Surgical management of jejuno-jejunal intussuception 7 years after Roux-en-Y gastric bypass (with video)

Role of endoscopy after Roux-en-Y gastric bypass surgery

The purpose of this study is to evaluate the effects of gastric bypass surgery and sleeve gastrectomy on vitamin B12 values in dogs. Gastric dilation and volvulus (GDV) is an acute disease with a high mortality rate in dogs. Either gastric bypass surgery or sleeve gastrectomy can be utilized as surgical treatments for GDV. These techniques can provide increased success and fewer complications, however, one undesirable outcome can be vitamin B12 insufficiency. Three groups of dogs received gastric surgeries, one group underwent gastric rotation and derotation with no tissue gastric incisions, the two other groups had gastric bypass surgery and sleeve gastrectomy. Vitamin B12 level was evaluated two weeks prior to surgery, at the time of surgery, two, four, and six weeks after surgery. The results demonstrated no inter-group differences two weeks prior to surgery until four weeks after surgery. However, six weeks post-operation, significant differences between the sleeve gastrectomy group, and the other two groups were shown in vitamin B12 levels. Gastric bypass surgery and sleeve gastrectomy can both be utilized as new surgical managements of GDV. However, as we have demonstrated in this article, an important expected side effect is vitamin B12 insufficiency, in dogs that receive sleeve gastrectomy for GDV treatment. This necessary element must be substituted artificially for all dogs which had received these surgical managements.

Bariatric surgery in class I obesity (body mass index 30–35 kg/m2)

Short bowel syndrome following bariatric surgical procedures

Successful management of early gastrogastric fistula using fully covered esophageal stent

Surgical management and outcomes of patients with marginal ulcer after Roux-en-Y gastric bypass

Gastro-gastric fistula is a complication that might happen after a bariatric procedure like Roux-en-Y gastric bypass. It is defined as an abnormal communication between the excluded gastric pouch and the gastric remnant after gastric bypass. Its incidence has substantially decreased since the technique evolved from a nondivided to a divided gastric pouch. The diagnosis of gastro-gastric fistula could be challenging because of the clinical presentation that varies depending on the etiology, the patient’s objective and subjective response, the time of onset, the medications administered, and the imaging sensitivity. Besides clinical evaluation, imaging studies like upper GI study and CT scan and esophagogastroduodenoscopy are useful tools in achieving a diagnosis. Finally, medical and surgical management are extensively discussed in this chapter.

Late marginal ulcer perforation after Roux-en-Y Gastric bypass – A case report with two-step management

Background Small bowel obstruction after RYGB for obesity can occur due to various common causes like internal hernia and adhesions. One of the rare complications of RYGB is retrograde intussusception of jejunum at the common channel. Since it does not present with typical symptoms of small bowel obstruction, it is often challenging to consider it as differential diagnosis at initial presentation. Also, managing the intussusception at non bariatric centres could prove difficult due to location of it in the common channel, which will require understanding of orientation of alimentary and biliary limbs as well as reconstruction after resection of the intussusception. Method We collected the details of our patients admission episode from a different centre where she was admitted initially to understand the clinical behaviour of the condition. Also, we conducted a systematic search of literature databases like PubMed, Embase, CINAHL, ProQuest Dissertations & Theses using MeSH terms and keywords Intussusception, Retrograde intussusception, J-J intussusception, Intestinal Obstruction, Small bowel obstruction, Bowel obstruction, Obesity, Morbid obesity, Gastric Bypass, Roux-en-Y gastric bypass, Jejunojejunostomy, Jejuno-jejunostomy, Gastric by-pass, RYGB, Roux-en-Y. Data were extracted on to Excel sheet for analysis. Results The search yielded 41 case reports. Patients were operated in most instances except in seven cases where they had multiple episodes. The average age of presentation was 38 mostly in females and few instances being during pregnancy including our patient. Intussusception happened between 5 to 360 months after the initial operation with the average time after the operation being 66 months. Pain was the principal mode of presentation without classical symptoms of bowel obstruction. There were few instances of coffee ground vomiting. CT was the diagnostic modality in almost all cases. Recurrence was invariable when not managed with resection. Conclusion Small bowel intussusception after RYGB occurs retrogradely and does not present with classical symptoms and signs of small bowel obstruction. It can be reliably diagnosed with CT abdomen. Of note, medical management and no-resectional surgical management results in recurrence of this condition.

