Near-total Gastrectomy Research Articles

EUS-guided hepaticojejunostomy for biliary obstruction in near-total gastrectomy with Roux-en-Y: Trials and tribulations (with videos).

EUS-guided hepaticojejunostomy for biliary obstruction in near-total gastrectomy with Roux-en-Y: Trials and tribulations (with videos).

Long-term Results of Totally Laparoscopic Near-total Gastrectomy for Middle-third Gastric Cancer.

In recent years, laparoscopic near-total gastrectomy (LnTG) has emerged as a surgical option for gastric cancer in the middle-third of the stomach. However, its application in locally advanced stages presents technical challenges. This study aims to provide a detailed analysis of the operative outcomes and long-term functional and oncological results of totally LnTG in combination with D2 lymphadenectomy for middle-third gastric cancer. A prospective study was conducted on 79 patients who underwent totally LnTG and D2 lymphadenectomy for middle-third gastric cancer between January 2017 and December 2021. Short-term outcomes included operative characteristics, and the evaluation of gastroesophageal reflux and gastric remnant condition using endoscopy based on the Los Angeles (LA) and Residue-Gastritis-Bile classifications. Long-term oncological outcomes included overall survival and disease-free survival. Totally LnTG was successfully performed in 98.7% of patients without intraoperative complications or conversions to laparotomy. The mean operation time was 202.2±43.0min, and the median blood loss was 50 (50;100)mL. The overall incidence of postoperative morbidities was 16.5%, with one patient experiencing a narrowing of the gastrojejunostomy, successfully treated by endoscopic balloon dilation. All patients had tumor-free resection margins, and there were no mortalities. The 5-year overall survival and disease-free survival rates were 80% and 55%, respectively. Totally LnTG is an effective and feasible approach for gastric cancer in the middle-third of the stomach, yielding favorable short-term outcomes and acceptable long-term results. Routine application of totally LnTG for middle-third gastric cancer is practical and promising.

Minimally Invasive Hand-Sewn Barbed Anastomosis After Total and Near-Total Gastrectomy: Standardized Azagra’s Technique

Minimally Invasive Hand-Sewn Barbed Anastomosis After Total and Near-Total Gastrectomy: Standardized Azagra’s Technique

NPTD classification: an updated classification of gastric cancer location for function preserving gastrectomy based on physiological lymphatic flow

BackgroundThe correlation between tumor location and lymphatic flow distribution in gastric cancer has been previously reported, and PTD (Proximal – Transitional – Distal) classification was proposed. Our group updated and developed the nPTD classification.MethodWe retrospectively studied gastric cancer patients who underwent the dye method sentinel node biopsy from 1993 to 2020. The inclusion criteria were a single lesion type 0 cancer of ≤5 cm in the long axis, clinically node-negative, and invasion within the proper muscle layer pathologically. In this study, the distribution of dyed lymphatic flow was evaluated for each occupied area of the tumor.ResultsWe included 416 patients in this study. The tumors located in the watershed of the right and left gastroepiploic arteries near greater curvature had extensive lymphatic flow; therefore, a newly circular region with a diameter of 5 cm is set on the watershed of the greater curvature between P and T zone as the ‘n’ zone. In addition, for cancers located in the lesser P curvature, lymphatic flow to the greater curvature was not observed. Therefore, the P zone was divided into two: the lesser curvature side (PL) and the greater curvature side (PG).ConclusionsThe advantage of the nPTD classification is that it provides not only proper nodal dissection but also adequate function-preserving gastrectomy. If the tumor is localized within the PL, the proximal gastrectomy resection area can be further reduced. In contrast, for cancers located in the ‘n’ zone, near-total gastrectomy is required because of the extensive lymphatic flow.

A rare case of polypoid primary anorectal melanoma with subsequent giant stomach metastasis: A gastrointestinal involvement of both primary and metastatic mucosal melanoma.

Melanoma can involve the gastrointestinal apparatus as both primary and metastatic lesions. Primary anorectal mucosal melanoma (ARMM) and metastatic gastric melanoma are rare entities and usually resulted in a poor prognosis. We presented a case of a 61-year-old man who after the complete excision of an ARMM developed a gastric metastasis after almost three years form the complete tumour excision. Upon esophagogastroduodenoscopy, a giant ulcered mass resulted in melanoma metastasis. The patient underwent a near-total gastrectomy. After five months of follow-up, the patient is disease-free. The incidence of ARMMs is increasing, highlighting the necessity of new prevention and treatment strategies in order to achieve a better prognosis for these patients. There are no known risk factor for ARMMs but surgery, together with the combination of anti-CTLA-4 and anti-PD-1 antibodies, are promising therapeutic options. Early and aggressive treatments are required, together with a strict multidisciplinary approach.

