The mesenteric defects in laparoscopic Roux-en-Y gastric bypass: 5 years follow-up of non-closure versus closure using the stapler technique

Characterization of Early Small Bowel Obstructions Following Elective Bariatric Surgery

PURPOSE

Small bowel obstruction (SBO) after bariatric surgery is an uncommon but important complication. We sought to characterize bariatric surgery patients who developed SBO, to compare 30-day complications, and to determine the influence of patient and procedure factors on the development of SBO.

METHODS AND MATERIALS

All data was extracted from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database using the 2020 operative year. Multivariable logistic regression modelling was used to determine the influence of patient and operative factors on the development of SBO.

RESULTS

Of a total of 142 111 patients, 408 (0.3%) were identified as having developed an SBO. SBO patients were older (45.7 ± 11.5 vs. 43.5 ± 11.9 years; p = 0.0002), of reduced BMI (43.6 ± 6.8 vs. 45.1 ± 7.7; p = 0.0001), and more likely to be of female sex (92.2% vs. 81.1%; p < 0.0001). At 30 days post-operation, serious complications were increased in SBO patients. Roux-en-Y gastric bypass (RYGB) was the largest independent predicator of the development of SBO (OR 11.91; 95% CI 8.92-15.90; p < 0.0001). With regard to patient factors, COPD (OR 2.60; 95% CI 1.54-4.38; p < 0.0001) and prior DVT (OR 2.37; 95% CI 1.49-3.77; p < 0.0001) were found to be independently predictive of the development of SBO. Additionally having a lower BMI and being of female sex were found to be independently predictive.

CONCLUSION

SBO occurred in approximately 0.3% of MBSAQIP cases. SBO is associated with serious outcome measures and patients of female sex and reduced index BMI, and those undergoing RYGB may be at an increased risk.

Smoking Is Correlated to Internal Hernia After Gastric Bypass Surgery: a Post hoc Analysis of Data from a Randomized Clinical Trial

PURPOSE

Internal herniation is a well-known complication of laparoscopic Roux-en-Y gastric bypass (L-RYGB). The aim of this study was to evaluate smoking as an independent risk factor for internal herniation after L-RYGB.

MATERIALS AND METHODS

This study was performed as an exploratory post hoc analysis of data from a previous published randomized controlled trial (RCT) designed to compare closure and non-closure of mesenteric defects in patients undergoing L-RYGB. The primary outcome of this study was to assess the significance of smoking as a risk factor for internal herniation after L-RYGB. Secondary outcome was early postoperative complications defined as Clavien-Dindo grade ≥ 2.

RESULTS

Four hundred one patients were available for post hoc analysis. The risk of internal herniation was significantly higher among patients who were smoking preoperatively (hazard ratio (HR) 2.4, 95% confidence interval (c.i.) 1.3 to 4.5; p = 0.005). This result persisted after adjusting for other patient characteristics (HR 2.2, 1.2 to 4.2; p = 0.016). 6.0% of the patients had postoperative complications within the first 30 days. 4.9% of these patients were smoking and 6.3% were not smoking, p = 0.657. 11.0% of the patients underwent surgery due to internal herniation by 5 years after the primary procedure.

CONCLUSION

Smoking is a significant risk factor for internal herniation but did not increase risk for 30 days postoperative complications.

Quality of stapled mesenteric defect closure influences the chance of reopening after laparoscopic Roux-en-Y gastric bypass surgery

Internal herniation (IH) is a common problem after laparoscopic Roux-en-Y gastric bypass surgery (RYGB). Routine closure of the mesenteric defects (MDs) reduces the risk of IH. Only very few articles report on risk factors for IH or describe detailed closing techniques. There is no consensus yet on the best closing method. The objective of this study is to determine the optimal stapling method for closure of MDs after RYGB. All performed RYGB procedures in our high-volume bariatric institute were included. Quality of the closure was scored in the categories poor, sub-optimal, and optimal, to see if the quality of the closure would predict the chance of reopening of the MDs and, therefore, the chance of IH. During any type of laparoscopy in the follow-up of the patient, the conditions of the MDs were stated, for example during diagnostic laparoscopy in symptomatic patients suspicious for IH or during laparoscopic cholecystectomy. Technically well-executed closure of Petersen's space (PS) with two rows of staples had a greater chance of still being closed upon re-inspection compared to closure with one row (odds ratio = 8.1; 95% confidence interval [1.2-53.2], p = 0.029). Optimal closure of the MD at the jejuno-jejunostomy (JJ-space, JJS) resulted in more closed JJSs upon re-inspection compared to sub-optimal closure (odds ratio = 3.6 [CI 95% 0.8-16.1], p = 0.099). Non-optimally closed MDs had higher reopening rates and, therefore, pose an additional risk for IH. Our classification provides a quality assessment of MD closure during RYGB and gives insight into how to optimize surgical technique.

The burden of abdominal pain after bariatric surgery in terms of diagnostic testing: the OPERATE study

BACKGROUND

Abdominal pain after bariatric surgery (BS) is frequently observed. Despite numerous diagnostic tests, the cause of abdominal pain is not always found.

OBJECTIVES

To quantify type and number of diagnostic tests performed in patients with abdominal pain after BS and evaluate the burden and their yield in the diagnostic process.

SETTING

A bariatric center in the Netherlands.

METHODS

In this prospective study, we included patients who presented with abdominal pain after BS between December 1, 2020, and December 1, 2021. All diagnostic tests and reoperations performed during one episode of abdominal pain were scored using a standardized protocol.

