International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases

Preoperative Serum Cortisol Level Is Predictive of Weight Loss After Laparoscopic Sleeve Gastrectomy in Men with Severe Obesity but Not Women

BACKGROUND

Bariatric surgery is an effective treatment for severe obesity and its associated medical problems. Preoperative factors that predict postoperative weight loss remain to be fully characterized, however.

METHODS

Anthropometric and laboratory data were collected retrospectively for severely obese patients who underwent laparoscopic sleeve gastrectomy (LSG) between April 2016 and July 2019 at our hospital. Preoperative factors that predicted weight loss at 1 year after LSG were investigated.

RESULTS

A total of 122 subjects (45 men and 77 women) underwent LSG. The mean ± SD age and body mass index at surgery were 44.4 ± 10.4 years and 40.7 ± 6.7 kg/m². The percent total weight loss (%TWL) was 27.0 ± 8.6 among all subjects, 26.4 ± 8.0 among men, and 27.4 ± 8.9 among women, with no significant difference between the sexes. The %TWL showed a significant inverse correlation with serum cortisol level in men and with age and the visceral/subcutaneous fat area ratio in women. Multivariable regression analysis revealed the presence of type 2 diabetes and the serum cortisol concentration to be negatively associated with %TWL among all subjects and men, respectively. Receiver operating characteristic curve analysis identified an optimal cutoff of 10 µg/dL for prediction of a %TWL of ≥ 25 in men by serum cortisol level.

CONCLUSIONS

Serum cortisol concentration was identified as a predictor for postoperative weight loss in men. Our results may thus help inform the decision to perform LSG or more effective surgical procedures in men with severe obesity.

Endoscopic management of refractory leak and gastro-cutaneous fistula after laparoscopic sleeve gastrectomy: a randomized controlled trial

BACKGROUND

Gastro-cutaneous fistula is a rare complication after laparoscopic sleeve gastrectomy (LSG) with incidence of occurrence 1-2%. Most of gastro-cutaneous fistulae do not respond to conservative management and need intervention either surgically or endoscopically.

METHODS

This prospective randomized clinical study included referred patients who had LSG performed at our department or other centers, and complicated with post-LSG leak or gastro-cutaneous fistula between December/2019 and March/2021. Included patients were ASA Physical status I-II. Primary and secondary outcomes were recurrence of the fistula and mortality in each group after the intervention during the 18 months follow-up period, respectively.

RESULTS

Thirty patients were randomized into two groups: Surgery Group (SG, n = 15) and Endoscopy Group (EG, n = 15). Mean age of patients was 42.3 ± 8.7 and 42.6 ± 8.3 years-old in SG and EG, respectively. Females constituted 73.3% and 80% in SG and EG, respectively. Median time-to-gastric leak post LSG was six (range: 4-7) days in both groups. SG patients were surgically managed with primary repair of the gastric fistula and gastrojejunostomy in 13 patients or converting SG into Roux-en-Y gastric bypass in two patients, while EG patients were endoscopically managed with stitching, stenting, stenting and dilation, and clipping and dilation in 5, 4, 4 and 2 patients, respectively. Incidence of recurrent leak during 1^st week was significantly higher in SG than EG (p < 0.001). No mortality reported in EG, while 2 patients died in SG (p = 0.48).

CONCLUSION

Endoscopic intervention may offer a successful modality in managing post-LSG gastric leak and gastro-cutaneous fistula that do not respond to conservative measures in stable patients.

Choosing the best endoscopic approach for post-bariatric surgical leaks and fistulas: Basic principles and recommendations

Post-surgical leaks and fistulas are the most feared complication of bariatric surgery. They have become more common in clinical practice given the increasing number of these procedures and can be very difficult to treat. These two related conditions must be distinguished and characterized to guide the appropriate treatment. Leak is defined as a transmural defect with communication between the intra and extraluminal compartments, while fistula is defined as an abnormal communication between two epithelialized surfaces. Traditionally, surgical treatment was the preferred approach for leaks and fistulas and was associated with high morbidity with significant mortality rates. However, with the development of novel devices and techniques, endoscopic therapy plays an increasingly essential role in managing these conditions. Early diagnosis and endoscopic therapy initiation after clinical stabilization are crucial to success since clinical success rates are higher for acute leaks and fistulas when compared to late and chronic leaks and fistulas. Several endoscopic techniques are available with different mechanisms of action, including direct closure, covering/diverting or draining. The treatment should be individualized by considering the characteristics of both the patient and the defect. Although there is a lack of high-quality studies to provide standardized treatment algorithms, this narrative review aims to provide a summary of the current scientific evidence and, based on this data and our extensive experience, make recommendations to help choose the best endoscopic approach for the management of post-bariatric surgical leaks and fistulas.

The Effect of Different Staple Sizes on Leak Pressure Among Patients Undergoing Sleeve Gastrectomy: a Pilot Study

Gastric leak after LSG is a devastating complication, reported in less than 1% of cases. Consensus is lacking regarding the best approach to construct the sleeve, staple sizes, and reinforcement methods on potential leak development. In this study, we have compared the leak pressure of two different staple sizes in the resected portion of the stomach, immediately after its removal. Fifteen patients were enrolled. Leak pressure of a vascular, small-size stapler was significantly higher than that of a medium-size one. All leaks appeared in the proximal third of the resected stomach. These results may have clinical implication. Since other factors may play a role in the risk for leaks following sleeve gastrectomy, a large, prospective clinical trial should be performed comparing the two staple sizes in laparoscopic sleeve gastrectomy.

Partial staple line reinforcement with synthetic buttressing material in laparoscopic sleeve gastrectomy: a propensity score-matched analysis

PURPOSE

Staple line leakage (SLL) and staple line bleeding (SLB) are the most relevant postoperative complications of sleeve gastrectomy (SG). It is controversial whether and which method of staple line reinforcement (SLR) can best reduce these complications. The primary objective of this study was to investigate whether reinforcement of the most proximal part of the staple line with synthetic buttressing material, a strategy we termed partial SLR (p-SLR), reduces the 30-day incidence of SLL.

METHODS

A retrospective search of medical records of all bariatric patients from 2010 to 2019 was performed. Patients who underwent SG with either p-SLR or non-SLR were included. Intraoperative and postoperative outcomes were analyzed before and after propensity score matching (PSM).

RESULTS

Data from 431 patients were analyzed (364 in the p-SLR group and 67 in the non-SLR group). No difference in the 30-day incidence of SLL was observed between the two groups. The 30-day incidence of SLB (1.1% vs. 6.0% in the p-SLR and non-SLR groups, respectively) was significantly lower in the p-SLR group. These results were confirmed by PSM analysis.

CONCLUSION

Partial staple line reinforcement with synthetic buttressing material does not reduce the 30-day incidence of SLL. Although our analysis showed a significant reduction in the 30-day incidence of SLB in the p-SLR group, this result should be interpreted with caution.

Endoscopic Management of Postoperative Esophageal and Upper GI Defects-A Narrative Review

Anastomotic defects are deleterious complications after either oncologic or bariatric surgery, leading to high morbidity and mortality. Besides surgical revision in early stages or instable patients, endoscopic treatment has become the mainstay. To date, many options for endoscopic treatment in this setting exist, including fully covered metal stent placement, endoscopic vacuum therapy (EVT), endoscopic internal drainage with pigtail placement (EID), leak closure with through the scope or over the scope clips, endoluminal suturing, fibrin glue sealing and a combination of all these techniques. Current evidence is mostly based on retrospective single and multicenter studies. No guidelines exist in this important field. Treatment options have to be chosen upon each case individually, taking into account clinical and anatomic criteria, such as timing, size, infectious wound complications and hemodynamic stability. Local expertise and availability of treatment devices need to be taken into account whenever choosing a treatment strategy. This review aimed to present current treatment options in terms of effectiveness, advantages and disadvantages in order to guide the clinician for his decision making. Additionally, we aimed to provide a treatment algorithm.

