Bowel Limb Research Articles

Long-term Outcome of the Dutch Common Channel Trial (DUCATI): Preservation of Superior Weight Loss Results Without Significant Malnutrition Side Effects.

The optimal bowel limb lengths for laparoscopic Roux-en-Y gastric bypass (LRYGB) to maximize weight loss while minimizing nutritional deficiencies in severe obesity treatment remain a topic of debate. The multi-center Dutch Common Channel Trial (DUCATI) aims to compare the outcomes of a very long Roux Limb Roux-en-Y gastric bypass (VLRL-LRYGB) with a standard Roux-en-Y gastric bypass (S-LRYGB). A total of 444 patients were randomly assigned in a 1:1, double-blind manner to undergo either VLRL-RYGB or S-LRYGB. Five-year follow-up data were assessed, concentrating on weight loss, obesity-related medical conditions, complications, re-operations, and malnutrition. Both groups had comparable total alimentary lengths (RL + CC). The VLRL-LRYGB group demonstrated significantly greater %TWL (32.2% vs. 28.6%, p = 0.002) and %EWL (81.2% vs. 70.3%, p = 0.002) at 5years. Eight (3.6%) patients in the VLRL-LRYGB group versus 2 (0.9%) in the S-LRYGB group (p = 0.055) needed modification surgery for malabsorption. Suboptimal clinical response rate was significantly higher (22.0% vs. 8.3%) in S-LRYGB group. No significant differences for nutrient deficiencies in favor of the S-LRYGB group were found. A 100-cm common channel with a relatively long Roux limb provides superior, sustainable weight loss over 5years, without significantly increased rate of malabsorption-related re-operations. These results suggest that a longer Roux limb can still ensure adequate micronutrient uptake in the total alimentary tract. These findings should be considered in discussions regarding the optimal Roux-en-Y limb length for severe obesity treatment.

Does the length of bypassed bowel during distal gastric bypass affect weight loss?

Weight recurrence (WR) affects > 20% of patients following Roux-en-Y gastric bypass (RYGB). Shortening of the common channel (CC) after RYGB (distal bypass) has been proposed for additional weight loss in patients with WR, but results vary, and concerns for vitamin deficiencies/malnutrition exist. Our aim was to determine whether the percentage of bowel bypassed after distal bypass is associated with the amount of postoperative weight loss. Patients undergoing distal bypass between 2018 and 2022 were reviewed. Small bowel limb lengths before and after distal bypass were measured, and the percentage of bypassed bowel was calculated (= bypassed biliopancreatic limb/total small bowel length). Patients were dichotomized into two groups based on the percentage bypassed bowel (≤ 50% vs. > 50%). Weight loss (measured as excess BMI loss; EBIL%), comorbidities resolution, complications, and nutritional deficiencies were reviewed. Thirty female patients underwent distal bypass during the study period. After distal bypass, the Roux was lengthened to 150cm (75-175cm) from 75cm (20-200cm), and the CC shortened to 150cm (100-310cm) from 510cm (250-1000cm). These changes resulted in an increase in the size of the bypassed biliopancreatic limb from 40cm (15-90cm) to 330cm (180-765cm) and a total alimentary limb (TALL; Roux + CC) shortening from 590cm (400-1075cm) to 300cm (250-400cm). The group with > 50% bowel bypassed had higher EBIL%. Overall EBIL% was 36.9 ± 14.7%, 53.3 ± 25.6%, and 62.1 ± 36.9% at 0.5, 1, and 2years, respectively. There were minimal vitamin deficiencies. Diabetes resolved in 100% (n = 3/3), HTN in 67% (n = 10/15), and GERD in 73% (n = 11/15). Complication rate was 23%. No reintervention for malnutrition or vitamin deficiencies was required. Distal bypass effectively leads to considerable weight loss and comorbidity improvement in patients with WR after RYGB, but the amount of weight loss depends on the percentage of bypassed bowel. An exact threshold of bypassed bowel that optimizes weight loss outcomes and simultaneously minimizes the nutritional complications needs to be determined. Meanwhile, close monitoring for vitamin deficiencies is recommended.

