Complications associated with laparoscopic sleeve gastrectomy for morbid obesity: a surgeon's guide

Mitochondrial oxygen metabolism as a potential predictor of weight loss after laparoscopic sleeve gastrectomy for class III obesity

The prevalence of obesity is increasing at an alarming rate in industrialized countries. Obesity is a systemic disease that causes not only macroscopic alterations, but also mitochondrial dysfunction. Laparoscopic sleeve gastrectomy (LSG) poses a potential therapeutic option for patients with severe obesity. In order to ascertain the efficacy of bariatric interventions, it is important to assess not only weight loss, but also changes in body composition. Additionally, the aim of this study was to investigate the association between weight loss and cellular oxygen metabolism, a surrogate for mitochondrial function. We used bioimpedance analysis (BIA) to assess changes in weight and body composition in patients up to one year after LSG. To evaluate mitochondrial oxygen metabolism, we used the Cellular Oxygen Metabolism Monitor (COMET) to non-invasively measure the mitochondrial oxygen tension (mitoPO2), mitochondrial oxygen consumption (mitoVO2) and mitochondrial oxygen delivery (mitoDO2). We compared the values obtained in patients with obesity with those of age- and sex-matched healthy controls and investigated changes up to one year after LSG. 48 patients (46.5 years [35.5-55.3]; 38/48 female (79.2%); BMI 46.7 [42.5-51.0]) completed the study. They showed a significant weight loss and a decrease in relative fat mass after six months. We found no differences in mitochondrial oxygen metabolism between obese patients and healthy controls. MitoPO2, mitoVO2 and mitoDO2 did not change up to one year after surgery. It is noteworthy that patients who exhibited higher mitoPO2, mitoVO2, and mitoDO2 values prior to surgery demonstrated superior weight loss outcomes one year after LSG. This was the first study to investigate the non-invasively measured mitochondrial oxygen metabolism in the long-term course after bariatric surgery. Further studies in larger cohorts are needed to confirm these findings.

Clinical trial registration

https://www.bfarm.de/DE/Das-BfArM/Aufgaben/Deutsches-Register-Klinischer-Studien/_node.html, identifier DRKS00015891.

Integrated Insights into Metabolic and Bariatric Surgery: Improving Life Quality and Reducing Mortality in Obesity

Metabolic and bariatric surgery (MBS) is an effective intervention for patients with severe obesity and metabolic comorbidities, particularly when non-surgical weight loss methods prove insufficient. MBS has shown significant potential for improving quality of life and metabolic health outcomes in individuals with obesity, yet it carries inherent risks. Although these procedures offer a multifaceted approach to obesity treatment and its clinical advantages are well-documented, the limited understanding of its long-term outcomes and the role of multidisciplinary care pose challenges. With an emphasis on quality-of-life enhancements and the handling of postoperative difficulties, the present narrative review seeks to compile the most recent findings on MBS while emphasizing the value of an integrated approach to maximize patient outcomes. Effective MBS and patients' management require a collaborative team approach, involving surgeons, dietitians, psychologists, pharmacists, and other healthcare providers to address not only physiological but also psychosocial patient needs. Comparative studies demonstrate the efficacy of various MBS methods, including Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy that may considerably decrease morbidity and mortality in individuals with obesity. Future studies should target long-term patient treatment, and decision making should be aided by knowledge of obesity, comorbidity recurrence rates, and permanence of benefits.

Assessment of arterial supply to the stomach after bariatric surgery using multidetector CT arteriography

PURPOSE

To describe residual arterial supply to the stomach after bariatric surgery via a systematic arterial-phase CT assessment approach that can aid in diagnosis and treatment of postoperative complications and facilitate planning for future procedures.

METHODS

Arterial-phase CT of 46 patients who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) at 3 academic institutions were retrospectively reviewed to assess patency of left gastric artery (LGA), right gastric artery (RGA), gastroepiploic artery (GEA), and left inferior phrenic artery (LIPA) and presence of gastric perforators.

RESULTS

In 25 RYGB and 21 SG patients, mean diameters were LGA 2.2 ± 0.4 mm, RGA 1.6 ± 0.5 mm, and GEA 1.7 ± 0.4 mm. On RYGB scans, all LGAs, RGAs, and 24/25 (96%) of GEAs were identified. Excellent to good patency was seen in 20/25 (80%) LGAs, 21/25 (84%) RGAs, and 23/24 (96%) GEAs. On SG scans, all LGAs, 18/21 (86%) of RGAs, and 20/21 (95%) GEAs were identified. Excellent to good patency was seen in 17/21 (81%) LGAs, 15/18 (83%) RGAs, and 20/20 (100%) GEAs. In terms of gastric perforators, LGA supply was seen on 23/25 (92%) of RYGB and 17/17 (100%) of SG scans. RGA supply was seen on 13/21 (62%) RYGB and 9/18 (50%) SG scans. GEA supply was seen on 19/23 (83%) RYGB scans. No gastric supply via GEA was seen on SG scans.

CONCLUSION

In this study, arterial supply to the stomach through the LGA was consistently identified in all RYGB and SG cases, indicating an uncomplicated surgical approach with regard to preserving the LGA. Dedicated CT angiography protocol or catheter-directed angiography is recommended for accurate and comprehensive assessment of the gastric blood supply, particularly before surgical re-intervention.

Comparable improvement and resolution of obesity-related comorbidities in endoscopic sleeve gastroplasty vs laparoscopic sleeve gastrectomy: single-center study

BACKGROUND

Despite excellent surgical outcomes, a minority of qualified patients undergo weight loss surgery. Endoscopic Sleeve Gastroplasty (ESG), an incisionless procedure, has proven to be effective in achieving weight loss and comorbidity improvement. We aim to compare outcomes of ESG to those of Laparoscopic Sleeve Gastrectomy (LSG).

METHOD

A retrospective review of a prospective database of patients who underwent ESG and LSG at NorthShore University HealthSystem from 2016 to 2023 was completed. Demographic and outcome data were analyzed. Pre- and post-surgical data were compared using chi-square and two-sample t tests. Improvement or resolution of obesity-related comorbidities were also assessed.

RESULTS

A total of 212 LSG and 68 ESG patients were reviewed. ESG patients were older (47 ± 10 vs. 43 ± 12, p = 0.006) and less obese (BMI 37.0 ± 5.5 vs. 45.8 ± 0.4, p < 0.001) than LSG patients. Median length of stay after ESG was 0 days and after LSG 1 day (p < 0.001). Severe adverse events were seen less frequent after ESG (1.47%, vs 3.77%). LSG achieved more significant %TBWL at 6 months (25.2 ± 8.9 vs 14.9 ± 7.4), 1 year (27.5 ± 10.8 vs 14.1 ± 9.8), and 2 years (25.7 ± 10.8 vs 10.5 ± 8.8, all p < 0.001) after surgery when compared to ESG. LSG achieved significantly greater %EWL compared to ESG at 6 months (57.0 ± 20.7 vs 50.4 ± 29.2, p = 0.137), 1 year (61.4 ± 24.6 vs 46.5 ± 34.0, p = 0.026), and 2 years postoperatively (59.7 ± 25.5 vs 32.6 ± 28.2, p = 0.001). There were no statistically significant differences in rates of improvement or resolution of diabetes, obstructive sleep apnea, hyperlipidemia, or hypertension.

CONCLUSION

ESG is an effective procedure for weight loss and comorbidity resolution. Obesity-related comorbidities are comparably improved and resolved following ESG vs LSG. Although the weight loss in LSG is significantly higher, patients can expect a shorter hospital length of stay and a lower rate of complications after ESG. ESG continues to show promise for long-term weight loss and improvement in health.

Ligamentum Teres Augmentation for Hiatus Hernia Repair After Bariatric Surgery: A Systematic Review and Meta-analysis

OBJECTIVE

Hiatal hernia (HH) and symptomatic gastroesophageal reflux disease are common complications after metabolic bariatric surgery. This meta-analysis aims to investigate the safety and efficacy of ligamentum teres augmentation (LTA) for HH repair after metabolic and bariatric surgeries (MBS).

MATERIALS AND METHODS

CENTRAL, Embase, PubMed, and Scopus were searched for articles from their inception to September 2023 by 2 independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis system.

RESULTS

Five studies met the eligibility criteria, with a total of 165 patients undergoing LTA for HH repair after MBS. The distribution of patients based on surgical procedures included 63% undergoing sleeve gastrectomy, 21% Roux-en-Y gastric bypass, and 16% having one anastomosis gastric bypass. The pooled proportion of reflux symptoms before LTA was 77% (95% CI: 0.580-0.960; I2 = 89%, n = 106). A pooled proportion of overall postoperative symptoms was 25.6% (95% CI: 0.190-0.321; I2 = 0%, n = 44), consisting of reflux at 14.5% (95% CI: 0.078-0.212; I2 = 0%, n = 15). The pooled proportion of unsuccessful LTA outcomes was 12.5% (95% CI: 0.075-0.175; I2 = 0%, n = 21).

