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Mesenteric defects: To close or not to close
To close or not to close a mesenteric defect that was the question asked of delegates by two teams of researchers. Although laparoscopic Roux-En Y Bypass (LRYGB) is the most common bariatric procedure it is still not clear whether closing mesenteric defects prevents internal hernias – these spaces are considered to be potential cause for bowel obstruction leading to increase in morbidity and mortality. The topic was discussed at this year’s Annual Scientific Meeting of the British Obesity and Metabolic Surgery Society in Leamington Spa, UK, from 22 – 24 January.
The first team from Sunderland Royal Hospital, Sunderland, UK, presented their experience of internal hernias from 1,325 LRYGBs before they started closing the mesenteric defects routinely. The majority of the patients had retro gastric and ante colic anastomosis as a standard procedure with linear stapling. All the enterotomies were closed in two layers and they routinely follow patients at six weeks, three months, six months and annually thereafter.
From 1,325 LRYGB procedures, 1,088 (82%) were female patients. Mean body weight of total cohort was 140.7Kg (81-304), mean excess body weight 67.5Kg (22.5-151.8) and mean BMI 45.9 (33.6-94.5).
A total of 8/1325 (0.60%) patients developed internal hernia post-operative in whom the mesenteric defects were not closed. All of these patients had subsequent surgery to reduce the hernia and close the mesenteric defect. Three patients required laparotomy and one of them required small bowel resection anastomosis. There was one mortality related to internal hernia.
“We observed a 0.60% incidence of internal hernia due to mesenteric defects,” said study presenter Dr Venkatesh Kanakala. “Recently, we have changed our practice to close all the mesenteric defects to avoid further events. We propose following a standardised technique to close these defects laparoscopically, as inadequate closure may lead to increase in the incidence of internal hernia.
In a separate presentation, the same research team conducted a literature review literature to compare the incidence of internal herniae with or without mesenteric defect closure.
They identified more than 100 articles of which only 16 articles (Level III and IV evidence) were considered to be suitable for the analysis. Most of the studies were retrospective and concluded that mesenteric defect closure was of benefit, although the benefit was not statistically significant. Only one study was conducted prospectively (non-randomised) and also showed a benefit of closing a mesenteric defect however, this study did not achieve statistical significance either.
“There are no randomised controlled studies to prove either technique is beneficial,” said Kanakala. “Although the majority of studies have shown the benefit of closing mesenteric defects to prevent internal hernia, the dilemma continues as there is no high quality studies to prove the same. A multicentre randomised controlled study with a standardised technique in closure of mesenteric defect should be performed.”
Co-authors of these studies were Venkatesh Kanakala, Dipankar Chatopadhyay, Rupa Sarkar, Neil Jennings, Kamal Mahawar, Schlok Balupuri and Peter Small.
In the third presentation researchers from the St James’s University Hospital, and Nuffield Hospital, Leeds, UK, reviewed the literature to determine whether closure of mesenteric spaces during LRYGB is associated with >50% reduction in the incidence of reoperation for internal hernia.
Internal hernia was defined as detection of prolapsed bowel at laparoscopy or laparotomy. Dr Abeezar Sarela and colleagues identified 298 reports. Overall, spaces were not closed in 5,880 patients vs. closure in 4,878 patients. The alimentary limb was ante-colic in 8,798 patients, retro-colic in 895 and unclear in 1,065; other technical differences were extent of mesenteric division, specification of spaces (mesenteric, Petersen’s and mesocolic) and method of closure.
The length of follow-up was derived from accrual and publication dates in seven studies and was notably longer for non-closure patients vs. closure. Because of substantial inter-study variations, the data were not suitable for meta-analysis. The reported incidence of internal hernia ranged from 2.9%- 6.8% (one outlier: 15.5%) for non-closure vs. 0-2.0% with closure.
“The available data are not sufficiently robust to state that non-closure of peritoneal spaces increases the incidence of internal hernia by >50% at comparable intervals,” concluded Sarela. “It is clinically prudent to close all spaces; but it is not clear that failure to close is legally negligent.”