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Clinical care pathways help guide and provide structure to clinicians and providers to improve healthcare delivery and quality. The Quality Improvement and Patient Safety Committee (QIPS) of the American Society for Metabolic and Bariatric Surgery (ASMBS) has previously published care pathways for the performance of laparoscopic sleeve gastrectomy (LSG) and pre-operative care of patients undergoing Roux-en-Y gastric bypass (RYGB). This current RYGB care pathway was created to address intraoperative care, defined as care occurring on the day of surgery from the preoperative holding area, through the operating room, and into the postanesthesia care unit (PACU). PubMed queries were performed from January 2001 to December 2019 and reviewed according to Level of Evidence regarding specific key questions developed by the committee. Evidence-based recommendations are made for care of patients undergoing RYGB including the pre-operative holding area, intra-operative management and performance of RYGB, and concurrent procedures. This document may provide guidance based on recent evidence to bariatric surgeons and providers for the intra-operative care for minimally invasive RYGB. [ABSTRACT FROM AUTHOR]

Introduction: Gastrojejunal anastomosis (GJA) dilation is an independent predictor of weight regain (WR) after Roux-en-Y gastric bypass (RYGB). However, the role of planimetric measurements in this context remains unknown. Methods: This is a retrospective cohort study including adult RYGB patients who underwent a diagnostic endoscopy with Endoflip assessment of the GJA. We excluded patients in the early postoperative period and those with abnormal endoscopic findings (marginal ulcers and gastro-gastric fistulas). Results: Thirty-four patients were initially included. Endoscopic GJA diameter had a moderate positive correlation with WR (r=+0.438, p=0.011). However, after excluding the 7 patients with GJA> 30 mm, there was no significant correlation. There was a moderate agreement between the EndoFLIP-GJA diameter at 60mL and endoscopic diameter (ICC=0.576, p=0.049). The distensibility index (DI) showed a consistent moderate negative correlation with WR. Considering the maximum DI at 40 ml, we found a cutoff of DI = 7 mm2/mmHg that split the sample in two significantly different populations in terms of WR (67.4% vs. 43.2%, p=0.04). Conclusion: Visual estimation of the GJA diameter correlates with EndoFLIP at 60mL. In the subset of patients with GJA ≤ 30 mm, more distensible GJAs are associated with lower rates of WR. Larger studies are needed to confirm this correlation and to validate its utility for clinical management. [ABSTRACT FROM AUTHOR]

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 < 0.05), p = NS among CS vs. HS, and LS vs. HS). The rate of GJA revision was 1.5%, 0.5%, and 0.1% (p = NS). In patients who had an EGD, excess BMI loss was 57.4%, 64.6%, and 59.2% (p = NS). In patients symptomatic from strictures, excess BMI loss was 69.4%, 83%, and 63.5% respectively (p = NS). Conclusion: The anastomotic technique for creating of the GJA may impact the formation of strictures. Based on our experience, gastrojejunostomies created with a 2-mm EEA-stapling technique are at higher risk of strictures. [ABSTRACT FROM AUTHOR]

Background: Obesity is becoming a worldwide health problem. Recently, bariatric surgeries are developing to combat with thisproblem. However, these surgical methods themselves have risks.Objectives: The present study investigated the preventive effect of routine leak test of both gastrojejunal and jejunojejunal anastomosesimmediately 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 2014to October 2016. After anastomoses, methylene blue and air leak tests were performed and the section line and both anastomosissites 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 werereinforced 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 ofleak during LRYGB surgery, especially in unskilled surgeons.

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. [ABSTRACT FROM AUTHOR]

