Efficacy and Safety of Novel, Disposable Endoscopic Scissors in Patients with Roux-en-Y Gastric Bypass: a Single-Center Feasibility Study

BACKGROUND

Retained suture material from primary Roux-en-Y gastric bypass or revisions may result in local inflammation, ulcer formation, and abdominal pain. The primary aim of this study was to evaluate the feasibility, efficacy, and safety of novel, disposable endoscopic scissors for suture removal.

METHODS

This was a single-center, retrospective analysis of prospectively collected data from December 2016 to January 2019. Patients with history of Roux-en-Y gastric bypass and upper endoscopy utilizing this novel, disposable endoscopic scissors device were reviewed. Measured outcomes included endoscopy indication, technical success (as determined by ability to achieve adequate cut and suture removal), improvement in abdominal pain if present prior to procedure, and adverse events.

RESULTS

Sixty-two patients were included in this analysis. Mean age was 54.69 ± 9.40 years. Eighty-eight percent of patients were female. Roux-en-Y gastric bypass occurred on average 142.43 ± 62.33 months prior to suture removal. Primary indications for endoscopy were evaluation of gastric pouch and gastrojejunal anastomosis for weight regain (37.10%) and abdominal pain (30.65%). Overall, technical success of these novel endoscopic scissors was 100% with a mean procedure duration of 23.00 ± 9.50 min. Symptom improvement post-suture removal occurred in approximately half of the patients (48.65%). Post-procedure bleeding was self-limited and occurred in 2 patients (3.23%). Two patients developed transient post-procedure abdominal pain.

CONCLUSIONS

Novel, disposable endoscopic scissors appear to be highly effective and safe for removal of suture material with high technical success and minimal adverse events.

Jejuno-jejunal intussusception caused by a percutaneous endoscopic gastrojejunostomy tube in a pediatric patient: A case report

RATIONALE

Although percutaneous endoscopic gastrojejunostomy (PEG-J) tubes are believed to reduce the side effect of aspiration, cautious catheter management is required. Intussusception is a serious complication of these tubes.

PATIENT CONCERNS

A 7-year-old boy bedridden with hypoxic encephalopathy owing to drowning at the age of 1 year was admitted our hospital with urinary retention for 1 month. At the age of 4 years, a PEG-J tube was inserted. Concomitant with hyperaldosteronemia, an intestinal intussusception from the duodenum to the jejunum was observed via computed tomography (CT). The patient's condition worsened dramatically; gastrointestinal perforation was suspected, and laparotomy was performed.

DIAGNOSIS

Jejuno-jejunal intussusception.

INTERVENTIONS

Open surgery was performed to release the intussusception. By assessing the reduced intestinal tract, the intussusception starting from a 50 cm portion from the Treitz ligament had been extended to 100 cm from the Treitz ligament. The oral side jejunum was dilated. No evidence of intestinal perforation or strangulated ileus was observed, and the intussusception was manually remediable.

OUTCOMES

Preoperative CT examination showed intussusception from the duodenum to the jejunum. Laparotomy showed intussusception on the anal side of the Treitz ligament. With regard to the CT findings associated with the progression of intussusception to the duodenal site, as a result of the telescope phenomenon extending to the duodenum due to the relaxation of the Treitz ligament through repeated intussusception, it was considered that CT examination revealed intussusception extending from the jejunum to the duodenum of oral side. After 3 postoperative weeks, the patient was finally able to return home.

LESSONS

If the ileus is observed during the insertion of a PEG-J, clinicians should consider the possibility of intussusception even in the duodenum.

Effectiveness of different recruitment strategies in an RCT of a surgical device: experience from the Endobarrier trial

Recruiting participants into clinical trials is notoriously difficult and poses the greatest challenge when planning any investigative study. Poor recruitment may not only have financial ramifications owing to increased time and resources being spent but could adversely influence the clinical impact of a study if it becomes underpowered. Herein, we present our own experience of recruiting into a nationally funded, multicentre, randomised controlled trial (RCT) of the Endobarrier versus standard medical therapy in obese patients with type 2diabetes. Despite these both being highly prevalent conditions, there were considerable barriers to the effectiveness of different recruitment strategies across each study site. Although recruitment from primary care proved extremely successful at one study site, this largely failed at another site prompting the implementation of multimodal recruitment strategies including a successful media campaign to ensure sufficient participants were enrolled and the study was adequately powered. From this experience, we propose where appropriate the early engagement and investment in media campaigns to enhance recruitment into clinical trials. Trial Registration: ISRCTN30845205.

Current status of endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy must be performed by a highly experienced endoscopist. The challenges are accessing the afferent limb in different types of reconstruction, cannulating a papilla with a reverse orientation, and performing therapeutic interventions with uncommon endoscopic accessories. The development of endoscopic techniques has led to higher success rates in this group of patients. Device-assisted ERCP is the endoscopic procedure of choice for high success rates in short-limb reconstruction; however, these success rate is lower in long-limb reconstruction. ERCP assisted by endoscopic ultrasonography is now popular because it can be performed independent of the limb length; however, it must be performed by a highly experienced and skilled endoscopist. Stent deployment and small stone removal can be performed immediately after ERCP assisted by endoscopic ultrasonography, but the second session is needed for other difficult procedures such as cholangioscopy-guided electrohydraulic lithotripsy. Laparoscopic-assisted ERCP has an almost 100% success rate in long-limb reconstruction because of the use of a conventional side-view duodenoscope, which is compatible with standard accessories. This requires cooperation between the surgeon and endoscopist and is suitable in urgent situations requiring concomitant cholecystectomy. This review focuses on the advantages, disadvantages, and outcomes of various procedures that are suitable in different situations and reconstruction types. Emerging new techniques and their outcomes are also discussed.

