Internal hernias in pregnant females with Roux-en-Y gastric bypass: a systematic review

Surgery for Obesity and Related Diseases - (2019) 1–8

Review article

Internal hernias in pregnant females with Roux-en-Y gastric bypass: a systematic review Devangi M. Dave, B.S.a,b, Kevin O. Clarke, M.D.a, John A. Manicone, M.D.a, Adam M. Kopelan, M.D.a, Alan A. Saber, M.D.a,* a

Department of Surgery, Newark Beth Israel Medical Center, RWJ Barnabas Health, Newark, New Jersey b St. George’s University School of Medicine, Grenada, West Indies Received 22 March 2019; accepted 7 June 2019

Abstract

Improved fertility following a Roux-en-Y gastric bypass (RYGB) can lead to pregnancy and increase the risk of internal herniation. A developing fetus and symptoms of pregnancy can mask the diagnosis and delay intervention, leading to deleterious maternal and fetal consequences. The aim of this systematic review is to summarize the literature regarding internal hernias during pregnancy, their management, and patient outcomes. A comprehensive literature search was undertaken on PubMed and Google Scholar to identify cases of internal hernias presenting during pregnancy after RYGB. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for eligibility and inclusion of articles. Twenty-seven articles, with a total of 59 patients, regarding internal herniation during pregnancy after RYGB were identified. Epigastric pain and nausea and vomiting was the most common presentation. Regardless of orientation of the Roux limb and despite previous closure of mesenteric defects, internal herniation can still occur. A triad of epigastric pain, pregnancy, and a history of RYGB should be a red flag for clinicians to consider internal hernias as a top differential diagnosis. Prompt bariatric consultation and rapid intervention will improve maternal and fetal outcomes. (Surg Obes Relat Dis 2019;-:1–8.) Ó 2019 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.

Key words:

Internal hernia; Gastric bypass; Pregnancy; Abdominal pain

Bariatric surgery has become one of the most effective solutions for sustained weight loss [1]. Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most common procedures for treatment of morbid obesity. Females are more likely to undergo a bariatric procedure for weight loss. While significant and sustained weight loss is the primary advantage to bariatric surgery, other positive outcomes include improved fertility in women

* Correspondence: Alan A. Saber, M.D., F.A.C.S., Department of Surgery, Newark Beth Israel Medical Center, 201 Lyons Avenue at Osborne Terrace, Newark, New Jersey 07112. E-mail address: [email protected] (A.A. Saber).

[2]. This improved fertility can increase the chances of pregnancy. However, a pregnancy after Roux-en-Y gastric bypass (RYGB) can increase the risk of internal hernia from associated increased intra-abdominal pressure during pregnancy. A developing fetus and the physiologic changes of pregnancy can mask the diagnosis and delay intervention, leading to deleterious maternal and fetal consequences. This systematic review of internal hernias during pregnancy in patients with previous RYGB identifies common presentations, diagnostic modalities, interventions performed, and outcomes and recommends a management plan for these patients.

https://doi.org/10.1016/j.soard.2019.06.009 1550-7289/Ó 2019 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.

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Devangi M. Dave et al. / Surgery for Obesity and Related Diseases - (2019) 1–8

Methods

Results

A comprehensive search was undertaken on PubMed and Google Scholar for full-text, English-language articles with the search keywords “internal hernia,” “RYGB” or “gastric bypass” or “Roux-en-Y gastric bypass,” and “pregnancy.” Articles that did not involve an internal hernia during pregnancy were excluded. All articles with male patients were excluded. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (Fig. 1) were followed. Articles mentioning “volvulus” or “intussusception” rather than “internal hernias” were excluded. Furthermore, articles including “ventral hernias,” “incisional hernias,” or any other types of hernias were also excluded. Articles about all other bariatric procedures except RYGB were excluded. Both open RYGB and LRYGB were included in this systematic review. All duplicates were removed.

The 27 studies included in this systematic review involved 59 patients with internal herniation during pregnancy. For all the cases reported, the average age of the patient was 29.91 6 5.23 years (range, 22–41 yr), the average gestational age was 28.69 6 5.05 weeks (range, 6–37.43 wk), the average RYGB to internal hernia interval was 2.65 6 1.98 years (range, 5 mo to 9 yr), and the approximate average weight loss was 46.03 6 14.82 kg (range, 18–78.81 kg). Only 1 paper reported the change in body mass index (BMI); hence, the average BMI for all reported cases at the time of internal hernia presentation was used [3]. This was determined to be 25.24 6 1.71 kg/m2 (range, 22–28 kg/m2). All the demographic findings of patients included within each study are outlined in Table 1.

