Petersen's hernia with chylous ascites following laparoscopic total gastrectomy and Roux-en-Y anastomosis: A case report and review of literature

Abstract

BACKGROUND

Petersen’s hernia occurring through the epiploic foramen of the greater omentum, is an uncommon type of internal hernia. When it presents with complications such as chylous ascites, which is the lymphatic fluid accumulation in the abdominal cavity, it is particularly rare. Following laparoscopic total gastrectomy and Roux-en-Y anastomosis, the incidence of this condition is exceedingly low.

CASE SUMMARY

A 62-year-old male patient developed Petersen’s hernia following laparoscopic total gastrectomy (LTG) for gastric cancer, after Roux-en-Y anastomosis. Intestinal torsion and obstruction were experienced by the patient, along with a small amount of chylous ascites. Imaging studies and clinical assessment confirmed the diagnosis. Emergency surgery was performed promptly for the patient in the operating room. The twisted small intestine was reduced and the defect in Petersen’s space was repaired. The procedure was successful in the correction of the intestinal torsion and approximation of the hernia without the need for bowel resection. The patient’s condition significantly improved following the surgery. The ascites evolved from a milky white appearance to a pale yellow, with a substantial decrease in the triglyceride levels in the ascitic fluid, implying a favorable recovery trajectory. The patient was monitored closely and received appropriate care postoperatively, including nutritional support and fluid management.

CONCLUSION

This report illustrates the significance of recognizing Petersen’s hernia as a potential complication following gastrectomy for gastric cancer. It highlights the fundamental role of early surgical intervention in the effective management of such complications. The favorable outcome in this patient illustrates that prompt and appropriate surgical management can deter the necessity for more extensive procedures such as bowel resection.

Key Words: Petersen's hernia; Chylous ascites; Laparoscopic total gastrectomy; Roux-en-Y anastomosis; Internal hernia; Case report

Core Tip: This report emphasizes the rare but critical occurrence of Petersen’s hernia complicated by chylous ascites following laparoscopic total gastrectomy and Roux-en-Y anastomosis. The report accentuates the importance of early diagnosis and prompt surgical intervention in managing this condition, significantly improving the outcomes in patients. The significance of recognizing non-specific clinical symptoms and utilization of imaging studies, particularly computed tomography scans, for accurate diagnosis, is underscored. Furthermore, the case and literature review emphasizes the need for heightened clinical vigilance and the development of effective preventive strategies to alleviate this potentially fatal postoperative complication risk.

INTRODUCTION

Gastric cancer is a predominant neoplasm, with early diagnosis being critical for the enhancement of the treatment outcomes[1]. A minimally invasive surgical approach, laparoscopic total gastrectomy (LTG), offers quicker recovery postoperatively and superior cosmetic results than traditional open surgeries[2,3]. However, laparoscopic surgery is associated with certain complications, such as internal hernias[4]. A rare and serious internal hernia, Petersen’s hernia, typically occurs during reconstruction surgeries of the digestive tract, particularly in iatrogenic spaces formed between elevated intestinal loops and the transverse colon with the posterior peritoneum[4]. The rate of incidence is relatively low post-gastric cancer surgery; however, can lead to adverse prognoses in male patients because of the acute onset and rapid progression[5]. A 1.61% incidence rate of Petersen’s hernia is indicated from the research data of 2021 following gastric cancer surgery[6]. An actual incidence rate of 0.7% was noted by a 2023 systematic review and meta-analysis in patients undergoing bariatric and upper gastrointestinal surgeries[7]. LTG comprises not only the removal of the stomach and lymph nodes but also Roux-en-Y anastomosis performance to prevent reflux postoperatively[8,9]. Although this reduces recovery and hospital stay times, the risk of complications like Petersen’s hernia may be increased.

