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Gastrojejunal Anastomotic Stenosis After Laparoscopic Gastric Bypass. Experience in 300 Cases in 8 Years
Estenosis de la anastomosis gastroyeyunal en el bypass gástrico laparoscópico. Experiencia en una serie de 300 casos en 8 años
María Luisa García-Garcíaa,
, Juan Gervasio Martín-Lorenzoa, Ramón Lirón-Ruiza, José Antonio Torralba-Martíneza, Álvaro Campillo-Sotoa, Joana Miguel-Perellóa, Enrique Pérez-Cuadradob, José Luis Aguayo-Albasinia,c
Corresponding author
a Servicio de Cirugía General, Hospital General Universitario J. M. Morales Meseguer, Murcia, Spain
b Sección de Gastroenterología y Endoscopia, Hospital General Universitario J. M. Morales Meseguer, Murcia, Spain
c Departamento de Cirugía, Campus de Excelencia Internacional Mare Nostrum, Universidad de Murcia, Murcia, Spain
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M. Morales Meseguer, Murcia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Sección de Gastroenterología y Endoscopia, Hospital General Universitario J. M. Morales Meseguer, Murcia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Cirugía, Campus de Excelencia Internacional Mare Nostrum, Universidad de Murcia, Murcia, Spain" "etiqueta" => "c" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Estenosis de la anastomosis gastroyeyunal en el bypass gástrico laparoscópico. Experiencia en una serie de 300 casos en 8 años" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Obesity is one of the main health problems in developed countries; in Spain, 15% of the people aged 25–64 are affected. Surgical treatment of morbid obesity is the only long-term effective strategy to obtain and maintain significant weight loss over time.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A good bariatric surgical procedure must be effective in achieving the desired weight loss; it must be safe, with less than 10% morbidity and less than 1% mortality; it must offer good quality of life and produce minimum side effects.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Over 30 bariatric techniques have been developed since its inception in the 1950s in the U.S., and currently, Roux-en-Y laparoscopic gastric bypass (LGB) is the most widely used procedure. However, today there is no consensus as far as the ideal technique for gastrojejunal anastomosis (GJ) with the least short-term and long-term complications.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Stenosis after laparoscopic gastrojejunal (GJ) anastomosis is the most frequent complication in laparoscopic gastric bypass surgery amongst the procedures listed above; it reaches 25% rates in some case series.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">This study aims to analyse long-term incidence of stenosis after laparoscopic gastrojejunal (GJ) anastomosis in our patients, to determine its clinical presentation, and its response to endoscopic dilation.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and Method</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients</span><p id="par0025" class="elsevierStylePara elsevierViewall">From January 2004 to December 2012, 280 patients at the General and Digestive Surgery Department of the Hospital General Universitario J. M. Morales Meseguer [J. M. Morales Meseguer University General Hospital] of Murcia underwent LGB according to the Wittgrove modified technique,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> which includes a bypass between the stomach and jejunum by circular or longitudinal anastomosis.</p><p id="par0030" class="elsevierStylePara elsevierViewall">There were 112 men and 158 women; their mean age was 44 years (25–60). After endocrinologist and psychiatric assessment, indications were: BMI equal to or greater than 40<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>, or BMI at 35 if associated with major comorbidities. Some patients with BMI>60 and severe disease were sent for temporary gastric balloon placement. After the anaesthetist assessed the surgical risk, they underwent surgery by the same group of surgeons specialised in bariatric surgery.</p><p id="par0035" class="elsevierStylePara elsevierViewall">GJ anastomosis was performed on 265 patients using a CEAA No. 21 AutoSuture instrument (ILS, Ethicon<span class="elsevierStyleSup">®</span>) with end-to-side construction. Fifteen patients underwent anastomosis using an Endo GIA 45 reload beige (Covidien<span class="elsevierStyleSup">®</span>) with side-to-side construction. In both techniques, after verifying anastomotic tightness, 2 or 3 Hoffmeister sutures were applied on each side and centre of the anastomosis.</p><p id="par0040" class="elsevierStylePara elsevierViewall">On the day before surgery and subsequent days, 5000 subcutaneous units of Heparin were given as antithrombotic prophylaxis. During surgery and on the first postoperative day, we used pneumatic compression stockings; early mobilisation was achieved after removal. Cefazolin 2<span class="elsevierStyleHsp" style=""></span>g was used routinely as antibiotic prophylaxis at anaesthetic induction. We followed up on the procedure according to our clinical care guidelines regarding medical, nursing and nutritional aspects.