Bariatric surgery today is the only effective therapy for morbid obesity. Commonly performed procedures include adjustable gastric banding and vertical banded gastroplasty, variations of the Roux-en-Y gastric bypass, biliopancreatic diversion or duodenal switch, and mixed procedures. This review discusses key issues in the surgical management of morbid obesity. The two most common bariatric procedures performed worldwide are laparoscopic adjustable gastric banding and laparoscopic Roux-en-Y gastric bypass. Controversy exists regarding the best surgical procedure. Weight loss decreases according to the procedures performed in following decreasing order: biliopancreatic diversion, Roux-en-Y gastric bypass, vertical banded gastroplasty, adjustable gastric banding. Concerning the complications and quality of life, there is no single operation for morbid obesity without drawbacks. Cost-effectiveness analyses have demonstrated that bariatric surgery is cost effective at less than 50,000 US dollars/quality-adjusted life years. According to current opinion, gastric restrictive procedures (adjustable gastric banding, vertical banded gastroplasty) are generally considered safe and quick to perform, but the long-term outcome and quality of life have been questioned. By contrast, the long-term efficacy of adjustable gastric banding can be improved by the development of new band devices. More complex bariatric procedures, such as the Roux-en-Y gastric bypass or biliopancreatic diversion, have a greater potential for serious perioperative complications but are associated with good long-term outcome in terms of weight loss combined with less dietary restriction.

The morbid obesity epidemic in the United States has resulted in increasing numbers of patients who have undergone Roux-en-Y gastric bypass who require surgical management of nonbariatric disorders. When pancreatic resection is indicated in bariatric patients, consideration of the altered foregut anatomy can be applied to the principles of pancreatic resection to foster effective techniques that minimize operative complications. A retrospective review and analysis of bariatric patients who underwent pancreatic resection at the Medical University of South Carolina Digestive Center over a 2-year period (2006 to 2007) was conducted to assess indications for operation, operative techniques, and postoperative outcome in patients with previous Roux-en-Y gastric bypass. There were five patients (four female, one male) identified with a mean age of 35 years (range, 32-50 years). The mean time interval from gastric bypass to pancreatic resection was 42.6 months (range, 10-72 months). Indications for pancreatic operations were islet hyperplasia in two patients, chronic pancreatitis in two, and serous cystadenoma in one. Two patients underwent duodenal-preserving pancreatic head resection (Beger procedure) and three underwent distal pancreatectomy and splenectomy. Mean length of hospital stay was 11.4 days (range, 5-22 days). Two patients had extended hospital stay as a result of gastrointestinal ileus. There was no other operative morbidity or mortality. Mean length of patient follow up was 9.8 months (range, 1-17 months). Specific operative techniques used in pancreatic head resection were duodenal preservation, pancreatic drainage with an omega loop constructed from a mid-Roux limb, and excluded stomach gastrostomy. Techniques used in pancreatic tail and body resection were splenectomy discontinuous from pancreatectomy, division of the splenic vein and artery at the pancreatic neck early in surgery, retrograde dissection of the pancreas body and tail, and dissection of the body and tail posterior to the Roux limb leaving the Roux limb intact. Pancreatic resection after Roux-en-Y gastric bypass is safe and effective when using prescribed operative principles that minimize disruption of the foregut reconstruction and adds protection to the gastric remnant with a gastrostomy for decompression and access for enteral alimentation when necessary.

Surgical management of obstructing clot at the jejunojejunostomy after gastric bypass: a single center experience and literature review.

Surgical management of the supersuper obese patient (BMI >60 kg/m2) has been a challenging problem associated with higher morbidity, mortality, and long-term weight loss failure. Current limited experience exists with a two-stage biliopancreatic diversion and duodenal switch in the supersuper obese patient, and we now present our early experience with a two-stage gastric bypass for these patients. We completed a retrospective bariatric database and chart review of super-super obese patients who underwent laparoscopic sleeve gastrectomy as a first-stage procedure followed by laparoscopic Roux-en-Y gastric bypass as a second-stage for more definitive treatment of obesity. During a two-year period, 7 patients with BMI 58-71 kg/m2 underwent a two-stage laparoscopic Roux-en-Y gastric bypass by two surgeons at the Mount Sinai Medical Center. 3 patients were female, 4 patients were male, and the average age was 43. Prior to the sleeve gastrectomy, the mean weight was 181 kg with a BMI of 63. Average time between procedures was 11 months. Prior to the second-stage procedure, the mean weight was 145 kg with a BMI of 50 and average excess weight loss of 37 kg (33% EWL). Six patients have had follow-up after the second-stage procedure with an average of 2.5 months. At follow-up the mean weight was 126 kg with a BMI of 44 and average excess weight loss of 51 kg (46% EWL). The mean operative times for the two procedures were 124 and 158 minutes respectively. The average length of stay for all procedures was 2.7 days. 4 patients had 5 complications, which included splenic injury, proximal anastomotic stricture, left arm nerve praxia, trocar site hernia, and urinary tract infection. There were no mortalities in the series. Laparoscopic sleeve gastrectomy with second-stage Roux-en-Y gastric bypass are feasible and effective procedures based on short-term results. This two-stage approach is a reasonable alternative for surgical treatment of the high-risk supersuper obese patient.

