Internal post-bariatric hernia due to hepatic adhesion: a case report

ABSTRACT Roux-en-Y gastric bypass, a procedure proven effective for treating morbid obesity and metabolic disorders, carries the risk of complications such as the formation of internal hernias. These hernias are often difficult to diagnose and can be potentially fatal because they can cause structural obstruction. Most internal hernias occur in the jejunojejunostomy mesentery space, followed by Petersen's space hernias, although herniation at other locations can also occur. Our case report presents an example of a rare internal hernia after laparoscopic Roux-en-Y gastric bypass. A 36-year-old woman presented with an uncommon internal hernia located between the liver and alimentary loop, resulting in the formation of a new space and consequently incarcerating the entire biliopancreatic loop. This type of internal hernia is rare and has not been reported in the literature, indicating that this is the first report of such a case. In this case, we realized that the diagnosis was challenging and imaging examinations could not help determine the etiology of the pain and obstruction. Therefore, videolaparoscopy revealed an uncommon hernia formed by firm adhesion between the hepatic segment III and the alimentary loop mesentery. Our case is an example of an internal hernia that was not detected with a normal computed tomography scan of the abdomen and pelvis. Only diagnostic laparoscopy revealed herniation, effectively preventing further complications for the patient.

Comparison of endoscopic retrograde cholangiopancreatography assisted with colonoscope and enteroscope in patients with history of Roux-en-Y anastomosis (with video) / 中华消化内镜杂志

Objective:To compare the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) assisted with colonoscope and enteroscope in patients with history of Roux-en-Y anastomosis.Methods:A retrospective study was performed on the data of 70 patients who underwent ERCP assisted with standard colonoscope or single balloon enteroscope after Roux-en-Y reconstruction in Hangzhou Hospital Affiliated to Nanjing Medical University from January 2017 to December 2020. Patients were divided into the standard colonoscopy group ( n=43) and the single balloon enteroscopy group ( n=27) according to endoscopy. The success rates of insertion, intubation and ERCP, and incidence of complications were compared. Results:A total of 81 ERCP procedures were performed in 70 patients. The insertion success rates of the standard colonoscopy group and the single balloon enteroscopy group were 91.8% (45/49) and 78.1% (25/32), respectively, showing no significant difference ( χ2=2.04, P=0.153). The success rates of primitive papilla intubation in the two groups were 74.1% (20/27) and 1/6, showing significant difference ( P=0.016). The ERCP success rates of the standard colonoscopy group and the single balloon enteroscopy group were 75.5% (37/49) and 59.4% (19/32), showing no significant difference ( χ2=2.36, P=0.124). The post operative complication incidences of the standard colonoscopy group and the single balloon enteroscopy group were 4.1% (2/49) and 9.4% (3/32), showing no significant difference ( χ2=0.25, P=0.620). Conclusion:ERCP assisted with standard colonoscope and single balloon enteroscope is safe and effective in patients after Roux-en-Y anastomosis. Standard colonoscopic ERCP can become an endoscopy solution for patients with biliary tract disease after Roux-en-Y reconstruction.

Advances in the treatment of iatrogenic bile duct injury / 临床肝胆病杂志

Iatrogenic bile duct injury (IBDI) refers to bile duct injury accidentally caused by medical factors such as surgical operation or other invasive operations during treatment. With the gradual maturity of surgical operation and minimally invasive techniques, the treatment of bile duct injury now includes endoscopic treatment, bile duct jejunum Roux-en-Y anastomosis, bile duct end-to-end anastomosis, hepatectomy, and liver transplantation. For IBDI, the selection of reasonable and effective treatment methods is currently an important and difficult issue in biliary surgery. Through a systematic review of the literature on the treatment of IBDI, this article analyzes and summarizes the different treatment modalities for IBDI.

Endoscopic negative pressure therapy for the closure of an esophagojejunal anastomosis fistula. Case report / Terapia endoscópica de presión negativa para cierre de fístula de la anastomosis esófago-yeyunal. Reporte de caso

Abstract Introduction: Post-surgical esophagojejunal anastomosis fistulas can be life-threatening. Currently, there are several treatment alternatives. In recent years, endoscopic negative pressure therapy has emerged as an innovative treatment for these fistulas, offering numerous benefits. Case presentation: A 72-year-old man diagnosed with gastric adenocarcinoma of the body and fundus underwent total gastrectomy with D2 lymphadenectomy and Roux-en-Y anastomosis with curative intent in a quaternary care hospital in Popayán, Colombia. However, in the postoperative period, he presented systemic inflammatory response syndrome and acute abdomen due to an esophagojejunal fistula. Initial management included a laparotomy, two peritoneal washings, and an abdominal drainage. Then the patient developed frozen abdomen, so it was not possible to access the esophagojejunal anastomosis. Fistula closure was attempted by inserting a self-expandable metallic stent, yet the procedure was not successful. Salvage therapy was started using an endoscopic vacuum-assisted closure (VAC) system. After 5 replacements of the VAC system, complete drainage of the intra-abdominal collection, complete closure of the peritoneal cavity, and closure of the esophagojejunal leak, with a small residual diverticular formation, were achieved. The patient's condition improved progressively, resuming oral intake 20 days after initiation of VAC therapy. In addition, no new abdominal complications were reported during the follow-up period (17 months). Conclusions: Endoscopic VAC therapy is a new safe and effective alternative to treat complex post-surgical fistulas caused by esophagojejunal anastomosis.