Gastric remnant perforation due to trocar site herniation after laparoscopic Roux-en-Y gastric bypass

A 39-year-old woman was admitted with colicky left upper-quadrant pain, dyspnoea, low-grade fever, tachycardia and a subtle left upper-quadrant tenderness without leucocytosis. Computed tomography revealed a distended gastric remnant due to small-bowel loop herniation at the trocar site. The patient underwent a diagnostic laparoscopy as her general condition worsened. Perforation across the staple line was seen and repaired. The postoperative period was uneventful. As a rare complication of laparoscopic Roux-en-Y gastric bypass, small-bowel obstruction is of great importance because it can lead to gastric remnant perforation if not managed correctly. There have been rare reports of trocar site herniation as a cause of small-bowel obstruction following laparoscopic Roux-en-Y gastric bypass. Prompt diagnostic laparoscopy should be considered. This is the first case reported in which the excluded stomach was perforated due to trocar site herniation of the small-bowel loop. It should be noted that the tissue around the perforation is fragile and proper tension should be employed when it is repaired. Generally, an omental patch is not encouraged.

Percutaneous transgastrostomic interventional radiology-operated endoscopy facilitates foreign body removal using rigid endobronchial forceps

Retained foreign bodies within the stomach and proximal small bowel may be problematic in patients with prior cerebrovascular injury or head, neck and esophageal malignancy, given the increased vulnerability of this patient population to complications from aspiration and increased difficulty of esophagogastroduodenoscopy in cases of tumoral obstruction. This article presents an alternative method for foreign body retrieval through an existing gastrostomy tract, which offers the benefits of fast procedure times, reduction in radiation dose and fluoroscopy time, and allows for safer retrieval of foreign bodies by using direct visualization. This technique may be performed entirely by interventional radiologists.

A randomised controlled trial of a duodenal-jejunal bypass sleeve device (EndoBarrier) compared with standard medical therapy for the management of obese subjects with type 2 diabetes mellitus

INTRODUCTION

The prevalence of obesity and obesity-related diseases, including type 2 diabetes mellitus (T2DM), is increasing. Exclusion of the foregut, as occurs in Roux-en-Y gastric bypass, has a key role in the metabolic improvements that occur following bariatric surgery, which are independent of weight loss. Endoscopically placed duodenal-jejunal bypass sleeve devices, such as the EndoBarrier (GI Dynamics, Lexington, Massachusetts, USA), have been designed to create an impermeable barrier between chyme exiting the stomach and the mucosa of the duodenum and proximal jejunum. The non-surgical and reversible nature of these devices represents an attractive therapeutic option for patients with obesity and T2DM by potentially improving glycaemic control and reducing their weight.

METHODS AND ANALYSIS

In this multicentre, randomised, controlled, non-blinded trial, male and female patients aged 18-65 years with a body mass index 30-50 kg/m² and inadequately controlled T2DM on oral antihyperglycaemic medications (glycosylated haemoglobin (HbA1c) 58-97 mmol/mol) will be randomised in a 1:1 ratio to receive either the EndoBarrier device (n=80) for 12 months or conventional medical therapy, diet and exercise (n=80). The primary outcome measure will be a reduction in HbA1c by 20% at 12 months. Secondary outcome measures will include percentage weight loss, change in cardiovascular risk factors and medications, quality of life, cost, quality-adjusted life years accrued and adverse events. Three additional subgroups will investigate the mechanisms behind the effect of the EndoBarrier device, looking at changes in gut hormones, metabolites, bile acids, microbiome, food hedonics and preferences, taste, brain reward system responses to food, eating and addictive behaviours, body fat content, insulin sensitivity, and intestinal tissue gene expression.

TRIAL REGISTRATION NUMBER

ISRCTN30845205, ClinicalTrials.gov Identifier NCT02459561.

How to treat intestinal obstruction due to malignant recurrence after Whipple’s resection for pancreatic head cancer: Description of 2 new endoscopic techniques

The prognosis of pancreatic cancer remains poor, even after initial surgical therapy. Local recurrence after Whipple’s pancreatico-duodenectomy may lead to intestinal obstruction at the level of the afferent limb or the alimentary limb. Endoscopic insertion of a self-expandable metal stent (SEMS) into the intestinal malignant stricture is the preferred method of choice for palliation. We describe two new endoscopic techniques to treat a malignant intestinal obstruction with the insertion of a SEMS into the afferent limb and the alimentary limb. A case of malignant gastric outlet obstruction after a Whipple’s resection was treated by the creation of an endoscopic gastrojejunostomy by the insertion of a lumen apposing HotAxios stent in between the stomach and the alimentary limb under fluoroscopic and endoscopic ultrasound control. Biliary obstruction and jaundice caused by a malignant stricture of the afferent limb after a Roux-en-Y Whipple’s resection was treated by the insertion of a SEMS by means of the single-balloon overtube-assisted technique under fluoroscopic control. Feasibility and advantages of both techniques are discussed.

Buttressing of the EEA stapler during gastrojejunal anastomosis decreases rate of bleeding-related complications for laparoscopic gastric bypass

BACKGROUND

Bariatric surgery is a well-tolerated and effective treatment for severe obesity. Newer surgical techniques and equipment have improved safety standards surrounding bariatric surgery. In particular, buttressing of the staple line in sleeve gastrectomy has decreased rates of clinically significant postoperative bleeding. The present study investigates the effectiveness of buttressing the circular stapled anastomosis during laparoscopic Roux-en-Y gastric bypass (LRYGB).

SETTING

Academic, accredited hospital.

METHODS

A total of 253 patients undergoing LRYGB at a single academic institution were included in this retrospective study between 2014 and 2015. Buttressing material was used in 125 of these cases. Demographic information was collected from both groups preoperatively. Surgical characteristics were also obtained analyzed using unpaired t or χ² tests.

RESULTS

Patients in both buttressing and nonbuttressing groups were on average 46 years old and predominantly female (79.2% versus 74.2% female, respectively), with a body mass index of approximately 48 kg/m². Postoperative weight loss did not significantly differ between groups at any time point (buttressing versus nonbuttressing percentage of excess weight loss: 39.5% versus 41.5% at 3 mo, P = .3860; 56.4% versus 56.7% at 6 mo, P = .9341). There were no significant differences for operating time, length of stay, readmissions, or reoperations. Complications due to strictures were found to be lower for the buttressing group (0% buttressing versus 2.3% nonbuttressing, P = .0851). Specific rates of bleeding-related complications were significantly lower for the group in which buttressing was used (0% buttressing versus 3.1% nonbuttressing, P = .0463).

