Anastomotic Stricture Rates Following Roux-en-Y Gastric Bypass for Morbid Obesity: A Comparison Between Linear and Circular-Stapled Anastomosis.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is an effective procedure in the management of morbid obesity with variations in outcome, which are technique dependent. Anastomotic stricture remains an important complication. The aim of this study was to assess the long-term outcome of patients undergoing either a linear-stapled anastomosis (LSA) or circular-stapled anastomosis (CSA) with an emphasis on postoperative stricture formation and excess body weight loss (EBWL). METHODS: Medical records of all patients who underwent bariatric surgery between 2008 and 2013 at a single bariatric surgical center were reviewed. All patients who had a LRYGB were included in the study. Patients were divided in two groups based on stapling technique-LSA and CSA. Patient groups were compared with regard to perioperative complication, EBWL. RESULTS: A total of 114 patients were included in the study. There were 51 patients in the LSA group and 63 in the CSA group. No differences were found between the two groups with regard to operative time, hospital stay, or in the EBWL over a 12-month follow-up period. Anastomotic stricture developed in 4 patients, all occurring in the LSA group (7.8%). Three of these patients had undergone successful endoscopic dilatation. CONCLUSIONS: Both stapling techniques resulted in a similar EBWL during the follow-up period and an acceptable safety profile. Anastomotic stricture rate was slightly higher in the LSA, but this did not affect EBWL.

Perforations following endoscopic retrograde cholangiopancreatography: a single institution experience and surgical recommendations.

BACKGROUND: Perforation after endoscopic retrograde cholangiopancreatography (ERCP) is uncommon, and its management is dependent on the mechanism and the graded classification of injury. METHODS: Records of patients undergoing ERCP were analyzed over a 16-year period, patterning the types of injuries, diagnosis, management, and patient outcome. Type I injuries damage the medial or lateral duodenal wall before sphincter cannulation. Type II injuries are periampullary and occur as a result of a precut or a papillotomy. Type III injuries occur secondary to guidewire insertion or stone extraction from the common bile duct. Type IV injuries are probably microperforations that are noted on excessive insufflation during and after ERCP withdrawal. RESULTS: Between 1995 and 2011, 27 perforations were identified from 1,638 ERCP procedures (1.6%). Nearly half of the procedures were regarded as difficult by the endoscopist, with 70% of the ERCPs (19 of 27) being for therapeutic indications. There were 5 type I, 12 type II, 5 type III, and 5 type IV perforations, of which 18 cases were diagnosed at the time of ERCP. Delayed diagnosis of type I perforations that were associated with free intraperitoneal air and contrast leakage proved fatal. Most type II perforations required immediate surgery with pyloric exclusion; delayed surgery with simple drainage had a high mortality rate. Most type III and type IV injuries can successfully be managed conservatively without delayed sepsis. CONCLUSIONS: In perforation, the mechanism of injury during ERCP predicts the need for surgical management. Type I and type II injuries require early diagnosis and aggressive surgery, whereas type III and type IV injuries may be managed conservatively.

One hundred transhiatal esophagectomies: a single-institution experience.

BACKGROUND: Surgery is considered the mainstay of treatment for esophageal carcinoma. Transhiatal esophagectomy with cervical esophagogastric anastomosis is considered relatively safe with an oncological outcome comparable to that using the transthoracic approach. OBJECTIVES: To review the results of the first 100 transhiatal esophagectomies performed in a single Israeli center. METHODS: The records of all patients who had undergone transhiatal esophagectomy during the period 2003-2009 were reviewed. The study group comprised the first 100 patients. All patients who had undergone colon or small bowel transposition were excluded. Indications for surgery included esophageal cancer, caustic injury and achalasia. RESULTS: The median follow-up period was 19.5 months. The anastomotic leakage rate was 15% and all were managed successfully with local wound care. The benign stricture rate was 10% and all were managed successfully with endoscopic balloon dilation. Anastomotic leakage was found to be a risk factor for stricture formation. Overall survival was 54%. Response to neoadjuvant therapy was associated with a favorable prognosis. CONCLUSIONS: Transhiatal esophagectomy is a relatively safe approach with adequate oncological results, as long as it is performed in a high volume center.

Disease-related mortality within the first year after subtotal esophagectomy for cancer.

BACKGROUND: Esophageal carcinoma has poor prognosis. Surgery is still considered to be the mainstay of treatment. The mortality rate within the first year after surgery is unknown, but identifying risk factors for early mortality would increase our ability to predict the outcome of these patients and might improve patient selection. METHODS: All patients who had undergone subtotal esophagectomy for cancer between 2003 and 2008 were included in this retrospective series. Patients with less than 12 months follow-up, perioperative mortality, and death from unrelated causes were excluded. Patients were divided into two groups. Group A included all oncological mortality cases within 12 months of surgery. Group B included all patients who survived longer than 12 months following surgery. RESULTS: Of 81 patients who met the inclusion criteria, group A included 18 patients and group B included 63 (median survival 10 and 25 months, respectively). A higher proportion of patients were operated for pN1 disease in group A (72% versus 33%, p = 0.0004). R(0) esophagectomy rate was lower in group A (39% versus 76%, p = 0.03). Metastatic lymph node ratio (LNR) was higher in group A (mean: 46% versus 10%, p = 0.0003). Multivariate analysis identified LNR as an independent risk factor for first-year oncological mortality [odds ratio (OR) = 1.04, p = 0.0001; 95% confidence interval (CI): 1.02-1.06]. No differences were found in preoperative variables including age, gender, tumor histology, type of operation, and administration of or response to neoadjuvant therapy. Response to neoadjuvant therapy was associated with R(0) resection. CONCLUSIONS: pN1 disease, resection margin involvement, and high LNR were found to be risk factors for first-year oncological mortality after esophagectomy for cancer.