Hernia Interna Complicaciones Ciruga Baritrica y Metablica Dra

Hernia Interna - Complicaciones Cirugía Bariátrica y Metabólica- Dra. Ana Paulina Pimienta.

Hernia Interna – Incidencia, 6% (sintomática) – Primeros dos años después de cirugía – Causa de obstrucción intestinal en pacientes post quirúrgicos de RYGB (42 -61% de los casos) – Evolución de la técnica quirúrgica - Creación del pouch Anastomosis gastro-entérica (engrapadora, manual) Realización (y posicionamiento) de asa alimentaria Defectos mesentéricos - Realización (y posicionamiento) de asa alimentaria Retrocólica – retrogástrica Retrocólica – antegástrica Antecólica – antegástrico Alhaj Saleh A. , Abbas M. (2018) Internal Hernia and Small Bowel Obstruction After Roux-en-Y Gastric Bypass. In: Camacho D. , Zundel N. (eds) Complications in Bariatric Surgery. pg. 167 -178. Springer, Cham

- Realización (y posicionamiento) de asa alimentaria - Defectos mesentéricos - Pérdida de peso – Rápida pérdida de grasa mesentérica que no permite el cierre completo de defecto mesentéricos. Schneider C, Cobb W, Scott J, Carbonell A, Myers K, Bour E. Rapid excess weight loss following laparoscopic gastric bypass leads to increased risk of internal hernia. Surg Endosc. 2011; 25(5): 1594– 8.

– Protrusión de una víscera a través de una apertura peritoneal o mesentérica, dentro de la cavidad peritoneal, que conduce a su encapsulación dentro de un compartimento en el interior de la cavidad abdominal. Alhaj Saleh A. , Abbas M. (2018) Internal Hernia and Small Bowel Obstruction After Roux-en-Y Gastric Bypass. In: Camacho D. , Zundel N. (eds) Complications in Bariatric Surgery. pg. 167 -178. Springer, Cham

– Hernia transmesocólica – Hernia transmesentérica (espacio Yeyuno-yeyunostomía) – Hernia Espacio Petersen – Dr. Walther Petersen (1900) Alhaj Saleh A. , Abbas M. (2018) Internal Hernia and Small Bowel Obstruction After Roux-en-Y Gastric Bypass. In: Camacho D. , Zundel N. (eds) Complications in Bariatric Surgery. pg. 167 -178. Springer, Cham

– Hernia Espacio anastomosis yeyuno Paroz A, Calmes JM, Romy S, Giusti V, Suter M. A new type of internal hernia after laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2009; 19(4): 527– 30.

Espacio transmesocólico Espacio Petersen Schneider C, Cobb W, Scott J, Carbonell A, Myers K, Bour E. Rapid excess weight loss following laparoscopic gastric bypass leads to increased risk of internal hernia. Surg Endosc. 2011; 25(5): 1594– 8. Espacio Mesoyeyunal Kawkabani Marchini, A. , Denys, A. , Paroz, A. , Romy, S. , Suter, M. , Desmartines, N. , Meuli, R. , & Schmidt, S. (2011). The four different types of internal hernia occurring after laparascopic Roux-en-Y gastric bypass performed for morbid obesity: are there any multidetector computed tomography (MDCT) features permitting their distinction? . Obesity surgery, 21(4), 506– 516. https: //doi. org/10. 1007/s 11695 -011 -0364 -7 Espacio Yeyuno yeyunostomía

Diagnóstico y tratamiento deben ser oportunos Cuadro agudo (estrangulación) puede poner en riesgo la vida del paaciente Se puede desarrollar una hernia interna en cualquier momento del post operatorio; incluso años después. Más frecuente 1 a 3 años (mayor pérdida de peso) Alhaj Saleh A. , Abbas M. (2018) Internal Hernia and Small Bowel Obstruction After Roux-en-Y Gastric Bypass. In: Camacho D. , Zundel N. (eds) Complications in Bariatric Surgery. pg. 167 -178. Springer, Cham

