Laparoscopic Roux-en- W gastric bypass.

OBJECTIVES: Roux-en-Y gastric bypass is the gold standard for treating morbid obesity in this country. The totally laparoscopic performance of this procedure, although quite demanding and technically difficult, has revolutionized it; and the demand for it has skyrocketed. We describe 2 cases where it became necessary to convert the Y into a W while performing the procedure. METHODS: A laparoscopic Roux-en-Y gastric bypass was attempted on 2 patients, 1 male and 1 female, both with body mass indexes greater than 40. During creation of the side to side jejunojejunostomy, ie, the Y, it became obvious that stenosis or obstruction would result. This area was partially resected and an additional side to side anastomosis was formed, creating a W. RESULTS: The operative time was 205 minutes and 180 minutes, respectively, which compared favorably with the average operative time of 151 minutes in that quartile of patients (patients #101-#150). Both patients had normal upper gastrointestinal and small bowel contrast x-rays the day following surgery and were started on clear liquids. They were discharged later that day. Weight loss of 119 lb at 8 months and 80 lb at 6 months was documented, respectively, with no gastrointestinal sequelae. CONCLUSION: If problems are encountered when creating the Y of a laparoscopic Roux-en-Y gastric bypass, a laparoscopic Roux-en-W may be performed. It appears safe, technically feasible, and with a postoperative course not unlike that of the standard approach

Hepatobiliary scintigraphy as a diagnostic modality for gastroparesis of the bypassed stomach after gastric bypass for morbid obesity.

After Roux-en-Y gastric bypass (RYGBP), the excluded gastric remnant represents a challenge for the surgeon. Many diseases are reported to take place in that remnant, such as cancer, gastritis, and ulcer. On the other hand, diagnosing these pathological changes requires invasive intervention. We report the use of a noninvasive study to diagnose pathology in the bypassed stomach

An Approach to Venous Thromboembolism Prophylaxis in Laparoscopic Roux-en-Y Gastric Bypass Surgery.

BACKGROUND: Venous thromboembolism (VTE) prophylaxis regimens for laparoscopic Roux-en-Y gastric bypass (LRYGBP) have not been adequately addressed in the literature. This study presents the results of our prophylactic regimen in LRYGBP at a tertiary care hospital. METHODS: A retrospective review of 255 morbidly obese patients undergoing LRYGBP between March 2000 and February 2003 was conducted. Patients received preoperative subcutaneous heparin (SQH) (5000u or 7500u) and every 8 hours thereafter during hospitalization. Sequential compression devices (SCD) were utilized during and after surgery unless ambulating. Early ambulation was enforced. RESULTS: 255 patients underwent LRYGBP, with 5 (1.9%) converted to open. Average preoperative weight and body mass index (BMI) were 138 kg and 50, respectively. Operative time averaged 174 minutes. Average length of stay was 2.2 days. 9 patients (3.6%) had a prior history of deep venous thrombosis/pulmonary embolism (DVT/PE), one of whom had a DVT/PE postoperatively. 2 patients developed DVT/PE within 30 days. Overall DVT/PE incidence was 1.2%. There were 6 postoperative bleeding episodes (2.4%). CONCLUSION: This regimen provides excellent prophylaxis against VTE in the hospital setting

Two Cases of Endometrioma in Cesarean Scars.

The occurrence of endometrioma in cesarean scar is an infrequent event usually presenting as a tender abdominal wall mass. Two cases are reported here. Diagnosis is suggested when the symptoms are cyclic and associated with the patient\u27s menstrual cycle, but this is not always the case. Surgical excision is the method of choice for diagnosing and ultimately treating the lesion

Laparoscopic Roux-en-Y Gastric Bypass in the Megaobese .

HYPOTHESIS: Laparoscopic Roux-en-Y gastric bypass is a safe and effective procedure in patients with a body mass index (BMI; calculated as weight in kilograms divided by the square of height in meters) of 70 or greater. DESIGN: A retrospective analysis of patients with a BMI of 70 or greater who underwent laparoscopic Roux-en-Y gastric bypass by a single surgeon. SETTING: A university-affiliated community hospital in Allentown, Pa. PATIENTS: A nonconsecutive series of 9 patients with a BMI of 70 or greater who met traditional criteria for a bariatric procedure. INTERVENTION: Laparoscopic approach to Roux-en-Y gastric bypass with stapled anastomoses. RESULTS: Patient medical records were reviewed for length of stay, complications, operative time, comorbidities, and weight loss. Seven patients were women and 2 were men. Comorbidities included dyspnea on exertion, peripheral edema, arthritis, sleep apnea, hypertension, diabetes mellitus, asthma, hypothyroidism, gastroesophageal reflux disease, peptic ulcer disease, and heart disease. Eight of 9 procedures were successfully completed laparoscopically. One patient was converted to an open procedure. One patient developed a marginal ulcer postoperatively. No other complications occurred. Operative time ranged from 122 to 330 minutes (mean, 203 minutes). Length of stay averaged 1.2 days. Overall weight loss was 49% of excess body weight at 1 year after surgery. CONCLUSION: Laparoscopic Roux-en-Y gastric bypass is safe and effective in patients with a BMI of 70 or greater

Obstructing Carcinoma of the Cecum.

Carcinoma of the cecum, the third most common location for malignancy of the large bowel, was examined with attention centered upon cecal cancers producing obstruction. Reviewing 136 patients revealed 11 obstructing lesions (8.1%) presenting as distal small bowel obstructions. The mean age of the patients was 74 years. All but one patient had resection for cure which consisted of a right hemicolectomy with ileotransverse colostomy. There was no operative mortality or significant morbidity. Bowel obstruction due to cecal carcinoma is an infrequent occurrence arising in elderly patients and carries a poor survival rate due to advanced disease at the time of diagnosis and treatment