Management of suspected anastomotic leak after bariatric laparoscopic Roux-en-y gastric bypass.

BACKGROUND: Anastomotic leak is one of the most serious complications following bariatric laparoscopic Roux-en-Y gastric bypass (LRYGB), and associated with high morbidity rates and prolonged hospital stay. Timely management is of utmost importance for the clinical outcome. This study evaluated the approach to suspected leakage in a high-volume bariatric surgery unit. METHODS: All consecutive patients who underwent LRYGB performed by the same team of surgeons were registered prospectively in a clinical database from September 2005 to June 2012. Suspected leaks were identified based on either clinical suspicion and/or associated laboratory values, or by a complication severity grade of at least II using the Clavien-Dindo score. RESULTS: A total of 6030 patients underwent LRYGB during the study period. The leakage rate was 1·1 per cent (64 patients). Forty-five leaks (70 per cent) were treated surgically and 19 (30 per cent) conservatively. Eight (13 per cent) of 64 patients needed intensive care and the mortality rate was 3 per cent (2 of 64). Early leaks (developing in 5 days or fewer after LRYGB) were treated by suture of the defect in 20 of 22 patients and/or operative drainage in 13. Late leaks (after 5 days) were managed with operative drainage in 19 of 23 patients and insertion of a gastrostomy tube in 15. Patients who underwent surgical treatment early after the symptoms of leakage developed had a shorter hospital stay than those who had symptoms for more than 24 h before reoperation (12·5 versus 24·4 days respectively; P < 0·001). CONCLUSION: Clinical suspicion of an anastomotic leak should prompt an aggressive surgical approach without undue delay. Early operative treatment was associated with shorter hospital stay. Delays in treatment, including patient delay, after symptom development were associated with adverse outcomes.

Gastroesophageal reflux after vertical banded gastroplasty is alleviated by conversion to gastric bypass.

BACKGROUND: Conversion operations after vertical banded gastroplasty (VBG) are sometimes performed because of vomiting and/or acid regurgitation. Primary operation with gastric bypass (GBP) is known to reduce gastroesophageal reflux (GERD). Previous studies have not been designed to differentiate between the effects of the altered anatomy and of the ensuing weight loss. No series has reported data on acid reflux before and after conversion from VBG to GBP. METHODS: We invited eight VBG patients with current symptoms of GERD. All had intact staple lines as assessed by barium meal and gastroscopy. Acid reflux was quantified using 48-h Bravo capsule measurements. Conversion operations were performed creating an isolated 15-20-ml pouch; the previously banded part of gastric wall was excised. Gastrojejunostomy was made end to end with a 28-mm circular stapler. The study is based on five patients consenting to early postoperative endoscopy and pH measurement. RESULTS: All patients were women with a mean age of 49.5 years and BMI of 36.3. Time since VBG was 132.1 months. Time from conversion to second measurement was 46.6 days and BMI at that time 32.7. There was no mortality and no serious morbidity. All patients improved clinically and no patient had to go back on proton pump inhibition or antacids. Total time with pH < 4.0 was reduced from 18.4% to 3.3% (p < 0.05). DeMeester score was reduced from 58.1 to 15.9 (p < 0.05). CONCLUSIONS: The effect of converting VBG-operated patients to GBP results in a near-normalisation of acid reflux parameters and a discontinuation of proton pump inhibitor medication.

Fully stapled gastric bypass with isolated pouch and terminal anastomosis: 1-3 year results.