RESULTS

A total of 441 patients were included; 401 (90.9%) were female, median time after BS was 37.0 months (IQR, 11.0-66.0) and mean percentage total weight loss was 31.41 (SD, 10.53). In total, 715 diagnostic tests were performed, of which 355 were abdominal CT scans, 155 were ultrasounds, and 106 were gastroscopies. These tests yielded a possible explanation for the pain in 40.2% of CT scans, 45.3% of ultrasounds, and 34.7% of gastroscopies. The diagnoses of internal herniation, ileus, and nephrolithiasis generally required only 1 diagnostic test, whereas patients with anterior cutaneous nerve entrapment syndrome, irritable bowel syndrome, and constipation required several tests before diagnosis. Even after several negative tests, a diagnosis was still found in the subsequent test: 86.7% of patients with 5 or more tests had a definitive diagnoses. Reoperations were performed in 37.2% of patients.

CONCLUSION

The diagnostic burden in patients with abdominal pain following BS is high. The most frequently performed diagnostic test is an abdominal CT scan, yielding the highest number of diagnoses in these patients.

A Prospective Study on the Diagnoses for Abdominal Pain After Bariatric Surgery: The OPERATE Study

PURPOSE

Long-term follow-up after bariatric surgery (BS) reveals high numbers of patients with abdominal pain that often remains unexplained. The aim of this prospective study was to give an overview of diagnoses for abdominal pain, percentage of unexplained complaints, number and yield of follow-up visits, and time to establish a diagnosis.

MATERIALS AND METHODS

Patients who visited the Spaarne Gasthuis Hospital, The Netherlands, between December 2020 and December 2021 for abdominal pain after BS, were eligible and followed throughout the entire episode of abdominal pain. Distinction was made between presumed and definitive diagnoses.

RESULTS

The study comprised 441 patients with abdominal pain; 401 (90.9%) females, 380 (87.7%) had Roux-en-Y gastric bypass, mean (SD) % total weight loss was 31.4 (10.5), and median (IQR) time after BS was 37.0 (11.0-66.0) months. Most patients had 1-5 follow-up visits. Readmissions and reoperations were present in 212 (48.1%) and 164 (37.2%) patients. At the end of the episode, 88 (20.0%) patients had a presumed diagnosis, 183 (41.5%) a definitive diagnosis, and 170 (38.5%) unexplained complaints. Most common definitive diagnoses were cholelithiasis, ulcers, internal herniations, and presumed diagnoses irritable bowel syndrome (IBS), anterior cutaneous nerve entrapment syndrome, and constipation. Median (IQR) time to presumed diagnoses, definitive diagnoses, or unexplained complaints was 16.0 (3.8-44.5), 2.0 (0.0-31.5), and 13.5 (1.0-53.8) days (p < 0.001). Patients with IBS more often had unexplained complaints (OR 95%CI: 4.457 [1.455-13.654], p = 0.009). At the end, 71 patients (16.1%) still experienced abdominal pain.

CONCLUSION

Over a third of abdominal complaints after BS remains unexplained. Most common diagnoses were cholelithiasis, ulcers, and internal herniations.

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

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

Internal hernia trends following gastric bypass surgery

BACKGROUND

Internal hernia is a well-known complication of laparoscopic Roux-en-Y gastric bypass (LRYGB), with reported rates ~ 5% within three months to three years after surgery. Internal hernia through a mesenteric defect can lead to small bowel obstruction. Mesenteric defects began to be more routinely closed, often considered standard practice by 2010. To our knowledge, there are no large population-based studies looking at rates of internal hernia post-LRYGB. This study utilizes a statewide database to characterize the trends of internal hernia post-LRYGB over the last two decades in multiple centers.

METHODS

LRYGB procedure records between January 2005 and September 2015 were extracted from the New York SPARCS database. Exclusion criteria included age < 18, in-hospital deaths, bariatric revision procedures, and internal hernia repair during the same hospitalization as LRYGB. Time to internal hernia was calculated from initial LRYGB hospital stay to admission date of the first internal hernia repair record. A multivariable proportional sub-distribution hazards model was utilized to analyze the trend of internal hernia incidence within three-year post-LRYGB.

RESULTS

46,918 patients were identified between 2005 and 2015, with 2950 (6.29) undergoing internal hernia repair post-LRYGB by the end of 2018. The cumulative incidence of internal hernia repair at the 3rd-year post-LRYGB was 4.80% (95% CI: 4.59%-5.02%). By the end of the 13th year, the longest follow-up period, the cumulative incidence was 12.00% (95% CI: 11.30%-12.70%). Overall, there was a decreasing trend over time of undergoing internal hernia repair within three-year post-LRYGB (HR = 0.94, 95% CI: 0.93-0.96), after adjusting for confounding factors.

CONCLUSION

This multicenter study maintains the rate of internal hernia following LRYGB reported in smaller studies and provides a longer follow-up period demonstrating decreasing occurrences of internal hernia after bypass as a function of year of index operation. This data is important as internal hernia continues to be a complication post-LRYGB.

Long-Term Follow-up and Risk of Recurrence of Internal Herniation after Roux-en-Y Gastric Bypass

PURPOSE

Internal herniation (IH) is the most common complication after Roux-en-Y gastric bypass surgery (RYGB). Although primary closure has reduced the incidence, recurrences are a continued problem. This study aimed to investigate long-term follow-up and recurrence risk of IH surgery.