Excess visceral fat area as an independent risk factor for early postoperative complications in patients with obesity undergoing bariatric surgery

BACKGROUND

Few studies have investigated the correlation between visceral fat area (VFA) and early postoperative complications in patients with obesity undergoing bariatric surgery. This study aimed to investigate the relationship between VFA and early postoperative complications in patients with obesity following bariatric surgery.

METHODS

The study was conducted at a tertiary university hospital. Patients with obesity who underwent laparoscopic sleeve gastrectomy between June 2016 and October 2020 were divided into two groups based on umbilical level VFA: high-VFA group (umbilical level VFA ≥ 100 cm²) and low-VFA group (umbilical level VFA < 100 cm²). Baseline characteristics, intraoperative and postoperative conditions, and early postoperative complications were compared between the groups. The primary outcome was early postoperative complications, and the secondary outcome was postoperative hospital stay.

RESULTS

The study included 152 patients, with 82 patients in the low-VFA group and 70 patients in the high-VFA group. The high-VFA group had a higher incidence of early postoperative complications (14.29% vs. 2.44%, P = 0.013) than the low-VFA group. The length of postoperative hospital stay did not differ significantly between the groups.

CONCLUSIONS

Our study suggests that excess VFA is an independent risk factor for early postoperative complications following bariatric surgery, and VFA may be used in preoperative evaluations.

Laparoscopic Roux-en-Y fistulojejunostomy as a salvage procedure in patients with chronic gastric leak after sleeve gastrectomy

BACKGROUND

The most common postoperative complication of laparoscopic sleeve gastrectomy (LSG) is staple-line leak. Even if its rate following LSG has been recently reduced, management of chronic leaks remains challenging.

OBJECTIVE

To present a series of patients treated with laparoscopic Roux-en-Y fistulojejunostomy (LRYFJ) for chronic gastric leak (>12 wk) post-LSG.

SETTING

University hospitals; specialized bariatric surgery units.

METHODS

Data were prospectively gathered and retrospectively analyzed. Parameters of interest were patient characteristics, perioperative data, and postoperative outcomes. Hemodynamically unstable patients and/or presentations of signs of severe sepsis were excluded. Surgical technique was standardized.

RESULTS

Fourteen patients underwent LRYFJ for chronic gastric leak (12 women, 2 men). The mean age was 49.2 years and the mean weight was 88.7 kg with a mean body mass index of 31.1 kg/m². All procedures were successfully performed by laparoscopy except 1 (7.1%) converted to open surgery. The mean operative time was 198 minutes, with a mean estimated blood loss of 135.7 mL and 2 patients necessitating transfusion (14.2%). Mortality was null. Five postoperative complications were noted (35.7%): 2 leaks of the fistulojejunostomy treated by antibiotherapy and endoscopic drainage; 1 perianastomotic hematoma treated by relaparoscopy and antibiotherapy; and 1 pleural effusion and 1 hematemesis both medically treated. The mean length of hospital stay was 14 days. The mean follow-up was 40 months, with all patients being in good health at last contact.

CONCLUSIONS

LRYFJ seems to be a good salvage option in selected patients for the treatment of chronic gastric leaks after LSG. However, it is a challenging procedure and should be performed in experienced bariatric centers by expert bariatric surgeons.

Gastrocolic Fistula: An Extraordinary Gastrointestinal Fistula

Gastrocolic (GC) fistula, a rare gastrointestinal pathological condition, is defined as an abnormal connection between the stomach and the colon. Mostly, it involves the greater curvature of the stomach and the transverse part of the colon. Its precise incidence rate is unknown and largely differs between western and eastern nations. Etiological causes differ as well between the two worlds. Although several precipitating diseases are reported, nowadays, the most common causes are malignant diseases of the stomach (eastern countries) and colon (western world). Patients with GC fistulas usually present late and complain mainly of vomiting, diarrhea, and severe weight loss. This in turn leads to malnutrition, vitamin deficiencies and electrolyte disturbances. Being a rare condition, and usually forgotten, diagnosis is usually challenging to the treating physicians. Workup usually involves a combination of radiological and endoscopic tests. Long-term survival is unknown, and patients usually have poor prognosis. The aim of this review is to summarize the relevant articles in the English literature for this abnormal medical condition, with emphasis on the different etiologies, pathogenesis, clinical presentation, and management, in order to increase physicians' awareness of such uncommon medical problem.

Endoscopic treatment of large gastric leaks after gastrectomy using the combination of double pigtail drains crossing a covered stent

BACKGROUND

Endoscopy is the gold standard for the treatment of postoperative gastric leaks (GL). Large fistulas are associated with high rate of treatment failure. The objective of this study was to assess the clinical efficacy of a combining technique using a covered stent (CS) crossing through pigtails (PDs) for large postsurgical GL leaks.

METHODS

All consecutive patients with large (> 10 mm) postsurgical GL treated endoscopically with a combination of a CS and PDs were included in a single-center retrospective study. The primary endpoint was the rate of GL closure.

RESULTS

A total of 29 patients were included. Twenty-five patients underwent sleeve gastrectomy. The fistula (median diameter 15 mm) was diagnosed 6 days (IQR 4-9) after surgery. Technical success was observed in all procedures. After a median follow-up of 10.7 months (IQR 3.8-20.7), GL closure was observed in 82.7% with a median time of 63 days (IQR 40-90). Surgical management was finally necessary in four patients after a median of 186 days (IQR 122-250). No complications related to combined endoscopic treatment were observed especially stent migration during the follow-up.

CONCLUSION

An endoscopic strategy combining CS crossing through PDs appears to be effective, safe and well tolerated for the treatment of large GL.

From surgery to endoscopy: the evolution of the bariatric discipline

ABSTRACT

Obesity, with its increasing morbidity and prevalence, is now a worldwide public health problem. Obesity and its related comorbidities impose a heavy burden on societal health and the economy. The practice of bariatric surgery has evolved from its early surgical procedures, many of which are no longer routine operations. With clinical practice, research, and experience, bariatric surgery has gradually become an important last resort for the control of weight and obesity-related metabolic diseases in moderately and severely obese patients. However, there is still room for further improvements in bariatric surgical procedures, especially with regard to long-term issues and complications. Endoscopic weight loss technology has developed rapidly in recent years. The advantages of this technology include minimal invasiveness, an obvious weight loss effect, and few complications, thus filling the gap between medications and lifestyle adjustments and surgical treatment of obesity. Endoscopic weight loss technology may even replace surgical bariatric procedures. This review summarized the current status of bariatric metabolic surgery and newly developed bariatric endoscopic procedures.

Prevalence, Predictors, and Management of Gastroesophageal Reflux Disease After Laparoscopic Sleeve Gastrectomy: a Multicenter Cohort Study

BACKGROUND

One of the most popular bariatric procedures is laparoscopic sleeve gastrectomy (LSG), which can either cause or worsen gastroesophageal reflux disease (GERD). Therefore, the goal of this study was to examine the prevalence, predictors, and management of GERD symptoms after LSG.

MATERIALS AND METHODS

From January 2017 to January 2022, we looked at patients who had a primary LSG and developed GERD. Before LSG, all patients underwent a barium meal and upper endoscopy. After LSG, barium meal, endoscopy, esophageal manometry, and 24-h pH measurements were performed for selected patients. The diagnosis of GERD is based on the GERD-HRQL questionnaire and upper endoscopy.