Several recent studies have described the feasibility, efficacy and safety of the placement of lumen‐apposing metal stents (LAMS) for the treatment of gastrointestinal strictures. However, the optimum stent indwelling time is unclear. We reviewed the literature on endoscopic gastroenterostomy (GE) with a focus on the stent indwelling time and we described the first reported case of iatrogenic perforation six months after Axios stent placement. In the literature review (n = 239), the composite technical success rate and clinical success rate were 93.7% and 87.9%, respectively. The mean follow‐up period was 191 days, and the mean stent indwelling time was 88 days. Among 13 studies (n = 202), the mean rate of complications was 13.4%. The principal complication was mis‐deployment of the stent (4.5%). We report a case report of delayed iatrogenic perforation. A 59‐year‐old male patient with cystic dystrophy of the duodenum has been followed for several years. He presented with anorexia following duodenal obstruction and underwent endoscopic ultrasound‐guided gastrojejunostomy. Six months later, he was referred to our center due to septic shock, and abdominal computed tomography revealed peritonitis secondary to a perforation of the small intestine, opposite the Axios stent. The mean LAMS indwelling time after GE was 88 days. To minimise the rate of adverse events, such as ulceration and mucosal overgrowth, regular abdominal computed tomography and endoscopy can be performed to evaluate the local effect of the stent. When the disease has resolved, the LAMS must be removed as soon as possible. [ABSTRACT FROM AUTHOR]

Introduction: An unusually high surgical site infection (SSI) rate after Roux-en-Y gastric bypass (RYGB) was noted on routine outcomes review. Surgeon A, who had a rate of 8.9%, utilized the transoral technique (passage down esophagus into gastric pouch) for anvil insertion for the circular-stapled gastrojejunostomy. By comparison, SSI rate was 0% for Surgeon B, who inserted anvil transabdominally (direct passage into stomach via gastrotomy) and used wound protection (wound protector and plastic drape over stapler). We sought to determine if it was the technique for anvil insertion (transoral or transabdominal) or use of wound protection that could help reduce SSIs.Methods: In mid-2017, Surgeon A added wound protection (wound protector and plastic drape over stapler) to the transoral technique to minimize oral flora wound contamination. Surgeon B made no changes. In this study, wound-related outcomes are examined, comparing patients who underwent surgery before (Group 1) versus after (Group 2) this intervention. Statistical analysis performed utilizing t tests and Chi square analysis; p < 0.05 considered significant.Results: Three hundred and thirty-three patients underwent RYGB. Group 1 consisted of 182 patients over 17 months; 151 patients over 13 months were in Group 2. Groups were similar in age, BMI, gender, and prevalence of diabetes. There was a decrease in SSIs between Group 1 and Group 2 (5 vs. 0, p = 0.04). 11 wound complications occurred in Group 1 (5 SSIs, 4 seromas and 2 hematomas); whereas 2 wound complications occurred in Group 2 (1 seroma and 1 hematoma); decrease from 6 to 1.3%, p = 0.03.Conclusions: This study demonstrates that changing technique can lead to best outcomes. There was a dramatic reduction of wound complications and complete elimination of SSIs with a change in operative technique. The higher risk of SSI with the transoral anvil insertion when preforming a circular-stapled anastomosis can be mitigated with use of wound protection. [ABSTRACT FROM AUTHOR]

Copyright of Cirugía y Cirujanos is the property of Publicidad Permanyer SLU and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Surgical staplers represent one of the important instruments in modern surgery. Laparoscopic Roux-en-Y gastric bypass is one of the most commonly performed bariatric procedures. Various techniques have been described for performing gastrojejunal (GJ) anastomosis, including linear stapled anastomosis (LSA), circular stapled anastomosis (CSA) and hand-sewn anastomosis (HSA). An ex-vivo porcine-based experiment was designed to compare the mechanical integrity of the GJ anastomosis among the 3 different techniques by measuring burst pressure (BP). Laboratory-based study conducted at the clinical skills laboratory at Birmingham Heartlands Hospitals, Birmingham, United Kingdom. Porcine stomachs and small bowels were used to create a GJ model. Four GJ anastomosis models each were created using circular stapler (CSA group) and hand-sewn techniques (HSA group). Stomach and small bowel thickness were recorded. BP was measured by sequential injections of methylene-blue diluted saline until a leak was detected. Total volume until leak is recorded. Compliance (C) was calculated using the formula C = ΔP/ΔV. Results from our previous experiment for the LSA group are included. One model was excluded from the CSA and the HSA groups due to technical errors. Results were presented as mean ± standard deviation. Total volume in LSA, CSA, and HSA groups was 60 ± 4.08 mL, 73.67 ± 3.22 mL, and 51.67 ± 20.21 mL, respectively. BP in LSA, CSA, and HSA groups was 18 ± 4.69 mm Hg, 20.33 ± 5.77 mm Hg, and 9.67 ± 3.79 mm Hg, respectively. There was a statistically significant difference in BP among the 3 groups (P =.033; Kruskal-Wallis test). C in LSA, CSA, and HSA were 3.50 ±.88 mm Hg/mL, 3.78 ±.85 mm Hg/mL, and 5.39 ± 1.34 mm Hg/mL, respectively (P =.064). BP was higher in CSA and LSA groups compared with the HSA group, suggesting a mechanically stronger anastomosis. Despite the lack of statistical significance, higher BP recorded in the CSA group than in the LSA group suggests better anastomotic integrity. • Gastro-jejunal anastomosis remains to be one of the most debatable steps in RYGB. • Mechanical anastomosis, linear or circular stapled, showed higher burst pressure in our simulated gastro-jejunal models when compared to hand-sewn anastomosis, suggesting a better anastomotic mechanical integrity. • Tissue compliance needs to be further investigated in order to evaluate its effect on anastomotic integrity and stapler function. [ABSTRACT FROM AUTHOR]

