Laparoscopic sleeve gastrectomy using a synthetic bioabsorbable staple line reinforcement material: Post-operative complications and 6 year outcomes

Essential updates 2020/2021: Advancing precision medicine for comprehensive rectal cancer treatment

In the paradigm shift related to rectal cancer treatment, we have to understand a variety of new emerging topics to provide appropriate treatment for individual patients as precision medicine. However, information on surgery, genomic medicine, and pharmacotherapy is highly specialized and subdivided, creating a barrier to achieving thorough knowledge. In this review, we summarize the perspective for rectal cancer treatment and management from the current standard-of-care to the latest findings to help optimize treatment strategy.

Long-Term Weight Outcome After Bariatric Surgery in Patients with Melanocortin-4 Receptor Gene Variants: a Case-Control Study of 105 Patients

INTRODUCTION

Pathogenic heterozygous MC4R variants are associated with hyperphagia and variable degrees of obesity. Several research groups have reported short-term weight loss outcomes after bariatric surgery in a few patients with MC4R variants, but lack of longer-term data prevents evidence-based clinical decision-making.

MATERIALS AND METHODS

Bariatric surgery patients with heterozygous (likely) pathogenic MC4R variants, from three collaborating centers in the Netherlands, France, and the UK, were compared to matched controls (matched 2:1 for age, sex, preoperative BMI, surgical procedure, and diabetes mellitus, but without MC4R mutations). Weight loss and regain outcomes up to 6 years of follow-up were compared.

RESULTS

At 60 months of follow-up after RYGB, cases with MC4R variants showed weight regain with a mean of 12.8% (± 10.4 SD) total weight loss (TWL) from nadir, compared to 7.9% (± 10.5 SD) in the controls (p = 0.062). Among patients receiving SG, the cases with MC4R variants experienced inferior weight loss (22.6% TWL) during the first year of follow-up compared to the controls (29.9% TWL) (p = 0.010).

CONCLUSIONS

This multicenter study reveals inferior mid-term weight outcomes of cases with MC4R variants after SG, compared to RYGB. Since adequate weight loss outcomes were observed after RYGB, this procedure would appear to be an appropriate surgical approach for this group. However, the pattern of weight regain seen in cases with MC4R variants after both RYGB and SG highlights the need for pro-active lifelong management to prevent relapse, as well as careful expectation management.

SERPINE-1 Gene Methylation and Protein as Molecular Predictors of Laparoscopic Sleeve Gastrectomy Outcome

BACKGROUND

Body weight is subjected to genetic and epigenetic modifiers that might affect the success of weight loss interventions. Because of its possible complications and disparity in patients' response, identification of predictors to the outcome of bariatric surgery is indispensable.

OBJECTIVES

This prospective study aims to investigate serpin peptidase inhibitor type 1 (SERPINE-1) protein and gene methylation as molecular predictors to the outcome of bariatric surgery.

PATIENTS AND METHODS

One hundred participants were enrolled and divided to control group (n = 50) and obese patients who underwent laparoscopic sleeve gastrectomy (LSG) (n = 50). Anthropometric measurements were assessed and blood samples were collected preoperatively and 6 months postoperatively for assessment of SERPINE-1 protein and gene methylation, C-reactive protein (CRP), and homeostatic model assessment of insulin resistance (HOMA-IR). Moreover, subjects were followed for 2 years for weight loss parameters.

RESULTS

Patients with obesity showed high baseline SERPINE-1 protein and gene hypermethylation where LSG was followed by a drop in SERPINE-1 protein level but not gene hypermethylation. Baseline SERPINE-1 gene methylation was negatively related to postoperative weight loss and was the independent predictor to weight loss after LSG. Likewise, postoperative SERPINE-1 protein was negatively related to weight loss with independent expression from its gene methylation state. Furthermore, postoperative SERPINE-1 gene methylation correlated to CRP and HOMA-IR.

CONCLUSION

Baseline SERPINE-1 gene methylation might be a predictor of weight loss after LSG. Meanwhile, postoperative SERPINE-1 protein could be a predictor to weight loss maintenance after LSG. Lastly, postoperative SERPINE-1 gene methylation might serve as an index to postoperative changes in obesity-related comorbidities.

Predictors and outcomes of bleed after sleeve gastrectomy: an analysis of the MBSAQIP data registry

BACKGROUND

Bleeding after laparoscopic sleeve gastrectomy (LSG) is an important complication associated with significant morbidity and a drastic increase in healthcare resources. Multiple strategies have been developed to minimize bleeding, including varying bougie size, line reinforcement, and intra-operative tranexamic acid. These techniques, however, have been implemented without a clear understanding of the pre-, intra-, and postoperative predictors of bleeding in patients undergoing SG.

OBJECTIVES

The purpose of this study was to examine predictors and outcomes associated with postoperative bleeding in patients undergoing LSG.

SETTING

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement data registry.

METHODS

We identified Metabolic and Bariatric Surgery Accreditation and Quality Improvement patients who underwent LSG in 2015 and 2016. Primary outcomes of interest include identifying the prevalence, impact, and predictors of bleeding in LSG patients. Our secondary outcomes of interest include characterizing overall complication rates in LSG patients. Univariate analysis of pre-, intra-, and postoperative variables was performed using Χ² tests for categorical data and independent sample t test for continuous data. A nonparsimonious multivariable logistic regression model was then developed to determine predictive factors for development of postoperative bleed.

