Laparoscopic Gastrojejunostomy Research Articles

Laparoscopic gastrojejunostomy revision: a novel approach to intractable marginal ulcer management

Marginal ulcers are a known complication after Rouxen-Y gastric bypass, with a variable incidence of .6–16% [1,2]. Initial therapy involves elimination of the inciting risk factors [3] and medical management with a proton pump inhibitor and sucralfate therapy [4]. Although most marginal ulcers will heal with such treatment, approximately one third of patients will require operative intervention [5]. Surgery typically involves total revision of the gastrojejunostomy [6]. Revisional bariatric surgery, however, is technically difficult and has been associated with high morbidity and mortality rates. This approach can threaten the integrity of the gastric pouch and potentially necessitate an esophageal anastomosis. We present a case study of an intractable marginal ulcer managed surgically through a nontraditional technique that aims to reduce such risk.

V-09: Laparoscopic gastrojejunostomy revision: A novel approach to intractable marginal ulcer management

Marginal ulceration is a morbid complication of Roux-en-Y gastric bypass, with varying incidence. Some patients require revisional surgery for intractability. There is little discussion in the literature addressing surgical options for marginal ulcers. We aim to describe an innovative approach to the surgical management of anastomotic ulcers.

Single-Layer versus Double-Layer Laparoscopic Intracorporeally Sutured Gastrointestinal Anastomoses in the Canine Model

The objective of this study was to compare the gross and histopathologic changes following 1- versus 2-layer hand-sewn suture techniques in laparoscopic gastrointestinal anastomosis in dogs. This was an experimental prospective study of 16 healthy mixed breed male and female dogs. Animals were randomly divided into 2 groups. Two-layer side-to-side hand-sewn laparoscopic gastrojejunostomies were performed in group A, so that simple interrupted sutures were placed in the outer layer and simple continuous suture was used in the inner layer. The 1-layer simple continuous anastomosis between the stomach and jejunum was done in group B precisely. Specimen were collected from the sites of anastomosis, and H&E statining was performed for light microscopic studies. All animals survived the surgery. There was no gross inflammation, ischemia, apparent granulation tissue, abscess or fistula formation, leakage or stricture formation, and all sites of anastomosis were patent. Several adhesion formations were found in the abdomen with the higher incidence in the control group. Mean scores of leukocyte infiltration and granulation tissue formation at the sites of anastomosis were statistically insignificant between groups (P>0.05). Gross and histopathologic findings revealed that hand-sewn laparoscopic gastrointestinal anastomosis with the 1-layer suture technique is comparable to the 2-layer suture technique.

Radiosurgery in the Treatment of Unresectable Hepatocellular Cancer and as a Bridge to Transplantation

Radiosurgery in the Treatment of Unresectable Hepatocellular Cancer and as a Bridge to Transplantation

Laparoscopic Gastrectomy for Gastric Cancer

Surgery in gastric cancer (GC) aims to achieve resection of the primary tumor and its lymphatic drain, with a minimal adverse effect on morbidity and mortality, and the best possible quality of life. From June 1993 to May 2008, 113 patients with a preoperative diagnosis of the GC were considered for laparoscopic gastrectomy at our institution. There was a predominance of males and mean age was 60 years. After peritoneal cavity inspection, laparoscopic ultrasound was used to determine the presence of deep liver metastasis. Total gastrectomy and Roux-en-Y reconstruction were performed in upper and middle-third tumors, and subtotal gastrectomy, either with Billroth II or Roux-en-Y reconstruction, in tumors affecting the lower third of the stomach. D2 lymphadenectomy was performed in both cases. There were 21 cases (18.5%) with distant metastases and/or an unresectable tumor due to the invasion of adjacent organs. In these patients the procedure was limited to laparoscopic biopsy in 16 cases and laparoscopic gastrojejunostomy in 5 cases. Laparoscopic gastrectomy was performed in 92 patients with a mean surgical time of 162 minutes and a mortality rate of 5.4%. Conversion was necessary in 7 cases (7.6%). The benefits and safety of laparoscopic gastrectomy are evident, with similar outcomes to conventional surgery and all the advantages of minimally invasive access. The learning curve is long. Laparoscopic gastrectomy is a safe and effective option for the treatment of GC, avoiding nontherapeutic laparotomy in patients with advanced disease. Comparative prospective studies evaluating the long-term survival of these patients are still necessary.