Selection of surgical procedures and analysis of prognostic factors in patients with primary gastric tumour based on Cox regression: a SEER database analysis based on data mining.

IntroductionThere are numerous types of surgery for patients with primary gastric tumour, which can be summarized as radical surgery or palliative surgery. Different surgical procedures will have further effects for different stage of patients.AimWe will use the resources of the SEER database (2010–2015) to explore the therapeutic value of surgery and prognostic factors.Material and methodsKaplan-Meier analysis/log-rank testing for data analysis and multivariate analysis was conducted through a Cox proportional model.ResultsFourteen thousand five hundred and seven cases of primary gastric tumours identified in the period from 2010 to 2015. In a multivariate cox regression analysis, the following factors were associated with better primary gastric patients survival (Surgical method, Age at diagnosis, histological grade). Through Kaplan-Meier analysis (p < 0.005) we also found that for the patient group the survival rate of using gastrectomy (partial, subtotal, hemi-) surgery is the lowest.ConclusionsAmong patients with multivariate Cox regression model, type of surgery, age at diagnosis, and histological grade were the top 3 factors affecting patient survival. In palliative surgery, laser excision is the best surgical method of local tumour excision, and the survival of patients of this group is obviously better than in other groups. In radical surgery, near-total gastrectomy and radical gastrectomy, in continuity with the resection of other organs, are better surgical methods, while gastrectomy (partial, subtotal, hemi-) is the worst type of surgery in terms of prognosis, and even the survival rate in the later stage (after 3 years) is worse than in the group without surgery.

Early Surgical and Long-term Oncological Outcomes of Totally Laparoscopic Near-total Gastrectomy in &gt;150 Cases

This study aimed to examine the early surgical outcomes and long-term oncological safety of totally laparoscopic near-total gastrectomy for the treatment of upper-third early gastric cancer. We retrospectively collected and analyzed the data of 167 consecutive patients who underwent totally laparoscopic near-total gastrectomy for upper-third early gastric cancer between January 2008 and May 2018. Data on clinical characteristics and surgical outcomes, including operation time, length of postoperative hospital stay, pathologic findings, and postoperative complications, were obtained. We also analyzed recurrence-free and overall survival rates to evaluate the oncological outcomes. The mean operation time was 149.44±37.59 minutes; none of the patients required conversion to laparotomy during surgery. The average postoperative hospital stay was 7.57±5.69 days. On final pathologic analysis, the mean proximal resection margin was 1.97±1.68 cm. No patients had an involved proximal resection margin. Twenty-seven patients (16.17%) had postoperative complications; of them, 6 patients (3.59%) had Clavien-Dindo classification grade 3 or higher complications, all within 1 month. The median follow-up duration was 54.35 months. The 3- and 5-year recurrence-free survival rates were 98.3% and 97.1%, respectively. The overall survival rate was 97.1% at both 3 and 5 years. Our study shows that totally laparoscopic near-total gastrectomy is a safe and feasible procedure for treating the upper-third early gastric cancer. Further, in the current study, the procedure demonstrated a favorable oncological outcome for a relatively long follow-up period and large sample size.

Early gastric cancer with three gastric gastrointestinal stromal tumors combined with synchronous colon cancer: a case report

BackgroundThere have been very few reports of patients with early gastric cancer (EGC) and colorectal cancer combined with gastric gastrointestinal stromal tumors (GISTs).Case presentationWe report the case of a patient with multiple tumors that were found at the same time in the abdomen. The patient was a 77-year-old man who was referred for a gastric GIST. Esophagogastroduodenoscopy showed the known lesion (a gastric GIST) on the lesser curvature of the upper body and a new lesion on the lesser curvature of the lower body of the stomach with suspicion of EGC. Computed tomography findings confirmed the presence of a GIST in the stomach and revealed two new lesions. One of these lesions was suspected to be a 4-cm submucosal tumor on the anterior wall of the upper body of the stomach. The other was a wall thickening of the descending colon that demonstrated the possibility of malignancy. Synchronous colon cancer was confirmed on colonoscopy. Laparoscopic near-total gastrectomy with D1+ lymph node dissection and left hemicolectomy were performed sequentially without significant events. The patient was discharged without any postoperative complications.ConclusionsWe reported a rare case of EGC with multiple gastric GISTs combined with synchronous colon cancer.

