Barbed Versus Usual Suture for Closure of the Gastrojejunal Anastomosis in Laparoscopic Gastric Bypass: a Comparative Trial

Background

Laparoscopic Roux-en-Y gastric bypass is one of the main bariatric procedures that require safe and reproducible anastomosis. The objective of this study is to compare the risk of leaks and stenosis of a mechanical gastric pouch jejunal anastomosis between the usual interrupted sutures and a continuous barbed suture for gastrojejunotomy, in order to reduce procedure time and costs.

Methods

A comparative trial of 100 consecutive patients undergoing laparoscopic Roux-en-Y gastric bypass was performed between October 2010 and July 2011. The population was divided into two groups of 50 consecutive patients. In the first group, gastrojejunotomy was sutured with resorbable interrupted sutures and the second with continuous barbed suture. Diabetes, body mass index and the American Society of Anaesthesiology score were compared. The time required for suturing and the incidence of anastomotic leaks and stricture were also compared after 6 months.

Results

No fistulas or anastomotic stenoses had occurred at post-operative month 6 in either group. Gastrojejunotomy suture time was significantly shorter in the barbed suture group (11 versus 8.22 min; p?<?0.01). Total costs of material to complete the reconstruction were significantly lower in the barbed suture group (€26.69 versus €18.33; p?<?0.001).

Conclusions

The use of barbed suture is as safe as usual sutures and allows easier and faster suture in the closure of gastrojejunotomy. This suture could be incorporated in the standard laparoscopic Roux-en-Y gastric bypass technique.     

Comparison Between Billroth-II with Braun and Roux-en-Y Reconstruction After Laparoscopic Distal Gastrectomy

Purpose

This study aims to compare the effectiveness of Billroth-II with Braun and Roux-en-Y reconstruction after laparoscopic distal gastrectomy.

Methods

From April 2010 to August 2012, 66 patients underwent laparoscopic distal gastrectomy (Billroth-II with Braun reconstruction, 26; Roux-en-Y, 40). The patients’ data were collected prospectively and reviewed retrospectively.

Results

The mean operation and reconstruction times were statistically shorter for Billroth-II with Braun reconstruction than Roux-en-Y (198.1?±?33.0 vs. 242.3?±?58.1 min, p?=?0.001). One case of postoperative stricture was observed in each group. One case each of intra-abdominal abscess and delayed gastric emptying occurred in the Billroth-II with Braun group. At 1 year postoperatively, gastric residue and reflux esophagitis were not significantly different between the groups. Gastritis and bile reflux were more frequently observed in the Billroth-II with Braun group (p?=?0.004 and p?<?0.001, respectively). At 2 years postoperatively, gastric residue was not significantly different, but gastritis, bile reflux, and esophagitis were more frequent in the Billroth-II with Braun group (p?=?0.029, p?<?0.001, and p?=?0.036, respectively).

Conclusion

The postoperative effectiveness of Roux-en-Y reconstruction may be superior to Billroth-II with Braun reconstruction after laparoscopic distal gastrectomy.

     

What is the best reconstruction method after distal gastrectomy for gastric cancer?

Background

We performed this prospective randomized study to evaluate what is the best reconstruction method after distal gastrectomy for gastric cancer.

Methods

One hundred fifty-nine patients who underwent laparoscopy-assisted or open gastrectomy for gastric cancer were analyzed from March 2006 to August 2007. Billroth I (B-I) anastomosis, Billroth II (B-II) with Braun anastomosis, and Roux-en-Y (R-Y) anastomosis were applied randomly. Additionally, the patients were divided into two groups based on treatment type: laparoscopic and open operation. Endoscopy and hepatobiliary scans were performed to investigate gastric stasis and enterogastric reflux. The Gastrointestinal Quality of Life Index (GIQLI) was used to evaluate postoperative quality of life, and the hematologic test was used to assess nutritional aspect.

