Gastrojejunal Strictures after Roux-en-Y Gastric Bypass With a 21-MM Circular Stapler

Introduction:

Intraluminal staplers for gastrojejunostomy construction during Roux-en-Y gastric bypass (RYGBP) may be associated with postoperative strictures. We analyzed outcomes of a transabdominal circular-stapled RYGBP with evaluation of short- and long-term anastomotic complications.

Methods:

All laparoscopic RYGBPs performed between January 2004 and December 2005 at an academic institution were reviewed. The gastrojejunostomy was created by using the transabdominal passage of a 21-mm intraluminal circular stapler into an antecolic, antegastric Roux limb. This retrospective chart review analyzes patient demographics, anastomotic complications, and weight loss.

Results:

Between January 2004 and December 2005, 159 patients underwent transabdominal circular-stapled RYGBP. Fifteen patients developed a stenosis at the gastrojejunostomy, all requiring endoscopic balloon dilatation. One of these patients required laparoscopic revision of the gastrojejunostomy. Eleven strictures occurred after 30 days, whereas only 4 strictures occurred within 30 days of surgery. Two marginal ulcerations were seen within 1 year of surgery.

Conclusion:

Our 9.4% stricture rate parallels what has been reported in the literature. The majority of strictures were amenable to one endoscopic treatment session. Transabdominal circular-stapled gastrojejunostomy is a reproducible construct for use in bariatric surgery.     

Complications of the Laparoscopic Roux-en-Y Gastric Bypass: 1,040 Patients - What Have We Learned?

Background:The Roux-en-Y gastric bypass (RYGBP) is one of the most common operations for morbid obesity. Laparoscopic techniques have been reported, but suffer from small numbers of patients, longer operative times and seemingly higher initial complication rates as compared to the traditional "open" procedure. The minimally invasive approach continues to be a challenge even to the most experienced laparoscopic surgeons.The purpose of this study is to describe our experience and complications of the laparoscopic Roux-en-Y gastric bypass with a totally hand-sewn gastrojejunostomy. Methods: 1,040 consecutive laparoscopic procedures were evaluated prospectively. Only patients who had a previous open gastric procedure were excluded initially. Eventually, even patients with failed "open" bariatric procedures and other gastric procedures were revised laparoscopically to the RYGBP. All patients met NIH criteria for consideration for weight reductive surgery. Results:There were no anastomotic leaks from the hand-sewn gastrojejunostomy. Early complications and open conversions were related to sub-optimal exposure and bowel fixation techniques. Several staple failures were attributed to a manufacturer redesign of an instrument. Average hospital stay was 1.9 days for all patients and 1.5 days for patients without complications. Operative times consistently approach 60 minutes. Average excess weight loss was 70% at 12 months.There were 5 deaths: perioperative pulmonary embolism (1), late pulmonary embolism (2), asthma (1), and suicide (1). Conclusions: The laparoscopic Roux-en-Y gastric bypass for morbid obesity with a totally hand-sewn gastrojejunostomy can be safely performed by the bariatric surgeon with advanced laparoscopic skills in the community setting. Fixation and closure of all potential hernia sites with non-absorbable sutures is essential. Stenosis of the hand-sewn gastrojejunal anastomosis is amenable to endoscopic balloon dilation. Meticulous attention must be paid to the operative and perioperative care of the patient.     

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.     

A biodegradeable membrane from porcine intestinal submucosa to reinforce the gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass: preliminary report

