Biliary reflux after laparoscopic modified antireflux monoanastomotic gastric bypass surgery

Aim. Determination of biliary reflux in patients with morbid obesity after a single-anastomotic gastric bypass operation performed in the clinic's modification and according to the classical Roux-en-Y gastric bypass technique. Development of diagnostic criteria for biliary reflux Materials and methods. The results of treatment of 36 patients with morbid obesity who underwent bypass surgery were studied. The patients are divided into two groups. Clinically modified laparoscopic monoanastomotic gastric bypass surgery was performed in 25 patients (main group). The control group included 11 patients after the standard technique of Roux-en-Y laparoscopic gastric bypass. Inclusion criteria were: persons of both sexes aged 18-60 years with morbid obesity and a body mass index of 40 or more, as well as 35 or more in the presence of comorbid diseases (type 2 diabetes mellitus, arterial hypertension, dyslipidemia, sleep apnea syndrome). In both groups, impedance pH measurements were performed in the postoperative period. Statistical processing was performed using the Statistica 13.0 software package using parametric and nonparametric statistical methods. Results: Clinical manifestations of the enterogastric biliary reflex were found in both groups; in addition, clinical manifestations of the corresponding symptoms were noted by patients of both groups. The analysis of daily pH-metry in the studied groups showed that in the esophagus the time with pH <4 in the main group 2.83 (1.55; 3.95)% 3.00 (2.30; 3.50)% in the control group, time with pH 4-6.9 (physiological for the esophagus) 92.40 (90.65; 94.20)% and 94.10 (89.80; 95.50)%, respectively, time with pH> 7 (weak alkaline) was 4.80 (3.45; 5.85)% and in the control group 2.90 (1.20; 7.20)%. There was no statistically significant difference in these indicators (p> 0.05). Conclusions. Monoanastomotic gastric bypass surgery in the modification of the clinic has the same positive properties as the Rouen-Wye technique, allowing you to avoid the risks associated with possible pathological reflux of bile into the esophagus. Patients who have undergone mini-gastric bypass surgery require a thorough examination with fibrogastroscopy in combination with pH impedance measurement at least 1 time per year in order to determine biliary reflux and morphological changes both in the lumen of the esophagus and in the stomach stump. The level of quality of life of patients after surgery in the control group and the main group does not significantly differ, as evidenced by the results of the questionnaire survey using the GERG Q questionnaire, which indicates the effectiveness of the methodology of laparoscopic monoanastomotic gastric bypass surgery modified in the clinic. Key words: morbid obesity, gastric bypass surgery, surgical treatment, mini-gastric bypass, biliary reflux.

Infectious Complications after Different Percutaneous External-Internal Biliary Drainage Techniques for Malignant Jaundice

Purpose: Analysis of infectious complications incidence in different types of percutaneous externalinternal biliary drainage in patients with obstructive jaundice of tumor genesis.Material and methods: The results of using antegrade external-internal drainage of the biliary tree in transpapillary and suprapapillary variants in 110 patients were analyzed. External-internal biliary drainage was performed in stages, after percutaneous transhepatic cholangiostomy or involuntarily primary with proximal obstruction of the biliary tree with bile duct segregation if it is impossible to form a fixing element of drainage proximal to the obstruction zone.Results: In the first group, transpapillary external-internal drainage was performed in 30 patients with peripapillary tumor obstruction. Of the 26 patients with proximal obstruction, suprapapillary external-internal drainage was performed in 8 patients, transpapillary — in 18 patients. Postmanipulation cholangitis in the first group occurred in 16 cases (28.6 %), liver abscesses developed 4 cases (7.1 %). In the second group, among 30 patients with transpapillary drainage on the background of peripapillary tumor obstruction, signs of acute cholangitis developed in 4 cases. Cholangitis was stopped by timely transfer of external-internal drainage to external. Among 24 patients with proximal obstruction of the biliary tree, suprapapillary external-internal drainage without complications was performed in 18 cases, transpapillary in 6 patients with the proximal block without disconnecting of the biliary tree. Acute cholangitis developed in 2 cases. Patients of the second group had no liver cholangigenic abscesses. There were no cases of hospital mortality in both groups.Conclusion: Factors in the development of postmanipulation cholangitis and liver abscesses during external-internal drainage of the biliary tree against the background of its tumor obstruction are the transpapillary position of endobiliary drainage with duodeno-biliary reflux in persistent biliary hypertension. In the case of suprapapillary location of the working end of external-internal drainage during antegrade drainage of the proximal tumor obstruction of the biliary tree with dissociation, the risk of postmanipulation cholangitis in non-drained liver segments is minimal. In the event of post-manipulation cholangitis in the case of transpapillary drainage of the biliary tree, a temporary transformation of external-internal drainage into external cholangiostomy is necessary.

Endoscopic Botulinum toxin as a treatment for delayed gastric emptying following oesophagogastrectomy

Introduction The incidence of delayed gastric emptying (DGE) following oesophagogastrectomy with gastric conduit reconstruction is reported to be between 1.7% and 50%. This variation is due to differing practices of intraoperative pylorus drainage procedures, which increase the risk of postoperative biliary reflux and dumping syndrome, resulting in significant morbidity. The aim of our study was to establish rates of DGE in people undergoing oesophagogastrectomy without routine intraoperative drainage procedures, and to evaluate outcomes of postoperative endoscopically administered Botulinum toxin into the pylorus (EBP) for people with DGE resistant to systemic pharmacological treatment. Methods All patients undergoing oesophagogastrectomy between 1 January 2016 and 31 March 2018 at our unit were included. No intraoperative pyloric drainage procedures were performed, and DGE resistant to systemic pharmacotherapy was managed with EBP. Results Ninety-seven patients were included. Postoperatively, 29 patients (30%) were diagnosed with DGE resistant to pharmacotherapy. Of these, 16 (16.5%) were diagnosed within 30 days of surgery. The median pre-procedure nasogastric tube aspirate was 780ml; following EBP, this fell to 125ml (p<0.001). Median delay from surgery to EBP in this cohort was 13 days (IQR 7–16 days). Six patients required a second course of EBP, with 100% successful resolution of DGE before discharge. There were no procedural complications. Conclusions This is the largest series of patients without routine intraoperative drainage procedures. Only 30% of patients developed DGE resistant to pharmacotherapy, which was managed safely with EBP in the postoperative period, thus minimising the risk of biliary reflux in people who would otherwise be at risk following prophylactic pylorus drainage procedures.