Reconfiguration of the alimentary tract with the Roux-en-Y has been utilized in a wide variety of contexts since its first description by Swiss physician César Roux. We present a novel and unique application of the Roux-en-Y whereby a chronically discharging cutaneous fistula originating at a retroperitoneal mature teratoma within the root of the mesentery was diverted enterically via a cystojejunostomy and the fistula tract excised, providing a resolution of symptoms. The location of the tumour in the root of the mesentery and the involvement of major mesenteric vessels made a radical resection of the tumour technically impossible but due to the distressing symptoms caused by the fistula made diversion of the fistula an excellent treatment option.

The management of patients with gastroparesis and recurrent reflux after previous fundoplication is challenging. The aim of this study was to evaluate the safety and efficacy of subtotal gastrectomy with Roux-en-Y reconstruction as a remedial procedure in this select patient population.
Retrospective analysis of a prospectively populated database identified all patients that underwent subtotal gastrectomy with Roux-en-Y reconstruction (SGRNY) due to reflux symptoms and delayed gastric emptying (DGE). Demographic, intra-operative and post-operative data including pre and post-operative modified reflux aspiration scintigraphy studies were evaluated. Standardized questionnaires were used to assess symptomatic outcomes.
From 2018 SGRNY has been selectively performed in 13 patients. Preoperative workup confirmed DGE and severe symptomatic reflux in all patients. The median number of previous fundoplication and or hiatal hernia operations was two (range 1-3). The mean hospital length of stay was 10 ± 6 days. Post-operative morbidity was experienced in three patients (23%). Seven patients (64%) had significant improvement or complete resolution of reflux on post-operative scintigraphy. Symptom improvement was reported in 92% of patients.
In a select patient cohort with post-fundoplication reflux and DGE symptoms, SGRNY is a moderately safe and effective salvage option.

Access to the Common Bile Duct in patients with surgically altered UGI anatomy such as RYGB is exceptionally challenging. Previously, these patients could only be treated by open surgery; however, multiple new advanced assisted ERCP techniques such as EDGE, LA-ERCP, and DEA-ERCP have now been developed and indeed successfully used to treat these patients. Despite growing experience, these techniques have yet to become part of our mainstream practice and many clinicians remain unfamiliar or even unaware of them; as a result, they are unfortunately often overlooked. We conducted this systematic review to try and shed more light on them and understand which of these techniques resulted in the best patient outcomes. We conducted a systematic review of PubMed database publications between December 2008 and December 2018. Keyword variants of \"EDGE, Enteroscopy-assisted & laparoscopy-assisted ERCP\" and \"altered surgical anatomy\" were combined to identify relevant papers for inclusion. We identified 34 studies, comprising a total of 1848 advanced assisted ERCPs in patients with altered UGI anatomy from 12 different countries. These papers were critically appraised, summarised, and presented in table format. EDGE and LA-ERCP were associated with both the highest overall combined CBD cannulation rates (99.3% for both vs 74.6% for DEA-ERCP) and ERCP interventional success (98.3% for EDGE vs 97.4% for LA-ERCP and 67.6% for DEA-ERCP). Advanced ERCP is associated with excellent success rates and a higher safety profile than surgery; however, patient selection and identification of the exact surgical anatomy are key.

BACKGROUND: Portomesenteric vein thrombosis is a rare but documented complication of laparoscopic surgery. This rare complication is currently being encountered more frequently with the increase in the rates of laparoscopic bariatric surgery procedures being performed worldwide.
METHODS: A retrospective analysis was performed on all bariatric procedures performed in our center between July 2012 & December 2017 to identify cases complicated by portomesenteric venous thrombosis. The cases were compared in terms of operative details, patient presentation, diagnosis, patient risk factors for developing thrombosis, demographics and thrombophilia analysis & subsequent treatment and prognosis.
RESULTS: A total of 1030 bariatric procedures were performed between July 2012 & December 2017. Portomesenteric venous thrombosis complicated 3 of these cases (0.29%). Two of these cases had underwent a laparoscopic sleeve gastrectomy while the third had underwent a gastric band removal and a conversion to a single anastomosis gastric bypass. Amongst these patients, 2 were female while 1 was male with an average BMI 38.9 kg/m2. Only one of these patients was a smoker while none of them tested positive for thrombophilias. The diagnosis of portomesenteric venous thrombosis was confirmed with a contrast CT of the abdomen as all patients were re-admitted between 4-20 days post operatively after being discharged on postoperative day 2. All three cases were managed with systemic anticoagulants and none underwent invasive procedures or were re-explored surgically. All were subsequently discharged in good condition.
CONCLUSIONS: Portomesenteric venous thrombosis is an uncommon yet potentially fatal complication of bariatric surgery. A high index of suspicion, early diagnosis and subsequent adequate management is required. Based on this case series and the potential risk of portomesenteric venous thrombosis, we altered our clinical practice to include a 1 week course of low molecular weight heparin to be administered to all patients after discharge.

