Choledochal anomalies in adults: A 20-year single-center retrospective cohort experience in the Middle East

BACKGROUND AND STUDY AIMS

Choledochal cysts are rare congenital cystic dilatations of the bile ducts that occur in fewer than 1% of individuals. The disease is common in East Asia, and most of the literature concerns those populations, but some data about Western populations have been published recently. Long-term reports about the disease in Middle Eastern populations, however, are currently lacking. We report a single-center 20-year experience in diagnosing and managing choledochal anomalies.

PATIENTS AND METHODS

Participants were adult patients in whom choledochal cysts were diagnosed over a 20-year (2000-2019) period at a single tertiary academic care center. Clinical data, including radiologic imaging findings, were retrieved from the patients' medical records. To describe the baseline characteristics of the population, we calculated descriptive statistics.

RESULTS

Choledochal anomalies were diagnosed in 19 adult patients, whose median age was 30 years (interquartile range [IQR], 23-67 years). Of the choledochal cysts 13 (68.4%) were classified as Todani type I, 4 (21.1%) as Todani type IV, and 3 (15.8%) as Todani type V (Caroli's disease). No patient had underlying chronic liver disease, and liver synthetic function was preserved in all. Eighteen patients (94.7%) underwent surgery: cyst excision with Roux-en-Y hepaticojejunostomy in 17 and liver transplantation in 1. All 18 survived surgery, and the median postoperative hospital stay was 11 days (IQR, 5-34 days). All 18 were alive 90 days after surgery, and the median follow-up period was 40 months (IQR, 12-140 months). Seven patients (36.8%) developed postoperative surgical complications; 2 patients required rehospitalization, and 1 required reoperation.

CONCLUSION

This description of adults with choledochal cysts is the latest long-term report about this disease in the Middle East. In our 20-year experience, the disease characteristics in our patients were moderately consistent with those described previously.

Mechanistic loop resolution strategy for short-type single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y reconstruction after gastrectomy (with video)

BACKGROUND

Endoscopic access to the targeted site is a major challenge for the endoscopic retrograde cholangiopancreatography (ERCP) in patients undergoing Roux-en-Y (R-Y) reconstruction after total or subtotal gastrectomy. We aimed to evaluate the feasibility, reproducibility, and safety of mechanistic loop resolution strategies using a short-type single-balloon enteroscopy (short SBE) system.

METHODS

Between February 2020 and March 2022, consecutive patients with a previous R-Y gastrectomy requiring ERCP were prospectively enrolled. Different mechanistic loop resolution strategies for two-dimensional loops, three-dimensionally rotated loops, and loops making a cane or S-shape were applied during the SBE approach.

RESULTS

Forty-three short SBE-ERCP procedures were performed on 37 patients, with an approach success rate of 100.0% (43/43). The mean time to reach the jejunojejunal anastomosis and target site were 8.0 (6.0-11.0) minutes and 26.0 (16.0-36.0) minutes, respectively. The major challenges for the approach were the cane or S-shaped loop in the jejunojejunal anastomosis or Treitz ligament. The retroflex positioning of a SBE in front of the papilla was achieved in 86.0% (37/43), and the cannulation success rate in patients with an intact papilla was 90.9% (30/33). The initial, overall therapeutic successes, median total procedure time, and adverse event rate were 87.8%, 92.7%, 77.0 (IQR 56-100.5) minutes, and 11.6%, respectively.

CONCLUSIONS

Short SBE-ERCP using standardized mechanistic loop resolution strategies is effective and reproducible in patients with R-Y reconstruction after gastrectomy.

TRIAL REGISTRATION

ClinicalTrial.gov (NCT04847167).

Severity of Pancreatic Leak in Relation to Gut Restoration After Pancreaticoduodenectomy: The Role of the Roux-en-Y Configuration

Background

Pancreatic leak after pancreaticoduodenectomy and gut restoration via a single jejunal loop remains the crucial predictor of patients' outcome. Our reasoning that active pancreatic enzymes may be more disruptive to the pancreatojejunostomy prompted us to explore a Roux-en-Y configuration for the gut restoration, anticipating diversion of bile salts away from the pancreatic stump. Our study aims at comparing two techniques regarding the severity of postoperative pancreatic fistula (POPF) and patients' outcome.

Methods

The files of 415 pancreaticoduodenectomy patients were retrospectively reviewed. Based on gut restoration, the patients were divided into: cohort A (n = 105), with gut restoration via a single jejunal loop, cohort B (n = 140) via a Roux-en-Y technique assigning the draining of pancreatic stump to the short limb and gastrojejunostomy and bile (hepaticojejunostomy) flow to long limb, and cohort C (n = 170) granting the short limb to the gastric and pancreatic anastomosis, whereas hepaticojejunostomy was performed to the long limp. The POPF-related morbidity and mortality were analyzed.

