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.     

Endoscopic evaluation of the gastrojejunostomy in laparoscopic gastric bypass

Background A significant and potentially deadly complication of the Roux-en-Y gastric bypass is leakage from the gastrojejunostomy (GJ). The aim of our study was to evaluate the efficacy of intraoperative endoscopy in preventing postoperative anastomotic leakage. Methods The study enrolled 340 consecutive patients undergoing laparoscopic gastric bypass procedures performed from January 2001 to July 2004. In all cases, an endoscopist performed video gastroscopy to evaluate the integrity of the GJ using air insufflation of the pouch after distal clamping of the Roux limb. Intraoperative leaks were repaired and the anastomosis was retested. Demographic, operative, and endoscopic data were collected and analyzed. Logistic regression was used in both univariate and multivariate modeling to identify independent preoperative variables associated with the presence of intraoperative leak. Model parameters were estimated by the maximum likelihood method. From these estimates, odds ratios (ORs) with 95% confidence intervals (CIs) were computed. Results There were no postoperative anastomotic leaks or mortalities in our series. Overall, endoscopic evaluation of the GJ resulted in the detection of 56 intraoperative leaks (16.4%). There was a significant difference in the incidence of intraoperative leakage for patients older than 40 years (21%) vs those younger than 40 years (10.5%; p = 0.01). In the initial 91 cases, the GJ was performed by the end-to-end anastomosis (EEA) technique; the subsequent 249 were performed with a combination of linear stapling and handsewn technique. There was a trend toward more leakage in the GIA group (18%) versus EEA (12%); however, the difference was not significant (p = 0.188). Age remained an independent risk factor for leak detected intraoperatively in the multivariate logistic regression model after adjusting for covariates. Age >40 years increased the risk of intraoperative leakage by 2.3 times (OR, 2.3; 95% CI, 1.2–4.6; p = 0.01). The rate of postoperative anastomotic stricture was the same among patients detected with an intraoperative leak (5.4%) and those without (5.6%; p = 0.934). Conclusions Endoscopic evaluation of the GJ is a sensitive and reliable technique for demonstrating anastomotic integrity and preventing postoperative morbidity after gastric bypass. Age >40 years was identified as an independent risk factor for intraoperative leak in this series. Presented at the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) meeting, Fort Lauderdale, FL, USA, April 2005     

A case-match analysis of failed prior bariatric procedures converted to resectional gastric bypass

BACKGROUND: Failure to lose weight or intractable symptoms after bariatric surgery presents a complex diagnostic and management challenge. The outcome of a standardized surgical approach to this problem has not been well described. Conversion of failed bariatric procedures to a resectional gastric bypass (RGB) can achieve symptomatic relief and acceptable weight loss. METHODS: We reviewed all patients in a prospectively maintained database who underwent reoperative bariatric surgery over a 4-year period. Reoperative patients (RO) were case-matched (by age, body mass index, and comorbidities) in a 1:2 ratio with control patients undergoing an initial bariatric procedure (IN). RESULTS: Twenty-seven reoperative patients and 54 case-matched control patients were identified. Mean body mass index was 42 in the RO group versus 45 in the IN group (P = not significant). Indications for conversion were weight gain (89%), dysphagia/emesis (30%), esophagitis (19%), and marginal ulcer (7%). All patients in both groups underwent RGB (subtotal gastrectomy with Roux-Y gastrojejunostomy). Compared with IN patients, the RO patients had significantly longer operative times (420 versus 268 minutes), greater blood loss (650 versus 315 cc), longer time to oral intake (3.1 versus 2.2 days), and longer hospital stays (6.5 versus 4.7 days), all P <0.01. There were no deaths or anastomotic leaks in either group. Excess body weight lost at 6 months was 46% for RO versus 54% for IN (P = 0.02). One-year excess weight lost was 71% for RO versus 77% for IN (P = not significant). All RO patients achieved symptomatic relief, and no patient required further bariatric revision. There was significant improvement in weight-related comorbidity in each group. CONCLUSIONS: Conversion of failed bariatric procedures to RGB, although technically demanding, resulted in relief of presenting symptoms, significant 6-month and 1-year weight loss, and improvement of major comorbidities. Conversion of failed bariatric procedures to resectional gastric bypass can achieve results comparable with those of patients undergoing an initial bariatric procedure.     

