Gastrojejunal anastomosis stricture after laparoscopic gastric bypass. Our experience with 62 patients.

OBJECTIVE: Gastrojejunal stricture (GYS), not only is a common complication after laparoscopic gastric bypass (LGBP), but its frequency is about 15% according to bibliography. Our aim is to present our experience after 62 LGBP. PATIENTS AND METHOD: From January 2004 to September-2006, we performed 62 consecutive laparoscopic gastric bypass (Wittgrove's technique). The gastrojejunal anastomosis is performed with auto suture material type CEAA No 21 termino-lateral (ILS, Ethicon). In 4 cases (6.45%) was converted to laparotomy, perform the anastomosis in the same way. Monitoring has a range of 3-35 months, conducted in 61 patients because one patient died of pulmonary thromboembolism in the immediate postoperative period after reoperation, after two weeks of gastric bypass, by necrosis of a small fragment of the remnant gastric. In all patients with persistent feeding intolerance were performed barium transit and/or gastroscopy. When gastrojejunal stricture showed proceeded to endoscopic pneumatic dilation (recommending dilate the anastomosis to a maximum 1.5 cm). RESULTS: Five cases (8.1%) developed a gastrojejunal stricture, in 4 of these cases the initial diagnosis was made by barium transit and in 1 case by endoscopy. Two patients had a history of digestive bleeding that required endoscopic sclerosis of the bleeding lesion (circumferentially sclerosis within 48 hours of surgery and sclerosis of bleeding points). All cases were resolved by endoscopic dilatation. At follow-up has not been detected re-stricture. CONCLUSION: Clinically, gastrojejunal stricture results in a progressive oral intolerance, revealing stenosis between 1 and 3 months postoperatively. The situations of sclerosis of the bleeding lesions favor, especially in cases of extensive sclerosis. In cases of suspected barium transit offers us a high diagnostic yield. Endoscopic dilatation resolved, so far, all cases.

Intestinal obstruction and bezoars.

BACKGROUND: Bezoars are large conglomerates of vegetable fibers, hairs, or concretions of various substances located in the stomach or small intestine of humans and certain animals, mainly ruminants. Gastrointestinal bezoars have constituted a relatively common clinical reality ever since the introduction of truncal vagotomy associated with drainage or gastric resection in the treatment of gastroduodenal peptic ulcer. STUDY DESIGN: This study presents a series of 87 cases of intestinal bezoar treated in our department of general surgery. Analysis was made of data obtained retrospectively from clinical histories, together with a clinical and endoscopic review of the patients. RESULTS: Most of the patients had had previous operative treatment (76.3 percent), the most commonly used technique being bilateral truncal vagotomy plus pyloroplasty (75.8 percent). An excessive intake of vegetable fiber was revealed in 39.5 percent of the cases, and alterations in dentition and mastication in 24 percent. Operative treatment was used in all patients. We attempted to fragment the bezoar and milk it to the cecum. Enterotomy and bezoar extraction were reserved for cases where fragmentation was impossible, as enterotomy was associated with more complications (p < 0.05). CONCLUSIONS: Bilateral truncal vagotomy plus pyloroplasty and a excessive ingestion of vegetable fiber are the main factors predisposing to bezoar formation. Clinically, intestinal bezoars manifest themselves in most cases as complete intestinal obstruction. Simple roentgenography of the abdomen is the fundamental technique for diagnosing the occlusive syndrome. Treatment must be operative, during which the bezoar is fragmented and milked to the cecum. The stomach must be explored for associated bezoars.

Quantification of duodenogastric reflux in patients with choledochoduodenostomy.

BACKGROUND: Frequently, patients present with symptoms after cholecystectomy (pain or discomfort in the upper part of the abdomen, postprandial fullness, bile vomiting, among others). Duodenogastric reflux has been associated with these symptoms in some patients. Therefore, this study was done to investigate this relationship. STUDY DESIGN: We evaluated duodenogastric reflux (DGR) in ten healthy patients, in ten patients who had asymptomatic simple cholecystectomy, in ten patients who had asymptomatic cholecystectomy with supraduodenal choledochoduodenostomy (CD), and in ten patients who had cholecystectomy plus CD followed by discomfort in the upper abdomen, postprandial fullness and bile vomiting, but no colicky pain or acute cholangitis. Duodenogastric reflux was quantified using continuous intravenous infusion of technetium-99m labeled hepatoiminodiacetic acid (99mTc-HIDA) and subsequently determining its concentration in gastric juice. RESULTS: All of the patients who underwent operation, whatever the technique used, had higher reflux rates than those in the control group (p < 0.001). Moreover, reflux rates were comparable in the patients who underwent simple cholecystectomy compared with patients in the asymptomatic cholecystectomy plus CD group. Conversely, when patients with cholecystectomy plus CD presented with discomfort in the upper part of the abdomen as well as bile vomiting, they had higher reflux rates than patients who underwent simple cholecystectomy (p < 0.001) and asymptomatic patients with associated CD (p < 0.001). CONCLUSIONS: Our results suggest that DGR must be involved in the genesis of these dyspeptic symptoms.