Backround: A Silastic ring has been used to prevent dilation of the gastrojejunostomy in Roux-en-Y gastricbypass (RYGBP). The use of a bio-membrane may prevent dilation of the anastomosis without the risks associated with prostheses. The aim of this studywas to evaluate the feasibility and safety of applying such a bio-mem brane around the gastrojejunostomy junostomy in Laparoscopic RYGBP (LRYGBP). Methods: We used a new bio-membrane, that is dreived from porcine small intestinal submucosa (SIS)and acts as a scaffolding for the ingrowth of connective tissue. Over a 4-month period, 14 LRYGBP patients had their proximal anastom osis wrapped with 10 x 2.5 cm SIS by a single surgeon. We compared these patients to a control group of LRYGBP patients matched for BMI. Results: The average age of the patients was 35.0 years (control group: 45.1 years). The patients had a mean initial BMI of 44.7 kg/m² (±5.9) standard error, and the control subjects had a mean initial BMI of 46.7 kg/m² (±6.5). SIS application took a mean time of 11 (±3) minutes without any intraoperative complication. The median hospital stay was 3.5 days in the experimental group and 3.7 days in controls. Three patients developed a symptomatic stenosis at the gastrojejunostomy following surgery. In the control group there were two stenoses. At an average follow-up of 87 days (controls: 95 days), the mean reduction in BMI was 7.8 (± 0.8) kg/m² [controls 8.6 kg/m² (± 1.5)]. Conclusion: Application of SIS around the gastrojejunostomy in patients undergoing LRYGBP is feasible and safe. Further follow-up is required, however, to evaluate the effectiveness in preventing dilation of the anastomosis.     

Laparoscopic Roux-en-Y gastric bypass for severe gastroesophageal reflux after vertical banded gastroplasty

Background: Vertical banded gastroplasty (VBG) is sometimes associated with complications such as pouch obstruction, dilatation, and gastroesophageal reflux. This occasionally requires surgical revision, in many cases to a Roux-en-Y gastric bypass (RYGBP). Case Report: A 47-year-old woman with severe obesity developed severe symptoms of stenosis of the pouch outlet and gastroesophageal reflux 15 years after VBG. Laparoscopic conversion to a RYGBP was performed. At 9-month follow-up, she lost an additional 32 kg and had complete resolution of her reflux. Conclusion: In this patient, laparoscopic re-operative RYGBP produced additional weight loss, and improved gastroesophageal reflux that occurred many years after having a VBG. Laparoscopic conversion of a VBG to RYGBP is feasible, and may confer the benefits of other minimally invasive abdominal procedures to this high-risk patient group.     

Comparison between Open Hand-sewn,Laparoscopic Stapled and Laparoscopic Computer-mediated,Circular Stapled Gastro-Jejunostomies in Roux-en-Y Gastric Bypass in the Porcine Model

Background: In this porcine survival model, we compared laparoscopic computer-mediated flexible circular stapled (SurgASSIST) gastro-jejunostomies in Roux-en-Y gastric bypass (RYGBP) to open hand-sewn (HS) and laparoscopic end-to-end (EEA) anastomosis. Methods: RYGBP was performed in 15 pigs. Depending on the technique used to create the gastro-jejunostomy, the pigs were divided in 3 groups. In group A, a standard two-layer hand-sewn anastomosis were performed. In group B and C, gastro-jejunostomies using EEA (B) or SurgASSIST (C) were attempted. Operation time, intraoperative technical failure, postoperative anastomotic leakage, and necropsy results were measured. Results: 14 pigs survived surgery. One leakage from the gastro-jejunostomy was detected intraoperatively in group B. There was no evidence of leakage postoperatively from the proximal gastro-jejunostomy in any groups. No statistical difference was found between the groups concerning the operation time or the diameter and degree of healing of the anastomosis. Conclusion: We found the SurgASSIST system safe for performing gastro-jejunostomies in laparoscopic RYGBP. There were no anastomotic failures intra- or postoperatively. At necropsy, there was no evidence of anastomotic stricture or delayed healing processes.     

Experience with the Circular Stapler for the Gastrojejunostomy in Laparoscopic Gastric Bypass (350 Cases)

Background: The increased incidence of morbid obesity has resulted in an increase in bariatric surgery. The gastrojejunostomy performed during Roux-en-Y gastric bypass (RYGBP) operations has technical variability with different outcomes and complication-rates immediate postoperatively and at long-term follow-up. Methods: Between Jan 2000 and Feb 2005, 350 laparoscopic RYGBP procedures were performed. We present our immediate and follow-up rate of complications with total intraabdominal gastrojejunostomy, performed with the circular stapler. Results: Complications of gastrojejunostomy were detected in 24 patients (6.8%): 3 anastomotic leaks (0.8%); 6 bleeding (1.7%) immediately postoperatively, and 4 stenoses (1.1%), 10 ulcers (2.8%) and 1 stenosis plus ulcer (0.3%) during long-term follow-up. There was no mortality related to the gastrojejunostomy. Conclusions: The gastrojejunostomy with circular stapler is an easily reproducible procedure. The rate of complications has been low. Surgeons who perform laparoscopic RYGBP should have a careful learning curve, and should be aware of the potential complications and their management.     

