Late-"de novo" paraesophageal hernia after Roux-en-Y gastric bypass (RYGB)-should it be repaired?

BACKGROUND: This study presents a case series of "de novo" paraesophageal hernia (dnPEH) in post-Roux-en-Y gastric bypass (RYGB) patients and analyzes the predisposing factors, symptoms, and outcomes after repair. This is a lesser known complication after RYGB and when symptomatic, may warrant surgery. METHODS: A retrospective review of data from a single academic institution from 2002 to 2022 was performed identifying patients who developed dnPEH after RYGB and compared them to patients with primary RYGB without post-operative symptomatic dnPEH. Patient characteristics from initial RYGB were analyzed to identify predisposing factors for dnPEH development. Additional information analyzed included time to dnPEH repair, indications for surgery, types of herniation, type of surgical repair, and symptom resolution. RESULTS: There were 6975 RYGB in the study period of which 6619 underwent RYGB alone at index surgery, with 31 of those patients developing late stage PEH requiring repair. Patients with older age (51.8 years with dnPEH vs 45.2 years without, p = 0.001) and increased weight loss at 1 year (33.4% vs 30.5%, p = 0.048) from index RYGB were more likely to develop dnPEH. The incidence of dnPEH was 31/6619 (0.47%). Late dnPEH after RYGB took an average of 74 months (45-102 months IQR) to develop symptoms and undergo repair. The most common symptoms were heartburn/reflux 19/31 (61.3%) and epigastric pain 13/31 (41.9%). Symptom resolution rate after repair was highest with 100% for globus and 89.5% heartburn/reflux. The most common form of dnPEH was pouch herniation in 25/31. Surgical repair most commonly included primary cruroplasty alone in 25/31 with additional mesh in 1 case. Recurrence rate was 2/31 (6.54%). CONCLUSION: Late dnPEH after RYGB is an emerging entity typically occurring years after index RYGB. Symptomatic patients with dnPEH warrant hernia repair and responded well to surgical repair in this case series.

Outcomes of laparoscopic-assisted ERCP in gastric bypass patients at a community hospital center.

BACKGROUND: Obesity is a prevalent issue in today's society, increasing the number of gastric weight loss surgeries (Bowman et al. in Surg Endosc. https://doi.org/10.1007/s00464-016-4746-8 , 2016; Choi et al. in Surg Endosc. https://doi.org/10.1007/s00464-013-2850-6 , 2013; Paranandi et al. in Frontline Gastroenterol. https://doi.org/10.1136/flgastro-2015-100556 , 2015; Richardson et al. in http://www.ingentaconnect.com/content/sesc/tas , 2012). This presents an anatomical challenge to biliary disease requiring endoscopic retrograde cholangiopancreatography (ERCP) as the traditional is technically difficult, requiring a longer endoscope with a reported success rate of less than 70% (Roberts et al. in https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016032/ , 2008). A solution is laparoscopic-assisted ERCP (LA-ERCP) via gastrostomy. We present our experience with LA-ERCP at our teaching community hospital in a large cohort of patients. METHODS: An IRB-approved retrospective chart review was performed on patients with prior gastric bypass surgery who underwent LA-ERCP from April 2008 to April 2016. The procedure involved two bariatric surgeons and one gastroenterologist. The gastric remnant was secured to the abdominal wall with a purse-string suture and transfascial stay sutures. After gastrostomy creation of a duodenoscope was inserted to perform ERCP. Biliary sphincterotomy, dilation, and stone removal were performed as indicated. We observed the incidence of postoperative outcomes, including acute pancreatitis, reoperation, post-procedure infection, pain control, hospital readmission, and bile leak. RESULTS: Thirty-two patients met inclusion criteria. The majority of indications for LA-ERCP was choledocholithiasis (16/32). The remainder of cases included indications such as abnormal LFTs with biliary dilation (11/32), acute pancreatitis (2/32), cholangitis (2/32), and bile leak (1/32). LA-ERCP was successfully performed in all patients. Biliary sphincterotomy and stone extraction were performed on 31/32 patients. One patient underwent sphincterotomy and stent placement for bile leak after recent laparoscopic cholecystectomy. One patient developed acute pancreatitis with elevated pancreatic enzymes which resolved on POD2. The median length of stay was 2 days. CONCLUSION: LA-ERCP is a safe and feasible alternative to open surgery and can be safely implemented at community hospitals with adequately trained providers. Our large study proves that in this minimally invasive era, LA-ERCP provides gastric bypass patients a safe alternative with less pain and increased satisfaction.

Portal Vein Thrombosis After a Right Hemicolectomy: A Case Report.

The patient, a 43-year-old male, underwent uneventful laparoscopic right-sided hemicolectomy for a benign polyp, too large to be removed by colonoscopy. His postoperative course was uneventful; however, he returned 16 days after discharge with vague abdominal pain. A CT scan of his abdomen and pelvis showed extensive acute thrombus in portal, superior mesenteric, and splenic veins. After initial intravenous anticoagu- lation, follow-up imaging showed a persistent clot. The patient then underwent catheter-guided portal vein thrombolysis with tissue plasminogen activator (tPA), on postoperative day 29. He was doing well on 12-month follow-up. Portomesenteric thrombosis is a rare complication of laparoscopic surgery. It can occur even in the absence of any direct vascular trauma, as well as in delayed fashion after an initially uneventful procedure. Gold standard for treatment has not been developed and remains individualized based on the extent ofthe thrombus, the patient's clinical status, and condition of the affected bowel.