Case report: optimal tumor cytoreduction and octreotide with durable disease control in a patient with MEN-1 and Zollinger-Ellison syndrome\u2014over a decade of follow-up

BackgroundZollinger-Ellison syndrome (ZES) is a rare condition characterized by hypersecretion of gastrin by gastrinoma tumors leading to severe peptic ulcer disease with potential development of gastric carcinoid tumors. Herein, we report the clinical course of a 68-year-old patient with multiple endocrine neoplasia type 1 (MEN-1) who underwent several surgeries to ultimately undergo optimal tumor cytoreduction of locally advanced gastrinomas and symptomatic gastric carcinoids. The patient was subsequently maintained on octreotide long-acting release (LAR). This case report supports consideration for aggressive tumor cytoreduction and octreotide in similar patients with MEN-1-associated ZES for durable disease control and symptom management.Case presentationThe patient is a 68-year-old male with multiple endocrine neoplasia type 1 (MEN-1), diagnosed in 1993 after presenting with recurrent renal calculi and hypercalcemia. Soon thereafter, he presented with symptoms and elevated gastrin levels suggestive of ZES prompting abdominal exploration with partial resection of the duodenum to remove gastrinoma tumor nodules. Within 4 years of the operation, he represented with intractable hypergastrinemia despite optimal medical management with peak gastrin levels exceeding 29,000 pg/mL, in 2006. In January 2007, the patient returned to the operating room for resection of regional peripancreatic and perigastric lymph nodes and enucleation of pancreatic body and tail gastrinoma tumors. Although his gastrin level decreased to 5000 pg/mL with resultant improvement of symptoms, in less than 2 years, he developed disease progression with obstructive symptomatology from enlarging gastric carcinoids and rising gastrin levels. In May of 2008, he underwent pancreaticoduodenectomy and near-total gastrectomy. Since June of 2008, the patient shows no demonstrable progression of disease and remains asymptomatic on LAR octreotide (30 mgs). Gastrin levels have been well controlled (range, 100–624 pg/mL; current 114 pg/mL).ConclusionSuccess of this procedure in our case report highlights the potential role for optimal tumor cytoreduction and LAR octreotide to control disease progression in a patient with MEN-I and Zollinger-Ellison syndrome with locally advanced gastrinoma and secondary large gastric carcinoids.

Pediatric gastric adenocarcinoma: A National Cancer Data Base review

PurposeWe sought to compare the presentation, management, and outcomes in gastric adenocarcinoma cancer for pediatric and adult patients. MethodsUsing the 2004 to 2014 National Cancer Database (NCDB), patients ≤21 years (pediatric) were retrospectively compared to >21 years (adult). Chi-squared tests were used to compare categorical variables, and Cox regression was used to estimate hazard ratios (HR) for survival differences. ResultsOf the 129,024 gastric adenocarcinoma cases identified, 129 (0.10%) occurred in pediatric patients. Pediatric cases presented with more advanced disease, including poorly differentiated tumors (81% vs 65%, p = 0.006) and stage 4 disease (56% vs 41%, p = 0.002). Signet ring adenocarcinoma comprised 45% of cases in the pediatric group as compared to 20% of cases in the adults (P < 0.001). Similar proportions in both groups underwent surgery. However, near-total gastrectomy was more common in the pediatric group (16% vs 6%, p < 0.001). The proportions of patients with negative margins, nodal examination, and presence of positive nodes were similar. There was no overall survival difference between the two age groups (HR 0.92, 95% Confidence interval 0.73–1.15). ConclusionWhile gastric adenocarcinoma in pediatric patients present with a more advanced stage and poorly differentiated tumors compared to adults, survival appears to be comparable. Type of studyRetrospective cohort study. Level of evidenceIII

Long-Term Nutritional Outcomes of Near-Total Gastrectomy in Gastric Cancer Treatment: a Comparison with Total Gastrectomy Using Propensity Score Matching Analysis.