METHODS

A retrospective cohort study of laparoscopic RYGB operated patients operated for a first IH between April 2012 and April 2015 at Skåne University Hospital in Malmö, Sweden. Status of primary closure of mesenteric gaps, time since RYGB, and findings at IH surgery were retrieved from medical records. Follow-up until December 31st, 2019, included recurrences of IH, number of computed tomography (CT) scans, emergency visits, readmissions, and other acute surgeries.

RESULTS

IH (n = 44) occurred almost equally in Petersen's space (n = 24) and beneath the jejunojejunostomy (n = 20). Long-term follow-up (median 75 months) of 43 patients registered an IH recurrence rate of 14% (n = 6). All recurrences occurred in the other mesenteric gap. One patient suffered a third IH, and one patient had four IH events. During follow-up, 56% (n = 24) had ER visits for abdominal pain, 47% (n = 20) had ≥ 1 abdominal CT scan, and 40% (n = 17) were readmitted. A third of readmitted (6/17) patients suffered a recurrence of internal herniation. Two other patients were readmitted ≥ 10 times for chronic abdominal pain.

CONCLUSION

Surgery for IH had a low risk of recurrence at the treated mesenteric gap, but a 14% recurrence risk at the other mesenteric gap, emphasizing the importance of carefully investigating weaknesses or gaps at the other mesenteric defect during surgery for IH.

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.

The effect of routine division of the greater omentum on small bowel obstruction after Roux-en-Y gastric bypass

BACKGROUND

It remains unknown whether routine division of the greater omentum during laparoscopic Roux-en-Y gastric bypass (LRYGB) influences the risk for small bowel obstruction (SBO) after RYGB.

OBJECTIVE

To evaluate the effect of omental division on SBO after LRYGB stratified by handling of the mesenteric defects.

SETTING

Nationwide, registry-based.

METHODS

In this registry-based cohort study, 40,517 patients who underwent LRYGB in Sweden within the period from January 1, 2007, to December 31, 2019, with data from the Scandinavian Obesity Surgery Registry (SOReg) were included. The study was based on combined data from the SOReg, the National Patient Register, the Swedish Prescribed Drugs Register, and the Total Population Registry. The main outcome was reoperation for SBO.

RESULTS

During a follow-up period of 5.9 ± 2.6 years, the cumulative incidence of SBO was 11.2% in the nondivision group compared with 9.7% among patients with divided omentum (hazard ratio [HR] = .83, 95% confidence interval [CI]: .77-.89, P < .001). The association was seen in patients without mesenteric defects closure (HR = .69, 95% CI: .61-.78, P < .001) as well as patients with closed mesenteric defects (HR = .80, 95% CI: .74-.87, P < .001).

CONCLUSION

Division of the greater omentum is associated with reduced risk for SBO after antecolic, antegastric LRYGB and should be considered as a complement to mesenteric defects closure to further reduce the risk for SBO after LRYGB.

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.

Gastric Bypass Versus Sleeve Gastrectomy: Comparison of Patient Outcomes, Satisfaction, and Quality of Life in a Single-Center Experience

Background: Laparoscopic sleeve gastrectomy (LSG) is the most common primary bariatric operation performed in the United States. Its relative technical ease, combined with a decreased risk for anatomic and malabsorptive complications make LSG an attractive option compared to laparoscopic gastric bypass (LGB) for many patients and surgeons. However, emerging evidence for progressive gastroesophageal reflux disease (GERD) after LSG, and the inferior weight loss in many studies, suggests that the enthusiasm for LSG requires reassessment. We hypothesized that patient satisfaction and quality of life (QoL) may be lower after LSG compared to LGB because of these differences. Methods: We distributed a survey querying weight-loss outcomes, complications, foregut symptoms, QoL, and overall satisfaction to patients who underwent bariatric operations at our institution between 2000 and 2020 and who had electronic mail contact information available. Mean follow-up was 2.75 ± 2.41 years for LGB patients and 3.37 ± 2.18 (P = .021) years for LSG patients. We compared these groups for weight-loss outcomes, changes in foregut symptoms, gastrointestinal QoL, postbariatric QoL, and overall satisfaction using appropriate statistical tests. Results: Among 323 respondents, 126 underwent LGB and 197 underwent LSG. LGB patients had larger body mass index (BMI) reduction than LSG patients (-17.16 ± 9.07 kg/m² versus -14.87 ± 7.4 kg/m², P = .023). LGB patients reported less reflux (P = .003), with decreased heartburn (P < .0001) and regurgitation (P = .0027). However, a greater proportion of LGB patients reported at least one complication (P = .025). Despite this, more LGB patients reported satisfaction (92.86%) than LSG patients (73.6%). Conclusion: LGB patients are significantly more likely to be satisfied than LSG patients. Factors contributing to the higher level of satisfaction include less GERD and better BMI decrease.

Incidence and risk factors of symptomatic Petersen's hernias in bariatric and upper gastrointestinal surgery: a systematic review and meta-analysis

PURPOSE

The aim of this study was to investigate the actual incidence of symptomatic Petersen's hernias (PH) as well as identify risk factors for their occurrence.

METHODS

Search was performed in Medline (via PubMed), Web of Science, and Cochrane library, using the keywords "Petersen Or Petersen's AND hernia" and "Internal hernia." Only studies of symptomatic PH were eligible. Fifty-three studies matched our criteria and were included. Risk of bias for each study was independently assessed using the checklist modification by Hoy et al. Analysis was performed using random-effects models, with subsequent subgroup analyses.

