Predictors, Treatment, and Outcomes of Gastrojejunostomy Stricture after Gastric Bypass for Morbid Obesity

Background The aims of this study were to determine the rate of gastrojejunostomy (GJ) stricture following Roux-en-Y gastric bypass (RYGBP), the independent predictors of stricture, and clinical outcomes with and without a stricture. Methods Univariate and multivariate analysis of peri-operative and outcomes data were prospectively collected from 379 morbidly obese patients who underwent consecutive open or laparoscopic RYGBP from January 2003 to August 2006. Predictors studied were age, gender, BMI, co-morbidities, surgical technique (hand-sewn vs linear stapler vs 21-mm vs 25-mm circular stapler; open vs laparoscopic; retrocolic retrogastric vs antecolic antegastric Roux limb course, and Roux limb length), and surgeon experience. Outcomes studied consisted of occurrence of GJ strictures, technical details and outcomes after endoscopic therapy, and excess weight loss (EWL) at 12 months. Results 15 patients (4.1%) developed a GJ stricture. The use of a 21-mm circular stapler was identified as the only independent predictor of a GJ stricture (odds ratio 11.3; 95% CI 2.2-57.4, P = 0.004). Endoscopic dilation relieved stricture symptoms in all patients (60% one dilation only). There was no significant difference in %EWL at 12 months between the patients with a stricture (median EWL 54%, IQR 49 – 63) vs those without a stricture (median EWL 61%, IQR 49-73, P = 0.33). Conclusion The rate of GJ strictures is 4.1%. The use of a 21-mm circular stapler is the only independent predictor of GJ stricture. Endoscopic dilation relieved symptoms in all patients.Weight loss is independent of the anastomotic technique used and occurrence of a GJ stricture.     

Gastrojejunal anastomotic stricture after Roux-en-Y gastric bypass: ambulatory management with the Savary–Gilliard dilator

Background Roux-en-Y gastric bypass (RYGBP) is currently one of the most frequently performed procedures for the surgical treatment of morbid obesity. The success of this procedure’s restrictive component requires a small gastrojejunostomy (GJ), which occasionally results in stenosis. The treatment of choice for this complication is balloon dilation. This study aimed to evaluate the feasibility and safety of ambulatory management for stenosis of the GJ using endoscopically guided Savary–Gilliard dilators. Methods Between January 1998 and October 2003, 769 patients underwent RYGBP. The mean age of these patients was 38 ± 12 years, and their mean body mass index (BMI) was 43 ± 6 kg/m². Of these 769 patients, 520 (68%) underwent open surgery and 249 (32%) underwent laparoscopic RYGBP. Patients suspected of GJ stenosis were referred for upper gastrointestinal endoscopy. Those who presented with stenosis were managed endoscopically with Savary–Gilliard dilators. Results Stenosis at the GJ was confirmed in 53 patients (6.9%). A total of 71 dilations were performed for these patients, resulting in a mean of 1.3 dilations per patient. One dilation was needed for 41 patients (75.5%), two dilations for 9 patients (16.9%), three dilations for 3 patients (5.7%), and four dilations 1 patient (1.9%). The patients subjected to open RYGBP required a mean of 1.57 dilations, and those who had laparoscopic RYGBP required mean of 1.08 dilations. The mean time for the first dilation was 51 ± 28 days after surgery (range, 20–178 days). All the dilations were performed in ambulatory settings. One patient (1.9%) was admitted after GJ dilation for pain. He was discharged without symptoms after 2 days with no need for invasive procedures. Conclusions The management and treatment of GJ stenosis after RYGBP can be effectively accomplished in ambulatory settings using endoscopically guided Savary–Gilliard dilators, with good and safe results. Presented at the 9th World Congress of Endoscopic Surgery, Cancún, México, February 2004     

Routine Preoperative Ultrasonography and Selective Cholecystectomy in Laparoscopic Roux-en-Y Gastric Bypass. Why Not?

