Giovanni Quartararo

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.

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.

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.

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.

The Role of Laparoscopy in Bariatric Surgery

Nowadays, laparoscopy is considered the “gold standard” for the surgical treatment of morbid obesity. Many different types of operations can be performed: vertical banded gastroplasty, adjustable gastric banding, Roux-en-Y Gatric bypass, sleeve gastrectomy, and biliopancreatic diversion. The preoperative workup is fundamental to establish whether the procedure chosen by the multidisciplinary equipe is safe and feasible. It consists in blood exams, abdominal ultrasound, barium radiography, upper gastro-intestinal endoscopy, 24-h pH monitoring, and esophageal manometry, depending on the chosen procedure. Super obesity (BMI >50 kg/m2) is associated with an increase in early and late morbidity and mortality. For this reason, the preoperative weight loss is used to reduce the conversion rate and improve the outcome—thanks to the significant reduction of the volume of the liver left lobe and visceral adipose tissue. The first attempt to gain preoperative weight loss is based on a conservative therapy such as the diet. In case of diet failure, the placement of an intragastric balloon is useful. In the field of laparoscopic bariatric surgery, the surgeon has different options to chose during the operation such as the laparoscopic access, drain placement, intraoperative testing of anastomotic leakage, staple-line reinforcement, and the timing to perform cholecystectomy. At last, the increase of the bariatric procedures worldwide has gradually lead to emerge a new group of surgeries known as revisional surgery and the number of patients who require this type of operations is progressively raised. It consists of re-intervention in patients who have undergone previous bariatric surgery.

Internal Hernia After Bariatric Procedures

Internal hernia (IH) represents the most common cause of small bowel obstruction after laparoscopic RYGBP, accounting for up to 61 % of cases of small bowel obstruction [1, 2]. The anatomic changes following bariatric surgery, the use of laparoscopy, the postoperative weight loss account for the high incidence of IH after bariatric procedures [1].

Indications for Bariatric Surgery

Early bariatric surgeries took place in the 1950s and initially consisted of the intestinal bypass procedure, aimed to induce an iatrogenic malabsorption resulting in weight loss.