Results

Endoscopy revealed that reflux after the R-Y anastomosis procedure was significantly less frequent than after the other anastomosis types at 12?months. Comparison of the GIQLI and the nutritional parameters between the reconstruction types revealed that there were no differences, but a significantly higher GIQLI score was observed in the laparoscopic group immediately following the procedure (P?=?0.042).

Conclusions

R-Y anastomosis is superior to B-I and B-II with Braun anastomosis in terms of frequency of bile reflux, despite the fact that there is no difference in the postoperative quality-of-life index and nutritional status between reconstructive procedures. The laparoscopic approach is the better option than open surgery in terms of QOL in the immediate postoperative period.     

Circular Stapler Size and Risk of Anastomotic Complications in Gastroduodenostomy for Gastric Cancer

Background

A Billroth I reconstruction with a mechanically sutured anastomosis is commonly performed in gastric cancer patients. Some surgeons prefer to use large circular staplers during suturing to minimize risks for anastomotic stricture and gastric stasis after surgery. The effect of stapler size on anastomotic complications has not been validated.

Methods

This study was conducted with 1,031 patients who underwent gastrectomy and Billroth I reconstruction at Samsung Medical Center in Seoul, Korea, between January 2007 and October 2008. Patients were assigned to group A (384 patients) or group B (647 patients) depending on the size of the circular stapler that the surgeon selected for mechanical anastomosis. A 25?mm circular stapler was used for patients in group A, and a 28 or 29?mm circular stapler was used for patients in group B. Postoperative complications were analyzed retrospectively.

Results

The incidence of complications (e.g., gastric stasis, anastomotic stricture, and bleeding) did not differ significantly between groups. Age greater than 60?years was the only significant risk factor for anastomotic complications identified in univariate and multivariate analyses.

Conclusions

Stapler size was unrelated to complications, such as stricture and gastric stasis. Age was the only significant risk factor for anastomotic complications after gastroduodenostomy.     

Risk Factors for Esophagojejunal Anastomotic Leakage After Elective Gastrectomy for Gastric Cancer

Objective

The aim of this study was to investigate the correlation between intraoperative anastomotic troubles and the incidence of esophagojejunal anastomotic leakage (EJAL), and to identify risk factors for EJAL after elective gastrectomy for gastric cancer.

Methods

This study reviewed the medical and surgical records of 327 patients who underwent elective gastrectomy followed by esophagojejunostomy. A multivariate analysis was performed to determine the risk factors for EJAL.

Results

An EJAL occurred in 19 patients (5.8?%). A multivariate analysis demonstrated that hemoglobin A1c ??7.0?% (p?<?0.01), chronic renal failure (p?<?0.01), proximal gastrectomy (p?<?0.05), and anastomotic trouble during construction of the esophagojejunostomy (p?<?0.01) were independent predictors for EJAL. Anastomotic trouble during construction of esophagojejunostomy occurred in 20 patients (6.1?%), and EJAL occurred in 6 of these 20 patients (30?%). Four of ten patients (40?%) in whom an incomplete anastomosis was repaired by suturing during surgery had an EJAL, while none of seven patients who underwent re-anastomosis had this complication.

Conclusions

EJAL is strongly associated with intraoperative technical errors. To reduce this complication, proper anastomotic techniques are required. Re-anastomosis should be performed when an incomplete anastomosis is discovered during surgery.     

Comparative Study of Diabetes Mellitus Resolution According to Reconstruction Type After Gastrectomy in Gastric Cancer Patients with Diabetes Mellitus

Background

This study was conducted to investigate diabetes mellitus (DM) resolution after gastrectomy according to reconstruction type in gastric cancer patients.

Methods

Two hundred twenty-nine gastric cancer patients with DM who underwent gastrectomy with curative intent from May 2003 to December 2009 were enrolled. Changes in fasting blood sugar concentration and the dosage of oral hyperglycemic agents or insulin were compared between reconstruction types.

