Combined vaginal and abdominal approach to sleeve gastrectomy for morbid obesity in women: a preliminary experience

Transvaginal Specimen Extraction After Laparoscopic Gastrectomy for Tumors

AIM

The aim was to evaluate the feasibility of transvaginal specimen extraction after laparoscopic gastrectomy for tumors.

METHOD

Inclusion criteria were females not planning to deliver a child and an accessible vaginal entry. Exclusion criteria were benign gastric pathologies and emergency cases.

RESULTS

There were 24 females with a mean age of 54.5±12.0. Subtotal, total, central, and vertical gastrectomies were implemented in 17, 4, 2, and 1 patients, respectively. There was no conversion to open or conventional laparoscopic surgery. Specimens were removed from the vagina in all cases successfully. Histopathologies were adenocarcinoma in 20, gastrointestinal stromal in 3, neuroendocrine tumors in 2 and high-grade dysplasia in the rest. Mean blood loss and duration of surgery were 122.5±163.4 (range: 10 to 800) ml. and 287.7±95.9 (range: 120 to 440) minutes, respectively. No patient required intraoperative blood transfusions. The median length of hospital stay was 7 days (range: 3 to 22). The mean tumor size was 7.8±6.5 (range: 0.5 to 24) cm. Fourteen of 24 cases were advanced gastric cancers. Mean dissected lymph node numbers in the patients with radical gastrectomy was 35.3±12.9 (range: 18 to 62). There were no early or late complications related to the specimen extraction and no wound-related problems were observed.

CONCLUSIONS

In the selected cases, transvaginal specimen extraction was feasible after laparoscopic gastric resections in patients with stomach tumors. As far as we know, this was the largest study on the transvaginal extraction of gastric tumors.

Three-Year Follow-Up of Laparoscopic Reduced Port Sleeve Gastrectomy in 808 Consecutive Patients

BACKGROUND

Sleeve gastrectomy (SG) is a very popular technique for the treatment of morbid obesity. Less and less invasive laparoscopic approaches to SG have been proposed and shown to be safe and feasible.

OBJECTIVES

We developed a reduced port laparoscopic approach to sleeve gastrectomy (_RLSG) with the aim to further optimize the advantages of laparoscopy. Preliminary and safety profile of _RLSG as well as 3 years weight loss outcome are hereby discussed.

SETTING

University Hospital, Kuwait.

MATERIALS AND METHODS

All patients had morbid obesity with history of failure of conservative treatment. The _RLSG procedure was performed using only two skin incisions.

RESULTS

The analyzed population comprised 808 patients, including 642 women and 166 men. Mean age and BMI were 28.34 ± 8.37 and 41.09 ± 6.34, respectively. Mean operative time was 43 ± 20 min (range, 31-185). Mortality was nil. Overall morbidity rate was (4.5%). Three patients had postoperative leak (0.4%). Median duration of hospital stay was 2 days (range, 1-5). Mean percentage of excess weight loss (% EWL) was 23.18 ± 17.3% at 1 month, 55.08 ± 22.9% at 6 months, 82.6 ± 22.6% at 1 year, and 84.3 ± 22.4% at 3 years. Mean percentage total weight loss (%TWL) was 9.34% at 1 month, 22.42% at 6 months, and 34.57% at 1 year.

CONCLUSION

_RLSG is a safe and effective surgical option in patients with morbid obesity. Moreover, 3-year follow-up assessment confirmed adequate % EWL.

Natural Orifice Translumenal Endoscopic Surgery: Review of Its Applications in Bariatric Procedures

This review aims to summarise clinical applications of natural orifice translumenal endoscopic surgery (NOTES) in bariatric surgery. A review of data, until December 2014, was carried out regarding techniques and outcomes of bariatric NOTES procedures. Nine publications were included in the final analysis, with another six papers describing endolumenal procedures included for comparison. All NOTES studies adopted a hybrid procedure. Hybrid NOTES sleeve gastrectomy (hNSG) was described in four humans and two porcine studies. In humans, six subjects (23.1 %) were converted to conventional laparoscopic methods, and one postoperative complication (3.8 %) was reported. Mean excess weight loss was 46.6 % (range 35.2–58.9). Transvaginal-assisted sleeve gastrectomy appears feasible and safe when performed by appropriately trained professionals. However, improvements must be made to overcome current technical limitations.

Single-incision or conventional laparoscopic adjustable gastric banding: A systematic review

INTRODUCTION

Single-incision laparoscopic surgery (SILS) in gastric banding (SI-LAGB) has been reported to be a safe and technically feasible procedure among various operating methods. However, there is little evidence with regard to the question whether SI-LAGB has more advantages and should be recommended compared with conventional LAGB (CLAGB). Thus, this study was performed to assess the safety and efficacy of SI-LAGB.

