Reverse peristaltic activity is a rare complication of Roux-en-Y gastric bypass. Symptoms may be nonspecific. This condition should be considered in the differential diagnosis of complicated postoperative gastric bypass patients.
Retrograde Roux limb peristalsis following laparoscopic Roux-en-Y gastric bypass is a rare complication that can be difficult to identify. It may present as persistent nausea, vomiting, abdominal pain, or even gastrointestinal bleeding related to an anastomotic ulcer. Upper gastrointestinal (UGI) series is an important diagnostic modality to identify this motility disorder; however, it may not be readily identifiable without specific delayed imaging. The etiology of this phenomenon is unclear, but attributing factors include the presence of ectopic pacemaker cells, variable lengths of the Roux limb and misconstructions. When this problem is identified, revisional surgery is indicated.
A 51-y-old female with morbid obesity presented with persistent nausea and vomiting following a laparoscopic gastric bypass. A CT scan showed a dilated Roux limb. Reverse peristalsis from the jejunojejunostomy toward the gastric pouch was identified on a UGI. Two laparoscopic revisions of the jejunojunostomy were attempted to correct this dysfunction.
An attempt at widening and relaxing the anastomosis was unsuccessful at providing relief of symptoms. A second revision with an anastomosis between the Roux limb and common channel provided long-term improvement. Identifying complications of gastric bypass surgery can be challenging. Imaging studies may be limited, and often diagnostic and revisional surgery is indicated.
Reverse peristalsis; Gastric bypass; Obstruction; Jejunojejunostomy
Gastric adenocarcinoma after gastric bypass for morbid obesity is rare but has been described. The diet restriction, weight loss, and difficult assessment of the bypassed stomach, after this procedure, hinder and delay its diagnosis. We present a 52-year-old man who underwent Roux-en-Y gastric bypass 2 years ago and whose previous upper digestive endoscopy was considered normal. He presented with weight loss, attributed to the procedure, and progressive dysphagia. Upper digestive endoscopy revealed stenosing tumor in gastric pouch whose biopsy showed diffuse-type gastric adenocarcinoma. He underwent total gastrectomy, left lobectomy, distal pancreatectomy and splenectomy, segmental colectomy, and bowel resection with esophagojejunal anastomosis. The histopathological analysis confirmed the presence of gastric cancer. The pathogenesis of gastric pouch adenocarcinoma is discussed with a literature review.
Background. Laparoscopic Roux-en-Y gastric bypass (LRYGB) has been shown to be an effective treatment for type 2 diabetes mellitus (T2DM) in patients with morbid obesity. However, it is unclear just how effective the LRYGB procedure is on T2DM for patients with BMI less than 35 kg/m2. We report one obese patient with T2DM who did not meet the current NIH criteria for morbid obesity surgery. This patient underwent a laparoscopic truncal vagotomy, subtotal gastrectomy, and Roux-en-Y gastrojejunostomy for intractable gastric ulcers and subsequently had full resolution of her T2DM. Methods. A 48-year-old patient with a BMI of 34.6 kg/m2 underwent a laparoscopic truncal vagotomy, subtotal gastrectomy, and Roux-en-Y gastrojejunostomy for intractable gastric ulcers. The patient was seen 3 months preoperatively, followed for 24 months postoperatively, and evaluated for postoperative complications, weight loss, and improvement in comorbidities. Results. The patient had no postoperative surgical complications. Her BMI decreased from 34.6 kg/m2 to 22.3 kg/m2 by 24 months postoperatively. Significant improvements in her fasting blood glucose levels were seen 10 days postoperatively from a preoperative level of 147 mg/dl to 97 mg/dl. Conclusion. Patients with a BMI less than 35 kg/m2 and uncontrolled T2DM may benefit from a laparoscopic Roux-en-Y gastric bypass.
A group of 133 patients treated for bleeding peptic ulcer in our Department, is reviewed.