Chylous ascites is an infrequently diagnosed disease, characterized by chyle-rich fluid accumulation in the peritoneal cavity, and its exact incidence remains unclear[10]. Approximately one case per 20000 hospitalized patients was indicated by the data from 1984 in the United States, with mortality rates as high as 40%-70%[11]. However, the mortality rate has significantly decreased, with the diversification of treatment modalities and advancements in medical care.

The diagnosis of Petersen’s hernia presents challenges owing to its non-specific clinical symptoms, which may include abdominal pain, nausea, and vomiting[12]. Severe consequences may arise owing to delayed diagnosis and treatment. The simultaneous occurrence of Petersen’s hernia and chylous ascites is exceptionally rare and barely documented in the literature, suggesting underlying complex pathological mechanisms requiring thorough diagnostic and therapeutic approaches by physicians. Through case reporting and literature review, this paper highlights the importance of diagnosing and managing Petersen’s hernia and chylous ascites post-gastric cancer surgery and the critical role of early diagnosis and timely intervention in improving the patient’s prognosis.

CASE PRESENTATION

Chief complaints

Acute abdominal pain, bloating, and nausea persisted for 2 hours.

History of present illness

A 62-year-old male patient reported a history of laparoscopic-assisted total gastrectomy performed for early-stage gastric cancer at the age of 55 years, followed by Roux-en-Y anastomosis. Similar symptoms were experienced by him on three occasions over the past year, diagnosed as incomplete intestinal obstruction and resolved without any surgical intervention.

History of past illness

Early-stage gastric cancer (stage IB, T2N0M0) with no residual disease at the surgical margins. There was an uneventful postoperative recovery.

Physical examination

The physical examination revealed mild abdominal distension with the upper abdomen tenderness. No rebound tenderness or rigidity in the muscles was noted. There were visible bowel loops, tympanic abdomen on percussion, and normal bowel sounds. The body temperature was normal.

Laboratory examinations

The white blood cell and neutrophil counts were elevated (11.6 × 10⁹/L and 10.18 × 10⁹/L, respectively). Other laboratory parameters were within normal limits.

Imaging examinations

Emergency abdominal computed tomography (CT) scan showed a “spiral” or “whirl” sign, which is characteristic of small bowel torsion. There was the presence of contents, gas, and fluid within the bowel lumen, and fluid in the abdominal and pelvic cavities (Figure 1).

Figure 1 Computed tomography. A: The white circle and white dashed area in the image illustrate the Petersen defect; B: The white circle and white dashed line highlight the "whirl" sign, which is indicative of small bowel torsion.

FINAL DIAGNOSIS

Petersen’s hernia, chylous ascites, intestinal obstruction, volvulus, and ascites following endoscopic total gastrectomy and Roux-en-Y anastomosis were noted as the final diagnosis.

Surgical findings

Approximately 50 mL of milky white fluid was detected in the abdomen, with the small intestine herniating through the Petersen defect that was formed after esophagogastric anastomosis. This led to torsion and obstruction that was accompanied by mesenteric chyle infiltration. There were no signs of perforation or malignancy (Figure 2).

Figure 2 Surgical findings. A: The black arrows in the image point to chylous ascites and mesenteric chyle infiltration; B and C: The black text description illustrates the relationship between the proximal jejunum, distal jejunum, and Petersen defect following total gastrectomy with Roux-en-Y Anastomosis; D: The black text indicates the closure of the Petersen defect.

TREATMENT

During the surgery, there was a reduction in the intestinal herniation, and the Petersen defect was intermittently sutured. Since the intestinal segments demonstrated no signs of ischemic necrosis, bowel resection was not performed. The abdominal cavity was thoroughly rinsed, with the placement of a peritoneal drain. The triglyceride (TG) levels in the ascitic fluid were initially high at 310 mg/dL, which subsequently reduced to 16 mg/dL.

OUTCOME AND FOLLOW-UP

The patient had an uneventful postoperative recovery. The color of the ascites and TG levels normalized. There was no requirement for a low-fat diet and the patient was discharged on the fourth postoperative day.

