patient was diagnosed with a diaphragmatic hernia using imaging, and the diagnosis was confirmed with exploratory laparoscopy. This case illustrates the importance of maintaining a high level of suspicion of diaphragmatic hernia in patients presenting with acute or recurrent atypical gastrointestinal and respiratory symptoms many years after open undivided RYGB. It also demonstrates the need for early radiological evaluation and involvement with the bariatric surgery team followed by prompt surgical intervention by laparoscopy or laparotomy.
Laparoscopic Roux-en-Y gastric bypass (RYGB) was the most common bariatric procedure performed in the United States from 2004 to 2012, after which sleeve gastrectomy (SG) became the most common procedure. Complications of RYGB are not uncommon, and the evaluation for gastrointestinal symptoms and abdominal pain can be difficult. Nausea, vomiting, and abdominal pain are common complaints following RYGB, with late complications most commonly due to internal hernias or small bowel obstruction etiologies. Internal hernias have been described in 0 to 5 percent of patients undergoing laparoscopic bariatric surgery and are well controlled by closing all potential internal hernia defects. However, internal hernias can be intermittent and, therefore, difficult to detect radiographically. Other causes of obstructive symptoms can be herniation at port sites, strictures at the jejunojejunal anastomosis, intussusception, and, especially in open cases, adhesions.
Here, we present a case of a patient who experienced nausea, vomiting, severe left upper quadrant abdominal pain, and shortness of breath 18 years following an open undivided RYGB. A computed tomography (CT) scan of her abdomen and pelvis showed a left-sided diaphragmatic hernia.
A 42-year-old female with a history of an open undivided RYGB in 1996 and chronic pain treated with opiates presented to the emergency department with the chief complaint of recurrent severe left upper quadrant (LUQ) abdominal pain with nausea and vomiting, as well as mild shortness of breath. Her body mass index (BMI) was 26.6kg/m2, her vital signs were stable and physical exam demonstrated a non-distended abdomen that was soft but tender upon palpation in the LUQ with minimal guarding and no rebound. Her past surgical history also included a vaginal hysterectomy (2006), bladder suspension (2006), and breast surgery (2008). A CT scan of the abdomen and pelvis with contrast showed a left sided diaphragmatic hernia containing a gas-distended gastric fundus without evidence of strangulation or volvulus (Figure 1 and Figure 2). The imaging studies were reviewed together with CT and gastrointestinal radiology attendings, however, no definite answer was obtained to delineate the nature of the patient’s diaphragmatic hernia. She was admitted by the general surgery service for intravenous hydration and bowel rest, as well as pain control, however, the patient declined to discuss any surgical options as her acute symptoms soon resolved. Therefore, she was discharged the following day due to symptom resolution and advised to follow up with bariatric surgery.
The patient presented to the emergency department two days later with renewal of symptoms and a new history of fever. An acute abdominal series again demonstrated a left sided diaphragmatic hernia with herniation of stomach and portions of bowel into the left thoracic cavity (Figure 3). The bowel was normal in caliber and there was no intraperitoneal free air. Due to the presence of air in the herniated gastric remnant, she underwent upper GI and small bowel follow through imaging, as well as upper endoscopy and esophagogastroduodenoscopy, which confirmed that no gastrogastric fistula was present (Figure 4). A repeat CT scan was not performed, as it was not deemed necessary to rule out pulmonary emboli as a cause of her shortness of breath in the setting of the demonstrated incarcerated abdominal content captured on CT scan two days prior. The patient was admitted by the bariatric surgery service, and diagnostic laparoscopy with laparoscopic diaphragmatic hernia repair with mesh and gastropexy was performed.
The operative procedure began with a 12mm camera-port off midline supraumbilically, three 5mm trocars in the right upper quadrant, left upper quadrant and high in the epigastric region, as well as a 12mm trocar in the right lower quadrant (Figure 5). After extensive laparoscopic lysis of adhesions, she was found to have a 4x5cm diaphragmatic defect less than 1cm from the left crus in close proximity to the gastroesophageal junction with incarceration of the distal transverse colon, the gastric remnant, and the upper pole of the spleen. These were carefully reduced back into the abdomen. No true hernia sac, gastrogastric fistula, or paraesophageal hernia were found (Figure 6 and Figure 7).