Within several hours of admission, all patients underwent upper gastrointestinal tract
gastroscopy and obliteration of the bleeding ulcer. Bleeding gastric ulcers were found in
41 patients, and duodenal ulcers in 92 patients. Patients were classified according to the
Forrest scale: IA – 11 patients, IB – 49 patients, IIA – 35 patients, lIB – 40 patients.
In 126 (94.7%) patients the bleeding was stopped, and 7 required urgent surgery: 3
patients with gastric ulcer underwent gastrectomy, and 4 with duodenal ulcer – truncal
vagotomy with pyloroplasty and had the bleeding site underpinned. Fifty-five patients
underwent elective surgery: gastrectomy and vagotomy (18 patients with gastric ulcer),
highly selective vagotomy (25 patients with duodenal ulcer) and truncal vagotomy and
pyloroplasty (12 patients with duodenal ulcer). None of the patients was observed to
have recurrent bleeding.
The only effective treatment for patients with morbid obesity is surgery. Laparoscopic bariatric surgery has become quite popular in attempts to decrease the morbidity associated with laparotomy. In this article, we describe the technical details of laparoscopic Roux-en-Y gastric bypass with three different techniques for creating the 15-cc gastric pouch. These techniques avoid upper endoscopy for the transoral introduction of the 21-mm circular stapler anvil down to the gastric pouch.
Gastric bypass; Morbid obesity; Obesity surgery; Laparoscopic gastric bypass
The past decade has seen an enormous increase in the number of bariatric, or weight loss, operations performed. This trend is likely to continue, mirroring the epidemic of obesity around the world and its rising prevalence among children. Bariatric surgery is considered by many to be the most effective treatment for obesity in terms of maintenance of long-term weight loss and improvement in obesity-related comorbid conditions. Although overly simplified, the primary mechanisms of the surgical interventions currently utilized to treat obesity are the creation of a restrictive or malabsorptive bowel anatomy. Operations based on these mechanisms include the laparoscopic adjustable gastric band and laparoscopic vertical sleeve gastrectomy (considered primarily restrictive operations), the laparoscopic biliopancreatic diversion with or without a duodenal switch (primarily malabsorptive operation), and the laparoscopic Roux-en-Y gastric bypass (considered a combination restrictive and selective malabsorptive procedure). Each operation has pros and cons. Important considerations, for the patient and surgeon alike, in the decision to proceed with bariatric surgery include the technical aspects of the operation, postoperative complications including long-term nutritional problems, magnitude of initial and sustained weight loss desired, and correction of obesity-related comorbidities. Herein, the pros and cons of the contemporary laparoscopic bariatric operations are reviewed and ongoing controversies relating to bariatric surgery are discussed: appropriate patient selection, appropriate operation selection for an individual patient, surgeon selection, and how to measure success after surgery.
Background and Objectives:
We hypothesized that patients who have previously had bariatric surgery and are undergoing revision to laparoscopic Roux-en-Y gastric bypass would have abnormal findings detected by upper endoscopy that could potentially influence patient management. The procedures that are being revised include vertical banded gastroplasty, laparoscopic adjustable gastric bands, nonadjustable gastric bands and previous Roux-en-Y gastric bypass (open and laparoscopic).
We conducted a retrospective chart review of patients who previously had undergone vertical banded gastroplasty or nonadjustable gastric banding. We preoperatively performed an upper endoscopy on all patients. The endoscopy reports were reviewed and the findings entered into a database.
Eighty-five percent of 46 patients undergoing revisional bariatric surgery had an abnormal upper endoscopy. Eleven percent had a gastrogastric fistula. Gastritis and esophagitis were noted in 65% and 37%, respectively. Eleven percent of patients had band erosion, 2 from a nonadjustable band, and 5 from vertical banded gastroplasties. Based on our findings, 65% of our patients required medical treatment.