Results

Overall POPF in cohort A versus cohorts B and C was 19% versus 12.1% and 9.4%, respectively (P = 0.01 A vs B + C). POPF-related morbidity in cohort A versus cohorts B and C was 10.5% versus 7.3% and 6.3%, respectively (P = 0.03 A vs B+C). POPF-related total hospital mortality in cohorts A versus B and C was 1.9% versus 0.8% and 0.59%, respectively (P = 0.02 A vs B+C).

Conclusion

Roux-en-Y configuration showed lower incidence and severity of POPF. Irrespective of technical skill, creating a gastrojejunostomy close to pancreatojejunostomy renders the pancreatic enzymes less active by leaping the bile salts away from the pancreatic duct and providing a lower pH.

Assessing optimal Roux-en-Y reconstruction technique after total gastrectomy using the Postgastrectomy Syndrome Assessment Scale-45

BACKGROUND

Following a total gastrectomy, patients suffer the most severe form of postgastrectomy syndrome. This is a significant clinical problem as it reduces quality of life (QOL). Roux-en-Y reconstruction, which is regarded as the gold standard for post-total gastrectomy reconstruction, can be performed using various techniques. Although the technique used could affect postoperative QOL, there are no previous reports regarding the same.

AIM

To investigate the effect of different techniques on postoperative QOL. The data was collected from the registry of the postgastrectomy syndrome assessment study (PGSAS).

METHODS

In the present study, we analyzed 393 total gastrectomy patients from those enrolled in PGSAS. Patients were divided into groups depending on whether antecolic or retrocolic jejunal elevation was performed, whether the Roux limb was “40 cm”, “shorter” (≤ 39 cm), or “longer” (≥ 41 cm), and whether the device used for esophageal and jejunal anastomosis was a circular or linear stapler. Subsequently, we comparatively investigated postoperative QOL of the patients.

RESULTS

Reconstruction route: Esophageal reflux subscale (SS) occurred significantly less frequently in patients who underwent antecolic reconstruction. Roux limb length: “Shorter” Roux limb did not facilitate esophageal reflux SS and somewhat attenuated indigestion SS and abdominal pain SS. Anastomosis technique: In terms of esophagojejunostomy techniques, no differences were observed.

CONCLUSION

The techniques used for total gastrectomy with Roux-en-Y reconstruction significantly affected postoperative symptoms. Our results suggest that elevating the Roux limb, which is not overly long, through an antecolic route may improve patients’ QOL.

Recurrent cholangitis after choledochoduodenostomy: A case report

Introduction

Recurrent cholangitis is a long-term consequence of choledochoduodenostomy (CDD) that requires urgent treatment. The frequency of recurrent cholangitis ranges between 2.5 and 15.7%. This case demonstrated the importance of rapid and precise diagnosis through screening and therapeutic modalities in recurrent cholangitis.

Presentation of case

A male patient presented with a history of recurring right upper abdominal discomfort during the previous 3 years. The pain had been intermittent but had become more intense during the prior month. The patient was diagnosed with recurrent cholangitis following CDD. The therapeutic plan was closure of the CDD, which was identified as the cause of the recurrent cholangitis, and biliary drainage by modified Roux-en-Y choledochojejunostomy.

Discussion

Recurrent cholangitis was diagnosed based on clinical manifestations, including recurring right upper abdomen discomfort, jaundice, and fever accompanied with consistent laboratory and imaging findings. Drainage of bile into the distal common bile duct (CBD) is reduced in the side-to-side CDD arrangement. Consequently, the distal CBD becomes a reservoir with inadequate drainage, predisposing this so-called ‘sump’ to debris accumulation and cholangitis. The surgery was considered successful in preventing the recurrent cholangitis.

Conclusion

The recurrent cholangitis was occurred due to inadequate biliary drainage. The choledochojejunostomy procedure with modified Roux-en-Y might prevent the recurrent cholangitis by improving biliary drainage to the enteric.

•

Recurrent cholangitis in side-to-side CDD may be induced by infection.

•

Recurrent cholangitis manifests with symptoms such as abdominal pain, jaundice, and fever.

•

The principal treatment is to enhance the biliary drainage of the CBD to the anastomosis

Techniques for reconstruction after distal gastrectomy for cancer: updated network meta-analysis of randomized controlled trials

BACKGROUND

The choice of the best reconstruction technique after distal gastrectomy (DG) remains controversial and still not defined. The purpose was to perform a comprehensive evaluation within the major type of intestinal reconstruction after DG for gastric cancer.

