Mesenteric defect closure in laparoscopic Roux-en-Y gastric bypass: a randomized controlled trial

Internal hernia in patients after duodenal switch: A multi-centred comparative analysis

Biliopancreatic diversion with duodenal switch (BPD-DS) and single anastomosis duodeno-ileostomy with sleeve (SADI-S) are associated with superior and sustained weight loss outcomes. Despite their growing popularity, long-term safety profiles, particularly the risk of internal hernia (IH), remain underexplored. This study aimed to evaluate the incidence and characteristics of IH following BPD-DS and SADI-S procedures, comparing their clinical presentation, diagnostic methods, and outcomes. A retrospective chart review was performed for patients who underwent BPD-DS or SADI-S between 2008 and 2023 in two high-volume tertiary referral centres for bariatric surgery in the United States. Demographic data, comorbidities, operative details, and follow-up outcomes were collected. A subgroup analysis of IH cases was conducted to compare the incidence, location of hernias, and diagnostic modalities between procedures. Out of 1160 patients (85.1% BPD-DS; 14.9% SADI-S), the overall incidence of IH was 1.12%, with a higher rate in BPD-DS (0.8%) than in SADI-S (0.57%). Most IHs occurred within the first 24 months postoperatively. The majority of IHs in BPD-DS patients were in the pseudo-Petersen's space. The single IH case in the SADI-S group occurred in the same space. Most patients presented with abdominal pain and were diagnosed by CT imaging. SADI-S showed a lower IH rate compared to BPD-DS, but further studies are needed to confirm these findings. The variability in clinical presentation complicates the diagnosis of IH, emphasizing the need for increased clinical vigilance.

Closure of mesenteric defects for prevention of internal hernia after Roux-en-Y gastric bypass in bariatric surgery

RATIONALE

Internal hernia is one of the most severe complications observed in people undergoing Roux-en-Y gastric bypass (RYGB). There are some who advocate for the closure of defects to prevent internal hernias. However, the closure of these defects might be associated with an increased risk of small bowel obstruction, resulting from a kink in the anastomosis of the small intestines. Currently, there is a lack of robust evidence demonstrating the benefits of defect closure.

OBJECTIVES

To assess the benefits and harms of defect closure for prevention of internal hernia after Roux-en Y gastric bypass in bariatric surgery.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase to August 2024. We reviewed the reference lists of included studies and reached out to the study authors to obtain any missing data. We also searched PubMed, grey literature in the OpenGrey database, Clinical Trials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP).

ELIGIBILITY CRITERIA

We included randomised controlled trials (RCTs) that included people with obesity (defined as a body-mass index (BMI) ≥ 35 kg/m²) who underwent laparoscopic or robotic RYGB in bariatric surgery, and compared the closure of defects with the non-closure of defects. We excluded quasi-randomised trials, cluster-RCTs, and cross-over trials.

OUTCOMES

The critical outcomes assessed were the incidence of internal hernia with bowel obstruction within 10 years, the incidence of postoperative overall complications within 30 days, and the incidence of postoperative mortality within 30 days. The important outcomes included the incidence of intraoperative overall complications, length of hospital stay, and the postoperative pain resulting from gastric bypass surgery, assessed using a visual analogue scale (VAS) two years after surgery.

RISK OF BIAS

Two review authors independently evaluated the risk of bias for each included study using the Cochrane RoB 2 tool.

SYNTHESIS METHODS

Two review authors independently assessed the methodological quality and extracted data from the included trials. We performed a random-effects meta-analysis for data synthesis. We calculated risk ratios (RR) with 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) with 95% CIs for continuous outcomes. We assessed the certainty of evidence based on the GRADE approach.

INCLUDED STUDIES

We identified three RCTs with 3010 participants, which met our inclusion criteria. The closure of mesenteric defects used non-absorbable, interrupt closure in one study, and non-absorbable running sutures in two studies.

SYNTHESIS OF RESULTS

The closure of defects during RYGB may reduce the incidence of internal hernia with bowel obstruction within 10 years compared with non-closure (RR 0.32, 95% CI 0.24 to 0.42; P < 0.00001, I² = 0 %; 3 studies, 3010 participants; low-certainty evidence). The closure of defects may result in little to no difference in the incidence of postoperative overall complications within 30 days compared to non-closure (RR 1.13, 95% CI 0.87 to 1.47; P = 0.35, I² = 0 %; 2 studies, 2609 participants; low-certainty evidence). The closure of defects may result in little to no difference in the incidence of postoperative mortality within 30 days compared to non-closure (RR 2.97, 95% CI 0.12 to 72.93; P = 0.50, I² not applicable; 2 studies, 2908 participants; very low-certainty evidence). The closure of defects may result in little to no difference in the incidence of intraoperative overall complications compared to non-closure (RR 0.87, 95% CI 0.54 to 1.42; P = 0.59, I² not applicable; 1 study, 2507 participants; very low-certainty evidence). Closure defects may lead to the longer length of hospital stay; however, the evidence is very uncertain (MD 0.27 days, 95% CI 0.15 to 0.38; P < 0.00001; I² = 93%; 2 studies, 2609 participants; very low-certainty evidence). Postoperative pain from gastric bypass surgery was not assessed because there was not enough information available for analysis.

