Previous bariatric surgery increases postoperative morbidity after sleeve gastrectomy for morbid obesity

Innovative Approaches to Address the Technical Challenge of Hernial Sac Distension Due to Pneumoperitoneum in the Synchronous Management of Complex Hernias in Individuals With Morbid Obesity

Although repairing ventral hernias in individuals who have undergone bariatric surgery is a common practice, persistent technical intricacies and controversies surround their management. Concurrently, addressing ventral hernias in morbidly obese patients undergoing bariatric surgery presents a significant surgical challenge, amplified by the larger intraperitoneal cavities and the presence of large hernial sacs. This technical report introduces two innovative techniques to alleviate the challenge of hernia sac distension due to pneumoperitoneum associated with simultaneous bariatric surgery and ventral hernia repair using laparoscopic technique. The methods are designed to address the complexities of the procedures, making their simultaneous execution feasible and safe. The goal is to eliminate the need for two separate interventions while ensuring the outcomes of each procedure remain uncompromised. The larger intraperitoneal cavities and the presence of large hernial sacs are managed successfully, demonstrating the feasibility and safety of the introduced methods. Importantly, the simultaneous execution of both procedures does not compromise the outcomes of either intervention. Concurrently managing ventral hernias in morbidly obese patients undergoing bariatric surgery requires innovative solutions to overcome technical challenges. The introduction of these two novel techniques proves to be a valuable approach, making simultaneous execution feasible and safe. Eliminating the need for two separate interventions streamlines the surgical process without compromising the outcomes of either bariatric surgery or ventral hernia repair.

Hernia repair in the bariatric patient: a systematic review and meta-analysis

BACKGROUND

Repair options for ventral hernias in bariatric patients include performing a staged approach in which bariatric surgery is performed before definitive hernia repair (BS-first), a staged approach in which hernia repair is performed before bariatric surgery (HR-first), or a concomitant approach.

OBJECTIVES

This meta-analysis aims to determine which surgical approach is best for bariatric patients with hernias.

SETTING

PubMed, CENTRAL, and Embase databases.

METHODS

A comprehensive search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to screen for all studies that focused on outcomes of patients who underwent both hernia repair and bariatric surgery, either simultaneously or separately. Exclusion criteria included hiatal and inguinal hernia studies, case reports, and case series.

RESULTS

27 studies fit our inclusion criteria after identifying 1584 studies initially. Seven comparative studies were included, enrolling 8548 staged patients (6458 BS-first) and 3528 concomitant patients. A total of 7 single-arm staged studies and 13 single-arm concomitant studies were also included. Data on hernia recurrence, mesh infection, reoperation, surgical site infections, seroma, bowel complications, and mortality were abstracted. The concomitant approach was associated with decreased odds of experiencing surgical site infections, reoperation, and seromas. The staged approach (BS-first) was associated with decreased odds of mesh infection. The single-arm studies suggest a lower incidence of hernia recurrence in a staged BS-first approach than in a concomitant approach.

CONCLUSIONS

The data suggest a concomitant approach is appropriate for hernias that the surgeon feels do not require mesh, while the staged (BS-first) approach is more appropriate if the hernia requires mesh placement.

Seamguard Buttressing of the Staple Line During Laparoscopic Sleeve Gastrectomy Appears to Decrease the Incidence of Postoperative Bleeding, Leaks, and Reoperations. A Systematic Review and Meta-Analysis of Non-Randomized Comparative Studies

Leaks and bleeding are major acute postoperative complications following laparoscopic sleeve gastrectomy (LSG). Various staple line reinforcement (SLR) methods have been invented such as oversewing/suturing (OS/S), omentopexy/gastropexy (OP/GP), gluing, and buttressing. However, many surgeons do not use any type of reinforcement. On the other hand, surgeons who use a reinforcement method are often confused of what kind of reinforcement they should use. No robust and high-quality data supports the use of one reinforcement over the other or even supports the use of reinforcement over no-reinforcement. Therefore, SLR is a controversial topic that is worth our focus. The aim of this study is to compare the outcomes of LSG with versus without Seamguard buttressing of the staple line during LSG.

