A 30 mm sized gastrojejunostomy may lead to a lower rate of therapy failure in comparison to a 45 mm sized gastrojejunostomy following laparoscopic Roux-en-Y gastric bypass.

Background: In bariatric surgery the laparoscopic Roux-en-Y gastric bypass (LRYGB) has been proven to be a safe and effective approach. Currently the optimal size of the linear-stapled gastrojejunostomy (GJ) and its impact on weight loss are not known due to a lack of clinical trials on that topic. We aimed to provide evidence on the impact of the GJ size in terms of gastric bypass weight loss. Methods: Patients who underwent LRYGB due to morbid obesity were retrospectively analyzed from January 2013 to January 2016. While the procedure was completely standardized, one surgeon continued using the 45 mm sized linear stapler to perform GJ while the other switched to using a 30 mm cartridge. Results: 277 patients were female (78%) and 77 males. The average age was 41.7 ± 12.3 years. In 118 cases a 30 mm sized GJ was conducted. 236 individuals received a 45 mm sized GJ. In terms of gender, age, length of biliary and alimentary limb both groups were homogenous. Individuals with a 30 mm sized GJ had a statistical significant lower rate of therapy failure (Excess weight loss <25%, 25-49%, ≥50% after 3 years, P value χ2 for trend <0.035).The excess weight loss did not significant differ between both groups. Conclusions: A 30 mm sized GJ may lead to a lower rate of therapy failure in comparison to a 45 mm sized GJ following laparoscopic Roux-en-Y gastric bypass. Prospective trials are mandatory to confirm our findings.

Mechanical ileus and mesenteric ischemia in a patient with simultaneous internal herniation through Petersen's and jejunojejunal spaces following laparoscopic Roux-en-Y gastric bypass: A case report.

INTRODUCTION: Internal herniation (IH) of the small bowel after laparoscopic Roux-en-Y gastric bypass (LRYGB) is a well-known complication, with an incidence ranging from 1 to 5% depending on the route of the Roux limb and the closure of the mesenteric defects at the time of the initial operation. Simultaneous herniation of the biliopancreatic and Roux limbs through both Petersen's and jejunojejunal spaces with mesenteric torsion resulting in early small bowel ischemia has not been described earlier. PRESENTATION OF CASE: A 63-year-old patient presented with mechanical small bowel ileus and early mesenteric ischemia due to simultaneous herniation of the alimentary and the biliopancreatic limb through the Petersen's and jejunojejunal spaces with subsequent rotation and torsion of the mesentery 33 months after LRYGB. The condition was managed by surgically reducing the hernias and closure of the mesenteric defects. Partial bowel resection was not performed. The patient's postoperative course was uneventful. DISCUSSION: Simultaneous herniation of the biliopancreatic and Roux limbs through both intermesenteric windows caused consequent life-threatening complications after LRYGB. Antecolic approach and closure of mesenteric defects with non-absorbable sutures are recommended when technically feasible. Proper history taking and clinical examination, as well as communication between surgeons and radiologists, are crucial in establishing a rapid diagnosis. CONCLUSION: Internal hernia following LRYGB can be fatal. In cases of uncertainty, emergency exploratory laparoscopy or laparotomy should be performed. The open approach seems superior for recurrent small bowel obstruction (SBO) due to recurrent IH. High vigilance is necessary when IH is suspected, despite normal laboratory and radiological findings.

Mechanical ileus and mesenteric ischemia as complications of MiniMizer-gastric-ring after laparoscopic banded Roux-en-Y-gastric bypass: A case report.

INTRODUCTION: Banded laparoscopic Roux-en-Y-gastric bypass (B-LRYGB) is a surgical technique that involves reinforcing the restriction by placing a silicone ring 2 cm above the gastrojejunostomy to prevent pouch dilation, thereby maintaining the achieved weight loss and preventing weight regain. Gastrojejunostomy stenosis, erosions, and ring-migration (slippage) are well-known complications in patients undergoing banded laparoscopic procedures. We believe that our study makes a significant contribution to the literature because, to the best of our knowledge, cranial slippage (herniation) of the alimentary limb through a non-slipped MiniMizer gastric ring after B-LRYGB as well as mesenteric ischemia because of ventral slippage have not been described before in the published literature. PRESENTATION OF CASE: This study presents two rare complications in middle-aged women 26 months after B-LRYGB. The first case presented with mechanical ileus due to herniation of the alimentary limb without slippage of the MiniMizer ring. The second case involved mesenteric ischemia following ventral migration of the MiniMizer ring with herniation of the alimentary limb and its mesentery through the ring with consequent torsion of the mesentery. Both patients were managed with surgical intervention and band removal. The postoperative course was uneventful. DISCUSSION: In cases of MiniMizer ring complications, the presentation can be either acute or chronic. Severe mesenteric ischemia is acute and can be fatal. Patients may also present with chronic recurrent abdominal pain or mechanical ileus. The loss of mesenteric fat after successful weight loss might lead to the cranial herniation of the alimentary limb. This could also be a result of dysmotility or reverse peristalsis secondary to ectopic pacemaker cells over a fixed point (in this case, the gastrojejunostomy with the MiniMizer ring) [4,5]. A gradual herniation of the intestinal wall over the fixed point can also occur due to recurrent dietary non-adherence (such as large portions and hard consistency of the food). CONCLUSION: A high sense of suspicion and radiological investigation are crucial factors in reaching the proper diagnosis. Further studies should be conducted to examine whether other forms of ring placement or fixation could help avoid the risk of potentially fatal complications.

