Multimedia article. Laparoscopic repair of a perforated marginal ulcer 2 years after gastric bypass

The authors present the case of a 43-year-old women who underwent a laparoscopic gastric bypass in 2003 for morbid obesity. They report that 2 years later, she had maintained significant weight loss, but had developed acute abdominal pain, followed by nausea and emesis. In the emergency room, she had diffuse tenderness, tachycardia, and leukocytosis. After initial resuscitation, a computed tomography was performed, which showed free air above the liver and thickened small bowel loops. She was brought emergently to the operating room for laparoscopy. At surgery, turbid fluid and inflamed small bowel loops were seen. A perforated marginal ulcer was discovered in the Roux limb, approximately 2 cm distal to the gastrojejunal anastomosis. The perforation was oversewn primarily and patched with omentum. The repair was tested by intraoperative endoscopy. A gastrostomy tube also was placed within the gastric remnant for enteral access. The patient did extremely well postoperatively, and had an uneventful postoperative course. She was discharged on postoperative day 4. The gastrostomy tube was removed at 1 month, and at this writing, she remains well since surgery. An upper endoscopy at 2 months was completely normal, and the Helicobacter pylori test results were negative. The gastric pouch had not significantly enlarged since initial surgery, as indicated by both endoscopy and barium study. Marginal ulcer is reported to be 0.6% to 16% after laparoscopic gastric bypass. Etiologies include gastrogastric fistula, excessively large gastric pouch containing antral mucosa, H. pylori infection, nonsteroidal antiinflammatory use, and smoking. Unfortunately, none of these applied to the reported patient. Because her exact etiology remains unknown, she at this writing continues to receive proton pump inhibitor therapy.     

Gastric bezoar after Roux-en-Y gastric bypass for morbid obesity: A case report

IntroductionWe aimed to present a patient with gastric pouch bezoar after having a bariatric surgery.Presentation of caseSixty-three years old morbid obese female had a laparoscopic Roux-en-Y gastric bypass surgery 14 months ago. She has lost 88% of her excess body mass index; but started to suffer from nausea, abdominal distention and vomiting lately, especially for the last two months. The initial evaluation by endoscopy, computed tomography (CT) and an upper gastrointestinal contrast series overlooked the pathology in the gastric pouch and did not display any abnormality. However, a second endoscopy revealed a 5 cm in diameter phytobezoar in the gastric pouch which was later endoscopically removed. After the bezoar removal, her complaints relieved completely.DiscussionThe gastric bezoars may be confused with the other pathologies because of the dyspeptic complaints of these patients. The patients that had a bariatric surgery; are more prone to bezoar formation due to their potential eating disorders and because of the gastro-enterostomy made to a small gastric pouch after the Roux-en-Y gastric bypass surgery.ConclusionPossibility of a bezoar formation should be kept in mind in Roux-en-Y gastric bypass patients who has nausea and vomiting complaints. Removal of the bezoar provides a dramatic improvement in the complaints of these patients.     

The Influence of Helicobacter pylori Infection on the Development of Gastric Ulcer in Symptomatic Patients after Bariatric Surgery

Background: There are few data relating to the role of H. pylori infection and surgical procedures on the occurrence of gastric ulcer following bariatric surgery. Methods: Subjects with upper gastrointestinal symptoms after bariatric surgery and receiving gastroscopic examinations were prospectively enrolled. All clinical data including age, sex, BMI before surgery, and surgical method were recorded. IgG antibodies against H. pylori were measured in preoperative serum by enzyme-linked immunosorbent assay (ELISA). Results: A cohort of 636 patients undergoing laparoscopic vertical banded gastroplasty (LVBG) or Roux-en-Y gastric bypass (LRYGBP) was recruited. The seropositivity of H. pylori in symptomatic and asymptomatic patients after surgery was 39% (32/82) and 39.7% (220/554) respectively. Endoscopic examinations revealed that 22 (26.8%) of 82 symptomatic patients had a gastric ulcer. Comparison of demographic characteristics between patients with ulcer (n=22) and patients without ulcer (n=60) showed no difference in distribution of gender, age, BMI, and seroprevalence of H. pylori (27.3%, 6/22 vs 43.3%, 26/60, P=0.212). Patients undergoing LRYGBP showed a higher rate of gastric ulcer (45.5%, 10/22) when compared to patients undergoing LVBG (20%, 12/60; P=0.027). Conclusion: Gastric ulcers in symptomatic patients following laparoscopic bariatric surgery are related to surgical procedures rather than exposure to H. pylori infection.     

