Jejunojejunostomy Research Articles

Monoquadrant Robotic Roux-en-Y Gastric Bypass

BackgroundWhile laparoscopic Roux-en-Y gastric bypass is one of the most commonly performed procedures for morbid obesity in the USA, robotic application has been viewed as a valid option. However, the technique is not firmly established with single robotic docking. The objective of this video is to demonstrate the technical details of performing a standardized monoquadrant robotic Roux-en-Y gastric bypass (RRYGB). MethodsBetween April 2008 and May 2009, 15 patients meeting the NIH consensus criteria for bariatric surgery underwent a monoquadrant RRYGB. The data were prospectively collected in a dedicated bariatric database and reviewed retrospectively. The patient was positioned supine. Subsequent to creating a 30-ml gastric pouch using a series of endostaplers, the da Vinci robotic system (Intuitive, Sunnyvale, CA) was docked cranially. The robotic arms were attached in the double cannulation fashion. The gastrojejunostomy (GJ) was performed by a robot-assisted hand-sewn double-layered technique, followed by the creation of a jejunojejunostomy (JJ) with an endostapler. The common enterotomy of the JJ was closed with robot-assisted hand-sewn double-layered fashion. The bridge of jejunum between the GJ and JJ was transected separating both anastomoses. The mesenteric defect was not routinely closed at the end of the procedure. ResultsThere were 13 women and 2 men with a median age of 36 years included in this study. The procedure was successfully accomplished by a monoquadrant robotic technique in 14 cases (93.3%). One case was converted to open procedure because of an intra-operative enterotomy by an endostapler. The mean operative time was 202 min (range 158–353 min). There was no postoperative complication, notably no GI leak or anastomotic bleeding. The median hospital stay was 2.4 days (range 1.7–4 days). The mean weight loss after 1 year was 38.5 kg. ConclusionsThis video highlights the feasibility of performing a standardized monoquadrant RRYGB in its entirety with single docking of the da Vinci robotic system.

Small Bowel Obstruction After Antecolic Antegastric Laparoscopic Roux-en-Y Gastric Bypass Without Division of Small Bowel Mesentery: A Single-Centre, 7-Year Review

Reported incidence of small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass varies between 1.5% and 3.5%. It has been suggested that the antecolic antegastric laparoscopic Roux-en-Y gastric bypass (AA-LRYGB) is associated with a low incidence of internal herniation (IH). Therefore we routinely did not close mesenteric defects. The records of 652 consecutive patients undergoing primary AA-LRYGB from January 2003 to December 2009 in a single institution were retrospectively reviewed to determine the incidence, etiology, clinical symptoms, radiologic diagnostic accuracy and operative outcomes of SBO. Of the 652 patients, 63 (9.6%) developed SBO. The majority (6.9%, 45 patients) had a SBO due to IH. In 41 (91%) cases, the IH was at the jejunojejunostomy (JJ), four cases had an IH at Petersen's space. Adhesions and ventral hernia were found in 14 (2.1%) and four (0.6%) cases, respectively. Twenty-nine out of 63 cases had negative computed tomography (CT) findings and IH was diagnosed on CT in only 33% (14/45) of patients with IH. All patients underwent diagnostic laparoscopy. No bowel resections had to be performed. In contrast to previous reports, a high incidence of SBO with a high rate of IH at the JJ site was found in our series. Accuracy of CT is low and diagnostic laparoscopy is mandatory when SBO is suspected. Since 2010 we have started closing the JJ site, and data on SBO are collected prospectively. We believe that closing of the mesenteric defects is a mandatory step, even in an AA-LRYGB.

Multicentric Malignant Peripheral Nerve Sheath Tumors of Small Intestine and Thigh: Report of a Case

Primary malignant peripheral nerve sheath tumor (MPNST) of the small bowel is an extremely rare disease. We report a multicentric MPNSTs of the left thigh and jejunum in a 59-year-old male, who visited our hospital twice in seven months because of a subcutaneous lump on the posterior aspect of the left thigh and life-threatening melena respectively. Laparotomy was performed for the small bowel tumor and a segment of the jejunum containing the tumor near its midportion was resected with end-to-end jejunojejunostomy. Histologically, the tumor which had been excised seven months previously was diagnosed as classical MPNST occurring in the left thigh, and that resected this time, as epithelioid MPNST occurring in the jejunum. Distant metastasis to multiple organs occurred one month after resection of the jejunal MPNST, and the patient died three months later. This is the first case of an MPNST arising in the small intestine reported in Taiwan.