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">All patients with persistent feeding intolerance underwent barium transit studies or gastroscopy. Pneumatic endoscopic dilation was performed (1.5<span class="elsevierStyleHsp" style=""></span>cm maximum dilation) on all patients with GJ stenosis (diameter <10<span class="elsevierStyleHsp" style=""></span>mm). We recorded the number of dilation sessions and complications.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Method</span><p id="par0050" class="elsevierStylePara elsevierViewall">Patients were examined in outpatient surgery consultations at the first postoperative month, and then periodically every 3 months.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Patient follow-up was performed prospectively from the postoperative period. The following variables were recorded: sociodemographics, personal history, BMI, type of surgical technique, average stay, rates of re-surgery, mortality and its causes. The statistical study was for descriptive purposes; mean values were used for continuous variables, and percentages for categorical variables.</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall">Between January 2004 and April 2013, 280 laparoscopic gastric bypasses were performed in our surgery department. They were followed up for an average of 89 months (3–108).</p><p id="par0065" class="elsevierStylePara elsevierViewall">In 20 cases (7.1%), patients who underwent circular mechanical anastomosis developed GJ stenosis. No stenosis cases occurred with linear side-to-side mechanical anastomosis.</p><p id="par0070" class="elsevierStylePara elsevierViewall">All patients had progressive oral intolerance during the first 3 postoperative months. Four cases were detected by barium transit study; subsequently, all cases were confirmed by gastroscopy.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Five patients had a history of upper digestive bleeding originated from the GJ anastomosis suture line; they needed endoscopic sclerosis for the bleeding lesion (circumferential sclerosis and sclerosis at bleeding sutures).</p><p id="par0080" class="elsevierStylePara elsevierViewall">All cases were solved by endoscopic dilation; one case needed 2 dilation sessions, 3 were performed on another, and a single session for the rest. No long-term restenosis was found.</p><p id="par0085" class="elsevierStylePara elsevierViewall">After the second dilation, one patient suffered a perforation from a post-anastomotic ulcer and required urgent surgery. No mortality occurred from this complication.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">Over 30 different surgeries have been reported for treating morbid obesity. According to Forbi,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> a good bariatric procedure must be effective in terms of obtaining the desired weight loss; it must be safe, with less than 10% morbidity, and less than 1% mortality; it must offer good quality of life, and produce minimum side effects. Although many techniques meet these characteristics in the short-term, sequelae occur in the long term, and this rules them out, as the type of possible complications depends on the type of surgery.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Therefore, bariatric surgery requires close postoperative and multidisciplinary follow-up for early detection and treatment of complications and sequelae.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">LGB is a widely used technique and it is considered the gold standard, as its complications are few and manageable.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Stenosis after laparoscopic gastrojejunal (GJ) anastomosis is a far from negligible complication of this technique, with variable incidence according to the case series (2.9%–25%).<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Stenosis may be functional or anatomical.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Incidence in asymptomatic patients is not known since routine endoscopy is not performed on all patients.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In our case series, we have had 7.1% incidence that has slightly diminished with respect to a previously published preliminary study, in which 62 patients were analysed who underwent gastric bypass with 8.1% stenosis incidence.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Symptoms include progressive oral intolerance and vomiting, with or without abdominal pain, usually appearing from the first 1–2 months from the postoperative period, during the phase where patients receive semi-solid diet, since during the first 4–6 weeks, patients who underwent LGB ingest a liquid diet.