AUTHORS' CONCLUSIONS

The closure of defects may be more effective than the non-closure of defects for prevention of internal hernia after RYGB. However, the small number of trials limited our confidence in the evidence. There is little to no difference between the closure and non-closure of defects in the incidence of postoperative overall complications, the incidence of postoperative mortality, and the incidence of intraoperative overall complications. The length of hospital stay may be longer for those undergoing defect closure than for those who did not have the defects closed. The evidence is very uncertain about the incidence of postoperative mortality, the incidence of intraoperative overall complications, and the length of hospital stay. Additional evidence based on trials designed to be at low risk of bias and with an adequate sample size is imperative.

FUNDING

This Cochrane review had no dedicated funding.

REGISTRATION

The protocol was registered in the Cochrane Library on 9 May 2023.

Incidence and management of internal hernia after laparoscopic Roux-en-Y gastric bypass without preventive closure of mesenteric defects: a single-center retrospective study

The rising prevalence of obesity has led to an increase in bariatric procedures, with laparoscopic Roux-en-Y gastric bypass (LRYGB) being one of the most commonly performed surgeries due to its efficacy and safety. However, internal hernia (IH) remains a significant complication post-LRYGB. The debate over preventive closure of mesenteric defects (MD) during LRYGB continues, with no consensus on the optimal technique. This study aims to document the incidence and management of symptomatic IH in patients undergoing LRYGB without preventive MD closure and compare findings with international literature. This retrospective study included patients undergoing LRYGB without preventive MD closure between January 2018 and December 2020. Demographic and clinical data were collected, and follow-up lasted approximately 3.5 years. Postoperative complications, including IH, were assessed. Among 261 patients who underwent LRYGB, 235 completed a minimal follow-up of 24 months. The incidence of IH was 5.9%, representing the most common cause of reoperation. Laparoscopic management successfully resolved 86% of IH cases, reaching 100% in early-diagnosed cases promptly referred to our surgical unit. Average surgical duration was 72 min, with a postoperative hospital stay of 48 h. Enhanced recovery protocols were employed for LRYGB patients. This study highlights the challenges in managing IH post-LRYGB without preventive MD closure. Although in our series IH incidence was lower than reported in many other studies, it still remains the most frequent complications following RYGB, suggesting that MD should be closed during primary surgery, when possible, as suggested by most recent studies. Standardized guidelines for MD closure are lacking, emphasizing the importance of appropriate surgical techniques. In our experience, laparoscopic management of IH was effective, especially in early-diagnosed cases.

Long-term incidence of bariatric related procedures following laparoscopic gastric bypass: 15 to 20 years single institution experience

BACKGROUND

Long-term data on the likelihood of undergoing additional related operations after Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) remain scarce.

OBJECTIVES

The aims of this study are to identify the long-term incidence of bariatric related operations, patient's predictive factors, and most common operations in the 15-20 years following LRYGB.

SETTING

Single Academic Institution, Center of Bariatric Excellence.

METHODS

We performed a retrospective analysis of all LRYGB performed at Single Institution from 2003 to 2008. All subsequent bariatric related operations performed were manually reviewed, excluding upper endoscopies. Kaplan-Meier analysis was utilized to estimate the time to procedure. Cox regression was used to determine patient's factors associated with time until procedure.

RESULTS

Of the 665 patients included, the median follow-up was 14 years. There were 248 (37.3%) patients with a related operation. After excluding panniculectomy, 199 (29.9%) had a related operation. The 3 most common operations were panniculectomy [n = 77 (12%)], followed by cholecystectomy [n = 64 (10%)], and internal hernia repair [n = 56 (8%)]. The Kaplan-Meier estimated incidence of related operation at 15 years was 43.7% and 35.3% after excluding panniculectomy. Females (HR = 1.77, 95% CI = [1.20, 2.62, p = 0.0039), age < 50 (HR = 1.42, 95% CI = [1.07, 1.88], p = 0.014), and BMI > 60 (HR = 2.77, 95% CI = [1.30, 5.91], p = 0.0083) were more likely to have a related operation.

CONCLUSION

Bariatric related operations are common after LRYGB. Nearly half of patients will eventually undergo a secondary operation as they approach 20 years post-LRYGB.

American society for metabolic and bariatric surgery: intra-operative care pathway for minimally invasive Roux-en-Y gastric bypass

BACKGROUND

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).

OBJECTIVE

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).

METHODS

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.

RESULTS

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.

CONCLUSIONS

This document may provide guidance based on recent evidence to bariatric surgeons and providers for the intra-operative care for minimally invasive RYGB.

Meticulous Closure of Mesenteric Defects Effectively Reduces the Incidence of Internal Hernia After Laparoscopic Roux-en-Y Gastric Bypass

INTRODUCTION

Internal hernia (IH) after Roux-Y gastric bypass (RYGB) can lead to extended small bowel ischemia if it not recognized and treated promptly. The aim of this study is to show whether improvement in mesenteric defect (MD) closure reduces the incidence of IH.

PATIENTS AND METHODS

Retrospective analysis of prospectively collected data from our database including all patients who underwent laparoscopic RYGB between 1999 and 2015. The usual technique was a retrocolic/retrogastric RYGB. We divided patients in four groups according to the closure technique for MD and compared incidences of IH between groups. All patients had at least 8 years of follow-up.