Changing patterns and surgical outcomes of small bowel obstruction in the era of minimally invasive surgery for colorectal cancer.

This study aimed to investigate whether the incidence, patterns, and surgical outcomes of small bowel obstruction (SBO) have changed in the era of minimally invasive surgery (MIS) for primary colorectal cancer (CRC). Consecutive patients who underwent laparotomy for SBO were divided into MIS and traditional open surgery (TOS) groups based on the previous colorectal cancer operation technique used. The MIS group was selected from 1544 consecutive patients who underwent MIS as a treatment for primary CRCs between 2014 and 2022, while the TOS group was selected from 1604 consecutive patients who underwent TOS as a treatment for primary CRCs between 2004 and 2013. The demographics, clinicopathological features, and surgical outcomes were compared between the two groups. The SBO incidence in patients who underwent MIS for primary CRC was significantly lower than that in patients who underwent TOS (4.4%, n =68/1544 vs. 9.7%, n =156/1604, P <0.0001). Compared with the TOS group, the MIS group had significantly different ( P <0.0001) SBO patterns: adhesion (48.5 vs. 91.7%), internal herniation (23.5 vs. 2.6%), external herniation (11.8 vs. 1.9%), twisted bowel limbs (4.4 vs. 0.6%), ileal volvulus with pelvic floor adhesion (5.9 vs. 1.9%), and nonspecific external compression (5.9 vs. 1.3%). A subset analysis of patients with adhesive SBO (ASBO) showed that the MIS group tended to ( P <0.0001) have bands or simple adhesions (75.8%), whereas the TOS group predominantly had matted-type adhesions (59.4%). Furthermore, SBO in the MIS group had an acute (<3 months) or early (3-12 months) onset (64.7%), while that in the TOS group ( P <0.0001) had an intermediate or a late onset. When the surgical outcomes of SBO were evaluated, the TOS group had significantly more ( P <0.0001) blood loss and longer operation time; however, no significant difference was observed in the surgical morbidity/mortality (Clavien-Dindo classification ≧3, 11.8 vs. 14.1%, P =0.6367), hospitalization, and readmission rates between the two groups. Postoperative follow-up showed that the estimated 3-year (11.37 vs. 18.8%) and 6-year (25.54 vs. 67.4%) recurrence rates of SBO were significantly lower ( P =0.016) in the MIS group than in the TOS group. The wide adoption of MIS to treat primary CRC has led to a lower incidence, altered patterns, and reduced recurrence rates of SBO. Awareness of this new trend will help develop surgical techniques to prevent incomplete restoration of anatomical defects and bowel malalignments specifically associated with MIS for CRC, as well as facilitate timely and appropriate management of SBO complications whenever they occur.

Optimal Small Bowel Limb Lengths of Roux-en-Y Gastric Bypass.

Gastric bypass and biliopancreatic diversion (BPD) have come full circle, from a loop configuration to a Roux-en-Y and finally back to a loop configuration as one anastomosis gastric bypass and single-anastomosis duodenal switch. Most surgeons performing Roux-en-Y gastric bypass (RYGB) do not measure the common channel (CC) length and most surgeons performing BPD do not measure the biliopancreatic limb length (BPL). The small bowel length in humans is variable from as short as < 400cm to as long as > 1000cm. The combination of these two facts means that even if surgeons keep the limb lengths constant, surgeons will get variable limb length due to the variability of small bowel length in patients. Hence, outcomes of weight loss, resolution of medical problems, or developing nutritional deficiencies which are related to limb length are variable. In this article, we evaluate the published literature related to the effect of varying the Roux limb, BPL, CC, and total alimentary limb lengths on the outcomes of RYGB. We have focused on historical and current randomized controlled trials as well as systematic reviews and meta-analysis to outline the current literature and our interpretation of this literature.