Background: Transoral outlet reduction (TORe) is a minimally invasive endoscopic revision of Roux-en-Y gastric bypass (RYGB) for weight recurrence; however, little has been published on its clinical implementation in the community setting., Aim: To characterize the safety and efficacy of TORe in the community setting for adults with weight recurrence after RYGB., Methods: This is a retrospective cohort study of argon plasma coagulation and purse-string suturing for gastric outlet reduction in consecutive adults with weight recurrence after RYGB at a single community center from September 2020 to September 2022. Patients were provided longitudinal nutritional support via virtual visits. The primary outcome was total body weight loss (TBWL) at twelve months from TORe. Secondary outcomes included TBWL at three months and six months; excess weight loss (EWL) at three, six, and twelve months; twelve-month TBWL by obesity class; predictors of twelve-month TBWL; rates of post-TORe stenosis; and serious adverse events (SAE). Outcomes were reported with descriptive statistics., Results: Two hundred eighty-four adults (91.9% female, age 51.3 years, body mass index 39.3 kg/m 2 ) underwent TORe an average of 13.3 years after RYGB. Median pre- and post-TORe outlet diameter was 35 mm and 8 mm, respectively. TBWL was 11.7% ± 4.6% at three months, 14.3% ± 6.3% at six months, and 17.3% ± 7.9% at twelve months. EWL was 38.4% ± 28.2% at three months, 46.5% ± 35.4% at six months, and 53.5% ± 39.2% at twelve months. The number of follow-up visits attended was the strongest predictor of TBWL at twelve months (R 2 = 0.0139, P = 0.0005). Outlet stenosis occurred in 11 patients (3.9%) and was successfully managed with endoscopic dilation. There was one instance of post-procedural nausea requiring overnight observation (SAE rate 0.4%)., Conclusion: When performed by an experienced endoscopist and combined with longitudinal nutritional support, purse-string TORe is safe and effective in the community setting for adults with weight recurrence after RYGB., Competing Interests: Conflict-of-interest statement: Dr. Daniel B Maselli is a consultant for Apollo Endosurgery, with no proprietary relationship. Dr. Christopher E McGowan previously served as a consultant for Apollo Endosurgery from 2019-2022, with no proprietary relationship. Dr. Vibhu Chittajallu, Dr. Lauren L Donnangelo, Dr. Brian Coan, Mr. Chase Wooley, Ms. Areebah Waseem, Ms. Michelle Secic, and Mr. Daniel Lee have no conflicts of interest or financial ties to disclose., (©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.)