RESULTS

The study included 1537 patients (62.5% women and 37.5% men) with a mean age of 34.4 years. The mean % TWL was 40.7% during a mean follow-up period of 15.9 months. A total of 379 patients (24.7%) experienced postoperative GERD, of whom 328 (21.3%) had postoperative de novo GERD symptoms, 25 (1.6%) had worsened preoperative GERD, and 26 (1.7%) had the same preoperative GERD symptoms. Antral preservation and gastropexy were protective factors against the development of GERD after LSG. LSG was converted to LRYGB in 15.8% of the patients with GERD. The response to medical treatment was observed in 300 (79.2%) patients with GERD.

CONCLUSION

Post-LSG GERD presented in 379 patients (24.7%). Antral preservation and gastropexy were protective factors for the development of postoperative GERD after LSG. Medical treatment was the main line of treatment for GERD.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT05416645.

Volumetric Pouch Study After Laparoscopic Sleeve Gastrectomy

Laparoscopic sleeve gastrectomy (LSG) is considerably utilized as a bariatric method for treating morbid obesity through the reduction of stomach volume. The present study attempted to assess the volumetric changes of the gastric reservoir 1 year after LSG using multi-slice spiral computed tomography (MSCT) as well as to verify their association with weight loss. The current study is a prospective study of 40 consecutive morbid obese patients managed with laparoscopic sleeve gastrectomy. All patients were referred to abdominal MSCT besides volumetric measurement of the gastric pouch 1 month and 12 months postoperatively after the LSG. There were statistically substantial differences throughout the whole period of follow-up (p value ≤ 0.05) regarding the ratio of excess weight loss, weight loss, and decreased BMI, in addition to the ratio of excess body mass index loss (% EBMIL) after LSG. Substantial elevation of the overall volume of the gastric reservoir (82.9 SD11 and 171.6 SD23.6 ml at 1 and 12 months, respectively) was observed. However, the current findings did not demonstrate any significant association (r = 0.131, p = 0.491) between excess weight loss percentage and the increase in gastric reservoir volume 1 year postoperatively. Sleeve dilatation is a common finding following sleeve gastrectomy (SG) even after conducting a narrow gastric pouch, yet dilatation was not correlated with insufficient weight loss after 1 year postoperatively. Trial registration number: NCT04880902.

Battle of the buttress: 5-year propensity-matched analysis of staple-line reinforcement techniques from the MBSAQIP database

BACKGROUND

Vertical sleeve gastrectomy (VSG) has demonstrated to be safe; however, controversy remains on how to decrease major complications, particularly bleeding and leaks. There are variations in staple-line reinforcement techniques, including no reinforcement, oversewing, and buttressing. We sought to evaluate the effect of those methods on post-operative complications using the Metabolic and Bariatric Surgery Accreditation Quality Initiative Program (MBSAQIP) database.

METHODS

The MBSAQIP was queried for patients who underwent VSG during 2015-2019. A propensity-matched analysis was performed between different staple-line reinforcement (SLR) methods, specifically No reinforcement (NR), Oversewing (OS), and Buttressing (BR). The primary outcome of interest was complications within 30 days.

RESULTS

A total of 513,354 VSG cases were analyzed. The cohort was majority female (79.0%), with mean (SD) age of 44.2 ± 11.9 years and mean BMI of 45 ± 7.8 kg/m². Frequency of SLR methods used was 54%BR, 25.6%NR, 10.8% BR + OS, and 9.8%OS. There were no differences in rate of leaks among SLR methods. Compared to NR, BR was associated with decreased rate of reoperations, overall bleeding, and major bleeding (p < 0.05) but prolonged operative time and length of stay (LOS) (p < 0.05). OS was associated with decreased overall bleeding (p < 0.05) but prolonged operative times and length of stay (p < 0.05) compared to NR. Compared to BR, OS was associated with increased operative times, LOS, and rates of post-operative ventilator use, pneumonia, and venous thrombosis (p < 0.05). Patients with bleeding were associated with lower rate of BR (56% vs 61%) and higher rate of NR (34% vs 28%) compared to patients with no bleeding. Bleeding was associated with a greater frequency of leaks (4.4% vs 0.3%), along with higher morbidity and mortality (p < 0.05).

CONCLUSIONS

Of the reinforcement methods evaluated, BR and OS were both associated with decreased bleeding despite longer operative times. No method was found to significantly reduce incidence of leaks; however, bleeding was associated with increased incidence of leaks, morbidity, and mortality. The liberal use of SLR techniques is recommended for further optimization of patient outcomes after VSG.

Gastroesophageal reflux after sleeve gastrectomy. Fact or fiction?

BACKGROUND

One of the most controversial issues surrounding laparoscopic sleeve gastrectomy is the development of gastroesophageal reflux disease following surgery. The aim of the study was to evaluate the occurrence of gastroesophageal reflux disease after laparoscopic sleeve gastrectomy and to analyze patients' weight loss, comorbidities, and quality of life after surgery.

METHODS

The clinical records of 52 patients submitted to laparoscopic sleeve gastrectomy between January and November 2018, with 3 years of follow-up, were retrospectively reviewed. At the end of the follow-up period, the patients underwent screening endoscopy, and those with postoperative esophagitis were submitted to endoscopic biopsies and pH-impedance monitoring (MII-pH). The presence of gastroesophageal reflux disease symptoms was assessed using the modified clinical DeMesteer score questionnaire. The Bariatric Analysis and Reporting Outcome System score and 36-Item Short Form Health Survey were used to assess the postoperative quality of life.

RESULTS

In the preoperative work-up, only 7.6% of patients had signs of esophagitis at esophagogastroduodenoscopy, whilst at 3-year follow-up, 50% of them had endoscopic signs of gastroesophageal reflux disease. Twenty-one out of 26 patients with signs of esophagitis agreed to undergo MII-pH. The median DeMesteer score questionnaire was 4.5, with only 4 patients (19%) exhibiting a value greater than the pH cut-off value (14.72), indicative of gastroesophageal reflux disease. MII-pH data analysis showed the presence of gastroesophageal reflux disease in 5 patients. An excellent outcome on the Bariatric Analysis and Reporting Outcome System score was reported in 50% of patients, and all 8 domains from the 36-Item Short Form Health Survey improved significantly.

CONCLUSION

This study showed an improvement in these patients' quality of life and the limited refluxogenic nature of laparoscopic sleeve gastrectomy at 3-year follow-up when diagnosis of gastroesophageal reflux disease is based on the Lyon consensus.

Gastroesophageal Reflux Disease as an Indication of Revisional Bariatric Surgery-Indication and Results-a Systematic Review and Metanalysis

This systematic review evaluates the indications and results of revisional bariatric surgery (RBS) in gastroesophageal reflux disease (GERD). A systematic literature search and meta-analysis was performed for articles published by April 1, 2021. After examining 722 papers involving 17,437 patients, 48 studies were included (n = 915 patients). RBS for GERD was mostly reported after sleeve gastrectomy (n = 796, 87%) and one anastomosis gastric bypass (n = 62, 6.8%) and was performed due to intractable GERD (71.6%), GERD and weight issues (16%), and biliary reflux (6.2%). Mean follow-up of the studies was 31.5 (3-84) months. Pooled estimation of a meta-analysis of studies reported 7% of GERD following primary surgery needing RBS, in which 99% of the patients experienced remission.

Diagnosis and Management of Postoperative Complications After Sleeve Gastrectomy

Sleeve gastrectomy (SG) has demonstrated excellent outcomes in terms of weight loss and resolution of obesity-related comorbidities as a single procedure. It has gained rapidly increasing popularity among bariatric surgeons and patients over the last two decades. This is due to its relative ease of use and less frequent morbidities related to the procedure. Even though the overall complication rate after SG is reported to be lower than conventional Roux-en-Y gastric bypass or biliopancreatic diversion, it still affects 1-10% of the patients undergoing SG, which is not negligible. Early postoperative complications that can occur within 30 days after SG include hemorrhage, leakage, sleeve stenosis, and reflux. Thromboembolic events are rare but can occur after surgery. Here, we review the incidence, diagnosis, and management of these early postoperative complications.

