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

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

Frequency and management of internal hernias after laparoscopic antecolic antegastric Roux-en-Y gastric bypass without division of the small bowel mesentery or closure of mesenteric defects: review of 1400 consecutive cases

BACKGROUND: It is common practice to close mesenteric defects in abdominal surgery to prevent postoperative herniation and subsequent closed-loop obstruction. The aim of this study was to review our experience with antecolic antegastric laparoscopic Roux-en-Y gastric bypass (AA-LRYGBP) without division of the small bowel mesentery or closure of potential mesenteric defects. METHODS: Data for 1400 patients who underwent AA-LRYGBP between January 2001 and December 2004 was prospectively collected and retrospectively analyzed for the incidence of internal hernias. In all cases, an antecolic antegastric approach was performed without division of the small bowel mesentery or closure of potential hernia defects. RESULTS: Three patients (0.2%) developed a symptomatic internal hernia. Two of these patients had a 200-cm-long Roux limb, and the other had a 100-cm-long Roux limb. All three patients exhibited mild symptoms of partial small bowel obstruction. In all three cases the internal hernia was clinically manifested more than 10 months after the original AA- LRYGBP. Exploration revealed that the hernia site was between the transverse colon and the mesentery of the alimentary limb at the level of the jejunojejunostomy (Petersen's defect) in all three cases. All three patients underwent successful laparoscopic revision, hernia reduction, and mesenteric defect closure. CONCLUSIONS: AA-LRYGBP without division of the small bowel mesentery or closure of mesenteric defects does not result in an increased incidence of internal hernias. The laparoscopic approach for reexploration appears to be an effective and safe option.     

Trends in Internal Hernia Incidence After Laparoscopic Roux-en-Y Gastric Bypass

Background Internal hernia is a known complication after gastric bypass, especially when performed laparoscopically. The aim of this study was to see when internal hernias occur in relation to weight loss and time course after surgery. Furthermore, we wish to examine the impact of Roux limb positioning ante- versus retrocolic and whether switching to running versus interrupted closure of the mesenteric defects created at surgery made any difference. Methods A retrospective chart review was performed of all patients undergoing laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) who developed symptomatic internal hernia requiring operative intervention between January 1, 2000 and September 15, 2006. Results Fifty-four internal hernias occurred in 2,572 patients, an incidence of 2.1%. The site of internal hernias varied: 25 (1%), transverse mesocolon; 22 (0.8%), enteroenterostomy; 7 (0.3%), Peterson’s space. The mean time to intervention for an internal hernia repair was 413 ± 46 days and average % excess body weight loss (%EBWL) in this period was 59 ± 3.3. Subgroup analysis demonstrates internal hernia incidence to be 2 in 357 (0.6%) in antecolic Roux versus 52 in 2,215 (2.4%) in retrocolic Roux limb (odds ratio = 4, P < 0.05). Continuous closure versus interrupted stitching of mesenteric defects does not seem to alter the incidence of internal hernias. Conclusion This study demonstrates that the majority of internal hernias occur after a significant (>50%) EBWL. Furthermore, the antecolic approach is associated with a much reduced incidence of internal hernia.     

