A complication of Roux-en-Y gastric bypass: intestinal obstruction

BACKGROUND

Intestinal obstruction is a significant and increasingly recognized complication after laparoscopic and open gastric bypass.

MATERIALS AND METHODS

The medical records of 3,463 patients who had gastric bypass during the study period from July 1997 to December 2004 at a single bariatric center were evaluated. 1,120 patients had retrocolic, retrogastric Roux limb placement and 2,343 patients had antecolic, antegastric.

RESULTS

40 patients had 44 intestinal obstructions (1.27%). The onset ranged from 1 day to 7 years postoperatively (mean 16.9 months). Internal hernia at the transverse mesocolon defect was the most common cause. 36 (3.2%) obstructions were observed in retrocolic, retrogastric vs. 8 (0.3%) in antecolic, antegastric approach. Internal hernia repair at mesocolinic effect (n = 11), jejunojejunostomy mesenteric defect repair (n = 7), lysis of adhesions (n = 16) were the most common procedures. A total of 70.5% were done laparoscopically.

CONCLUSIONS

A high index of suspicion is needed to diagnose bowel obstruction after gastric bypass. Radiological imaging of the abdomen has significant limitations. Surgical exploration should be performed without delay. Diagnostic laparoscopy is a safe and effective therapy. We recommend closing all mesenteric defects to prevent internal hernias. The antecolic, antegastric technique reduces the incidence of internal hernias.

Laparoscopic gastric bypass with silicone band in a pig model: prevention of anastomotic dilatation -- feasibility study

BACKGROUND

Morbid obesity has become a major global health problem. Surgery remains the only effective treatment for patients with severe obesity, because diet reduction methods and pharmacologic agents have not resulted in long-term weight reduction. Gastric bypass (GBP) can provide adequate weight loss, but after some years, dilatation of the gastric pouch and outlet may lead to weight regain by allowing the patient to increase food intake.

METHODS

2 groups of 6 pigs underwent laparoscopic GBP. In the first group, a non-adjustable silicone band (Proring-band, IOC, Innovative Obesity Care, Saint Etienne, France) was positioned 1 cm proximal to the gastrojejunal anastomosis. In the second group, the device used to stabilize the gastric pouch was an adjustable silicone band (Mid-band, Medical Innovation Developpement, Villeurbanne, France). Weight loss, complications and histological reaction were evaluated after 3 months.

RESULTS

Mortality rate was 25% (cardiac arrythmia in 2 pigs). Conversion rate was 25%. The positioning of the band was more difficult with the Mid-band because of its larger size and the presence of the catheter. The average weight change in the Proring group was 15.8 kg (3.5-25.1 kg), and in the Mid-band group was 12.0 kg (6.2-15.1 kg). Morbidity consisted of one intragastric migration of the Proring band into the gastrojejunal anastomosis, and one infection of the port in the Mid-band group treated by removal of the port and antibiotics.

CONCLUSION

Use of silicone devices may be safe and effective in the prevention of pouch or outlet dilatation after GBP.

[Medullary thyroid carcinoma--personal observations]

The paper presents the rules of surgical treatment in medullary carcinoma of the thyroid gland based on own experience and survey of literature. Changing trends in diagnostic and therapeutic approach were described. The results achieved encouraged authors to find some conclusions. Long term results of therapy depend mostly on stage of disease in time of initial surgery, radicality of primary operation and further supportive treatment. Systematic follow-up after surgery makes it possible to early detect the recurrence and has an influence on survival rate. In cases of poorly differentiated medullary thyroid cancer even radical surgical procedure followed by the appropriate supportive treatment results in a not satisfactory survival.

[Ultrasonographic evaluation of thyroid tissue perfusion in patients with Graves-Basedow disease as preparation for surgery]

The aim of this work was to asses the usefulness of a new colour Doppler ultrasonography technique, namely power Doppler (PD), in the management of thyroid tissue perfusion in patients with Graves' disease before surgery. Forty six patients with Graves' disease treated conventionally with Lugol's solution before the operation were examined with power-Doppler scanner. The distribution of the vascular patterns of both lobes was analysed by computer program. Results were compared with bleeding during surgery subjectively and objectively. The analysis of power-Doppler thyroid perfusion showed significantly higher values of blood flow in patients suffering from Graves disease when compared with control group. Pre-operative preparation with Lugol's iodine decreases parenchymal blood flow. Auscultation of vascular murmur over the gland fading after Lugol's treatment does not always reflect parenchymal high value of blood flow measured by density of microvessels.

[Intrathoracic goiter as a cause of superior vena cava syndrome]

Between 1984 and 1997 year 4985 patients underwent surgical treatment due to various thyroid gland diseases, among them were 28 (0.6%) patients with intrathoracic goitre, but only in one case (0.002%) the signs of superior vena cava syndrome (SVCS) were observed: oedema and lividity of the face, enlargement of jugular veins and superior limbs' veins. In addition the patient manifested subsequently growing dyspnoea, dysphagia and hoarseness. In diagnose essential were X-ray examination of the chest (widening of mediastinal shadow), X-ray examination of the trachea (dislocation and compression of the trachea), X-ray of esophagus with contrast (compression from the outside), ultrasonography of thyroid gland. Intraoperatively, after it was confirmed that the SVCS was caused by compression of the intrathoracic right lobe of thyroid gland, the oblong sternotomy was performed to provide the proper surgical access for subtotal thyroidectomy. The weight of resected tissues of thyroid gland was 1036 g. In histopathological examination the diagnosis of multinodular toxic goitre was confirmed.

[Acute intestinal ischemia in material of the III Clinic of General Surgery, Collegium Medicum at the Jagellonian University]

The research work below focuses on a retrospective analysis of a group of 28 patients who suffered from acute intestinal ischaemia caused by upper mesenteric artery embolism of thrombus. The analysis is based on Clinic's own data in the years 1991-1995. The above mentioned patients constituted 3.4% of the 828 patients suffering from acute diseases of the abdominal cavity, accepted and treated in our Clinic. Their age ranged from 38 to 89 and average age was 72.4 y. There were 18 women (64.3%). Mesenteric embolism was the cause of intestinal ischaemia with 21 patients, whereas mesenteric thrombus with 7. Twenty four patients were operated on, the remaining 4 patients were disqualified from the operative procedure, 27 patients died. A considerable progression of the necrotic lesions of the intestines was found in all the patients operated on.