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Khrucharoen U, Weitzner ZN, Chen Y, Dutson EP. Incidence and risk factors for early gastrojejunostomy anastomotic stricture requiring endoscopic intervention following laparoscopic Roux-en-Y gastric bypass: a MBSAQIP analysis. Surg Endosc 2022; 36:3833-3842. [PMID: 34471978 DOI: 10.1007/s00464-021-08700-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 08/23/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Gastrojejunostomy (GJ) stricture is one of the most commonly recognized complications following laparoscopic Roux-en-Y gastric bypass (LRYGB). The risks involving the formation of early GJ stomal stenosis are largely unknown. The aims of this study are to evaluate the rate and risk factors associated with GJ stricture in patients requiring esophagogastroduodenoscopy (EGD) within 30 days after LRYGB. METHODS This is a retrospective study of patients who underwent EGD for GJ stricture following LRYGB. Data were retrieved from MBSAQIP database from 2015 to 2018. Descriptive, bivariate, and logistic regression analyses were performed. Those who had reoperation, readmission, and intervention for other indications rather than GJ stricture were excluded from the risk factor analysis. RESULTS 760,076 patients underwent bariatric surgery. Of these, 184,660 (24.3%) underwent LRYGB and 875 had GJ stricture within 30 days postoperatively. The overall incidence of early GJ stricture after LRYGB was 4.7 per 1000 person-years. The incidence decreased from 6.2 to 3.4 per 1000 person-years during the 4-year period. 85% of patients with GJ stricture required therapeutic intervention. Median (IQR) day to the first endoscopic intervention was 25 (21-28) days. The overall 30-day readmission rate was 40%. 30-day reoperation rate due to GJ stricture was 5.6%. No 30-day mortality occurred. Factors independently associated with an increased risk for early GJ stricture include concurrent hiatal hernia repair (Adjusted Odds Ratio-AOR 1.8, 95% CI 1.5-2.2), revision case (AOR 1.4, 95% CI 1.1-1.6), African American (AOR 1.4, 95% CI 1.2-1.7), gastroesophageal reflux disease-GERD (AOR 1.4, 95% CI 1.2-1.5), drain placement (AOR 1.3, 95% CI1.1-1.4), and routine postoperative swallow study (AOR 1.3, 95% CI 1.1-1.50). CONCLUSION The incidence of early GJ stricture following LRYGB decreased at MBSAQIP-accredited centers over the review period. Patients having additional manipulation at or around GJ were at risk of developing early GJ stricture after LRYGB.
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Affiliation(s)
- Usah Khrucharoen
- Department of Surgery, Section of Minimally Invasive and Bariatric Surgery, David Geffen School of Medicine at University of California, Box 956904, 72-239 CHS, Los Angeles, CA, 90095, USA.,UCLA Center for Obesity and METabolic Health (COMET), Los Angeles, CA, USA.,UCLA Center for Advanced Surgical & Interventional Technology (CASIT), Los Angeles, CA, USA
| | - Zachary N Weitzner
- Department of Surgery, Section of Minimally Invasive and Bariatric Surgery, David Geffen School of Medicine at University of California, Box 956904, 72-239 CHS, Los Angeles, CA, 90095, USA.,UCLA Center for Obesity and METabolic Health (COMET), Los Angeles, CA, USA.,UCLA Center for Advanced Surgical & Interventional Technology (CASIT), Los Angeles, CA, USA
| | - Yijun Chen
- Department of Surgery, Section of Minimally Invasive and Bariatric Surgery, David Geffen School of Medicine at University of California, Box 956904, 72-239 CHS, Los Angeles, CA, 90095, USA.,UCLA Center for Obesity and METabolic Health (COMET), Los Angeles, CA, USA
| | - Erik P Dutson
- Department of Surgery, Section of Minimally Invasive and Bariatric Surgery, David Geffen School of Medicine at University of California, Box 956904, 72-239 CHS, Los Angeles, CA, 90095, USA. .,UCLA Center for Obesity and METabolic Health (COMET), Los Angeles, CA, USA. .,UCLA Center for Advanced Surgical & Interventional Technology (CASIT), Los Angeles, CA, USA.
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First fully endoscopic metabolic procedure with NOTES gastrojejunostomy, controlled bypass length and duodenal exclusion: a 9-month porcine study. Sci Rep 2022; 12:21. [PMID: 34996894 PMCID: PMC8741923 DOI: 10.1038/s41598-021-02921-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 11/18/2021] [Indexed: 01/14/2023] Open
Abstract
We conducted a pilot study of a potential endoscopic alternative to bariatric surgery. We developed a Natural Orifice Transluminal Endoscopic Surgery (NOTES) gastric bypass with controlled bypass limb length using four new devices including a dedicated lumen-apposing metal stent (GJ-LAMS) and pyloric duodenal exclusion device (DED). We evaluated procedural technical success, weight change from baseline, and adverse events in growing Landrace/Large-White pigs through 38 weeks after GJ-LAMS placement. Six pigs (age 2.5 months, mean baseline weight 26.1 ± 2.7 kg) had initial GJ-LAMS placement with controlled bypass limb length, followed by DED placement at 2 weeks. Technical success was 100%. GJ-LAMS migrated in 3 of 6, and DED migrated in 3 of 5 surviving pigs after mucosal abrasion. One pig died by Day 94. At 38 weeks, necropsy showed 100–240 cm limb length except for one at 760 cm. Weight gain was significantly lower in the pigs that underwent endoscopic bypass procedures compared to expected weight for age. This first survival study of a fully endoscopic controlled bypass length gastrojejunostomy with duodenal exclusion in a growing porcine model showed high technical success but significant adverse events. Future studies will include procedural and device optimizations and comparison to a control group.
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Schulman AR, Watson RR, Abu Dayyeh BK, Bhutani MS, Chandrasekhara V, Jirapinyo P, Krishnan K, Kumta NA, Melson J, Pannala R, Parsi MA, Trikudanathan G, Trindade AJ, Maple JT, Lichtenstein DR. Endoscopic devices and techniques for the management of bariatric surgical adverse events (with videos). Gastrointest Endosc 2020; 92:492-507. [PMID: 32800313 DOI: 10.1016/j.gie.2020.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 04/02/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS As the prevalence of obesity continues to rise, increasing numbers of patients undergo bariatric surgery. Management of adverse events of bariatric surgery may be challenging and often requires a multidisciplinary approach. Endoscopic intervention is often the first line of therapy for management of these adverse events. This document reviews technologies and techniques used for endoscopic management of adverse events of bariatric surgery, organized by surgery type. METHODS The MEDLINE database was searched through May 2018 for articles related to endoscopic management of adverse events of bariatric interventions by using relevant keywords such as adverse events related to "gastric bypass," "sleeve gastrectomy," "laparoscopic adjustable banding," and "vertical banded sleeve gastroplasty," in addition to "endoscopic treatment" and "endoscopic management," among others. Available data regarding efficacy, safety, and financial considerations are summarized. RESULTS Common adverse events of bariatric surgery include anastomotic ulcers, luminal stenoses, fistulae/leaks, and inadequate initial weight loss or weight regain. Devices used for endoscopic management of bariatric surgical adverse events include balloon dilators (hydrostatic, pneumatic), mechanical closure devices (clips, endoscopic suturing system, endoscopic plication platform), luminal stents (covered esophageal stents, lumen-apposing metal stents, plastic stents), and thermal therapy (argon plasma coagulation, needle-knives), among others. Available data, composed mainly of case series and retrospective cohort studies, support the primary role of endoscopic management. Multiple procedures and techniques are often required to achieve clinical success, and existing management algorithms are evolving. CONCLUSIONS Endoscopy is a less invasive alternative for management of adverse events of bariatric surgery and for revisional procedures. Endoscopic procedures are frequently performed in the context of multidisciplinary management with bariatric surgeons and interventional radiologists. Treatment algorithms and standards of practice for endoscopic management will continue to be refined as new dedicated technology and data emerge.
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Affiliation(s)
- Allison R Schulman
- Department of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Rabindra R Watson
- Department of Gastroenterology, Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, USA
| | - Barham K Abu Dayyeh
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Manoop S Bhutani
- Department of Gastroenterology Hepatology and Nutrition, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Vinay Chandrasekhara
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kumar Krishnan
- Division of Gastroenterology, Department of Internal Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nikhil A Kumta
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York, USA
| | - Joshua Melson
- Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Rahul Pannala
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Mansour A Parsi
- Section for Gastroenterology and Hepatology, Tulane University Health Sciences Center, New Orleans, Louisiana, USA
| | - Guru Trikudanathan
- Department of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Arvind J Trindade
- Department of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - John T Maple
- Division of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - David R Lichtenstein
- Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
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Paspatis GA, Arvanitakis M, Dumonceau JM, Barthet M, Saunders B, Turino SY, Dhillon A, Fragaki M, Gonzalez JM, Repici A, van Wanrooij RLJ, van Hooft JE. Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement - Update 2020. Endoscopy 2020; 52:792-810. [PMID: 32781470 DOI: 10.1055/a-1222-3191] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
1: ESGE recommends that each center implements a written policy regarding the management of iatrogenic perforations, including the definition of procedures that carry a higher risk of this complication. This policy should be shared with the radiologists and surgeons at each center. 2 : ESGE recommends that in the case of an endoscopically identified perforation, the endoscopist reports its size and location, with an image, and statement of the endoscopic treatment that has been applied. 3: ESGE recommends that symptoms or signs suggestive of iatrogenic perforation after an endoscopic procedure should be rapidly and carefully evaluated and documented with a computed tomography (CT) scan. 4 : ESGE recommends that endoscopic closure should be considered depending on the type of the iatrogenic perforation, its size, and the endoscopist expertise available at the center. Switch to carbon dioxide (CO2) endoscopic insufflation, diversion of digestive luminal content, and decompression of tension pneumoperitoneum or pneumothorax should also be performed. 5 : ESGE recommends that after endoscopic closure of an iatrogenic perforation, further management should be based on the estimated success of the endoscopic closure and on the general clinical condition of the patient. In the case of no or failed endoscopic closure of an iatrogenic perforation, and in patients whose clinical condition is deteriorating, hospitalization and surgical consultation are recommended.