Causes of small bowel obstruction after laparoscopic gastric bypass

Background Small bowel obstruction after laparoscopic Roux-en-Y gastric bypass is not a rare complication, occurring in approximately 3% of patients. The goal of this study was to review the causes and timing of small bowel obstruction as an aid to diagnosis, treatment, and prevention. Methods The records of consecutive patients who underwent laparoscopic Roux-en-Y gastric bypass at the authors' center from 4/99 to 7/03 were retrospectively reviewed. All the patients had a laparoscopic handsewn gastrojejunostomy and a stapled jejunojej-unostomy. The Roux limb was placed retrocolically in the first 405 patients and antecolically in the next 1,310 patients. Results Altogether, 1,715 patients underwent a total laparoscopic Roux-en-Y gastric bypass at the authors' bariatric center. In 51 patients, 55 small bowel obstructions occurred (3%) during a median follow-up period of 21 months (range 1–52 months). Small bowel obstruction developed in 27 (7%) of the retrocolic patients, as compared with 24 (2%) of the antecolic patients (p<0.001, chi-square). The cause of small bowel obstruction were adhesive bands (n=14), obstruction at the jejunojejunostomy from kinking or narrowing (n=13), internal hernia or external compression at the transverse mesocolon (n=11), internal hernia through the jejunal mesentery (n=8) incarcerated abdominal wall hernia (n=4), and other (n=5). For patients in whom small bowel obstruction developed in the first 3 weeks after their bypass surgery bowel resection was required in 19 of 24 patients, as compared with 6 of 31 patients in whom obstruction develop after 3 weeks (p<0.001, chi-square). Conclusions Early small bowel obstructions tend to result from technical problems with the Roux limb and require revision of the bypass or small bowel resection significantly more often than late obstructions. The latter group of obstructions usually result from adhesions or hernias, which could be handled laparoscopically without bowel resection. The position of the Roux limb (retrocolic vs antecolic) appeared to influence the incidence of small bowel obstruction. In the current series, changing the position of the jejunal bypass limb from retrocolic to antecolic significantly decreased the overall incidence of small bowel obstruction because it eliminated one of the most common sites for obstruction: the mesocolon. Online publication: 13 October 2004     

Internal hernia at Petersen's space after laparoscopic Roux-en-Y gastric bypass: 6.2% incidence without closure—a single surgeon series of 1047 cases

BackgroundRecent reports describing a gastric bypass technique and the need for closure at Petersen's space using an antecolic antegastric laparoscopic method have differed in the incidence of internal hernia. We report a 6.2% incidence without closure of Petersen's space in a 1047-case, single-surgeon practice.MethodsThe data from 1047 patients undergoing antecolic antegastric gastric bypass between January 2001 and December 2006 were prospectively collected and retrospectively evaluated for formation of an internal hernia at Petersen's space. All cases were performed by a single surgeon using an antecolic antegastric technique without closure of the mesenteric space and with division of 5 cm of small bowel mesentery. The biliopancreatic limb length was created at 50 cm during the first 2 years of the study and then at 50 or 100 cm depending on the patient's body mass index.ResultsOf the 1047 patients, 73 underwent laparoscopic exploration for varying degrees of abdominal pain, unexplained nausea or vomiting, or radiographic evidence of an internal hernia. Of the 73 cases, 65 were Petersen's space hernias, for an incidence of 6.2%, 7 were mesenteric enteroenterostomy hernias, for an incidence of .7%, and 1 was negative for intra-abdominal pathologic findings. A direct relationship was found between the biliopancreatic limb length and the frequency of biliopancreatic internal hernia formation (P = .0194), and a high rate of false-negative radiographic reports were noted. Subsequent to these 1047 patients, we have had no internal hernias with space closure in 339 cases.ConclusionClosure of Petersen's space is important in preventing the morbidity of reoperation and the incidence of internal hernia.     

Root cause analysis of internal hernia and Roux limb compression after laparoscopic Roux-en-Y gastric bypass using observational clinical human reliability assessment

BackgroundInternal hernia (IH) and Roux limb compression (RC) are recognized complications after retrocolic laparoscopic Roux-en-Y gastric bypass for obesity. The aim of the present study was to systematically identify the surgical technical errors leading to these complications.MethodsAn observational clinical human reliability assessment approach was used to analyze the operating videos of 3 groups: an IH group (n = 12), a Roux compression group (n = 13), and a control group (no complications, n = 21). Two investigators, unaware of the outcomes, reviewed all videos, using special rating software. All errors were categorized using the external error mode system and further described if a direct consequential error (e.g., bleeding) was found.ResultsAn analysis of data showed that, on average, more errors occurred in the complication groups than in the control group (IH 5.85, Roux compression 3.54, control .90, P < .001). The strongest differences were found for missing intermesenteric stitches on both sides of the Roux limb. Logistic regression analysis showed that a missed stitch between the mesentery of the Roux limb and the transverse mesocolon was an independent predictor for IH (B = 1.727, P = .025). No technical or consequential errors could be identified as responsible for RC.ConclusionThe observational clinical human reliability analysis is a useful method to identify operative failure. For retrocolic, retrogastric laparoscopic Roux-en-Y gastric bypass, a systematic approach for the closure of the transverse mesenteric window might prevent IH complications.     