CONCLUSION

Buttressing of the gastrojejunal anastomosis during LRYGB significantly reduces bleeding-related complications and increases tolerability of the procedure.

Ex vivo comparison of the lumen-apposing properties of EUS-specific stents (with video)

BACKGROUND AND AIMS

Several EUS-specific stents have become available. It has been claimed that some of these stents have lumen-apposing properties, but objective data measuring such properties are not available. The aim of this study is to measure the lumen-apposing force (LAF) of these stents.

METHODS

The LAF of 3 EUS-specific metallic stents (stents A, N, and S) were compared in an ex vivo setting. Four types of anastomoses were performed with the stents including cholecysto-duodenal, cholecysto-gastric, gastro-gastric, and gastro-jejunal and compared with a hand-sewn (HS) equivalent of the anastomosis. The outcome parameter was the LAF created by each type of stent.

RESULTS

Sixty-four anastomoses were created. The overall mean (standard deviation) LAFs were significantly higher for stents A and S (P < .001). This difference persisted regardless of the type of anastomosis: gastro-gastric (P = .002), gastro-jejunal (P = .005), cholecysto-gastric (P = .002), and cholecysto-jejunal (P = .003). The differences in LAF created by each type of stent across different types of anastomoses were also compared. A trend to significance was observed in the anastomoses created by stent N (P = .064) and stent A (P =.052); a significant difference in LAF was observed among different anastomoses created by stent S (P = .015). The LAF created by HS anastomosis was significantly higher than that for all stents across all anastomoses.

CONCLUSIONS

Stents A and S had a higher LAF. The use of these stents should be considered when performing EUS-guided transmural luminal anastomoses in non-adherent organs. Further studies are required to confirm the clinical efficacies of these EUS-specific stents.

Endoscopic Therapeutic Option for Weight Loss and Control of Type 2 Diabetes: the Duodenal-Jejunal Bypass Liner

For a long time, obesity has been known as a risk factor for cardiovascular disease, which is one of the main causes of death in developed countries. This risk is due to the coexistence of other factors associated with obesity, such as hypertension, dyslipidemia, nonalcoholic fatty liver disease, and abnormalities in glycemic metabolism. Obesity is also a major risk factor for type 2 diabetes, and it is not surprising that the global prevalence of this disease continues to increase. Surgical intervention is now the most effective modality to treat severe obesity and its comorbidities. However, endoluminal interventions performed entirely through the gastrointestinal tract by using endoscopic devices offer the potential for an outpatient weight loss procedure that may be safer, less invasive, and more cost-effective, compared with current surgical approaches. Given the emerging role of endoscopic procedures in the treatment of obesity and rapid changes in endoscopic technologies and techniques, this review considers the current state of endoscopic management of obesity and type 2 diabetes. Endoscopic techniques attempt to mimic some of the anatomic features of bariatric surgery and rely on gastric restriction and duodenal exclusion. The endoscopic placement of the duodenal-jejunal bypass liner in morbidly obese patients induces significant weight loss. Additionally, early studies reported significant improvements in several parameters of glucose homeostasis in morbidly obese patients with type 2 diabetes. In this article we will review the available results obtained with the duodenal-jejunal bypass liner.

Intraperitoneal elemental mercury exposure from a mercury-weighted bougie

INTRODUCTION

Significant exposure to elemental mercury can occur if a mercury-weighted medical device is damaged during use. We report a case of an elemental mercury spill into the peritoneum of a patient undergoing laparoscopic gastric bypass surgery.

CASE REPORT

A 64-year-old man with multiple comorbidities underwent an elective Roux-en-Y gastric bypass procedure for the treatment of morbid obesity. A mercury-weighted esophageal bougie was inadvertently used during construction of the anastomosis. A suture placed through the distal tip of the device caused elemental mercury to leak into the peritoneum. Two days later, the patient underwent another surgical procedure for removal of the mercury. Intermittent air measurements taken from the laparoscope exhaust showed a peak intraperitoneal mercury concentration of 98,169 ng/m³. Blood mercury levels peaked at 146 μg/L on day 22 after the exposure, and urine mercury concentrations peaked on day 43 at 227 μg/L. The patient had no evidence of acute toxicity, but he was found to have proteinuria on follow-up evaluation.

DISCUSSION

Patients can be exposed inadvertently to toxic amounts of elemental mercury when the integrity of medical devices is compromised. We encourage hospitals to discontinue the use of devices that contain mercury. Effective alternatives that do not pose exposure risks to patients or health care workers are readily available.

Duodenal-jejunal bypass liners: outcomes in glycaemic control and weight loss

PURPOSE OF REVIEW

Duodenal-jejunal bypass liners (DJBLs) are a novel therapy with potential treating a range of metabolic diseases. This review discusses the weight loss and glycaemic improvements observed following the use of the DJBL.

RECENT FINDINGS

We summarize the evidence for the clinical application of DJBL to date. Within this, we outline the evidence available on the mechanisms of the observed effects.

SUMMARY

Based on the most recent trials, we cannot fully mimic the clinical or physiological effects of bariatric surgery with this device, but we are getting closer.

Endoscopic gastrojejunostomy with a natural orifice transluminal endoscopic surgery technique

AIM: To determine the technical feasibility and safety of an endoscopic gastrojejunostomy with a pure natural orifice transluminal endoscopic surgery (NOTES) technique using a T-anchoring device in a porcine survival model.

METHODS: An endoscopic gastrojejunostomy with a pure NOTES technique using a T-anchoring device was performed on 10 healthy female minipigs weighing approximately 40 kg each under general anesthesia. All procedures were performed with a transgastric approach using a 2-channel therapeutic endoscope.

RESULTS: The transgastric gastrojejunostomy was technically successful in all cases. A total of four to six stitched pairs of a T-anchoring device were used to secure the anastomosis. The median time required to enter the peritoneal cavity and pull the small bowel into the stomach was 34 min (range: 19-41 min); the median time required to suture the anastomosis was 67 min (range: 44-78 min). An obstruction of the efferent limb occurred in one case, and a rupture of the anastomosis site occurred in another case. As a result, the functional success rate was 80% (8/10). Small bowel adhesion to the stomach and liver occurred in one case, but the anastomosis was intact without leakage or obstruction.

