Afferent Loop Syndrome after Roux-en-Y Total Gastrectomy Caused by Volvulus of the Roux-Limb

Laparoscopic Fundoplication Using the Excluded Stomach as a Novel Management Option for Refractory Bile Reflux Following One Anastomosis Gastric Bypass (OAGB)

Background

One anastomosis gastric bypass (OAGB) is now a mainstream bariatric procedure. Refractory gastroesophageal reflux is a significant complication following OAGB, and conversion to Roux-en-Y has long been the treatment of choice for this issue. Strengthening the lower esophageal sphincter by Nissen fundoplication (NF) has been reported as an effective anti-reflux surgery. Here we report the short-term outcomes of a modified NF procedure using the excluded stomach (excluded stomach fundoplication—ESF) to treat refractory bile reflux in post-OAGB patients.

Methods

Thirteen post-OAGB patients underwent ESF for refractory bile reflux during the study, as detailed in the surgical technique. This paper reports the 12 patients whose follow-up data are available.

Results

Following ESF, the GERD-HRQL heartburn score improved from 22.7 ± 3.9 to 1.8 ± 3.5 (p < 0.05). The mean aggregate GERD-HRQL score improved from 27.9 ± 5.3 to 5.7 ± 5.9 (p < 0.05). The GERD-HRQL global satisfaction score showed that 100% of patients were satisfied with the improvement of symptoms. The mean VISICK score improved from 3.8 ± 0.39 to 1.2 ± 0.39 (p < 0.05). One patient was returned to the operating theatre to have the wrap loosened due to dysphagia. Eleven patients did not require PPIs after surgery.

Conclusions

ESF significantly improved the VISICK score and GERD-HRQL of post-OAGB patients with refractory bile reflux in the short term. The current study is being continued to increase the sample size and the follow-up period.

Percutaneous Transhepatic Bowel Stent Deployment: An Alternative Approach for Malignant Afferent Loop Obstruction Following Whipple's Procedure

Afferent loop syndrome is an uncommon postoperative complication. Currently, we lack a therapeutic option for treatment of malignant afferent loop obstruction following procedures like Whipple's. Here we present a case of afferent loop obstruction in a known case of pancreatic carcinoma, status after Whipple’s procedure, in which we used a percutaneous transhepatic approach to relieve the afferent loop obstruction using a self-expanding bare metal stent.

EUS-guided hepaticogastrostomy for patients with afferent loop syndrome: a comparison with EUS-guided gastroenterostomy or percutaneous drainage

OBJECTIVES

Where palliative surgery or percutaneous drainage used to be the only option in patients with afferent loop syndrome, endoscopic management by EUS-guided gastroenterostomy has been gaining ground. However, EUS-guided hepaticogastrostomy might also provide sufficient biliary drainage. Our aim was to evaluate the feasibility of EUS-guided hepaticogastrostomy for the management of afferent loop syndrome and provide comparative data on the different approaches.

METHODS

The institutional databases were queried for all consecutive minimally invasive procedures for afferent loop syndrome. A retrospective, dual-centre analysis was performed, separately analysing EUS-guided hepaticogastrostomy, EUS-guided gastroenterostomy and percutaneous drainage. Efficacy, safety, need for re-intervention, hospital stay and overall survival were compared.

RESULTS

In total, 17 patients were included (mean age 59 years (± SD 10.5), 23.5% female). Six patients, which were ineligible for EUS-guided gastroenterostomy, were treated with EUS-guided hepaticogastrostomy. EUS-guided gastroenterostomy and percutaneous drainage were performed in 6 and 5 patients respectively. Clinical success was achieved in all EUS-treated patients, versus 80% in the percutaneous drainage group (p = 0.455). Furthermore, higher rates of bilirubin decrease were seen among patients undergoing EUS: > 25% bilirubin decrease in 10 vs. 1 patient(s) in the percutaneously drained group (p = 0.028), with > 50% and > 75% decrease identified only in the EUS group. Using the ASGE lexicon for adverse event grading, adverse events occurred only in patients treated with percutaneous drainage (60%, p = 0.015). And last, the median number of re-interventions was significantly lower in patients undergoing EUS (0 (IQR 0.0-1.0) vs. 1 (0.5-2.5), p = 0.045) when compared to percutaneous drainage.

CONCLUSIONS

In the management of afferent loop syndrome, EUS seems to outperform percutaneous drainage. Moreover, in our cohort, EUS-guided gastroenterostomy and hepaticogastrostomy provided similar outcomes, suggesting EUS-guided hepaticogastrostomy as the salvage procedure in situations where EUS-guided gastroenterostomy is not feasible or has failed.

Gallstone Ileus Decades after Cholecystectomy and Pylorus-Preserving Whipples

We report a case of small bowel obstruction due to gallstone ileus found in a patient with previous pancreaticoduodenectomy (Whipple procedure). Investigation by computed tomography of the abdomen showed a transition point in the midjejunum due to a radioopaque intraluminal mass. Following resuscitation, the patient underwent laparotomy to remove the offending mass from the midjejunum. Subsequent stone analysis confirmed a cholesterol-rich gallstone. This is thus the first description of gallstone ileus following Whipple procedure. The rarity of this presentation and a literature review is presented.

Biliopancreatic limb obstruction after laparoscopic Roux-en-Y gastric bypass: a rare and potentially fatal condition

Biliopancreatic limb obstruction after laparoscopic Roux‐en‐Y gastric bypass is a challenging diagnosis as the symptoms are very nonspecific. CT scan is the optimal study for evaluation. Early diagnosis and treatment is essential in reducing the morbidity and mortality associated with this condition.