Small-Bowel Volvulus in Late Pregnancy Due to Internal Hernia After Laparoscopic Roux-en-Y Gastric Bypass

Internal hernias are a specific cause of acute abdominal pain and are a well-known complication after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Although internal hernias are a rare cause of intestinal obstruction, they may evolve towards serious complications, such as extensive bowel ischemia and gangrene, with the need for bowel resection and sometimes for a challenging reconstruction of intestinal continuity. The antecolic position of the Roux limb is associated with a decrease in the incidence of small-bowel obstruction and internal hernias. The best prevention of the formation of these hernias is probably by closure of potential mesenteric defects at the initial operation with a non-absorbable running suture. We present a patient in late pregnancy with a small-bowel volvulus following laparoscopic Roux-en-Y gastric bypass for morbid obesity and discuss the available literature. For a favorable obstetric and neonatal outcome, it is crucial not to delay surgical exploration and an emergency operation usually is mandatory.     

The Orientation of the Antecolic Roux Limb Markedly Affects the Incidence of Internal Hernias after Laparoscopic Gastric Bypass

Background: Internal herniation of the bowel may be a late complication after the laparoscopic Roux-en-Y gastric bypass (RYGBP). A seemingly minor change in technique is described that significantly prevents herniation behind the Roux limb mesentery. We hypothesized that internal hernias behind the Roux limb mesentery occur more frequently when the Roux limb is oriented such that the distal tip is toward the lesser curvature of the gastric pouch with the bowel then curving to the patient's left, compared with the opposite orientation. Methods: A retrospective chart review was performed of our prospectively collected database. A change in surgical technique occurred June 2003, in an attempt to reduce internal hernia formation. We compared 200 consecutive antecolic left-oriented RYGBP operations performed immediately previous to June 2003 (Group A) with 200 consecutive antecolic right-oriented RYGBP operations performed after June 2003 (Group B). Results: There was an 9.0% rate of internal hernia formation in Group A (18/200) and a 0.5% rate of internal hernia formation in Group B. Internal hernias were repaired an average of 1.2 years after surgery (range 4–30 months, median 14.3 months). The average length of follow-up was 2.1 and 1.6 years in Groups A and B, respectively. All herniations were behind the Roux limb mesentery. The difference in hernia formation after the change in technique was significant (P<0.005). Conclusions: With a simple change in technique, the incidence of internal herniation behind the Roux limb mesentery may be significantly reduced or eliminated.     

Internal hernia after laparoscopic Roux-en-Y gastric bypass

BACKGROUND: Internal hernia (IH) is a technical complication of laparoscopic Roux-en-Y gastric bypass (LRYGBP) that can have severe consequences. Little has been written on characterizing this complication. Antecolic Roux limb passage has been suggested to be safe without defect closure. METHODS: The records of 785 patients who underwent LRYGBP (136 antecolic, 649 retrocolic) between 1998 and 2003 were reviewed. In our early experience (n = 107), we used a retrocolic technique without defect closure. RESULTS: Twenty patients underwent surgical intervention for IH. The median interval between LRYGBP and symptom onset was 303 days (range, 25 to 1642 days). Abdominal pain was uniformly present, and 63% of patients developed nausea and/or vomiting. Exploratory laparoscopy was attempted in 94% of patients; conversion was necessary in 33%. A total of 21 IHs were identified (13 Petersen's, 5 mesocolic, 2 jejunojejunal, and 1 adhesion-related hernia). No nonviable bowel was identified, and no deaths occurred. A retrocolic technique involving closure of all defects resulted in the lowest rate of hernias (3/542; 0.55%) compared with the antecolic (12/136; 8.81%; P < .0001) and early retrocolic techniques (6/107; 5.6%; P < .0002). CONCLUSION: IH can occur long after gastric bypass surgery, and a low threshold for reoperation is crucial to avoid gut infarction. A retrocolic technique with defect closure appears to afford the lowest risk of IH. The lower incidence of IH in other series after antecolic technique likely results from a less aggressive detection and management approach, because our nonclosure technique could not differ from that of other authors. All defects must be closed to minimize the risk of hernia, whether antecolic or retrocolic.     

