Postoperative pain after conventional laparoscopic versus single-port sleeve gastrectomy: a prospective, randomized, controlled pilot study

Single Incision Versus Conventional Multiport Laparoscopic Sleeve Gastrectomy: Meta-Analysis and Systematic Review

Laparoscopic sleeve gastrectomy (LSG) is the most widely performed bariatric surgery and has been associated with excellent outcomes and a significant reduction in obesity-related morbidity and mortality. Traditionally, this surgery is performed using five to seven trocars. However, LSG performed through a single trocar is emerging as a less invasive method of performing this surgery. This systematic review and meta-analysis compare the outcomes and complication rates of single-port versus multi-port LSG. We searched PubMed, Medline, Scopus, and the Cochrane Library for articles published from 2008 to 2023, in accordance with the PRISMA 2020 guidelines. Data on variables such as operative time, excess weight loss, intraoperative bleeding, postoperative leak, and incisional hernia rates were collected and analyzed using a random-effects model. Fourteen articles met the inclusion criteria and were included in the meta-analysis. No significant differences were found between the single-port LSG (SILSG) and conventional LSG (CLSG) groups in terms of operative time, rate, intraoperative complications, length of hospital stay, postoperative complications, and excess weight loss (EWL). Furthermore, single incision sleeve gastrectomy showed better satisfaction with the cosmetic score. SILSG is a viable alternative procedure, showing comparable outcomes to multiport conventional sleeve gastrectomy, in addition, to a better cosmetic satisfaction score.

Trocar number and placement for laparoscopic sleeve gastrectomy and comparison of single-incision and conventional laparoscopic sleeve gastrectomy: a systematic review and meta-analysis

BACKGROUND

Conventional laparoscopic sleeve gastrectomy (CLSG) has been conducted in multiple centers for treating morbid obesity, however, there are no standard criteria for (1) placing the trocar; and (2) how many trocars should be used. Single-incision laparoscopic sleeve gastrectomy (SLSG), a newly emerged technique in 2008, has been proposed as an alternative to CLSG in recent years, however, there is no definite evidence for this.

MATERIALS AND METHODS

A systematic literature search was performed using the PubMed, Embase, Web of Science, and Cochrane Library databases for laparoscopic sleeve gastrectomy cases from January 2006 to October 2022. We then summarized the trocar numbers and placement patterns among these studies. A meta-analysis was conducted to compare the difference between SLSG and CLSG in the perioperative and postoperative indices.

RESULTS

A total of 61 studies involving 20 180 patients who underwent laparoscopic sleeve gastrectomy for treating morbid obesity were included in the systematic review, including 11 on SLSG, 35 on CLSG, and 15 studies comparing SLSG and CLSG. A systematic review showed that the trocar number varied in different CLSG studies, mainly using four or five trocars. The trocars were mainly placed in position, presenting an inverted trapezoid pattern and a left-predominant pattern. Meta-analysis showed that the operative time in the SLSG was significantly higher than that in the CLSG, and the pain Visual Analog Scale rating on postoperative day 1 in the CLSG was significantly higher than in the SLSG. There were no statistical significances in the other complications or surgical efficiency.

CONCLUSIONS

In the CLSG, the majority of the trocars were arranged in an inverted trapezoid pattern and were of the left-predominant type. Although SLSG is a feasible technique in selected patients, there is insufficient evidence to recommend its widespread use compared with CLSG. High-quality randomized controlled trials with large study populations and long follow-up periods will be required in the future.

Magnetic device in reduced port and single port bariatric surgery: First 170 cases experience

INTRODUCTION

Magnetic devices have been successfully used in bariatric surgery. To the date, the only reported use of the magnet was for liver retraction. Our purpose in this study is to demonstrate the safety and viability of using a magnetic system in different steps in single port and reduced port bariatric surgery.

METHODS

Prospective and observational study was performed. Patients older than 18 years, undergoing primary laparoscopic sleeve gastrectomy (SG), one-anastomosis gastric bypass (OAGB), and Roux-en-Y gastric bypass (RYGB) or revisional surgery by single-port or reduced-port approach between July 2020 and June 2021 were included.