Indocyanine Green Fluorescence Angiography During Laparoscopic Bariatric Surgery: A Pilot Study

Aims

Indocyanine green (ICG) fluorescence angiography (FA) is used for several purposes in general surgery, but its use in bariatric surgery is still debated. The objective of the present pilot study is to evaluate the intraoperative utility of ICG-FA during bariatric surgery in order to focus future research on a reliable tool to reduce the postoperative leak rate.

Methods

Thirteen patients (4 men, 30.8%, 9 women, 69.2%) with median age of 52 years (confidence interval, CI, 95% 46.2–58.7 years) and preoperative median body mass index of 42.6 kg/m² (CI, 95% 36 to 49.3 kg/m²) underwent bariatric surgery with ICG-FA in our center. Three mL of ICG diluted with 10 cc sterile water were intravenously injected after gastric tube creation during laparoscopic sleeve gastrectomy (LSG) and after the gastric pouch and gastro-jejunal anastomosis creation during laparoscopic gastric by-pass (LGB). For the ICG-FA, Karl Storz Image 1S D-Light system (Karl Storz Endoscope GmbH & C. K., Tuttlingen, Germany) placed at a fixed distance of 5 cm from the structures of interest and zoomed vision modality were used to identify the vascular supply. The perfusion pattern was assessed by the surgical team according to a score. The score ranged from 1 (poor vascularization) to 5 (excellent vascularization) based on the intensity and timing of fluorescence of the vascularized structures.

Results

Fom January 2021 to February 2022, six patients underwent LSG (46.2%), three patients underwent LGB (23.1%), and four patients underwent re-do LGB after LSG (30.8%). No adverse effects to ICG were observed. In 11 patients (84.6%) ICG-FA score was 5. During two laparoscopic re-do LGB, the vascular supply was not satisfactory (score 2/5) and the surgical strategy was changed based on ICG-FA (15.4%). At a median follow-up of five months postoperatively, leaks did not occur in any case.

Conclusions

ICG-FA during bariatric surgery is a safe, feasible and promising procedure. It could help to reduce the ischemic leak rate, even if standardization of the procedure and objective fluorescence quantification are still missing. Further prospective studies with a larger sample of patients are required to draw definitive conclusions.

Development and Validation of an Artificial Intelligence-Based Model to Predict Gastroesophageal Reflux Disease After Sleeve Gastrectomy

Purpose

Prediction of the onset of de novo gastroesophageal reflux disease (GERD) after sleeve gastrectomy (SG) would be helpful in decision-making and selection of the optimal bariatric procedure for every patient. The present study aimed to develop an artificial intelligence (AI)-based model to predict the onset of GERD after SG to help clinicians and surgeons in decision-making.

Materials and Methods

A prospectively maintained database of patients with severe obesity who underwent SG was used for the development of the AI model using all the available data points. The dataset was arbitrarily split into two parts: 70% for training and 30% for testing. Then ranking of the variables was performed in two steps. Different learning algorithms were used, and the best model that showed maximum performance was selected for the further steps of machine learning. A multitask AI platform was used to determine the cutoff points for the top numerical predictors of GERD.

Results

In total, 441 patients (76.2% female) of a mean age of 43.7 ± 10 years were included. The ensemble model outperformed the other models. The model achieved an AUC of 0.93 (95%CI 0.88–0.99), sensitivity of 79.2% (95% CI 57.9–92.9%), and specificity of 86.1% (95%CI 70.5–95.3%). The top five ranked predictors were age, weight, preoperative GERD, size of orogastric tube, and distance of first stapler firing from the pylorus.

Conclusion

An AI-based model for the prediction of GERD after SG was developed. The model had excellent accuracy, yet a moderate sensitivity and specificity. Further prospective multicenter trials are needed to externally validate the model developed.

Graphical Abstract

Drug absorption in bariatric surgery patients: A narrative review

Background

Despite the increase in the number of bariatric surgeries performed, little is known about the impact of the surgery on drug absorption. Unpredictability is assumed with drugs, given the anatomical changes after surgery.

Objective

To evaluate the impact of bariatric surgery on drug absorption based on the type of procedure performed.

Methods

We conducted a comprehensive literature review searching PubMed/Medline for published studies (from inception to December 2017) that evaluate the use of drugs and the assessment of drug absorption after bariatric surgery. Pharmacokinetic/pharmacodynamic studies, case reports, and observational studies were included in our review.

Results

We found 60 studies addressing drug use after bariatric surgery. Twenty‐eight studies reported a decrease in drug absorption after bariatric surgery while only four studies showed an increase in drug absorption. Unchanged absorption of drugs was seen in 23 studies after the surgery.

Conclusion

The available information shows variations in drug absorption after bariatric surgery. The unpredictability may result from factors related to the patient, drug, and/or type of surgery. Therefore, pharmacists' involvement and close monitoring of patients after bariatric surgery could be effective to avoid sub‐/supratherapeutic responses.

The Effect of Laparoscopic Sleeve Gastrectomy With Concomitant Hiatal Hernia Repair on Gastroesophageal Reflux Disease

AIM

The aim of this study is to reveal incidence of gastroesophageal reflux disease (GERD) after laparoscopic sleeve gastrectomy (LSG) and to determine the effect of LSG with hiatal hernia repair on GERD.

METHODS

A total of 440 patients, 395 of them underwent primary LSG (group A) and 45 of them underwent LSG with concomitant hiatal hernia repair (group B) between March 2018 and September 2020 were included in the study. Presence of hiatal hernia was evaluated with endoscopy and confirmed intraoperatively. Patients were evaluated for GERD symptoms in the pre and postoperative period. Two groups' data were compared.

RESULTS

Mean age of the 440 patients was 38.4±11 years (56% female) and mean body mass index was 44.2±7 kg/m2. Symptomatic GERD was detected in 103 (23.4%) and hiatal hernia was detected in 45 (10.2%) patients. İn the preoperative assessment there was no difference with regard to demographics and symptomatic GERD between the 2 groups. Mean duration of follow-up was 17±5.7 (12 to 28) months in the overall study population. Mean body mass index decreased to 28.3±4.9 kg/m2at 12 months after LSG. Excess weight loss ratio was found to be 81±20.4%. The rate of symptomatic GERD after LSG in group A was found to be 20% (n=79/395). Of these patients, 46 (11.6%) had de novo GERD and 33 (38%) had persistent GERD. GERD resolved completely in 54 (62%) patients. In the group B, the rate of symptomatic GERD was detected as 33% (n=15/45) (P=0.04). The rate of de novo GERD (20%) was also higher in group B (P=0.03). The rate of persistent GERD (37%) and GERD resolution (62%) were similar in both groups.

CONCLUSION

İn our study, symptomatic and de novo GERD rates were detected to be higher in the LSG+HH group than LSG alone.

Is Sleeve Gastrectomy as Effective in Older Patients as in Younger Patients? A Comparative Analysis of Weight Loss, Related Comorbidities, and Medication Requirements

Background

Bariatric surgery in the older population has been the subject of ongoing debate but several studies have recently demonstrated its short-term advantages in this age group. It is not yet clear, however, whether these benefits are long-lasting.

Methods

We retrospectively analyzed patients with morbid obesity who underwent laparoscopy sleeve gastrectomy (LSG). These patients were divided into two groups: those above 60 years of age (older group) and those of 60 years or under (younger group). Variables evaluated included demographics and anthropometrics data, comorbidities, and daily medication requirements.