An Unusual Complication of Gastric Bypass: Perforated Duodenal Ulcer

Peptic ulcer in the excluded segment of a gastric bypass has been reported in the literature in only 17 cases.We report a 54-year-old woman with a perforated duodenal ulcer, who had undergone laparoscopic Roux-en-Y gastric bypass surgery for morbid obesity 15 months previously. She was successfully treated by a laparoscopic repair of the perforated duodenal ulcer.     

Management of duodenal ulcer perforation with combined laparoscopic and endoscopic methods

In the past, primary closes for perforated duodenal ulcer were not effective because of the high incidence of recurrence (42%), therefore most surgeons preferred definitive procedures to control acid production [1, 2]. Since the association of Helicobacter pylori with peptic ulcers and the effectiveness of the medication for acid control, definitive surgery is less frequently used. Today, primary closes of the perforation are the immediate alternative. Furthermore laparoscopic repair allows to perform the same technique than open surgery but with the benefits of the minimum invasion [1, 2, 3, 4, 5, 6, 7].The video shows the management of a 51-year-old woman who came to the emergency room with acute abdomen, leukocytosis, and fever. Laparoscopy showed peritonitis with apparent gastric perforation. Duodenal perforation was confirmed by endoscopy. Primary closes of the perforation, cavity cleaning, and placement of drainages were performed by laparoscopy. Evolution was excellent; the patient left the hospital 3 days after surgery. The contribution of laparoscopic and endoscopic surgery were shown to be highly beneficial for the patient, since an endoscopic view of the stomach and the duodenum was the pertinent approach to assure the correct perforation closes as well as to obtain diagnostic biopsy.This multimedia article (video) has been published online and is available for viewing at http://www.springerlink.com. Its abstract is presented here. As a subscriber to Surgical Endoscopy you have access to our SpringerLink electronic service, including Online First.This revised version was published online in November 2004 with corrections to the multimedia link.     

Laparoscopic Splenectomy Combined with Revision of Previous Laparoscopic Gastric Bypass

Advanced laparoscopic operations can be performed in patients who have previously undergone laparoscopic gastric bypass, because there are fewer adhesions than after open procedures. Also, revisions of previous laparoscopic gastric bypasses can be done laparoscopically for the same reasons. To demonstrate this, we present a patient who had undergone a laparoscopic gastric bypass. The operation was successful initially. After 10 months, she started to regain some of her lost weight. It was also found that she had developed idiopathic thrombocytopenia purpura, which was unresponsive to steroids. She underwent a splenectomy and revision of her gastric bypass, both done laparoscopically. This case demonstrates that these advanced laparoscopic procedures can be performed safely, even after previous surgery.     

Preoperative upper endoscopy is useful before revisional bariatric surgery.