Conversion of both Versions of Vertical Banded Gastroplasty to Laparoscopic Roux-en-Y Gastric Bypass: Analysis of Short-term Outcomes

BACKGROUND

Conversional bariatric surgery has relatively high rates of complications. We aimed to analyze our single-center experience with patients requiring conversional laparoscopic Roux-en-Y gastric bypass (LRYGB) following a failed primary open or laparoscopic vertical banded gastroplasty (OVBG or LVBG, respectively).

METHODS

The records of patients who underwent LRYGB as a conversional procedure after VBG between November 2004 and December 2017 were reviewed. Characteristics, body mass index (BMI), operation time, intraoperative problems, length of hospitalization, and early (< 30 days) morbidity and mortality were analyzed. Data were expressed as mean ± standard deviation or frequency.

RESULTS

A total of 329 patients (81.76% females) who underwent conversional RYGB were included. For the LVBG group (224 patients) and OVBG group (105 patients), respectively, BMI was 34.15 ± 6.38 and 37.79 ± 6.31 kg/m2 (p < 0.05), the operation time was 96.00 ± 31.40 and 123.15 ± 40.26 min (p < 0.05), hospitalization duration was 2.96 ± 1.13 and 3.20 ± 1.20 days (p = 0.08), the early complication rate was 7.14 and 11.43% (p = 0.19), and the reoperation rate was 2.23 and 2.86% (p = 0.73). There were no major intraoperative problems. Three patients with OVBG were converted to open RYGB (2.86%). There was no mortality.

CONCLUSION

The conversion of OVBG and LVBG to laparoscopic RYGB is technically feasible and provides comparably low early morbidity rates and length of hospitalization. However, compared to LVBG, conversional laparoscopic RYGB following OVBG is technically more challenging and time-consuming, with a slightly higher risk of conversion to open surgery. We support the use of such conversional bariatric surgery in specialized, high-volume bariatric centers.

Sleeve Gastrectomy After Liver Transplantation: Feasibility and Outcomes

BACKGROUND

Knowledge regarding the feasibility and safety of sleeve gastrectomy (SG) in obese liver transplant recipients is scarce. We report our experience of sleeve gastrectomy following liver transplantation (LT).

METHODS

All patients who had undergone LT and subsequently underwent SG at our institution were retrospectively reviewed. Surgical outcomes, liver and kidney function tests, outcomes of obesity-related comorbidities, and excess weight loss were analyzed.

RESULTS

Between May 2008 and February 2015, six consecutive patients underwent SG after LT. Three procedures (50%) were performed totally by laparoscopy, and three by upfront laparotomy for concomitant incisional hernia complex repair. Within the first 30 days, one complication occurred: early gastric fistula that required multiple endoscopic procedures and re-intervention, followed by death 19 months after SG due to multi-organ failure. Another patient had one late complication: chronic infection on a parietal mesh successfully controlled by mesh removal. Excess weight loss averaged 76% at 2 years with a median BMI of 28 (21-39) kg/m². Median follow-up was 37.2 months (range 13-101 months). Median length of stay was 9 days (range: 6-81 days).

CONCLUSIONS

SG is technically feasible after LT and resulted in weight loss without adversely affecting graft function and immunosuppression. However, morbidity and mortality are high.

Risk factors of perioperative morbimortality after laparoscopic sleeve gastrectomy: a club coelio multicenter study

OBJECTIVES

Postoperative complications after Laparoscopic sleeve gastrectomy (LSG) can dramatically compromise patient's outcome. The aim of this study is to analyze the per- and postoperative short-term outcomes after LSG and to assess predictive risk factors of complications.

METHODS

The study group consisted of 790 patients (610 women and 180 men) who underwent LSG In 2014. All interventions were performed by 18 experienced surgeons members of the Club Coelio. Data about preoperative work-up, surgical techniques, 30-days postoperative morbidity and mortality were collected. Endpoints were perioperative morbidity and mortality and assessment of potential risk factors for complications.