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Oesophagogastric transit is useful as a first screening study when compatible symptoms occur, although diagnostic radiological image testing is being dropped due to low specificity and low positive predictive value.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Therefore, if symptoms are suspected, it is always necessary to perform an endoscopy as a diagnostic method. Stenosis is considered to have occurred when anastomotic diameter <10<span class="elsevierStyleHsp" style=""></span>mm is found or when the endoscope is unable to pass through it.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,9,10</span></a> Stenosis can be classified by anastomosis diameter: mild (7–9<span class="elsevierStyleHsp" style=""></span>mm), moderate (5–6<span class="elsevierStyleHsp" style=""></span>mm) and serious (<4<span class="elsevierStyleHsp" style=""></span>mm).<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Endoscopic treatment is the first choice and consists of pneumatic dilation in single or multiple sessions. We recommend progressive dilation and avoid dilating to diameter >18<span class="elsevierStyleHsp" style=""></span>mm, due to perforation risk (approximately 2% risk); this provides excellent long-term results in terms of low rates for complications and failures; therefore, most GJ stenosis can be managed without surgery.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,10</span></a> Although balloon dilation has few complications, it is not free of risks. In our series, one patient (5%) suffered perforation after pneumatic dilation, and needed subsequent surgery. No failure was recorded with endoscopic treatment for all other patients.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Its physiopathology is not fully known. Some favouring factors may be possible anastomosis subclinical leaks, ischaemia from vascular changes in the jejunum handle, anastomosis pressure or delay in healing after marginal ulcer.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12</span></a> Digestive bleeding history in 5 patients (25%) during the immediate postoperative period that required circumferential endoscopy electrocoagulation lead us to think that it can be a risk factor for subsequent stenosis as a result of secondary inflammatory-scarring reaction. This association has not been reported in the literature and additional studies would be necessary to reach sound conclusions.</p><p id="par0125" class="elsevierStylePara elsevierViewall">To date, there is great controversy about which GJ anastomosis and which technique is the most suitable one. Factors involved include technical errors: small diameter anastomosis to avoid fast gastric evacuating, and a mechanical factor: type of anastomosis, whether manual or mechanical.</p><p id="par0130" class="elsevierStylePara elsevierViewall">González et al.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> published a study comparing mechanical to manual circular anastomosis, in which they found 30.7% stenosis from mechanical anastomosis vs 3% from manual anastomosis. A 21<span class="elsevierStyleHsp" style=""></span>mm circular stapler was used in that study, and later studies have found greater stenosis incidence with this diameter compared to 25<span class="elsevierStyleHsp" style=""></span>mm circular staplers, without finding differences in the loss of weight between the two groups.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,12,14,15</span></a> Between 4% and 7% have been reported for linear mechanical anastomosis, results which are similar to those of manual anastomosis.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Bohdjalian et al.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> recently compared 25<span class="elsevierStyleHsp" style=""></span>mm circular anastomosis to longitudinal anastomosis, with 5.3% and 0% stenosis incidence, respectively. Bendewald et al.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> analysed 835 patients who underwent Roux-en-Y laparoscopic gastric bypass, and conducted a comparative study between the 3 GJ anastomosis techniques (manual, linear mechanical, circular mechanical). Stenosis incidence was 6.1% for manual, 6% for linear mechanical, and 4.3% for 25<span class="elsevierStyleHsp" style=""></span>mm circular mechanical, without statistically significant differences. No differences in other complications were found, such as leakage or marginal ulcer. Therefore, the type of anastomosis does not affect the incidence of early complications.</p><p id="par0135" class="elsevierStylePara elsevierViewall">In our case series we have not yet had any case of stenosis in patients who underwent linear anastomosis. Therefore, we considered that although results when using the mechanical circular anastomosis technique meet published standards, at an average stenosis percentage, we could lower complication incidence further by using linear anastomosis.