Introduction

Retrograde intussusception, known in our bariatric office as RINT, is also called reverse intussusception or antiperistaltic intussusception. Retrograde describes the direction the bowel intussuscepts—from distalto proximal (Figure 1). The much more common is operistaltic or antegrade intussusception, where the bowel intussuscepts from proximal to distal, is seen in children and adults. Antegrade intussusception is usually associated with a lead point, such as a pyerspatch or small bowel tumor that gets dragged in the direction of normal peristalsis. RINT does not appear to have an anatomic lead point. RINT is unique to Roux-en-Y anatomy and almost exclusively involves the jejunojejunostomy or near vicinity regardless ofthe use of the Roux-en-Y, such as with gastric bypass or biliary reconstruction. The diagnosisis made on computed tomography (CT) scan (Figure 2) with the classic “target” sign at the jejunojejunostomy, along with symptoms of nausea, vomiting, and epigastric and periumbilical or abdominal pain on the left side made worse with eating. Read the rest of this article »

Ariel U. Spencer, MD; Thomas H. Magnuson, MD, FACS; Hien Nguyen, MD; Kimberley E. Steele, MD, FACS; Anne O. Lidor, MD, FACS; and
Michael A. Schweitzer, MD, FACS.

From The Johns Hopkins Medical Institutions, Baltimore, Maryland

Introduction
Staple line buttress material—either absorbable or permanent—is widely used in bariatric surgery. While many surgeons have anecdotal experience with a particular material, this review will examine the data currently available to support the use of buttress material, the indications for its use, and possible advantages of specific types of material, based on current human and animal studies.

Most bariatric surgical procedures—with the exception of adjustable gastric banding—require the creation of staple lines along the margins of gastric pouch, gastric remnant, or as a component of the anastomoses between hollow viscera. While there are a large number of potential complications from bariatric surgery, one of the most clinically significant complications is leakage of enteric contents along either a marginal staple line or an anastomotic staple line.  Read the rest of this article »

by Jacques Himpens, MD; Giovanni Dapri, MD; and Guy-Bernard Cadière, MD, PhD

Dr. Himpens and Dr. Dapri are from St. Blasius Hospital Dendermonde and St. Pierre Hospital, Brussels, Belgium. Dr. Cadière is from St. Pierre Hospitial, Brussels, Belgium

Introduction
In Europe, sleeve gastrectomy (SG) is swiftly replacing adjustable band gastroplasty (ABG) as the most commonly performed restrictive bariatric procedure. Increasing numbers and longer follow-up times allow us to better evaluate the pros and cons of this relatively new operation. One of the drawbacks of the procedure appears to be the relative frequency and severity of its complications. Reportedly, leaks occur in up to nine percent of the cases, and even more often in revision cases. A majority of leaks appear close to the gastroesophageal junction. These leaks are known to be difficult to treat by conventional means. This retrospective study presents the results of the treatment strategy we offer our patients suffering from leaks at the angle of His after SG. Read the rest of this article »

by Jon Gould, MD, and Daniel Jones, MD
Dr. Gould is Associate Professor of Surgery at University of Wisconsin School of Medicine and Public Health. Dr. Jones is Associate Professor of Surgery at Harvard Medical School.

This article is a summary of a panel sponsored by the Society of American Gastrointestinal and Endoscopic Surgeons. Read the rest of this article »

by David S. Wernsing, MD, FACS
Assistant Professor of Surgery, University of Pennsylvania, Pennsylvania Hospital, Philadelphia, Pennsylvania

INTRODUCTION
The management of primary and incisional abdominal wall hernias continues to evolve from the early days of primary hernia repair. There has been progress in the surgical approach to hernias with application of minimally invasive surgical techniques and an improved understanding of how to apply this to reconstructing abdominal wall defects. There has been development of synthetic meshes with a better understanding of the mechanical properties necessary for a secure hernia repair. There are also newer biomaterials that provide for tissue ingrowth and may be more resistant to infection than traditional meshes. This has allowed for opportunity to repair hernias during potentially contaminated operations that may have otherwise required a second operation to fix. Lastly, there has been a return to primary tissue repairs using component separation technique, augmented with mesh as necessary. This combination of education and materials has provided the surgeon with a basis of performing a better hernia repair. Read the rest of this article »

by Juan Camilo Barreto, MD; Michael G. Sarr, MD; and James M. Swain, MD

All from the Division of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, Minnesota.

The Problem
Cirrhosis is an unexpected finding at the time of bariatric surgery in about 1 to 2 percent of the patients undergoing elective bariatric surgery. The surgeon is then suddenly faced with several questions that may be difficult to address at the moment of a planned bariatric operation, with the patient already under general anesthesia. Would it be appropriate to continue with the planned elective bariatric procedure? Is it necessary to consider a different alternative, and if so, which one? Is portal hypertension present and, if so, is it an absolute contraindication to proceed?

A different situation occurs when a patient with known hepatic cirrhosis presents for consideration for bariatric surgery. What type of workup is required? At what point would a bariatric procedure be contraindicated? What about the patient with morbid obesity who is being evaluated for a liver transplant?

Read the rest of this article »

by Daniel J. Rosen, MD; Shirlee Jaffe, MD; Lawrence Cutler, MD; Alfons Pomp, MD
All from Departments of Obstetrics and Gynecology and Surgery New York Presbyterian Hospital, Weill Cornell Medical College

ABSTRACT
Intussusception is a rare complication of Roux-en-Y gastric bypass, and can present a difficult diagnostic challenge in the pregnant patient. We describe a case of a 20-year-old woman at 32 weeks gestation that presented with sudden onset abdominal pain. On exploration, an intussuception with necrotic bowel was found and resected. Intraoperatively, a cesarean section was emergently performed for active labor and breech presentation. With the increasing number of bariatric procedures being performed in obese women of childbearing age, practitioners should be aware of this serious complication. Read the rest of this article »

By Ismael Court, MD; Omar Bellorin, MD; Fernando Dip, MD; Christopher DuCoin, MD; Samuel Szomstein, MD, FACS; and Raul J. Rosenthal, MD, FACS

All from the Bariatric & Metabolic Institute, Section of Minimally Invasive Surgery, Cleveland Clinic Florida, Weston, Florida

Key words: Bariatric surgery, laparoscopy, morbid obesity, Roux-en-Y gastric bypass, sleeve gastrectomy

Introduction
Surgery has become the most effective option in the management of morbid obesity and comorbid conditions.[1–3] Surgery for morbid obesity provides excellent short-term and long-term outcomes, decreasing overall mortality and providing a marked survival advantage.[5] Sleeve gastrectomy (SG) appears as a novel surgical treatment option to manage morbid obesity.[3–10] Read the rest of this article »