Laparoscopic Surgical Treatment for Refractory Gastric Antral Vascular Ectasia

Gastric antral vascular ectasia (GAVE) is an angiodysplastic disorder of unclear etiology and rare cause of upper gastrointestinal bleeding. Endoscopic findings of hyperemic antral folds with dilated, tortuous vessels extending radially from the pylorus are diagnostic. Ectatic submucosal capillaries, microvascular fibrin thrombosis, and fibromuscular hyperplasia in the lamina propria are distinctive histologic features. Diverse treatment options are available, ranging from conservative medical or endoscopic therapy to surgical resection of affected gastric region. Surgery is the only known curative treatment and is traditionally pursued after failure of conservative therapy, as high postoperative mortality has been reported. A case of refractory GAVE in a 71-year-old female patient after 5 years of conservative management, is presented. The patient underwent successful laparoscopic distal gastrectomy and gastrojejunostomy with resolution of symptomatic anemia and melena. Clinical findings, diagnosis, etiology, and treatment of GAVE are reviewed here, with discussion of safety and efficacy of laparoscopic gastric resection for its treatment.

A systematic review of methods to palliate malignant gastric outlet obstruction

The traditional approach to palliating patients with malignant gastric outlet obstruction (GOO) has been open gastrojejunostomy (OGJ). More recently endoscopic stenting (ES) and laparoscopic gastrojejunostomy (LGJ) have been introduced as alternatives, and some studies have suggested improved outcomes with ES. The aim of this review is to compare ES with OGJ and LGJ in terms of clinical outcome. A systematic literature search and review was performed for the period January 1990 to May 2008. Original comparative studies were included where ES was compared with either LGJ or OGJ or both, for the palliation of malignant GOO. Thirteen studies met the inclusion criteria (10 retrospective cohort studies, two randomised controlled trials and one prospective study). Compared with OGJ, ES resulted in an increased likelihood of tolerating an oral intake [odds ratio (OR) 2.6, p = 0.02], a shorter time to tolerating an oral intake (mean difference 6.9 days, p < 0.001) and a shorter post-procedural hospital stay (mean difference 11.8 days, p < 0.001). There were no significant differences between 30-day mortality, complication rates or survival. There were an inadequate number of cases to quantitatively compare ES with LGJ. This review demonstrates improved clinical outcomes with ES over OGJ for patients with malignant GOO. However, there is insufficient data to adequately compare ES with LGJ, which is the current standard for operative management. As these conclusions are based on observational studies only, future large well-designed randomised controlled trials (RCTs) would be required to ensure the estimates of the relative efficacy of these interventions are valid.

Laparoscopic-assisted Stomach-partitioning Gastrojejunostomy for the Palliation of Gastric Outlet Obstruction From Antral Gastric Cancer

Conventional gastrojejunostomy is performed for gastric outlet obstruction; however, we have experience of some patients for whom oral intake was not adequately restored. Open stomach-partitioning gastrojejunostomy is a useful technique for the relief of unresectable and obstructing antral gastric cancers. We herein report the successful laparoscopic application of this technique in 2 patients: a 62-year-old male and a 65-year-old female with obstructing antral gastric cancer. There were no operative complications, and blood loss was minimal. Oral fluid intake was resumed 3 and 4 days postoperatively. Chemotherapy by oral administration was possible for each patient. There was no recurrence of the gastric outlet obstruction in either patient up until they died 6 and 10 months after surgery. Laparoscopic stomach-partitioning gastrojejunostomy is a safe and useful technique for treating unresectable and obstructing antral gastric cancer, allowing the possibility of adequate oral intake and permitting the administration of anticancer drugs.