CONCLUSION

Our meta-analysis demonstrated that LTA appears to be a safe and efficacious procedure in the management of HH after MBS.

Reoperation After Loop Duodenojejunal Bypass with Sleeve Gastrectomy: A 9-Year Experience

PURPOSE

Loop duodenojejunal bypass with sleeve gastrectomy (LDJBSG) is effective for weight loss and resolution of obesity-related associated medical problems. However, a description of the reoperative surgery following LDJBSG is lacking.

MATERIAL AND METHODS

In this retrospective study, we analyzed the surgical complications and reoperation (conversion or revision) following LDJBSG from 2011 to 2019 in a single institution.

RESULTS

A total of 337 patients underwent LDJBSG during this period. Reoperative surgery (RS) was required in 10LDJBSG patients (3%). The mean age and BMI before RS were 47 ± 9 years and 28.9 ± 3.6 kg/m2, respectively. The mean interval between primary surgery and RS for early (n = 5) and late (n = 5)complications was 8 ± 11 days and 32 ± 15.8 months, respectively. The conversion procedures were Roux-en-Y gastric bypass(n = 5), followed by Roux-en-Y duodenojejunal bypass (n = 2) and one-anastomosis gastric bypass (n = 1); other revision procedures were seromyotomy (n = 1) and re-laparoscopy (n = 1). Perioperative complications were observed in four patients after conversion surgery such as multiorgan failure (n = 1), re-laparoscopy (n = 1), marginal ulcer (n = 1), GERD (n = 1), and dumping syndrome (n = 1).

CONCLUSION

LDJBSG has low reoperative rates and conversion RYGB could effectively treat the early and late complications of LDJBSG. Because of its technical demands and risk of perioperative complications, conversion surgery should be reserved for a selected group of patients and performed by an experienced metabolic bariatric surgical team.

Primary Repair of Gastrobronchial Fistula Presenting 12 Years Post Uncomplicated Laparoscopic Sleeve Gastrectomy

Background

Obesity is an alarmingly increasing global public health issue. Laparoscopic sleeve gastrectomy (LSG) is the most common bariatric surgery owing to its simplicity, effectiveness, and low complication rates. The complications can be classified as early or late, with fistula formation being one of the most severe complications. Here, we report a rare gastrobronchial fistula (GBF) that presented 12 years post LSG.

Case Presentation

A 34-year-old woman who underwent LSG in 2011 was referred to our institution. The patient complained of recurrent upper respiratory tract infections, nausea, and vomiting. Abdominal computed tomography (CT) with oral contrast showed abnormal fistulous communication between the fundus and left lung. Conservative management was initiated but failed multiple times. After counseling the patient on the surgical options, she underwent fistula removal and primary repair of the fundus with a healthy omental wrap and an omental diaphragmatic flap. She tolerated the procedure well, recovered uneventfully, and was discharged on postoperative day 7.

Conclusion

GBF diagnosis is challenging. Imaging studies, such as CT and radiography with contrast and endoluminal diagnosis with esophagogastroduodenoscopy (EGD), bronchoscopy, and bronchial secretion analysis, aid in the diagnosis. GBF management requires a multidisciplinary team. Patients should be initially offered conservative management with the understanding that reoperation would be the only option if failure is seen for 3 months.

Ileum Obstruction Following Appendix Adhesion Band after Sleeve Surgery: A Case Report and Review of Literature

Sleeve gastrectomy is a popular surgical procedure for weight loss. Although it is basically a safe surgery; however, it can lead to serious complications such as intestinal obstruction. The present report describes a 55-year-old woman who attended with complications of abdominal pain and vomiting that underwent laparoscopic exploratory intervention and ileum obstruction due to adherent bands of the appendix was considered as final diagnosis.

Endoscopic Management of Post-Sleeve Gastrectomy Complications

Obesity is associated with several chronic conditions including diabetes, cardiovascular disease, and metabolic dysfunction-associated steatotic liver disease and malignancy. Bariatric surgery, most commonly Roux-en-Y gastric bypass and sleeve gastrectomy, is an effective treatment modality for obesity and can improve associated comorbidities. Over the last 20 years, there has been an increase in the rate of bariatric surgeries associated with the growing obesity epidemic. Sleeve gastrectomy is the most widely performed bariatric surgery currently, and while it serves as a durable option for some patients, it is important to note that several complications, including sleeve leak, stenosis, chronic fistula, gastrointestinal hemorrhage, and gastroesophageal reflux disease, may occur. Endoscopic methods to manage post-sleeve gastrectomy complications are often considered due to the risks associated with a reoperation, and endoscopy plays a significant role in the diagnosis and management of post-sleeve gastrectomy complications. We perform a detailed review of the current endoscopic management of post-sleeve gastrectomy complications.

The Association Between Appetite and Quality of Life in Adults with Obesity or Severe Obesity Post-Sleeve Gastrectomy Procedure: A Cross-Sectional Study

Background

Sleeve gastrectomy (SG) is considered as the most common bariatric procedure in Saudi Arabia. It is a non-reversible procedure defined as removal of a large portion of the stomach.

Objective

The objective of the current study is to compare the appetite and quality of life (QoL) between adults' post-sleeve gastrectomy and obese/morbidly obese adults (pre-SG).

Methods

A cross-sectional study design was conducted in adults (aged between 18 and 65 years), post-sleeve gastrectomy (n = 80, 41 Males and 39 Females) and obese group (n = 60, 28 Males and 32 Females). The study population was recruited from the bariatric surgery clinic of King Abdullah Bin Abdul-Aziz University Hospital. A self-reported questionnaire was collected that included a visual analogue scale (VAS) to assess the appetite level, and SF-36 QoL questionnaire.

Results

No significant differences were found in age and gender between the study groups (p > 0.05). The median score feeling of fullness was significantly higher in the SG group (77.5, IQR: 48 and 50, IQR: 40, respectively) than in the obese group (p < 0.001). The amount of food eaten was statistically lower in the SG group (30, IQR: 20) than the obese group (50, IQR: 60) (p = 0.005). Patients post SG had significantly higher QoL scores in all physical and mental scales, physical component summary and mental component summary (p < 0.003).

Conclusion

Patients post SG have improved appetite and QoL. Satiety, less prospective food consumption, BMI, age, gender and comorbidities are associated with QoL. Future studies are needed to compare the QoL in post-SG patients with the normative values of the QoL in Saudi Arabia.

Magnetic anchoring device assisted-laparoscopic sleeve gastrectomy versus conventional laparoscopic sleeve gastrectomy: A retrospective cohort study

Background

Bariatric surgeries, including the sleeve gastrectomy, have been recognized as the most effectively treatment strategy for severe obesity. Magnetic devices have been successfully used in bariatric surgeries. Here, we intended to evaluate the safety and efficiency of magnetic anchoring device assisted-laparoscopic sleeve gastrectomy (MLSG), and to make a comparison of the short-term results between conventional laparoscopic sleeve gastrectomy (CLSG) and MLSG.

Methods

The retrospective cohort study was carried out by analyzing and summarizing the data from a database of routinely collected data. The cohort included the patients who underwent either CLSG (n = 120) or MLSG (n = 115) at a single center between January 2018 and December 2020 with a two-year follow-up. The effects of these two surgeries on the weight loss, resolution of comorbidities and quality of life (QOL) were analyzed.

Results

The two groups were similar in gender, age, body mass index, abdominal girth, as well as the type and proportion of comorbidities. And the cases in MLSG group had a markedly shorter time of operation (MLSG, 72.59 min vs. CLSG, 76.67 min; P = 0.003). Length of stay in hospital was significantly shorter in the MLSG group than that in the CLSG group (MLSG, 5.59 days vs. CLSG, 5.96 days; P = 0.016). Neither fatal event nor conversion to open surgery happened among all cases. There were no differences in terms of the postoperative complications between the two groups. Magnetic device-related mild hepatic lacerations occurred and were handled by hemostatic treatments in 3 cases. The QOL of patients in MLSG was better at 6-month after surgery, but there was no significant difference between the two groups at 1-year or 2-year after surgery.

Conclusion

Both MLSG and CLSG prove safe and effective, and the patients underwent MLSG have a shorter length of stay in hospital, and a better QOL during 6 months after surgery.