Fig. 1. PRISMA diagram.

Devangi M. Dave et al. / Surgery for Obesity and Related Diseases - (2019) 1–8

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Table 1 Preoperative demographic characteristics First Author (yr) [Ref]

n

Age (yr)

GA (wk)

Bypass-hernia interval (yr)

Current BMI (kg/m2)

Weight loss (kg)

Warsza (2018) [15] Kannan (2018) [7] Goldberg (2017) [3] Guilbaud (2016) [5] Vannevel (2016) [25] Altieri (2015) [26] Gudbrand (2015) [4] Andreasen (2014) [19] Caranta (2014) [27] Gruetter (2014) [28] Borghede (2013) [29] Leal-Gonzalez (2013) [30] Polavarapu (2012) [31] Renault (2012) [22] Tuyeras (2012) [32] Gagne (2010) [33] Hooks (2010) [34] Naef (2010) [35] Torres-Villalobos (2009) [36] Efthimiou (2009) [20] Wang (2007) [37] Ahmed (2006) [10] Bellanger (2006) [8] Baker (2005) [9] Charles (2005) [23] Kakarla (2005) [38] Moore (2004) [21] Total Average Standard deviation Range

1 1 2 1 5 2 18 3 2 1 1 2 1 1 1 4 1 1 2 1 1 1 1 1 1 2 1 59

37 30 31 36 NA 28 27.6 22.7 NA 27 22 33.5 28 22 34 29 38 34 26 26 32 26 27 33 23 34 41

31.6 21 25.5 17 29.2 29.5 27.3 24.4 26.5 34 26 31.4 33 35 31 21.8 36 35 31 24 37 30 33 25 25 23.5 31

7.0 3.0 1.3 2.0 3.4 5.0 2.2 .8 2.0 3.0 2.9 4.5 4.0 1.0 1.0 3.1 4.0 2.0 1.9 9.0 .9 .7 2.0 .8 1.0 1.7 1.5

NA NA 25.00 NA 25.66 27.50 NA 3 NA NA NA NA NA NA 26.00 NA 24.00 NA 26.80 NA 22.00 NA NA 25.00 NA NA NA NA

NA 54.43 46.04 NA NA NA 29.58 NA 68.04 50.00 50.00 NA 78.80 38.48 43.00 53.98 NA 40.01 NA NA 18.00 22.70 NA 40.82 45.36 36.51 NA

29.91 5.23 22–41

28.69 5.05 6–37.43

2.65 1.98 5 mo–9 yr

25.24 1.71 22–27.50

46.03 14.82 18.0–78.81

GA 5 gestational age; BMI 5 body mass index; NA 5 not available.

The location of pain was also determined for all reported cases. Some studies did not include the presentation of pain [4,5]. Hence, only 40 patients were included in the location of pain analysis. Some of these patients had overlapping pain symptoms such as “diffuse and epigastric.” In these cases, each pain location was marked separately. The

location of pain is outlined in Table 2. In addition to pain, patients also experienced other symptoms such as nausea, vomiting, hematemesis, or bloody diarrhea. These findings are also explored further in Table 2. In 47 out of 51 reported cases (92.2%), patients had an LRYGB performed, and 4 out of 51 (7.8%) had an open

Table 2 Presentation

Location of pain Epigastric Diffuse LUQ L sided Radiating to back Other locations Other symptoms Nausea 6 vomiting No other symptoms Hematemesis Bloody diarrhea

Percentage

References

21 out of 40 (52.50%) 10 out of 40 (25%) 7 out of 40 (17.50%) 3 out of 40 (7.50%) 2 out of 40 (5%) 6 out of 40 (15%)

[3,7,8,15,19–21,26,27,29,32,33,36–38] [10,15,19,22,23,30,33,34] [9,20,33,36,38] [3,19,31] [26] [8,27,28,30,35,38]

26 out of 37 (70.27%) 6 out of 37 (16.22%) 3 out of 37 (8.11%) 2 out of 37 (5.40%)

[3,7,9,10,15,19–21,23,25,26,30–34,36–38] [25,27,33] [5,27,29] [19,22]

LUQ 5 left upper quadrant; L sided 5 left sided.