BACKGROUND: Single loop reconstruction (SLR) was routine in our institution for patients undergoing pancreatico-duodenectomy (PD). Roux-en Y reconstruction with an isolated gastric limb (RIGL) recently became the reconstruction of choice.
OBJECTIVE: To evaluate the impact of RIGL on incidence and severity of delayed gastric emptying (DGE).
METHODS: This is a single institution, retrospective analysis of patients undergoing PD. All patients undergoing PD from July 2010 through December 2016 were included in the study. Outcome of RIGL were compared to SLR. Primary measure of outcome included incidence and severity of DGE. Secondary measures of outcome were overall complications and postoperative mortality.
RESULTS: One hundred and seventy-nine patients were included in the study. Fifty-two had RIGL, 127 had SLR. Overall complication rate was 40.2%, patients in the RIGL group experienced lower rates of DGE (15.4% vs 59.1%, P = 0.001). Other patient related outcomes were also significantly reduced: day of nasogastric tube removal (3 vs 5, P < 0.001), regain of normal diet (8 vs 9, P < 0.001). On multivariate analysis RIGL was associated independently with reduced rates of DGE (P < 0.001, OR 0.14).
CONCLUSIONS: The current study shows that RIGL reduces the rate of DGE after PD. Further prospective randomized controlled trials are required to affirm the current data.

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.

This meta-analysis aimed to compare outcomes following bile duct reconstruction in patients with primary sclerosing cholangitis (PSC) undergoing liver transplantation depending on whether duct-to-duct or Roux-en-Y anastomosis was utilized. An electronic search was performed of the MEDLINE, EMBASE, PubMed databases using both subject headings (MeSH) and truncated word searches. Pooled risk ratios and mean difference were calculated using the fixed-effects and random-effects models for meta-analysis. Ten studies including 910 patients met the inclusion criteria. There was no difference in the overall incidence of biliary strictures between the two groups [odds ratio (OR) 1.06 (0.68, 1.66); (P = 0.80)]. The anastomotic stricture rate was similar, [OR 1.18 (0.56, 2.50); (P = 0.67)]. Ascending cholangitis was higher in the Roux-en-Y group [OR 2.91 (1.17, 7.23); (P = 0.02)]. Anastomotic bile leak rates, graft survival, PSC recurrence and number of patients diagnosed with cholangiocarcinoma following transplantation were comparable between both groups. Duct-to-duct and Roux-en-Y reconstruction had comparable outcomes. Both techniques are associated with similar incidence of biliary stricture. The bilioenteric reconstruction was associated with a higher risk of cholangitis. The incidence of de novo cholangiocarcinoma was similar in both groups. Duct-to-duct reconstruction should be considered when feasible in patients with PSC.

Several techniques for the surgical management of obesity are available to bariatric surgeons. These interventions are performed more frequently with worsening of the obesity epidemic. Radiologists should be familiar with the surgical techniques, normal postoperative appearances, and potential complications for which imaging may be employed to establish a diagnosis to optimize patient care.

OBJECTIVE: The intracorporeal reconstruction after laparoscopic gastrectomy can minimize postoperative pain, and give better cosmetic effect, while it may have technical difficulties and require the learning curve. This study aimed to analyze the surgical outcome of intracorporeal reconstruction according to the surgeon\'s experience comparing with extracorporeal procedure.
METHODS: From January 2009 to September 2011, intracorporeal reconstruction in laparoscopic surgery for gastric cancer was performed for 71 patients (Intra group). During same period, 231 patients underwent laparoscopy-assisted gastrectomy (Extra group). These patients were classified into initial (1st to 20th case of intra group), intermediate (21th to 46th case), and experienced (after 47th case) phases.
RESULTS: Intracorporeal procedures included 35 cases of Billroth-I, 30 Billroth-II and 6 Roux en Y reconstructions. In the initial phase, operation time (P=0.022) were significantly longer for the patients of intra group than them of extra group. Although the difference was not significant, the length of hospital stay was longer and complication rate was higher in the intra group. In intermediate and experienced phases, there was no difference between two groups in operation time and hospital stay. In these phases, complication rate was lower in the intra group than the extra group (3.9% versus 9.7%). The pain scale was significantly lower post operation day 5 in the intra group.
CONCLUSIONS: Intracorporeal reconstruction after laparoscopic distal gastrectomy was feasible and safe, and the technique was stabilized after 20th case if the surgeon has sufficient experiences when we compared it with extracorporeal reconstruction.