- Email: [email protected]
mini gastric bypass
Surgery for Obesity and Related Diseases ] (2017) 00–00
Case report
Efferent limb obstruction and unexpected perforated marginal ulcer in a pregnant patient after one anastomosis gastric bypass/mini gastric bypass Abdelrahman Nimeri, M.D., F.A.C.S., F.A.S.M.B.S.*, Ahmed Maasher, M.D., F.A.C.S., Talat Al Shaban, M.D. Bariatric & Metabolic Institute Abu Dhabi, Chief Division of General, Thoracic and Vascular Surgery, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates Received December 12, 2016; accepted January 3, 2017
Despite the low rate of bile reflux gastritis and marginal ulceration after one anastomosis gastric bypass/mini gastric bypass (OAGB/MGB) in expert hands, we continue to see these complications after OAGB/MGB done in the United Arab Emirates [1–5]. We have reported previously on 2 patients with bile reflux gastritis with or without Braun sideto-side Braun jejunojejunostomy after OAGB/MGB in which both patients had a short pouch and needed conversion to Roux-en-Y gastric bypass [4,5]. We present a video case report of laparoscopic management of a patient who presented during the first trimester of pregnancy with efferent limb obstruction, marginal ulceration, bile reflux gastritis, and severe malnutrition after OAGB/MGB.
Methods We have described previously our management strategy for patients presenting with bile reflux gastritis after OAGB/ MGB, which includes endoscopic and radiographic evaluation. In addition, we presented our technique for converting patients with bile reflux gastritis after OAGB/MGB to hand sewn ante-colic Roux-en-Y gastric bypass (RYGB) [4,5]. In this patient, we were able to obtain the previous operative records, including the video of the index operation OAGB/ MGB, as well as the reoperative video of Braun jejunojejunostomy to correct bile reflux gastritis by the primary surgeon. * Correspondence: Abdelrahman A. Nimeri, Bariatric & Metabolic Institute Abu Dhabi, Chief Division of General, Thoracic and Vascular Surgery, Sheikh Khalifa Medical City, Abu Dhabi, UAE. E-mail: [email protected]
Case details Our patient is a 33-year-old female patient with body mass index of 46 kg/m2 and no previous medical problems. She underwent OAGB/MGB at an outside facility and developed severe bile reflux gastritis/esophagitis, inability to tolerate oral diet, and failure to thrive in the immediate postoperative period. In addition, she was found to be pregnant and failed initial conservative management by the primary surgeon. Furthermore, she underwent re-exploration by the primary surgeon and creation of a Braun side-to-side jejunojejunostomy anastomosis without improvement in her clinical condition. When the patient arrived at our institution several weeks after reoperative surgery, she was 3 months pregnant, malnourished, unable to tolerate her own saliva, and had severe bile reflux gastritis/esophagitis. We could not repeat an upper gastrointestinal study because she was pregnant. Upper endoscopy showed that the patient had a short gastric pouch o4 cm, bile reflux gastritis/esophagitis, nonabsorbable sutures at the gastrojejunostomy, marginal ulceration, and efferent limb obstruction; we could only enter the afferent limb of the OAGB/MGB. She was initially treated with total parenteral nutrition (TPN) because we could not place a naso-jejunal feeding tube due to obstruction of the efferent limb of the OAGB/MGB. In addition, the patient was not able to swallow her saliva or tolerate any oral feeding, including liquids. The patient’s pre-albumin, transferrin, and albumin improved from .09 to .10 and then to .26 gm/L, .9 to 1.5 and then to 1.7 gm/L, and 13 to 15 and then to 25 gm/L, respectively. Evaluation by ultrasound when she arrived at our institution showed that she had positive fetal heart beats
http://dx.doi.org/10.1016/j.soard.2017.01.012 1550-7289/r 2017 American Society for Metabolic and Bariatric Surgery. All rights reserved.