Results

The numbers of patients who underwent distal gastrectomy with a Billroth I (BI), Billroth II (BII), Roux-en-Y gastrojejunostomy (RYGJ), or total gastrectomy with Roux-en-Y esophagojejunostomy (RYEJ) were 119 (51.7%), 54 (23.5%), 40 (17.4%), and 16 (6.9%), respectively. DM remitted in 45 (19.7%) patients: 18 BI patients (15.1%), 11 BII patients (20.3%), 8 RYGJ patients (20.0%), and 8 RYEJ patients (50.0%). DM improved in 85 (37.1%) patients: 41 BI patients (34.4%), 25 BII patients (46.2%), 15 RYGJ patients (37.5%), and 4 RYEJ patients (25.0%). The DM remission or improvement rate was higher in the duodenal bypass group (BII, RYGJ, RYEJ) than in the BI group (67.2% vs. 49.5%, P?=?0.022), and the DM remission rate was higher in the RYEJ group than in the distal gastrectomy group (50.0% vs. 17.3%, P?=?0.002).

Conclusions

Many gastric cancer patients with DM who received a gastrectomy showed remission or improvement of DM. The duodenal bypass group had higher DM remission or improvement rate than the BI group, and the RYEJ group had the highest DM remission rate.     

Esophagogastrostomy Plus Gastrojejunostomy: A Novel Reconstruction Procedure after Curative Resection for Proximal Gastric Cancer

Objective

The choice of surgical strategy for patients with proximal gastric cancer remains controversial. In this study, we recommend that a new reconstruction procedure be performed following proximal gastrectomy.

Methods

We conducted a retrospective study involving 71 patients who underwent gastrectomy for proximal gastric cancer. Clinicopathological features, postoperative complications, nutritional status, and overall survival (OS) rate were compared among three different reconstruction approaches.

Results

There were 34 cases of proximal gastrectomy followed by esophagogastrostomy reconstruction (EG), 16 cases of total gastrectomy and Roux-en Y reconstruction (RY) and 21 cases of proximal gastrectomy followed by esophagogastrostomy plus gastrojejunostomy reconstruction (EGJ). Though the clinicopathological features, the nutritional status and OS rate were similar among the three groups of patients, the incidence of reflux esophagitis was significantly higher in the EG group (35.3 %) than the RY (6.2 %) and EGJ (9.6 %) groups(P?<?0.05). Few EGJ patients suffered from either reflux esophagitis or anastomotic stenosis.

Conclusions

The EGJ reconstruction method helps to resolve the syndrome of reflux esophagitis. Our data indicates that it is a simple, safe, and effective reconstruction procedure for PGC.     

Intracorporeal circular stapling esophagojejunostomy using the transorally inserted anvil (OrVil™) after laparoscopic total gastrectomy

Background

Laparoscopic total gastrectomy (LTG) has not become as popular as laparoscopic distal gastrectomy (LDG) because of the more difficult reconstruction technique. Despite various modifications of reconstruction methods after LTG, an optimal procedure has yet to be established. The authors report the newly developed reconstruction technique after LTG: intracorporeal circular stapling esophagojejunostomy using the transorally inserted anvil (OrVil?; Covidien, Mansfield, MA, USA).

Methods

After full mobilization of the abdominal esophagus, the esophagus is transected with an endoscopic linear stapler. The anvil is then transorally inserted into the esophagus by using the OrVil? system. After jejunojejunostomy is performed through a 4-cm midline minilaparotomy, preparing a 50-cm Roux-en-Y jejunal limb, a circular stapler is inserted into the jejunum and introduced into the abdominal cavity. Pneumoperitoneum is established by sealing off the laparotomy wound retractor with a surgical glove attached to the circular stapler. Double-stapling esophagojejunostomy with a circular stapler is performed intracorporeally, and the jejunal stump is closed with an endoscopic linear stapler.