RESULTS

A total of 1927 patients (1497 females/460 males, mean age of 41.5 ± 11 years) were operated. A retrocolic/retrogastric RYGB was performed in 1747 (90.7%) and an antecolic RYGB in 180 patients. Mean duration of follow-up was 15 (8-24) years. 111 patients (5.8%) developed IH, the majority through the jejunojejunostomy (JJ, 3.7%) and Petersen (1.7%) defects. With improvement of closure technique, the incidence decreased over time, from 12.9% in the group with separate sutures to 1.05% in the most recent group with running non-absorbable sutures and an additional purse-string at the JJ defect (p < 0.0001).

CONCLUSION

Meticulous closure of MD during RYGB is a very important step that significantly reduces the IH risk after RYGB, even with a retrocolic/retrogastric anatomy. Using running non absorbable braided sutures and an additional purse-string suture at the JJ is the most effective technique, but a small IH risk persists. A high index of suspicion remains necessary in patients who present with acute abdominal pain after RYGB.

Mesenteric Defect Closure and the Rate of Internal Hernia in Laparoscopic Roux-en-Y Gastric Bypass: A Systematic Review and Meta-analysis

Internal hernias are a worrying complication from laparoscopic Roux-en-Y gastric bypass (LRGB), with potential small bowel necrosis and obstruction. An electronic database search of Medline, Embase, and Pubmed was performed. All studies investigating the internal hernia rates in patients whose mesenteric defects were closed vs. not closed during LRGB were analysed. Odds ratios were calculated to assess the difference in internal hernia rate. A total of 14 studies totalling 20,553 patients undergoing LRGB were included. Internal hernia rate (220/12,445 (2%) closure vs. 509/8108 (6%) non-closure) and re-operation for small bowel obstruction (86/5437 (2%) closed vs. 300/3132 (10%) non-closure) were reduced when defects were closed. There was no difference observed when sutures were used to close the defects compared to clips/staples.

Long-term Safety and Efficacy of Closure of Mesenteric Defects in Laparoscopic Gastric Bypass Surgery: A Randomized Clinical Trial

Importance

Short-term and midterm data suggest that mesenteric defects closure during laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery reduces the risk of internal herniation with small bowel obstruction (SBO) but may increase risk of kinking of the jejunojejunostomy in the early postoperative period. However, to our knowledge, there are no clinical trials reporting long-term results from this intervention in terms of risk for SBO or opioid use.

Objective

To evaluate long-term safety and efficacy outcomes of closure of mesenteric defects during LRYGB.

Design, Setting, and Participants

This randomized clinical trial with a 2-arm, parallel, open-label design included patients with severe obesity scheduled for LRYGB bariatric surgery at 12 centers in Sweden from May 1, 2010, through November 14, 2011, with 10 years of follow-up after the intervention.

Interventions

During the operation, patients were randomly assigned 1:1 to closure of mesenteric defects beneath the jejunojejunostomy and at the Petersen space using nonabsorbable running sutures during LRYGB or to nonclosure.

Main Outcome and Measures

The primary outcome was reoperation for SBO. New incident, chronic opioid use was a secondary end point as a measure of harm.

Results

A total of 2507 patients (mean [SD] age, 41.7 [10.7] years; 1863 female [74.3%]) were randomly assigned to closure of mesenteric defects (n = 1259) or nonclosure (n = 1248). After censoring for death and emigration, 1193 patients in the closure group (94.8%) and 1198 in the nonclosure group (96.0%) were followed up until the study closed. Over a median follow-up of 10 years (IQR, 10.0-10.0 years), a reoperation for SBO from day 31 to 10 years after surgery was performed in 185 patients with nonclosure (10-year cumulative incidence, 14.9%; 95% CI, 13.0%-16.9%) and in 98 patients with closure (10-year cumulative incidence, 7.8%; 95% CI, 6.4%-9.4%) (subhazard ratio [SHR], 0.42; 95% CI, 0.32-0.55). New incident chronic opioid use was seen among 175 of 863 opioid-naive patients with nonclosure (10-year cumulative incidence, 20.4%; 95% CI, 17.7%-23.0%) and 166 of 895 opioid-naive patients with closure (10-year cumulative incidence, 18.7%; 95% CI, 16.2%-21.3%) (SHR, 0.90; 95% CI, 0.73-1.11).

Conclusions and Relevance

This randomized clinical trial found long-term reduced risk of SBO after mesenteric defects closure in LRYGB. The findings suggest that routine use of this procedure during LRYGB should be considered.

Trial Registration

ClinicalTrials.gov Identifier: NCT01137201.

Closed or Unclosed Mesentery? A Meta-analysis of Internal Herniation After Laparoscopic Roux-en-Y Gastric Bypass

During the laparoscopic Roux-en-Y gastric bypass procedure, closing mesentery or not was still controversial according to preexisted studies. So, the current meta-analysis aimed to compare the outcome of closure versus non-closure of mesenteric defects in laparoscopic Roux-en-Y gastric bypass. Fifteen studies were included, enrolling 53,488 patients. Based on the outcome of analysis, regarding internal hernia, Petersen space's IH, jejunal mesenteric's IH, hospital days, and reoperation, closure of the mesentery was better than non-closure. Besides, small bowel obstruction, anastomosis ulcer, stenosis, leakage, bleeding, gastrointestinal perforation, and postoperative BMI of patients show no difference between non-closure and closure.

Effect of Suture Used for Closure of Mesenteric Defects After Laparoscopic Roux-en-Y Gastric Bypass: Single-Center Study

INTRODUCTION

Small bowel obstruction (SBO) due to internal herniation (IH) is a well-known complication of laparoscopic Roux-en-Y gastric bypass (LRYGBP). The objective of this study is to evaluate different types of non-absorbable sutures used for closure of the defects regarding the incidence of SBO due to IH/adhesions, adhesion formation in general, or reopening of the defects.