Perforated Ulcer at the Gastrojejunostomy: Laparoscopic Repair after Roux-en-Y Gastric Bypass

A 44-year-old woman was admitted from the emergency department with severe acute upper abominal pain. The patient had undergone a laparoscopic Roux-en-Y gastric bypass (RYGBP) operation 16 months previously. CT scan showed intraabdominal free air. At emergency laparoscopic reoperation, a perforated ulcer at the gastrojejunostomy was found. This late complication of RYGBP can be a rapidly progressing life-threatening situation, and requires prompt treatment. Closure and omental patch were successful laparoscopically.     

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.     

Laparoscopic inflatable band with Roux-en-Y gastric bypass

Background: Roux-en-Y gastric bypass (RYGBP) leaves a large blind gastric segment, which is inaccessible for conventional endoscopy. Method: A case is reported, describing a variation of laparoscopic RYGBP by partitioning the stomach by an inflatable band rather than by stapling or division. Results:The stomach was partitioned into a proximal 15 cc pouch and a distal part by an adjustable gastric band. A RYGBP was fashioned from the proximal pouch. 9 patients were treated with this technique: 7 as an initial procedure and 2 after previous gastric banding which had been followed by insufficient weight loss. 1 of these latter patients developed erosion of the band through the gastrojejunostomy 7 months postoperatively. Conclusion: Laparoscopic proximal RYGBP with inflatable-band gastric partitioning is feasible. Erosion of the band though the gastrojejunostomy, however, might be a serious side-effect of this technique.     

Initial results with a stapled gastrojejunostomy for the laparoscopic isolated roux-en-Y gastric bypass

BACKGROUND: The gastric pouch to jejunum anastomosis is a critical step in the performance of an isolated Roux-en-Y gastric bypass. When performing this procedure laparoscopically, intracorporeal suturing of the gastric pouch to Roux-en-Y jejunum anastomosis is technically demanding, time consuming, and perhaps the most prohibitive part of the operation. We devised a unique, effective, and simple method to perform this anastomosis using an EEA stapler. This report describes this technique and its follow-up in our series of patients undergoing a laparoscopic isolated Roux-en-Y gastric bypass utilizing this technique. METHODS: A prospective analysis was performed identifying the technical success, leak rate, and postoperative incidence of anastomotic stenosis and its management in a consecutive series of patients undergoing a laparoscopic isolated Roux-en-Y gastric bypass with a gastrojejunal anastomosis constructed with a 21-mm or 25-mm EEA stapler. RESULTS: Forty-eight patients underwent laparoscopic isolated Roux-en-Y gastric bypass. Mean age was 40.9 years (range 22 to 64) and mean body mass index was 52.3 kg/m(2) (range 31 to 76 kg/m(2)). There were no mortalities. Three patients (6.3%) were converted to an open procedure, but only 1 because of an inability to perform the gastrojejunal anastomosis (short jejunal mesentery). There was 1 leak (2.1%) from the gastrojejunal anastomosis. It was successfully managed nonoperatively. Thirteen patients (27.1%) patients developed an anastomotic stenosis requiring endoscopic balloon dilatation. Seven of the 13 patients required only a single dilatation and have had no recurrence of dysphagia. Six of the 13 patients needed 2 to 4 dilatations, and all are swallowing normally. None have required surgical revision. After 12 months of follow-up, the mean weight loss was 115 pounds and mean decrease in body mass index was 18.5 kg/m(2). CONCLUSIONS: The stapled EEA gastrojejunal anastomosis for the laparoscopic isolated Roux-en-Y gastric bypass is safe and effective. Anastomotic stenosis occurs in approximately one quarter of patients, but it can be managed well with endoscopic balloon dilatation.     

