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The article discusses the challenges of performing precise cannulation and endoscopic sphincterotomy in patients with surgically altered anatomy during balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP). A novel highly rotatable and dual-action sphincterotome (ENGETSU) is introduced as a potential solution to orient the blade in any direction, enabling efficient cannulation and incision. The device was successfully used in a case of choledocholithiasis in a patient with Roux-en-Y reconstruction, demonstrating its utility in both normal and surgically altered anatomy. The authors declare no conflict of interest in the study. [Extracted from the article]

Background: Roux‐en‐Y gastric bypass (RYGBS), a surgery that creates a smaller stomach pouch and reduces the length of small intestine, is one of the most common medical interventions for the treatment of obesity. Aim: The aim of this study was to determine how RYGBS affects the absorption and metabolism of acetaminophen. Materials and Methods: Ten morbidly obese patients received 1.5 g of liquid acetaminophen (APAP) orally on three separate pharmacokinetic study days (i.e., pre‐RYGBS baseline and 3 and 12 months post‐RYGBS). Plasma was collected at pre‐specified timepoints over 24 hours, and the samples were analyzed using liquid chromatography–mass spectrometry for APAP, APAPglucuronide (APAP‐gluc), APAP‐sulfate (APAP‐sulf), APAP‐cysteine (APAP‐cys), and APAP‐Nacetylcysteine (APAP‐nac). Result: Following RYGBS, peak APAP concentrations at the 3‐month and 12‐month visits increased by 2.0‐fold compared to baseline (p=0.0039 and p=0.0078, respectively) and the median time to peak concentration decreased from 35 to 10 minutes. In contrast, peak concentrations of APAP‐gluc, APAP‐sulf, APAP‐cys, and APAP‐nac were unchanged following RYGBS. The apparent oral clearance of APAP and the ratios of metabolite area under the curve (AUC)‐to‐APAP AUC for all four metabolites decreased at 3 and 12 months post‐RYGBS compared to the presurgical baseline. In a simulation of expected steady‐state plasma concentrations following multiple dosing of 650 mg APAP every 4 hours, post‐RYGBS patients had higher steady‐state peak APAP concentrations compared to healthy individuals and obese pre‐RYGBS patients, though APAP exposure was unchanged compared to healthy individuals. Conclusion: Following RYGBS, the rate and extent of APAP absorption increased and decreased formation of APAP metabolites was observed, possibly due to downregulation of Phase II and cytochrome P450 2E1 enzymes. [ABSTRACT FROM AUTHOR]

Background: The optimal standard reconstruction procedure after distal gastrectomy is controversial. No large‐scale persuasive clinical studies from long‐term perspectives on this topic have yet been conducted. Study design: This retrospective multicenter study analyzed a database of 2510 consecutive patients with clinical stage I gastric cancer who underwent distal gastrectomy followed by Billroth‐I (B‐I) or Roux‐en‐Y (R‐Y) anastomosis from 2006 to 2012. After adjusting for 30 potential confounding factors using propensity score matching, we compared the body weight loss and other nutritional status for 5 years as primary outcomes between the two groups. We also investigated surgical outcomes, endoscopic findings, and long‐term survival rates as secondary outcomes. Results: After matching the inclusion criteria, 940 patients (470 in each group) were enrolled. There was no marked difference in the body weight loss and other nutritional indicators. The incidence of grade ≥3 postoperative complications (Clavien‐Dindo classification) or the incidence of gallstone formation was not markedly different between the two groups. The postoperative hospital stay after surgery was significantly longer, and the readmission rate was significantly higher in the R‐Y group than in the B‐I group. An endoscopic examination revealed no trends regarding the incidence and severity of gastritis or residual food in the remnant stomach. The 5‐year overall survival rate was 92.6% in the B‐I group and 91.8% in the R‐Y group, with no significant difference (P =.379, log‐rank test). Conclusions: Roux‐en‐Y reconstruction may be nearly equal to Billroth‐I with regard to the long‐term nutritional perspectives. [ABSTRACT FROM AUTHOR]

Abstract: Background: Morbid obesity is a chronic condition that may be challenging to treat. Gastric bypass surgery is used to treat morbid obesity and its complications. Hypocalcemia, a known complication after thyroidectomy, is usually transient and treatable. There is a growing body of literature indicating that patients with previous gastric bypass surgery are at an increased risk for recalcitrant, symptomatic hypocalcemia after thyroidectomy. The management of hypocalcemia in patients with prior gastric bypass surgery may be exceedingly difficult. Methods: Relevant articles published between 2008 and January 2017 were reviewed by topic. The review of literature was conducted using a systematic search of database resources, such as PubMed and EMBASE. Results: Prior gastric bypass surgery may be an independent risk factor for developing profound hypocalcemia after thyroid surgery. Conclusion: Refractory hypocalcemia in patients who have undergone gastric bypass surgery is underreported. Careful consideration should be given to performing staged thyroidectomy and, in some cases, reversal of the bariatric surgery. [ABSTRACT FROM AUTHOR]

