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Roux-en-Y gastric bypass (RYGB) is considered as the gold standard for surgical management of morbid obesity due to its good results on weight loss and correction of comorbidities related to obesity and its few complication rates. Here, we describe a present strategy for dealing with an unusual complication after RYGB, responsible for chronic pain, as a chronic dilatation of excluded stomach. The video shows our laparoscopic treatment of an excluded gastric fundus dilatation. A 21-year-old woman with history of RYGB was admitted in our center for recurrent abdominal pain. Many consultations have been performed before for the same reason and without explanation for this chronic abdominal pain. We found that a dilatation of the excluded gastric fundus was responsible for recurrent abdominal pain and thus required revisional surgery. An abdominal computed tomography with oral contrast study showed an atypical dilatation of the excluded stomach without gastro-gastric fistula or others abnormal findings. Intra-operative exploration then revealed multiple adhesions. During surgery, released of the excluded stomach allow to confirm a dilatation of the excluded fundus due to error in stapling when performing the vertical part of the gastric pouch of the RYGB. We resected the excluded dilated gastric fundus. An uneventful post-operative course enabled rapid discharge (post-operative day 3). Dilatation of the excluded gastric pouch due to staple line misfiring during RYGB is a rare complication and can explain chronic abdominal pain. Laparoscopy can be useful to confirm the diagnosis and allow treatment using gastric resection in our case.

Few series are available on the results of repeat sleeve gastrectomy (re-SG) and Roux-en-Y gastric bypass (RYGB) performed to manage the failure of primary sleeve gastrectomy (SG). The objective of this study was to compare the short- and medium-term outcomes of re-SG and RYGB after SG. Between January 2010 and December 2017, patients undergoing re-SG (n = 61) and RYGB (n = 83) for failure of primary SG were included in this study. Revisional surgery was proposed for patients with insufficient excess weight loss (EWL ≤ 50%) or weight regain. The primary endpoint was the comparison of weight loss in the re-SG group and the RYGB group at the 1-year follow-up. The secondary endpoints were overall mortality and morbidity, specific morbidity, length of stay, weight loss, and correction of comorbidities. The mean interval between SG and re-SG was 41.5 vs. 43.2 months between SG and RYGB (p = 0.32). The mean operative time was 103 min (re-SG group) vs. 129.4 min (RYGB group). One death (1.7%; re-SG group) and 25 complications (17.4%; 9 in the re-SG group, 16 in the RYGB group) were observed. At the 1 year, mean body mass index was 31.6 in the re-SG group and 32.5 in the RYGB group (p = 0.61) and excess weight loss was 69.5 vs. 61.2, respectively (p = 0.05). Re-SG and RYGB as revisional surgery for SG are feasible with acceptable outcomes and similar results on weight loss on the first postoperative year.

Bariatric surgery as laparoscopic Roux-en-Y gastric bypass (LRYGB) is increasing throughout the world and women represent the majority (70%) of patients. Most of them are of reproductive age. As a consequence, surgeons will have to treat more and more pregnant patients with a history of LRYGB for surgical abdominal pain. Reported incidence of small bowel obstruction (SBO) varies from 1.5% to 3.5% after LRYGB including internal hernias, intussusception and volvulus. As two cases of maternal postoperative death have been reported in the literature, diagnosis and surgical treatment shouldn’t be delayed especially during pregnancy. To underline the necessity of a rapid diagnosis and surgical treatment, we reported two cases of severe SBO during pregnancy.