Objectives: to assess the clinical effectiveness and cost-effectiveness of bariatric surgery for obesity. Data sources: seventeen electronic databases were searched [MEDLINE; EMBASE; PreMedline In-Process & Other Non-Indexed Citations; The Cochrane Library including the Cochrane Systematic Reviews Database, Cochrane Controlled Trials Register, DARE, NHS EED and HTA databases; Web of Knowledge Science Citation Index (SCI); Web of Knowledge ISI Proceedings; PsycInfo; CRD databases; BIOSIS; and databases listing ongoing clinical trials] from inception to August 2008. Bibliographies of related papers were assessed and experts were contacted to identify additional published and unpublished references Review methods: two reviewers independently screened titles and abstracts for eligibility. Inclusion criteria were applied to the full text using a standard form. Interventions investigated were open and laparoscopic bariatric surgical procedures in widespread current use compared with one another and with non-surgical interventions. Population comprised adult patients with body mass index (BMI) ? 30 and young obese people. Main outcomes were at least one of the following after at least 12 months follow-up: measures of weight change; quality of life (QoL); perioperative and postoperative mortality and morbidity; change in obesity-related comorbidities; cost-effectiveness. Studies eligible for inclusion in the systematic review for comparisons of Surgery versus Surgery were RCTs. For comparisons of Surgery versus Non-surgical procedures eligible studies were RCTs, controlled clinical trials and prospective cohort studies (with a control cohort). Studies eligible for inclusion in the systematic review of cost-effectiveness were full cost-effectiveness analyses, cost-utility analyses, cost-benefit analyses and cost-consequence analyses. One reviewer performed data extraction, which was checked by two reviewers independently. Two reviewers independently applied quality assessment criteria and differences in opinion were resolved at each stage. Studies were synthesised through a narrative review with full tabulation of the results of all included studies. In the economic model the analysis was developed for three patient populations, those with BMI ? 40; BMI ? 30 and Results: a total of 5386 references were identified of which 26 were included in the clinical effectiveness review: three randomised controlled trials (RCTs) and three cohort studies compared surgery with non-surgical interventions and 20 RCTs compared different surgical procedures. Bariatric surgery was a more effective intervention for weight loss than non-surgical options. In one large cohort study weight loss was still apparent 10 years after surgery, whereas patients receiving conventional treatment had gained weight. Some measures of QoL improved after surgery, but not others. After surgery statistically fewer people had metabolic syndrome and there was higher remission of Type 2 diabetes than in non-surgical groups. In one large cohort study the incidence of three out of six comorbidities assessed 10 years after surgery was significantly reduced compared with conventional therapy. Gastric bypass (GBP) was more effective for weight loss than vertical banded gastroplasty (VBG) and adjustable gastric banding (AGB). Laparoscopic isolated sleeve gastrectomy (LISG) was more effective than AGB in one study. GBP and banded GBP led to similar weight loss and results for GBP versus LISG and VBG versus AGB were equivocal. All comparisons of open versus laparoscopic surgeries found similar weight losses in each group. Comorbidities after surgery improved in all groups, but with no significant differences between different surgical interventions. Adverse event reporting varied; mortality ranged from none to 10%. Adverse events from conventional therapy included intolerance to medication, acute cholecystitis and gastrointestinal problems. Major adverse events following surgery, some necessitating reoperation, included anastomosis leakage, pneumonia, pulmonary embolism, band slippage and band erosion. Bariatric surgery was cost-effective in comparison to non-surgical treatment in the reviewed published estimates of cost-effectiveness. However, these estimates are likely to be unreliable and not generalisable because of methodological shortcomings and the modelling assumptions made. Therefore a new economic model was developed. Surgical management was more costly than non-surgical management in each of the three patient populations analysed, but gave improved outcomes. For morbid obesity, incremental cost-effectiveness ratios (ICERs) (base case) ranged between £2000 and £4000 per QALY gained. They remained within the range regarded as cost-effective from an NHS decision-making perspective when assumptions for deterministic sensitivity analysis were changed. For BMI ? 30 and Conclusions: bariatric surgery appears to be a clinically effective and cost-effective intervention for moderately to severely obese people compared with non-surgical interventions. Uncertainties remain and further research is required to provide detailed data on patient QoL; impact of surgeon experience on outcome; late complications leading to reoperation; duration of comorbidity remission; resource use. Good-quality RCTs will provide evidence on bariatric surgery for young people and for adults with class I or class II obesity. New research must report on the resolution and/or development of comorbidities such as Type 2 diabetes and hypertension so that the potential benefits of early intervention can be assessed.

