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BackgroundTotally laparoscopic gastrectomy (LG) is preferred over open gastrectomy because it allows safe anastomosis, a small wound, and early bowel recovery. However, esophagojejunostomy (EJS) following laparoscopic total gastrectomy (LTG) remains technically challenging. To popularize LTG, a secure method of reconstruction must be developed. We present a simple and safe technique for intracorporeal EJS following LTG.MethodsOur modified technique for intracorporeal EJS as a part of Roux-en-Y reconstruction following LTG incorporates an isoperistaltic stapled EJS with closure of the entry hole using two unidirectional barbed sutures. First, a side-to-side isoperistaltic EJS is created between the dorsal and left side of the esophagus and the jejunal arm. Second, the opening for the stapler is closed with a two-layer continuous suture using two 15-cm 3-0 V-Loc suture devices. The full-thickness inner layer closure commences from the sides of the staple lines and progresses toward the center of the enterotomy. During suturing, the remaining thread is utilized to apply tension and lift the enterotomy. Once the full-thickness layer closure is complete at the center of the enterotomy, suturing of the second seromuscular layer is started in the forward direction toward each corner to give a crossover-shaped suturing line.ResultsFrom February 2012 to October 2017, 27 patients with gastric cancer underwent LTG with intracorporeal stapled EJS as a part of Roux-en-Y reconstruction. All procedures were successfully performed without any intra- or postoperative anastomosis-related complications. No conversion to other procedures was required. The mean suturing time was 19.1 ± 9.5 min. The mean postoperative time to tolerating a liquid diet was 3.3 days, and the mean hospital stay was 12.1 days.ConclusionsWe herein report our procedure for intracorporeal EJS using a linear stapler and barbed sutures. This technique is simple and feasible and has acceptable morbidity.

Background and study aims Fail to reach the bilioenteric anastomosis is the main cause of treatment failure during single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (SBE-assisted ERCP) in patients after bilioenteric Roux-en-Y anastomosis. We aim to evaluate factors influencing the endoscopic insertion failure. Patients and methods We retrospectively reviewed the clinical data of 231 cases undergoing SBE-assisted ERCP from January 2016 to December 2021. Treatment details and outcomes were studied to analyze the factors involved in endoscopic insertion failure. Results The enteroscopy success rate and procedural success rate were 88.3% and 84.4%. Incidence of postoperative adverse events was 3.9%. No serious adverse events occurred. Risk factors of endoscopic insertion failure include first ERCP attempt, side to side anastomosis at the Rou-Y anastomosis, the use of Endo-GIA anastomosis, three bowel lumens seen at the Rou-Y anastomosis under endoscopy, steep angle of the afferent loop at the Rou-Y anastomosis with a U-shape, length of the afferent loop ≥ 50 cm, and twisted afferent loop. Among which the multifactorial analysis suggested that the presence of three bowel lumens at the Rou-Y anastomosis and twisted afferent loop were independent risk factors for enteroscopy failure. For case with twisted afferent loop, the use of a transparent cap with X-ray-assisted guidance during insertion is an effective strategy to improve the success rate. Conclusions SBE-assisted ERCP is safe and effective in patients after bilioenteric Roux-en-Y anastomosis. The severity of afferent loop twisting and Rou-Y anastomosis shape were risk factors for endoscopic insertion failure. Surgeons should take into account the feasibility of postoperative ERCP treatment at the time of operation.