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Affiliation(s)
- Gregorios A Paspatis
- Gastroenterology Department, Venizelion General Hospital, Heraklion, Crete-Greece
| | - Marianna Arvanitakis
- Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme Hospital, Universite Libre de Bruxelles, Brussels, Belgium
| | - Jean-Marc Dumonceau
- Gastroenterology Service, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | | | - Brian Saunders
- St Mark's Hospital, Wolfson Unit for Endoscopy, North West London Hospitals University Trust, Harrow, London, UK
| | | | - Angad Dhillon
- St Mark's Hospital, Wolfson Unit for Endoscopy, North West London Hospitals University Trust, Harrow, London, UK
| | - Maria Fragaki
- Gastroenterology Department, Venizelion General Hospital, Heraklion, Crete-Greece
| | | | - Alessandro Repici
- Department of Gastroenterology, Digestive Endoscopy Unit, IRCCS Istituto Clinico Humanitas, Milan, Italy
| | - Roy L J van Wanrooij
- Department of Gastroenterology and Hepatology, AG&M Research Institute, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, The Netherlands
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Palermo M, Duza G, Serra E. Revisional Surgery: Aphagia After Gastric Bypass. J Laparoendosc Adv Surg Tech A 2020; 30:887-890. [PMID: 32352889 DOI: 10.1089/lap.2020.0203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Gastric bypass is one of the most widely performed bariatric procedures worldwide and continues to be the gold standard in obese patients with metabolic disorders.1 Regarding the complications, these can appear early or late, the most frequent of the latter being anastomosis stenosis, especially the gastrojejunal (G-J) stenosis. The first treatment option in stenosis is the endoscopic approach, but in cases wherein it fails or the diagnosis is kinking, revisional surgery should be performed. Methods: We describe the technique, step by step, we use to perform a very complex revisional surgery in a patient with aphagia after gastric bypass. Results: This is the case of a 38-year-old female patient who underwent laparoscopic adjustable gastric band in 2011; due to her poor tolerance, a laparoscopic gastric bypass was done. She began with vomiting and gastroesophageal reflux with remarkable symptoms. Diagnosis of stenosis of the jejunojejunal anastomosis of the Roux-en-Y was made and two surgeries were done to treat it. Later the patient referred aphagia and a kink of the gastrojejunal (G-J) anastomosis were observed in the gastrointestinal series. We decided to do a revisional surgery and we describe it step by step in this article. Conclusion: The G-J anastomosis stenosis is the most frequent late complication. Also kinking has to be considered strongly when aphagia or symptoms of obstruction are present. If endoscopic treatment for stenosis or cases of kinking is unsuccessful and fails, then revisional surgery should be considered.
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Affiliation(s)
- Mariano Palermo
- Division of Bariatric Surgery of Diagnomed, Affiliated Institution of the University of Buenos Aires, Buenos Aires, Argentina
| | - Guillermo Duza
- Division of Bariatric Surgery of Diagnomed, Affiliated Institution of the University of Buenos Aires, Buenos Aires, Argentina
| | - Edgardo Serra
- Division of Bariatric Surgery of Diagnomed, Affiliated Institution of the University of Buenos Aires, Buenos Aires, Argentina
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Almby K, Edholm D. Anastomotic Strictures After Roux-en-Y Gastric Bypass: a Cohort Study from the Scandinavian Obesity Surgery Registry. Obes Surg 2019; 29:172-177. [PMID: 30206785 DOI: 10.1007/s11695-018-3500-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) is the most common bariatric procedure worldwide. Anastomotic stricture is a known complication of RYGB. The aim was to explore the incidence and outcomes of strictures within the Scandinavian Obesity Surgery Registry (SOReg). METHOD SOReg included prospective data from 36,362 patients undergoing bariatric surgery in the years 2007-2013. Outcomes were recorded at 30-day and at 1-year follow-up according to the standard SOReg routine. The medical charts of patients suffering from stricture after RYGB were requested and assessed. SETTING National bariatric surgery registry RESULTS: Anastomotic stricture within 1 year of surgery was confirmed in 101 patients representing an incidence of 0.3%. Risk factors for stricture were patient age above 60 years (odds ratio (OR), 6.2 95% confidence interval (CI) 2.7-14.3), circular stapled gastrojejunostomy (OR 2.7, 95% CI 1.4-5.5), postoperative anastomotic leak (OR 8.9 95%, CI 4.7-17.0), and marginal ulcer (OR 30.0, 95% CI 19.2-47.0). Seventy-five percent of the strictures were diagnosed within 70 days of surgery. Two dilatations or less was sufficient to successfully treat 50% of patients. Ten pecent of patients developed perforation during dilatation, and the risk of perforating at each dilatation was 3.8%. Perforation required surgery in six cases but there was no mortality. Strictures in SOReg may be underreported, which could explain the low incidence in the study. CONCLUSION Most strictures present within 2 months and are successfully treated with two dilatations or less. Dilating a strictured gastrojejunostomy entails a risk of perforation (3.8%).
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Affiliation(s)
- Kristina Almby
- Institution of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - David Edholm
- Department of Surgery and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
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Mason Hedberg H, Ujiki M. Endoscopic Best Practices. QUALITY IN OBESITY TREATMENT 2019:101-109. [DOI: 10.1007/978-3-030-25173-4_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Mansoor MS, Tejada J, Parsa NA, Yoon E, Hida S. Off label use of lumen-apposing metal stent for persistent gastro-jejunal anastomotic stricture. World J Gastrointest Endosc 2018; 10:117-120. [PMID: 29988884 PMCID: PMC6033719 DOI: 10.4253/wjge.v10.i6.117] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 03/30/2018] [Accepted: 04/19/2018] [Indexed: 02/06/2023] Open
Abstract
We are reporting a novel “off-label” use of lumen apposing metal stent (LAMS) for management of refractory gastro-jejunal (GJ) anastomotic stricture after Roux-en-y gastric bypass (RYGB). With increasing prevalence of obesity, bariatric surgery is performed more frequently than ever. RYGB is one of the most commonly performed bariatric procedures. GJ anastomotic stricture is a late complication of this procedure. Our patient, seven years after RYGB developed GJ anastomotic ulcer and subsequently a stricture not amendable to repeated pneumatic dilations. Instead of using the conventional fully covered self-expanding metal stent (fcSEMS) we deployed the relatively new LAMS keeping in mind its novel dumbbell shaped design. Our patient’s symptoms were controlled successfully and she remained asymptomatic on follow-up. Despite initial approval for pancreatic pseudocyst drainage, LAMS has been used with increased frequency at various locations within gastrointestinal tract including GJ anastomotic strictures. Future randomized control trials are warranted to compare the efficacy of fcSEMS to LAMS.
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Affiliation(s)
| | - Juan Tejada
- Department of Gastroenterology, Albany Medical Center, Albany, NY 12047, United States
| | - Nour A Parsa
- Department of Gastroenterology, Albany Medical Center, Albany, NY 12047, United States
| | - Eric Yoon
- Department of Gastroenterology, Albany Medical Center, Albany, NY 12047, United States
| | - Sven Hida
- Department of Gastroenterology, Albany Medical Center, Albany, NY 12047, United States
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Docimo S, Svestka M. Endoscopic Evaluation and Treatment of Postoperative Bariatric Surgery Complications. Surg Innov 2017; 24:616-624. [PMID: 29072533 DOI: 10.1177/1553350617736651] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The number of patients undergoing bariatric surgery continues to increase. The American Society for Metabolic and Bariatric Surgery (ASMBS) estimates the number of bariatric surgical procedures performed increased from 158 000 in 2011 to 190 000 in 2015. Concurrently, the incidence of postoperative complications specific to bariatric patients will inevitably increase as well. Endoscopic evaluation of postoperative bariatric patients and endoscopic interventions are rapidly evolving. We present a review of the postoperative anatomy of bariatric patients, what complications to expect, and treatment options.
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Vines L, Frick T, Aczél S, L'Allemand D, Borovicka J, Schiesser M. Linear stapled gastrojejunostomy results in fewer strictures compared to circular stapled gastrojejunostomy in laparoscopic gastric bypass surgery. Langenbecks Arch Surg 2017; 402:911-916. [PMID: 28689322 DOI: 10.1007/s00423-017-1598-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 06/21/2017] [Indexed: 01/14/2023]
Abstract
PURPOSE Currently, there are two laparoscopic stapling techniques to perform the gastrojejunostomy in gastric bypass surgery: the linear stapling and circular stapling techniques. The aim of the study was to compare the two techniques regarding postoperative morbidity and weight loss at an accredited bariatric reference center in Switzerland. METHODS We compared two consecutive cohorts at a single institution between November 2012 and June 2014 undergoing laparoscopic gastric bypass surgery. The frequency of complications and weight loss at 1 year was assessed in 109 patients with the 21-mm circular stapling technique (CSA) and 134 patients with the linear stapling technique (LSA). RESULTS Postoperative complications were more frequent in the CSA group with 23.9 versus 4.5% in the LSA group (p = <0.0001). The main difference was the frequency of strictures, which occurred in 15.6% in the CSA group versus 0% in the LSA group. As a result, endoscopic dilation was required at least once in 15 patients. There was no statistically significant difference in percentage of excessive weight loss (EWL) in both groups; EWL was 74% in the CSA group and 73% in the LSA group (p = 0.68). CONCLUSION Linear stapled laparoscopic gastric bypass had fewer stenotic strictures with similar weight loss at 1 year compared to circular stapling technique.