METHODS

A single-center retrospective study was performed. Patients who underwent LRYGBP were divided in 3 groups: group A closure of the defects with monofilament Polypropylene suture (Prolene®), group B with braided polyester suture (Ethibond®), group C with barbed knotless Polybutester suture (V-Loc®). Descriptive statistics were performed regarding SBO due to IH/adhesions, adhesion formation, and reopening of closed defects.

RESULTS

From 5145 patients, 224 patients underwent exploratory laparoscopy for suspicion of SBO. Mean time interval was 28.4 months. IH or intermittent IH was found in 1.94% in group A, 1.78% in group B, and 1.40% in group C. Obstruction due to adhesions was found in 0.70%, 0.36%, and 0.42% per group, respectively. Adhesions in general were observed in 1.47% in group A, 1.43% in group B, and 1.06% in group C. The incidence of reopening was higher in group A (2.24%) in comparison with group B (1.13%, P = 0.041) and group C (1.05%, P = 0.001).

CONCLUSIONS

After descriptive analysis, these results can withhold no difference among the 3 non-absorbable sutures regarding incidence of SBO due to IH or SBO due to adhesions, yet tendency for higher reopening rates after closure with monofilament Polypropylene suture is observed.

Risk of Reopening of the Mesenteric Defects After Routine Closure in Laparoscopic Roux-en-Y Gastric Bypass: a Single-Centre Experience

PURPOSE

Small bowel obstruction (SBO) due to internal hernias (IH) is a well-recognised complication after laparoscopic Roux-en-Y gastric bypass (LRYGB). Routine closure of the mesenteric defects (MDs) is recommended to reduce the risk of IH and subsequent SBO. However, data about the rates of reopening of the MDs after LRYGB is scarce. The main aim of this study was to evaluate the risk of reopening of the MDs after routine closure during LRYGB. The secondary objective was to determine any risk factors associated with the reopening of the MDs.

METHODS

Data of all patients who underwent reoperations after LRYGB with closure of both MDs between January 2010 and December 2018 were retrospectively reviewed.

RESULTS

A total of 162 patients were included. The median time between LRYGB and reoperation was 17 months. At the time of reoperation, both MDs were closed in 83 patients (51.2%); thus, 79 patients (48.8%) presented at least one open MD. The group of patients with preoperative diagnosis of SBO or with recurrent abdominal pain showed significantly higher rates of open Petersen's space compared to the group of patients with other preoperative diagnoses. Preoperative body mass index (BMI) less than 40 kg/m² at time of LRYGB was associated with a higher risk for an open MD.

CONCLUSION

At least one MD reopened in almost half of the patients despite routine closure during LRYGB. Therefore, the status of MDs should be routinely examined during every reoperation after LRYGB and closure of open MDs should be performed.

Development and Validation of a Predictive Model for Internal Hernia After Roux-en-Y Gastric Bypass in a Multicentric Retrospective Cohort: The Swirl, Weight Excess Loss, Liquid Score

OBJECTIVE

The aim of this study was to develop and validate a prediction score for internal hernia (IH) after Roux-en-Y gastric bypass (RYGB).

SUMMARY BACKGROUND DATA

The clinical diagnosis of IH is challenging. A sensitivity of 63% to 92% was reported for computed tomography (CT).

METHODS

Consecutive patients admitted for abdominal pain after RYGB and undergoing CT and surgical exploration were included retrospectively. Potential clinical predictors and radiological signs of IH were entered in binary logistic regression analysis to determine a predictive score of surgically confirmed IH in the Geneva training set (January 2006-December 2014), and validated in 3 centers, Geneva (January 2015-December 2017) and Neuchâtel and Strasbourg (January 2012-December 2017).

RESULTS

Two hundred twenty-eight patients were included, 80 of whom (35.5%) had surgically confirmed IH, 38 (16.6%) had a negative laparoscopy, and 110 (48.2%) had an alternate diagnosis. In the training set of 61 patients, excess body weight loss >95% (odds ratio [OR] 6.73, 95% confidence interval [CI]: 1.13-39.96), swirl sign (OR 8.93, 95% CI: 2.30-34.70), and free liquid (OR 4.53, 95% CI: 1.08-19.0) were independent predictors of IH. Area under the curve (AUC) of the score was 0.799. In the validation set of 167 patients, AUC was 0.846. A score ≥2 was associated with an IH incidence of 60.7% (34/56), and 5.3% (3/56) had a negative laparoscopy.

CONCLUSIONS

The score could be incorporated in the clinical setting. To reduce the risk of delayed IH diagnosis, emergency explorative laparoscopy in patients with a score ≥ 2 should be considered.

Mesenteric closure after laparoscopic total gastrectomy with Roux-en-Y reconstruction is effective for prevention of internal hernia: a multicenter retrospective study

BACKGROUND

Internal hernia (IH) is one of the critical complications after gastrectomy with Roux-en-Y reconstruction, which can be prevented by closing mesenteric defects. However, only few studies have investigated the incidence of IH after laparoscopic total gastrectomy (LTG) with Roux-en-Y reconstruction for gastric cancer till date. This study aimed to assess the efficacy of defect closure for the prevention of IH after LTG.