S1822 Recurrent Pancreatitis Secondary to Common Channel Volvulus Through Petersen’s Space Defect in a Patient With Roux-en-Y Bypass

Introduction: Petersen’s space hernia is an internal hernia that can occur after Roux-en-Y gastrojejunostomy. The intestinal loops herniate through a defect between the retroperitoneum, the transverse mesocolon and the small bowel limbs. We present a case of recurrent pancreatitis in a patient with Roux-En-Y bypass found to have common channel hernia through a Petersen’s space defect. Case Description/Methods: We present the case of a 34-year-old female with a history of Roux-en-Y surgery in 2018 and subsequent recurrent pancreatitis who presented to the emergency department with a chief complaint of severe epigastric and left lower quadrant abdominal pain associated with hematemesis. Patient reported 3 episodes of pancreatitis within 1 year previously. CT abdomen and pelvis showed mildly dilated common bile duct and intrahepatic biliary dilatation with no evidence of pancreatitis. Significant lab work included elevated lipase at 184 U/L. Patient was admitted to the medical service. Gallbladder ultrasound revealed no evidence of cholelithiasis, a prominent CBD of 9 mm and redemonstrated mild intrahepatic biliary dilatation. MRCP revealed a mesenteric swirl in the mid abdomen which was suspicious for an internal hernia in the setting of antecolic Roux-en-Y gastric bypass. It also showed focally dilated intrahepatic with underlying segmental atrophy. General surgery consultation was sought, with eventual plans for diagnostic laparoscopy after ruling out marginal ulcer via EGD. An EGD was performed which did not show evidence of marginal ulcer. Patient then underwent diagnostic laparoscopy which revealed a 360-degree volvulus of the common channel through a Petersen’s space defect; this was carefully reduced, and the Petersen’s space defect was closed. Patient also underwent laparoscopic cholecystectomy. Patient did not have any further episodes of pancreatitis after surgery. Discussion: This case demonstrates recurrent pancreatitis in a patient with a history of Roux-En-Y bypass found to have a common channel volvulus through a Petersen’s space defect. It is our understanding that the volvulus likely caused compression of the pancreaticobiliary system, thus causing recurrent pancreatitis. Reduction of the volvulus and closing of the Petersen’s defect resulted in complete resolution of recurrent pancreatitis in the patient.

Length of biliopancreatic limb in Roux-en-Y gastric bypass and its impact on post-operative outcomes in metabolic and obesity surgery—systematic review and meta-analysis

BackgroundRoux-en-Y gastric bypass (RYGB) is a gold-standard procedure for treatment of obesity and associated comorbidities. No consensus on the optimal design of this operation has been achieved, with various lengths of bypassed small bowel limb lengths being used by bariatric surgeons. This aim of this systematic review and meta-analysis was to determine whether biliopancreatic limb (BPL) length in RYGB affects postoperative outcomes including superior reduction in weight, body mass index (BMI), and resolution of metabolic comorbidities associated with obesity.MethodsA systematic search of the literature was conducted up until 1st June 2021. Meta-analysis of primary outcomes was performed utilising a random-effects model. Statistical significance was determined by p value < 0.05.ResultsTen randomised controlled trials were included in the final quantitative analysis. No difference in outcomes following short versus long BLP in RYGB was identified at 12–72 months post-operatively, namely in BMI reduction, remission or improvement of type 2 diabetes mellitus, hypertension, dyslipidaemia, and complications (p > 0.05). Even though results of four studies showed superior total body weight loss in the long BPL cohorts at 24 months post-operatively (pooled mean difference −6.92, 95% CI –12.37, −1.48, p = 0.01), this outcome was not observed at any other timepoint.ConclusionBased on the outcomes of the present study, there is no definitive evidence to suggest that alteration of the BPL affects the quantity of weight loss or resolution of co-existent metabolic comorbidities associated with obesity.

Comparing bowel lengthening procedures: which, when, and why?

