Endoscopic hemostasis using endoclip in early gastrointestinal hemorrhage after gastric bypass surgery

Roux-en-Y gastric bypass (RYGBP) is the most commonly performed bariatric operation in the USA. In the early postoperative stage, gastrointestinal (GI) bleeding is an infrequent but potentially serious complication that usually results from bleeding at the gastroje-junostomy staple-line. Observant management with transfusion for stable patients and surgical exploration for unstable patients is typically recommended for early GI bleeding. We hypothesized that use of endoclips, which do not cause thermal injury to the surrounding tissues (or anastomosis), may be preferable to thermal approaches which could cause tissue injury. We report 2 cases of early GI bleeding after RYGBP that were successfully managed with endoclip application to bleeding lesions. Emergent endoscopy was performed, and major stigmata such as active spurting vessel and adherent clot were noted at the gastrojejunostomy staple-lines. Endoscopic hemostasis using endoclips was readily applied to bleeding lesions at staple-lines. Primary hemostasis was achieved, and there was no recurrent bleeding or complication. We conclude that therapeutic endoscopy can be performed safely for early bleeding after RYGBP. In patients with early bleeding after RYGBP, use of endoclips is mechanistically preferable to other options.     

Reduction of Circular Stapler-Related Wound Infection in Patients Undergoing Laparoscopic Roux-en-Y Gastric Bypass,Cleveland Clinic Technique

Background  

Circular-stapled anastomosis with trans-oral anvil insertion for the creation of the gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass (LRYGBP) is associated with frequent infections at the abdominal wall site where the circular stapler is inserted.     

Effect of staple height on gastrojejunostomy during laparoscopic gastric bypass: a multicenter prospective randomized trial

BackgroundGastrointestinal (GI) bleeding and anastomotic stricture are frequent complications associated with the construction of the gastrojejunostomy during laparoscopic gastric bypass. Staplers with shorter staple height can reduce the rate of postoperative GI hemorrhage. The aim of the present study was to assess the outcomes of patients who had undergone gastric bypass with construction of the gastrojejunostomy using a 25-mm circular stapler with a 3.5- versus 4.8-mm staple height.MethodsFrom January 2007 to February 2009, 357 patients underwent laparoscopic gastric bypass using a circular stapler for construction of the gastrojejunostomy were randomly assigned to either the 3.5-mm (n = 180) or 4.8-mm (n = 177) group. Two patients randomized to the 4.8-mm group did not undergo the operative procedure and were excluded from the analysis. The primary outcome measures included the rate of GI hemorrhage, anastomotic stricture, and wound infection.ResultsThe 2 groups were similar with regard to the demographics and baseline body mass index (47 versus 48 kg/m²). The operative time, blood loss, and postoperative hematocrit on day 2 were similar between the 2 groups. No significant differences were seen in the overall rate of intraoperative GI bleeding or postoperative GI bleeding from all sources (3.3% for 3.5 mm versus 6.3% for 4.8 mm, P >.05); however, a trend was seen toward a lower rate of postoperative GI bleeding from the gastric pouch or gastrojejunostomy (.5% for 3.5 mm versus 3.4% for 4.8 mm, P = .06). The rate of anastomotic stricture was significantly lower in the 3.5-mm group (3.9% versus 16.0%, P <.01). No significant differences were seen in rate of wound infection between the 2 groups. Other morbidities for the entire study cohort included leaks (1.1%), pulmonary embolism (.6%), gastrointestinal obstruction (1.4%), and reoperation (3.4%). The overall in-hospital mortality rate was .3%, and the 30-day mortality rate was .8%.ConclusionsIn the present prospective, randomized trial, using a circular stapler with a shorter staple height (3.5 mm) during construction of the gastrojejunostomy, significantly reduced the rate of postoperative anastomotic stricture, with a trend toward a lower rate of GI bleeding from the gastrojejunostomy.     

