Gastrobronchial fistula after sleeve gastrectomy and gastric bypass: endoscopic management and prevention.

Gastrobronchial fistula (GBF) is a serious complication following bariatric surgery, whose treatment by thoracotomy and/or laparotomy involves a high morbidity rate. We present the outcomes of endoscopic management for GBF as a helpful technique for its healing process. This is a multicenter retrospective study of 15 patients who underwent gastric bypass (n = 10) and sleeve gastrectomy (n = 5) and presented GBF postoperatively (mean of 6.7 months). Ten patients developed lung abscess and were treated by antibiotic therapy (n = 10) and thoracotomy (n = 3). Abdominal reoperation was performed in nine patients for abscess drainage (n = 9) and/or ring removal (n = 4) and/or nutritional access (n = 6). The source of the GBF was at the angle of His (n = 14). Furthermore, 14 patients presented a narrowing of the gastric pouch treated by 20 or 30 mm aggressive balloon dilation (n = 11), stricturotomy or septoplasty (n = 10) and/or stent (n = 7). Fibrin glue was used in one patient. We performed, on average, 4.5 endoscopic sessions per patient. Endotherapy led to a 93.3% (14 out of 15) success rate in GBF closure with an average healing time of 4.4 months (range, 1-10 months), being shorter in the stent group (2.5 × 9.5 months). There was no recurrence during the average 27.3-month follow-up. A patient persisted with GBF, despite the fibrin glue application, and decided to discontinue it. GBF is a highly morbid complication, which usually arises late in the postoperative period. Endotherapy through different strategies is a highly effective therapeutic option and should be implemented early in order to shorten leakage healing time.

Atividade mioelétrica do intestino delgado de cães submetidos à oclusão parcial da veia porta / Myoelectric activity of the small bowel of dogs submitted to partial occlusion of the portal vein

RACIONAL: A oclusão temporária da veia porta causa estase esplâncnica e pode causar dismotilidade intestinal. OBJETIVO: Avaliar as alterações da atividade mioelétrica e da histologia do intestino delgado, além da pressão arterial média (PAM), frequência cardíaca (FC), pressão venosa central (PVC) e pressão portal (PP), na fase de pré-oclusão e de oclusão portal. MÉTODO: Realizou-se anestesia geral em seis cães, seguido de monitorização da PAM, FC e PVC, laparotomia, aferição da PP, fixação de três pares de eletrodos na parede intestinal, biópsias jejunais e oclusão parcial da veia porta, sendo programado aumento da PP entre 2,5 e 3 vezes. Os eletrodos foram conectados a um microcomputador com software de aquisição para armazenamento e análise da atividade mioelétrica, cujo registro ocorreu nos 30 minutos da fase de pré-oclusão e nos 60 minutos de oclusão. Determinouse a variância e a média do RMS (root mean square) da atividade mioelétrica. RESULTADOS: Na fase de oclusão, houve diminuição significativa da média do RMS e aumento da frequência de hemorragia da lâmina própria, sendo proporcional ao tempo de estase.Infiltrado inflamatório, dilatação vascular e desprendimento epitelial não apresentaram diferença entre as duas fases. Durante a estase, PAM, FC e PVC diminuíram (p=0,326; 0,375 e 0,008; respectivamente), e PP aumentou (p=0,015). CONCLUSÃO: A oclusão parcial da veia porta de cães promoveu diminuição da atividade mioelétrica e aumento da frequência percentual da hemorragia da lâmina própria, além de queda da PVC.