METHODS

This multicenter, retrospective cohort study collected data from 714 gastric cancer patients who underwent LTG with Rou-en-Y reconstruction between 2010 and 2016 in 13 hospitals. We evaluated the incidence of postoperative IH by comparing closure and non-closure groups of Petersen's defect, jejunojejunostomy mesenteric defect, and transverse mesenteric defect.

RESULTS

The closure group for Petersen's defect included 609 cases, while the non-closure group included 105 cases. The incidence of postoperative IH in the closure group for Petersen's defect was significantly lower than it was in the non-closure group (0.5% vs. 4.8%, p < 0.001). The closure group for jejunojejunostomy mesenteric defect included 641 cases, while the non-closure group included 73 cases. The incidence of postoperative IH in the closure group of jejunojejunostomy mesenteric defect was significantly lower than that in the non-closure group (0.8% vs. 4.1%, p = 0.004). Out of 714 patients, 41 underwent retro-colic reconstruction. No patients in the transverse mesenteric defect group developed IH.

CONCLUSION

Mesenteric defect closure after LTG with Roux-en-Y reconstruction may reduce postoperative IH incidence. Endoscopic surgeons should take great care to prevent IH by closing mesenteric defects.

The Panoramic View of Revisional Bariatric Surgery

Introduction: Obesity remains a major public chronic disease, and the multifactorial components of its relapse in many patients remain inevitable. Methods: This article provides a panoramic view of the most commonly performed revisional bariatric surgery (RBS). RBS is a complex procedure; thus, primary procedures should be well chosen and performed to avoid the increasing number of RBS cases. Results: Bariatric surgery is the only successful long-term treatment for obesity. However, a proportion of primary bariatric surgeries has failed during the follow-up period. In recent decades, the solution for these complications is by performing RBS. It is mandatory to understand obesity as a chronic disease to appropriately treat patients. Treatment strategies are needed to determine the indications for revision. RBS requires a meticulous evaluation to facilitate good long-term results. Conclusions: Treatment strategies will be a fundamental pillar to wisely determine the indications for revision and identify the factors influencing failure by prudently and rationally evaluating the revisional procedure that the patient will benefit from and acquiring a high level of surgical skills.

One Anastomosis Gastric Bypass in Patients with Gastrooesophageal Reflux Disease and/or Hiatus Hernia

INTRODUCTION

One anastomosis gastric bypass (OAGB) offers favourable weight loss outcomes and is associated with reduced morbidity and mortality when compared to other mainstream bariatric procedures. However, a randomised trial reported a conversion rate to roux-en-Y configuration (RYC) of 3.1%, and some surgeons consider the procedure unsuitable for patients with a preoperative hiatus hernia (HH) or symptoms of gastrooesophageal reflux disease (GORD).

METHODS

We carried out a retrospective review of patients undergoing OAGB in our institution. Included were all patients on PPI for symptoms of GORD preoperatively, as well as patients with HH or oesophagitis on preoperative endoscopy. We recorded GORD outcomes as well as rates of conversion to RYC in patients.

RESULTS

Medium term follow up data at 23-28 months was available for 89 patients. Of these, 63 had HH, 34 had preoperative GORD requiring PPI and 9 had confirmed oesophagitis. The conversion rate to RYC was nil (0/63) in patients with HH. At the same time, 14.7% (5/34) of patients with preop GORD on PPI required conversion to RYC at a median time interval of 16 months. In patients already on PPI preoperatively, 16/34 (47.1%) needed to continue on PPI long term. In patients with HH, 20.6% (13/63) suffered de novo GORD symptoms.

CONCLUSION

OAGB can be offered to patients with HH with acceptable GORD outcomes but caution is advised in patients with preoperative GORD symptoms. Larger prospective and randomised studies are required to further assess this subgroup.

Robotic "Double Loop" Roux-en-Y gastric bypass reduces the risk of postoperative internal hernias: a prospective observational study

Background

Internal herniation (IH) is a potentially serious complication after laparoscopic Roux-en-Y gastric bypass (RYGB). The aim of the study is to evaluate the incidence of IH after robot-assisted RYGB (RA-RYGB) performed with the “Double Loop” technique at our Institution.

Methods

Prospective cohort study of patients submitted to RA-RYGB with the “Double Loop” technique, with a minimum follow-up of 2 years. Patients with complaints of abdominal pain at clinical visits or entering the emergency department were evaluated. Primary outcome was the incidence of IH, defined as the presence of herniated bowel through a mesenteric defect, diagnosed at imaging or at surgical exploration.

Results

A total of 129 patients were included: 65 (50.4%) were primary procedures, while 64 (49.6%) were revisional operations after primary restrictive bariatric surgery. Mean age was 47.9 ± 10.2 years, mean weight, and body mass index were, respectively, 105.3 ± 22.6 kg and 39.7 ± 9.6 kg/m². Postoperative morbidity rate was 7.0%. Mean follow-up was 53.2 ± 22.6 (range 24–94) months. During the follow-up period, a total of 14 (10.8%) patients entered the emergency department: 1 patient had melena, 4 renal colic, 1 acute cholecystitis, 2 gynecologic pathologies, 2 anastomotic ulcers, 1 perforated gastric ulcer, 1 diverticulitis and 2 gastroenteritis. There were no diagnoses of IH. During the follow-up period, no patient experienced recurrence of symptoms.

Conclusions

In the present study, the robotic approach confirms the low complication rate and absence of IH after “Double Loop” RA-RYGB in a large case-series at a medium-term follow-up.