Preoperative upper endoscopy provides valuable information before revisional laparoscopic bariatric surgery. In addition to identifying patients who need preoperative medications, the preoperative upper endoscopy also provided valuable information regarding pouch size and anatomy. Preoperative upper endoscopy should be performed by the operating surgeon on every patient undergoing revisional bariatric surgery.
Endoscopy; Bariatric surgery; Revisional surgery; Gastrogastric fistulae
Conventional laparoscopic Roux-en-Y gastric bypass (LRYGB) is a gold standard for bariatric surgery, but the procedure requires five to seven incisions for placement of multiple trocars and thus may produce less-than-ideal cosmetic results. We have developed a new approach, single-incision transumbilical LRYGB (SITU-LRYGB) to treat morbid obesity. We compared the surgical results and patient satisfaction in a study of five-port LRYGB and SITU-LRYGB. Fifty morbidly obese patients (14 males, 36 females) underwent either Roux-en-Y gastric bypass with five-port LRYGB or the SITU-LRYGB approach. During the operation, we used a novel intraoperative liver traction method with a “liver suspension tape” that we specifically designed for SITU-LRYGB. Compared to five-port surgery with SITU-LRYGB, there were no intraoperative complications, wound healing was excellent, and there was no abdominal scarring. SITU surgical time was longer than that with five-port LRYGB (99.8 vs. 67.6 min, P < 0.001). Patients treated with the five-port method were more obese than those in the SITU group (127.9 vs. 112.4 kg, P = 0.016). After the bariatric surgery, no difference in comorbidity was found in both groups. Patient satisfaction was greater with SITU than with the five-port method (4.48 vs. 3.96, P = 0.006). Roux-en-Y gastric bypass can be successfully achieved via a single umbilical incision, a method that provides a short operative time and good recovery and eliminates abdominal scarring.
Laparoscopic Roux-en-Y gastric bypass; Single-incision transumbilical laparoscopic surgery; SILS; Gastric bypass; Laparoscopy; Bariatric surgery
As recently as 40 years ago, a decline in the incidence of peptic ulcers was observed. The discovery of Helicobacter pylori had a further major impact on the incidence of ulcer disease. Our aim was to evaluate the trends in the incidence and bleeding complications of ulcer disease in the Netherlands.
From a computerized endoscopy database of a district hospital, the data of all patients who underwent upper gastrointestinal endoscopy from 1996 to 2005 were analyzed. The incidence of duodenal and gastric ulcers, with and without complications, were compared over time.
Overall, 20,006 upper gastrointestinal endoscopies were performed. Duodenal ulcers were diagnosed in 696 (3.5%) cases, with signs of bleeding in 158 (22.7%). Forty-five (6.5%) of these ulcers were classified as Forrest I and 113 (16.2%) as Forrest II. Gastric ulcers were diagnosed in 487 cases (2.4%), with signs of bleeding in 60 (12.3%). A Forrest 1 designation was diagnosed in 19 patients (3.9%) and Forrest 2 in 41 patients (8.4%). The incidence of gastric ulcers was stable over time, while the incidence of duodenal ulcers declined.
The incidence of duodenal ulcer disease in the Dutch population is steadily decreasing over time. Test and treatment regimens for H pylori have possibly contributed to this decline. With a further decline in the prevalence of H pylori, the incidence of gastric ulcers is likely to exceed the incidence of duodenal ulcers in the very near future, revisiting a similar situation that was present at the beginning of the previous century.
Duodenal ulcer; Endoscopy; Epidemiology; Helicobacter pylori; Peptic ulcer; Stomach ulcer
This study is a single institution retrospective evaluation of imaging findings of small bowel obstruction (SBO) after retrocolic antegastric Roux-en-Y gastric bypass surgery for morbid obesity.
The radiological database of 490 patients who underwent gastric bypass surgery for morbid obesity from January 2001–2005 at the Royal Victoria Hospital McGill University Health Center was searched for SBO complications related to the procedure. There were 22 cases of small bowel obstruction related to the procedure. Ten patients had abdominal and pelvic computed tomography (CT) scans, 12 patients had upper gastrointestinal (UGI) and small bowel follow through (SBFT).