The impact of circular stapler diameter on the incidence of gastrojejunostomy stenosis and weight loss following laparoscopic Roux-en-Y gastric bypass

Background Gastrojejunostomy stenosis after laparoscopic Roux-en-Y gastric bypass is a common occurrence. The incidence varies widely among reported series. We evaluated the impact of circular stapler size on the rate of stenosis and weight loss. Methods Our initial technique utilized a 21-mm circular stapler to construct the gastrojejunostomy. We switched to a 25-mm stapler after a large preliminary experience. Stenosis was confirmed by endoscopy in patients complaining of the inability to eat or excessive vomiting, and was defined as a gastrojejunostomy diameter less than that of a therapeutic endoscope (11-mm). Results Stenosis occurred in 23 of 145 patients (15.9%) with a 21-mm gastrojejunostomy. Five of 81 patients with a 25-mm circular stapled anastomosis have developed a stenosis (6.2%, p = 0.03). Weight loss was similar for each sized stapler at 6 and 12 months. Conclusions The use of a 25-mm circular stapler in laparoscopic gastric bypass is preferable to a 21-mm stapler. The larger stapler is associated with a significantly decreased incidence of gastrojejunostomy stenosis without compromising early weight loss.     

Transumbilical single-incision laparoscopic intracorporeal anastomosis for gastrojejunostomy: case report

Background  Laparoscopic gastrojejunostomy allows effective palliation and rapid recovery for the patient with limited survival due to advanced pancreatic cancer presenting with gastric outlet obstruction. Transumbilical single-incision laparoscopic surgery (SILS) offers excellent cosmetic results and may be associated with decreased postoperative pain, reduced need for analgesia, and thus accelerated recovery. The authors report the first transumbilical single-incision laparoscopic intracorporeal anastomosis for gastrojejunostomy. Methods  Preliminary experience with transumbilical single-incision, intracorporeal anastomosis for gastrojejunostomy for a patient with gastric outlet obstruction caused by advanced pancreatic cancer is reported. Results  Transumbilical single-incision laparoscopic intracorporeal anastomosis for gastrojejunostomy was performed with a linear endoscopic stapler using an omega loop. The operative time was 117 min. No intra- or postoperative complications were recorded. Conclusion  Transumbilical single-incision laparoscopic intracorporeal anastomoses are feasible using the endoscopic linear stapler. Transumbilical single-incision gastrojejunostomy for gastric outlet obstruction may improve cosmetic results and allow accelerated recovery for patients with limited survival. This anastomosis technique of single-incision laparoscopic surgery for other digestive tract procedures needs further evaluation.     

Evaluation of the excluded stomach by double-balloon endoscopy after laparoscopic Roux-en-Y gastric bypass

Background: Morbid obesity has become a serious health problem. We have been performing laparoscopic Roux-en-Y gastric bypass (LRYGBP) for morbid obesity since February 2002. Although LRYGBP ameliorates complications of morbid obesity, postoperative investigation of the excluded stomach is difficult. In patients with a family history of gastric cancer, resection of the bypassed stomach is sometimes added, but this requires longer operating time. There are two problems associated with LRYGBP: the high rate of gastric cancer in Japan, and how to investigate the excluded stomach. Methods: To resolve these problems, we introduced double-balloon intestinal endoscopy. We report double-balloon endoscopy (DBE) in 4 patients. Results: No problems with advancing the endoscope were encountered during observation. We used an overtube to insert the scope further in order to avoid forming redundant loops in the small intestine, and two balloons to grip the intestinal wall. Although performing DBE involves a learning curve, there were no major obstacles to passage of the scope into the esophagus, small gastric pouch, lifted jejunum, the jejunojejunal anastomosis, Y-loop, duodenum and excluded stomach. Conclusion: Use of the double-balloon technique makes it possible to observe the GI tract after laparoscopic LRYGBP irrespective of the length between the gastrojejunostomy and the jejunojejunostomy.     

Laparoscopic Roux-en-Y gastric bypass with linear cutter technique: comparison of four-row versus six-row cartridge in creation of anastomosis.