Omental Wrap: A Simple Technique for Reinforcement of the Gastrojejunostomy during Roux-en-Y Gastric Bypass

Background Anastomotic leak is one of the most dreaded complications following Roux-en-Y gastric bypass (RYGBP). A simple technique for reinforcement of the gastrojejunal anastomosis using an omental wrap during laparoscopic RYGBP is described.We recommend this technique particularly in those patients at high risk for gastrojejunal leak. Methods A 20 ml vertically-oriented gastric pouch, based on the lesser curvature of the stomach, is created using linear cutter staplers (endo-GIA).The gastrojejunal anastomosis is reinforced with an omental wrap (omental flap). The jejunojejunostomy is created 100–150 cm from the gastrojejunostomy, depending on the BMI. Results 124 laparoscopic RYGBPs were performed by the same surgeon. The omental wrap was successfully performed in all patients but two. There were no mortalities, leakages, or stenoses noted during follow-up. Conclusion During RYGBP, reinforcement of the gastrojejunostomy with an omental wrap is a simple, feasible, and protective adjunctive maneuver that can minimize the risk of gastrojejunal leak.     

Randomized clinical trial of hand-assisted laparoscopic versus open Roux-en-Y gastric bypass for the treatment of morbid obesity

BACKGROUND:: Roux-en-Y gastric bypass (RYGBP) has increased in popularity since the introduction of the laparoscopic procedure, but this approach requires extensive surgical skill and the learning curve is steep. The present study examined the suitability of hand-assisted laparoscopy for RYGBP. METHODS: In a prospective trial, 50 patients (median age 38 years, body mass index 45 kg/m(2)) were randomized to either hand-assisted (n = 25) or open (n = 25) RYGBP. The hand-assisted device was introduced through a right subcostal incision. Laparoscopic staplers were also used in the open group, allowing a short upper midline incision. The gastrojejunostomy was made by means of a circular stapler and the Roux limb placed behind the colon and excluded stomach. RESULTS: The postoperative outcome, with respect to morphine consumption, complications, hospital stay (6 days) and weight loss, was similar in the two groups. The operating time was significantly longer in the hand-assisted group (150 versus 85 min; P < 0.001) but there was no conversion to open operation. One patient in the hand-assisted group was reoperated owing to leakage and one patient developed an incisional hernia after open RYGBP. CONCLUSION: The hand-assisted technique was feasible and allowed good working conditions in all patients. However, the postoperative outcome was excellent in both groups and there was no advantage to the hand-assisted technique.     

Robot-assisted laparoscopic intestinal anastomosis

Introduction: Robotic telemanipulation systems have been introduced recently to enhance the surgeon's dexterity and visualization in videoscopic surgery in order to facilitate refined dissection, suturing, and knot tying. The aim of this study was to demonstrate the technical feasibility of performing a safe and efficient robot-assisted handsewn laparoscopic intestinal anastomosis in a pig model. Methods: Thirty intestinal anastomoses were performed in pigs. Twenty anastomoses were performed laparoscopically with the da Vinci robotic system (robot-assisted group), the remaining 10 anastomoses by laparotomy (control group). OR time, anastomosis time and complications were recorded. Effectiveness of the laparoscopic anastomoses was evaluated by postoperative observation of 10/20 pigs of the robot-assisted group for 14 days and by testing mechanical integrity in all pigs by measuring passage, circumference, number of stitches, and bursting pressure. These parameters and anastomosis time were compared to the anastomoses performed in the control group. Results: In all cases of the robot-assisted group the procedure was completed laparoscopically. The only perioperative complication was an intestinal perforation, caused by an assisting instrument. The median procedure time was 77 min. Anastomosis time was longer in the laparoscopic cases than in the controls (25 vs 10 min; p <0.001). Postoperatively, one pig developed an ileus, based on a herniation of the spiral colon through a trocar-port. For this reason it was terminated on the sixth postoperative day. All anastomoses of the robot-assisted group were mechanically intact and all parameters were comparable to those of the control group. Conclusion: Technical feasibility of performing a safe and efficient robot-assisted laparoscopic intestinal anastomosis in a pig model was repeatedly demonstrated in this study, with a reasonable time required for the anastomosis.     