METHODS

Systematic review and network meta-analyses of randomized controlled trials (RCTs) to compare Billroth I (BI), Billroth II (BII), Billroth II Braun (BII Braun), Roux-en-Y (RY), and Uncut Roux-en-Y (URY). Risk ratio (RR) and weighted mean difference (WMD) were used as pooled effect size measures while 95% credible intervals (CrI) were used to assess relative inference.

RESULTS

Ten RCTs (1456 patients) were included. Of these, 448 (33.7%) underwent BI, 220 (15.1%) BII, 114 BII Braun (7.8%), 533 (36.6%) RY, and 141 URY (9.6%). No significant differences were found among treatments for 30-day mortality, anastomotic leak, anastomotic stricture, and overall complications. At 12-month follow-up, RY was associated with a significantly reduced risk of remnant gastritis compared to BI (RR=0.56; 95% Crl 0.35-0.76) and BII reconstruction (RR=0.47; 95% Crl 0.22-0.97). Similarly, despite the lack of statistical significance, RY seems associated with a trend toward reduced endoscopically proven esophagitis compared to BI (RR=0.58; 95% Crl 0.24-1.51) and bile reflux compared to BI (RR=0.48; 95% Crl 0.17-1.41), BII (RR=0.74; 95% Crl 0.20-2.81), and BII Braun (RR=0.65; 95% Crl 0.30-1.43).

CONCLUSIONS

This network meta-analysis shows that there are five main options for intestinal anastomosis after DG. All techniques seem equally safe with comparable anastomotic leak, anastomotic stricture, overall morbidity, and short-term outcomes. In the short-term follow-up (12 months), RY seems associated with a reduced risk of remnant gastritis and a trend toward a reduced risk of bile reflux and esophagitis.

Billroth-II with Braun versus Roux-en-Y reconstruction in totally laparoscopic distal gastrectomy for gastric cancer

Introduction

Totally laparoscopic distal gastrectomy (TLDG) has been increasingly adopted for the treatment of gastric cancer. Both Billroth-II with Braun (B-IIB) reconstruction and Roux-en-Y (R-Y) reconstruction are commonly performed in TLDG; however, which of these reconstruction techniques is better remains unclear.

Aim

To compare the efficacy of B-IIB reconstruction and R-Y reconstruction in TLDG for gastric cancer.

Material and methods

A total of 105 gastric cancer patients who underwent TLDG with B-IIB or R-Y reconstruction were reviewed from January 2019 to July 2020. Clinicopathological characteristics and perioperative data of the B-IIB and R-Y groups were compared.

Results

Clinicopathological characteristics were not significantly different between the B-IIB and R-Y groups. The average total operative time for the R-Y group (161.9 ±20.7 min) was significantly longer than that for the B-IIB group (141.9 ±16.7 min). The average anastomosis time for the R-Y group (25.5 ±4.1 min) was also significantly longer than that for the B-IIB group (18.9 ±3.3 min). Blood loss volume, number of retrieved lymph nodes, time to first flatus, average length of postoperative hospital stay, inflammatory parameters and postoperative complications did not differ between the two groups.

Conclusions

Both B-IIB reconstruction and R-Y reconstruction are safe and effective in TLDG. B-IIB reconstruction is easier and faster to perform than R-Y reconstruction in TLDG.

Intussusception after reconstruction following gastrectomy for gastric cancer

Background

Gastric cancer is the most prevalent tumor in Chinese men, and surgery is currently the most important treatment. Billroth II and Roux-en-Y are the anastomosis methods used for reconstruction after gastrectomy. Jejunal intussusception is a rare complication after gastric surgery.

Main Body

Intussusception after gastric surgery occurs mostly at the gastrojejunostomy site for Billroth II reconstruction, and the Y-anastomosis site for Roux-en-Y reconstruction. Many studies have reported that postoperative intussusception appears at the anastomosis after bariatric surgery, while a few have reported intussusception at the anastomosis and its distal end after radical gastrectomy.

Conclusion

A review was carried out to analyze intussusception after radical gastrectomy with roux-en-y anastomosis during the current situation. And the relevant mechanisms, diagnosis, treatment methods, etc. are described, hoping to provide better guidance for clinicians

Rates, Risks, and Time to Fracture in Patients Undergoing Laparoscopic Vertical Sleeve Gastrectomy versus Roux-en-Y Gastric Bypass

Objective

To assess the rates, risks, and time to fracture in patients undergoing laparoscopic vertical sleeve gastrectomy (VSG) versus those undergoing Roux-en-Y gastric bypass (RYGB).

Summary Background Data

Metabolic and bariatric surgery has been implicated in significant bone loss and may increase fracture risk. Preoperative patient characteristics that might impact fracture risk and the time to fractures have not been established. Furthermore, the patient characteristics that might impact fracture risk and the time to fractures by surgical approach are unknown.

