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Background and Aims An enlarged gastrojejunal anastomosis (GJA) is associated with weight regain after Roux-en-Y gastric bypass (RYGB) and can be corrected with endoscopic or surgical revision; however, there has been no direct comparison between techniques. This study aims to compare serious adverse event (AE) rates and weight loss profiles between endoscopic and surgical revisional techniques over a 5-year period. Methods This is a retrospective matched cohort study of RYGB patients who underwent endoscopic or surgical revision for weight regain with an enlarged GJA (>12 mm). Patients who underwent endoscopic revision (ENDO group) were matched 1:1 to those undergoing surgical revision (SURG group) based on completion of 5-year follow-up, age, sex, body mass index, initial weight loss, and weight regain. Demographics, GJA size, serious AEs, and weight profiles were collected. The primary outcome was comparison of serious AE rates between groups. Secondary outcomes included weight loss comparisons. A Fisher exact test was used to compare the serious AE rate, and a Student t test was used for weight comparisons. Results Sixty-two RYGB patients with weight regain and an enlarged GJA (31 ENDO, 31 matched SURG) were included. Baseline characteristics were similar between groups. The AE rate in the ENDO group (6.5%) was lower than the SURG group (29.0%, P = .043). Zero and 6 (19.4%) serious (severe) AEs occurred in the ENDO and SURG groups, respectively (P = .02). There was no significant difference in weight loss at 1, 3, and 5 years. Conclusions Endoscopic revision of the GJA is associated with significantly fewer total and serious AEs and similar long-term weight loss when compared with surgical revision.

Video Video 1 This video case presentation highlights a 65-year-old woman with weight regain after Roux-en-Y gastric bypass and a dilated gastrojejunal anastomosis who presented for endoscopic revision of her gastric bypass involving a plication technique, followed by gastrojejunal anastomosis stenosis dilation.

A dilated gastrojejunal anastomosis (GJA) diameter is an independent predictor of weight regain following Roux-en-Y gastric bypass (RYGB). Despite this, there is no standardized method for GJA diameter measurement. We performed a retrospective analysis to compare endoscopic visual estimation and endoluminal functional impedance planimetry (EndoFLIP) for measuring GJA diameter in patients with weight regain post-RYGB. Visual estimation was found to overestimate GJA diameter by a mean of 4.2mm ± 4.6mm when compared with EndoFLIP. Furthermore, we identified symptomatic patients with normal GJA diameter but increased distensibility, which may represent a previously unrecognized subgroup. Our findings suggest the potential utility of EndoFLIP in the evaluation of post-RYGB weight regain and support the need for prospective studies to investigate the relationship between GJA distensibility and weight regain.

Laparoscopic roux-en-Y gastric bypass (LRYGB) is the gold standard weight-loss procedure. There are different techniques to perform the gastrojejunal (GJ) anastomosis, but there is no consensus as to which one is superior for weight loss. Our goal in this study was to assess one-year weight loss after LRYGB comparing the three different techniques at our tertiary care center. The American college of surgeons (ACS) Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP®) data for Montefiore Medical Center for years 2014–2017 were analyzed. Three surgeons were included in this study; each type of anastomosis was performed by a single surgeon. Patients were included if they underwent primary LRYGB. Patients were designated to one of three different groups depending of the type of gastrojejunal anastomosis performed: hand sewn, circular stapled, or linear stapled. One-year weight loss was assessed as primary endpoint of the study. A descriptive analysis of perioperative variables for each group was included as well. A total of 1011 patients underwent primary LRYGB. 429 (42.1%) were performed with circular-stapled GJ anastomosis, 433 (42.5%) with a hand-sewn GJ anastomosis, and 149 (14.6%) linear-stapled GJ anastomosis. The median BMI was 46.08 ± 6.43, with no difference between groups (p = .405). Procedure time was 106.70 ± 28.23 min for the circular group, 108.27 ± 28.59 min for the hand-sewn group, and 115.78 ± 36.11 min for the linear group (p > 0.005). There were no significant differences in complications except for the need of postoperative transfusions (p