[Subcutaneous emphysema as the initial manifestation of perforation of a hollow abdominal viscus]. / Enfisema subcutáneo como manifestación inicial de perforación de víscera hueca abdominal.

The authors reports a case of cervical and abdominal subcutaneous emphysema, associated to pneumoretroperitoneum and pneumomediastinum, with no free air in the abdominal cavity, secondary to perforated diverticulitis of the sigmoid colon. We comment the rarity of this clinical presentation, the physiopathologic mechanisms of subcutaneous air presence in cases of non instrumental perforation of abdominal viscera and the ominous significance of the subcutaneous emphysema in such perforations.

Bariatric surgery, a risk factor for rhabdomyolysis.

Rhabdomyolysis has been increasingly recognized as a complication of bariatric surgery. We report a case of this complication and its consequences, in a patient who had undergone bariatric surgery, with a very high creatine kinase (CK) concentration, and whose renal function failed. Obesity causes a range of effects on all major organ systems. Knowledge of these effects and issues specific to the intensive care unit care of bariatric patients can help to predict and manage this underestimated complication in this population in which early diagnosis can alter the outcome.

Estenosis de la anastomosis gastroyeyunal en el bypass gástrico laparoscópico. Nuestra experiencia con 62 pacientes / Gastrojejunal anastomosis stricture after laparoscopic gastric bypass. Our experience with 62 patients

Objetivo: la estenosis de la anastomosis gastroyeyunal representauna complicación nada desdeñable en la cirugía bariátricapor laparoscopia, llegándose, en algunas series, a alcanzar el15%. Presentamos nuestra casuística en una serie de 62 casosconsecutivos y el manejo realizado.Pacientes y método: desde enero-2004 a septiembre-2006hemos realizado de manera consecutiva 62 bypass gástricos porlaparoscopia según técnica de Wittgrove modificada. La anastomosisgastroyeyunal se realiza con material de autosutura tipoCEAA nº 21 término-lateral (ILS; Ethicon) y después de comprobarla estanqueidad anastomótica se dan dos puntos de válvulatipo Hoffmeister a cada lado de la anastomosis. En 4 casos(6,45%) se reconvirtió a laparotomía, realizándose la anastomosisde la misma manera. El seguimiento tiene un rango de 3-35 meses,realizado en 61 enfermos, pues un paciente falleció por tromboembolismopulmonar en el postoperatorio inmediato tras reintervención,a las dos semanas del bypass gástrico, por necrosis deun pequeño fragmento del remanente gástrico.En todos los pacientes con intolerancia persistente a la alimentaciónse realizó tránsito baritado y/o gastroscopia. Cuando seevidenció estenosis gastroyeyunal se procedió a dilatación neumáticaendoscópica (recomendando dilatar la anastomosis hastacomo máximo 1,5 cm).Resultados: en 5 casos (8,1%) se desarrolló una estenosisgastroyeyunal, en 4 de estos casos el diagnóstico inicial fue portránsito baritado y en 1 caso por endoscopia. Dos pacientes teníanantecedentes de HDA que precisaron esclerosis endoscópicade la lesión sangrante (esclerosis circunferencial a las 48 horas dela cirugía y esclerosis de puntos sangrantes). Todos los casos seresolvieron mediante dilatación endoscópica, precisando en doscasos dos sesiones de dilatación y el resto una. En el seguimientono se han detectado re-estenosis...(AU)

