Laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography (ERCP) after Roux-en-Y gastric bypass: technical features.

BACKGROUND: Laparoscopic gastric bypass is one of the most performed bariatric operations worldwide. The exclusion of stomach and duodenum after this operation makes the access to the biliary tree, in order to perform an endoscopic retrograde cholangiopancreatography (ERCP), very difficult. This procedure could be more often required than in overall population due to the increased incidence of gallstones after bariatric operations. Among the different techniques proposed to overcome this drawback, laparoscopic access to the excluded stomach has been described by many authors with a high rate of success reported. METHODS: We herein describe our technique to perform laparoscopic transgastric ERCP. A gastrotomy on the excluded stomach is performed to introduce a 15-mm trocar. Two stitches are passed through the abdominal wall and placed at the two sides of the gastrotomy for traction. The intragastric trocar is used to pass a side-viewing endoscope to access the biliary tree. CONCLUSION: In patients with a past history of Roux-en-Y gastric bypass (RYGB), the present technique allows us a standardized, safe, and reproducible access to the major papilla and the biliary tree using a transgastric access. This will lead to simplify the procedure and reduce the risk of peritoneal contamination.

Upper gastrointestinal series after Roux-en-Y gastric bypass for morbid obesity: effectiveness in leakage detection. a systematic review of the literature.

The aim of this study is to evaluate the results of routine and selective postoperative upper gastrointestinal series (UGIS) after Roux-en-Y gastric bypass (RYGB) for morbid obesity in different published series to assessing its utility and cost-effectiveness. A search in PubMed's MEDLINE was performed for English-spoken articles published from January 2002 to December 2012. Keywords used were upper GI series, RYGB, and obesity. Only cases of anastomotic leaks were considered. A total of 22 studies have been evaluated, 15 recommended a selective use of postoperative UGIS. No differences in leakage detection or in clinical benefit between routine and selective approaches were found. Tachycardia and respiratory distress represent the best criteria to perform UGIS for early diagnosis of anastomotic leak after a RYGB.

The role of drainage after Roux-en-Y gastric bypass for morbid obesity: a systematic review.

BACKGROUND: Intraperitoneal drainage after gastrointestinal surgery is still routinely used in many hospitals. The objective of this study was to determine the evidence-based value of routine drainage after Roux-en-Y gastric bypass (RYGB). METHODS: An electronic search of the MEDLINE, Cochrane, and Embase databases from 2002 to 2012 was performed to identify articles analyzing the use of drainage after RYGB, its efficacy in determining the presence of an anastomotic leak, and its role in nonoperative treatment of the leakage. RESULTS: Eighteen articles were identified: 6 nonrandomized prospective cohort studies, 1 cohort retrospective study that compared routine drainage versus no drainage, 11 retrospective cohort studies, and no randomized controlled trials (RCTs). The sensitivity of drainage in detecting postoperative leakage varied between 0% and 94.1% in 10 articles (3 prospective and 6 retrospective) reporting data about this matter. The efficacy of drainage for the nonoperative treatment of postoperative leakage could be estimated in 11 articles (5 prospective and 6 retrospective) and varied between 12.5% and 100%. Only 2 studies reported data about nonoperative treatment of leakage without drainage, which was pursued in 0% and 33% of patients, respectively. CONCLUSION: Evidence-based recommendations on the use of drainage after RYGB cannot be given. Without RCTs, the value of routine drainage cannot be ascertained.

Radiofrequency on the liver remnant after liver resection to reach the haemostasis not otherwise achievable with conventional techniques.

INTRODUCTION: During liver resection, in same case of inflamed, steatotic or neo-vascularized liver parenchyma, reaching of haemostasis on the liver resection surface could be very difficult for the surgeon because of the presence of fragile tissue that does not allows the proper placement of stitches, and the conventional method fail. PRESENTATION OF CASE: The authors describe a novel technique in which, after a formal liver resection, liver haemostasis is achieved using radiofrequency energy on the resected surface. A patient affected by a hystiocytic sarcoma localized on the VI-V and IVa segments was scheduled for liver resection. During the resection a diffuse bleeding from the resected surface started with little success obtained with conventional method. So we decided to use the coagulative necrosis generated by the radiofrequency, using a cool type cluster needle, hand-piece with 3 needle, bending 2 needles in a way resembling a "fork", to reach a complete and definitive haemostasis. DISCUSSION: Haemostasis remains a critical issue in liver surgery not only for the catastrophic effect of haemorrhage but also because it is correlated to complications rate and to survival. The coagulative necrosis generated by the radiofrequency could be used to facilitate the creation of a necrotic plane to be transacted. CONCLUSION: The use of the radiofrequency energy, delivered through needles, is suggested when the conventional techniques fail to reach a proper haemostasis after a liver resection or, to consider its use, prior to resect the liver in presence of fragile parenchyma.

Do preoperative eating behaviors influence weight loss after biliopancreatic diversion?