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Affiliation(s)
- Larissa Vines
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
| | - Thomas Frick
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
| | - Stefan Aczél
- Klinik für Endokrinologie, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
| | - Dagmar L'Allemand
- Ostschweizer Kinderspital, St. Gallen, Claudiusstrasse 6, 9006, St. Gallen, Switzerland
| | - Jan Borovicka
- Klinik für Gastroenterologie und Hepatologie, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
| | - Marc Schiesser
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland.
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AcÍN-GÁNdara DÉB, Pereira-PÉRez F, Medina-GarcÍA M, Rodriguez-Caravaca G, MartÍNez-Torres B, Antequera-PÉRez A, García-Muñoz ANÁJ. Early and Late Complications in Laparoscopic Gastric Bypass: Comparative Study between Manual and Stapled Anastomosis. Am Surg 2017. [DOI: 10.1177/000313481708300520] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The aim of this study is to evaluate the early and late complications of laparoscopic gastric bypass (GBP) with manual versus stapled gastrojejunal anastomosis. Eighty-two patients with morbid obesity and body mass index (35–56 kg/m2) who underwent GBP were divided into two groups: manual gastrojejunal anastomosis (Group 1) and stapled anastomosis (Group 2). Early and late complications were evaluated. No differences were found between both groups in age, sex, body mass index, American Society of Anesthesia classification, and comorbidity. The mean operative time was 184.8 minutes [standard deviation (SD) = 61]; 203.5 minutes (SD = 51.9) in Group 1 and 167.4 minutes (SD = 64.2) in Group 2 (P = 0.001). The average length of stay was 5.9 days (SD = 3.9) in Group 1 and 5 days (SD = 2.1) in Group 2 (P = 0.039). Early complications were recorded in 9.7 per cent of the cases, without any differences between the two groups: 12.2 per cent in Group 1 and 7.3 per cent in Group 2 (P > 0.05). Late complication rate was 8.5 per cent, significantly higher in Group 1 (14.6%) than in Group 2 (2.4%; P < 0.05). However, in the logistic regression analysis these differences were not statistically significant (OR 0.48; 95% CI 0.03–8.37; P = 0.61). In our series, the GBP with stapled gastrojejunal anastomosis has shown lower hospital length of stay and operative time than the hand-sewn anastomosis. We have not found significant differences between both groups in early complications or in the need for reoperation. Fewer late complications were found in the group of stapled anastomosis; however, this has not been confirmed in the logistic regression analysis.
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Affiliation(s)
- DÉBora AcÍN-GÁNdara
- Department of General and Digestive Surgery, Hospital Universitario de Fuenlabrada, Madrid, Spain and
| | - Fernando Pereira-PÉRez
- Department of General and Digestive Surgery, Hospital Universitario de Fuenlabrada, Madrid, Spain and
| | - Manuel Medina-GarcÍA
- Department of General and Digestive Surgery, Hospital Universitario de Fuenlabrada, Madrid, Spain and
| | | | - Beatriz MartÍNez-Torres
- Department of General and Digestive Surgery, Hospital Universitario de Fuenlabrada, Madrid, Spain and
| | - Alfonso Antequera-PÉRez
- Department of General and Digestive Surgery, Hospital Universitario de Fuenlabrada, Madrid, Spain and
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Souto-Rodríguez R, Alvarez-Sánchez MV. Endoluminal solutions to bariatric surgery complications: A review with a focus on technical aspects and results. World J Gastrointest Endosc 2017; 9:105-126. [PMID: 28360973 PMCID: PMC5355758 DOI: 10.4253/wjge.v9.i3.105] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 10/12/2016] [Accepted: 12/14/2016] [Indexed: 02/06/2023] Open
Abstract
Obesity is a growing problem in developed countries, and surgery is the most effective treatment in terms of weight loss and improving medical comorbidity in a high proportion of obese patients. Despite the advances in surgical techniques, some patients still develop acute and late postoperative complications, and an endoscopic evaluation is often required for diagnosis. Moreover, the high morbidity related to surgical reintervention, the important enhancement of endoscopic procedures and technological innovations introduced in endoscopic equipment have made the endoscopic approach a minimally-invasive alternative to surgery, and, in many cases, a suitable first-line treatment of bariatric surgery complications. There is now evidence in the literature supporting endoscopic management for some of these complications, such as gastrointestinal bleeding, stomal and marginal ulcers, stomal stenosis, leaks and fistulas or pancreatobiliary disorders. However, endoscopic treatment in this setting is not standardized, and there is no consensus on its optimal timing. In this article, we aim to analyze the secondary complications of the most expanded techniques of bariatric surgery with special emphasis on those where more solid evidence exists in favor of the endoscopic treatment. Based on a thorough review of the literature, we evaluated the performance and safety of different endoscopic options for every type of complication, highlighting the most recent innovations and including comparative data with surgical alternatives whenever feasible.
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Garg T, Rosas U, Rogan D, Hines H, Rivas H, Morton JM, Azagury D. Characterizing Readmissions After Bariatric Surgery. J Gastrointest Surg 2016; 20:1797-1801. [PMID: 27613733 DOI: 10.1007/s11605-016-3247-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 08/10/2016] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Readmissions are an important quality metric for surgery. Here, we compare characteristics of readmissions across laparoscopic Roux-en-Y gastric bypass (LRYGB), sleeve gastrectomy (LSG), and adjustable gastric band (LAGB). METHODS Demographic, intraoperative, anthropometric, and laboratory data were prospectively obtained for 1775 patients at a single academic institution. All instances of readmissions within 1 year were recorded. Data were analyzed using STATA, release 12. RESULTS For the 1775 patients, 113 (6.37 %) were readmitted. Mean time to readmission was 52.1 days. Of all the readmissions, 64.6 % were within 30 days, 22.1 % from 30 to 90 days, 1.77 % from 90 to 180 days, and 11.5 % from 180 to 365 days. Incidence of 30-day readmissions varied across surgeries (LRYGB: 7.17 %; LAGB: 3.05 %; LSG: 4.25 %, p = 0.04). Time to readmission varied as well, with 90.0 % of LSG and 80.0 % of LABG patients within the first 30 days, versus 60.8 % of LRYGB (p = 0.02). The most common causes of readmissions were gastrointestinal issues related to index procedure (34.5 %) and did not vary across surgeries. In multivariable logistic regression, index hospital length of stay (LOS) was associated with readmission (OR = 1.07, 95 % CI 1.02-1.13, p = 0.01). CONCLUSIONS Readmissions after bariatric surgery are associated with high index hospital LOS, and a measureable proportion of procedure-related readmissions can occur up to 1 year, especially for LRYGB.
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Affiliation(s)
- Trit Garg
- Bariatric and Minimally Invasive Surgery, Stanford School of Medicine, Stanford, USA
| | - Ulysses Rosas
- Bariatric and Minimally Invasive Surgery, Stanford School of Medicine, Stanford, USA
| | - Daniel Rogan
- Bariatric and Minimally Invasive Surgery, Stanford School of Medicine, Stanford, USA
| | - Harrison Hines
- Bariatric and Minimally Invasive Surgery, Stanford School of Medicine, Stanford, USA
| | - Homero Rivas
- Bariatric and Minimally Invasive Surgery, Stanford School of Medicine, Stanford, USA
| | - John M Morton
- Bariatric and Minimally Invasive Surgery, Stanford School of Medicine, Stanford, USA.
- , 300 Pasteur Drive, H3680, Stanford, CA, 94305, USA.
| | - Dan Azagury
- Bariatric and Minimally Invasive Surgery, Stanford School of Medicine, Stanford, USA
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Abstract
INTRODUCTION The increasing number of morbidly obese patients leads to a rising number of bariatric procedures in Germany. The operative techniques are highly standardized but such a standardization is lacking for the management of postoperative complications such as stenosis and ulceration after Roux-en-Y gastric bypass (RYGB) surgery and sleeve gastrectomy (SG). METHODS The current literature is reviewed and a complication management is developed and presented in this article. RESULTS AND CONCLUSION Postoperative stenoses occure with a frequency of 0.1-3.9% after SG and 3-27% after RYGB. Stenosis is secondary to inadequate surgical technique or microinsufficiency. Ulcers can be due to reaction to foreign body, local ischemia, peptic lesion, fistula and microinsufficiency. CONCLUSION Endoscopic interventions are successful in most cases for stenosis after RYGB and for short stenoses after SG. After SG long stenoses require redo surgery and conversion to RYGB. Ulcers can be managed by medication with the exception of perforation and hemorrhage, which require emergency laparoscopy.
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Malli CP, Sioulas AD, Emmanouil T, Dimitriadis GD, Triantafyllou K. Endoscopy after bariatric surgery. Ann Gastroenterol 2016; 29:249-257. [PMID: 27366025 PMCID: PMC4923810 DOI: 10.20524/aog.2016.0034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 04/08/2016] [Indexed: 12/16/2022] Open
Abstract
Obesity is a global epidemic with significant morbidity and mortality. Weight loss results in reduction of health risks and improvement in quality of life, thus representing a goal of paramount importance. Bariatric surgery is the most efficacious choice compared to conservative alternatives including diet, exercise, drugs and behavioral modification to treat obese patients. Following bariatric operations, patients may present with upper gastrointestinal tract complaints that warrant endoscopic evaluation and the various bariatric surgery types are often linked to complications. A subset of these complications necessitates endoscopic interventions for accurate diagnosis and effective, minimal invasive treatment. This review aims to highlight the role of upper gastrointestinal endoscopy in patients who have undergone bariatric surgery to evaluate and potentially treat surgery-related complications and upper gastrointestinal symptoms.
