Ana Maria Burgos

Conservative Management of Anastomotic Leaks after 557 Open Gastric Bypasses

Background: One of the most serious complications after gastric bypass is an anastomotic leak. In a prospective surgical protocol for the management of this complication, the authors determined the incidence of anastomotic leaks Methods: From August 1999 to January 2005, 557 patients with morbid obesity were submitted to laparotomic resectional gastric bypass. In all patients a left drain was placed during surgery. All patients had a radiological study with liquid barium sulphate on the 5th postoperative day. After the occurrence of an anastomotic leak, the daily output of the leak was carefully measured. Results: 12 patients developed an anastomotic leak at the gastrojejunostomy. All were managed medically, with antibiotics if necessary, enteral or parenteral feeding and frequent control by imaging procedures. In 8 patients, the left drain was maintained in situ up to 43 days after surgery. In 4 patients, the drain had been removed between the 5th and 8th days after surgery after a normal radiologic study, but had to be inserted under radiological control 2-3 weeks after the gastric bypass. Daily output increased significantly the second week after surgery, and the leak closed at a mean of 30 days after surgery. One patient of the 12 (8%) died 32 days after surgery from septic shock, without any abdominal collection secondary to the leak. Conclusion: The occurrence of an anastomotic leak is nearly 2% after gastric bypass. The majority of them can be managed medically, without the need for a reoperation, due to the fact that there is no acid production in the small gastric pouch and there is no intestinal reflux due to the long Roux loop.

Late follow-up of polypoid lesions of the gallbladder smaller than 10 mm.

ObjectiveTo determine the variation in number, size, and symptoms in patients with polypoid lesions of the gallbladder. Summary Background DataA polypoid lesion is any elevated lesion of the gallbladder mucosa. Several studies have been reported in patients undergoing cholecystectomy, but little information exits regarding the natural history of these lesions in nonoperated patients. MethodsA total of 111 patients with ultrasound diagnosis of polypoid lesions smaller than 10 mm were followed up by clinical evaluation and ultrasonography. Twenty-seven patients underwent cholecystectomy. ResultsThere was no difference in terms of gender. Nearly 80% of the lesions were smaller than 5 mm; they were single in 74%. In nonoperated patients, 50% remained of similar size at the late follow-up, 26.5% increased in number and size, and 23.5% shrank or disappeared. Among the operated patients, 70% corresponded to cholesterol polyps. None of the patients developed symptoms of biliary disease or gallstones or adenocarcinoma. ConclusionsUltrasound is useful in the follow-up of patients with polypoid lesions of the gallbladder. Lesions smaller than 10 mm do not progress to malignancy or to development of stones, and none produced symptoms or complications of biliary disease.

Effect of gastric bypass on Barrett's esophagus and intestinal metaplasia of the cardia in patients with morbid obesity.

Gastric bypass in patients with morbid obesity should be an excellent antireflux procedure, because no acid is produced at the small gastric pouch and no duodenal reflux is present, due to the long Roux-en-Y limb. Five hundred fifty-seven patients with morbid obesity submitted to resectional gastric bypass, and routine preoperative upper endoscopy with biopsy samples demonstrated 12 patients with Barrett’s esophagus (2.1%) and three patients with intestinal metaplasia of the cardia (CIM). An endoscopic procedure was repeated twice after surgery, producing seven patients with short-segment Barrett’s esophagus (BE) and five patients with long-segment BE. Body mass index (BMI) decreased significantly, from 43.2 kg/m2 to 29.4 kg/m2 2 years after surgery. Symptoms of reflux esophagitis, which were present in 14 of the 15 patients, disappeared in all patients 1 year after surgery. Preoperative erosive esophagitis and peptic ulcer of the esophagus healed in all patients. There was regression from intestinal metaplasia to cardiac mucosa in four patients (57%) with short-segment BE, and in one patient (20%) with long-segment BE. Two (67%) of three cases with CIM had regression to cardiac mucosa. There was no progression to low- or high-grade dysplasia. Gastric bypass in patients with Barrett’s esophagus and morbid obesity is an excellent antireflux operation, proved by the disappearance of symptoms and the healing of endoscopic esophagitis or peptic ulcer in all patients, which is followed by an important regression to cardiac mucosa that is length-dependent and time-dependent.

Latest results (12-21 years) of a prospective randomized study comparing Billroth II and Roux-en-Y anastomosis after a partial gastrectomy plus vagotomy in patients with duodenal ulcers.