Methods

This population-based retrospective cohort analysis used Humana claims data from January 1, 2007 to March 31, 2017, and included 4073 patients undergoing laparoscopic RYGB and VSG as a first surgical intervention for weight loss. The primary outcomes were the incidence of fractures (Humeral, Radial or Ulnar, Pelvic, Hip, and Vertebral) within 48 months after laparoscopic VSG versus RYGB and days to these fractures.

Results

An analysis of total fractures (odds ratio [OR] 0.53; 95% confidence interval [CI], 0.38-0.73), vertebral fractures (OR 0.61; 95% CI, 0.38-0.99), hip fractures (OR 0.36; 95% CI, 0.15-0.84), and humeral fractures (OR 0.44; 95% CI, 0.22-0.90) demonstrated a reduction in fracture risk in patients undergoing VSG versus RYGB. Furthermore, postmenopausal status was independently associated with increased odds of total fractures and hip fractures (OR 2.18; 95% CI, 1.06-4.50; OR 5.83; 95% CI, 1.16-29.27; respectively). Likewise, osteoporosis at the time of surgery was associated with increased odds of total fractures (OR 1.61; 95% CI, 1.09-2.37), vertebral fractures (OR 2.01; 95% CI, 1.19-3.39), and hip fractures (OR 2.38; 95% CI, 1.19-4.77). Except for a significantly decreased odds of vertebral fractures in osteoporotic patients undergoing VSG versus RYGB (OR 0.41; 95% CI, 0.18-0.95), osteoporotic or postmenopausal status at the time of surgery was not found to increase odds of fracture depending on surgical intervention. However, time to fracture (total) and for all site-specific fractures, except for pelvic fractures, was significantly reduced in postmenopausal women undergoing RYGB versus VSG. Time to fracture (total) and for all site-specific fractures except pelvic and radial or ulnar fractures was significantly reduced in osteoporotic patients undergoing RYGB versus VSG.

Conclusions and Relevance

Though bariatric surgery is associated with several health-related benefits, increased fracture risk is an important factor to discuss with patients undergoing bariatric surgery. Bariatric surgery strategy, RYGB versus VSG, carries a differential risk of fracture, with RYGB carrying a higher risk of fracture and decreased time to fracture. Furthermore, patients who are postmenopausal or osteoporotic at the time of surgery carry an increased risk of total fractures, independent of bariatric surgery strategy. Being mindful of patient-specific fracture risk after bariatric surgery may help anticipate, identify, and prevent fractures.

Laparotomy-Assisted Direct Cholangioscopy for Bile Duct Stone Removal via an Incision of the Jejunum

A 77-year-old man presented to our hospital with epigastric pain. He had previously undergone hepatic left lateral segmentectomy, cholangiojejunostomy, and Roux-en-Y reconstruction at 42 years of age for intrahepatic stones and liver abscesses. Abdominal computed tomography and magnetic resonance cholangiopancreatography revealed bile duct stones and intrahepatic bile duct dilation of the caudate lobe. Bile duct drainage for the caudate lobe was necessary; however, the volume of his caudate lobe was very small, making percutaneous transhepatic biliary drainage (PTBD) or endoscopic ultrasound-guided biliary drainage (EUS-BD) difficult. Therefore, we attempted laparotomy-assisted endoscopic biliary drainage. Under general anesthesia, an incision was made on the jejunum approximately 15 cm from the Y-leg anastomosis. An esophagogastroduodenoscope was directly inserted into the common hepatic duct anastomosed with the jejunum. The caudate lobe branch had severe stenosis, and the area upstream of the stenosis was filled with stones, sludge, and pus. The biliary stenosis was dilated using a balloon, and the stones were completely removed using a basket and a balloon catheter. There are various methods of biliary and pancreatic surgery and gastrointestinal reconstruction, and there are cases in which PTBD, EUS-BD, and endoscopic retrograde cholangiopancreatography (ERCP) with an enteroscope are difficult. In such cases, ERCP under laparotomy could be a good treatment option.

Roux-en-O: How It Happens and How to Fix It

The Roux-en-Y gastric bypass surgery improper technique can cause complications such as Roux-en-O, which is caused by an inadvertent anastomosis of the biliopancreatic limb to the gastric pouch, creating an "O" form to the bypass. We present intraoperative images of a mistaken Roux-en-Y's technique that caused the "O" anatomy and its successful reconstruction.

Bariatric surgery induces morphological changes in the extensor digitorum longus muscle in the offspring of obese rats

INTRODUCTION

The effects of the maternal nutritional environment on the growth and metabolism of the offspring, and its impacts on health in adult life are defined as metabolic programming. Thus, the objective of this study was to evaluate the effects of Roux-en-Y gastric bypass (RYGB) on the morphology of muscle fiber and neuromuscular junction (NMJ) of the offspring of rats submitted to RYGB.

