Clinical symptoms are correlated with gastrojejunal anastomosis complications only during the first year after laparoscopic Roux-en-Y gastric bypass.

INTRODUCTION: Introduction: after laparoscopic Roux-en-Y gastric bypass (LRYGBP) many patients complain of epigastric pain or food intolerance, leading to the performance of upper gastrointestinal (UGI) endoscopy. Objective: this study aims to assess which symptomatology as reported by LRYGBP patients during follow-up suggested correlation with pathological findings of endoscopy, and which factors might play a role, taking the timing of symptom presentation into account. Materials and methods: a retrospective cohort study was performed identifying LRYGBP patients presenting with food intolerance and/or epigastric pain who had undergone endoscopy. Primary outcomes were endoscopy findings, their association with patient characteristics, and timing of symptom presentation. Results: of the 514 patients complaining of epigastric pain and/or food intolerance, 81 (15.6 %) underwent endoscopy. A gastrojejunostomy complication was found in 58 % of cases. All patients who complained about food intolerance and epigastric pain presented pathological findings. The only preoperative factor associated with a gastrojejunostomy complication was being a smoker (p = 0.021). Time between surgery and endoscopy was also a predictive factor for endoscopic pathological findings (p = 0.007); in cases of epigastric pain, symptom onset during the first year (median: 10 months) was related to increased risk of gastrojejunal complications (p < 0.05). Conclusions: endoscopies performed within one year of surgery were significantly more likely to reveal pathological findings than endoscopies performed after the first postoperative year, especially in patients experiencing epigastric pain.

INTRODUCCIÓN: Introducción: tras un baipás gástrico laparoscópico en "Y de Roux" muchos pacientes refieren dolor epigástrico o intolerancia alimenticia, lo que motiva la realización de una endoscopia digestiva alta. Objetivos: el objetivo de este estudio es intentar establecer una relación entre la sintomatología referida por los pacientes sometidos a baipás gástrico con los hallazgos endoscópicos patológicos y conocer qué factores pueden estar implicados, considerando el momento de presentación. Material y métodos: estudio retrospectivo de cohortes, identificando a los pacientes sometidos a baipás gástrico laparoscópico que presentan dolor epigástrico o intolerancia alimenticia durante el seguimiento y a los que se realizó una endoscopia digestiva alta. El objetivo primario es relacionar los hallazgos endoscópicos con la sintomatología y el momento de aparición. Resultados: de los 514 pacientes que presentaban dolor epigástrico o intolerancia alimenticia, 81 (15,6 %) fueron sometidos a endoscopia digestiva alta. En un 58 % de los casos se encontraron complicaciones relacionadas con la gastroyeyunostomía. En todos los pacientes que presentaban simultáneamente dolor e intolerancia aparecieron hallazgos endoscópicos patológicos. El único factor preoperatorio relacionado con las complicaciones fue el hábito tabáquico (p = 0,021). El tiempo entre la cirugía y la realización de la endoscopia también fue un factor significativamente relacionado con los hallazgos endoscópicos (p = 0,007). En los casos de dolor epigástrico durante el primer año (media: 10 meses) existía un incremento del riesgo de aparición de complicaciones de la gastroyeyunostomía (p < 0,05). Conclusiones: las endoscopias realizadas durante el primer año postoperatorio tenían más probabilidades de presentar hallazgos patológicos, sobre todo en los pacientes afectos de dolor epigástrico.

Removal of Nasogastric Tube Accidentally Stitched to Roux-en-Y Oesophagojejunostomy Following a Radical Gastrectomy for Stomach Cancer: Case report and review of the literature.

Nasogastric tubes (NGTs) are important for feeding, stenting and decompression after gastrointestinal surgeries, particularly in the upper gastrointestinal tract. Resistance in the removal of a NGT is a rare surgical complication and may be due to a knot in the tube or a stitch anchoring the tube to an anastomosis. We report a 41-year-old male patient who was admitted to the King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia, in 2015 with stomach cancer. He underwent a radical total gastrectomy with a Roux-en-Y oesophagojejunostomy. One week after the surgery, removal of the NGT was attempted; however, this was very difficult and the proximal end of the tube was cut off as a temporary measure. Six weeks later, an upper gastrointestinal tract endoscopy revealed that the distal end of the NGT had been accidentally stitched to the Roux-en-Y oesophagojejunostomy. The stitch was removed and the rest of the NGT was successfully extracted using a snare.