CONCLUSION: A transgastric gastrojejunostomy with a T-anchoring device may be safe and technically feasible. A T-anchoring device may provide a simple and effective endoscopic suturing method.

Endoluminal revision of gastric bypass for weight regain--a systematic review

BACKGROUND

Weight recidivism after Roux-en-Y gastric bypass (RYGB) is a challenging problem for patients and bariatric surgeons alike. Traditional operative strategies to combat weight regain are technically challenging and associated with a high morbidity rate. Endoluminal interventions are thus an attractive alternative that may offer a good combination of results coupled with lower periprocedure risk that might one day provide a solution to this increasingly prevalent problem. The purpose of this article is to systematically review the available literature on endoluminal procedures used to address weight regain after RYGB, with specific attention to the safety profile, efficacy, cost, and current availability. This review focuses only on endoluminal procedures that are performed for weight regain after RYGB, as opposed to primary endoluminal obesity procedures.

METHODS

This study was a retrospective review.

RESULTS

Several methods of endoluminal intervention for weight regain are reviewed, ranging from injection of inert substances to suturing and clipping devices. The literature review shows the procedures on the whole to be well tolerated with limited efficacy. The majority of the literature is limited to small case series. Most of the reviewed devices are no longer commercially available.

CONCLUSIONS

Endoluminal therapy represents an intriguing strategy for weight regain after RYGB. However, the current and future technologies must be rigorously studied and improved such that they offer durable, repeatable, cost-effective solutions.

Ventricular fibrillation resulting from diaphragmatic stimulation during gastric bypass surgery

OBJECTIVE

Gastric bypass operations are common and severely obese patients are prone to arrhythmias, particularly atrial fibrillation. Intraoperative ventricular arrhythmias during bariatric surgery have not been reported previously.

CASE REPORT

A 35-year-old, severely obese, diabetic woman with no other prior medical history underwent thorough preoperative cardiovascular evaluation before having laparoscopic Roux-en-Y gastric bypass. Intraoperatively she developed sudden onset ventricular fibrillation during the use of unipolar electrocautery near the Angle of His. The procedure was aborted, and the patient underwent repeat cardiovascular assessment including coronary angiography and serial electrophysiology studies before being unremarkably re-operated 6 months later, at which time a harmonic scalpel was used for dissection. 12 months post operation, the patient remains asymptomatic.

CONCLUSION

Owing to the proximity of the right ventricle overlying the diaphragm, far-field stimulation was likely responsible for inducing VF.

Human experience with an endoluminal, endoscopic, gastrojejunal bypass sleeve

BACKGROUND

This report describes the authors' experience with a unique endoluminal, endoscopically delivered and retrieved gastroduodenojejunal bypass sleeve, including short-term weight loss and changes in comorbidities.

METHODS

A prospective, single-center trial was designed. The patients were morbidly obese individuals who met the National Institutes of Health criteria for bariatric surgery. The device used was a unique gastroduodenojejunal bypass sleeve secured at the esophagogastric junction with endoscopic and laparoscopic techniques and designed to create an endoluminal gastroduodenojejunal bypass. At completion of the trial, the device was explanted with endoscopic retrieval. The primary end points were safety and incidence of adverse events. The secondary outcomes included the percentage of excess weight loss and changes in comorbidities, specifically glucose control, use of antihyperglycemic medications, and changes in hemoglobin A1c levels.

RESULTS

From July 2008 to February 2010, 24 patients were enrolled in the trial. The gastroduodenojejunal bypass sleeve was implanted, left in situ, and then retrieved. The 7 men and 17 women in the study had a mean preoperative body mass index of 42 kg/m(2). The device was successfully delivered in 22 of the 24 patients (92%) and retrieved endoscopically from all 22 patients in whom it was implanted (100%). Two patients were excluded from the study preprocedurally. The one patient was excluded preoperatively due to noncompliance with the preoperative liquid diet. For the other excluded patient, the device was not attempted endoscopically due to significant inflammation at the gastroesophageal junction at the time of laparoscopic evaluation. Of the 22 patients who had the device implanted, 17 maintained it (77%) and completed the full 12-week trial. These patients had 39.7% excess weight loss at completion of the study. The primary reason for early explantation of the device was early postoperative dysphagia. The seven patients with preoperative diabetes mellitus all had normal blood glucose levels throughout the trial, and none required antihyperglycemic medications. All four patients with elevated hemoglobin A1c levels preoperatively showed improvement by the end of the trial.

CONCLUSIONS

This trial demonstrated that the endoluminal gastroduodenojejunal sleeve can achieve excellent weight loss at 12 weeks. No patient safety issues were encountered. Adverse effects were minimal and resolved at endoscopic device removal. Effective glycemic control was demonstrated through use of the device during the trial. Long-term results are needed.

Robotic-assisted Roux-en-Y Gastric bypass: minimizing morbidity and mortality

BACKGROUND

Despite the rapid acceptance of laparoscopic Roux-en-Y gastric bypass (RYGB) by the community and increase in the number of these procedures being done, there is still significant morbidity and mortality.

METHODS

At the University of Texas Medical School at Houston, we have performed 320 RYGB with robotic assistance (RARYGB). Surgical times, length of stay, morbidity, and mortality have been recorded since the beginning of our robotic experience and represent the world's largest single institution series of RARYGB. Outcome data were examined in a postoperative cohort.

RESULTS

The average starting BMI was 49.1 kg/m(2), and it declined by 66% to 32.5 kg/m(2) by the end of 1 year. The average operative time was 192 min, and the average length of stay was 2.7 days. Within the first year, there were a total of 77 (24.1%) complications. The foremost complications noted in the literature to be 3% to 11% were all <1% in our series, and we have no mortalities. Compared to our 356 laparoscopic RYGB, there was a significantly lower gastrointestinal leak rate in the robotic arm. A cohort of 79 postoperative patients was analyzed with respect to weight loss, resolution of co-morbidity, and quality of life. While there was no variation in quality of life over time, weight loss, resolution of co-morbidities, and overall outcome score were significantly improved.