METHODS

Three-week-old Wistar rats were separated into two groups: 1) CAF SHAM which received a cafeteria diet and was submitted to a sham operation and 2) CAF RYGB, which received a cafeteria diet and was submitted to RYGB. The first generation (F1) offspring (male) was named according to the treatment of mothers as CAF SHAM-F1 and CAF RYGB-F1 and received a standard diet after weaning. At 17 weeks, the animals were euthanized, and the extensor digitorum longus muscle (EDL) was collected and processed in light microscopy and transmission electron microscopy for morphological and morphometric analysis.

RESULTS

The CAF RYGB-F1 group showed a reduction in the weight of the EDL muscle and also a reduction in the area of type I, IIa and IIb fibers and a nucleus/fiber ratio. This same group also showed an increase in the capillary density and myofibrillar disorganization and in the Z-line, as well as a reduction in the area of the NMJs.

CONCLUSION

The RYGB surgery in mothers produced morphological changes in the skeletal striated muscles of the offspring.

The effect of weight reduction surgery on the efficacy and tolerability of epilepsy pharmacotherapy

BACKGROUND

Bariatric surgery is an increasingly utilized procedure among patients with obesity-related medical complications. The impact of bariatric surgery on seizure frequency and antiseizure drug (ASD) levels are not well described.

METHODS

We conducted a retrospective chart review of adult patients with a history of epilepsy or seizures undergoing bariatric surgery for morbid obesity from September 1997-September 2019. The median follow-up was 60 months [range 9-220 months].

RESULTS

Forty-six patients with a history of seizures were identified (38 female); 44 patients had recurrent and unprovoked seizures. Seventeen sets of pre- and post-surgery drug concentrations from 14 patients were reviewed. The median age at surgery was 44 years (range, 19-68). Thirty-three patients were prescribed ASDs at the time of bariatric surgery (median 1 drug [range, 1-3]). Laparoscopic Roux-en-Y was performed in 40 patients, and sleeve gastrectomy in 6 patients. Median pre-surgery weight was 120.75 kg (range, 71-230) and BMI 44.4 kg/m2 (range, 34-77.6). Six months following surgery the median weight was 89.5 kg (range, 58.2-202) and BMI 34.2 kg/m2 (range, 24.5-61.9). Nine patients (19.6%) had a worsening of seizure control on long-term follow-up (median 60, range 9-220 months) following bariatric surgery, including five (10.8%) who suffered seizures within 6 months of bariatric surgery. Five patients developed ASD-associated side effects following bariatric surgery including irritability in two patients (levetiracetam and phenytoin) and one patient each suffering from somnolence (phenytoin), hyperammonemic encephalopathy (sodium valproate), and nausea and vomiting (carbamazepine). Subtherapeutic post-surgery drug concentrations were identified in 5 patients and supratherapeutic concentrations in one patient. In the initial 6 months following surgery, ASD doses were increased in five patients and reduced in five.

CONCLUSIONS

The majority of patients with epilepsy who undergo bariatric surgery have no change in seizure frequency. However, a significant minority of patients may experience medication side effects or an increase in seizure tendency due to the impact of bariatric surgery on ASD drug absorption and metabolism leading. Pre- and post-surgical serum concentrations should be measured in patients with seizures or epilepsy receiving ASDs.

Apprising the choice of bariatric surgery in patients with compensated cirrhosis with morbid obesity: results of a national analysis

Bariatric surgery (BS) was proved safe in carefully selected patients with compensated cirrhosis (CC). However, limited data exist on differential impact of bariatric surgery type on clinical outcomes and health care utilization. This retrospective study utilizes the 2010-2014 Nationwide Readmissions Database. We included obese adults with CC who underwent the two most commonly used BS, Roux-en-Y (RYGB) and laparoscopic sleeve gastrectomy (LSG). Those with decompensation within 6 months of BS were excluded. Rates of hepatic decompensation (new-onset ascites, variceal bleed, encephalopathy, spontaneous bacterial peritonitis, and/or hepatorenal syndrome), surgical complications, health care utilization, and mortality were compared between RYGB and LSG. Multivariable analysis was performed to fit various models. A total of 3032 patients with CC underwent BS, including 1864 (61.5%) RYGB and 1168 (38.5%) LSG. The majority (56%) of BS were performed at large, metropolitan teaching hospitals. There were no significant differences in various decompensations and surgical complications comparing RYGB to LSG. Healthcare utilization including index length of stay (RYGB: 3.4 days vs LSG: 3.0 days), 30-day readmission rate (RYGB: 9.5% vs LSG: 3.7%), and cost of admission (RYGB: $14,006 vs LSG: $12,523) were higher in RYGB (p values < 0.001). Index admission and calendar year mortality could not be analyzed due to the few number of events. Two types of bariatric surgeries in obese patients with compensated cirrhosis have similar rates of decompensated cirrhosis events and surgical complications. However, RYGB procedure incurred increased healthcare utilization. Therefore, LSG may be the preferred BS for patients with CC. Prospective, randomized studies comparing the types of BS are needed to confirm our observations.