– Dolor abdominal 53. 4% – Náusea ± vómito 16% – Dolor abdominal agudo Náusea ± vómito (8. 8%) – Dolor abdominal agudo Peritonitis (2. 2%) Alhaj Saleh A. , Abbas M. (2018) Internal Hernia and Small Bowel Obstruction After Roux-en-Y Gastric Bypass. In: Camacho D. , Zundel N. (eds) Complications in Bariatric Surgery. pg. 167 -178. Springer, Cham

– Obstrucción intestinal, aumento de amilasa y lipasa en 40 % de los casos – Elevación de amilasa es sospecha diagnóstica importante (* asa biliopancreática) – En estudios de imagen, el 20% de los casos son negativos. Estudios de laboratorio son inespecíficos Alhaj Saleh A. , Abbas M. (2018) Internal Hernia and Small Bowel Obstruction After Roux-en-Y Gastric Bypass. In: Camacho D. , Zundel N. (eds) Complications in Bariatric Surgery. pg. 167 -178. Springer, Cham

Ahmed AR, Rickards G, Johnson J, Boss T, O'Malley W. Radiological findings in symptomatic internal hernias after laparoscopic gastric bypass. Obes Surg. 2009; 19(11): 1530– 5.

Tomografía + contraste (34 pacientes) • Dilatación de asas • Distensión remanente gástrico • Asas en hipocondrio izquierdo • Edema interasa – 3 con TAC negativa: 2 dx: rx + contraste 1 laparoscopía diagnóstica Ahmed AR, Rickards G, Johnson J, Boss T, O'Malley W. Radiological findings in symptomatic internal hernias after laparoscopic gastric bypass. Obes Surg. 2009; 19(11): 1530– 5.

RX abdominal + contraste (17 pacientes) • Dilatación de asas • Asa alimentaria redundante • Asas en hipocondrio izquierdo • Tránsito lento – 9 con Rx + contraste negativa: TAC positiva (dx hernia interna) Ahmed AR, Rickards G, Johnson J, Boss T, O'Malley W. Radiological findings in symptomatic internal hernias after laparoscopic gastric bypass. Obes Surg. 2009; 19(11): 1530– 5.

92%, TAC + Doble contraste TAC + RX contrastada = 100% No retrasar tratamiento en pacientes con cuadros agudos y/ó inestabilidad hemodinámica; independientemente del resultado de imagen. Ahmed AR, Rickards G, Johnson J, Boss T, O'Malley W. Radiological findings in symptomatic internal hernias after laparoscopic gastric bypass. Obes Surg. 2009; 19(11): 1530– 5.

Signo del champiñon Signo del ojo del huracán Lockhart, M. E. , Tessler, F. N. , Canon, C. L. , Smith, J. K. , Larrison, M. C. , Fineberg, N. S. , Roy, B. P. , & Clements, R. H. (2007). Internal hernia after gastric bypass: sensitivity and specificity of seven CT signs with surgical correlation and controls. AJR. American journal of roentgenology, 188(3), 745– 750. https: //doi. org/10. 2214/AJR. 06. 0541

Sheafor, D. (2018). Imaging of postoperative internal hernias. Applied radiology. https: //www. appliedradiology. com

Hernia transmesocólica Sheafor, D. (2018). Imaging of postoperative internal hernias. Applied radiology. https: //www. appliedradiology. com

Hernia transmesentérica Sheafor, D. (2018). Imaging of postoperative internal hernias. Applied radiology. https: //www. appliedradiology. com

Hernia transmesentérica Sheafor, D. (2018). Imaging of postoperative internal hernias. Applied radiology. https: //www. appliedradiology. com

Hernia Petersen Compresión de VMS, 70% M. T. Ong, V. Leung, E. Haider, L. C. Zurita(2014). Early CT detection of Petersen's Hernias in Antecolic Rouxen-Y Gastric Bypass patients with Surgical Correlation. ESR. European Society of Radiology. DOI: 10. 1594/ecr 2014/C-1542

