腹腔镜胃旁路术的并发症及其防治

腹腔镜Roux-en-Y胃旁路手术（LRYGB）治疗病态肥胖,因其疗效快捷、持久而成为减重外科的“金标准”术式。然而,由于其手术操作复杂和学习曲线较长,故具有潜在风险。LRYGB术后并发症分为早期和晚期两类,并发症如果发现不及时或处理不当,可导致严重的后果,甚至死亡。因此,预防和及早诊断LRYGB术后出现的并发症,并及时有效地进行处理,对LRYGB的健康开展具有重要意义。     

Small Bowel Obstruction Due to Retrograde Intussusception After Laparoscopic Roux-en-Y Gastric Bypass

A 39-year-old female presented 4 years after laparoscopic Roux-en-Y gastric bypass with colicky abdominal pain, vomiting and inability to pass flatus. She had lost 100% of her excess weight after surgery and her body mass index had dropped from 46 to 22 kg/m(2). At exploration, a retrograde intussusception of the small bowel was noted distally to the jejunojejunostomy causing obstruction of the alimentary and biliopancreatic limb and gastric remnant. The intussusception was irreducible with signs of bowel ischaemia and required excision. The patient made an uneventful recovery. Colicky abdominal pain in a bariatric patient persisting more than 4 h mandates urgent investigation with abdominal computed tomography. Emergency care doctors should be aware of this specific complication in bariatric patients and seek expert advice.     

Intussusception After Laparoscopic Roux-en-Y Gastric Bypass

Intussusception after open Roux-en-Y gastric bypass procedure (RYGBP) is a rare complication. We present a retrospective review of three cases of antegrade intussusception occurring after laparoscopic RYGBP. To our knowledge, these are the first documented cases of intussusception after laparoscopic RYGBP. We describe the clinical presentation and our management of these three cases. Furthermore, we believe that the initial clinical presentation, radiographic findings, and management of these patients may be different than those patients who have undergone an open RYGBP. With increasing popularity of laparoscopic RYGBP, we are likely to see more of this entity.     

Laparoscopic resolution of intussusception after Roux-en-Y gastric bypass

Introduction

Roux-en-Y gastric bypass (RYGB) has been the most common surgical operation used to treat obesity and its inherent co-morbidities. Intussusception with bowel obstruction after RYGB is a rare complication and its physiopathology remains unclear. The diagnosis is generally based on typical image of computed tomography (CT) scan and a surgical exploration is generally recommended.

Preoperative factors predictive of complicated postoperative management after Roux-en-Y gastric bypass for morbid obesity

Introduction: This study was undertaken to determine preoperative predictive factors of complicated postoperative management after Roux-en-Y gastric bypass (RYGB) for morbid obesity.Methods: Between January 1999 and January 2002, 158 patients who underwent a RYGB received a standardized preoperative evaluation and data were collected prospectively. Complicated postoperative management was defined as patients requiring postoperative ICU admission for 48 h, or those needing transfer from the floor to the ICU. Patients with complicated management were compared with those in whom ICU admission was not necessary.Results: Twenty-three patients (14.5%) required prolonged ICU admission (mean stay of 6.3 ± 1.7 days). After multivariate analysis, body mass index (BMI) >50 kg/m², forced expiratory volume (FEV₁) <80% predicted, previous abdominal surgeries, and abnormal EKG were found to be independently associated with an increased likelihood of complicated postoperative care.Conclusion: BMI >50 kg/m², FEV₁ <80% predicted, previous abdominal surgeries, and abnormal EKG increase the likelihood of complicated postoperative management after RYGB for morbid obesity. Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) Los Angeles, CA, USA, March 15, 2003.     

Intussusception after Roux-en-Y gastric bypass

Intussusception is a common pediatric surgical problem. Its occurrence in adults is rare and usually involves a specific lead point such as a small bowel tumor or other mass. We describe two adults who developed intussusception after Roux-en-Y gastric bypass. Signs and symptoms of small bowel obstruction were seen in both of these patients, but the responsible pathology was unusual. Because of the increasing frequency with which these gastric bypass procedures are being performed, a high index of suspicion must be employed when dealing with these postoperative patients who present with abdominal complaints.     