RESULTS

A total of 170 patients (mean BMI, 41.47kg/m²; mean age 36.92 yrs) completed laparoscopic bariatric surgery (54 single-port sleeve gastrectomy [SPSG], 16 reduced-port SG, 83 RYGB, 4 OAGB and 14 revision surgeries), using the magnetic surgical system in different steps of the surgery. Mean surgical time for SPSG and reduced-port SG was 65.52min and 59.36min respectively; and for RYGB 74.19min, OAGB 70.98min, and revisional surgeries 88.38min. As for intraoperative complications, 2.94% mild liver laceration without significant bleeding was reported. There were no 30-day mortalities and no major complications.

CONCLUSION

Magnetic assistance in single-port and reduced-port bariatric surgery is an innovative technique. With this prospective study we attempt to demonstrate the safety profile and potential uses that may improve the implementation of new surgical approaches in bariatric surgery.

Immediate postoperative pain does not predict pain at home after ambulatory single-port sleeve gastrectomy

PURPOSE

Single-port sleeve gastrectomy (SPSG) is increasingly performed in an ambulatory setting. Pain intensity when returning home remains a problem. The challenge is to be able to predict the evolution of postoperative pain (POP) at home by using parameters collected during the hospital stay. This study aimed to investigate whether immediate POP in the postanesthesia care unit (PACU) can predict pain intensity 24 h after surgery.

METHODS

Single-center retrospective study in patients with obesity who underwent ambulatory SPSG. POP and opiate requirements during PACU stay were registered. Patients were followed up at home during the first 4 postoperative days. The primary outcome was the correlation between opiate requirements in the PACU and Numerical Rating Scale (NRS) at home 24 h after surgery. Secondly, logistic regression was used to identify risk factors for moderate/intense pain 24 h after surgery.

RESULTS

Ninety-four patients were included during the study period. Twenty-two patients had NRS > 3/10 24 h after surgery. No correlation was found between the total dose of morphine in the PACU and pain intensity 24 h after surgery (r² =  - 0.07; P = 0.49). No predictive factor for moderate/intense pain 24 h after surgery was found.

CONCLUSION

No correlation was found between opiate requirements in the PACU and pain at home 24 h after SPSG. Based on these results, it does not seem possible to predict intense pain at home from pain profile and morphine requirement during the immediate postoperative period.

Magnetic device in reduced port and single port bariatric surgery: First 170 cases experience

INTRODUCTION

Magnetic devices have been successfully used in bariatric surgery. To the date, the only reported use of the magnet was for liver retraction. Our purpose in this study is to demonstrate the safety and viability of using a magnetic system in different steps in single port and reduced port bariatric surgery.

METHODS

Prospective and observational study was performed. Patients older than 18 years, undergoing primary laparoscopic sleeve gastrectomy (SG), one-anastomosis gastric bypass (OAGB), and Roux-en-Y gastric bypass (RYGB) or revisional surgery by single-port or reduced-port approach between July 2020 and June 2021 were included.

RESULTS

A total of 170 patients (mean BMI, 41.47kg/m2; mean age 36.92 yrs) completed laparoscopic bariatric surgery (54 single-port sleeve gastrectomy [SPSG], 16 reduced-port SG, 83 RYGB, 4 OAGB and 14 revision surgeries), using the magnetic surgical system in different steps of the surgery. Mean surgical time for SPSG and reduced-port SG was 65.52min and 59.36min respectively; and for RYGB 74.19min, OAGB 70.98min, and revisional surgeries 88.38min. As for intraoperative complications, 2.94% mild liver laceration without significant bleeding was reported. There were no 30-day mortalities and no major complications.

CONCLUSION

Magnetic assistance in single-port and reduced-port bariatric surgery is an innovative technique. With this prospective study we attempt to demonstrate the safety profile and potential uses that may improve the implementation of new surgical approaches in bariatric surgery.

A randomized controlled trial of single-port versus multi-port laparoscopic distal gastrectomy for gastric cancer

OBJECTIVE

This prospective randomized trial compared the invasiveness of laparoscopic gastrectomy using a single-port approach with that of a conventional multi-port approach in the treatment of gastric cancer. The benefit of single-port laparoscopic gastrectomy (SLG) over multi-port laparoscopic gastrectomy (MLG) has yet to be confirmed in a well-designed study.

