Single Anastomosis Jejuno-ileal (SAJI): a New Model of Malabsorptive Revisional Procedure for Insufficient Weight Loss or Weight Regain After Roux-en-Y Gastric Bypass.

BACKGROUND: In case of insufficient weight loss or weight regain or relapse of weight-related comorbidities after Roux-en-Y gastric bypass (RYGB), other procedures such as reduction of a large gastric pouch and stoma, lengthening of the Roux limb, conversion to sleeve gastrectomy and/or bilio-pancreatic diversion with duodenal switch have been advocated. Single anastomosis jejuno-ileal (SAJI) is a new revisional simple operation performed after RYGB failure which adds malabsorption to the previous gastric bypass. METHODS: SAJI includes a single jejuno-ileal anastomosis specifically joining the ileum 250-300 cm proximal to the ileo-caecal valve and the jejunum 30 cm below the gastro-jejunal anastomosis on the Roux limb of the previous RYGB. Thirty-one patients underwent SAJI for insufficient weight loss and/or weight regain after RYGB. The percent total weight loss (%TWL) after RYGB and before SAJI was 21.8 ± 7.8. All SAJI operations were performed laparoscopically. The SAJI mean operating time was 145 min. RESULTS: Regarding weight loss after SAJI, %TWL is 27.2 ± 7.4, 31.2 ± 6.4, 33.7 ± 5.9 and 32.9 ± 5.2 at 12, 24, 36 and 48 months, respectively. Our series recorded a low rate of peri-operative and medium-term complications with a low grade of severity (Clavien-Dindo classification grade). One patient required reoperation 36 days after SAJI for epigastrium incarcerated incisional hernia at the previous RYGB laparotomy site. Mortality was 0. Comorbidity reduction/resolution after SAJI is 83.2% for type 2 diabetes mellitus, 42.8% for arterial hypertension, 72.8% for dyslipidemia and 45.3% for OSA. CONCLUSIONS: Treatment of failed RYGB is challenging. SAJI is a less complicated, purely low invasive malabsorptive operation that should reach satisfactory %TWL and comorbidity reduction/resolution.

Laparoendoscopic Percutaneous Endoscopic Gastrostomy in Adults.

BACKGROUND: Since its introduction, the placement of percutaneous endoscopic gastrostomy (PEG) has been increasing in the Western countries. Nevertheless, it is not always possible to perform this operation. Laparoscopic-assisted endoscopic gastrostomy (LAPEG) is an effective alternative solution. MATERIALS AND METHODS: Indication to PEG placement was established only for people who required a nutritional support of >4 weeks and without metastatic carcinoma. Sixteen patients underwent LAPEG after the failure of the original PEG operation. Two trocars of 5 mm and one of 12 mm were used, and a fourth trocar of 5 mm was placed when necessary to lift the liver. In four cases a gastrotomy was performed, in seven patients it was not necessary. When PEG was placed, the stomach was not fixed with stitches to the abdominal wall. RESULTS: Sixteen patients were selected for LAPEG and were all successful; in one case it was necessary to replace the PEG, and the same procedure was performed again. Median age was 73 years. Placement of laparoscopic PEG was not associated with other surgical procedures. Nutritional feeding started the day after for patients with sutureless technique and 2 days after in patients with gastrotomy. CONCLUSION: LAPEG is a safe technique with a low complication rate. It should be considered a minimal alternative in all cases where the placement of PEG is not possible.

Complications of laparoscopic gastric banding: detection and treatment.

INTRODUCTION: Laparoscopic adjustable gastric banding (LAGB) is acknownledged as a popular and effective surgical option in the management of obesity and related metabolic diseases. This procedure is a remarkably safe operation from both a general surgical and bariatric perspective. It facilitates brief hospitalization and can be performed by single incision. METHODS: We analyzed the most common LAGB complications as intraoperative and postoperative gastric perforation, stomach slippage/dilatation, port/tubing complications and intragastric band migration which occurred in our long decades clinical experience. Detection, treatment and rate of presentation of each complication was evaluated. RESULTS: LAGB showed good long term results in terms of weight loss and resolution of obesity related diseases. Moreover, mortality due to obesity and related diseases appeared significantly lower in LAGB patients than in medically treated patients. CONCLUSION: Gastric Banding has a very low rate of early and late complications; these are also less severe when compared to more invasive procedures and are likely to be managed with mini-invasive techniques. In any case referral to a bariatric surgeon is deemed appropriate. KEY WORDS: Complication, Laparoscopic gastric banding, Morbid obesity.

A New Concept in Bariatric Surgery. Single Anastomosis Gastro-Ileal (SAGI): Technical Details and Preliminary Results.

BACKGROUND: In one anastomosis gastric bypass (OAGB), the measurement of the afferent limb starting at the angle of Treitz may result in insufficient absorptive surface of the intestine of the remaining efferent limb. To address this concern, we recently modified the technique of OAGB by constructing the gastrointestinal anastomosis at a fixed distance from the ileocecal valve (i.e., 300 cm). We adopted the new concept and named it the single anastomosis gastro-ileal bypass (SAGI). METHODS: Seven consecutive patients with morbid obesity underwent the SAGI procedure. RESULTS: There were no intraoperative complications and there were no deaths. The mean excess weight (EW) loss was 55.1 % at 3 months and 82.1 % at 6 months. CONCLUSIONS: The SAGI procedure may constitute a safer alternative to the conventional OAGB.