DISCUSSION

Petersen’s hernia, a specific type of internal hernia, is highly correlated with abdominal surgery, leading to severe clinical consequences[11,12]. For instance, procedures such as Roux-en-Y gastric bypass surgery, radical gastrectomy, gastrectomy, open Beger surgery, and one anastomosis gastric bypass/mini gastric bypass surgery, involve the reconstruction of anatomical structures possibly creating new potential spaces between the intestinal loops, transverse mesocolon, and posterior peritoneum, thus providing conducive conditions to the occurrence of internal hernias[12-19].

There are significant variations in the incidence rates of Petersen’s hernia across different surgical types. The rate of incidence of symptomatic Petersen’s hernia is approximately 4.44%, following bariatric surgery, particularly laparoscopic gastrectomy with Roux-en-Y gastric bypass, with most cases diagnosed within 21.3 months postoperatively[20]. In contrast, the incidence rate in patients who undergo post-radical gastrectomy is relatively lower, at approximately 1.61%[11]. Notably, the incidence rate of Petersen’s hernia following LTG is extremely low, that is, less than 0.1%[21]. Although Petersen’s hernia is a rare but potentially fatal complication, these statistical data reveal that its probability of occurrence following gastrointestinal surgery cannot be overlooked.

By altering the abdominal anatomy and increasing abdominal pressure, these surgeries may facilitate the formation of visceral hernias. Although gastrectomy is a major surgical procedure, it does not induce Petersen’s hernia directly. Alternatively, it may be more closely associated with the postoperative restructuring of anatomy[16]. Consequently, total gastrectomy does not have a direct causal relationship with Petersen’s hernia but may be more directly associated with subsequent reconstructive surgeries. Roux-en-Y reconstruction surgery alters the postoperative abdominal anatomy and rearranges the position of visceral organs[22]. Additionally, the application of laparoscopic techniques may assist in reduction of the postoperative intra-abdominal adhesions[12]. Moreover, the changes in postoperative abdominal pressure[13] may also be a contributing factor. The combined effects may lead to the abnormal accumulation of intestinal contents and organ torsion, potentially resulting in internal hernia formation.

The clinical manifestations of Petersen's hernia may include severe abdominal pain and distension, typically caused by mechanical obstruction due to a portion of the small intestine being trapped in the Petersen defect[23]. Vomiting and diarrhea may indicate intestinal dysfunction[24]. When Petersen's hernia progresses to a closed-loop obstruction, symptoms may become more severe, including torsion or ischemia[14]. Imaging studies, particularly CT scans, play a crucial role in the diagnosis and management of Petersen's hernia. CT imaging can reveal features such as rotation of the mesenteric vessels, small bowel dilation, and torsion[24,16]. Abnormal positioning of the small bowel, displacement of the Treitz angle, and the mushroom-like shape of the mesentery are key indicators for the diagnosis of Petersen's hernia following gastric cancer resection[25]. Magnetic resonance imaging is also a useful diagnostic tool in certain situations, such as during pregnancy[18].

Chylous ascites is a rare condition that is characterized by a milky white fluid accumulation in the abdominal cavity, which is rich in TGs, because of the damage to the lymphatic system[26]. This condition may be due to various factors, including surgery, tumors, or infections. It more likely occurs after gastric bypass surgery, where damage to or blockage of the lymphatic vessels can lead to the development of chylous ascites. In addition, chylous ascites may also be associated with intestinal volvulus, leading to bowel dysfunction, and can affect the normal drainage of lymphatic fluid[27]. For example, the presence of chylous ascites was reported owing to closed-loop small bowel obstruction, suggesting that chylous ascites may serve as an intestinal viability marker in patients with bowel obstruction[11]. Other reports have linked chylous ascites following colorectal resection to internal hernias, illustrating the correlation between intestinal structural abnormalities and chylous ascites[28]. Although chylous ascites appears unusual, this finding should not be interpreted as a poor prognostic sign. Athanasiadis et al[29] proposed that chylous ascites with intestinal strangulation is a benign finding, indicating the presence of an internal hernia through an unclosed Petersen defect[29]. Hayama et al[30] suggested that chylous ascites in patients with intestinal torsion or internal hernias are harmless, possibly revealing the patency of the mesenteric vessels. This case and that of Imam et al[31] reflected that indirect damage to the lymphatic system may occur by affecting the normal function and structure of the intestine, thereby promoting chylous ascites formation.