The frequency of bariatric surgery has increased markedly in France in recent years, partly due to a better appreciation of the problem of morbid obesity but also due to the commercial introduction of adjustable gastric banding devices which can be placed by laparoscopic approach. Numerous complications of this surgery are known and require recognition to be appropriately treated. Studies of complications suffer from selection bias, methodologic flaws, and lack of follow-up. The incidence and type of complication are affected by the learning curve and surgical techniques. Postoperative mortality varies from 0.14% for laparoscopic gastric banding (LGB), to 0.31% for vertical banded gastroplasty (VBGP) and 0.35% for Roux-en-Y gastric bypass (GBP); pulmonary embolus accounts for 60-70% of deaths in all groups combined. Early post-operative complications vary with specific procedures. Abdominal wall complications, already frequent in an obese population, are decreased from 10% for open procedures to 6% for laparoscopic gastric banding. Both VBGP and GBP are now being done laparoscopically with increasing frequency. Complications specific to LGB include gastric perforation (0.3%), or port problems (5%). Complications with VBGP and GBP include fistula (1-3%), deep abscess, and pulmonary embolus (2%). Global early morbidity is 4.2% for LGB, and varies from 6.4%-22% for VBGP and 6.2%-11.3% for GBP depending on laparoscopic versus open approach. Late mechanical complications are also specific to type of surgery. Pouch dilatation is the most common late complication of LGB (6.3%) and seems related both to operative experience and to site of placement of the band; it has decreased with higher positioning of the band to leave a minimal gastric pouch and with dissection through the pars flaccida of the lesser omentum instead of directly along the muscular wall of the stomach. It usually requires reintervention. Erosion of the gastric band into the stomach (1.6%) is often asymptomatic and is suggested by late weight gain. With VBGP, disruption of a gastric staple line occurs in 12.1% and stenosis of the outlet with proximal dilatation in 6.5%; erosion of the calibrating band of Marlex or silastic occurs in 2.7%. With GBP, the disruption of a staple line across an intact stomach (23%) has become less of a problem with division of the gastric pouch from the distal stomach (2%). Stenosis of the gastrojejunostomy (3.7%) and marginal ulcer (3.5%) are not uncommon. The incidence of wound hernia, obstructive adhesions, and late cholecystectomy vary with the length and thoroughness of follow-up. Late functional complications such as vomiting, dysphagia, heartburn and esophagitis vary with the quality and length of follow-up study. GBP may cause diarrhea and dumping syndrome. Nutritional complications are more common with GPB than with purely restrictive procedures; iron, folate, and Vitamin B12 deficiency are the rule with GBP and require routine replacement therapy; iron deficiency has been noted even with LGB. ate death seems more related to co-morbidities than to the intervention itself. Thorough long-term follow-up study of complications is indispensable for assessment of outcomes and improvement of laparoscopic techniques. Even the less traumatic surgical approach of laparoscopic band placement should not be considered free of risk; strict adherence to pre-operative surgical indications should be maintained.

Obesity is defined as morbid when the Body Mass Index (BMI) exceeds 40 kg/m(2). The initial approach should be a multidisciplinary medical assessment. The three principal surgical interventions practiced in France are: placement of an adjustable gastroplasty ring, vertical banded gastroplasty, and Roux-en-Y gastric bypass (short circuit). The indications for surgical therapy are those defined by recent consensus conferences: Morbid Obesity (BMI 40), Major Obesity (BMI 35) with associated factors of co-morbidity, or stable or worsening obesity of five years duration resistant to multidisciplinary medical management for a least a year. Studies of these three surgical techniques with at least one year of follow-up shows significant average weight loss on the order of 20-50 kg. Studies of adjustable ring gastroplasty show an average loss of 45% of excess weight at one year; maintenance of weight loss beyond one year is not yet well documented. Long term results of vertical banded gastroplasty and gastric bypass are better defined. Initial weight loss for vertical banded gastroplasty is about 61%; some patients maintain this weight loss and others tend to regain some of their excess weight. For gastric bypass, the initial weight loss is about 68% of excess weight and there is a greater tendency to maintain this weight loss. Comparative studies, mostly from North America and of variable methodologic quality, conclude that weight loss with gastric bypass is superior to that with vertical banded gastroplasty. The indications for the respective techniques vary according to the severity of the obesity (BMI), and to the patient's eating habits. Gastric bypass which has the best short and long term results may be best reserved for patients with the most severe obesity or co-morbid conditions.