Results

Of the 16 patients who underwent this operation, there was no intraoperative complication or conversion to open surgery, and no patient required an extension of the initial incision for anastomosis. Mean operation time and blood loss were 194 min and 272 ml, respectively. One patient developed an intra-abdominal abscess postoperatively. Postoperative fluorography revealed no anastomosis leakage or stenosis in any of the patients. Patients resumed an oral liquid diet on postoperative day 3–5, and the mean postoperative hospital stay was 11 days.

Conclusions

We have successfully performed LTG with Roux-en-Y reconstruction using our technique in 16 patients without any anastomosis complications. We believe that our procedure is a secure and reliable reconstruction method after LTG, which is especially useful in obese patients, in whom conventional extracorporeal anastomosis often is difficult.     

Evaluation of symptoms related to reflux esophagitis in patients with esophagogastrostomy after proximal gastrectomy

Purpose

We investigated postoperative symptoms related to reflux esophagitis in patients who underwent esophagogastrostomy reconstruction after proximal gastrectomy (PG) by conducting a questionnaire survey.

Method

Quality of life was assessed using two different questionnaires, the gastrointestinal symptom rating scale (GSRS) for postoperative abdominal symptoms and F-scale for reflux esophagitis. The survey was conducted among 39 patients who underwent esophagogastrostomy after proximal gastrectomy for gastric cancer in the upper third of the stomach, and findings were compared with those in patients who underwent total gastrectomy (TG).

Results

The questionnaire was returned by 32 of 39 patients (82%) in the PG group and 40 of 45 patients (89%) in the TG group. On GSRS, the score for indigestion syndrome tended to be higher in the TG group than in the PG group (p?<?0.10), and the score for constipation was significantly higher in the PG group than in the TG group (p?<?0.05). The score for reflux syndrome, however, was almost the same in both groups. Similarly, there was no significant difference in the frequency of GERD symptoms between the PG and TG groups on F-scale questionnaire (47% vs. 63%, p?=?0.18).

Conclusions

Esophagogastrostomy after PG in an end-to-side manner with creation of acute angle at the anastomosis is not associated with an increased risk of reflux esophagitis compared with TG.     

Laparoscopic gastrointestinal anastomoses using knotless barbed sutures are safe and reproducible: a single-center experience with 201 patients

Background

Intestinal anastomosis is a complex procedure during laparoscopy, mainly due to the difficulties knotting the sutures. Unidirectional barbed sutures have been proposed to simplify wall and mesentery closure, but the results for intestinal anastomosis are not clear. This study aimed to establish the feasibility and the safety of laparoscopic intestinal anastomosis using barbed suture.

Methods

Between June 2011 and May 2012, 15-cm-long unidirectional absorbable barbed sutures (V-Loc; Covidien, Mansfield, MA, USA) were used for all laparoscopic intestinal anastomoses: one suture for closure of intestinal openings after mechanical anastomoses and two sutures for hand-sewn anastomoses.

Results

Over a 1-year period, 201 consecutive patients required 220 laparoscopic anastomoses for gastrojejunostomy (n = 177; 172 during Roux-en-Y gastric bypass and 5 after gastrectomy), ileocolostomy (n = 15), colocolostomy (n = 1), esophagojejunostomy (n = 5), and jejunojejunostomy (n = 22; 4 after small bowel resection and 18 during gastric bypass or gastrectomy). Senior and training surgeons performed 209 closures of intestinal openings and 11 hand-sewn anastomoses. There was no conversion to usual sutures. One fistula occurred in an esophagojejunostomy and was managed conservatively. One self-limited anastomotic bleeding occurred, and no anastomotic stenosis occurred during 6 months of follow-up evaluation.

Conclusions

The use of knotless barbed suture for laparoscopic intestinal anastomosis is safe and reproducible.     