RESULTS

Mean age and body mass index were respectively 39 years and 41.5kg/m². Ninety-one patients (11.5%) had previous bariatric surgery. Morbidity rate was 4.7% (37/790) including 16 leaks (2.0%) and 9 bleedings (1.1%) and no deaths. Risk factors for leak were: previous adjustable banding (p = .0051), with no difference between removal of the banding and LSG in 1 or 2 steps, and type of endostapler (p = .0129).

CONCLUSIONS

Leakage after Sleeve was rare but still observed even in experienced hands. The leak rate is particularly high when LSG is performed after adjustable gastric banding removal.

Clinical and Economic Evaluation of Absorbable Staple Line Buttressing in Sleeve Gastrectomy in High-Risk Patients

BACKGROUND

Gastric leaks and bleeding are the most important complications after laparoscopic sleeve gastrectomy (LSG). The use of absorbable membranes as staple line reinforcement may decrease this risk. On the other hand, these materials bring additional costs and their economic impact is not well known. The purpose of this study was to assess the clinical and economic performance of one of the commercially available buttressing absorbable materials when treating a high-risk population.

METHODS

A retrospective, observational, and comparative study was conducted at Montpellier University Hospital, France, between July 2013 and September 2014. Patients undergoing LSG, who were at a high risk for leaks and bleeding, were included and treated according to two groups: no buttressing (July 2013 to January 2014) and buttressing (February 2014 to September 2014). Clinical and economic outcomes were measured throughout the first 6 months.

RESULTS

Two hundred two patients were included in the study: 116 during the no stapling reinforcement period and 86 during the buttressing period. Baseline characteristics were similar. There was no significant difference between the two groups regarding gastric leaks. However, buttressing reduced hemorrhagic complications (0 vs 8.6 %, p = 0.005) and decreased average total hospital costs for the first hospitalization (5768 vs 6025 €, p < 0.001), as well as 6-month total inpatient cost (5944 vs. 6246 €, p < 0.001).

CONCLUSIONS

Staple line reinforcement with absorbable material reduces bleeding in high-risk population. Therefore, this type of material can also result in cost-savings.

Trends in Bariatric Surgery: Procedure Selection, Revisional Surgeries, and Readmissions

BACKGROUND

There are limited data quantifying national trends, post-operative readmissions, and revisional surgeries for bariatric procedures. We hypothesized that there is a trend away from Roux en Y gastric bypass (RYGB) and laparoscopic adjustable gastric bands (LAGB) in favor of vertical sleeve gastrectomies (VSG). We hypothesized that VSG was associated with fewer revisions and readmissions, and that demographics and comorbidities were associated with surgery received.

METHODS

We used the US-based Premier database, 2008-2013 and 2014 first and second quarters to 1. Examine trends in incidence of RYGB, LAGB and VSG. 2. Quantify occurrence of revisional surgeries and readmissions. 3. Identify predictors of receipt of procedure and of readmissions.

RESULTS

The proportion of VSG increased from 3.0 to 54 % from 2008 to 2014. RYGB decreased from 52 % in 2008 to 32 % by 2014. Earlier year, female sex, white race, western (versus southern) region, and Medicaid predicted receipt of RYGB. Later year, male sex, nonwhite race, northeast or western (versus southern) regions, and insurance type predicted VSG. Readmission was less likely for VSG (OR 0.72, 95 % CI 0.65-0.81), male sex (OR 0.83, 95 % CI 0.72-0.95), and more likely for black race (OR Black vs White 1.2, 95 % CI 1.1-1.4).

CONCLUSIONS

Discharge year strongly predicted surgery type. Females, whites, and Medicaid recipients received RYGB more than referents. Conversely, males, non-whites, and insured patients were more likely to receive VSG. Underinsured, regardless of surgery type, were more likely to be readmitted. These findings have important implications for health policy and cost-containment strategies.