Devangi M. Dave et al. / Surgery for Obesity and Related Diseases - (2019) 1–8

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Table 3 Technical considerations of original RYGB

Approach of RYGB Laparoscopic Open Roux limb orientation Antecolic Retrocolic Closure of mesenteric defects Previous closure at initial RYGB

Percentage

References

47 out of 51 (92.16%) 4 out of 51 (7.84%)

[3–5,7–10,15,19,22,27–36,38] [20,23,37,38]

13 out of 21 (61.91%) 8 out of 21 (38.09%)

[3,5,7,28,30–33,35,36] [8–10,20,33,37]

5 out of 59 (8.47%)

[4,7–10]

RYGB 5 Roux-en-Y gastric bypass.

RYGB (Table 3). Thirteen out of 21 (61.9%) patients had an antecolic orientation of their Roux limb; 8 out of 21 (38.1%) had retrocolic orientation (Table 3). Furthermore, closure of mesenteric defects to prevent internal hernia formation during the original RYGB surgery was performed in 5 out of 59 patients (8.47%). However, only 5 studies reported this finding. It remains unknown whether other patients had this preventative measure and whether it affected internal hernia formation. Several diagnostic tests and imaging modalities were identified in all articles. In terms of serum and blood laboratory values, white blood count and lactate levels were also extracted and are outlined in Table 4. White blood count was found to be normal in 22 out of 32 (68.75%) reported cases and elevated in 10 out of 32 (31.25%) reported cases. Serum lactate levels were also found to be normal in 18 out of 20 (90%) of reported cases and elevated in 2 out of 20 (10%) reported cases. Despite the risk of radiation effects on the fetus, computed tomography (CT) scan was the most commonly used imaging modality in 20 out of 59 (33.9%) cases and, in most cases, provided a confirmation of diagnoses of internal hernias. Ultrasonography was the second most commonly utilized imaging modality used in 18 out of 59 cases (30.51%). The various diagnostic modalities used are illustrated in Table 5. The intraoperative management of these patients is outlined in Table 6. Eight out of 59 (13.6%) patients had conversions from laparoscopies to laparotomies. Twenty out of 59 patients had emergency C-sections. For repair of the internal hernia, 31 (52.5%) patients had bowel reductions and 9 (15.3%) patients had resections. Two patients had reversals of their RYGB, and 3 patients needed reconstruction of their RYGB.

The location of the internal hernias was also determined (Table 7). Of all reported cases, 31 out of 54 (57.4%) patients had a Petersen type internal hernia, 25 out of 54 (46.3%) patients had a jejunojejunal internal hernia, and 1 out of 59 (1.7%) patients had a transverse mesocolic hernia. Five out of 59 (8.5%) patients developed an internal hernia despite previous closure of mesenteric defects during the gastric bypass procedure. The postoperative findings are given in Table 8. The average hospital length of stay was 12.48 6 25.42 days (range, 2–124 d). Three maternal deaths and 4 fetal deaths were noted. The reasons for these deaths varied and included delayed diagnosis, extensive gangrenous bowel, and postoperative cardiac complications. Discussion The risk of internal hernias after a RYGB is lifelong. During pregnancy, this risk increases because of increasing intra-abdominal pressure owing to the growing fetus and poses a threat to both mother and fetus. The most common presenting symptom of internal hernias during pregnancy was epigastric pain with nausea and vomiting. This presentation should alert the physician to the possibility of internal herniation. Early diagnosis and intervention is crucial for positive maternal and fetal outcomes. While the treatment of morbid obesity and associated comorbidities remains the primary advantage of RYGB, Schneider et al. reported that rapid, excess weight loss is predictive of an increased risk of internal hernia formation [6]. The study further adds that patients who undergo periods of rapid weight loss are twice as likely to develop an

Table 4 Laboratory values Laboratory Values

Percentage

References

WBC

22 out of 32 (68.75%) 10 out of 32 (31.25%) 18 out of 20 (90%) 2 out of 20 (10%)

[3,7–10,15,23,25–27,30,33,35,36,38] [3,19,21,22,25,31,33,36,37] [8–10,20,22,23,27,30,31,33,35,37,38] [3,15]

Lactate

Normal Elevated Normal Elevated

WBC 5 white blood cells.