Internal Hernias and Nonclosure of Mesenteric Defects During Laparoscopic Roux-en-Y Gastric Bypass

Background  Internal hernias have been described after laparoscopic Roux-en-Y gastric bypass (LRYGB) as a major problem. Thus, many routinely close defects during LRYGB. In our technique, we do not close any defects. We hypothesize that not closing the defects would not cause a significant internal hernia rate diagnosed during reoperations. Methods  Patients who were reoperated after LRYGB were included in this study. Only patients who had a laparoscopic or open exploration focused on inspecting for internal hernias are reported here. The LRYGB technique that was utilized included an antecolic, antegastric gastrojejunostomy, minimal division of the small bowel mesentery, a long jejunojejunostomy performed with three staple lines, adequate division of the omentum, and placement of the jejunojejunostomy above the colon in the left upper quadrant. Results  There were a total of 387 patients who had LRYGB from 2002 to 2007 utilizing this particular technique. Fifty-four patients had a reoperation at an average of 24 (Range: 1–60) months postoperatively. The procedures were abdominoplasty, cholecystectomy, diagnostic laparoscopy, and lysis of adhesions. While two patients had a defect present, no patient had an internal hernia despite aggressive attempts to diagnose one. Conclusions  Internals hernias are not common after our particular method of LRYGB. Before adopting and advocating routine closure, surgeons should consider the surgical technique and the true associated incidence of internal hernias. We do not recommend routine closure of these defects with our technique. Presented in part at International Federation for the Surgery of Obesity annual meeting; August 2006; Sydney, Australia.     

Small Bowel Obstruction and Internal Hernias after Laparoscopic Roux-en-Y Gastric Bypass

Background: Small bowel obstruction (SBO) is a recognized complication of open bariatric surgery; however, the incidence after laparoscopic procedures is not clearly established. This paper reviews our experience with small bowel obstruction after laparoscopic Roux-en-Y gastric bypass. Methods: Between 1995 and 2001, 711 (246 antecolic, 465 retrocolic) patients underwent a laparoscopic proximal divided Roux-en-Y gastric bypass via the linear endostapler technique. 13 patients (1.8%) developed SBO requiring surgical intervention.There were 11 females and 2 males, ages 29-60 (mean 38), with mean weight 126 kg (range 105-188), and mean BMI 50 (range 41-59). 7 obstructive patients (55%) had undergone previous open abdominal surgery. Median time to obstruction was 21 days (range 5-1095). Mean follow-up of all patients is 43 months (range 3-79). Results: Etiology of obstruction was internal hernia - 6, adhesive bands - 5 (only 2 were related to prior open surgery), mesocolon window scarring - 1, and incarcerated ventral hernia - 1. The incidence of SBO was 4.5% (11/246) in the retrocolic group, and 0.43% (2/465) in the antecolic group, which was highly significant (P=.006). 1 adhesive patient required an open bowel resection for ischemia. There was 1 death. Conclusion: SBO occurred with an overall incidence of 1.8% in a large series of laparoscopic gastric bypass patients, and was associated with a high morbidity. A significant decrease in occurrence was found after adoption of antecolic placement of the Roux limb.     

Small Bowel Obstruction After Antecolic Antegastric Laparoscopic Roux-en-Y Gastric Bypass Without Division of Small Bowel Mesentery: A Single-Centre, 7-Year Review