BACKGROUND: Temporary occlusion of the portal vein causes splancnic venous stasis and intestinal disfunction, that can produce alterations in the motility, and this fact is not vastly known. AIM: To evaluate the small bowel myoelectric activity and histology in the six dogs, also covering mean arterial blood pressure (AP), pulse rate (PR), central venous pressure (CVP) e portal pressure (PP), in two phases: pre-occlusion and occlusion. METHODS: It was done general anesthesia, invasive monitorization of the AP, PR e CVP, laparotomy, measure of the PP, fixation of the three pairs of electrodes in the intestinal wall, jejunal biopsy and parcial occlusion of the portal vein, being programmed the increase of the PP between 2.5 and 3 times baseline. Electrodes were connected to a computer system that captured electrical signals from the intestine. The computer has a software of acquisition to store and analyse the myoelectric activity after registering, what happened in 30 minutes of the pre-occlusion phase and in 60 minutes of occlusion. The variance and the mean RMS(root mean square) of the myoeletric activity were determined. The statistical analysis was done with Friedman, Dunn, Cochran and Students t tests. RESULTS: Mean RMS of myoeletric activity showed significant decrease in the phase of portal occlusion, in comparison to preocclusion phase. The frequency of hemorrhage of the lamina propria was major during occlusion. It was proportional at stasis time, with significant difference between the preocclusion and the occlusion of 60 minutes. Inflammatory infiltration, vascular dilation and epithelial detachment did not show any differences between two phases. During the stasis, AP, PR and CVP decreased (p=0,326; 0,375 e 0,008, respectively), and PP increased(p=0,015). CONCLUSIONS: Parcial occlusion of the portal vein produced reduction of the myoeletric activity and elevation of the percentage frequency of hemorrhage in lamina propria, and a fall of CVP, with relative hemodynamic stabilization.

Small erosion of adjustable gastric band: endoscopic removal through incision in gastric wall.

The erosion of a laparoscopic adjustable gastric band (LAGB) can cause pain that is not controlled by analgesics. In such cases, early endoscopic removal may be indicated, but only when gastric penetration is greater than 50%. We report the case of a patient with severe shoulder pain due to a small area of LAGB erosion, which was treated with early endoscopic removal through an incision in the gastric wall. The pain worsened after eating and gastroscopy revealed slight gastric erosion of the band under the cardia. The gastric wall covering the LAGB was incised using an endoscopic needle knife. In a second upper endoscopy performed 7 days later at the endoscopy suite, endoscopic scissors were used to cut the thread and part of the band lock. The open band was then removed orally. This novel endoscopic incision in the gastric wall hastened band erosion and avoided abdominal reoperation.

Treatment of ring slippage after gastric bypass: long-term results after endoscopic dilation with an achalasia balloon (with videos).

BACKGROUND: Silastic rings are used in gastric bypass procedures for the treatment of obesity, but ring slippage may lead to gastric pouch outlet stenosis (GPOS). Conventional management has been ring removal through abdominal surgery. OBJECTIVE: To describe a novel, safe, minimally invasive, endoscopic technique for the treatment of GPOS caused by ring slippage after gastric bypass. DESIGN: Case series. SETTING: Federal University of Pernambuco and São Paulo University. PATIENTS: This study involved 39 consecutive patients who were screened for inclusion. INTERVENTION: Endoscopic dilation with an achalasia balloon. MAIN OUTCOME MEASUREMENTS: Technical success and safety of the procedure. RESULTS: Among the 39 patients, 35 underwent endoscopic dilation at the ring slippage site for the relief of GPOS. The 4 patients who did not undergo endoscopic dilation underwent surgical removal of the ring, based on the exclusion criteria. The endoscopic approach was successful in 1 to 4 sessions in 100% of cases with radioscopic control (n = 12). The duration of the procedures ranged from 5 to 30 minutes, and the average internment was 14.4 hours. Dilation promoted either rupture (65.7%) or stretching (34.3%) of the thread within the ring, thereby increasing the luminal diameter of the GPOS. Complications included self-limited upper digestive tract hemorrhage (n = 1) and asymptomatic ring erosion (n = 4). There were no recurrences of obstructive symptoms during the follow-up period (mean of 33.3 months). LIMITATIONS: This was not a randomized, comparison study, and the number of patients was relatively small. CONCLUSION: The technique described promotes the relief of GPOS with low overall morbidity and avoids abdominal reoperation for ring removal.

Laparoscopic greater curvature plication: initial results of an alternative restrictive bariatric procedure.