MATERIAL AND METHODS

A computerized search of the electronic databases PubMed and EMBASE was performed. Data regarding operative parameters, postoperative recovery parameters, follow-up time, percentage of excess weight loss, and postoperative complication were pooled and analyzed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations.

RESULTS

Ten comparative studies including 2,073 patients (1,038 patients who received SI-LAGB and 1,035 patients who received CLAGB) were included and analyzed. Compared with CLAGB, a similar weight loss could be obtained using SI-LAGB. The postoperative complications of SI-LAGB were within the acceptable range, but one study reported one perioperative death. SI-LAGB required a longer operative time. Other outcome variables, such as blood loss, days of hospitalization, pain score, and hospitalization costs, were not significantly different between the two groups.

CONCLUSIONS

SI-LAGB might be a safe and effective alternative to C-LAGB when performed by experienced surgeons, but available data do not allow to give a definitive answer and randomized controlled trials are needed.

Complications of transvaginal natural orifice transluminal endoscopic surgery: a series of 102 patients

OBJECTIVE

To review the complications encountered in our facility and in previously published studies of transvaginal (TV) natural orifice transluminal endoscopic surgery (NOTES) to date.

BACKGROUND

TV NOTES is currently observed with critical eyes from the surgical community, despite encouraging data to suggest improved short-term recovery and pain.

METHODS

All TV NOTES procedures performed in female patients between 18 and 65 years of age were included. The median follow-up was 90 days. The TV appendectomies and ventral hernia repairs were pure NOTES, through a SILS port in the vagina, whereas TV cholecystectomies were hybrid procedures with the addition of a 5-mm port in the umbilicus.

RESULTS

A total of 102 TV NOTES procedures, including 72 TV cholecystectomies, 24 TV appendectomies, and 6 TV ventral hernia repairs, were performed. The average age was 37 years old and body mass index was 29 kg/m. Three major and 7 minor complications occurred. The first major complication was a rectal injury during a TV access port insertion. The second major complication was an omental vessel bleed after a TV cholecystectomy. The third complication was an intra-abdominal abscess after a TV appendectomy. Seven minor complications were urinary retention (4), transient brachial plexus injury, dislodgement of an intrauterine device, and vaginal granulation tissue.

CONCLUSIONS

As techniques in TV surgery are adopted, inevitably, complications may occur due to the inherent learning curve. Laparoscopic instruments, although adaptable to TV approaches, have yet to be optimized. A high index of suspicion is necessary to identify complications and optimize outcomes for patients.

Natural orifice transluminal endoscopic surgery (NOTES) for clinical management of intra-abdominal diseases

Clinical research on natural orifice transluminal endoscopic surgery (NOTES) has been increasingly reported over the past 5 years and more than 1200 patients have received various NOTES procedures. The present article reviews the clinical practice of NOTES for the treatment of intra-abdominal diseases, and was carried out through systematic search with specific keywords in major databases for NOTES-related clinical literature. The last date of the search was 15 August, 2012. Transvaginal cholecystectomy is the commonest NOTES procedure reported, and its clinical feasibility and safety was established through prospective case series and randomized trials. There is a regional difference in NOTES development with the majority of NOTES fromCaucasian countries being transvaginal cholecystectomy and most reports from Asian countries being NOTES-related procedures. Safe closure of gastrointestinal access remains challenging, and novel endoscopic instruments are essential to enhance future development of NOTES.

Is the transvaginal route appropriate for intra-abdominal NOTES procedures? Experience and follow-up of 222 cases

BACKGROUND

Since 2007, natural orifice transluminal endoscopic surgery (NOTES) has been applied in humans. We performed this prospective study to evaluate the transvaginal route in terms of risks, complication rate, and long-term side effects such as dyspareunia.

METHODS

From June 2007 to September 2011, we performed 222 transvaginal hybrid NOTES procedures: 220 transvaginal cholecystectomies (TVC) and 2 transvaginal appendectomies (TVA). All patients were asked to present to our associated gynecologists within 1 week for an examination. After at least 3 months, the patients were interviewed using a standard questionnaire.

RESULTS

All operations could be successfully performed in this technique except two cases, which were converted to conventional laparoscopic cholecystectomy. The only intraoperative complication was the puncture of the urine bladder. We observed two postoperative complications: one biliary fistula 3 days after TVC, and one abscess in the Douglas pouch 3 weeks after TVC. The gynecological examinations revealed no abnormalities. The interview (median postoperative time, 6 months) with a follow-up rate of 93 % revealed no pain in the pelvis, dyspareunia, or sexual dysfunction after TVC.