EDITOR: Implications for anaesthetic and perioperative care of severely obese patients are considerable and escalate in the presence of comorbidities [1]. However, a review of anaesthetic perioperative care and pain management over a 10-yr period (1994-2004) concluded that outcome data are scarce and that literature evaluating the impact of specific care plans on short- and long-term perioperative outcome in bariatric surgical patients is lacking [2]. The objective of the present study was to review in a retrospective manner the anaesthetic and perioperative data from 195 consecutive patients admitted to our Medical Centre for weight loss surgery between May 2000 and March 2006 (72 months). Our institutional Ethics Committee considered the study as an audit of service development, and therefore not requiring formal permission. All the obese patients were evaluated before surgery (between 10 and 30 days) in the anaesthetic assessment clinic. Anticipated difficulties in airway management were based on the following clinical sings: Mallampati score >3, neck circumference >40 cm, thyromental distance <6.5 cm, large tongue or limitations in cervical or mandibular movements. In addition to routine intraoperative monitoring, neuromuscular transmission was assessed using acceleromyography of the adductor pollicis muscle (TOF-Guard; Organon Teknica, BV, The Netherlands). Since 2004 a bispectral index monitor was routinely introduced (BIS Monitor Model A 2000, Aspect Medical System Inc., Newton, MA, USA). For super-obese patients (body mass index (BMI) > 50) non-invasive haemodynamic monitoring was performed by HemoSonic transoesophageal echo-Doppler (HemoSonic™ 100, Arrow International Everett, MA, USA). At the end of the surgery, trocar sites were infiltrated with ropivacaine. Extubation was performed only on fully awake patients with a train-of-four ratio of 0.9 and in 30° reverse Trendelenburg position. The anaesthetic management, postoperative care, intraoperative and postoperative complications were evaluated and recorded. The same surgeon performed all surgical procedures while anaesthetic pre-, intra- and postoperative management was by members of our anaesthesiology staff. In order to evaluate the evolution of the surgical and perioperative management between these dates, the patients were divided into three consecutive and equal groups (Group A, B and C each with 65 patients) and compared. One-way analysis of variance was used to compare continuous variables among three groups. We used χ2 test or, when necessary, Fisher exact test, for testing univariate association between socio-demographic or clinical variables and χ2 test for trend to assess the linear trend when comparing proportions. The null hypothesis was rejected with α < 0.05. Data are presented as mean ± standard deviation (SD). Of the 195 obese patients, 28.2% (n = 55) were male and 71.8% (n = 140) were female. Mean age was 44 ± 11 yr, mean BMI 44.8 ± 6.8 and mean weight excess at the first interview was of 55 ± 21 kg. Concomitant disease was present in 56% of patients (n = 109). Arterial hypertension was the main associated disease (21%, n = 41), followed by chronic gastritis (16%, n = 24), while diabetes was diagnosed in only 4% of patients (n = 7). There were no laboratory test abnormalities in 80.6% of patients (n = 157). Chest X-ray examination was positive for mild cardiomegaly only in two patients; the remaining films were unremarkable. Results of pulmonary function tests were moderately abnormal in 6.7% (n = 13): 2 obstructive, 10 restrictive and 1 combined. Liver steatosis was present in 16% of patients (n = 31), while chronic gastritis and gastroesophageal reflux were diagnosed by direct gastroscopy in 15% (n = 29). Using our criteria for preoperative airway assessment, we classified 5% of patients (n = 10) as at risk for problematic tracheal intubation. Preoperative evaluation did not lead in any case to delay or cancellation of scheduled surgery. Laparoscopic adjustable gastric banding was performed in 64.6% of patients (n = 126) and laparoscopic Roux-en-Y gastric bypass in 35.4% (n = 69). The average surgical time for gastric banding was of 90 ± 12 min and that for gastric bypass was 241 ± 23 min. In four cases conversion to open surgery was required due to surgical difficulties. Other intraoperative complications included intra-abdominal adhesions (3.6%), hypoxia (2%), tooth damage (1%), severe bradycardia (1%), soft palate lesions (1%) and bronchospasm (0.5%). In patients with anticipated high risk of a problematic tracheal intubation, awake fibreoptic intubation was performed. No difficult intubation by direct laryngoscopy occurred in the remainder 95% following rapid sequence induction. In all patients, tracheal intubation was performed