Jejunojejunal intussusception after Roux-en-Y gastric bypass: a review.

Small bowel intussusception is a rare long-term complication after Roux-en-Y gastric bypass, the etiology of which remains unclear. Except for one series reporting on 23 patients, case reports represent the vast majority of all cases reported so far. With this complete review of the world literature, based on a total of 63 patients including 2 of our own cases, we provide an extensive overview of the subject. The origin of intussusception after gastric bypass is different from that of intussusception of other causes, in that there is usually no lead point. It is likely related to motility disorders in the divided small bowel, especially in the Roux limb. This rare condition may cause obstruction and lead to bowel necrosis if not recognized and treated promptly. Clinical presentation is not specific. Computerized tomography scan represents the diagnostic test of choice, but surgery is sometimes the only way to establish the diagnosis. Treatment may be limited to reduction if the small bowel is viable, but resection of the affected segment is recommended on the basis of this review, since it seems to result in fewer recurrences. Knowledge of this entity and a high index of suspicion are required to make the correct diagnosis and offer appropriate treatment in a timely fashion.

What is the Omega-Loop Gastric Bypass and Why is it Criticized?

The omega-loop gastric bypass (OLGBP), also called "mini-gastric bypass" or "single-anastomosis" gastric bypass is a form of gastric bypass where a long, narrow gastric pouch is created and anastomosed to the jejunum about 200- 250 cm from the angle of Treitz in an omega loop fashion, thereby avoiding a jejuno-jejunostomy.Proponents of the OLGBP claim that it is a safer and simpler operation than the traditional Roux-en-Y gastric bypass (RYGBP), easier to teach, that gives the same results in terms of weight loss than the RYGBP. One randomized study comparing the two techniques showed similar results after five years.The OLGBP is criticized because it creates an anastomosis between the gastric pouch and the jejunum where a large amount of biliopancreatic juices travel, thereby creating a situation where reflux of the latter into the stomach and distal esophagus is likely to develop. Such a situation has clearly been associated, in several animal studies, with an increased incidence of gastric cancer, especially at or close to the gastro-jejunostomy, and with an increased risk of lower esophageal cancer. In clinical practice, omega-loop gastrojejunostomies such as those used for reconstruction after gastric resection for benign disease or distal gastric cancer have been associated with the so called classical anastomotic cancer, linked to biliary reflux into the stomach, despite the fact that epidemiological studies about this do not show uniform results. Although no evidence at the present time links OLGBP to an increased risk of gastric cancer in the human, this possibility raises a concern among many bariatric surgeons, especially in the view that bariatric surgery is performed in relatively young patients with a long life expectancy, hence prone to develop cancer if indeed the risk is increased. Another arguments used against the OLGBP is that the jejuno-jejunostomy in the traditional RYGBP is easy to perform and associated with virtually no complication.Supporters of the OLGBP claim that the liquid that refluxes into the stomach after their procedure is not pure bile and pancreatic juice, but a combination of those with jejunal secretions, and that the latter is not as harmful. We would urge the proponents of the OLGBP to undertake the necessary animal studies to show that their assumption is indeed true before the procedure is performed widely, possibly leading to the development of hundreds of late gastric or esophageal carcinoma in the bariatric population. In the meantime, we strongly believe that RYGBP should remain the gold standard in gastric bypass surgery for morbid obesity.

Recent patterns in gastric cancer: a global overview.

Until the mid-1990s, gastric cancer has been the first cause of cancer death worldwide, although rates had been declining for several decades and gastric cancer has become a relatively rare cancer in North America and in most Northern and Western Europe, but not in Eastern Europe, Russia and selected areas of Central and South America or East Asia. We analyzed gastric cancer mortality in Europe and other areas of the world from 1980 to 2005 using joinpoint regression analysis, and provided updated site-specific incidence rates from 51 selected registries. Over the last decade, the annual percent change (APC) in mortality rate was around -3, -4% for the major European countries. The APC were similar for the Republic of Korea (APC = -4.3%), Australia (-3.7%), the USA (-3.6%), Japan (-3.5%), Ukraine (-3%) and the Russian Federation (-2.8%). In Latin America, the decline was less marked, but constant with APC around -1.6% in Chile and Brazil, -2.3% in Argentina and Mexico and -2.6% in Colombia. Cancers in the fundus and pylorus are more common in high incidence and mortality areas and have been declining more than cardia gastric cancer. Steady downward trends persist in gastric cancer mortality worldwide even in middle aged population, and hence further appreciable declines are likely in the near future.

Preoperative upper gastrointestinal testing can help predicting long-term outcome after gastric banding for morbid obesity.

BACKGROUND: Gastric banding (GB) is one of the most popular bariatric procedures for morbid obesity. Apart from causing weight loss by alimentary restriction, it can interfere with functions of the esophagus and upper stomach. The aim of this study was to evaluate if the results of extensive preoperative upper GI testing were correlated with long-term outcome and complications after GB. METHODS: Using a prospectively maintained computerized database including all the patients undergoing bariatric operations in both our hospitals, we performed a retrospective analysis of the patients who underwent complete upper gastrointestinal (GI) testing (endoscopy, pH monitoring, and manometry) before GB. RESULTS: One hundred thirty-four patients underwent complete testing before GB. Abnormal pH monitoring (increased total reflux time, increased diurnal reflux time, increased number of reflux episodes) predicted the development of complications and especially pouch dilatation and food intolerance. The mean De Meester score was higher among patients who developed complications than in the remaining ones (25.4 vs 17.7, P=0.03). High lower esophageal sphincter pressure also predicted progressive long-term food intolerance. Endoscopic findings were not predictive of the long-term outcome. CONCLUSIONS: There is some association between the function of the upper digestive tract and long-term complications after gastric banding. Abnormal pH monitoring predicts overall long-term complications, especially food intolerance with or without reflux, and pouch dilatation, and a high lower esophageal sphincter pressure predicts long-term food intolerance. Extended upper gastrointestinal testing with endoscopy, 24-h pH monitoring, and esophageal manometry is probably worthwhile in selecting patients for gastric banding.