BACKGROUND AND OBJECTIVES: We hypothesized that patients who have previously had bariatric surgery and are undergoing revision to laparoscopic Roux-en-Y gastric bypass would have abnormal findings detected by upper endoscopy that could potentially influence patient management. The procedures that are being revised include vertical banded gastroplasty, laparoscopic adjustable gastric bands, nonadjustable gastric bands and previous Roux-en-Y gastric bypass (open and laparoscopic). METHODS: We conducted a retrospective chart review of patients who previously had undergone vertical banded gastroplasty or nonadjustable gastric banding. We preoperatively performed an upper endoscopy on all patients. The endoscopy reports were reviewed and the findings entered into a database. RESULTS: Eighty-five percent of 46 patients undergoing revisional bariatric surgery had an abnormal upper endoscopy. Eleven percent had a gastrogastric fistula. Gastritis and esophagitis were noted in 65% and 37%, respectively. Eleven percent of patients had band erosion, 2 from a nonadjustable band, and 5 from vertical banded gastroplasties. Based on our findings, 65% of our patients required medical treatment. CONCLUSIONS: Preoperative upper endoscopy provides valuable information before revisional laparoscopic bariatric surgery. In addition to identifying patients who need preoperative medications, the preoperative upper endoscopy also provided valuable information regarding pouch size and anatomy. Preoperative upper endoscopy should be performed by the operating surgeon on every patient undergoing revisional bariatric surgery.     

Gastric MALT Lymphoma and Grade II Obesity: Gastric Bypass Surgery as a Therapeutic Option

Mucosa-associated lymphoid tissue (MALT) is the most common extranodal lymphoma, with one third of the cases occurring in the stomach. Surgical treatment is a possible option. This case report describes an obese woman (body mass index 46 kg/m²) seeking bariatric surgery, with elevated serum cholesterol and uric acid, negative for Helicobacter pylori but with a positive biopsy for MALT (immunohistochemistry), stage IA. She was submitted to a Roux-en-Y gastric bypass and gastric resection. Two months later, she had lost 20 kg and the MALT lymphoma was in complete remission.     

Laparoscopic retrieval of intraabdominal foreign bodies

The use of laparoscopy has been described as the means of removing intraabdominal foreign bodies, both intraperitoneal and intraluminal, from the stomach or bowel. An early report detailed the laparoscopic removal of translocated intrauterine devices from the peritoneal cavity [2]. Laparoscopic removal of a retained surgical sponge also has been reported [1]. For large ingested objects that cannot be retrieved by flexible endoscopy, laparoscopic gastrotomy and foreign body removal have been described [3] . The authors recently had three cases of laparoscopic foreign body retrieval. The first case involved a young man who had ingested latex gloves, causing gastrointestinal bleeding. Endoscopic retrieval was unsuccessful. A laparoscopic gastrotomy was performed, with the retrieval of four gloves, followed by intracorporeal, sutured closure of the gastrotomy. The second case involved the laparoscopic removal of a Penrose drain around the distal esophagus. The patient had initially undergone a laparoscopic Nissen fundoplication, vagotomy, and gastrojejunostomy for the management of reflux and a duodenal stricture. He had persistent dysphagia after surgery, prompting takedown of the fundoplication several months later. When his dysphagia did not improve, a retained Penrose drain that had been placed around the distal esophagus at the initial operation was discovered on computed tomography. This was removed laparoscopically. At this writing, 18 months after the initial operation, the patient has complete resolution of dysphagia. The third case involved a duodenojejunal fistula caused by multiple ingested magnets that had eroded through the bowel wall. The fistula was divided laparoscopically, and 16 disk-shaped magnets were removed. The duodenum and jejunum were repaired with laparoscopic suturing and stapling. All three patients did well after surgery. Laparoscopy can be an excellent method for abdominal foreign body retrieval. Electronic supplementary material The online version of this article (doi: ) contains supplementary material, which is available to authorized users.     

Endoscopic and Histologic Findings in the Gastric Pouch and the Roux Limb after Gastric Bypass