Purpose of reviewIntestinal failure secondary to short bowel syndrome is still a very serious condition. Treatment consists of parenteral nutrition to provide nutrients and maintain body weight. During the last decades, intestinal lengthening procedures have become more available. The goal of this review is to discuss the results of the literature on the most commonly performed intestinal lengthening procedures.Recent findingsLongitudinal Intestinal Lengthening, Serial Transverse Enteroplasty (STEP), and Spiral Intestinal Lengthening and Tailoring (SILT) are currently the most frequently reported intestinal lengthening procedures. The most recent literature of these procedures is described with respect to indication, technical details, complications, short and long-term outcome, and PN independence.SummaryOn the basis of indication, surgical complexity, complications, and clinical success, we conclude that the STEP procedure is probably the best choice for most centers.

A Technique for Witzel Tunnel Catheter Drainage of the Biliary and Pancreatic Anastomosis of a Whipple Procedure

Introduction: Stenting the pancreatic and biliary anastomoses in a Whipple procedure has been shown to lower the rate of anastomotic leak. Method: We have identified a combined biliary and pancreatic ductal external drainage catheter/stent to decompress the small bowel limb and both anastomoses. The single catheter is a combination of a red Robinson catheter and a silastic pediatric feeding tube each of appropriate size for the duct they are draining. The silastic feeding tube is inserted into the lumen of the red rubber catheter though a small tight fenestration in the elastic external segment of the red catheter and exits the red rubber catheter through a similar fenestration at the level of the hepatico-jejunostomy. The silastic feeding tube is then advanced into the pancreatic duct where it is secured to the small bowel mucosa with a fine absorbable suture to prevent dislodgement. The combined tubes then exits the small bowel “Whipple limb” though a Witzel tunnel. The small bowel is secured to the right upper quadrant abdominal wall with several interrupted 3-0 Vicryl sutures. Results: Our technique offers several advantages. It’s a more durable way of stenting the two anastomoses and prevents stent migration. It provides an opportunity to study the two anastomosis via contrast administration. The witzel tunnel and the anchoring of the jejunal limb to the lateral abdominal wall opens the door for several IR/endoscopic interventions. Conclusion: The use of a combined biliary and pancreatic ductal external drainage catheter/stent system has many theoretical advantages.

Small Bowel Skewer Technique for Pancreatic Stenting in Robotic Whipple

Use of an external pancreatic stent is a proven fistula mitigation strategy for high risk anastomoses during PD. We propose a novel technique for passing and securing an internal - external pancreatic stent from skin via small bowel limb and into pancreas during PJ to facilitate totally robotic reconstruction phase in high fistula risk situations. This will be several slides and a 3 minute video outing the process and technique to be presented in ´Tricks of the Trade´.

A technique for witzel tunnel catheter drainage of the biliary and pancreatic anastomosis of a Whipple procedure

Presenter: Mridul Pansari MD | Florida Atlantic University Background: Stenting of the pancreatic and biliary anastomoses of a Whipple procedure has been shown to lower the rate of anastomotic leak in several retrospective and prospective studies. We describe here a combined biliary and pancreatic ductal external drainage catheter we have used successfully in our pancreatico-duodenectomy operations. Methods: We have identified a combined biliary and pancreatic ductal external drainage catheter / stent which we construct on the operating table to decompress the small bowel limb and both anastomoses. The single catheter is a combination of a red Robinson catheter and a silastic pediatric feeding tube each of appropriate size for the duct they are draining. The silastic feeding tube is inserted into the lumen of the red rubber catheter though a small tight fenestration in the elastic external segment of the red catheter and exits the red rubber catheter through a similar fenestration at the level of the choledocho or hepatico- jejunostomy. The silastic feeding tube is then advanced well into the lumen of the pancreatic duct where it is secured to the small bowel mucosa with a fine absorbable suture to prevent dislodgement. Multiple small extra openings are cut into both tubes at their distal segments to facilitate ductal drainage. The combined tubes then exeunt the small bowel “Whipple limb” though a Witzel tunnel. The small bowel is secured to the right upper quadrant abdominal wall with several interrupted 3-0 Vicryl sutures. The tube is secured to the skin externally with a heavy nylon suture. The pediatric feeding tube is then secured to the outer part of the red rubber catheter with benzoin and three ¼ inch steri-strips. Both catheters are connected to separate external drainage bags. We perform our pancraetico- jejunostomy with a single layer of interrupted 3-0 silk suture and our bile duct anastomosis with a single layer of 4-0 or 5-0 PDS or Maxon suture. Two 10 mm Jackson Pratt drains are then placed in the right upper quadrant. Results: There are several theoretical advantages that our procedure offers. First, it diverts the pancreatic fluid and bile, decreasing it's flow through the respective anastomosis which helps in the healing of the anastomosis. Secondly, our technique is a more durable way of stenting the two anastomoses and prevent the migration of the stents. The pediatric feeding tube has three areas of resistance that prevents its migration. The fenestration in the external portion, the fenestration in the internal portion and the mucosal stitch that is placed to hold it in place. The red rubber catheter is kept in place by the Witzel tunnel itself. Third advantage is that it provides an opportunity to study the two anastomosis via contrast administration. Fourth, the witzel tunnel and the anchoring of the jejunal limb to the lateral abdominal wall opens the door for several wire based treatments in a Seldinger fashion, should a leak be identified in the post operative period. Conclusion: The use of a combined biliary and pancreatic ductal external drainage catheter / stent system has many theoretical advantages.