An age-period-cohort analysis of gastric cancer mortality from 1950 to 2007 in Europe.

PURPOSE: To analyze the components of the favorable trends in gastric cancer in Europe. METHODS: From official certified deaths from gastric cancer and population estimates for 42 countries of the European geographical region, during the period 1950 to 2007, age-standardized death rates (World Standard Population) were computed, and an age-period-cohort analysis was performed. RESULTS: Central and Northern countries with lower rates in the 2005 to 2007 period, such as France (5.28 and 1.93/100,000, men and women respectively) and Sweden (4.49 and 2.21/100,000), had descending period and cohort effects that decreased steeply from the earliest cohorts until those born in the 1940s, to then stabilize. Former nonmarket economy countries had mortality rates greater than 20/100,000 men and 10/100,000 women, and displayed a later start in the cohort effect fall, which continued in the younger cohorts. Mortality remained high in some countries of Southern and Eastern Europe. CONCLUSIONS: The decrease in gastric cancer mortality was observed in both cohort and period effects but was larger in the cohorts, suggesting that the downward trends are likely to persist in countries with higher rates. In a few Western countries with very low rates an asymptote appears to have been reached for cohorts born after the 1940s, particularly in women.

TLR5 signaling stimulates the innate production of IL-17 and IL-22 by CD3(neg)CD127+ immune cells in spleen and mucosa.

In adaptive immunity, Th17 lymphocytes produce the IL-17 and IL-22 cytokines that stimulate mucosal antimicrobial defenses and tissue repair. In this study, we observed that the TLR5 agonist flagellin induced swift and transient transcription of genes encoding IL-17 and IL-22 in lymphoid, gut, and lung tissues. This innate response also temporarily enhanced the expression of genes associated with the antimicrobial Th17 signature. The source of the Th17-related cytokines was identified as novel populations of CD3(neg)CD127(+) immune cells among which CD4-expressing cells resembling lymphoid tissue inducer cells. We also demonstrated that dendritic cells are essential for expression of Th17-related cytokines and so for stimulation of innate cells. These data define that TLR-induced activation of CD3(neg)CD127(+) cells and production of Th17-related cytokines may be crucial for the early defenses against pathogen invasion of host tissues.

Buccal mucosa graft for laryngotracheal reconstruction in severe laryngeal stenosis.

OBJECTIVE: An operative technique is described as a salvage treatment for severe subglottic and supraglottic laryngeal stenosis. In addition to expansion of the laryngeal framework with an anterior cartilage graft, as used in a classical laryngotracheal reconstruction, the scar tissue obliterating the airway lumen is excised and a mucosal graft is placed to reconstruct the inner lining of the airway. The graft is harvested from buccal mucosa. METHODS: The operative technique is outlined. Three cases, 2 paediatric and one adult, with complete or near complete laryngeal stenosis are presented where this operative technique was employed. In all patients several surgeries had been performed previously which were unsuccessful. RESULTS: In all 3 patients a patent airway was achieved with decannulation of the tracheostomy in the 2 paediatric patients. CONCLUSIONS: In patients with severe subglottic or supraglottic airway stenosis where other surgeries have failed, excision of endoluminal scar tissue and placement of a buccal mucosal graft, in addition to conventional laryngotracheal reconstruction, is a promising technique. In revision cases of subglottic stenosis cricotracheal resection might not be an option because of scarring from previous surgeries. This operation is an alternative, which allows an increase in the airway lumen by excising the scar tissue then re-lining the exposed internal lumen. The buccal mucosa reduces granulation formation and re-stenosis.

Human cytomegalovirus induced pseudotumor of upper gastrointestinal tract mucosa: Effects of long-term chronic disease?

Human cytomegalovirus-induced lesions resembling malignancies have been described in the gastrointestinal tract and include ulcerated or exophytic large masses. The aim of this study was to review the cases registered in the databases of two academic hospitals and formulate a hypothesis concerning the pathogenic mechanisms responsible for cytomegalovirus-induced pseudotumor development. All the diagnoses of human cytomegalovirus infections of the upper gastrointestinal tract recorded from 1991 to 2013 were reviewed. Cases of mucosal alterations misdiagnosed endoscopically as malignancies were selected. Large ulcers occurring in the stomach (three cases) and an irregular exophytic mass at the gastro-jejunal anastomosis were misdiagnosed endoscopically as malignancies (4 cases out of 53). Histologically, all lesions reflected hyperplastic mucosal changes with a prevalence of epithelial and stroma infected cells, without signs of cell atypia. The hypothesis presented is that the development of human cytomegalovirus-induced pseudotumors may be the morphological expression of chronic mucosa damage underlying long-term infection.