BACKGROUND: Vertical sleeve gastrectomy (VSG) is a surgical technique that involves resection of a significant portion of the stomach. This surgery is sometimes associated with gastric leaks, which can be difficult to treat. The present study reports findings from laparoscopic greater curvature plication (LGCP), which is an alternative bariatric procedure similar to VSG but without the need for gastric resection. METHODS: A prospective study was carried out, following LGCP in 42 morbidly obese patients (30 female/12 male) with a mean age of 33.5 years (23 to 48) and mean BMI of 41 kg/m(2) (35 to 46). Through a five-port approach, the stomach was reduced by dissecting the greater omentum and short gastric vessels, as in VSG, and the greater curvature was then invaginated using multiple rows of non-absorbable suture performed over a 32-Fr bougie to ensure a patent lumen. RESULTS: All procedures were completed laparoscopically. Mean operative time was 50 min (40 to 100 min) and mean hospital stay was 36 h (24 to 96). Patients returned to their regular activities at an average of 7 days (4 to 13) following surgery. No intra-operative complications occurred. All patients experienced excess weight loss (EWL) of at least 20% after 1 month. Mean EWL was 62% (45% to 77%) in nine patients after 18 months. There has been no record of weight regain in any patient to date. CONCLUSIONS: LGCP is feasible, safe, and effective for at least 18 months when performed on morbidly obese patients. Longer follow-up and prospective comparative trials are needed.

Translumenal endoscopic drainage of abdominal abscess due to early migration of adjustable gastric band.

We describe the case of early band migration that developed into intraabdominal infection treated by natural orifice translumenal endoscopic surgery. A 40-year-old man was seen 4 years after gastric band placement. He complained of epigastric pain and fever. Gastroscopy revealed minimal gastric fundus erosion and a bulging of the antrum wall. Abdominal CT scan showed perigastric abscess surrounding the band tube. Antibiotic therapy was initiated, and endoscopic transgastric abscess drainage was performed. The endoscope was guided into the abscess cavity, and the band tubing was brought into the gastric lumen to serve as a stent to drain the infection, which ceased 5 days later. During the follow-up, the mucosa covering the band was incised in two more sessions to hasten the erosion process. Endoscopic removal was done 7 months after the drainage.

Endoscopic removal of eroded adjustable gastric band: lessons learned after 5 years and 78 cases.

BACKGROUND: One of the complications of laparoscopic adjustable gastric banding is intragastric erosion, leading to a revisional procedure to remove the band. Our aim was to present the procedure and results of endoscopic band removal in a 5-year multicenter experience from the Gastro Obeso Center and Universidade de São Paulo, São Paulo, and Universidade Federal de Pernambuco, Recife, Brazil. METHODS: From 2003 to 2008, 82 patients were diagnosed with band erosion. The clinical data concerning the endoscopic procedure were prospectively recorded and retrospectively reviewed. RESULTS: The average preoperative body mass index was 43.2 kg/m(2) (range 34-50). At the diagnosis of intragastric erosion, the body mass index was 24-41 kg/m(2) (average 31.8). The erosion occurred an average of 16.3 months (range 6-36) postoperatively. The symptoms included pain in 25 (31%), port infection in 21 patients (27%), and weight regain in 20 (25%), and 12 patients (15%) were asymptomatic. Endoscopic removal was possible for 78 patients (95%). In 85% of patients, the band was removed in the first session, with an average duration of 55 minutes (range 25-150). Five cases of pneumoperitoneum occurred after the procedure. Of these, 3 were treated conservatively, 1 was treated by laparoscopy, and 1 was treated by abdominal puncture using the Veress needle. CONCLUSION: Endoscopic removal of eroded laparoscopic adjustable gastric banding is safe and effective. It can be used as a first choice procedure in clinical practice.

Diverticulite em adolescente com Síndrome de Williams: relato de caso / Diverticulitis in adolescent with Williams Syndrome: case report

A Síndrome de Williams é uma doença genética rara, atribuída a deleção do gene da elastina no cromossomo 7. É caracterizada por estenose de aorta, divertículos de bexiga, constipação, retardo mental leve, fácies dismórfica, fraqueza da parede da bexiga e do cólon que levam ao surgimento de divertículos. Relata-se um caso de diverticulite aguda em paciente de 18 anos, o resultado do tratamento clínico durante 5 anos e o diagnóstico diferencial de abdome agudo nesta doença. A indicação de colectomia eletiva é discutida, considerando o pouco conhecimento da história natural da diverticulite nesta síndrome.

The Syndrome of Williams is a rare genetic illness, attributed the deletion of the gene of the elastin in chromosome 7. It is characterized by aortic stenosis, bladder diverticula's, constipation, light mental retardation, dysmorphic facies, weakness of the wall of the bladder and colon that they lead to the sprouting of diverticula. A case of acute diverticulitis in patient of 18 years is told, the result of the clinical treatment during 5 years and the differential diagnosis of acute abdomen in this illness. The indication of elective colectomy is argued, considering the unfamiliarity of the natural history of the diverticulitis in the syndrome.