Analysis of Morbidity Data of 308 Cases of Laparoscopic Sleeve Gastrectomy--the Soroka Experience

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) became a prevalent bariatric procedure in Israel, while laparoscopic adjustable gastric banding (LAGB) was losing ground, due to high failure rates (40 % at 10 years). Many patients after LAGB failure choose LSG as a further bariatric surgery (secondary LSG). However, LAGB often impairs upper stomach anatomy and physiology, which may contribute to complications increased risk after secondary LSG, in comparison to surgery-naive obese patients choosing LSG (primary LSG).

METHODS

A retrospective cohort study was conducted on a prospective database, looking at morbidly obese patients for LSG surgery. All procedures were done by a single surgeon at the Soroka Medical Center between January 2008 and March 2013. Data were collected from hospitalization charts on demographics, biometric and bariatric status, medical and bariatric surgical history, post-LSG morbidity, and mortality.

RESULTS

Three hundred eight patients underwent LSG during the study period, 181 (58.8 %) had a primary LSG while 127 (41.2 %) had a secondary LSG. No mortality occurred in both groups. Odds ratio for major complication (leak, stenosis) was 3.12 [CI 0.90-10.75] among the secondary LSG group, compared to the primary LSG (p = 0.071). The risk for major complication was doubled (OR = 2, 95 % CI [1.36-3.06]) for each one of previous bariatric procedure underwent (p = 0.001). Significant differences were found between the two groups regarding number and length of readmissions and number of imaging tests (p value = 0.027, 0.022, and 0.049, respectively).

CONCLUSIONS

Primary LSG is a safe and efficient bariatric procedure. After failed LAGB, secondary LSG should be carefully considered, because of a potentially higher risk of complications.

Revisional Roux-en-Y Gastric Bypass and Sleeve Gastrectomy: a Systematic Review of Comparative Outcomes with Respective Primary Procedures

Though primary bariatric surgery is now firmly established as the first-line treatment for morbid obesity, this is not the case with revisional bariatric surgery. Despite proven benefits and patient demand, revisional bariatric surgery continues to attract controversy. Even though it is widely believed to be riskier and less effective than primary bariatric surgery, there is currently no systematic review in literature addressing this point. This review aims to establish outcomes after revisional bariatric surgery in comparison with those after primary bariatric surgery. Since Roux-en-Y gastric bypass or sleeve gastrectomy is currently the commonest anatomy achieved after revisional bariatric surgery, this review focuses on the outcome of revisional Roux-en-Y gastric bypass and revisional sleeve gastrectomy in comparison with respective primary procedures.

Reduction in early mortality outcomes after bariatric surgery in France between 2007 and 2012: A nationwide study of 133,000 obese patients

BACKGROUND

Early postoperative mortality after bariatric surgery has been reported in large national studies before sleeve gastrectomy (SG) was introduced as a stand-alone procedure. The aim of this study was to investigate the 90-day postoperative mortality rates after bariatric surgery in France on a nationwide basis.

METHODS

All morbidly obese patients who underwent adjustable gastric banding (AGB), gastric bypass (GBP), or SG in France between 2007 and 2012 were included in this study. Multivariate analyses were conducted using the French National Health Service Database data to ascertain predictive factors for 90-day postoperative mortality.

RESULTS

Data from 133,804 patients were analyzed. SG was performed in 36.5% of cases, GBP in 31.2%, AGB in 32.3%, and revisional surgery in 5.1%. The postoperative mortality rate (POM) for the 3 procedures was 0.12%. The rate of POM remained stable for AGB (0.01%), and it decreased from 0.25 to 0.08% and from 0.36 to 0.11% for SG and GBP, respectively. POM was greater among male patients and was associated with age, type-2 diabetes, high blood pressure, body mass index, open surgery, and hospital procedural volume.

CONCLUSION

The rate of early mortality after bariatric surgery was low, and has decreased greatly during the past few years. AGB presents a mortality rate close to nil and SG has a risk of early mortality that is about half that of GBP.