Closure of Mesenteric Defects in Laparoscopic Gastric Bypass: a Meta-Analysis

INTRODUCTION

The purpose of the current study was to review the available literature on morbidly obese patients treated with laparoscopic Roux-en-Y gastric bypass (LRYGB) in order to assess the clinical outcomes of the routine closure of the mesenteric defects.

METHODS

A literature search was performed in PubMed, Cochrane library, and Scopus, in accordance with the PRISMA guidelines.

RESULTS

Nine studies met the inclusion criteria. A total of 16,520 patients were incorporated with a mean follow-up ranging from 34 to 120 months. The closure of the mesenteric defects was associated with a lower incidence of internal hernias (odds ratio, 0.25 [95% confidence interval 0.20, 0.31]; p < 0.01), small bowel obstruction (SBO) (0.30 [0.17, 0.52]; p < 0.0001) and reoperations (0.28 [0.15, 0.52]; p < 0.001). Both approaches presented similar complication rates and % excess weight loss (%EWL).

CONCLUSION

The present meta-analysis is the best currently available evidence on the topic and supports the routine closure of the mesenteric defects.

Closure versus non-closure of mesenteric defects in laparoscopic Roux-en-Y gastric bypass: a systematic review and meta-analysis

BACKGROUND

The comparative evidence regarding the outcomes of closure versus non-closure of mesenteric defects in laparoscopic Roux-en-Y gastric bypass (LRYGB) is poorly understood. We aimed to compare the outcomes of closure versus non-closure of mesenteric defects in LRYGB for morbid obesity.

METHODS

We conducted a search of electronic information sources to identify all comparative studies investigating the outcomes of closure versus non-closure of mesenteric defects in patients undergoing LRYGB for morbid obesity. We used the Cochrane risk of bias tool and the ROBINS-I tool to assess the risk of bias of RCTs and observational studies, respectively. Random or fixed effects modelling was applied as appropriate.

RESULTS

We included 10,031 patients from six observational studies and 2609 patients from two RCTs. Analysis of observational studies showed closure defects resulted in lower risks of internal hernia (OR 0.28, 95% CI 0.15, 0.54) and reoperation for small bowel obstruction (SBO) (OR 0.30, 95% CI 0.10, 0.83); no difference was found between the two groups in terms of SBO not related to internal hernia (OR 1.19, 95% CI 0.47, 2.99), early SBO (OR 0.74, 95% CI 0.04, 14.38), anastomotic leak (OR 0.84, 95% CI 0.45, 1.57), bleeding (OR 1.08, 95% CI 0.62, 1.89), and anastomotic ulcer (OR 2.08, 95% CI 0.62, 6.94). Analysis of RCTs showed closure of defects resulted in lower risks of internal hernia (OR 0.29, 95% CI 0.19,0.45) and reoperation for SBO (OR 0.51, 95% CI 0.38, 0.69) but higher risks of SBO not related to internal hernia (OR 1.90, 95% CI 1.09, 3.34) and early SBO (OR 2.63, 95% CI 1.16, 5.96); no difference was found between the two groups in terms of anastomotic leak (OR 1.95, 95% CI 0.80, 4.72), bleeding (OR 0.67, 95% CI 0.38, 1.17), and anastomotic ulcer (OR 2.08, 95% CI 0.62, 6.94).

CONCLUSIONS

Our results suggest that closure of mesenteric defects in LRYGB may be associated with lower risks of internal herniation and reoperation for SBO compared with non-closure of the defects (moderate certainty). The available evidence is inconclusive regarding the risks of SBO not related to internal hernia and early SBO (low certainty). More RCTs are needed to improve the robustness of the available evidence.

Different surgical techniques that influenced internal hernia prevalence rate after laparoscopic roux-en-Y gastric bypass: a retrospective analysis of 331 cases

BACKGROUND

Internal hernia (IH) is a serious complication following laparoscopic Roux-en-Y gastric bypass (LRYGB), and closure of mesenteric defect has been recommended to reduce this complication. But what kind of material about suture and how to close the mesenteric defects were still controversial. The main aim of this study was to compare the incidence rate of internal hernia after LRYGB between patients with different surgical techniques.

METHOD

Three hundred and thirty-one patients underwent LRYGB between June 2004 and December 2017 in one single institute were retrospective analysed. The IH rate was evaluated according to different surgical methods and surgical materials before and 12 months after LRYGB.

RESULTS

All the cases were subdivided into three groups based on the suturing method, Roux limb position, and Suture material. The mean follow up time was 36 ± 12 months, and the total incident rate of IH was 1.8% (n = 6). In the six IH cases, the duration of IH occurred time ranged from 1 month to 36 months postoperatively, and for the IH sites, one for intestinal defect, three for transverse mesocolon defect and two Peterson defect respectively. There was a significant difference about IH rate between interrupted suture and running suture groups (p = 0.011), and there were no significant differences between the other two groups.

CONCLUSION

Compare with interrupted suture, running suture may prevent IH after LRYGB. Patient's gender, age, body mass index(BMI), glycometabolism condition, and Roux limb position and suture material had no effects on the IH prevalence after LRYGB.