Objective To investigate the safety and feasibility of totally laparoscopic uncut Roux-en-Y anastomosis in the distal gastrectomy with D2 dissection for gastric cancer. We also summarized the preliminary experience of totally laparoscopic uncut Roux-en-Y anastomosis. Methods A retrospective analysis was done in 51 cases of total laparoscopic uncut Roux-en-Y anastomosis in the distant gastrectomy with D2 dissection for gastric cancer in our hospital from September 2014 to December 2015. Results All of 51 cases underwent total laparoscopic uncut Roux-en-Y anastomosis. All the procedures were performed successfully. There were neither conversions to open surgery nor intraoperative complications in all 51 cases. In this study, the median operative time was 170 (135–210) min and the median time of anastomosis was 27 (24–41) min. The blood loss was 60 (30–110) ml. The time to flatus and length of postoperative hospital stay were 2 (1–3) days, and 8 (7–12) days, respectively. The mean lymph node harvest was 34 (18–49). One anastomotic bleeding occurred postoperatively which was cured by conservative treatment. No major postoperative complication occurred, such as anastomotic leak, anastomotic stenosis, and Roux stasis syndrome. After a short-term follow-up, no recanalization or reflux gastritis was encountered by endoscopy. Conclusion The totally laparoscopic uncut Roux-en-Y anastomosis in distal gastrectomy with lymph node dissection for gastric cancer is safe and feasible, with a very low rate of recanalization and reflux gastritis.

One anastomosis gastric bypass (OAGB) is increasingly used in the treatment of morbid obesity. However, the efficacy and safety outcomes of this procedure remain debated. We report the results of a randomised trial (YOMEGA) comparing the outcomes of OAGB versus standard Roux-en-Y gastric bypass (RYGB). This prospective, multicentre, randomised non-inferiority trial, was held in nine obesity centres in France. Patients were eligible for inclusion if their body-mass index (BMI) was 40 kg/m2 or higher, or 35 kg/m2 or higher with the presence of at least one comorbidity (type 2 diabetes, high blood pressure, obstructive sleep apnoea, dyslipidaemia, or arthritis), and were aged 18–65 years. Key exclusion criteria were a history of oesophagitis, Barrett's oesophagus, severe gastro-oesophageal reflux disease resistant to proton-pump inhibitors, and previous bariatric surgery. Participants were randomly assigned (1:1) to OAGB or RYGB, stratified by centre with blocks of variable size; the study was open-label, with no masking required. RYGB consisted of a 150 cm alimentary limb and a 50 cm biliary limb and OAGB of a single gastrojejunal anastomosis with a 200 cm biliopancreatic limb. The primary endpoint was percentage excess BMI loss at 2 years. The primary endpoint was assessed in the per-protocol population and safety was assessed in all randomised participants. This study is registered with ClinicalTrials.gov, number NCT02139813, and is now completed. From May 13, 2014, to March 2, 2016, of 261 patients screened for eligibility, 253 (97%) were randomly assigned to OAGB (n=129) or RYGB (n=124). Five patients did not undergo their assigned surgery, and after undergoing their surgery 14 were excluded from the per-protocol analysis (seven due to pregnancy, two deaths, one withdrawal, and four revisions from OAGB to RYGB) In the per-protocol population (n=117 OAGB, n=117 RYGB), mean age was 43·5 years (SD 10·8), mean BMI was 43·9 kg/m2 (SD 5·6), 176 (75%) of 234 participants were female, and 58 (27%) of 211 with available data had type 2 diabetes. After 2 years, mean percentage excess BMI loss was −87·9% (SD 23·6) in the OAGB group and −85·8% (SD 23·1) in the RYGB group, confirming non-inferiority of OAGB (mean difference −3·3%, 95% CI −9·1 to 2·6). 66 serious adverse events associated with surgery were reported (24 in the RYGB group vs 42 in the OAGB group; p=0·042), of which nine (21·4%) in the OAGB group were nutritional complications versus none in the RYGB group (p=0·0034). OAGB is not inferior to RYGB regarding weight loss and metabolic improvement at 2 years. Higher incidences of diarrhoea, steatorrhoea, and nutritional adverse events were observed with a 200 cm biliopancreatic limb OAGB, suggesting a malabsorptive effect. French Ministry of Health.