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Affiliation(s)
- Chrysoula P. Malli
- Hepatogastroenterology Unit, Second Department of Internal Medicine, Research Institute and Diabetes Center, Attikon University General Hospital, Medical School, National and Kapodistrian University, Athens, Greece
| | - Athanasios D. Sioulas
- Hepatogastroenterology Unit, Second Department of Internal Medicine, Research Institute and Diabetes Center, Attikon University General Hospital, Medical School, National and Kapodistrian University, Athens, Greece
| | - Theodoros Emmanouil
- Hepatogastroenterology Unit, Second Department of Internal Medicine, Research Institute and Diabetes Center, Attikon University General Hospital, Medical School, National and Kapodistrian University, Athens, Greece
| | - George D. Dimitriadis
- Hepatogastroenterology Unit, Second Department of Internal Medicine, Research Institute and Diabetes Center, Attikon University General Hospital, Medical School, National and Kapodistrian University, Athens, Greece
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine, Research Institute and Diabetes Center, Attikon University General Hospital, Medical School, National and Kapodistrian University, Athens, Greece
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Lim CH, Jahansouz C, Abraham AA, Leslie DB, Ikramuddin S. The future of the Roux-en-Y gastric bypass. Expert Rev Gastroenterol Hepatol 2016; 10:777-84. [PMID: 27027414 DOI: 10.1586/17474124.2016.1169921] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Archaic surgical procedures such as the jejunoileal bypass, vertical banded gastroplasty and duodenal switch have contributed to the current best practice of Roux-en-Y gastric bypass (RYGB) procedure for the treatment of obesity and its consequences. Despite this, RYGB has been blighted with late occurring adverse events such as severe malnutrition, marginal ulcer and reactive hypoglycemia. Despite this, RYGB has given us an opportunity to examine the effect of surgery on gut hormones and the impact on metabolic syndrome which in turn has allowed us to carry out a lower impact but equally, if not more effective, procedure - the vertical sleeve gastrectomy (VSG). We examine the benefits of sleeve gastrectomy from the less challenging technical aspect to the effect on obesity and its metabolic syndrome long-term and have concluded that sleeve gastrectomy is possibly the next current best practice.
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Affiliation(s)
- Chin Hong Lim
- a Division of Minimally Invasive Gastrointestinal Surgery and Medicine, Department of Surgery , University of Minnesota Medical Center , Minneapolis , MN , USA
| | - Cyrus Jahansouz
- a Division of Minimally Invasive Gastrointestinal Surgery and Medicine, Department of Surgery , University of Minnesota Medical Center , Minneapolis , MN , USA
| | - Anasooya A Abraham
- a Division of Minimally Invasive Gastrointestinal Surgery and Medicine, Department of Surgery , University of Minnesota Medical Center , Minneapolis , MN , USA
| | - Daniel B Leslie
- a Division of Minimally Invasive Gastrointestinal Surgery and Medicine, Department of Surgery , University of Minnesota Medical Center , Minneapolis , MN , USA
| | - Sayeed Ikramuddin
- a Division of Minimally Invasive Gastrointestinal Surgery and Medicine, Department of Surgery , University of Minnesota Medical Center , Minneapolis , MN , USA
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Parikh M, Gagner M. Laparoscopic Revision of Gastrogastric Stricture With a Transoral Circular Stapler. Surg Innov 2016; 14:225-30. [DOI: 10.1177/1553350607308306] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Most anastomotic strictures can be effectively managed by endoscopic dilations. Patients with severe strictures refractory to balloon dilations may require surgical revision. Revision of a strictured anastomosis (open or laparoscopic) is often technically demanding because of the severity of adhesion formation and difficulty in correctly identifying the anatomy. We discuss a laparoscopic method of safely revising an anastomotic stricture with a circular stapler.
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Affiliation(s)
- Manish Parikh
- Laparoscopic and Bariatric Surgery, Joan and Sanford I. Weill College of Medicine of Cornell University, New York-Presbyterian Hospital, New York, New York
| | - Michel Gagner
- Laparoscopic and Bariatric Surgery, Joan and Sanford I. Weill College of Medicine of Cornell University, New York-Presbyterian Hospital, New York, New York, ,
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de Moura EGH, Orso IRB, Aurélio EF, de Moura ETH, de Moura DTH, Santo MA. Factors associated with complications or failure of endoscopic balloon dilation of anastomotic stricture secondary to Roux-en-Y gastric bypass surgery. Surg Obes Relat Dis 2016; 12:582-586. [PMID: 27174245 DOI: 10.1016/j.soard.2015.11.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 11/02/2015] [Accepted: 11/11/2015] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Roux-en-Y gastric bypass is a commonly used technique of bariatric surgery. One of the most important complications is gastrojejunal anastomotic stricture. Endoscopic balloon dilation appears to be well tolerated and effective, but well-designed randomized, controlled trials have not yet been conducted. OBJECTIVE Identify factors associated with complications or failure of endoscopic balloon dilation of anastomotic stricture secondary to Roux-en-Y gastric bypass surgery. SETTING Gastrointestinal endoscopy service, university hospital, Brazil. METHODS The records of 64 patients with anastomotic stricture submitted to endoscopic dilation with hydrostatic balloon dilation were reviewed. Information was collected on gastric pouch length, anastomosis diameter before dilation, number of dilation sessions, balloon diameter at each session, anastomosis diameter after the last dilation session, presence of postsurgical complications, endoscopic complications, and outcome of dilation. Comparisons were made among postsurgical and endoscopic complications; number of dilations, balloon diameter; anastomosis diameter before dilation; and dilation outcome. RESULTS Success of dilation treatment was 95%. Perforation was positively and significantly associated with the number of dilation sessions (P = .03). Highly significant associations were found between ischemic segment and perforation (P<.001) and between ischemic segment and bleeding (P = .047). Ischemic segment (P = .02) and fistula (P = .032) were also associated with dilation failure. CONCLUSION Ischemic segment and fistula were found to be important risk factors for balloon dilation failure. The greater the number of dilation sessions, the greater the number of endoscopic complications.
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Affiliation(s)
- Eduardo G H de Moura
- Gastrointestinal Endoscopy Service, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil; Gastrointestinal Endoscopy Service, Hospital São Luiz Morumbi, São Paulo, Brazil
| | - Ivan R B Orso
- Gastrointestinal Endoscopy Service, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil; Gastroclínica Cascavel - Assis Gurgacz Medical School, Paraná, Brazil.
| | - Eduardo F Aurélio
- Gastrointestinal Endoscopy Service, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Eduardo T H de Moura
- Gastrointestinal Endoscopy Service, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Diogo T H de Moura
- Gastrointestinal Endoscopy Service, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Marco A Santo
- Gastrointestinal Endoscopy Service, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
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20
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Walsh C, Karmali S. Endoscopic management of bariatric complications: A review and update. World J Gastrointest Endosc 2015. [PMID: 25992190 DOI: 10.4253/wjge.v7.i5.518.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
With over a third of Americans being considered obese, bariatric procedures have now become the most performed operation be general surgeons in the United States. The most common operations are the Laparoscopic Roux-en-Y Gastric Bypass, the Laparoscopic Sleeve Gastrectomy, and the Laparoscopic Adjustable Gastric Band. With over 340000 bariatric procedures preformed worldwide in 2011, the absolute number of complications related to these operations is also increasing. Complications, although few, can be life threatening. One of the most dreaded acute complication is the anastomotic/staple line leak. If left undiagnosed or untreated they can lead to sepsis, multi organ failure, and death. Smaller or contained leaks can develop into fistulas. Although most patients with an acute anastomotic leak return to the operating room, there has been a trend to manage the stable patient with an endoscopic stent. They offer an advantage by creating a barrier between enteric content and the leak, and will allow the patients to resume enteral feeding much earlier. Fistulas are a complex and chronic complication with high morbidity and mortality. Postoperative bleeding although rare may also be treated locally with endoscopy. Stenosis is a more frequent late complication and is best-managed with endoscopic therapy. Stents may not heal every fistula or stenosis, however they may prevent certain patients the need for additional revisional surgery.
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Affiliation(s)
- Caolan Walsh
- Caolan Walsh, Department of Surgery, Dalhousie University, Halifax, Nova Scotia B3H 2Y9, Canada
| | - Shahzeer Karmali
- Caolan Walsh, Department of Surgery, Dalhousie University, Halifax, Nova Scotia B3H 2Y9, Canada
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Walsh C, Karmali S. Endoscopic management of bariatric complications: A review and update. World J Gastrointest Endosc 2015; 7:518-523. [PMID: 25992190 PMCID: PMC4436919 DOI: 10.4253/wjge.v7.i5.518] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 12/06/2014] [Accepted: 02/12/2015] [Indexed: 02/05/2023] Open
Abstract
With over a third of Americans being considered obese, bariatric procedures have now become the most performed operation be general surgeons in the United States. The most common operations are the Laparoscopic Roux-en-Y Gastric Bypass, the Laparoscopic Sleeve Gastrectomy, and the Laparoscopic Adjustable Gastric Band. With over 340000 bariatric procedures preformed worldwide in 2011, the absolute number of complications related to these operations is also increasing. Complications, although few, can be life threatening. One of the most dreaded acute complication is the anastomotic/staple line leak. If left undiagnosed or untreated they can lead to sepsis, multi organ failure, and death. Smaller or contained leaks can develop into fistulas. Although most patients with an acute anastomotic leak return to the operating room, there has been a trend to manage the stable patient with an endoscopic stent. They offer an advantage by creating a barrier between enteric content and the leak, and will allow the patients to resume enteral feeding much earlier. Fistulas are a complex and chronic complication with high morbidity and mortality. Postoperative bleeding although rare may also be treated locally with endoscopy. Stenosis is a more frequent late complication and is best-managed with endoscopic therapy. Stents may not heal every fistula or stenosis, however they may prevent certain patients the need for additional revisional surgery.