A complication of Roux-en-Y gastric bypass: intestinal obstruction

Background Intestinal obstruction is a significant and increasingly recognized complication after laparoscopic and open gastric bypass. Materials and methods The medical records of 3,463 patients who had gastric bypass during the study period from July 1997 to December 2004 at a single bariatric center were evaluated. 1,120 patients had retrocolic, retrogastric Roux limb placement and 2,343 patients had antecolic, antegastric. Results 40 patients had 44 intestinal obstructions (1.27%). The onset ranged from 1 day to 7 years postoperatively (mean 16.9 months). Internal hernia at the transverse mesocolon defect was the most common cause. 36 (3.2%) obstructions were observed in retrocolic, retrogastric vs. 8 (0.3%) in antecolic, antegastric approach. Internal hernia repair at mesocolinic effect (n = 11), jejunojejunostomy mesenteric defect repair (n = 7), lysis of adhesions (n = 16) were the most common procedures. A total of 70.5% were done laparoscopically. Conclusions A high index of suspicion is needed to diagnose bowel obstruction after gastric bypass. Radiological imaging of the abdomen has significant limitations. Surgical exploration should be performed without delay. Diagnostic laparoscopy is a safe and effective therapy. We recommend closing all mesenteric defects to prevent internal hernias. The antecolic, antegastric technique reduces the incidence of internal hernias.     

Experience with the optical access trocar for safe and rapid entry in the performance of laparoscopic gastric bypass

Background In laparoscopic surgery, serious complications caused by the blind insertion of trocars are well known. The open technique is compromised by the leakage of carbon dioxide and can also be time consuming, especially in morbidly obese patients. Our aim was to determine whether the optical access trocar can be used to establish a safe and rapid entry during laparoscopic gastric bypass. Methods The data on a single surgeon’s experience with 370 laparoscopic gastric bypass procedures during a 4-year period were reviewed. The Optiview trocar was used for all except the initial 21 patients. The entry time for the optical trocar was measured in 10 patients. Results Of the 370 patients undergoing laparoscopic gastric bypass from November 2000 to September 2004, the initial 21 were treated using the standard Veress needle to create the pneumoperitoneum. The next 22 were treated using the Veress needle to create the pneumoperitoneum, followed by insertion of the optical access trocar in the left upper quadrant as the initial trocar. From this point to the present, the optical access trocar has been inserted without the use of a Veress needle. There have been no trocar-related bowel or vascular injuries in the entire series. The mean optical trocar insertion time was 28 ± 1.2 s. Conclusions This is the first laparoscopic gastric bypass series to report the results of its experience with the optical access trocar. This device provides a safe and rapid technique for placement of the initial trocar for laparoscopic gastric bypass. Insertion of the optical trocar with a 10-mm laparoscope into the left upper quadrant is our procedure of choice for obtaining the pneumoperitoneum in this patient population.     

Ten-year outcome of one-anastomosis gastric bypass with a biliopancreatic limb of 150 cm versus Roux-en-Y gastric bypass: a single-institution series of 940 patients