Resumen Introducción. Las fístulas de las anastomosis esófago-yeyunales postquirúrgicas pueden llegar a ser mortales. En la actualidad, existen varias alternativas de tratamiento, y en los últimos años la terapia endoscópica de presión negativa se ha convertido en un método innovador y con grandes ventajas para el manejo de estas fístulas. Presentación del caso. Hombre de 72 años diagnosticado con adenocarcinoma gástrico de cuerpo y fondo a quien se le realizó una gastrectomía total con linfadenectomía D2 y una anastomosis en Y de Roux con intención curativa en un hospital de cuarto nivel en Popayán, Colombia. Sin embargo, en el posoperatorio presentó síndrome de respuesta inflamatoria sistémica y abdomen agudo producto de fístula esófago-yeyunal. Se realizó manejo inicial con laparotomía, dos lavados de cavidad peritoneal y drenaje abdominal. Posteriormente, el paciente desarrolló abdomen congelado, por lo que no fue posible acceder a la anastomosis esófago-yeyunal. Se intentó cierre de fístula mediante la inserción de prótesis metálica autoexpandible, pero el procedimiento no fue exitoso. Se inició terapia de rescate mediante sistema de cierre asistido por vacío (VAC) por vía endoscópica. Luego de 5 recambios del sistema VAC, se logró el drenaje completo de la colección intraabdominal encontrada, el cierre completo de la cavidad peritoneal y el cierre de la fuga esófago-yeyunal, con una pequeña formación diverticular residual. La condición del paciente mejoró progresivamente, con reinicio de la vía oral a los 20 días del inicio de la terapia VAC. Además, no se reportaron nuevas complicaciones abdominales en el periodo de seguimiento (17 meses). Conclusión. La terapia endoscópica de VAC es una nueva alternativa segura y efectiva para el tratamiento de fístulas postquirúrgicas complejas producto de anastomosis esófago-yeyunales.

Safety and efficacy of roux-en-y gastric bypass in older aged patients / Segurança e eficácia do bypas gástrico em Y de Roux em pacientes idosos

ABSTRACT Introduction: laparoscopic Roux-en-Y Gastric Bypass (LRYGB) has been a revolutionary intervention for weight loss with reduction of up to 60-70% of excess body weight. However, these outcomes are not as well validated at the extremes of age, where the safety of the intervention still has some caveats. The aim of this study is to assess the efficacy and safety of primary LRYGB among different age groups. Methods: the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was queried for patients who underwent primary LRYGB from January 2014 to December 2017 at a single institution. Four groups were created and compared by dividing our sample by age quartiles. The primary outcome was percent excess weight loss (%EWL) at 1 year. Additional operative outcomes and complications were also compared across groups. Results: a total of 1013 patients underwent non-revisional LRYGB during the study period. Mean %EWL at one year was 55%. When compared between quartiles, there was a statistically significant difference in %EWL: 1st 62%, 2nd 57%, 3rd 54% and 4th 47% (p=0.010). The differences in the secondary outcomes between age groups did not demonstrate statistical significance. Conclusions: though patients in the fourth age quartile (range) did not demonstrate a statistically significant increase in adverse outcomes, they did lose less weight compared to other cohorts. The %EWL at one year after RYGB varied by age in our cohort. Goals after bariatric surgery should be individualized as weight loss is less robust with aging.

RESUMO Introdução: o Bypass Gástrico Laparoscópico em Y de Roux (LRYGB) tem sido uma intervenção revolucionária para perda de peso com redução de até 60-70% do excesso de peso corporal. No entanto, esses resultados não são tão bem validados nos extremos de idade, onde a segurança da intervenção ainda possui algumas ressalvas. O objetivo deste estudo é avaliar a eficácia e segurança do LRYGB entre diferentes faixas etárias. Métodos: O banco de dados do Programa de Acreditação e Melhoria da Qualidade da Cirurgia Metabólica e Bariátrica (MBSAQIP) foi consultado para pacientes submetidos a LRYGB de janeiro de 2014 a dezembro de 2017 em uma única instituição. Quatro grupos foram criados e comparados dividindo a amostra por quartis de idade. O desfecho primário foi perda percentual de excesso de peso (%EWL) em 1 ano. Resultados: 1013 pacientes foram submetidos a LRYGB durante o período do estudo. A média de %EWL em um ano foi de 55%. Quando comparados entre os quartis, houve diferença significante no %EWL: 1º 62%, 2º 57%, 3º 54%, e 4º 47% (p=0,010). As diferenças nos desfechos secundários entre as faixas etárias não demonstraram significância estatística. Conclusões: embora os pacientes no quarto quartil de idade não tenham demonstrado um aumento estatisticamente significativo nos resultados adversos, eles perderam menos peso em comparação com outras coortes. O %EWL um ano após RYGB variou de acordo com a idade em nossa coorte. Os objetivos após a cirurgia bariátrica devem ser individualizados, pois a perda de peso é menos robusta com o envelhecimento.