RESULTS

A total of 81,701 patients were included. Mean time interval from index operation to PH diagnosis was 17.8 months. Total small bowel obstruction (SBO) events at Petersen's site were 737 (0.7%). SBO incidence was significantly higher in patients without defect closure (1.2% vs 0.3%, p < 0.01), but was not significantly affected by anastomosis fashion (retrocolic 0.7% vs antecolic 0.8%, p = 0.99). SBO incidence was also not significantly affected by the surgical approach (laparoscopic = 0.7% vs open = 0.1%, p = 0.18). However, retrocolic anastomosis was found to be associated with marginally, but not significantly, increased SBO rate in patients with Petersen's space closure, compared with the antecolic anastomosis (p = 0.09).

CONCLUSION

PH development may occur after any gastric operation with gastrojejunal anastomosis. Contrary to anastomosis fashion and surgical approach, defect closure was demonstrated to significantly reduce SBO incidence. Limitations of this study may include the high heterogeneity and the possible publication bias across the included studies.

Establishing Methods of Defect Closure in Roux-en-Y Gastric Bypass: an International Survey

INTRODUCTION

Internal herniation (IH) can be a life-threatening complication of Roux-en-Y gastric bypass (RYGB). Randomised controlled trials support the routine closure of mesenteric spaces at RYGB. However, there is currently no consensus on the method of closure in clinical practice. The purpose of this survey is to understand bariatric surgeons' practice in this regard.

METHODS

We conducted an international survey, whereby questions were created through collaboration of a consensus group of bariatric surgeons and hosted on the SurveyMonkey platform. The survey was distributed among British Obesity and Metabolic Surgery Society (BOMSS) members and international professional channels including The Upper Gastrointestinal Society (TUGS) and social media.

RESULTS

One hundred and thirty-six surgeons from 34 countries completed the survey. Of these, 49 respondents were UK-based surgeons with a cumulative experience of approximately 2500 RYGB per annum. Forty-five (91.8%) respondents reported always closing mesenteric defects, of whom 57.8% elected to use non-absorbable non-barbed sutures, followed by staples/clips in 28.9% and a selection of other methods. Most respondents used more than one method. A total of 2 UK and 14 non-UK participants reported never closing mesenteric spaces.

CONCLUSIONS

This survey has shown heterogeneity among defect closure and no consensus on preferred type. Additionally, there remains a practice of non-closure of mesenteric defects. We hope these findings help to inform further needed research and consensus building among experts.

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.

Surgical Treatment of Obesity. Special Mention to Roux-en-Y Gastric Bypass and Vertical Gastrectomy

INTRODUCTION

The prevalence of obesity has increased exponentially in recent decades, being one of the diseases that most affects global health. It is a chronic disease associated with multiple comorbidities, which lead to a decrease in life expectancy and quality of life. It requires a multidisciplinary approach by a specialized medical team. Obesity can be treated with conservative or with surgical treatments that will depend on the characteristics of the patient.

OBJECTIVE/METHODOLOGY

The referenced surgery can be performed using different surgical techniques that are analyzed in the present work through an exhaustive narrative bibliographic review in the PubMed and Cochrane databases, as well as in UpToDate.

RESULTS

Currently, those most used are restrictive techniques, specifically vertical gastrectomy and mixed techniques, with gastric bypass being the "gold standard".

CONCLUSIONS

In order to choose one technique or another, the characteristics of each patient and the experience of the surgical team must be taken into account.

Current status of internal hernia after gastrectomy for gastric cancer

BACKGROUND

Internal hernia is a well-known postoperative complication after Roux-en-Y gastric bypass. However, it has not been considered a recognized complication for gastric cancer.

METHODS

We reviewed the literature in the past decade to clarify the current status of internal hernia after gastrectomy including its incidence, high-risk factors, and treatment.

RESULTS

The incidence of internal hernia after gastrectomy was found to be between 0.2 and 5.63%, and the median interval time was less than 2 years. High-risk factors include laparoscopic approach, non-closure of all the mesenteric defects, and Roux-en-Y reconstruction. The rate of bowel resection was significantly higher than that of adhesive small bowel obstruction.

CONCLUSION

The true incidence of internal hernia after gastrectomy is generally underestimated. Closure of all the mesenteric defects is one of the most effective methods to prevent postoperative internal hernia. Early surgical exploration is necessary when internal hernia is suspected.

Small Bowel Obstruction

Small bowel obstruction (SBO) remains a common problem for surgeons and nonsurgeons alike. Management of SBO has shifted from primarily being surgical to a nonoperative approach, which can be attributed to a multitude of reasons, including better understanding of the pathophysiology of SBO, the advent of laparoscopy, and improvement in diagnostic imaging. But given the nature of SBO, the need for surgical consultation continues to remain a necessity. This article will review the etiology, diagnosis, and management of SBO.

Small bowel obstruction following laparoscopic Roux-en-Y gastric bypass: is it always necessary to operate? A 5-year, high volume center experience

PURPOSE

This study aims to describe the incidence, associated factors, etiology, and management of small bowel obstructions following laparoscopic Roux-en-Y gastric bypass (LRYGB).

METHODS

A retrospective analysis was conducted between January 15 and December 19 using the surgery database of our hospital. Included LRYGB patients were those that evolved with a prolonged length of stay; readmission; emergency room consult; and re-intervention due to small bowel obstruction (SBO) related symptoms with compatible radiological or intraoperative findings. The LRYGB technique implied an antecolic alimentary limb reconstruction and systematic closure of mesenteric defects. Descriptive and analytical statistics were carried out, using a parametric or non-parametric approach as needed.