Long- and short-type double-balloon enteroscopy-assisted therapeutic ERCP for intact papilla in patients with a Roux-en-Y anastomosis

Background

There have been a few previous reports on attempted double-balloon endoscopy (DBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y anastomosis and an intact papilla. This study was designed to evaluate the usefulness of DBE-assisted ERCP in patients with Roux-en-Y anastomosis and an intact papilla of Vater.

Methods

Thirteen DBE procedures were performed in nine patients who had undergone Roux-en-Y reconstruction combined with eight total gastrectomies and one partial gastrectomy. Both short-type and long-type DBE were used. Long-type DBE was replaced with a conventional forward-viewing upper endoscope after reaching the papilla. Technical success rate, measurement of procedure times, and adverse events were evaluated in the retrospective study.

Results

In all cases, the scopes could reach the papilla. The mean time required to reach the papilla was 48 (range, 13?C90) min. There was a statistically significant difference with the short and long scope (29.0?±?19.2?min vs. 64.8?±?24.7?min, respectively; P?=?0.044). The success rate of bile duct cannulation, resulting in achieving therapeutic ERCP on the first session was 66.7% (6/9). The mean procedural time in the successful cases was 128 (range, 47?C183) min. Finally, therapeutic ERCP was achieved in all nine cases. There was one adverse event in which retroperitoneal perforation during lithotripsy, but that was successfully treated by conservative therapy alone.

Conclusion

DBE-assisted ERCP seems to be a promising option to perform therapeutic ERCP for intact papilla in patients with a Roux-en-Y anastomosis.     

Effects of Roux-en-Y operations on glucose homeostasis in obese GK rats

Aim

To investigate the therapeutic effects of different styles of gastric bypass surgery on type 2 diabetes mellitus (T2DM) GK rats.

Methods

Twenty 6?C8-week-old male GK rats were randomly divided into four groups: group A was operated by Roux-en-Y gastrojejunostomy with duodenum exclusion and stomach capacity maintenance, group B was operated by loop-type gastrojejunostomy with duodenum exclusion and stomach capacity maintenance, group C was operated by Roux-en-Y gastrojejunostomy with partial gastrectomy, and group D was operated by loop-type gastrojejunostomy with partial gastrectomy. Changes of fasting blood glucose, oral glucose tolerance test (OGTT), and insulin tolerance test (ITT) in different operations were detected.

Results

The operations exerted good effects on controlling blood glucose in groups A, B, C, and D. There was no significant difference between groups A and C (P?>?0.05) or between groups B and D (P?>?0.05), while operations in groups A and C were more effective than groups B and D (P?P?P?Conclusions Gastric bypass surgery might be effective to treat type 2 diabetes mellitus (T2DM), and Roux-en-Y gastrojejunostomy might be more effective than other operative styles.     

Superiority of stapled side-to-side gastrojejunostomy over conventional hand-sewn end-to-side gastrojejunostomy for reducing the risk of primary delayed gastric emptying after subtotal stomach-preserving pancreaticoduodenectomy

Background and purpose

Delayed gastric emptying (DGE) is the most common complication following pancreaticoduodenectomy (PD). The clinical efficacy of stapled side-to-side anastomosis using a laparoscopic stapling device during alimentary reconstruction in PD is not well understood and its superiority over conventional hand-sewn end-to-side anastomosis remains controversial. The objective of this study was to evaluate the effectiveness of the stapled side-to-side anastomosis in preventing the development of DGE after PD.

Methods

The subjects of this retrospective study were 137 patients who underwent pancreaticoduodenectomy, as subtotal stomach-preserving pancreaticoduodenectomy (SSPPD; n?=?130), or conventional whipple procedure (n?=?7) with Child reconstruction, between January 2010 and May 2014. The patients were divided into two groups according to whether they had had a stapled side-to-side anastomosis (SA group; n?=?57) or a conventional hand-sewn end-to-side anastomosis (HA group; n?=?80).