Effect of Location and Speed of Diagnosis on Anastomotic Leak Outcomes in 3828 Gastric Bypass Cases

IntroductionLeaks after Roux-en-Y gastric bypass are a major cause of mortality. This study attempts to define the relationship between the leak site, time from surgery to detection, and outcome. MethodsRetrospective review of 3,828 gastric bypass procedures. ResultsOf the leaks (3.9% overall), 60/2,337 (2.6%) occurred after open gastric bypass, 57/1,080 (5.2%) after laparoscopic gastric bypass, and 33/411 (8.0%) after revisions. Overall leak-related mortality after Roux-en-Y gastric bypass was 0.6% (22/3,828). Mortality rate from gastrojejunostomy leaks (38 in the open gastric bypass, and 43 in the laparoscopic) was higher in the open group than the laparoscopic group (18.4 vs 2.3%, p = 0.015). Median time of detection for a gastrojejunostomy leak in the open group was longer than in the laparoscopic group (3 vs 1 days, Wilcoxon score p < 0.001). Jejunojejunostomy (JJ) leak was associated with a 40% mortality rate. Initial upper gastrointestinal series did not detect 9/10 jejunojejunostomy leaks. Median detection time was longer in the jejunojejunostomy leak group than the gastrojejunostomy leak group (4 vs 2 days, p = 0.037). DiscussionLeak mortality and time of detection was higher after open gastric bypass than laparoscopic gastric bypass. GBP patients with normal upper gastrointestinal (UGI) studies may harbor leaks, especially at the JJ or excluded stomach. Normal UGI findings should not delay therapy if clinical signs suggest a leak.

Non-closure of Defects during Laparoscopic Roux-en-Y Gastric Bypass

The concern about internal hernias has prompted recommendations for routine closure of defects during laparoscopic Roux-en-Y gastric bypass (LRYGBP). Our belief is that not all techniques require closure of defects. We hypothesize that non-closure of defects with our particular technique would not cause a significant clinically evident internal hernia rate. All patients who were operated on between December 2002 and June 2005 were included in this study. The technique that was utilized included an antecolic antegastric gastrojejunostomy (GJ), division of the greater omentum, a long jejunojejunostomy (JJ) performed with three staple-lines, a short (< 4 cm) division of the small bowel mesentery, and placement of the JJ above the colon in the left upper quadrant. Clinical records were reviewed for reoperations. There was a total of 300 patients, and no incidence of internal hernia. In the first 100 patients, there was 97% follow-up for 1 year or more. Four patients underwent reoperations for unexplained abdominal pain. Intraoperative findings included an adhesive band from the JJ to the colon (1), an adhesive band from the JJ to the anterior abdominal wall (1), an adhesive band 3 cm from the GJ to the anterior abdominal wall (1), and adhesions of the jejunum to the anterior abdominal wall (1). No patient had an internal hernia. Internal hernias are not common after this particular method of LRYGBP. Before adopting routine closure of potential spaces, surgeons should consider their technique, follow-up, and incidence of internal hernias. Routine closure of these defects is not always necessary.

Duodenoscopic treatment of biliary tract diseases in patients after gastrectomy and Billroth II gastrojejunostomy

