Imaging appearance on CT post laparoscopic Roux-en-Y gastric bypass using bioabsorbable prosthesis with fibrin glue fixation to prevent a Petersen's space hernia.

Imaging post bariatric surgery is becoming more common over the past decade due to increasing incidence of obesity in the population and subsequent treatment. In recent years, the use of topical haemostatic agents and bioabsorbable prostheses has increased leading to higher likelihood of encountering these agents on post-operative imaging. Imaging in the post-operative period is occasionally performed to assess for complications such as obstruction, leak and abscess formation. Familiarity with these agents is crucial in preventing incorrect diagnosis. Laparoscopic Roux-en-Y gastric bypass (RYGB) is favoured over the open approach as it is safer and more effective, with a mortality rate of 0.5% and morbidity around 7-14 %. The main cause of late post-RYGB complications is the development of internal hernias such as a Petersen's hernia. During the procedure, a space between the alimentary loop of the small bowel and the transverse mesocolon is created and is called the Petersen's defect. Subsequently, a part of the small bowel can herniate through this orifice. As this operation is becoming more common, the incidence of internal herniation has been increasing. This case report describes a new bariatric surgical technique and the associated post-operative radiological appearances on CT. The surgical technique has been pioneered in Sydney, Australia and involves a laparoscopic RYGB using bioabsorbable prosthesis with fibrin glue fixation to prevent a Petersen's space hernia.

Novel technique using a bioabsorbable prosthesis with fibrin glue fixation to prevent a Petersen's space hernia.

INTRODUCTION: Laparoscopic Roux-en-Y gastric bypass is a bariatric operation that is effective for long-term weight loss. Although rare, one serious complication is an internal hernia through Petersen's space, which may result in bowel strangulation. Although the incidence of internal hernia can be reduced through closing the Petersen's defect, it does not eliminate the risk. This case describes a novel and reliable method to close Petersen's defect. We report the case of a 30-year-old female who underwent a laparoscopic Roux-en-Y gastric bypass for the management of morbid obesity. Following her Roux-en-Y reconstruction, a prosthetic bioabsorbable mesh was placed in Petersen's space and reinforced with fibrin glue to prevent internal herniation through Petersen's defect. The use of a bioabsorbable mesh in Petersen's space is a novel and easy technique that could be used to reduce the incidence of an internal hernia through Petersen's defect.

A histologic evaluation of the laparoscopic adjustable gastric band capsule by tissue sampling during sleeve gastrectomy performed at different time points after band removal.

BACKGROUND: Laparoscopic sleeve gastrectomy (SG) is gaining popularity as a revision option after failed laparoscopic adjustable gastric banding (LAGB). Data have shown that single stage revisions may be associated with a higher complication rate. A histologic basis for this observation has not been studied. The objective of this study was to document the histologic properties of the LAGB capsule across the gastric staple line after SG at various time points after LAGB removal. METHODS: Gastric sleeve specimens of all LAGB to SG revisions were identified from January to May 2013 and underwent histologic evaluation of the LAGB capsule. Single blinded pathologist interpretation was performed, with inflammation, fibrosis, neovascularization, foreign body (FB) reaction, and wall thickness assessed semi-quantitatively and scored from 0-3. Based on combined features, an attempt was made to predict the timing of revision surgery. RESULTS: The study identified 19 revisions performed for inadequate excess weight loss or weight regain. The mean age for revision was 44 (19-65). The minimum time to revision was 42 days, the longest 1,188 days. There were no surgical complications. Varying degrees of inflammation and fibrosis were common features at all times. Angiogenesis, neovascularization and FB reaction were prominent in revisions performed before 80 days. The gastric wall was thicker during early revision. The optimal time to perform revision was difficult to determine. CONCLUSIONS: LAGB caused varying degrees of inflammatory and FB reaction that time did not fully resolve. The lower leak rates observed with delayed revisions do not appear to be attributable to gastric histology.