Indications, Operative Technique and Outcomes of Revisional Operations Following One Anastomosis Gastric Bypass: a Syste
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LETTER TO THE EDITOR
Indications, Operative Technique and Outcomes of Revisional Operations Following One Anastomosis Gastric Bypass: a Systemic Review Abdulzahra Hussain 1,2
&
Shamsi El-Hasani 3
# Springer Science+Business Media, LLC, part of Springer Nature 2020
We have adopted OAGB as a mainstream bariatric surgical procedure in our units, and we read the article of Khrucharoen et al. [1] with great interest. We agree with the contents of the article and to disseminate the scientific value to the wider bariatric community; we felt to share our practical experience in this particular aspect of this growing procedure. We acknowledged that one of the possible problems following this procedure was gastric pouch oesophageal reflux and/or pouch biliary gastritis. There are several etiological factors for this problem, but what we want to display is that in our hands, the majority of these patients benefited from the laparoscopic exploration of the oesophageal diaphragmatic hiatus, reduction of oesophagus into the abdominal cavity and hiatal repair. This was always associated with jejunojejunostomy [Braun anastomosis], i.e. anastomosing the afferent and the efferent limbs 30–50 cm distal to the gastro-gejunosromy to divert the bile from the gastrojejunal anastomosis. The second point is that ischemia is the most credible cause of stomal ulcer following RYGB or OAGB procedures [2]. We have reduced the incidents of our marginal ulcer by taking utmost care to decrease the amount of gastric tissue between two staple lines at the site of gastrojejunal anastomosis. This tissue will have impaired blood supply, the subsequent death of mucosa and smooth muscle layers and fibrosis. Ongoing ischemia results in full-thickness haemorrhagic necrosis with deep ulceration [3]. In the animal models, linear mucosal
* Abdulzahra Hussain [email protected] 1
Bariatric Unit, Department of General Surgery, Doncaster and Bassetlaw Teaching Hospitals, Doncaster, UK
2
Sheffield University, Sheffield, UK
3
Bariatric Unit, Department of General Surgery, PRUH, King’s College Hospitals, London, UK
haemorrhage appears within 8 h of significant ischemia. Large haemorrhagic ulcers develop by day 3–5, and thick granulation tissue fills the submucosa [4]. The third point will be regarding conversion of OAGB to sleeve gastrectomy that we have performed for patients with malnutrition and/or diarrhoea. We found that it is very safe to adopt the staged procedure where the patient is admitted for nutritional support and then has the first operation, which will be jejunojejunostomy, anastomosing the afferent and efferent limbs. Two weeks later, we perform excision of the gastrojejunal anastomosis and anastomosing the pouch to the antral part of the stomach. This staged approach decreases the possible morbidities and physiological trauma of a larger operation. These patients are followed up for several months to recover from their symptoms, and if their weight starts to become a problem, only then a third operation will be offered to excise t
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