Metastatic Adenocarcinoma of the Gastric Pouch 5 Years After Roux-en-Y Gastric Bypass

A 65-year-old male presented 5 years after Roux-en-Y gastric bypass (RYGBP) with cancer of the gastric pouch. At the time of detection, the cancer was already metastatic. This case represents the first reported metastatic gastric adenocarcinoma arising from the gastric pouch following RYGBP.     

Is a Pouch Compulsory in Roux-en-Y Gastric Bypass After Failed Adjustable Gastric Banding?

Background  Pouch formation after failed gastric banding bears a risk of anastomotic leakage, bleeding or ischemic damage due to an impaired vascular supply or demanding preparation in the scarry tissue. We evaluated the clinical outcome in patients following Roux-en-Y gastric bypass (RYBP) with and without gastric pouch reconstruction after removal of adjustable gastric bands. Methods  This study comprised 24 morbidly obese patients undergoing RYBP as their final bariatric procedure. Group 1 consisted of eight patients after band migration or pouch dilatation. An esophago-jejunal anastomosis was performed. Group 2 comprised 16 patients with esophageal motility disorders or pouch dilation after banding. A regular-sized pouch was created. Clinical parameters, such as weight loss, complications and a satiety score were assessed. Serum values of ghrelin and gastrin were measured. Results  All but one procedure (Group 2) could be performed by laparoscopy. Mortality rate was 0%. One patient of Group 1 developed a liver abscess that required percutaneous drainage and one patient of Group 2 developed stenosis at the gastrojejunostomy that necessitated endoscopic balloon-dilation. All patients significantly reduced body weight (p < 0.01 compared to preoperative values) during a median follow-up of 37.5 and 31.5 months, respectively. Two out of 16 (12.5%) patients of Group 2 showed pathologic postoperative DeMeester scores. Esophageal body peristalsis did not reveal statistically significant differences between the two groups. Parameters of satiety assessment did not differ between the two groups as did serum values of gastrin and ghrelin. Conclusion  RYBP in patients experiencing adjustable gastric band failure is technically demanding. Esophago-jejunostomy avoids preparation in scarred tissue whereas routine pouch formation may increase the risk for complications. Adapted procedural strategy is recommended based on intraoperative decision making.     

Gastric Emptying is not Affected by Sleeve Gastrectomy—Scintigraphic Evaluation of Gastric Emptying after Sleeve Gastrectomy without Removal of the Gastric Antrum

Background  The aim of this study is to clarify whether laparoscopic sleeve gastrectomy (LSG) to treat morbid obesity causes changes in gastric emptying. Methods  Gastric emptying scintigraphy was performed before and 3 months after LSG, in 21 consecutive morbidly obese patients. After an overnight fast, subjects consumed a standard semi-solid meal, to which 0.5 mCi Tc⁹⁹-labeled sulfur colloid had been added. The meal was consumed within 10 min. Scintigraphic imaging was performed with a gamma camera immediately after the completion of the meal as well as after 30, 60, 120, 180, and 240 min. Quantitative and qualitative analysis was performed by drawing a region of interest (ROI) enclosing the stomach on the anterior and the posterior images. Time 0 was considered the time of meal completion (all the ingested activity) and was defined as 100% retention. The same ROI was used on all consecutive images of the same projection for the same patient. The geometric mean of the anterior and the posterior counts for each time point is calculated and corrected for Tc^99m decay. Gastric emptying curves were constructed. T 1/2 is the time interval between completion of the meal and the point at which half of the meal (by radioactivity counts) has left the stomach. Retention is expressed as the percent remaining in the stomach at each time point (half, 1, 2, 3, 4 h). Results  The mean T 1/2 raw data was 62.39 ± 19.83 and 56.79 ± 18.72 min (p = 0.36, t = −0.92, NS) before and 3 months after LSG, respectively. The T 1/2 linear was 103.64 ± 9.82 and 106.92 ± 14.55, (p = 0.43, t = −0.43, NS), and the linear fit slope 0.48 ± 0.04 and 0.47 ± 0.05 (p = 0.48, t = 0.7, NS). Conclusions  LSG with antrum preservation as performed in this series has no effect on gastric emptying. This work was performed in partial fulfillment of the requirements for a MSc degree of Ronit Tzioni Yehoshua, Sackler Faculty of Medicine, Tel Aviv University, Israel.     

Who Benefits from Gastric Banding?