BACKGROUND: Morbid obesity is refractory to medical treatment. The introduction of laparoscopic linear staplers in the early 1990s contributed to the development of the laparoscopic Roux-en-Y gastric bypass technique. Many series have compared different brands of circular and linear staplers. The purpose of this study was to evaluate the 4-row versus 6-row endoscopic staplers in laparoscopic Roux-en-Y gastric bypass for creation of the anastomosis. METHODS: Between July 2000 and April 2004, 1240 patients underwent laparoscopic Roux-en-Y gastric bypass. The 4-row linear stapler was used in the first 664 cases (group 1) and the 6-row stapler in the latter 576 patients (group 2) to create the anastomosis. The medical records of those patients who developed leaks, gastrogastric fistulas, strictures, or bleeding were reviewed. Strictures were diagnosed using radiologic or endoscopic techniques. RESULTS: Leaks were more frequent in group 2 than in group 1 (1.56% versus 1.05%, respectively, P = .46). Documented bleeding occurred in 15 and 13 patients in groups 1 and 2, respectively (2.26% for both). Strictures were diagnosed in 7.68% of patients in group 1 (51 gastrojejunostomy and 4 jejunojejunostomy), and in 4.3% of those in group 2 (25 gastrojejunostomy stenosis, P = .017). Gastrogastric fistulas were found in 5 patients (.75%) in group 1 and 6 (1.04%) in group 2. CONCLUSION: Using a 6-row instead of a 4-row linear cutter technique to create the anastomosis yielded similar results, but the stricture rate at the gastrojejunal anastomosis was significantly lower with the newer, 6-row staplers.     

Lessons Learned from the First 100 Cases in a New Minimally Invasive Bariatric Surgery Program

Background:Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a technically demanding procedure with a steep learning curve. Experienced laparoscopic surgeons and bariatric surgeons can learn from the outcomes and complications of their initial experience in LRYGBP.n Methods: Between August of 2002 and July of 2003, we performed our first 100 LRYGBPs. Our surgical technique involves the ante-colic, ante-gastric placement of the Roux-limb. A 21-mm circular stapler is used to create the gastrojejunostomy. The stapler anvil is placed transgastrically.n Results:The mean preoperative BMI was 49.7 kg/m² (range 37-70). 12% of patients were male. Early complications (14%) included 3 leaks, 4 bleeding episodes and 2 gastrogastric fistulas. There was 1 peri-operative mortality and 1 conversion to laparotomy. Late complications (17%) included stenosis of the gastrojejunostomy which occurred in 14 patients. Leaks occurred more commonly in males (16% vs 1%, P<0.05). Elevated BMI was also found to be a risk factor for leak (BMI 58.7 leak vs 49.3 no leak, P<0.05). Stenosis was often associated with other complications such as leak or marginal ulcer. Stenosis responded well to endoscopic dilation. Co-morbid medical conditions responded to weight loss in all patients, regardless of initial BMI. Mean excess weight loss was 69% at 1 year, but varied according to preoperative BMI. Conclusions: Careful recording of patient outcomes and complications is important, particularly in a new minimally invasive bariatric surgery program. Review and analysis of specific complications may help to minimize the occurrence of similar subsequent complications.     

Laparoscopic Roux-en-Y Gastric Bypass:Transoral Or Transgastric Anvil Placement?

Background: Laparoscopic techniques have been used to perform the Roux-en-Y gastric bypass (RYGBP). The gastrojejunostomy may be constructed using an end-to-end anastomosis (EEA) stapler. Most reports describe passing the EEA anvil transorally using an esophagogastroscope and a pullwire technique. Method: We describe problems experienced using this technique and present an alternative method. Results: Esophageal injury may occur during laparoscopic RYGBP (LRYGBP) using the transoral anvil placement technique. When the anvil is retrieved into the gastric pouch, the anvil may become lodged at the cricopharngeus muscle. Dislodgment can be problematic and time-consuming. We present a case of mild esophageal injury which occurred during transoral anvil placement. The patient had transient postoperative dysphagia and recovered without sequelae. We present an alternative method in which the anvil is passed through a gastrotomy. Conclusion: Transgastric anvil placement alleviates the need for endoscopy, thereby saving time and resources.This technique eliminates the potential for esophageal injury. The transgastric anvil placement technique has proven reliable. The transgastric method may make the LRYGBP operation safer and easier to perform.     