Purpose The gastrojejunostomy during laparoscopic Roux-en-Y gastric bypass (LRYGB) can be constructed by hand sewn (HSA), linear (LSA) and circular (CSA) stapler technique. They are all considered safe; however, it is not known which the best technique is. Short-term follow-up suggest no difference in weight loss or weight regain between them. However, there is no information on these parameters in the long term. Theatre time and cost are other important factors defining the best way to form gastrojejunostomy. Materials and Methods In a prospective longitudinal cohort study consecutive patients following primary LRYGB were recruited to a bariatric database in a tertiary care centre. Anastomotic technique, diameter, the length of operations and associated costs, weight loss and weight regain were recorded. Patients were followed up for 5 years. Results A total of 385 patients with an initial body mass index of 47.1 kg/m2 (35–68) were enrolled to this study. This decreased to 33.3 kg/m2 (21–54 kg/m2) after 5 years. There was no difference in %TWL after 3 years, P = 0.296, or 5 years, P = 0.187, between the techniques. The number of patients with weight regain was not different after 3 years, P = 0.224, or 5 years, P = 0.795. All techniques had similar operative time. CSA has a higher material cost. Early anastomotic stricture was more common following HSA; however, the difference was not significant. Conclusion Mid-term weight loss and weight regain are not related to anastomotic technique, and there is no difference in operative time associated to them. Circular stapler technique has a higher material cost due to the additional stapler.

Background When performing a Roux-en-Y gastric bypass (RYGB), the gastroenterostomy can be constructed with a circular stapled or linear stapled technique. The size of the gastroenterostomy depends on the stapling method and this may affect weight loss outcomes. The aim of this study was to examine the impact of the stapling technique on weight loss outcomes after RYGB. Methods This is a nationwide population-based cohort study of patients that received a RYGB. Data were derived from the Dutch Audit of Treatment of Obesity. Primary outcome was the impact of stapling technique on the rate of non-response defined as significant weight regain (≥20% of a patients’ lost weight) 2–4 years post-surgery, after initial successful weight loss (≥20% total weight loss, TWL). Secondary outcomes were the rate of response, defined as successful weight loss (≥20% TWL) within 1.5 years post-surgery, the incidence of complications and the progression of comorbidities. Results In a cohort of 12,468 patients, non-response was equally distributed between both groups (circular 18.0% vs. linear 17.6%). No differences in response rate (circular 97.0% vs. linear 96.5%) or %TWL were observed up to 4 years post-surgery. Patients in the circular stapled group experienced more complications, specifically major bleedings (2.4% vs. 1.2%; p=0.002) within 30 days postoperatively. No differences were found in deteriorated comorbidities, neither in de novo developed comorbidities. Conclusion When comparing stapling technique in RYGB, weight loss outcomes did not differ during a 4-year follow-up period. The linear stapled gastroenterostomy could pose an advantage due to its lower complication rate. Graphical abstract

Stricture of the gastrojejunostomy is a possible complication after laparoscopic Roux-en-Y gastric bypass. We present the case of a patient with stricture refractory to endoscopic dilation. The patient underwent laparoscopic revision of the gastrojejunostomy with a hand-sewn anastomosis.

Roux-n-Y gastric bypass was considered the gold standard of bariatric surgery for a long time. It is one of the eldest bariatric procedure that continues to be performed. Specific characteristics of the design of this surgery are a small pouch and a moderate or significant malabsorption. The gastrojejunal anastomosis may lead to the appearance of dumping, and distal bypasses may lead to malnutrition. These characteristics are essential in the design of the nutritional reccommendations for operated patients. Recommendations vary from early postoperative time to long-term follow-up. Some food intolerances due to small pouches need to be also considered. This chapter reviews the nutritional recommendations for gastric bypass patients from early stages to long-term follow-up, and management of potential complications.