RACIONAL: Bypass gástrico em Y-de-Roux é a operação bariátrica mais comumente realizada. Pequena bolsa gástrica é criada, deixando uma anastomose gastrojejunal estreita, com uma alça jejunal mais comprida. Muito pouco é conhecido sobre o comportamento desta bolsa em anos após o procedimento. OBJETIVO: Determinar através de estudos prospectivos endoscópico e histológico seqüenciais o tamanho da bolsa gástrica, o diâmetro da anastomose e o comportamento da infecção por H. pylori após a operação. MÉTODOS: Em 130 pacientes submetidos ao bypass gástrico foram realizadas várias avaliações sequenciais endoscópica (até 120 meses) e histológica de rotina da bolsa gástrica. RESULTADOS: Após a operação, foram realizadas em média 3,6 endoscopias por paciente. Macroscopicamente quase 95% das pequenas bolsas gástricas eram normais, e o principal achado patológico foi uma úlcera marginal. Esofagite erosiva desapareceu em 93% dos pacientes. Não houve aumento no tamanho orocaudal da bolsa durante o período de observação. Não houve dilatação do diâmetro da anastomose gastrojejunal. Perto de 54% de todos os pacientes tinham mucosa fúndica normal, enquanto 18% tinham gastrite crônica ativa, coincidente com a infecção por H. pylori. Cinco pacientes tinham metaplasia intestinal. CONCLUSÃO: Com base nesta avaliação endoscópica sequencial, não houve aumento no tamanho orocaudal da bolsa gástrica, nem do diâmetro da anastomose gastrojejunal. O comportamento do H. pylori foi inconsistente e difícil de interpretar.BACKGROUND: Roux-en-Y gastric bypass is the most common performed bariatric surgery. A small gastric pouch is created, leaving a narrow gastrojejunal anastomosis, with a long jejunal limb. Very little is known regarding the behavior of this pouch years after surgery. AIM: To determine through prospective sequential endoscopic studies the size of the gastric pouch, the diameter of the anastomosis, and the behavior of H. pylori infection after surgery. METHODS: In 130 patients subjected to resectional gastric bypass, several routine sequential endoscopic (until 120 months) and histological evaluations of the gastric pouch were performed. RESULTS: After surgery, a mean of 3.6 endoscopies/patient were performed. Macroscopically nearly 95% of the small gastric pouches were normal, and the main pathological finding was a marginal ulcer. Erosive esophagitis disappeared in 93% of the patients. There was no increase in the orocaudal size of the pouch during this period of observation. There was no dilatation of the diameter of gastrojejunal anastomosis. Near 54% of all patients had normal fundic mucosa, while 18% had chronic active gastritis, coincident with H. pylori infection. Five patients had intestinal metaplasia. CONCLUSION: Based on this sequential endoscopic evaluation, there was no increase in the orocaudal size of the gastric pouch nor increase in the diameter of the gastrojejunal anastomosis. H. pylori behavior was inconsistent and difficult to interpret.

Background: Different anastomotic techniques have been evaluated during a laparoscopic Roux-en-Y gastric bypass (RYGB); however, no techniques have proven to be better than any other regarding complications and the percentage of weight loss (excess weight loss (%EWL)), and there are few controlled prospective studies to compare them. Methods: A randomized, prospective study was conducted in 238 patients undergoing RYGB for morbid obesity between July 2008 and September 2012 to compare the early and late postoperative complications between the two surgical techniques: gastrojejunal hand-sutured anastomosis (HSA) and circular-stapled anastomosis (CSA). Minimum follow-up was 24 months. Results: The two groups of patients were similar for demographic data and preoperative comorbidities. There were no significant differences between the surgical techniques regarding %EWL at 3, 12, and 24 months. The patients with CSA had a greater frequency of postoperative gastrointestinal bleeding (GIB) (4.2 vs. 0 %, p = 0.024) and surgical wound infection (11.1 vs. 3.4 %, p = 0.025) than the patients with HSA, with no significant differences in the other early complications. There were no significant differences in either group for late complications (gastrojejunal anastomosis (GJA) stricture, marginal ulcer, GJA perforation, bowel obstruction, and eventration). No significant differences were observed in operative time, rate of reoperation and postoperative length of hospital stay. Conclusions: HSA and CSA were techniques with similar safety and effectiveness in our study. HSA had a lower rate of bleeding complications and surgical wound infection, although it does require greater experience in laparoscopic hand suturing. [ABSTRACT FROM AUTHOR]

