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

A case-control comparative study between Toupet-Sleeve and conventional sleeve gastrectomy in patients with preoperative gastroesophageal reflux

INTRODUCTION

The aim of that study was to compare outcomes after Toupet-Sleeve (T-Sleeve) and sleeve gastrectomy (SG) as primary bariatric procedures in obese patients presenting with preoperative gastro-esophageal reflux disease (GERD).

MATERIAL AND METHODS

The outcomes of 19 consecutive patients operated between 2017 and 2019 by T-Sleeve were compared to the outcomes of 38 patients operated in 2014 by SG. The two groups were matched by age, sex, ASA classification, BMI, food habits and severity of esophagitis. Postoperative weight loss and evolution of GERD symptoms were the study end-points.

RESULTS

The preoperative BMI was 43 ± 5 in the T-Sleeve and 42 ± 5 in the SG group (NS). All the procedures were completed by laparoscopy. The operative time was higher in the T-Sleeve group: 89 ± 18 vs. 68 ± 12 min. (p < 0.001). A lower weight loss was observed in the T-Sleeve group. Respectively 1 and 2 years after surgery, the mean BMI were: 32 ± 6 and 34 ± 6 in the T-Sleeve vs. 28 ± 5 (p < 0.006) and 30 ± 6 (p < 0.05) in the SG group and the mean %EWL were: 61 ± 23 and 54 ± 26% in the T-Sleeve vs. 86 ± 25 (p < 0.002) and 75 ± 28% (p < 0.03) in the SG group. Better control of GERD was noted in the T-Sleeve group: the number of patients with complete resolution of GERD symptoms was 17 (89%) vs. 13 (34%) in the SG group (p < 0.001).

CONCLUSION

T-Sleeve was an effective procedure for GERD treatment but, the weight loss was significantly much lower than after conventional SG. Studies with longer follow-up are mandatory to validate the T-Sleeve procedure.

Initial radiologic appearance rather than management strategy predicts the outcomes of sleeve gastrectomy leaks

BACKGROUND

Initial radiologic appearance rather than management strategy predicts the outcomes of sleeve gastrectomy leaks.

OBJECTIVE

Multiple modalities have been advocated for the treatment of sleeve gastrectomy leak, and there remains no consensus on the best treatment paradigm. For more than 10 years, we have variably attempted luminal occlusive therapies and repeated endoscopic debridement as treatment options. By evaluating the outcomes from these approaches, we aimed to determine whether the first management strategy is superior to the second in terms of outcomes.

METHODS

Patients were analyzed by group (luminal occlusive therapy versus repeated endoscopic debridement). Leaks were then stratified by radiologic appearance on computed tomography, defined as phlegmon, collection, contrast medium leak, or fistula. The primary outcome was length of stay (LOS). Secondary outcomes were comprehensive complication index and the need for resection.

RESULTS

There were 54 patients, with 22 in the luminal occlusion group and 32 in the repeated debridement group. There was no difference in LOS (59.8 ± 41.6 versus 46.5 ± 51.2 days, P = .179) and no difference in the requirement for resection (4 versus 3 resections, p = .425). Subset analysis suggested that patients who underwent operative versus conservative management (P = .006) had a longer LOS. Excluding management strategy, radiologic appearance on admission significantly predicted LOS (P = .0053). Patients presenting with fistula (84 ± 25.4 days) and contrast medium leak (64.1 ± 40 days) had a significantly longer LOS than those diagnosed with phlegmon (13.5 ± 5.5 days). Radiologic appearance was predictive of complication severity (P < .0001) and salvage resection (P = .008).

CONCLUSION

There was no significant difference in outcomes between patients treated with intraluminal occlusion or repeated debridement. Initial radiologic appearance was predictive of LOS and complication severity. This highlights the need for routine use of a validated classification system in studies reporting outcomes and treatment of sleeve leaks.

A Comprehensive Review of Endoscopic Management of Sleeve Gastrectomy Leaks

BACKGROUND

Bariatric surgery leaks result in significant morbidity and mortality. Experts report variable therapeutic approaches, without uniform guidelines or consensus.

OBJECTIVE

To review the pathogenesis, risk factors, prevention, and treatment of gastric sleeve leaks, with a focus on endoscopic approaches. In addition, the efficacy and success rates of different treatment modalities are assessed.

DESIGN

A comprehensive review was conducted using a thorough literature search of 5 online electronic databases (PubMed, PubMed Central, Cochrane, EMBASE, and Web of Science) from the time of their inception through March 2020. Studies evaluating gastric sleeve leaks were included. MeSH terms related to "endoscopic," "leak," "sleeve," "gastrectomy," "anastomotic," and "bariatric" were applied to a highly sensitive search strategy. The main outcomes were epidemiology, pathophysiology, diagnosis, treatment, and outcomes.

RESULTS

Literature search yielded 2418 studies of which 438 were incorporated into the review. Shock and peritonitis necessitate early surgical intervention for leaks. Endoscopic therapies in acute and early leaks involve modalities with a focus on one of: (i) defect closure, (ii) wall diversion, or (iii) wall exclusion. Surgical revision is required if endoscopic therapies fail to control leaks after 6 months. Chronic leaks require one or more endoscopic, radiologic, or surgical approaches for fluid collection drainage to facilitate adequate healing. Success rates depend on provider and center expertise.

CONCLUSION

Endoscopic management of leaks post sleeve gastrectomy is a minimally invasive and effective alternative to surgery. Their effect may vary based on clinical presentation, timing or leak morphology, and should be tailored to the appropriate endoscopic modality of treatment.

Long-Term Complications of Open Mason's Vertical Banded Gastroplasty at a Single Tertiary Center and Literature Review

Vertical banded gastroplasty (VBG), introduced by Mason in 1982, is now discarded because of important long-term complications and technical difficulties to do revisional surgery. We investigated the long-term complications of VBG in our center and compared it with the literature data. Patients who underwent an open VBG at the University Hospital of Nantes between October 1991 and May 2006 were included. We reviewed preoperative clinical data, long-term outcome in weight loss, complications, and revisional surgeries with a long follow-up. Sixty-three patients (52 women and 11 men) were included, with a mean age of 43 ± 10 years and a body mass index of 46.7 ± 8.3 kg/m. The mean follow-up was 8.2 ± 4.2 years. At the end of follow-up, the mean excess weight loss (EWL) was 29.8%. Long-term success (excess weight loss > 50%) of the procedure was observed in 25 patients (39.7%). A second intervention was performed in 15 patients (23.8%), and three needed a third redo procedure. Six patients (40%) had this new intervention for late complications, and nine (60%) for weight regain. Weight loss is satisfying in the long term although the rate of reintervention is high. Long-term complication can be severe, especially with gastric stenosis that could lead to esophageal cancer. A second reintervention could be technically demanding, especially by laparoscopy, and the patients should be referred to a specialized center.