Ongoing Inconsistencies in Weight Loss Reporting Following Bariatric Surgery: a Systematic Review

Weight loss is the primary outcome following bariatric surgery; however, its documentation within current literature is heterogeneous and poorly defined, limiting meaningful comparison between studies. Randomized controlled trials from 2012 to 2016 were identified using the Medline database through "Gastric bypass OR sleeve gastrectomy AND weight" search terms. A total of 73 studies with 5948 patients were included. Reporting of preoperative weight was done primarily using mean body mass index (BMI) (87.7%) and mean weight (65.8%). Postoperative weight reporting was more variable, with the most frequently reported measure being mean postoperative BMI (71.2%). Overall, nearly one third of all bariatric literature contained discrepancies that precluded meaningful meta-analysis. Reporting of weight loss following bariatric surgery is becoming increasingly diverse for both pre- and post-operative outcomes. Ongoing heterogeneity will continue to act as a barrier to meaningful comparison of bariatric outcomes until standardized reporting practices become adopted.

Diaphragmatic Hernia After Totally Laparoscopic Total Gastrectomy for Gastric Cancer

This study aimed to investigate the occurrence of diaphragmatic hernia (DH) after totally laparoscopic total gastrectomy (TLTG) for gastric cancer. We reviewed retrospectively collected data from 490 consecutive patients who underwent TLTG (functional method, 365; overlap method, 125) for upper body gastric cancer, between January 2011 and May 2017, performed by a single surgeon. The median follow-up period was 40.6 months. Of 490 patients, 8 (1.63%) developed DH at a mean interval after TLTG of 7.3 (range, 3.4 to 12.8) months. All 8 patients were from the functional group, and presented with abdominal pain or vomiting. They were managed with emergency surgery (5 laparoscopic hernia reduction, 3 open hernia reduction). The grade of complication according to Clavien-Dindo classification (CDC) was CDC-III in 7 cases and CDC-IV in 1 case. There was no death associated with DH complications. None of the patients in the overlap group developed DH. The incidence of DH after TLTG is negligible in the overlap method. Therefore, the overlap method may be a safe reconstruction technique that can reduce the occurrence of DC after TLTG for gastric cancer.

Alternative Method of Mesenteric Defect Closure after Roux-en-Y Gastric Bypass

BACKGROUND

Roux-en-Y gastric bypass is the gold standard for weight loss surgery. This procedure creates two to three mesenteric defects, depending on ante-colic versus retro-colic technique. Current literature supports mesenteric defect closure, but there is no consensus on how to best close these defects. Described options include running separate suture lines for each defect, or employing endoscopic staplers for defect closure.

METHODS

This is a video/dynamic manuscript on operative technique.

RESULTS

We describe an alternative technique that does not require an extra laparoscopic instrument and is more efficient than traditional suture lines due to less suturing.

CONCLUSIONS

The technique maintains low gastric bypass complication rates by closing mesenteric defects, while keeping intra-operative costs low, and minimizing time spent on the defect closures.

Clinical characteristics and surgical outcomes of internal hernia after gastrectomy in gastric cancer patients: retrospective case control study

BACKGROUND

Although the internal hernia is rare after gastric cancer surgery, it is a serious complication, and prompt surgical treatment is essential. However, internal hernia has not been studied because of low incidence and difficulty of diagnosis. This study investigated the clinical characteristics and proper management of internal hernia after gastrectomy.

METHODS

From June 2001 to June 2016, patients who underwent gastrectomy, either open or laparoscopic (robotic) surgery, with potential internal hernia defect were enrolled. The hernia defect was not closed in any of the enrolled patients. The clinicopathological data of internal hernia patients were compared to patients without internal hernia to identify risk factors. Surgical outcomes of internal hernia were compared between patients who underwent early and late intervention group according to time interval from symptom onset to operation.

RESULTS

Of 5777 patients who underwent gastrectomy with possible internal hernia, 24 (0.4%) underwent emergency or scheduled surgery for internal hernia. Internal hernia through the Petersen space was observed in 15 cases, and through the jejunojejunostomy mesenteric defect in 9 cases. Low body mass index (odds ratio [OR] 4.403, p = 0.003) and laparoscopic approach (OR 6.930 p < 0.001) were statistically significant factors in multivariate analysis. Postoperative complication rate (16.7% vs. 50% p = 0.083) and mortality rate (8.3% vs. 25.0% p = 0.273) were slightly higher in the late intervention group.

CONCLUSIONS

Although internal hernia is a rare complication, it is difficult to diagnose and cause serious complications. To prevent internal hernia, the necessity of hernia defect closure should be investigated in the further studies. Early surgical treatment is necessary when it is suspected.

CT Scan Reliability in Detecting Internal Hernia after Gastric Bypass

Background and Objectives:

Internal hernia (IH) after gastric bypass can be a life-threatening complication. Obstruction presents acutely or as chronic relapses, with symptoms of abdominal pain, nausea, and vomiting. Early detection and exploration of IH as the cause of small bowel obstruction (SBO) is critical in this surgical emergency and can reduce morbidity and mortality. We conducted a retrospective review of laparoscopic Roux-en-Y bypass (LRYGB) records to determine the specificity and sensitivity of computed tomography (CT) in identifying postoperative IH.

Methods:

Records of 550 patients who underwent antecolic antegastric laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery over a 5-year period (2010–2014) were retrospectively reviewed for complications. Our study population comprised patients who returned with signs and symptoms of obstruction who underwent CT imaging followed by laparoscopic exploration.

