Perioperative complications of sleeve gastrectomy: Review of the literature

Adding Branched-Chain Amino Acids and Vitamin D to Whey Protein Is More Effective than Protein Alone in Preserving Fat Free Mass and Muscle Strength in the First Month after Sleeve Gastrectomy

OBJECTIVES

Sleeve gastrectomy (SG) is one of the most commonly performed weight loss (WL) bariatric procedures. The main goal of WL is reducing total body weight (TBW) and fat mass (FM). However, TBW loss is systematically accompanied by a decline in fat-free mass (FFM), predominantly in the first post-surgical month, despite protein supplementation. Branched-chain amino acids (BCAAs) and vitamin D seem to attenuate loss of FFM and, thus, reduce the decline in muscle strength (MS). However, data on the role of an integrated supplementation with whey protein plus BCAAs plus vitamin D (P+BCAAs+Vit.D) vs. protein alone on total weight loss (TWL), fat mass (FM), fat-free mass (FFM), and (MS) in the first month after SG are lacking. Therefore, the present study aims to evaluate the impact of P+BCAAs+Vit.D vs. protein alone supplementation on TWL, FM, FFM, and MS in the first month after SG.

MATERIALS AND METHODS

Before SG and at 1 month afterward, we prospectively measured and compared TBW, FM, FFM, and MS in 57 patients who received either a supplementation with P+BCAAs+Vit.D (n = 31) or protein alone (n = 26). The impact of P+BCAAs+Vit.D and protein alone supplementation on clinical status was also evaluated.

RESULTS

Despite non-significant variation in TBW, FM decreased more significantly (18.5% vs. 13.2%, p = 0.023) with the P+BCAA+Vit.D supplementation compared to protein alone. Furthermore, the P+BCAA+Vit.D group showed a significantly lower decrease in FFM (4.1% vs. 11.4%, p < 0.001) and MS (3.8% vs. 18.5%, p < 0.001) compared to the protein alone group. No significant alterations in clinical status were seen in either group.

CONCLUSION

P+BCAA+Vit.D supplementation is more effective than protein alone in determining FM loss and is associated with a lower decrease in FFM and MS, without interfering with clinical status in patients 1 month after SG.

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.

How Does Oversewing/Suturing (OS/S) Compare to Other Staple Line Reinforcement Methods? A Systematic Review and Meta-Analysis

Various staple line reinforcement (SLR) techniques in sleeve gastrectomy, including oversewing/suturing (OS/S), gluing, and buttressing, have emerged to mitigate postoperative complications such as bleeding and leaks. A meta-analysis of randomized controlled trials has demonstrated OS/S as an efficacious strategy for preventing postoperative complications, encompassing leaks, bleeding, and reoperations. Given that OS/S is the sole SLR technique not incurring additional costs during surgery, our study aimed to compare postoperative outcomes associated with OS/S versus alternative SLR methods. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we reviewed the literature and conducted fifteen pairwise meta-analyses of comparative studies, each evaluating an outcome between OS/S and another SLR technique. Thirteen of these analyses showed no statistically significant differences, whereas two revealed notable distinctions.

Implementation of Artificial Intelligence-Based Computer Vision Model for Sleeve Gastrectomy: Experience in One Tertiary Center

INTRODUCTION

Sleeve gastrectomy (SG) is the most common metabolic and bariatric procedure performed. Leveraging artificial intelligence (AI) for automated real-time data structuring and annotations of surgical videos has immense potential of clinical applications. This study presents initial real-world implementation of AI-based computer vision model in sleeve gastrectomy (SG) and external validation of accuracy of safety milestone annotations.

METHODS

A retrospective single-center study of 49 consecutive SG videos was captured and analyzed by the AI platform (December 2020-August 2023). A bariatric surgeon viewed all videos and assessed safety milestones adherence, compared to the AI annotations. Patients' data were retrieved from the bariatric unit registry.

RESULTS

SG total duration was 47.5 min (interquartile range 36-64). Main steps included preparation (12.2%), dissection of the greater curvature (30.8%), gastric transection (28.5%), specimen extraction (7.2%), and final inspection (14.4%). Out of body time comprised 6.9% of the total video. Safety milestones components and AI-surgeon agreements included the following: bougie insertion (100%), distance from pylorus ≥ 2 cm (100%), parallel to lesser curvature (98%), fundus mobilization (100%), and distance from esophagus ≥ 1 cm (true-100%, false-13.6%; kappa coefficient 0.2, p = 0.006). Intraoperative complications included notable hemorrhage (n = 4) and parenchymal injury (n = 1).