RESULTS

Nine hundred forty-one LRYGB were performed. 9.9% were revisional surgeries of patients with a laparoscopic sleeve gastrectomy. During the study period, 36 SBOs occurred, representing 3.8% of operated patients, with no mortality. 58.3% had successful non-operative management, while 41.7% required surgical exploration, of which 73.3% were treated laparoscopically and 20% needed conversion to open surgery. Etiologies of SBO were jejuno-jejunostomy (JJO) related stenosis (22, 61.1%), internal hernias (6, 16.7%), adherences (3, 8.3%), and other diagnoses (5, 13.9%). Regarding JJO stenosis and internal hernias, median time to diagnosis was 8 days (IQR 7-11) and 12 months (IQR 8.7-16) respectively. Previous sleeve gastrectomy, age, or sex was not associated to the incidence of small bowel obstruction.

CONCLUSIONS

LRYGB is safe when performed by experienced surgeons. SBO due to internal hernias were scarce in this series. JJO stenosis could explain most cases of SBO; under this diagnosis, non-surgical management was successful frequently.

Long-term Emergency Department Visits and Readmissions After Laparoscopic Roux-en-Y Gastric Bypass: a Systematic Review

PURPOSE

There is considerable evidence on short-term outcomes after laparoscopic Roux-en-Y gastric bypass (LRYGB), but data on long-term outcome is scarce, especially on postoperative emergency department (ED) visits and readmissions. We aim to systematically review evidence on the incidence, indications, and risk factors of ED visits and readmissions beyond 30 days after LRYGB.

MATERIALS AND METHODS

A systematic search in PubMed, Scopus, Embase.com , Cochrane Library, and PsycINFO was performed. All studies reporting ED visits and readmissions > 30 days after LRYGB, with ≥ 50 patients, were included. PRISMA statement was used and the Newcastle-Ottawa Scale for quality assessment.

RESULTS

Twenty articles were included. Six studies reported on ED visits (n = 2818) and 19 on readmissions (n = 276,543). The rate of patients with an ED visit within 90 days after surgery ranged from 3.9 to 32.6%. ED visits at 1, 2, and 3 years occurred in 25.6%, 30.0%, and 31.1% of patients. Readmissions within 90 days and at 1-year follow-up ranged from 4.1 to 20.5% and 4.75 to 16.6%, respectively. Readmission was 29% at 2 years and 23.9% at 4.2 years of follow-up. The most common reason for ED visits and readmissions was abdominal pain.

CONCLUSION

Emergency department visits and readmissions have been reported in up to almost one in three patients on the long-term after LRYGB. Both are mainly indicated for abdominal pain. The report on indications and risk factors is very concise. A better understanding of ED visits and readmissions after LRYGB is warranted to improve long-term care, in particular for patients with abdominal pains.

Does the non-absorbable suture closure of the jejunal mesenteric defect reduce the incidence and severity of internal hernias after laparoscopic Roux-en-Y gastric bypass?

Purpose

Internal hernias (IH) are frequent complications after laparoscopic Roux-en-Y gastric bypass (LRYGB). Closure of the jejunal mesenteric and the Petersen defect reduces IH incidence in prospective and retrospective trials. This study investigates whether closing the jejunal mesenteric space alone by non-absorbable suture and splitting the omentum can be beneficial to prevent IH after LRYGB.

Methods

Observational cohort study of 785 patients undergoing linear LRYGB including omental split at a single institution, with 493 patients without jejunal mesenteric defect closure and 292 patients with closure by non-absorbable suture, and a minimal follow-up of 2 years. Patients were assessed for appearance and severity of IH. Additionally, open mesenteric gaps without herniated bowel as well as early obstructions due to kinking of the entero-enterostomy (EE) were explored.

Results

Through primary mesenteric defect closure, the rate of manifest jejunal mesenteric and Petersen IH could be reduced from 6.5 to 3.8%, but without reaching statistical significance. The most common location for an IH was the jejunal mesenteric space, where defect closure during primary surgery reduced the rate of IH from 5.3 to 2.4%. Higher weight loss seemed to increase the risk of developing an IH.

Conclusion

The closure of the jejunal mesenteric defect by non-absorbable suture may reduce the rate of IH at the jejunal mesenteric space after LRYGB. However, the beneficial effect in our collective is smaller than expected, particularly in patients with good weight loss. The Petersen IH rate remained low by consequent T-shape split of the omentum without suturing of the defect.

Randomized clinical trial on closure versus non-closure of mesenteric defects during laparoscopic gastric bypass surgery

BACKGROUND

Internal herniation is a well known and potentially life-threatening complication of laparoscopic Roux-en-Y gastric bypass (LRYGB). The aim of this study was to evaluate the benefit and harm of closing the mesenteric defects with clips during LRYGB to prevent internal herniation.

METHODS

This was a single-centre, single-blinded RCT. Patients eligible for LRYGB were randomized to surgery with or without closure of mesenteric defects with clips. The primary endpoint was the incidence of (intermittent) internal herniation after LRYGB with a minimum follow-up of 24 months. Secondary outcomes were duration of surgery, number of clips used, trocars and sutures used, postoperative pain measured by a visual analogue scale (VAS), and postoperative complications.