Purpose. Although laparoscopic Roux-en-Y gastric bypass (LRYGB) is a frequently performed bariatric procedure, there is still no consensus on its technical implementation. Methods. 211 patients treated with LRYGB in a single institution between March 2011 and October 2016 were analyzed retrospectively. A subgroup analysis for the linear (LSA) versus circular stapler technique (CSA) for gastrojejunal anastomosis (GJA) was performed to evaluate complications and outcomes. Results. 128 (60.6%) patients received GJA with CSA and 83 (39.4%) with LSA. Average weight loss one year after surgery, respectively, BMI after one year of follow-up (kg/m2), showed no significant difference. Median surgery time was significantly shorter in the LSA group. If the procedure was performed with CSA, significantly more wound infections occurred. Conclusions. Both the circular and the linear stapler techniques for gastrojejunal anastomosis in laparoscopic Roux-en-Y gastric bypass are safe methods with comparable outcomes. A disadvantage of CSA is the significantly higher rate of wound infections, a circumstance which requires increased attention.

Rats are suitable animal models in which to study the effects of gastric bypass surgery. However, construction of gastrojejunal anastomosis in the rat is technically demanding and is associated with high rate of postoperative complications. The aim of this study was to explore the feasibility and efficacy of the magnetic compression technique (MCT) in side-to-side gastrojejunal anastomosis in rats. Thirty male rats underwent gastrojejunal anastomosis using one of three techniques: hand-sewn, magnetic compression using cuboid magnets, and magnetic compression using magnetic rings. The mean anastomosis time using the magnetic compression technique was significantly less than that of the hand-sewn technique (3.6 ± 0.96 and 6.50 ± 1.58 vs. 14.40 ± 2.37 minutes,). The survival rate was highest in animals treated with magnetic compression using cuboid magnets (100%), followed by animals treated with magnetic compression using magnetic rings (90%) and then hand sewing (70%). The mean burst pressure did not differ significantly between the magnetic compression and hand-sewn anastomoses. Anastomoses constructed by magnetic compression were smoother and flatter than hand-sewn anastomoses. The results showed that MCT is a simple and feasible method for gastrojejunal anastomosis in the rat.

Objective The aim was to compare clinical outcomes of patients treated with totally robotic Roux-en-Y gastric bypass (TRRYGB) with those treated with the different laparoscopic Roux-en-Y gastric bypass (LRYGB) techniques. Summary Background Data The clinical benefit of the robotic approach to bariatric surgery compared to the standard laparoscopic approach is unclear. There are no studies directly comparing outcomes of TRRYGB with different LRYGB techniques. Methods Outcomes of 578 obese patients who underwent RYGB between 2011 and 2014 at an academic center were assessed. Multivariable analysis and propensity matching were used for comparing TRRYGB to different LRYGB techniques, including 21-mm EEA circular-stapled gastrojejunal anastomosis (GJA, LRYGB-21CS), linear-stapled GJA (LRYGB-LS), and hand-sewn GJA (LRYGB-HS). Results The TRRYGB technique required a longer mean operative time compared to the other groups, respectively 204 ± 46 vs. 139 ± 30 min (LRYGB-21CS), 206 ± 37 vs. 158 ± 30 min (LRYGB-LS), and 210 ± 36 vs. 167 ± 30 min (LRYGB-HS). TRRYGB experienced a lower stricture rate (2 vs. 17%, P = 0.003), shorter hospital stay (2.6 ± 1.2 vs. 4.3 ± 5.5 days, P = 0.008), and lower readmission rate (12 vs. 28%, P = 0.009). No significant differences in outcomes were observed when comparing RRYGB to LRYGB-LS or LRYGB-HS. Conclusions TRRYGB increases operative time compared to all LRYGB techniques. TRRYGB was superior to LRYGB-21CS in terms of significantly shorter hospital stay, lower readmission rate, and less frequent GJA stricture formation. TRRYGB provides no clinical advantages over the LRYGB-LS and LRYGB-HS techniques. Electronic supplementary material The online version of this article (10.1007/s11695-018-3228-6) contains supplementary material, which is available to authorized users.

