Roux-en-Y Gastric Bypass for Obesity. How We Do It.

In 1994, Wittgrove and Clark first described the laparoscopic technique for the Roux-en-Y gastric bypass. Many techniques have been used over the years, mostly based on the use of linear and circular stapling devices for the two anastomoses-the jejeunojejunostomy and the gastrojejunostomy. In 2000, Dr. Kelvin Higa from Fresno described a different technique, with the performance of a hand-sewn gastrojejunostomy. In this article we do review our technique, which is based on Dr. Higa's initial description. The steps of the operation will be illustrated by intraoperative pictures.

Laparoscopic Heller Myotomy and Dor Fundoplication: How I Do It?

Achalasia is a primary esophageal motility disorder characterized by lack of esophageal peristalsis and partial or absent relaxation of the lower esophageal sphincter in response to swallowing. Available treatment modalities are not curative but rather intend to relieve patient' symptoms. A laparoscopic Heller myotomy with Dor fundoplication is associated with high clinical success rates and low incidence of postoperative reflux. A properly executed operation following critical surgical steps is key for the success of the operation.

Antireflux Surgery for Gastroesophageal Reflux Refractory to Medical Treatment After Peroral Endoscopic Myotomy.

Background: Between 1995 and 2010, the laparoscopic Heller myotomy (LHM) was considered in most centers the treatment of choice for esophageal achalasia. The technique evolved over time, and the initial thoracoscopic approach was abandoned in favor of LHM with the addition of a fundoplication, due to the high incidence of postoperative reflux. Recently, a new endoscopic technique has been adopted in the treatment of achalasia-peroral endoscopic myotomy (POEM), which has slowly become the preferred treatment modality in many centers. While POEM is as effective as LHM in relieving symptoms, it has been associated with a very high rate of pathological reflux, development of strictures, Barrett's esophagus, and adenocarcinoma. In addition, many patients still complain of heartburn and regurgitation even when treated with high doses of proton pump inhibitors. Methods: We described 3 cases of achalasia patients with reflux symptoms refractory to medical treatment after POEM who underwent laparoscopic antireflux surgery. Results: The operations were completed laparoscopically despite presence of mediastinal adhesions, probably secondary to micro-leaks during POEM. All patients had resolution of their symptoms. Conclusions: This is the first report that describes patients who developed severe heartburn and regurgitation refractory to medical treatment following POEM, who eventually underwent a laparoscopic partial fundoplication with resolution of their symptoms. Our experience shows that post-POEM reflux is a serious concern, especially when refractory to medical treatment. We feel that this is a worrisome problem that will require frequent surgical interventions in the future.