Comparison of the Long-term Outcome Between Billroth-I and Roux-en-Y Reconstruction Following Distal Gastrectomy for Gastric Cancer

BACKGROUND

Various reconstruction methods have been performed following distal gastrectomy; however, each reconstruction method has its own advantages and disadvantages. This study aims to compare the long-term outcomes between Billroth-I (B-I) and Roux-en-Y (RY) reconstruction after distal gastrectomy for gastric cancer.

METHODS

A total of 459 patients who underwent distal gastrectomy (B-I: 166, RY: 293) were included. Postoperative endoscopic findings and biliary tract stone formation were compared between the two groups.

RESULTS

At 1 year and 2 years postoperatively, gastric residue was more common in the RY group, gastritis was similar between groups, and bile reflux was more common in the B-I group. At 5 years postoperatively, gastric residue was similar between the groups, while gastritis and bile reflux were more common in the B-I group. Gastroesophageal reflux was more common in the B-I group at 1 year postoperatively, but gastroesophageal reflux became not significantly different between the groups at 2 and 5 years postoperatively. Gallstone formation was more common in the RY group and in patients aged ≥ 65 years.

CONCLUSION

During long-term follow-up, RY reconstruction was associated with lower incidence of bile reflux and gastritis, and higher incidence of gallstone formation than B-I reconstruction. The incidence of gastric residue was more common in the RY reconstruction group in the early postoperative period and became not significantly different between the two groups over time. For aged patients with RY reconstruction, cholecystectomy is recommended concurrently as gastrectomy.

The clinical effectiveness of the method by establishing a proximal jejunum pouch after laparoscopic total gastrectomy: A propensity score-based analysis

BACKGROUND

In this study, we propose an improved Roux-en-Y (RY) surgical method by constructing a proximal jejunum pouch (PP-RY). Postoperative results were evaluated among patients with gastric cancer who underwent PP-RY and standard RY anastomosis.

METHODS

The clinical data of patients with gastric cancer who underwent laparoscopic total gastrectomy (LTG) in our center from May 2019 to May 2020 were collected retrospectively. We compared the short-term results of patients in the PP-RY and RY groups using 1:1 propensity score matching (PSM).

RESULTS

A total of 317 patients were selected, including those who received RY (n = 249) or PP-RY (n = 68) after LTG. After PSM, both groups had a sample size of 68. During the one-year follow-up period, the incidences of postoperative dumping syndrome (5.6%) and reflux esophagitis (14.8%) were significantly lower in the PP-RY group (P = 0.001 and P = 0.010, respectively). Weight loss (6.5 ± 2.0 kg) and albumin decrease (0.2 ± 0.1 g/dl) were significantly lower (P = 0.038 and P < 0.001, respectively), and the prognostic nutritional index (PNI) was significantly higher in the PP-RY group (P = 0.009). In the QLQ-C30 scale, the degree of anorexia in the PP-RY group was significantly lower than that in the RY group (P＜0.05). In the QLQ-STO22 scale, chest and abdomen pain, dietary restriction, and anxiety were significantly lower in the PP-RY group (all P＜0.05).

CONCLUSION

PP-RY can lead to obvious improvements in nutritional status, reduce short-term complications, and improve quality of life (QoL) for patients after LTG.

Perioperative Cost Differences Between Laparoscopic Sleeve Gastrectomy and Laparoscopic Roux-en-Y Gastric Bypass: A Single Institutional Review

Background: Minimizing bariatric surgery care costs is important since more than 250,000 patients undergo bariatric surgery annually in the United States. The study objective was to compare perioperative costs for the two most common bariatric procedures: laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). In addition, we sought to identify predictors of high-cost perioperative care. Methods: Adult patients who underwent LSG or LRYGB from 2012 to 2017 were identified using our institutional bariatric surgery database. Perioperative costs, defined as costs incurred from the time of entering the preoperative unit until exiting the postanesthesia care unit, were obtained through billing data. Median perioperative cost components of LSG and LRYGB were compared using Mann-Whitney tests. Multivariable logistic regression was performed to investigate patient-level predictors of high-cost care, defined as the top tercile of perioperative costs. Results: We included 546 bariatric surgery patients with a mean age and body mass index (BMI) of 49.7 years and 45.9 kg/m², respectively. There were no significant differences in median perioperative costs between LSG and LRYGB ($14,942 versus $15,016; P = .80). Stapler use was the largest cost contributor for both procedures, accounting for 27.7% and 29.2% of costs for LSG and LRYGB, respectively. In multivariable analyses, preoperative patient characteristics, including BMI, were not associated with high-cost perioperative care. Conclusions: Perioperative costs for LSG and LRYGB were similar in our single institution study. Reducing costs outside of the operating room, including those related to ED visits and complications, may be more impactful than focusing on cost reduction directly related to perioperative care.