Gastrogastric fistula: a possible complication of Roux-en-Y gastric bypass.

BACKGROUND: Gastrogastric fistula is a communication between the proximal gastric pouch and the distal gastric remnant, rarely described in the realm of bariatric procedures. The aim of this study was to review the existing literature about this topic and to demonstrate its laparoscopic treatment. METHODS: An extensive literature review found several articles reporting this complication. However, no citation was found describing the steps of the laparoscopic management of this situation. RESULTS: Gastrogastric fistula occurs in up to 6% of Roux-en-Y gastric bypasses. Two theories exist for fistula formation: (1) it is a technical complication derived from the incomplete division of the stomach during the creation of the pouch, and (2) it occurs after a staple-line failure, developing a leak with an abscess, which then drains into the distal stomach forming the fistula. Early symptoms include fever, tachycardia, and abdominal pain. Failure in weight loss is a late clinical sign observed in these patients. Diagnosis is based on radiologic study, upper endoscopy and computed tomography. When identified in the acute postoperative course, laparoscopic treatment is easy. Chronic fistulas are difficult to manage, and the laparoscopic approach is an alternative to open surgery. CONCLUSIONS: Gastrogastric fistula is a possible complication of Roux-en-Y gastric bypass and its laparoscopic treatment is feasible.     

Counterregulatory responses to postprandial hypoglycemia after Roux-en-Y gastric bypass

BackgroundPostbariatric hypoglycemia (PBH) is a potentially serious complication after Roux-en-Y gastric bypass (RYGB), and impaired counterregulatory hormone responses have been suggested to contribute to the condition.ObjectivesWe evaluated counterregulatory responses during postprandial hypoglycemia in individuals with PBH who underwent RYGB.SettingUniversity hospital.MethodsEleven women with documented PBH who had RYGB underwent a baseline liquid mixed meal test (MMT) followed by 5 MMTs preceded by treatment with (1) acarbose 50 mg, (2) sitagliptin 100 mg, (3) verapamil 120 mg, (4) liraglutide 1.2 mg, and (5) pasireotide 300 μg. Blood was collected at fixed time intervals. Plasma and serum were analyzed for glucose, insulin, glucagon, epinephrine, norepinephrine, pancreatic polypeptide (PP), and cortisol.ResultsDuring the baseline MMT, participants had nadir blood glucose concentrations of 3.3 ± .2 mmol/L. At the time of nadir glucose, there was a small but significant increase in plasma glucagon. Plasma epinephrine concentrations were not increased at nadir glucose but were significantly elevated by the end of the MMT. There were no changes in norepinephrine, PP, and cortisol concentrations in response to hypoglycemia. After treatment with sitagliptin, 8 individuals had glucose nadirs <3.2 mmol/L (versus 4 individuals at baseline), and significant increases in glucagon, PP, and cortisol responses were observed.ConclusionsIn response to postprandial hypoglycemia, individuals with PBH who underwent RYGB only had minor increases in counterregulatory hormones, while larger hormone responses occurred when glucose levels were lowered during treatment with sitagliptin. The glycemic threshold for counterregulatory activation could be altered in individuals with PBH, possibly explained by recurrent hypoglycemia.     

Intussusception in pregnancy after gastric bypass: a case report

Laparoscopic Roux-en-Y gastric bypass (RYGB) remains the gold standard procedure in obesity surgery and is mostly performed in young women of reproductive age. Since the worldwide prevalence of obesity is increasing and fertility improves after surgery, more complications in the pregnant population will emerge. The differential diagnosis of acute abdominal pain in patients with a history of gastric bypass is rather broad and includes mainly anastomotic ulcers, leaks, and small bowel obstructions. Early diagnosis and treatment of these complications is of utmost importance and should be performed on a multidisciplinary basis. Whether surgery should be performed by laparoscopy or laparotomy remains subject of discussion. We report a case of a 29-year-old pregnant woman at 33?+?5 weeks gestational age, presenting with an intussusception after RYGB. A successful surgical reduction was performed by laparotomy.     