Laparoscopic Roux-en-Y gastric bypass--evaluation of three different techniques

Background:The Roux-en-Y gastric bypass (RYGBP) is one of the ideal operations for morbid obesity.The minimal invasive laparoscopic technique has been performed to shorten the operative time and to reduce the complications of the open surgery. Methods: From Jan 1999 through Jan 2001, laparoscopic RYGBP (LRYGBP) was attempted in 90 patients. Median age was 30, with median preoperative BMI 47. The preoperative nutritional habits and comorbidities were recorded. LRYGBP was done by three different techniques in three equal groups. In the first group, the gastrojejunostomy was constructed by passing the EEA anvil transorally, using a pull-wire technique. In the second group, the gastrojejunostomy was fashioned with a totally hand-sewn technique. In the third group, the gastrojejunostomy was performed with an endo-cutter cartridge and the anastomotic incision was closed with an endo TA30 stapler. Results: The results were nearly identical in the three groups. Average excess weight loss at 1 year was 70%. The mean operating time was 120 min in the first group, 100 min in the second group and 75 min in the third group. Esophageal injury was the most common problem in the first group. Incidence of gastrojejunostomy stenosis was higher in the second group (36.6%). Incidence of internal herniation was higher in the second (17%) and first (13.6%) groups than in the third group (3.3%). Conclusion: Whichever technique is used to construct the gastrojejunostomy, LRYGBP is a safe, effective and technically feasible operation for morbidly obese patients. We recommend the technique of constructing the gastrojejunostomy with an endocutter cartridge and closing the anastomotic incision with an endo TA stapler, as it saved time and reduced the incidence of the essential complications in gastric bypass surgery.     

Laparoscopic Roux-en-Y Gastric Bypass with Remnant Gastrectomy for Focal Intestinal Metaplasia of the Gastric Antrum

Background: Inaccessibilility of the excluded stomach after isolated gastric bypass prevents postoperative evaluation and treatment of disorders of the gastric remnant. Bleeding complications, peptic ulcer disease, and gastric malignancy in the gastric remnant have all been reported. We report a patient with morbid obesity and focal intestinal metaplasia in the antrum of the stomach that was treated with laparoscopic Roux-en-y gastric bypass (LRYGBP) with remnant gastrectomy. Case Report: A 46-year-old female with a long history of morbid obesity presented with a BMI of 47 kg/m². Preoperative upper endoscopy revealed focal intestinal metaplasia. Since intestinal metaplasia is a risk factor for gastric cancer, a LRYGBP with remnant gastrectomy was performed. Conclusions: LRYGBP with remnant gastrectomy is a safe and cost-effective treatment for morbidly obese patients with focal intestinal metaplasia of the stomach.     

A zero leak rate in 251 consecutive laparoscopic gastric bypass operations using a two-layer gastrojejunostomy technique

PURPOSE: Laparoscopic Roux-en-Y gastric bypass is quickly replacing open techniques in the morbidly obese patient who presents for surgical treatment. Safety concerns about the laparoscopic technique have arisen in the literature with gastrojejunostomy leak rates of 5% or greater reported in several series. MATERIALS AND METHODS: A total of 251 consecutive gastric bypass operations were performed from August 2001 to January 2004 by a single surgeon with over 6 years' experience. A double layer technique was used for every gastrojejunostomy anastomosis. This consisted of end-to-side stapled anastomosis using only 30 mm of a 45 mm blue (3.5 mm) staple cartridge that was fired inside the gastric pouch and Roux limb. A posterior running suture was then used to reinforce the back wall. An intraluminal 32F bougie was placed before the stapler opening was closed. Finally, 2 running sutures were used to reinforce the anterior and lateral sides of the anastomosis. RESULTS: The average patient age was 43 years (range, 18-67 years), 89% were female, average preoperative weight was 137 kg (range, 89.5-214.5 kg), and average body mass index of 49 kg/m2 (range, 35-75). One hundred forty-two cases were performed with the Ethicon endoscopic linear stapler and 109 with the United States Surgical endoscopic linear stapler. There were no anastomotic leaks, staple line leaks, pulmonary emboli, or in-hospital deaths recorded. Endoscopic dilation successfully treated 10 (4%) cases of stomal stenosis. Eleven (4%) patients developed marginal ulcers that were easily treated with a proton pump inhibitor. Average excess weight loss at 12 months and 18 months was 63% and 71%, respectively. CONCLUSIONS: Laparoscopic results are as good as or better than open surgery in the morbidly obese patient. The learning curve for this operation is steep and this may be reflected in the higher leak rates reported in earlier series. However, the technique used to create the gastrojejunostomy anastomosis may also account for a lower leak rate. The two-layer gastrojejunostomy anastomotic technique combines an inner stapled layer and outer sutured layer that yields excellent results.     