Background Preoperative evaluation and treatment of biliary lithiasis in morbid obese patients who are candidates to bariatric surgery raise a series of questions which to date has no clear consensus. The aim of this study was to evaluate the results of routine preoperative abdominal ultrasonography and selective cholecystectomy comparing patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGBP) with and without simultaneous cholecystectomy. Methods The prospective database of all the patients who underwent laparoscopic RYGBP in our institution was reviewed. The demographic characteristics, comorbidities, operative time, hospital stay, and postoperative complications were analyzed. Results From August 2001 to December 2006, 1,311 patients underwent laparoscopic RYGBP, 137 (10.4%) of them were excluded due to previous cholecystectomy. In 128 (10.9%) of the remaining 1,174 patients, a cholecystectomy associated to laparoscopic RYGBP was performed. The mean age was 38.5 ± 10.1 years, and 106 (82.8%) were women. The mean operative time in patients with and without simultaneous cholecystectomy was 129.8 ± 45 and 108.5 ± 43 min, respectively (p < 0.001). The hospital stay was 3.6 ± 0.8 days in patients with simultaneous cholecystectomy and 4 ± 3 days in patients without simultaneous cholecystectomy (p = 0.003). There were no deaths. Postoperative complications were observed in 9 (7%) and 73 (6.9%) patients with and without simultaneous cholecystectomy respectively (p = NS). Postoperative complications were not related to the cholecystectomy. Conclusion Cholecystectomy associated to laparoscopic RYGBP should be considered in all patients with preoperative ultrasound diagnosis of cholelithiasis.     

Incidence and outcome of anastomotic stricture after laparoscopic gastric bypass

Anastomotic stricture is a frequent complication after Roux-en-Y gastric bypass (GBP). We evaluated the frequency of anastomotic stricture following laparoscopic GBP using a 21 mm. vs. a 25 mm circular stapler for construction of the gastrojejunostomy and the safety and efficacy of endoscopic balloon dilation in the management of anastomotic stricture. We reviewed data on 29 patients in whom anastomotic strictures developed after laparoscopic GBP. All strictures were managed with endoscopic balloon dilation using an 18 mm balloon catheter under fluoroscopic guidance. Main outcome measures were the number of anastomotic strictures in patients in whom the 21 mm (vs. 25 mm) circular stapler was used to create the gastrojejunostomy, time interval between the primary operation and symptoms, complications of endoscopic balloon dilation, the number of patients with resolution of obstructive symptoms, and body weight loss. There were 28 females with a mean age of 39 years and a mean body mass index of 48 kg/ m2. Anastomotic stricture occurred significantly more frequently with the use of the 21 mm compared to the 25 mm circular stapler (26.8% vs. 8.8%, respectively; P<0.01). The median time interval between the primary operation and presentation of stricture was 46 days. After the initial dilation, recurrent stricture developed in 5 (17.2%) of 29 patients. These five patients underwent a second endoscopic dilation, and only one of these five patients required a third endoscopic dilation. None of the 29 patients required more than three endoscopic dilations. The mean percentage of excess body weight loss at 1 year for patients in whom the 21 mm circular stapler was used for creation of the gastrojejunostomy was similar to that for patients in whom the 25 mm circular stapler was used (68.2% vs. 70.2%, P = 0.8). In this series the rate of anastomotic stricture significantly decreased with the use of the 2 5 mm circular stapler for construction of the gastrojejunostomy without compromising weight loss. Endoscopic balloon dilation is a safe and effective option in the management of anastomotic stricture following laparoscopic GBP. Presented at the Forty-Fourth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Florida, May 18–21, 2003.     

Inadequate Weight Loss vs Secondary Weight Regain: Laparoscopic Conversion from Gastric Banding to Roux-en-Y Gastric Bypass

Background  Beside complications like band migration, pouch-enlargement, esophageal dilation, or port-site infections, laparoscopic adjustable gastric banding (LAGB) has shown poor long-term outcome in a growing number of patients, due to primary inadequate weight loss or secondary weight regain. The aim of this study was to assess the safety and efficacy of laparoscopic conversion to Roux-en-Y gastric bypass (RYGBP) in these two indications. Methods  A total of 25 patients, who underwent laparoscopic conversion to RYGBP due to inadequate weight loss (n = 10) or uncontrollable weight regain (n = 15) following LAGB, were included to this prospective study analyzing weight loss and postoperative complications. Results  All procedures were completed laparoscopically within a mean duration of 219 ± 52 (135–375) min. Mean body weight was reduced from 131 ± 22 kg (range 95–194) at time of the RYGBP to 113 ± 25, 107 ± 22, and 100 ± 21 kg at 3, 6, and 12 months, respectively, which results in excess weight losses (EWL) of 28.3 ± 9.9%, 40.5 ± 12.3%, and 50.8 ± 15.2%. No statistically significant differences were found comparing weight loss within these two groups. Conclusion  RYGBP was able to achieve EWLs of 37.6 ± 16.1%, 48.5 ± 15.1%, and 56.9 ± 15.0% at 3, 6, and 12 months following conversion, respectively, based on the body weight at LAGB.     