BackgroundLong-term outcomes of one-anastomosis gastric bypass (OAGB) need to be compared with those of Roux-en-Y gastric bypass (RYGB).ObjectiveThe present study evaluates the long-term outcomes at 10-year follow-up of OAGB with a biliopancreatic limb of 150 cm versus RYGB.SettingPrivate practice, France.MethodsData of patients who underwent OAGB or RYGB as primary or secondary procedures between 2010 and 2011 at a referral center were collected prospectively and analyzed retrospectively.ResultsA total of 940 patients underwent OAGB (n = 405) or RYGB (n = 535). Operative time was significantly shorter in the OAGB group. Postoperative morbidity occurred in 17.2% of patients after RYGB versus 8.1% after OAGB (P ≤ .0001). Patients in the RYGB group had a significantly higher rate of kinking of the jejuno-jejunal anastomosis, stenosis of the gastrojejunal anastomosis, and dysphagia for early ulcers. At long term, no differences were found in the rate of severe malnutrition. Cumulated morbidity was significantly higher after RYGB, with higher incidence of internal hernia, anastomotic ulcer, blind-loop syndrome, and hypoglycemia. Conversion to RYGB and laparoscopic exploration for chronic pain were more frequent after OAGB. Surgery for weight regain was significantly more frequent after RYGB. Patients in the OAGB group had significantly lower weight, body mass index, and greater percentage excess, and total weight losses at 120 months. No significant differences were detected in co-morbidity outcomes.ConclusionAfter 10 years, both RYGB and OAGB are effective procedures. However, OAGB is associated with shorter operative times and better results in short- and long-term morbidity and weight loss outcomes.     

Enhanced recovery after surgery (ERAS) in one-anastomosis gastric bypass surgery: a matched-cohort study

Background

One-anastomosis gastric bypass (OAGB) is considered new from the bariatric standpoint.

Abdominal pain after gastric bypass in the acute general surgical care setting

BackgroundManaging acute abdominal pain in the large and growing population of Roux-en-Y gastric bypass (RYGB)–operated patients poses a challenge to general surgeons, because of diagnostic limitations and the risk of internal herniation.ObjectiveTo investigate the diagnoses, management, and outcome of RYGB patients admitted for acute abdominal pain.SettingUniversity Hospital, Sweden.MethodsProspective inclusion of 280 consecutive RYGB patients admitted for acute abdominal pain between April 2012 and June 2015. Readmissions, surgical procedures, and overall mortality were recorded until October 2018. Medical records were retrospectively reviewed for anthropometric measures, medical history, time from RYGB surgery, and previous closure of mesenteric gaps. Admissions were separated into early (≤30 d) or late (>30 d) after RYGB. Procedures performed were categorized as follows: RYGB complication, other surgery, or unremarkable laparoscopy. Patients discharged with diagnosis of unspecified abdominal pain were separately analyzed. Diagnostic investigations, bariatric competency, on call surgery, surgical complications, and length of stay were registered.ResultsIn late admissions, the cause of the abdominal complaints remained unexplained in 127 of 262 (48%) patients despite 95 abdominal computed tomographies and 28 diagnostic laparoscopies. Emergency surgery was performed in 128 of 262 (49%) patients. RYGB complications (n = 66), mainly internal herniation (n = 42), were >2 times more frequent than other surgical procedures (n = 32), such as cholecystectomies (n = 23). Internal herniation could occur at any time interval from RYGB surgery and regardless of previously closed mesenteric gaps.ConclusionBetter tools for evaluation of acute abdominal pain in RYGB patients are needed to reduce the number of unremarkable laparoscopies and admissions of patients with unspecified abdominal pain.     

Perforated marginal ulcers after laparoscopic gastric bypass

Background  Perforated marginal ulcer (PMU) after laparoscopic Roux-en-Y gastric bypass (LRYGB) is a serious complication, but its incidence and etiology have rarely been investigated. Therefore, a retrospective review of all patients undergoing LRYGB at the authors’ center was conducted to determine the incidence of PMU and whether any causative factors were present. Methods  A prospectively kept database of all patients at the authors’ bariatric center was retrospectively reviewed. The complete records of patients with a PMU were examined individually for accuracy and analyzed for treatment, outcome, and possible underlying causes of the marginal perforation. Results  Between April 1999 and August 2007, 1% of the patients (35/3,430) undergoing laparoscopic gastric bypass experienced one or more perforated marginal ulcers 3 to 70 months (median, 18 months) after LRYGB. The patients with and without perforation were not significantly different in terms of mean age (37 vs 41 years), weight (286 vs 287 lb), body mass index (BMI) (46 vs 47), or female gender (89% vs 83%). Of the patients with perforations, 2 (6%) were taking steroids, 10 (29%) were receiving nonsteroidal antiinflammatory drugs (NSAIDs) at the time of the perforation, 18 (51%) were actively smoking, and 6 of the smokers also were taking NSAIDs. Eleven of the patients (31%) who perforated did not have at least one of these possible risk factors, but 4 (36%) of the 11 patients in this group had been treated after bypass for a marginal ulcer. Only 7 (20%) of the 35 patients who had laparoscopic bypass, or 7 (0.2%) in the entire group of 3,430 patients, perforated without any warning. There were no deaths, but three patients reperforated. Conclusions  The incidence of a marginal ulcer perforating after LRYGB was significant (>1%) and appeared to be related to smoking or the use of NSAIDs or steroids. Because only 0.2% of all patients acutely perforated without some risk factor or warning, long-term ulcer prophylaxis or treatment may be necessary for only a select group of high-risk patients.     

