Effect of location and speed of diagnosis on anastomotic leak outcomes in 3828 gastric bypass cases

Effectiveness of robotic metabolic and bariatric surgery in patients with BMI ≥ 50-59.9 and BMI ≥ 60 for the treatment of severe obesity in a national medical center in Mexico

INTRODUCTION

Obesity is a global health issue that significantly increases morbidity and mortality when the Body Mass Index (BMI) reaches values ≥ 50. While metabolic and bariatric surgery (MBS) is the most effective treatment for severe obesity, it carries risks. Robotic surgery is promising but not extensively studied in Mexico, which presents an opportunity for research at a National Hospital with an academic program.

METHODS

This retrospective study reviewed 44 patients who underwent robotic MBS using the da Vinci surgical system from January 2018 to August 2023 at Centro Médico Nacional 20 de Noviembre, ISSSTE. Data collected included surgery type, duration, complications, and weight loss metrics over 54 months post-operatively.

RESULTS

The study involved 44 patients with severe obesity including BMI ≥ 50-59.9 kg/m2 for group 1 and BMI ≥ 60 kg/m2 for group 2. The average initial BMI was 54.7 kg/m2 for group 1 and 68 kg/m2 for group 2. The average operative times for group 1 were 10.09 min for docking, 86.23 min for robotic console time, and 95.73 min for total intraoperative time. Group 2 had average times of 9.80 min for docking, 82.4 min for robotic console time, and 92.2 min for total intraoperative time. Follow-up showed significant weight loss initially, with weight recurrence after 24 months due to different factors. No serious complications or mortality were observed.

CONCLUSION

Robotic MBS at a national academic medical center in Mexico shows promising outcomes for patients with BMI ≥ 50-59.9 and BMI ≥ 60, with significant weight and BMI improvements at 54 month follow-up. Further studies with larger cohorts and longer follow-up are needed to strengthen these findings.

Robot-assisted vs laparoscopic bariatric procedures in super-obese patients: clinical and economic outcomes

The increased operative time and costs represent the main limitations of robotic technology application to bariatric surgery. Robotic platforms may help the surgeon to overcome the technical difficulties in super-obese (SO, BMI ≥ 50 kg/m2) patients, in which multi-quadrant operations could be challenging. We aimed to evaluate the effect of robot-assisted (R) versus laparoscopic (L) approaches in Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S) and Roux-en-Y Gastric Bypass (RYGB) in SO and Super-Super Obese (SSO, BMI ≥ 60 kg/m2) patients in terms of outcomes and cost-effectiveness. Bariatric procedures performed from 2012 to 2023 were retrospectively reviewed. The inclusion criteria were BMI ≥ 50 kg/m2, primary SADI-S or RYGB. Operative time (OT), early complications, post-operative stay (POS), overall costs and follow-up data were analyzed. A subgroup analysis for surgical procedures and SSO patients was also performed. Among 4596 patients, 174 RYGB and 91 SADI-S in BMI ≥ 50 kg/m2 patients were selected. After Propensity Score Matching analysis, two groups of patients were identified (laparoscopic and robot-assisted), each one composed of 18 RYGB and 26 SADI-S. Intraoperative and post-operative complication rates and POS were comparable. Mean OT was longer in robotic procedures compared with laparoscopy (199.1 ± 65.7 and 109.5 ± 39.1 min, respectively, p < 0.001). The difference in OT was eliminated after only SSO patients were included in the analysis (172.7 ± 24.1 vs 152.6 ± 26.2 min for R-SADI-S and L-SADI-S, respectively, p = 0.107). Robotic surgeries were associated with higher costs (8134.6 ± 1886.7 and 2386.7 ± 388.2 € in R-RYGB and L-RYGB, respectively; 7996.6 ± 873.1 and 3954.6 ± 631.1 € in R-SADI-S and L-SADI-S). Despite increased costs, robotic approach may represent an added value in more complex cases such as SSO patients.

Bariatric Surgery Emergencies in Acute Care Surgery

Patients who have undergone bariatric surgery present unique challenges in the acute care surgery setting. This review includes the presentation, workup, and management of most common bariatric surgery emergencies encountered by acute care surgery.

Surgical Sealant with Integrated Shape-Morphing Dual Modality Ultrasound and Computed Tomography Sensors for Gastric Leak Detection

Postoperative anastomotic leaks are the most feared complications after gastric surgery. For diagnostics clinicians mostly rely on clinical symptoms such as fever and tachycardia, often developing as a result of an already fully developed, i.e., symptomatic, surgical leak. A gastric fluid responsive, dual modality, electronic-free, leak sensor system integrable into surgical adhesive suture support materials is introduced. Leak sensors contain high atomic number carbonates embedded in a polyacrylamide matrix, that upon exposure to gastric fluid convert into gaseous carbon dioxide (CO2 ). CO2 bubbles remain entrapped in the hydrogel matrix, leading to a distinctly increased echogenic contrast detectable by a low-cost and portable ultrasound transducer, while the dissolution of the carbonate species and the resulting diffusion of the cation produces a markedly reduced contrast in computed tomography imaging. The sensing elements can be patterned into a variety of characteristic shapes and can be combined with nonreactive tantalum oxide reference elements, allowing the design of shape-morphing sensing elements visible to the naked eye as well as artificial intelligence-assisted automated detection. In summary, shape-morphing dual modality sensors for the early and robust detection of postoperative complications at deep tissue sites, opening new routes for postoperative patient surveillance using existing hospital infrastructure is reported.