Transumbilical single-incision laparoscopic intracorporeal anastomosis for gastrojejunostomy: case report

Laparoscopic gastrojejunostomy allows effective palliation and rapid recovery for the patient with limited survival due to advanced pancreatic cancer presenting with gastric outlet obstruction. Transumbilical single-incision laparoscopic surgery (SILS) offers excellent cosmetic results and may be associated with decreased postoperative pain, reduced need for analgesia, and thus accelerated recovery. The authors report the first transumbilical single-incision laparoscopic intracorporeal anastomosis for gastrojejunostomy. Preliminary experience with transumbilical single-incision, intracorporeal anastomosis for gastrojejunostomy for a patient with gastric outlet obstruction caused by advanced pancreatic cancer is reported. Transumbilical single-incision laparoscopic intracorporeal anastomosis for gastrojejunostomy was performed with a linear endoscopic stapler using an omega loop. The operative time was 117 min. No intra- or postoperative complications were recorded. Transumbilical single-incision laparoscopic intracorporeal anastomoses are feasible using the endoscopic linear stapler. Transumbilical single-incision gastrojejunostomy for gastric outlet obstruction may improve cosmetic results and allow accelerated recovery for patients with limited survival. This anastomosis technique of single-incision laparoscopic surgery for other digestive tract procedures needs further evaluation.

A Meta-Analysis of Approaches to Palliate Malignant Gastric Outlet Obstruction

Background and Aims: The traditional approach for the palliation of patients with malignant gastric outlet obstruction has been open gastrojejunostomy (OGJ). In recent years, endoscopic stenting (ES) and laparoscopic gastrojejunostomy (LGJ) have been introduced as alternatives, and some studies have suggested improved outcomes with ES. The aim of this meta-analysis was to compare ES with OGJ and LGJ for clinical outcome. Methods: A systematic literature search and review was performed for the period January 1990 to May 2008. Original studies that compared ES to either LGJ or OGJ or both, for the palliation of malignant gastric outlet obstruction, were included. Due to limited availability of randomised controlled trials (RCTs) evaluating these interventions, prospective and retrospective cohort comparison studies were also included. The primary outcomes examined were: number of patients tolerating an oral intake, time to oral intake, length of hospital stay (after intervention to hospital discharge), 30-day mortality, survival and complications. Results: Thirteen studies met the inclusion criteria (10 retrospective cohort studies, 2 randomised controlled trials and 1 prospective study). Compared with OGJ, ES resulted in an increased likelihood of tolerating an oral intake (OR 2.6, p=0.02), a shorter time to tolerating an oral intake (mean difference 6.9 days, p<0.001) and a shorter post-procedural hospital stay (mean difference 11.8 days, p<0.001). There were no significant differences between mortality at 30 days, complication rates or survival. There were an inadequate number of cases to complete a formal meta-analysis comparing ES with LGJ. Conclusion: This meta-analysis has demonstrated improved outcomes with ES over OGJ for the palliation of symptoms associated with malignant gastric outlet obstruction. Further high-quality RCTs would be beneficial to confirm this benefit, and to further evaluate the role of LGJ. Overall, on the basis of the best available current evidence, most patients with malignant gastric outlet obstruction are likely to sustain a higher quality of life when treated with ES.

Laparoscopic Transumbilical Gastrojejunostomy: An Advanced Anastomotic Procedure Performed Through a Single Site

Single-site laparoscopic surgery and natural orifice transumbilical surgery (NOTUS) have become exciting areas of surgical development. However, most reported case series consist of basic laparoscopic procedures, such as cholecystectomy and appendectomy. In this paper, we present the case of an advanced laparoscopic operation-construction of a gastrointestinal anastomosis-that was performed through ports placed entirely within the umbilicus. In this paper, we describe a 61-year-old male with a history of advanced pancreatic carcinoma who was referred with a gastric outlet obstruction. A laparoscopic gastrojejunostomy bypass, using a linear stapler with suture closure of the enterotomy, was performed through three abdominal trocars placed entirely within the umbilicus. Some potential advantages of NOTUS palliative gastrojejunostomy include reduced postoperative pain and the lack of visible abdominal scars. The operation was completed uneventfully in 40 minutes. The patient recovered without complications and was discharged on postoperative day 2. At 1-month follow-up, the patient had improved oral intake without any further vomiting symptoms. This case report documents the feasibility of an advanced anastomotic gastrojejunostomy procedure which can be performed through a single site. However, benefits of this approach, compared to conventional laparoscopic procedures, will require a prospective randomized clinical trial.