Redo fundoplication and early Roux-en-Y diversion for failed fundoplication: a 3-year single-center experience

BACKGROUND

Redo fundoplication (RF) and Roux-en-Y diversion (RNY) are both accepted surgical treatments after failed fundoplication. However, due to higher reported morbidity, RNY is more commonly performed only after several surgical failures. In our experience, RNY at an earlier point of the disease progression seems to be related with better outcomes. The aim of this study was to investigate this aspect by comparing the results between RF and RNY performed by a single surgeon over 3 years at our institution.

METHODS

A prospectively maintained database was reviewed to identify patients who underwent RF or RNY at our institution between 2016 and 2019 by a single surgeon (author SKM). Patients with previous bariatric surgery were excluded.

RESULTS

Of 43 patients, 28 underwent RF and 15 underwent RNY (mean body mass index 28.6 and 32.7 kg/m², respectively, p = 0.01). The number of previous antireflux surgeries for the RF and RNY groups was 1 (82% vs 80%, p > 0.99), 2 (18% vs 7%, p = 0.4), and more than 2 (0% vs 13%, p = 0.1). RNY took longer than RF (median, 165 vs 137 min, p = 0.02), but both groups had a median estimated blood loss of 50 ml (p = 0.82). There was no difference in intraoperative complications (25% vs 20% for RF and RYN, respectively, p > 0.99). Postoperative complications were more common in the RF than in the RYN group (21% vs 7%, p = 0.39). Median hospital stay was 3 days for both groups (p = 0.78). At short-term follow-up, the mean quality of life score was similar for the RF and RYN groups (11.5 vs 12.2, p = 0.8).

CONCLUSIONS

RNY diversion, if performed by experienced hands and at an earlier point of disease progression, has comparable perioperative morbidity to RF and should be considered as a feasible and safe option for definitive treatment of failed antireflux surgery.

Comparison of Billroth I, Billroth II, and Roux-en-Y reconstructions following distal gastrectomy: A systematic review and network meta-analysis

Major surgical treatment for distal gastric cancer include Billroth I (BI), Billroth II (BII), and Roux-en-Y (RY). Since the optimal reconstruction methods remains inconclusive, we aimed to compare these treatments in terms of intraoperative and postoperative course after distal gastrectomy with a systematic review and random-effects network meta-analysis. We searched PubMed, Web of Knowledge, Ovid's database for prospective, randomized, controlled trials comparing the outcomes of BI, BII, and RY reconstruction after distal gastrectomy until January 2020. From the included studies, operative time, intraoperative blood loss, postoperative hospital stay, endoscopic findings and complications were extracted as the short- and long-term outcomes of reconstructions. The network meta-analysis was performed with R 3.5.2 software as well as "gemtc" and "forestplot" packages. Twelve randomized controlled trials (RCTs) involving 1662 patients were included. RY reconstruction has a lower risk and degree of remnant gastritis than BI and BII reconstructions(OR 0.40, 95%Crl: 0.24-0.64; OR 0.36, 95% Crl: 0.16-0.83, respectively). BI reconstruction method took significantly less time to perform as compared to BII and RY reconstruction (WMD 20, 95% Crl: 0.18-41; WMD 30, 95% Crl: 14-25, respectively). No differences in intraoperative blood loss, time to resumed oral intake, postoperative hospital stay, reflux oesophagitis and complications among the three reconstructions. The RY reconstruction after distal gastrectomy was more effective in preventing remnant gastritis than Billroth I and Billroth II reconstruction, although RY reconstruction was considered as technical complexity.

Controlling Nutritional Status (CONUT) Score and Micronutrient Deficiency in Bariatric Patients: Midterm Outcomes of Roux-en-Y Gastric Bypass Versus One Anastomosis Gastric Bypass/Mini Gastric Bypass

BACKGROUND

Two of the most common bariatric procedures performed worldwide are Roux-en-Y gastric bypass (RYGB) and one anastomosis gastric bypass (OAGB). Comparative data regarding nutritional status are lacking and no previous study focus on malnutrition according to a validated score.

METHODS

Retrospective data from a single institution were reviewed. Anthropometric variables and nutritional data were assessed. The primary aim was to analyze and compare the nutritional status before and 3 years after RYGB vs OAGB using the controlling nutritional status (CONUT) score. The incidence of micronutrient deficiency and the remission of comorbidities in each group were defined as secondary outcomes.

