Benjamin Clapp

Small bowel obstruction after floseal use

The authors present a series of small bowel obstruction after FloSeal use and suggest prompt reexploration if early small bowel obstruction is found after FloSeal use for hemostasis.

Superior mesenteric artery syndrome after Roux-en-y gastric bypass.

Superior mesenteric artery syndrome caused by weight loss after gastric bypass surgery may be successfully treated with laparoscopic intestinal bypass procedures.

Prosthetic bioabsorbable mesh for hiatal hernia repair during sleeve gastrectomy.

The use of a prosthetic bioabsorbable mesh to repair hiatal hernia simultaneously with sleeve gastrectomy appears to be safe, as there were no mesh-related complications after 1 year in this case series.

Histopathologic findings in the resected specimen of a sleeve gastrectomy.

Background and Objectives: The vertical sleeve gastrectomy is quickly becoming a preferred bariatric operation. There is a dearth of published data about histopathologic changes in the specimens of morbidly obese patients, especially sleeve patients. The aim of this study is to add more data about the characteristics of the resected gastric specimens to the published literature. Methods: A prospective database of all patients undergoing laparoscopic sleeve gastrectomies at a single institution was used to gather our data. Patient characteristics such as age, sex, and initial body mass index were examined. The pathology reports of these patients were examined for any histopathologic changes or findings. Results: One hundred forty-five patients over a 3-year period had specimens available for review. Ninety-seven of the patients were women. The mean starting body mass index was 47.5 kg/m2 (range, 35–72.8 kg/m2). The mean age at the time of the operation was 43.1 years. A minority of patients, 62 (49.7%), had histopathologic findings in the resected specimens. The main histopathologic findings were acute and chronic gastritis in 4 patients, chronic gastritis in 61, and follicular lymphoid hyperplasia in 11. One leiomyoma and 2 fundic polyps were found. Seventy-three patients had no histopathologic changes. Conclusion: A minority of patients had pathologic findings in the resected specimens. This study will help build a dataset regarding the resected stomachs of morbidly obese individuals. These results can help determine what histopathologic findings can be expected after sleeve gastrectomies.

Small bowel obstruction after laparoscopic gastric bypass with nonclosure of mesenteric defects.

Background and Objectives: There is a wide variation of reported incidence of small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass (LGB). There is also wide variation in technique, not only in placement of the Roux limb, but also regarding closure or nonclosure of the mesenteric defects. The objective of this study was to examine the incidence and characteristics of SBO after antecolic antegastric bypass with nonclosure of the mesenteric defect of the jejunojejunal anastomosis. Methods: This is a retrospective review of a series of consecutive LGBs over a 3-year period. All procedures were performed by the same surgeon using the same technique. In no case was the mesenteric defect closed. A prospectively maintained database was used for data collection. Patients who returned with an SBO were the study group, and those who underwent revisional bariatric surgery or conversion to open operation were excluded. Results: There were 249 primary LGBs performed during the study period; 15 of the operations were followed by SBO, for an incidence of 6.0%. Four cases were caused by an internal hernia (IH), for an incidence of 1.6%, and 11 were caused by adhesions, which accounted for 73% of the SBOs. Conclusions: SBO after LGB is a relatively common complication. The incidence of SBO from IH with nonclosure of the mesenteric defect is similar to that in other series where the defect is closed. Regardless of the cause of the SBO, operative treatment of the patient who has a gastric bypass remains the definitive standard and should not be delayed.

Anatomic landmarks in the sleeve gastrectomy.

The second branch of the right gastroepiploic artery can safely be used as a landmark for marking the distal extent of resection during vertical sleeve gastrectomy.

CT Scan Reliability in Detecting Internal Hernia after Gastric Bypass

Background and Objectives: Internal hernia (IH) after gastric bypass can be a life-threatening complication. Obstruction presents acutely or as chronic relapses, with symptoms of abdominal pain, nausea, and vomiting. Early detection and exploration of IH as the cause of small bowel obstruction (SBO) is critical in this surgical emergency and can reduce morbidity and mortality. We conducted a retrospective review of laparoscopic Roux-en-Y bypass (LRYGB) records to determine the specificity and sensitivity of computed tomography (CT) in identifying postoperative IH. Methods: Records of 550 patients who underwent antecolic antegastric laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery over a 5-year period (2010–2014) were retrospectively reviewed for complications. Our study population comprised patients who returned with signs and symptoms of obstruction who underwent CT imaging followed by laparoscopic exploration. Results: Thirty-four patients were found to have obstruction on CT scan at ≥6 weeks after LRYGB. Six (17.7%) were found to have IH by preoperative CT imaging before laparoscopic exploration. Of the 6 patients identified to have IH before exploration, 4 (28%) had consistent findings at operation, yielding a sensitivity of 28.6% and specificity of 90.0%. Operative findings identified other causes of SBO: adhesions (n = 17), IH (n = 14), jejunojejunostomy stenosis (n = 2), and phytobezoar (n = 1). Conclusions: IH after LRYGB is difficult to detect. Our study found CT to have a low sensitivity but a high specificity in detecting IH. Therefore, laparoscopic exploration continues to be the best diagnostic and therapeutic intervention for this complication.