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22
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PALERMO M, ACQUAFRESCA PA, ROGULA T, DUZA GE, SERRA E. Late surgical complications after gastric by-pass: a literature review. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2015; 28:139-43. [PMID: 26176254 PMCID: PMC4737339 DOI: 10.1590/s0102-67202015000200014] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Accepted: 11/27/2014] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Gastric bypass is today the most frequently performed bariatric procedure, but, despite of it, several complications can occur with varied morbimortality. Probably all bariatric surgeons know these complications, but, as bariatric surgery continues to spread, general surgeon must be familiarized to it and its management. Gastric bypass complications can be divided into two groups: early and late complications, taking into account the two weeks period after the surgery. This paper will focus the late ones. METHOD Literature review was carried out using Medline/PubMed, Cochrane Library, SciELO, and additional information on institutional sites of interest crossing the headings: gastric bypass AND complications; follow-up studies AND complications; postoperative complications AND anastomosis, Roux-en-Y; obesity AND postoperative complications. Search language was English. RESULTS There were selected 35 studies that matched the headings. Late complications were considered as: anastomotic strictures, marginal ulceration and gastrogastric fistula. CONCLUSION Knowledge on strategies on how to reduce the risk and incidence of complications must be acquired, and every surgeon must be familiar with these complications in order to achieve an earlier recognition and perform the best intervention.
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Affiliation(s)
- Mariano PALERMO
- Division of Bariatric Surgery - CIEN-DIAGNOMED - affiliated to the
University of Buenos Aires, Buenos Aires, Argentina
| | - Pablo A. ACQUAFRESCA
- Division of Bariatric Surgery - CIEN-DIAGNOMED - affiliated to the
University of Buenos Aires, Buenos Aires, Argentina
| | - Tomasz ROGULA
- Cleveland Clinic Foundation, Bariatric and Metabolic Institute,
Cleveland, OH, USA
| | - Guillermo E. DUZA
- Division of Bariatric Surgery - CIEN-DIAGNOMED - affiliated to the
University of Buenos Aires, Buenos Aires, Argentina
| | - Edgardo SERRA
- Division of Bariatric Surgery - CIEN-DIAGNOMED - affiliated to the
University of Buenos Aires, Buenos Aires, Argentina
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Ribeiro-Parenti L, Arapis K, Chosidow D, Dumont JL, Demetriou M, Marmuse JP. Gastrojejunostomy stricture rate: comparison between antecolic and retrocolic laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2015; 11:1076-84. [PMID: 25892346 DOI: 10.1016/j.soard.2015.01.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 01/15/2015] [Accepted: 01/26/2015] [Indexed: 01/21/2023]
Abstract
BACKGROUND Roux-en-Y gastric bypass procedure is an effective treatment for morbid obesity. One of the most frequent complications after this operation is the appearance of a gastrojejunal anastomotic stricture. Mechanisms underlying the development of such complication are unclear. OBJECTIVE The aim of the present retrospective study was to compare the rates of gastrojejunostomy stricture between the antecolic and retrocolic technique in a large cohort of patients undergoing Roux-en-Y gastric bypass for morbid obesity, with the same gastrojejunal anastomotic technique. SETTING University Hospital, France. METHODS From November 2000 to March 2012, 1500 patients underwent laparoscopic Roux-en-Y gastric bypass. The antecolic and the retrocolic technique were used in respectively 572 and 928 consecutive patients. All procedures were performed using a circular stapled gastrojejunostomy and absorbable sutures. RESULTS There was no significant difference with respect to gender, age, body mass index, and obesity related co-morbidities between both groups. Patients were followed for 24-146 months (mean 67.5 mo). Fifty-one patients developed a gastrojejunal stricture (3.4%), 37 in the antecolic group (6.5%) and 14 in the retrocolic group (1.5%). The difference was significant (P< .0001). The mean time to onset of gastrojejunal stricture symptoms after surgery was 1 month, ranging from 1 to 3 months. All patients were successfully treated using Savary-Gilliard dilatators. All patients with a gastrojejunal stricture were followed up for a minimum of 36 months. No recurrence was observed and no revisional surgery was needed. Weight loss was similar in patients who developed an anastomotic stricture compared with those without stricture. In the antecolic group internal hernia occurred in 12 of the 110 with no closure of mesenteric defects and in 8 of the 462 (1.7%) with defects closed. In the retrocolic group, 11 patients (1.2%) developed an internal hernia. CONCLUSIONS A significant lower gastrojejunal stricture rate was observed in the retrocolic group, with no increased risk of internal hernia, when mesenteric defects were closed. The antecolic technique seems to be a risk factor for gastrojejunal stricture development after laparoscopic gastric bypass.
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Affiliation(s)
- Lara Ribeiro-Parenti
- Service de Chirurgie Générale et Digestive, Hôpital Bichat Claude Bernard, Paris, France.
| | - Konstantinos Arapis
- Service de Chirurgie Générale et Digestive, Hôpital Bichat Claude Bernard, Paris, France
| | - Denis Chosidow
- Service de Chirurgie Générale et Digestive, Hôpital Bichat Claude Bernard, Paris, France
| | - Jean-Loup Dumont
- Service d'Endoscopie Digestive. Hôpital Privé des Peupliers, Paris, France
| | - Monique Demetriou
- Service de d'Anesthésie Réanimation, Hôpital Bichat Claude Bernard, Paris, France
| | - Jean-Pierre Marmuse
- Service de Chirurgie Générale et Digestive, Hôpital Bichat Claude Bernard, Paris, France
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Tan QH, Dai YC. Etiology and non-surgical treatment of pyloric obstruction. Shijie Huaren Xiaohua Zazhi 2014; 22:4250-4256. [DOI: 10.11569/wcjd.v22.i28.4250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Pyloric stenosis is a common type of upper gastrointestinal obstruction, which is a result of progression of many diseases. This paper will review the common causes of pyloric stenosis and its non-surgical treatments, mainly endoscopic treatment, in recent years. With the development of endoscopic technology, endoscopic treatment will gradually replace surgical treatment for treatment of pyloric obstruction.
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Mathus-Vliegen EMH. The cooperation between endoscopists and surgeons in treating complications of bariatric surgery. Best Pract Res Clin Gastroenterol 2014; 28:703-25. [PMID: 25194185 DOI: 10.1016/j.bpg.2014.07.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 06/18/2014] [Accepted: 07/05/2014] [Indexed: 02/09/2023]
Abstract
The results of lifestyle interventions and pharmacotherapy are disappointing in severe obesity which is characterised by premature death and many obesity-associated co-morbidities. Only surgery may achieve significant and durable weight losses associated with increased life expectancy and improvement of co-morbidities. Bariatric surgery involves the gastrointestinal tract and may therefore increase gastrointestinal complaints. Bariatric surgery may also result in complications which in many cases can be solved by endoscopic interventions. This requires a close cooperation between surgeons and endoscopists. This chapter will concentrate on the most commonly performed operations such as the Roux-en-Y gastric bypass, the adjustable gastric banding and the sleeve gastrectomy, in the majority of cases performed by laparoscopy. Operations such as the vertical banded gastroplasty and the biliopancreatic diversion with or without duodenal switch will not be discussed at length as patients with these operations will not be encountered frequently and their management can be found under the headings of the other operations.
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Affiliation(s)
- E M H Mathus-Vliegen
- Academic Medical Centre, University of Amsterdam, Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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26
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De Palma GD, Forestieri P. Role of endoscopy in the bariatric surgery of patients. World J Gastroenterol 2014; 20:7777-7784. [PMID: 24976715 PMCID: PMC4069306 DOI: 10.3748/wjg.v20.i24.7777] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Revised: 12/31/2013] [Accepted: 03/08/2014] [Indexed: 02/06/2023] Open
Abstract
Obesity is an increasingly serious health problem in nearly all Western countries. It represents an important risk factor for several gastrointestinal diseases, such as gastroesophageal reflux disease, erosive esophagitis, hiatal hernia, Barrett's esophagus, esophageal adenocarcinoma, Helicobacter pylori infection, colorectal polyps and cancer, non-alcoholic fatty liver disease, cirrhosis, and hepatocellular carcinoma. Surgery is the most effective treatment to date, resulting in sustainable and significant weight loss, along with the resolution of metabolic comorbidities in up to 80% of cases. Many of these conditions can be clinically relevant and have a significant impact on patients undergoing bariatric surgery. There is evidence that the chosen procedure might be changed if specific pathological upper gastrointestinal findings, such as large hiatal hernia or Barrett's esophagus, are detected preoperatively. The value of a routine endoscopy before bariatric surgery in asymptomatic patients (screening esophagogastroduodenoscopy) remains controversial. The common indications for endoscopy in the postoperative bariatric patient include the evaluation of symptoms, the management of complications, and the evaluation of weight loss failure. It is of critical importance for the endoscopist to be familiar with the postoperative anatomy and to work in close collaboration with bariatric surgery colleagues in order to maximize the outcome and safety of endoscopy in this setting. The purpose of this article is to review the role of the endoscopist in a multidisciplinary obesity center as it pertains to the preoperative and postoperative management of bariatric surgery patients.
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Mueller CL, Jackson TD, Swanson T, Pitzul K, Daigle C, Penner T, Urbach DR, Okrainec A. Linear-stapled gastrojejunostomy with transverse hand-sewn enterotomy closure significantly reduces strictures for laparoscopic Roux-en-Y gastric bypass. Obes Surg 2014; 23:1302-8. [PMID: 23526084 DOI: 10.1007/s11695-013-0920-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Gastrojejunostomy (GJ) stricture is a common complication after Roux-en-Y gastric bypass (RYGB) for morbid obesity, and the optimal anastomotic technique remains uncertain. The objective of this study was to use cumulative summation (CUSUM) analysis to compare rates of gastrojejunostomy strictures after linear stapling with longitudinal versus transverse enterotomy closure in gastric bypass patients. METHODS Charts of all consecutive patients with at least 60 days of post-operative follow-up after laparoscopic RYGB (LRYGB) at our tertiary care institution from Nov 2009 to Dec, 2011 were retrospectively reviewed. Gastrojejunostomy stricture was diagnosed by history and upper endoscopy. CUSUM method of quality control analysis was used to determine sequential improvement in stricture rates with the change in technique. RESULTS A total of 197 patients were included (97 longitudinal closure, median age 44 (21-67), median BMI 47 (35-80), 85.8 % female). Gastrojejunostomy strictures occurred in 16 % of longitudinal and 0 % of transverse patients (p = <0.0001). CUSUM analysis demonstrated sequential statistically significant improvement in stricture rates after the change in technique was applied. The longitudinal group had a statistically significant increased rate of surgery-related readmissions (15.5 vs 6.0 %, p = 0.038), with 43.7 % of those readmissions related to GJ strictures. There were no other significant outcome differences between groups. CONCLUSIONS Linear-stapled anastomosis with a transverse enterotomy closure significantly reduces the rate of gastrojejunostomy stricture for LRYGB, considerably reducing procedural morbidity.