Results:

Thirty-four patients were found to have obstruction on CT scan at ≥6 weeks after LRYGB. Six (17.7%) were found to have IH by preoperative CT imaging before laparoscopic exploration. Of the 6 patients identified to have IH before exploration, 4 (28%) had consistent findings at operation, yielding a sensitivity of 28.6% and specificity of 90.0%. Operative findings identified other causes of SBO: adhesions (n = 17), IH (n = 14), jejunojejunostomy stenosis (n = 2), and phytobezoar (n = 1).

Conclusions:

IH after LRYGB is difficult to detect. Our study found CT to have a low sensitivity but a high specificity in detecting IH. Therefore, laparoscopic exploration continues to be the best diagnostic and therapeutic intervention for this complication.

Guiding the non-bariatric surgeon through complications of bariatric surgery

Complications in bariatric surgery are varied; they are severe at times but infrequent. They may be surgical or non-surgical, and may occur early or late. The goal of this systematic review is to inform and help the attending physician, the emergency physician and the non-bariatric surgeon who may be called upon to manage surgical complications that arise after adjustable gastric band (AGB), sleeve gastrectomy (SG), or gastric bypass (GBP). Data from evidence-based medicine were extracted from the literature by a review of the Medline database and also of the most recent recommendations of the learned societies implicated. The main complications were classified for each intervention, and a distinction was made between early and late complications. Early complications after AGB include prosthetic slippage or perforation; SG can be complicated early by staple line leak or fistula, and BPG by fistula, stenosis and postoperative hemorrhage. Delayed complications of AGB include intragastric migration of the prosthesis, late prosthetic slippage and infection, while SG can be complicated by gastro-esophageal reflux, and BPG by anastomotic ulcer and internal hernia. The analysis of available data allowed us to develop decisional algorithms for the management of each of these complications.

FIXING JEJUNAL MANEUVER TO PREVENT PETERSEN HERNIA IN GASTRIC BYPASS

Background

: Among Roux-en-Y gastric bypass complications is the occurrence of intestinal obstruction by the appearance of internal hernias, which may occur in Petersen space or the opening in mesenteric enteroenteroanastomosis.

Aim

: To evaluate the efficiency and safety in performing a fixing jejunal maneuver in the transverse mesocolon to prevent internal hernia formation in Petersen space.

Method

: Two surgical points between the jejunum and the transverse mesocolon, being 5 cm and 10 cm from duodenojejunal angle are made. In all patients was left Petersen space open and closing the opening of the mesenteric enteroenteroanastomosis.

Results

: Among 52 operated patients, 35 were women (67.3%). The age ranged 18-63 years, mean 39.2 years. BMI ranged from 35 to 56 kg/m² (mean 40.5 kg/m²). Mean follow-up was 15.1 months (12-18 months). The operative time ranged from 68-138 min. There were no intraoperative complications, and there were no major postoperative complications and no reoperations. The hospital stay ranged from 2-3 days. During the follow-up, no one patient developed suspect clinical presentation of internal hernia. Follow-up in nine patients (17.3%) showed asymptomatic cholelithiasis and underwent elective laparoscopic cholecystectomy. During these procedures were verified the Petersen space and jejunal fixation. In all nine, there was no herniation of the jejunum to the right side in Petersen space.

Conclusion

: The fixation of the first part of the jejunum to left side of the transverse mesocolon is safe and effective to prevent internal Petersen hernia in RYGB postoperatively in the short and medium term. It may be interesting alternative to closing the Petersen space.

Reoperation risk following the first operation for internal herniation in patients with laparoscopic Roux-en-Y gastric bypass

Background

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the most commonly used surgical procedure in the treatment of morbid obesity in Denmark. Internal herniation (IH) and intermittent internal herniation (IIH) are probably the most common late complications in patients with LRYGB. The aim of this study was to investigate a possible increased risk of subsequent operations after an initial IH or IIH event.

Methods

This long-term follow-up study of patients who had surgery for an initial IH or IIH event in 2006–2011, based on the Danish National Patient Registry (NPR), was performed to 2013. During this period, mesenteric defects were not closed routinely during LRYGB.

Results

Data were retrieved from 12 221 patients with LRYGB from the NPR. A total of 383 patients had surgery for an initial IH or IIH event. Some 102 patients (26·6 (95 per cent c.i. 22·5 to 31·3) per cent) had a second operation. Twenty-seven (26·5 (18·9 to 35·8) per cent) of these 102 patients had a third operation, and five (19 (8 to 37) per cent) of the 27 had a fourth operation. Of the 383 patients diagnosed with an initial IH or IIH event, 72 (18·8 per cent) had a second IH/IIH event, 14 (3·7 per cent) had a third event, and three (0·8 per cent) a fourth event requiring surgery.

Conclusion

Patients who have surgery for IH or IIH have a substantial risk of needing further operations.

[Internal hernias after bariatric surgery]

Hernias are among the most common long-term complications after bariatric surgery. Besides incisional hernias, which occur very often after conventional open bariatric surgery, internal hernias after bariatric surgery constitute a special challenge. The incidence of internal hernias after bariatric surgery is more common than for other upper gastrointestinal tract operations. Internal hernias are not limited to laparoscopic procedures but are also observed after conventional open gastric bypass surgery. As the incidence is significantly increased after laparoscopic interventions, there seems to be a close association with minimally invasive procedures. The clinical symptoms of internal hernias without complete obstruction are non-specific and the correct diagnosis is often not straightforward. In addition to the aspects of prevention of internal hernias in laparoscopic surgery, this article discusses the diagnosis and treatment, taking into account the various forms of internal hernia after bariatric operations.