Internal Hernia After One Anastomosis Gastric Bypass (OAGB): Lessons Learned from a Retrospective Series of 3368 Consecutive Patients Undergoing OAGB with a Biliopancreatic Limb of 150 cm

Background

Internal hernia (IH) represents a relatively common and well-known complication after Roux-en-Y gastric bypass. IH after one anastomosis gastric bypass (OAGB) is less frequent and rarely reported in the literature. This study presents a series of IH after OAGB observed in a high-volume bariatric center.

Methods

Data of patients who underwent OAGB with an afferent limb of 150 cm between May 2010 and September 2019 were prospectively collected and retrospectively analyzed. Data of patients undergoing surgery for IH during follow-up were collected and analyzed.

Results

Ninety-six patients out of 3368 with a history of OAGB had intestinal incarceration in the Petersen’s orifice (2.8%). Specificity and sensitivity of computed tomography scans in the diagnosis of IH were 59% and 76%, respectively. The mean timeframe between OAGB and surgery for IH was 21.9±18.3 months. Mean body mass index at the time of IH surgery was 24.7 ± 3.6. Surgery was completed laparoscopically in 96.8% of cases. Nine patients (9.3%) had signs of bowel hypovascularization. In all patients, the herniated bowel was repositioned, and the Petersen’s orifice was closed, without the need for bowel resection. Mean hospital stay was 1.9 ± 4.8 days. The postoperative morbidity rate was 8.3%. Long-term IH relapse was observed in 14 patients; signs of bowel hypovascularization due to incarceration in a small orifice was observed in eight of these patients (57%).

Conclusions

Incidence of IH after OAGB is 2.8%. IH is associated with a low rate of bowel ischemia and the need for intestinal resection.

Multidisciplinary Management of Leaks After One-Anastomosis Gastric Bypass in a Single-Center Series of 2780 Consecutive Patients

PURPOSE

Few data exist in the literature concerning leaks after one-anastomosis gastric bypass (OAGB). Our aim was to describe the incidence, presentation, and management of leaks after OAGB.

SETTING

A private clinic in France.

METHODS

Between May 2010 and December 2017, 2780 consecutive patients underwent OAGB. A retrospective chart review was performed on the 46 patients (1.7%) who experienced postoperative leaks.

RESULTS

Leaks arose from the anastomosis in 6 cases (13%) and from the gastric pouch in 27 cases (59%), while the remaining 13 patients (28%) had leaks from an undetermined origin. Management followed a standardized algorithm taking into consideration the clinical situation and findings on an oral contrast computed tomography (CT) scan. All patients were treated by fasting, total parenteral nutrition, and antimicrobial therapy. Nine patients (20%) could be managed by medical treatment only, 13 patients (28%) underwent laparoscopic management (washout and drainage plus T-tube placement in 5 cases or conversion to Roux-en-Y gastric bypass (RYGB) in one case). The remaining 23 patients (50%) were managed by percutaneous drainage and/or endoscopy. No mortality was observed; the major morbidity rate was 20%. The median length of a hospital stay was 17 days (5-80).

CONCLUSION

Management of leaks after OAGB depends on clinical conditions and presence, size, and location of an abscess and/or a fistula. If endoscopy and interventional radiology are available, reoperation can be avoided in most patients. In most leaks at the gastrojejunal anastomosis, inserting a T-tube in the leak orifice avoids the necessity for conversion to RYGB.

Perioperative complications of sleeve gastrectomy: Review of the literature

Sleeve gastrectomy (SG) has known a spectacular rise worldwide during the last decade. The absence of digestive anastomosis simplifies the surgical technique, reducing anastomosis-related complications such as fistula, stricture and marginal ulcer. Furthermore, the respect for digestive continuity preserves the functions of pylorus, that regulates gastric emptying, and duodenum, where calcium, B vitamins and iron are absorbed. Despite the multiple advantages, SG also has specific complications such as bleeding, stenosis, portal thrombosis and leak. The staple line leak at the oesophagogastric junction is the most feared complication and its prevention remains difficult, as the involved mechanisms have been only partially elucidated. Its management is long and requires a multidisciplinary technical platform including Intensive Care Unit, digestive endoscopy and interventional radiology as well as a specialised surgeon. The aim of this review is to explain in detail the perioperative complications of SG, their prevention and treatment, referring to the most recent available literature.

Predictors of metabolic syndrome persistence 1 year after laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is effective in reversing the metabolic syndrome (MS) in up to 90% of patients.

OBJECTIVES

The aim of this study was to determine predictors of MS persistence 1 year after LRYGB.

SETTING

University Hospital, France.

METHODS

Ninety-one patients with a mean age of 44.4 years and a mean body mass index (BMI) of 43.1 kg/m² meeting the criteria for MS were enrolled in this prospective study. Anthropometric, metabolic, and inflammatory biological parameters were assessed before and 1 year after LRYGB. Patients were divided into 2 groups according to the persistence (MS nonresponders) or resolution of MS (MS responders) 1 year after LRYGB and a comparison was performed at baseline and 1 year after surgery.

RESULTS

Sixty-nine patients (75.8%) underwent remission, while 22 (24.2%) showed persistence of MS 1 year after LRYGB. At baseline the MS nonresponders group presented significantly higher values of fasting plasma glucose (7.8 versus 5.3 mmol/L, P = .004), glycosylated hemoglobin (HbA1c, 7.3% versus 5.9%, P = .0004), triglycerides (TG, 2.37 versus 1.33 mmol/L, P = .006), and homeostasis model assessment of insulin resistance (HOMA-IR, 442.5 versus 256, P = .006). The rate of diabetes was significantly higher in this group (68.2% versus 36.8%, P = .0086), as well as the number of MS components per patient. One year after LRYGB, the MS nonresponders showed a significantly lower excess BMI lost (EBMIL) (56.1% versus 82.4%, P = .00008). On multivariate analysis, baseline levels of TG, glucose metabolism markers and EBMIL were associated with the persistence of MS.

CONCLUSION

Baseline levels of TG, plasma fasting glucose, and HbA1c, as well as history of type 2 diabetes and EBMIL, represent predictors of MS persistence 1 year after LRYGB.