This report details a 62-year-old man who experienced three episodes of intestinal obstruction over 6 years following LTG and Roux-en-Y reconstruction. All these episodes were conservatively resolved. Recently, the patient was admitted urgently owing to acute abdominal pain and distension. The development of Petersen’s hernia, in this case, was likely progressive, based on the medical history. Neglecting early symptoms and a lack of timely imaging assessment led to the current emergency. An abdominal CT scan revealed spiral congestion of the mesentery and vessels, small bowel dilation, and peritoneal effusion, indicating small bowel torsion, consistent with the CT characteristics of Petersen’s hernia post-gastric cancer resection. The surgical intervention successfully evaded intestinal necrosis and bowel resection. This case focuses on the importance of early diagnosis and prompt treatment. The patient’s TG level in the ascites was abnormally elevated to 310 mg/dL, confirming chylous ascites, with a TG level above 200 mg/dL being a key diagnostic criterion.

A comprehensive literature review retrieved data from 16 patients with Petersen’s hernia from eight articles. The patient cohort, aged between 53 to 75 years, predominantly comprised men (15 cases) with one woman, with an average age of 63.7 years. The ratio of open surgery to laparoscopic surgery was 11:5, in the initial total gastrectomy. The esophagogastric anastomosis was the preferred choice in 16/17 cases and anterior colonic anastomosis was performed in 94% of the cases. The onset of Petersen’s hernia ranged from 6 to 128 months postoperatively, with an average duration of approximately 32.5 months. CT scans consistently revealed a typical imaging feature of Petersen’s hernia, the mesenteric whirl sign. As a complication, chylous ascites was noted in two patients. All patients underwent emergency surgery, with a ratio of 13:3 for open to laparoscopic surgery. All patients underwent internal hernia reduction and repair of the Petersen defect; however, three patients required small bowel resection and anastomosis because of intestinal necrosis. Unfortunately, two patients ultimately did not survive. These findings indicate that although chylous ascites are not common in Petersen’s hernia, it should be considered a cause for high clinical alertness. The association of chylous ascites with Petersen’s hernia and its underlying mechanisms warrant further investigation, despite its rarity. Furthermore, the cases of intestinal necrosis and mortality underscore the severity of Petersen’s hernia and highlight the importance of early identification and intervention for such complications (Table 1 and Table 2)[32-39].

Table 1 Literature review of Petersen’s hernia following total gastrectomy with Roux-en-Y anastomosis.

Age	Gender	Type of surgery	R-Y approach	Postoperative time (month)	CT findings	Ref.
56	M	OS, R-Y	Anterior colon	48	"Spiral" or "whirl" sign	[32]
72	M	OS, R-Y	Anterior colon	6	"Spiral" or "whirl" sign	[33]
52	M	OS, R-Y	Anterior colon	11	"Spiral" or "whirl" sign
73	M	LS, R-Y	Anterior colon	24	"Spiral" or "whirl" sign
54	M	LS, R-Y	Anterior colon	26	"Spiral" or "whirl" sign
62	M	OS, R-Y	Anterior colon	60	"Spiral" or "whirl" sign	[34]
54	M	OS, R-Y	Anterior colon	6	"Spiral" or "whirl" sign
69	M	OS, R-Y	Posterior colon	24	"Spiral" or "whirl" sign	[35]
70	M	OS, R-Y	Anterior colon	-	"Spiral" or "whirl" sign	[36]
50	M	OS, R-Y	Anterior colon	18	"Spiral" or "whirl" sign
71	M	LS, R-Y	Anterior colon	11	"Spiral" or "whirl" sign	[37]
75	W	LS, R-Y	Anterior colon	128	"Spiral" or "whirl" sign
66	M	LS, R-Y	Anterior colon	0.5	"Spiral" or "whirl" sign	[38]
71	M	OS, R-Y	Anterior colon	24	"Spiral" or "whirl" sign	[39]
73	M	OS, R-Y	Anterior colon	7	"Spiral" or "whirl" sign
62	M	LS, R-Y	Anterior colon	84	"Spiral" or "whirl" sign

