Gastrojejunocolic fistula: case report of a rare late complication of laparoscopic Roux-en-Y gastric bypass and review of the literature.

INTRODUCTION: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is known as the weight loss surgery to which other bariatric procedures are compared. While morbidity and mortality of this procedure are low, serious complications do exist which can be life-threatening and sometimes require surgical correction. CASE PRESENTATION: A 63-year-old woman underwent LRYGB outside of the United States, later complicated by biliary colic treated with cholecystectomy and upper gastrointestinal bleeding secondary to H. pylori-related ulcer at her gastrojejunostomy. Following adequate treatment of the patients marginal ulcer, the patient experienced several months of progressive severe abdominal pain, frequent vomiting and diarrhea, and unintentional weight loss refractory to pharmacologic therapy. The patient underwent multiple medical and endoscopic evaluations unrevealing of an organic cause of her symptoms. At presentation, the patient was found to be profoundly weak, dehydrated and malnourished with metabolic derangements and was subsequently diagnosed with a gastrojejunocolic fistula via upper endoscopy and radiography. We provided excluded stomach gastrostomy tube feeding to the patient for three months to improve the patients nutritional status before definitive surgical correction was successfully performed. DISCUSSION: Large bowel fistulas are a rare and highly morbid late complication following LRYGB and are likely secondary to marginal ulcers and/or instrumentation such as endoscopy. Surgery represents the definitive treatment. CONCLUSION: LRYGB is typically a safe and effective intervention for obesity. Large bowel fistulas are rare complications following this surgery. We highlight difficulties in diagnosing and treating this condition.

Robotic-assisted deep inferior epigastric artery perforator flap abdominal harvest for breast reconstruction: A case report.

The deep inferior epigastric perforator (DIEP) flap is a mainstay of autologous breast reconstruction. The da Vinci robot has recently been adapted for an increasing number of reconstructive surgeries. The literature has yet to describe its use for the intra-abdominal harvest of the deep inferior epigastric vessels (DIEV) during DIEP flap breast reconstruction. We show the use of the da Vinci robotic surgical system for the intra-abdominal dissection of DIEV during delayed breast reconstruction with a DIEP flap in a 51-year-old female who had undergone a right modified radical mastectomy. After dissecting the flap from the anterior abdominal wall leaving only the targeted perforating vessels intact, a 1.5 cm fascial incision was made adjacent to the perforator and the vessels were dissected to below the level of the fascia. The intra-abdominal robotic-assisted dissection of the DIEV up to the perforator was then completed. The DIEV were divided at their origin using the robot and the flap removed from the abdomen for subsequent reconstruction. This technique enabled improved precision of flap harvest while also decreasing the donor-site morbidity by minimizing the incision length of the anterior rectus sheath. The patient had an uneventful postoperative course and, at 9-month follow-up, exhibited no evidence of flap or donor-site complications, specifically hernia or bulge. This novel approach for the harvest of a DIEP flap introduces an alternative technique to the conventional DIEP flap procedure in the appropriate patient population. Risks inherent to this technique as well as additional costs must be considered.

Systematic review of transgastric ERCP in Roux-en-Y gastric bypass patients.

Balloon-assisted endoscopic retrograde cholangiopancreatoscopy (ERCP) in Roux-en-Y gastric bypass (RYGB) patients is technically challenging due to anatomic and accessory constraints, thus success rates are modest. Transgastric ERCP (TG-ERCP) offers a viable alternative. We aimed to systematically review the literature on TG-ERCP in RYGB patients to better define the technical approaches, success rates, and adverse events of this procedure. A computer-assisted search of the Embase and PubMed databases was performed to identify studies that focused on the techniques and clinical outcomes of TG-ERCP. Two investigators independently identified studies and abstracted relevant data. The literature search yielded 26 eligible studies comprising 509 TG-ERCP cases. Access to the excluded stomach to facilitate ERCP was achieved laparoscopically in 58% of reported cases, via open surgery (6% of reported cases), by antecedent placement of a percutaneous gastrostomy tube (33%), or with endoscopic ultrasound assistance (3%). Successful gastric access was reported in 100% of cases and successful ductal cannulation in 98.5%. Adverse events were reported in 14% of cases; 80% of these were related to gastrostomy creation and the rest were attributable to ERCP. Wound infections (n = 19, 3.7%) were the most common gastrostomy-related adverse event, and post-ERCP pancreatitis (n = 7, 1.4%) was the most common ERCP-related adverse event. No deaths were reported. Based on existing observational studies, TG-ERCP appears to be a safe and highly effective approach in patients with RYGB anatomy. Additional research and clinical experience are needed to more precisely define the risk-benefit ratio and optimal technique of TG-ERCP.

Laparoscopic repair of gastro-duodenal fistula secondary to band erosion.

Laparoscopic gastric banding is one of the most common surgical treatments for morbid obesity performed worldwide. The procedure, however, has many well-documented risks and complications, including band erosion. We present here a gastric banding patient who was referred to our tertiary care centre after secondarily forming an entero-enteric fistula with complaints of pain, nausea, vomiting and severe reflux. She was successfully treated with laparoscopic dissection and due to her existing anatomy, and the patient's desire for continued weight loss, she was converted to Roux-en-Y gastric bypass.

The Diagnostic Significance of a Mucocele of the Appendix.

Appendiceal mucoceles are rare lesions with a variable clinical presentation often identified incidentally on imaging or at laparotomy/laparoscopy for an unrelated diagnosis. Mucocele of the appendix may be a benign or malignant process, making early recognition based on symptoms and key radiographic characteristics of the utmost importance for optimal patient management. Here we present the case of a patient presenting with non-specific abdominal complaints suffering from appendiceal mucocele perforation due to low-grade mucinous adenocarcinoma.