Laparoscopic Gastrojejunostomy in Patients with Obstruction of the Gastric Outlet Secondary to Advanced Malignancies

Surgical palliation is an important therapeutic goal in patients with gastric outlet obstruction from cancer. The use of laparoscopic approaches for this condition has not been well studied. Our objective is to compare surgical outcomes of laparoscopic and open gastrojejunostomies in patients with gastric outlet obstruction secondary to advanced malignancies. We did a retrospective review of 20 patients who underwent a palliative gastrojejunostomy as their primary surgical procedure. There were 10 patients in the laparoscopic group and 10 patients in the open one. We identified no significant difference between groups in mean surgery time (116 vs 116 minutes) (P = 0.99), blood loss (23 vs 142 mL) (P = 0.19), or length of stay (8 vs 14 days) (P = 0.14). We also identified no difference in median time to tolerate a regular diet (7 vs 8 days) (P = 0.49) and median survival (11.2 vs 9.0 months) (P = 0.83). Delayed gastric emptying was the most common complication occurring in four patients. There is no detectable difference in surgical outcomes between laparoscopic and open gastrojejunostomies in the management of patients with obstruction of the gastric outlet secondary to cancer. Laparoscopic gastrojejunostomy is a safe and feasible operation in this setting.

Surgical Bypass Versus Endoscopic Stenting for Malignant Gastroduodenal Obstruction: A Decision Analysis

The treatment options for palliating malignant gastroduodenal obstruction include open gastrojejunostomy (OGJ), laparoscopic gastrojejunostomy (LGJ), and endoscopic stenting (ES). The aim of this study was to compare the clinical outcomes and costs among ES, OGJ, and LGJ in patients who present with gastroduodenal obstruction from advanced upper gastrointestinal tract cancer. We designed a model for patients with malignant gastroduodenal obstruction. We analyzed success rates, complication rates and costs of the three treatment modalities: ES, OGJ, and LGJ. Baseline outcomes and costs were based on published reports. Success was defined as no major procedure-related and long-term complications over a 1-month period. Failure of therapy was defined as recurrent symptoms or death due to a procedural complication. Sensitivity analyses and cost-effectiveness analyses for the various strategies were performed. ES resulted in the lowest mortality rate and the lowest cost of the three treatment options analyzed. Mortality in the OGJ group was 2.1 times that in the ES cohort and 1.8 times that in the LGJ cohort. Sensitivity analyses confirmed ES as the dominant strategy. In conclusion, ES is the preferred treatment for palliation of duodenal obstruction due to advanced upper gastrointestinal tract cancer.

Palliative antecolic isoperistaltic gastrojejunostomy: a randomized controlled trial comparing open and laparoscopic approaches

Gastric outlet obstruction is a common, often preterminal, event for patients with inoperable neoplasms of the distal stomach, duodenum, and biliopancreatic area. It can be surgically managed by open or laparoscopic gastrojejunostomy. This study aimed to compare the results of open and laparoscopic palliative gastrojejunostomy for patients with gastric outlet obstruction resulting from inoperable neoplasms. A total of 24 patients were randomized prospectively to undergo laparoscopic (12 patients) or open (12 patients) palliative laterolateral antecolic isoperistaltic gastrojejunostomy. All the procedures were completed as planned. The mean duration of surgery was not significantly different between the two groups (p = 0.75). The mean intraoperative blood loss was significantly less after laparoscopic gastrojejunostomy (LGJ) (p = 0.0001). Time to oral solid food intake was longer after open gastrojejunostomy (OGJ) (p = 0.04). Two patients in the OGJ group experienced postoperative delayed gastric empting, whereas no patients in the LGJ group experienced such a complication (p = 0.04). The mean postoperative stay was shorter in the LGJ group, but the difference did not reach statistical significance (p = 0.65). No readmissions were registered after a minimum follow-up period of 2 months. The findings show that LGJ is a safe, feasible, and effective alternative to OGJ. However, because the current data involved only a small number of patients, large studies still are required for further evaluation of the this operation's effectiveness.