Does Omentopexy Make a Difference in Laparoscopic Sleeve Gastrectomy for Obesity Treatment? A Systematic Review and Meta-Analysis

This systematic review and meta-analysis aimed to evaluate the comparative outcomes of laparoscopic sleeve gastrectomy with omentopexy (LSGO) versus conventional laparoscopic sleeve gastrectomy (LSG) for obesity treatment. A systematic online search was conducted using the available online databases, and Revman software was used for data analysis. Twenty-two eligible comparative studies were included (n = 9,321). LSGO showed a significantly lower rate of gastric leak (P = 0.0001), staple line bleeding (P = 0.00001), and gastric torsion (P = 0.002) in comparison to the LSG group. Operative time was significantly shorter in the LSG group (P = 0.00001); however, the length of hospital stay was in favour of the LSGO (P = 0.00001). Compared to LSG without omentopexy, LSG with omentopexy provides a significantly lower rate of postoperative complications and shorter LOS at the expense of operative time.

Incidence of Kidney Stones After Bariatric Surgeries: Comparing Roux-en-Y Gastric Bypass and Sleeve Gastrectomy

INTRODUCTION/PURPOSE

The two most common procedures performed to treat obesity are Roux-En-Y gastric bypass (RNYGB) and laparoscopic sleeve gastrectomy (LSG). Due to changes in enteric absorption, bariatric surgery increases rates of nephrolithiasis. As population-based data are limited, we aimed to compare the incidence of kidney stones after RNYGB and LSG.

MATERIALS AND METHODS

We queried Explorys (Cleveland, OH), a database that aggregated data from 26 healthcare systems. We identified patients who were newly diagnosed with nephrolithiasis 3, 6, and 12 months after their RNYGB or LSG. Additionally, a multivariate analysis was conducted to investigate the association of nephrolithiasis with RNYGB as compared to LSG. This analysis adjusted for other risk factors, including age above 65, male gender, Caucasian race, diabetes mellitus, hypertension, primary hyperparathyroidism, gout, and obesity.

RESULTS

From 1999 to 2019, there were 11,480 patients who underwent RNYGB and 22,770 patients who underwent LSG. The incidence of nephrolithiasis in the RNYGB cohort at all three time points was higher than in the LSG cohort (3 months, 7.1% vs. 2.4%; 6 months, 6.6% vs. 2.0%; 1 year, 5.8% vs. 1.4%; P < 0.001). After the multivariate analysis, it was found that, though both RNYGB and LSG were independently associated with the development of nephrolithiasis, the risk of nephrolithiasis was higher in those who underwent RNYGB compared to those who underwent LSG (OR 1.594, 95% CI 1.494 to 1.701, P < 0.001).

CONCLUSION

RNYGB is associated with a higher risk of nephrolithiasis when compared to LSG.

Portomesenteric Vein Thrombosis in Patients Undergoing Sleeve Gastrectomy: an Updated Systematic Review and Meta-Analysis of 101,914 Patients

INTRODUCTION

Portomesenteric vein thrombosis (PMVT) is a rare but potentially fatal complication of sleeve gastrectomy (SG). The rising prevalence of SG has led to a surge in the occurrence of PMVT, while the associated risk factors have not been fully elucidated. This study aims to determine the incidence and risk factors of PMVT in patients undergoing SG.

METHODS

A comprehensive literature search was performed in PubMed and EMBASE databases. Proportion and regression meta-analyses were conducted.

RESULTS

In a total of 76 studies including 101,914 patients undergoing SG, we identified 357 patients with PMVT. Mean follow-up was 14.4 (SD: 16.3) months. The incidence of PMVT was found to be 0.50% (95%CI: 0.40-0.61%). The majority of the population presented with abdominal pain (91.8%) at an average of 22.4 days postoperatively and PMVT was mainly diagnosed with computed tomography (CT) (96.0%). Hematologic abnormalities predisposing to thrombophilia were identified in 34.9% of the population. Advanced age (p=0.02) and low center volume (p <0.0001) were significantly associated with PMVT, while gender, BMI, hematologic abnormality, prior history of deep vein thrombosis or pulmonary embolism, type of prophylactic anticoagulation, and duration of prophylactic anticoagulation were not associated with the incidence of PMVT in meta-regression analyses. Treatment included therapeutic anticoagulation in 93.4% and the mortality rate was 4/357 (1.1%).

CONCLUSION

PMVT is a rare complication of sleeve gastrectomy with an incidence rate <1% that is associated with low center volume and advanced age but is not affected by the duration or type of thromboprophylaxis administered postoperatively.

Post-gastric Sleeve Surgery Chronic Symptoms From a Sample of Patients in Saudi Community

BACKGROUND

A common bariatric procedure known as gastric sleeve surgery can cause significant weight loss and co-morbid condition alleviation. However, patients could experience persistent problems such as gastrointestinal, musculoskeletal/neural, and psychiatric disorders after surgery. This study aims to identify the most prevalent chronic symptoms following sleeve gastrectomy among a sample of Saudi patients and the impact these symptoms have on patients' lives.

METHODOLOGY

Patients who underwent gastric sleeve surgery at the Ensan Clinic, a facility specializing in gastroenterology, were the subjects of this retrospective cohort analysis. The study population consisted of patients who underwent gastric sleeve surgery, showed up for follow-up after the procedure, and met the inclusion and exclusion criteria. The data collection sheet is divided into seven sections. Sociodemographic information was required in the first section, gastric sleeve surgery information in the second, vital signs in the third, lab results in the fourth, past medical history in the fifth, current treatments in the sixth, and postoperative complications and chronic symptoms in the seventh and final sections.

RESULTS

In 117 patients, the study evaluated the effects of gastric sleeve surgery. Participants had an average age of 40.21 years, and 61.5% were female. Regarding persistent symptoms after surgery, a sizable percentage of patients mentioned digestive issues such as GERD (44.4%), dyspepsia (60.7%), vomiting (23.1%), nausea (39.3%), and abdominal distention (45.3%). A total of 34.2% of patients reported experiencing anxiety, compared to 11.1% who said they had depression or 2.6% who said they had social issues. A few patients reported experiencing neurological or musculoskeletal issues, including exhaustion (7.7%), faintness (5.1%), back or joint discomfort (7.7%), and shortness of breath (8.5%).

CONCLUSION

After undergoing gastric sleeve surgery, a sizable proportion of patients complained of various chronic symptoms and nutritional inadequacies, primarily gastrointestinal problems and musculoskeletal/neurological issues. The study's findings show a connection between these symptoms and surgery.

Reflux disease following primary sleeve gastrectomy: risk factors and possible causes

INTRODUCTION

One of the most severe side effects of sleeve gastrectomy (SG) is the development or aggravation of reflux disease. This study investigates the effect of SG on the development of reflux disease and the variables that may impact this development. In addition, trends in revision surgery, weight, and comorbidity are examined among patients with reflux disease and SG and those without reflux disease and SG. This study includes 3379 individuals without reflux disease who had primary SG and were followed for three years. The demographic characteristics, comorbidities, technical features, and complications of SG were analyzed. Data were collected by the German Bariatric Surgery Registry (GBSR). 860 (25.45%) Group A patients had reflux disease following SG (Group B: no reflux after SG; 74.55%). Patients with reflux disease had longer operating times (83.8 min vs. 77.5 min, p < 0.001) and longer postoperative hospital admissions (6 days vs. 5.5 days). In group A, the %EWL was substantially greater than in group B (64.1 vs. 61.1%). 42 patients were converted from SG to RYGB (4.88%), 2 had hiatoplasty, and 5 got Endostim. There is no significant variation in perioperative complications (p value > 0.05). The incidence of complete remission of sleep apnea was higher in group A than in group B (p = 0.013; 50% vs. 44.8%). Other comorbidities were not substantially different. Reflux illness after SG is still poorly understood, despite much research. Technical and preoperative variables may promote its development. However, these assumptions remain theoretical and are not confirmed by scientific data. The majority of patients may be successfully treated using non-invasive methods, although sometimes further surgery is necessary. Despite our results and the literature, this subject is intriguing for further research.

Duodenal Varices: A Rare Cause of Bleeding in a Bariatric Patient

We report a rare but potentially fatal complication of duodenal variceal bleeding in a patient status postsleeve gastrectomy. A 52-year-old woman with a history of sleeve gastrectomy presented with melena. Upper gastrointestinal endoscopy revealed bleeding varices in the duodenum that was clipped. After being referred to our institution for further management, CT scans were re-reviewed and revealed large varices in the fourth/fifth segment of the duodenum and proximal jejunum. The patient was referred to surgery. This case highlighted the potential ectopic variceal bleeding after bariatric surgery and calls for detailed examination and open mind when managing postbariatric gastrointestinal bleeders.

