Enrico Facchiano

Internal Hernia after Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is associated with a relatively high incidence of internal hernias (IH) when compared to the open operation. Methods: A search in PubMed MEDLINE from January 1994 through January 2006 was performed (keywords: obesity, laparoscopy, gastric bypass and internal hernia). Results: 26 studies with a total of 11,918 patients were considered. 300 cases of IH occurred (rate 2.51%). IH occurred 116 times at the level of the transverse colon mesentery (69%), 30 at the Petersens space (18%), and 22 at the entero-enterostomy site (13%). 142 re-operations were performed laparoscopically (85.6%), and 24 by laparotomy (14.4%). Bowel resection was done in 5 cases (4.7%). Mortality was 1.17%. Conclusions: IH after LRYGBP has an incidence of 2.51%. Closure of mesenteric defects with non-absorbable running suture and antecolic Roux limb are recommended. Surgical exploration for suspicion of IH after LRYGBP should be first done by laparoscopy.

Gastric necrosis: a rare complication of gastric banding.

In the last decade, laparoscopic gastric banding has become an increasingly popular surgical option for morbidly obese patients, because of the minimally invasive and easy surgical technique, its reversibility, and the possibility to calibrate the stoma. Gastric necrosis, as a complication of laparoscopic gastric banding, has been only rarely reported. Herein described is the case of a 45-year-old obese patient with gastric necrosis occurring 2 years after the placement of the band. After initial conservative management, the patient underwent urgent surgery. A huge anterior gastric prolapse through the band was found to be responsible for necrosis of the herniated stomach. An upper polar gastrectomy was performed. The mechanisms responsible for this life-threatening complication are discussed.

Upper Gastrointestinal Series after Roux-en-Y Gastric Bypass for Morbid Obesity: Effectiveness in Leakage Detection. a Systematic Review of the Literature

The aim of this study is to evaluate the results of routine and selective postoperative upper gastrointestinal series (UGIS) after Roux-en-Y gastric bypass (RYGB) for morbid obesity in different published series to assessing its utility and cost-effectiveness. A search in PubMed’s MEDLINE was performed for English-spoken articles published from January 2002 to December 2012. Keywords used were upper GI series, RYGB, and obesity. Only cases of anastomotic leaks were considered. A total of 22 studies have been evaluated, 15 recommended a selective use of postoperative UGIS. No differences in leakage detection or in clinical benefit between routine and selective approaches were found. Tachycardia and respiratory distress represent the best criteria to perform UGIS for early diagnosis of anastomotic leak after a RYGB.

Hypogonadism as an additional indication for bariatric surgery in male morbid obesity

OBJECTIVE Male obesity is often associated with reduced levels of circulating total (TT) and calculated free testosterone (cFT), with normal/reduced gonadotropins. Bariatric surgery often improves sex steroid and sex hormone-binding globulin (SHBG) levels. The aim of this study was to assess the effects of bariatric surgery on waist circumference (WC) and BMI, and on TT levels, in morbidly obese men, stratified, according to the gonadal state, in eugonadal and hypogonadal (TT<8 nmol/l) subjects. DESIGN A cohort of morbidly obese patients (29 with hypogonadism (HG) and 26 without) undergoing bariatric surgery (37, 10, 6, and 2, with Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, biliopancreatic diversion and gastric sleeve, respectively) was studied at 6 and 12 months from the operation. METHODS Anthropometric parameters (weight, BMI, WC) and sex hormones (gonadotropins, TT, cFT, estradiol (E2), SHBG) were assessed. RESULTS WC was the only parameter significantly correlated with androgens, but not with E2, SHBG, and gonadotropins, at baseline. After surgery, a significant increase in TT, cFT, and SHBG, accompanied by a decrease in E2, was evident in the two groups. However, both TT and cFT, but not E2, SHBG, and gonadotropin variations, were significantly higher in the hypogonadal group at follow-up, with an overall 93% complete recovery from HG. Reduction in WC, but not BMI, was significantly greater in hypogonadal men (ΔWC=-29.4±21.6 vs -14.4±17.4 at 12 months, P=0.047). CONCLUSIONS Recovery from obesity-associated HG is one of the beneficial effects of bariatric surgery in morbidly obese men. The present findings suggest that the gonadal state is a predictor of WC decrease after bariatric surgery.