Background: Different gastrojejunal anastomotic (GJA) techniques have been described in laparoscopic Roux-en-Y gastric bypass (LRYGB). There is conflicting data on whether one technique is superior to the other. We aimed to compare hand-sewn (HSA), circular-stapled (CSA) and linear-stapled (LSA) anastomotic techniques in terms of stricture rates and their impact on subsequent weight loss. Methods: A prospectively collected database was used to identify patients undergoing LRYGB surgery between March 2005 and May 2012. Anastomotic technique (HSA, CSA, LSA) was performed according to individual surgeon preference. The database recorded patient demographics, relevant comorbidities and the type of GJA performed. Serial weight measurements and percentage excess weight loss (%EWL) were available at defined follow-up intervals. Results: Included in the data were 426 patients, divided between HSA ( n = 174, 40.8 %), CSA ( n = 110, 25.8 %) and LSA ( n = 142, 33.3 %). There was no significant difference in the stricture rates (HSA n = 17, 9.72 %; CSA n = 9, 8.18 %; LSA n = 8, 5.63 %; p = 0.4006). Weight loss was similar between the three techniques (HSA, CSA and LSA) at 3 months (40.6 % ± 16.2 % vs 35.92 % ± 21.42 % vs 48.21 % ± 14.79 %; p = 0.0821), 6 months (61.48 % ± 23.94 % vs 58.16 % ± 27.31 % vs 60.18 % ± 22.26 %; p = 0.2296), 12 months (72.94 % ± 19.93 % vs 69.72 ± 21.42 % vs 66.05 % ± 17.75 %; p = 0.0617) and 24 months (73.29 % ± 22.31 % vs 68.75 % ± 24.71 % vs 69.40 % ± 23.10 %; p = 0.7242), respectively. The stricture group lost significantly greater weight (%EWL) within the first 3 months compared to the non-stricture group (45.39 % ± 16.82 % vs 39.22 % ± 21.93 %; p = 0.0340); however, this difference had resolved at 6 months (61.29 % ± 18.50 % vs 59.79 % ± 23.03 %; p = 0.8802) and 12 months (71.59 % ± 18.67 % vs 68.69 % ± 22.19 %; p = 0.5970). Conclusions: There was no significant difference in the rate of strictures between the three techniques, although the linear technique appears to have the lowest requirement for post-operative dilatation. The re-intervention rate will, in part, be dictated by the threshold for endoscopy, which will vary between units. Weight loss was similar between the three anastomotic techniques. Surgeons should use techniques that they are most familiar with, as stricture and weight loss rates are not significantly different. [ABSTRACT FROM AUTHOR]

Copyright of Journal Africain D'Hépato-Gastroentérologie is the property of Lavoisier and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: Laparoscopic Roux-en-Y gastric bypass is the most commonly adopted bariatric procedure. The predominant majority of surgeons construct the anastomoses using stapled techniques. We describe our technique of complete laparoscopically sutured gastrojejunal anastomosis (GJA) and its outcomes. Methods: Electronic database was used to collect data retrospectively for patients undergoing laparoscopic gastric bypass at the senior author's bariatric institutions. The results shown represent median (interquartile range). Results: Between April 2002 and April 2012, 1,754 consecutive patients (78 % female) aged 43 (35-50) years with BMI 51 (44.5-56.7) kg/m underwent laparoscopic gastric bypass (1,679 primary bypasses, 75 revision procedures). All the GJA were hand-sutured. The operative mortality was 0.17 %. Four patients (0.22 %) developed GJA/gastric pouch leak of whom two died, while a further three patients (0.17 %) needed endoscopic dilatation of GJA stricture during the initial 2 years after surgery. Conclusions: In the hands of an experienced laparoscopic surgeon, laparoscopic hand-sutured GJA in patients undergoing gastric bypass is safe and effective with very low anastomotic leak and stricture rates. [ABSTRACT FROM AUTHOR]