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Affiliation(s)
- Carmen L Mueller
- Division of General Surgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, Toronto, ON, Canada M8Y 1E8
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Medbery RL, Coefield R, Patel AD, Pettitt BJ, Singh A, Srinivasan JK, Woods K, Davis SS. Endoscopic Management of Gastrojejunostomy Strictures: One Institution's Approach. Bariatr Surg Pract Patient Care 2014. [DOI: 10.1089/bari.2014.0002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- Rachel L. Medbery
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Rebecca Coefield
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Ankit D. Patel
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Barbara J. Pettitt
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Arvinpal Singh
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | | | - Kevin Woods
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - S. Scott Davis
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
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Systematic review on reoperative bariatric surgery: American Society for Metabolic and Bariatric Surgery Revision Task Force. Surg Obes Relat Dis 2014; 10:952-72. [PMID: 24776071 DOI: 10.1016/j.soard.2014.02.014] [Citation(s) in RCA: 259] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 02/09/2014] [Accepted: 02/10/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Reoperative bariatric surgery has become a common practice in many bariatric surgery programs. There is currently little evidence-based guidance regarding specific indications and outcomes for reoperative bariatric surgery. A task force was convened to review the current evidence regarding reoperative bariatric surgery. The aim of the review was to identify procedure-specific indications and outcomes for reoperative procedures. METHODS Literature search was conducted to identify studies reporting indications for and outcomes after reoperative bariatric surgery. Specifically, operations to treat complications, failed weight loss, and weight regain were evaluated. Abstract and manuscript reviews were completed by the task force members to identify, grade, and categorize relevant studies. RESULTS A total of 819 articles were identified in the initial search. After review for inclusion criteria and data quality, 175 articles were included in the systematic review and analysis. The majority of published studies are single center retrospective reviews. The evidence supporting reoperative surgery for acute and chronic complications is described. The evidence regarding reoperative surgery for failed weight loss and weight regain generally demonstrates improved weight loss and co-morbidity reduction after reintervention. Procedure-specific outcomes are described. Complication rates are generally reported to be higher after reoperative surgery compared to primary surgery. CONCLUSION The indications and outcomes for reoperative bariatric surgery are procedure-specific but the current evidence does support additional treatment for persistent obesity, co-morbid disease, and complications.
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Griffith PS, Birch DW, Sharma AM, Karmali S. Managing complications associated with laparoscopic Roux-en-Y gastric bypass for morbid obesity. Can J Surg 2012; 55:329-36. [PMID: 22854113 DOI: 10.1503/cjs.002011] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Obesity has become a major health concern in Canada. This has resulted in a steady rise in the number of bariatric surgical procedures being performed nationwide. The laparoscopic Roux-en-Y gastric bypass (LRYGB) is not only the most common bariatric procedure, but also the gold standard to which all others are compared. With this in mind, it is imperative that all gastrointestinal surgeons understand the LRYGB and have a working knowledge of the common postoperative complications and their management. Early postoperative complications following LRYGB that demand immediate recognition include anastomotic or staple line leak, postoperative hemorrhage, bowel obstruction and incorrect Roux limb reconstructions. Later complications may be challenging to differentiate from other gastrointestinal disorders and include anastomotic stricture, marginal ulceration, fistula formation, weight gain and nutritional deficiencies. We discuss the principles involved in the management of each complication and the timing of referral to specialist bariatric centres.
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Affiliation(s)
- P S Griffith
- The Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
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Espinel J, Pinedo E. Stenosis in gastric bypass: Endoscopic management. World J Gastrointest Endosc 2012; 4:290-5. [PMID: 22816008 PMCID: PMC3399006 DOI: 10.4253/wjge.v4.i7.290] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Revised: 05/02/2012] [Accepted: 07/01/2012] [Indexed: 02/05/2023] Open
Abstract
Gastric bypass is a treatment option for morbid obesity. Stenosis of the gastrojejunal anastomosis is a recognized complication. The pathophysiological mechanisms involved in the formation of stenosis are not well known. Gastrojejunal strictures can be classified based on time of onset, mechanism of formation, and endoscopic aspect. Diagnosis is usually obtained by endoscopy. The two main treatment alternatives for stomal stricture are: endoscopic dilatation (balloon or bouginage) and surgical revision (open or laparoscopic). Both techniques of dilation [through-the-scope (TTS) balloon dilators, Bougienage dilators] are considered safe, effective, and do not require hospitalization. The optimal technique for dilation of stomal strictures remains to be determined, but many authors prefer the use of TTS balloon catheters. Most patients can be successfully treated with 1 or 2 sessions. The need for reconstructive surgery of a stomal stricture is extremely rare.
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Affiliation(s)
- Jesús Espinel
- Jesús Espinel, Endoscopy Unit, Gastroenterology Department, Hospital de León, 24071 León, Spain
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Rondan A, Nijhawan S, Majid S, Martinez T, Wittgrove AC. Low Anastomotic Stricture Rate After Roux-en-Y Gastric Bypass Using a 21-mm Circular Stapling Device. Obes Surg 2012; 22:1491-5. [DOI: 10.1007/s11695-012-0671-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Yimcharoen P, Heneghan H, Chand B, Talarico JA, Tariq N, Kroh M, Brethauer SA. Successful management of gastrojejunal strictures after gastric bypass: is timing important? Surg Obes Relat Dis 2012; 8:151-7. [DOI: 10.1016/j.soard.2011.01.043] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Revised: 01/12/2011] [Accepted: 01/28/2011] [Indexed: 01/26/2023]
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Gill RS, Whitlock KA, Mohamed R, Birch DW, Karmali S. Endoscopic Treatment Options in Patients With Gastrojejunal Anastomosis Stricture Following Roux-en-Y Gastric Bypass. Gastroenterology Res 2012; 5:1-5. [PMID: 27785171 PMCID: PMC5051034 DOI: 10.4021/gr385w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2012] [Indexed: 12/16/2022] Open
Abstract
The proportion of obese individuals continues to increase worldwide. Bariatric surgery remains the only evidence-based treatment strategy to produce marked weight loss. Roux-en-Y gastric bypass is an effective and common bariatric surgical procedure offered to obese patients. However, a small percentage of individuals can develop narrowing or stricture formation of the gastrojejunal anastomosis. Endoscopic treatment of gastrojejunostomy (GJ) is preferred compared to surgical revision, as it is less invasive. The endoscopic treatment strategy most common employed is balloon dilatation. Endoscopic balloon dilatation is successful in majority of cases with low morbidity, however multiple dilatation may be required. Other endoscopic strategies such as incisional therapy has been successful in treating other gastrointestinal anastomotic strictures, however remain to be evaluated in post-RYGB GJ strictures. Further research is needed to determine the effectiveness of incision therapy and other endoscopic treatment strategies compared to endoscopic balloon dilatation.
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Affiliation(s)
- Richdeep S Gill
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada; Richdeep S. Gill and Kevin A. Whitlock were co-first authors
| | - Kevin A Whitlock
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada; Richdeep S. Gill and Kevin A. Whitlock were co-first authors
| | - Rachid Mohamed
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Daniel W Birch
- Center of the Advancement of Minimally Invasive Surgery (CAMIS), Royal Alexandria Hospital, Edmonton, Alberta, Canada
| | - Shahzeer Karmali
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
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Gill RS, Whitlock KA, Mohamed R, Sarkhosh K, Birch DW, Karmali S. The role of upper gastrointestinal endoscopy in treating postoperative complications in bariatric surgery. JOURNAL OF INTERVENTIONAL GASTROENTEROLOGY 2012; 2:37-41. [PMID: 22586549 DOI: 10.4161/jig.20133] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Revised: 12/21/2011] [Accepted: 12/23/2011] [Indexed: 12/17/2022]
Abstract
There are an estimated 500 million obese individuals worldwide. Currently, bariatric surgery has been shown to result in clinically significant weight loss. With increasing demand for bariatric surgery, endoscopic techniques used intra and postoperatively continue to evolve. Endoscopic evaluation of anastomotic integrity following RYGB allows for early detection of anastomotic leaks. Furthermore, endoscopy is a valuable tool to diagnose and treat RYGB postoperative surgical complications such as anastomotic leakage, hemorrhage and stricture formation. Early evidence suggests that endoscopic management of upper gastrointestinal hemorrhage following RYGB is effective. In addition, endoscopic balloon dilatation is able to effectively treat obstruction in the setting of gastrojejunal anastomotic strictures. With successful endoscopic management of these complications, bariatric patients may avoid more invasive surgical procedures.