Reported incidence of small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass varies between 1.5% and 3.5%. It has been suggested that the antecolic antegastric laparoscopic Roux-en-Y gastric bypass (AA-LRYGB) is associated with a low incidence of internal herniation (IH). Therefore we routinely did not close mesenteric defects. The records of 652 consecutive patients undergoing primary AA-LRYGB from January 2003 to December 2009 in a single institution were retrospectively reviewed to determine the incidence, etiology, clinical symptoms, radiologic diagnostic accuracy and operative outcomes of SBO. Of the 652 patients, 63 (9.6%) developed SBO. The majority (6.9%, 45 patients) had a SBO due to IH. In 41 (91%) cases, the IH was at the jejunojejunostomy (JJ), four cases had an IH at Petersen’s space. Adhesions and ventral hernia were found in 14 (2.1%) and four (0.6%) cases, respectively. Twenty-nine out of 63 cases had negative computed tomography (CT) findings and IH was diagnosed on CT in only 33% (14/45) of patients with IH. All patients underwent diagnostic laparoscopy. No bowel resections had to be performed. In contrast to previous reports, a high incidence of SBO with a high rate of IH at the JJ site was found in our series. Accuracy of CT is low and diagnostic laparoscopy is mandatory when SBO is suspected. Since 2010 we have started closing the JJ site, and data on SBO are collected prospectively. We believe that closing of the mesenteric defects is a mandatory step, even in an AA-LRYGB.     

Small Bowel Obstruction and Internal Hernias during Pregnancy after Gastric Bypass Surgery

Small bowel obstruction (SBO) is a recognized complication of Roux-en-Y gastric bypass (RYGB) surgery. Internal hernia (IH) a potential problem associated with RYGB, can have severe consequences if not diagnosed. We present two cases of SBO due to IH during pregnancy after laparoscopic RYGB (LRYGB). Both patients underwent an antecolic, antegastric LRYGB. In both patients a Petersen’s type IH was found. We reviewed the cases reported in the literature of SBO during pregnancy after RYGB. IH should always be ruled out in pregnant patients with previous RYGB and abdominal pain. Prompt surgical intervention is mandatory for a good outcome.     

Favorable internal hernia rate achieved using retrocolic,retrogastric alimentary limb in laparoscopic Roux-en-Y gastric bypass

BackgroundThe present study was performed at a tertiary care university hospital. The present study examined the incidence of internal hernia (IH) in our series of laparoscopic Roux-en-Y gastric bypass (LRYGB) with retrocolic, retrogastric routing of the alimentary limb accompanied by routine secure closure of all mesenteric defects.MethodsDuring a 4-year period, 847 patients underwent LRYGB. Our operative technique included retrocolic, retrogastric placement of the alimentary limb. The enteroenterostomy mesenteric defect, mesocolic defect, and Petersen defect were routinely closed in running fashion with nonabsorbable suture.ResultsThe study population had a mean age of 42.4 ± 9.3 years and a mean preoperative body mass index of 45.3 ± 5.6 kg/m². The mean operative time was 154 ± 25 minutes. The mean excess body weight loss at 1 year was 70%. The incidence of IH among this large study population was 0%. A total of 11 patients (1.3%) presented with symptoms concerning for IH, most commonly nausea, vomiting, and crampy abdominal pain, from 1 month to 6 years after the initial surgery. On re-exploration, 4 patients had adhesive small bowel obstruction, 4 had adhesions without obstruction, 1 had small bowel intussusception, and 2 patients had negative findings.ConclusionIH is a serious complication of LRYGB that can lead to catastrophic morbidity and mortality. We advocate vigilant screening for this complication and laparoscopic exploration for patients with worrisome symptoms. Our data have indicated that a routine and consistent technique to securely close the mesenteric defects can significantly reduce the risk of IH associated with retrocolic, retrogastric placement of the alimentary limb during LRYGB.     

Small-bowel obstruction after laparoscopic Roux-en-Y gastric bypass: etiology, diagnosis, and management