A retrospective study on combined percutaneous transhepatic one-step biliary fistulation followed by two stages cholangioscopic treatment for type Ⅰ and Ⅱa hepatolithiasis after cholangiojejunostomy / 中华肝胆外科杂志

Objective:To study the treatment outcomes of combining percutaneous transhepatic one-step biliary fistulation (PTOBF) followed by two stages cholangioscopic treatment for type Ⅰ and Ⅱa hepatolithiasis which developed after Roux-en-Y cholangiojejunostomy, and in treatment of cholangiojejunostomy stenosis.Methods:The clinical data of 95 patients with type Ⅰ and Ⅱa hepatolithiasis which developed after Roux-en-Y cholangiojejunostomy and were treated at Shandong Second Provincial General Hospital from September 2016 to December 2020 were analyzed retrospectively. There were 36 males and 59 females, with the age of (51.2±15.3) years (range 14 to 75 years). These patients initially underwent PTOBF rigid choledochoscopy, followed by electronic choledochoscopy via the fistula tract after 6-8 weeks. The hepatolithiasis removal, complications and hepatolithiasis recurrence rates, and the cholangio-intestinal anastomotic stenosis rate and treatments were recorded. The follow-up was performed to analyse prognosis.Results:All 95 patients successfully underwent PTOBF rigid choledochoscopy and electronic choledochoscopy via the fistula tract. In 92 patients (96.8%), stones were completely removed. In 3 patients, small amounts of peripheral bile duct stones were left behind. Of 49 patients had cholangio-intestinal anastomotic strictures. On cholangioscopic examination, the strictures were caused by anastomotic knots in the suture line in 25 patients and cicatricial stenosis in 24 patients. After biliary balloon dilation and removal of anastomotic suture line knots, the strictures were relieved in 49 patients. There were 2 patients who developed biliary bleeding and 2 patients pleural effusion after PTOBF rigid choledochoscopy. Hepatolithiasis recurred in 4 patients in 6 to 36 months later.Conclusion:PTOBF followed by two stages cholangioscopic treatment were safe and effective in treatment of type Ⅰ and Ⅱa hepatolithiasis after Roux-en-Y cholangiojejunostomy. A high hepatolithiasis removal rate was obtained. Balloon dilation and removal of biliary intestinal anastomotic suture knots effectively relieved biliary intestinal anastomotic stenosis. The long-term results needs to be further determined.

Overlap esophagojejunostomy with multi-mode modifications in totally laparoscopic total gastrectomy: safety and feasibility of 152 cases from a single center / 中华胃肠外科杂志

Objective: Currently, the Overlap anastomosis is one of the most favored reconstruction methods of intracorporeal esophagojejunostomy (EJS). Despite many advantages of the method, it remains some shortcomings to be improved when it comes to the retraction of the esophagus stump, the insertion of the anvil fork of the linear stapler into a "pseudo" lumen, and the closure of the common entry hole. This study aims to investigate the safety and feasibility of a multi-mode modified Overlap anastomosis. Methods: A descriptive case series study was conducted. Medical records of 152 consecutive patients who underwent totally laparoscopic total gastrectomy (TLTG) with our multi-mode modified Overlap EJS method by the same surgical team at our department from February 2017 to June 2020 were retrospectively analyzed. The multi-mode modified Overlap method mainly included (1) After ensuring the safety of tumor resection margin (proximal margin was at least 3 cm from the tumor), the esophagus was partially transected from left to right (with 5-8 mm width esophagus continuation). The specimen was then placed in a plastic bag which was tied up at the mouth using strings with a part of the esophageal wall poking through. Then the plastic bag containing the specimen was transferred to the right lumbar region, while the patient's body position was adjusted so that the abdominal esophagus could be pulled by the gravity of the specimen. (2) Using the "three-direction traction" method. The esophageal lumen was properly exposed, then guided by the gastric tube, the anvil fork was accurately placed into the esophageal lumen for completing the side-to-side EJS. (3) The 3-0 barbed suture was used in the closure of the common entry hole of the stapler from dorsally to ventrally with simple one-layer continuous suture (the stitch going from inside to inside) followed by continuous Lembert's suture (the stitch going from outside to outside). Combined with clinicopathological characteristics, the perioperative outcomes and postoperative complications of the whole group were analyzed and evaluated. Results: The study cohort included 129 men and 23 women, with a mean age of (60.2±9.1) years and a mean body mass index (BMI) of (23.2±3.1) kg/m(2). Of the 152 patients, 23 patients (15.1%) had a history of previous abdominal surgery; dentate line was invaded by tumor in 21 patients (13.8%). The mean length of the proximal resection margin was (3.3±0.3) cm and the postoperative pathological examination indicated negative resection margin tumor. The mean operative time and anastomotic time were (302.1±39.9) minutes and (29.8±5.4) minutes, respectively. The mean estimated blood loss was (87.9±46.4) ml. The mean length of postoperative hospital stay was (12.3±7.3) days. The overall severe postoperative complications (Clavien-Dindo ≥ II) occurred in 22 patients (14.5%). Six cases of pancreatic leakage were successfully recovered by adequate drainage, inhibition of pancreatic exocrine secretion and nutritional support. Ten cases of pneumonia and three cases of abdominal infection were cured with anti-infection and physical therapy. Two patients developed anastomotic leakage postoperatively. One case was caused by excessive tension of the Roux loop of the jejunum and excessive opening on the side of the jejunum after side-to-side anastomosis, and the other case was caused by an accidental intraoperative occurrence of "nasogastric tube stapled to the side-to-side anastomosis". Both of them recovered after conservative treatment including adequate drainage, anti-infection, and adequate nutritional support. One patient underwent immediate open surgery because of Peterson's hernia 7 days after TLTG, and the patient died due to extensive small bowel necrosis. Conclusions: Multi-mode modified overlap method simplifies the operation and reduces the difficulty of EJS. It is a safe and feasible method for EJS.

Perda de peso e o comprimento do intestino delgado na cirurgia de fobi-capella: há relação? / Weight loss and the length of the small intestine in the fobi-capella surgery: is there a relationship?