CONCLUSIONS

The transvaginal route is appropriate for NOTES procedures; there is only a minor and acceptable rate of intra- and postoperative morbidity.

Natural orifice translumenal endoscopic surgery applications in clinical practice

To review natural orifice translumenal endoscopic surgery (NOTES) applications in clinical practice and assess the evidence base for each application as reported in the literature. An electronic literature search was performed. Inclusion criteria were publications relating to NOTES applications in humans. For each type of operation the highest level of evidence available for clinical NOTES publications was evaluated. Morbidity and short-term operative outcomes were compared with gold standard published evidence where available. Finally, registered trials recruiting patients for NOTES applications were identified. Human NOTES publications with the highest level of evidence in each application are identified. There were no RCTs in the literature to date. The strongest evidence came in the form of large, multi-centre trials with 300-500 patients. The results are encouraging, comparable with gold standard techniques on morbidity and mortality. While short-term operative outcomes were also similar when compared to the gold standard techniques, other than improved cosmesis little else can definitely be concluded as a clear benefit of a NOTES procedure. The most common procedures are cholecystectomy, appendicectomy and peritoneoscopy mainly performed via transvaginal access. It is evident that morbidity appears to be higher when the transgastric route is used. The safety profile of hybrid NOTES transvaginal procedures is beginning to be confirmed as is evident from the large number of procedures presented in this review. A number of authors have presented work on pure NOTES procedures but the results are inconsistent and thus the vast majority of NOTES procedures worldwide are performed in a hybrid fashion with a variable amount of laparoscopy. This review of the clinical applications of NOTES summarises the growing evidence behind this surgical discipline and highlights NOTES procedures with an acceptable safety profile.

Natural Orifice Surgery (NOS)-the next step in the evolution of minimally invasive surgery

Endoscopy, which was introduced in the 20(th) century, changed the outcome of surgery by reducing the need for analgesia and shortening hospital stay. Any new surgical method should improve safety and outcome. At the beginning of the 21(st) century, the use of natural orifice surgery is a promising progress. The transgastric and transdouglas approaches are currently being investigated and evaluated. The transgastric approach still has a long way to go due to objective problems such as infections, stomach acidity, and the optimal way to ensure the safe closure of gastrotomy. The transdouglas approach, however, is already starting to establish itself and it seems that with the construction of designated instruments it will prevail in the 21(st) century.

Third International Summit: Current status of sleeve gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has been performed for morbid obesity in the past 10 years. LSG was originally intended as a first-stage procedure in high-risk patients but has become a stand-alone operation for many bariatric surgeons. Ongoing review is necessary regarding the durability of the weight loss, complications, and need for second-stage operations.

METHODS

The first International Summit for LSG was held in October 2007, the second in March 2009, and this third in December 2010. There were presentations by experts, and, to provide a consensus, a questionnaire was completed by 88 attendees who had >1 year (mean 3.6 ± 1.5, range 1-8) of experience with LSG.

RESULTS

The results of the questionnaire were based on 19,605 LSGs performed within 3.6 ± 1.5 years (228.8 ± 275.0 LSGs/surgeon). LSG had been intended as the sole operation in 86.4% of the cases; in these, a second-second stage became necessary in 2.2%. LSG was completed laparoscopically in 99.7% of the cases. The mean percentage of excess weight loss at 1, 2, 3, 4, and 5 years was 62.7%, 64.7%, 64.0%, 57.3%, and 60.0%, respectively. The bougie size was 28-60F (mean 36F, 70% blunt tip). Resection began 1.5-7.0 cm (mean 4.8) proximal to the pylorus. Of the surgeons, 67.1% reinforced the staple line, 57% with buttress material and 43% with oversewing. The respondents excised an estimated 92.9% ± 8.0% (median 95.0%) of fundus (i.e., a tiny portion is maintained lateral to the angle of His). A drain is left by 57.6%, usually closed suction. High leaks occurred in 1.3% of cases (range 0-10%); lower leaks occurred in .5%. Intraluminal bleeding occurred in 2.0% of cases. The mortality rate was .1% ± .3%.

CONCLUSION

According to the questionnaire, presentations, and debates, the weight loss and improvement in diabetes appear to be better than with laparoscopic adjustable gastric banding and on par with Roux-en-Y gastric bypass. High leaks are infrequent but problematic.