Laparoscopy-Assisted Transgastric Endoscopic Retrograde Cholangiopancreatography (ERCP) After Roux-en-Y Gastric Bypass: Technical Features

BackgroundLaparoscopic gastric bypass is one of the most performed bariatric operations worldwide. The exclusion of stomach and duodenum after this operation makes the access to the biliary tree, in order to perform an endoscopic retrograde cholangiopancreatography (ERCP), very difficult. This procedure could be more often required than in overall population due to the increased incidence of gallstones after bariatric operations. Among the different techniques proposed to overcome this drawback, laparoscopic access to the excluded stomach has been described by many authors with a high rate of success reported.MethodsWe herein describe our technique to perform laparoscopic transgastric ERCP. A gastrotomy on the excluded stomach is performed to introduce a 15-mm trocar. Two stitches are passed through the abdominal wall and placed at the two sides of the gastrotomy for traction. The intragastric trocar is used to pass a side-viewing endoscope to access the biliary tree.ConclusionIn patients with a past history of Roux-en-Y gastric bypass (RYGB), the present technique allows us a standardized, safe, and reproducible access to the major papilla and the biliary tree using a transgastric access. This will lead to simplify the procedure and reduce the risk of peritoneal contamination.

Osteocalcin increase after bariatric surgery predicts androgen recovery in hypogonadal obese males

OBJECTIVE:Bone modulates testis function through osteocalcin (OCN) production. This paper assesses the association between serum OCN and androgen production recovery in morbidly obese males at 9 months after bariatric surgery.SUBJECTS:A cohort of n=103 obese males with mean±s.d. body mass index (BMI) 47.7±8.2 kg m–2, age 42±11 years, consisting of n=76 patients undergoing gastric bypass and n=27 in the waiting list for surgery.RESULTS:At 9 months from surgery, a significant increase was observed in mean±s.d. total OCN (tOCN=10.4±10.3 ng ml–1, P<0.001) and undercarboxylated OCN (ucOCN=5.4±3.7 ng ml–1, P<0.001), total testosterone (TT, 5.6±6.5 nM, P<0.001) and calculated free testosterone (cFT, 0.035±0.133 nM, P<0.006), sex hormone binding globulin (SHBG, 21.2±16.7 nM, P<0.001) and decrease in estradiol (E2, −30.1±51.9 pM, P<0.001) levels only in operated patients, with a significant reduction in BMI (24%) and waist (20%). A positive correlation existed between tOCN and ucOCN (age-adjustment (age-adj.): β=0.692, P<0.001) and their variations (age-adj.: β=0.629, P<0.001) after surgery. Multivariate analysis in operated patients showed a significant positive association between variations in tOCN and TT (age-adj.: β=0.289, P=0.012), SHBG (age-adj.: β=0.326, P=0.005) but not with cFT variation. tOCN, but not luteinizing hormone (LH) variation was the only significant predictive factor of cFT recovery in the hypogonadal (TT<12 nM) operated subjects even after age- and BMI-adjustment (adj.: β=0.582, P<0.05). cFT improvement was significantly higher when considering operated patients with tOCN increase (0.045±0.123 vs −0.02±0.118 nM, P=0.015), hypogonadism (0.059±0.111 vs –0.059±0.138 nM, P=0.002) and younger than 35 years (0.102±0.108 vs –0.019±0.123 nM, P=0.009).CONCLUSION:OCN recovery observed after bariatric surgery is significantly associated with cFT improvement independently of BMI variation and age in hypogonadal morbidly obese males.

The role of drainage after Roux-en-Y gastric bypass for morbid obesity: A systematic review

BACKGROUND Intraperitoneal drainage after gastrointestinal surgery is still routinely used in many hospitals. The objective of this study was to determine the evidence-based value of routine drainage after Roux-en-Y gastric bypass (RYGB). METHODS An electronic search of the MEDLINE, Cochrane, and Embase databases from 2002 to 2012 was performed to identify articles analyzing the use of drainage after RYGB, its efficacy in determining the presence of an anastomotic leak, and its role in nonoperative treatment of the leakage. RESULTS Eighteen articles were identified: 6 nonrandomized prospective cohort studies, 1 cohort retrospective study that compared routine drainage versus no drainage, 11 retrospective cohort studies, and no randomized controlled trials (RCTs). The sensitivity of drainage in detecting postoperative leakage varied between 0% and 94.1% in 10 articles (3 prospective and 6 retrospective) reporting data about this matter. The efficacy of drainage for the nonoperative treatment of postoperative leakage could be estimated in 11 articles (5 prospective and 6 retrospective) and varied between 12.5% and 100%. Only 2 studies reported data about nonoperative treatment of leakage without drainage, which was pursued in 0% and 33% of patients, respectively. CONCLUSION Evidence-based recommendations on the use of drainage after RYGB cannot be given. Without RCTs, the value of routine drainage cannot be ascertained.

Temporary Restoration of Digestive Continuity After Laparoscopic Gastric Bypass to Allow Endoscopic Sphincterotomy and Retrograde Exploration of the Biliary Tract

The prevalence of morbid obesity is rapidly increasing worldwide. As surgery has been recognized to be the only effective treatment for morbid obesity, the number of bariatric procedure realized each year has dramatically increased. Among all the surgical options, gastric bypass in considered as the gold standard. A possible drawback of this operation is the difficult access to the excluded proximal intestinal tract and, consequently, to the biliary tract. As gallstone formation may be frequent after a rapid weight loss induced by surgery, surgeons could be frequently asked to face the need of exploration of the biliary tree after anatomical changes induced by this kind of surgery. Many technical solutions, mainly based on a combined laparoscopic and endoscopic approach, have been proposed by several authors to face this problem. We herein describe an original technique to allow endoscopic exploration of biliary tract after a laparoscopic gastric bypass based on temporary restoration of physiological digestive continuity followed by re-establishment of the Roux-en-Y loop.