BACKGROUND: The presence of disturbed eating patterns can affect the short- and long-term outcomes after bariatric surgery. Data about the influence of preoperative eating patterns on outcomes after biliopancreatic diversion (BPD) are lacking. The aim of the present study was to assess the role of preoperative eating behavior in patients' selection for biliopancreatic diversion. METHODS: Sixty-one consecutive patients who underwent BPD were evaluated for the present study. For each patient, the following preoperative eating patterns were evaluated: sweet eating, snacking, hyperphagia, and gorging. The primary outcome measure was the percentage of excess weight loss (%EWL) at 3, 6, and 12 months in the groups of patients with different eating patterns at the preoperative evaluation. RESULTS: At the preoperative evaluation, snacking was found in 31 patients (50.8 %), sweet eating in 15 patients (24.6 %), hyperphagia in 48 patients (78.7 %), and gorging in 45 patients (73.8 %). For each eating behavior, there was no significant difference in mean preoperative BMI and weight loss at 3, 6, and 12 months between the group of patients with and the group of patients without the eating pattern considered. At the analysis of variance in the four groups of patients presenting the eating patterns considered, there was no difference in mean preoperative BMI (P = 0.66), %EWL at 3 months (P = 0.62), %EWL at 6 months (P = 0.94), and %EWL at 12 months (P = 0.95). CONCLUSIONS: Preoperative eating behaviors do not represent reliable outcome predictors for BPD, and they should not be used as a selection criterion for patients who are candidates to this operation.

Is lymphatic status related to regression of inflammation in Crohn's disease?

AIM: To investigate the status of the lymphatic vessels in the small bowel affected by Crohn's disease (CD) at the moment of surgery. METHODS: During the period January 2011-June 2011, 25 consecutive patients affected by CD were operated on in our Institution. During surgery, Patent Blue V was injected subserosally and the way it spread along the subserosa of the intestinal wall, through the mesenterial layers towards the main lymphatic collectors and eventually to the lymph nodes was observed and recorded. Since some patients had been undergone strictureplasty at previous surgery, we also examined the status of intestinal lymph vessels after previous strictureplasties. The same procedure was performed in a control group of 5 patients affected by colorectal cancer. Length of lesions, caliber, maximal thickness of the diseased intestinal wall, thickness of the wall at injection site and thickness of the mesentery were evaluated at surgery. RESULTS: We observed three features after the injection of Patent Blue V in the intestinal loops: (1) Macroscopically healthy terminal ileum of patients with CD or colon cancer showed thin lymphatic vessels linearly directed toward the mesentery; (2) In mild lesions in which the intestinal wall did not reach 8 mm of thickness, we observed short, wide and tortuous lymphatic vessels directed longitudinally along the intestinal axis toward disease-free areas and then transversally toward the mesentery; and (3) Injection in the severely affected lesions, that had a thickness of the intestinal wall over 10 mm, did not show any feature of lymphatic vessels at least on the subserosal surface. There was a correlation between the thickness of the parietal wall and the severity of the lymphatic alterations. Normal lymphatic vessels were observed at previous strictureplasties in the presence of complete regression of the inflammation. CONCLUSION: Injection of Patent Blue V in the intestinal wall could help distinguish healthy tracts of the small bowel from those macroscopically borderline.

[Diverticular disease of the colon: diagnosis and treatment. Consensus Conference, 5th National Congress of the Italian Society of Academic Surgeons]. / La malattia diverticolare del colon: quando e come trattarla. Consensus Conference- del quinto Congresso Nazionale della Società Italiana dei Chirurghi Universitari (S.I.C.U.).

Diverticular disease (DD) is one of the most common disorders of the colon with an increased prevalence in Western populations. There are still many unsolved issues about indications, timing of surgery and modality of surgical treatment. These topics were discussed during the Consensus Conference (CC). There is still common agreement indicating surgery after the second acute episode of diverticular disease; however, patients younger than 50 years should undergo surgery after the first acute episode, because of a higher risk of recurrence compared to older patients. It is not clear though how to uniformly classify an acute episode (severe, moderate or mild): an accurate clinical and instrumental valuation (based on CT scan) is recommended to establish the real severity of the acute episode before recommending a surgical procedure. In presence of septic complications (abscess or peritonitis) of DD, colonic resection is indicated, but a primary anastomosis could be at risk of failure due to sepsis. Therefore a Hartmann's procedure or protective stoma could be preferable. However, instead of a staged procedure, an appropriate strategy should be to resolve sepsis and perform resection and anastomosis in election. Abscesses smaller than 5 cm intra-meso-colic or para-colic can be successfully treated medically; vice versa larger or pelvic abscesses should undergo percutaneous or laparoscopic drainage, postponing colonic resection in elective conditions. Limited purulent peritonitis can be favourably treated by means of laparoscopic approach and simple lavage and drainage of peritoneal cavity. Diffuse purulent or faecal peritonitis is the most dramatic complication which still has a high risk of mortality and morbidity. Surgical risk is related to clinical conditions, duration of peritonitis, age of patient and comorbidities. Thus it is not possible to state a univocal approach, although Hartmann's procedure keeps being the first choice. On this matter farther randomized studies are required to compare Hartmann's procedure with other techniques (such as primary anastomosis with or without diverting colostomy). A wide left colonic resection (with splenic flexure mobilization) extended beneath sigmoid-rectal junction is recommended to avoid immediate or late complications. Laparoscopic approach is feasible, even for management of complicated diverticular disease, if strict patient selection criteria are followed, duration of the procedure is comparable to open surgery and conversion rate is under 10%.