Laparoscopic Common Bile Duct Exploration Using a Single-Operator Cholangioscope.

Background: Gallbladder stones are a very common disease, with a prevalence of 21.9% in Argentina. The incidence of common bile duct stones (CBDS) varies with age and with the clinical presentation; ∼3%-10% of patients with gallbladder lithiasis have concomitant choledocholithiasis. In the past decades, the development of ultrasound and magnetic resonance cholangiography and endoscopic ultrasound has expanded for the preoperative diagnosis of gallbladder lithiasis. Materials and Methods: We describe the step-by-step technique using the single-operator cholangioscope (pSOC) (SpyGlass™ Discover; Boston Scientific, Natick, MA) under laparoscopic guidance, in a patient with huge stones in the bile duct that was treated with a choledocotomy. Results: The patient underwent the procedure well and the closure of the bile duct was with a primary suture. The current devices, standard cholangioscopes or bronchoscopes, only have a two-way deflection. This problem might be solved with the introduction of a new pSOC device (SpyGlass Discover; Boston Scientific). Conclusion: In conclusion, the combination of laparoscopy and pSOC is a feasible, safe, and effective technique for the treatment of CBDS, and may be considered as an alternative approach in clinical cases where gastrointestinal anatomy is altered or when endoscopic retrograde cholangio-pancreatography (ERCP) failed. pSOC has the potential to reduce peri-procedural adverse events and costs.

Treatment option in patient presenting with small bowel obstruction from phytobezoar at the jejunojejunal anastomosis after Roux-en-Y gastric bypass.

Bezoar is a rare cause of small bowel obstruction after Roux-en-Y gastric bypass (RYGB). We report the case of a 34-year-old man who developed small bowel obstruction secondary to a phytobezoar at the jejunojejunal anastomosis, 5½ years after the patient underwent RYGB for morbid obesity. The phytobezoar developed in the background of recurring abdominal pain. Imaging studies suggested complete obstruction of the alimentary limb. Laparoscopic exploration demonstrated complete obstruction of the alimentary and biliopancreatic limb. Patient had successful treatment with laparoscopic enterototomy. Six months after the laparoscopic removal of phytobezoar, patient remained asymptomatic. Phytobezoar formation must be considered in the differential diagnosis when postgastric bypass patients present late with obstructive symptoms. We believe that this is the first report of a phytobezoar obstructing at the jejunojejunal anastomosis after RYGB.

Outcomes of bariatric surgery in patients with body mass index <35 kg/m2.

BACKGROUND: Patients who are categorized with class I obesity have a body mass index (BMI) of 30-34.99 kg/m(2). This population of patients has a predisposition to diabetes, hypertension, and dyslipidemia. The aim of the present study was to investigate the improvements of these co-morbidities in a class I obese population that had undergone a bariatric procedure. METHODS: After internal review board approval and with adherence to the Health Insurance Portability and Accountability Act guidelines, a retrospective review was performed of a prospectively maintained database of 42 class I obese patients who underwent a bariatric procedure at our institution during a 10-year period, from February 2000 to May 2010. The fasting glucose level, glycosylated hemoglobin level, lipid profile, initial weight, and BMI were measured in the preoperative and postoperative periods. RESULTS: Our patient population consisted of 30 women and 12 men, with a preoperative mean BMI of 33.9 kg/m(2). Laparoscopic sleeve gastrectomy was performed in 24 patients (57%), laparoscopic Roux-en-Y gastric bypass in 8 (19%), and laparoscopic adjustable gastric banding in 10 (24%). Of these 42 patients, 25 (60%) had type 2 diabetes, 1 patient was glucose intolerant, 27 (64%) had arterial hypertension, 25 (60%) had dyslipidemia, 17 (40%) had sleep apnea, and 8 (19%) had osteoarthritis. The postoperative findings included a mean BMI of 26.5 kg/m(2) and a mean weight loss of 41.4 lb. Of the 25 diabetic patients, 5 (20%) gained remission and 12 (48%) improvement of their diabetic status. The single patient with glucose intolerance showed improvement. Of the 27 patients with arterial hypertension, 9 (33%) showed remission and 13 (52%) improvement. Dyslipidemia resolved in 5 patients (20%) and improved in 13 (52%). Obstructive sleep apnea resolved in 10 (59%) and improvement was seen in 1 patient (6%). Finally, osteoarthritis resolved in 1 patient (12%) and improved in 5 (63%). CONCLUSION: Bariatric surgery can significantly improve or resolve co-morbid metabolic conditions in patients with class I obesity.