Long-term outcomes of revisional one anastomosis gastric bypass post laparoscopic sleeve gastrectomy

PURPOSE

Revisional bariatric surgeries following laparoscopic sleeve gastrectomy (LSG) have demonstrated a dramatic increase worldwide. Recently, one-anastomosis gastric bypass (OAGB) has become a contender as an appropriate revisional procedure; however, no long-term data currently exist on the effectiveness of it as a revisional surgery post-LSG.

METHODS

A retrospective analysis was performed on all patients who underwent LSG at a public hospital in Kuwait from 2008 to 2017. A list was obtained of those who underwent revisional OAGB surgery after initial LSG, after which a phone survey was performed and demographics were analyzed.

RESULTS

A total of 29 patients underwent revisional OAGB post-initial LSG, of which 89.7% were female. Prior to LSG, the mean weight of the patients was 127.5 kg, and the mean BMI was 49.0 kg/m2. The mean weight loss after initial LSG was 43.8 kg, while the average duration until patients underwent revisional OAGB was 5.3 years. The cause for revision was weight regain (86.2%) or inadequate weight loss (13.8%). Prior to undergoing revisional OAGB, the weight and BMI of the patients was 110.9 kg and 42.4 kg/m2, respectively. Revisional OAGB demonstrated a %excess weight loss of 14.5%, 31.9%, 48.0%, 56.3%, 57.2%, and 54.7% at 2 weeks, 3 months, 6 months, 1 year, 4 years, and 5 years, respectively. Twelve morbidities were reported during the follow-up period.

CONCLUSION

Revisional bariatric surgery is technically demanding and may be associated with a high complication rate. However, OAGB as a revisional procedure has proven to be safe and effective in the long-term outcomes of revisional OAGB patients post-LSG.

Robotic vs laparoscopic approach for single anastomosis duodenal-ileal bypass with sleeve gastrectomy: a propensity score matching analysis

Biliopancreatic diversion with duodenal switch and single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) are technically demanding hypo-absorptive bariatric procedures. They are often indicated in superobese patients (BMI ≥ 50 kg/m²), as robotic platform could improve ergonomics against a thick abdominal wall, preventing bending of instruments and simplifying hand-sewn anastomoses. We aimed to report our experience with robotic SADI-S (R-group) and to compare outcomes with the laparoscopic (L-group) approach. Among 2143 patients who underwent bariatric procedures at our institution between July 2016 and June 2021, 116 (5.4%) consenting patients were scheduled for SADI-S as primary or revisional procedure: 94 L-group, 22 R-group. R-group and L-group patients were matched using PSM analysis to overcome patients selection bias. Postoperative complications, operative time (OT), post-operative stay (POS) and follow-up data were compared. After PSM, 44 patients (22 patients for each group) were compared (Chi-square 0.317, p = 0.985). Median age, gender, median BMI, preoperative rates of comorbidities, previous abdominal bariatric and non-bariatric surgeries and type of surgical procedures (SADI-S/SADI) were comparable. Median OT was shorter in the L-group (130 Vs 191 min, p < 0.001). 30-days' re-operative complications and late complications rates were comparable. At 25-months' mean follow-up, the median Percentage Excess Weight Loss (72%) was comparable between the groups (p = 0.989). L-group and R-group were comparable in terms of re-operative complication rate and short-term outcomes. The robotic platform may increase the rate of single step procedure in challenging cases. Larger studies with longer follow-up and cost-analysis are necessary to draw definitive conclusions.

Assessment of predictors of early postoperative complications after primary robotically assisted Roux-en-Y gastric bypass: a multicenter, retrospective cohort study

Background

Robotic Roux-en-Y gastric bypass (RRYGB) is performed in an increasing number of bariatric centers worldwide. Previous studies have identified a number of demographic and clinical variables as predictors of postoperative complications after laparoscopic Roux-en-Y gastric bypass (LRYGB). Some authors have suggested better early postoperative outcomes after RRYGB compared to LRYGB. The objective of the present study was to assess potential predictors of early postoperative complications after RRYGB.

Methods

A retrospective analysis of two prospective databases containing patients who underwent RRYGB between 2006 and 2019 at two high volumes, accredited bariatric centers was performed. Primary outcome was rate of 30 day postoperative complications. Relevant demographic, clinical and biological variables were entered in a multivariate, logistic regression analysis to identify potential predictors.

Results

Data of 1276 patients were analyzed, including 958 female and 318 male patients. Rates of overall and severe 30 day complications were 12.5% (160/1276) and 3.9% (50/1276), respectively. Rate of 30 day reoperations was 1.6% (21/1276). The overall gastrointestinal leak rate was 0.2% (3/1276). Among various demographic, clinical and biological variables, male sex and ASA score >2 were significantly correlated with an increased risk of 30 day complication rates on multivariate analysis (OR 1.68 and 1.67, p=0.005 and 0.005, respectively).

Conclusion

This study identified male sex and ASA score >2 as independent predictors of early postoperative complications after RRYGB. These data suggest a potentially different risk profile in terms of early postoperative complications after RRYGB compared to LYRGB. The robotic approach might have a benefit for patients traditionally considered to be at higher risk of complications after LRYGB, such as those with BMI >50. The present study was however not designed to assess this hypothesis and larger, prospective studies are necessary to confirm these results.

Single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S): experience from a high-bariatric volume center

Purpose

Biliopancreatic diversion with duodenal switch and single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) are technically demanding hypo-absorptive bariatric procedures generally indicated in super-obese patients (BMI ≥ 50 kg/m2). Data from the literature prove the procedure to be safe and effective, with promising bariatric and metabolic effects. Anyway, international societies support the creation of multicentric national and international registries to obtain more homogeneous data over the long period. We aimed to report our experience with this procedure.

