Laparoscopic remnant gastrectomy as a novel approach for treatment of gastrogastric fistula.

BACKGROUND: Gastrogastric fistula (GGF) is a rare complication after divided Roux-en-Y gastric bypass (RYGBP). The incidence can be as high as 49% in patients who undergo nondivided or partially divided RYGBP. We have previously reported a GGF rate of 1.5% after divided RYGBP. Remnant gastrectomy has been advocated by our group as a treatment option for this complication. We report our initial experience using the laparoscopic approach. METHODS: After IRB approval and following HIPAA guidelines, we conducted a retrospective review of prospectively collected database of 1,796 patients who underwent RYGB from 2001 and to 2008 at the Bariatric and Metabolic Institute. Data included mean time to laparoscopic remnant gastrectomy (LRG), mean length of hospital stay, follow-up period after laparoscopic remnant gastrectomy, rate of conversion, type of procedure performed, and early and late postoperative complications. RESULTS: Twenty-one (1.1%) patients have been diagnosed with GGF; 11 more patients were admitted with GGF after undergoing initial RYGB at another institution. All patients (n = 32) were initially treated with sucralfate and proton pump inhibitors, and 22 of 32 patients eventually underwent LRG: 1 underwent fistulectomy, 1 underwent conversion of vertical banded gastroplasty to RYGB, and the remaining 8 patients have undergone only medical treatment. The mean time to LRG was 9 months from the time of diagnosis of GGF. Two of the 22 patients had conversion to an open approach: one because of a loss of poor visual surgical field resulting from excessive intraluminal air from intraoperative endoscopy and the other as a result of the inability to understand the anatomy laparoscopically. Three of the 22 patients (13%) underwent LRG and redo gastrojejunostomy because of a stenosed gastrojejunostomy. The mean hospital stay after LRG was 4.7 (range, 3-8) days. Early postoperative complications included intra-abdominal bleeding, pneumonia, wound infections, and fever of unknown origin. Late complications included intra-abdominal abscess, wound infections, fever, and food impactation. The follow-up period after LRG was an average of 4 (range, 1-11) months. During the follow-up period, there was no evidence of marginal ulceration, bleeding, abdominal pain, or recurrence of the GGF in any patient. CONCLUSIONS: Laparoscopic remnant gastrectomy seems to be a safe and effective treatment option for patients with GGF after RYGBP.

Comparison of return of bowel function and length of stay in patients undergoing laparoscopic versus open colectomy.

BACKGROUND: Over the last decade, many advances have been made in laparoscopic techniques in various surgical specialties. The technique of laparoscopic-assisted colectomy (LAC) has been reported since 1992 and has been slowly gaining popularity in the surgical community. Several studies have compared laparoscopic versus open colectomy, assessing its applicability to patients with colon cancer, Crohn's disease, and diverticular disease. Studies to date have assessed length of stay, operative time, and clinical outcome. This study focuses on return of bowel function and length of hospital stay in patients undergoing LAC compared with those undergoing open colectomy. METHODS: We performed a retrospective review of patients undergoing either open colon resection or LAC between January 2000 and December 2005. All disease processes and both emergent and elective cases were included. Return of bowel function was determined by passage of flatus or first passage of stool and compared between the 2 groups. The data were statistically analyzed using the Student t test for interval data, and nominal data were analyzed using the chi-square analysis (95% confidence interval; CI). RESULTS: The study included 247 patients; 179 (72.5%) underwent open colectomy and 68 (27.5%) underwent LAC. Passage of flatus took 3.6 days (95% CI .18 or 3.4 to 3.8) for open colectomy, and 2.9 days (95% CI .19 or 2.7 to 3.1) for LAC. First bowel movement took 4.4 days (95% CI .19 or 4.2 to 4.6) for open colectomy and 3.7 days (95% CI .22 or 3.5 to 3.9) for LAC. When compared between the groups, mean length of hospital stay was 8.01 days (95% CI .93 or 7.1 to 8.9) for open colectomy and 4.38 days (95% CI .38 or 4.0 to 4.8) for LAC. CONCLUSION: Both return of bowel function and length of stay were statistically significantly shorter in LAC compared with those in open colectomy, which may indicate faster recovery after bowel surgery in patients undergoing the laparoscopic approach.