Improved Surgical Technique for Laparoscopic Roux-en-Y Gastric Bypass Reduces Complications at the Gastrojejunostomy

Roux-en-Y gastric bypass (RYGBP) is one of the most commonly performed bariatric procedures for morbidly obese patients. It is associated with effective long-term weight loss, but can lead to significant complications, especially at the gastrojejunostomy (GJS). All the patients undergoing laparoscopic RYGBP at one of our two institutions were included in this study. The prospectively collected data were reviewed retrospectively for the purpose of this study, in which we compared two different techniques for the construction of the GJS and their effects on the incidence of complications. In group A, anastomosis was performed on the posterior aspect of the gastric pouch. In group B, it was performed across the staple line used to form the gastric pouch. A 21-mm circular stapler was used in all patients. A total of 1,128 patients were included between June 1999 and September 2009—639 in group A and 488 in group B. Sixty patients developed a total of 65 complications at the GJS, with 14 (1.2%) leaks, 42 (3.7%) strictures, and 9 (0.8%) marginal ulcers. Leaks (0.2% versus 2%, p = 0.005) and strictures (0.8% versus 5.9%, p < 0.0001) were significantly fewer in group B than in group A. Improved surgical technique, as we propose, with the GJS across the staple line used to form the gastric pouch, significantly reduces the rate of anastomotic complications at the GJS. A circular 21-mm stapler can be used with a low complication rate, and especially a low stricture rate. Additional methods to limit complications at the GJS are probably not routinely warranted.     

Gastrojejunal strictures following laparoscopic Roux-en-Y gastric bypass for morbid obesity

Background Gastrojejunal strictures following laparoscopic Roux-en-Y gastric bypass (LRYGBP) present with dysphagia, nausea, and vomiting. Diagnosis is made by endoscopy and/or radiographic studies. Therapeutic options include endoscopic dilation and surgical revision.Methods Of 369 LRYGBP performed, 19 patients developed anastomotic stricture (5.1%). One additional patient was referred from another facility. Pneumatic balloons were used for initial dilation in all patients. Savary-Gilliard bougies were used for some of the subsequent dilations.Results Flexible endoscopy was diagnostic in all 20 patients allowing dilation in 18 (90%). Two patients did not undergo endoscopic dilation because of anastomotic obstruction and ulcer. The median time to stricture development was 32 days (range: 17–85). Most patients (78%) required more than two dilations. The complication rate was 1.6% (one case of microperforation). At a mean follow-up of 21 months, all patients were symptom-free.Conclusions Gastrojejunostomy stricture following LRYGBP is associated with substantial morbidity and patient dissatisfaction. Based on our experience, we propose a clinical grading system and present our strategy for managing gastrojejunal strictures.Presented as a poster of distinction at the 12th Congress of the European Association of Endoscopic Surgery, Barcelona, Spain, June 2004     

Outcome of endoscopic balloon dilation of strictures after laparoscopic gastric bypass

