Case report about the management of a late Gastro-Gastric Fistula after Laparoscopic Gastric Bypass, with the finding of an unexpected foreign body.

BACKGROUND: Gastro-Gastric Fistula is a rare but potentially serious complication of Roux-en-Y Gastric Bypass. Orogastric tube stapling is an adverse bariatric surgery iatrogenic complication that surgeons should be aware of and that has rarely been described. CLINICAL CASE: A 51-year-old patient, operated in our University Hospital Center of a Gastric Bypass 3 years ago, presented on consultation with anemia and weight regain (BMI 36). An upper Gastrointestinal (GI) endoscopy showed a Gastro-Gastric Fistula and visualized the tip of a Faucher tube fixed in the blind pouch and an erosive ulceration on the gastrojejunal anastomosis. Multiple biopsies showed a low-grade dysplasia in the remnant stomach. A subtotal gastrectomy was performed with refashioning of the gastrojejunal anastomosis. DISCUSSION: Anemia and weight regain, with or without the association of marginal ulcers are the most common signs of Gastro-Gastric Fistula after Gastric Bypass (1-6%). Surgical treatment remains the standard of care and should be tailored to the size and location of the fistula and the status of the gastrojejunal anastomosis. Orogastric tube perioperative complications are rare occurrences during bariatric surgery and not reported at a later stage. They can be associated with significant morbidity. Prevention strategies must be taken and standardized to prevent such events. CONCLUSION: The surgical option remains the standard of treatment and can be performed safely in Gastro-Gastric Fistula Type II. Orogastric tube accidental complications should be identified preferably perioperatively and measures of prevention should be implied to avoid such events.

Consecutive Versus Selective Primary and Revisional Single Incision Laparoscopic Bariatric Surgery: Personal Experience in 330 Cases.

BACKGROUND: This paper aims to retrospectively evaluate the feasibility, safety, and standardization for both consecutive primary and revisional SILS bariatric surgeries, and to analyze incisional hernia's prevalence, technical improvements, and limiting factors. METHODS: A retrospective database review was undertaken involving, in Part I (Belgium), 290 consecutive SILS, including 80.68% primary bariatric surgeries, and 19.32% revisional gastric bypass, followed in Part II (Lebanon), by 40 selective primary SILS. Training for and standardization of the trans-umbilical technique was done for the operating room team, and was executed in part II. RESULTS: The procedure of single incision was successfully completed in all of the 330 cases part I & part II. There was a need for additional salvage for one or two trocars in respectively 3.1% and 2.75% of the cases. There were no deaths or conversions in either group. Early complications included one medically healed fistula after revisional GB, and two secondary gastric and intestinal perforation requiring reoperations. Late surgical complications were: "3 patients (1.03%) in Part I and 2 (5%) in Part II suffered occlusions, requiring laparoscopic mesenteric defect's closure on an internal herniation." Twelve patients (4.1%) from part I and 5 (12.5%) in part II suffered an incisional hernia. CONCLUSION: Selective SILS, when standardized, tends to be superior to consecutive SILS in terms of overall morbidity, operative time, and need for additional salvage trocars. Cost effectiveness and higher midterm rate of umbilical port site incisional hernia should be weighed against the beneficial cosmetic effect for the patient.

Large paraesophageal hernia in elderly patients: Two case reports of laparoscopic posterior cruroplasty and anterior gastropexy.

BACKGROUND: Paraesophageal hernia (PEH) is a rare form of hiatal hernia, which commonly occurs in elderly people. Although asymptomatic, it can be associated with severe life-threatening complications, such as gastric volvulus. Surgical treatment is reserved for symptomatic patients. Herein, we present two cases of complicated PEH that were treated with laparoscopic posterior cruroplasty and anterior gastropexy. CASE SUMMARY: An 88-year old woman presented with epigastric pain, hematemesis and food intolerance for the last two days. Physical exam revealed mild abdominal distention. Chest X-ray showed a left thoracic opacity, and barium swallow images showed a mixed type III PEH. Abdominal CT-scan images confirmed the diagnosis of incomplete gastric volvulus. The patient underwent a laparoscopic hernia reduction with sac excision, posterior cruroplasty and anterior gastropexy with continuous barbed suturing. The postoperative course was uneventful, and follow-up showed complete resolution of her symptoms. A 91-year old patient was admitted for dyspnea and fever, with vomiting and food intolerance for the last 7 days. Physical exam revealed absent sounds on both lungs. Chest X-ray showed a large left opacity. CT-scan images revealed a giant PEH with complete gastric volvulus. The patient underwent emergency laparoscopic hernia reduction and sac excision, with re-inforced posterior cruroplasty, and anterior gastropexy with continuous barbed suturing. There were no surgical complications, but the patient died on the 4th day postoperatively due to respiratory failure. CONCLUSION: Early laparoscopic posterior cruroplasty and anterior gastropexy is a safe and effective surgical alternative for elderly patients with comorbidities, presenting with symptomatic PEH.

Transabdominal Laparoscopic Repair of Amyand's Hernia: A Case Report.

The occurrence of appendicitis within an inguinal hernia, known as Amyand's hernia, is a rare condition. Laparoscopic approach to this type of hernia is not widely used, and there is little data comparing it to the open surgery approach. This article presents a case of Amyand's hernia treated successfully by laparoscopy via a transabdominal approach supported by a short review of literature on this rare condition.