Does the Length of the Common Channel as Part of the Total Alimentary Tract Matter? One Year Results from the Multicenter Dutch Common Channel Trial (DUCATI) Comparing Standard Versus Distal Roux-en-Y Gastric Bypass with Similar Biliopancreatic Bowel Limb Lengths.

Although the laparoscopic Roux-en-Y Gastric Bypass (LRYGB) is the gold-standard bariatric procedure, it remains uncertain what the optimal bowel limb lengths are to accomplish maximal weight loss while minimizing nutritional deficiencies and related gastro-intestinal complaints. The aim of this randomized controlled multicenter trial is to investigate the effect of significant lengthening of the length of the Roux limb (RL) at the cost of the length of the common channel (CC) while keeping the biliopancreatic limb (BPL) lengths the same on both study arms. Four hundred forty-four patients were randomized to receive either a Very Long Roux Limb LRYGB (VLRL-LRYGB) (variable RL length, BPL 60cm, and CC 100cm) or a Standard LRYGB (S-LRYGB) (RL 150cm, BPL 60cm, and a variable CC length). Results at 1-year follow-up for weight loss, effect on obesity-related comorbid conditions, complications, re-operation rate, malnutrition rate, and re-admission rate were investigated. Weight loss at 1-year showed no significant differences for %EWL (84.3% versus 85.3%, p= 0.72) and %TWL (34.2% versus 33.6%, p= 0.359) comparing VLRL-LRYGB versus S-LRYGB. Malabsorption requiring surgical bowel length adjustment was observed in 1.4% in VLRL-LRYGB group versus 0.9% in S-LRYGB group (p= 0.316). Significant lengthening of the RL at the cost of the common channel seems to have no effect on the weight loss at 1-year follow-up, which supports the theory that absorption of nutrients also occurs in the RL. Nevertheless, long-term results of the VLRL-LRYGB have to be awaited to draw final conclusions as part of the discussion towards optimal limb length in LRYGB surgery.

Lengthening of the common channel improves hypoalbuminemia and intractable diarrhea after OAGB/MGB.

Abstract Introduction Bariatric surgery is the only sustainable therapy for morbid obesity and its comorbidities. The outcome of any operation is determined by many factors including the limb length in cases involving bypass of various bowel limb lengths. The OAGB combines restrictive as well as malabsorptive properties for weight loss. It is an effective therapy for morbid obesity, but may reduce protein absorption and induce protein deficiency. Objectives & methods: A video of a laparoscopic revision of an OAGB/MGB in a patient with hypoalbuminemia and intractable diarrhea was done edited and is presented. Results The patient was found at surgery to have a 180cm BP limb, and only 200cm common limb. The albumen level dropped from pre-operative 3.25 g/dl to 2.23 g/dl post first OAGB. The gastro enterostomy was taken down and a new anastomosis was made at a point 50cm from the ligaments of Treitz. This left the patient with a BP limb of 50cm and a common limb of 330cm. The Patient had an unremarkable recovery. Her albumen raised to 2.89 g/dl in two months post revision surgery. Conclusion Most patients require at least 300cm of a common limb after OAGB/MGB to minimize the incidence of hypoalbuminemia and intractable diarrhoea. These types of cases can easily be managed by altering the limb lengths of the patient by increasing the common channel to a minimum of 300cms at the expense of the biliopancreatic limb.