Among 22 cases of SBO, 14 cases were due to anastomotic stenosis or adhesion, 7 due to internal hernia and one to jejuno-jejunal intussusception. Among the 14 patients with SBO related to adhesion and anastomotic narrowing, 11 patients were managed medically and 3 cases managed surgically. CT scans correctly diagnosed 4 out of 5 cases including the 3 patients managed surgically and UGI and SBFT examinations diagnosed the remaining 9 cases that were managed medically. Among the 7 patients with internal hernias, CT scans correctly diagnosed 2 out of 4 cases, while UGI and SBFT examinations correctly diagnosed 1 out of 3. The jejuno-jejunal intussusception was correctly diagnosed by CT scan.
The most frequent cause of SBO is anastomotic narrowing or adhesion. CT scan remains the most appropriate imaging modality in diagnosing acute presentation of SBO caused by internal hernia or adhesion/anastomotic narrowing. UGI and SBFT appear more appropriate for diagnosing the subacute insidious presentation of adhesive partial SBO.
Gastric bypass surgery; Small bowel obstruction; Morbid obesity; Anastomotic narrowing
We present a randomized controlled trial of laparoscopic gastric bypass comparing 2 techniques of gastrojejunostomy in patients with morbid obesity.
Eighty consecutive patients underwent laparoscopic Roux-en-Y gastric bypass between September 2005 and August 2006. Patients were randomly assigned to 2 groups by the use of sealed envelopes. In group A, the gastrojejunal anastomosis was performed with a 21-mm circular-stapler, and in group B, this anastomosis was performed with a 45-mm linear-stapler. The rest of the procedure was identical in both groups. Variables evaluated were complications involving the gastrojejunostomy, operative time, length of stay, and percentage of excess weight loss.
Both groups were similar in age and body mass index. No patients experienced leakage or gastrojejunal anastomosis fistula, but group A patients had a more frequent stricture rate (P<0.05). Operative time and hospital stay were comparable in both groups (P>0.05). Percentage excess weight loss at one year following surgery was satisfactory in both groups, without a statistically significant difference (P>0.05).
Gastrojejunal anastomosis does not seem to be a critical factor in excess weight loss for morbidly obese patients who underwent laparoscopic gastric bypass. The 2 techniques used in this experience are safe and effective; however, the 45-mm liner-stapler is preferable because it has a lower stricture rate.
Laparoscopic gastric bypass; Stricture; Gastrojejunostomy; Excess weight loss
A “swirl sign” on computerized tomography is an indicator of internal herniation through Petersen’s space and should prompt immediate diagnostic laparoscopy in patients following laparoscopic Roux-en-Y gastric bypass.
Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most commonly performed bariatric surgical procedures. A laparoscopic gastric bypass is associated with specific complications: internal herniation is one of these.
A 47-year-old woman had undergone a laparoscopic Roux-en-Y gastric bypass (LRYGB) 18 months before presentation at our emergency department with mild abdominal complaints. Physical examination showed signs of an ileus in the absence of an acute abdomen. Laboratory investigations revealed no abnormalities (CRP 2.0 mg/L, white blood count 6.3 × 109/L). During admission, there was clinical deterioration on the third day. Emergency laparotomy was performed. An internal herniation through Petersen's space was found that strangulated and perforated the small bowel. A resection with primary anastomosis and closure of the defects was performed.
Diagnosing an internal herniation through Petersen's space is difficult due to the nonspecific clinical presentation. The interpretation of the CT scan poses another diagnostic challenge. This sign is present in 74% of the cases with this herniation. A missed diagnosis of internal herniation may cause potentially serious complications. A patient with a gastric bypass who experiences intermittent abdominal complaints should undergo laparoscopy to rule out internal herniation.