Weight regain occurs in about 20% of patients after Roux-en-Y gastric bypass (RYGB). Studies have reported that in most cases this regain is associated with dilatation of the gastrojejunal anastomosis. To correct this dilatation, one of the methods used is the application of argon plasma coagulation (APC).The authors report the case of a 39-year-old woman submitted to RYGB who had weight regain. In the endoscopic evaluation, the patient presented with dilatation of the gastrojejunal anastomosis, for which treatment with APC and an adjusted diet was proposed. After 3 sessions of APC, the patient presented with a reduction of the anastomosis diameter, weight loss, and increased satiety to food, with an increased gastric emptying time evidenced by scintigraphy.APC proved to be a safe and efficacious method.O reganho de peso após bypass gástrico em Y de Roux (RYGB) ocorre em cerca de 20% dos doentes. Estudos relatam que na maioria dos casos este reganho está associado a dilatação da anastomose gastrojejunal. Para corrigir esta dilatação um dos métodos utilizados é a apli-cação de árgon plasma (APC).Os autores relatam o caso de uma mulher de 39 anos de idade, submetida a RYGB, que apresentou reganho de peso. Na avaliação en-doscópica a doente apresentava dilatação da anastomose gastrojejunal sendo proposta a realização de APC e dieta ajustada. Após 3 sessões de APC, a doente apresentou redução do diâmetro da anastomose associada a perda de peso, aumento da saciedade alimentar e aumento do tempo de esvaziamento gástrico documentado em cintigrafia.O tratamento com APC mostrou ser um méto-do seguro e eficaz.

Surgical gastrojejunal anastomosis (GJJ) is considered the standard palliative option for gastric outlet obstruction. The use of endoscopic GJJ has generated a lot of attention and has enlarged the horizon for patients with open surgery contraindications. Our study aimed to assess and compare 2 purely endoscopic GJJ approaches using a lumen-apposing hot tip double-flanged metal stent, with focus on technical and clinical success rates on experimental animals.Two endoscopic GJJ techniques using a double-flanged self-expandable metal stent were compared on 8 pigs. Natural orifice transluminal endoscopic surgery (NOTES) was used on 4 pigs, while the other group was subjected to an endoscopic ultrasound (EUS) balloon-guided approach.On a 21-day follow-up, both EUS and NOTES-GJJ were technically successful in all experimental animals, and necropsy confirmed full integrity of the anastomosis. Adhesions were confirmed only on 2 pigs after NOTES procedure. The mean time for GJJ-NOTES completion was 31.375 ± 2.03, whereas EUS-GJJ was completed with a median time of 20.275 ± 0.65. The stent distance from the stomach varied; in NOTES-GJJ it was 47.8 ± 11.13 cm away from the pylorus, whereas in EUS-GJJ was at 37 ± 1.85 cm.No major complications were encountered during both procedures. EUS-GJJ balloon-guided approach might be a more attractive technique by using sonographic guidance, because of less endoscopic instrument changing as well as in achieving the desired anastomotic distance.

Background Bariatric surgery is a well-tolerated and effective treatment for severe obesity. Newer surgical techniques and equipment have improved safety standards surrounding bariatric surgery. In particular, buttressing of the staple line in sleeve gastrectomy has decreased rates of clinically significant postoperative bleeding. The present study investigates the effectiveness of buttressing the circular stapled anastomosis during laparoscopic Roux-en-Y gastric bypass (LRYGB). Setting Academic, accredited hospital. Methods A total of 253 patients undergoing LRYGB at a single academic institution were included in this retrospective study between 2014 and 2015. Buttressing material was used in 125 of these cases. Demographic information was collected from both groups preoperatively. Surgical characteristics were also obtained analyzed using unpaired t or χ 2 tests. Results Patients in both buttressing and nonbuttressing groups were on average 46 years old and predominantly female (79.2% versus 74.2% female, respectively), with a body mass index of approximately 48 kg/m 2 . Postoperative weight loss did not significantly differ between groups at any time point (buttressing versus nonbuttressing percentage of excess weight loss: 39.5% versus 41.5% at 3 mo, P = .3860; 56.4% versus 56.7% at 6 mo, P = .9341). There were no significant differences for operating time, length of stay, readmissions, or reoperations. Complications due to strictures were found to be lower for the buttressing group (0% buttressing versus 2.3% nonbuttressing, P = .0851). Specific rates of bleeding-related complications were significantly lower for the group in which buttressing was used (0% buttressing versus 3.1% nonbuttressing, P = .0463). Conclusion Buttressing of the gastrojejunal anastomosis during LRYGB significantly reduces bleeding-related complications and increases tolerability of the procedure.