BackgroundAlthough commonly used procedure, Roux-en-Y hepaticojejunostomy (RYHJ) remains to be complicated, time consuming, and has a relatively poor prognosis. We designed the magnetic compressive anastomats (MCAs) to perform RYHJ more efficiently and safely.Materials and methods36 dogs were divided into two groups randomly. After obstructive jaundice model construction, RYHJ was performed with MCAs in study group or by hand-sewn in control group. Both groups were followed for 1, 3, and 6 months after RYHJ. The liver function and postoperative complications were recorded throughout the follow-up. At the end of each time point, dogs were sent for magnetic resonance imaging (MRI) and sacrificed. Anastomotic samples were taken for anastomotic narrowing rate calculation, histological analyses, tensile strength testing, and hydroxyproline content testing.ResultsThe anastomotic construction times were 44.20 ± 23.02 min in study group, compared of 60.53 ± 11.89 min in control group (p < 0.05). The liver function recovered gradually after RYHJ in both groups (p > 0.05). All anastomats were expelled out of the body in 8.81 ± 2.01 days. The gross incidence of morbidity and mortality was 33.3% (6/18) and 16.7% (3/18) in study group compared with 38.9% (7/18) and 22.2% (4/18) in control group (p > 0.05), and there is no single case of anastomotic-specific complications happened in study group. The narrowing rates of anastomosis were 14.6, 18.5, and 18.7% in study group compared with 35.4, 36.9, and 34% in control group at 1st, 3rd, and 6th month after RYHJ (p < 0.05). In study group, preciser alignment of tissue layers and milder inflammatory reaction contributed to the fast and better wound healing process.ConclusionPerform RYHJ with MCAs is safer, more efficient than by hand-sewn method in obstructive jaundice dog models.

Background The aim of this study is to analyze the production of 76 specialist hospitals for the morbidly obese in Brazil’s public healthcare system (SUS) from 2010 to 2014 in terms of quantity and costs of bariatric surgery and its complications. Methods Secondary data from the SUS Hospital Information System and the National Healthcare Establishments Registry were used. Current spending on bariatric surgery and its medical and postoperative complications were analyzed. Results There was a 60 % rise in the number of surgeries between 2010 and 2014. This increase was not homogeneous among the hospitals studied, since only 19 performed the minimum number of surgeries required. Women accounted for 85 % of the surgeries carried out, and 32 % were aged between 35 and 44 years. The Roux-en-Y technique was the most widely used (93.7 % of the total), followed by sleeve gastrectomy. The ratio between the occurrence of medical complications and total number of surgeries performed in each hospital varied significantly (between 0 and 5.97 %) but was lower for postoperative complications, ranging from 0 to 1.7 %. There was a nominal increase of 44 % in average expenditure on postoperative complications between 2013 and 2014, while the average cost of medical complications decreased by 8.7 % in the same period. Conclusions Despite the rise in the number of bariatric surgeries in Brazil, there is still a high demand for surgeries that is not being met, while most specialist hospitals fail to perform the minimum number of surgeries stipulated by the Ministry of Health.

A 39-year-old woman was admitted with colicky left upper-quadrant pain, dyspnoea, low-grade fever, tachycardia and a subtle left upper-quadrant tenderness without leucocytosis. Computed tomography revealed a distended gastric remnant due to small-bowel loop herniation at the trocar site. The patient underwent a diagnostic laparoscopy as her general condition worsened. Perforation across the staple line was seen and repaired. The postoperative period was uneventful. As a rare complication of laparoscopic Roux-en-Y gastric bypass, small-bowel obstruction is of great importance because it can lead to gastric remnant perforation if not managed correctly. There have been rare reports of trocar site herniation as a cause of small-bowel obstruction following laparoscopic Roux-en-Y gastric bypass. Prompt diagnostic laparoscopy should be considered. This is the first case reported in which the excluded stomach was perforated due to trocar site herniation of the small-bowel loop. It should be noted that the tissue around the perforation is fragile and proper tension should be employed when it is repaired. Generally, an omental patch is not encouraged.

Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been shown to be safe and effective. Little information is available about the subgroup of patients with BMI > or = 60. The goal of this study was to evaluate the feasibility and safety of LRYGBP for patients with BMI > or = 60. The study consisted of the first 300 attempted LRYGBPs performed by one surgeon (HJS). This population was analyzed as 2 groups of patients: those with BMI < 60 and those with BMI > or = 60. Outcome variables included mortality, complications, conversion, and operative time. Of the first 300 LRYGBP patients, 261 had BMI < 60 and 39 had BMI > or = 60. Age, comorbidity rate, and gender distribution were similar in both BMI groups. Conversion rates were < 3% in both groups. Mean operative time for the BMI > or = 60 group was 156 minutes vs 139 minutes in the lighter group (P = 0.04). Major complications occurred more commonly in the BMI > or = 60 group (10% vs 6%) but this difference was not significant. The types of complications differed between the 2 groups, with infectious complications and gastrointestinal leak occurring more frequently in the heavier group. The mortality rate was higher in the heavier group (5% vs 0.4%, P = 0.055). LRYGBP is feasible for patients with BMI > or = 60. Our data suggest that these patients are at a higher risk for GI leak, postoperative infection, and death.

Background Although a novel technique for the performance of intestinal sutureless anastomosis using a compression device has recently been investigated, it has not yet received widespread acceptance. We performed a multicenter prospective randomized trial in order to determine the clinical efficacy of the NiTi Hand CAC™ 30, a type of compression anastomosis clip (CAC), for jejunojejunostomy in gastric cancer surgery. Methods Forty-seven patients from 6 institutions, who were diagnosed with gastric adenocarcinoma, were enrolled; these patients were randomized to a CAC group and a hand-sewn (control) group. Three patients dropped out for various reasons, and results for 44 patients were finally analyzed. The CAC group consisted of 20 patients, and there were 24 patients in the control group. Results Anastomosis time, the primary endpoint of this trial, was shorter in the CAC group than in the control group ( P  < 0.001). However, total operation times ( P  = 0.055) did not differ. All reconstructions were completed by Roux-en-Y anastomosis, and the complication rates of the two groups did not differ ( P  = 0.908); however, jejunojejunostomy leakage occurred in two patients in the CAC group. Conclusions Our prospective multicenter clinical trial showed that the use of the NiTi Hand CAC™ 30 for jejunojejunostomy in gastric cancer surgery was feasible and could reduce anastomosis time. However, considering that there were two cases of leakage, extended use of the NiTi Hand CAC™ 30 should be carefully applied.

Roux-en-Y hepaticojejunostomy is a crucial procedure for treating biliary diseases, especially in patients with recurrent hepatolithiasis. However, the safety and efficacy of repeat laparoscopic Roux-en-Y hepaticojejunostomy(R-LRHJS) remain controversial due to the complexity of hepatobiliary stones and the potential for complications. A total of 41 patients admitted to the Department of Hepatobiliary Surgery at the Second Affiliated Hospital of Kunming Medical University from June 2019 to December 2023 were reviewed. 20 patients who underwent repeat R-LRHJS were included in the final analysis. Surgical techniques emphasized meticulous dissection of intra-abdominal adhesions, precise identification of the hepatic hilum bile duct, and careful reconstruction of the biliary-enteric anastomosis. The mean patient age was 54.6 ± 10.7 years. Operative time ranged from 120 to 378 min, with intraoperative blood loss between 10 and 200 ml. Postoperative complications included anastomotic bleeding (2 cases), pancreatic stump bleeding (1 case), duodenal fistula (1 case), and biliary leakage (5 cases). No perioperative deaths occurred. During a 1- to 3-year follow-up, no recurrence of anastomotic stenosis or stone formation was observed on MRCP. The study concludes that R-LRHJS is a feasible and effective treatment for recurrent biliary strictures or stones following initial choledochojejunostomy.