Roux-en-Y gastric bypass; Peterson's space; Herniation; Laparoscopy
The use of bariatric surgery in the management of morbid obesity is rapidly increasing. The two most frequently performed procedures are laparoscopic Roux-en-Y bypass and laparoscopic gastric banding. The objective of this short overview is to provide a critical appraisal of the most relevant scientific evidence comparing laparoscopic gastric banding versus laparoscopic Roux-en-Y bypass in the treatment of morbidly obese patients.
Results and discussion
There is mounting and convincing evidence that laparoscopic gastric banding is suboptimal at best in the management of morbid obesity. Although short-term morbidity is low and hospital length of stay is short, the rates of long-term complications and band removals are high, and failure to lose weight after laparoscopic gastric banding is prevalent.
The placement of a gastric band appears to be a disservice to many morbidly obese patients and therefore, in the current culture of evidence based medicine, the prevalent use of laparoscopic gastric banding can no longer be justified. Based on the current scientific literature, the laparoscopic gastric bypass should be considered the treatment of choice in the management of morbidly obese patients.
While repair of giant paraesophageal hernia is associated with a high failure rate in the morbidly obese, laparoscopic Roux-en-Y gastric bypass and repair of giant paraesophageal hernia in the morbidly obese may be safe and effective.
Repair of large paraesophageal hernias by itself is associated with high failure rates in the morbidly obese. A surgical approach addressing both giant paraesophageal hernia and morbid obesity has, to our knowledge, not been explored in the surgical literature.
A retrospective review of a bariatric surgery database identified patients who underwent simultaneous repair of large type 3 paraesophageal hernias with primary crus closure and Roux-en-Y gastric bypass (RYGB). Operative time, intraoperative and 30-day morbidity, weight loss, resolution of comorbid conditions and use of anti-reflux medication were outcome measures. Integrity of crural closure was studied with a barium swallow.
Three patients with a mean body mass index of 46kg/m2 and mean age of 46 years underwent repair of a large paraesophageal hernia, primary crus closure, and RYGB. Mean operative time was 241 minutes and length of stay was 4 days. There was no intraoperative or 30-day morbidity. One patient required endoscopic balloon dilatation of the gastrojejunostomy. At 12 months, all patients were asymptomatic with excellent weight loss and resolution of comorbidities. Contrast studies showed no recurrence of the hiatal hernia.
Simultaneous laparoscopic repair of large paraesophageal hernias in the morbidly obese is safe and effective.
Hiatal hernia; Morbid obesity; Paraesophageal hernia; Roux-en-Y gastric bypass
Surgery is currently the only effective treatment for morbid obesity. The two most commonly accepted operations are the Roux-en-Y gastric bypass and vertical banded gastroplasty. Although multiple authors have reported on a laparoscopic approach to gastric banding, the Roux-en-Y gastric bypass is a complex operation to be replicated using laparoscopic techniques. In this article, we describe our technique of the Roux-en-Y gastric bypass using a laparoscopic approach in four cases.
Laparoscopy; Obesity; Gastric bypass; Weight reduction
Hyperplastic gastric polyps are incidentally diagnosed during upper gastrointestinal endoscopy. They are known to cause gastric outlet obstruction and chronic blood loss leading to iron deficiency anemia. However, hyperplastic gastric polyp presenting as acute severe upper gastrointestinal bleeding is very rare. To the best of our knowledge, there have been two cases of hyperplastic gastric polyps presenting as acute gastrointestinal bleeding in the medical literature. We present a case of a 56-year-old African American woman who was admitted to our hospital with symptomatic anemia and sepsis. The patient developed acute upper gastrointestinal bleeding during her hospital stay. She underwent emergent endoscopy, but bleeding could not be controlled. She underwent emergent laparotomy and wedge resection to control the bleeding. Biopsy of surgical specimen was reported as hyperplastic gastric polyp. We recommend that physicians should be aware of this rare serious complication of hyperplastic gastric polyps as endoscopic polypectomy has diagnostic and therapeutic benefits in preventing future complications including bleeding.