Methods

Among 2313 patients who underwent bariatric procedures at our institution, between July 2016 and August 2021, 121 (5.2%) consenting patients were scheduled for SADI-S as primary (SADIS) or revisional procedure after sleeve gastrectomy (SADI) (respectively 87 and 34 patients). Early and late post-operative complications, operative time, post-operative stay, and follow-up data were analyzed.

Results

Overall, the median preoperative BMI was 52.3 (48.75–57.05) kg/m2 with a median age of 44 (39–51) years, the median operative time was 120 (100–155) min. Complications at 30th-day post-op were registered in 4 (3.3%) patients and late complications in 4 (3.3%) patients. At a median follow-up of 31 (14–39) months, the median percentage excess weight loss was 79.8 (55.15–91.45)%, and the median total weight loss was 57.0650 (43.3925–71.3475)%.

Conclusion

Our data, coherently with the literature, confirm that SADI-S is a safe, effective procedure with acceptable complications rate. Larger studies with longer follow-ups are necessary to draw definitive conclusions.

The Relationship Between Tachycardia After Laparoscopic Sleeve Gastrectomy and the Development of Postoperative Complications

BACKGROUND

Bariatric surgery can be associated with severe complications. Tachycardia is an important indicator of certain complications, such as anastomotic leak and hemorrhage. Our aim was to examine the relationship between tachycardia following sleeve gastrectomy and the appearance of associated complications.

METHODS

Patients who underwent sleeve gastrectomy over a 2-year period were included in the study. Participants were divided into two groups: the first included patients who suffered from postoperative tachycardia and the second patients with normal postoperative heart rates. Complications in both groups were examined. Other parameters that predict the onset of complications were also reviewed.

RESULTS

A total of 457 patients were included. Postoperative tachycardia was measured in 181 (39.6%) patients; 17 (3.7%) suffered from bleeding and 4 (1%) from staple line leakage. Postoperative bleeding was more common among patients with tachycardia than among those without (14 (7.7%) vs. 3 (1.1%), respectively). Patients in the tachycardia group had more staple line leakages than those in the normal heart rate group (3 (2%) vs. 1 (0%), respectively); tachycardia was also attributed to postoperative pain or other minor complications in 160 (88%) patients. Age ≥ 40 years was found to be predictive factor for postoperative complications.

CONCLUSIONS

The most common causes of tachycardia postoperatively were pain and minor complications. Tachycardia is an essential indicator of postoperative minor and major complications, mainly staple line leakage and bleeding. This should prompt immediate medical intervention in order to avoid serious adverse events.

Management of Postoperative Complications Following Bariatric and Metabolic Procedures

Bariatric and metabolic surgery is a safe and effective treatment of morbid obesity, a disease that continues to increase in prevalence in the United States and worldwide. The two most commonly performed operations are the sleeve gastrectomy and the gastric bypass. Early and late complications can occur, and although referral to a bariatric surgeon or center is ideal, emergency management of acute problems is relevant to all general surgeons. Bariatric surgery can have surgical and metabolic consequences. An understanding of the altered anatomy and physiology helps to guide management of morbidities. This article discusses surgical postoperative complications and metabolic complications.

Gastrojejunostomy in Roux-En-Y Gastric Bypass for Morbid Obesity: Linear Stapler Length Does Not Affect Mid-term Outcomes

BACKGROUND

The purpose of this study was to compare whether different linear stapler lengths used to form the gastrojejunostomy during laparoscopic Roux-En-Y gastric bypass affects mid-term weight loss outcomes.

MATERIALS AND METHODS

A retrospective single center analysis was performed. Surgical technique was identical other than either a 35 or 45 mm linear stapler being used to form the gastrojejunostomy. Multivariate regression was used to assess the relationship between the different stapler lengths and weight loss outcomes 2 years following surgery.

RESULTS

Of the 97 patients identified, 67 (69.1%) were included in the study. There were 30 patients in the 35 mm group and 37 in the 45 mm group. The groups were comparable in terms of basic demographic data and preoperative weight characteristics. There was no significant difference in weight loss outcomes 2 years following surgery when comparing between the different linear stapler lengths.

CONCLUSION

Thirty-five versus 45 mm linear stapler lengths does not affect mid-term weight loss outcomes.

Remodifying Omentopexy Technique Used with Laparoscopic Sleeve Gastrectomy: Does It Change any Outcomes?

BACKGROUND

Gastric obstructions, leaks and staple line bleeding are reported after laparoscopic sleeve gastrectomy (LSG). There is no ideal method or technique to avoid these mishaps. We added modified omentopexy (OP) to LSG to determine if there is any effect on gastric leaks and some other complications.

METHODS

This single institution case control study included two groups of morbidly obese patients undergoing LSG. They were grouped as omentopexy (OP) or no omentopexy (NP). Patient characteristics such as age, sex, ASA (American Society of Anesthesiologists) risk, body mass index (BMI), nutritional status and comorbidities were comparable. Postoperative follow-up was scheduled at 1 week, 1 month, 3 months, 6 months and 12 months. All received standard postoperative clinical, nutritional evaluation and PPI therapy for at least 3 months.