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     

Treatment of nonadhesive bowel obstruction following gastric bypass

BACKGROUND: Bowel obstruction secondary to internal hernias following laparoscopic and open gastric bypass is well reported. The number of gastric bypasses being performed in the United States continues to increase. As many patients undergo surgery at centers geographically distant from their home, increasing numbers of patients will present to their local emergency rooms with abdominal complaints that will need to be addressed by general surgeons who are not performing bariatric surgery. METHODS: Review of a prospective database of patients operated on in a general surgery practice performing bariatric surgery. RESULTS: Over a 14-month period, 9 patients requiring operative intervention presented to our practice with nonadhesive bowel obstruction following both open and laparoscopic bariatric surgery. Causes of obstructions included cicatrical narrowing in the Roux limb at the transverse mesocolon defect (1 patient) and internal hernias through the transverse mesocolon (5 patients), Petersen's hernia (2 patients), and at the jejunojejunostomy (1 patient). Seven patients were treated laparoscopically and 2 underwent laparotomy. Our diagnostic and operative approach is described. CONCLUSIONS: Surgeons, including those not performing bariatric surgery, will be treating more patients with bowel obstruction following gastric bypass in the future. The etiology and management of bowel obstruction after gastric bypass differs from the conventional management of bowel obstruction. When surgery is required, most of these patients can be treated laparoscopically.     

Roux-en-Y gastric bypass as a re-do procedure for failed restricive gastric surgery

Background Gastric restrictive procedures such as laparoscopic gastric banding or vertical banded gastroplasty show, at longer follow up, more and more failures and complications. This study focuses on the results of Roux-en-Y gastric bypass procedure (RYGBP) done as a re-do procedure, both after a technically failed restrictive procedure or when the restrictive procedure failed to obtain substantial weight loss. Methods We reviewed data concerning the postoperative complications and weight loss of 36 patients undergoing re-do surgery for failed restrictive procedures. Results Over a period of two years, 36 patients with a mean age of 40.9 years were converted to a RYGBP. Median time to conversion was 4.9 years, median follow up after conversion was 6.6 months. Early postoperative complications (less than 30 days postoperatively) were noted in 11 patients (30%). A greater number of early complications were noticed in group A (technical complications) compared to group B (insufficient weight loss) (39% vs. 22%). Late postoperative complications were seen in six patients (16%). In this relatively short follow up period we noticed a drop in body mass index (BMI) from a mean of 38.8kg/m² to 30.9 kg/m² with a mean excess body weight loss (EBWL) of 33.1% after the re-do procedure. Body mass index decreased from a mean preoperative value of 37.6kg/m² to 28.9 kg/m² in group A patients with an EBWL 36%, while group B patients had a change in BMI from 40.1kg/m² to 32.9 kg/m² with a mean EBWL of 30%. Conclusion Based on the literature, we can presume that restrictive surgery for morbidly obese patients will require many reoperations in the future. The standard operation of choice is RYGBP. In our study this procedure showed a higher, but not significantly early morbidity rate when the indication for re-do surgery was a technical complication of the initial procedure.     