Objective  Stricture formation at the gastrojejunal anastomosis is a relatively common complication after laparoscopic Roux-en-Y gastric bypass (LRYGB). The objective of this study was to report the incidence of stomal strictures after LRYGB in our institution and report our experience with their management by endoscopic balloon dilatation. Methods  This is a retrospective study of 1012 patients who underwent LRYGB from January 2001 to May 2004. Patients with nausea and vomiting after the surgery, suspected of having gastrojejunal (GJ) anastomotic stricture, had upper endoscopy. Stomas less than 10 mm in diameter, or those not allowing passage of the scope were considered significant strictures and were treated with balloon dilations. Dilations were performed with a through-the-scope (TTS) balloon, with sizes ranging from 6 to 18 mm. The following data were collected from these patients: age, sex, body mass index (BMI), comorbidities, size of balloon catheter, time from surgery until symptoms onset, number of endoscopies needed to relief symptoms, and complications of the procedure. Results  Sixty-one patients (46 females and 15 males) were found to have anastomotic strictures, corresponding to an incidence of 6%. In total, 134 upper endoscopies were performed, with 128 dilatations. The average age was 41.7 years (range: 19–68 years); mean preoperative BMI was 45 kg/m² (range: 42–61 kg/m²). Mean time from surgery to symptoms onset was 2 months (range: 1–6 months). The number of dilations per patient was as follows: a single dilation in 28% of patients, two dilations in 33%, three dilations in 26%, four dilations in 11.5%, and five dilations in 1.5% of patients. All the patients responded to dilation without need for formal surgical revision. However, after balloon dilatation three patients (4.9%), all females, had bowel perforation by radiological criteria (free air on X-ray), which corresponded to 2.2% of all dilatations. The maximum balloon size used in this group was 13.5 mm. All three patients had exploratory laparoscopy without finding of perforation site. They were treated with bowel rest, intravenous antibiotics for 7 days, and drain placement. No factors were identified to predict a risk of perforation. Conclusion  This is the largest study to evaluate the outcome of endoscopic dilatations of GJ strictures after RYGB. Endoscopic balloon dilation is a safe and effective treatment for anastomotic strictures. However, it carries a small risk of perforation. Further case studies are needed to determine risk factors for perforation and if the patients can be managed conservatively in this setting.     

Successful management of gastrojejunal strictures after gastric bypass: is timing important?

BackgroundEndoscopic balloon dilation is an effective treatment of gastrojejunal (GJ) strictures after Roux-en-Y gastric bypass (RYGB), although its success might depend on the point at which they occur postoperatively. We hypothesized that “late” strictures (≥90 d after RYGB) might be less amenable to balloon dilations than “early” strictures occurring within 90 days postoperatively.MethodsA review of a prospectively maintained database at a bariatric center was conducted to identify all patients who underwent upper endoscopy (UE) for investigation of gastrointestinal symptoms after RYGB. Those who were diagnosed with a GJ anastomotic stricture at endoscopy were selected for additional evaluation. The patients were classified into 1 of 3 groups, according to the point at which they presented with stricture symptoms (group 1, 0–90 d after RYGB; group 2, 91–365 d after RYGB; and group 3, >1 yr after RYGB). All strictures were dilated using through-the-scope controlled radial expansion balloons.ResultsFrom July 2006 to July 2009, 929 RYGB procedures were performed in our bariatric unit. Our surgical endoscopy team performs approximately 1500 UE investigations annually. Most investigations were for preoperative assessment of bariatric patients; however, a proportion is indicated for the investigation of postoperative weight regain and complications of foregut surgery, as well as endoluminal surgery. In the present study period, 591 gastric bypass patients underwent UE for investigation of gastrointestinal symptoms postoperatively. In total, 72 patients were diagnosed with a symptomatic GJ anastomotic stricture and underwent balloon dilation. Almost two thirds (63.9%) of the dilations were performed within 90 days after RYGB; 98% of these “early” strictures resolved with dilation. In comparison, of the “late” strictures, only 61% (16 of 26 patients) resolved and 38.5% (n = 10) required revisional surgery for additional management.ConclusionEndoscopic balloon dilation is effective in treating early GJ strictures after RYGB. Late strictures are less amenable to endoscopic dilation and often require revisional surgery. Patients presenting with upper gastrointestinal symptoms after RYGB warrant early investigation with UE to investigate for a GJ stricture, which if present, should be promptly dilated.     

Surgeon-Performed Endoscopic Dilatation of Symptomatic Gastrojejunal Anastomotic Strictures following Laparoscopic Roux-en-Y Gastric Bypass

Background: With increasing performance of Roux-en-Y gastric bypass (RYGBP), the postoperative complications are becoming more apparent. Gastrojejunal anastomotic strictures develop in 4.7 to 27% of patients undergoing laparoscopic RYGBP. This paper details two endoscopic techniques for dilating gastrojejunal anastomotic strictures. Methods: 3 patients developed gastrojejunal anastomotic strictures. In each patient, the operating surgeon performed a diagnostic upper endoscopy, followed by stricture dilatation using either Savary or balloon method. Results: Patients lost a mean weight of 42 kg (range 33-50 kg) before definitive stricture treatment. Once adequately dilated, all patients received an excellent symptomatic result. Conclusions: For the treatment of gastrojejunal anastomotic strictures, both Savary and balloon dilatation have been efficacious and easy to perform. The endpoint for stricture dilatation is 12 mm or slightly larger. The operating surgeon should acquire a working knowledge of these techniques.     

