Surgical Management of Small Intestinal Bacterial Overgrowth After Roux-en-Y Gastric Bypass.

INTRODUCTION: Small intestinal bacterial overgrowth (SIBO) is a common adverse effect after laparoscopic Roux-en-Y gastric bypass (LRYGB) and may be responsible for chronic diarrhea, abdominal pain, and discomfort. Although its pathophysiology is still unclear, surgical management may be appropriate in selected cases. METHODS: In this video, we present a surgical revision of LRYGB, 12 years after the initial surgery, for late postoperative chronic diarrhea. The diagnosis of SIBO was finally established and associated with a dilated jejuno-jejunostomy diagnosed through a small bowel follow-through. RESULTS: Revision of the RYGB was performed by resecting the dilated jejunostomy and fashioning a new one with a shorter Roux-en-Y limb. During follow-up, the patient showed fast improvement and complete resolution of symptoms was obtained at 12 months. CONCLUSION: SIBO may be responsible for postoperative chronic diarrhea in RYGB patients, possibly in the long term, and it is often misdiagnosed. Primary treatment is conservative with appropriate dietary measures, antibiotics, and probiotics but surgical management can be very effective in selected patients presenting with failure of prolonged medical treatment and an anatomic abnormality.

Facial artery perforator flap for reconstruction of perinasal defects: An anatomical study and clinical application.

BACKGROUND: The concept of the facial artery perforator flap was developed for improved freedom during the reconstruction of perioral and perinasal defects. This flap enables tailor-made reconstruction and a shift from the traditional two-stage procedure to a one-stage technique. In this cadaveric study, the authors quantify the number, length, and diameter of facial artery perforators (FAPs) and present their clinical experience with the FAP flap. METHODS: The authors performed 20 dissections of facial arteries (FAs). All FAPs greater than 0.5 mm were dissected to study the number, length, and diameter of FAPs. In addition, the authors report a case series of 15 perinasal defect reconstruction procedures performed using facial artery-based perforator flap. RESULTS: A total of 125 FAPs were dissected. We identified a mean of six FAPs per hemiface (range five to eight). The average length of all FAPs was 17.6 ± 1.9 mm, and the mean diameter of the FAPs was 0.91 ± 0.2. Fifteen patients underwent a perinasal defect reconstruction using a FAP flap with good aesthetic and functional results. CONCLUSIONS: The following study thus improves our understanding of FAP anatomy and clinical application and will enable the nasolabial fold to become the area where perinasal defect reconstruction using perforator flaps is performed.