Background: An increasing number of minimally invasive oesophagogastrectomies (MIOG) are being performed. However, the complexity of the surgical skills required and the steep learning curve have thus far confined the minimally invasive approach to selected tertiary centres. The oesophagogastric and the oesophagojejunal anastomosis can be challenging and often time-consuming. The recently developed transorally inserted anvil (OrVil) is a technique aimed to simplify the anastomotic procedure. The aim of the study was to evaluate the safety, feasibility, and efficacy of OrVil-assisted anastomosis during laparoscopic surgery in a tertiary upper-GI cancer centre. Methods: From July 2008 to July 2010, 53 consecutive patients underwent MIOG for cancer performed by one surgeon at our institution. Thirty patients underwent laparoscopic Ivor-Lewis oesophagectomy (ILO) and 23 patients underwent laparoscopic gastrectomy. Of the latter group, 13 had a total gastrectomy (TG) and 10 had a subtotal gastrectomy (SG). The gastrointestinal anastomosis was checked with intraoperative endoscopy in all cases. Results: There were three in-hospital deaths. Median hospital stay was 14 days for oesophagectomies and 11 days for gastrectomies. There were three anastomotic leaks (5.6%), all in the oesophageal group, successfully treated conservatively. Two patients needed conversion to open surgery (3.7%), 3 patients (5.6%) required re-exploration (for bleeding, infected haematoma, and diaphragmatic hernia), and 18 patients (34%) had respiratory complications (pneumonia, pleural effusions, respiratory failure). Four patients developed anastomotic stricture requiring endoscopic balloon dilatation. The average number of lymph nodes harvested was 22 (range = 11-39) and 26 (range = 5-78) for oesophagectomies and gastrectomies, respectively. Conclusions: The principles of a good anastomosis are good vascular supply, must be tension-free, and the use of a high-quality surgical technique. The use of the OrVil in laparoscopic upper-gastrointestinal surgery is safe and does not have an increased complication rate. It is quicker and easier compared to the traditional purse-string technique and it may help to expand the adoption of MIOG surgery. [ABSTRACT FROM AUTHOR]

Abstract: Background: Endoscopic balloon dilation is an effective treatment of gastrojejunal (GJ) strictures after Roux-en-Y gastric bypass (RYGB), although its success might depend on the point at which they occur postoperatively. We hypothesized that “late” strictures (≥90 d after RYGB) might be less amenable to balloon dilations than “early” strictures occurring within 90 days postoperatively. Methods: A review of a prospectively maintained database at a bariatric center was conducted to identify all patients who underwent upper endoscopy (UE) for investigation of gastrointestinal symptoms after RYGB. Those who were diagnosed with a GJ anastomotic stricture at endoscopy were selected for additional evaluation. The patients were classified into 1 of 3 groups, according to the point at which they presented with stricture symptoms (group 1, 0–90 d after RYGB; group 2, 91–365 d after RYGB; and group 3, >1 yr after RYGB). All strictures were dilated using through-the-scope controlled radial expansion balloons. Results: From July 2006 to July 2009, 929 RYGB procedures were performed in our bariatric unit. Our surgical endoscopy team performs approximately 1500 UE investigations annually. Most investigations were for preoperative assessment of bariatric patients; however, a proportion is indicated for the investigation of postoperative weight regain and complications of foregut surgery, as well as endoluminal surgery. In the present study period, 591 gastric bypass patients underwent UE for investigation of gastrointestinal symptoms postoperatively. In total, 72 patients were diagnosed with a symptomatic GJ anastomotic stricture and underwent balloon dilation. Almost two thirds (63.9%) of the dilations were performed within 90 days after RYGB; 98% of these “early” strictures resolved with dilation. In comparison, of the “late” strictures, only 61% (16 of 26 patients) resolved and 38.5% (n = 10) required revisional surgery for additional management. Conclusion: Endoscopic balloon dilation is effective in treating early GJ strictures after RYGB. Late strictures are less amenable to endoscopic dilation and often require revisional surgery. Patients presenting with upper gastrointestinal symptoms after RYGB warrant early investigation with UE to investigate for a GJ stricture, which if present, should be promptly dilated. [Copyright &y& Elsevier]