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Affiliation(s)
- Richdeep S Gill
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
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Jarry J, Wagner T, de Pommerol M, Sa Cunha A, Collet D. Laparoscopic Roux-en-Y gastric bypass: comparison between hand-sewn and mechanical gastrojejunostomy. Updates Surg 2011; 64:25-30. [PMID: 22167407 DOI: 10.1007/s13304-011-0126-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 11/19/2011] [Indexed: 01/25/2023]
Abstract
The laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the ideal operations in the treatment of morbid obesity. There are several variations in the operation, especially during the construction of the gastrojejunostomy (GJA). From June 2006 to September 2008, 104 consecutive obese patients underwent LRYGB. The procedure was standardized, with the exception of the construction of the GJA, which was linear-stapled in 51 patients and hand-sewn in 53 other patients. A retrospective analysis was performed to compare the procedures. The series comprised 81 women and 23 men with a median age of 44 years, and a median BMI of 46.7 kg/m(2). There was no significant difference between the two groups of patients with respect to age, gender, BMI, ASA, and previously failed bariatric surgery. There was no significant difference between the two groups with respect to mortality, conversion, early reoperation, surgical complications, GJA leakage or stricture, and bariatric results. The only significant differences between the two groups were in regards to operating time (190 min for stapled GJA vs. 160 min for hand-sewn GJA, p value 0.029) and operating supply cost (100 Euros less for hand-sewn GJA). In our experience, hand-sewn GJA during LRYGB appears to be as safe as linear-stapled GJA and provides the same bariatric results while remaining slightly less expensive.
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Affiliation(s)
- Julien Jarry
- Department of Endoscopic Surgery, Haut Lévèque Hospital, Bordeaux, France.
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Da Costa M, Mata A, Espinós J, Vila V, Roca JM, Turró J, Ballesta C. Endoscopic dilation of gastrojejunal anastomotic strictures after laparoscopic gastric bypass. Predictors of initial failure. Obes Surg 2011; 21:36-41. [PMID: 20396992 DOI: 10.1007/s11695-010-0154-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the most frequent technique performed in bariatric surgery. Gastrojejunal anastomotic stricture is one of the most common postoperative complications. The aims of this study were to evaluate the efficacy and safety of endoscopic balloon dilation in the treatment of the gastrojejunal anastomotic strictures after LRYGB and to look for predicting factors that would indicate the need of repeated dilations. METHODS We included all patients with morbid obesity who underwent a LRYGB at our institution between January 2002 and July 2007. All patients who developed symptoms compatible with stricture of the gastrojejunostomy were referred to upper gastrointestinal endoscopy and underwent endoscopic balloon dilation. RESULTS One hundred and five out of the 1,330 patients (7.8%) developed an anastomotic stricture. The mean time to diagnosis was 3 months after the surgery. The mean diameter of the stricture was 5 mm. Sixty out of the 105 patients required only one dilation (57%), 29 required two dilations (27,6%), 13 required three dilations, and 3 patients underwent a fourth dilation. Clinical success was achieved in 100% of the cases, with an average of 1.6 dilations. The statistical analysis showed that only the time from surgery to stricture formation (p = 0.007) and the diameter achieved at the first dilation (p = 0.015) had statistical significance as predictors of the need of one or more dilations. CONCLUSIONS Endoscopic balloon dilation is a safe and effective method. Most of the patients are successfully managed with one or two dilations. The longer time from surgery to the appearance of symptoms ant the largest diameter achieved at the first dilation are the only predicting factors of success with only one dilation.
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Cusati D, Sarr M, Kendrick M, Que F, Swain JM. Refractory strictures after Roux-en-Y gastric bypass: operative management. Surg Obes Relat Dis 2011; 7:165-9. [DOI: 10.1016/j.soard.2010.11.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Revised: 08/13/2010] [Accepted: 11/05/2010] [Indexed: 10/18/2022]
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Fernández-Esparrach G, Córdova H, Bordas JM, Gómez-Molins I, Ginès A, Pellisé M, Sendino O, González-Suárez B, Cárdenas A, Balderramo D, Lacy AM, Delgado S, Llach J. [Endoscopic management of the complications of bariatric surgery. Experience of more than 400 interventions]. GASTROENTEROLOGIA Y HEPATOLOGIA 2011; 34:131-136. [PMID: 21377237 DOI: 10.1016/j.gastrohep.2010.12.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Revised: 12/16/2010] [Accepted: 12/24/2010] [Indexed: 12/17/2022]
Abstract
BACKGROUND Many patients who undergo bariatric surgery develop postoperative gastrointestinal complications that can require upper gastrointestinal endoscopy. OBJECTIVE To prospectively describe the gastrointestinal complications diagnosed by endoscopy after bariatric surgery. PATIENTS AND METHODS We followed up patients undergoing laparoscopic bariatric surgery between January 1998 and December 2006. The following data were recorded: age, sex, body mass index, comorbidity, type and duration of bariatric surgery, clinical presentation of complications, time of presentation, endoscopic treatment and follow-up. RESULTS A total of 474 patients underwent surgery (74% women, 26% men) with a mean age of 44±11 years (range, 15-66) and a mean BMI of 47±7 (range, 33-82). The most frequent surgical procedure was Roux-en-Y gastric bypass (90%). We identified 68 complications (14%) requiring upper gastrointestinal endoscopy: anastomotic stenosis (21 cases, 5%), upper gastrointestinal hemorrhage (16 cases, 3.6%), epigastric pain (12 cases, 2.5%), vomiting (7 cases, 1.5%), heartburn (6 cases, 1.3%) and other (6 cases, 1.3%). No prognostic factor for the development of complications requiring postsurgical endoscopy was identified. CONCLUSIONS Anastomotic stenosis is the most common complication requiring endoscopic treatment after bariatric surgery. Upper gastrointestinal bleeding in the immediate and late postoperative period can be safely and effectively treated with endoscopic techniques.
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Affiliation(s)
- Gloria Fernández-Esparrach
- Unidad de Endoscopia, Servicio de Gastroenterología, ICMDiM, Hospital Clínic, Universidad de Barcelona, IDIBAPS, CIBEREHD, España.
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Potack J. Management of post bariatric surgery anastomotic strictures. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2010. [DOI: 10.1016/j.tgie.2010.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Radtka JF, Puleo FJ, Wang L, Cooney RN. Revisional bariatric surgery: who, what, where, and when? Surg Obes Relat Dis 2010; 6:635-42. [PMID: 20702147 DOI: 10.1016/j.soard.2010.04.005] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Revised: 02/05/2010] [Accepted: 04/21/2010] [Indexed: 01/01/2023]
Abstract
BACKGROUND Revisional bariatric surgery (RBS) outcomes have been poorly characterized. We compared the RBS and primary bariatric surgery (PBS) outcomes at the Penn State Milton S. Hershey Medical Center in the United States. METHODS A total of 72 RBS cases from 2000 to 2007 were reviewed and grouped by indication: failure of weight loss, gastrojejunal complications, or other. The RBS patients were compared with the 856 PBS patients who underwent Roux-en-Y gastric bypass. The mean follow-up time was 12.6 ± 1.2 months for the RBS group and 16 ± 0.5 months for the PBS group. Weight loss was analyzed as the kilograms lost and patients with ≥ 50% excess body weight loss (EBWL). Outcomes included mortality, leaks, surgical site infections, and length of stay. RESULTS The weight loss was 23 ± 2.8 kg after RBS and 41.3 ± 0.7 kg after PBS (P <.05 versus PBS). The post-RBS weight loss varied by surgical indication: failure of weight loss, 27.1 ± 2 kg; gastrojejunal complications, 8.7 ± 3.4 kg; and other 23.5 ± 10.6 kg. Also, 29% of the RBS patients had ≥ 50% excess body weight loss (versus the prerevision weight) and 61% (versus the initial weight) compared with 52.7% after PBS. Only age ≤ 50 years was associated with ≥ 50% excess body weight loss after RBS for the failure of weight loss group. No RBS patients died. However, leaks, surgical site infections, and length of stay were increased after RBS. CONCLUSION The results of our study have shown that weight loss after RBS varies with the surgical indication and is affected by age >50 years. Although the RBS patients had decreased weight loss and increased complications compared with the PBS patients, ≥ 50% EBWL was achieved by a significant number of RBS patients.
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Affiliation(s)
- John F Radtka
- Department of Surgery, Penn State College of Medicine, Hershey, Pennsylvania 17033, USA
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Abstract
Obese patients present many unique challenges to the endoscopist. Special consideration should be given to these patients, and endoscopists need to be aware of the additional challenges that may be present while performing endoscopic procedures on obese patients. This article reviews the special risks that obese patients face while undergoing endoscopy, endoscopic management of patients postbariatric surgery, and future role of endoscopy in the management of obese patients.
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Affiliation(s)
- Mitchal A Schreiner
- Division of Gastroenterology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
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Huang CS. The role of the endoscopist in a multidisciplinary obesity center. Gastrointest Endosc 2009; 70:763-7. [PMID: 19555946 DOI: 10.1016/j.gie.2009.01.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2008] [Accepted: 01/12/2009] [Indexed: 12/16/2022]
Affiliation(s)
- Christopher S Huang
- Section of Gastroenterology, Boston Medical Center, Boston University School of Medicine, 85 E Concord St, no. 7714, Boston, MA 02118, USA
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Gastrojejunal stricture after gastric bypass and efficacy of endoscopic intervention. Dig Dis Sci 2009; 54:1971-8. [PMID: 19051026 DOI: 10.1007/s10620-008-0581-7] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2008] [Accepted: 10/13/2008] [Indexed: 12/11/2022]
Abstract
The Roux-en-Y gastric bypass procedure (RYGBP) is an effective treatment for morbid obesity. Anastomotic strictures are a common complication after RYGBP. This study examines the frequency of post-RYGBP gastrojejunal strictures (GJS), methods of evaluation, and the outcome of endoscopic intervention. Medical records of patients who had RYGBP for morbid obesity at our institution during four consecutive years were reviewed for patient demographics, medical comorbidities, surgical technique, and outcomes. Radiographic and endoscopic findings of those patients suspected to have GJS were noted. The impact of patient-related variables and surgical technique on risk of GJS, time to diagnosis of GJS, and treatment outcomes for GJS was determined. Of 888 patients, 503 had open RYGBP (57%) and 385 laparoscopic RYGBP (43%). Ninety-four patients (10.6%) underwent esophagogastroduodenoscopy (EGD) for possible GJS and 58 (6.5%) were found to have anastomotic stricture. Laparoscopic RYGBP was associated with increased incidence of GJS (43/385, 11.1%) compared with open RYGBP (15/503 or 2.9%, P = 0.0003). A total of 125 dilations were performed with an average of 2.2 dilations per patient. None of the strictures needed surgical revision. There were four perforations (3.2%) related to EGD. Mean time to diagnosis of GJS was 66.2 days. Eighty-seven of 94 patients underwent radiologic upper gastrointestinal (UGI) evaluation prior to EGD. UGI evaluation demonstrated a positive predictive value (PPV) of only 66% [95% confidence interval (CI) 52-77], and negative predictive value (NPV) of 83% (95% CI 65-93). Laparoscopic GBP is associated with increased risk of GJS. Endoscopic dilation of GJS is an effective treatment with minimal risk. Radiographic studies appear to have poor specificity for diagnosis of GJS and have a low positive predictive value. EGD should be performed in all suspected cases of GJS.