METHODS

One hundred and one patients who were scheduled to undergo laparoscopic distal gastrectomy for histologically confirmed clinical stage I gastric cancer between April 2016 and September 2018 were randomly allocated to SLG (n = 50) or MLG (n = 51). The primary endpoints were the postoperative visual analog scale pain scores. Secondary endpoints were frequency of use of analgesia, short-term outcomes, such as operating time, intraoperative blood loss, inflammatory reactions, postoperative morbidity, and 90-day mortality.

RESULTS

The postoperative pain score was significantly lower in the SLG group than in the MLG group (p < 0.001) on the operative day and the postoperative day 1-7. Analgesics were administered significantly less often in the SLG group than in the MLG group (1 vs. 3 days, p = 0.0078) and the duration of use of analgesics was significantly shorter in the SLG group (2 vs. 3 days, p = 0.0171). The operating time was significantly shorter in the SLG group than in the MLG group (169 vs. 182 min, p = 0.0399). Other surgical outcomes were comparable between the study groups.

CONCLUSIONS

SLG was shown to be safe and feasible in the treatment of gastric cancer with better short-term results in terms of less severe pain and may be suitable for treatment of cStage I gastric cancer.

CLINICAL TRIAL REGISTRATION

UMIN000022218.

Outcomes of endoscopic sleeve gastroplasty; how does it compare to laparoscopic sleeve gastrectomy? A systematic review and meta-analysis

Background and study aims Endoscopic sleeve gastroplasty (ESG) is a novel moderately invasive technique in endo-bariatrics as compared to laparoscopic sleeve gastrectomy (LSG). Data is limited as to its efficacy and safety.

Methods We searched multiple databases from inception through August 2019 to identify studies that reported on ESG in the treatment of obesity. Our goals were to calculate the pooled rates of total weight loss (%TWL), excess weight loss (%EWL), and body mass index (BMI) at 1 month, 6 months, and 12 months with ESG. We included studies that reported on LSG, in a similar time frame as ESG, and compared the 12-month outcomes.

Results From eight studies on ESG (1815 patients), the pooled rates of %TWL at 1 month, 6 months, and 12 months were 8.7 (7.2–10.2), 15.3 (14.1–16.6) and 17.1 (15.1–19.1), respectively. The pooled rates of %EWL at 1 month, 6 months, and 12 months were 31.7 (29.3–34.1), 59.4 (57–61.8) and 63 (51.3–74.6), respectively. The pooled rates of BMI at 1 m, 6 m, and 12 m were 32.6 (31–34.3), 30.4 (29–31.8) and 30 (27.7–32.3, I2 = 97), respectively. At 12 months, the pooled %TWL, %EWL and BMI with LSG (7 studies, 2179 patients) were 30.5 (27.4–33.5), 69.3 (60.1–78.4) and 29.3 (27.1–31.4) respectively. On comparison analysis, %TWL with LSG was superior to ESG (P = 0.001). %EWL and BMI were comparable. All adverse events, bleeding and gastro-esophageal reflux disease were significantly lower with ESG when compared to LSG.

Conclusion ESG demonstrates acceptable weight loss parameters and seems to have a better safety profile when compared to LSG.

Comparison of Single-Incision and Conventional Laparoscopic Sleeve Gastrectomy for Morbid Obesity: a Meta-Analysis

BACKGROUND

Single-incision laparoscopic sleeve gastrectomy (SILSG) has been proposed as an alternative to conventional laparoscopic sleeve gastrectomy (CLSG) in obese patients. This study aims to compare the surgical outcomes of these two techniques.

METHODS

A meta-analysis of existing literature obtained through a systematic literature search in the PubMed, EMBASE, and Cochrane Library CENTRAL databases from 2009 to 2019 was conducted.