Results

SA reduced the operative time (SA vs. HA: 508 vs. 557 min, p?=?0.028) and the incidence of delayed gastric emptying (SA vs. HA: 21.1 vs. 46.3%, p?=?0.003) and was associated with shorter hospitalization (SA vs. HA: 33 vs. 39.5 days, p?=?0.007). In this cohort, SA was the only significant factor contributing to a reduction in the incidence of DGE (p?=?0.002).

Conclusions

Stapled side-to-side gastrojejunostomy reduced the operative time and the incidence of DGE following PD with Child reconstruction, thereby also reducing the length of hospitalization.

     

Outcome After Curative Surgery for Gastric Cancer Patients with Type 2 Diabetes

Background

Bariatric surgery has been adapted to the management of morbid obesity, leading to not only loss of body weight but also improvement of type 2 diabetes mellitus (DM). The goal of our study was to evaluate the effect of gastrectomy in gastric cancer patients with type 2 DM.

Methods

From 1989 to 2011, a total of 69 gastric cancer patients receiving curative surgery were enrolled in this study. They were diagnosed with type 2 DM preoperatively and all are alive without tumor recurrence. The clinical characteristics were compared between groups with improved or unimproved DM, and groups were also analyzed based on the extent of gastrectomy and different reconstruction methods.

Results

Of the 69 patients, 58 received subtotal gastrectomy and 11 received total gastrectomy. The frequency of DM improvement was significantly higher after total gastrectomy than subtotal gastrectomy (81.8 vs. 36.2 %; p = 0.007). Patients with DM duration of less than 5 years tended to experience DM improvement after surgery more frequently than patients with DM duration of more than 5 years (p = 0.028). Roux-en-Y esophagojejunostomy (R-Ye) led to a higher rate of DM improvement than did R-Y gastrojejunostomy (R-Yg), especially in patients with DM duration more than 5 years. Among patients receiving duodenal bypass after gastrectomy, R-Ye was associated with a higher frequency of DM improvement than R-Yg and B-II.

Conclusions

The extent of gastrectomy rather than the reconstruction method played an important role in DM improvement after curative surgery for gastric cancer.     

Usefulness of Pyloric Reconstruction Without Compromising Curative Resection in Gastric Cancer Treatment

Introduction

We herein report the short-term results of the newly developed modified technique of Billroth I (modified B-I; pylorus reconstruction) that prevents duodenogastric reflux (DGR) and remnant gastritis after distal gastrectomy.

Patients and Methods

Distal gastrectomy with this technique was performed in 20 patients (age, 41 to 86?years [mean, 68.5?±?11.8?years], male/female?=?12:8) with gastric cancer from June 2006 through December 2009. These patients were compared with another 20 patients who underwent conventional B-I after distal gastrectomy (age, 41 to 85?years [mean, 69.3?±?8.69?years], male/female?=?11:9). The side effects of gastric surgery evaluated in this study were the degree of remnant gastritis, the presence of dumping syndrome, and the degree of weight loss.

Results

By gastrografin contrast imaging on the fifth day after pylorus reconstruction, the remnant stomach was not dilated and gastrografin flowed physiologically to the duodenum without backward reflux into the remnant stomach. By gastroscopy at 6?months after the operation, DGR and the degree of remnant gastritis after pylorus reconstruction was lower than those of conventional B-I (P?=?0.00068). The bile acid concentration of remnant gastric juice of pylorus reconstruction was lower than that of conventional B-I (55.5?±?93.5 vs. 1,369.5?±?2,502.1???mol/L, P?=?0.0415). Weight loss at 1?year after distal gastrectomy was less in pylorus reconstruction compared with conventional B-I (6.2?±?5.2% vs. 9.8?±?8.7%, P?=?0.0725).

Conclusion

Pylorus reconstruction is a simple and safe anastomotic technique that reduces the side effects of B-I reconstruction.     