RESULTS

Fifty-seven patients in each arm were enrolled. A 3-year mild malnutrition (CONUT score 2-3) was found in 38% and 37.05% in the RYGB and OAGB groups, respectively (p > 0.05). In terms of percentage of total weight loss (%TWL) and percentage of adjustable weight loss (%AWL), no differences were found between OAGB and RYGB groups. OAGB and RYGB patients had similar vitamin deficiencies. Anemia, hypoproteinemia, hypoalbuminemia, and hypocalcemia were comparable between groups. At 3-year follow-up, total protein and albumin values were similar between arms while prealbumin deficit was more frequent after OAGB than after RYGB. The rate of type 2 diabetes (87.5% in OAGB and 92% in RYGB), arterial hypertension (51.6% in OAGB and 58.3% in RYGB), and dyslipidemia (69.7% in OAGB and 78.6% in RYGB) remission was not significantly different between the two groups.

CONCLUSIONS

Postoperative CONUT score, micronutrient deficiency, comorbidity remission, and improvement of anthropometric parameters 3 years postoperatively were comparable between RYGB and OAGB groups.

Retrocolic retrogastric ROUX-EN-Y gastric bypass: how I do it

INTRODUCTION

Technical variations of the laparoscopic Roux-en-Y gastric bypass may influence the incidence of complications such as fistulas, marginal ulcers, stenosis, and internal hernias.

METHODS

We described the technical aspects of a retrocolic, retrogastric, laparoscopic gastric bypass procedure with manual gastrojejunostomy and the closure technique for the three mesenteric defects generated by the Roux-en-Y limb reconstruction.

RESULTS

We summarized the data from 587 patients concerning complications directly related to the surgical technique. There were no internal hernias in patients followed, and in only 2 cases, small bowel obstruction related to defect closure occurred.

CONCLUSIONS

The retrocolic, retrogastric gastric bypass performed with a meticulous closure of all three mesenteric defects reflects a low incidence of internal hernias and low complication rates related to the closure itself. The technique also allows less tension at the gastrojejunostomy.

Health-related quality of life after curative resection for gastric adenocarcinoma

BACKGROUND

With improved survival in gastric cancer patients, health-related quality of life has become an important clinical endpoint alongside primary oncological outcomes.

AIM

To investigate health-related quality of life after various surgical procedures for gastric cancer treatment.

METHODS

The validated Slovenian version of the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire (QLQ-C30) and its gastric cancer-specific module (QLQ STO-22) was sent for self-completion to patients that underwent curative resection for gastric adenocarcinoma between January 2014 and December 2018 at our centre. In total, 116 patients responded. Scores were compared between patients after subtotal distal vs total gastrectomy and patients after subtotal distal gastrectomy with Billroth II vs Roux-en-Y reconstruction.

RESULTS

Interestingly, the extent of resection did not influence daily functioning; however, more dysphagia and eating restrictions were reported in patients after total gastrectomy when compared to patients after subtotal distal gastrectomy. Moreover, patients with Billroth II reconstruction after subtotal distal resection experienced worse physical and role functioning and reported more pain, fatigue and reflux compared to Roux-en-Y reconstruction.

CONCLUSION

Based on our results, Roux-en-Y reconstruction after subtotal distal gastrectomy should be preferred over Billroth II reconstruction. The data obtained from this study will help surgeons when preoperatively informing their patients about expected functional outcomes after gastrectomy and enable them to ensure proper supportive care of their patients in the postoperative period.

Surgical Management of Small Intestinal Bacterial Overgrowth After Roux-en-Y Gastric Bypass

INTRODUCTION

Small intestinal bacterial overgrowth (SIBO) is a common adverse effect after laparoscopic Roux-en-Y gastric bypass (LRYGB) and may be responsible for chronic diarrhea, abdominal pain, and discomfort. Although its pathophysiology is still unclear, surgical management may be appropriate in selected cases.

METHODS

In this video, we present a surgical revision of LRYGB, 12 years after the initial surgery, for late postoperative chronic diarrhea. The diagnosis of SIBO was finally established and associated with a dilated jejuno-jejunostomy diagnosed through a small bowel follow-through.

RESULTS

Revision of the RYGB was performed by resecting the dilated jejunostomy and fashioning a new one with a shorter Roux-en-Y limb. During follow-up, the patient showed fast improvement and complete resolution of symptoms was obtained at 12 months.

CONCLUSION

SIBO may be responsible for postoperative chronic diarrhea in RYGB patients, possibly in the long term, and it is often misdiagnosed. Primary treatment is conservative with appropriate dietary measures, antibiotics, and probiotics but surgical management can be very effective in selected patients presenting with failure of prolonged medical treatment and an anatomic abnormality.