Laparoscopic Roux-en-Y gastric bypass at a Veterans Affairs and high-volume academic facilities: a comparison of institutional outcomes.

BACKGROUND: Outcomes of bariatric surgery have been linked to institutional case volume. The objective of our study was to compare outcome of laparoscopic Roux-en-y gastric bypass (RYGB) in 2 settings: a low-volume Veterans Affairs (VA) and a high-volume university hospital (UH). METHODS: Over a period of 27 months, 140 patients underwent RYGB (137 laparoscopic, 3 open) performed by 1 surgeon. Fifty-five were performed at a VA and 85 at a UH with an annual caseload close to 300. RESULTS: The body mass index in both groups was similar, but patients at the VA were older, mostly men, and more likely to have hypertension (HTN), obstructive sleep apnea, and diabetes mellitus (DM). Operative and anesthesia times were significantly longer at the VA. There were no differences in 30-day mortality (none), major morbidity, conversion rates, or reoperation rates. CONCLUSION: Laparoscopic RYGB can be performed safely at a VA facility despite a higher risk population and low annual volume.

Effect of the learning curve on the early outcomes of laparoscopic Roux-en-Y gastric bypass.

Open gastric bypass has been demonstrated to provide durable weight loss in morbidly obese patients. As laparoscopic techniques have evolved surgeons are offering patients such an approach for performance of gastric bypass. The purpose of this study was to evaluate the relationship between increasing experience and outcome for this technically challenging operation. A retrospective analysis was performed on the initial 160 consecutive patients undergoing laparoscopic gastric bypass by a single surgeon over a 24-month period. Patients were divided into quartiles for data analysis. Duration of surgery decreased significantly between quartiles: 324 +/- 124, 225 +/- 70, 190 +/- 47, and 168 +/- 40 minutes, respectively (P < 0.01). However, the conversion rate (3.1%) and mean hospital length of stay (2.1 +/- 2.4 days) were unaffected by surgeon experience. The early and late postoperative complication rates were 9.4 and 3.1 per cent, respectively. Early complications included: leak (1.3%), bleeding (3.8%), obstruction (1.9%), acute gastric distention (0.6%), subphrenic abscess (0.6%), and wound infection (0.6%). Late complications include: obstruction (1.3%), anastomotic stricture (1.3%), and marginal ulcer (0.6%). The complication rates did not change statistically between quartiles. The excess weight loss at one year was 77.4 +/- 16.7 per cent. These data suggest that throughout the learning curve laparoscopic gastric bypass can be accomplished with acceptable complication rates, conversion rates, and hospital length of stay. Duration of surgery improves with experience. Early weight loss results compare favorably with those of open gastric bypass.

Evaluation of a biofragmentable anastomosis ring for small intestinal anastomosis in ponies.