Single-stage repair of a large acquired tracheoesophageal fistula with interposition of 2 muscle pedicle flaps and laparoscopic gastrojejunostomy

Single-stage repair of a large acquired tracheoesophageal fistula with interposition of 2 muscle pedicle flaps and laparoscopic gastrojejunostomy

Surgical Bypass Versus Endoscopic Stenting for Malignant Duodenal Obstruction Due to Advanced Pancreatic Cancer: A Decision Analysis

Introduction: The optimal procedure for palliating duodenal obstruction from advanced pancreatic cancer remains controversial. Treatment options include open gastrojejunostomy (OGJ), laparoscopic gastrojejunostomy (LGJ) and endoscopic stenting (ES). OGJ and LGJ have higher initial costs and higher rates of early morbidity and mortality, but may require fewer late interventions for recurrent obstruction than ES. It is not clear how these factors influence the overall cost-efficacy of the palliative procedures. Aim: To compare the clinical outcomes and costs among ES, OGJ and LGJ in patients who present with duodenal obstruction from advanced pancreatic cancer using a decision model. Methods: We designed our model for patients seen initially with duodenal obstruction from advanced pancreatic cancer. We analyzed failure rates, testing characteristics, complication rates and costs of the three treatment modalities: ES, OGJ and LGJ. Baseline assumptions and outcomes were based on published reports and direct costs were based on 2005 Medicare reimbursement rates. Success was defined as no major procedure-related complication and no obstructive symptoms over a 3 month period after therapy. One-way and multi-way sensitivity analyses were performed to determine the threshold complication rates that would alter treatment strategies. We also compared total costs and performed cost-effectiveness analyses for the various strategies. Results: Under base case assumptions, ES resulted in the highest rate of success, the lowest mortality rate and the lowest cost of the three treatment options (Table 1). Mortality in the OGJ group was 2.7 times that of the ES cohort and 1.8 times that of the LGJ cohort. One- and three-way sensitivity analyses identified ES as the dominant strategy in all cases except when complications for ES exceeded 26.4% and 35.2%, respectively. OGJ and LGJ were inferior strategies based on lower success rates, greater mortality and higher costs. Conclusions: Endoscopic placement of endoluminal, self-expanding metallic stents is the preferred treatment for palliation of duodenal obstruction due to advanced pancreatic cancer. Compared to surgical procedures, ES has a greater success rate, fewer complications and lower cost. Table 1 Clinical Outcomes Strategy Success (%) Mortality (%) Costs (\$) ES 79 1.47 7215 OGJ 70 4.01 10190 LGJ 74 2.59 9766 Open table in a new tab

Annular Pancreas in the Adult: Management with Laparoscopic Gastrojejunostomy

Annular pancreas is an uncommon congenital anomaly associated with duodenal atresia in neonates. Rarely, the condition may manifest later in life. These symptoms include abdominal pain, nausea, and vomiting and usually arise due to obstruction to gastric emptying. Abdominal CT scan with high resolution and angiography protocol and magnetic resonance imaging are useful in confirming the presence of annular pancreas. Operative management involves bypassing the obstructed duodenum. Duodenoduodenostomy is routinely performed in neonates with annular pancreas. In adults, the duodenum is less mobile, and duodenojejunostomy or gastrojejunostomy are recommended. We report two cases of annular pancreas in adults treated with laparoscopic gastrojejunostomy.

Prospective randomized trial of laparoscopic gastrojejunostomy versus duodenal stenting for malignant gastric outflow obstruction

We prospectively compared laparoscopic gastrojejunostomy with duodenal stenting as a means of palliating malignant gastric outflow obstruction. A total of 27 patients with malignant gastric outflow obstruction were randomized to either laparoscopic gastrojejunostomy (LGJ) or duodenal stenting (DS) over a 3-year period. Thirteen patients underwent successful LGJ and 10 had successful DS. Eight patients had complications after LGJ, but none had complications after DS. Patients who underwent LGJ had a significant increase in visual analog pain score at day 1 (p = 0.05), and also had a longer hospital stay compared to those who underwent DS (11.4 vs. 5.2 days, p = 0.02). After DS, patients experienced an improvement in physical health at 1 month as measured using the Short Form-36 (SF-36) questionnaire (p < 0.01). There was no change following LGJ. Duodenal stenting is a safe means of palliating malignant gastric outflow obstruction. It offers significant advantages for patients compared with minimal-access surgery.