in the ‘ramped' position as suggested by Collins and colleagues [3]. Narcosis was maintained with propofol infusion (44%), sevoflurane inhalation (44%), desflurane (9%) or nitrous oxide in oxygen and sevoflurane (3%); neuromuscular blockade with cisatracurium (56%), rocuronium (23%) or vecuronium (21%). Analgesia was provided by continuous infusion of remifentanil (88%) or boluses of fentanyl (12%). Extubation was performed in 96% of cases (n = 187) in the operating theatre. Neuromuscular blockade was reversed in 59% (n = 115) of patients, the others recovered spontaneously. Direct ICU admission from the operating theatre occurred in 3.6% of patients (n = 7). The remaining 96.4% were monitored in the post-anaesthesia care unit (PACU). The mean ICU stay was 1.5 ± 0.5 days, whereas in PACU it was 213 ± 62 min. Mechanical ventilation was protracted in PACU for an average of 30 ± 7 min in 4% of patients due to extreme obesity, delayed recovery and severe hypoxia. The mean visual analogical pain score on admission to PACU was 3 ± 2, while before discharge to the surgical ward it was 1 ± 1. Postoperative analgesia was managed with meperidine (56%), ketorolac (22%), continuous infusion of remifentanil (11%), or the association of ketorolac and meperidine (9%) or morphine (2%). The most frequent complications observed in PACU were gastrointestinal (6.6%), respiratory (4.6%), cardiovascular (4.1%), bleeding (3.6%) and agitation (3.1%). Subsequently, on the surgical ward, the predominant problems encountered were pain (15%) and nausea (12%), followed by fever (8%) and persistent reflux (5%). In patients who underwent gastric banding, mean hospitalization was 3.2 ± 1.6 days, while in patients who underwent laparoscopic Roux-en-Y gastric bypass it was 9.1 ± 3.1 days. A decreasing trend was observed for the duration of surgery of the laparoscopic gastric banding procedures (Group A 103 ± 35 vs. Group B 88 ± 31 vs. Group C 71 ± 18; P < 0.01), and also their PACU stay (Group A 313 ± 100 vs. Group B 217 ± 63 vs. Group C 200 ± 57; P < 0.01). There was a progressive decrease in the gastric banding group (P < 0.01) with an increase in Roux-en-Y gastric bypass (P < 0.01) group. There were no other significant differences among the three groups. With the growing experience over the years of the surgical and anaesthesiological staff, we observed a reduction in the duration of laparoscopic gastric banding procedures and PACU length of stay. Probably the most important contributing factor to the observed outcome is the concept of ‘perioperative medicine' as stressed by Dahl and Kehlet [4], according to which the end result is determined by the management and strict interdependence among the pre-, intra- and post-operative periods. Several studies looking at the relationship between obesity and perioperative complications in patients undergoing laparoscopic surgery have reported no increased risk [5]. The principal risk factor is the presence of co-morbidities, particularly cardiorespiratory disease, and not obesity per se. In different studies, routine laboratory preoperative tests have shown a low incidence of abnormal results (0.3-6.5%) with an even lower proportion of these results leading to modifications in patient management (0-2.6%) [6]. Indeed, laboratory tests were abnormal in 20% of our population of obese and did not influence our perioperative management in any patient. We therefore agree with Ramaswamy and colleagues [6] that chest X-ray examination, coagulation studies, cardiac stress tests and pulmonary function tests should be selectively performed on the basis of morbidly obese patient history and clinics. Moreover, Brodsky and colleagues [7] demonstrated that only obesity with clinical signs such as large neck circumference and a high Mallampati score are predictors of potentially difficult intubation, whereas BMI or weight per se were not. Our experience is in line with such evidence since awake fibreoptic endotracheal intubation was performed in only 5% of patients and no difficult intubation occurred in the remaining patients. Although specific anaesthetic maintenance agents have been recommended, there is insufficient evidence to support one agent or technique over another [2]. In fact, several different anaesthetic approaches were used over the study period, and none were associated with any increased morbidity or worse outcome. In conclusion, anaesthesia for these patients can be safely performed when understanding that morbidly obese patients are not at risk per se due to their BMI but based on the existence and severity of co-morbidities. The concept of perioperative medicine with the strict interdependence of pre-, intra- and post-operative management is the key to a rational approach to morbidly obese patients.