Shorter circular staple is height associated with lower anastomotic stricture rate in laparoscopic gastric bypass

BackgroundAnastomotic stenosis, leak, and hemorrhage are common stapler-related complications of laparoscopic Roux-en-Y gastric bypass. In May 2007, we transitioned from a 25-mm diameter, 4.8-mm-height circular stapler to a 25-mm, 3.5-mm-height circular stapler. We hypothesized that the staple height would be associated with a decreased incidence of perioperative complications.MethodsThe records of 360 consecutive patients who had undergone laparoscopic Roux-en-Y gastric bypass from May 1, 2006 to March 31, 2008 were retrospectively abstracted. The National Surgical Quality Improvement Project and Michigan Bariatric Surgery Collaborative databases were used to collect the patient demographics and track complications of laparoscopic Roux-en-Y gastric bypass. Data were collected on the rates of anastomotic stenosis requiring dilation of the gastrojejunostomy, anastomotic leak, hemorrhage requiring transfusion, and wound infection. Patients with a 4.8-mm staple height gastrojejunostomy were compared with those with a 3.5-mm staple height gastrojejunostomy for differences in complications.ResultsThe groups were similar with respect to age, gender, body mass index, hypertension, hyperlipidemia, diabetes, sleep apnea, and surgery duration. In the 4.8- and 3.5-mm staple height groups, 15% and 6.1% required gastrojejunal dilation, respectively (P = .01). A trend was seen toward a decrease in postoperative hemorrhage (5% versus 2.8%) with the shorter staple height. No anastomotic leaks occurred, and the incidence of wound infection (1.7% versus 2.2%) was similar between the 2 groups.ConclusionIn the present study, the use of a 25-mm, 3.5-mm staple height circular stapler was associated with a decreased rate of anastomotic stenosis.     

Fatal Fulminant Pancreatitis After Laparoscopic Gastric Bypass Surgery

Current widespread application of laparoscopic techniques in Roux-en-Y gastric bypass (RYGBP) is making surgical safety an increasingly important issue. We report one case that resulted in death due to postoperative fulminant acute pancreatitis after laparoscopic RYGBP was performed when this procedure was still relatively new in China. The patient was a chronically obese 19-year-old male. Weight loss medications had been ineffective, and preoperative body mass index was 40.7. Preoperative examination revealed moderate steatohepatitis. Laparoscopic RYGBP (LRYGBP) was performed. Early manifestations of clinical shock appeared 13 h after the laparoscopic surgery. A second laparoscopic examination showed small-vessel hemorrhage at the posterior wall of the jejunojejunal anastomosis, with blood clot formation resulting in Roux limb and afferent loop obstruction. Fulminant acute pancreatitis developed in the patient 18 h after the second surgery. The patient died 15 days later from systemic multiorgan insufficiency. LRYGBP (postcolon) is a technically demanding procedure for surgeons who are not experienced in this operation. In addition, surgical tolerance is reduced in morbidly obese patients. Therefore, special care should be taken during surgery, and hemostasis must be achieved at all bleeding sites. Increased perioperative surveillance allows for early detection and management of severe complications.     

Hand-Assisted Laparoscopic Roux-En-Y Gastric Bypass: Aspects of Surgical Technique and Early Results

Background: The efficacy of Roux-en-y gastric bypass (RYGBP) for morbid obesity is well documented. We investigated the role of the Hand-assisted laparoscopic technique for performing RYGBP. Methods: In an open series, 13 patients (all female, median age 38, BMI 45 kg/m2) underwent Hand-assisted laparoscopic RYGBP. The HandPort was introduced through an 8-cm right subcostal incision. The stomach was always completely transected.The Roux limb was made > 50 cm and brought to the proximal gastric pouch (4 x 3 cm) behind the colon and the excluded stomach. A circular stapler (no. 21) was used for the gastrojejunostomy, with the anvil introduced through a gastrotomy. Results: The HandPort device could be successfully placed and allowed good working conditions in all patients. Median duration of surgery (including learning-curve time) and postoperative hospital stay were 205 min and 5 days, respectively. The amount of morphine needed (PCA) during postoperative day 1-3 were 45, 32 and 18 mg, respectively. One patient (8%) was converted to full laparotomy for safe closure of a small perforation of the proximal gastric pouch caused by the anvil of the circular stapler. All patients made an uneventful recovery. Two patients needed endoscopic dilatation of a relative stricture at the gastrojejunostomy. Conclusion: We believe that Hand-assistance makes Lap-RYGBP faster and safer without losing the essential benefits of total laparoscopy.     