Introduction:After a partial resection of the stomach, the continuity of the gastrointestinal tract can be restored either by a Billroth II gastrojejunal anastomosis or a Roux-en-Y gastrojejunostomy. Each procedure has its advantages and disadvantages. Objective:To determine through a prospective and random clinical trial, the clinical outcome and the endoscopic and histologic alterations of the distal esophagus and the gastric remnant in patients who received a partial distal gastrectomy due to duodenal ulcers and a Billroth II or Roux-en-Y reconstruction. Material and Methods:In this prospective random trial, a total of 75 patients with duodenal ulcers were included. A bilateral selective vagotomy and partial distal gastrectomy were performed in all patients. A Billroth II or Roux-en-Y 60-cm-long loop was randomly used for reconstruction of the gastrointestinal tract. During the latest follow-up clinical evaluation, upper endoscopy and biopsy samples from the distal esophagus and gastric remnant were obtained. Results:There was 1 operative mortality and 6 patients had some morbidity. The average follow-up period was 15.5 years (range, 11–21). Patients with Roux-en-Y gastrojejunostomy were significantly more asymptomatic and had greater Visick I grading than patients with Billroth II reconstruction (P < 0.001). In the distal esophagus, endoscopic findings were normal in 90% of the Roux-en-Y group, but only in 51% of the Billroth II group (P < 0.0009). Nearly 25% of the latter group had the appearance of a short-segment Barrett esophagus compared with 3% of the Roux-en-Y group (P < 0.0001). The gastric remnant endoscopic findings were normal in 100% of the Roux-en-Y group and in 18% of the Billroth II group (P < 0.02). Histologic analyses showed similar proportions of normal fundic mucosa and chronic active fundic gastritis. However, chronic atrophic fundic gastritis and intestinal metaplasia were significantly more frequent after Billroth II reconstruction (P < 0.008). Helicobacter pylorus was present in a similar proportion of patients. Conclusions:This prospective and random study showed that Roux-en-Y gastrojejunostomy is significantly better than a Billroth II reconstruction in patients with duodenal ulcers, through subjective and objective endoscopic and histologic evaluations during the latest follow-up evaluation.

Histological Findings in the Liver Before and After Gastric Bypass

Background: Bariatric surgery results in massive loss of excess weight, changes in co-morbidities and improvement in quality of life. In these patients, liver histology taken before or during surgery reveals several histological abnormalities. In a prospective study of patients previously submitted to gastric bypass, we determined the changes in liver histology late after the surgery. Methods: In 16 out of a total of 557 patients who were submitted to open gastric bypass, a second liver biopsy was taken during the repair of an incisional hernia, performed at a mean of 17 months after the gastric bypass. Results: All patients had lost weight, now having a mean BMI of 28.6 kg/m2 (which had been 44.3 kg/m2 before gastric bypass). One patient with normal pre-operative liver histology remained normal at the second study. 11 out of 15 who had had liver abnormalities returned to a normal condition or had only minimal change (73.3%). 2 patients (13.3%) showed improvement, while 1 patient presented a slight worsening of liver condition. One patient who had had liver cirrhosis showed no change. Conclusion: Gastric bypass for morbid obesity is followed by a dramatic improvement or normalization of liver histological abnormalities in the great majority of the patients. Liver cirrhosis in the one patient remained unchanged.

Classification and Management of Leaks after Gastric Bypass for Patients with Morbid Obesity: A Prospective Study of 60 Patients

The most important and frequent major complication after gastric bypass is the appearance of a leak, which can result in death of a patient. The purpose of this prospective study was to determine the incidence of a postoperative leak, to propose a classification and to evaluate the results of conservative or surgical treatment. All patients submitted to gastric bypass either laparotomic or laparoscopic were included in a prospective protocol. In all radiological evaluation at 4th day after surgery was performed. The presence of a leak was evaluated according to the day of appearance, its location and its severity. Results of medical or surgical treatment were analyzed. From 1764 patients submitted to Roux-en-Y gastric bypass, 60 had a postoperative leak (3.4%). This leak appeared early after surgery (before 4 days) in 20%. It was a localized subclinical leak in 20% and clinical – septic in 80%. There were 7 possible anatomic location of a leak, being the gastrojejunal anastomosis the most frequent location (53%) followed by gastric pouch. The highest mortality was associated to the jejuno-jejunal anastomosis. Conservative treatment was employed in near 65% of the patients: The mean time of closure of a leak was 34 days. The appearance of a postoperative leak is a major and serious complication. It can be classified according to the day of appearance, its severity and its location. Conservative or surgical treatment can be employed properly if these 3 parameters are carefully evaluated.

