Unusual presentation of trocar site hernia after Roux-en-Y gastric bypass: case report.

INTRODUCTION: The exponential increase of bariatric surgery has resulted in a new diagnostic field of postoperative complications. One of the possibly serious complications is trocar site hernia. CASE REPORT: We present a rare case of trocar site hernia, in particular herniation of the blind loop of the jejunojejunostomy in a patient previously operated for laparoscopic gastric bypass. CONCLUSION: In patients with intermittent epigastric pain and regurgitation or nausea after RYGB, the differential diagnosis should include internal herniation and cholecystitis. Besides that, incarcerated trocar site hernia should also be considered. If obstructive symptoms are lacking, this might indicate Richter's hernia or herniation of the blind loop of the jejunojejunostomy. Due to the vague symptoms and the potentially late presentation, diagnosis can be challenging. However, this is a dangerous complication possibly leading to bowel strangulation and perforation, requiring urgent surgical repair.

A one-step conversion from gastric banding to laparoscopic Roux-en-Y gastric bypass is as safe as a two-step conversion: A comparative analysis of 885 patients.

AIMS: To achieve additional weight loss or to resolve band-related problems, a laparoscopic adjustable gastric banding (LAGB) can be converted to a laparoscopic Roux-en-Y gastric bypass (RYGB). There is limited data on the feasibility and safety of routinely performing a single-step conversion. We assessed the efficacy of this revisional approach in a large cohort of patients operated in a high-volume bariatric institution. METHODS: Between October 2004 and December 2015, a total of 885 patients who underwent LAGB removal with RYGB were identified from a prospectively collected database. In all cases, a single-stage conversion procedure was planned. The feasibility of this approach and peri-operative outcomes of these patients were evaluated and analyzed. RESULTS: A single-step approach was successfully achieved in 738 (83.4%) of the 885 patients. During the study period, there was a significant increase in performing the conversion from LAGB to RYGB single-staged. No mortality or anastomotic leakage was observed in both groups. Only 45 patients (5.1%) had a 30-d complication: most commonly hemorrhage (N = 20/45), with no significant difference between the groups. CONCLUSION: Converting a LAGB to RYGB can be performed with a very low morbidity and zero-mortality in a high-volume revisional bariatric center. With increasing experience and full standardization of the conversion, the vast majority of operations can be performed as a single-stage procedure. Only a migrated band remains a formal contraindication for a one-step approach.

Noninvasive monitoring of radiotherapy-induced microvascular changes using dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) in a colorectal tumor model.

PURPOSE: To examine dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) with a macromolecular contrast agent (P792) to visualize effects of radiotherapy (RT) on microvascular leakage in a colorectal cancer model. METHODS AND MATERIALS: CC531 tumors were induced in WAG/Rij rats. DCE-MRI was performed before and 5 days after 5 x 5 Gy of RT and parametric maps generated of the endothelial transfer constant (K(trans)) and the fractional interstitial space (Ve) according to the Tofts model. Tissue pO2 mapping was performed in each tumor core and rim before and after RT. Microvessel density (MVD), vascular endothelial growth factor (VEGF) expression, and pimonidazole hypoxia staining were compared with a control group of tumor-bearing rats. RESULTS: Mean K(trans) and v(e) were significantly reduced after RT in all tumor regions. Mean pO2 was 6.8 mm Hg before RT vs. 7.7 mm Hg after RT (p < 0.001) in the tumor rim and 3.5 mm Hg before RT vs. 4.4 mm Hg after RT (p < 0.001) in the tumor core. Mean MVD in the tumor rim was 10.4 in the RT treated group vs. 16.9 in the control group (p = 0.061). VEGF expression was significantly higher in RT-treated rats. After RT, no correlation was found between DCE-MRI parameters and histologic parameters. A correlation was seen after RT between pO2 and K(trans) (r = -0.57, p = 0.08) and between pO2 and v(e) (r = -0.65, p = 0.04). CONCLUSIONS: Dynamic contrast-enhanced-MRI with P792 allows quantification of microvascular changes in this colorectal model. RT significantly reduces neovascular leakage and enhances tissue oxygenation and VEGF expression. After RT, DCE-MRI parameters are related to tumor pO2, but not to MVD or VEGF expression.

Short- and long-term outcomes of vertical banded gastroplasty converted to Roux-en-Y gastric bypass.

BACKGROUND: Vertical banded gastroplasty (VBG) often necessitates revisional surgery for weight regain or symptoms related to gastric outlet obstruction. Roux-en-Y gastric bypass (RYGB) is considered as the revisional procedure of choice. However, revisional bariatric surgery is associated with relatively higher rates of complications. The aim of the current study is to analyse our single-centre experience with patients requiring revisional RYGB following primary VBG. METHODS: Retrospective review of the prospectively collected database identified 153 patients who underwent RYGB as a revisional procedure after VBG from Feb 2004-Feb 2011. Early and late complications, weight data and resolution of symptoms related to gastric outlet obstruction were analysed. RESULTS: One hundred twenty-three females and 30 males underwent revisional RYGB post VBG. Mean age was 44.4 (15-74) years with a mean pre-operative body mass index (BMI) of 34.2 (23.5-65.5) kg/m(2). Mean hospital stay was 4.3 days. Early complication rate was 3.9 % with a 30-day re-operation rate of 1.3 %. Mortality and leak rate were zero. After a mean follow-up of 48 months, the mean BMI decreased significantly to 28.8 kg/m(2) and a complete resolution of the obstructive symptoms was achieved in nearly all patients. Late complications developed in 11 (7.7 %) of the patients of which seven (4.9 %) required surgery. CONCLUSIONS: Revisional RYGB following VBG is technically challenging but safe with low rates of morbidity and mortality, comparable to primary RYGB. It produces a significant reduction in body weight and in symptoms resolution. We recommend RYGB as the procedure of choice in patients requiring revisional surgery following VBG.

Smaller staple height for circular stapled gastrojejunostomy in laparoscopic gastric bypass: early results in 1,074 morbidly obese patients.

BACKGROUND: Anastomotic leaks, stenosis, and bleeding from the gastrojejunal anastomosis (GJA) after gastric bypass may carry high morbidity and mortality. To date, the standard operation with the circular stapler (CS) used the 25 mm with a staple height of 4.8 mm. We present herein our experience with the 3.5-mm staple height. METHODS: A total of 1,074 morbidly obese patients who underwent fully stapled laparoscopic Roux-en-Y Gastric Bypass over a period of 18 months were included in the study. Mean body mass index was 41.9 (range 28.6-70.7). Mean age was 40.9 years (range 15-74 years). Mean operating time was 73 min (range 43-210 min) and the mean length of stay was 4.2 days (range 1-25 days). The 30-day complication rate associated with GJA was prospectively analyzed. RESULTS: Twenty patients (1.86%) developed postoperative bleeding. Four developed GJA bleeding (0.37%). One leak was recorded from the vertical staple line of the gastric pouch, but no leaks from the GJA were seen. Conversion to open approach was required in two patients (0.18%). Reoperation and readmission rates were 1.7% and 1.8%, respectively. Perioperative complications were observed in 34 patients (3.1%). One case of clinical GJA stenosis was detected in a mean follow-up of 10.5 months (range 5-20 months). There was no mortality in our series. CONCLUSION: Compared to our previous experience with 4.8 mm CS, creating the GJA using a smaller staple height significantly reduced the bleeding rate and seems to be a safe technique that potentially reduces other complications related to the GJA as reported in the literature.