In 1966, Edward Mason presented the first gastric bypass procedure aiming to treat severe obesity and its consequences. It was based mostly in restriction of food ingestion by reducing gastric capacity. Over two decades passed before the approach reached a satisfactory status that lasts till the present day. Several improvements were incorporated to the primitive model: reduction of the proximal pouch; surgical staplers to build the pouch; Roux-en-Y gastrojejunal anastomosis to prevent biliopancreatic reflux (RYGBP); dividing the stapled stomach to facilitate anastomosis and prevent rupture of the staple line; locating the proximal pouch near the small curvature, thicker, to prevent dilatation.

Roux-en-Y gastric bypass (RYGB) is recently the second most frequent operation worldwide and is only preceded by sleeve gastrectomy. We present an alternative technique of reversal of RYGB. There is no need to dissect or resect the gastrojejunal anastomosis. This dissection might be difficult as the gastrojejunal anastomosis might be adherent to the residual stomach. The 2 anastomoses performed are technically easy and done on healthy non-inflammatory tissue.

PURPOSE Patients undergoing laparoscopic Roux-en-Y gastric bypass (RYGB) are at risk of developing strictures of the gastrojejunal anastomosis (GJA). Several variables can affect this, one of which may be the method of anastomosis. Between 2010 and 2014, our institution utilized three different anastomotic techniques for creating the GJA (25 mm end-to-end circular-stapled (CS), linear-stapled (LS), and robotic hand sewn (HS)). Our objectives were to compare the method of GJA relative to the subsequent development of anastomotic stricture. METHODS We queried our electronic health record for all patients who underwent an upper endoscopy (EGD) after RYGB (2010-2014). Patient charts were retrospectively reviewed for type of GJA, weight loss, complications, interventions, and revisions of the GJA. RESULTS In total, 1112 RYGB were performed at our institute, and 17.4% of patients (194/1112) had an upper endoscopy (EGD). Overall, 3.1% (34/1112) were found to have a stricture of the GJA. Patients undergoing a CS, LS, and HS anastomosis had GJA stricture rates of 4.9%, 0.5%, and 1.2% respectively (CS to LS (p

Background Obesity is becoming a worldwide health problem. Recently, bariatric surgeries are developing to combat with this problem. However, these surgical methods themselves have risks. Objectives The present study investigated the preventive effect of routine leak test of both gastrojejunal and jejunojejunal anastomoses immediately after laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery against post-operative leak by inexperienced surgeons. Methods In a prospective interventional study, this research enrolled 52 morbid obese patients with LRYGB from September 2014 to October 2016. After anastomoses, methylene blue and air leak tests were performed and the section line and both anastomosis sites for patency and inspected for air and dye leaks were examined. Results Mean body mass index of patients was 48.84 ± 6.8 kg/m2. Twelve patients had positive leak test and the anastomoses were reinforced by additional sutures. All patients were discharged with no leak and no patient had leak during the routine follow-up period. Conclusions Intraoperative leak test of both gastrojejunal and jejunojejunal anastomoses is a valuable test in the assessment of leak during LRYGB surgery, especially in unskilled surgeons.

The video shows, step-by-step, the hybrid laparoscopic conversion of vertical banded gastroplasty (VBG) to Roux-en-Y gastric bypass (RYGB) with a robotic-assisted hand-sewn technique (HST) for gastrojejunal anastomosis (GJA).