Background: In Australia, there is limited access to public revisional bariatric procedures. However, the need for such procedures is rising. We investigated the safety and efficacy of band‐to‐bypass procedures in our experience at a public teaching hospital over a period of 10 years. Methods: Using a prospectively maintained bariatric surgical database, we analysed 91 consecutive planned band‐to‐bypass procedures from 2007 to November 2016. All patients had prior laparoscopic adjustable gastric bands removed and formation of Roux‐en‐Y gastric bypass, in one or two stages. Primary outcomes were 30‐day complication rate and excess weight loss from 12 months. The impact of fellows as primary operators on these outcomes was assessed. Results: Eighty‐two patients met the inclusion criteria. Seventy‐one (84.5%) were females. Mean age was 48.8 years (SD: 8.85). Immediate post‐operative complications included six (7.3%) patients with gastrojejunostomy leak, three of whom required conversion to laparotomy, with one mortality (1.22%). Fifty‐two patients had follow‐up of 1 year or more (median: 2.36, range: 1–9.24). Mean excess weight loss at the end of follow‐up was 52.79% (SD: 46.46). Twenty‐eight (34.14%) cases were performed primarily by a fellow under the guidance of an experienced bariatric surgeon, with equivalent results. Conclusion: Revisional band‐to‐bypass in the public setting is an effective but complex procedure associated with morbidity. Some risk may be ameliorated by development of selection criteria to exclude certain high‐risk groups. We hope discussion amongst other bariatric groups will further refine this approach. [ABSTRACT FROM AUTHOR]

Introduction Roux-en-Y choledochojejunostomy and duct-to-duct (D-D) anastomosis are biliary reconstruction methods for liver transplantation. However, there is a controversy over which method produces better results. We have compared the outcome of D-D anastomosis vs. Roux-en-Y hepaticojejunostomy in patients with primary sclerosing cholangitis who had undergone liver transplant in Shiraz Organ Transplant Center. Materials The medical records of 405 patients with primary sclerosing cholangitis ( PSC) who had undergone liver transplant from 1996 to 2015 were reviewed. Patients were divided into two groups: Roux-en-Y group and D-D group. Morbidity, disease recurrence, and graft and patient survival rates were compared between the two groups. Results Total of 143 patients underwent a D-D biliary reconstruction, and 260 patients had a Roux-en-Y loop. Biliary complication involved 4.2% of patients from the D-D group, and 3.9% from the Roux-en-Y group ( P=. 863). Actuarial 1-, 3-, and 5-year patient survival for D-D and Roux-en-Y group was 92%, 85%, and 74%; and 87%, 83%, and 79%, respectively ( P=.384). The corresponding 1-, 3-, and 5-year probability of biliary complication was 97%, 95%, and 92%; and 98%, 97%, and 94%, respectively ( P=.61). Conclusion Duct-to-duct biliary reconstruction in liver transplantation for selected patients with PSC is a good alternative instead of Roux-en-Y biliary reconstruction. [ABSTRACT FROM AUTHOR]

Background and Aim Endoscopic retrograde cholangiopancreatography ( ERCP) in patients with roux-en-Y anastomosis ( REYA) is challenging. Use of double balloon enteroscope-assisted ERCP ( DBE- ERCP) has been successful. We aim to determine predictors of successful biliary cannulation with DBE- ERCP in patients with REYA. Methods We retrospectively studied patients with REYA who had DBE- ERCP between 2009 and 2015. Results 86 DBE- ERCP were done on 52 patients. Patients had REYA for liver transplant ( n = 26), gastrojejunostomy ( n = 9), previous bile duct injury ( n = 9), biliary atresia ( n = 2) and other ( n = 6). The biliary-enteric anastomosis was reached in 76% and cholangiogram was successful in 70%. Highest success rates were in patients with previous bile duct injury (94%) or gastrojejunostomy (89%). Post-transplant patients had intermediate success (64%). Patients with redo surgery (46%) and childhood surgery (38%), especially Kasai procedure (20%), had low success. Patients with previous bile duct injury were more likely to succeed (94% vs 63%, P = 0.010). Those more likely to fail were patients with childhood surgery (38% vs 73%, P = 0.037), biliary atresia (20% vs 73%, P = 0.013) and second operation post-transplant (25% vs 70%, P = 0.046). Conclusion Indication for REYA impacts on successful biliary cannulation in patients undergoing DBE- ERCP. The procedure is most successful in non-liver transplant adult surgery and post-transplant patients without a second operation. It is least successful in patients with surgically corrected biliary atresia and post-transplant patients with second operation. Alternative methods of biliary access should be considered in these patients. [ABSTRACT FROM AUTHOR]