Background: Despite the large number of gastric bypasses performed for morbid obesity, very little is known about the endoscopic and histologic aspects of the gastric pouch and the Roux-limb late after surgery. We performed prospective routine endoscopic and histologic studies of the pouch and Roux-limb 2 years after gastric bypass. Methods: The present study includes 227 patients submitted to resectional gastric bypass and followed for a mean of 27 months after surgery. Mean BMI before bypass was 44 kg/m². In all patients, upper endoscopy of the pouch and of the jejunal limb was performed, taking 3 biopsy samples of the gastric pouch in 171 patients and 2 samples of the jejunum in 40 patients. Results: Macroscopic appearance of the gastric pouch was normal in 99% of the patients and of the jejunal limb in 100%. Histologic analysis revealed normal fundic mucosa in 56%. Chronic active gastritis was the most frequent abnormal histologic finding. 7 patients (4.1%) showed intestinal metaplasia. H. pylori infection was present in the gastric pouch in 31% of the patients. Conclusions: The proximal gastric pouch after gastric bypass is endoscopically normal in 99% of patients 2 years after surgery, while the Roux-limb is normal in 100%. Histologic analysis of gastric mucosa revealed normal fundic mucosa in 56%. There are some chronic histologic changes, even intestinal metaplasia, whose behavior at late follow-up is not yet known. H. pylori is present in nearly 1/3 of the patients.     

Alternative operative techniques in laparoscopic Roux-en-Y gastric bypass for morbid obesity.

The only effective treatment for patients with morbid obesity is surgery. Laparoscopic bariatric surgery has become quite popular in attempts to decrease the morbidity associated with laparotomy. In this article, we describe the technical details of laparoscopic Roux-en-Y gastric bypass with three different techniques for creating the 15-cc gastric pouch. These techniques avoid upper endoscopy for the transoral introduction of the 21-mm circular stapler anvil down to the gastric pouch.     

MINIMAL ACCESS GASTRODUODENAL SURGERY

Considerable advances are occurring in the application of laparoscopic techniques to gastrointestinal and hepatobiliary disorders. Following studies in experimental animals, surgeons with an interest in gastroduodenal disease have now introduced laparoscopic techniques into current surgical practice. Elective intervention for peptic ulcer disease is currently being established, particularly in patients with proven negative Helicobacter pylori (HP) status, or when eradication has proved unsuccessful with various drug regimens. In addition, emergency laparoscopic intervention for perforation is gaining acceptance, with or without a definitive anti-ulcer procedure. Therapeutic endoscopy for bleeding peptic ulcer may well be followed by anti-ulcer laparoscopic surgery in selected patients. Laparoscopic techniques have been utilized for the treatment of Mallory Weiss tear, congenital hypertrophic pyloric stenosis, Dieulafoy's lesion, gastric trauma or volvulus and benign gastric tumours. More ergonomic instruments are required before laparoscopic gastric resection becomes more widely acceptable. It is essential that objective evaluation of variations on vagotomy themes be undertaken in prospective clinical trials and that the safety and efficacy of gastric resection procedures be substantiated if this renaissance is to revolutionize gastroduodenal surgical practice.     

Thoracoscopic-assisted esophagectomy and laparoscopic gastric pull-up for lye injury.

BACKGROUND: Acquired esophageal strictures in children are often the result of ingestion of caustic agents. We describe 2 children with severe esophageal strictures following lye ingestion, who successfully underwent esophagectomy and gastric pull-up utilizing combined thoracoscopic and laparoscopic techniques. METHODS: This was a retrospective chart analysis of both patients. CASE 1: A 17-year-old female, who ingested a lye-containing substance, which lead to the need for gastrostomy and esophageal dilatations, developed an esophageal stricture. Thoracoscopic esophagectomy, laparoscopic gastric conduit creation, pyloroplasty, gastric pull-up, and esophagogastric anastomosis was performed one year later. She was tolerating a regular diet for almost 4 years following esophageal replacement when she developed a gastric ulcer with gastrobronchial fistula that required open repair via a right thoracotomy. She has since recovered and resumed her regular diet. CASE 2: A 13-month-old female who ingested a lye-based cleaner underwent tracheostomy and gastrostomy on the day of injury, and esophageal dilatations beginning 1 month later. Despite dilatations, she developed severe strictures for which at age 21 months she underwent thoracoscopic esophageal mobilization, laparoscopic creation of gastric conduit, pyloroplasty, and esophagogastric anastomosis. A right thoracotomy was necessary to negotiate the conduit safely up to the neck. She is tolerating feeds and has not developed any complications for nearly 3 years following esophageal replacement. CONCLUSIONS: Esophagectomy and gastric pull-up for esophageal lye injuries can be accomplished utilizing a combination of thoracoscopy and laparoscopy with excellent results. Long-term follow-up is necessary to manage potential complications in these patients.     