OBJECTIVE: To summarize our experience with small-bowel obstructions after laparoscopic Roux-en-Y gastric bypass. DESIGN: Retrospective record review. SETTING: University-affiliated hospital. PATIENTS: One hundred five consecutive patients undergoing surgery for intestinal obstruction after laparoscopic Roux-en-Y gastric bypass between May 24, 2001, and December 1, 2006. MAIN OUTCOME MEASURES: Common presenting symptoms, causes, yield of radiological studies, and types of surgical procedures performed for post-gastric bypass bowel obstruction. RESULTS: A total of 2325 laparoscopic Roux-en-Y gastric bypass procedures were performed during the study period. A total of 105 patients underwent 111 procedures. Bowel obstruction was confirmed in 102 patients, yielding an overall incidence of 4.4%. The most common presenting symptom was abdominal pain (82.0%), followed by nausea (48.6%) and vomiting (46.8%). Thirty-one patients (27.9%) presented with all of the 3 mentioned symptoms. The mean time to presentation was 313 days after bypass (range, 3-1215 days). Among the studies, results in 48.0% of computed tomographic scans, 55.4% of upper gastrointestinal studies, and 34.8% of plain abdominal radiography studies were positive for intestinal obstruction. In 15 patients (13.5%), all of the radiological study results were negative. The most common causes were internal hernias (53.9%), Roux compression due to mesocolon scarring (20.5%), and adhesions (13.7%). Laparoscopic explorations were carried out in 92 cases (82.9%). The incidences of bowel obstructions were 4.8% with retrocolic Roux placement and 1.8% with antecolic Roux placement. CONCLUSIONS: Altered gastrointestinal tract anatomy results in vague symptoms and a poor yield with imaging studies. A sound knowledge of altered anatomy is the key to correct interpretation of imaging studies and prompt diagnosis.     

Retrospective analysis of abdominal pain in postoperative laparoscopic Roux-en-Y gastric bypass patients: is a simple algorithm the answer?

BackgroundPatients who have undergone laparoscopic gastric bypass have a high risk of developing an internal hernia. Most patients present 9–18 months postoperatively with a weight loss of 75–120 lb and pain out of proportion to the physical findings. Given the risks of internal hernias and the difficulty in radiologic diagnosis, we have developed a single algorithm to avoid the triage complication of a “missed” diagnosis.MethodsA retrospective review was performed of 1500 bariatric procedures performed from 2001 to 2006, 33% (laparoscopic Roux-en-Y gastric bypass) of which were performed using an antecolic antegastric Roux limb, with all potential defects, including Peterson's, closed. Of these 1500 patients, 75 were evaluated for abdominal pain to rule out an internal hernia.ResultsOf the 75 patients, 40 had signs of an internal hernia or abdominal obstruction on computed tomography and underwent laparoscopy. The operative time was 38–45 minutes, and the length of stay was 1.5 days. The remaining 35 patient's computed tomography scans were interpreted as “no evidence” of internal hernia or obstruction. Of the 35 patients, 29 underwent diagnostic laparoscopy and had either an internal hernia or critical adhesions. Thus, 69 patients (92%) underwent diagnostic laparoscopy. In 6 patients, the symptoms resolved completely without any surgical intervention.ConclusionAt our institution, patients who undergo laparoscopic Roux-en-Y gastric bypass with a weight loss of 75–120 lb undergo computed tomography with contrast to rule out other potential nonoperative causes. Also, unless clinically stable or the patient has complete resolution of their pain, they then undergo laparoscopy for evaluation.     

Three-Year Follow-Up Study of Retrocolic versus Antecolic Laparoscopic Roux-en-Y Gastric Bypass

Background Since 1994, laparoscopic Roux-en-Y gastric bypass (LRYGBP) has gained popularity for the treatment of morbid obesity. In analogy to open surgery, the operation was initially performed in a retrocolic fashion. Later, an antecolic procedure was introduced. According to short-term studies, the antecolic technique is favorable. In this study, we compared the retrocolic vs the antecolic technique with 3 years of follow-up. We hypothesized that the antecolic technique is superior to the retrocolic in terms of operation time and morbidity. Methods 33 consecutive patients with retrocolic technique and 33 patients with antecolic technique of LRYGBP were compared, using a matched-pair analysis. Data were extracted from a prospectively collected database. The matching criteria were: BMI, age, gender and type of bypass (proximal or distal). The end-points of the study were: operation time, length of hospital stay, incidence of early and late complications, reoperation rates and weight loss in the followup over 36 months. Results In the retrocolic group, operation time was 219 min compared to 188 min in the antecolic group (P = 0.036). In the retrocolic group, 3 patients (9.1%) developed an internal hernia and 4 patients (12.1%) suffered from anastomotic strictures. In the antecolic group, 2 patients (6.1%) developed internal hernias and in 3 patients (9.1%) anastomotic strictures occurred. Median hospital stay in the retrocolic group was 8 days compared to 7 days in the antecolic group. In the antecolic group, the mean BMI dropped from 46 kg/m2 to 32 kg/m2 postoperatively after 36 months. This corresponds to an excess BMI loss of 66%. In the retrocolic group, we found a similar decrease in BMI from preoperative 45 kg/m2 to 34 kg/m2 after 36 months (P = 0.276). Conclusion The results of our study demonstrate a reduction of operation time and hospital stay in the antecolic group compared to the retrocolic group. No differences between the two groups were found regarding morbidity and weight loss. Taken together, the antecolic seems to be superior to the retrocolic technique.     