Results

Two hundred fifty-two patients underwent LSG, 57 in the older group and 195 in the younger group. Outcomes related to weight loss in the older subjects were modest compared to those in the younger population (older group %EWL 41.6 vs younger group %EWL 51.1, p < 0.05, older group %TWL 24.9% vs younger group %TWL 25.2%, p < 0.05). During follow-up, both older and younger patients showed an improvement in all the comorbidities: hypertension (older 82.5% vs 38.1%, younger 52.6% vs 29.2%, p < 0.05), type 2 diabetes mellitus (older 38.6% vs 27.3%, 34.9% vs 23.9%, p < 0.05), hyperlipidemia (older 75.4% vs 42.9%, younger 35.9% vs 21.1%, p < 0.05), and OSAHS (older 57.9% vs 30%, younger 40.4% vs 7.1%, p < 0.05). The average number of daily medications used to manage comorbidities decreased in both groups.

Conclusion

LSG in older patients is effective in terms of weight loss, improvement of comorbidities, and lower daily medication requirements up to 5 years of follow-up.

Graphical abstract

The Association of Helicobacter pylori, Eradication, and Early Complications of Laparoscopic Sleeve Gastrectomy

PURPOSE

Laparoscopic sleeve gastrectomy (SG) is a common and effective bariatric surgery, with low postoperative complication rates. It is important to define modifiable risk factors for complications. The possible association of Helicobacter pylori (HP) on SG outcomes is still being investigated. We aimed to examine HP prevalence in SG specimens, the association to early (30-day) complications, and impact of preoperative HP eradication on outcomes.

MATERIALS AND METHODS

This is a retrospective analysis of all consecutive patients who underwent SG between January 2012 and December 2020 in a single bariatric center. Data were retrieved from our prospectively maintained patient registry database. The 30-day outcomes were compared according to the HP status of the resected specimen: positive and negative, with or without preoperative HP eradication therapy.

RESULTS

There were 1985 patients; of them, 179 patients were HP positive and 1806 were HP negative in resected specimens. The overall early complication and major (Clavien-Dindo ≥ 3) complication rates were 8.6% and 3.2% (p = 0.48 and p = 0.21), respectively. A total of 111 patients were HP positive on preoperative endoscopic biopsy and received eradication therapy. All were HP negative on preoperative urea breath test, and 65.45% had HP negative resected specimens. HP eradication did not affect overall and major complications (p = 0.68 and p = 0.48, respectively).

CONCLUSION

The presence of HP does not seem to affect the early outcomes of SG. HP eradication does not change the early postoperative course either. Therefore, the role of routine preoperative HP screening may be limited, and eradication can be completed following SG.

Sleeve gastrectomy in the surgical management of obesity in Cameroon (a sub-Saharan country): A single-institute retrospective review of 30-day postoperative morbidity and mortality

BACKGROUND

METHODS

RESULTS

CONCLUSION

•

Sleeve gastrectomy is a safe procedure in a sub-Saharan African low setting.

•

Bleeding is the only intraoperative complication encountered in 14.3% of cases.

•

The prevalence of 30-day postoperative morbidity of sleeve gastrectomy is 38.1%.

•

Postoperative 30-day complications after sleeve gastrectomy are minor.

•

The 30-day postoperative mortality after sleeve gastrectomy is nil.

Staple Line Reinforcement During Laparoscopic Sleeve Gastrectomy: Systematic Review and Network Meta-analysis of Randomized Controlled Trials

Purpose

Staple line reinforcement (SLR) during laparoscopic sleeve gastrectomy (LSG) is controversial. The purpose of this study was to perform a comprehensive evaluation of the most commonly utilized techniques for SLR.

Materials and Methods

Network meta-analysis of randomized controlled trials (RCTs) to compare no reinforcement (NR), suture oversewing (SR), glue reinforcement (GR), bioabsorbable staple line reinforcement (Gore® Seamguard®) (GoR), and clips reinforcement (CR). Risk Ratio (RR), weighted mean difference (WMD), and 95% credible intervals (CrI) were used as pooled effect size measures.

Results

Overall, 3994 patients (17 RCTs) were included. Of those, 1641 (41.1%) underwent NR, 1507 (37.7%) SR, 689 (17.2%) GR, 107 (2.7%) GoR, and 50 (1.3%) CR. SR was associated with a significantly reduced risk of bleeding (RR=0.51; 95% CrI 0.31–0.88), staple line leak (RR=0.56; 95% CrI 0.32–0.99), and overall complications (RR=0.50; 95% CrI 0.30–0.88) compared to NR while no differences were found vs. GR, GoR, and CR. Operative time was significantly longer for SR (WMD=16.2; 95% CrI 10.8–21.7), GR (WMD=15.0; 95% CrI 7.7–22.4), and GoR (WMD=15.5; 95% CrI 5.6–25.4) compared to NR. Among treatments, there were no significant differences for surgical site infection (SSI), sleeve stenosis, reoperation, hospital length of stay, and 30-day mortality.

Conclusions

SR seems associated with a reduced risk of bleeding, leak, and overall complications compared to NR while no differences were found vs. GR, GoR, and CR. Data regarding GoR and CR are limited while further trials reporting outcomes for these techniques are warranted.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-022-05950-z.

Stent Management of Leaks After Bariatric Surgery: a Systematic Review and Meta-analysis

BACKGROUND

Despite the low rates of complications of bariatric surgery, gastrointestinal leaks are major adverse events that increase post-operative morbidity and mortality. Endoscopic treatment using self-expanding stents has been used in the therapeutic management of these complications with preliminary good results.

METHODS

We performed a systematic review and meta-analysis of self-expanding stents placement for the management of gastrointestinal leaks after obesity surgery. Overall proportion of successful leak closure, stent migration, and reoperation were analysed as primary outcomes. Secondary outcomes were patients' clinical characteristics, duration and type of stent, other stent complications, and mortality.

RESULTS

A meta-analysis of studies reporting stents was performed, including 488 patients. The overall proportion of successful leak closure was 85.89% (95% CI, 82.52-89.25%), median interval between stent placement and its removal of 44 days. Stent migration was noted in 18.65% (95% CI, 14.32-22.98%) and the overall proportion of re-operation was in 13.54% (95% CI, 9.94-17.14%). The agreement between reviewers for the collected data gave a Cohen's κ value of 1.0. No deaths were caused directly by complications with the stent placement.

CONCLUSIONS

Endoscopic placement of self-expanding stents can be used, in selected patients, for the management of leaks after bariatric surgery with a high rate of effectiveness and low mortality rates. Nevertheless, reducing stent migration and re-operation rates represents an important challenge for future studies.

Vacuum Therapy and Internal Drainage as the First-Line Endoscopic Treatment for Post-Bariatric Leaks: A Systematic Review and Meta-Analysis

Introduction

Several endoscopic methods can be employed to manage post-bariatric leaks. However, endoluminal vacuum therapy (EVT) and endoscopic internal drainage (EID) are relatively new methods, and studies regarding these methods are scarce. We performed a systematic review of the literature and a meta-analysis to evaluate the efficacy of EVT and EID.

Methods

Databases were searched for eligible studies. The clinical success of leak closure was the primary outcome of interest. A proportional meta-analysis was performed for pooling the primary outcome using a fixed-effects model. A meta-analysis or descriptive analysis of other outcomes was performed based on the data availability.

Results

Data from 3 EVT and 10 EID studies (n = 279) were used for evidence synthesis. The leak closure rates (95% confidence interval [CI]) of EVT and EID were 85.2% (75.1%-95.4%) and 91.6% (88.1%-95.2%), respectively. The corresponding mean treatment durations (95% CI) were 28 (2.4-53.6) and 78.4 (50.1-106.7) days, respectively. However, data about other outcomes were extremely limited; thus, a pooled analysis could not be performed.