Endoscopic management of stomal stenosis after Roux-en-Y gastric bypass

Background: In the United States, Roux-en-Y gastric bypass has evolved into the procedure of choice for clinically severe obesity. Stomal stenosis resulting in gastric outlet obstruction is a recognized complication. Endoscopic balloon dilation is often used to treat this condition. To evaluate the safety and efficacy of endoscopic management of stomal stenosis we evaluated our treatment methods and outcomes. Methods: The records of all patients undergoing Roux-en-Y gastric bypass from 1 July 2000 to 30 June 2002 were studied. Stenosis was defined as signs and symptoms of obstruction with inability to cannulate the gastrojejunostomy using an 8.5-mm diagnostic endoscope. Charts were reviewed and demographic data, operative course, symptoms, and outcomes were recorded. Results: A total of 562 patients underwent Roux-en-Y gastric bypass for obesity during the study period. Of these, 38 patients underwent endoscopic balloon dilation for stomal stenosis, for a stenosis rate of 6.8%. The average time from surgery to initial dilation was 7.7 weeks (range 3 to 24). The average number of dilations required was 2.1 (range one to six). The mean initial balloon size was 13 mm and the mean final balloon size was 16 mm. Two patients failed endoscopic dilation and proceeded to surgery, including one patient who developed pneumomediastinum and pneumothorax after dilation. All patients were relieved of their gastric outlet obstruction. The success rate for endoscopic balloon dilation was 95% with a 3% complication rate. Conclusions: In our experience, the rate of gastrojejunostomy stenosis following Roux-en-Y gastric bypass is 6.8%. Endoscopic balloon dilation is a safe and effective therapy for stomal stenosis with a high success rate. It should be considered an appropriate intervention with a low risk for reoperation.     

Mucosal and hormonal adaptations after Roux-en-Y gastric bypass

The aim of this study was to perform a comprehensive literature review regarding the relevant hormonal and histologic changes observed after Roux-en-Y gastric bypass (RYGB). We aimed to describe the relevant hormonal (glucagon-like peptides 1 and 2 [GLP-1 and GLP-2], peptide YY [PYY], oxyntomodulin [OXM], bile acids [BA], cholecystokinin [CCK], ghrelin, glucagon, gastric inhibitory polypeptide [GIP], and amylin) profiles, as well as the histologic (mucosal cellular) adaptations happening after patients undergo RYGB. Our review compiles the current evidence and furthers the understanding of the rationale behind the food intake regulatory adaptations occurring after RYGB surgery. We identify gaps in the literature where the potential for future investigations and therapeutics may lie. We performed a comprehensive database search without language restrictions looking for RYGB bariatric surgery outcomes in patients with pre- and postoperative blood work hormonal profiling and/or gut mucosal biopsies. We gathered the relevant study results and describe them in this review. Where human findings were lacking, we included animal model studies. The amalgamation of physiologic, metabolic, and cellular adaptations following RYGB is yet to be fully characterized. This constitutes a fundamental aspiration for enhancing and individualizing obesity therapy.     