Gastroesophageal Reflux Disease in Morbid Obesity: The Effect of Roux-en-Y Gastric Bypass

Background  Gastroesophageal reflux disease (GERD) is a common condition in obesity. The impact of Roux-en-Y gastric bypass (RYGBP) on GERD is poorly known. We studied the effect of the RYGBP on GERD in patients with morbid obesity (MO). Methods  Twenty consecutive patients with MO (BMI > 40 kg/m²) were studied before and 6 months after RYGBP. GERD symptoms were evaluated with Carlsson–Dent questionnaire (CDQ). All the patients underwent esophageal manometry and ambulatory 24-h pH-metry. Chi-square test was used to compare categorical variables, and Wilcoxon test was used for numerical variables. A p value under 0.05 was considered significant. Results  There were 16 women (80%) and 4 men (20%) with mean age 38.9 ± 6.9 years included in this study. BMI was 48.5 ± 6.2 kg/m² and 33.2 ± 4.5 kg/m² before and after RYGBP, respectively. Mean weight reduction was 42.5 ± 9.7 kg (p < 0.001). Reflux symptoms measured by CDQ and esophageal acid exposure improved significantly after RYGBP. The percentage of time of pH < 4 was 10.7 ± 6.7 before and 1.6 ± 1.2 after the surgical procedure (p < 0.001). LES basal pressure before and after the RYGBP was 18 ± 11 and 20.1 ± 5.6 mmHg (p = 0.372), and the esophageal body amplitude was 104.2 ± 47.2 and 75.1 ± 36.2 mmHg, respectively (p = 0.005). Conclusion  RYGBP improves GERD symptoms and reduces esophageal acid exposure in patients with MO.     

Laparoscopic Placement of Non-Adjustable Silicone Ring for Weight Regain After Roux-en-Y Gastric Bypass

Background  Roux-en-Y gastric bypass (RYGBP) is presently one of the most popular surgical procedures for obesity. One of the possible long-term problems is weight regain, usually after a period of successful weight loss. Weight regain after RYGBP can be due to new eating habits, like sweet-eating or grazing, or volume eating because of impaired restriction. This paper reports our experience in patients who presented weight regain after laparoscopic RYGBP, because of new appearance of volume eating or hyperphagia, treated by the laparoscopic placement of a non-adjustable silicone ring around the gastric pouch. Methods  From July 2004 to November 2007, six patients affected by weight regain due to hyperphagic behavior, benefited from revision of RYGBP consisting of the placement of a non-adjustable silicone ring loosely encircling the stomach part. Mean weight and body mass index (BMI) at the time of RYGBP were 105.0 kg ± 12.3 and 36.3 ± 3.0 kg/m², respectively, and all patients suffered from obesity-related co-morbidities. After a mean time from RYGBP of 26.0 ± 14.2 months, patients presented a weight regain of 4.7 ± 3.4 kg compared with their minimal weight, with a final mean weight, BMI, and percentage of excess weight loss (%EWL) at the time of the silicone ring of 86.0 ± 13.1 kg, 29.5 ± 3.9 kg/m², and 47.0 ± 24.7%, respectively. Preoperative evaluation for each patient included history and physical examination, nutritional and psychiatric evaluation, laboratory tests, and barium swallow check. Outcome measures included evaluation of the Roux-en-Y construction, operative time, postoperative morbidity and mortality, and weight loss in terms of absolute weight loss, BMI, and %EWL. Results  Any modification of the digestive circuit was evidenced. Mean operative time was 82.5 ± 18.3 min. No operative mortality and no conversion to open surgery were achieved. No postoperative complications were achieved. Mean hospital stay was 2.6 ± 1.5 days. After a mean follow-up of 14.0 ± 9.2 months, the six patients presented a mean weight loss of 9.1 ± 2.4 kg, with a final mean weight, BMI, and %EWL of 76.8 ± 13.7 kg, 26.4 ± 4.2 kg/m², and 70.4 ± 30.4%, respectively. Difference in term of %EWL before and after revision (23.4 ± 5.7) is statistically significant (p < 0.05). There have been no erosions or slippage of the ring during this follow-up. Conclusion  One of the possible causes of weight regain after RYGBP is the new eating behavior of the patient, one of which is hyperphagia. Treatment of this condition can be the placement of a non-adjustable silicone ring loosely fitted around the gastric pouch which contributes to improved weight loss. This paper was presented at the XIII World Congress of International Federation for the Surgery of Obesity and metabolic disorders, Buenos Aires, Argentina, September 24–27, 2008.     