Conclusions

Both EVT and EID were effective when used as the first-line treatment for post-bariatric leaks. However, larger studies must be conducted to compare the efficacy of the 2 interventions.

Sleeve gastrectomy as a surgical technique in bariatric surgery: Results of safety and effectiveness

INTRODUCTION

The aim of this study is to evaluate the safety and effectiveness results of sleeve gastrectomy as a bariatric technique.

METHODS

Observational follow-up study of a cohort of patients who underwent sleeve gastrectomy in our center between 2008 and 2017. A total of 223 patients were included: 166 as a primary technique (group 1) and 57 as a hypothetical first stage (group 2).

RESULTS

In group 1, the postoperative morbidity is 12.6%, with a fistula rate of 4.2%; 5.4% required reoperation and mortality was 0.6%. In group 2, postoperative morbidity is 14%, with a fistula rate of 5.3%; 10.5% required reoperation and mortality was 5.3%. In group 1, 79.6% and 62.5% of patients at 2 and 5 years respectively managed to achieve a % EBMIL > 50%. In group 2, the second stage was completed only in 8 patients (14.0%). Of the patients who did not complete the second stage, 32.2% and 5.9% achieved a % EEBMIL > 100% at 2 and 5 years. Analyzing those who completed the second stage, the mean EEBMIL% was 90.5% and 93.4% at 2 and 5 years.

CONCLUSIONS

Sleeve gastrectomy is a safe technique in patients with BMI < 45 and effective in terms of weight loss in the short-medium term. In patients with BMI > 55, a preoperative optimization aimed at reducing morbidity and mortality is necessary, as well as adequately planning the second stage, without which it is clearly insufficient.

Relationship between residual gastric area and weight loss after sleeve gastrectomy: A Cohort study

BACKGROUND

The aim of this study is to evaluate the impact of the actual size and area of the remnant stomach, as measured by Upper gastrointestinal tract radiography, on weight loss after sleeve gastrectomy.

MATERIALS AND METHODS

From May 2017 to December 2019, 56 patients with morbid obesity were admitted to the Department of Medical and Surgical Sciences, University of Foggia and underwent laparoscopic sleeve gastrectomy.

RESULTS

56 patients underwent sleeve gastrectomy with a mean age of 43,5 ± 11 years of which 40 were female. The mean Excess Weight Loss (EWL) at 1 month was 24,09 ± 15,04%, at 6 months was 27,07 ± 19,55% and at 12 months was 69,9 ± 23,7%. The mean Excess Body Mass Index Loss (EBMIL) at 1 month was 23,1 ± 12,5%, at 6 months was 56,6 ± 19,7% and at 12 months was 69,7 ± 23,7%.The EWL % was correlated with the residual stomach area (RSA) at 1 month (r = -0,242 p = 0,072), at 6 months (r = -0,249 p = 0,064) and at 12 months (r = -0,451 p = 0,0005).The EBMIL % was correlated with the RSA at 1 month (r = -0,270; p = 0,043), at 6 months (r = -0,270; p = 0,043) andat 12 months (r = -0,46; p = 0,0004).

CONCLUSION

A greater postoperative EWL % was correlated with a smaller RSA and this resulted in a statistically significant change at 12 months after surgery.

Risk Factors for Readmission After Same-Day Discharge Sleeve Gastrectomy: a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Database Analysis

Background

Same-day discharge after sleeve gastrectomy (SG) is gaining popularity. We aimed to determine risk factors associated with readmission in patients who underwent same-day discharge SG.

Methods

We performed a retrospective analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database for the period 2015–2018. Patients who underwent SG and were discharged the same day of the operation were included in the analysis. Multivariable logistic regression analysis was performed to determine risk factors for readmission.

Results

A total of 466,270 SG were performed during the study period; 14,624 (3.1%) patients were discharged the same day and were included in the analysis. Mean age was 43.4 (14.7–80) years and 11,718 (80.1%) were female. Mean preoperative BMI was 43.7 ± 7.4 kg/m². Mean operative time was 58.3 ± 32.4 min. Thirty-day reoperation, reintervention, and mortality rates were 0.7%, 0.7%, and 0.1%, respectively. Readmission rates were similar in same-day discharge and inpatient SG (2.9% vs. 3%, p = 0.5). Female sex (OR 1.52, 95% CI 1.15–2.00), preoperative gastroesophageal reflux disease (OR 1.33, 95% CI 1.08–1.64), renal insufficiency (OR 3.06, 95% CI 1.01–9.32), and intraoperative drain placement (OR 1.78, 95% CI 1.37–2.31) were independent risk factors for readmission following same-day discharge SG.

Conclusions

Same-day discharge SG appears to be safe and is associated with low readmission rates. However, the identification of preoperative and intraoperative variables associated with higher risk of readmission might help defining safer and more effective same-day discharge protocols.

Graphical abstract

Staple line reinforcement with nebulized cyanoacrylate glue in laparoscopic sleeve gastrectomy: A propensity score-matched study

Background

A dreaded complication of laparoscopic sleeve gastrectomy (LSG) is suture leak. The study aimed to assess the efficacy of the nebulized comonomer Glubran 2^® (N-butyl-cyanoacrylate + metacrylosysolfolane) applied to the LSG staple line.

Methods

A propensity-matched comparison analysis was conducted in 125 patients undergoing LSG between 2017 and 2019. Groups included those treated with Glubran^® (group 1, n = 70) and those without Glubran^® treatment (group 2, n = 55).

Results

There were differences in the mean body mass index (44.4 vs 43 kg/m²; P < 0.05) between the groups. There was a non-significant increase in the operative time for group 1 compared with group 2 (97 ± 8 vs 93.8 ± 10.7 min; P = 0.07), with a greater amount of estimated blood loss (94.5 mL vs 87.8; P < 0.01). There were more severe complications in group 2 over group 1 cases (8 vs 0%; P < 0.05), although postoperative bleeding did not differ between the two groups (1.4 vs 5.4%). There were no postoperative leaks in group 1 patients, but there were two leaks in group 2 cases with an increased length of hospital stay in patients with a leak.

Conclusion

Glubran^® LSG support may reduce leak risk without increasing operating time.

Safety considerations in laparoscopic surgery: A narrative review

Laparoscopic surgery has many advantages over open surgery. At the same time, it is not without its risks. In this review, we discuss steps that could enhance the safety of laparoscopic surgery. Some of the important safety considerations are ruling out pregnancy in women of the childbearing age group; advanced discussion with the patient regarding unexpected intraoperative situations, and ensuring appropriate equipment is available. Important perioperative safety considerations include thromboprophylaxis; antibiotic prophylaxis; patient allergies; proper positioning of the patient, stack, and monitor(s); patient appropriate pneumoperitoneum; ergonomic port placement; use of lowest possible intra-abdominal pressure; use of additional five-millimetre (mm) ports as needed; safe use of energy devices and laparoscopic staplers; low threshold for a second opinion; backing out if unsafe to proceed; avoiding hand-over in the middle of the procedure; ensuring all planned procedures have been performed; inclusion of laparoscopic retrieval bags and specimens in the operating count; avoiding 10-15 mm ports for placement of drains; appropriate port closures; and use of long-acting local anaesthetic agents for analgesia. Important postoperative considerations include adequate analgesia; early ambulation; careful attention to early warning scores; and appropriate discharge advice.