Are There Ideal Small Bowel Limb Lengths for One-Anastomosis Gastric Bypass (OAGB) to Obtain Optimal Weight Loss and Remission of Comorbidities with Minimal Nutritional Deficiencies?

Ideal jejunal and ileal lengths in bariatric/metabolic procedures to be left in alimentary continuity still remain unclear. We aimed to evaluate different lengths of biliopancreatic limb (BPL) and common limb (CL) performed in a series of patients submitted to OAGB, and correlate them with weight loss and nutritional deficits. A prospective observational study of 350 consecutive morbidly obese patients undergoing OAGB was performed. BPL and CL lengths were determined intraoperatively; BPL/TBL and CL/TBL ratios were then calculated. Anthropometric variables, remission of comorbidities and specific supplementation needs were recorded at 1, 2 and 5years after surgery. Three hundred patients were included for final analysis. BPL length and BPL/TBL ratio directly correlated with Units of BMI lost (UBMIL). Conversely, CL length and CL/TBL ratio showed an inverse correlation with UBMIL. Establishing a BMI ≤ 25kg/m2 as ideal, the most accurate AUC, to predict achieving an ideal BMI at 1, 2 and 5years after surgery, was obtained for the CL/TBL ratio, followed by the CL length at 1, 2 and 5years. An ideal range was established between 0.40 and 0.43 for the CL/TBL ratio, and 200 to 220cm for the CL length. Among these ranges, there were no cases of protein or calorie malnutrition. TBL measurement is essential to obtain optimal outcomes after OAGB, both in terms of excellent weight loss and remission/improvement of comorbidities, as well as with a low risk of nutritional deficiencies. The CL/TBL ratio, followed by CL length, arethe most accurate parameters to predict a 5-year postoperative BMI ≤ 25kg/m2.

A simple method to avoid an incorrect end colostomy formation by using the wrong bowel limb (with video).

A simple method to avoid an incorrect end colostomy formation by using the wrong bowel limb (with video).

Validation of a Simulation-training Model for Robotic Intracorporeal Bowel Anastomosis Using a Step-by-step Technique

ObjectiveTo develop and validate a training model for the robotic intracorporeal bowel anastomosis. MethodsFor simulation, surgeons with varying levels of experience were instructed about bowel anastomosis robotic surgical simulation in a short educational video. All participants performed the required steps for the intracorporeal bowel anastomosis under standardized conditions. The procedure consists of the following steps: division of the bowel with a stapler (1), incision and opening of the bowel limbs at the antimesenteric angle (2), insertion of the stapler into the 2 bowel limbs for the side-to-side anastomosis (3), and transverse closure of the anastomosis with the stapler (4). All simulations were performed using the daVinci SI robotic system. Face and content validity were assessed using a standardized questionnaire. Construct validity was evaluated using the Global Evaluative Assessment of Robotic Skills, a validated global performance rating scale. ResultsTwenty-two surgeons participated including 6 robotic experts and 16 trainees. The expert participants rated the bowel anastomosis model highly for face validity (median 4/5; 64% agree or strongly agree), and all participants rated the content as a training model very highly (median 4.5/5; 100% agree or strongly agree). Discrimination between experts and trainees using Global Evaluative Assessment of Robotic Skills demonstrated construct validity (novice 17.6 vs expert 24.7, P = .03). ConclusionWe demonstrate that the bowel anastomosis robotic surgical simulator is a reproducible and realistic simulation that allows for an objective skills assessment. We establish face, content, and construct validity for this model. This step-by-step technique may be utilized in training surgeons desiring to acquire skills in robotic intracorporeal urinary diversion.