RESUMO - RACIONAL: Os fatores relacionados à perda de peso nos pacientes obesos submetidos à cirurgia bariátrica sempre foram exaustivamente estudados na tentativa de propor a melhor técnica cirúrgica com maior perda de peso e resolução as comorbidades à longo prazo. Os pacientes apresentam variações anatômicas no que tange o comprimento do intestino delgado. Há estudos que demonstram alterações de peso nos pacientes que apresentam diferentes comprimentos das alças intestinais na técnica do by-pass em Y de Roux. O presente trabalho realizou um estudo entre a influência do IMC, a perda de peso e o comprimento da alça comum nos resultados cirúrgicos à longo prazo. MÉTODOS: Estudo transversal descritivo pela análise retrospectiva de 112 prontuários de pacientes submetidos à cirurgia bariátrica aberta pela técnica do bypass gástrico no Hospital de Clínicas -UFPR. Os dados foram correlacionados em programas estatísticos para este fim. RESULTADOS: Dos 112 pacientes, 83,03% eram do sexo feminino, média de idade de 41,52 anos. O comprimento médio do intestino delgado total dos pacientes foi de 5,02 metros. Houve uma relação diretamente proporcional entre o comprimento do intestino delgado e a perda de peso (p=0,0428). CONCLUSÃO: Há uma ampla gama de variáveis relacionadas à perda de peso nos pacientes submetidos à cirurgia bariátrica, tais como a técnica utilizada, o comprimento das alças no by-pass gástrico em Y de Roux e a rotina de acompanhamento nutricional e físico do paciente. É importante considerar os detalhes técnicos do procedimento cirúrgico, e verificar a perda de peso avaliando-se o paciente como um todo e outras variáveis.

ABSTRACT - BACKGROUND: Factors related to weight loss in obese patients undergoing bariatric surgery have always been exhaustively studied in an attempt to propose the best surgical technique with greater weight loss and long-term resolution of comorbidities. Patients present anatomical variations regarding the length of the small intestine. Some studies demonstrate weight changes in patients with different lengths of the intestinal loops in the Roux-en-Y bypass technique. The present work carried out a study on the influence of body mass index, weight loss, and common loop length on long-term surgical outcomes. METHODS: This is a descriptive cross-sectional study by retrospective analysis of 112 medical records of patients undergoing open bariatric surgery using the gastric bypass technique at University Hospital - UFPR. The data were correlated in statistical programs for this purpose. RESULTS: Out of 112 patients, 83.03% were women, with mean age of 41.52 years. The mean length of the total small bowel of the patients was 5.02 m. There was a directly proportional relationship between the length of the small intestine and weight loss (p=0.0428). CONCLUSION: There is a wide range of variables related to weight loss in patients undergoing bariatric surgery, such as the technique used, the length of the loops in the Roux-en-Y gastric bypass, and the routine of nutritional and physical monitoring of the patient. It is important to assess the technical details of the surgical procedure and to verify the weight loss by evaluating integrally the patient and other variables.

Is the waist/height ratio a better parameter than bmi in determining the cardiometabolic risk profile of obese people? / A razão cintura/estatura é melhor parâmetro que o imc na determinação do perfil de risco cardiometabólico dos obesos?

ABSTRACT Background: The increased prevalence of obesity has led to a significant increase in the occurrence of metabolic syndrome, a recognized risk factor for increased morbidity and mortality from cardiovascular diseases. Hyperglycemia or type 2 diabetes mellitus, dyslipidemia and arterial hypertension are its main components. Since 2015, international guidelines have recognized the benefits of bariatric surgery in each isolated factor of this syndrome. Aim: To evaluate the impact of Roux-en-Y gastric bypass in this syndrome comparing pre- and postoperative periods with laboratory analysis and to compare waist/height ratio and BMI in relation to the determination of the cardiometabolic risk profile. Methods: A retrospective study was carried out, selecting 80 patients undergoing Roux-en-Y gastric bypass. Total cholesterol, HDL, LDL, triglycerides, fasting glucose, glycated hemoglobin, insulin, body mass index (BMI), vitamin D, vitamin B12, waist circumference and waist/height ratio in three periods were analyzed: the preoperative period from 1 to 6 months, postoperative from 1 to 6 months and postoperative from 1 to 2 years. Results: There was an improvement in all parameters of the clinical analyses. The preoperative BMI had a mean value of 39.8, in the preoperative period from 1 to 6 months, the values ​​dropped to 33.2 and in the postoperative period of 1 year, the mean was 26. The perimeter mean values ​​of 118.5 preoperatively, 105.2 postoperatively from 1 to 6 months and 90.3 postoperatively from 1 to 2 years. Waist/height ratio was 0.73, 0.65 and 0.56 in pre, post 1 to 6 months and 1 to 2 years respectively. Conclusion: Roux-en-Y gastric bypass improves metabolic syndrome and waist-to-height ratio is superior to BMI in the assessment of the cardiometabolic risk profile.