Short-term surgical outcomes and operative risks of laparoscopic total gastrectomy (LTG) for gastric carcinoma: experience at a large-volume center

Background

Despite the popularity of laparoscopic distal gastrectomy (LDG), laparoscopic total gastrectomy (LTG) remains a challenging procedure because of its technical difficulties and possible complications. In this study, the authors evaluated the short-term surgical outcomes and operative risks of LTG.

Methods

The records of 118 patients who underwent LTG for middle or upper gastric cancer were retrieved from a prospectively constructed database of 1,064 patients who underwent laparoscopic gastrectomy between 2007 and 2011. Surgical outcomes of LTG, such as operative results, postoperative courses, morbidities, and mortality, were investigated and compared with those of LDG patients.

Results

Of the 118 LTG patients, one underwent open conversion and three experienced an intraoperative complication. Mean operating time was 292?±?88?min, and the mean total number of harvested lymph nodes was 41?±?16. As compared with the LDG group, the LTG group had a significantly longer operation time (292 vs. 220?min, p?<?0.001), and significantly more intraoperative blood loss (256 vs. 191?ml, p?=?0.002). The overall morbidity rate after LTG was 22.9?%, which was significantly higher than after LDG (12.7?%, p?=?0.002). There were two postoperative mortalities in the LTG group. The most common complications after LTG were anastomosis leakage (n?=?9) and luminal bleeding (n?=?9), which were followed by anastomosis stricture (n?=?4) and abdominal infection (n?=?3). Univariate and multivariate analysis revealed that old age [??60?years, odds ratio (OR)?=?2.55, 95?% confidence interval (CI)?=?0.95?C6.84], intraoperative blood loss >200?ml (OR?=?3.33, 95?% CI?=?1.14?C9.70), and D2 lymphadenectomy (OR?=?3.87, 95?% CI?=?1.30?C11.55) were independent risk factors for postoperative complications after LTG.

Conclusions

LTG is a feasible and acceptable procedure for treatment of middle or upper early gastric cancer. Further refinement of anastomosis techniques and considerable experience of laparoscopic gastrectomy are required for proper application of LTG in gastric carcinoma.     

Anastomosen im oberen Gastrointestinaltrakt

Background

Anastomotic leaks are the major postoperative complications mainly due to technical difficulties. The aim was to review anastomotic techniques and risk factors for leak development.

Methods

A Pubmed search was perfomed using the terms esophagogastric/esophagojejunal anastomosis, gastrojejunostomy, gastric bypass, esophagectomy, anastomotic leak/risk factors, gastrectomy, TEA, fluid management, early enteral feeding and reinforcement. English and German literature sources were included with the accent on recent prospective randomized controlled trials (pRCT) with high numbers of cases as well as meta-analyses.

Conclusions

There is not enough evidence to recommend either hand sewn or mechanical anastomoses. Surgical skills and routine as well as precise work are necessary to reduce complications. Although stapling leads to uniformity of anastomoses it cannot compensate for surgical deficits.     

Robot-Assisted Versus Laparoscopic Gastric Bypass: Comparison of Short-Term Outcomes

Background

Roux-en-Y gastric bypass is an effective treatment for severe obesity and obesity-related comorbidities. Presently, gastric bypass is performed most often laparoscopically, although a robotic-assisted procedure is the preferred approach for an increasing number of bariatric surgeons.

Methods

This retrospective study compared the results of 100 Roux-en-Y gastric bypass operations using the da Vinci robot and 100 laparoscopic Roux-en-Y gastric bypasses performed laparoscopically. Short-term outcomes were determined by evaluating mortality, length of stay, length of operation, return to the operating room within 90 days of operation, conversions to open procedure, leaks, strictures, transfusions, and hospital readmissions.