PurposeThis study sought to examine whether near total gastrectomy (nTG) confers a long-term nutritional benefit when compared with total gastrectomy (TG) for the treatment of gastric cancer.Materials and MethodsPatients who underwent nTG or TG for gastric cancer were included (n=570). Using the 1:2 matched propensity score, 25 patients from the nTG group and 50 patients from the TG group were compared retrospectively for oncologic outcomes, including long-term survival and nutritional status.ResultsThe length of the proximal resection margin, number of retrieved lymph nodes and tumor nodes, metastasis stage, short-term postoperative outcomes, and long-term survival were not significantly different between the groups. The body mass index values, and serum total protein and hemoglobin levels of the patients decreased significantly until postoperative 6 months, and then recovered slightly over time (P<0.05); however, there was no difference in the levels between the groups. The prognostic nutritional index values and serum albumin levels decreased significantly until postoperative 6 months and then recovered (P<0.05); the levels decreased more in the nTG group than in the TG group (P<0.05). The mean corpuscular volumes and serum transferrin levels increased significantly until postoperative 1 year and then recovered slightly over time (P<0.05); however, there was no difference between the groups. Serum vitamin B12, iron, and ferritin levels of the patients did not change significantly over time, and no difference existed between the groups.ConclusionsA small remnant stomach after nTG conferred no significant nutritional benefits over TG.

Surgical treatment of medically refractory gastroparesis in the morbidly obese.

Surgical management of medically refractory gastroparesis remains a challenge. Case series and small retrospective studies describe clinical benefits from surgical intervention; however, no study reports the efficacy of gastric electrical stimulation (GES) or Roux-en-Y gastrojejunostomy with or without near-total gastrectomy (RYGJ) in morbidly obese patients with severe gastroparesis. A chart review was performed on all morbidly obese patients (BMI > 35 kg/m(2)) who underwent GES or RYGJ for medically refractory gastroparesis from March 2002 to December 2012 at the Cleveland Clinic. The main outcomes examined were symptom improvement, postoperative complications, and change in BMI. A total of 20 morbidly obese patients underwent GES placement. Seven morbidly obese patients had RYGJ with or without resection of the remnant stomach surgery. All operations were completed laparoscopically. In GES group, 18 patients had initial symptom improvement (90%) and 11 (55%) rated their symptom improved at the last follow-up. During the average 23 months' follow-up, 9 patients (45%) experienced at least one readmission for gastrointestinal reasons. Early complications included two infections at a simultaneously placed J-tube site and one seroma. In the RYGJ group, all patients, including 4 patients who failed GES and subsequently converted to RYGJ, experienced short-term symptom improvement and 5 patients (71%) rated their symptoms as improved at last follow-up. One duodenal stump leak happened in the RYGJ group. There were no 30-day mortalities in either group. The BMI change after GES implantation was 0.6 ± 4 kg/m(2) versus -7.7 ± 4 kg/m(2) after RYGJ (p < 0.01). GES implantation and RYGJ are both effective in terms of symptom control for medically refractory gastroparesis in morbidly obese. Both options can be performed in a minimally invasive fashion with low morbidity. Patients who have no improvement of symptoms for refractory gastroparesis after GES implantation can be successfully converted laparoscopically to RYGJ.

End of the Road for a Dysfunctional End Organ: Laparoscopic Gastrectomy for Refractory Gastroparesis

IntroductionGastroparesis is a functional disorder resulting in debilitating nausea, esophageal reflux, and abdominal pain and is frequently refractory to medical treatment. Therapies such as pyloroplasty and neurostimulators can improve symptoms. When medical and surgical treatments fail, palliative gastrectomy is an option. We examined outcomes after gastrectomy for postoperative, diabetic, and idiopathic gastroparesis. MethodsA prospective database was queried for gastrectomies performed for gastroparesis from 1999 to 2013. Primary outcomes were improvements in pre- versus postoperative symptoms at last follow-up, measured on a five-point scale. Secondary outcome was operative morbidity. ResultsThirty-five patients underwent laparoscopic total or near-total gastrectomies for postoperative (43 %), diabetic (34 %), or idiopathic (23 %) gastroparesis. Antiemetics and prokinetics afforded minimal relief for one third of patients. There were no mortalities. Six patients suffered a leak, all treated with surgical reintervention. With a median follow-up of 6 months, nausea improved or resolved in 69 %. Chronic abdominal pain improved or resolved in 70 %. Belching and bloating resolved for 79 and 89 %, respectively (p < 0.01). ConclusionsRegardless of etiology, medically refractory gastroparesis can be a devastating disease. Near-total gastrectomy can ameliorate or relieve nausea, belching, and bloating. Chronic abdominal pain commonly resolved or improved with resection. Despite attendant morbidity, gastrectomy can effectively palliate symptoms of gastroparesis.