RESUMO Racional: O aumento da prevalência da obesidade levou ao aumento significativo da ocorrência de síndrome metabólica, fator de risco reconhecido para aumento da morbimortalidade por doenças cardiovasculares. A hiperglicemia ou diabetes mellitus do tipo 2, dislipidemia e hipertensão arterial são seus principais componentes. Desde 2015, diretrizes internacionais reconheceram os benefícios da cirurgia bariátrica em cada fator isolado desta síndrome. Objetivos: Avaliar o impacto do bypass gástrico em Y-de-Roux nesta síndrome comparando períodos pré e pós-operatório com análise laboratorial, e comparar a razão cintura/estatura e o IMC em relação a determinação do perfil de risco cardiometabólico. Métodos: Realizou-se um estudo retrospectivo com base prospectiva selecionando 80 pacientes submetidos à bypass gástrico em Y-de-Roux. Foram analisados o colesterol total, HDL, LDL, triglicerídeos, glicemia de jejum, hemoglobina glicada, insulina, índice de massa corpórea (IMC), vitamina D, vitamina B12, perímetro abdominal e relação cintura/estatura em três períodos: o pré-operatório de 1 a 6 meses, pós-operatório de 1 a 6 meses e pós-operatório de 1 a 2 anos. Resultados: Houve melhora em todos os parâmetros das análises clínicas. O IMC, no pré-operatório, teve a média dos valores de 39,8, no pré-operatório de 1 a 6 meses, os valores caíram para 33,2 e no pós-operatório de 1 ano média foi de 26. O perímetro abdominal teve média dos valores de 118,5, no pré-operatório, 105,2 no pós-operatório de 1 a 6 meses e 90,3 no pós-operatório de 1 a 2 anos. A relação cintura/estatura teve 0,73, 0,65 e 0,56 no pré, pós 1 a 6 meses e 1 a 2 anos respectivamente. Conclusão: O bypass gástrico em Y-de-Roux melhora a síndrome metabólica e a relação cintura/estatura é superior ao IMC na avaliação do perfil do risco cardiometabólico.

Safety and effectiveness of laparoscopic Y-en-Roux gastric bypass surgery in obese elderly patients

Abstract Purpose To analyze, in aged obese patients, the weight loss, comorbidity control, and safety postoperative complications of bariatric surgery by Roux-en-Y gastric bypass technique. Methods Twenty-seven patients who underwent laparoscopic weight-reducing gastroplasty with Roux-en-Y gastric bypass to treat obesity were included. All patients were ≥ 60 years old at the time of surgery. The Wilcoxon test was used for statistical analysis, and a p-value ≤0.05it was considered significant. Results Ten (90.9%) patients with dyslipidemia were cured (p < 0.001). Nine (81.8%) patients with type 2 diabetes mellitus had total improvement and 2 (18.2%) had partial improvement (p = 0.003). In 23 patients with systemic arterial hypertension, 9 (39.1%) achieved total improvement and 14 (60.9%) partial improvement (p = 0.140). Five (71.4%) patients with obstructive sleep apnea syndrome were cured (p = <0.001). For other comorbidities, no partial improvement or cure was shown. Conclusions Roux-en-Y gastric bypass surgery in obese elderly patients can be performed safely and with low morbidity and mortality rates. The benefits of weight loss and reduced comorbidities are promising and like those of the younger population.

Detalles técnicos de la doble anastomosis hepático-yeyuno en Y de Roux, con base en la descripción de un caso / Technical details of double Roux-en-Y hepaticojejunostomy based on a clinical case description

La anastomosis hepático-yeyuno en Y de Roux se considera la técnica de elección para tratar lesiones quirúrgicas de la vía biliar, como su sección o resección. La pérdida de confluencia de los conductos hepáticos principales derecho e izquierdo es uno de los factores que incrementan la complejidad técnica durante el procedimiento y, en algunos de estos pacientes, se requiere una doble anastomosis hepático-yeyuno para garantizar resultados satisfactorios a largo plazo. Se describen los aspectos técnicos y los resultados posoperatorios del tratamiento quirúrgico empleado, con base en la intervención de una paciente con una lesión quirúrgica de la vía biliar y pérdida de la confluencia de los conductos hepáticos. La evolución de la paciente fue satisfactoria y se mantiene asintomática después de 12 meses de seguimiento. A pesar de ser una técnica compleja, la doble anastomosis hepático-yeyuno en Y de Roux resultó una opción segura de tratamiento en esta paciente

Roux-en-Y hepato-jejunostomy (RYHJ) is the technique of choice for the surgical treatment of bile duct injuries (BDI), such as section or resection. The loss of the hepatic confluence (LHC) increases the technical difficulties during the procedure and, in some of these patients, a doble-RYHJ is required to achieve a long term successful result. We report the technical aspects of the surgical technique as well as the results, based on the case of a young female patient with BDI and LHC. The patient shows a satisfactory evolution and remains asymptomatic during the 12 months of follow up. Double RYHJ, although technically demanding, resulted a safe option for treating this patient

Diagnosis and treatment of Roux and Y space hernia after Roux-en-Y gastric bypass surgery for gastric cancer patients: a clinical analysis of 12 cases / 中华全科医师杂志

Clinical data of 12 patients with gastric cancer, in whom the Roux and Y space hernia developed after gastrectomy with Roux-en-Y anastomosis in our hospital from June 2010 to December 2018, were retrospectively analyzed. The clinical symptoms of patients were abdominal pain, distension and ileus. The main CT findings were torsion of mesentery with whirlpool sign, intestinal obstruction and exudants around the small bowels. During the operation it was found that small bowels herniated into the Roux and Y space in all 12 patients, the necrotic small intestines were resected in 4 patients. Ten patients were recovered, and 2 died. No recurrence was observed in all 10 patients during 3 month-follow up. The postoperative Roux and Y space hernia is a internal hernia and difficult to be diagnosed. The CT scan is valuable for diagnosis of Roux and Y space hernia; the main CT signs were swirled appearance of mesentery and small bowel obstruction. Once diagnosis is made the emergency operation is necessary.