Objective: gastrojejunal stricture (GYS), not only is a commoncomplication after laparoscopic gastric bypass (LGBP), butits frequency is about 15% according to bibliography. Our aim isto present our experience after 62 LGBP.Patients and method: from January 2004 to September-2006, we performed 62 consecutive laparoscopic gastric bypass(Wittgrove´s technique). The gastrojejunal anastomosis is performedwith auto suture material type CEAA No 21 termino-lateral(ILS, Ethicon). In 4 cases (6.45%) was converted to laparotomy,perform the anastomosis in the same way. Monitoring has arange of 3-35 months, conducted in 61 patients because one patientdied of pulmonary thromboembolism in the immediate postoperativeperiod after reoperation, after two weeks of gastric bypass,by necrosis of a small fragment of the remnant gastric. In allpatients with persistent feeding intolerance were performed bariumtransit and/or gastroscopy. When gastrojejunal strictureshowed proceeded to endoscopic pneumatic dilation (recommendingdilate the anastomosis to a maximum 1.5 cm).Results: five cases (8.1%) developed a gastrojejunal stricture,in 4 of these cases the initial diagnosis was made by barium transitand in 1 case by endoscopy. Two patients had a history of digestivebleeding that required endoscopic sclerosis of the bleeding lesion(circumferentially sclerosis within 48 hours of surgery andsclerosis of bleeding points). All cases were resolved by endoscopicdilatation. At follow-up has not been detected re-stricture.Conclusion: Clinically, gastrojejunal stricture results in a progressiveoral intolerance, revealing stenosis between 1 and 3months postoperatively. The situations of sclerosis of the bleedinglesions favor, especially in cases of extensive sclerosis. In cases ofsuspected barium transit offers us a high diagnostic yield. Endoscopicdilatation resolved, so far, all cases(AU)

Intestinal invagination in adults: preoperative diagnosis and management.

BACKGROUND AND AIMS: Intestinal invagination in adults is an uncommon but potentially serious condition that is usually diagnosed during surgery by the presence of a mechanical obstructive syndrome. We report a series of adults with intestinal invagination and discuss preoperative diagnosis and surgical procedures. PATIENTS AND METHODS: We analyzed the files of all the seven patients aged over 18 years with a postoperative diagnosis of intestinal invagination and treated at our center between 1996 and 2000. RESULTS: Preoperative causal diagnosis was established in six cases by ultrasonography and computed tomography. All the patients received surgery, three as emergency and four programmed. The lesions causing the invagination were: three benign (Meckel's diverticulum, inflammatory pseudotumor, fibroid polyp) and one malignant (degenerative villous adenoma polyp) located in the terminal ileum, two malignant lesions in the cecum (both adenocarcinomas over a polyp), and in the remaining case a double lymphoma of the jejunum and ileum. The intussusceptions were ileoileal in three cases and ileocolic in four. We performed intestinal resection in six cases and one excision of Meckel's diverticulum. CONCLUSION: Preoperative diagnosis of intussusception was possible in most cases. Sonography and computed tomography proved the most effective and useful preoperative diagnostic methods. In adults colonic invagination is almost always malignant while small bowel is almost always benign. Invagination in adults must be clarified by surgery, and intestinal resection is the procedure of choice.

Treatment of long-standing extensive perianal hidradenitis suppurativa using double rotation plasty, V-Y plasty and free grafts.

BACKGROUND: Perianal hidradenitis suppurativa is a chronic recurrent inflammatory, suppurating, and fistulizing disease of apocrine glands, adjacent anal canal skin, and soft tissues. The standard treatment used for extensive cases is a staged surgical procedure allowing the wound to heal by secondary intention or the delayed use of skin grafts. CASE PRESENTATION: A long-standing case, disabling for the patient, with extensive involvement of the buttock region, treated in one stage, which for reconstruction required the use of sliding plasties and free skin grafts, is reported. RESULTS: The outcome was satisfactory. Primary closure after wide excision using plastic-surgery techniques may help us resolve complex situations and obtain good results and a rapid recovery. CONCLUSION: The method of closure with a combination of skin flaps and skin graft in one stage can be considered a valid surgical option for a group of patients with extensive perianal hidradenitis.

Duodenogastric reflux in patients with biliary lithiasis before and after cholecystectomy.

Duodenogastric reflux is quantified in ten patients with biliary lithiasis and a functioning gallbladder, before and six months after performing cholecystectomy. The results are compared with those of a control group (n = 10) with similar age and gender, without gastric or hepatobiliary pathologic factors. To evaluate reflux, we used six hour continuous intravenous infusion and subsequent determination in gastric juice of 99mTc-diethyliminodiacetic acid. Our results showed that patients with cholelithiasis have higher reflux rates than those in the control group (p < 0.001). When comparing patients before and after cholecystectomy, we confirmed that removal of the gallbladder produces a significant increase (p < 0.001) in reflux rates compared with preoperative values.

Role of Helicobacter pylori infection and duodenogastric reflux in the pathogenesis of alkaline reflux gastritis after gastric operations.