The incremental value of multislice CT in diagnosis of late bariatric surgery complications

Background

Bariatric surgery has become a widely accepted treatment option among the population for obesity management. Nevertheless, different complications may still be encountered during the late post-operative period. Our prospective cross-sectional study aimed to show the incremental value of multislice CT for diagnosis of such complications.

Results

Within the included twenty patients who underwent multislice CT of upper abdomen, gastric pouch dilatation causing recurrent weight gain was the commonest complication detected in 70% of the studied patients and was found mainly after sleeve gastrectomy in whom mean gastric pouch volume was 248.4 ml. Gastric stricture, gastric herniation through plication suture, hiatus hernia and incisional hernia were less commonly encountered complications.

Conclusion

Multislice CT is a useful non-invasive imaging modality for detection of late bariatric surgery complications.

Gastroesophageal Reflux Disease Symptoms after Laparoscopic Sleeve Gastrectomy: A Retrospective Study

(1) Background: Laparoscopic sleeve gastrectomy (LSG) is widely performed in bariatric surgery. However, the prevalence and risk factors of gastroesophageal reflux disease (GERD) symptoms after LSG remain unclear to date. This study aimed to identify risk factors of GERD after LSG. (2) Methods: We conducted a retrospective study at Linkou Chang Gung Memorial Hospital and reviewed 296 patients who underwent LSG from 2016 to 2019. A total of 143 patients who underwent preoperative esophagogastroduodenoscopy and completed the 12-month postoperative follow-up were enrolled. Patients’ demographic data, comorbidities, and postoperative weight loss results were recorded for analysis. The GerdQ questionnaire was used to assess GERD after LSG. (3) Results: There were eight surgical complications (5.6%) among the 143 studied patients (median age, 36 years; 56 (39.2%) men; median body weight 105.5 kg; median body mass index [BMI], 38.5 kg/m2). Twenty-three patients (16.1%) developed de novo GERD symptoms. GERD was significantly associated with older age (p = 0.022) and lower BMI (<35 kg/m2, p = 0.028). In multiple logistic regression analysis, age and BMI were significantly associated with GERD. (4) Conclusions: LSG is a safe and effective weight loss surgery. In our study, it led to 16.1% of de novo GERD symptoms, which were significantly related to older age and lower BMI (<35 kg/m2).

Pancreatic Leak After a Laparoscopic Sleeve Gastrectomy

INTRODUCTION

Severe adhesions in patients with previous abdominal operations may lead to a more challenging subsequent bariatric surgery [1, 2]. In this context, sleeve gastrectomy (SG) is the preferred weight loss surgery since it solely involves stomach resection (without bowel involvement) in one abdominal compartment. Additionally, SG has lower complication rates and a shorter operative time than other bariatric procedures [3, 4]. In this paper, we present a multimedia video of the management of a pancreatic leak after SG in a patient with multiple previous abdominal surgeries.

MATERIALS AND METHODS

A 40-year-old female with a BMI of 36 kg/m² and obesity-related comorbidities presented to our clinic for bariatric surgery evaluation. The patient had a history of a motor vehicle accident requiring a splenectomy, a liver laceration requiring packing and reoperation with an open abdomen for more than a month. This was followed by a hernia repair with component separation. Preoperative workup was completed, including an upper endoscopy (EGD) that was negative for esophagitis. The computed tomography (CT) scan showed an area in the left upper quadrant with no bowel loops adherent to the abdominal wall, thus a safer area for accessing the abdominal cavity (Fig. 1). The SG itself was challenging due to severe adhesions. These adhesions were between the bowel and abdominal wall, bowel and bowel, stomach and liver, and posterior stomach and pancreas (video). Once adhesiolysis was completed, the stomach was tailored successfully without intraoperative complications. The patient was discharged on postoperative day 1 with stable vitals and laboratory exams while tolerating a liquid diet.

RESULTS

On postoperative day 2, the patient returned to the emergency department with abdominal pain, increased heart rate (120 per minute), and a white blood cell count (WBC) of 20,000 th/µL. The CT scan showed a left upper quadrant collection with no evidence of air or contrast extravasation from the sleeve, as shown in Fig. 2. The patient became unstable and did not respond adequately to resuscitation efforts. Due to the extensive dissection in the primary operation, we elected to perform a laparoscopic exploration on an urgent basis. A collection (dark fluid) was noted in the left upper quadrant, but no sleeve staple line leak was found even with the air leak test (Fig. 2). Drainage and wash out were completed, and 2 abdominal drains were placed. Although the patient had symptomatic improvement postoperatively, an EGD with fluoroscopy was repeated, and no leak was noted (Fig. 3). The fluid evaluation showed increased lipase suggesting the diagnosis of a pancreatic leak. A liquid diet was initiated, and the initial drain in the left upper quadrant was exchanged to a higher caliber one (16F 40 cm locking loop drain). The patient was stable and eventually discharged home on postoperative day 6. Eventually, the drains were draining less than 10 mL and then downsized and removed. The patient's weight loss journey continued afterward with no other complications at 10-month follow-up.

CONCLUSIONS

Pancreatic leak is a rare but potentially severe complication after SG, especially in the difficult abdomen.

Radiological stent placement of post sleeve gastrectomy leak: efficacy, imaging features and post-procedure complications

Laparoscopic sleeve gastrectomy (SG) is the most commonly performed bariatric procedure. The primary and insidious early post-SG complication is the gastric leak (GL). In literature, there are many studies describing the endoscopic stent placement as treatment of GL and few studies about stent placement performed by interventional radiology under fluoroscopic guide. Our aims were to describe the radiological stent placement technique, to compare endoscopic and radiological stent placement, to illustrate normal diagnostic features and summarise the incidence of complications after stent placement, removal, and their imaging features. This was a single centre retrospective study of 595 patients who underwent SG between 2011 and 2019. Inclusion criteria: patients who developed GL after SG and treated with gastro-oesophageal stent placement by endoscopy or interventional radiology; availability of medical history and imaging studies; follow-up time after stent removal (1 year). The rates of technical success, clinical success and complications after stent placement and removal were collected and compared between the two methods of stent positioning. A total of 17/595 (2.8%) patients developed a radiologically diagnosed GL after SG. The type II-III GLs (15/17) were treated with endoscopic or radiological stent placement. 9/15 (60%/Group A) patients underwent gastro-oesophageal stenting by interventional radiology and 6/15 (40%/Group B) were treated with endoscopic stent placement. The technical and clinical success rate was 100% for both groups. Stent migration occurred in 22% and 27% for Group A and B respectively. Post-extraction stenosis was the main late complication, occurring in 22% in Group A and 0% in Group B. Gastro-esophageal stent placement performed by interventional radiologists is a valid "mini-invasive" treatment for GL. This procedure is not inferior to endoscopic positioning regarding efficacy, periprocedural and postprocedural complication rate. It's necessary to be familiar with radiological findings after stent placement and removal. Computed tomography (CT) scan is the main radiological technique to identify stent placement complications. Upper gastrointestinal (UGI) series are the first radiological procedures used to detect late complications after stent removal.

Gastric volvulus after laparoscopic sleeve gastrectomy managed by conversion to Roux-en-Y gastric bypass. A case report and literature review

INTRODUCTION AND IMPORTANCE

One of the most performed bariatric procedures, Laparoscopic sleeve gastrectomy (LSG) can be utilized not only as a primary bariatric procedure to achieve weight loss but also as a staged procedure, as it attains durable weight loss on long term follow up with remission of obesity-related comorbidities. There are several complications associated with LSG in the short and long terms, including hemorrhage, gastric leakage, and gastroesophageal reflux disease (GERD), yet gastric volvulus after sleeve gastrectomy is a rare entity.

CASE PRESENTATION AND CLINICAL DISCUSSION

We present a morbid obese female patient 32 years old -with no known medical comorbidity- presented to our bariatric outpatient clinic after laparoscopic sleeve gastrectomy with a chronic progressive history of vomiting, regurgitation, and heartburn of three months which started once/week then progress to 3 times/week duration. After a normal abdominal x-ray, Pelvi-abdominal ultrasound showed mild colonic gaseous distension. The CT virtual gastroscopy with 3D reconstruction revealed significant mid-body kinking with a wavy appearance. A decision was made on a multi-disciplinary approach to do a diagnostic laparoscopy for the patient with a revision of the previous sleeve gastrectomy. Upon entering the intra-abdominal there were extensive adhesions between the sleeved stomach, liver, and pancreas. Intra-operative upper endoscopy was done, and the scope didn't pass at the mid-portion of the sleeved stomach. Conversion to Roux-en-Y gastric bypass had been done with successful results.

CONCLUSION

Gastric volvulus after sleeve gastrectomy is a rare entity presenting vague symptoms and signs and requires a high index of suspicion from the physicians for the proper diagnosis.