Anastomosis distal, hacia izquierda de línea media (100%) M. T. Ong, V. Leung, E. Haider, L. C. Zurita(2014). Early CT detection of Petersen's Hernias in Antecolic Rouxen-Y Gastric Bypass patients with Surgical Correlation. ESR. European Society of Radiology. DOI: 10. 1594/ecr 2014/C-1542

Tratamiento (quirúrgico) La urgencia quirúrgica dependerá del estado clínico del paciente Alhaj Saleh A. , Abbas M. (2018) Internal Hernia and Small Bowel Obstruction After Roux-en-Y Gastric Bypass. In: Camacho D. , Zundel N. (eds) Complications in Bariatric Surgery. pg. 167 -178. Springer, Cham

• Respuesta inflamatoria sistémica / compromiso hemodinámico • Abdomen agudo • Obstrucción (aguda) grave Alhaj Saleh A. , Abbas M. (2018) Internal Hernia and Small Bowel Obstruction After Roux-en-Y Gastric Bypass. In: Camacho D. , Zundel N. (eds) Complications in Bariatric Surgery. pg. 167 -178. Springer, Cham

– Dolor + distensión abdominal – Datos obstrucción (náusea± vómitos) – 9(11): Hernia interna – 2: regresaron cuadro agudo Intervención quirúrgica temprana es importante para evitar complicaciones graves. Gandhi, Alok & Patel, Rohit & Brolin, Robert. (2008). Elective laparoscopy for herald symptoms of mesenteric/internal hernia after laparoscopic Roux-en-Y gastric bypass. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery. 5. 144 -9; discussion 149. 1016/j. soard. 2008. 11. 002.

– Estabilizar paciente – Mejorar condición clínica del paciente – Terapía hídrica – Desorden hidroelectrolítico (K) – Descompresión gástrica Alhaj Saleh A. , Abbas M. (2018) Internal Hernia and Small Bowel Obstruction After Roux-en-Y Gastric Bypass. In: Camacho D. , Zundel N. (eds) Complications in Bariatric Surgery. pg. 167 -178. Springer, Cham

– Descompresión gástrica – SNG (8 cm distales fenestras) – Pouch gástrico (5 -6 cm) Van Dinter, T. G. , Jr, John, L. , Guileyardo, J. M. , & John S, F. (2013). Intestinal perforation caused by insertion of a nasogastric tube late after gastric bypass. Proceedings (Baylor University. Medical Center), 26(1), 11– 15. https: //doi. org/10. 1080/08998280. 2013. 11928900

[(NEX – 50) / 2] + 50 • = 50 -70 cm • Restando 10 -15 cm, podemos disminuir riesgo de perforación/ complicación • Guiada por fluoroscopía Van Dinter, T. G. , Jr, John, L. , Guileyardo, J. M. , & John S, F. (2013). Intestinal perforation caused by insertion of a nasogastric tube late after gastric bypass. Proceedings (Baylor University. Medical Center), 26(1), 11– 15. https: //doi. org/10. 1080/08998280. 2013. 11928900 NEX

– Distensión del remanente gástrico – Descompresión percutánea – Sonda de gastrostomía Van Dinter, T. G. , Jr, John, L. , Guileyardo, J. M. , & John S, F. (2013). Intestinal perforation caused by insertion of a nasogastric tube late after gastric bypass. Proceedings (Baylor University. Medical Center), 26(1), 11– 15. https: //doi. org/10. 1080/08998280. 2013. 11928900

Puntos importantes durante la intervención quirúrgica 1. Abierta / Laparoscópica (8% conversión) 2. Revisión total del intestino, iniciando por Treitz ó VIC • Intestino colapsado posterior a obstrucción • Identificación de asa biliopancreática y asa alimentaria 3. Revisar todos los sitios potenciales para hernia interna • 4. Reducción de cualquier hernia interna que se encuentre Viabilidad intestinal • Estrangulación Resección intestinal Alhaj Saleh A. , Abbas M. (2018) Internal Hernia and Small Bowel Obstruction After Roux-en-Y Gastric Bypass. In: Camacho D. , Zundel N. (eds) Complications in Bariatric Surgery. pg. 167 -178. Springer, Cham