Objective To introduce and discuss the treatment of patients with biliary tract diseases after gastrectomy and Billroth Ⅱ gastrojejunostomy under electronic side-view duodenoscopy. Methods Twenty-five patients with biliary tract diseases who had undergone gastrectomy and Billroth Ⅱ gastrojejunostomy before were diagnosed and treated by using electronic side-view duodenoscopic techniques including ERCP, ENBD, ERBD and EST. Results For the 20 patients without Braun＇s anastomosis （side-to-side jejunojejunostomy）, duodenoscope insertion was completed in 19 （95 % ） and failed in 1 due to the stenosis of jejune lumen （5 %）. For the patients with Braun＇s anastomosis, duodenoscope insertion was completed in 2 （40%） and failed in 3 because of the prolonged jejune loop （60%）. Of the 21 patients who had successful ERCP, 17 with common bile duct stones were treated by EST＋ENBD （n=9）, ENBD （n=6） and ERBD （n=2）, respectively, 3 with bile duct cancers by ERBD and 1 with postoperative distal common bile duct stenosis by ERBD. Two patients treated by ERBD had complication of transient acute pancreatitis and relieved soon after medical treatment. All the patients had no complications of perforation and hemorrhage caused by endoscopic management. Conclusions Electronic duodenoscopic treatment is a mini traumatic and safe therapeutic technique for patients with biliary tract diseases after gastrectomy and Billroth Ⅱ gastrojejunostomy. The success rate of the treatment is related to the ways of postgastrectomic reconstructive operation. Key words: Biliary tract diseases; Duodenoscopy; Postgastectomy and Billroth Ⅱ gastrojejunostomy; ERCP; EST; ENBD; ERBD

Novel procedures for enhancing high jejunal atresia repair: bilateral side-plication and plication before anastomosis

In high jejunal atresia (HJA), discrepancy between the diameters of the proximal and distal jejunum can often be significant and cause major anastomotic complications. We developed 2 novel procedures to enhance conventional jejuno-jejunostomy (JJ): bilateral side-plication during JJ (BSP): plication of both lateral aspects of the dilated proximal jejunum, and jejunal plication before JJ (pre-P): plication of the jejunum proximal to the planned JJ site along the anti-mesenteric line. We used BSP in a neonate with a membranous stenosis 5 cm distal to the duodeno-jejunal flexure, and pre-P in 2 neonates, both with HJA and hugely dilated proximal jejunum. By using BSP, the jejunum could be plicated symmetrically near the closed jejunotomy, allowing the caliber change at the closed jejunotomy to be smooth without any kinking. If simple anti-mesenteric plication had been performed instead, proximal-to-distal kinking caused by closing the jejunotomy site transversely after the membrane was excised could have worsened. By using pre-P, the caliber change across the JJ could be made smooth and symmetric. If plication had been performed along the anti-mesenteric line after completing the JJ, the proximal jejunum near the JJ would have become asymmetrical causing the JJ to become kinked. Postoperatively, there were no JJ-related complications, and all subjects are well after a mean follow-up period of 3.0 years. Our novel procedures are simple and appear to enhance JJ by controlling kinking at the JJ site.

Acute, complete proximal small bowel obstruction after laparoscopic gastric bypass due to intraluminal blood clot formation

Background To report the presentation and management of early complete proximal small bowel obstruction from intraluminal clot after laparoscopic Roux-en-Y gastric bypass. Methods We performed a retrospective chart review of 5 female patients who developed small bowel obstruction at the jejunojejunostomy (JJ) secondary to intraluminal clot from January 2001 to January 2003. We analyzed the signs and symptoms, etiology of bowel obstruction, and operative treatment. Results From January 2001 to January 2003, 5 patients who had undergone successful laparoscopic Roux-en-Y gastric bypass developed proximal small bowel obstruction from a solid intraluminal clot secondary to staple line bleeding. All patients were women, with an average age and body mass index of 37 years and 43.41 kg/m 2, respectively. All patients underwent an upper gastrointestinal series on postoperative day 1, which revealed no leak, and all became symptomatic on postoperative day 2. Tachycardia and a “sense of impending doom” were both observed in 80% of the patients with this clinical syndrome. The intraoperative findings consistently revealed intraluminal clot obstructing the JJ. After reexploration and anastomotic revision, all patients had an uneventful recovery, with an average hospital length of stay of 9.8 days (range 8–11). Conclusion Staple line bleeding potentially exacerbated by perioperative subcutaneous heparin use can cause proximal small bowel obstruction at the JJ after laparoscopic Roux-en-Y gastric bypass. It presents on postoperative day 2 most commonly as tachycardia and a “sense of impending doom.” Prompt recognition and immediate reexploration will lead to an uneventful recovery. The need for complete anastomotic JJ revision is discussed.