Results

There was no mortality, pulmonary embolus, or conversion to open procedure in either group. Both the laparoscopic and robotic operative times decreased progressively, although the robotic operation time was longer (mean, 144 versus 87 min, P?<?0.001). The length of stay was shorter for the robotic-assisted group (37 versus 52 h, P?<?0.001), and 60 % of these patients were discharged after one night’s stay (P?<?0.001). There were fewer transfusions (P?=?0.005) and readmissions (P?=?.560) in the robotic group. The stricture rate was higher in the first 50 robotic procedures (17 mm gastrotomy) but resolved in the second 50 procedures (21 mm gastrotomy). There was no difference in the rate of leak and return to the operating room between groups (both P?>?0.05).

Conclusions

These results indicate that Roux-en-Y gastric bypass can be performed safely with robotic assistance, even during the first 100 cases.     

Early Post-operative Complications: Incidence, Management, and Impact on Length of Hospital Stay. A Retrospective Comparison Between Laparoscopic Gastric Bypass and Sleeve Gastrectomy

Background

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are the most common obesity surgeries. Their early complications may prolong hospital stay (HS).

Methods

Data for patients who underwent LRYGB and LSG in our clinic from 2009 through August 2012 were collected. Early post-operative complications prolonging HS (>5 days) were retrospectively analyzed, highlighting their relative incidence, management, and impact on length of HS.

Results

Sixty-six patients (4.9 %) after 1,345 LRYGB operations vs. 49 patients (7.14 %) after 686 LSG operations developed early complications. This difference is statistically significant (p?=?0.039). Male gender percentage was significantly higher in complicated LSG group vs. complicated LRYGB group [23 patients (46.9 %) vs. 16 patients (24.2 %)] (p?=?0.042). Mean BMI was significantly higher in the complicated LSG group (54.2?±?8.3) vs. complicated LRYGB group (46.8?±?5.7; p?=?0.004). Median length of HS was not longer after complicated LSG compared with complicated LRYGB (11 vs. 10 days; p?=?0.287). Leakage and bleeding were the most common complications after either procedure. Leakage rate was not higher after LSG (12 patients, 1.7 %) compared with LRYGB (22 patients, 1.6 %; p?=?0.304). Bleeding rate was significantly higher after LSG (19 patients, 2.7 %) than after LRYGB (10 patients, 0.7 %; p?=?0.004). Prolonged elevation of inflammatory markers was the most common presentation for complications after LSG (18 patients, 36.7 %) and LRYGB (31 patients, 46.9 %).

Conclusions

LSG was associated with more early complications. This may be attributed to higher BMI and predominance of males in LSG group.     

Clinical significance of medial approach for suprapancreatic lymph node dissection during laparoscopic gastric cancer surgery

Objective

Suprapancreatic lymph node dissection is critical for gastric cancer surgery. Beginning in 2010, a medial approach was adopted for suprapancreatic lymph node dissection during laparoscopic gastrectomy for distal gastric cancer in our institution. The aim of this study was to compare surgical outcomes of the medial approach and conventional approach in laparoscopic gastric surgery.

Methods

Between January 2007 and December 2012, a total of 100 patients with clinical T1 or T2 tumors underwent laparoscopic distal gastrectomy involving suprapancreatic lymph node dissection by the medial approach (n = 44) and conventional approach (n = 56) with curative intent. The comparison was based on clinicopathological characteristics and surgical outcome.

Results

The laparoscopic procedure was not converted to laparotomy in any patient. The patients’ demographics and tumor characteristics did not show any statistically significant difference, except for tumor location. In the conventional approach group, the tumors were at a higher position (p = 0.037) and more frequently received Roux-en-Y reconstruction (p < 0.001). Intracorporeal anastomosis was significantly more common in the medial approach group (p < 0.001). Compared with the conventional approach, the medial approach was associated with significantly less operative blood loss (p < 0.001), more retrieved suprapancreatic lymph nodes (p = 0.019), and a shorter hospital stay (p = 0.018). The rates of complications were comparable between the two groups.

Conclusion

This study suggests that the medial approach to suprapancreatic lymph node dissection seems to be convenient and useful in laparoscopic gastric cancer surgery.