A paradoxical internal hernia at Brolin's anti-obstruction stitch following Roux-en-Y gastric bypass: a case report.

Internal hernias are a rare but morbid complication following Roux-en-Y gastric bypass surgery. The incorporation of Brolin's anti-obstruction stitch has historically demonstrated a significant reduction in the incidence of internal hernias following Roux-en-Y gastric bypass. We present an ironic and unique case of a patient with small bowel herniation into a defect between Brolin's stitch and the stapled closed common enterotomy of the jejunojejunostomy and technical considerations to decrease internal hernias at this site in the future.

Operative technique for a successful laparoscopic en-bloc resection of gastrogastric fistula following roux-en-Y gastric bypass.

Gastrogastric fistulas are rare complications following Roux-en-Y gastric bypass surgery and are characterized by a fistulous connection between the gastric pouch and the remnant stomach. The presentation is often variable and a high-index of suspicion must be maintained for accurate and timely diagnosis. In this case report, we provide a detailed review of the technical steps taken to successfully resect a gastrogastric fistula en-bloc laparoscopically with an unremarkable post-operative course.

The 15-cm Roux Limb: a Technical Misadventure.

BACKGROUND: Despite effectively treating obesity and its comorbidities, only a fraction of the growing obese population is evaluated for bariatric surgery. Aside from barriers including resources and social support, patients report personal experience with friends and relatives suffering poor outcomes after bariatric surgery. Rates of mortality, leaks, and strictures have decreased over the past 20 years, but few instances of gross surgeon error have been reported in the literature. Our objective is to report and demonstrate the revision of a critically shortened Roux limb in a patient with chronic nausea and dysphagia found to have a 15-cm Roux limb and briefly discuss its implications. METHODS: We performed a successful laparoscopic revision of this patient's previous Roux-en-Y gastric bypass, with creation of a 125-cm Roux limb. RESULTS: Total operative time was 87 min, there were no major intraoperative complications, and the post-operative course was unremarkable. At one-month follow-up, the patient reported complete resolution of all prior symptoms. At three-month follow-up, BMI decreased from 37 prior to revision to 31. CONCLUSIONS: Reducing complications and improving quality of care will support the necessary growth of bariatric surgery. Standards set forth by accreditation bodies such as the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) assist in this endeavor, and technical errors, though difficult to evaluate, should be monitored.

Endoscopic closure of colon perforation compared to surgery in a porcine model: a randomized controlled trial (with videos).

BACKGROUND: Endoscopic closure of inadvertent or intentional colon perforations might be valuable if comparable to surgical closure. OBJECTIVE: The aim of this study was to compare endoscopic closure of a 4-cm colon perforation in a porcine model with surgical closure in a multicenter study. SETTING: University hospitals in the United States and Europe. DESIGN AND INTERVENTIONS: After creating a 4-cm linear colon perforation, the animals were randomized to either endoscopic or surgical closure. The total procedure time from the beginning of perforation to the completion of procedure was measured. The animals were euthanized after 2 weeks to evaluate healing, unless there was a complication. RESULTS: Fifty-four animals were randomized to either surgical or endoscopic closure of colon perforation. Eight animals developed complications, and 7 of these were euthanized before 2 weeks. Twenty-three animals in each group survived for 2 weeks. Surgical closure of the perforation was successful in all animals in that group, and endoscopic closure was successful in 25 of the 27 animals. The median procedure time was shorter in the surgery group compared to the endoscopy group (35 vs 44 minutes, P = .016). Peritonitis, local adhesions, and leak test results were comparable in both groups. Distant adhesions were less frequent in the endoscopic closure group (26.1% vs 56.5%, P = .03). Five of the 186 T-tags (2.7%) were noted in the adjacent viscera. LIMITATION: This porcine study does not mimic clean colon perforation in humans; it mimics dirty colon perforation in humans. CONCLUSIONS: Endoscopic closure of a 4-cm colon perforation was comparable to surgery, and this technique can be potentially used for closure of intentional or inadvertent colon perforations.

Emotional eating and emotional eating alternatives in subjects undergoing bariatric surgery.

BACKGROUND: The purpose of this study was to characterize emotional eating and its alternatives in obese patients undergoing bariatric surgery. METHODS: The medical charts of 178 consecutive patients who had laparoscopic Roux-en-Y gastric bypass provided by a multidisciplinary bariatric program were reviewed. Data from patients who had emotional eating, reported strategies to overcome their urges to emotionally eat, and had their 6 months follow-up after surgery (N=50) were further analyzed in terms of weight history, medical co-morbidity prior to surgery, weight loss after surgery, and lifetime psychiatric status. RESULTS: 38.7% of the 178 bariatric surgery patients reported emotional eating. Patients reported using three main types of behaviors (oral, sedentary and physical activity) to overcome urges to eat emotionally. Most patients (42%) experiencing emotional eating chose sedentary behaviors to overcome urges to eat in response to emotion. The three groups did not differ in any of the examined variables. CONCLUSIONS: While patients using different coping mechanisms to overcome urges to eat emotionally did not differ before and 6 months after surgery, further research is needed to examine the frequency and long-term effects of emotional eating in bariatric surgery patients.