Laparoscopic gastric bypass for gastric outlet obstruction is associated with smoother, faster recovery and shorter hospital stay compared with open surgery

Laparoscopic gastric bypass for relief of gastric outlet obstruction (GOO) is feasible and safe. However, comparative data to confirm the benefits of the laparoscopic approach remain scarce. Between 1998 and 2003, 26 patients underwent 15 laparoscopic (surgeon A) and 12 open (surgeon B) gastrojejunostomies (GJs) for GOO. The indications for surgery included malignant (n = 17) and benign (n = 10) diseases. There were no conversions to open surgery in the laparoscopic group, and no operative mortality occurred in either group. The groups were comparable for age, sex, American Society of Anesthesiology (ASA) score, frequencies of previous abdominal surgery and of malignant or benign disease, and type of GJ fashioned. There were no differences between the laparoscopic and open groups with regard to the operating time (median, 90 vs 111 min; P = 0.113), and patients receiving intraoperative blood transfusion. However, laparoscopic surgery was associated with significantly shorter durations of postoperative intravenous hydration (60 vs 234 h; P = 0.001), opiate analgesia (49 vs 128 h; P = 0.025), and hospital stay (3 vs 15 days; P = 0.005). Operative morbidity occurred more frequently following open surgery (33% vs 13%; P = 0.219). Laparoscopic GJ for the relief of GOO is associated with a smoother and more rapid postoperative recovery and shorter hospital stay compared with open surgery. In experienced hands, the laparoscopic approach to GJ should become the new gold standard.

Endoscopy or surgery for malignant GI outlet obstruction?

The treatment of gastroduodenal outflow obstruction (GOO) caused by malignant diseases represents a significant challenge. Open surgical gastrojejunostomy (GJ) has been the treatment of choice, but it has high morbidity and mortality rates. More recently, endoscopic placement of self-expanding metallic stents (SEMS) has been proposed and the results of small, preliminary studies are encouraging. This study compared technical and clinical success, morbidity, mortality, and hospital stay in patients undergoing endoscopic and surgical treatment of GOO. Medical records of 60 consecutive patients with GOO seen between April 1997 and November 2002 were retrospectively reviewed. Because of extremely short life expectancy, 13 patients were treated by insertion of a double-lumen nasogastric-jejunal tube. The remaining 47 patients (28 men, 19 women; mean age 73.5 years, range 48-92 years) with unresectable pancreatic (33), gastric (7), metastatic lymph nodal (4), papillary (2), and biliary (1) tumors were treated by placement of a SEMS (24) or open surgical GJ (23). The technical success rates were similar, but clinical success was lower in the GJ group (92% vs. 56%, p = 0.0067). The SEMS group had a shorter length of hospital stay (3.0 [1.4] days vs. 24.1 [10.3], p < 0.001). Thirty-day mortality was 30% in the GJ group, and 0% in the SEMS group ( p = 0.004). Morbidity was higher in the GJ compared with the SEMS group (61% vs. 17%, p = 0.0021). Mean survival was longer in the SEMS group (96.1 [9.6] days vs. 70.2 [36.2] days, p = 0.0165 for a single test of hypothesis; Bonferroni correction for a multiple testing removes this significance), consequently, out-of-hospital survival was longer for the SEMS group (93.2 [9.3] days vs. 46.0 [31.5] days, p < 0.001). None of the endoscopic procedures required the assistance of an anesthesiologist or the use of an operating room. The results of this retrospective study suggest that SEMS insertion is better than surgical GJ for palliation of patients with GOO in terms of clinical success, morbidity, and mortality. Technical success rates were similar. SEMS placement should be proposed as the first-line treatment for relief of GOO. However, a randomized, comparative, prospective study of SEMS vs. laparoscopic GJ is needed.