2
A. Nimeri et al. / Surgery for Obesity and Related Diseases ] (2017) 00–00
with reduced amniotic fluid. Repeat ultrasound 2 weeks later showed a viable fetus with low-lying placenta. Further repeat ultrasound 2 days, 4 days, 2 weeks, and 3 weeks after conversion to RYGB showed a viable fetus with normal growth, fetal movement, and amniotic fluid. Our obstetric physicians believed that TPN would not be adequate for fetal or maternal health throughout the pregnancy and recommended surgical intervention. Hence, after several weeks of TPN and after she entered her second trimester, she was laparoscopically explored. Several measures were done to ensure the safety of the fetus, including obstetric evaluation clinically and by ultrasound. We placed the first port at Palmer’s point in the left upper quadrant and made sure all ports were higher up to avoid injury to the gravid uterus. Our plan was not to revise the gastrojejunostomy, to transect the biliary limb between the Braun jejunojejunostomy and the OAGB/MGB gastrojejunostomy, and to create a new stapled gastrojejunostomy to relieve the efferent obstruction and bile reflux gastritis. However, she was found to have a short pouch (o4 cm) and a perforated sealed marginal ulcer (the efferent limb was sealing the ulcer and causing a kink and outflow obstruction). In addition, the patient was found to have 500 cm of total small bowel length with a 300-cm common channel and 200-cm bilio-pancreatic limb. We then revised our operative plan, and she underwent conversion to Roux-en-Y gastric bypass with a 30-cm biliary limb and 75-cm Roux limb. In addition, we placed a feeding gastrostomy tube to help with her feeding during pregnancy. She did well initially, and the bile reflux gastritis resolved and her inability to tolerate oral feeding improved. However, she presented again several weeks after surgery with severe abdominal pain; a computed tomography scan of the abdomen showed small bowel obstruction. She was explored laparoscopically and found to have bowel obstruction from adhesions to the gastrostomy tube; a Pettersen internal hernia was found as well. She was treated laparoscopically with lysis of adhesions and a repair of the Pettersen internal hernia was done. She was readmitted several weeks later with abdominal pain, loss of fetal movement, and elevated procalcitonin and was found to have intrauterine fetal death. After delivery, her clinical condition improved and bile reflux gastritis/esophagitis resolved. she was able to tolerate oral diet and is doing well 6 months after surgery. Discussion Our patient had efferent limb obstruction after OAGB/ MGB in the immediate postoperative period, leading to severe bile reflux gastritis, marginal ulceration, inability to swallow her own saliva, and severe malnutrition. However, this presentation was interpreted by her surgeon as bile reflux gastritis only, and she was laparoscopically explored while pregnant and she underwent
Braun jejunojejunostomy. When we reviewed the operative video of the index OAGB/MGB operation, it was evident that the surgeon created a short pouch and made it even shorter while creating the stapled gastrojejunostomy because the stapler jaws were placed high into the gastric pouch. In addition, while closing the gastrojejunostomy, the efferent limb was kinked, and the surgeon used nonabsorbable sutures. It is our impression that her main problem was efferent limb obstruction after OAGB/MGB for several reasons. First, she was not able to tolerate any liquids and was not even able to swallow her own saliva (possibly this was made worse by her pregnancy). In addition, upon review of the reoperative video, upper endoscopy from the referring surgeon, and our own repeat upper endoscopy, it was clear to us that only the