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Gastrojejunal Anastomotic Stenosis in Laparoscopic Gastric Bypass with a Circular Stapler (21 mm): Incidence, Treatment and Long-term Follow-up. Obes Surg 2009; 19:1631-35. [DOI: 10.1007/s11695-009-9962-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2009] [Accepted: 08/17/2009] [Indexed: 11/30/2022]
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Ryskina KL, Miller KM, Aisenberg J, Herron DM, Kini SU. Routine management of stricture after gastric bypass and predictors of subsequent weight loss. Surg Endosc 2009; 24:554-60. [PMID: 19585070 DOI: 10.1007/s00464-009-0605-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Revised: 05/11/2009] [Accepted: 06/16/2009] [Indexed: 01/11/2023]
Abstract
BACKGROUND Gastrojejunal anastomotic stricture is the most commonly occurring short-term complication after Roux-en-Y gastric bypass. Endoscopic balloon dilation is the first-line treatment for stricture. However, an optimal dilation protocol has not been identified. This study aimed to document routine management of stricture after laparoscopic gastric bypass and its impact on postoperative weight loss. METHODS Charts of patients who underwent gastric bypass from 2000 to 2006 were reviewed using a standardized abstraction form. Patients with stricture were matched with control subjects based on age +/-5 years, gender, and preoperative body mass index (BMI +/- 5). Patients with at least 6 months of follow-up assessment were included in the study. RESULTS Of the 113 patients included in the study, 20% were male, 26% black, 19% Hispanic, and 51% white. Their mean age was 42 +/- 10 years (range, 22-66 years). The mean preoperative BMI was 47.0 +/- 5.4 kg/m(2) for the case group and 46.6 +/- 5.5 kg/m(2) for the control group (p = 0.3). After adjustment for patient characteristics, using a larger balloon was associated with reduced odds of stricture recurrence (odds ratio [OR], 0.32; 95% confidence interval [CI], 0.12-0.85; p = 0.02). All the patients were without signs or symptoms of stricture at the last follow-up visit (20 +/- 17 months). Weight loss was similar between the two groups. The percentage of estimated weight loss (%EWL) at 12 months postoperatively was 66% for the study participants and 67% for the control subjects (p = 0.5). Baseline alcohol use and higher preoperative BMI were associated with a higher BMI 6 months postoperatively (p = 0.004 and p < 0.001, respectively). CONCLUSIONS Initial dilation with a larger balloon is safe and may prevent stricture recurrence. Further study of modifiable risk factors for reduced weight loss after surgery, such as alcohol use, may improve patient outcomes.
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Affiliation(s)
- Kira L Ryskina
- Division of Gastroenterology, Department of Medicine, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029, USA.
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Ruiz de Adana JC, Hernández Matías A, Hernández Bartolomé M, Manzanedo Romero I, Leon Ledesma R, Valle Rubio A, López Herrero J, Limones Esteban M. Risk of gastrojejunal anastomotic stricture with multifilament and monofilament sutures after hand-sewn laparoscopic gastric bypass: a prospective cohort study. Obes Surg 2009; 19:1274-7. [PMID: 19557484 DOI: 10.1007/s11695-009-9897-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2009] [Accepted: 06/01/2009] [Indexed: 01/01/2023]
Abstract
BACKGROUND Gastrojejunal (GJ) stricture is one of the most common late complications after laparoscopic Roux-en-Y gastric bypass (LRYGBP) with a hand-sewn anastomosis. The object of this study was to assess the risk of stricture for two types of resorbable suture (multifilament and monofilament) in a series of LRYGBPs performed by the same surgeon. METHODS DESIGN Prospective cohort study. The study population consisted of a series of consecutive morbidly obese patients who underwent primary hand-sewn LRYGBP between March 2004 and May 2008 at the University Hospital in Getafe, Madrid, Spain. The study comprised 242 LRYGBPs with a four-layer continuous hand-sewn anastomosis using absorbable 3/0 gauge suture. The suture material was Ethicon Vicryl multifilament in the first 105 cases and Ethicon Monocryl monofilament in the following 137 cases. All patients were followed up monthly for the first 6 months and then every 6 months after that. RESULTS The mean BMI was 46 +/- 4 for the multifilament cohort and 48 +/- 6 for the monofilament cohort with no significant difference between the two (p = 0.567). There were no anastomotic leaks, and no cases of marginal ulcer, abscess, abdominal sepsis, deep vein thrombosis, or pulmonary embolism were recorded. No cases required conversion to open surgery, and perioperative mortality was zero. In all, 11 cases of stricture (4.4%) were recorded, 10 in the multifilament suture cohort (9.5%), and only one in the monofilament suture cohort (0.7%; p = 0.001). The odds ratio was 14.3 (95% CI = 1.8-113.4). The mean outpatient follow-up period was 30 months (range = 6-42). CONCLUSIONS Anastomotic GJ stricture is a common and well-known complication of laparoscopic gastric bypass for morbid obesity. Hand sewing with monofilament suture significantly lowered the frequency of this complication, and hence, monofilament should be the suture material of choice for this suturing technique.
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Affiliation(s)
- Juan Carlos Ruiz de Adana
- Cirugía General y Digestivo, Hospital Universitario de Getafe, Crta Toledo Km 12.5, 28905-Getafe, Madrid, Spain.
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Results of gastrojejunal anastomotic technique designed to reduce stricture. Surg Obes Relat Dis 2009; 5:77-80. [DOI: 10.1016/j.soard.2008.10.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2008] [Revised: 08/31/2008] [Accepted: 10/11/2008] [Indexed: 11/22/2022]
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Meyer G, Stier C, Markovsky O. [Postoperative complications after laparoscopic Roux-en-Y gastric bypass in bariatric surgery]. Obes Facts 2009; 2 Suppl 1:41-8. [PMID: 20124778 PMCID: PMC6444587 DOI: 10.1159/000198259] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Der laparoskopische Roux-Y-Magenbypass weist eine Reihe charakteristischer chirurgischer KomplikationsmÖglichkeiten neben den in der bariatrischen Chirurgie generell vorhandenen Risiken auf. Durch die minimal-invasive Technik konnte das Risiko insgesamt vermindert werden. Die MortalitÄt betrÄgt 0–0,5%, das MorbiditÄtsrisiko betrÄgt zwischen 6 und 30%. Dabei erschweren die speziellen UmstÄnde des morbid adipÖsen Patienten hÄufig die Diagnosestellung, und insbesondere septische Komplikationen mit einem hohen MortalitÄtsrisiko stellen eine große Gefahr dar. GrÖßt mÖgliche Sicherheit und PrÄvention sind daher besonders wichtig. Die hÄufigsten Todesursachen sind Lungenembolie und Anastomoseninsuffizienz. Die hÄufigsten Komplikationen haben pulmonale und kardiale Ursachen. Wundkomplikationen werden als Folge des laparoskopischen Zugangssehrselten beobachtet. Chirurgische Komplikationen resultieren im Wesentlichen aus Blutungen, Problemen an den Anastomosen und NÄhten sowie dem DÜnndarm in Form von PassagestÖrungen unterschiedlicher Genese. Die chirurgischen wie bariatrischen Ergebnisse zeigen, dass das Ausmaß der FrÜh- und SpÄtkomplikationen im Vergleich zu den Folgeneiner fehlenden operativen Behandlung akzeptabel ist. Postoperative Complications after Laparoscopic Roux-en-Y Gastric Bypass in Bariatric Surgery The laparoscopic Roux-en-Y gastric bypass surgery involves some characteristic surgical complications besides the general risks associated with bariatric surgery. The overall risk could be effectively decreased due to the minimal invasive technique, though. The mortality is 0–0.5% and the risk ofmorbidity varies between 6 and 30%. However, the specific circumstances of morbidly obese patients make diagnostics difficult. Especially septic complications of any kind represent a high risk ofmortality. Therefore, maximal safety und prevention are very important issues to consider. The most common causes of death are pulmonary embolismand insufficiency of anastomosis. Due to the laparoscopic approach complications of wound healing are scarcely observed. The most frequent complications result from pulmonary and cardiac dysfunctions. Surgical complications mainly result from bleedings, problems with the anastomoses and sutures as well as from the small intestine showing any kind of passage malfunction. Overall, the surgical and bariatric results reveal that early postoperative and long-term complications remain within tolerable limits when compared toconsequences of a lack of surgery.
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Affiliation(s)
- Günther Meyer
- *Abteilung für Allgemein-, Viszeral- und Gefäßchirurgie, Chirurgische Klinik München-Bogenhausen, Denninger Straße 44, 81679 München, Germany, Tel. +49 8 99 27 94-16 00, Fax −16 03
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Vasquez JC, Wayne Overby D, Farrell TM. Fewer gastrojejunostomy strictures and marginal ulcers with absorbable suture. Surg Endosc 2008; 23:2011-5. [DOI: 10.1007/s00464-008-0220-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2008] [Revised: 10/15/2008] [Accepted: 10/20/2008] [Indexed: 01/11/2023]
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