Devangi M. Dave et al. / Surgery for Obesity and Related Diseases - (2019) 1–8

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Table 5 Diagnostic modalities Imaging

Percentage

References

CT Ultrasound X-Ray MRI Upper GI contrast study

20 out of 59 (33.89%) 18 out of 59 (30.51%) 8 out of 59 (13.56%) 3 out of 59 (5.08%) 1 out of 59 (1.69%)

[3,5,7–10,15,19,20,23,26,31–34,36,38] [3–5,8,9,19,21,25,27–29,32,37,38] [15,19,22,23,27,30,32,38] [25,29] [9]

CT 5 computerized tomography; MRI 5 magnetic resonance imaging; GI 5 gastrointestinal.

internal hernia compared to other gastric bypass patients [6]. This finding can be explained by the excess loss of mesenteric fat, which leads to more open spaces for internal hernia formation. While closure of these mesenteric defects during the initial RYGB procedure remains a preventative strategy, evidence shows that closing these defects will decrease but not eliminate the risk of internal herniation [4,7–10]. Escalona et al reported that a greater incidence of internal hernias was observed in retrocolic RYGB than in antecolic RYGB patients [11]. Regardless of Roux limb orientation, however, internal hernias remain a lifelong risk. In terms of laboratory values, leukocytosis was only found in 31.25% of cases, and elevated serum lactate levels were only found in 10% of the cases. Hence, leukocytosis and elevated serum lactate should not be used as markers for internal herniation. An explanation of these findings could be that multivisceral involvement and ischemia needs to occur to increase systemic lactate [12]. Furthermore, the amount of released lactate from ischemic regions of the bowel needs to exceed the metabolic capacity of the liver through the Cori cycle [13]. While CT and radiographs provide a wealth of information for preoperative diagnoses, their use needs to be carefully evaluated during pregnancy. Radiation exposure is known to have detrimental consequences on the developing fetus in utero, such as congenital malformations and mutagenic effects. However, Nguyen and Goodman reported that a total fetal dose of ,50 mGy (5 rad) from diagnostic imaging has not been associated with any adverse fetal effects [14]. Despite the dangers and threats of radiation to the developing fetus, CT scans were the most commonly used imaging modality for identification of internal hernias during pregnancy, followed by ultrasonography. However,

although several case reports acknowledged the usage of radiographs, CT, and MRI, only 1 paper reported the amount of radiation received by the fetus during the CT scan and radiograph. It reported that the total fetal dose of radiation was 35.4 mGy during these procedures [15]. While the use of CT scans to identify internal hernias should not be withheld during pregnancy, accurate reporting of fetal doses of radiation and maintenance below 50 mGy can reduce fetal risk of malformations and mutagenic effects. However, many studies have expressed concern about the safety of CT scan during pregnancy. We found that MRI, an alternative imaging technique, was utilized in 5.08% of the patients included in our systematic review. A retrospective cohort study indicated that maternal MRI in the first trimester was not associated with a higher risk of neonatal death, congenital anomalies, neoplasm, or hearing loss [16]. However, use of gadolinium MRI at any time during pregnancy increased the risk of rheumatological, inflammatory, or infiltrate skin conditions and stillbirth or neonatal death [16]. Recently, laparoscopic sleeve gastrectomy (SG) has become the most frequently utilized procedure, surpassing RYGB [17]. This may be because SG is technically easier and potentially safer compared with the RYGB. SG eliminates the risk of internal hernia formation, marginal ulcer, and gastrogastric fistulae that may occur after RYGB. It is important to evaluate patients individually, along with their relevant co-morbidities, and weigh the risks and benefits of each bariatric procedure. According to recent evidence comparing outcomes between SG and RYGB, there was no significant difference in complications necessitating surgical or endoscopic revision within the first 5 years

Table 6 Intraoperative management Management

Percentage

References

Laparotomy Bowel reduction Laparoscopy Emergency C section Bowel resection Laparoscopy to laparotomy conversion Reconstruction of RYGB

31 out of 59 (52.54%) 31 out of 59 (52.54%) 29 out of 59 (49.15%) 20 out of 59 (33.89%) 9 out of 59 (15.25%) 8 out of 59 (13.56%) 3 out of 59 (5.08%)

[3–5,8,9,15,19–23,25–38] [3,5,7,9,10,15,19,23,25–28,30–33,35,36,38] [3,4,7,9,10,15,19,25–28,31–34,38] [4,19,21,22,25–27,29–31,33,35,37,38] [5,8,20,21,23,25,29,37] [4,9,15,28,31,32,34] [20,29,34]

RYGB 5 Roux-en-Y gastric bypass.