The role of endoscopic stents in the management of chronic anastomotic and staple line leaks and chronic strictures after bariatric surgery

BackgroundThe use of endoluminal stents has been proposed for the management of fistulas and anastomotic strictures after bariatric surgery. The objective of our study was to determine the success of endoscopically placed, self-expandable metal stents (SEMS) in bariatric patients specifically with either chronic persistent anastomotic or staple line leaks/fistulas or chronic, persistent anastomotic strictures.MethodsWe treated 21 patients including 5 with chronic staple line leaks/fistulas (4 from the gastric sleeve after biliopancreatic diversion with duodenal switch [BPD/DS] and 1 after removal of an eroding laparoscopic adjustable gastric band) and 16 with chronic anastomotic strictures (15 at the gastrojejunostomy after Roux-en-Y gastric bypass and 1 at the duodenoileal anastomosis after BPD/DS). Patients with early leaks or anastomotic strictures were excluded.ResultsAll but one of these patients had been referred to our institution after chronic treatment elsewhere was unsuccessful with prior stent placement for fistulas or multiple endoscopic dilations for strictures. Their bariatric operations had been performed a mean of 386 days beforehand. Stent placement was performed successfully in all patients without complications but was successful in only 4 of 21 patients (19%)—2 with chronic fistulas and 2 with chronic anastomotic strictures. Stent migration occurred in 10 patients (47%); the migrated stents were removed/replaced endoscopically in 7 patients but required elective operative removal in 3 with concomitant correction of the leak, fistula, or anastomotic stricture; none were operated emergently.ConclusionOnly 4 of 21 patients with a chronic persistent leak or anastomotic stricture were treated definitively using a SEMS. Although endoluminal stents may not lead to resolution of a chronic leak or stricture, SEMS may suppress ongoing sepsis and allow patients to undergo nutritional resuscitation orally before operative correction.     

Revision of Failed Laparoscopic Adjustable Gastric Banding to Roux-en-Y Gastric Bypass

Background: The most common bariatric surgical operation in Europe, laparoscopic adjustable gastric banding (LAGB), is reported to have a high incidence of long-term complications. Also, insufficient weight loss is reported. We investigated whether revision to Roux-en-Y gastric bypass (RYGBP) is a safe and effective therapy for failed LAGB and for further weight loss. Methods: From Jan 1999 to May 2004, 613 patients underwent LAGB. Of these, 47 underwent later revisional Roux-en-Y gastric bypass (RYGBP). Using a prospectively collected database, we analyzed these revisions. All procedures were done by two surgeons with extensive experience in bariatric surgery. Results: All patients were treated with laparoscopic (n=26) or open (n=21) RYGBP after failed LAGB. Total follow-up after LAGB was 5.5±2.0 years. For the RYGBP, mean operating time was 161±53 minutes, estimated blood loss was 219±329 ml, and hospital stay was 6.7±4.5 days. There has been no mortality. Early complications occurred in 17%. There was only one late complication (2%) – a ventral hernia. The mean BMI prior to any form of bariatric surgery was 49.2±9.3 kg/m², and decreased to 45.8±8.9 kg/m² after LAGB and was again reduced to 37.7±8.7 kg/m² after RYGBP within our follow-up period. Conclusion: Conversion of LAGB to RYGBP is effective to treat complications of LAGB and to further reduce the weight to healthier levels in morbidly obese patients.     