Spectrum of Endoscopic Findings and Therapy in Patients with Upper Gastrointestinal Symptoms after Laparoscopic Bariatric Surgery

Background: More should be known about the spectrum of endoscopic abnormalities and treatments in patients with upper gastrointestinal (UGI) symptoms after laparoscopic bariatric surgery. Methods: Patients referred for endoscopic evaluation of UGI symptoms after laparoscopic bariatric surgery were studied. Clinical manifestations, endoscopic findings and therapy were recorded and correlated. Results: 76 patients who had undergone laparoscopic vertical banded gastroplasty (LVBG) and 28 who had undergone laparoscopic Roux-en-Y gastric bypass (LRYGBP) underwent 160 instances of upper endoscopy. The symptoms included nausea or vomiting (n=47, 29.4%), epigastric discomfort (n=44, 27.5%), UGI bleeding (n=26, 16.3%), heartburn or acid regurgitation (n=26, 16.3%), dysphagia (n=10, 6.3%) and anemia with dizziness (n=7, 4.4%). The endoscopic diagnosis consisted of normal findings (n=57, 35.6%), marginal ulcer (n=39, 24.4%), erosive esophagitis or esophageal ulcer (n=21, 13.1%), food impaction (n=21, 13.1%), stenosis or stricture (n=14, 8.8%), gastric ulcer (n=7, 4.4%), and duodenal ulcer (n=1, 0.6%). Patients with UGI bleeding, dysphagia and LRYGBP tended to have endoscopic abnormalities (P<0.001, P=0.09 and P=0.021, respectively). Endoscopic therapy was successful in resolving the complications including stenosis, UGI bleeding and food impaction. Conclusions: Endoscopy is an essential method of combining relevant endoscopic findings and therapeutic intervention in symptomatic patients following laparoscopic bariatric surgery.     

Combined laparoscopic/endoscopic anvil placement for the performance of the gastroenterostomy

Background:We developed the laparoscopic gastric bypass in 1993 and first reported the technique and results in 1994. The technique for the gastroenterostomy was derived from the method used in the percutaneous endoscopic gastrostomy tube placement. Some have questioned the safety of this technique, and alternatives have been proposed. Method: Prospectively, we have followed and recorded the results of our laparoscopic patients. To date we have performed over 1,400 laparoscopic gastric bypass operations using the same technique of anvil placement: pulling the anvil down from the mouth to the stomach pouch with a percutaneously placed wire. All patients underwent upper GI endoscopy following the anvil placement, and a water-soluble upper GI series was obtained on the first postoperative day. Results: There have been no esophageal injuries in the first 1400 patients on whom this technique was done. Conclusion:The percutaneous pull-wire technique is a safe and effective method to place the 21-mm circular stapler anvil for the performance of a laparoscopic gastroenterostomy     

An Unusual Suspect: Coconut Bezoar After Laparoscopic Roux-en-Y Gastric Bypass

Nausea and vomiting after gastric bypass are common, but some of the underlying causes may be life threatening or, in some cases, unusual. This case report describes a patient who underwent laparoscopic Roux-en-Y gastric bypass and whose postoperative course was complicated by a bezoar in the gastric pouch. To our knowledge, this is the first published report addressing a coconut bezoar in the gastric pouch after gastric bypass surgery. Coconut (cocos nucifera) is known to form emulsions and suspensions, properties likely to have contributed to this patient’s condition. Nutritional counseling should be an ongoing process in the postoperative care of gastric bypass patients in an effort to prevent serious complications that may arise from dietary indiscretions.     

