Maternal and Fetal Deaths after Gastric Bypass Surgery for Morbid Obesity
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《新英格兰医药杂志》
At 31 weeks' gestation, a 41-year-old woman (gravida 1) presented at her community hospital with midepigastric pain, nausea, and vomiting that had begun 30 minutes after she had ingested a fatty meal. She had undergone Roux-en-Y gastric bypass surgery 18 months previously but still weighed 199.6 kg (440 lb). Initial evaluation revealed a tender epigastrum without rebound. The white-cell count was 14,500 per cubic millimeter; the amylase level was 54 units per liter. The fetal heart rate was 160 beats per minute. An ultrasonographic study of the right upper quadrant was negative for gallstones. After 48 hours, the patient was transferred to our obstetrical service with a presumed diagnosis of worsening pancreatitis in the setting of clinical deterioration and a rising amylase level (500 U per liter at the time of the transfer). Her temperature was 39°C (102.2°F), her heart rate was 170 beats per minute, her respiratory rate was 40 breaths per minute, and her systolic blood pressure was 78 mm Hg. Measurements of arterial-blood gas revealed a pH of 7.13 and a base deficit of 12 mmol per liter. Ultrasonography showed fetal death. The patient was intubated, and fluids and vasopressors were administered. She underwent an emergency laparotomy, which revealed that most of her small bowel was herniated through a mesenteric defect resulting from the gastric bypass surgery. Gangrenous bowel 61 cm (2 ft) in length was resected (Figure 1). A cesarean section was performed to evacuate the nonviable fetus. Three hours postoperatively, the patient had a ventricular fibrillatory arrest and died.
Figure 1. Gangrenous Bowel from an Internal Hernia.
Close-up shows the serosal erythema and erosions most visible at the junction of the bowel and the mesentery. (Courtesy of Mary Kwaan, M.D., Brigham and Women's Hospital.)
Of patients undergoing Roux-en-Y gastric bypass surgery, 84 percent are women, and most are of childbearing age.2 Weight loss in morbidly obese women may result in increased sexual activity and improved fertility.3 Thus, the number of women who undergo this procedure and become pregnant is likely to increase.
A catastrophic complication of a Roux-en-Y gastric bypass is intestinal infarction resulting from herniation through an anatomical defect created during the procedure. This has been estimated to occur in up to 2 percent of patients. Symptoms and signs of internal herniation can be subtle and nonspecific; the diagnosis is often established only after frank intestinal infarction or at laparotomy. The increased abdominal pressure and cephalad intestinal displacement associated with the enlarging gravid uterus may contribute to the pathogenesis of intestinal herniation.4
Potential complications of the procedure should be routinely considered in pregnant and nonpregnant patients who have had this surgery and present with abdominal pain. Computed tomographic (CT) scanning poses a minimal risk to a fetus5 and is recommended in these patients. Because CT is relatively insensitive for detecting internal herniation, however, exploratory laparotomy should be considered in appropriate clinical circumstances.
Kimberly A. Moore, M.D.
David W. Ouyang, M.D.
Edward E. Whang, M.D.
Brigham and Women's Hospital
Boston, MA 02115
References
Steinbrook R. Surgery for severe obesity. N Engl J Med 2004;350:1075-1079.
Pope GD, Birkmeyer JD, Finlayson SR. National trends in utilization and in-hospital outcomes of bariatric surgery. J Gastrointest Surg 2002;6:855-860.
Marceau P, Kaufman D, Biron S, et al. Outcome of pregnancies after biliopancreatic diversion. Obes Surg 2004;14:318-324.
Johnson BL, Lind JF, Ulich PJ. Transmesosigmoid hernia during pregnancy. South Med J 1992;85:650-652.
Committee on Obstetric Practice. Guidelines for diagnostic imaging during pregnancy. Committee opinion no. 158. Washington, D.C.: American College of Obstetricians and Gynecologists, September 1995.(To the Editor: Antiobesit)
Figure 1. Gangrenous Bowel from an Internal Hernia.
Close-up shows the serosal erythema and erosions most visible at the junction of the bowel and the mesentery. (Courtesy of Mary Kwaan, M.D., Brigham and Women's Hospital.)
Of patients undergoing Roux-en-Y gastric bypass surgery, 84 percent are women, and most are of childbearing age.2 Weight loss in morbidly obese women may result in increased sexual activity and improved fertility.3 Thus, the number of women who undergo this procedure and become pregnant is likely to increase.
A catastrophic complication of a Roux-en-Y gastric bypass is intestinal infarction resulting from herniation through an anatomical defect created during the procedure. This has been estimated to occur in up to 2 percent of patients. Symptoms and signs of internal herniation can be subtle and nonspecific; the diagnosis is often established only after frank intestinal infarction or at laparotomy. The increased abdominal pressure and cephalad intestinal displacement associated with the enlarging gravid uterus may contribute to the pathogenesis of intestinal herniation.4
Potential complications of the procedure should be routinely considered in pregnant and nonpregnant patients who have had this surgery and present with abdominal pain. Computed tomographic (CT) scanning poses a minimal risk to a fetus5 and is recommended in these patients. Because CT is relatively insensitive for detecting internal herniation, however, exploratory laparotomy should be considered in appropriate clinical circumstances.
Kimberly A. Moore, M.D.
David W. Ouyang, M.D.
Edward E. Whang, M.D.
Brigham and Women's Hospital
Boston, MA 02115
References
Steinbrook R. Surgery for severe obesity. N Engl J Med 2004;350:1075-1079.
Pope GD, Birkmeyer JD, Finlayson SR. National trends in utilization and in-hospital outcomes of bariatric surgery. J Gastrointest Surg 2002;6:855-860.
Marceau P, Kaufman D, Biron S, et al. Outcome of pregnancies after biliopancreatic diversion. Obes Surg 2004;14:318-324.
Johnson BL, Lind JF, Ulich PJ. Transmesosigmoid hernia during pregnancy. South Med J 1992;85:650-652.
Committee on Obstetric Practice. Guidelines for diagnostic imaging during pregnancy. Committee opinion no. 158. Washington, D.C.: American College of Obstetricians and Gynecologists, September 1995.(To the Editor: Antiobesit)