RESULTS

Total 737 patients underwent LSG from January 2012 to December 2017. Out of these, 370 that had OP and 367 that had NP were analyzed. NP group was subdivided into Lemberted Staple line (LS) and bioabsorbable staple line reinforcement (BSLR) groups. Gastric leaks and perforations were clubbed together as gastric disruptions (GD). Patients with at least 15 months of postoperative follow-up were included. Those who failed to follow up were excluded. GD was reported in 7 out of 367 NP patients (1.9%), while no GD was seen in 370 OP patients (P = 0.01). Bleeding was seen in 1 OP versus 2 NP patients (P = 0.6). Venous thromboembolism was reported in 2 OP versus 1 NP patients (P = 1). Wound infection was seen in 1 OP versus 2 NP patients (P = 0.6). Readmissions were noted in 2 OP versus 6 NP patients (P = 0.1). Pneumonia was seen in 2 OP and 2 NP patients (P = 1). Postoperative dehydration was seen in zero OP versus 1 NP patients (P = 0.4). Gastric obstruction was not seen in any of the patients. Postoperative gastric reflux was present in 49/370(13.2%) OP versus 57/367(15.4%) NP patients (P = 0.4). Within NP group, LS (Lemberting of Staple line) patients (286/367) had 4 GD (1.39%) versus no GD in OP (P = 0.03). BSLR (Bioabsorbable Staple line re-enforcement) patients (81/367) had 3 GD (3.7%) versus no GD in OP (P = 0.005). None of the groups had any mortality.

CONCLUSIONS

GD (gastric disruptions) were statistically significant, but the following bleeding, venous thromboembolism and gastroesophageal reflux did not reach statistical significance, which indicates that OP, if performed correctly with LSG, has favorable effects on gastric leaks.

Laparoscopic Gastric Bypass: Still the Gold Standard?

Roux-en-Y gastric bypass has been considered the gold standard bariatric procedure for decades. The surgical technique for Roux-en-Y gastric bypass and perioperative management for patients who undergo the procedure are still being improved for better clinical outcomes, shorter hospitalization, and faster return to normal activity. In the past 15 years there have been similar improvements and further development of novel surgical weight loss procedures. As data on other surgical alternatives emerge, the data need to be compared with Roux-en-Y gastric bypass to determine noninferiority. Further long-term investigations are needed to determine superiority of one bariatric procedure over another.

Revisional bariatric surgery to single-anastomosis gastric bypass: a large multi-institutional series

BACKGROUND

Reoperation is often required after bariatric procedures. Single-anastomosis gastric bypass (SAGB) is increasingly utilized as a primary bariatric procedure. Few series document SAGB as a revisional bariatric procedure.

OBJECTIVES

To describe our short-term experience with revisional SAGB, focusing on weight loss and reflux symptom outcomes.

SETTING

Three hospitals in Australia with both private and public (government funded) patients.

METHODS

We reviewed all revisional SAGB cases from 2012 to 2019 at. Complications were considered significant if they were Clavien-Dindo grade 3a or higher. A phone survey was conducted to assess weight loss outcomes, patient satisfaction, reflux symptoms, and other complications.

RESULTS

We identified 254 patients who had a revisional bariatric procedure to SAGB (21 previous sleeve gastrectomies and 233 previous adjustable bands), with a mean follow-up of 22 ± 15.6 months (range, 1-55 mo). The mean percentage of excess weight loss was 77% (183 patients, 72%), and the number of patients with follow-ups at 1 and 4 years was 184 (73%) and 35 patients (14%). Within 30 days, there were 29 patients (11%) who required reinterventions (21 endoscopies, 1 interventional radiology procedure, and 7 reoperations) with no deaths. Beyond 30 days, 27 patients (11%) required rerevision to Roux-en-Y gastric bypass for reflux symptoms and 10 (4%) required a laparotomy or laparoscopy for another reason (e.g., bowel obstruction). At a median follow-up of 36.6 months, 87 patients (34%) completed a phone survey, 45 (52%) of whom were taking proton pump inhibitors and 66 patients (76%) of whom were satisfied with their experience.

CONCLUSION

In our series, revision to SAGB was safe, with low short-term morbidity and favorable weight loss outcomes. However, beyond 1 year, a large proportion of patients experienced severe reflux symptoms and required rerevision.

Endoscopic Double-Pigtail Catheter (EDPC) Internal Drainage as First-Line Treatment of Gastric Leak: A Case Series during Laparoscopic Sleeve Gastrectomy Learning Curve for Morbid Obesity

OBJECTIVES

The prevalence of morbid obesity has dramatically increased over the last several decades worldwide, currently reaching epidemic proportions. Gastric leak (GL) remains the potentially fatal main complication after sleeve gastrectomy (SG) for morbid obesity. To our knowledge, there are no standardized guidelines for GL treatment after laparoscopic sleeve gastrectomy (LSG) yet. The aim of this study was to represent our institutional preliminary experience using the endoscopic double-pigtail catheter (EDPC) as the method of internal drainage and propose it as first-line treatment in case of GL after LSG.

METHODS

One hundred and seventeen patients were admitted to our surgical department and underwent laparoscopic sleeve gastrectomy (LSG) for morbid obesity from March 2014 to June 2019. In 5 patients (4.3%) of our series, GL occurred as a complication of LSG. EPDC was the stand-alone procedure of internal drainage and GL first-line treatment. The internal pig tail was endoscopically removed from 30th to 40th POD in all cases.

RESULTS

Present data (clinical, biochemical, and instrumental tests) showed a complete resolution of GL, with promotion of a pseudodiverticula and complete re-epithelialization of leak. Follow-up was more strict than usual (clinical visit and biochemical test on 7th, 14th, and 21st day after discharge; a CT scan with gastrografin on 30th day from discharge if clinical visit and exams were normal).

CONCLUSION

This was a preliminary retrospective observational study, conducted on 5 patients affected by GL as a complication of LSG for morbid obesity. EDPC maintains the safety, efficacy, and nonexpensive characteristic and may be proposed as better first-line treatment in case of GL after bariatric surgery.