RESULTS

A total of 175,353 patients underwent LSG from 2015 to 2016. The majority of patients were female (79.0%), with a mean age of 44.4 ± 12.0 years and a mean body mass index of 45.2 kg/m² ± standard deviation of 7.9 kg/m². A total of 1116 (.6%) patients had a postoperative bleed. Bleeding was associated with a mortality of 1.0% versus .1% among patients without bleeding. The mean operative time was 74.0 ± 36.6 minutes with a mean bougie size of 36.9 ± 2.9 Fr, and a mean pylorus distance of 4.80 ± 1.1 cm. Staple-line reinforcement was used in 67.8% of patients while 22.4% were oversewn. Bleeds were associated with a statistically significant increase in all complications, readmission, reoperation, and mortality rates at 30 days. The following statistically significant independent predictors of bleed after LSG were identified using multivariable logistic regression analysis: bougie size, age, prior cardiac procedure, hypertension, renal insufficiency, therapeutic anticoagulation, diabetes, obstructive sleep apnea, and operative length. Staple-line reinforcement, staple-line oversewing, and higher body mass index were found to be protective for bleed after adjusting for confounders and interactions. An increase in pylorus distance did show a signal toward a protective effect; however, this was not statistically significant.

CONCLUSION

Bleeding after LSG is associated with increased complications, readmission and reoperation rates, and mortality at 30 days. Staple-line reinforcement techniques independently predict a lower risk of postoperative bleeding after LSG. Adoption of these techniques may therefore have an important role in reducing morbidity and mortality for patients who undergo LSG.

Standardised Sleeve Gastrectomy Without Reinforcement

Background and Objectives:

Laparoscopic sleeve gastrectomy (LSG) has some unique complications, the most concerning of which is sleeve leak. Staple line reinforcement (SLR) has been suggested as a means of decreasing the risk of sleeve leak, but it increases the cost. However, there is little in the literature regarding the effect of standardized operative technique in reducing the complications and improving the outcomes in LSG. We sought to demonstrate that standardization of the operative procedure and perioperative care is the key to an excellent 30-day outcome and that SLR is not necessary to ensure a negligible staple line leak and bleeding rate.

Methods:

A prospectively maintained database was analyzed to identify 303 consecutive patients undergoing LSG between July 2010 and November 2017. Data on patient demographics, length of hospital stay, conversion to open surgery, perioperative complications, and mortality were analyzed. Standardized operative technique and postoperative protocol were followed in all cases. SLR was not used in any case.

Results:

Among 303 cases, there were 15 complications (5%), 5 (1.7%) of which were severe (Clavien-Dindo grade ≥3a). There were no conversions to open procedure, no staple line leaks, and no inpatient deaths in the cohort. No patient was readmitted with an early stricture.

Conclusions:

The use of a standardized operative and postoperative protocol led to an excellent early outcome in our LSG cases. Standardization may act to obviate the need for routine SLR techniques which are associated with a significant financial cost to both patient and hospital.

Outcomes of laparoscopic sleeve gastrectomy at a bariatric unit in South Africa

Background

Laparoscopic sleeve gastrectomy (LSG) has gained popularity over the years as a standalone procedure. In 2014, it was the most rapidly growing bariatric procedure. The aim of this study was to describe the outcomes of LSG at a single bariatric unit in Johannesburg, South Africa, using the Bariatric Analysis and Reporting Outcome System (BAROS) standardised scoring.

Methods

A retrospective record review and analysis was carried out using data collected from patients who had LSGs. The information obtained included patient demographics, comorbidities, preoperative weight and height, operative technique, time and complications, postoperative gastrografin swallow results, hospital stay, and weight at 6 months postoperatively. The percentage of excess body mass index (BMI) loss (%EBMIL) was calculated at 6 months, and included in the BAROS questionnaire completed by the patients at the 6-month follow-up visit. Statistical significance was set at p < 0.05.

Results

A total of 103 patients were included in the study; of these, 85.4% were female and 14.6% were male. The mean preoperative BMI was 42.1 kg/m²; additionally, 77.7% of the patients in the study had comorbidities prior to the procedure. The mean operative time was 104.3 min, with a mean hospital stay of 2.5 days. No mortalities occurred, and a complication rate of 7.7% was encountered. At the 6-month follow-up, the mean %EBMIL was 65%. When followed up at 6 months, all 103 patients demonstrated no failures according to the BAROS assessment. It was found that 96.1% had good, very good or excellent outcomes. In total, 9.7% of the patients had an excellent outcome.

Conclusions

LSG was shown to produce an adequate %EBMIL loss at 6 months, resulting in a significant improvement in the quality of life (QoL), coupled with good BAROS outcomes. The results of this research are comparable to other studies of LSGs, and the low complication rate supports the use of the procedure and accounts for no observed mortality.

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First study of laparoscopic sleeve gastrectomy performed in South Africa.

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Laparoscopic sleeve gastrectomy produces an adequate percentage excess BMI loss at 6 months.

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A significant improvement in the quality of life was observed.

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Results of this research are comparable to other studies of LSGs.

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Low complication rate supports the use of the procedure.