RESULTS

Between 13 August 2012 and 18 May 2017, 401 patients were randomized to closure (201) or non-closure (200) of mesenteric defects. Median follow-up for both groups was 59 months (range 8-67 and 16-67 months in non-closure and closure groups respectively). The cumulated risk of internal herniation after 2 years was 8.0 per cent in the non-closure group compared with 4.5 per cent in the closure group (hazard ratio (HR) 1.81, 95 per cent c.i. 0.80 to 4.12; P = 0.231). At 5 years, rates were 15.5 and 6.5 per cent respectively (HR 2.52, 1.32 to 4.81; P = 0.005). Closure of mesenteric defects increased operating time by a median of 4 min (95 per cent c.i. 52 to 56 min for the non-closure group and 56 to 60 min for the closure group; P = 0.002). There was no difference in postoperative blood transfusion rates and VAS scores between the groups.

CONCLUSION

Routine closure of the mesenteric defects in LRYGB with clips is associated with a lower rate of internal herniation. Registration number: NCT01595230 (http://www.clinicaltrials.gov).

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.

Internal Hernia After Laparoscopic Gastric Bypass Without Preventive Closure of Mesenteric Defects: a Single Institution's Experience

BACKGROUND

Internal herniation (IH) is a well-known complication after laparoscopic gastric bypass (LGB). Diagnosing and managing IH can be challenging. This retrospective cohort study aimed to achieve a greater understanding of symptomatology, diagnostic tools, complications, risk of IH recurrence, and symptom relief in IH patients.

METHODS

We included patients who underwent LGB surgery at our institution between 2011 and 2015. Mesenteric defects were not preventively closed during LGB. We focused on LGB patients who underwent surgical intervention(s) for suspected IH during a 7-year study period. We studied patient characteristics, (predictive) symptoms and signs, abdominal imaging, operative findings, post-operative course, and risk of (recurrent) IH.

RESULTS

A total of 1588 patients were included. In total, 243 patients underwent IH-related diagnostic laparoscopy. Radiating pain to the back (OR 2.45, p = .03), post-prandial pain (OR 3.23, p = .00), and leukocytosis (OR 15.53, p = .01) were identified as predictors of IH. The estimated risk of IH-related diagnostic laparoscopy was 16% at 3 years post-LGB, and the risk of confirmed IH was 12%. The estimated risk of diagnostic laparoscopy for suspected recurrent IH was 10% at 5 years post-LGB. In patients who underwent secondary mesenteric defects closure, post-operative symptom relief was reported in 84%.

CONCLUSION

This study demonstrates a considerable risk of developing IH after LGB without preventive closure of the mesenteric defects. We emphasize the value of diagnostic laparoscopy to achieve symptom relief in patients with suspicion of IH. Preoperative diagnosis of IH can be improved by being watchful of specific symptoms and signs which can predict the intra-operative presence of IH.

Metabolic surgery: A clinical update

Metabolic and bariatric surgery has grown beyond 'experimental' weight-loss surgery. As techniques have advanced over the last few decades, so has the growing body of research and evidence, proving that both weight-loss and metabolic health improvement are induced. Metabolic surgery has become the more appropriate term for weight-loss surgery because of the altered gastrointestinal anatomy and subsequent beneficial metabolic effects. Although the tool of metabolic surgery has been well refined, a large portion of the global population does not have adequate access to it. This clinical update aims to (a) inform healthcare providers from all disciplines about the myriad of benefits of metabolic surgery and (b) equip them with the necessary knowledge to bridge the gap between patients in need of metabolic treatment and the therapies in metabolic surgery available to them.

Early small bowel obstruction in laparoscopic Roux-en-Y gastric bypass

Alimentary limb kinking after laparoscopic Roux-en-Y gastric bypass suggested by CT-scan and diagnosed at laparoscopic surgery. Surgical treatment principles.

Internal Herniation Incidence After RYGB and the Predictive Ability of a CT Scan as a Diagnostic Tool

PURPOSE

The clinical diagnosis of an internal herniation (IH) after a Roux-en-Y Gastric Bypass (RYGB) remains difficult; therefore, performing a CT scan is usually part of the diagnostic process. The goal of this study was to assess the incidence of IH in patients with open and closed MD (mesenteric defect) and to study if the ability to diagnose an IH with a CT scan is different between these groups.

MATERIALS AND METHODS

IH was defined as a visible intestine through the mesenteric defect underneath the jejunojejunostomy and/or in the Petersen's space. CT scan outcomes were compared with the clinical diagnosis of an IH. Until 31 June 2013, standard care was to leave mesenteric defects (MDs) open; after this date, they were always closed.

RESULTS

The incidence of IH in the primarily non-closed group was 3.9%, and in the primarily closed group, this was 1.3% (p = 0.001). In group A (non-closed MD and CT), the sensitivity of the CT scan was 80%, and specificity was 0%. In group C (closed MD and CT), the sensitivity was 64.7%, and specificity was 89.5%. In group B (non-closed, no CT), an IH was visible in 58.7% of the cases and not in 41.3%. In group D (only a re-laparoscopy), an IH was visible in 34.3% of the cases and not in 65.7%.

CONCLUSIONS

Using the CT scan in suspected IH is not useful in if the MDs were not closed. If the MDs were closed, then a CT scan is predictive for the diagnosis IH.

Prevention of Petersen's hernia using jejunal mesentery fixing (Mefix)

BACKGROUND

The aim of this study was to compare the 1 year incidence of Petersen's hernia between individuals who were treated with the jejunal mesentery fixing (Mefix) method and those with the closure of Petersen's space method.

