Korean J Gastroenterol.  2019 Feb;73(2):109-113. 10.4166/kjg.2019.73.2.109.

Ischemic Necrosis Caused by Retroanastomotic Hernia after Subtotal Gastrectomy

• Lee SH
• Park SC
• Lee SJ
• Kang CD
• Nam SJ
• Lee SY
• Hong SK
• Lee SK

• KMID: 2438711
• DOI: http://doi.org/10.4166/kjg.2019.73.2.109

Abstract

After gastrojejunostomy, a small space can occur between the jejunum at the anastomosis site, the transverse mesocolon, and retroperitoneum, which may cause an intestinal hernia. This report presents a rare case of intestinal ischemic necrosis caused by retroanastomotic hernia after subtotal gastrectomy. A 56-year-old male was admitted to Kangwon National University Hospital with melena, abdominal pain, and nausea. His only relevant medical history was gastrectomy due to stomach cancer. Endoscopic findings revealed subtotal gastrectomy with Billroth-II reconstruction and a bluish edematous mucosal change with necrotic tissue in afferent and efferent loops including the anastomosis site. Abdominopelvic CT showed strangulation of proximal small bowel loops due to mesenteric torsion and thickening of the wall of the gastric remnant. Emergency laparotomy was performed. Surgical findings revealed the internal hernia through the defect behind the anastomosis site with strangulation of the jejunum between 20 cm below the Treitz ligament and the proximal ileum. Roux-en-Y anastomosis was performed, and he was discharged without complication. Retroanastomotic hernia, also called Petersen's space hernia, is a rare complication after gastric surgery, cannot be easily recognized, and leads to strangulation.

Keyword

Hernia; Ischemia; Necrosis; Gastrectomy

MeSH Terms

Abdominal Pain
Anastomosis, Roux-en-Y
Emergencies
Gangwon-do
Gastrectomy*
Gastric Bypass
Gastric Stump
Hernia*
Humans
Ileum
Ischemia
Jejunum
Laparotomy
Ligaments
Male
Melena
Mesocolon
Middle Aged
Nausea
Necrosis*
Stomach Neoplasms

Figure

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  Fig. 1 Representation of retroanastomotic hernia (arrow) among the afferent loop, the transverse mesocolon, and retroperitoneum.

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  Fig. 2 Initial upper gastrointestinal endoscopic findings. (A) Color change was observed in the vicinity of the anastomotic mucosa. (B) Bluish, edematous, mucosal change with necrotic tissue in efferent loop mucosa.

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  Fig. 3 Abdominopelvic CT findings. (A) Strangulation of proximal small bowel loops due to mesenteric torsion. (B) Contrast abdominopelvic CT image showing thickening of the wall of the gastric remnant (white arrow). CT, computed tomography.

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  Fig. 4 The mucosal surface of the specimen showing diffuse mucosal edema with a region of relatively well-demarcated dark-purple discoloration (white arrow).

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  Fig. 5 Histopathologic findings. (A) Wall of the lesion shows coagulative necrosis of the superficial half of mucosa with submucosal edema and dilated blood vessels. Remaining layers of the bowel wall were unremarkable (H&E, ×40). (B) Mucosa of the lesion showing hemorrhagic necrosis with surface inflammatory exudate (H&E, ×100).

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  Fig. 6 Endoscopic findings one month after surgery. The ischemia-induced color change was no longer observed in the remnant stomach.

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