Anatomical Basis for the Low Incidence of Internal Hernia After a Laparoscopic Roux-en-Y Gastric Bypass Without Mesenteric Closure

Dear Editor, We congratulate Dr. Ortega et al. for their valuable study on the incidence of internal hernia after laparoscopic Roux-en-Y gastric bypass (LRYGBP) as well as their research on the anatomical basis of internal hernia formation [1]. We also congratulate the authors for their outstanding results with very few early postoperative complications, including, interestingly, no anastomotic leak and a nearly 100 % follow-up rate. We agree with the authors that the positioning of the blind end of Roux-en-Y loop toward patient’s left, the avoidance of mesentery and greater omentum division, and the antecolic positioning of the Roux-en-Y loop contribute to reduce the risk of internal hernia. However, we believe that several points need to be further underlined and discussed. The technique described by the authors is in no way original, as it has been described and divulgated by Lonroth et al. [2] since more than 15 years. The division of the greater omentum can be avoided in most of the cases but it remains advised in patients with central obesity displaying a thick omentum that impairs the antecolic ascension of the Roux-en-Y loop to the stomach. Furthermore, although the omentum fills partially the Petersen’s defect at time of surgery, this effect is no more relevant with the loss of weight. The position of the mesenteric defect, created by the surgical modification of the bowel anatomy as stressed by the authors, depends mainly on the length of the gastric pouch and the site on the Roux-en-Y loop where the gastrojejunal anastomosis is fashioned. In other words, a long and narrow pouch with a gastrojejunal anastomosis at the top of the Roux-en-Y loop results in a lower position of the mesenteric defect as compared with a short pouch with a side-to-side gastrojejunal anastomosis. However, the former anatomical condition reduces the tension on the gastrojejunal anastomosis, reducing in turn the risk of anastomotic leak and marginal ulcer that are linked to the ischemic effect of tension on the gastrojejunostomy. Furthermore, the creation of the jejunojejunostmy at the supra-mesocolic space as described by the authors does not imply that the mesenteric defect remains entirely above the common channel when the patient is standing, especially after a significant loss of weight. Moreover, even if we admit that the common channel remains below the level of the defect as suggested by the authors, one should not forget that the biliopancreatic loop might herniate into the mesenteric defect as well as in the Petersen’s space. This may happen to the alimentary limb as well, although this condition is rare especially when the stapled end of the Roux-en-Y loop is correctly placed toward the patient’s left. In their paper, the authors experimented the closure of the defects with a running suture in the anatomical model; however, this is what others and we currently do since several years at the time of surgery. Careful surgical technique is the only mainstay rule to avoid complication at time of defects closure such as hematoma, bleeding, and partial closure. The approximation of the two mesenteric leafs and the mesenteric and mesocolic leafs with a nonabsorbable running suture that bites the visceral serosa of the peritoneum leaving less than E. Facchiano :M. Lucchese Bariatric and Metabolic Surgery Unit, Careggi University Hospital, L.go Brambilla, 3, 50134 Florence, Italy

Large Hemobezoar Causing Acute Small Bowel Obstruction After Roux-en-Y Gastric Bypass: Laparoscopic Management

The present video shows the laparoscopic management of an acute small bowel obstruction (ASBO) after a Roux-en-Y Gastric Bypass (RYGBP), due to the development of an intraluminal hemobezoar involving the jejuno-jejunostomy (j-j). On the first postoperative day (POD), the patient presented persistent abdominal pain, sense of fullness, nausea, and vomiting with traces of blood. The abdominal tube drained a small amount of serous fluid, while blood tests revealed a mild leukocytosis and a slight decrease of the hemoglobin. A CT scan showed the dilation of the excluded stomach, duodenum, and both the alimentary and biliopancreatic limbs. The transition point was located in the common limb, just beyond the j-j, which was dilated by a fluid collection with the radiological aspect of a blood clot. The patient underwent an emergency laparoscopy which confirmed the preoperative radiological findings. An enterotomy was performed at the biliopancreatic stump, and the blood clot was pulled out by suction. The enterotomy was then closed by means of a linear stapler. Postoperative course was uneventful, except for the development of low-grade pneumonia. The patient was discharged on POD 8. ASBO is a worrisome postoperative complication of RYGBP. Although rare, the development of intraluminal hemobezoar should always be considered as a possible cause of ASBO. Laparoscopic management is feasible and effective and does not necessarily entail the complete revision of the j-j.