Imaging after laparoscopic sleeve gastrectomy - literature review with practical recommendations

In the XXI century obesity has become one of the most demanding epidemiological threats worldwide. At the same time, bariatric surgery has established itself as an effective treatment for morbidly obese patients, with laparoscopic sleeve gastrectomy (LSG) emerging as the most popular bariatric procedure. This paper reviews the role of imaging studies of patients after LSG. Computed tomography is widely considered as the method of choice in detection of complications in early postoperative period. The dynamic character of upper gastrointestinal examination allows for the assessment of passage through the gastric remnant. The paper also discusses evaluation of the shape and volume of the gastric remnant assessed by imaging studies.

Impact of Laparoscopic Sleeve Gastrectomy on Gastroesophageal Reflux Disease and Risk Factors Associated with Its Occurrence Based Upon Quality of Life

BACKGROUND

To assess the impact of laparoscopic sleeve gastrectomy (LSG) on gastroesophageal reflux disease (GERD) symptoms and to determine factors associated with the occurrence of post-LSG GERD symptoms.

MATERIAL AND METHODS

This is a retrospective study that included all obese patients who underwent LSG in Aseer Central Hospital, during the period from August 2017 to August 2019. GERD-Health-Related Quality of Life questionnaire was used to assess the patients' pre- and postoperative GERD symptoms and their satisfaction toward their general health.

RESULTS

The study included 326 patients (195 males and 131 females) with a mean age of 39.43 ± 11.17 years. Postoperatively, GERD symptoms newly developed in 105 patients (32.2%), while 25 patients out of 127 with preoperative GERD symptoms (19.69%) showed resolution of symptoms. There were significant associations (p < 0.001) between the old age, smoking and existence of comorbidities, and the occurrence of postoperative heartburn and regurgitation symptoms. Postoperatively, excess weight loss (EWL) was significantly associated with postoperative regurgitation (p = 0.045) and patients showed significant improvement in their satisfaction toward their health condition even those who developed GERD symptoms.

CONCLUSIONS

After LSG, GERD symptoms developed in about one-third of the patients while symptoms improved in only one-fifth of patients. Older patients, smokers, patients with comorbidities, and patients with more EWL had significantly worse GERD symptoms postoperatively. Weight loss rather than GERD symptoms significantly influenced patients' satisfaction toward their general health. Further prospective studies are needed to determine the relationship between weight loss and other factors associated with post-LSG reflux and overall quality of life.

Treating Porcine Abscesses with Histotripsy: A Pilot Study

Infected abscesses are walled-off collections of pus and bacteria. They are a common sequela of complications in the setting of surgery, trauma, systemic infections and other disease states. Current treatment is typically limited to antibiotics with long-term catheter drainage, or surgical washout when inaccessible to percutaneous drainage or unresponsive to initial care efforts. Antibiotic resistance is also a growing concern. Although bacteria can develop drug resistance, they remain susceptible to thermal and mechanical damage. In particular, short pulses of focused ultrasound (i.e., histotripsy) generate mechanical damage through localized cavitation, representing a potential new paradigm for treating abscesses non-invasively, without the need for long-term catheterization and antibiotics. In this pilot study, boiling and cavitation histotripsy treatments were applied to subcutaneous and intramuscular abscesses developed in a novel porcine model. Ultrasound imaging was used to evaluate abscess maturity for treatment monitoring and assessment of post-treatment outcomes. Disinfection was quantified by counting bacteria colonies from samples aspirated before and after treatment. Histopathological evaluation of the abscesses was performed to identify changes resulting from histotripsy treatment and potential collateral damage. Cavitation histotripsy was more successful in reducing the bacterial load while having a smaller treatment volume compared with boiling histotripsy. The results of this pilot study suggest focused ultrasound may lead to a technology for in situ treatment of acoustically accessible abscesses.

Roux-en-Y gastric bypass as revisional surgery

The Roux-en-Y gastric bypass (RYGB) is a worldwide-performed procedure as primary surgery, and as conversional procedure after complications and/or failure of other bariatric procedures. RYGB can be performed as revisional surgery after adjustable gastric banding, vertical banded gastroplasty, sleeve gastrectomy and one anastomosis gastric bypass. Each of these revisional procedures may be technically challenging, and accurate preoperative work-up and operative planning is required. If correctly performed, RYGB as revisional procedure is associated with satisfying outcomes and is indicated in the treatment of insufficient weight loss and postoperative complications of a primary bariatric procedure - such as chronic leak or gastroesophageal reflux after sleeve gastrectomy. The present article analyzes the most important indications, technical points and tips and tricks to safely perform RYGB as a secondary procedure.

Incidence and treatment outcomes of leakage after gastrectomy for gastric cancer: Experience of 14,075 patients from a large volume centre

INTRODUCTION

Leakage is a serious and potentially fatal complication of gastrectomy for gastric cancer. However, comprehensive reports regarding leakage after gastrectomy remain limited. We aimed to evaluate the incidence and treatment outcomes of leakage after gastrectomy for cancer.

METHODS

We reviewed the prospectively collected data of 14,075 Patients who underwent gastrectomy for gastric cancer between 2005 and 2017. Outcomes included incidence, risk factors of leakage, and leakage treatment outcomes.

RESULTS

The median day of leakage detection was postoperative day 7 (range 1-29days). The overall leakage incidence was 1.51% (213/14,075), and the most frequent location was the oesophagojejunostomy (2.07%). Leakage after total gastrectomy was more frequent with minimally invasive surgery (open:1.64%, laparoscopic:3.56%, robotic:5.83%; P < 0.001). Leakage incidence was higher in the surgeon's initial 100 cases than in later cases (2.4 vs. 1.3%; P < 0.001), especially with minimally invasive surgery. Early leakage (within 4 days of surgery) occurred more often after minimally invasive surgery (open:12.7%, laparoscopic:35.4%, robotic:29.0%; P = 0.006). The success rate for initial treatment of leakage was 70.4% (150/213). Surgery after initial treatment failure demonstrated a higher success rate for early leakage than for late leakage (80.0 vs. 22.2%). Among 213 patients who experienced leakage, fifteen patients (7.0%) died, and leakage-related mortality accounted for 38.5% (15/39) of all surgery-related mortality after gastrectomy.

CONCLUSIONS

Leakage after gastric cancer surgery is associated with high mortality. Improved surgeon experience using minimally invasive techniques is required to reduce the risk of leakage. Surgery is an effective treatment for early leakage, although further studies are needed to establish the most appropriate treatment strategies.

Implications of Technical Factors in Development of Early Sleeve Stenosis After Laparoscopic Sleeve Gastrectomy: an Analysis Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Database

PURPOSE

Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure worldwide. Sleeve stenosis (SS) is a rare complication of LSG and is associated with significant morbidity and economic burden. The objective of this study was to determine the prevalence and impact of early SS and identify technical factors which may predict its development.

MATERIALS AND METHODS

Data was extracted from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry from 2015 to 2018. Patients undergoing primary LSG were included, while patients undergoing revisional bariatric surgery were excluded. A multivariable logistic regression analysis was performed to identify technical factors associated with SS.

RESULTS

A total of 389,839 patients (79.4% female) were included with a mean age of 44.2 ± 12.0 years and mean body mass index of 45.1 ± 7.8 kg/m². SS was rare, occurring in only 0.09% (n=345) of patients within 30 days of the operation. Following multivariable analysis, technical factors associated with early SS included prolonged operative time > 60 min (OR 1.32, 95% CI 1.17-1.48, p < 0.001) and a shorter PD (OR 0.864, 95% CI 0.784-0.951, p=0.003). For every 1-cm increase in PD, the odds of SS decreased by 13.6%.

CONCLUSION

Overall, early SS is a rare complication, affecting only 0.09% of patients undergoing primary LSG. Technical factors associated with 30-day SS included PD and operative time. Though current guidelines suggest a PD as short as 2 cm, our findings suggest this may be associated with an increased risk of early postoperative SS.

Preoperative risk factors for early hemorrhagic complications in bariatric surgery: a case-control study

BACKGROUND

Although a reliable procedure in morbid obesity treatment, bariatric surgery may be associated with serious complications such as leakage or bleeding. We aimed to analyze the preoperative factors involved in patients with early postoperative hemorrhage after any type of bariatric surgery who required conservative treatment or reoperation for this complication.

METHODS

Retrospective case-controlled study (1:3) of 2 patient cohorts (postoperative bleeding/controls) matched by type of surgical intervention.

RESULTS

Hypertension (Odds Ratio 5.029; 95% Confidence Interval 1.78-14.13) and history of antiplatelet medication (OR 13.263; 95% CI 1.39-125.9) were independent risk factors in the bivariate analyses, confirmed in the logistic regression model on multivariate analysis.