M: Man; W: Woman; OS: Open surgery; LS: Laparoscopic surgery; R-Y: R-Y anastomosis technique; CT: Computed tomography.

Table 2 Literature review of Petersen’s hernia following total gastrectomy with Roux-en-Y anastomosis.

Chylous ascites	Surgical approach	Intestinal management of internal hernia	Close Peterson's defect	From onset to operation time (hour)	Prognosis	Ref.
N	OS	IR	Y	4	Recovery	[32]
N	OS	IR	Y	30	Death	[33]
N	OS	IR	Y	150	Recovery
N	OS	IR	Y	48	Recovery
N	OS	IR	Y	48	Recovery
N	OS	IR	Y	31	Recovery
N	OS	IR	Y	24	Recovery	[34]
N	OS	IR	Y	120	Recovery
Y	LS	IR	Y	48	Recovery	[35]
N	OS	IR	Y	24	Recovery	[36]
N	OS	IR	Y	24	Recovery
N	LS	IR	Y	-	Recovery	[37]
N	LS	IR	Y	-	Recovery
N	OS	IR, IPR	Y	24	Recovery	[38]
N	OS	IR, IRA	Y	70	Death	[39]
N	OS	IR, IRA	Y	22	Recovery
Y	OS	IR	Y	4	Recovery

Y: Yes; N: No; OS: Open surgery; LS: Laparoscopic surgery; IR: Intestinal reduction; IRA: Intestinal resection and anastomosis; IPR: Intestinal perforation repair.

Petersen’s hernia is primarily managed through prevention, with specific suturing techniques being paramount. The Mefix method, barbed sutures, and double-row suturing techniques are examples of preventive measures that are more critical than post-event repairs[37,38]. The multicenter trial conducted by Korean scholars showed that the Mefix method is a rapid and straightforward technique for approximating Peterson’s defect, without an increase in postoperative complications when compared to conventional methods[39]. Postoperative regular monitoring[14] is essential for patients with high risk. Furthermore, controlling body mass index can mitigate the impact of obesity on abdominal pressure, thereby reducing the risk of the formation of hernia[11]. Enhancing the sensitivity to symptoms and early diagnostic capabilities for conditions like small bowel torsion or other severe complications caused by Petersen’s hernia is critical for timely surgical intervention to prevent further tissue damage and potentially fatal consequences. Postoperatively, patients should be monitored closely for early detection of the recurrence of hernia or other complications.

CONCLUSION

Petersen’s hernia is a rare but critical complication, especially after a laparoscopic total gastrectomy. This report emphasizes the importance of exploratory surgery in the absence of clear symptoms and definitive results of CT scan, and the consideration of Petersen’s hernia as a possibility in patients with a history of Roux-en-Y anastomosis surgery, especially in those with intestinal torsion. Timely diagnosis and emergency surgery can significantly improve patient outcomes, despite the presence of chylous ascites. Future research should focus on optimizing surgical techniques, postoperative management, and preventive measures development, as well as conducting more clinical studies and case reports to enhance healthcare professionals’ ability to diagnose and treat Petersen’s hernia.