Variceal bleeding is the most challenging emergent situation among the causes of upper gastrointestinal bleeding. Despite substantial improvement, a need remains for therapeutic armamentarium of such cases, which is easy, effective and without side-effect. Ankaferd blood stopper (ABS) is a standardized herbal extract acting as a hemostatic agent on the bleeding or injured areas. In this observational study, a total of four patients with variceal bleeding were treated with endoscopic ABS application. The lesions were bleeding gastric varices (n:3) and bleeding duodenal varix (n:1). ABS was selected as a bridge to definitive therapies due to unavailability or inappropriateness of bleeding lesions to conventional measures. ABS was instilled or flushed onto the bleeding areas by sclerotherotherapy needle or heater probe catheter. Periprocedural control of the bleeding was achieved in all instances. Thereafter, on an elective basis, two patients with gastric varices underwent cyanoacrylate injection, while third underwent Transjugular intrahepatic portosystemic shunt and embolization. The patient with duodenal varix refused further therapy, after a few hours after admission and was discharged. He again presented the same day with rebleeding, but died before any attempt could be made to control his bleeding. ABS seems to be effective in cases of variceal bleeding as a bridge to therapy. Its major advantages are the ease of use and lack of side-effects.
Ankaferd blood stopper; duodenal varices; endoscopy; gastric varices
Introduction. Glomus tumors (GTs) are benign neoplasm originating from the glomus body, commonly described in subungual region. The involvement abdominal is rare. Our aim is to describe a case of glomus tumor of the stomach that presented upper gastrointestinal bleeding. A 34-year-old woman was admitted with upper gastrointestinal bleeding and underwent an upper endoscopy that showed bleeding arising from an ulcerated lesion, treated by sclerosis therapy. A new endoscopy confirmed a submucosal lesion in upper portion of the stomach. During the laparotomy, a tumor at the upper anterior wall of gastric body was found and resected by a vertical gastrectomy. The pathological exam revealed hyperplastic smooth muscle fibers of the muscularis propria of the stomach wall, surrounded by hyaline stroma. The immunohistochemistry panel was positive for smooth muscle actin and type IV collagen, with low rate of mitosis studied by Ki-67 which allowed the final diagnosis of a gastric glomus tumor. Discussion. The majority of intraperitoneal glomus tumors occur in the stomach, and it is phenotypically similar to those localized in peripheral sites. Gastric GT generally is a benign tumor although it can be malignant and have the potential to metastasize. Conclusion. Even though gastric glomus tumor is rarely described, it should be considered as a possible cause of a major upper gastrointestinal bleeding.
Intractable bleeding from gastric and duodenal ulcers is associated with significant morbidity and mortality. Aggressive treatment with early endoscopic hemostasis is essential for a favourable outcome. In as many as 12%-17% of patients, endoscopy is either not available or unsuccessful. Endovascular therapy with selective catheterization of the culprit vessel and injection of embolic material has emerged as an alternative to emergent operative intervention in high-risk patients. There has not been a systematic literature review to assess the role for embolotherapy in the treatment of acute upper gastrointestinal bleeding from gastroduodenal ulcers after failed endoscopic hemostasis. Here, we present an overview of indications, techniques, and clinical outcomes after endovascular embolization of acute peptic-ulcer bleeding. Topics of particular relevance to technical and clinical success are also discussed. Our review shows that transcatheter arterial embolization is a safe alternative to surgery for massive gastroduodenal bleeding that is refractory to endoscopic treatment, can be performed with high technical and clinical success rates, and should be considered the salvage treatment of choice in patients at high surgical risk.
Peptic ulcer; Massive bleeding; Endoscopy; Angiography; Embolization
Roux-en-Y gastric bypass is the gold standard for treating morbid obesity in this country. The totally laparoscopic performance of this procedure, although quite demanding and technically difficult, has revolutionized it; and the demand for it has skyrocketed. We describe 2 cases where it became necessary to convert the Y into a “W” while performing the procedure.