Laparoscopic Conversion of Vertical Banded Gastroplasty (Mason MacLean) into Roux-en-Y Gastric Bypass

Background Revision of bariatric procedures is required in 10 to 25% of patients either for insufficient weight loss or for complications. Patients undergoing vertical banded gastroplasty (VBG; Mason MacLean) may require revision in up to half of the cases in the long term. Roux-en-Y gastric bypass (RYGBP) is considered the procedure of choice for revision of VBG gastroplasty. Patients and Methods Eighteen patients, 16 women and 2 men with a mean age of 41.7 years (range 27–72) and a mean BMI at 37.6 kg/m² (range 22.5–47), underwent laparoscopic conversion of VBG into RYGBP. Indications for revisional surgery were insufficient weight loss (11 patients), stoma stenosis (4 patients), and acid reflux (3 patients). Results Operative time was on average 203 min (range 60–300 min), and conversion was required in one patient (5.5%). There was no early postoperative mortality, and four patients (22.2%) developed immediate postoperative complications (gastrojejunostomy leak 1; stenosis of the gastrojejunal anastomosis 2; liver abscess 1). One patient died 6 months after conversion because of a bleeding anastomotic ulcer (late mortality 5.5%). Two patients (11.5%) developed late complications (incisional hernia 1; internal hernia 1). At a mean follow-up of 23, 4 months BMI is on average 29.8 kg/m² (range 22.7–37). Conclusion Although revision of failed VBG into RYGBP gives good functional results, the risk of postoperative serious complications must be carefully evaluated before revision.     

Endoclip Closure of Jejunal Perforation after Balloon Dilatation

Endoscopy is commonly used in patients undergoing Roux-en-Y gastric bypass (RYGBP) for diagnosis and intervention. Stomal stricture at the gastrojejunostomy occurs in approximately 3% to 17% of patients after laparoscopic RYGBP. The incidence of iatrogenic perforation during stomal balloon dilatation is reported to be 3% to 12% among these patients. Surgery has typically been required for iatrogenic perforation. With the availability of the endoclip, endoscopists are able to manage iatrogenic perforation non-operatively. We report a patient who had jejunal perforation during balloon dilatation after RYBGP, who was successfully closed with endoclip applications and managed non-operatively.     

Laparoscopic Pouch Resizing and Redo of Gastro-jejunal Anastomosis for Pouch Dilatation following Gastric Bypass

Background: With a dramatically increasing number of bariatric operations performed world-wide in the recent years, more late complications have been noticed. Proximal gastric pouch dilatation is a known late complication after laparoscopic or open restrictive surgery for morbid obesity. In the present paper, we report our experience with laparoscopic re-operation of enlarged gastric pouches after laparoscopic gastric bypass, with emphasis on technique and outcome. Methods: Data were retrieved from a prospective database of 334 patients who underwent a laparoscopic gastric bypass operation at the University Hospital of Zurich from July 2000 to December 2004. Five laparoscopic revisions for pouch dilatation after primary bypass were performed. Results: 3 female and 2 male patients with median age 40 years (range 32-55) underwent a laparoscopic pouch resizing. At the time of the re-operation, the median BMI was 32.0 kg/m² (range 28.4-48.4). All procedures were performed laparoscopically with no conversion to open surgery. The median operating-time was 110 minutes (95-120). The median hospital stay was 6 days (range 5-14). The median BMI in the follow-up of 12 months (9-14) was 28.0 kg/m² (25.5-45.8). Diabetes mellitus improved in 4 cases during follow-up. Conclusion: Laparoscopic pouch resizing with redo of the gastro-jejunal anastomosis was feasible, safe and effective in this small series. It led to further weight loss and improved symptoms of poor pouch emptying.     

Laparoscopic Conversion of Laparoscopic Gastric Banding to Roux-en-Y Gastric Bypass: a Review of 70 Patients