CONCLUSIONS

With no between-group differences in Body Mass Index (BMI) and type 2 Diabetes (T2D), early hemorrhagic complications were found to be more frequent in patients with hypertension or antiplatelet drug treatment.

Weighing in on heart failure: the potential impact of bariatric surgery

Obesity is a growing worldwide epidemic with significant economic burden that carries with it impacts on every physiologic system including the cardiovascular system. Specifically, the risk of heart failure has been shown to increase dramatically in obese individuals. The purpose of this review is to provide background on the individual burdens of heart failure and obesity, followed by exploring proposed physiologic mechanisms that interconnect these conditions, and furthermore introduce treatment strategies for weight loss focusing on bariatric surgery. Review of the existing literature on patients with obesity and heart failure who have undergone bariatric surgery is presented, compared, and contrasted.

Laparoscopic Sleeve Gastrectomy under Awake Paravertebral Blockade Versus General Anesthesia: Comparison of Short-Term Outcomes

AIMS

This study aimed at comparing the pre-, intra-, and early postoperative outcomes, between patients who underwent PVB vs general anesthesia (GA) during LSG. Follow-up of weight loss at least 1 year postoperatively was also evaluated.

METHODS

A cohort study was conducted by selecting all patients who underwent LSG under PVB and GA at Makassed General Hospital between 2010 and 2016. Demographic, social, pre-op health status, body mass index (BMI), operative time, postoperative pain and pain medication consumption, postoperative complications and length of hospital stay, all were studied. Follow-up weight loss was collected up to 5 years postoperatively. Data entry, management, and descriptive and inferential statistics were performed using SPSS.

RESULTS

A total of 210 participants were included in this study of which 48 constituted the PVB group and 162 patients composed the GA group. Both groups were similar in baseline demographic factors, with patients in PVB suffering from higher number and advanced stage of comorbidities than the GA group. Mean operative time was similar in between the two groups with 80 ± 20 min for PVB and 82 ± 18 min for GA group. Intraoperative complications were scarce among both study groups. GA group requested a second dose of analgesia earlier than PVB group. After at least 1 year postoperatively, the mean percentage of excess weight loss was 81.35 ± 15.5% and 77.89 ± 14.3% for the PVB and GA groups, respectively, P value 0.45.

CONCLUSION

Outcomes of LSG under both types of anesthesia (PVB alone and GA alone) were found to be comparable. However, the need for analgesia was significantly less in the PVB group compared to GA group.

Small hiatal hernia and postprandial reflux after vertical sleeve gastrectomy: A multiethnic Asian cohort

Background

Laparoscopic vertical sleeve gastrectomy (LSG) is a popular bariatric procedure performed in Asia, as obesity continues to be on the rise in our population. A major problem faced is the development of de novo gastroesophageal reflux disease (GERD) after LSG, which can be chronic and debilitating. In this study, we aim to assess the relationship between the presence of small hiatal hernia (HH) and the development of postoperative GERD, as well as to explore the correlation between GERD symptoms after LSG and timing of meals. In doing so, we hope to gain a better understanding about the type of reflux that occurs after LSG and take a step closer towards effectively managing this difficult to treat condition.

Methods

We retrospectively reviewed data collected from patients who underwent LSG in our hospital from Dec 2008 to Dec 2016. All patients underwent preoperative upper GI endoscopy, during which the identification of hiatal hernia takes place. Patients' information and reflux symptoms are recorded using standardized questionnaires, which are administered preoperatively, and again during postoperative follow up visits.

Results

Of the 255 patients, 125 patients (74%) developed de novo GERD within 6 months post-sleeve gastrectomy. The rate of de novo GERD was 57.1% in the group with HH, and 76.4% in the group without HH. Adjusted analysis showed no significant association between HH and GERD (RR = 0.682; 95% CI 0.419 to 1.111; P = 0.125). 88% of the patients who developed postoperative GERD reported postprandial symptoms occurring only after meals, and the remaining 12% of patients reported no correlation between the timing of GERD symptoms and meals.

Conclusion

There is no direct correlation between the presence of small hiatal hernia and GERD symptoms after LSG. Hence, the presence of a small sliding hiatal hernia should not be exclusion for sleeve gastrectomy. Electing not to perform concomitant hiatal hernia repair also does not appear to result in higher rates of postoperative or de novo GERD.

Clinical utility of transient elastography as an imaging tool to assess the short-term impact of laparoscopic sleeve gastrectomy, together with clinical and biochemical parameters and clinico-biochemical indices, on obese patients with nonalcoholic fatty liver disease: An Egyptian pilot study

INTRODUCTION

Nonalcoholic fatty liver disease (NAFLD) is a metabolic liver disorder commonly attributed to fatty acid deposition that can induce hepatic necroinflammation, defined as nonalcoholic steatohepatitis (NASH). It is strongly associated with obesity. Laparoscopic sleeve gastrectomy (LSG) is a favorable surgical modality for the treatment of morbid obesity.

AIM

Our study evaluated the impact of LSG on patients with NAFLD and morbid obesity, 3 months after the operation, through clinical and biochemical characteristics, clinico-biochemical indices, and imaging parameters.

PATIENTS AND METHODS

Morbidly obese patients with NAFLD±NASH underwent LSG. They were thoroughly evaluated clinically (body weight, body mass index, waist circumference) and biochemically (transaminases and triglycerides), as well as through the fatty liver index (FLI), the hepatic steatosis index (HSI), and ultrasound elastography imaging studies (liver stiffness measurement [LSM] and the controlled attenuation parameter [CAP]), before and 3 months after the LSG.

RESULTS

Twenty-six obese patients with NAFLD underwent LSG that resulted in a significantly high reduction in all the parameters analyzed, except for liver transaminases.

CONCLUSION

LSG is considered an efficient surgical modality for the treatment of morbidly obese patients with NAFLD.

Surgical Outcomes, Health Care Utilization, and Costs Associated with Staple Line Buttressing Among Primary Sleeve Gastrectomy Patients

Purpose

Staple line buttressing is a method of reinforcing surgical staple lines using buttress materials. This study evaluated surgical outcomes, hospital utilization, and hospital costs associated with staple line buttressing among patients who underwent primary laparoscopic sleeve gastrectomy (PLSG) in the United States.

Methods

This was a retrospective cohort study using Premier Healthcare Database data from January 1, 2012 to December 31, 2017. Patients aged ≥ 18 years who underwent PLSG were selected and assigned to buttress or non-buttress cohorts based on the use of buttress material during their hospitalization for PLSG (index). Propensity score matching (PSM) was conducted to balance patient demographic and clinical characteristics between the cohorts. Generalized estimating equation models were used to compare the clinical and economic outcomes of the matched buttress and non-buttress users during the index hospitalization.

Results

A total of 38,231 buttress and 27,349 non-buttress patients were included in the study. After PSM, 24,049 patients were retained in each cohort. Compared with non-buttress cohort, the buttress cohort patients had a similar rate of in-hospital leaks (0.28% vs 0.39%; p = 0.160) and a lower rate of bleeding (1.37% vs 1.80%, p = 0.015), transfusion (0.56% vs 0.77%, p = 0.050), and composite bleeding/transfusion (1.57% vs 2.04%, p = 0.019). Total costs ($12,201 vs $10,986, p < 0.001) and supply costs ($5366 vs $4320, p < 0.001) were higher in the buttress cohort compared with the non-buttress cohort.

Conclusions

Staple line buttressing was associated with an improvement in complication rates for bleeding and transfusion. Total and supply costs were higher in the buttress cohort, necessitating further research into cost-effective buttressing materials.

Electronic supplementary material

The online version of this article (10.1007/s11695-020-04917-2) contains supplementary material, which is available to authorized users.

Normal and Abnormal Postoperative Imaging Findings after Gastric Oncologic and Bariatric Surgery

Surgical resection remains the primary choice of treatment and the only potentially curative option for gastric carcinoma, and is increasingly performed laparoscopically. Gastric resection represents a challenging procedure, with a significant morbidity and non-negligible postoperative mortality. The interpretation of imaging after gastric surgery can be challenging due to significant modifications of the normal anatomy. After the surgery, the familiarity with expected imaging appearances is crucial for diagnosis and appropriate management of potentially life-threatening complications in patients who underwent gastric surgery. We review various surgical techniques used in gastric surgery and describe fluoroscopic and cross-sectional imaging appearances of normal postoperative anatomic changes as well as early and late complications after gastric surgery.

Long-Term Results of the Mediterranean Diet After Sleeve Gastrectomy

BACKGROUND

To assess dietary habits in a cohort of patients at minimum follow-up of 4 years after sleeve gastrectomy (SG) by comparing their dietary records to the Italian Mediterranean diet (IMD) recommendations.