Therapeutic endoscopy for the treatment of post-bariatric surgery complications

Obesity rates continue to climb worldwide. Obesity often contributes to other comorbidities such as type 2 diabetes, hypertension, heart disease and is a known risk factor for many malignancies. Bariatric surgeries are by far the most invasive treatment options available but are often the most effective and can result in profound, durable weight loss with improvement in or resolution of weight associated comorbidities. Currently performed bariatric surgeries include Roux-en-Y gastric bypass, sleeve gastrectomy, and laparoscopic gastric banding. These surgeries are associated with significant weight loss, but also with significant rates of major complications. The complexity of these patients and surgical anatomies makes management of these complications by a multidisciplinary team critical for optimal outcomes. Minimally invasive treatments for complications are typically preferred because of the high risk associated with repeat operations. Endoscopy plays a large role in both the diagnosis and the management of complications. Endoscopy can provide therapeutic interventions for many bariatric surgical complications including anastomotic strictures, anastomotic leaks, choledocholithiasis, sleeve stenosis, weight regain, and eroded bands. Endoscopists should be familiar with the various surgical anatomies as well as the various therapeutic options available. This review article serves to delineate the current role of endoscopy in the management of complications after bariatric surgery.

THE ROUTINE USE OF THE METHYLENE BLUE TEST IN SLEEVE GASTRECTOMY: WHY NOT?

Background:

Although considered a safe procedure, sleeve gastrectomy (SG) has a non-negligible risk of major postoperative complications related to it, with special attention to gastric leaks.

Aim:

Evaluate the clinical value of the methylene blue test (MBT) in predicting the occurrence of post-SG leaks.

Methods:

Retrospective study that included 1136 patients who underwent SG with intraoperative MBT between 2012 and 2016. Sensitivity, specificity, positive predictive value (PPV) and negative predicted value (NPV) were calculated to determine the clinical correlation between the MBT and the occurrence of postoperative leaks. Staple line oversewing was performed in all patients who presented positive MBT.

Results:

Laparoscopic SG was performed in 97.0% of cases; open in 2.3%, and robotic in 0.7%. MBT was positive in 19 cases (1.67%). One positive MBT occurred during an open SG and the other 18 at laparoscopy. Moreover, there were nine cases (0.8%) of postoperative leaks, among which, only two presented positive MBT. MBT diagnostic value was evaluated through the calculation of sensitivity (22.0%), specificity (98.0%), PPV (11.0%) and NPV (99.0%). There were no cases of allergic reaction or any other side effect with the use of the methylene blue solution.

Conclusion:

MBT showed high specificity and negative predictive value, thus presenting an important value to rule out the occurrence of postoperative leaks.

Sleeve Gastrectomy Performed with Single Staple Height and Bioabsorbable Reinforcement in a Single Surgeon > 2500 Consecutive Case Series: Is Smart Technology Necessary?

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is shown to have durable and sustained weight reduction outcomes and improvement in comorbid conditions in patients with severe clinical obesity. Discussions regarding "proper" staple height for various gastric locations continue. We propose a standard approach of consistent use of single staple load height and bioabsorbable staple line reinforcement during the LSG to reduce variability.

METHODS

A retrospective chart review of 2556 consecutive cases of adult patients who underwent LSG evaluated perioperative complications, postoperative leaks or bleeding, and average weight and body mass index (BMI) change and excess weight loss (EWL) at 6, 12, and 24 months. The same green staple load (2.0 mm) and staple line reinforcement were used in all cases for all staple firings, regardless of patient size or gastric location.

RESULTS

Patients were a mean age of 42 years, 87.3% were female, and the mean preoperative weight was 134.2 kg and BMI was 48.2 kg/m². No staple line leak was detected. Three bleeding events occurred but did not require readmission or rehospitalization. Mean EWL and BMI, respectively, were 49.0% and 35.5 kg/m² at 6 months, 69.8% and 29.6 kg/m² at 12 months, and 70.0% and 29.5 kg/m² at 24 months.

CONCLUSION

In this case series of 2556 consecutive LSG performed by a single surgeon, clinically meaningful EWL and decreased BMI were achieved. Streamlining the LSG procedure by utilizing the same staple height and a bioabsorbable staple line reinforcement proved safe with minimal complications.

GASTRIC TWIST AFTER SLEEVE GASTRECTOMY: A PROPOSAL FOR ENDOSCOPIC CLASSIFICATION

ABSTRACT - BACKGROUND: The twisting of the gastric tube is one of the main causes of persistent reflux and food intolerance after sleeve gastrectomy (SG). To date, there is no classification for gastric twist after SG. OBJECTIVE: This study aimed to propose an endoscopic classification for this condition and outline the clinical profile of these patients with sleeve gastrectomy. METHODS: Patients in the postoperative period of SG presenting endoscopic findings of gastric twist were included. All patients underwent an esophagogastroduodenoscopy 12 months after SG. The classification proposed consists of three degrees: degree I: mild rotation of the staple line without relevant shrinkage of the gastric lumen; degree II: moderate rotation of the staple line, leading to a focal area of fixed narrowing that requires additional maneuvers for its transposition; and degree III: severe rotation of the staple line leading to stenosis, with increased difficulty for transposition or complete blockage. RESULTS: Out of 2,723 patients who underwent SG, 45 (1.6%) presented gastric twist. Most patients were female (85%), with mean age of 39±10.4 years. In all, 41 (91.1%) presented degree I, 3 (6.7%) presented degree II, and 1 (2.2%) had degree III. Most patients were asymptomatic (n=26). Vomiting was the most prevalent symptom (15.5%). Statistically significant correlation of twisting degrees was not observed for both the presence of symptoms and the degrees of esophagitis. CONCLUSION: Gastric twist after SG is rare, with generally mild and asymptomatic presentation. The endoscopic classification was not statistically related to clinical presentation but set the ground for further analysis.

Surgical Treatment of Obesity. Special Mention to Roux-en-Y Gastric Bypass and Vertical Gastrectomy

INTRODUCTION

The prevalence of obesity has increased exponentially in recent decades, being one of the diseases that most affects global health. It is a chronic disease associated with multiple comorbidities, which lead to a decrease in life expectancy and quality of life. It requires a multidisciplinary approach by a specialized medical team. Obesity can be treated with conservative or with surgical treatments that will depend on the characteristics of the patient.

OBJECTIVE/METHODOLOGY

The referenced surgery can be performed using different surgical techniques that are analyzed in the present work through an exhaustive narrative bibliographic review in the PubMed and Cochrane databases, as well as in UpToDate.

RESULTS

Currently, those most used are restrictive techniques, specifically vertical gastrectomy and mixed techniques, with gastric bypass being the "gold standard".

CONCLUSIONS

In order to choose one technique or another, the characteristics of each patient and the experience of the surgical team must be taken into account.

Radiological stent placement of post sleeve gastrectomy leak: efficacy, imaging features and post-procedure complications

Laparoscopic sleeve gastrectomy (SG) is the most commonly performed bariatric procedure. The primary and insidious early post-SG complication is the gastric leak (GL). In literature, there are many studies describing the endoscopic stent placement as treatment of GL and few studies about stent placement performed by interventional radiology under fluoroscopic guide. Our aims were to describe the radiological stent placement technique, to compare endoscopic and radiological stent placement, to illustrate normal diagnostic features and summarise the incidence of complications after stent placement, removal, and their imaging features. This was a single centre retrospective study of 595 patients who underwent SG between 2011 and 2019. Inclusion criteria: patients who developed GL after SG and treated with gastro-oesophageal stent placement by endoscopy or interventional radiology; availability of medical history and imaging studies; follow-up time after stent removal (1 year). The rates of technical success, clinical success and complications after stent placement and removal were collected and compared between the two methods of stent positioning. A total of 17/595 (2.8%) patients developed a radiologically diagnosed GL after SG. The type II-III GLs (15/17) were treated with endoscopic or radiological stent placement. 9/15 (60%/Group A) patients underwent gastro-oesophageal stenting by interventional radiology and 6/15 (40%/Group B) were treated with endoscopic stent placement. The technical and clinical success rate was 100% for both groups. Stent migration occurred in 22% and 27% for Group A and B respectively. Post-extraction stenosis was the main late complication, occurring in 22% in Group A and 0% in Group B. Gastro-esophageal stent placement performed by interventional radiologists is a valid "mini-invasive" treatment for GL. This procedure is not inferior to endoscopic positioning regarding efficacy, periprocedural and postprocedural complication rate. It's necessary to be familiar with radiological findings after stent placement and removal. Computed tomography (CT) scan is the main radiological technique to identify stent placement complications. Upper gastrointestinal (UGI) series are the first radiological procedures used to detect late complications after stent removal.