Comparison of gastrojejunostomy techniques and anastomotic complications: a systematic literature review

BACKGROUND

There are several ways to perform the gastrojejunostomy (GJ) anastomosis in laparoscopic Roux-en-Y gastric bypass (LRYGB). Surgeons typically use a variation of three techniques: Hand-sewn anastomosis (HSA), Linear stapled (LS) and Circular stapled anastomosis (CSA). The purpose of this literature review is to determine which of the GJ techniques, if any, is superior and results in the least amount of postoperative complications, with a specific focus on rates of marginal ulcers, postoperative bleeding, and strictures.

METHODS

PubMed, Embase, and Cochrane electronic databases were consulted for studies on LRYGB procedures utilizing a GJ anastomosis, from January 1, 2015 to December 31, 2019. Cochrane and PRISMA screening methods were used to select the studies.

RESULTS

Eleven studies published between 2015 and 2019 were selected and included 135,899 patients that underwent LRYGB with a GJ anastomosis. Sample sizes ranged from 114 to 49,331 patients. Four studies reported that CSA had statistically significant higher rates of marginal ulcers when compared to HSA and LS techniques. Three studies concluded that CSA had statistically significant higher rates of postoperative bleeding when compared to HSA and LS. Five studies observed that CSA had statistically significant higher rates of strictures when compared to HSA and LS techniques. There was no consensus whether HSA or LS was superior in terms of reduced postoperative complications.

CONCLUSION

This study revealed statistically significant increases in rates of postoperative bleeding, marginal ulcer, and strictures with the use of mechanical circular staplers at the GJ anastomosis in LRYGB. Based on our results, avoiding the use of mechanical circular staplers can result in fewer postoperative complications. Nevertheless, there are limitations to retrospective studies which may influence the results and therefore a randomized controlled trial directly comparing HSA, CSA, and LS should be performed to truly determine which technique is superior.

Outcomes of primary versus revisional robotically assisted laparoscopic Roux-en-Y gastric bypass: a multicenter analysis of ten-year experience

Background

Postoperative morbidity after laparoscopic bariatric surgery is considered higher for patients undergoing revisional versus primary procedures. The objective of this retrospective cohort study was to compare outcomes between patients undergoing primary versus revisional robotically assisted laparoscopic (RAL) Roux-en-Y gastric bypass (RYGB).

Methods

Data of all patients who underwent RAL primary and revisional RYGB between 2009 and 2019 at two accredited, high-volume bariatric surgery centers—the Memorial Hermann – Texas Medical Center, Houston, TX, and the Tower Health, Reading Hospital, Reading, PA, were analyzed. Primary outcomes were early (< 30 days) and overall postoperative complications. Secondary outcomes included intraoperative complications, operative times, conversions to laparotomy, length of hospital stay, early (< 30 days) postoperative readmissions and deaths.

Results

Data of 1072 patients were analyzed, including 806 primary and 266 revisional RAL RYGB procedures. Longer operative times (203 versus 154 min, P < 0.001), increased number of readmissions for oral intolerance (10.5% versus 6.7%, P = 0.046) and higher rate of gastrojejunal stricture (6.4% versus 2.7%, P = 0.013) were found in the revisional group. Gastrointestinal leak rates were 0.2% for the primary versus 1.1% for the revisional group (P = 0.101). Early (< 30 days) reoperations rates were 2.2% for the primary versus 1.1% for the revisional group (P = 0.318). There were no statistically significant differences between groups in overall and severe complication rates.

Conclusion

Patients undergoing RAL primary and revisional RYGB had comparable overall outcomes, with a non-significant higher early complication rate in the revisional group. Despite the study being underpowered to detect differences in specific complication rates, the morbidity seen in the revisional RYGB group remains markedly below literature reports of revisional laparoscopic RYGB and might suggest a benefit of robotic assistance. Further prospective studies are needed to confirm these results.

Incidence and treatment of small bowel leak after Roux-en-Y gastric bypass: a cohort study from the Scandinavian Obesity Surgery Registry

BACKGROUND

Anastomotic leak at the gastrojejunostomy in Roux-en-Y gastric bypass is a rare, but serious, complication. Little has been published on leaks at other sites.

OBJECTIVES

To assess incidence, risk factors, treatment, and outcome of small bowel leaks at the enteroenteral anastomosis (EA) and undiagnosed iatrogenic small bowel perforations in primary Roux-en-Y gastric bypass.

SETTING

Nationwide cohort, Sweden.

METHODS

All leaks within 30 days in 41,342 patients (age 40.8 [standard deviation 11.1] yr, females 68%, and body mass index 42.4 [standard deviation 5.4] kg/m²) between 2007 and 2014 in the Scandinavian Obesity Surgery Registry were assessed. Register data and outcomes were verified by reviewing patient charts. Logistic regression estimated odds ratios (OR) and 95% confidence intervals for significant risk factors.

RESULTS

The incidence of small bowel leaks was .3%. Iatrogenic perforations were diagnosed earlier than EA leaks, 3.6 versus 6.5 days after surgery (P = .02). EA leaks were seen in 75 patients (.2%), with surgery at a low-volume center (<125 cases/yr, OR 2.1 [1.0-4.1]) and prolonged operative time (≥90 min, OR 3.5 [1.1-11.0]) as risk factors. The risk of iatrogenic small bowel perforations, .1%, was tripled by prolonged operative time (OR 3.4 [1.2-9.4]). Surgical reintervention was required in 97% of leaks, repairing the defect and draining the abdominal cavity in most cases. A third of the patients required intensive care, of which 5% developed multiorgan failure and 1% died.