Stenosis of the Gastroenterostomy after Laparoscopic Gastric Bypass

Background: Stenosis of the gastroenterostomy after laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a serious problem that occurs after stapled (linear or circular) and hand-sewn anastomoses. Methods: Data was prospectively entered into a database to track complications of bariatric surgery. Between Feb 27, 1999 and June 13, 2000, 1000 patients underwent LRYGBP. All patients met NIH criteria for bariatric surgery.The gastroenterostomy was constructed with a linear stapler inserted to 20 mm (15 mm cut). The stapler defect was closed with a polyester running suture to construct a 12-mm diameter anastomosis. The anastomosis was banded with fascia lata to prevent late enlargement. All patients with suspected stenosis were endoscoped. Results: 32 patients (3.2%) developed stenosis (<10 mm diameter orifice) at the gastroenterostomy.There were 27 females. Average age was 44.8. Average BMI was 45.0. Average stenotic orifice was 5.7 mm in diameter. Stenoses occurred in 18 of 32 patients (56.3%) by 3 months, 26 (81.3%) by 6 months, and 31 (96.9%) by 1 year. 30 of the 32 patients underwent endoscopic dilation as initial therapy. 17 of the 32 underwent multiple dilations. Dilation caused 4 perforations, resulting in 2 emergency operations. Perforation occurred at the first attempt at dilation in 3 of 4 patients. Stenoses could not be successfully dilated in 8 patients, and all 8 underwent surgical revision. There were no deaths in these 32 patients, but there were 68 dilations and 10 re-operations. Conclusion: Stenosis of the gastroenterostomy after LRYGBP is an infrequent but serious problem, which results in considerable morbidity.     

Non-closure of Defects during Laparoscopic Roux-en-Y Gastric Bypass

Background The concern about internal hernias has prompted recommendations for routine closure of defects during laparoscopic Roux-en-Y gastric bypass (LRYGBP). Our belief is that not all techniques require closure of defects. We hypothesize that nonclosure of defects with our particular technique would not cause a significant clinically evident internal hernia rate. Methods All patients who were operated on between December 2002 and June 2005 were included in this study. The technique that was utilized included an antecolic antegastric gastrojejunostomy (GJ), division of the greater omentum, a long jejunojejunostomy (JJ) performed with three staple-lines, a short (<4 cm) division of the small bowel mesentery, and placement of the JJ above the colon in the left upper quadrant. Clinical records were reviewed for reoperations. Results here was a total of 300 patients, and no incidence of internal hernia. In the first 100 patients, there was 97% follow-up for 1 year or more. Four patients underwent reoperations for unexplained abdominal pain. Intraoperative findings included an adhesive band from the JJ to the colon (1), an adhesive band from the JJ to the anterior abdominal wall (1), an adhesive band 3 cm from the GJ to the anterior abdominal wall (1), and adhesions of the jejunum to the anterior abdominal wall (1). No patient had an internal hernia. Conclusions Internal hernias are not common after this particular method of LRYGBP. Before adopting routine closure of potential spaces, surgeons should consider their technique, follow-up, and incidence of internal hernias. Routine closure of these defects is not always necessary.     