CONCLUSIONS

We effectively perform robotic-assisted RYGB that lowers the morbidity and mortality of this procedure compared to today's standard while maintaining thriving outcomes.

Study of the patency of different peritoneal drains used prophylactically in bariatric surgery

AIM

To compare the performance of different types of abdominal drains used in bariatric surgery.

METHODS

A vertical banded Roux-en-Y gastric bypass was performed in 33 morbidly obese patients. Drainage of the peritoneal cavity was performed in each case using three different types of drain selected in a randomized manner: a latex tubular drain, a Watterman tubulolaminar drain, and a silicone channeled drain. Drain permeability, contamination of the drained fluid, ease of handling, and patient discomfort were evaluated postoperatively over a period of 7 d.

RESULTS

The patients with the silicone channeled drain had larger volumes of drainage compared to patients with tubular and tubulolaminar drains between the third and seventh postoperative days. In addition, a lower incidence of discomfort and of contamination with bacteria of a more pathogenic profile was observed in the patients with the silicone channeled drain.

CONCLUSION

The silicone channeled drain was more comfortable and had less chance of occlusion, which is important in the detection of delayed dehiscence.

Advances in circular stapling techniques for gastric bypass: the circular stapler introducer

BACKGROUND

Modern laparoscopic bariatric surgery relies strongly on stapling devices and the perfection of the anastomotic technique is at the core of the patient's safety.

METHODS

Circular stapler anastomosis is a common technique for performing gastro-jejunostomy in gastric bypass surgery. In obese patients, transabdominal circular stapler introduction can be challenging and associated with morbidity. To overcome these technical obstacles, we have developed a new device, circular stapler introducer (CSI) to assist both the abdominal wall passage of the circular staplers and its introduction into the jejunum.

RESULTS

The CSI facilitates the insertion of the circular stapler not only into the abdomen but also into the jejunum enhancing safety and swiftness of laparoscopic Roux-en-Y gastric bypass.

CONCLUSIONS

Our innovative CSI device facilitates this part of the operation significantly and makes the performance of bariatric surgery more convenient.

NOTES and anastomosis

The history and development for forming anastomoses using natural orifice translumenal endoscopic surgery (NOTES) techniques is described. Sutured gastrojejunostomy, enteroenteral anastomosis, and ileocolonic anastomoses using rigid and circular staplers passed through the rectum and vaginal wall using a transgastric supervising endoscope using a natural orifice translumenal endoscopic surgery hybrid approach. The staplers for this type of approach have to change. They need to be longer, more flexible, and able to change shape (eg, becoming smaller for introduction and then expanding in the peritoneal cavity). Different methods of introduction over guidewires or in combination with flexible gastroscopes are also needed. There is still a requirement for more ingenuity, persistence, and research if the goal of safer effective formation of anastomoses by less invasive means is to be realized.

Compression anastomosis for Roux-en-Y gastric bypass: observations in a large animal model

BACKGROUND

In the morbidly obese, laparoscopic Roux-en-Y gastric bypass (RYGB) effectively achieves weight loss with the resolution of co-morbidities. The goal is to create a small-volume gastric pouch with a narrow gastrojejunal anastomosis (GJA). The procedure is associated with a GJA stricture rate of approximately 3%. The use of a compression anastomotic device to create a sutureless gastrointestinal anastomosis, replacing sutures or staples, might reduce tissue trauma and improve the GJA patency rate. A temperature-dependent, memory-shape, Nitinol Compression Anastomosis Clip (CAC) has been successfully used in intestinal anastomoses. Compression of the entrapped bowel leads to necrosis, with device expulsion after 7-10 days.

METHODS

We designed a pilot animal model study of open RYGB to examine the clip's safety in the performance of upper gastrointestinal anastomoses. Six 40-kg female pigs underwent RYGB. Group 1 (n = 3) underwent GJA with the CAC and a stapled jejunojejunal anastomosis (JJA). Group 2 (n = 3) underwent GJA and JJA with the CAC. One pig from each group was euthanized at 1, 4, and 8 weeks postoperatively.

RESULTS

Two pigs, one from each group, developed gastroparesis. At autopsy, all anastomoses were patent; the mean GJA diameter with the CAC was 1.6 cm (range 0.6-3), the mean JJA diameter with the stapler was 3.8 cm (range 35-40), and the mean JJA diameter with the CAC was 3 cm (range 3-3.2). Anastomotic burst pressures were similar between the stapled and CAC anastomoses. The device was passed per rectum by postoperative day 9 (range 8-12). Histologic examination of the CAC anastomoses demonstrated a complete mucosal lining with no evidence of stricture formation at 2 months.

CONCLUSION

The results of this small animal study have demonstrated the safety of sutureless compression anastomoses in an animal model of open RYGB.

Percutaneous endoscopic gastrojejunostomy tube placement in healthy dogs and cats

BACKGROUND

Pancreatitis, hepatobiliary disease, and proximal gastrointestinal tract disorders are clinical situations where delivery of nutrients via jejunostomy tube is preferable to a feeding gastrostomy. A thorough description of the percutaneous endoscopic gastrojejunostomy (PEG-J) technique and practical guidelines for its use in small animals have not been reported.

HYPOTHESIS

That a simple technique of PEG-J tube placement in humans would be useful and safe in healthy dogs and cats.

ANIMALS

Twelve healthy dogs and 5 healthy cats were included in the study.

MATERIALS AND METHODS

Commercially prepared PEG-J tubes were modified for use in animals and positioned in the small intestine by endoscopic guidance. Eight dogs and 5 cats were bolus fed enteral diets for 14 days. Complications associated with the use of the PEG-J tube and responses to bolus feedings were assessed.

RESULTS

Jejunostomy tubes were placed distal to the caudal duodenal flexure in all dogs and cats. Complications associated with PEG-J tubes occurred in 5/12 dogs and 4/5 cats and included J-tube removal, local pain/inflammation, retrograde tube migration, and diarrhea. Bolus feeding (daily maintenance energy requirement [MER] divided q8h) through the jejunostomy catheter was well tolerated, maintained normal body weight, and was not associated with adverse gastrointestinal signs.