CONCLUSION

Small bowel leaks, seen in .3%, were associated to prolonged operative time, and surgery at a low-volume center for EA leaks. Surgical reintervention was common, while mortality was low.

Efficacy and Safety of Stents in the Treatment of Fistula After Bariatric Surgery: a Systematic Review and Meta-analysis

Fistula development is a serious complication after bariatric surgery. We performed a systematic review and meta-analysis to assess the efficacy of fistula closure and complications associated with endoscopic stent treatment of fistulas, developed after bariatric surgeries, particularly Roux-en-Y gastric bypass (RYGB) and gastric sleeve (GS). Studies involving patients with fistula after RYGB or GS and those who received stent treatment only were selected. The analyzed outcomes were overall success rate of fistula closure, mean number of stents per patient, mean stent dwelling time, and procedure-associated complications. Current evidence from identified studies demonstrates that, in selected patients, endoscopic stent treatment of fistulas after GS or RYGB can be safe and effective.

A Retrospective Comparative Study of Primary Versus Revisional Roux-en-Y Gastric Bypass: Long-Term Results

AIMS

To compare the perioperative parameters and excess weight loss between patients operated by laporoscopic Roux-en-Y gastric bypass (LRYGB), as a primary operation or a revisional, for insufficient weight loss after vertical banded gastroplasty (VBG) or adjustable gastric banding (AGB).

METHODS

A retrospective analysis of all patients who underwent a LRYGB was performed for the period 2004-2011. Demographics, preoperative body mass index (BMI), co-morbidities, operation time, conversion rate, perioperative complications, hospitalization period, and % of excess BMI loss (%EBMIL) were investigated and compared between groups.

RESULTS

Three hundred forty-two laparoscopic gastric bypass operations were performed, 245 were primary, and 97 revisional. Median follow-up was 30 months (range 0-108 months). Mean BMI (kg/m²) before bypass was 45.2 for primary laparoscopic Roux-en-Y gastric bypass (pLRYGB) and 41.1 for revisional laparoscopic Roux-en-Y gastric bypass (rLRYGB). Median operative time and length of stay were longer for rLRYGB 157.5 versus 235 min (p < 0.001) and 6 versus 6.5 days (p = 0.05). Conversion to laparotomy was performed in eight patients, 0.4% of primary and 7.2% of revisional. Morbidity rate was 6.5% in pLRYGB versus 10% in rLRYGB (NS). There was one death in the primary group. Percentage of EBMIL was significantly lower in the revisional group at 12, 18, and 24 months of follow-up.

CONCLUSIONS

Revisional and primary gastric bypass have no statistical differences in terms of morbidity. The % of excess BMI loss is lower after revisional gastric bypass during the first 2 years of follow-up. The trend of weight loss or weight regain was similar in both groups.

Incidence and treatment of leak at the gastrojejunostomy in Roux-en-Y gastric bypass: a cohort study of 40,844 patients

BACKGROUND

Leak at the gastrojejunostomy (GJ) after Roux-en-Y gastric bypass is a rare but life-threatening complication.

OBJECTIVES

To assess incidence, risk factors, treatment, and outcome of leaks at the GJ after Roux-en-Y gastric bypass in a nationwide cohort.

SETTING

Sweden.

METHODS

Leaks at GJ within 30 days postoperatively in 40,844 patients (age 41 yr, females 76%, and body mass index of 42.4 kg/m²) between 2007 and 2014 in the Scandinavian Obesity Surgery Registry were assessed. Register data and outcomes were verified by reviewing patient charts. Logistic regression was done to estimate odds ratios (ORs) for significant risk factors.

RESULTS

Leak at the GJ was registered in 262 (.6%) patients, with 44% diagnosed within the first 3 postoperative days. Risk factors were male sex (OR 1.5 [1.1-1.9]), age ≥49 years (OR 1.9 [1.3-2.7]), diabetes (OR 1.4 [1.1-1.9]), conversion to open surgery (OR 3.9 [2.2-6.9]), and operative time ≥90 minutes (OR 2.6 [1.8-3.8]). In most patients, the leak resulted in a severe complication. Reoperative surgery was done in 85%, with the placement of a feeding gastrostomy in 24%. Stents were used at some time point in 31% of leaks. Of all patients with leaks, 25% required intensive care, 4% developed multiorgan failure, and 1% died. Median duration of stay for patients with leaks was 22 days, versus 2 days for others (P < .001).

CONCLUSION

GJ leaks occurred in .6% of patients. Risk factors were male sex, age ≥49 years, diabetes, operative time ≥90 minutes, and conversion to open surgery. Surgical reintervention was common. Mortality was 1%.

Preoperative liver shrinking diet for bariatric surgery may impact wound healing: a randomized controlled trial

BACKGROUND

In bariatric surgery, preoperative very low-calorie diets (VLCD) may better meet the technical demands of surgery by shrinking the liver. However, diets may affect tissue healing and influence bowel anastomosis in an as-yet-undefined manner.

OBJECTIVE

This randomized controlled trial aimed to examine the effect on collagen deposition in wounds in patients on a 4-week VLCD before laparoscopic gastric bypass.

SETTING

University hospital.

METHODS

The trial was undertaken in patients undergoing laparoscopic Roux-en-Y gastric bypass, with a control group (n = 10) on normal diet and an intervention group (n = 10) on VLCD (800 kcal) for 4 weeks. The primary outcome measured was expression of collagen I and III in skin wounds, with biopsies taken before and after the diet and 7 days postoperatively as a surrogate of anastomotic healing. Secondary outcome measures included liver volume and fibrosis score, body composition, operating time, blood loss, hospital stay, and complications.