A laparoscopic Roux-en-Y gastric bypass was attempted on 2 patients, 1 male and 1 female, both with body mass indexes greater than 40. During creation of the side to side jejunojejunostomy, ie, the Y, it became obvious that stenosis or obstruction would result. This area was partially resected and an additional side to side anastomosis was formed, creating a “W.”
The operative time was 205 minutes and 180 minutes, respectively, which compared favorably with the average operative time of 151 minutes in that quartile of patients (patients #101–#150). Both patients had normal upper gastrointestinal and small bowel contrast x-rays the day following surgery and were started on clear liquids. They were discharged later that day. Weight loss of 119 lb at 8 months and 80 lb at 6 months was documented, respectively, with no gastrointestinal sequelae.
If problems are encountered when creating the Y of a laparoscopic Roux-en-Y gastric bypass, a laparoscopic Roux-en-W may be performed. It appears safe, technically feasible, and with a postoperative course not unlike that of the standard approach.
Laparoscopy; Roux-en-Y gastric bypass; Jejunojejunostomy; Roux-en-W gastric bypass
Haemorrhage via the pancreatic duct, a rare cause of upper gastrointestinal bleeding (GIB), often poses a diagnostic dilemma. We analysed our experience with 10 patients (8 men, 2 women; mean age 44 years, range 34 – 62) treated during a 12 year period. All had a history of alcohol abuse and presented with major upper GIB requiring a median of 8 units (range 2 – 40) blood, transfusion. Nine had upper abdominal pain at the time of admission and nine had a history of pancreatitis. Upper gastroduodenal endoscopy (median 4; range 1 – 9), was diagnostic in only one. Side-viewing endoscopy showed bleeding from the pancreatic duct in 7 of 8 patients. Visceral aneurysms were demonstrated in 7 of 9 patients in whom coeliac angiography was carried out: (splenic artery 4, gastroduodenal artery 2, and pancreaticoduodenal artery 1). Two of 4 selective embolisations were successful. Six patients underwent distal pancreatectomy, 1 had gastroduodenal artery ligation and 1 died of coagulopathy following a total pancreatectomy. Pancreatic duct haemorrhage should be considered in patients with unexplained recurrent upper GIB, alcohol abuse and epigastric pain, particularly in those with established chronic pancreatitis. Selective angiography is essential for diagnosis and management. For bleeding sites in the head of the pancreas, embolisation should be attempted to avoid major resection. Distal pancreatectomy
is preferred for splenic artery lesions.
The findings from 480 patients who had emergency endoscopy for acute upper gastrointestinal bleeding of non-variceal origin at our institution were analysed. Twenty eight patients (5.8%) had a Dieulafoy lesion. In 27 patients (96.4%) bleeding could be successfully managed by injection of norepinephrine and polidocanol, in repeated sessions if needed. Two patients had to be treated surgically: one because of uncontrollable bleeding from the Dieulafoy lesion and one despite endoscopic control of the bleeding Dieulafoy lesion because of a concomitant bleeding from an anastomosal ulcer after gastric resection. Three patients died during hospital stay from causes unrelated to bleeding from Dieulafoy lesion. Out of the 25 patients discharged from the hospital 21 treated by endoscopy and two treated with surgery were followed up for a mean of 28.3 and 22.5 months, respectively. Twenty endoscopically treated patients (95%) had no recurrence of Dieulafoy's bleeding. One patient experienced severe rebleeding from the original site after a transient endoscopy confirmed complete disappearance. He had emergency operation without a further attempt to control bleeding by endoscopy. It is concluded that bleeding from Dieulafoy's disease can be successfully managed by endoscopic injection treatment. The longterm outcome is favourable.