In patients undergoing gastric operations, we studied the relationship between data suggesting alkaline reflux gastritis (symptoms, endoscopic alterations and histologic lesions) and two factors that produce chronic gastritis (helicobacter pylori and duodenogastric reflux). Of 225 patients who underwent operations for gastroduodenal gastric ulcer at our General Surgery Unit between 1980 and 1982, 63 agreed to undergo endoscopy and biopsies. Of these 63 patients, 38 agreed to a test to quantify duodenogastric reflux (24 hour gastric pH monitoring associated with the determination of bile acids in gastric juice). According to the clinical questionnaire, patients were classified as symptomatic and asymptomatic. Endoscopy was considered either normal with mucosal lesions or mucosal lesions plus bile. In the histologic study, we considered normal mucosa, superficial chronic gastritis and atrophic chronic gastritis. Furthermore, the presence of atrophy, metaplasia, foveolar hyperplasia and helicobacter pylori was studied. Symptoms, endoscopic alterations and histologic lesions were not significantly related to helicobacter pylori, but were significantly related to the quantity of duodenogastric reflux. The symptomatic patients presented with a greater quantity of reflux than the asymptomatic patients (p < 0.05). The patients with mucosal lesions plus bile who had endoscopy showed a greater quantity of reflux than those with normal endoscopy (p < 0.001) and those with mucosal lesions without bile (p < 0.02 for pH values and p < 0.001 for bile acids). The patients with atrophic chronic gastritis presented with a greater quantity of reflux than those with normal mucosa and superficial chronic gastritis (p < 0.05, respectively), and the patients with atrophy and metaplasia and foveolar hyperplasia had more reflux than those without (p < 0.001, respectively). The patients who were helicobacter positive and negative presented with similar quantities of reflux.

Gastric surgery and bezoars.

We present a series of 56 patients with gastrointestinal bezoar following previous gastric surgery for gastroduodenal peptic ulcer. The following parameters were studied: factors predisposing to bezoar formation (type of previous surgery, alimentation, and mastication), form of clinical presentation, diagnostic tests, and treatment. A bilateral truncal vagotomy plus pyloroplasty had been performed previously on 84% of patients, 44% revealed excessive intake of vegetable fiber, and 30% presented with bad dentition. The most frequent clinical presentation was intestinal obstruction (80%). This was diagnosed mainly by clinical data and simple abdominal radiology. The main exploratory technique for diagnosing cases of gastric bezoar was endoscopy. Surgery is necessary for treating the intestinal forms, and one should always attempt to fragment the bezoar and milk it to the cecum, reserving enterotomy and extraction for cases where this is not possible. The small intestine and stomach should always be explored for retained bezoars. Gastric bezoars should always receive conservative treatment, endoscopic extraction, and/or enzymatic dissolution; gastrotomy and extraction should be performed when this fails.

Management of the perineal wound following abdominoperineal resection: prospective study of three methods.

A prospective study was made of three procedures for treating the perineal wound and presacral cavity in 102 patients undergoing abdominoperineal excision for cancer of the rectum: (1) packing of the presacral space after suture of the pelvic peritoneum; (2) suture of the pelvic peritoneum and perineal wound, leaving two drains through the perineum; and (3) no suture of the pelvic peritoneum, and primary closure of the perineal wound, leaving drains through the abdomen for physiological saline irrigation. The parameters analysed were incidence of infection, primary healing of the perineum, extraperineal complications and mean hospital stay. Primary healing of the perineum was best with method 3, and overall incidence of infection highest with method 2. There were no differences between the methods with regard to extraperineal complications. Hospital stay was shortest with method 3.

Bariatric surgery, a risk factor for rhabdomyolysis

La rabdomiolisis tras cirugía bariatrica es una complicación rara pero posible. Presentamos un caso de rabdomiolisis y fallo renal agudo tras by-pass gástrico laparoscópico en paciente con obesidad mórbida. Su conocimiento puede ayudar a predecir y manejar esta complicación infradiagnosticada cuyo diagnostico precoz mejora el tratamiento de estos pacientes y previene las complicaciones posteriores (AU)

Rhabdomyolysis has been increasingly recognized as a complication of bariatric surgery. We report a case of this complication and its consequences, in a patient who had undergone bariatric surgery, with a very high creatine kinase (CK) concentration, and whose renal function failed. Obesity causes a range of effects on all major organ systems. Knowledge of these effects and issues specific to the intensive care unit care of bariatric patients can help to predict and manage this underestimated complication in this population in which early diagnosis can alter the outcome (AU)