biliopancreatic limb was patent, and the endoscopist was not able to intubate the efferent limb. Furthermore, she had a short pouch and failed Braun side-to-side jejunojejunostomy to correct bile reflux gastritis. The presence of inability to tolerate her own saliva was the most subtle hint to the efferent limb obstruction clinically, and this was confirmed by upper endoscopy. Similarly, Noun et al. have described efferent limb obstruction after OAGB/MGB, and we have reported previously on patients presenting with bile reflux gastritis associated with a short pouch and failing Braun side-toside jejunojejunostomy [4–8]. We believe that efferent limb obstruction, similar to bile reflux gastritis, is related to the early learning curve and attention to technical details after OAGB/MGB because these are rare complications in large series from experienced surgeons [6,7]. Our patient presented in her first trimester of pregnancy, and this presentation complicated the diagnostic and management plan. Patients presenting with surgical complications during pregnancy require a high index of suspicion and are more difficult to manage because of the reluctance of patients and healthcare providers to obtain radiographic tests or propose surgical intervention [9–12]. It is possible that she was pregnant when she underwent OAGB/MGB or that she became pregnant soon after OAGB/MGB because it is not unusual for patients to become pregnant soon after bariatric surgery due to improvement in the fertility of morbidly obese women [12]. We were not able to place a naso-jejunal feeding tube; thus, the patient was placed on TPN, and evaluation by the obstetrics physician recommended surgical intervention to correct the efferent limb obstruction because she could not complete a safe pregnancy with severe malnutrition on TPN. Recent studies have shown that proper maternal nutrition is important for a safe pregnancy and improved fetal and neonatal outcomes [13]. Our patient developed intrauterine fetal death several weeks after reoperation for small bowel obstruction resulting from a combination of adhesions and internal
Efferent Obstruction After OAGB/MGB in a Pregnant Patient / Surgery for Obesity and Related Diseases ] (2017) 00–00
hernia. It is possible that the 3 operations to correct bile reflux gastritis, efferent limb obstruction, and small bowel obstruction during pregnancy contributed to the loss of her pregnancy. Other possible contributory factors include maternal obesity and maternal malnutrition [14,15]. Nevertheless, maintaining a high index of suspicion and having a low threshold to perform a computed tomography scan of the abdomen and exploring pregnant patients presenting with abdominal pain after RYGB is paramount to prevent maternal mortality or severe morbidity from surgical conditions presenting in pregnant patients [15]. Our patient had a total small bowel length of 500 cm, and this was another unexpected intraoperative finding. We have stated previously that it is essential to measure the entire bowel length before embarking on conversion from OAGB/MGB to Roux-en-Y reconstruction [5]. It was evident in this patient with only 500 cm of small bowel that we had to reconstruct relatively shorter biliopancreatic and Roux limbs to avoid significant malabsorption with a short pouch and a common channel shorter than 3 m. Conclusion Efferent limb obstruction after OAGB/MGB during pregnancy requires a high index of suspicion. Conversion to RYGB is necessary when it is combined with a marginal ulcer. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. Appendix A Supplementary data Supplementary data are available in the online version of this article at http://dx.doi.org/10.1016/j.soard.2017.01.012