MATERIAL AND METHODS

We retrospectively collected clinical data of patients who underwent gastrectomy for gastric cancers with the closure of Petersen's space defect (N = 49) and Mefix (N = 26). The Mefix method was performed by fixing the jejunal mesentery (jejunojejunostomy below 30 cm) to the transverse mesocolon using nonabsorbable barbed sutures.

RESULTS

The procedure time for mesentery fixing (3.7 ± 1.1 mins) was significantly shorter than that for Petersen's space closure (7.5 ± 1.5 mins) (p < .001) although the operation times were similar between the two groups. There was no incidence of Petersen's hernias postoperatively in both groups. One case of reoperation was reported in the closure group due to small bowel obstruction by kinking of the jejunojejunostomy.

CONCLUSION

We found no occurrence of Petersen's hernias postoperatively in either group. We also found that the Mefix method was faster and easier to perform than the closure method. The Mefix method is an excellent alternative method to prevent the occurrence of Petersen's hernia after B-II or Roux-en-Y reconstruction.

Does the Length of the Common Channel as Part of the Total Alimentary Tract Matter? One Year Results from the Multicenter Dutch Common Channel Trial (DUCATI) Comparing Standard Versus Distal Roux-en-Y Gastric Bypass with Similar Biliopancreatic Bowel Limb Lengths

PURPOSE

Although the laparoscopic Roux-en-Y Gastric Bypass (LRYGB) is the gold-standard bariatric procedure, it remains uncertain what the optimal bowel limb lengths are to accomplish maximal weight loss while minimizing nutritional deficiencies and related gastro-intestinal complaints. The aim of this randomized controlled multicenter trial is to investigate the effect of significant lengthening of the length of the Roux limb (RL) at the cost of the length of the common channel (CC) while keeping the biliopancreatic limb (BPL) lengths the same on both study arms.

METHODS

Four hundred forty-four patients were randomized to receive either a Very Long Roux Limb LRYGB (VLRL-LRYGB) (variable RL length, BPL 60 cm, and CC 100 cm) or a Standard LRYGB (S-LRYGB) (RL 150 cm, BPL 60 cm, and a variable CC length). Results at 1-year follow-up for weight loss, effect on obesity-related comorbid conditions, complications, re-operation rate, malnutrition rate, and re-admission rate were investigated.

RESULTS

Weight loss at 1-year showed no significant differences for %EWL (84.3% versus 85.3%, p = 0.72) and %TWL (34.2% versus 33.6%, p = 0.359) comparing VLRL-LRYGB versus S-LRYGB. Malabsorption requiring surgical bowel length adjustment was observed in 1.4% in VLRL-LRYGB group versus 0.9% in S-LRYGB group (p = 0.316).

CONCLUSION

Significant lengthening of the RL at the cost of the common channel seems to have no effect on the weight loss at 1-year follow-up, which supports the theory that absorption of nutrients also occurs in the RL. Nevertheless, long-term results of the VLRL-LRYGB have to be awaited to draw final conclusions as part of the discussion towards optimal limb length in LRYGB surgery.

Effect of different limb lengths on quality of life, eating patterns and gastrointestinal symptoms after Roux-en-Y gastric bypass in superobese patients: randomized study

BACKGROUND

Distal Roux-en-Y gastrojejunal bypass (DRYGJB) gives better weight reduction than standard Roux-en-Y gastric bypass (RYGB) but at the risk of increased malnutrition side-effects. This study compared the effects of RYGB and DRYGJB on gastrointestinal symptoms, eating patterns and health-related quality of life (QoL).

METHODS

This was a single-blind RCT from a university-affiliated obesity centre. Patients with a BMI of 50 kg/m2 or above were invited to participate. Treatment arms were standard gastric bypass with an alimentary limb of 150 cm and a biliopancreatic limb of 60 cm, with a variable common channel length, or DRYGJB with biliopancreatic limb of 200 cm, common channel limb of 150 cm and variable alimentary limb length. Baseline and follow-up data to 5 years on quality of life, obesity-related problems and gastrointestinal symptoms were collected using prospectively created and validated questionnaires.

RESULTS

Some 140 patients were included. Those with a DRYGJB had better weight loss at 5 years (mean(s.d.) 68·3(21·8) kg versus 55·7(19·8) kg for standard RYGB; P = 0·011). Eating patterns improved, with no difference between the groups. Gastrointestinal symptoms (diarrhoea, indigestion) worsened significantly in both groups, but only patients with DRYGJB had significantly worse diarrhoea at the end of the study than at baseline (P = 0·006). Both groups had improved perceived generic QoL over baseline, and obesity-related problems were markedly reduced.

CONCLUSION

Standard RYGB and both improved generic and disease-specific QoL and eating behavioural pattern. Diarrhoea was increased more following DRYGJB than after RYGB. Registration number: NCT01514799 (https://clinicaltrials.gov).

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.

GLP-1 Analogues as a Complementary Therapy in Patients after Metabolic Surgery: a Systematic Review and Qualitative Synthesis

The evidence is strong that bariatric surgery is superior to medical treatment in terms of weight loss and comorbidities in patients with severe obesity. However, a considerable part of patients presents with unsatisfactory response in the long term. It remains unclear whether postoperative administration of glucagon-like peptide-1 analogues can promote additional benefits. Therefore, a systematic review of the current literature on the management of postoperative GLP-1 analogue usage after metabolic surgery was performed. From 4663 identified articles, 6 met the inclusion criteria, but only one was a randomized controlled trial. The papers reviewed revealed that GLP-1 analogues may have beneficial effects on additional weight loss and T2D remission postoperatively. Thus, the use of GLP-1 analogues in addition to surgery promises good results concerning weight loss and improvements of comorbidities and can be used in patients with unsatisfactory results after bariatric surgery.

