Closure of defects may be more effective for preventing internal hernia post-RYGB

A Cochrane systematic review has concluded that the closure of defects may be more effective than the non‐closure of defects for prevention of internal hernia after Roux‐en‐Y gastric bypass (RYGB), according to researchers from Kyoto University Hospital, Kyoto, Japan.

However, they noted that due to the small number of trials, the evidence is limited. There is little to no difference between the closure and non‐closure of defects in the incidence of postoperative overall complications, the incidence of postoperative mortality, and the incidence of intraoperative overall complications. Furthermore, the length of hospital stay may be longer for those undergoing defect closure than for those who did not have the defects closed. The evidence is ‘very uncertain’ about the incidence of postoperative mortality, the incidence of intraoperative overall complications, and the length of hospital stay.

The authors noted that internal hernia is one of the most severe complications observed in people undergoing RYGB. Some surgeons advocate for the closure of defects to prevent internal hernias. However, the closure of these defects might be associated with an increased risk of small bowel obstruction, resulting from a kink in the anastomosis of the small intestines.

The researchers sought to assess the benefits and harms of defect closure for prevention of internal hernia after RYGB. The literature search criteria included randomised controlled trials (RCTs) that included people with obesity (defined as a body‐mass index (BMI) ≥ 35 kg/m²) who underwent laparoscopic or robotic RYGB and compared the closure of defects with the non‐closure of defects. The excluded quasi‐randomised trials, cluster‐RCTs and cross‐over trials.

The primary outcomes were the incidence of internal hernia with bowel obstruction within ten years, the incidence of postoperative overall complications and the incidence of postoperative mortality within 30 days. Secondary outcomes included the incidence of intraoperative overall complications, length of hospital stay, and the postoperative pain resulting from gastric bypass surgery, assessed using a visual analogue scale (VAS) two years after surgery.

The identified three RCTs (conducted in Denmark, the US and Sweden) with 3,010 participants, which met their inclusion criteria. The closure of mesenteric defects used non‐absorbable, interrupt closure in one study, and non‐absorbable running sutures in two studies.

Outcomes

They reported that closure of defects during RYGB may reduce the incidence of internal hernia with bowel obstruction within 10 years compared with non‐closure (RR 0.32, 95% CI 0.24 to 0.42; p<0.00001, I² = 0 %; 3 studies, 3010 participants; low‐certainty evidence). The closure of defects may result in little to no difference in the incidence of postoperative overall complications within 30 days compared to non‐closure (RR 1.13, 95% CI 0.87 to 1.47; p=0.35, I² = 0 %; 2 studies, 2609 participants; low‐certainty evidence). The closure of defects may result in little to no difference in the incidence of postoperative mortality within 30 days compared to non‐closure (RR 2.97, 95% CI 0.12 to 72.93; p=0.50, I² not applicable; 2 studies, 2908 participants; very low‐certainty evidence).

However, the closure of defects may result in little to no difference in the incidence of intraoperative overall complications compared to non‐closure (RR 0.87, 95% CI 0.54 to 1.42; p=0.59, I² not applicable; 1 study, 2507 participants; very low‐certainty evidence). Closure defects may lead to the longer length of hospital stay; however, the evidence is very uncertain (MD 0.27 days, 95% CI 0.15 to 0.38; p<0.00001; I² = 93%; 2 studies, 2609 participants; very low‐certainty evidence). There was not enough information available to analyse post-operative pain from RYGB.

“The closure of defects may be more effective than the non‐closure of defects for prevention of internal hernia after RYGB. However, the small number of trials limited our confidence in the evidence” they concluded. “...The evidence is very uncertain about the incidence of postoperative mortality, the incidence of intraoperative overall complications, and the length of hospital stay.”

The findings were published ion the paper, ‘Closure of mesenteric defects for prevention of internal hernia after Roux‐en‐Y gastric bypass in bariatric surgery’, published in Cochrane Database of Systematic Reviews. To access this paper, please click here (log-in maybe required)