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.     

Predictors, Treatment, and Outcomes of Gastrojejunostomy Stricture after Gastric Bypass for Morbid Obesity

Background The aims of this study were to determine the rate of gastrojejunostomy (GJ) stricture following Roux-en-Y gastric bypass (RYGBP), the independent predictors of stricture, and clinical outcomes with and without a stricture. Methods Univariate and multivariate analysis of peri-operative and outcomes data were prospectively collected from 379 morbidly obese patients who underwent consecutive open or laparoscopic RYGBP from January 2003 to August 2006. Predictors studied were age, gender, BMI, co-morbidities, surgical technique (hand-sewn vs linear stapler vs 21-mm vs 25-mm circular stapler; open vs laparoscopic; retrocolic retrogastric vs antecolic antegastric Roux limb course, and Roux limb length), and surgeon experience. Outcomes studied consisted of occurrence of GJ strictures, technical details and outcomes after endoscopic therapy, and excess weight loss (EWL) at 12 months. Results 15 patients (4.1%) developed a GJ stricture. The use of a 21-mm circular stapler was identified as the only independent predictor of a GJ stricture (odds ratio 11.3; 95% CI 2.2-57.4, P = 0.004). Endoscopic dilation relieved stricture symptoms in all patients (60% one dilation only). There was no significant difference in %EWL at 12 months between the patients with a stricture (median EWL 54%, IQR 49 – 63) vs those without a stricture (median EWL 61%, IQR 49-73, P = 0.33). Conclusion The rate of GJ strictures is 4.1%. The use of a 21-mm circular stapler is the only independent predictor of GJ stricture. Endoscopic dilation relieved symptoms in all patients.Weight loss is independent of the anastomotic technique used and occurrence of a GJ stricture.     

Impact of complete mesenteric closure on small bowel obstruction and internal mesenteric hernia after laparoscopic Roux-en-Y gastric bypass

BackgroundAlthough it is generally accepted that closure of mesenteric defects after laparoscopic Roux-en-Y gastric bypass (LRYGB) reduces the incidence of small bowel obstruction (SBO), data supporting this belief are inconsistent. After a spike in acute SBO cases in our LRYGB patients, we changed our technique of mesenteric closure. The objective of this study was to determine whether modification of our technique of mesenteric closure would decrease the incidence of SBO and internal hernia after LRYGB.MethodsThe records of 872 consecutive patients who had antecolic LRYGB by 1 surgeon over a 9-year interval were reviewed for acute SBO. The first 654 patients, mean follow up = 100±12 months, had incomplete mesenteric closure versus complete closure in 218 remaining patients, mean follow up = 40±14 months. Minimum follow up was 1 year.ResultsTotal incidence of acute SBO was 4.0% (35/872), including 4.4% (29/654) in the incomplete closure group versus 2.8% (6/218) in the complete closure patients. Seventeen (2.6%) of the incomplete closure patients with acute SBO had internal hernias versus 1 (.5%) in the complete closure group. Twenty-six patients with incomplete closure developed symptoms of SBO and subsequently had elective repair of mesenteric hernias versus none in complete closure group (P<.02). Postoperative morbidity and mortality rates after surgery for SBO were 30% and 7.4% in incomplete group versus zero in patients with complete closure.ConclusionComplete closure of mesenteric defects in antecolic LRYGB resulted in a significant reduction in internal mesenteric hernias. Complications were also reduced after operations for SBO in patients who had complete mesenteric closure.