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References [1] Bruzzi M, Rau C, Voron T, Guenzi M, Berger A, Chevallier JM. Single anastomosis or mini-gastric bypass: long-term results and quality of life after a 5-year follow-up. Surg Obes Relat Dis 2015;11 (2):321–6. [2] Noun R, Skaff J, Riachi E, Daher R, Antoun NA, Nasr M. One thousand consecutive mini-gastric bypass: short- and long-term outcome. Obes Surg 2012;22(5):697–703. [3] Musella M, Susa A, Greco F, et al. The laparoscopic mini-gastric bypass: the Italian experience: outcomes from 974 consecutive cases in a multicenter review. Surg Endosc 2014;28(1):156–63. [4] Nimeri A, Al Shaban T, Maasher A. Laparoscopic conversion of one anastomosis gastric bypass/mini gastric bypass to Roux-en-Y gastric bypass for bile reflux gastritis. Surg Obes Relat Dis. Epub 2016 Sep 29. [5] Nimeri A, Al Shaban T, Maasher A. Conversion of one anastomosis gastric bypass/mini gastric bypass to Roux-en-Y gastric bypass for bile reflux gastritis after failed Braun jejunojejunostomy. Surg Obes Relat Dis. Epub 2016 Oct 31. [6] Carbajo MA, Luque-de-León E. Differentiating mini-gastric bypass/ one-anastomosis gastric bypass from the single-anastomosis duodenoileal bypass procedures. Surg Obes Relat Dis 2016;12(4):933–4. [7] Rutledge R. The mini-gastric bypass: experience with the first 1,274 cases. Obes Surg 2001;11(3):276–80. [8] Noun R, Zeidan S, Safa N. Laparoscopic latero-lateral jejunojejunostomy as a rescue procedure after complicated mini-gastric bypass. Obes Surg 2006;16(11):1539–41. [9] Narayanan RP, Syed AA. Pregnancy following bariatric surgerymedical complications and management. Obes Surg 2016;26 (10):2523–9. [10] Gudbrand C, Andreasen LA, Boilesen AE. Internal hernia in pregnant women after gastric bypass: a retrospective register-based cohort study. Obes Surg 2015;25(12):2257–62. [11] Gruetter F, Kraljević M, Nebiker CA, Delko T. Internal hernia in late pregnancy after laparoscopic Roux-en-Y gastric bypass. BMJ Case Rep 2014: bcr2014206770. [12] de Raaff CA, Eshuis WJ, van Wagensveld BA, van Veen RN. Complications of banded laparoscopic Roux-en-Y gastric bypass in a 33-week pregnant woman. J Surg Case Rep 2016;2016(8):rjw137. [13] Nnam NM. Improving maternal nutrition for better pregnancy outcomes. Proc Nutr Soc 2015;74(4):454–9. [14] Haider BA, Bhutta ZA. Multiple-micronutrient supplementation for women during pregnancy. Cochrane Database Syst Rev 2015; (11):CD004905. [15] Renault K, Gyrtrup HJ, Damgaard K, Hedegaard M, Sørensen JL. Pregnant woman with fatal complication after laparoscopic Roux-enY gastric bypass. Acta Obstet Gynecol Scand 2012;91(7):873–5.
Case report
Efferent limb obstruction and unexpected perforated marginal ulcer in a pregnant patient after one anastomosis gastric bypass/mini gastric bypass Abdelrahman Nimeri, M.D., F.A.C.S., F.A.S.M.B.S.*, Ahmed Maasher, M.D., F.A.C.S., Talat Al Shaban, M.D. Bariatric & Metabolic Institute Abu Dhabi, Chief Division of General, Thoracic and Vascular Surgery, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates Received December 12, 2016; accepted January 3, 2017
Despite the low rate of bile reflux gastritis and marginal ulceration after one anastomosis gastric bypass/mini gastric bypass (OAGB/MGB) in expert hands, we continue to see these complications after OAGB/MGB done in the United Arab Emirates [1–5]. We have reported previously on 2 patients with bile reflux gastritis with or without Braun sideto-side Braun jejunojejunostomy after OAGB/MGB in which both patients had a short pouch and needed conversion to Roux-en-Y gastric bypass [4,5]. We present a video case report of laparoscopic management of a patient who presented during the first trimester of pregnancy with efferent limb obstruction, marginal ulceration, bile reflux gastritis, and severe malnutrition after OAGB/MGB.