Differential effects of galvanic vestibular stimulation on arm position sense in right- vs. left-handers.

The human brain is organized asymmetrically in two hemispheres with different functional specializations. Left- and right-handers differ in many functional capacities and their anatomical representations. Right-handers often show a stronger functional lateralization than left-handers, the latter showing a more bilateral, symmetrical brain organization. Recent functional imaging evidence shows a different lateralization of the cortical vestibular system towards the side of the preferred hand in left- vs. right-handers as well. Since the vestibular system is involved in somatosensory processing and the coding of body position, vestibular stimulation should affect such capacities differentially in left- vs. right-handers. In the present, sham-stimulation-controlled study we explored this hypothesis by studying the effects of galvanic vestibular stimulation (GVS) on proprioception in both forearms in left- and right-handers. Horizontal arm position sense (APS) was measured with an opto-electronic device. Second, the polarity-specific online- and after-effects of subsensory, bipolar GVS on APS were investigated in different sessions separately for both forearms. At baseline, both groups did not differ in their unsigned errors for both arms. However, right-handers showed significant directional errors in APS of both arms towards their own body. Right-cathodal/left-anodal GVS, resulting in right vestibular cortex activation, significantly deteriorated left APS in right-handers, but had no detectable effect on APS in left-handers in either arm. These findings are compatible with a right-hemisphere dominance for vestibular functions in right-handers and a differential vestibular organization in left-handers that compensates for the disturbing effects of GVS on APS. Moreover, our results show superior arm proprioception in left-handers in both forearms.

Galvanic vestibular stimulation improves arm position sense in spatial neglect: a sham-stimulation-controlled study.

BACKGROUND: Disturbed arm position sense (APS) is a frequent and debilitating condition in patients with hemiparesis after stroke. Patients with neglect, in particular, show a significantly impaired contralesional APS. Currently, there is no treatment available for this disorder. Galvanic vestibular stimulation (GVS) may ameliorate neglect and extinction by activating the thalamocortical network. OBJECTIVE: The present study aimed to investigate the immediate effects and aftereffects (AEs; 20 minutes) of subsensory, bipolar GVS (M = 0.6 mA current intensity) on APS in stroke patients with versus without spatial neglect and matched healthy controls. METHODS: A novel optoelectronic arm position device was developed, enabling the precise measurement of the horizontal APS of both arms. In all, 10 healthy controls, 7 patients with left-sided hemiparesis and left-spatial neglect, and 15 patients with left hemiparesis but without neglect were tested. Horizontal APS was measured separately for both forearms under 4 experimental conditions (baseline without GVS, left-cathodal/right-anodal GVS, right-cathodal/left-anodal GVS, sham GVS). The immediate effects during GVS and the AEs 20 minutes after termination of GVS were examined. RESULTS: Patients with neglect showed an impaired contralateral APS in contrast to patients without neglect and healthy controls. Left-cathodal/right-anodal GVS improved left APS significantly, which further improved into the normal range 20 minutes poststimulation. GVS had no effect in patients without neglect but right-cathodal/left-anodal GVS worsened left APS in healthy participants significantly. CONCLUSIONS: GVS can significantly improve the impaired APS in neglect. Multisession GVS can be tested to induce enduring therapeutic effects.

Intraperitoneal splenosis: a simple diagnosis if you remember to think of it.

A 72-year old man presented with clinical signs of small bowel obstruction. The medical history revealed an asymptomatic retrogastric tumor 5 cm in diameter with impression of the gastric fundus that was found 10 years ago and showed no progression. This diagnosis was made endoscopically, by endosonography and abdominal computed tomography. Finally, as the small bowel obstruction occurred, an explorative laparotomy was performed to clarify the ambiguous abdominal scenario. The intraoperative situs showed multiple red nodules with diameters of up to 1 cm based on the serosa of the small bowel. The histopathological assessments of the peritoneal nodules as well as of the resected retrogastric tumor revealed the diagnosis of splenosis. Retrospectively, the patient reported a road accident with splenic rupture and splenectomy more than 30 years ago. He had simply forgotten this fact and thus had not mentioned it to the examining doctors. The decisive hint for the diagnosis of splenosis results from the thorough inquiry of the medical history, revealing experienced splenectomy. Splenosis should be considered as a crucial differential diagnosis of unexplained masses or occult bleeding in individuals who underwent splenectomy to avoid unnecessary diagnostic or therapeutic procedures.