Petersen\u2019s hernia after living donor liver transplantation

BackgroundHepaticojejunostomy may be used for biliary reconstruction in certain cases of liver transplantation. In this occasion, Roux-en-Y biliary reconstruction is predominantly performed. Petersen’s hernia is an internal hernia that can occur after Roux-en-Y reconstruction, and it may lead to extensive ischemic changes affecting incarcerated portions of the small bowel or Roux limb resulting in severe complications with a poor prognosis.Case presentationThe present case was a 44-year-old male who underwent living donor liver transplantation (LDLT) for familial amyloid polyneuropathy and in whom biliary reconstruction was performed with Roux-en-Y hepaticojejunostomy. Two years after liver transplantation, symptomatic bowel strangulation was diagnosed by CT examination and emergent surgery was performed accordingly. On exploration, an ischemic limb associated with Petersen’s hernia was observed. Although repositioning of the incarcerated bowel loop gradually improved the color of the limb, the limb failed to completely recover to a normal color. To allow accurate evaluation for the viability of the limb, we decided to perform a second-look operation after 48 h. On re-exploration, the surface of the limb remained a dark color; however, intraoperative endoscopic findings revealed only partial necrosis of the mucosa. Next, we resected the portion of ischemic damaged limb only following side-to-side jejunojejunostomy. Consequently, redoing of biliary reconstruction could be avoided and the original hepaticojejunostomy site was preserved. Although the stricture of the remnant Roux limb occurred 1 month thereafter, it was successfully managed by balloon dilation via percutaneous transhepatic biliary drainage route.ConclusionsThe occurrence of Petersen’s hernia should always be considered in cases of liver transplantation with Roux-en-Y biliary reconstruction. On the basis of an accurate assessment of the extent of jejunal limb injury, reanastomosis of the hepaticojejunostomy, a potentially high-risk surgical procedure, can be avoided in emergent situations.

Small Bowel Limb Lengths and Roux-en-Y Gastric Bypass: a Systematic Review.

There is currently no consensus on the combined length of small bowel that should be bypassed as biliopancreatic or alimentary limb for optimum results with Roux-en-Y gastric bypass. A number of different limb lengths exist, and there is significant variation in practice amongst surgeons. Inevitably, this means that some patients have too much small bowel bypassed and end up with malnutrition and others end up with a less effective operation. Lack of standardisation poses further problems with interpretation and comparison of scientific literature. This systematic review concludes that a range of 100-200 cm for combined length of biliopancreatic or alimentary limb gives optimum results with Roux-en-Y gastric bypass in most patients.

Intestinal Microbiome of Pediatric Surgery Patients Demonstrates a High Level of Endemism Between Limbs of Discontinuous Bowel

Intestinal Microbiome of Pediatric Surgery Patients Demonstrates a High Level of Endemism Between Limbs of Discontinuous Bowel

Study protocol of the DUCATI-study: a randomized controlled trial investigating the optimal common channel length in laparoscopic gastric bypass for morbid obese patients.