Devangi M. Dave et al. / Surgery for Obesity and Related Diseases - (2019) 1–8

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Table 7 Types of internal hernias Type of internal hernias

Percentage

References

Petersen’s defect Jejunojejunal defect Transverse mesocolic defect

31 out of 54 (57.4%) 25 out of 54 (46.3%) 1 out of 54 (1.85%)

[3–5,9,19,20,23,25,27,29–31,33,36,38] [4,7,8,15,19,21,25,28,32–38] [10]

postoperatively [18]. The most common complication found in the SG patients requiring reoperation was gastroesophageal reflux disease and insufficient weight loss; the complications associated with RYGB included internal hernia

formation, a more dangerous consequence [18]. Hence, a careful evaluation of the individual patient must be performed before choosing the type of bariatric procedure. This evaluation should include relevant co-morbidities,

Table 8 Postoperative results First Author (yr) [Ref] Warsza (2018) [15] Kannan (2018) [7] Goldberg (2017) [3] Guilbaud (2016) [5] Vannevel (2016) [25] Altieri (2015) [26]

LOS (d) 7 NA 4 3 12 NA

Gudbrand (2015) [4]

NA NA 6.5

Andreasen (2014) [19]

2

Caranta (2014) [27]

21

Gruetter (2014) [28] Borghede (2013) [29]

2 10 124

Outcome

Cause of death

Mother

Baby

A&W A&W A&W A&W A&W 1 pt: SBS 4 pts: A&W A&W A&W A&W

A&W Delivery at 40 wk CS* at 39 wk SVD at 40 wk Death 1 pt: IVH, ROP 4 pts: A&W CS* at 40 wk SVD at 37 wk 1 baby: cleft palate, intestinal malformation 3 A&W

Polavarapu (2012) [31] Renault (2012) [22]

2 2 NA NA

1 death 2 A&W Amenorrhea for 6 mo A&W UTI SF, jejunostomy, pneumothorax A&W A&W A&W Death

Tuyeras (2012) [32] Gagne (2010) [33] Hooks (2010) [34] Naef (2010) [35] Torres-Villalobos (2009) [36] Efthimiou (2009) [20] Wang (2007) [37] Ahmed (2006) [10] Bellanger (2006) [8] Baker (2005) [9] Charles (2005) [23] Kakarla (2005) [38] Moore (2004) [21]

17 2 6 10 8 10 9 2 5 NA 10 NA NA

Volvulus 4 A&W A&W A&W A&W A&W A&W A&W A&W A&W A&W 1 pt: endometritis, DVT Death

Full recovery 4 A&W SVD A&W A&W Neonatal death after delivery A&W Delivery at term Delivered at 39 wk Delivery 3 mo later SVD of nonviable fetus Both: A&W Death

Average

12.5

3 maternal deaths

4 fetal deaths

Leal-Gonzalez (2012) [30]

w w w w Not reported w w w w

Shunting for IVH

Gangrenous bowel w

A&W CS* 4 wk later A&W

w w w

A&W A&W A&W Delivered by CS

w w w Gangrenous bowel

Unknown

Not reported Maternal death: VFib

LOS 5 length of stay; A&W 5 alive and well; NA 5 not available; CS 5 Caesarean section; SVD 5 spontaneous vaginal delivery; pt 5 patient; SBS 5 short bowel syndrome; IVH 5 intraventricular hemorrhage; ROP 5 retinopathy of maturity; UTI 5 urinary tract infection; SF 5 salivary fistula; DVT 5 deep vein thrombosis; VFib 5 ventricular fibrillation. * Planned Caesarean section.

