bariatric surgery is most often performed with the laparoscopic roux - en - y gastric bypass ( lrgb ) .
lrgb has favourable effects such as weight loss and correction of metabolic disturbances , but is also associated with serious complications .
it is a severe complication , which can lead to massive bowel necrosis that may result in short bowel syndrome ( sbs ) and sometimes death .
pregnant women , who have previously undergone lrbg , represent a diagnostic challenge when presenting with acute abdomen and internal hernia in this setting might be particularly risky . in this case , we present a 22-year - old woman , who had undergone lrgb and who suffered a massive internal hernia during pregnancy leading to short bowel syndrome .
in january 2012 , at 26 weeks of gestation , a 22-year - old woman was admitted to our surgical department due to sudden onset of upper abdominal pain .
the patient was otherwise healthy and had at the time she became pregnant lost 50  kg following a lrgb done two years and 11 months earlier .
following admission , an acute ultrasound showed gall bladder stones , and a mri scan showed no definite signs of internal hernia but could not demonstrate gallstones . due to severe pain
a trans - cystic balloon dilation of the papilla of vater was done as the cholangiogram demonstrated poor drainage caused by small gallstones in the common hepatic bile duct . on the 5th postoperative day
she was re - operated due to cholascos with renewed cystic duct ligation and drainage . on the following day , endoscopy was performed because of hematamesis , with the finding of blood in the jejunum , but no specific bleeding site was identified .
the clinical condition worsened and she was transferred to the intensive care unit ( icu ) with severe septicaemia and acute respiratory distress syndrome ( ards ) . on day 13 , a laparotomy was performed . an internal hernia through petersen 's space with necrosis of 1  m jejunum starting 10  cm below the pouch - enteric anastomosis
a vital premature girl of 1020  g was delivered by caesarean and the necrotic intestine was removed .
second and third look operations were performed the next days with further small bowel resections leaving her with a saliva fistula 10  cm below the pouch - enteric anastomosis , a jejunostomy 15  cm from the ligament of treitz and a blind closed ileum 35  cm from the ileo - coecal valve ( fig .
1 ) . after 3 months in the icu and surgical ward with several other complications , such as infectious complications , pneumothorax , thrombosis of the superior mesenteric vein as well as the iliac veins and a exposed bowel parquet covered with split skin ,
the patient had a good appetite and enjoyed the meals , but obviously she had no absorption of food due to the very short fistula below the pouch - enteric anastomosis . through a central venous line ( hickmann catheter ) she initially received 2200  kcal and later when she increased her daily activities this
was increased according to 2700  kcal given as smof kabiven ( fresenius ) added with vitamins and trace elements , and in addition 3  l of isotonic saline to maintain the fluid balance .
also in this phase complications occurred , and the hickmann catheter eventually had to be removed due to a yeast infection with candida albicans .
the nutrition was thereafter delivered through a peripherally inserted central venous catheter ( piccline ) . after four months of hospitalization
the patient was discharged with home parenteral nutrition . in november 2012 , ten month after the internal herniation , intestinal continuity was reconstructed , and a defect having a width of up to 12  cm in the anterior abdominal wall was closed with bilateral partial component separation technique ad modum ramirez .
the patient insisted on trying without parenteral nutrition , and 10 weeks later , she was doing well .
her weight had increased 2  kg since the operation , she had 12 bowel movements a day and blood values for haemoglobin and albumin had increased as well .
this patient suffered from massive small bowel internal hernia with extensive bowel resection leading to sbs dependent on parenteral nutrition during her pregnancy .
the patient was left with an intact duodenum , 15  cm of jejunum , 35  cm of ileum and her colon .
initially she was treated with 100% parenteral nutrition , but after reconstructive surgery with re - established intestinal continuity the amount of parenteral nutrition was rapidly reduced , and after six weeks she was weaned off parenteral nutrition .
several cases of internal hernias during pregnancies have been reported and three maternal deaths have been described .
describe severe internal hernias in pregnant women , involving the entire small intestine , parts of the colon and in renault et al .
she underwent extensive bowel resection leading to an acute intestinal failure associated with severe complications ( type 2 intestinal failure ) .
after treatment in a specialized intestinal failure unit , she underwent a long and complicated rehabilitation period and was discharged with a short bowel syndrome treated with home parenteral nutrition and fluids ( type 3 intestinal failure ) , and she survived . to our knowledge , no pregnant woman with lrgb has previously survived an internal herniation with such massive bowel necrosis as in this case , see table 1 .
the university of nebraska medical center describes in a series of papers that 5 out of 210 patient with postoperative sbs had previous gastric bypass operation , and thereafter they scrutinized 9 patients with sbs that had bariatric surgery performed . in a more recent paper , they reviewed 9 cases with massive bowel resection during pregnancy leading to small bowel syndrome .
it is believed to be caused by the growing uterus , which increases the intra - abdominal pressure , or postpartum as the uterus rapidly decreases in size .
the surveys of series of patients with previous bariatric surgery demonstrate that up to 16% of the patients develop internal herniation .
most bariatric surgeries have been performed in women of reproductive age , and as lrgb increases fertility , complications during pregnancy are to be expected . it is suggested that the changed anatomy during pregnancy disposes for herniation to occur . during pregnancy , the cause of abdominal pain can be difficult to diagnose , with potentially fatal consequences for both mother and foetus .
it is most important that relevant tools such as mri or ct scans are not postponed .
interpretation of mri and ct scan can be difficult especially in pregnant women , thus laparoscopy should be performed on a wide indication , when there is clinical suspicion of internal hernia and laparotomy performed if the anatomy is not clear . in the present paper
the literature provides other successful reconstructions after lrgb complicated with internal obstruction . a case report of a 44-year - old woman , who suffered from volvulus after lrgb , leaving her with an intact duodenum
the younger age of our patient leaves her with an even better chance to stay off parenteral nutrition .
since internal hernia is potentially life threatening for mother and foetus , both obstetricians and abdominal surgeons must be aware of this condition and surgery should be performed on a wide indication .
when bowel necrosis is found it should be resected and in case of extensive bowel resection the patient should start parenteral nutrition , and an evaluation should be made in centres specialized in intestinal failure .
all authors have contributed to acquisition of data , analysis and interpretation of data , writing , drafting the article and revising it critically for important intellectual content and approved of the final version .
written informed consent was obtained from the patient for publication of this case report and case series and accompanying images .
a copy of the written consent is available for review by the editor - in - chief of this journal on request .
 introductionbariatric surgery is most often performed with the laparoscopic roux - en - y gastric bypass . 
 a complication to the laparoscopic roux - en - y gastric bypass is internal hernia , which occurs in up to 16% of the patients . 
 since the laparoscopic roux - en - y gastric bypass is performed in women of fertile age , internal hernia may occur during pregnancy.presentation of casea 22-year old woman with a history of laparoscopic roux - en - y gastric bypass suffered from massive internal hernia during pregnancy with widespread bowel necrosis . 
 extensive surgery was performed leaving the patient with an intact duodenum , 15  cm of jejunum , 35  cm of ileum and colon . 
 parenteral nutrition was initiated and ten months after the internal hernia , intestinal continuity was re - established . 
 ten weeks later the patient reached parenteral nutrition independence.discussioninternal hernia after laparoscopic roux - en - y gastric bypass can be difficult to diagnose , especially during pregnancy and might be severe and life threatening for both mother and child.conclusionobstetricians and abdominal surgeons must be aware of this condition . 
 surgery should be performed on a wide indication . when bowel necrosis is found it should be resected and in case of extensive bowel resection the patient should be evaluated in centres specialized in intestinal failure . 