Background: Anastomotic strictures at the gastrojejunal anastomosis (GJA) are relatively common after a laparoscopic Roux-en-Y gastric bypass (LRYGB). There are three different ways to perform a GJA: circular stapled (CS), linear stapled (LS), and hand-sewn (HS). The CS technique provides the most standard diameter, and the LS and HS techniques can be standardized by using a bougie to calibrate the diameter of the anastomosis. However, they can all become strictured. This study examines the stricture rate of a hand-sewn GJA over a 4-year period. Methods: A prospectively maintained database was used to retrospectively evaluate patient outcomes at our bariatric center. This database was evaluated for strictures. The gastric bypasses were performed over a 4-year period by a single surgeon. The technique remained standard over the study period. This was a two-layered HS anastomosis with four different sutures of an absorbable suture (2.0 VICRYL®). Inclusion criteria were primary laparoscopic gastric bypasses....

The number of overweight and obese people has been increasing year by year for decades, and the number of surgeries and procedures to control this disease has increased proportionately. Bariatric surgery is the best treatment for advanced cases, but presents a relapse rate of around 20%. In cases of weight recidivism after gastric bypass, endolumenal treatments are important adjuvant therapies to reintegrate patients with the specialized multidisciplinary team. Therapies using endoscopic sutures with or without argon plasma coagulation are notable in the treatment of dilated gastrojejunal anastomosis and enlarged pouches. In conclusion, endolumenal procedures have been shown to be safe and effective for this purpose with high success rates.

Background. Complications at the gastrojejunal anastomosis after laparoscopic Roux-en-Y gastric bypass (LRYGB) are challenging in terms of diagnosis, therapy, and prevention. This study aims at identifying these complications and discussing their management.Methods. Data of 228 patients who underwent a LRYGB between October 2008 and December 2011 were reviewed retrospectively to evaluate the frequency and treatment of complications such as stenoses, marginal ulcers, perforated marginal ulcers, or anastomotic leaks related to the operation.Results. Follow-up information was available for 209 patients (91.7%) with a median follow-up of 38 months (range 24–62 months). Of these patients 16 patients (7.7%) experienced complications at the gastrojejunostomy. Four patients (1.9%) had stenoses and 12 patients (5.7%) marginal ulcers, one of them with perforation (0.5%). No anastomotic leaks were reported. One case with perforated ulcer and one with recurrent ulcers required surgical revision.Conclusion. Gastrojejunal anastomotic complications are frequent and occur within the first few days or up to several years after surgery. Stenoses or marginal ulcers are usually successfully treated nonoperatively. Laparoscopic repair, meanwhile, is an appropriate therapeutic option for perforated ulcers.

The failure of approximately 20 % of obese patients who undergo Roux-en-Y gastric bypass (RYGB) to maintain weight loss over the following 18–24 months is related to the surgical procedure, to the patient, or both. Although the underlying mechanisms are uncertain, one factor that has been postulated is the dilation of the gastrojejunal anastomosis. The objective was to evaluate the safety and efficacy of the serial use of argon plasma coagulation (APC) in reducing the diameter of the dilated gastrojejunal anastomosis and post-RYGB weight regain. We carried out a prospective, nonrandomized study of 30 patients, with no control or sham group, monitoring RYGB weight regain associated with dilation of the gastrojejunal anastomosis over a postoperative period of 18 months. Each patient underwent three sessions of APC in the anastomosis separated by 8 weeks, with a final endoscopic examination 8 weeks after the last session. There was a loss of 15.48 kg (range = 8.0–16.0 kg) of the 19.6 kg (range = 7.0–39.0 kg) of regained weight after RYGB and a reduction of 66.89 % in the final anastomotic diameter, with statistically significant reductions between each APC session. Previous body mass index significantly decreased up to the final examination, and the final weight was close to but not at the same level as the nadir. Our study indicates that the use of APC to treat weight regain after RYGB is a safe and effective procedure and promotes a reduction in gastrojejunal anastomosis, final weight, and BMI, with a low rate of complications.