In 277 consecutive episodes of suspected upper gastrointestinal bleeding, lesions bearing stigmata of recent haemorrhage (stigmata) were found by endoscopy in 110 (47%) out of 233 patients who were judged to have bled; 78 (33%) had lesions without stigmata, and in 45 (19%) no lesion was seen. Results in 176 entirely unselected admissions for upper gastrointestinal bleeding were similar.
Forty-eight chronic duodenal and 41 chronic gastric ulcers were identified by endoscopy. Stigmata were found in 27 (56%) and 33 (80%) of these cases respectively. Sixteen patients had multiple lesions, and in 12 (75%) the presence of stigmata permitted diagnosis of the source of the haemorrhage. Stigmata were more likely to be seen in cases of duodenal ulcer, Mallory-Weiss lesions, and oesophageal varices when endoscopy was performed within 12 hours of bleeding, but were as common in cases of gastric ulcer after longer intervals.
In the absence of stigmata one out of 21 patients with duodenal ulcer had further haemorrhage and one other needed emergency surgery; no patient with gastric ulcer had further haemorrhage or needed emergency surgery. In contrast, when stigmata were present 15 of the 27 patients with duodenal ulcer (56%) had further haemorrhage and 17 (63%) needed emergency surgery; of the 33 patients with gastric ulcer, 10 (30%) had further haemorrhage and 15 (45%) required emergency surgery. Superficial mucosal lesions may have been the source of haemorrhage when an ulcer unmarked by stigmata was seen at endoscopy. Stigmata were superior to any other single factor or combination of factors in predicting rebleeding and the need for emergency surgery.
Gastrojejunostomy stricture after Roux-en-Y gastric bypass occurs in 3 to 27% of morbidly obese patients in the USA. We questioned whether preoperative patient characteristics, including demographic attributes and comorbid disease, might be significant factors in the etiology of stricture. In this study from November 2001 to February 2006 (51 months), at a high-volume bariatric center, of the 1,351 patients who underwent laparoscopic gastric bypass, 92 developed stricture (6.8%). All but two were treated successfully by endoscopic dilation. All patients stopped nonsteroidal anti-inflammatory medications 2 weeks prior to surgery and did not restart them. The operative procedure included the use of a 21-mm transoral circular stapler to create the gastrojejunostomy; the Roux limb was brought retrogastric, retrocolic. In an effort to reduce our center’s stricture rate, late in the study, U-clips used at the gastrojejunostomy were replaced by absorbable sutures, and postoperative H2 antagonists were added to the treatment protocol. The change to absorbable polyglactin suture proved to be significant, resulting in a lower stricture rate. The addition of H2 antagonists showed no significant effect. Following the retrospective review of the prospective database, univariate and multivariate logistic regression analyses identified factors associated with the development of stricture. Gastroesophageal reflux disease and age were each shown to be statistically significant independent predictors of stricture following laparoscopic gastric bypass.
Obesity; Bariatric surgery; Stricture; Gastric bypass; Gastrojejunostomy
Morbid obesity, a physiological dysfunction in humans associated with environmental, genetic and endocrinological origins, has significantly increased in the past few decades in the USA. Many methods have emerged for treating morbid obesity, such as diets, exercise, behavior modification, liposuction, drugs, and surgery; among these, bariatric surgery reduces weight and appears to have other curative effects. Roux-en-Y gastric bypass is the principal form of bariatric surgery, followed by laparoscopic adjustable gastric banding, gastric sleeve operation, duodenojejunal bypass and biliopancreatic diversion. This weight-loss surgery may also affect comorbidities of morbid obesity, such as type 2 diabetes mellitus (T2D), atherosclerosis, hypertension and steatohepatitis. Weight-loss surgery, for example, is associated with a more than 80% diabetes (data indicates > 80%) remission rate in severely obese persons. Empirical evidence also suggests that the use of bariatric surgery reduces atherosclerosis, and may ameliorate other comorbities. This warrants closer examination.
bariatric surgery; atherosclerosis; morbid obesity; diabetes mellitus