During the intraoperative endoscopy, the anterior wall of the Roux limb was perforated. We repaired this enterotomy in two full thickness layers using 2-0 absorbable suture while the endoscope acted as a stent to prevent narrowing or catching of the posterior wall (Figure 8). The integrity of the Roux limb repair was tested and was confirmed to be patent with a negative air leak (Figure 9).
Due to the location of the diaphragmatic defect and its proximity to the left crus and gastroesophageal junction, we elected to place a biological thick AlloDerm® mesh (LifeCell Corporation, Bridgewater, New Jersey) instead of permanent synthetic mesh. Trimmed to 5x6cm, the mesh was secured all around using six nonabsorbable 0-0 sutures, which broadly covered the defect. The mesh was secured again between these sutures using 4.5mm tacks (Figure 10). A 22-French gastrostomy tube was placed into the gastric remnant and placed to gravity (Figure 11).
The patient tolerated the procedure well and was extubated in the operating room and transferred to the surgical ICU for further observation. Her postoperative course was uncomplicated and, due to her chronic pain issue, she was discharged on postoperative day eight. One year later, she was seen in the emergency department for biliary type colic and an abdominal ultrasound and CT scan confirmed the diagnosis of gallbladder stones (Figure 12).
The development of intractable nausea and vomiting coupled with shortness of breath are nonspecific late complications of RYGB. The most common causes of such symptoms include small bowel obstruction and internal hernias, but here we described a patient who presented years after RYGB surgery with abdominal pain, nausea, and vomiting, occasional shortness of breath, and a diaphragmatic hernia identified using CT scan. Diaphragmatic hernias in adults are exceedingly rare and most often are due to hiatal hernias, paraesophageal hernias, or traumatic disruption of the diaphragm. The position of the defect was less than 1cm from the left diaphragmatic crus, and thus not congruent with standard hiatal and paraesophageal hernia locations. Bochdalek hernias are a form of congenital diaphragmatic hernia that rarely present in adulthood. These hernias arise from a defect in the posterolateral surface of the diaphragm, often presenting in neonates as respiratory distress. There have been less than 200 reports of Bochdalek hernias in adults, who typically present with abdominal pain. Only 18 percent of Bochdalek hernias are located on the left-side of the diaphragm, as the anterior portion of the left hemidiaphragm is protected from herniation by overlying pericardial sac.
A second type of congenital diaphragmatic hernia, Morgagni hernia, is the least common type of diaphragmatic hernia, accounting for 1 to 6 percent of all diaphragmatic hernias. Morgagni hernias are most commonly right-sided but, unlike Bochdalek hernias, they are usually lined by a peritoneal sac and are anterior. This patient’s diaphragmatic hernia was left sided, posterior, and the herniated contents were not contained in a true hernia sac, making neither Bochadalek nor Morgagni hernia a likely etiology of new onset intractable nausea and vomiting in middle age. In light of these considerations, we believe the hernia in this patient was caused by trauma to the diaphragm experienced during her open undivided RYGB procedure.
Diaphragmatic herniation following RYGB is an extremely rare and potentially fatal complication that must be considered in patients that present with acute or recurrent intermittent symptoms indicative of obstruction, including nausea, vomiting, and shortness of breath. Management should focus on prompt resuscitation, evaluation by CT scan, and surgery to avoid strangulation of herniated organs. In our case, the diaphragmatic defect was likely iatrogenic, caused by a stapler used during the open undivided RYGB procedure. It is most likely that the defect enlarged over time and the gastric remnant, the upper pole of the spleen, and a portion of the colon eventually herniated into the thoracic cavity.
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FUNDING: No funding was provided.
DISCLOSURES: The authors report no conflicts relevant to the content of this article.