Surgical and postoperative factors influencing short-term survival of horses following small intestinal resection: 92 cases (1994-2001).

Although short-term survival rates following small intestinal resection reportedly range from 48-88%, there is little information on predicting which horse may or may not survive small intestinal (SI) resection and anastomosis. The aim of this study was to identify factors that contribute to nonsurvival in horses following small intestinal resection. Medical records of horses which recovered from anaesthesia following SI resection were reviewed. Clinical and surgical variables were evaluated for their association with short-term survival using logistic regression and were reported as odds ratios (OR), including the 95% confidence interval (CI), indicating the likelihood of horses not surviving to hospital discharge. Ninety-two records met the criteria for inclusion. Thirty-six (81.8%) of the horses that underwent jejunojejunostomy (JJ) and 34 (70.8%) of the horses that underwent jejunocaecostomy (JC) survived to discharge. Multiple logistic analysis indicated that postoperative ileus (OR = 29.7; 95% CI 2.5-354.6), repeat celiotomy (OR = 18; CI 1.7-187.6), and an elevated heart rate of > or = 60 beats/min (OR = 5.6; CI 1.5-20.6) were the principal factors associated with nonsurvival. A low total plasma protein of <55 g/l (OR = 1.8; CI 0.-7.6) was incorporated in the final model because its inclusion improved the overall validity of the model, Clinicians should be aware of the factors associated with the greatest likelihood of nonsurvival following small intestinal resection, so that they can institute aggressive treatment and accurately inform owners on the likelihood of survival.

Recurrent Intestinal Bleeding from jejunojejunostomy Caused by Portal Hypertension Following Hepatoportojejunostomy in Extra Hepatic Biliary Atresia (EHBA) - Successful Treatment by Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Premier rapport sur l'application d'un shunt transjugulaire intra-hepatique portosystemique (TIPS) pour traiter une hemorragie intestinale recidivante venant de l'anastomose distale de l'hepatoportojejunostomie chez un enfant presentant une atresie biliaire extra-hepatique et une hypertension portale.

Effect of intraoperative fluid administration and colloid osmotic pressure on the formation of intestinal edema during gastrointestinal surgery

The effects of intraoperative changes in plasma colloid osmotic pressure (COP) on the formation of intestinal edema were studied in patients during modified Whipple's operation (hemipancreato-duodenectomy). Eighteen patients (ASA physical status I or II) were randomly assigned to one o f three groups. They received either lactated Ringer's (RL group, n = 6), 10% hydroxyethyl starch (HES group, n = 6), or 20% human albumin (HA group, n = 6) as a volume replacement solution, which was given to maintain central venous pressure (CVP) at the preoperative level. Jejunal specimens were obtained after the first transsection of the jejunum and prior to the jejuno jejunostomy. Their water, fraction (g H 2O/g tissue dry weight) was measured gravimetrically. COP was determined prior to induction of anesthesia and upon removal of the second jejunal sample. In the RL group, 3,850 ± 584 ml (data are means ± SEM) of volume replacement solution were infused from induction of anesthesia to removal of the second jejunal sample. In the HES group, 1,358 ± 45 ml were infused, and in the HA group, 463 ± 49 ml were infused. During this time, COP decreased from 20.3 ± 0.5 mmHg to 14.1 ± 0.6 mmHg in the RL group, remained at 22.0 ± 0.9 mmHg in the HES group, and increased from 20.7 ± 0.9 mmHg to 28.1 ± 0.9 mmHg in the HA group. The water fractions of the jejunal samples increased from 4.45 ± 0.13 g H 2O/g tissue dry weight to 4.79 ± 0.2 in the RL group; remained unchanged with 4.18 ± 0.16 and 4.10 ± 0.26 in the HES group; and decreased from 4.13 ± 0.15 to 3.68 ± 0.1 in the HA group. All changes were statistically significant (Student's t-test for paired data; p ⩽ 0.05). The authors conclude that formation of intestinal edema during lengthy gastrointestinal (GI) surgery can be prevented by avoiding COP decreases.