Methods We have described previously our management strategy for patients presenting with bile reflux gastritis after OAGB/ MGB, which includes endoscopic and radiographic evaluation. In addition, we presented our technique for converting patients with bile reflux gastritis after OAGB/MGB to hand sewn ante-colic Roux-en-Y gastric bypass (RYGB) [4,5]. In this patient, we were able to obtain the previous operative records, including the video of the index operation OAGB/ MGB, as well as the reoperative video of Braun jejunojejunostomy to correct bile reflux gastritis by the primary surgeon. * Correspondence: Abdelrahman A. Nimeri, Bariatric & Metabolic Institute Abu Dhabi, Chief Division of General, Thoracic and Vascular Surgery, Sheikh Khalifa Medical City, Abu Dhabi, UAE. E-mail: [email protected]
Case details Our patient is a 33-year-old female patient with body mass index of 46 kg/m2 and no previous medical problems. She underwent OAGB/MGB at an outside facility and developed severe bile reflux gastritis/esophagitis, inability to tolerate oral diet, and failure to thrive in the immediate postoperative period. In addition, she was found to be pregnant and failed initial conservative management by the primary surgeon. Furthermore, she underwent re-exploration by the primary surgeon and creation of a Braun side-to-side jejunojejunostomy anastomosis without improvement in her clinical condition. When the patient arrived at our institution several weeks after reoperative surgery, she was 3 months pregnant, malnourished, unable to tolerate her own saliva, and had severe bile reflux gastritis/esophagitis. We could not repeat an upper gastrointestinal study because she was pregnant. Upper endoscopy showed that the patient had a short gastric pouch o4 cm, bile reflux gastritis/esophagitis, nonabsorbable sutures at the gastrojejunostomy, marginal ulceration, and efferent limb obstruction; we could only enter the afferent limb of the OAGB/MGB. She was initially treated with total parenteral nutrition (TPN) because we could not place a naso-jejunal feeding tube due to obstruction of the efferent limb of the OAGB/MGB. In addition, the patient was not able to swallow her saliva or tolerate any oral feeding, including liquids. The patient’s pre-albumin, transferrin, and albumin improved from .09 to .10 and then to .26 gm/L, .9 to 1.5 and then to 1.7 gm/L, and 13 to 15 and then to 25 gm/L, respectively. Evaluation by ultrasound when she arrived at our institution showed that she had positive fetal heart beats
http://dx.doi.org/10.1016/j.soard.2017.01.012 1550-7289/r 2017 American Society for Metabolic and Bariatric Surgery. All rights reserved.
2
A. Nimeri et al. / Surgery for Obesity and Related Diseases ] (2017) 00–00
with reduced amniotic fluid. Repeat ultrasound 2 weeks later showed a viable fetus with low-lying placenta. Further repeat ultrasound 2 days, 4 days, 2 weeks, and 3 weeks after conversion to RYGB showed a viable fetus with normal growth, fetal movement, and amniotic fluid. Our obstetric physicians believed that TPN would not be adequate for fetal or maternal health throughout the pregnancy and recommended surgical intervention. Hence, after several weeks of TPN and after she entered her second trimester, she was laparoscopically explored. Several measures were done to ensure the safety of the fetus, including obstetric evaluation clinically and by ultrasound. We placed the first port at Palmer’s point in the left upper quadrant and made sure all ports were higher up to avoid injury to the gravid uterus. Our plan was not to revise the gastrojejunostomy, to transect the biliary limb between the Braun jejunojejunostomy and the OAGB/MGB gastrojejunostomy, and to create a new stapled gastrojejunostomy to relieve the efferent obstruction and bile reflux gastritis. However, she was found to have a short pouch (o4 cm) and a perforated sealed marginal ulcer (the efferent limb was sealing the ulcer and causing a kink and outflow obstruction). In addition, the patient was found to have 500 cm of total small bowel length with a 300-cm common channel and 200-cm bilio-pancreatic limb. We then revised our operative plan, and she underwent conversion to Roux-en-Y gastric bypass with a 30-cm biliary limb and 75-cm