Linear or circular: Anastomotic ulcer after gastric bypass surgery

Background After laparoscopic Gastric Bypass Procedure (GBP), anastomotic ulcers (AU) at the gastrojejunostomy (GJ) occur in up to 16% of the patients. Surgical techniques seem to influence the development of AU, but this is still a matter of discussion. This study aims to compare the incidence of AU in circular-stapled (CS) versus linear-stapled (LS) gastrojejunostomy. Methods Single-centre retrospective analysis of 241 (m 77 /f 164) consecutive patients (126 CS, 115 LS) with primary or revisional GBP including Roux-Y-Gastric Bypass (RYGB) and One-Anastomosis Gastric Bypass (OAGB) between 01/2014 and 01/2018. Follow-up with oesophagogastroduodenoscopy was only performed in symptomatic patients. Age, body mass index (BMI), comorbidities, smoking and medication were analyzed in both groups. The data are reported as total numbers (%) and mean ± standard deviation. Results AU occurred significantly more often in the CS group than in the LS group (p = 0.0034). Moreover, refractory AU and the need for revisional surgery were higher in the CS group. Smoking correlates significantly with the development of AU, whereas other risk factors had no impact on its incidence. Conclusion Linear-stapled gastrojejunostomy with a long and narrow pouch should be the preferable procedure for reducing AU development risk. Smoking cessation minimizes the risk for AU and is a necessary part of the treatment.

Blind Pouch Syndrome-Associated Enterolithiasis Successfully Treated with Colonoscopy

Enterolithiasis associated with blind pouch syndrome secondary to functional end-to-end anastomosis is rare, and its endoscopic and radiological features remain poorly described. A 72-year-old woman was admitted to our hospital for abdominal pain and difficulty defecating. Colonoscopy (CS) with Gastrografin revealed a 10 × 8 cm calculus, an anastomotic ulcer, a blind pouch, and an end-to-end anastomosis in the transverse colon. The calculus was successfully crushed and removed with snares and alligator forceps through CS during the ensuing 4-day period. To our knowledge, this is the first report describing the endoscopic and radiological features of blind pouch syndrome-associated enterolithiasis successfully treated with CS.

Anastomotic Ulcers After Ileocolic Resection for Crohn’s Disease Are Common and Predict Recurrence

Background Crohn’s disease recurrence after ileocolic resection is common and graded with the Rutgeerts score. There is controversy whether anastomotic ulcers represent disease recurrence and should be included in the grading system. The aim of this study was to determine the impact of anastomotic ulcers on Crohn’s disease recurrence in patients with prior ileocolic resections. Secondary aims included defining the prevalence of anastomotic ulcers, risk factors for development, and their natural history. Methods We conducted a retrospective cohort study of patients undergoing an ileocolic resection between 2008 and 2017 at a large academic center, with a postoperative colonoscopy assessing the neoterminal ileum and ileocolic anastomosis. The primary outcome was disease recurrence defined as endoscopic recurrence (>5 ulcers in the neoterminal ileum) or need for another ileocolic resection among patients with or without an anastomotic ulcer in endoscopic remission. Results One hundred eighty-two subjects with Crohn’s disease and an ileocolic resection were included. Anastomotic ulcers were present in 95 (52.2%) subjects. No factors were associated with anastomotic ulcer development. One hundred eleven patients were in endoscopic remission on the first postoperative colonoscopy. On multivariable analysis, anastomotic ulcers were associated with disease recurrence (adjusted hazard ratio [aHR] 3.64; 95% CI, 1.21–10.95; P = 0.02). Sixty-six subjects with anastomotic ulcers underwent a second colonoscopy, with 31 patients (79.5%) having persistent ulcers independent of medication escalation. Conclusion Anastomotic ulcers occur in over half of Crohn’s disease patients after ileocolic resection. No factors are associated with their development. They are associated with Crohn’s disease recurrence and are persistent.