Introduction: Occurrence of anastomotic leaks following Roux-en-Y gastric bypass (RYGB), arising principally from the gastro-jejunal anastomosis, is associated with significant morbidity and mortality. Their early detection and treatment is essential. However, a significant number of postoperative oral contrast studies fail to identify leaks, and a negative study providing false reassurance can lead to a delay in diagnosis and treatment. Physiological features including tachycardia, increased respiratory rate and pyrexia or elevations in C-reactive protein and white cell count are seen in patients with leaks. In this study we examine physiological and laboratory parameters in patients with and without anastomotic leaks following RYGB to try and improve the detection of leaks. Aim: To evaluate clinical signs and laboratory tests in determination of the development of gastrojejunal leaks after gastric bypass surgery. Material and methods: The study examined 116 consecutive patients undergoing laparoscopic RYGB. Clinical signs and laboratory results were reviewed retrospectively. Results: Four gastrojejunostomy leaks in our series were identified after RYGB surgery. All these patients were treat- ed successfully. Leak patients' in-hospital stay was longer. Tachycardia among leak patients occurs from day 1 with 100% sensitivity and 87% specificity at a cut-off point of 90 bpm. A temperature difference appears on day 2 in leak patients. The CRP was higher on day 2 and 3 in leak patients. Higher intravenous fluid requirements were observed in patients with leaks. Conclusions: Gastrojejunal anastomosis leak is associated with longer in-hospital treatment. The earliest significant indicators of a leak are tachycardia and positive fluid balance. A temperature spike and CRP rise occur on day 2. Leak patients matched SIRS WBC count criteria on day 3.

Several types of endoscopic suturing systems have been developed for the last two decades. OverStitch (Apollo Endosurgery Inc, Austin, TX, USA) is the most widely used endoscopic suturing device. The device assembly and use are straightforward, are easy, and closely resemble surgical suturing. Endoscopic suturing with the OverStitch device has been successfully used for numerous clinical indications: Closure of GI tract fistulas Fixation of internal stents to prevent stent migration Repair of dilated gastrojejunal anastomosis postprevious gastric bypass and primary bariatric procedures for treatment of obesity Facilitation of endoscopic submucosal dissection with a suture-pulley technique, repair of inadvertent iatrogenic GI tract perforations Closure of large mucosal defect postendoscopic mucosal resection or endoscopic submucosal dissection (ESD) Closure of full-thickness GI wall defects postfull-thickness resection of GI tract lesions

INTRODUÇÃO: Bypass gástrico em Y-de-Roux pode resultar em estenose de anastomose gastrojejunal. Não há protocolo de tratamento bem definido para essa complicação. OBJETIVO: Analisar os resultados da dilatação endoscópica em pacientes com estenose, através de revisão sistemática, incluindo complicações e taxa de sucesso. MÉTODOS: Foi realizada busca dos estudos relevantes publicados de 1988 a 2010 na base de dados do PubMed, sendo identificados 23 estudos para análise. Apenas os que descreviam o tratamento de estenose de anastomose após bypass gástrico em Y-de-Roux foram incluídos e relatos de caso que apresentavam menos de três pacientes foram excluídos. RESULTADOS: A idade média da população foi de 42,3 anos e o índice de massa corpórea pré-operatório médio foi de 48,8 kg/m². No total, 760 pacientes (81% feminino) foram submetidos a 1298 procedimentos, sendo realizadas 1,7 dilatações por paciente. Balões Through-the-scope foram utilizados em 16 estudos (69,5%) e dilatador de Savary-Gilliard em quatro. Apenas 2% dos pacientes necessitaram revisão cirúrgica após a dilatação; a taxa de complicações reportada foi de 2,5% (n=19). A taxa de sucesso anual foi maior que 98% nos anos 1992 a 2010, exceto por uma de 73% em 2004. Sete estudos relataram complicações, sendo perfuração a mais comum, relatada em 14 pacientes (1,82%), necessitando operação imediata em dois pacientes. Outras complicações foram também relatadas: um hematoma esofágico, uma lesão de Mallory-Weiss, um caso grave de náusea e vômito, e dois casos de dor abdominal importante. CONCLUSÃO: Tratamento endoscópico de estenose é seguro e eficaz; entretanto, mais estudos controlados randomizados devem ser realizados a fim de confirmar esses achados. INTRODUCTION: Roux-en-Y gastric bypass may result in stenosis of the gastrojejunal anastomosis. There is currently no well-defined management protocol for this complication. AIM: Through systematic review, to analyze the results of endoscopic dilation in patients with stenosis, including complication and success rates. METHODS: The PubMed database was searched for relevant studies published each year from 1988 to 2010, and 23 studies were identified for analysis. Only papers describing the treatment of anastomotic stricture after Roux-en-Y gastric bypass were included, and case reports featuring less than three patients were excluded. RESULTS: The mean age of the trial populations was 42.3 years and mean preoperative body mass index was 48.8 kg/m². A total of 1,298 procedures were undertaken in 760 patients (81% female), performing 1.7 dilations per patient. Through-the-scope balloons were used in 16 studies (69.5%) and Savary-Gilliard bougies in four. Only 2% of patients required surgical revision after dilation; the reported complication rate was 2.5% (n=19). Annual success rate was greater than 98% each year from 1992 to 2010, except for a 73% success rate in 2004. Seven studies reported complications, being perforation the most common, reported in 14 patients (1.82%) and requiring immediate operation in two patients. Other complications were also reported: one esophageal hematoma, one Mallory-Weiss tear, one case of severe nausea and vomiting, and two cases of severe abdominal pain. CONCLUSION: Endoscopic treatment of stenosis is safe and effective; however, further high-quality randomized controlled trials should be conducted to confirm these findings.