BackgroundMorbid obesity has become one of the most frequent chronic medical disorders in Western countries, affecting 1.5-2 % of the Dutch population. Currently, the laparoscopic Roux-Y gastric bypass is considered to be the most effective bariatric treatment option for morbid obesity as it results in adequate weight loss and a significant decrease in comorbidity. Although this technique has been applied for years, the optimal lengths of the three bowel limbs (alimentary limb, biliopancreatic limb, and common channel) in order to achieve maximal percentage excess weight loss with minimal side effects (i.e. malabsorption symptoms), are unknown. As ‘normal’ sized gastric bypasses achieve an average of 60 − 80 % excess weight loss after one year, one could hypothesize that afferent limb lengths should be longer in order to reduce the common channel length, thereby improving outcome in terms of excess weight loss.The aim of the current study is to investigate the effect of the length of the common channel in gastric bypass surgery for morbid obesity. In this randomized controlled trial the very long Roux limb gastric bypass will be compared to the standard gastric bypass, in order to conclude which option is the optimal therapeutic strategy in the morbidly obese patient.Methods/designIn this multicentre trial patients will be randomized either to a very long Roux limb gastric bypass with a fixed common channel length of 100 cm, or to a standard gastric bypass with a variable common channel length.The primary objective is to evaluate whether the very long Roux limb gastric bypass is superior in terms of percentage excess weight loss after one year follow-up compared to the standard gastric bypass.Secondary endpoints are quality-of-life, cure /improvement of obesity related comorbidity, complications, malnutrition, re-admission rate, and re-operation rate.DiscussionWe hypothesize that our proposed distal LRYGB will provide for improved results concerning % EWL with an acceptable rate of (metabolic) complications.Our main point of interest is to determine if the distal LRYGB is a superior alternative to standard LRYGB in terms of percentage excess weight loss and to put more focus on the role of the common channel. Therefore we will perform this randomized controlled trial comparing both techniques, with % EWL as a primary outcome.Trial registrationCCMO registration number: NL43951.101.13 and Netherlands Trial Registry number: NTR4466.

V8-03 STEP-BY-STEP TECHNIQUE FOR ROBOTIC INTRACORPOREAL BOWEL ANASTOMOSIS AND DEVELOPMENT OF A SIMULATION TRAINING MODEL

You have accessJournal of UrologyBladder Oncology/Testis/Transplantation/Trauma1 Apr 2015V8-03 STEP-BY-STEP TECHNIQUE FOR ROBOTIC INTRACORPOREAL BOWEL ANASTOMOSIS AND DEVELOPMENT OF A SIMULATION TRAINING MODEL Friedrich-Carl von Rundstedt, Selcuk Silay, Monty Aghazadeh, and Alvin Goh Friedrich-Carl von RundstedtFriedrich-Carl von Rundstedt More articles by this author , Selcuk SilaySelcuk Silay More articles by this author , Monty AghazadehMonty Aghazadeh More articles by this author , and Alvin GohAlvin Goh More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2127AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Our group has previously reported on the development and validation of an inanimate robotic skills simulator. There is an increased utility of robotic cystectomy in the treatment of bladder cancer. The performance of a completely intracorporeal urinary diversion requires an effective technique for an intracorporeal bowel anastomosis. We present a surgical approach that has deconstructed the procedure to 4 essential steps. Our goal was to create a novel training model for the intracorporeal bowel anastomosis in robotic surgery (BARS). METHODS The BARS technique consists of the following steps: division of the bowel with a stapler (1), incision and opening of the bowel limbs at the antimesenterial angle (2), insertion of the stapler into the two bowel limbs for the side-to-side anastomosis (3), transverse closure of the anastomosis with the stapler (4). For the simulation surgeons with varying levels of experience were instructed about BARS in a short educational video. The simulation setup included an abdominal trainer with porcine bowel as well as a bedside surgeon who operated the stapling device. All participants performed the required steps for the intracorporeal bowel anastomosis under standardized conditions. Face and content validity were derived from participants' rating of the tasks on a 5-point Likert scale. RESULTS A total of 14 participants completed all four tasks of the BARS simulation. 2 experts and 10 trainees in robotic surgery completed the online-based survey that we shared with all participants for the evaluation of the BARS exercise. 67% of participants agreed that the technical skills required to complete the training model reflected technical skills required to perform actual robotic intracorporeal reconstruction. 91% of participants found the model to be appropriate in difficulty. 91% of participants agreed that a robotic surgeon skilled in urinary diversion should be able to perform the tasks presented. 88 % of participants agreed that the model would be useful for the evaluation of robotic technical skills proficiency and 91% thought it to be useful for training robotic surgical skills. CONCLUSIONS We were able to demonstrate that the BARS simulator is a reproducible and realistic simulation which allows for an objective skills assessment. This can have implications for the training of surgeons engaged in robotic intracorporeal urinary diversions. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e714-e715 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Friedrich-Carl von Rundstedt More articles by this author Selcuk Silay More articles by this author Monty Aghazadeh More articles by this author Alvin Goh More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...