Calcium oxalate supersaturation increases early after Roux-en-Y gastric bypass

BackgroundCalcium oxalate (CaOx) nephrolithiasis is an adverse effect of Roux-en-Y gastric bypass surgery (RYGB). It is unknown when the increased risk for CaOx stone formation occurs after surgery.MethodsWe studied 13 morbidly obese adults undergoing RYGB with 24-hour urine collections at 4 weeks before and 1, 2, 4, and 6 months after surgery and computed CaOx relative saturation ratio (RSR) by EQUIL2.ResultsEleven patients were female, mean±standard deviation age was 41.1±7.2 years, and none had diabetes or chronic kidney disease. Median (interquartile range) urinary oxalate excretion increased linearly from 12.6 (10.9–37.9) mg/24 hr at baseline to 28.4 (14.4–44.0) mg/24 hr at 6 months (slope = .188; P = .005). CaOx RSR increased significantly at 2 months after RYGB (1.4 [1.2–2.4] to 4.9 [1.7–10.0]; P = .017) and rose throughout the study to 5.7 (3.7–12.2) at 6 months (P = .001) with a positive linear slope (.255; P = .001). One patient had critical CaOx supersaturation (RSR = 34.7) and severe hyperoxaluria (101.7 mg/24 hr) at 6 months after RYGB. Significant decreases over time were seen in urine volume and sodium and potassium excretion, but no changes were noted in urinary pH, calcium, magnesium, or citrate.ConclusionsOur data suggest that CaOx RSR, and thus risk for nephrolithiasis, rises as early as 2 months after RYGB and increases gradually in the first 6 months, largely because of reduced urine volume and increased urinary oxalate excretion. Interventions to reduce CaOx RSR, such as adequate fluid intake and agents to bind enteric oxalate, need to be evaluated in patients at risk for nephrolithiasis after RYGB.     

Conversion of laparoscopic Roux-en-Y gastric bypass

BACKGROUND: To determine the incidence and causes of conversion from a laparoscopic to an open gastric bypass for morbid obesity, we reviewed the experience of our bariatric center. METHODS: We performed a retrospective review of the records of consecutive patients undergoing laparoscopic Roux-en-Y gastric bypass at our center. RESULTS: In all, 1,236 consecutive patients with body mass indes (BMI) from 35 to 82 were approached laparoscopically. In 97%, bypasses were completed laparoscopically and in 3% (40 patients), a conversion was required to complete the procedure. Older age and male sex were greater in the converted group, whereas BMI was not different nor was the proportion of super obese patients. The cause of conversion was technical in 80%, bleeding in 10%, and a massive liver in 10%. CONCLUSIONS: Our risk of conversion was generally low, but increased in older patients and males. In 33% of patients, conversions could have been avoided with technical lessons learned by experience.     

Vitamin D depletion impairs hypertension resolution after Roux-en-Y gastric bypass

BACKGROUND: Morbid obesity is a risk factor for hypertension (HTN) and vitamin D (VitD) depletion. Gastric bypass (GBP) resolves HTN in many patients. The goal of this study was to evaluate the potential role of VitD nutritional status on HTN resolution in patients undergoing GBP. METHODS: A retrospective review of morbidly obese patients taking antihypertensive medications and undergoing GBP from September 1, 2002, through February 28, 2006 was performed. RESULTS: At 1 year postoperatively HTN resolved in 53%, improved in 36%, and was unchanged in 11%. Sex, race, body mass index, and percentage of excess weight loss did not impact HTN resolution. Younger patients experienced a greater rate of HTN resolution. Patients with VitD depletion had significantly lower rates of HTN resolution compared to those with adequate levels of VitD (42% vs 61%; P = .008). CONCLUSIONS: VitD nutritional status impacts the resolution rate of HTN after GBP. All morbidly obese patients undergoing GBP should be monitored and treated for VitD depletion.     

Conversion of gastric sleeve to Roux-en-Y gastric bypass: overall outcomes and predictors of below-average weight loss

BackgroundConversion of sleeve gastrectomy (SG) to Roux-en-Y gastric bypass (RYGB) has been utilized to promote further weight loss, but results are variable in available literature.ObjectivesTo evaluate outcomes of SG to RYGB conversion for weight loss and to identify predictors of below-average weight loss.SettingUniversity-affiliated hospital, United States.MethodsChart review was performed of our patients who underwent SG to RYGB conversion from November 1, 2013, to November 1, 2020. Primary outcomes were below-average percent excess weight loss (%EWL) at 1 and 2 years. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for preconversion demographics to evaluate their relationship to the primary outcome.ResultsSixty-two patients underwent conversion from SG to RYGB with weight loss as a goal. One-year data was available for 47 patients. The average %EWL at 1 year was 41.5%. Twenty-six patients had below-average %EWL at 1 year. Interval to conversion <2 years (OR = 4.41, 95% CI [1.28,15.17], P = .019) and preconversion body mass index (BMI) >40 (OR = 4.00, 95% CI [1.17,13.73], P = .028) were statistically significant predictors of below-average 1-year %EWL. Two-year data was available for 36 patients. The average %EWL at 2 years was 30.8%. Seventeen patients had below-average %EWL at 2 years. Evaluated demographics were not statistically significant predictors of below-average 2-year %EWL.ConclusionsFollowing SG to RYGB conversion, %EWL outcomes are lower at 1 year (41.5%) and 2 years (30.8%) than reported values for primary RYGB. Interval to conversion <2 years and preconversion BMI >40 are predictors of below-average 1-year weight loss after conversion.     