CONCLUSIONS AND CLINICAL IMPORTANCE

Placement of a PEG-J tube is an effective, noninvasive technique for providing enteral nutritional support of healthy dogs and cats. Bolus-feeding techniques via PEG-J tubes maintain normal nutritional status in healthy dogs and cats. This procedure for jejunostomy feeding may be easily adapted for use in clinical practice outside of an intensive care facility.

New device for the introduction of a circular stapler in laparoscopic gastric bypass surgery

BACKGROUND

In laparoscopic Roux-en-Y gastric bypass (LRYGBP) surgery, the anastomosis between the gastric pouch and the jejunum can be performed using a circular stapler, as described in the original publication by Wittgrove in 1994. The introduction of the circular stapler through the thick abdominal wall in morbidly obese patients can be challenging. To overcome the difficulties of this task, a new device was developed and its use is presented.

METHOD

The new device has the shape of a trocar tip which can be mounted on the circular stapler, giving it the properties of a trocar. Therefore, easier introduction into the abdominal cavity is feasible. The use of the device was assessed analyzing the data of a prospective database, comparing patient groups operated without the device (n=301) and patients operated with the device (n=100).

RESULTS

The groups were comparable in age, sex, BMI and number of previous abdominal operations. The wound infection rate at the site of stapler introduction decreased from 6.6% to 1% (P=0.035). The overall operating time, hospital stay and complication rate were unchanged.

CONCLUSION

The new device proved to be useful in daily practice and enabled an easier stapler introduction with fewer wound infections.

What ring size should be used in association with vertical gastric bypass?

BACKGROUND

The placement of a ring circumferentially around the gastric pouch of a vertical gastric bypass has the advantage of permanently fixing the size of the gastric outlet and slowing the passage of food into the jejunum. Opinion remains divided about the use of rings, and the optimal size.

METHODS

Since 1990, we have consistently placed a ring at the time of gastric bypass surgery and have an experience with three ring sizes (circumference); 5.5 cm, 6.0 cm and 6.5 cm. Patient data has been recorded prospectively in a computerized database. We have reviewed the outcomes of all patients with at least 12 months follow-up with respect to quality of eating, the need for subsequent ring removal and weight loss.

RESULTS

Quality of eating was better in those with the larger rings. Ring removal was undertaken in 7 (14%) of those with a 5.5-cm ring, in 11 (5.1%) with a 6.0 cm ring and in 3 (2%) with a 6.5-cm ring (P<0.05). Ring removal led to a median recorded weight gain of 6.8 kg (-4.13 kg to 32.2 kg). When only those 415 patients in whom the ring was still in situ and there was no known staple-line disruption were considered (5.5 cm - 50, 6 cm - 215, 6.5 cm -150), there was no difference in the weight loss achieved and maintained out to 5 years, although there was a trend for this to be better in those with the larger rings.

CONCLUSION

We conclude that the inclusion of a ring placed around the gastric pouch of a vertical gastric bypass is beneficial for maintenance of weight loss, and a ring size of 6.5-cm circumference should be recommended.

Fifty consecutive patients with the GaBP ring system used in the banded gastric bypass operation for obesity with follow up of at least 1 year

BACKGROUND

The premanufactured GaBP ring system can be used in the banded gastric bypass operation instead of a surgeon-fashioned ring or band in current use.

METHODS

The GaBP ring system was used in 50 consecutive patients, and the outcomes were reviewed after 1 year of follow-up. Data were kept prospectively.

RESULTS

The GaBP ring system was used in 50 patients undergoing gastric bypass surgery, 9 with an open procedure and 41 with a laparoscopic approach. Placement took an average of < 5 minutes, and there were no GaBP ring system-related complications at the 1-year follow-up. The outcomes in terms of weight loss and resolution of comorbidities are similar to those previously reported for banded gastric bypass.

CONCLUSION

The GaBP ring system provides a premanufactured standardized ring for use in the banded gastric bypass operation.

Direct visual insertion of primary trocar and avoidance of fascial closure with laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (RYGBP) has been used increasingly more often in the past 10 years. The authors summarize their experience and safety/complications data based on 849 laparoscopic RYGBP procedures. They also evaluate the use of the Endopath trocar in terms of trocar-site hernias, bowel obstruction, and elimination of time-consuming fascial closure.

METHODS

From July 2000 to December 2003, 849 laparoscopic RYGBP procedures were performed using a bladeless, 12-mm, visual entry trocar. The patients' average body mass index (BMI) was 53.2 kg/m2. The trocar ports (n = 3,744) were not closed. Perioperative and postoperative assessments were performed.

RESULTS

In this study, 74% of the patients were retained for follow-up evaluation (mean, 10 months). Among these patients, no intraoperative bowel or vascular injuries, no mortality, and two trocar-site hernias (0.2%) were found. At 1 year, the mean excess weight loss was 73.4%.

CONCLUSIONS

The Endopath trocar system shows a trend toward reducing trocar-site hernias, decreasing bowel obstruction, and eliminating the need for time-consuming fascial closure, although further studies are needed to confirm these findings.

Experience with the optical access trocar for safe and rapid entry in the performance of laparoscopic gastric bypass

BACKGROUND

In laparoscopic surgery, serious complications caused by the blind insertion of trocars are well known. The open technique is compromised by the leakage of carbon dioxide and can also be time consuming, especially in morbidly obese patients. Our aim was to determine whether the optical access trocar can be used to establish a safe and rapid entry during laparoscopic gastric bypass.

METHODS

The data on a single surgeon's experience with 370 laparoscopic gastric bypass procedures during a 4-year period were reviewed. The Optiview trocar was used for all except the initial 21 patients. The entry time for the optical trocar was measured in 10 patients.