Limb Length in Gastric Bypass in Super-Obese Patients-Importance of Length of Total Alimentary Small Bowel Tract

BACKGROUND

In super-obese patients, rates of weight loss failure and weight regain are high after RYGB. In order to improve weight loss, lengthening of the biliopancreatic limb is vital. In this study, efficacy and safety of two types of RYGB with 2-m BP-limb were assessed in improving weight loss and in the resolution of comorbidities compared with standard RYGB in a long-term follow-up.

METHODS

This is a retrospective cohort analysis on 671 super-obese patients operated in a 10-year period. Patients were classified into three groups: (1) 155 patients; roux limb 150 cm, BP-limb 60 cm; (2) 230 patients; roux limb 60 cm, BP-limb 200 cm; and (3) 286 patients; roux limb 150 cm, BP-limb 200 cm. EWL, TWL, BMI, failure, weight regain, comorbidity resolution, nutritional status, and complications were assessed.

RESULTS

Total alimentary limb length was shortened with 60 cm in group 1 and with 200 cm in groups 2 and 3. EWL, BMI change, and TWL were higher in the 2-m BP-limb groups vs group 1. No differences in complication rates were found, except higher frequency of marginal ulcers in patients with a shorter roux limb. EWL failure was higher in group 1 (10.3%) vs the other groups (4.3%; 5.2%). Group 3 had significantly less weight regain (26.6%). Remission of comorbidities was higher in the 2-m BP-limb groups at expense of nutritional and vitamin deficiencies (3.9%; 5.9%). No difference in hypoalbuminemia was noted.

CONCLUSION

Lengthening of the BP-limb gives significantly higher weight loss, lower rate of EWL failure, and lesser weight regain along with better resolution of obesity-associated comorbidities.

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.

High-Frequency of Computer Tomography and Surgery for Abdominal Pain After Roux-en-Y Gastric Bypass

INTRODUCTION

Acute, intermittent, and chronic abdominal pain is a common complaint after Roux-en-Y gastric bypass (RYGB).

OBJECTIVES

The aim of the study was to evaluate the use of medical imaging and the need for surgery treating abdominal pain after RYGB in a cohort with long-term follow-up.

METHODS

Data from 569 patients who underwent RYGB as the primary bariatric procedure at a public hospital in Norway between April 2004 and June 2011 were prospectively registered in a local quality registry for bariatric surgery. All abdominal imaging and abdominal surgical procedures were registered until August 2017.

RESULTS

Mean follow-up was 100 months (61-159). During the observation period, 22% had one CT, 9% had two CTs, 4% had three CTs, and 5% had four or more CTs for abdominal pain. Twenty-two percent underwent abdominal surgery, as 16% had one and 6% had two or more operations and gynecological procedures excluded. The purpose of operation was postoperative complications (1.4%), suspected internal herniation (9.3%), cholecystectomy (9.3%), appendectomy (2.3%), hernias (3.2%), and perforated ulcer in the gastrojejunal anastomosis (0.7%). Mean time interval was 42 ± 27 months from RYGB to cholecystectomy and 51 ± 26 months for suspected IH.

CONCLUSION

With a mean follow-up period of more than 8 years after RYGB, 40% of the patients suffered from abdominal pain, needing one or more CT scans. The need for surgery treating suspected internal hernia and cholecystectomy was equal, at 9.3% for both procedures, but the mean time from RYGB to operation was shorter for cholecystectomies.

Diagnosing Internal Herniation After Roux-en-Y Gastric Bypass Surgery: Literature Overview, Cadaver Study and the Added Value of 3D CT Angiography

Purpose

The purposes of the study are to outline the complexity of diagnosing internal herniation after Roux-en-Y gastric bypass (RYGB) surgery and to investigate the added value of computed tomography angiography (CTA) for diagnosing internal herniation.

Materials and Methods

A cadaver study was performed to investigate the manifestations of internal hernias and mesenteric vascularization. Furthermore, a prospective, ethics approved study with retrospective interpretation was conducted. Ten patients, clinically suspected for internal herniation, were prospectively included. After informed consent was obtained, these subjects underwent abdominal CT examination, including additional arterial phase CTA. All subjects underwent diagnostic laparoscopy for suspected internal herniation. The CTA was used to create a 3D reconstruction of the mesenteric arteries and surgical staples (3D CTA). The 3D CTA was interpreted, taking into account the presence and type of internal hernia that was found upon laparoscopy.

Results

Cadaveric analysis demonstrated the complexity of internal herniation. It also confirmed the expected changes in vascular structure and surgical staple arrangement in the presence of internal herniation. 3D CTA studies of the subjects with active internal hernias demonstrated remarkable differences when compared to control 3D CTA studies. The blood supply of herniated intestinal limbs in particular showed abnormal trajectories. Additionally, enteroenterostomy staple lines had migrated or altered orientation.

Conclusion

3D CTA is a promising technique for diagnosing active internal hernias. Our findings suggest that for diagnosing internal hernias, focus should probably shift from routine abdominal CT examination towards the 3D assessment of the mesenteric vasculature and surgical staples.

Electronic supplementary material

The online version of this article (10.1007/s11695-018-3121-3) contains supplementary material, which is available to authorized users.