Duodenal switch with omentopexy and feeding jejunostomy--a safe and effective revisional operation for failed previous weight loss surgery.

BACKGROUND: As the number of weight loss operations has increased, the number of patients who have failed to maintain sufficient weight loss has also increased, providing a management challenge to the bariatric surgeon. Conversion to a duodenal switch with omentopexy and feeding jejunostomy was performed for these patients. METHODS: Between September 2006 and January 2010, 41 revisional operations were performed at 1 institution and by 1 operating surgeon. The data were prospectively collected and reviewed for several parameters, including excess weight loss, mortality, and morbidity. These results are reported. RESULTS: A total of 41 patients underwent conversion of their original bariatric operation to a duodenal switch with omentopexy and feeding jejunostomy. The initial operations had been gastric bypass in 32 patients, vertical banded gastroplasty in 5, and laparoscopic adjustable gastric banding in 4. The average excess weight loss was 54% in 31 patients at 6 months, 66% in 22 patients at 1 year, and 75% in 9 patients at 2 years. No patients died. The average hospital stay was 6.4 days. A total of 9 proven or suspected leaks (22%) developed. One was at the enverted staple line of a jejunojejunostomy that was diagnosed and treated the next day with little subsequent morbidity. The others were at the gastrogastrostomy or lateral gastric staple line and all occurred in conversions from gastric bypass. They were all ischemic type leaks and presented 5-11 days after surgery and closed relatively uneventfully with J-tube feedings and antibiotic/antifungal treatment. Other major complications included 1 pulmonary embolism (2%), 1 small bowel obstruction at the site of the feeding jejunostomy (2%), 2 stenoses (4%)-1 at the duodenoenterostomy and 1 in the body of the vertical gastrectomy. This gives a total major complication rate of 30%. A total of 3 patients required reoperation because of a jejunojejunostomy leak, small bowel obstruction, and stenosis at the vertical gastrectomy. No gastrogastrostomy leaks required surgical or radiologic intervention. One required revision for malnutrition, but otherwise the nutrition remained good. CONCLUSION: Revisional surgery to a duodenal switch is a complex operation and carries a high potential for major complications. Nonetheless, it can be accomplished safely with good long-term results. Omentopexy, drainage, and feeding jejunostomy should be considered at surgery to treat the high potential for delayed ischemic leaks.

Unanticipated findings at bariatric surgery.

BACKGROUND: Obesity is associated with an increased prevalence of various intra-abdominal malignancies. There is little consensus as to the screening of the morbidly obese for these malignancies, and there are no guidelines for screening these subjects before bariatric surgery or performing a survey examination during abdominal bariatric surgery. METHODS: A prospective analysis of 400 consecutive patients (362 women and 38 men) undergoing gastric bypass surgery was performed to identify the incidence of unanticipated intra-abdominal pathology. RESULTS: All patients underwent abdominal exploration via an upper midline abdominal incision before gastric bypass surgery. Of the 400 patients, abnormalities were found in 31 (8%); 25 of these abnormalities were related to the ovaries. In only three cases (one case each of carcinoid of the appendix, Sertoli-Leydig cell tumor of the ovary, and serous cystadenocarcinoma of the ovary) would there have been a significant difference in the patient's prognosis had the problem been left undiagnosed. CONCLUSION: It is reasonable to at least evaluate the ovaries in all female patients before proceeding with weight-loss surgery.

Chronic abdominal wall pain: a frequently overlooked problem. Practical approach to diagnosis and management.

Chronic abdominal wall pain is frequently misdiagnosed as arising from a visceral source, often resulting in inappropriate diagnostic testing, unsatisfactory treatment, and considerable cost. Its prevalence in general medical practice is unknown, although it may account for about 10% of patients with chronic idiopathic abdominal pain seen in gastroenterological practices. The most common cause appears to be entrapment of an anterior cutaneous branch of one or more thoracic intercostal nerves; myofascial pain and radiculopathy are less frequent. Sharply localized pain and superficial tenderness are suggestive of abdominal wall origin. Carnett's test (accentuated localized tenderness with abdominal wall tensing) is a helpful diagnostic sign, especially when incorporated with other findings. Early exclusion of a parietal source should increase diagnostic accuracy when evaluating patients with chronic abdominal pain. Reassurance of patients by the correct diagnosis and avoidance of precipitating causes is often sufficient treatment. However, accurately placed anesthetic/corticosteroid injections give substantial pain relief to more than 75% of patients, often for prolonged periods, and may be confirmatory for the source of the complaint. The probability of missing visceral disease is small (probably less than 7%) with strict adherence to diagnostic criteria and diligent observation of patients.