BACKGROUND: Roux-en-Y gastric bypass is a bariatric procedure of choice. There is evidence supporting a small isolated pouch and a wide anastomosis. Gastric vascular anatomy renders the ventral aspect less suited for anastomotic construction. The lesser curvature has abundant blood supply that should preferably not be interfered with. Terminal anastomosis is a logical choice. METHODS: We devised a way of making a fully stapled gastric bypass with complete separation of a pouch that empties dependently. The technique obviates the oral passage of the stapler anvil. Such a procedure facilitates the creation of an "end-of-pouch to end-of-jejunal limb" wide-diameter anastomosis and precludes the risk of staple-line disruption. RESULTS: Since October 1997 we have performed 227 such anastomoses (146 primary, 81 reoperative procedures) in consecutive patients with no leaks, no gastro-gastric fistulas and no mortality. The postoperative hospital time was 3.6 (3-8) days (median, range). In primary operations baseline BMI was 47.5, 1-yr 29.7 and 3-yr 29.2. Corresponding values for reoperations were 39.3, 30.8 and 31.5. Weight loss was adequate, and complications were limited to three anastomotic ulcers and two narrow stomas without visible ulcers but necessitating endoscopic dilatation. CONCLUSION: The technique confers distinctive advantages.

Neither low-calorie diet nor vertical banded gastroplasty influence gastro-oesophageal reflux in morbidly obese patients.

OBJECTIVE: Investigate the effect of a liquid diet, and of vertical banded gastroplasty, on gastro-oesophageal reflux in morbidly obese patients. DESIGN: Prospective study, patients being their own controls. SETTING: University hospital, Sweden. SUBJECTS: 25 morbidly obese patients, listed for vertical banded gastroplasty. INTERVENTIONS: 24 hour ambulatory intra-oesophageal pH-monitoring three weeks before operation and repeated after 10-14 days on a liquid very low calorie diet, and finally three weeks after operation, while still on a liquid very low calorie diet. MAIN OUTCOME MEASURES: Percentage of time that pH in the oesophagus was < or =4. RESULTS: There were no changes in the amount of reflux, either after a liquid diet or after vertical banded gastroplasty. CONCLUSIONS: Neither the liquid diet nor vertical banded gastroplasty alone had any appreciable effect on gastro-oesophageal reflux.

Quality of life after gastroplasty is normal: a controlled study.

OBJECTIVE: To assess the quality of life of patients 1 1/2-5 1/2 years after vertical banded gastroplasty for morbid obesity. DESIGN: Retrospective study by questionnaire. SETTING: University hospital, Sweden. SUBJECTS: 102 of the 127 patients (80%) operated on for morbid obesity between January 1989 and February 1993 responded to the questionnaire. 74 patients who underwent routine cholecystectomy were matched for age and time of surgery, of whom 55 (74%) responded to the questionnaire and acted as controls. INTERVENTION: Standardised questionnaire of 112 items, 28 of which referred to problems with eating (Gothenburg Quality of Life Scale). MAIN OUTCOME MEASURES: Differences in scores between the groups. RESULTS: Gastroplasty caused profound changes in patients' lives, cholecystectomy did not. This was reflected in self esteem, relations with partners, and social networking for both sexes. There was no difference between groups in overall quality of life, the mean (SEM) scores for women being 5.32 (0.09) compared with 5.33 (0.07) and for men 5.32 (0.17) compared with 5.40 (0.14). CONCLUSION: Vertical banded gastroplasty seems to offer morbidly obese patients not only reduction in weight but also improved quality of life.

Anticholinergic medication in diagnostic endoscopy of the upper gastrointestinal tract.

The effects of two different forms of anticholinergic medication on endoscopic quality and patient discomfort were studied in 235 consecutively observed out-patients. Patients were randomized to receive either scopolamine i.v. and placebo transdermally, saline i.v. and saline transdermally, or placebo i.v. and scopolamine transdermally. No differences could be observed between the groups with respect to gastric motor function or endoscopic quality (as judged by the endoscopist), or discomfort during endoscopy (as judged by the patient). Transdermally applied scopolamin resulted in a significant increase (2p = 0.002) in post-endoscopy discomfort due to dryness of the mouth. The findings speak against the use of i.v. scopolamine (20 mg) or transdermally applied scopolamine (0.5 mg) in endoscopy of the upper gastrointestinal tract.