Diagnosis and treatment of Roux and Y space hernia after Roux-en-Y gastric bypass surgery for gastric cancer patients: a clinical analysis of 12 cases / 中华全科医师杂志

Clinical data of 12 patients with gastric cancer,in whom the Roux and Y space hernia developed after gastrectomy with Roux-en-Y anastomosis in our hospital from June 2010 to December 2018,were retrospectively analyzed.The clinical symptoms of patients were abdominal pain,distension and ileus.The main CT findings were torsion of mesentery with whirlpool sign,intestinal obstruction and exudants around the small bowels.During the operation it was found that small bowels herniated into the Roux and Y space in all 12 patients,the necrotic small intestines were resected in 4 patients.Ten patients were recovered,and 2 died.No recurrence was observed in all 10 patients during 3 month-follow up.The postoperative Roux and Y space hernia is a internal hernia and difficult to be diagnosed.The CT scan is valuable for diagnosis of Roux and Y space hernia;the main CT signs were swirled appearance of mesentery and small bowel obstruction.Once diagnosis is made the emergency operation is necessary.

Esophagojejunal Anastomosis after Laparoscopic Total Gastrectomy for Gastric Cancer: Circular versus Linear Stapling

PURPOSE: No standard technique has been established for esophagojejunal anastomosis during laparoscopic total gastrectomy (LTG) for gastric cancer owing to the technical difficulty and high complication rate of this procedure. This study was performed to compare the short-term outcomes of circular and linear stapling methods after LTG. MATERIALS AND METHODS: A total of 106 patients treated between July 2010 and July 2018 were divided into 2 groups according to the following anastomosis procedures: hemi-double-stapling technique (HDST; circular stapling method; group C, n=77) or overlap method (linear stapling method; group L, n= 29). The clinicopathological features and postoperative outcomes, including complications, were analyzed. Multivariate analysis was performed using a logistic regression model to identify the independent risk factors for anastomotic complications. RESULTS: The incidence of anastomotic complications was significantly higher in group C than in group L (28.0% vs. 6.9%, P=0.031). The incidence of anastomosis leakage did not differ between the groups (6.5% vs. 6.9%, P=1.000). However, anastomosis stricture occurred only in group C (13% vs. 0%, P=0.018). Multivariate analysis showed that the anastomosis type was significantly related to the risk of anastomotic complications (P=0.045). CONCLUSIONS: The overlap method was superior to the HDST with respect to anastomotic complications, especially anastomosis stricture.

Total laparoscopic distal gastrectomy for gastric cancer: uncut Roux-en-Y anastomosis versus Billroth Ⅱ anastomosis / 中华全科医师杂志

Objective To compare the advantages and disadvantages between Uncut Roux-en-Y anastomosis and Billroth Ⅱ anastomosis in total laparoscopic distal gastrectomy (TLDG) for gastric cancer.Methods The clinical data of 132 patients with distal gastric cancer,who underwent TLDG with Uncut Roux-en-Y anastomosis or Billroth Ⅱ anastomosis in the Affiliated Hospital,Medical School of Ningbo University from February 2015 to December 2017,were retrospectively analyzed.There were 52 patients receiving TLDG with uncut Roux-en-Y anastomosis (RA group) and 80 patients receiving TLDG with Billroth Ⅱ anastomosis (BA group).Results Compared with BA group,the RA group had a longer operation time [(240.6±49.6)min vs.(202.2±36.4)min,F=2.356,P =0.000]and anastomosis time[(49.1 ±5.9)min vs.(47.3±4.2)min,F=4.45,P =0.043],more intraoperative blood loss[(128.9 ± 130.0)ml vs.(79.2 ± 62.5)ml,F=5.66,P =0.004];and short times to first flatus[(2.7±0.8)d vs.(3.0±0.6)d,F=6.61,P =0.031],for liquid diet[(3.7±0.8)d vs.(4.0 ± 0.6)d,F=7.35,P=0.022] and semifluid diet[(4.7 ± 0.8)d vs.(5.0 ± 0.6)d,F=6.43,P=0.013].No perioperative death occurred in two groups;there were no significant differences in length of postoperative hospital stay [(9.4±4.2)d vs.(l0.9±6.4)d,F=0.83,P =0.117]and the incidence of postoperative complication [5.8％(3/52) vs.8.8％(7/80),x2=0.40,P =0.527)].Compared to BA group,alkaline reflex gastritis rate [3.8％(2/52) vs.52.5％(42/80),x2=40.04,P =0.000]and marginal ulcer rate were lower[0(0/52) vs.11.3％(9/80),x2=6.28,P =0.012].There was no significant difference in dumping syndrome rate[0(0/52) vs.3.8％(3/80),x2=0.20,P=0.158] between two groups.Conclusion Uncut Roux-en-Y anastomosis can prevent alkaline reflex gastritis,marginal ulcer and Roux-en-Y stasis syndrome,it may be the preferable technique for reconstruction after total laparoscopic distal gastrectomy.

