Surgery and considerations for the repair of Petersen's space hernia after mini gastric bypass.

This paper reports a case of Petersen's space hernia after mini gastric bypass. This is an anecdotal post-operative complication in the mini gastric bypass technique, with an estimated rate of 1/5000 cases. Similar cases described in the literature were treated by the surgical hernia reduction and the closure of the mesenteric defect. Our patient had a unique management, performing a conversion to Roux-en-Y gastric bypass with dissection of the biliopancreatic limb at the anastomosis and creation of a variable foot-point anastomosis with excellent mid-term post-operative results. This should provide better long-term results as compared to simple mesenteric closure, avoiding the complications of mini gastric bypass technique.

INTRODUCTION

Numerous complications have been reported in association with mini gastric bypass. Amongst them, bile reflux is of particular interest because of potential esophageal epithelial damage in the long run.

We report the case of a patient who received a mini gastric bypass in a different center, and now presents with nonspecific chronic abdominal pain of unknown origin. Abdominal CT and the rest of the workup ruled out technical complications, and a laparoscopic revision revealed a Petersen's space hernia with a bent biliopancreatic loop secondary to adhesions to the staple line of the gastric remnant. The afferent biliopancreatic limb was freed and sectioned, and the technique converted to Roux-en-Y gastric bypass with excellent mid-term postoperative results.

CASE REPORT

A 26-year-old male with body mass index (BMI) 51 kg/m2 (weight 151 kg, height 172 cm) was laparoscopically operated on 2010 to receive a single-anastomosis gastric bypass at 250 cm from the Treitz ligament.

He visits our clinic 5 years after surgery (weight 65 kg, BMI 22 kg/m2) for intermittent and chronic abdominal pain. An abdominal computed tomography (CT) scan is normal, only a non-collapsed gastric remnant with fluid inside is noted [Figure 1]. Upper and lower digestive endoscopies obtain normal results. Laboratory parameters are within the normal range except for ferropenic anaemia: Hb 11.8 g/dL; mean corpuscular volume 71.5 fL; albumin 4.7 g/dL; iron 17 μg/dL (60–150); ferritin 8.3 ng/mL (20.0–250.0); and Vitamin B12 508 pg/mL (191–663).

Figure 1

Pre-operative abdominal computed tomography. Arrow marks the gastric remnant filled with fluid inside. The square marks the bent biliopancreatic loop

Despite these findings, a laparoscopic revision is decided upon. During surgery, biliopancreatic loop adhesions are noted (the loop itself was angled and posterior to the gastrojejunal anastomosis), which are freed using a harmonic scalpel, and then, firm adhesions to the staple line of the gastric remnant are encountered. All this gave rise to a Petersen's space hernia, fixed by the biliopancreatic loop adhesions, which was responsible for the patient's subocclusive events, with no signs of intestinal ischemia. The mini gastric bypass was turned into a Roux-en-Y gastric bypass with section of the afferent biliopancreatic limb using a 45-mm Endo GIA (Medtronic, USA), vascular load and enteroenteric anastomosis at 80 cm from the gastrojejunal anastomosis performed in the previous procedure. Subsequently, the mesenteric defect was closed with running silk suture (2-0). An intraoperative endoscopic procedure excluded perforations and gastrogastric fistulae.

The post-operative course was favourable and the patient was discharged on the 3rd day after surgery. Post-operative weight loss stabilised, with neither malnutrition nor weight gain. After 6 months, the patient remains free from abdominal pain episodes.

DISCUSSION

Mini gastric bypass emerged as an attempt to simplify Roux-en-Y bypass technique by using a single gastrojejunal anastomosis. The most common complication is gastritis and esophagitis from biliary juice, with the ensuing potential risk of developing a carcinoma.[1]

Petersen's hernia is an internal hernia that develops from the passage of the small intestine through the space between the transverse mesocolon and gastrojejunal anastomosis. This complication is more common with the Roux-en-Y gastric bypass, with an incidence of 10% that boils down to 1%–2% when the mesenteric defect is closed.[2] However, the closure of the mesenteric defect is not currently indicated for mini gastric bypass since hernias are anecdotal with this technique, with an estimated rate of 1/5000 cases.[3]

Clinical manifestations are usually non-specific; therefore, diagnosis is commonly delayed. Abdominal CT is the most useful diagnostic modality. Treatment consists of surgical hernia reduction; relapse risk decreases with closure of the mesenteric defect. Conversion to Roux-en-Y is another available option, previously made by Chevallier et al. to manage biliopancreatic reflux refractory to medical treatment.[4] The technique involves resecting the gastrojejunal anastomosis and creating a foot-point anastomosis, with resection being required to increase the absorptive channel to preclude malabsorption. Another less common, simplified variant of conversion involves sectioning the afferent biliopancreatic limb at the anastomosis [Figure 2] and creating a foot-point to manage the complication that led to the procedure, as in our case report.[5] The surgeon must ensure a wide common channel to avoid malabsorption. Our patient had a wide, 350 cm-long common channel; hence, anastomosis resection was not required. As a technical consideration, the importance of completely dissecting the afferent limb to the anastomotic end to avoid a long stump potentially resulting in bacterial overgrowth and halitosis cannot be overstated.

Figure 2

Intraoperative findings. (a and b) The biliopancreatic loop bent and attached to the anastomosis. (c) Biliopancreatic limb behind the gastroyeyunal anastomosis, becoming the Petersen's hernia. (d) The section of the biliopancreatic limb. R: Reservoir, GR: Gastric remnant, BPL: Biliopancreatic limb, AL: Alimentary limb

In our patient, in contrast with the other two cases thus far reported,[67] conversion to Roux-en-Y rather than mesenteric closure was decided upon. With such conversion and an appropriate closure of mesenteric defects, relapsing hernia is prevented, as are the complications associated with mini gastric bypass, including reflux.[5]

CONCLUSION

Petersen's hernia is an anecdotal complication with mini gastric bypass technique, so the closure of the mesenteric defect is not currently indicated. We have described a unique case of Petersen's hernia after mini gastric bypass given the peculiarities involved in its diagnosis and management. For similar patients with a long biliopancreatic limb, we deem it most appropriate to perform a conversion to Roux-en-Y gastric bypass with dissection of the biliopancreatic limb at the anastomosis and creation of a variable foot-point anastomosis, thus avoiding the resection of the anastomosis itself; this should provide better long-term results as compared to simple mesenteric closure,[67] avoiding the complications of mini gastric bypass technique.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.