The laparoscopic Roux Y gastric bypass (LRYGB) is one of the most often performed bariatric surgical intervention. Intraoperative gastroscopy (IOG) seems to be reliable to decrease the leakage rate of gastrojejunal anastomosis (GJA) and of gastric pouch (GP). Our aim was to test the efficacy and the safety of this method. Two hundred fifty-two LRYGB operations were performed in our institution between 1 January 2008 and 1 January 2010. IOG is routinely made to test the integrity of GJA and of GP. Patients' dates were retrospectively analysed. The intragastric pressure developed during gastroscopy in humans was measured and compared with pressure values led to destruction (positive air test) of the GJA and/or GP in animal models (hybrid pigs). Stomach and bowel wall samples from the test animals without pressure strain, with pressure strain developed at gastroscopy in humans and with pressure strains led to destruction of GJA and/or GP were histologically examined. IOG resulted in six of our cases (2.3%) positive air test. There was no anastomosis insufficiency in postoperative period. Mean pressure during IOG was 32 mmHg, mean time of examination was 3.8 min and mean maximal pressure was 43 mmHg in humans. The mean pressure leading to positive air test in pigs was 150 mmHg. We could not detect any microscopical difference between stomach and jejunum samples without pressure strain and after pressure strain developed in humans during the gastroscopy. We conclude that intraoperative gastroscopy is an effective and safe method to test the integrity of GJA and GP in LRYGB surgery.

In this study, the application of reinforced circular staplers reduced the incidence of gastrojejunal anastomotic complications in patients undergoing Roux-en-Y gastric bypass., Background: Roux-en-Y gastric bypass (RYGBP) is the most common procedure for weight loss surgery but has multiple complications. This study evaluates the use of reinforced circular staplers (RCS) and their effects on reducing gastrojejunal anastomotic complications. Methods: We conducted a retrospective chart review from January 2007 to November 2008. Laparoscopic RYGBP were performed in 287 patients. A comparison was made of the complications with and without the use of reinforced circular staplers. The comparison was between a nonreinforced circular stapler (NRCS) group comprising 182 patients and an RCS group comprising 105 patients. Results: Complications at gastrojejunal anastomosis were experienced by 15.3% of the patients; 9.5% were in the RCS group and 18.7% were in the NRCS group (P=0.026). Neither group had anastomotic leaks. Bleeding rate was 4.8% in the RCS group vs. 6.6% in the NRCS group. Ulcers occurred in 2.9% of the RCS group vs. 6.0% of the NRCS group. Stricture rate was 1.9% in the RCS group vs. 6.6% in the NRCS group. Conclusion: The application of RCS reduced the incidence of gastrojejunal anastomotic complications. Patients are twice as likely to develop complications when no RCS device is used (95% CI 1.03, 4.623). Therefore, it is beneficial to utilize RCS for the gastrojejunal anastomosis in RYGBP procedures.