Choledochal cyst in the pediatric population: experience of 13 laparoscopic procedures in two years at a single institution / Cisto de colédoco na população pediátrica: experiência de 13 procedimentos laparoscópicos em dois anos de uma única instituição

ABSTRACT Objective: to describe the first 13 cases of laparoscopic correction of common bile duct cyst in the Pequeno Príncipe Hospital, Curitiba, Paraná, Brazil. Methods: we performed a retrospective analysis of medical records of cases of choledochal cyst operated by laparoscopy between March 2014 and September 2016. Results: of the 13 patients, eight were female and the mean age at surgery was 7.8 years. The most common symptom was abdominal pain. The hepaticoduodenal anastomosis was the most used reconstruction technique, in 84.6% of the cases. There was no conversion to laparotomy or intraoperative complications. Only one patient presented anastomotic fistula and was reoperated by laparotomy. All patients were followed up in an outpatient clinic, were asymptomatic and had no episode of cholangitis after surgery, with a mean follow-up of 16 months. Conclusion: laparoscopy is a safe method to correct choledochal cysts, even in younger children, with low rates of complications and low rates of conversion to open surgery when performed by well trained surgeons.

RESUMO Objetivo: descrever os primeiros 13 casos de correção laparoscópica de cisto do ducto biliar comum no Hospital Pequeno Príncipe, Curitiba, Paraná, Brasil. Métodos: análise retrospectiva dos registros médicos em prontuário dos casos de cisto de colédoco operados por via laparoscópica entre março de 2014 e setembro de 2016. Resultados: dos 13 pacientes, oito eram do sexo feminino e a média de idade na ocasião da cirurgia foi de 7,8 anos. O sintoma mais comum foi dor abdominal. A anastomose hepático-duodenal foi a técnica de reconstrução mais utilizada, em 84,6% dos casos. Não houve conversão para laparotomia ou complicações intraoperatórias. Apenas um paciente apresentou fístula da anastomose e foi reoperado por laparotomia. Todos permanecem em acompanhamento ambulatorial, com tempo de seguimento médio de 16 meses, assintomáticos e não apresentaram episódio de colangite após a cirurgia. Conclusão: a laparoscopia é um método seguro para correção dos cistos de colédoco, mesmo em crianças mais jovens, com baixas taxas de complicações e baixas taxas de conversão para cirurgia aberta quando realizada por cirurgiões com bom treinamento.

Impact of bariatric surgery on the inflammatory state based on cpr value / Impacto da cirurgia bariátrica no estado inflamatório baseado no valor da pcr

ABSTRACT Background: PCR (C-reactive protein), produced in the liver after stimuli of inflammatory mediators, is determined as a marker of inflammatory activity (adipocytokines) and is present within adipocyte cells; besides being an inflammatory product, many studies have shown to be a predictor of complications. Aim: To determine if the inflammatory state of the obese patient decreases after bariatric surgery, based on pre and post-operative PCR. Methods: A prospective, observational study in patients undergoing Roux-en-Y gastric by-pass surgery followed up for three months after surgery, with serum preoperative CRP in 30, 60 and 90 days after surgery. Results: A total of 19 patients, who had a mean CRP value before the surgical procedure of 0.80(±0.54) mg/dl, were followed, and when compared to the CRP with 30 days of surgery, they presented a significant increase to 2.68 mg/dl (p=0.012). When compared with the PCR of 60 days after the surgical procedure, it was also higher with the value of 3.32 mg/dl (p=0.27). However, at three months after surgery, the CRP showed a decrease when compared to the preoperative mark, with value of 0.45 mg/dl (p=0.0042). Conclusion: Roux-en-Y gastric bypass was able to decrease the chronic inflammation status of these patients, based on the value of CRP, with three months of surgery.

RESUMO Racional: PCR (proteína C-reativa) produzida no fígado após estímulos de mediadores inflamatórios é determinada como um marcador de atividade inflamatória (adipocitocinas) e está presente nos adipócitos; além de ser um produto inflamatório, muitos estudos já mostraram ser ela um preditor de complicações. Objetivos: Determinar se o estado inflamatório do paciente obeso diminui após a realização de cirurgia bariátrica, com base na PCR do pré e pós-operatório. Métodos: Estudo prospectivo, observacional em pacientes submetidos à operação de by-pass gástrico em Y-de-Roux acompanhados por três meses após o procedimento com dosagem sérica da PCR no pré-operatório, 30, 60 e 90 dias após. Resultados: Foram acompanhados 19 pacientes, que apresentaram valor médio da PCR antes do procedimento cirúrgico de 0,80(±0,54) mg/dl e quando comparado à PCR com 30 dias de operados ela apresentou aumento significativo para 2,68 mg/dl (p=0,012). A análise da PCR de 60 dias após o procedimento cirúrgico mostrou-se maior também com o valor de 3,32 mg/dl (p=0,27). Entretanto no 3º mês após ela mostrou queda quando comparado ao pré-operatório (0,45 mg/dl (p=0,0042). Conclusão: O bypass gástrico em Y-de-Roux foi capaz de diminuir o estado de inflamação crônico desses pacientes com três meses de pós-operatório.