Managing Obesity and Glucose Intolerance with Bariatric Surgery, An Experience in Birdem General Hospital

Background: Weight reduction is the cornerstone for managing obesity and Type 2 diabetes. Bariatric surgery, a concept used worldwide and recently introduced in Bangladesh is effective in achieving significant weight loss, improving and resolving comorbidities.Materials and methods: This was a retrospective study thirty cases in whom bariatric surgery was carried out in the Department of Surgery in BIRDEM General Hospital were purposively sample for analysis.Results: Thirty patients were operated of whom 3 were male and 27 female with the mean age of 40 years. Preoperative mean BMI was 47.1 kg/m2, 83% patients had diabetes, 60% had hypertension. Twenty eight patients underwent laparoscopic sleeve gastrectomy, 1 gastric bypass and 1 open near-total gastrectomy with Roux-en-Y gastrojejunostomy. Postoperative mean BMI achieved was 34.4 kg/m2. in the first year. Fifty two percent of the diabetic patients are now in good glycemic control with minimum drugs and 48% are in complete resolution.Conclusion: Obesity and type 2 diabetes mellitus can be managed successfully with bariatric surgery.Birdem Med J 2014; 4(2): 70-73

620 End of the Road for a Dysfunctional End-Organ: Gastrectomy for Refractory Gastroparesis

INTRODUCTION Gastroparesis is a functional disorder resulting in debilitating nausea, overflow esophageal reflux & abdominal pain and is frequently refractory to medical treatment. Surgical therapies such as pyloroplasty and neurostimulators aim to facilitate emptying. When treatments to facilitate gastric emptying fail, subtotal gastrectomy has been employed with varying success. Herein, we examined outcomes after gastrectomy for diabetic and idiopathic gastroparesis. METHODS A prospective database was queried for gastrectomies with Roux-en-Y reconstruction performed for gastroparesis from 1993-2013. Primary outcomes were improvements in preversus post-operative symptoms at last followup, measured on a 5-point scale. Secondary outcomewas operative morbidity. RESULTS Thirty-five patients underwent total or near-total gastrectomies for idiopathic (23%), post-operative(43%), or diabetic (34%) gastroparesis. Anti-emetics and pro-kinetics afforded no relief in 34.5% of patients. There were no operative mortalities. Six patients suffered a leak requiring anastomotic revision. With a median follow-up of 11.4 months, nausea improved or resolved in 70% after surgery. Chronic abdominal pain improved or resolved in 69% of patients. Belching and bloating resolved for 75% & 81%, respectively (p<0.01). CONCLUSIONS Regardless of etiology, medically-refractrory gastroparesis is a chronic and devastating disease. Surgery can ameliorate, and often relieve symptoms of nausea, excessive belching and gas bloat. Chronic abdominal pain commonly resolved or improved with resection. Despite attendant morbidity, gastrectomy can palliate symptoms of gastroparesis.

Near-Total Gastrectomy Preserving the Lower Esophageal Sphincter Followed by Jejunal Pouch Interposition as a Treatment for Upper Gastric Cancer

Purpose: Conventional total gastrectomy with Roux-en-Y esophagojejunostomy has certain limitations such as insufficient food reservoir and malabsorption of nutrients. Therefore, we performed reconstruction of the jejunal pouch interposition (JPI) after near-total gastrectomy preserving the lower esophageal sphincter (LES). We compared the technical feasibility, safety, and surgical outcome of this operation with conventional total gastrectomy accompanying with Roux-en-Y esophagojejunostomy. Methods: From April 2003 to October 2005, 15 LES-preserving, near-total gastrectomies with JPI (LES-JPI group) were performed. The clinical features and surgical outcomes were retrospectively compared with 17 cases of conventional R-Y esophagojejunostomy. Statistical analysis was performed using Fisher’s exact test for categorical data and an unpaired t-test for continuous data. Results: Clinicopathological features of the LES-JPI and R-Y groups did not show differences excepting patient age (50.8±5.8 years vs. 62.8±12.4, respectively; P=0.002) and the depth of tumor invasion (T1-T2; 11∼4 vs. 5∼12; P=0.032). The operative outcomes for the two groups significantly differed in terms of operation time (676 vs. 484 min; P=0.008) and blood loss (424 vs. 336 ㎖; P=0.006). Postoperative gastrofiberscopic examination of all LES-JPI patients showed no esophageal reflux or strictures and intact LES. In addition, the LES-JPI group did not experience swallowing difficulty or stricture. Conclusion: LES-preserving total gastrectomy with JPI is a feasible and safe procedure for patients with upper gastric cancer.