</p><p id="par0140" class="elsevierStylePara elsevierViewall">In conclusion, stenosis after laparoscopic gastrojejunal (GJ) anastomosis is a frequent complication following Roux-en-Y laparoscopic gastric bypass. Endoscopy is key for diagnosis and treatment because it solves most cases, and revision surgeries are rare. Therefore, bariatric surgery requires close and multidisciplinary postoperative follow-up. As the number of bariatric procedures increases, interrelation between surgeons and endoscopy specialists is crucial to recognise and to treat associated complications.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Funding</span><p id="par0145" class="elsevierStylePara elsevierViewall">Paper financed partly by the <span class="elsevierStyleGrantSponsor" id="gs1">Fundación para la Formación e Investigación Sanitaria de la Región de Murcia</span> [Foundation for Health Training and Research of the Region of Murcia], Spain, Group FFIS-008.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of Interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors declare having no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres382056" "titulo" => array:5 [ 0 => "Abstract" 1 => "Objective" 2 => "Patients and method" 3 => "Results" 4 => "Conclusion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec360959" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres382055" "titulo" => array:5 [ 0 => "Resumen" 1 => "Introducción" 2 => "Material y método" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec360958" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Patients and Method" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Patients" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Method" ] ] ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflict of Interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-02-24" "fechaAceptado" => "2014-06-10" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec360959" "palabras" => array:5 [ 0 => "Morbid obesity" 1 => "Gastrointestinal bleeding" 2 => "Bariatric surgery" 3 => "Laparoscopic gastric bypass" 4 => "Postoperative complications" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec360958" "palabras" => array:5 [ 0 => "Obesidad mórbida" 1 => "Estenosis gastrointestinal" 2 => "Cirugía bariátrica" 3 => "Bypass gástrico laparoscópico" 4 => "Complicaciones postoperatorias" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Gastrojejunal stricture (GYS), is not only a common complication after laparoscopic gastric bypass, but its frequency is also about 15% according to bibliography. Our aim is to present our experience after 280 laparoscopic gastric bypass.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Patients and method</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">From January 2004 to December 2012, 280 patients underwent a laparoscopic Roux en Y gastric bypass with creation of the gastrojejunal anastomosis, which was performed with circular stapler type CEAA No 21 in 265 patients and with a linear stapler in 15 patients. In all patients with persistent feeding intolerance barium transit and/or gastroscopy were performed. When gastrojejunal stricture showed proceeded to endoscopic pneumatic dilation.</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Twenty cases (7.1%) developed a gastrojejunal stricture; in 4 of these cases the initial diagnosis was made by barium transit and all cases were confirmed by endoscopy. Five patients had a history of digestive bleeding that required endoscopic sclerosis of the bleeding lesion. All cases were resolved by endoscopic dilatation. One patient suffered a perforation and a re-intervention. At follow-up re-stricture has not been detected.</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Stricture at the gastrojejunal anastomosis after gastric bypass is the commonest complication early after surgery. Endoscopic balloon dilatation is a safe and effective therapy.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La estenosis de la anastomosis gastroyeyunal (GY) representa la complicación más frecuente en la cirugía de derivación gástrica por laparoscopia, llegando en algunas series a alcanzar el 15%. Presentamos nuestra incidencia de estenosis de la anastomosis GY en el bypass gástrico laparoscópico, su forma de presentación y su manejo a largo plazo.</p> <span class="elsevierStyleSectionTitle" id="sect0040">Material y método</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Desde enero del 2004 hasta diciembre del 2012 se han realizado 280 bypass gástricos por la laparoscopia, según la técnica de Wittgrove modificada. La anastomosis GY circular se practicó con material de autosutura tipo CEAA n.° 21 en 265 casos, en los restantes se realizó con una anastomosis longitudinal con grapadora lineal de 45<span class="elsevierStyleHsp" style=""></span>mm. A todos los pacientes con intolerancia persistente a la alimentación se les realizó tránsito baritado o gastroscopia. Cuando se evidenció estenosis GY (diámetro <10<span class="elsevierStyleHsp" style=""></span>mm), se procedió a dilatación neumática endoscópica.