Late Results of the Surgical Treatment of 125 Patients With Short-Segment Barrett Esophagus

HYPOTHESIS The results of surgical treatment of patients with long-segment Barrett esophagus (BE) have been extensively reported. However, few publications refer to the results of surgery 5 years after the fact among patients with short-segment BE. This study aimed to determine the late results of 3 surgical procedures in patients with short-segment BE by subjective and objective measurements. DESIGN Prospective, nonrandomized study starting on March 1, 1987, and ending on December 31, 2005. SETTING A prospective, descriptive study of a group of patients. PATIENTS A total of 125 patients with short-segment BE underwent 3 operations in different periods: duodenal switch plus highly selective vagotomy and antireflux technique in 31 patients, vagotomy plus partial gastrectomy and Roux-en-Y loop with antireflux surgery in 58 patients, and laparoscopic Nissen fundoplication in 36 patients. MAIN OUTCOME MEASURES Late subjective and objective outcomes of the 3 different surgical procedures. RESULTS No operative mortality and only 2 postoperative complications (1.6%) occurred. The regression from intestinal metaplasia to cardiac or oxyntocardiac mucosa occurred in 60.8% to 65.4% of the patients, at a mean time of 39 to 56 months after surgery. Visick grading showed Visick grade I or II in 86.3% to 100.0% of the patients. No progression to low- or high-grade dysplasia or adenocarcinoma occurred. CONCLUSIONS On the basis of these results, laparoscopic Nissen fundoplication seems to be the surgical option for patients with short-segment BE because it is less invasive, has fewer side effects, and produces good results in the long-term follow-up.

Endoscopic and Histologic Findings in the Gastric Pouch and the Roux Limb after Gastric Bypass

Background: Despite the large number of gastric bypasses performed for morbid obesity, very little is known about the endoscopic and histologic aspects of the gastric pouch and the Roux-limb late after surgery. We performed prospective routine endoscopic and histologic studies of the pouch and Roux-limb 2 years after gastric bypass. Methods: The present study includes 227 patients submitted to resectional gastric bypass and followed for a mean of 27 months after surgery. Mean BMI before bypass was 44 kg/m2. In all patients, upper endoscopy of the pouch and of the jejunal limb was performed, taking 3 biopsy samples of the gastric pouch in 171 patients and 2 samples of the jejunum in 40 patients. Results: Macroscopic appearance of the gastric pouch was normal in 99% of the patients and of the jejunal limb in 100%. Histologic analysis revealed normal fundic mucosa in 56%. Chronic active gastritis was the most frequent abnormal histologic finding. 7 patients (4.1%) showed intestinal metaplasia. H. pylori infection was present in the gastric pouch in 31% of the patients. Conclusions: The proximal gastric pouch after gastric bypass is endoscopically normal in 99% of patients 2 years after surgery, while the Roux-limb is normal in 100%. Histologic analysis of gastric mucosa revealed normal fundic mucosa in 56%. There are some chronic histologic changes, even intestinal metaplasia, whose behavior at late follow-up is not yet known. H. pylori is present in nearly 1/3 of the patients.

Size, Volume and Weight of the Stomach in Patients with Morbid Obesity Compared to Controls

Background: There is no mention in surgical literature regarding anatomic measurements of the stomach in patients with morbid obesity. We investigated by a prospective study the length of the lesser and greater curvature, the volume or total capacity and the weight of the stomach in morbidly obese patients compared to controls. Methods: 30 patients with different degrees of morbid obesity were compared to 20 controls. Measurements included length of both curvatures of the stomach, weight and total volume of saline needed to distend the stomach. Patients with morbid obesity were submitted to resectional gastric bypass. The stomach of controls was obtained from autopsy material during the first day after death. Results: The length of the lesser curvature, total gastric capacity and weight of the stomach of morbidly obese patients were similar to control subjects. The length of greater curvature was significantly less in patients with morbid obesity. Conclusions: No significant differences were found in anatomic measurements of the stomach between control subjects and patients with morbid obesity.

Evolutive Radiological Changes of the Esophagus in Patients with Achalasia Who Did Not Receive Treatment

PurposeThe radiological features of achalasia of the esophagus are well known and have been described. However, very little is known concerning the natural history of this disease. We aimed to determine the evolutive radiological changes of the esophagus in a group of patients with achalasia who had not previously undergone any treatment.MethodsWe undertook a prospective study of 14 patients with achalasia from a group of 205 patients. They included 9 women and 5 men who did not receive any treatment at the initial diagnosis. Two radiological parameters were evaluated: (a) the maximal internal diameter of the middle third of the thoracic esophagus in millimeters and (b) the internal diameter of the esophagogastric junction in millimeters.ResultsAt a mean follow-up of 5-years without any treatment, there was a significant increase in the diameter of the thoracic esophagus, with a rate of “dilatation” of 6.1 mm/year. In addition, there was a significant decrease of the internal diameter of the esophagogastric junction, with a rate of “stenosis” of 1 mm/year. The lower esophageal sphincter was hypertensive in all with an incomplete relaxation.ConclusionThese results suggest that there is a progressive deterioration in the radiological parameters of the esophagus in patients with achalasia not treated over a 5-year period of observation.