Late Results of Patients Undergoing Remedial Operations for Alkaline Reflux Gastritis Syndrome

Purpose: Many different remedial operations for alkaline reflux gastritis have been described. Analysis of their efficacy is difficult, because while many of the procedures have good early results, there are long-term failures due to their own complications. The aim of this study is to evaluate our experience with patients undergoing remedial operations for alkaline reflux gastritis syndrome.Material and methods: The clinical features and results of remedial operations of 65 patients with alkaline reflux gastritis syndrome were reviewed retrospectively. Data on the hospital course were collected by interviewing patients directly or by telephone contact. An assessment of each patient’s response to remedial operation was then made and a Visick score assigned.Results: All patients had been tried on a medical treatment and dietary restriction or both prior to remedial operation. Long-term follow up was possible in 46 patients.Seventy-six percent of patients who at the final state had a truncal vagotomy, distal gestrectomy and Roux-en-Y gastrojejunostomy have been found to show satisfactory results (Visick-I/Visick II).Three patients who had previously undergone a Roux-en-Y conversion later required re-operation for Roux-stasis syndrome and a near-total gastrectomy was performed on these patients. Other operations performed for alkaline reflux gastritis were converted to “uncut” Roux-en-Y in five patients and dismantling of gastrojejunostomy in two patients.Conclusions: For patients unresponsive to medical treatment, we reccommend the following strategy :a) for patients with truncal vagotomy plus gastrojejunostomy, dismantling of gastrojejunostomy should be the first choiceb) for patients with prior Billroth-II gastrectomy, Roux-en-Y conversion is the most effective corrective operation, although it has its proper including Roux statis syndrome.

Isolated diffuse hyperplastic gastric polyposis presenting with severe anemia

IntroductionGastric polyps exist in a wide variety of types, most of which are small and often benign. Discovery of gastric polyps during Endoscopy necessitates biopsies.Case presentationWe present a case report of an isolated diffuse hyperplastic gastric polyposis in a 26 years old Hispanic female when she was investigated for profound anemia. The Esophagogastroduodenoscopy revealed numerous gastric polyps filling the entire stomach. She was treated with near-total gastrectomy and her anemia resolvedConclusionIsolated diffuse hyperplasic gastric polyposis with normal gastrin level is a rare entity and can present with severe anemia.

Laparoscopic Solution for Early Gastric Cancer in a Morbidly Obese Patient

During preoperative work-up for laparoscopic gastric bypass in a morbidly obese female, gastroscopy visualized two small ulcers in the antrum. Biopsies diagnosed adenocarcinoma of the diffuse type. Staging was performed, and endoscopic ultrasonography showed early gastric cancer. A laparoscopic neartotal gastrectomy with D1 resection and perigastric lymph node dissection and full omentectomy in combination with a gastric bypass, was peformed. This approach respects the oncologic and bariatric principles and gives a combined solution for the patient.

Value of Preoperative Upper Endoscopy in Patients Undergoing Laparoscopic Gastric Bypass

Preoperative evaluation of patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP) has included esophagogastroduodenoscopy (EGD) with little data to substantiate its use. A retrospective analysis was conducted of patients from Feb 04 to Mar 05 who underwent preoperative EGD and subsequently LRYGBP. 169 patients underwent EGD prior to surgery. Their mean age was 41.1 years (range 14-66), mean BMI 49.7 (range 35-78), and 82% were females. There were no complications from EGD. Significant findings in patients at EGD included gastric ulceration in 3 (2%), duodenal ulcer in 1 (0.7%), Barrett's esophagus in 2 (1.3%), and a GI stromal tumor (GIST) in 1 (0.7%). EGD revealed hiatal hernias in 56 (35.2%), esophagitis in 28 (17%), Schatzki's ring in 5 (3%), gastritis in 43 (27%), gastric polyps in 8 (5%), and duodenitis in 9 (6%). 53 patients (33.3%) had a negative EGD. Ulcer and severe gastritis, esophagitis, and duodenitis diagnosed preoperatively were treated medically before surgery. 9 hiatal hernias were repaired intraoperatively. The patient with the GIST underwent laparoscopic near-total gastrectomy and gastric bypass, while 1 patient with an antral polyp underwent laparoscopic partial gastrectomy in addition to the LRYGBP. EGD is essential for diagnosis of GI diseases including tumors, ulcers, and hiatal hernias that alter the medical and surgical management of patients undergoing gastric bypass.