Safe intestinal decompression in fresh postoperative gastric bypass.

BACKGROUND: Dilatation of the Roux-limb is sometimes found following Roux-en-Y gastric bypass (RYGBP) procedures. This could be the result of a transient episode due to ileus, or a partial or complete obstruction. The risk of this complication is an increase in intraluminal pressure with the potential for leak. Blind insertion of a nasogastric tube for decompression could be risky due to possible perforation at the stapled or sutured edges. METHODS AND RESULTS: The diagnosis was made with routine extended upper gastrointestinal x-rays 24 hours after surgery. To determine the relationship of the intestinal dilatation, increase in intraluminal pressures and leaks, measurements were taken in porcine models duplicating a RYGBP. Pressures obtained at the anastomoses were higher than pressures in the jejunum between the anastomoses, and related directly to the production of leaks. Elevations of intraluminal intestinal pressures have also been observed in patients who required decompression. The angles of a freshly constructed pouch and the recent stapled or sutured edges may be easily perforated with a nasogastric tube, especially a hard one. We use a soft flexible tube. An angled-end 0.035" wire is introduced into the intestines with fluoroscopic assistance. The tube tip is perforated with a needle, and through this opening, the wire is passed into the tube. The tube is then fed over the wire for safe decompression. CONCLUSION: Decreasing the intestinal pressure by safe decompression may avoid one of the causes of leaks.

Total stapled, total intra-abdominal (TSTI) laparoscopic Roux-en-Y gastric bypass: one leak in 1000 cases.

BACKGROUND: Variations in technique of laparoscopic Roux-en-Y gastric bypass (LRYGBP) have been reported. These changes, mainly in the construction of the gastro-jejunostomy, are intended to decrease complications. METHODS: 1000 consecutive LRYGBPs were performed using the Total Stapled Total Intra-abdominal (TSTI) technique antecolic and antegastric approach. Technical details and results, including perioperative morbidity and mortality, are reported. RESULTS: Although the correction or improvement of the most serious co-morbidities with the use of the TSTI technique were similar to results reported by other gastric bypass surgeons, we noted a considerable difference in the development of leaks using this surgical approach. Current literature on gastric bypass reports a 2-5% incidence of leaks. Using the TSTI approach, the incidence of leaks at our facility was 0.1% (one in 1000 cases). After analysis of the factors involved, it was concluded that the use of the antecolic and antegastric approach in gastric bypass, as described in the TSTI,should be an important consideration by the surgeon. This technique, which uses a circular stapler, was found to be easy to perform while maintaining a reproducible, controlled opening of the anastomosis. CONCLUSION: Although this was a non-randomized study, the results found a considerable improvement in the incidence of morbidity and mortality, and a remarkable decrease in the frequency of leaks.