Daniel Gero

Laparoscopic Roux-en-Y gastric bypass for failed gastric banding: outcomes in 642 patients.

BACKGROUND Laparoscopic adjustable gastric banding (LAGB) is a well-tolerated procedure but has high long-term complication and failure rates. Laparoscopic conversion to Roux-en-Y gastric bypass (LRYGB) is one of the rescue strategies. OBJECTIVES To analyze short- and long-term results of reoperative LRYGB after failed LAGB. SETTING Three European expert bariatric center (2 university hospitals and 1 regional hospital). METHODS A retrospective review of prospectively collected data, including all consecutive patients submitted to revisional LRYGB for failed LAGB between 1999 and 2013, was performed. Complications were classified according to the Dindo-Clavien system. Long-term results in terms of weight loss were analyzed in a subgroup of patients. RESULTS A total of 642 patients (569 women and 73 men) were included. Mean±standard deviation operating time was 188±43 minutes. There was no mortality and an overall complication rate of 9.7%, including 3.6% major complications, with no difference between the 1- or 2-step approaches. Follow-up rate was 88% at 10 years for the Swiss patient cohort. The mean excess body mass index loss was between 65% and 70% throughout the study period, and the mean total weight loss was between 28% and 30% based on the maximum weight. The mean body mass index decreased from 44.7 kg/m(2) before LAGB to 31.6, 32.2, and 32.5 kg/m(2) at 1, 5, and 10 years after revision. CONCLUSIONS Revisional LRYGB is well tolerated and feasible after failed LAGB. A 1-step approach, in cases without erosion, does not increase operative morbidity. Results up to 10 years after revision are comparable to those reported after primary LRYGB.

An unusual cause of solid food intolerance and gastric pouch dilation 5 years after Roux-en-Y gastric bypass: agar-agar bezoar

Fig 2. Abdominal computed tomography with oral and intravenous contrast agent showing gastric-pouch dilation caused by agar-agar bezoar and presence of the contrast agent in the small bowel (coronal plane). We present the case of a 64-year-old female patient who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) in 2010 for morbid obesity. Her body mass index (BMI) decreased from 38 to 21 kg/m without any postoperative complication. She consulted the emergency department in April 2015 for nausea, vomiting, and dysphagia over 72 hours, since ingestion of an agar-agar– based dessert. Presuming that agar-agar was biodegradable, the patient was reassured by the emergency physician and

A Simple Trick to Prevent VOMIT After Sleeve Gastrectomy

Victim of medical imaging technologies (VOMIT) is a term coined by a pediatric neurosurgeon to describe anxiety-inducing false-positive results on radiologic imaging [1]. Morbidly obese patients have a low functional physiological reserve that constrains to a fast diagnostic work-up, and an aggressive and early treatment of potential complications [2]. Upper gastrointestinal contrast study (UGI) is a useful modality to detect functional and surgical complications after sleeve gastrectomy (SG) [3]. However, in some cases, the residual gastric tube is floppy, and the findings are hard to interpret. In this paper, we present a simple trick which aims to prevent SG patients from suffering physically as well as mentally and from undergoing unnecessary further diagnostic interventions due to a false-positive UGI finding. Discussion

Accuracy of sentinel lymph node dissection for melanoma staging in the presence of a collision tumour with a lymphoproliferative disease.

Sentinel lymph node dissection (SLND) identifies melanoma patients with metastatic disease who would benefit from radical lymph node dissection (RLND). Rarely, patients with melanoma have an underlying lymphoproliferative disease, and melanoma metastases might develop as collision tumours in the sentinel lymph node (SLN). The aim of this study was to measure the incidence and examine the effect of collision tumours on the accuracy of SLND and on the validity of staging in this setting. Between 1998 and 2012, 750 consecutive SLNDs were performed in melanoma patients using the triple technique (lymphoscintigraphy, gamma probe and blue dye). The validity of SLND in collision tumours was analysed. False negativity was reflected by the disease-free survival. The literature was reviewed on collision tumours in melanoma. Collision tumours of melanoma and chronic lymphocytic leukaemia (CLL) were found in two SLN and in one RLND (0.4%). Subsequent RLNDs of SLND-positive cases were negative for melanoma. The patient with negative SLND developed relapse after 28 months with an inguinal lymph node metastasis of melanoma; RLND showed collision tumours. The literature review identified 12 cases of collision tumours. CLL was associated with increased melanoma incidence and reduced overall survival. This is, to our knowledge, the first assessment of the clinical value of SLND when collision tumours of melanoma and CLL are found. In this small series of three patients with both malignancies present in the same lymph node basin, lymphocytic infiltration of the CLL did not alter radioisotope uptake into the SLN. No false-negative result was observed. Our data suggest the validity of SLND in collision tumours, but given the rarity of the problem, further studies are necessary to confirm this reliability.

Arterial embolization in idiopathic spontaneous intra-peritoneal hemorrhage: Case report and review

A 64-year-old man presented to the Emergency Department of our tertiary center with lower abdominal tenderness. The patient described the sudden onset of infra-umbilical discomfort 6 h prior to admission, with progression of the pain and two episodes of self-resolving syncopes. History was negative for fever, chills, nausea, vomiting, diarrhea, hematochezia, melaena, dysuria or substance abuse. Medical history revealed prostate cancer treated by radical prostatectomy by laparotomy 10 years prior, without radiation therapy. The patient was normotensive but tachycardiac at 107 bpm. Laboratory tests showed hemoglobin at 124 g/L, WBC 12.2 G/L, INR 1.1, electrolytes and liver function tests in normal range. Contrast enhanced multiple detector computed tomography (MDCT) revealed intra-abdominal free fluid with a radiological density of 35 Hounsfield units, compatible with hemoperitoneum (Fig. 1). The most likely origin of the abdominal bleed was identified by contrast extravasation in the vicinity of the left branch of the superior rectal artery (Fig. 2). The patient was monitored overnight at the intermediate care unit of the Emergency Department and received crystalloid resuscitation. Hemoglobin plummeted to 84 g/L through the next 14 hours. At this point, a control MDCT showed slight augmentation of the hemoperitoneum, without visualization of an active bleeding source. The patient has undergone transcatheter arterial embolization (TAE). During the procedure, no significant vascular anomaly was visualized and the rectal arterial vasculature appeared normal. The anterior branch of the left superior rectal artery showed signs of spasm and was embolized by gelatin sponge (Gelfoam Slurry® Ethicon, Somerville, NJ, USA) through a 2.7F microcatheter on the basis of the first MDCT findings (Fig. 3). The procedure lasted 45 minutes, was well tolerated, the postinterventional hemoglobin levels were stable around 95 g/L and the patient was discharged 3 days later. At a telephonic t t t n