Long-term Anastomotic Complications After Pancreaticoduodenectomy for Benign Diseases

Background The study of long-term complications after pancreaticoduodenectomy (PD) for malignant disease has been problematic given the paucity of patients with long-term survival after diagnosis and surgical resection. We therefore studied patients who were surgically treated with a PD for a benign diagnosis to evaluate long-term anastomotic durability. Methods A retrospective analysis of 122 patients who had PD performed in the interval 1993–2003 inclusive for benign pancreatic diseases was undertaken. Long-term morbidity and mortality (specifically biliary, pancreaticojejunostomy [PJ], and gastrojejunostomy [GJ] strictures) were evaluated. Results Gender was equally represented with 53% female and 47% male. The median age at surgery was 55 years (range 15–81 years). The three most frequent diagnoses were chronic pancreatitis (40%), intraductal papillary mucinous neoplasm (16%), and cystic neoplasms (9%). Median follow-up in the 95 patients alive at last follow-up was 4.1 years (10 days–12.6 years). The 5- and 10-year survival rates were 83% (76, 91%) and 62% (49%, 78%), respectively. The observed survival was significantly lower than the expected survival in an age- and gender-matched U.S. white population, p < 0.001 (one-sample log-rank test). The 5- and 10-year cumulative probability of biliary stricture was 8% (2%, 14%) and 13% (4%, 22%), respectively. For pancreatic strictures the 5- and 10-year rates were 5% (0%, 9%) and 5% (0%, 9%), respectively. No GJ strictures were noted. The management of biliary strictures was primarily with dilatation and stent (78%) and less commonly operative intervention (22%). Pancreatic strictures required surgery alone (25%), surgery followed by endoscopic intervention (25%), or endoscopic therapy alone (50%). Conclusion Intervention for anastomotic strictures after pancreaticoduodenectomy is uncommon. Biliary strictures can usually be treated nonoperatively with dilation and stent. Our study likely underestimates the incidence of stricture formation. Prospective imaging studies may be warranted for a more accurate assessment of the rate of long-term anastomotic complications.     

Gastro-Esophageal Reflux and Esophageal Motility Disorders in Morbidly Obese Patients before and after Bariatric Surgery

Background Obesity is a predisposing factor to gastro- esophageal reflux disease (GERD), but esophageal function remains poorly studied in morbidly obese patients and could be modified by bariatric surgery. Methods Every morbidly obese patient (BMI ≥40 kg/m² or ≥35 in association with co-morbidity) was prospectively included with an evaluation of GERD symptoms, endoscopy, 24-hour pH monitoring and esophageal manometry before and after adjustable gastric banding (AGB) or Roux-en-Y gastric bypass (RYGBP). Results Before surgery, 100 patients were included (84 F, age 38.4 ± 10.9 years, BMI 45.1 ± 6.02 kg/m2), of whom 73% reported GERD symptoms. Endoscopy evidenced hiatus hernia in 39.4% and esophagitis in 6.4%. The DeMeester score was pathological in 53.3%; 69% of patients had lower esophageal sphincter (LES) pressure <15 mmHg and 7 had esophageal dyskinesia. BMI was significantly related to the DeMeester score (P = 0.018) but not to LES tone or esophageal dyskinesia. Postoperative data were available in 27 patients (AGB n = 12/60, RYGBP n = 15/36). The DeMeester score (normal <14.72) was significantly decreased after RYGBP (24.8 ± 13.7 before vs 5.8 ± 4.9 after; P < 0.001) but tended to increase after AGB (11.5 ± 5.1 before vs 51.7 ± 70.7 after; P = 0.09), with severe dyskinesia in 2 cases. Conclusion: GERD and LES incompetence are highly prevalent in morbidly obese patients. Preliminary postoperative data show different effects of RYGBP and AGB on esophageal function, with worsening of pH-metric data with occasional severe dyskinesia after AGB.     

Endoscopic Dilation of Gastrojejunal Anastomotic Strictures After Laparoscopic Gastric Bypass. Predictors of Initial Failure

Background and aims  

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the most frequent technique performed in bariatric surgery. Gastrojejunal anastomotic stricture is one of the most common postoperative complications. The aims of this study were to evaluate the efficacy and safety of endoscopic balloon dilation in the treatment of the gastrojejunal anastomotic strictures after LRYGB and to look for predicting factors that would indicate the need of repeated dilations.     

Hospital Discharge in the Day Following Open Roux-en-Y Gastric Bypass: Is it Feasible and Safe?