Roux limb. In addition, we placed a feeding gastrostomy tube to help with her feeding during pregnancy. She did well initially, and the bile reflux gastritis resolved and her inability to tolerate oral feeding improved. However, she presented again several weeks after surgery with severe abdominal pain; a computed tomography scan of the abdomen showed small bowel obstruction. She was explored laparoscopically and found to have bowel obstruction from adhesions to the gastrostomy tube; a Pettersen internal hernia was found as well. She was treated laparoscopically with lysis of adhesions and a repair of the Pettersen internal hernia was done. She was readmitted several weeks later with abdominal pain, loss of fetal movement, and elevated procalcitonin and was found to have intrauterine fetal death. After delivery, her clinical condition improved and bile reflux gastritis/esophagitis resolved. she was able to tolerate oral diet and is doing well 6 months after surgery. Discussion Our patient had efferent limb obstruction after OAGB/ MGB in the immediate postoperative period, leading to severe bile reflux gastritis, marginal ulceration, inability to swallow her own saliva, and severe malnutrition. However, this presentation was interpreted by her surgeon as bile reflux gastritis only, and she was laparoscopically explored while pregnant and she underwent
Braun jejunojejunostomy. When we reviewed the operative video of the index OAGB/MGB operation, it was evident that the surgeon created a short pouch and made it even shorter while creating the stapled gastrojejunostomy because the stapler jaws were placed high into the gastric pouch. In addition, while closing the gastrojejunostomy, the efferent limb was kinked, and the surgeon used nonabsorbable sutures. It is our impression that her main problem was efferent limb obstruction after OAGB/MGB for several reasons. First, she was not able to tolerate any liquids and was not even able to swallow her own saliva (possibly this was made worse by her pregnancy). In addition, upon review of the reoperative video, upper endoscopy from the referring surgeon, and our own repeat upper endoscopy, it was clear to us that only the biliopancreatic limb was patent, and the endoscopist was not able to intubate the efferent limb. Furthermore, she had a short pouch and failed Braun side-to-side jejunojejunostomy to correct bile reflux gastritis. The presence of inability to tolerate her own saliva was the most subtle hint to the efferent limb obstruction clinically, and this was confirmed by upper endoscopy. Similarly, Noun et al. have described efferent limb obstruction after OAGB/MGB, and we have reported previously on patients presenting with bile reflux gastritis associated with a short pouch and failing Braun side-toside jejunojejunostomy [4–8]. We believe that efferent limb obstruction, similar to bile reflux gastritis, is related to the early learning curve and attention to technical details after OAGB/MGB because these are rare complications in large series from experienced surgeons [6,7]. Our patient presented in her first trimester of pregnancy, and this presentation complicated the diagnostic and management plan. Patients presenting with surgical complications during pregnancy require a high index of suspicion and are more difficult to manage because of the reluctance of patients and healthcare providers to obtain radiographic tests or propose surgical intervention [9–12]. It is possible that she was pregnant when she underwent OAGB/MGB or that she became pregnant soon after OAGB/MGB because it is not unusual for patients to become pregnant soon after bariatric surgery due to improvement in the fertility of morbidly obese women [12]. We were not able to place a naso-jejunal feeding tube; thus, the patient was placed on TPN, and evaluation by the obstetrics physician recommended surgical intervention to correct the efferent limb obstruction because she could not complete a safe pregnancy with severe malnutrition on TPN. Recent studies have shown that proper maternal nutrition is important for a safe pregnancy and improved fetal and neonatal outcomes [13]. Our patient developed intrauterine fetal death several weeks after reoperation for small bowel obstruction resulting from a combination of adhesions and internal
