Comparison between Open Hand-sewn, Laparoscopic Stapled and Laparoscopic Computer-mediated, Circular Stapled Gastro-Jejunostomies in Roux-en-Y Gastric Bypass in the Porcine Model

A pilot study about the development and characterization of a Roux en Y gastric bypass model in obese Yucatan minipigs

Performing the Roux-en-Y gastric bypass (RYGBP) in obese Yucatan minipigs provides an opportunity to explore the mechanisms behind the effects of this surgery in controlled environmental and nutritional conditions. We hypothesized that RYGBP in these minipigs would induce changes at multiple levels, as in obese humans. We sought to characterize RYGBP in a diet-induced obese minipig model, compared with a pair-fed sham group. After inducing obesity with an ad libitum high-fat/high-sugar diet, we performed RYGBP (n = 7) or sham surgery (n = 6). Oral glucose tolerance tests (OGTT) were performed before and after surgery. Histological analyses were conducted to compare the alimentary limb at sacrifice with tissue sampled during RYGBP surgery. One death occurred in the RYGBP group at postoperative day (POD) 3. Before sacrifice, weight loss was the same across groups. GLP-1 secretion (OGTT) was significantly higher at 15, 30 and 60 min at POD 7, and at 30 and 60 min at POD 30 in the RYGBP group. Incremental insulin area under the curve increased significantly after RYGBP (p = 0.02). RYGBP induced extensive remodeling of the alimentary limb. Results show that RYGBP can be safely performed in obese minipigs, and changes mimic those observed in humans.

Robot-assisted laparoscopic intracorporeal hand-sewn bowel anastomosis during pediatric bladder reconstructive surgery

Bowel anastomosis performed during robot-assisted laparoscopic surgery in both adult and pediatric populations has typically been performed using endoscopic staplers or with exteriorization of the bowel. In the pediatric population, no articles have been published that explore the possibility of a completely intracorporeal hand-sewn anastomosis during robot-assisted laparoscopic surgery. We report our series of six children who were undergoing robot-assisted laparoscopic intracorporeal hand-sewn bowel anastomosis during bladder reconstructive surgery for neurogenic bladder. The postoperative course was uncomplicated with regard to the bowel anastomosis, demonstrating the feasibility of the technique in experienced hands.

Laparoscopic sleeve gastrectomy with duodeno-jejunal bypass: a new surgical procedure for weight control. Feasibility and safety study in a porcine model

BACKGROUND

One limit of the Roux-en-Y gastric bypass (GBP) is the preclusion of exploring the bypassed stomach with conventional endoscopy and radiological studies. In this study, we explored the feasibility, safety, and weight progression of a new bariatric procedure that eliminates this inconvenience.

METHODS

Eleven 40- to 50-kg Yorkshire pigs underwent laparoscopic sleeve gastrectomy and Roux-en-Y duodeno-jejunal bypass (SG-DJBP). Weight was monitored at postoperative days 15 and 30 and after 3 months; weight progression was compared with an identical group that underwent a sham procedure or GBP. At autopsy, surgical site was evaluated at microscopic and macroscopic level.

RESULTS

Mean operating time was 66 +/- 5.76 min. All the survivors tolerated the procedure well, except one subject that experienced a gastric leak from the stapler line. The SG-DJBP had a had significantly slower weight gains than the sham group (P = 0.005). The absence of histological abnormalities in the duodenal wall was confirmed at autopsy.

CONCLUSION

SG-DJBP is feasible and produces effects of weight progression comparable to those of GBP. Being a combination of previously standardized procedures, we are confident to propose this procedure as a bariatric alternative in humans. Long-term follow-up will be required to establish the efficacy on weight loss in humans.

Laparoscopic duodenal switch for pathologic duodenogastric reflux: initial experience

Duodenogastric reflux (DGR) is barely responsive to medications and antireflux fundoplication is not able to control the gastric symptoms. Duodenal switch (DS) preserves the physiologic food transit while creating an effective Roux-en-Y diversion to duodenal juice. However, it never enjoyed great popularity, perhaps due to the invasiveness of the open approach. The paper reports our initial experience with laparoscopic DS. Preoperative assessment, surgical technique, and outcomes are described. Normalization of DGR was demonstrated by preoperative and postoperative 24-hour bilimetry and pH-multichannel intraluminal impedance. The procedure was completed under laparoscopy in all the cases with a mean operative time of 165 minutes. Mean blood loss was 200 mL. No patient required admission to the intensive care unit. Initial experience with laparoscopic DS encourages continued use of the minimally invasive approach. A meticulous preoperative evaluation is essential to place a correct indication.

Development of a porcine Roux-en-Y gastric bypass survival model for the study of post-surgical physiology

BACKGROUND

Rodents have been used to examine physiologic changes after bariatric surgery, but differences in gastric/vagal anatomy may limit their utility. Swine may be a more appropriate animal model because of anatomic and physiologic similarities to humans. The aim of this study was to establish a survival model of Roux-en-Y gastric bypass (RYGBP) in swine and to evaluate its potential in studies of physiology.

METHODS

13 miniature swine, 5 Yucatan [26.4 +/- 1.6 kg], 4 Hanford [28.3 +/- 0.6 kg] and 4 other breed [54.9 +/- 6.2 kg] underwent open RYGBP, and were kept alive to 30 (n=4), 60 (n=1) or 90 (n=2) postoperative days.

RESULTS

4 early animals had staple-line leakage within 7 days from surgery and 1 animal experienced unmanageable pain at 42 days after surgery. One animal experienced immediate cardiopulmonary collapse. 58% of animals survived to their projected endpoint. Necropsy of 1 animal at its 90-day endpoint revealed a gastro-gastric fistula. Anatomic features in swine that differ from humans, such as thick perigastric membranes, required adjustment to the standard RYGBP technique used in humans to achieve satisfactory results. Caloric intake decreased in some but not all animals, and was linked to feeding regimen. By postoperative day 30, animals weighed 5.7-29.1% less than their projected, non-operative weight. Serum assays of ghrelin and PYY were conducted, with results consistent with the procedure.

CONCLUSIONS

The use of swine as a model for bariatric surgery has promise, but also has associated pitfalls that must be addressed for this to be an effective model.

Computer assisted surgical stapling

Computer assisted surgical stapling is the application of new technology to conventional staplers. The components of the system, their use in open thoracic surgery and a review of the literature to date are presented.