Mechanisms of amelioration in hepatic insulin sensitivity after Roux-en-Y gastric bypass surgery in type 2 diabetic rats / 中华普通外科杂志

Objective To investigate the effects of RYGB on hepatic and peripheral insulin sensitivity in type 2 diabetes rats and the mechanisms.Methods Sprague-Dawley rats were divided into 2 groups:diabetic RYGB group (n =10) and diabetic sham RYGB group (n =10).The hyperinsulinemiceuglycemic clamp with tracer infusion was completed at 2 weeks postoperatively to assess insulin sensitivity.The lipid content in liver tissue was examined.Malondialdehyde (MDA) and superoxide dismutase (SOD) activities in the liver were measured.The protein expressions of PERK and p-PERK in livers were also detected by Western blot.Results RYGB significantly improved hepatic insulin sensitivity index and decreased hepatic triglyceride concentration (P ＜ 0.05),without an improvement in peripheral insulin sensitivity.The ratio of MDA to SOD and the protein expression of p-PERK in the livers were lower in the RYGB group than in the sham RYGB group.Conclusions The increased insulin sensitivity after RYGB occurs earlier in the liver than in the muscle tissue.The amelioration of hepatic tissue lipotoxicity after RYGB decreased the degrees of oxidative stress and endoplasmic reticulum stress,which may contribute to the improved hepatic insulin sensitivity.

Effects of Roux-en-Y gastric bypass on hepatic lipid metabolism in obese diabetic rats / 中华普通外科杂志

Objective To explore the effects of Roux-en-Y gastric bypass (RYGB) on hepatic autophagy in obese diabetic rats.Methods Sprague-Dawley diabetes rats were randomly divided into three groups:diabetic group(n =8),diabetic sham RYGB group (n =8) and diabetic RYGB group (n =8).Hyperinsulinemic-euglycemic clamps with tracer infusion were completed to assess insulin sensitivity (IS).Triglyceride (TG) levels in liver tissue were tested.The protein expression levels of P62 (sequestosome 1)and the conversion of LC3 (microtubule-associatedprotein 1 light chain 3) in liver were detected by Western blot.The concentration of glucagon-like peptide-1 (GLP-1) in plasma was detected by ELISA and the correlation between GLP-1 and autophagy was analyzed in 2 weeks after operation.Results In comparison with diabetic and diabetic sham RYGB groups,IS increased by 63％ (F =10.87,P ＜ 0.01) and TG content decreased by 91％ (F =146.3,P ＜ 0.01) in the liver in RYGB group.In RYGB group,the conversion of LC3-Ⅰ to LC3-Ⅱ raised(F =17.01,P ＜ 0.01),the protein expression of P62 decreased(F =19.77,P ＜0.01) and the concentration of GLP-1 in plasma increased by 90％ (F =112.8,P ＜ 0.01).The marked increase of autophagy in liver after RYGB correlated with the plasma GLP-1 level (r2 =0.66,P =0.014 3)Conclusions RYGB reduces hepatic lipid toxicity and improves lipid metabolism disorder by increasing autophagy,increased GLP-1 secretion after RYGB may be one of the reasons for activating autophagy.

Caso Clínico: Quiste de Colédoco Tipo IA, Resolución Quirúrgica / Case Report: Type IA Choledochal Cyst, Surgical Resolution

INTRODUCCIÓN: El quiste del colédoco es una malformación congénita de etiología desconocida, caracterizada por diversos grados de dilatación del sistema biliar. El examen inicial para la valoración de la vía biliar debe ser una ecografía abdominal,sin embargo, la resonancia magnética con contraste es el estudio de elección para valorar estas estructuras. El tratamiento quirúrgico final depende del grado de dilatación quística y generalmente está basado en la escisión completa de la vía biliar extrahepática. CASO CLÍNICO: Paciente de sexo femenino de 27 años con dolor abdominal tipo cólico a nivel de epigastrio e hipocondrio derecho de 7 días de evolución. Se realizaron exámenes de Imagenología (ecografía­ TAC ­colangio RM)que reportaron colédoco con marcada dilatación fusiforme en toda su extensión, en relación a quiste de colédoco tipo IA. EVOLUCIÓN: Se planificó la exéresis del quiste de colédoco, anastomosis bilio-digestiva en «Y de Roux¼ y colecistectomía. El procedimiento quirúrgico no tuvo complicaciones. La paciente permaneció hospitalizada por 5 días con adecuada evolución y tolerancia a dieta. CONCLUSIÓN: El quiste de colédoco es una patología congénita infrecuente en la edad adulta generalmente diagnosticada como un hallazgo incidental. El diagnóstico y tratamiento oportuno aseguran el éxito del procedimiento quirúrgico y evita la aparición de complicaciones graves (colangiocarcinoma); con la escisión completa el pronóstico es excelente, la mortalidad posoperatoria es mínima. (au)

BACKGROUND: The choledochal cyst is a congenital malformation of unknown etiology characterized by different grades of dilatation of the biliary system. The first exam to evaluate the bile duct should be the abdominal ultrasound, which suggests the diagnosis of choledochal cyst. However, the magnetic resonance imagin with contrast is the gold standard to assess these structures. The final surgery treatment depends of the grade of cyst dilatation, the main procedure is based on the complete excision of the extrahepatic bile duct. CASE REPORT: A female 27-years old patient who reffered colic abdominal pain localized in epigastrium and right hypochondrium for 7 days. Imaging exams were performed (US­CT Scan­ choledochal MRI) which reported the bile duct with a severe fusiform dilatation, in complete extension related to type IA choledochal cyst. EVOLUTION: Choledocal cyst exeresis, «Roux-en-Y¼ bilio digestive anastomosis and cholecystectomy were planned. Surgical procedure had no complications. Patient was hospitalized for 5 days with proper evolution and oral diet tolerance. CONCLUSION: The choledochal cyst is a rare congenital disease in adult hood mostly diagnosed as an incidental finding. Early diagnosis and treatment ensure the success of the surgical procedure and prevents appearance of serious complications (cholangiocarcinoma).The prognosis after complete excision is excellent with minimal postoperative mortality(au)