</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">En 20 casos (7,1%) se desarrolló una estenosis GY, en 4 de ellos el diagnóstico inicial fue con tránsito baritado. Todos los casos fueron confirmados por gastroscopia. De ellos, 5 pacientes tenían antecedentes de hemorragia digestiva alta que precisaron esclerosis endoscópica de la línea de sutura de la anastomosis GY. Todos los casos se han resuelto mediante dilatación endoscópica, precisando en un caso 2 sesiones de dilatación, en otro caso 3 sesiones y el resto, una. No se han detectado reestenosis. Uno de los pacientes sufrió una perforación de úlcera postanastomótica.</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La estenosis de la anastomosis GY es una complicación frecuente tras el bypass gástrico en Y de Roux. Favorecida por anastomosis de pequeño calibre. La endoscopia es la piedra angular para el diagnóstico y tratamiento, pues resuelve la mayoría de casos, siendo rara la revisión quirúrgica.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: García-García ML, Martín-Lorenzo JG, Lirón-Ruiz R, Torralba-Martínez JA, Campillo-Soto Á, Miguel-Perelló J, et al. Estenosis de la anastomosis gastroyeyunal en el bypass gástrico laparoscópico. Experiencia en una serie de 300 casos en 8 años. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 39 | 8 | 47 |
| 2024 September | 108 | 10 | 118 |
| 2024 August | 96 | 15 | 111 |
| 2024 July | 70 | 11 | 81 |
| 2024 June | 75 | 9 | 84 |
| 2024 May | 62 | 10 | 72 |
| 2024 April | 57 | 8 | 65 |
| 2024 March | 81 | 12 | 93 |
| 2024 February | 45 | 4 | 49 |
| 2024 January | 117 | 9 | 126 |
| 2023 December | 97 | 7 | 104 |
| 2023 November | 89 | 8 | 97 |
| 2023 October | 93 | 7 | 100 |
| 2023 September | 54 | 4 | 58 |
| 2023 August | 57 | 3 | 60 |
| 2023 July | 91 | 7 | 98 |
| 2023 June | 63 | 8 | 71 |
| 2023 May | 83 | 3 | 86 |
| 2023 April | 56 | 9 | 65 |
| 2023 March | 61 | 10 | 71 |
| 2023 February | 55 | 23 | 78 |
| 2023 January | 52 | 8 | 60 |
| 2022 December | 54 | 5 | 59 |
| 2022 November | 46 | 12 | 58 |
| 2022 October | 56 | 16 | 72 |
| 2022 September | 59 | 20 | 79 |
| 2022 August | 40 | 13 | 53 |
| 2022 July | 29 | 5 | 34 |
| 2022 June | 32 | 9 | 41 |
| 2022 May | 30 | 14 | 44 |
| 2022 April | 32 | 23 | 55 |
| 2022 March | 48 | 14 | 62 |
| 2022 February | 46 | 7 | 53 |
| 2022 January | 92 | 10 | 102 |
| 2021 December | 44 | 11 | 55 |
| 2021 November | 49 | 18 | 67 |
| 2021 October | 47 | 12 | 59 |
| 2021 September | 40 | 17 | 57 |
| 2021 August | 57 | 5 | 62 |
| 2021 July | 55 | 12 | 67 |
| 2021 June | 36 | 7 | 43 |
| 2021 May | 40 | 12 | 52 |
| 2021 April | 123 | 9 | 132 |
| 2021 March | 83 | 4 | 87 |
| 2021 February | 84 | 15 | 99 |
| 2021 January | 61 | 9 | 70 |
| 2020 December | 57 | 14 | 71 |
| 2020 November | 50 | 7 | 57 |
| 2020 October | 37 | 4 | 41 |
| 2020 September | 55 | 7 | 62 |
| 2020 August | 62 | 10 | 72 |
| 2020 July | 53 | 4 | 57 |
| 2020 June | 34 | 5 | 39 |
| 2020 May | 51 | 14 | 65 |
| 2020 April | 27 | 4 | 31 |
| 2020 March | 64 | 5 | 69 |
| 2020 February | 65 | 7 | 72 |
| 2020 January | 58 | 4 | 62 |
| 2019 December | 57 | 10 | 67 |
| 2019 November | 65 | 10 | 75 |
| 2019 October | 56 | 8 | 64 |
| 2019 September | 60 | 8 | 68 |
| 2019 August | 44 | 4 | 48 |
| 2019 July | 35 | 22 | 57 |
| 2019 June | 76 | 24 | 100 |
| 2019 May | 165 | 23 | 188 |
| 2019 April | 65 | 12 | 77 |
| 2019 March | 40 | 2 | 42 |
| 2019 February | 38 | 7 | 45 |
| 2019 January | 34 | 7 | 41 |
| 2018 December | 38 | 7 | 45 |
| 2018 November | 55 | 4 | 59 |
| 2018 October | 37 | 3 | 40 |
| 2018 September | 54 | 2 | 56 |
| 2018 August | 32 | 1 | 33 |
| 2018 July | 6 | 3 | 9 |
| 2018 June | 9 | 2 | 11 |
| 2018 May | 12 | 6 | 18 |
| 2018 April | 7 | 2 | 9 |
| 2018 March | 17 | 0 | 17 |
| 2018 February | 10 | 0 | 10 |
| 2018 January | 14 | 2 | 16 |
| 2017 December | 22 | 0 | 22 |
| 2017 November | 16 | 2 | 18 |
| 2017 October | 20 | 2 | 22 |
| 2017 September | 10 | 9 | 19 |
| 2017 August | 17 | 2 | 19 |
| 2017 July | 19 | 7 | 26 |
| 2017 June | 19 | 12 | 31 |
| 2017 May | 26 | 7 | 33 |
| 2017 April | 23 | 2 | 25 |
| 2017 March | 37 | 18 | 55 |
| 2017 February | 22 | 2 | 24 |
| 2017 January | 8 | 2 | 10 |
| 2016 December | 28 | 10 | 38 |
| 2016 November | 41 | 6 | 47 |
| 2016 October | 63 | 9 | 72 |
| 2016 September | 43 | 15 | 58 |
| 2016 August | 24 | 2 | 26 |
| 2016 July | 29 | 4 | 33 |
| 2016 June | 31 | 4 | 35 |
| 2016 May | 29 | 9 | 38 |
| 2016 April | 26 | 12 | 38 |
| 2016 March | 41 | 17 | 58 |
| 2016 February | 31 | 13 | 44 |
| 2016 January | 31 | 13 | 44 |
| 2015 December | 36 | 14 | 50 |
| 2015 November | 23 | 5 | 28 |
| 2015 October | 44 | 13 | 57 |
| 2015 September | 41 | 17 | 58 |
| 2015 August | 60 | 15 | 75 |
| 2015 July | 26 | 9 | 35 |
| 2015 June | 28 | 13 | 41 |
| 2015 May | 50 | 14 | 64 |
| 2015 April | 39 | 20 | 59 |
| 2015 March | 19 | 9 | 28 |
| 2015 February | 1 | 0 | 1 |
| 2015 January | 0 | 1 | 1 |
| 2014 December | 2 | 1 | 3 |
| 2014 November | 8 | 0 | 8 |
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