Abstract: Background: Anastomotic stricture remains the most common complication after laparoscopic gastric bypass with a circular-stapled gastrojejunostomy. The present study examined the effect of the use of bioabsorbable circular staple line reinforcement on the incidence of gastrojejunostomy anastomotic strictures as a complication of laparoscopic Roux-en-Y gastric bypass. Methods: A retrospective review was performed of 851 consecutive patients who underwent laparoscopic Roux-en-Y gastric bypass with circular-stapled gastrojejunostomy. Gore SeamGuard bioabsorbable circular staple line reinforcement was used in 596 consecutive patients subsequent to 255 consecutive patients without anastomotic reinforcement. The incidence of anastomotic stricture was compared after mean follow-up periods of 19 and 22 months for the two groups. Results: Anastomotic stricture requiring intervention was identified in 28 patients (2.94%). Only four patients (.67%) in the SeamGuard group developed anastomotic stricture compared with 24 patients (9.41%) in the no SeamGuard group. The use of staple line reinforcement is consistent with a 94% risk reduction in stricture formation. Conclusion: The results have shown that the use of bioabsorbable circular staple line reinforcement on gastrojejunal anastomoses in laparoscopic Roux-en-Y gastric bypass significantly reduces the incidence of anastomotic stricture. The standard use of the bioabsorbable reinforcement on circular staple line anastomoses could be a part of the solution to the most common complication of laparoscopic gastric bypass. [Copyright &y& Elsevier]

Background: Traditional laparoscopic surgery presents some difficulties for morbidly obese patients due to limited motion of instruments related to a thick abdominal wall, intraabdominal fat, and a large hepatic left lobe, with consequent loss of dexterity and greater musculoskeletal discomfort. Robotic technique could potentially overcome these limitations. This study aimed to evaluate robot-assisted laparoscopic Roux-en-Y gastric bypass in morbidly obese patients and to compare the results of robotic assistance with those of traditional laparoscopic technique. Methods: Between September 2006 and June 2009, 110 morbidly obese patients underwent laparoscopic Roux-en-Y gastric bypass with robot-assisted hand-sewn gastrojejunal anastomosis using the da Vinci Surgical System. The data for these patients was compared with the data for 423 consecutive patients treated in a standard laparoscopic manner during the same period. Results: The patients had a mean preoperative age of 42.6 years, a mean weight of 127.5 kg, and a mean body mass index (BMI) of 46.7 kg/m. The total mean operative time was 247.5 min. The robotic setup time was 10.1 min, and the robotic operative time was 54.5 min. The conversion rate was nil. The intraoperative complication rate was 4.5%. The early and late major postoperative complication rates were 3.6 and 6.4% respectively. The cost per patient was 5777.76 €. For the standard laparoscopy, the operative time was significantly shorter (187 min; p < 0.001), and the costs per patient were significantly lower (4658.28 €; p < 0.001), whereas no differences were found in terms of the intra- or postoperative complication rates, revisional surgery, or hospital length of stay. Conclusions: Although safe and intuitive, the robotic approach was burdened by a longer operative time and higher equipment costs. Moreover, it did not seem to provide a real advantage over standard laparoscopy in terms of hospital length of stay and complications rates. [ABSTRACT FROM AUTHOR]

To facilitate endolumenal and natural orifice procedures, this study evaluated a novel technique using external and endoscopically placed magnets to create suture-free gastroenteral anastomoses. Seven anesthetized adult swine underwent endoscopic placement of magnets into the small bowel and stomach. Using external magnets, the endoscopically placed internal magnets were brought into opposition under endoscopic view. After 1–2 weeks, the pigs were killed and analyzed. At laparotomy and under sterile conditions, peritoneal cultures were obtained. The anastomoses were evaluated endoscopically and tested using an air insufflation test. Finally, the anastomoses were resected and evaluated microscopically. The average operative time for endoscopic placement of the magnets was 34.3 ± 14.8 min. Successful placement and creation of anastomoses occurred in six of the pigs. One pig did not form an anastomosis because the magnets were too large to pass through the pylorus at the time of attempted magnet placement. Six swine experienced uncomplicated postoperative courses. One pig’s postoperative course involved constipation for several days, requiring additional fluids and fiber supplementation. The findings at endoscopy showed that the magnets were adhered to the anastomosis, which were easily freed, or within the stomach. The air insufflation test results were negative for all the pigs. At laparotomy, there was no evidence of infection, abscess, or leak, but two peritoneal culture results were positive with scant growth of Staphylococcus aureus and coagulase-negative staphylococcus, presumably contaminants. Microscopically, the anastomoses illustrated granulation and fibrous connective tissue without evidence of infection or leak. Endoscopically placed magnets with external magnet guidance is a feasible and novel approach to creating patent gastroenteral anastomoses without abdominal incisions or sutures. [ABSTRACT FROM AUTHOR]