Six ponies divided into two groups of three were used in a double crossover study design. Group 1 ponies had a small intestinal resection and anastomosis performed using a biofragmentable anastomosis ring (BAR); group 2 ponies had a hand-sewn small intestinal resection and anastomosis using a Gambee suture pattern. Approximately 30 days later, all ponies had a second celiotomy and anastomosed segments were removed. Group 1 ponies had a hand-sewn anastomosis performed and group 2 had a BAR. The anastomotic sites were collected at necropsy approximately 30 days later. Anastomosed intestinal segments were evaluated with ultrasound to determine lumen diameter, area, circumference, and wall thickness. Gross descriptions of adhesions were recorded and sections of the anastomotic site were taken for histological evaluation. Time to perform the BAR anastomosis was significantly less (P = .0004) than for the hand-sewn Gambee anastomosis. Ponies with handsewn anastomoses had no signs of colic, whereas five of six ponies with BAR anastomoses had several episodes of abdominal discomfort, between day 16 to 18, corresponding to the time of BAR disintegration as determined by abdominal radiographs. Hand-sewn anastomoses had a tendency to have more adhesion formation than BAR anastomoses, but all anastomoses, except one BAR anastomosis, were graded as having a low obstructive potential. BAR anastomoses had a significantly larger mean index of stenosis for intraluminal diameter (76% +/- 13.6), area (93.7% +/- 6.01) and circumference (75.8% +/- 14.0) than the hand-sewn anastomoses (26.6% +/- 11.9; 44.6% +/- 19.5; 26.8% +/- 12.7). The BAR anastomoses also had a significantly smaller mean intraluminal diameter (0.96 cm +/- 0.49), area (0.838 cm2 +/- 0.65) and circumference (3.28 cm +/- 1.63) than the hand sewn anastomoses (3.11 cm +/- 0.73; 7.99 cm2 +/- 3.9; 10.3 cm +/- 2.47). In addition, the BAR anastomoses had a significantly larger (P = .0069) bowel wall thickness at the anastomoses and a significantly larger (P = .047) wall thickness proximal to the anastomosis than the hand-sewn anastomoses, indicating some degree of hypertrophy because of chronic obstruction. No significant difference was found in the diameter, area, or circumference between bowel proximal and distal to the anastomosis for either the BAR or Gambee techniques, or between the BAR and Gambee anastomosis as a measure of chronic obstruction. There was a significantly higher (P = .0043) histological score (worse healing) for mucosal healing and continuity for the BAR, as well as a tendency to score higher for inflammation, anastomotic alignment, and anastomotic fibrosis. The BAR technique had a significantly higher (P = .0043) total histological score than the Gambee technique. Although the BAR was advantageous in many respects, results of this study suggest that it should not be used for equine small intestinal anastomosis because of the potential for stricture formation.

Surgical treatment of the enterogastric reflux syndrome: preoperative and postoperative estimation by 99mTc-HIDA scintigraphy.

Twenty-nine patients with enterogastric reflux syndrome after anti-ulcer gastric surgery underwent a revisional Roux-en-Y gastrectomy. The diagnosis of enterogastric reflux syndrome was based on symptomatology and endoscopy in the first eight patients. The latter 21 patients had, in addition, a 99mTc-HIDA scintigraphy for the documentation and measurement of reflux. An enterogastric reflux index > 20 per cent is considered to justify symptoms due to reflux. Three of the first eight patients continued postoperatively to experience the same symptoms as before. These symptoms were eventually attributed to other than enterogastric reflux syndromes. The latter 21 patients were relieved from their preoperative symptoms and classified as Visick I and II (18 patients) and Visick III (3 patients). The authors conclude that enterogastric reflux syndrome must be documented on scintigraphy before the patient is subjected to revisional anti-reflux surgery in order for failures due to misdiagnosis to be avoided.

The Roux stasis syndrome. Treatment by pacing and prevention by use of an 'uncut' Roux limb.

Ectopic pacemakers in the Roux limb are associated with delayed gastric emptying after Roux gastrectomy. The aim herein was to suppress the ectopic pacemakers by electrical pacing or to prevent them by maintaining enteric myoneural continuity with an "uncut" Roux limb, and so improve the delayed emptying. Among eight dogs with truncal vagotomy and Roux hemigastrectomy, four dogs had a pacing electrode applied to the proximal end of the Roux limb. The other four dogs had a gastrojejunostomy to an uncut Roux limb. In them, the afferent jejunal limb was occluded by staples but not divided, and a diverting jejuno-jejunostomy was performed. Roux pacing and the uncut Roux operation abolished ectopic pacemakers in the Roux limb and speeded the slow gastric emptying present in unpaced control tests. At autopsy, however, dehiscences were found in the staple line in the dogs with the uncut Roux procedures. In conclusion, electrical pacing and the uncut Roux limb show promise as techniques to prevent ectopic jejunal pacemakers and gastric stasis after Roux gastrectomy. Both must be improved before they can be used in patients.