Effect of Suture Used for Closure of Mesenteric Defects After Laparoscopic Roux-en-Y Gastric Bypass: Single-Center Study.

INTRODUCTION: Small bowel obstruction (SBO) due to internal herniation (IH) is a well-known complication of laparoscopic Roux-en-Y gastric bypass (LRYGBP). The objective of this study is to evaluate different types of non-absorbable sutures used for closure of the defects regarding the incidence of SBO due to IH/adhesions, adhesion formation in general, or reopening of the defects. METHODS: A single-center retrospective study was performed. Patients who underwent LRYGBP were divided in 3 groups: group A closure of the defects with monofilament Polypropylene suture (Prolene®), group B with braided polyester suture (Ethibond®), group C with barbed knotless Polybutester suture (V-Loc®). Descriptive statistics were performed regarding SBO due to IH/adhesions, adhesion formation, and reopening of closed defects. RESULTS: From 5145 patients, 224 patients underwent exploratory laparoscopy for suspicion of SBO. Mean time interval was 28.4 months. IH or intermittent IH was found in 1.94% in group A, 1.78% in group B, and 1.40% in group C. Obstruction due to adhesions was found in 0.70%, 0.36%, and 0.42% per group, respectively. Adhesions in general were observed in 1.47% in group A, 1.43% in group B, and 1.06% in group C. The incidence of reopening was higher in group A (2.24%) in comparison with group B (1.13%, P = 0.041) and group C (1.05%, P = 0.001). CONCLUSIONS: After descriptive analysis, these results can withhold no difference among the 3 non-absorbable sutures regarding incidence of SBO due to IH or SBO due to adhesions, yet tendency for higher reopening rates after closure with monofilament Polypropylene suture is observed.

Internal Hernia After Laparoscopic Gastric Bypass: Effect of Closure of the Petersen Defect - Single-Center Study.

BACKGROUND AND AIMS: Bowel obstruction due to internal hernia (IH) is a well-known late complication of a laparoscopic roux-en-y gastric bypass (LRYGBP). The objective of this study is to evaluate if closure of the mesenteric defect and Petersen's space will decrease the rate of internal hernias compared to only closure of the mesenteric defect. METHODS: A single-center retrospective descriptive study was performed. All patients with LRYGBP from 2011 till April 2017 were included. An antecolic technique was used with closure of the mesenteric defect with a non-absorbable running suture between 2011 and October 2013 (group A), and from November 2013, we added closure of the Petersen defect (group B). RESULTS: From a total of 3124 patients, 116 patients (3.71%) had an exploratory laparoscopy due to suspicion of bowel obstruction, but in only 67 (2.14%) patients, an IH was found. Preoperative CT predicted the diagnosis in only 73%. In group A, including 1586 patients, 53 (3.34%) were diagnosed with an internal hernia: 39 at Petersen's space and 14 at the mesenteric defect. The mean time interval was 24.2 months and the mean BMI 25.7 kg/m2. After routine closure of the Petersen defect in 1538 patients in group B, an internal hernia during laparoscopy was found in 14 (0.91%) patients after a mean period of 13.5 months: 11 at Petersen's space and 3 at the mesenteric defect. In two subgroups (C and D) with an equal follow-up time (24-42 m), the incidence of 1.15% (8/699) was halved in the closure group of both defects compared to the incidence of 2.58% (23/893) in the group with only closure of the mesenteric defect. CONCLUSIONS: After descriptive analysis, these results can provide strong recommendation of closure of the mesenteric defect and Petersen's space, as we notice a tendency to lower incidence of internal hernias.

Perforated duodenal ulcer after laparoscopic gastric bypass.

A patient with a history of a laparoscopic gastric bypass presented with a perforated duodenal ulcer. The ulcer was laparoscopically oversewn, and an omentoplasty was performed. Postoperatively, a broad spectrum antibiotic and a proton pump inhibitor were administrated. Several questions arise regarding the diagnosis and treatment of duodenal ulcers after gastric bypass. What are the diagnostic tools to detect a duodenal ulcer, and how should Helicobacter pylori be diagnosed after gastric bypass? The key question is whether the bypassed stomach should be resected as a definitive treatment for complicated duodenal ulcers.

Severe hemoptysis 6 years after coronary artery bypass grafting.

A patient with a history of coronary artery bypass grafting was admitted with severe hemoptysis. Bronchoscopy showed recent bleeding with clot formation in the lingular bronchus, but no tumor was visualized. Several biopsies of the underlying mucosa were negative. Coronary angiography showed patent venous and arterial bypass grafts. Selective angiography of the left internal mammary artery revealed one large and two smaller aberrant bronchial side branches, which probably caused the lingular hemorrhage. We performed embolization of the largest aberrant branch. After a follow-up of 3 months, hemoptysis had not recurred.