The influence of staple height on postoperative complication rates after laparoscopic gastric bypass surgery using linear staplers

BackgroundThe use of circular staplers with a low staple height is associated with a lower risk for complication when used to construct the gastroenterostomy in laparoscopic gastric bypass surgery. The influence of staple height on outcome when using linear staplers has not been studied.ObjectivesTo investigate the influence of staple height when constructing the gastric pouch and gastroenterostomy using a linear stapler in laparoscopic gastric bypass surgery.SettingNationwide, Sweden.MethodsA retrospective, register-based cohort study, including all primary laparoscopic gastric bypass surgical procedures in Sweden registered in the Scandinavian Obesity Surgery Registry from January 2010 until January 2017, where linear staplers were used to construct the gastric pouch and the gastroenterostomy. Low stapler heights (closed height ≤1.0 mm) were compared with higher stapler heights (closed height ≥1.5 mm). The main outcome was postoperative complication within 30 days of surgery.ResultsWithin the study period, 27,975 patients were identified from the Scandinavian Obesity Surgery Registry. A closed staple height ≥1.5 mm was associated with higher risk for postoperative complication within 30 days of surgery compared with lower staple height. The risk was greater when used to construct the gastric pouch (adjusted odd ratio 1.30, 95% confidence interval 1.17–1.44, P < .001) as well as when constructing the gastroenterostomy (adjusted odd ratio 1.32, 95% confidence interval 1.20–1.45, P < .001).ConclusionThe use of low staple height for construction of the gastric pouch and gastroenterostomy in laparoscopic gastric bypass surgery was associated with lower complication rates.     

Ulcer disease after gastric bypass surgery

BACKGROUND: The mechanism of marginal ulceration after laparoscopic gastric bypass surgery is poorly understood. We reviewed the incidence, presentation, and outcome of ulcer disease in consecutive patients undergoing laparoscopic gastric bypass surgery. METHODS: The outcomes of 201 consecutive laparoscopic gastric bypass surgery procedures were prospectively analyzed for complications. All procedures were performed using a linear stapled anastomosis and absorbable suture. RESULTS: The incidence of marginal ulcer disease was 3.5% (7 patients). One patient, the only smoker, presented with an acute perforation 4 months postoperatively. Three other patients presented with bleeding-all required transfusion. The remaining 3 patients presented with severe pain. At endoscopy, all patients had ulcerations associated with the Roux limb mucosa and were all successfully treated using proton pump inhibitors and sucralfate therapy. Symptoms of marginal ulceration occurred an average of 7.4 months (range 3-14) after surgery. The average follow-up was 19.8 months. No preoperative factors were predictors of ulcer disease, including body mass index, age, gender, or co-morbidities. CONCLUSION: Marginal ulcers using the linear-stapled technique occurred in 3.5% of patients. Three distinct clinical presentations occurred: bleeding, pain, or perforation. No preoperative risk factors were identified that predicted for this complication. Medical management is an effective treatment.     

Helicobacter pylori Infection in Patients Undergoing Gastric Bypass Surgery for Morbid Obesity

Background: Studies suggest that the incidence of Helicobacter pylori infection in obese patients, including those undergoing gastric reduction surgery, may be increased. Methods: We examined the histologic findings at the time of surgery in a series of patients who were undergoing Roux-en-Y gastric bypass (RYGBP) for morbid obesity and compared these results with patients in our institution undergoing endoscopy. Results: Of 60 patients undergoing RYGBP,material for histologic examination was available in 56 cases, and in 40 cases gastric fundic mucosa from the anastomotic site was sampled at the time of surgery. Active chronic gastritis was present in 6 (15%), and chronic gastritis was present in 27 (68%). H. pylori was present in all 6 cases of active chronic gastritis and in 9 cases of chronic gastritis (total 38%).This incidence of H. pylori infection was higher than that found in the series of gastric biopsies (107/500, 21%, p = 0.03) and fundic biopsies (10/80, 13%, p = 0.003), but was not different when compared with age-matched gastric biopsies (44/177, 25%, p = 0.12). Conclusions: The incidence of H. pylori in patients undergoing RYGBP was higher than that found in all patients undergoing endoscopy and biopsy and than those undergoing fundic biopsies, but not higher when age-matched controls were considered.