An institutional experience with laparoscopic gastric bypass complications seen in the first year compared with open gastric bypass complications during the same period

BACKGROUND: Complication rates for laparoscopic bariatric surgery remain in evolution. METHODS: Single institution review of the initial year's experience with laparoscopic gastric bypass compared with open gastric bypass complications for the same period. RESULTS: There were 20 laparoscopic and 52 open gastric bypass procedures. Five laparoscopic patients had major complications. There were 4 anastomotic leaks. Nine open bypass patients had major complications, with 2 leaks. Leak rate was 20% for the laparoscopic group and 4% for the open group. All leaks in both groups led to substantial morbidity. There were two deaths, one in each group. The laparoscopic death was from postleak sepsis. CONCLUSIONS: Gastric bypass, whether done open or laparoscopically, has significant surgical risk. Complication profiles differed between the two groups. Anastomotic leaks were significantly more frequent in the laparoscopic group, probably related to the learning curve. There is a continued need for open surgery in many bariatric patients.     

Omental infarction: a cause of acute abdominal pain after antecolic gastric bypass

BACKGROUND: The antecolic approach to the laparoscopic Roux-en-Y gastric bypass (LGB) has been demonstrated to decrease the incidence of internal herniation. However, specific complications of this approach have not been documented. We describe the clinical presentation related to complications of this technique. METHODS: The outcomes of 201 consecutive patients who had undergone antecolic LGB by a single surgeon during a 24-month period were retrospectively evaluated for complications. RESULTS: Of the 201 LGB patients, 3 (1.5%) developed complications attributable to omental division. All 3 had an identical presentation of acute, localized abdominal pain without significant signs of systemic illness. All 3 patients developed acute symptoms on postoperative day 3. Laparoscopic reexploration on postoperative day 3, 4, and 4 demonstrated partial omental infarction without other pathologic findings. All patients had immediate relief of symptoms and had no further complications. CONCLUSION: Partial omental infarction is a complication of omental transection while performing the antecolic approach to the LGB. Omental infarction should be part of the differential diagnosis, including anastomotic leak, in patients who develop abdominal pain 3-4 days after LGB.     

Postoperative complications are not increased in super-super obese patients who undergo laparoscopic Roux-en-Y gastric bypass

Background It has been suggested that super-super obesity (body mass index [BMI] ≥60 kg/m²) increases the risk of complications after laparoscopic Roux-en-Y gastric bypass (LapRYGB). We hypothesized that a higher BMI does not increase risk the morbidity or mortality rate.Methods Complication rates for patients with a BMI ≥60 kg/m² were compared to those for patients with a BMI <60 kg/m² who underwent LapRYGB during the same time period. Differences between the groups were analyzed by Fisher’s exact test, t-tests, and analysis of variance.Results Forty-five patients with a BMI ≥60 kg/m² and 640 patients with a BMI <60 kg/m² underwent LapRYGB. There were no statistically significant differences between the two groups in the complication or mortality rates. Excess weight loss was less, but actual weight lost was greater in the BMI ≥60 kg/m² group.Conclusions The complication and mortality rates are not increased in super-super obese patients who undergo LapRYGB. Acceptable weight loss can be achieved safely in these patients.     

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.     

Caution in using a unique technique of banded revision gastric bypass: Successful endosopic and surgical management of a rare complication

INTRODUCTIONRevision surgery is increasingly performed as result of the increase in primary bariatric procedures. We describe a new technique of revision Roux-en-Y gastric bypass (RYGB) acombining stapled gastroenterostomy with fixed band placement. We report two cases of unique complications and its successful endoscopic and surgical management.PRESENTATION OF CASETwo out of twenty patients undergoing this revision RYGB procedure presented with gastric outlet obstruction due to band erosion within 10 weeks. Endoscopic band retrieval was successful in the first patient but the second patient required surgical removal.DISCUSSIONWe report the new complication of band erosion in 10% patients using a unique revision RYGB technique combining restriction of the gastric outlet and band placement. We advise using one or the other technique but not both in combination. Surgeons need to be aware of this as erosion which occurs early due to close proximity of band with fresh staple line. We report successful endoscopic and surgical management.CONCLUSIONRevision surgery using this technique predisposes to bande erosion, presenting as gastric outlet obstruction. Endoscopic management should be attempted prior to surgical removal.