RESULTS

Eleven articles including 1168 patients were analyzed. Patients in the SILSG group reported greater satisfaction with cosmetic scar outcomes than those in the CLSG group (SMD = 2.47, 95% CI = 1.10 to 3.83, P = 0.00). There was no significant difference between the SILSG group and the CLSG group regarding operative time, intraoperative estimated blood loss, conversion rate, intraoperative complications, length of hospital stay, postoperative analgesia, postoperative complications, excess weight loss (EWL), and improvements in comorbidities (P > 0.05).

CONCLUSIONS

Compared to CLSG, SILSG resulted in improved cosmetic satisfaction and showed no disadvantages in terms of surgical outcomes; thus, SILSG can serve as an alternative to CLSG for obese patients. Nonetheless, high-quality randomized controlled trials (RCTs) with large study populations and long follow-up periods are needed.

Effect of Trocar Site Bupivacaine Administration, Time of First Passage of Flatus, and Duration of the Surgery on Postoperative Pain After Sleeve Gastrectomy: a Case Control Study

INTRODUCTION

The effect of local anesthetic applications to trocar sites on postoperative pain control has been studied many times, and different results have been obtained. We planned a controlled study evaluating the effect of bupivacaine administration and other contributing factors on postoperative pain following sleeve gastrectomy.

MATERIAL AND METHODS

Patients who underwent laparoscopic sleeve gastrectomy were included in the study. Patients were randomized into two groups according to local application as either a local or non-local group. Also, the patients were grouped separately from local group allocation according to time to first passage of flatus (< 12 h, ≥ 12 h) and duration of surgery (> 50 min, ≤ 50 min). A visual analogue scale (VAS) was performed at 4, 8, 12, 24, and 48 h postoperatively. Opioid analgesics (pethidine HCl) were administered if the patient's VAS score was greater than 5. Demographic characteristics, such as age, gender, height, weight, body mass index (BMI), and operative time, were recorded. Demographic characteristics and VAS scores were compared between groups.

RESULTS

A total of 168 patients were included in the study. Of these, 84 patients were included in both of the local and non-local groups. The demographic characteristics between groups were similar. There was no significant difference between groups in terms of VAS scores (p > 0.05). In the analysis according to the time to first passage of flatus, the 48th-hour VAS scores were lower in the early flatus group (p = 0.036). According to the duration of surgery, first flatus was detected earlier, and VAS scores at the 8th and 12th hours were less in the short operation group (p < 0.001, p = 0.005, p = 0.031, respectively).

DISCUSSION

Although we did not show any effect of local administration of bupivacaine in LSG on pain, we concluded that other factors like duration of surgery and first flatus time have an impact on this issue.

European association for endoscopic surgery (EAES) consensus statement on single-incision endoscopic surgery

Background

Laparoscopic surgery changed the management of numerous surgical conditions. It was associated with many advantages over open surgery, such as decreased postoperative pain, faster recovery, shorter hospital stay and excellent cosmesis. Since two decades single-incision endoscopic surgery (SIES) was introduced to the surgical community. SIES could possibly result in even better postoperative outcomes than multi-port laparoscopic surgery, especially concerning cosmetic outcomes and pain. However, the single-incision surgical procedure is associated with quite some challenges.

Methods

An expert panel of surgeons has been selected and invited to participate in the preparation of the material for a consensus meeting on the topic SIES, which was held during the EAES congress in Frankfurt, June 16, 2017. The material presented during the consensus meeting was based on evidence identified through a systematic search of literature according to a pre-specified protocol. Three main topics with respect to SIES have been identified by the panel: (1) General, (2) Organ specific, (3) New development. Within each of these topics, subcategories have been defined. Evidence was graded according to the Oxford 2011 Levels of Evidence. Recommendations were made according to the GRADE criteria.

Results

In general, there is a lack of high level evidence and a lack of long-term follow-up in the field of single-incision endoscopic surgery. In selected patients, the single-incision approach seems to be safe and effective in terms of perioperative morbidity. Satisfaction with cosmesis has been established to be the main advantage of the single-incision approach. Less pain after single-incision approach compared to conventional laparoscopy seems to be considered an advantage, although it has not been consistently demonstrated across studies.

Conclusions

Considering the increased direct costs (devices, instruments and operating time) of the SIES procedure and the prolonged learning curve, wider acceptance of the procedure should be supported only after demonstration of clear benefits.