Laparoscopic Roux-en- Y gastric bypass is the most commonly performed surgical procedure for obesity and, consequently, post-operative patients are increasingly encountered by all specialties. This is a case of a patient presenting with abdominal pain, nausea and fever 9 months following gastric bypass surgery caused by diffuse large B-cell lymphoma ( DLBCL) in the bypassed stomach. It demonstrates well that symptoms that may normally be considered 'red-flags' may not be as obvious or specific following an operation. The case also indicates the importance of considering diagnoses unrelated to surgery presenting in the post-operative period (especially when conventional investigation methods are not feasible), and the potential danger of assuming they are due to the operation alone; had this occurred in this patient then a malignancy may have been missed. This is only the second reported case of DLBCL in the bypassed stomach, and the third for lymphoma of any type. [ABSTRACT FROM AUTHOR]

Background and Aim: In patients with Roux-en-Y hepaticojejunostomy (HJ with R-Y) and Whipple resection, endoscopic retrograde cholangiopancreatography (ERCP) can be challenging. We report our experience with ERCP using balloon-assisted enteroscopy (BAE) (BAE-ERCP) in patients with HJ with R-Y, and Whipple resection. Methods: BAE-ERCP procedures were carried out in 62 patients (HJ with R-Y : Whipple resection = 34:28). Results: Overall, the rates of reaching the anastomosis were 85.3% (29/34) in HJ with R-Y and 96.4% (27/28) in Whipple resection. In terms of HJ with R-Y, insertion success rate by standard single-balloon enteroscopy (SBE) was 89.3% (25/28). Insertion success rate by short BAE, including SBE and double-balloon enteroscopy (DBE), was 50% (3/6). There was a statistically significant difference of insertion success rate between standard long BE and short BE (P = 0.021). However, in the Whipple patients, insertion success rate by standard and short SBE was 93.8% (15/16) and 91.7% (11/12), respectively. Initial insertion success rate by short BAE in Whipple patients was significantly higher than in HJ with R-Y (91.7% vs 50%, P = 0.045). Therapeutic interventions included dilation of anastomosis stricture, stone extraction, endoscopic mechanical lithotripsy, biliary stent placement, stent extraction, endoscopic nasobiliary drainage, direct cholangioscopy, and electrohydraulic lithotripsy. Our HJ with R-Y series and Whipple series treatment success rate was 90% (18/20) and 95.0% (19/20), respectively. Conclusions: BAE-ERCP enabled ERCP to be carried out in patients with HJ. It is considered safe and feasible. Further experience and device improvement are needed. [ABSTRACT FROM AUTHOR]

Benign postoperative anastomotic strictures after hepaticojejunostomy are difficult to manage. Before interventional techniques were developed, surgical intervention was the only option for treatment. A 28-year-old man underwent Whipple procedure with Roux-en-Y hepaticojejunostomy for abdominal trauma. Two years later, a late anastomotic biliary stricture was diagnosed. A percutaneous cholangiography showed a severe stricture in the hepaticojejunostomy. Because of the severity and length of the stricture, and the failure of repeated percutaneous balloon-dilations, we percutaneously placed a self-expandable metal stent, a nitinol polytetrafluoroethylene fully covered flared-type stent, 3 cm in length, with 10 mm of diameter. The patient was soon discharged home in good general condition that remained stable in the 6 months of follow up. To remove the biliary stent, we carried out single-balloon enteroscopy. The stent was captured with a standard polypectomy snare. To avoid injury to the mucosa, the stent was removed through the overtube, which remained in situ. Cholangiogram showed a normal biliary tree, with resolution of the anastomotic stenosis. The patient remained stable throughout the 8 months of follow up, and required no further biliary procedures. In cases of failure of standard procedures, this new two-step, combined percutaneous and endoscopic approach can be useful and feasible, avoiding surgery-related morbidity and mortality. However, the fact that these procedures should be carried out only by highly experienced endoscopists and interventional radiologists familiar with these specialized procedures cannot be overstressed. [ABSTRACT FROM AUTHOR]