Puntos quirúrgicos para la prevención de hernias internas 1. Cierre ( ó no ) de defectos mesentéricos 2. Posicionamiento de asa alimentaria antecólica ó retrocólica Alhaj Saleh A. , Abbas M. (2018) Internal Hernia and Small Bowel Obstruction After Roux-en-Y Gastric Bypass. In: Camacho D. , Zundel N. (eds) Complications in Bariatric Surgery. pg. 167 -178. Springer, Cham

1. Cierre ( ó no ) de defectos mesentéricos • Cierre con sutura continua no absorbible Hernia de Petersen • De 6. 2 a <1% Bauman, R. W. , & Pirrello, J. R. (2009). 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. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery, 5(5), 565– 570. https: //doi. org/10. 1016/j. soard. 2008. 10. 013 Hernia Interna • De 2. 6% a 0. 5% Brolin, R. E. , & Kella, V. N. (2013). Impact of complete mesenteric closure on small bowel obstruction and internal mesenteric hernia after laparoscopic Roux-en-Y gastric bypass. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery, 9(6), 850– 854. https: //doi. org/10. 1016/j. soard. 2012. 11. 007

2. Posicionamiento asa antecólica / retrocólica Alhaj Saleh A. , Abbas M. (2018) Internal Hernia and Small Bowel Obstruction After Roux-en-Y Gastric Bypass. In: Camacho D. , Zundel N. (eds) Complications in Bariatric Surgery. pg. 167 -178. Springer, Cham

RYGB Retrocólico RYGB Antecólico 2. 4 % 0. 3 % p <0. 0001 Koppman, J. S. , Li, C. , & Gandsas, A. (2008). Small bowel obstruction after laparoscopic Roux-en-Y gastric bypass: a review of 9, 527 patients. Journal of the American College of Surgeons, 206(3), 571– 584. https: //doi. org/10. 1016/j. jamcollsurg. 2007. 10. 008

0. 7% 6. 9% p = 0. 0018 Nandipati, K. C. , Lin, E. , Husain, F. , Srinivasan, J. , Sweeney, J. F. , & Davis, S. S. (2012). Counterclockwise rotation of Roux-en-Y limb significantly reduces internal herniation in laparoscopic Roux-en-Y gastric bypass (LRYGB). Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract, 16(4), 675– 681. https: //doi. org/10. 1007/s 11605 -011 -1755 -8

• División mínima de mesenterio • No dividir omento • Muñón de asa alimentaria hacia la izquierda y desciende hacia la derecha; asa biliopancreática a la izquierda Ortega, J. , Cassinello, N. , Sánchez-Antúnez, D. , Sebastián, C. , & Martínez-Soriano, F. (2013). Anatomical basis for the low incidence of internal hernia after a laparoscopic Roux-en-Y gastric bypass without mesenteric closure. Obesity surgery, 23(8), 1273– 1280. https: //doi. org/10. 1007/s 11695 -013 -0902 -6