METHODS

We prospectively evaluated in 74 patients who had the SG in 2014 dietary habits by a 7-day food dietary records, weight and micronutrient status, evolution of comorbidities, use of micronutrient supplements, and frequency of physical activity.

RESULTS

The IMD recommendations in terms of daily/weekly portions of fruits, vegetables, and complex carbohydrates were followed by 40.5%, 35.1%, and 40.5% of the participants, respectively. Concerning milk/dairy, olive oil, poultry, fish/shellfish, eggs, legumes, processed/red meat, and cold cuts, 54.1%, 85.1%, 44.5%, 75.7%, 67.6%, 35.1%, 87.8%, and 55.4% of the participants, respectively, followed the IMD recommendations. Weight regain appeared in 37.8% of participants, while physical activity was reported by the 54.0% of them. Deficiencies of vitamin B12, vitamin D, folate, iron, and anemia were found present in 6.8%, 8.1%, 24.3%, 33.8%, and 59.5% of the participants, respectively, and 18.9% of them were found to take micronutrient supplements. Improvement/remission of type 2 diabetes, hypertension, or obstructive sleep apnea was 73.3%, 64.7%, and 100% respectively.

CONCLUSIONS

In this prospective cohort with a minimum follow-up of 4 years after SG, we found an inadequate intake of fruit, vegetables, poultry, and complex carbohydrates according to the IMD recommendations; the frequency of physical activity and the use of micronutrients supplements were also inadequate. This may contribute to weight regain and micronutrient deficiencies in the long term.

Endoscopic balloon dilation for treatment of sleeve gastrectomy stenosis: a systematic review and meta-analysis

BACKGROUND AND AIMS

Gastric stenosis is a rare but potentially serious adverse event after sleeve gastrectomy. Despite current suboptimal treatments, endoscopic balloon dilatation (EBD) has emerged as a safe and efficacious approach. The purpose of this study is to assess the overall success of EBD for sleeve gastrectomy stenosis (SGS) as first-line therapy.

METHODS

MEDLINE, Embase, Web of Science, Google Scholar, and Cochrane Database were searched from inception to July 2018. The primary outcome was defined as overall success rate of clinical resolution of SGS obstructive symptoms with EBD, expressed as pooled event rate and 95% confidence interval (CI). The secondary predefined outcomes include EBD success rates for SGS in the proximal (cardia) location or mid-distal location (antrum/incisura), in early SGS (up to 3 months after laparoscopic sleeve gastrectomy), and late SGS (3 months or longer after laparoscopic sleeve gastrectomy) and success rate of cases requiring stents or salvage surgery.

RESULTS

Eighteen studies encompassing 426 patients were analyzed. The average age and body mass index were 41.7 years and 40.1 kg/m², respectively, and the average number of dilations for all cases was 1.8 per person. Overall EBD success rate was 76% (95% CI, .67-.86). EBD success rate in the proximal SGS was 90% (95% CI, 63%-98%), distal SGS was 70% (95% CI, 47%-86%), early SGS within 3 months was 59% (95% CI, 34%-79%), and late SGS after 3 months was 61% (95% CI, 41%-78%). Seventeen percent of patients underwent secondary salvage surgery, with a success rate of 91% (95% CI, 80%-96%).

CONCLUSIONS

Endoscopic balloon dilation appears to be a safe and effective minimally invasive alternative to surgical revision and should be used as first-line therapy for SGS.

Late Gastropleural Fistula after the Management of Laparoscopic Sleeve Gastrectomy Leakage

One of the rare but serious complications of laparoscopic sleeve gastrectomy (LSG) with significant morbidity and mortality is gastropleural fistula (GPF). Here, we present a 34-year-old woman who underwent LSG. Due to leakage in the proximal site of the stapler line and splenic artery erosion into the site of leakage after 1 month, splenectomy and drainage catheter insertion was done. Three months later, she presented with dyspnea, fever, and lung abscess, GPF was diagnosed, and Roux-en-Y fistulo-jejunostomy was done. After 10 days, her clinical condition improved, but the patient expired due to hemorrhagic cerebrovascular accident (CVA). Therefore, GPF along with other common complications should be seriously considered in patients developing post-LSG chronic respiratory symptoms.

Laparoscopic vertical sleeve gastrectomy, long and short-term impact on weight loss and associated co-morbidities

The laparoscopic vertical sleeve gastrectomy (LVSG) has become the most popular operation for the treatment of morbid obesity in the United States. Being a purely restrictive procedure, the LVSG works to reduce the caloric intake of patients as well as decrease appetite through removal of ghrelin producing cells. Initially developed as the first part of a combined two step restrictive and malabsorptive procedure, the LVSG developed as a standalone procedure when patients lost significant weight with the restrictive portion of the operation alone. Short term outcomes have been promising in terms of weight loss and resolution of comorbid conditions. Long term outcomes are still evolving, but do demonstrate durable weight loss for a significant number of patients. Concerns with the LVSG in the long term revolve around development or worsening of gastroesophageal reflux disease or weight regain. The LVSG has been demonstrated to be a useful tool in the surgical management of morbid obesity.

Endoscopic treatment of early leaks and strictures after laparoscopic one anastomosis gastric bypass

BACKGROUND

Laparoscopic one anastomosis gastric bypass has become a prominent bariatric procedure. Yet, early and late complications, primarily leaks and strictures, are not uncommon. This study summarizes our experience with endoscopic treatment of laparoscopic one anastomosis gastric bypass complications.

METHODS

This is a retrospective study of consecutive patients referred to our hospital from 2015 to 2017 with post laparoscopic one anastomosis gastric bypass complications. Therapy was tailored to each case, including fully covered self-expandable metal stents, fibrin glue, septotomy, internal drainage with pigtail stents, through-the-scope and pneumatic dilation. Success was defined as resuming oral nutrition without enteral or parenteral support or further surgical intervention.

RESULTS

Nine patients presented with acute or early leaks: 5 (56%) had staple-line leaks, 3 (33%) had anastomotic leaks and 1 (11%) had both. All were treated with stents. Adjunctive endoscopic drainage was applied in 4 patients (44%). Overall 5 patients (56%) with acute/ early leaks recovered completely, including all 3 patients with anastomotic leak and the patient with both leaks but only 1/5 with staple line leak (20%). Complication rate in the leak group reached 22%. Eight patients presented with strictures, 7 at the anastomosis and one due to remnant stomach misalignment. All anastomotic strictures were dilated successfully. However, the patient with the pouch stricture required conversion to Roux-en-Y gastric bypass after 3 failed attempts of dilation.

CONCLUSION

Endoscopic treatments of laparoscopic one anastomosis gastric bypass complications are relatively effective and safe. Anastomosis-related complications are more amenable to endoscopic treatment compared to staple line leaks.

Diet change affects intestinal microbiota restoration and improves vertical sleeve gastrectomy outcome in diet-induced obese rats

Purpose

Obesity, a worldwide health problem, is linked to an abnormal gut microbiota and is currently most effectively treated by bariatric surgery. Our aim was to characterize the microbiota of high-fat fed Sprague–Dawley rats when subjected to bariatric surgery (i.e., vertical sleeve gastrectomy) and posterior refeeding with either a high-fat or control diet. We hypothesized that bariatric surgery followed by the control diet was more effective in reverting the microbiota modifications caused by the high-fat diet when compared to either of the two factors alone.

Methods

Using next-generation sequencing of ribosomal RNA amplicons, we analyzed and compared the composition of the cecal microbiota after vertical sleeve gastrectomy with control groups representing non-operated rats, control fed, high-fat fed, and post-operative diet-switched animals. Rats were fed either a high-fat or control low-fat diet and were separated into three comparison groups after eight weeks comprising no surgery, sham surgery, and vertical sleeve gastrectomy. Half of the rats were then moved from the HFD to the control diet. Using next-generation sequencing of ribosomal RNA amplicons, we analyzed the composition of the cecal microbiota of rats allocated to the vertical sleeve gastrectomy group and compared it to that of the non-surgical, control fed, high-fat fed, and post-operative diet-switched groups. Additionally, we correlated different biological parameters with the genera exhibiting the highest variation in abundance between the groups.

Results

The high-fat diet was the strongest driver of altered taxonomic composition, relative microbial abundance, and diversity in the cecum. These effects were partially reversed in the diet-switched cohort, especially when combined with sleeve gastrectomy, resulting in increased diversity and shifting relative abundances. Several highly-affected genera were correlated with obesity-related parameters.

Conclusions

The dysbiotic state caused by high-fat diet was improved by the change to the lower fat, higher fiber control diet. Bariatric surgery contributed significantly and additively to the diet in restoring microbiome diversity and complexity. These results highlight the importance of dietary intervention following bariatric surgery for improved restoration of cecal diversity, as neither surgery nor change of diet alone had the same effects as when combined.