Efferent Obstruction After OAGB/MGB in a Pregnant Patient / Surgery for Obesity and Related Diseases ] (2017) 00–00
hernia. It is possible that the 3 operations to correct bile reflux gastritis, efferent limb obstruction, and small bowel obstruction during pregnancy contributed to the loss of her pregnancy. Other possible contributory factors include maternal obesity and maternal malnutrition [14,15]. Nevertheless, maintaining a high index of suspicion and having a low threshold to perform a computed tomography scan of the abdomen and exploring pregnant patients presenting with abdominal pain after RYGB is paramount to prevent maternal mortality or severe morbidity from surgical conditions presenting in pregnant patients [15]. Our patient had a total small bowel length of 500 cm, and this was another unexpected intraoperative finding. We have stated previously that it is essential to measure the entire bowel length before embarking on conversion from OAGB/MGB to Roux-en-Y reconstruction [5]. It was evident in this patient with only 500 cm of small bowel that we had to reconstruct relatively shorter biliopancreatic and Roux limbs to avoid significant malabsorption with a short pouch and a common channel shorter than 3 m. Conclusion Efferent limb obstruction after OAGB/MGB during pregnancy requires a high index of suspicion. Conversion to RYGB is necessary when it is combined with a marginal ulcer. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. Appendix A Supplementary data Supplementary data are available in the online version of this article at http://dx.doi.org/10.1016/j.soard.2017.01.012
3
References [1] Bruzzi M, Rau C, Voron T, Guenzi M, Berger A, Chevallier JM. Single anastomosis or mini-gastric bypass: long-term results and quality of life after a 5-year follow-up. Surg Obes Relat Dis 2015;11 (2):321–6. [2] Noun R, Skaff J, Riachi E, Daher R, Antoun NA, Nasr M. One thousand consecutive mini-gastric bypass: short- and long-term outcome. Obes Surg 2012;22(5):697–703. [3] Musella M, Susa A, Greco F, et al. The laparoscopic mini-gastric bypass: the Italian experience: outcomes from 974 consecutive cases in a multicenter review. Surg Endosc 2014;28(1):156–63. [4] Nimeri A, Al Shaban T, Maasher A. Laparoscopic conversion of one anastomosis gastric bypass/mini gastric bypass to Roux-en-Y gastric bypass for bile reflux gastritis. Surg Obes Relat Dis. Epub 2016 Sep 29. [5] Nimeri A, Al Shaban T, Maasher A. Conversion of one anastomosis gastric bypass/mini gastric bypass to Roux-en-Y gastric bypass for bile reflux gastritis after failed Braun jejunojejunostomy. Surg Obes Relat Dis. Epub 2016 Oct 31. [6] Carbajo MA, Luque-de-León E. Differentiating mini-gastric bypass/ one-anastomosis gastric bypass from the single-anastomosis duodenoileal bypass procedures. Surg Obes Relat Dis 2016;12(4):933–4. [7] Rutledge R. The mini-gastric bypass: experience with the first 1,274 cases. Obes Surg 2001;11(3):276–80. [8] Noun R, Zeidan S, Safa N. Laparoscopic latero-lateral jejunojejunostomy as a rescue procedure after complicated mini-gastric bypass. Obes Surg 2006;16(11):1539–41. [9] Narayanan RP, Syed AA. Pregnancy following bariatric surgerymedical complications and management. Obes Surg 2016;26 (10):2523–9. [10] Gudbrand C, Andreasen LA, Boilesen AE. Internal hernia in pregnant women after gastric bypass: a retrospective register-based cohort study. Obes Surg 2015;25(12):2257–62. [11] Gruetter F, Kraljević M, Nebiker CA, Delko T. Internal hernia in late pregnancy after laparoscopic Roux-en-Y gastric bypass. BMJ Case Rep 2014: bcr2014206770. [12] de Raaff CA, Eshuis WJ, van Wagensveld BA, van Veen RN. Complications of banded laparoscopic Roux-en-Y gastric bypass in a 33-week pregnant woman. J Surg Case Rep 2016;2016(8):rjw137. [13] Nnam NM. Improving maternal nutrition for better pregnancy outcomes. Proc Nutr Soc 2015;74(4):454–9. [14] Haider BA, Bhutta ZA. Multiple-micronutrient supplementation for women during pregnancy. Cochrane Database Syst Rev 2015; (11):CD004905. [15] Renault K, Gyrtrup HJ, Damgaard K, Hedegaard M, Sørensen JL. Pregnant woman with fatal complication after laparoscopic Roux-enY gastric bypass. Acta Obstet Gynecol Scand 2012;91(7):873–5.