Bypass gástrico laparoscópico com uso reduzido de suturas mecânicas / Laparoscopic gastric bypass with low use of stapler sutures

RACIONAL: A execução de bypass gástrico laparoscópico em hospital universitário público tem sido difícil devido ao elevado custo dos grampeadores cirúrgicos que prejudica o treinamento de médicos residentes e tem motivado a busca por técnicas alternativas, de baixo custo, mantendo a eficácia. OBJETIVO: Apresentar a viabilidade de um método com menor uso de suturas mecânicas. MÉTODOS: Foram operados 63 pacientes em 2 hospitais universitários, sendo 12 homens e 51 mulheres (81 por cento), com média de 33,5 anos de idade e IMC médio de 43. Aplicou-se a seguinte padronização técnica: Secção da alça com bisturi elétrico a 50 cm do ângulo duodeno-jejunal, anastomose término-lateral, passagem da alça retrocólica e retrogástrica, confecção da parede lateral da bolsa gástrica com 1 carga azul de 45 e outra de 60 mm após a secção horizontal com bisturi elétrico, sutura do estômago excluso e anastomose gastrojejunal. As anastomoses foram manuais e contínuas com fio absorvível. RESULTADOS: O tempo operatório médio foi de 5,5 horas. As complicações precoces foram: fístula no ângulo de esôfago-gástrico (1,6 por cento), estenose (1,6 por cento) e fístula na anastomose gastrojejunal (1,6 por cento) e torção da anastomose intestinal (1,6 por cento). A estenose foi tratada por dilatação endoscópica e as outras complicações através de 3 re-operações (2 laparoscópicas e 1 laparotômica). O tempo de internação variou de 2 a 20 dias, com média de 4 dias, não havendo óbito. CONCLUSÃO: Este método é viável e com baixo custo operacional; todavia, é complexo e requer habilidade principalmente em suturas laparoscópicas.

BACKGROUND: To perform laparoscopic gastric bypass in public university hospital has been difficult due to the high cost of the surgical staplers. This fact induced to look for different technical options, with low cost, maintaining the efficacy. AIM: To present the viability of a new method with the use of a low number of stapler devices. METHODS: Sixty three patients were operated in two university hospitals, 12 men and 51 women (81 percent), with mean age of 33.5y and average BMI of 43. The surgical technique used followed this sequence: loop section with electrical scalpel 50 cm of the duodenojejunal angle; termino-lateral anastomosis; retrogastric-retrocolic passage of the Roux limb; construction of the lateral wall of the pouch using 1 blue load of 45 and other of 60 mm after horizontal section with electrical scalpel; suture of the excluded stomach and gastrojejunal anastomosis. The anastomoses were hand-sewn made and a single-layer continuous absorble suture was performed. RESULTS: The average surgical time was 5.5 hours. The early complications were: fistula in the esophago-gastric angle (1.6 percent), stenosis (1.6 percent); fistula in the gastro-jejunal anastomosis (1.6 percent); obstruction of the intestinal anastomosis (1.6 percent). The stenosis was treated by endoscopic dilation. The remaining complications, with 3 re-operations (2 with laparoscopic and 1 with laparotomic approaches). The length of hospital stay was in average 4 days. CONCLUSION: This method is viable with low cost; however, it is complex and requires ability mainly in laparoscopic handsewn sutures.

Hypovolemic shock due to intragastric migration of an adjustable gastric band.

Migration of the adjustable gastric band (AGB) is a serious complication which usually does not require emergency treatment, except when there is a risk to life. We report a 30-year-old patient who presented with syncope, melena and hypovolemic shock due to the intragastric erosion of an AGB, 13 months after laparoscopic band placement. The diagnosis of migration had been made 7 months after placement, and bleeding only occurred 6 months later. Greater intraluminal penetration had been awaited to facilitate gastroscopic extraction, but, faced with hemodynamic instability, resuscitation was carried out followed by emergency endoscopy to cut the device, using endoscopic scissors. Then, the band was removed orally. There has been no recurrence of hemorrhage 12 months later. Delayed treatment may be indicated in cases of initial band migration; however, rigorous follow-up is necessary with frequent re-evaluation, to diagnose potentially life-threatening complications promptly.