Introduction: Roux-en-Y gastric bypass is increasingly performed in the United States. In addition, liver transplantation and other complex hepatobiliary surgeries are increasingly performed with creation of a Roux-en-Y hepaticojejunostomy. Consequently, endoscopists more frequently need to carry out endoscopic procedures in patients with Roux-en-Y anatomy. Materials and methods: The present article discusses the techniques and instruments available to therapeutic endoscopists who are faced with the challenge of performing endoscopic retrograde cholangiopancreatography (ERCP) in patients with long- or short-limb Roux-en-Y anatomy. Conclusion: Endoscopists can successfully perform ERCP in patients with Roux-en-Y anatomy by making use of appropriate techniques and instruments. [ABSTRACT FROM AUTHOR]

Background: The efficacy of double-balloon enteroscopy (DBE) for biliary interventions has been shown in patients with surgical anatomy. However, the use of available endoscopic retrograde cholangiography accessories during this procedure is limited because of the length of the conventional instrument (200 cm). The aim of this study was to evaluate the feasibility of short DBE for managing biliary disorders in patients with a Roux-en-Y gastrectomy or hepaticojejunostomy (HJ). Patients and Methods: Using a short enteroscope (152 cm) and commercially available endoscopic retrograde cholangiography accessories, biliary interventions were performed in six patients with Roux-en-Y reconstruction or HJ anastomosis. Results: A total of 12 biliary interventions were performed; balloon dilations of the HJ anastomosis or intrahepatic ducts (four patients), nasobiliary drainages (three patients), bile duct stone removal after endoscopic papillary large balloon dilation with or without small sphincterotomy (two patients), and a biliary stent placement (one patient). One patient showed retroperitoneal air following endoscopic papillary large balloon dilation, but recovered conservatively. Conclusions: Biliary interventions via DBE using a short enteroscope are feasible in patients with surgical anatomy. [ABSTRACT FROM AUTHOR]

Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for the treatment of patients with pancreaticobiliary disorders, but endoscopic therapy is very difficult to carry out in patients with a Roux-en-Y anastomosis. We herein present the results of ERCP for patients with a Roux-en-Y anastomosis using a double-balloon endoscope. Six patients (six men with a mean age of 69 years) who had undergone prior gastric resection with Roux-en-Y reconstruction were enrolled in the present study and underwent ERCP and associated procedures. ERCP was carried out with a double balloon endoscope, which has one balloon attached to the tip of the endoscope and another attached to the distal end of the soft overtube. In all patients, entering the Y loop was successfully accomplished, and the papilla of Vater was also reached in all cases (100%). Cannulation was successful in four patients (66.7%). The final diagnosis was choledocholithiasis in two patients, biliary fistula in one patient and pancreatic cancer in one patient. A needle-knife precut papillotomy was carried out after placement of a bile duct stent in two patients, and injection of N-butyl-2-cyanoacrylate into a biliary fistula was carried out in one patient. None of the patients suffered from any complications. A double balloon endoscope is therefore considered to be useful for carrying out ERCP and associated procedures in patients with a Roux-en-Y anastomosis. [ABSTRACT FROM AUTHOR]

There is increasing realization that gastric inhibitory polypeptide (GIP) has actions outside of the pancreas and gastrointestinal tract. Most significant is the presence of functional GIP receptors on adipocytes and the appreciation that GIP, secreted strongly in response to fat ingestion, plays a role in the translation of excessive amounts of dietary fat into adipocyte tissue stores. Such effects open up the possibility of exploiting GIP receptor antagonism for the treatment of obesity and insulin resistance. This is borne out by studies in high-fat-fed mice or ob/ob mice with either genetic knockout of GIP receptor or chemical ablation of GIP action using the GIP receptor antagonist, (Pro3)GIP. By causing preferential oxidation of fat, blockade of GIP signalling clears triglyceride deposits from liver and muscle, thereby respectively restoring mechanisms for suppression of hepatic glucose output and cellular glucose uptake. Further studies are needed to determine the applicability of this research to human obesity–diabetes. However, proof of concept is provided by emerging evidence that rapid cure of diabetes in grossly obese subjects undergoing Roux-en-Y bypass surgery is mediated in part by surgical bypass of GIP-secreting K-cells in the upper small intestine. [ABSTRACT FROM AUTHOR]

A 40-year-old male developed sepsis due to cholangitis. Five years earlier he underwent liver transplantation with hepaticojejunostomy. Over the past 18 months, he had 6 episodes of cholangitis. Radiologic studies demonstrated no biliary obstruction. Surgical intervention to eliminate bile reflux and stasis by lengthening the Roux-en-Y limb from 30 to 90 cm was curative. He has had no further episodes of cholangitis or hospitalization in the past 2 years. This case is the first description to our knowledge of a simple technique to treat recurrent cholangitis in patients with normal biliary anatomy, but inadequate biliary drainage following liver transplantation. [ABSTRACT FROM AUTHOR]