Laparoscopic Gastric Bypass for Morbid Obesity with Linear Gastroenterostomy

Background: Laparoscopic gastric bypass (LGBP) is a well-established procedure for the surgical management of morbid obesity. Most surgeons create the gastroenteral anastomosis by using the circular EEA stapler. We describe an alternative laparoscopic anastomotic technique using the EndoGIA linear stapling device. Methods: The stomach was proximally transected with a linear stapler (45 mm, Endo-GIA) to create a 15 to 20 ml pouch. Next, an antecolic Roux-en-Y gastroenterostomy was performed, using the 45 mm Endo-GIA. The proximal loop of the intestine was then separated from the anastomotic site by the Endo-GIA. Finally, the Endo-GIA was used for the intraabdominal creation of a side-to-side enteroenterostomy. Results: Between June and August 2001, 5 patients with mean BMI 56.7 kg/m²±7.3 underwent LGBP. All patients were seen 6 months post-surgery. Operating time was 7.5 and 6.5 hours for the first 2 operations, but was under 4.5 h for the next 3 cases. 1 patient suffered from perioperative hypoxia leading to long-term artificial respiration. 6 weeks after surgery, 1 patient developed obstruction due to torsion of the enteroenterostomy and required open revision. The 3 remaining patients made an uneventful recovery. All patients lost considerable weight (mean 36.5 kg; [range 32 to 45] after 6 months). No stenosis or anastomotic leakage was noted. Conclusions: A linear stapled anastomosis is an alternative to the use of the circular stapler.     

Value of Preoperative Upper Endoscopy in Patients Undergoing Laparoscopic Gastric Bypass

Background: Preoperative evaluation of patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP) has included esophagogastroduodenoscopy (EGD) with little data to substantiate its use. Methods: A retrospective analysis was conducted of patients from Feb 04 to Mar 05 who underwent preoperative EGD and subsequently LRYGBP. Results: 169 patients underwent EGD prior to surgery. Their mean age was 41.1 years (range 14-66), mean BMI 49.7 (range 35-78), and 82% were females. There were no complications from EGD. Significant findings in patients at EGD included gastric ulceration in 3 (2%), duodenal ulcer in 1 (0.7%), Barrett's esophagus in 2 (1.3%), and a GI stromal tumor (GIST) in 1 (0.7%). EGD revealed hiatal hernias in 56 (35.2%), esophagitis in 28 (17%), Schatzki's ring in 5 (3%), gastritis in 43 (27%), gastric polyps in 8 (5%), and duodenitis in 9 (6%). 53 patients (33.3%) had a negative EGD. Ulcer and severe gastritis, esophagitis, and duodenitis diagnosed preoperatively were treated medically before surgery. 9 hiatal hernias were repaired intraoperatively. The patient with the GIST underwent laparoscopic near-total gastrectomy and gastric bypass, while 1 patient with an antral polyp underwent laparoscopic partial gastrectomy in addition to the LRYGBP. Conclusion: EGD is essential for diagnosis of GI diseases including tumors, ulcers, and hiatal hernias that alter the medical and surgical management of patients undergoing gastric bypass.     

胃次全切除后圆形吻合器完成残胃-空肠端侧吻合的实验与临床应用研究

目的探讨胃次全切除后采用圆形吻合器行残胃．空肠端侧吻合的实验与临床可行性。方法Beagle＇s犬12条，随机分成A、B两组，在胃窦切除后分别以器械或手工行残胃-十二指肠端侧吻合术。3个月后，以器械行残胃-十二指肠侧侧吻合术。测量残胃十二指肠侧侧吻合处及邻近的十二指肠周长；并观察残胃空肠端侧吻合口直径及愈合情况。选择163例远端胃癌患者，随机分成C、D两组，C组89例，D组74例。胃次全切除后，分别以器械或手工行残胃-空肠端侧吻合术，手术后观察吻合口漏、狭窄等并发症，1年后行稀钡上消化道造影，观察吻合口钡剂通过和2h后残胃钡剂残留情况。结果手术后12条Beagle＇s犬术后均恢复良好，残胃十二指肠侧侧吻合处及邻近的十二指肠周长分别是（6．46±0．06）cm，（7．26±0．12）cm。残胃空肠端侧吻合口及小弯侧三角处愈合均良好，A、B两组吻合口直径分别为（1．18±0．13）cm和（1．20±0．09）cm。两组比较差异无显著性意义（t=0．255，P=0．804）。163例患者均顺利完成手术，术后未出现吻合口漏、狭窄等并发症，术后1年，2组分别行上消化道稀钡造影，均显示吻合口无明显狭窄，钡剂通过顺利，2h后残胃仅见少量钡剂残留。结论胃次全切除后应用器械行残胃-空肠端侧吻合能够在残胃的原位完成消化道重建，降低吻合难度，方法可行。