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.     

腹腔镜下胃旁路手术并发症的预防及处理

目的 探讨腹腔镜下胃旁路手术并发症的处理及预防.方法 回顾性分析2010年5月至2013年5月间在苏州大学附属第一医院腹腔镜外科接受腹腔镜下胃旁路手术的82例患者（单纯性肥胖9例、肥胖合并2型糖尿病55例,非肥胖单纯2型糖尿病18例）临床资料,探讨该术式并发症发生的原因,总结经验及教训.结果 全组无术后死亡患者,其中9例（11.0％）患者有并发症发生,其中穿刺损伤1例（1.2％）中转开腹行缝扎止血;吻合口出血4例（4.9％,1例合并吻合口溃疡）,经去甲肾上腺素生理盐水洗胃或内镜下电灼止血后治愈;吻合口瘘1例（1.2％）,放置鼻-空肠营养管、予全肠内营养1个月后瘘口愈合;吻合口狭窄1例（1.2％）,行球囊扩张后出现弥漫性腹膜炎,遂行腹腔镜下修补术;胃瘫2例（2.4％）,经禁食、胃肠减压、胃肠动力药物及肠内营养等保守治疗好转.所有并发症均治愈.随访19.0～35.0（29.1±5.4）月,全组患者体质量指数较术前均有不同程度的下降.结论 胃旁路手术虽然有一定的风险,但可通过积极的术前准备、提高手术精细程度及细致的术后护理及观察来预防并发症的发生,而即便发生了并发症,也有治疗措施可循.     

Laparoscopic revision of Nissen fundoplication to Roux-en-Y gastric bypass in morbidly obese patients

Background  We present a case of a morbidly obese patient with previous laparoscopic Nissen fundoplication (LNF) who was successfully treated by revision to a laparoscopic Roux-en-Y gastric bypass (RYGB) and discuss our collective experience. Methods  Between June 2000 and April 2006 seven morbidly obese patients with mean body mass index (BMI) of 39.4 kg/m² underwent laparoscopic revision of LNF to RYGB by our group. Important steps of the revision include lysis of all adhesions between the liver and the stomach, dissection of the diaphragmatic crura and gastroesophageal fat pad, reduction and repair of hiatal hernia and complete take-down of the wrap to avoid stapling over the fundoplication which can create an obstructed, septated pouch. Results  There was one (14.3%) conversion. Mean operative time (OT) was 324 (206–419) minutes and length of stay was 4.9 (3–8) days. Early complications occurred in 3/7 (42.9%) patients including a staple line hemorrhage without a need for re-exploration, a small pulmonary embolism without hemodynamic instability and a small-bowel obstruction due to a pre-existing incisional ventral hernia that was not repaired on original operation. There were no anastomotic leaks or deaths. At a mean follow-up of 32.9 (12–39) months, mean percentage excess weight loss was 79.5% and 18/28 (64.3%) comorbid conditions were improved or resolved. Gastroesophageal reflux disease (GERD) evaluation with the GERD health-related quality of life (GERD-HRQL) scale showed a significant reduction of GERD scores postoperatively (16.7 versus 4.4). Conclusions  Although laparoscopic RYGB after antireflux surgery is technically difficult and carries higher morbidity, it is feasible and effective in the treatment of recurrent GERD in morbidly obese patients. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.