Background In the present study, criteria were investigated to predict major benefit after laparoscopic adjustable gastric banding (LAGB). Materials and Methods 85 morbidly obese patients were operated with LAGB between 1999 and 2005. Seventy-one of these patients were analyzed according to several possible predictive characteristics for success as the primary endpoint. Success was defined as excess body weight loss (EBWL) >50% and no band removal. Median follow-up was 27 months (range 8–90 months). Results In total, median EBWL was 43% (−41 to 171.5%) with a decrease in BMI of 8.0 kg/m² (−9 to 35 kg/m²). Success rate was 37% (n = 26). These patients were compared to all other patients (n = 45). Significant success predictors were baseline absolute BW, EBW, BMI (p < 0.01), BMI with a threshold value of 50 kg/m² (p = 0.02), and female sex (p = 0.02) as well as postoperative vomiting (p = 0.02), eating behavior and physical activity after LAGB (p < 0.01). Baseline EBW and change in eating behavior after surgery were identified as independent predictors in multivariate analysis. Conclusion Patients with a lower excess body weight who improve especially their eating behavior after surgery have the highest chance of success after LAGB.     

Does Gastric Resection Have a Role in the Management of Severe Postfundoplication Gastric Dysfunction?

Background  

Bloating, flatulence, early satiety, and dysphagia resolve in more than 90% of patients early after fundoplication. Gastric dysfunction can persist, however, and a small number of patients develop severe gastric dysfunction (gastroparesis). Management of gastroparesis after antireflux procedures is generally conservative, but gastroparesis can become refractory to medical therapy. The aim of this study was to assess the role of gastric resection in the management of the unusual patient with severe postfundoplication gastric dysfunction.     

Gastric resection Billroth or Rydygier?

The Authors present the history of the first gastric resections and of the two men who first made this bold step in surgery. Although the famous Viennese surgeon Theodor Billroth is credited with the first gastric resection, known as the Billroth I procedure, the less well known Ludwik Rydygier from Chelmno, Poland, performed and described the procedure several months earlier. The Authors present the lives and major achievements of these two pioneering surgeons.     

Gastric Gangrene “An Iatrogenic Misadventure”

In gastrointestinal system gangrene commonly involves intestines. Involvement of stomach is a rare finding. Herein we describe a case of gastric gangrene secondary to herniation of stomach through an iatrogenic defect. Gangrene of the stomach is a rare and a catastrophic occurrence as stomach is a highly vascularised organ. Gastric gangrene could be secondary to atherosclerosis, arterial embolism, iatrogenic gelfoam embolism, venous thrombosis, gastric volvulus, bulimia nervosa, endoscopic haemostatic injections, diaphragmatic hernia and infectious gastritis. Most reported cases have occurred due to gastric volvulus (Amin El-Gohary and Etiaby, Paedr Surg Intl 9:486–488, 1994; Al-Salem, Pediatr Radiol 30(12):842–5, 2000). Few cases have been reported as complicated hernias either a Bochdalek hernia (Ghanem, Chankun, Brooks, BJS V74(9):779, 2005) or as peristomal hernias which initially lead to gastric outlet obstruction (Ellingson, Maki, Kozarek, Patterson, J Clin Gastroenterol 17(4):314–6, 1993).     

Are Laparoscopic Gastric Bypass After Gastroplasty and Primary Laparoscopic Gastric Bypass Similar in Terms of Results?

Background  

This retrospective study compares the results of primary gastric bypass (PGB) versus secondary gastric bypass (SGB) performed after gastroplasty.     

Seven Cases of Gastric Perforation in Roux-en-Y Gastric Bypass Patients: What Lessons Can We Learn?

Background Patients undergoing Roux-en-Y gastric bypass for the resolution of morbid obesity have significant medical sequelae related to their weight. One of the most common comorbid conditions is joint pain requiring the use of non-steroidal anti-inflammatory medications (NSAIDs). In addition to NSAIDs, patients may engage in behaviors such as smoking and alcohol misuse that increase the risk of long-term postoperative complications to include gastric perforation. Methods Data on 1,690 patients undergoing gastric bypass surgery were collected prospectively and reviewed retrospectively. Results We identified seven patients who presented to an emergency room and subsequently required emergent surgical intervention for repair of gastric perforation. Six of the seven cases involved use or abuse of NSAIDs. Conclusion Important characteristics were identified including the use of NSAIDs, alcohol use, and non-compliance with routine long-term postoperative follow-up. Identifying those patients at high risk may decrease the incidence of this potentially life-threatening complication.     