Devangi M. Dave et al. / Surgery for Obesity and Related Diseases - (2019) 1–8

such as gastroesophageal reflux disease, type 2 diabetes, and the patient’s desire to conceive after surgery. Another challenge in management is the suggestion of termination of pregnancy if the diagnosis of internal hernia is made early during pregnancy. This systematic review did not reveal any encouragement of termination of pregnancy. Several studies included in this review reported maternal and/or fetal death because of internal herniation during pregnancy in patients with previous RYGB [5,19–23]. The causes of death in some cases were unknown. However, a common theme was a delay in diagnosis and increased time until intervention. Certainly, a delay in diagnosis led to extensive bowel necrosis, which resulted in mortality. An evidence-based surgical treatment protocol published in 2001 reported that bowel infarction can occur within 8 to 16 hours if there is total or near total ischemia [24]. Hence, prompt diagnosis and intervention time are critical. These cases of fetal and maternal mortalities should be studied carefully to identify more overlapping themes and prevent tragic consequences in pregnant bariatric patients. Certainly, an early bariatric consultation should be the prime surgical intervention in these cases and would facilitate rapid diagnosis and treatment. Limitations The studies included in this systematic review were mostly case reports or retrospective reviews of patients who underwent an RYGB and presented with internal hernias during pregnancy. Due to lack of reporting on certain variables in the included studies, it was not possible to synthesize data on the change in BMI after the RYGB, the time from presentation to intervention, the method of closure of mesenteric defects, and the fetal dose of radiation. Future studies are required to report long-term follow-up of female patients who undergo a RYGB and their clinical outcomes during pregnancy. Conclusions The triad of epigastric pain, pregnancy, and a history of LRYGB should be a red flag for clinicians to consider internal hernias as a top differential diagnosis and schedule a bariatric consultation as soon as possible. Internal hernias must be ruled out, as bowel necrosis can occur within 16 hours. Failure to identify internal herniation can lead to life-threatening consequences for both mother and the developing fetus. Imaging procedures should be performed cautiously in these patients to prevent adverse radiation-associated in utero events, and total fetal dose of radiation should be maintained below 50 mGy. A prompt surgical intervention can decrease the risk of bowel necrosis and thus improve maternal and fetal outcomes.

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Acknowledgment We would like to express our appreciation to Anabela Rodrigues for her endeavors in preparation of this manuscript. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. Supplementary materials Supplementary material associated with this article can be found, in the online version, at https://doi.org/10.1016/ j.soard.2019.06.009. References [1] Kang JH, Le QA. Effectiveness of bariatric surgical procedures: a systematic review and network meta-analysis of randomized controlled trials. Medicine (Baltimore) 2017;96(46):e8632. [2] Nilsson-Condori E, Hedenbro JL, Thurin-Kjellberg A, Giwercman A, Friberg B. Impact of diet and bariatric surgery on anti-M€ullerian hormone levels. Hum Reprod 2018;33(4):690–3. [3] Goldberg MB, Tavakkoli A, Robinson MK. Petersen’s hernia after laparoscopic Roux-en-Y gastric bypass presenting in second trimester pregnancy. JSM Gastroenterol Hepatol 2017;5(1):1079–82. [4] 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. [5] Guilbaud T, Bouayed A, Ouaissi M. Emergency reversal of gastric bypass for missed diagnosis of internal hernia and bowel ischemia in a pregnant woman. Surg Obes Relat Dis 2016;12(8): 68–71. [6] 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. [7] Kannan U, Gupta R, Gilchrist BF, Kella VN. Laparoscopic management of an internal hernia in a pregnant woman with Roux-en-Y gastric bypass. BMJ Case Rep 2018;2018:bcr-2017-221979. [8] Bellanger DE, Ruiz JF, Solar K. Small bowel obstruction complicating pregnancy after laparoscopic gastric bypass. Surg Obes Relat Dis 2006;2(4):490–2. [9] Baker MT, Kothari SN. Successful surgical treatment of a pregnancyinduced Petersen’s hernia after laparoscopic gastric bypass. Surg Obes Relat Dis 2005;1(5):506–8. [10] Ahmed A, O’Malley W. Internal hernia with Roux loop obstruction during pregnancy after gastric bypass surgery. Obes Surg 2006;16(9):1246–8. [11] Escalona A, Devaud N, Perez G, et al. Antecolic versus retrocolic alimentary limb in laparoscopic Roux-en-Y gastric bypass: a comparative study. Surg Obes Relat Dis 2007;3(4):423–7. [12] Ambe PC, Kang K, Papadakis M, Zirngibl H. Can the preoperative serum lactate level predict the extent of bowel ischemia in patients presenting to the emergency department with acute mesenteric ischemia? BioMed Res Int 2017;2017:8038796. [13] Demir IE, Ceyhan GO, Friess H. Beyond lactate: is there a role for serum lactate measurement in diagnosing acute mesenteric ischemia. Dig Surg 2012;29(3):226–35. [14] Nguyen CP, Goodman LH. Fetal risk in diagnostic radiology. Semin Ultrasound CT MR 2012;33(1):4–10.

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