Endoscopic Stent Placement Can Successfully Treat Gastric Leak Following Laparoscopic Sleeve Gastrectomy If and Only If an Esophagoduodenal Megastent Is Used

PURPOSE

Gastric staple line leakage (GL) is a serious complication of laparoscopic sleeve gastrectomy (LSG), with a specific mortality ranging from 0.2 to 3.7%. The current treatment of choice is stent insertion. However, it is unclear whether the type of stent which is inserted affects treatment outcome. Therefore, we aimed not only to determine the effectiveness of stent treatment for GL but also to specifically clarify whether treatment outcome was dependent on the type of stent (small- (SS) or megastent (MS)) which was used.

PATIENTS AND METHODS

A single-centre retrospective study of 23 consecutive patients was conducted to compare the outcomes of SS (n = 12) and MS (n = 11) for the treatment of GL following LSG. The primary outcome measure was the success rate of stenting, defined as complete healing of the GL without changing the treatment strategy. Treatment change or death were both coded as failure.

RESULTS

The success rate of MS was 91% (10/11) compared to only 50% (6/12) for SS (p = 0.006). An average of 2.3 ± 0.5 and 6.8 ± 3.7 endoscopies were required to achieve healing in the MS and SS groups respectively (p < 0.001). The average time to resumption of oral nutrition was shorter in the MS group (1.4 ± 1.1 days vs. 23.1 ± 33.1 days, p = 0.003).

CONCLUSIONS

Stent therapy is only effective and safe for the treatment of GL after LSG if a MS is used. Treatment with a MS may not only increase treatment success rates but may also facilitate earlier resumption of oral nutrition and shorten the duration of hospitalization.

Portomesenteric venous thrombosis in a prophylactically anticoagulated obese patient after laparoscopic sleeve gastrectomy: a case report

Background

Obesity is associated with an increased risk of morbidity and mortality, so weight reduction is important. Bariatric surgery is a well-tolerated approach for reducing body weight, with laparoscopic sleeve gastrectomy commonly performed. An uncommon and potentially fatal sequela of laparoscopic sleeve gastrectomy is portomesenteric vein thrombosis, which may result in severe bowel ischemia.

Case report

A 32-year-old Middle Eastern obese man (body mass index 33) presented to the emergency department with severe, generalized abdominal pain 2 weeks after laparoscopic sleeve gastrectomy. Computed tomography of the abdomen and pelvis revealed extensive acute on chronic portosplenic and superior mesenteric vein thrombosis with associated small bowel ischemia. Laparoscopic exploration was converted to midline laparotomy and an extensive ischemic small bowel resection.

Conclusion

Laparoscopic sleeve gastrectomy carries a risk of both morbidity and mortality. Venous thromboembolism is a well-known risk of bariatric surgery, but portomesenteric vein thrombosis is also a rare but sometimes serious complication. A high index of suspicion for portomesenteric vein thrombosis to prompt early detection is essential in patients who have undergone laparoscopic sleeve gastrectomy to minimize complications and optimize outcomes. Uncertainty still remains around the optimal dose and duration of anticoagulation after laparoscopic sleeve gastrectomy.

Role of the Autonomic Nervous System in Mechanism of Energy and Glucose Regulation Post Bariatric Surgery

Even though lifestyle changes are the mainstay approach to address obesity, Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are the most effective and durable treatments facing this pandemic and its associated metabolic conditions. The traditional classifications of bariatric surgeries labeled them as “restrictive,” “malabsorptive,” or “mixed” types of procedures depending on the anatomical rearrangement of each one of them. This conventional categorization of bariatric surgeries assumed that the “restrictive” procedures induce their weight loss and metabolic effects by reducing gastric content and therefore having a smaller reservoir. Similarly, the “malabsorptive” procedures were thought to induce their main energy homeostatic effects from fecal calorie loss due to intestinal malabsorption. Observational data from human subjects and several studies from rodent models of bariatric surgery showed that neither of those concepts is completely true, at least in explaining the multiple metabolic changes and the alteration in energy balance that those two surgeries induce. Rather, neuro-hormonal mechanisms have been postulated to underly the physiologic effects of those two most performed bariatric procedures. In this review, we go over the role the autonomic nervous system plays- through its parasympathetic and sympathetic branches- in regulating weight balance and glucose homeostasis after SG and RYGB.

Changes in the gut microbiota of morbidly obese patients after laparoscopic sleeve gastrectomy

Aims: Permanent treatment of morbid obesity with medication or diet is nearly impossible. Laparoscopic sleeve gastrectomy (LSG) is becoming a widely accepted treatment option. This study profiled and compared gut microbiota composition before and after LSG. Methods & results: A total of 54 stool samples were collected from 27 morbidly obese individuals before and after LSG. The gut microbiota was profiled with 16S amplicon sequencing. After LSG, patients demonstrated a significant decrease (p < 0.001) in BMI and an increase in bacterial diversity. An increased Firmicutes/Bacteroidetes ratio was also noticed after LSG. The families Prevotellaceae and Veillonellaceae predominated in preoperative samples but were markedly lowered after LSG. A marked increase in Akkermansia, Alistipes, Streptococcus, Ruminococcus and Parabacteroides was observed after LSG. Conclusion: In addition to lowering BMI, LSG remodeled gut microbiota composition.

Does Sleeve Gastrectomy Worsen Gastroesophageal Reflux Disease in Obese Patients? A Prospective Study

BACKGROUND

To evaluate the impact of laparoscopic sleeve gastrectomy (LSG) and gastric bypass (LGB) on gastroesophageal reflux disease (GERD).

METHODS

GERD was evaluated by the Modified Italian Gastroesophageal reflux disease-Health-Related Quality of Life (MI-GERD-HRQL) questionnaire, pH-manometry, endoscopy, and Rx-esophagogram, before and 12 months after surgery. Based on these exams, patients without GERD underwent LSG, and patients with GERD underwent LGB.

RESULTS

Thirteen and six patients underwent LSG and LGB, respectively. After LSG, the only statistically significant difference observed at pH-manometry was the median DeMeester score, from 5.7 to 22.7 (P = .0026). De novo GERD occurred in 6 patients (46.2%), with erosive esophagitis in one. The median MI-GERD-HRQL score improved from 3 to 0. Overall, nine patients underwent LGB, but three were lost to follow-up. Preoperative pH-manometry changed the surgical indication from LSG to LGB in 7 out of 9 patients (77.8%). Six patients who underwent LGB completed the study, and at pH-manometry, statistically significant differences were observed in the percentage of total acid exposure time, with the number of reflux episodes lasting >5 minutes and DeMeester score (P = .009). The median MI-GERD-HRQL score improved from 6.5 to 0. Statistically significant differences were not observed at endoscopy and Rx-esophagogram findings in both groups.

CONCLUSIONS

LSG has a negative impact on GERD, even in patients without preoperative GERD. LGB confirmed to be the intervention of choice in patients with GERD. Preoperative pH-manometry may identify patients with silent GERD, to candidate them to LGB rather than LSG. pH-manometry should be used more liberally to establish the correct surgical indication on objective grounds.