Gastric Antral Vascular Ectasia — An Unusual Cause of Gastric Outlet Obstruction: Report of a Case

Gastric antral vascular ectasia is an important cause of gastric bleeding. We herein report a case of gastric outlet syndrome due to a gastric antral vascular ectasia in a patient with a negative history for anemia or gastric bleeding. The patient underwent an antral resection. The specimen showed vascular ectasia, fibromuscular hyperplasia, and fibrin thrombosis, especially localized in the submucosa. The pathogenesis of this syndrome remains unclear. Surgery in cases of gastric outlet obstruction is the only reliable method to cure the patient. An antrectomy has been shown to be the procedure of choice. It carries a remarkably low rate of long-term sequelae and it can be performed in the majority of cases with low risk, especially in those patients not affected by cirrhosis or portal hypertension.     

Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy as Revisional Procedure after Adjustable Gastric Band—a Systematic Review

The adjustable gastric band (L)AGB gained popularity as a weight loss procedure. However, long-term results are disappointing; many patients need revision to laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (LSG). The purpose of this study was to assess morbidity, mortality, and results of these two revisional procedures. Fifteen LRYGB studies with a total of 588 patients and eight LSG studies with 286 patients were included. The reason for revision was insufficient weight loss or weight regain in 62.2 and 63.9 % in LRYGB and LSG patients. Short-term complications occurred in 8.5 and 15.7 % and long-term complications in 8.9 and 2.5 %. Reoperation was performed in 6.5 and 3.5 %. Revision to LRYGB or LSG after (L)AGB is feasible and relatively safe. Complication rate is higher than in primary procedures.     

Is Lymphadenectomy Necessary for Early Gastric Cancer?

Background: Although early gastric cancer (T1, NX) in Japan has been reported to have an excellent prognosis, the experience with this cancer in the United States is limited. The treatment of these tumors in Japan is becoming less aggressive as good prognostic factors are increasingly recognized. Our objective was to identify predictors of nodal disease and survival in a large cohort of Western patients with T1 tumors.Methods: A retrospective review of our prospective data base from July 1985 to March 1998 revealed 165 patients undergoing surgical resection for T1 gastric tumors. Clinicopathological factors analyzed and compared included presence of positive nodes, tumor size (4.5 vs.,4.5 cm), depth (mucosal vs. submucosal), grade (poor vs. moderate and well), and tumor site (proximal vs. distal), presence of venous or perineural invasion, and Laurens classification. Factors predicting lymph node involvement and disease-specific survival were evaluated by univariate and multivariate analysis.Results: Median follow-up time was 36 months. The actuarial 5-year survival was 88%. Thirteen patients (8%) died of disease. Lymph node involvement was present in 31 tumors (19%), with a 5-year survival of 91% with negative nodes vs. 78% with positive nodes. On univariate and multivariate analysis, the presence of tumor submucosal invasion (P,.05), venous invasion (P 5.02), and size of 4.5 cm and larger (P 5.02) was significantly associated with an increased risk for nodal positivity. On univariate analysis of survival, node-positive tumors (P 5.02) and tumors 4.5 cm and larger (P 5.008) were significantly associated with decreased survival. On multivariate analysis, only node-positive tumors were significantly (P 5.01) associated with decreased survival. Those tumors that were limited to the mucosa and less than 4.5 cm in size (n = 47) had a 4% rate of positive nodes. In contrast, those tumors that were 4.5 cm and larger and had penetrated into the submucosa (n = 16) had a 56% chance of positive nodes.Conclusions: Early gastric carcinoma in North America has an excellent prognosis, similar to that in Japan. Tumors that are limited to the mucosa and smaller than 4.5 cm could be considered for limited resection without lymphadenectomy.     

Combination of Laparoscopic Adjustable Gastric Banding and Gastric Bypass: Current Situation and Future Prospects – Routine Use Not Advised

Although bariatric surgery has proven to be the most effective treatment for morbid obesity, most surgical techniques do have failures. In an effort to improve the reliability, several surgeons started to use a combination of a laparoscopic gastric bypass with an adjustable gastric band. Because of concerns regarding a possible negative outcome, an expert meeting was organized to evaluate the current situation and future application. In total, 104 operations were reported,with several technical variations. The overall complication rate was acceptable, but the percentage of the band erosions was 6.7%, which is too high. The potential advantages (adjustability, maintained access to the stomach and biliary tree, and reversibility) do not compensate for this complication rate. Based on the results and the opinion of the surgeons experienced in this technique, it is concluded that the combination of gastric bypass with an adjustable gastric band to form the pouch is not recommended.