Referencias Bibliográficas 1. Alhaj Saleh A. , Abbas M. (2018) Internal Hernia and Small Bowel Obstruction After Roux-en-Y Gastric Bypass. In: Camacho D. , Zundel N. (eds) Complications in Bariatric Surgery. pg. 167 -178. Springer, Cham 2. Kawkabani Marchini, A. , Denys, A. , Paroz, A. , Romy, S. , Suter, M. , Desmartines, N. , Meuli, R. , & Schmidt, S. (2011). The four different types of internal hernia occurring after laparascopic Roux-en-Y gastric bypass performed for morbid obesity: are there any multidetector computed tomography (MDCT) features permitting their distinction? . Obesity surgery, 21(4), 506– 516. https: //doi. org/10. 1007/s 11695 -011 -0364 -7 3. Paroz A, Calmes JM, Romy S, Giusti V, Suter M. A new type of internal hernia after laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2009; 19(4): 527– 30. 4. Schneider C, Cobb W, Scott J, Carbonell A, Myers K, Bour E. Rapid excess weight loss following laparoscopic gastric bypass leads to increased risk of internal hernia. Surg Endosc. 2011; 25(5): 1594– 8. 5. Ahmed AR, Rickards G, Johnson J, Boss T, O'Malley W. Radiological findings in symptomatic internal hernias after laparoscopic gastric bypass. Obes Surg. 2009; 19(11): 1530– 5. 6. Lockhart, M. E. , Tessler, F. N. , Canon, C. L. , Smith, J. K. , Larrison, M. C. , Fineberg, N. S. , Roy, B. P. , & Clements, R. H. (2007). Internal hernia after gastric bypass: sensitivity and specificity of seven CT signs with surgical correlation and controls. AJR. American journal of roentgenology, 188(3), 745– 750. https: //doi. org/10. 2214/AJR. 06. 0541 7. Sheafor, D. (2018). Imaging of postoperative internal hernias. Applied radiology. https: //www. appliedradiology. com 8. M. T. Ong, V. Leung, E. Haider, L. C. Zurita(2014). Early CT detection of Petersen's Hernias in Antecolic Rouxen-Y Gastric Bypass patients with Surgical Correlation. ESR. European Society of Radiology. DOI: 10. 1594/ecr 2014/C-1542 9. Gandhi, Alok & Patel, Rohit & Brolin, Robert. (2008). Elective laparoscopy for herald symptoms of mesenteric/internal hernia after laparoscopic Roux-en-Y gastric bypass. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery. 5. 144 -9; discussion 149. 1016/j. soard. 2008. 11. 002. 10. Van Dinter, T. G. , Jr, John, L. , Guileyardo, J. M. , & John S, F. (2013). Intestinal perforation caused by insertion of a nasogastric tube late after gastric bypass. Proceedings (Baylor University. Medical Center), 26(1), 11– 15. https: //doi. org/10. 1080/08998280. 2013. 11928900 11. Bauman, R. W. , & Pirrello, J. R. (2009). 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. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery, 5(5), 565– 570. https: //doi. org/10. 1016/j. soard. 2008. 10. 013 12. Brolin, R. E. , & Kella, V. N. (2013). Impact of complete mesenteric closure on small bowel obstruction and internal mesenteric hernia after laparoscopic Roux-en-Y gastric bypass. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery, 9(6), 850– 854. https: //doi. org/10. 1016/j. soard. 2012. 11. 007 13. Koppman, J. S. , Li, C. , & Gandsas, A. (2008). Small bowel obstruction after laparoscopic Roux-en-Y gastric bypass: a review of 9, 527 patients. Journal of the American College of Surgeons, 206(3), 571– 584. https: //doi. org/10. 1016/j. jamcollsurg. 2007. 10. 008 14. Nandipati, K. C. , Lin, E. , Husain, F. , Srinivasan, J. , Sweeney, J. F. , & Davis, S. S. (2012). Counterclockwise rotation of Roux-en-Y limb significantly reduces internal herniation in laparoscopic Roux-en-Y gastric bypass (LRYGB). Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract, 16(4), 675– 681. https: //doi. org/10. 1007/s 11605 -011 -1755 -8 15. Ortega, J. , Cassinello, N. , Sánchez-Antúnez, D. , Sebastián, C. , & Martínez-Soriano, F. (2013). Anatomical basis for the low incidence of internal hernia after a laparoscopic Roux-en-Y gastric bypass without mesenteric closure. Obesity surgery, 23(8), 1273– 1280. https: //doi. org/10. 1007/s 11695 -013 -0902 -6