RESULTS

Of the 370 patients undergoing laparoscopic gastric bypass from November 2000 to September 2004, the initial 21 were treated using the standard Veress needle to create the pneumoperitoneum. The next 22 were treated using the Veress needle to create the pneumoperitoneum, followed by insertion of the optical access trocar in the left upper quadrant as the initial trocar. From this point to the present, the optical access trocar has been inserted without the use of a Veress needle. There have been no trocar-related bowel or vascular injuries in the entire series. The mean optical trocar insertion time was 28 +/- 1.2 s.

CONCLUSIONS

This is the first laparoscopic gastric bypass series to report the results of its experience with the optical access trocar. This device provides a safe and rapid technique for placement of the initial trocar for laparoscopic gastric bypass. Insertion of the optical trocar with a 10-mm laparoscope into the left upper quadrant is our procedure of choice for obtaining the pneumoperitoneum in this patient population.

Prevention of trocar-wound hernia in laparoscopic bariatric operations

BACKGROUND

Morbid obesity is a risk for fascial wound dehiscence and incisional hernia after abdominal surgery. The development of minimally invasive surgical techniques has led to a dramatic decrease in these complications. However, laparoscopic surgery may still be followed by trocar-wound herniation. Various methods have been advocated for its prevention.

METHODS

The records of 752 patients who underwent laparoscopic bariatric operations (610 mini-gastric bypass and 142 gastric banding) as treatment for morbid obesity between October 2001 and June 2005, with regular follow-up, were retrospectively reviewed. In all patients, the fascial layer of trocar wounds was not closed. Instead, a Surgicel plug was inserted into the muscle layer of trocar wounds of 10- and 12-mm diameter.

RESULTS

2 male patients in the mini-gastric bypass group developed a trocar wound hernia, for an overall prevalence of 0.33% (2/610). The intervals between surgery and diagnosis were 3 and 5 months respectively. In these 2 patients, the hernia occurred at the 12-mm trocar wound of the left midclavicular line, 2-3 cm below the costal margin, outside the left rectus muscle. These 2 patients have not developed intestinal obstruction as a consequence of the hernia, and have not undergone hernia repair. No patient in the gastric banding group has been found to develop a hernia.

CONCLUSION

With our technique, the prevalence of trocar-wound hernia after laparoscopic bariatric surgery has been very rare.

Laparoscopic Gastric Banding in the Rat Model as a Means of Videolaparoscopic Training

BACKGROUND

The development of laparoscopy in bariatric surgery has attracted a large number of surgeons. Learning this method for future clinical practice requires intensive training with inert tissues, simulators and experimental surgery in animals. Performing these procedures in small animals, with the same equipment used in humans, is feasible, allowing familiarization with and comprehension of the basic techniques. Wistar rats weighing 300-600 g were used. The animals were kept in standard laboratory conditions. A laparoscopic video-system, Veress needle, three ports, a 0 degree optic, a laparoscopic needle-holder, two 5-mm graspers, a 5-mm dissection clamp and a 5-mm scissors were used. An orogastric catheter with three 4-0 nylon sutures and one 6-0 nylon suture were also utilized. For the gastric band, we used a plastic device similar to the human gastric band. The present study describes a simple, inexpensive and reproducible technique for laparoscopic gastric banding in a rat model utilizing the same instruments developed for humans. The experimental rat model is more motivating than simulators, requires less space, and has easier maintenance compared with bigger animals, and consequently allows the use of more animals for teaching, training and application in many scientific studies.

Closure of the abdominal cavity after severe peritonitis in bariatric surgery utilizing a mesh and plastic device

The major cause of peritonitis in bariatric surgery is leakage of GI contents, which can have a catastrophic outcome for the bariatric patient. To resolve this serious problem, the surgeon must act quickly. This paper describes a 27-year-old female after gastric bypass with disruption of the gastroenterostomy and severe contamination and peritonitis. Closure of the anastomotic leak, drainage, and gastrostomy in the bypassed stomach were performed, but the abdomen could not be closed, due to dilated bowel and the intra-abdominal edema with the sepsis. Temporary laparostomy closure was performed; a plastic sheet with an overlying mesh was sutured to the fascial margins. Planned multiple reoperations permitted removal of necrotic and infected debris, with progressive approximation and ultimate closure of the fascia. This treatment resulted in a successful outcome for the patient.

A novel technique for fascial fixation of laparoscopic adjustable gastric band ports

Access port dislodgement after laparoscopic adjustable gastric banding is a recurring problem that often requires operative revision. Securing the port to the abdominal wall fascia in the traditional way with standard instruments is challenging in obese patients due to a thick abdominal wall. Therefore, we have devised a novel and simple technique for access port fixation using the EndoStitch device.

Staple-line buttressing material in gastric-bypass surgery

The problem of obesity has reached epidemic proportions in the USA. More than 50% of adults are obese or overweight. The only therapeutic intervention that provides effective long-term weight loss for the severely obese is bariatric surgery. Roux-en-Y gastric bypass is the most commonly performed bariatric operation in the USA. Anastomotic leaks can cause life-threatening sepsis in the immediate postoperative period or delayed presentations with fistulas. Fibrin sealant and bovine pericardium have been used to reinforce the anastomosis in order to decrease the rate of this dreaded complication. This review will summarize current literature on the subject.

Experience with the circular stapler for the gastrojejunostomy in laparoscopic gastric bypass (350 cases)

BACKGROUND

The increased incidence of morbid obesity has resulted in an increase in bariatric surgery. The gastrojejunostomy performed during Roux-en-Y gastric bypass (RYGBP) operations has technical variability with different outcomes and complication-rates immediate postoperatively and at long-term follow-up.

METHODS

Between Jan 2000 and Feb 2005, 350 laparoscopic RYGBP procedures were performed. We present our immediate and follow-up rate of complications with total intraabdominal gastrojejunostomy, performed with the circular stapler.

RESULTS

Complications of gastrojejunostomy were detected in 24 patients (6.8%): 3 anastomotic leaks (0.8%); 6 bleeding (1.7%) immediately postoperatively, and 4 stenoses (1.1%), 10 ulcers (2.8%) and 1 stenosis plus ulcer (0.3%) during long-term follow-up. There was no mortality related to the gastrojejunostomy.