Background: The feasibility and outcomes of conversion of laparoscopic adjustable gastric banding (LAGB) to laparoscopic Roux-en-Y gastric bypass (LRYGBP) was evaluated. Methods: From November 2000 to March 2004, all patients who underwent laparoscopic conversion of LAGB to LRYGBP were retrospectively analyzed. The procedure included adhesiolysis, resection of the previous band, creation of an isolated gastric pouch, 100-cm Roux-limb, side-to-side jejuno-jejunostomy, and end-to-end gastro-jejunostomy. Results: 70 patients (58 female, mean age 41) with a median BMI of 45±11 (27-81) underwent attempted laparoscopic conversion of LAGB to an RYGBP. Indications for conversion were insufficient weight loss or weight regain after band deflation for gastric pouch dilatation in 34 patients (49%), inadequate weight loss in 17 patients (25%), symptomatic proximal gastric pouch dilatation in 15 patients (20%), intragastric band migration in 3 patients (5%), and psychological band intolerance in 1 patient. 3 of 70 patients (4.3%) had to be converted to a laparotomy because of severe adhesions. Mean operative time was 240±40 SD min (210-280). Mean hospital length of stay was 7.2 days. Early complication rate was 14.3% (10/70). Late major complications occurred in 6 patients (8.6%). There was no mortality. Median excess body weight loss was 70±20%. 60% of patients achieved a BMI of <33 with mean follow-up 18 months. Conclusion: Laparoscopic conversion of LAGB to RYGBP is a technically challenging procedure that can be safely integrated into a bariatric treatment program with good results. Short-term weight loss is very good.     

Roux-en-Y Gastric Bypass after Failed Vertical Banded Gastroplasty

BACKGROUND: Vertical banded gastroplasty (VBG) was the restrictive procedure of choice for many years. However, VBG has been associated with a high rate of long-term failure. We reviewed our experience of conversion of failed VBG to Roux-en-Y gastric bypass (RYGBP). METHODS: The data on all patients undergoing conversion of failed VBG to RYGBP were reviewed. Failed VBG was defined as insufficient weight loss (BMI > 35 kg/m2) and/or VBG-related complications. RESULTS: We performed 24 conversions from VBG to RYGBP. Median age was 40 +/- 8 years (range 28 to 61). Preoperative weight was 111 +/- 25 kg (range 85 to 181), and median BMI was 41 +/- 8 kg/m2 (range 30 to 69 kg/m2). Indication for conversion was: VBG failure in 18 patients and VBG complications in 6 patients. A gastrectomy (total or proximal) had to be performed in 5 cases (21%). The conversion was performed by laparoscopy in 13 cases. Postoperative complications occurred in 4 patients (16.7%). There were no leaks, nor mortality. Postoperative BMI was 31 kg/m2 (range 25 to 42) at a median follow-up of 12 months (range 3 to 36 months). The average percentage of excess weight loss was 62% at 1 year. CONCLUSION: VBG has been associated with a significant reoperation rate for failure and/or complications. Conversion to RYGBP is effective in terms of weight loss and treatment of complications after VBG. Gastrectomy and resection of the staple-line could reduce such complications as leaks and mucocele. Although technically challenging, conversion of VBG to RYGBP is feasible, with acceptable morbidity and no mortality. The conversion is feasible laparoscopically.     

A Prospective Evaluation of Intracorporeal Laparoscopic Small Bowel Anastomosis during Gastric Bypass

Background: We evaluated the safety and feasibility of performing a laparoscopic intracorporeal end-toside small bowel anastomosis using a stapling technique as part of a Roux-en-Y gastric bypass operation (RYGBP). Methods: 80 consecutive patients who underwent RYGBP with laparoscopic jejunojejunostomy were evaluated. Operative time and intraoperative and postoperative complications directly related to the jejunojejunostomy anastomosis were recorded. Results: All 80 laparoscopic jejunojejunostomy procedures were successfully performed without conversion to laparotomy. Mean operative time was longer for the first 40 laparoscopic RYGBP than for the last 40 RYGBP (32±18 min vs 21±14 min, respectively, p<0.05). Intraoperative complications were staple-line bleeding (2 patients) and narrowing of the anastomosis (1 patient). Postoperative complications were four small bowel obstructions: technical narrowing at jejunojejunostomy site (2 patients), angulation of the afferent limb (1 patient), and food impaction at the jejunojejunostomy anastomosis (1 patient). These four patients underwent successful laparoscopic re-exploration and creation of another jejunojejunostomy proximal to the original anastomosis. There were no small bowel anastomotic leaks. The median time to resuming oral diet was 2 days. Conclusions: Laparoscopic jejunojejunostomy as part of the RYGBP operation is a safe and technically feasible procedure. Postoperative small bowel obstruction is a potential complication, which can be prevented by avoiding technical narrowing of the afferent limb.