Background  Roux-en-Y gastric bypass (RYGBP) either laparoscopic or open has been increasingly employed in the treatment of patients with morbid obesity. Laparoscopic approach is believed to be superior over open approach in terms of shorter hospital stay and easier recovery. We aimed to assess feasibility and safety of open RYGBP with short stay in comparison with laparoscopic RYGBP. Methods  One hundred and ninety consecutive patients were assigned to open (n = 103) or laparoscopic (n = 87) RYGBP. The first 20 patients of the laparoscopic arm were excluded due to procedure learning curve. Patients were treated by a multidisciplinary team focused on successfully RYGBP with short stay (1 day). Results  Short stay was reached by 90% of patients operated with open approach and 81% by laparoscopy (P = 0.070). Discharge in the second day was reached by 97% of patients in both groups. Procedure length [(median (IQR)] was faster for open RYGBP [103 (70–180 min) vs. 169 (105–248 min); P < 0.0001]. Thirty-day readmission rate was similar between groups (3% vs. 7%; P = 0.266). There was no death in either group. Conclusion  Short stay (1 day) following open gastric bypass was a feasible and safe procedure. This approach might have economic impact and might increase patient acceptance for open RYGBP.     

Predicting Maximum Roux-en-Y Gastric Bypass-Induced Weight Reduction — Preoperative Plasma Leptin or Body Weight?

Background Weight loss after bariatric surgery varies between patients, and predicting the extent thereof is often inaccurate. The aim of this study was to assess the potential of preoperative plasma leptin and body weight in predicting the maximum weight loss within 2 years after Roux-en-Y gastric bypass (RYGBP). Methods The study comprised 68 subjects (39 women, 29 men; mean age 36.4 ± 10.2 years, body weight 130.3 ± 24.8 kg, BMI 44.4 ± 6.8 kg/m²) undergoing RYGBP who were followed for 2 years. Baseline and maximum follow-up plasma leptin and weight were assessed. Results Mean maximum weight reduction of 50.5 ± 19.1 kg (38.0 ± 9.0%, range 24 – 100 kg) was noted at 15 ± 4 months after RYGBP. Baseline plasma leptin was 37.9 ± 14.5 ng/ml, and decreased to 17.4 ± 8.1 ng/ml (P < 0.001) at maximum weight reduction. No significant correlation between baseline plasma leptin and absolute or relative weight reduction or minimum body weight achieved was noted. No significant plasma leptin threshold which would be predictive for any consistent extent of weight loss was found. However, baseline body weight was a strong determinant of minimum body weight attained (r = 0.67; P < 0.01) and of maximum absolute weight reduction (r = 0.81; P < 0.01). Conclusion Preoperative plasma leptin concentration cannot be used as a predictor of weight reduction following RYGBP. Preoperative body weight is a reliable predictor of post-RYGBP weight loss.     

Improvement of Associated Respiratory Problems in Morbidly Obese Patients after Open Roux-en-Y Gastric Bypass

Background Obstructive sleep apnea syndrome (OSAS) is present in 44% of patients scheduled for bariatric surgery. Respiratory dysfunction associated with this syndrome is attributable to chronic obstructive pulmonary disease (COPD) and/or obesity hypoventilation syndrome (OHS).We studied the long-term effect of bariatric surgery on weight loss, on the respiratory comorbidities associated with obesity, and on the need for non-invasive positive pressure ventilation. Methods We followed a sample of patients with respiratory co-morbidity scheduled for open Capella Roux-en-Y gastric bypass (RYGBP) over 5-years. Patients who were positive for polysomnographic studies and required continous positive airway pressure (CPAP) before surgery were included. All patients were subjected to the same anesthetic and surgical protocols. At 1 year after surgery, polysomnographic studies were performed and arterial blood gases and pulmonary function were tested. Results Of the 209 patients scheduled for bariatric surgery during the study period, 105 had respiratory co-morbidity. Of these, 30 required CPAP-BiPAP treatment before surgery and were included in our study. Surgery took 128 minutes (range 70 to 210 minutes). Tracheal extubation in the operating theater was possible for 26 patients (86.7%). During the early postoperative period, 7 patients (23.3%) presented respiratory complications. Length of hospitalization was 6.87 days (range 4 to 11 days). At 1 year after RYGBP, patients presented significant weight loss and improvement of hypoxemia (from 73.3 ± 10.6 to 90.5 ± 11.5, P = 0.000), hypercarbia (from 44.5 ± 5.7 to 40.6 ± 4.9, P = 0.005), and in spirometric (P = 0.004) and polysomnographic results (P = 0.001). CPAP-BiPAP treatment after weight loss was necessary in only 14% of patients (P = 0.001). Conclusions Weight loss after RYGBP improved arterial blood gases, respiratory tests and polysomnographic studies. CPAP treatment can be withdrawn in most patients.