Gadiel Liscia

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.

Is lymphatic status related to regression of inflammation in Crohn's disease?

AIM To investigate the status of the lymphatic vessels in the small bowel affected by Crohns disease (CD) at the moment of surgery. METHODS During the period January 2011-June 2011, 25 consecutive patients affected by CD were operated on in our Institution. During surgery, Patent Blue V was injected subserosally and the way it spread along the subserosa of the intestinal wall, through the mesenterial layers towards the main lymphatic collectors and eventually to the lymph nodes was observed and recorded. Since some patients had been undergone strictureplasty at previous surgery, we also examined the status of intestinal lymph vessels after previous strictureplasties. The same procedure was performed in a control group of 5 patients affected by colorectal cancer. Length of lesions, caliber, maximal thickness of the diseased intestinal wall, thickness of the wall at injection site and thickness of the mesentery were evaluated at surgery. RESULTS We observed three features after the injection of Patent Blue V in the intestinal loops: (1) Macroscopically healthy terminal ileum of patients with CD or colon cancer showed thin lymphatic vessels linearly directed toward the mesentery; (2) In mild lesions in which the intestinal wall did not reach 8 mm of thickness, we observed short, wide and tortuous lymphatic vessels directed longitudinally along the intestinal axis toward disease-free areas and then transversally toward the mesentery; and (3) Injection in the severely affected lesions, that had a thickness of the intestinal wall over 10 mm, did not show any feature of lymphatic vessels at least on the subserosal surface. There was a correlation between the thickness of the parietal wall and the severity of the lymphatic alterations. Normal lymphatic vessels were observed at previous strictureplasties in the presence of complete regression of the inflammation. CONCLUSION Injection of Patent Blue V in the intestinal wall could help distinguish healthy tracts of the small bowel from those macroscopically borderline.

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.

Single‐port laparoscopic access for Crohn's disease complicated by enterocutaneous fistula

appeared few days later. Endoscopy with biopsies of the terminal ileum confirmed the diagnosis of CD. Computed tomography showed a thickened terminal ileum with an enterocutaneous fistula penetrating through the previous surgical incision; no other proximal sites of disease were detected with a small bowel enema. Despite medical treatment and good general and nutritional status, the fistula persisted, and the patient was referred for surgery. The patient consented to the intervention and was fully informed about the risk of conversion. He was positioned in the supine position, and a single port type Olympus asc-Triport (distributed by Olympus M.S.C., Japan) was inserted through the umbilicus. A 5-mm deflectable video laparoscope type Olympus HD EndoEYE (Olympus M.S.C., Japan) was used. The terminal ileum was grossly inflamed for 15 cm and adherent to the right iliac fossa. Adhesions were carefully liberated, and a full mobilization of the ascending colon was obtained starting by the right colic flexure. An incision contouring the previous McBurney’s site was realized, and the enterocutaneous fistula tract was extracted en bloc with the ileocecal region. Mesenteric vessel ligation and a hand-sewn side-to-side anastomosis was performed extracorporeally. Intraoperative as well as postoperative and specimen images are showed in Figure 1. Operative time was 115 minutes,