RESULTS

Patients in both groups were similar in age, sex, body mass index (53.4 versus 52.8 kg/m²), co-morbidities, liver volume, and body composition. Expression of mature collagen type I was significantly decreased in diet patients compared with controls after 4 weeks of diet and 7 days after surgery. This was significant decrease in liver volume (23% versus 2%, P = .03) but no difference in operating times (129 versus 139 min, P = .16), blood loss, length of stay, or incidence of complications.

CONCLUSIONS

Preoperative diets shrink liver volume and decrease expression of mature collagen in wounds after surgery. Whether the latter has a detrimental effect on clinical outcomes requires further evaluation.

Bariatric Surgery: A Perspective for Primary Care

IN BRIEF Bariatric surgery is the most efficacious treatment for obesity, type 2 diabetes, and other obesity-related comorbidities. In this article, the authors review the current indications for bariatric surgery and discuss the most commonly performed procedures. They analyze medical outcomes of bariatric procedures by reviewing key prospective trials and discuss changes in physiology after these procedures. They conclude by discussing long-term management of bariatric patients by reviewing current guidelines for nutritional support and listing common complications related to these procedures.

Management of gastric leaks after laparoscopic sleeve gastrectomy for morbid obesity: A tertiary care experience and design of a management algorithm

BACKGROUND:

Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed ‘standalone’ bariatric procedure in India. Staple line gastric leaks occur infrequently but cause significant and prolonged morbidity. The aim of this retrospective study was to analyse the management of patients with a gastric leak after LSG for morbid obesity at our institution.

PATIENTS AND METHODS:

From February 2008 to 2014, 650 patients with different degrees of morbid obesity underwent LSG. Among these, all those diagnosed with a gastric leak were included in the study. Patients referred to our institution with gastric leak after LSG were also included. The time of presentation, site of leak, investigations performed, treatment given and time of closure of all leaks were analysed.

RESULTS:

Among the 650 patients who underwent LSG, 3 (0.46%) developed a gastric leak. Two patients were referred after LSG was performed at another institution. The mean age was 45.60 ± 15.43 years. Mean body mass index (BMI) was 44.79 ± 5.35. Gastric leak was diagnosed 24 h to 7 months after surgery. One was early, two were intermediate and two were late leaks. Two were type I and three were type II gastric leaks. Endoscopic oesophageal stenting was used variably before or after re-surgery. Re-surgery was performed in all and included stapled fistula excision (re-sleeve), suture repair only or with conversion to roux-en-Y gastric bypass or fistula jujenostomy. There was no mortality.

CONCLUSION:

Leakage closure time may be shorter with intervention than expectant management. Sequence and choice of endoscopic oesophageal stenting and/or surgical re-intervention should be individualized according to clinical presentation.

Endoscopy after bariatric surgery

Obesity is a global epidemic with significant morbidity and mortality. Weight loss results in reduction of health risks and improvement in quality of life, thus representing a goal of paramount importance. Bariatric surgery is the most efficacious choice compared to conservative alternatives including diet, exercise, drugs and behavioral modification to treat obese patients. Following bariatric operations, patients may present with upper gastrointestinal tract complaints that warrant endoscopic evaluation and the various bariatric surgery types are often linked to complications. A subset of these complications necessitates endoscopic interventions for accurate diagnosis and effective, minimal invasive treatment. This review aims to highlight the role of upper gastrointestinal endoscopy in patients who have undergone bariatric surgery to evaluate and potentially treat surgery-related complications and upper gastrointestinal symptoms.

Effect of Early Use of Covered Self-Expandable Endoscopic Stent on the Treatment of Postoperative Stapler Line Leaks

BACKGROUND

Postoperative leaks are a dreaded complication after bariatric surgery (BS). Its treatment is based on nutritional support and sepsis control by antibiotics, collections drainage and/or prosthesis, and/or surgery.

OBJECTIVES

The aim of this study is to report our experience with coated self-expandable endoscopic stents (SEES) for leaks treatment.

SETTING

This study was performed in a University Hospital, (censored).

METHODS

We performed a retrospective analysis of our BS database from January 2007 to December 2013. All patients with leak after BS treated with SEES were included.

RESULTS

We identified 29 patients; 17 (59%) were women, with median age of 37 (19-65) years, and preoperative body mass index of 40 (28.7-56-6) kg/m(2). Nineteen (65.5%) patients had a sleeve gastrectomy and 10 (34.5%) a Roux-en-Y gastric bypass. All patients had a leak in the stapler line. Median time from surgery to leak diagnosis was 7 (1-51) days, and SEES were installed 8 (0-104) days after diagnosis. Twenty-one (72%) patients also had abdominal exploration. Median length of SEES use was 60 (1-299) days. Patients who had SEES as primary treatment (with or without simultaneous reoperation) had a shorter leak closure time (50 [6-112] vs 109 [60-352] days; p = 0.008). Twenty-eight (96.5%) patients successfully achieved leak closure with SEES. There were 16 migrations in 10 (34%) patients, 1 (3%) stent fracture, 1 opening of the blind end of alimentary limb (3%), and 5 patients (17%) required a second stent due to leak persistence.

CONCLUSIONS

SEES is a feasible, safe, and effective management of post BS leaks, although patients may also require prosthesis revision and abdominal exploration. Primary SEES placement is associated with a shorter leak resolution time.