CONCLUSIONS

The gastrojejunostomy with circular stapler is an easily reproducible procedure. The rate of complications has been low. Surgeons who perform laparoscopic RYGBP should have a careful learning curve, and should be aware of the potential complications and their management.

Glycolide copolymer staple-line reinforcement reduces staple site bleeding during laparoscopic gastric bypass: a prospective randomized trial

HYPOTHESIS

The use of staple-line reinforcement sleeves during laparoscopic gastric bypass reduces staple-line bleeding, which may translate into a reduction in the rate of gastrointestinal hemorrhage.

DESIGN

Prospective randomized trial.

SETTING

University hospital.

PATIENTS AND INTERVENTIONS

Thirty-four patients undergoing laparoscopic gastric bypass were randomly assigned to receive either no reinforcement (control group, n = 17) or reinforcement of the staple line with glycolic copolymer sleeves (treatment group, n = 17).

MAIN OUTCOME MEASURES

Demographic data, the number of stapler loads used, the number of staple-line bleeding sites, the amount of blood loss, the length of time required to obtain hemostasis of the staple lines, operative time, intraoperative and postoperative complications, and serial hemoglobin levels.

RESULTS

The mean number of stapler loads used was similar between groups. The mean number of staple-line bleeding sites was significantly fewer in the treatment group for division of gastric tissue (0.4 vs 2.5 bleeding sites), jejunal tissue (0.1 vs 0.6 bleeding site), and mesenteric tissue (0 vs 0.8 bleeding site). The mean blood loss was lower in the treatment group (84 vs 129 mL). Staple misfire occurred in 1 (0.7%) of 143 stapler loads used in the treatment group compared with 0 (0%) of 138 stapler loads used in the control group. The time to obtain staple-line hemostasis was shorter in the treatment group (1.2 vs 10.1 minutes). The total operative time was similar between groups. There was no mortality or postoperative leaks. One patient in the control group had postoperative gastrointestinal hemorrhage requiring blood transfusion and reoperation. There was no significant difference in the mean hemoglobin level between groups on the first postoperative day.

CONCLUSIONS

The use of glycolide copolymer staple-line reinforcement sleeves in patients undergoing laparoscopic gastric bypass is safe and significantly reduces staple-line bleeding sites and may reduce the incidence of gastrointestinal hemorrhage.

Placement of the GaBP Ring System in the Banded Gastric Bypass Operation

Currently, bariatric surgeons fashion the band or ring reinforcement prosthesis, to control the stoma in the vertical banded gastroplasty and gastric bypass operations for morbid obesity. To meet this need, the GaBP Ring system has been developed in various sizes, and consists of 4 main parts to provide a means for inserting a ring around the gastric pouch in the banded gastric bypass or the vertical banded gastroplasty. The pre-manufactured and sterilized device provides for better standardization and quality control than individually surgeon-fashioned devices. The GaBP Ring system is described, and the technique of placement and the pertinent initial clinical results are presented.

Totally robotic Roux-en-Y gastric bypass

HYPOTHESIS

We hypothesized that we could develop a safe and effective technique for performing a totally robotic laparoscopic Roux-en-Y gastric bypass procedure using the da Vinci surgical system. We anticipated that the learning curve for this totally robotic procedure could be shorter than the learning curve for standard laparoscopic bariatric surgery.

DESIGN

Retrospective case comparison study.

SETTING

Academic tertiary care center.

PATIENTS

Consecutive samples of patients who met National Institutes of Health (NIH) criteria for morbid obesity and who completed the Stanford Bariatric Surgery Program evaluation process.

INTERVENTION

A port placement and robot positioning scheme was developed so that the entire case could be performed robotically. The first 10 patients who underwent a totally robotic laparoscopic Roux-en-Y gastric bypass were compared with a retrospective sample of 10 patients who had undergone laparoscopic Roux-en-Y gastric bypass surgery.

MAIN OUTCOME MEASURES

Patient age, gender, body mass index (BMI), numbers of NIH-defined comorbidities, operative time, length of stay, and complications.

RESULTS

No significant differences existed between the 2 patient series with regard to age, gender, or BMI. The median surgical times were significantly lower for the robotic procedures (169 vs 208 minutes; P = .03), as was the ratio of procedure time to BMI (3.8 vs 5.0 minutes per BMI for the laparoscopic cases; P = .04).

CONCLUSIONS

This study details the first report, to our knowledge, of a totally robotic laparoscopic Roux-en-Y gastric bypass and demonstrates the feasibility, safety, and potential superiority of such a procedure. In addition, the learning curve may be significantly shorter with the robotic procedure. Further experience is needed to understand the long-term advantages and disadvantages of the totally robotic approach.

Per-oral circular stapler in laparoscopic Roux-en-Y gastric bypass

Circular staplers are used to create the gastrojejunostomy of the Roux-en-Y gastric bypass. The anvil of the stapler can be placed within the pouch by way of the oropharynx or trans-abdominally, but these methods have limitations. The SurgASSIST Computer Mediated Stapler (Power Medical Interventions, New Hope, PA, USA) is a new technology that changes surgical stapling. The staplers are closed and fired under surgeon control by a computer for better accuracy and reliability. It has a 21-mm stapler, which can be passed orally for endoluminal stapling. The SurgASSIST has several advantages over the traditional circular stapled gastrojejunal anastomosis, including no need to dilate trocars to accommodate the stapler through the abdominal wall and decreased wound infections.

Band Slippage – a Potentially Life-Threatening Complication after Laparoscopic Adjustable Gastric Banding

BACKGROUND

Although gastric bands are safe and effective devices, severe late complications may develop in rare cases.

PATIENTS

3 patients were treated for complete dysphagia after slippage of gastric bands. 2 of the patients were admitted for severe dehydration, 1 of whom developed cerebral venous infarction. Ischemia of the gastric pouch occurred in 1 patient.

RESULTS

All 3 patients survived after successful medical therapy and surgical removal of the bands. Bariatric reoperations were performed in 2 patients (gastric sleeve resection, gastric bypass).

CONCLUSION

Complete dysphagia on the basis of band slippage represents a life-threatening acute event, which may occur even years after implantation. Patients and doctors should be informed about this long-term risk of gastric banding.