Electronic supplementary material

The online version of this article (10.1007/s00394-020-02190-8) contains supplementary material, which is available to authorized users.

Technical review: Vertical sleeve gastrectomy in adolescents

Sleeve gastrectomy is an effective tool for inducing sustainable weight loss in adolescents with obesity. It is a seemingly straight-forward procedure, and yet deceptive in technical nuances. This review highlights the technical preparation (equipment, patient positioning, pre-operative management), and conduct (anatomy, instruments, methodology, pitfalls) of the operation, and concludes with essentials for anticipating and managing complications of the operation. Throughout the discussion, we emphasize practical techniques to maintain patient safety while achieving maximum weight loss benefits.

Endoscopic septotomy as a treatment for leaks after sleeve gastrectomy: Meeting presentations: Digestive Disease Week 2019

Background and study aims  Sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure in the world. Leaks are the most feared complications after this procedure. Endoscopic septotomy has been described as a resolution technique that could be useful in the setting of late and chronic leaks. We present our experience in the management of gastric leaks with this advanced endoscopic technique. Patients and methods  Retrospective review of patients who have been admitted to our hospital from January 2016 to December 2018. Results  Five patients were found. All had their index surgery in outside hospitals. The average age was 51 years (range 40 - 69), and four patients were female. Mean time from LSG to leak presentation was 15 days (range 7 - 25). Mean time from leak presentation to septotomy procedure was 61 days (range 21 - 110). All patients were treated with sleeve dilatation before septotomy using endoscopic achalasia balloons. Mean procedure time was 79 minutes (range 55 - 125). Success was achieved in 80 % of patients, and no complications related to the procedure were identified. One patient underwent total gastrectomy for definitive management. Mean follow-up time was 14.25 months (range 6 - 26), and the average time for fistula closure was 60.25 days. Conclusion  Endoscopic septotomy is safe and effective for management of chronic leaks after LSG. Associated non-selective dilatation may be a crucial step to allow distal patency and axis rectification for appropriate leak closure.

Esophageal stricture as a complication of stent placement for leak after sleeve gastrectomy

Obesity is defined as body mass index (BMI) greater than 30. Weight loss improves the quality of life and alleviates or even treats some obesity-related comorbidities with general improvement in the quality of life. Sleeve gastrectomy results in major reduction of the size of the stomach and decreases the sense of hunger due to various hormonal and neuronal pathways. A 31-year-old lady had BMI of 49 underwent sleeve gastrectomy. Three weeks after surgery, she presented with epigastric pain and vomiting with radiological signs of leak. Endoscopic esophageal stent placed with resultant improvement of the condition; after stent removal, she developed esophageal stricture diagnosed with barium study. The patient underwent repeated successful endoscopic dilatation. Leak and bleeding are the most serious complications after sleeve gastrectomy. Subclinical leak is treated with antibiotics, drainage of the collection and stent, critical patients need stenting with operative repair of the site of leak.

Laparoscopic sleeve gastrectomy for morbid obesity: role of intraluminal and intraperitoneal postoperative drainage

BACKGROUND AND AIMS

Bleeding and staple line leak are the most common postoperative complications of LSG. To prevent and/or to promptly identify such complications, conventional peri-operative protocols imply post-operative gastric decompression (NGT) and staple line drain (IAD). Our aim was to evaluate the role of naso-gastric tube (NGT) and intra-abdominal drain (IAD) in preventing and/or facilitating identification and treatment of post-operative complications after sleeve gastrectomy.

PATIENTS AND METHODS

A retrospective observational study on two consecutive series has been undertaken to evaluate the real utility of routine placement of NGT and IAD at the end of a LSG to prevent (primary end-point), promptly identify (secondary end-point) and manage (tertiary end-point) bleeding and staple line leakage. Collected outcome data of all consecutive cases, which underwent primary LSG at our Department, were analyzed. The first 100 consecutive patients (group A) received the standard perioperative protocol and the other consecutive 100 (group B) received a fast track protocol (no NGT neither IAD).

RESULTS

The two groups were not different in their outcome. Two bleeding occurred in Group A and were conservatively treated. One abscess developed in group B soon after surgery. It was diagnosed by an abdominal CT performed because patients presented fever, leucocitosis and tachycardia. It was successfully treated by percutaneous ultrasound-guided drainage. One fistula occurred in group B after discharge on 30th post-operative day. Fistula was suspected based on fever and tachycardia in absence of any abdominal discomfort and was confirmed by an abdominal CT. The patient was successfully treated in 40 days by endoscopic positioning of a gastric tube-prosthesis and percutaneous ultrasound-guided drainage of abdominal collection. A third patient in group B experienced bleeding suspected due to hemoglobin drop and confirmed by abdominal CT. He also was conservatively treated.

CONCLUSIONS

In conclusion, placement of drains does not facilitate detection of leak, abscess, or bleeding after primary LSG.

Correcting micronutrient deficiencies before sleeve gastrectomy may be useful in preventing early postoperative micronutrient deficiencies

Micronutrient deficiencies (MD) shortly after sleeve gastrectomy (SG) are frequent and patients with obesity often show MD preoperatively. Our aim was to assess whether the correction of MD before SG could play a role in preventing early postoperative MD. Eighty patients (58 females, 22 males) who underwent SG were evaluated retrospectively. Patients were divided according to whether they had received preoperative MD correction (Group A, n = 42; 30 females, 12 males) or not (Group B, n = 38; 28 females, 10 males). Micronutrient status was assessed preoperatively, at 3 and 12-months after SG in both groups. After SG, Group A and Group B patients received the same multivitamin supplement and followed the same diet. Nutrient intake of all patients was evaluated by food frequency questionnaires. Before SG, patients of Group A had no MD, whereas patients of Group B were mostly deficient in vitamin B12 (10.5%, 3 women, 1 man), folate (15.8%, 5 women, 1 man), 25-vitamin D (39.5%, 10 women, 5 men), iron (26.3%, 8 women, 2 men), and zinc (7.9%, 2 women, 1 men). At 3- and 12-month follow-up, no patient in group A had developed new MD, whereas all patients of Group B continued to be deficient in one or more micronutrient, despite systematic postoperative supplementation. No statistical differences (p<0.05) in estimated nutrient intake were observed in either group. Based on our findings, we are able to support the hypothesis that pre-SG correction of MD may be useful in preventing early post-SG MD.

High-Amplitude Gastric Contractions following Laparoscopic Sleeve Gastrectomy

A proportion of laparoscopic sleeve gastrectomy patients experience symptoms of regurgitation and epigastric pain postoperation. The appearance of gastric sleeve contractions has been documented but its implications have not been adequately investigated. This case describes a 61-year-old female following laparoscopic sleeve gastrectomy. The patient underwent high-resolution impedance esophageal manometry that identified compartmentalized pressurization leading to propagating contractions throughout the gastric sleeve. Combined treatment with calcium channel blockers and gastric sleeve dilation relieved all symptoms. This case highlights the application of high-resolution impedance esophageal manometry to assess motor function and bolus transit in patients following laparoscopic sleeve gastrectomy.

Laparoscopic adjustable gastric banding on 3566 patients up to 20-year follow-up: Long-term results of a standardized technique

BACKGROUND

As obesity is a chronic disease, any bariatric procedure should be validated by long-term results.

OBJECTIVE

To present our long-term results after laparoscopic adjustable gastric banding over a period of >20 years and to investigate the outcomes in terms of efficacy, complications, and reoperations.

SETTING

Private practice, Italy.

METHODS

From October 1995 to February 2018, 3566 laparoscopic adjustable gastric banding were performed by a single surgeon. Data were retrieved from a prospectively collected computer database and retrospectively analyzed. Furthermore, patients were stratified according to body mass index and age and results are evaluated for each subgroup.

RESULTS

All the operations were performed laparoscopically without any mortality and/or major specific complications. Nine hundred twenty-six patients (71.6%) completed at least 10-years follow-up and 180 (58.4%) reached 15-years follow-up. There was a mean of 49%, 52.6%, and 59.2% of excess weight loss at 10, 15, and 20 years, respectively. Major late complications were pouch herniation-dilation (5.8%) and erosion (2.5%), both solved by a replicable, less invasive operation. Total reoperation rate was 24.1%.

CONCLUSION

Our experience suggested that the combination of a standardized surgical technique and close patient follow-up, performed in collaboration with an interdisciplinary team, may make the laparoscopic adjustable gastric banding system a powerful long-term surgical tool in the treatment of morbid obesity. The best results were obtained in young patients with high body mass index but results were also satisfactory in elderly patients and in those with low body mass index.