Endoluminal vacuum therapy for gastrojejunal anastomotic leaks after Roux-en-Y gastric bypass: a pilot study in a swine model

BACKGROUND

Roux-en-Y gastric bypass (RYGB) consistently produces the most sustainable weight loss among common interventions for morbid obesity. Anastomotic leaks at the gastrojejunal (GJ) connection result in severe morbidity. We apply endoluminal negative pressure vacuum devices (EVD) to heal anastomotic leaks in a swine model.

METHODS

RYGB was performed in 10 pigs (3 control, 7 experimental). GJ anastomoses were fashioned, and a 2-cm defect was made across the staple line. In controls, the defects remained open. In experimental pigs, the EVD was placed across the defect and kept at continuous 50 mmHg suction. All pigs were euthanized on postoperative day seven unless they displayed signs of peritonitis or sepsis. Fluoroscopy and necropsy were performed to assess a persistent leak, and tissue specimens were sent to histology to evaluate for degree of inflammation and ischemia.

RESULTS

All three control pigs' GJ anastomoses demonstrated evidence of a persistent leak. All seven experimental pigs with the EVD in place showed evidence that their leak had sealed at time of fluoroscopy (p value 0.008).

CONCLUSIONS

Endoluminal vacuum therapy is well tolerated in a swine model. GJ anastomotic leaks were consistently sealed with our device in place compared to controls. This therapy shows promise as a method to address GJ leaks in the bariatric population, and thus, we believe additional evaluation is warranted.

Endoscopic Treatment of Gastrointestinal Perforations, Leaks, and Fistulae

Gastrointestinal leaks and fistulae are common postoperative complications, whereas intestinal perforation more commonly complicates advanced endoscopic procedures. Although these complications have classically been managed surgically, there exists an ever-expanding role for endoscopic therapy and the involvement of advanced endoscopists as part of a multidisciplinary team including surgeons and interventional radiologists. This review will serve to highlight the innovative endoscopic interventions that provide an expanding range of viable endoscopic approaches to the management and therapy of gastrointestinal perforation, leaks, and fistulae.

Comprehensive management of full-thickness luminal defects: The next frontier of gastrointestinal endoscopy

Full thickness gastrointestinal defects such as perforations, leaks, and fistulae are a relatively common result of many of the endoscopic and surgical procedures performed in modern health care. As the number of these procedures increases, so too will the number of resultant defects. Historically, these were all treated by open surgical means with the associated morbidity and mortality. With the recent advent of advanced endoscopic techniques, these defects can be treated definitively while avoiding an open surgical procedure. Here we explore the various techniques and tools that are currently available for the treatment of gastrointestinal defects including through the scope clips, endoscopic suturing devices, over the scope clips, sealants, endoluminal stents, endoscopic suction devices, and fistula plugs. As fistulae represent the most recalcitrant of defects, we focus this editorial on a multimodal approach of treatment. This includes optimization of nutrition, treatment of infection, ablation of tracts, removal of foreign bodies, and treatment of distal obstructions. We believe that by addressing all of these factors at the time of attempted closure, the patient is optimized and has the best chance at long-term closure. However, even with all of these factors addressed, failure does occur and in those cases, endoscopic therapies may still play a role in that they allow the patient to avoid a definitive surgical therapy for a time while nutrition is optimized, and infections are addressed.

Endoscopic management of bariatric complications: A review and update

With over a third of Americans being considered obese, bariatric procedures have now become the most performed operation be general surgeons in the United States. The most common operations are the Laparoscopic Roux-en-Y Gastric Bypass, the Laparoscopic Sleeve Gastrectomy, and the Laparoscopic Adjustable Gastric Band. With over 340000 bariatric procedures preformed worldwide in 2011, the absolute number of complications related to these operations is also increasing. Complications, although few, can be life threatening. One of the most dreaded acute complication is the anastomotic/staple line leak. If left undiagnosed or untreated they can lead to sepsis, multi organ failure, and death. Smaller or contained leaks can develop into fistulas. Although most patients with an acute anastomotic leak return to the operating room, there has been a trend to manage the stable patient with an endoscopic stent. They offer an advantage by creating a barrier between enteric content and the leak, and will allow the patients to resume enteral feeding much earlier. Fistulas are a complex and chronic complication with high morbidity and mortality. Postoperative bleeding although rare may also be treated locally with endoscopy. Stenosis is a more frequent late complication and is best-managed with endoscopic therapy. Stents may not heal every fistula or stenosis, however they may prevent certain patients the need for additional revisional surgery.

Endoscopic management of bariatric complications: A review and update

With over a third of Americans being considered obese, bariatric procedures have now become the most performed operation be general surgeons in the United States. The most common operations are the Laparoscopic Roux-en-Y Gastric Bypass, the Laparoscopic Sleeve Gastrectomy, and the Laparoscopic Adjustable Gastric Band. With over 340000 bariatric procedures preformed worldwide in 2011, the absolute number of complications related to these operations is also increasing. Complications, although few, can be life threatening. One of the most dreaded acute complication is the anastomotic/staple line leak. If left undiagnosed or untreated they can lead to sepsis, multi organ failure, and death. Smaller or contained leaks can develop into fistulas. Although most patients with an acute anastomotic leak return to the operating room, there has been a trend to manage the stable patient with an endoscopic stent. They offer an advantage by creating a barrier between enteric content and the leak, and will allow the patients to resume enteral feeding much earlier. Fistulas are a complex and chronic complication with high morbidity and mortality. Postoperative bleeding although rare may also be treated locally with endoscopy. Stenosis is a more frequent late complication and is best-managed with endoscopic therapy. Stents may not heal every fistula or stenosis, however they may prevent certain patients the need for additional revisional surgery.