CONCLUSIONS

The AI model provides a fully automated SG video analysis. Outcomes suggest its accuracy in four of five safety milestone annotations. This data is valuable, as it reflects objective performance measures which can help us improve the surgical quality and efficiency of SG. Larger cohorts will enable SG standardization and clinical correlations with outcomes, aiming to improve patients' safety.

Outcomes of Laparoscopic Sleeve Gastrectomy (LSG) vs One-Anastomosis Gastric Bypass (OAGB) in Patients with Super-Super Obesity (BMI ≥ 60 kg/m2)

INTRODUCTION

The data comparing laparoscopic sleeve gastrectomy (LSG) and one-anastomosis gastric bypass (OAGB) in patients with BMI ≥ 60 kg/m2 is scarce.

METHODS

Prospectively collected data of patients with BMI ≥ 60 kg/m2 undergoing LSG or OAGB from January 2008 until June 2022 was analyzed retrospectively. Weight loss outcomes, impact on comorbidities, and complications were compared in both groups.

RESULTS

Fifty-six patients underwent LSG and 13 patients underwent OAGB. The median age and BMI were 37 (34-44) years and 63 (61.3-64.6) kg/m2 respectively. Both the groups had similar baseline demographic parameters. The percentage excess BMI loss (%EBMIL) was statistically similar in LSG and OAGB groups at 1 year (46.2% vs 46.1%), 3 years (52.9% vs 56.7%), and 5 years (51.1% vs 62.3%). The percentage excess BMI regain was lower (although statistically similar) following OAGB at 3 years (5.3% vs 0.1%) and 5 years (12.9% vs 4.4%). OAGB was found to correlate positively with weight loss and negatively with weight regain (p > 0.05). There was one 30-day mortality due to postoperative lower respiratory infection in the LSG group.

CONCLUSION

OAGB has a trend towards better weight loss outcomes as compared to LSG in patients with a BMI ≥ 60 kg/m2 with lesser complication rates and might be a preferred option. LSG also has acceptable weight loss and should be considered a standalone procedure if OAGB is not feasible technically.

Jejunal stenosis as a sequela after laparoscopic sleeve gastrectomy for morbid obesity: a case series

Porto-mesenteric venous thrombosis (PMVT) is a rare complication that is encountered in less than 1% of patients following laparoscopic sleeve gastrectomy (LSG). This condition could be conservatively managed in stable patients with no evidence of peritonitis or bowel wall ischemia. Nonetheless, conservative management may be followed by ischemic small bowel stricture, which is poorly reported in the literature. Herein, we present our experience regarding three patients who presented with manifestations of jejunal stricture after initial successful conservative management of PMVT. Retrospective analysis of patients who developed jejunal stenosis as a sequela after LSG. The three included patients had undergone LSG with an uneventful post-operative course. All of them developed PMVT that was conservatively managed mainly by anticoagulation. After they were discharged, all of them returned with manifestations of upper bowel obstruction. Upper gastrointestinal series and abdominal computed tomography confirmed the diagnosis of jejunal stricture. The three patients were explored via laparoscopy, and resection anastomosis of the stenosed segment was performed. Bariatric surgeons should be aware of the association between PMVT, following LSG, and ischemic bowel strictures. That should help in the rapid diagnosis of the rare and difficult entity.

Omentopexy/Gastropexy (OP/GP) Following Sleeve Gastrectomy Might be an Effective 2-in-1 Method (Reinforcement and Fixation): A Meta-Analysis of 14 Studies and a Call for Randomized Controlled Trials

BACKGROUND

Laparoscopic sleeve gastrectomy can lead to dangerous complications as leaks and hemorrhage. In addition, it can lead to gastric twist/torsion, prolonged postoperative nausea and vomiting (PONV), and de novo gastroesophageal reflux disease (GERD). We aimed to study the efficacy of omentopexy/gastropexy (OP/GP) in the prevention of these postoperative complications.

MATERIALS AND METHODS

PubMed and Google Scholar were queried in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data was analyzed using the Review Manager (RevMen) 5.4.1 software. Mantel-Haenszel statistical method and random effects analysis model were used in all meta-analyses. The odds ratio was used for dichotomous data. Subgroup analysis was done according to bougie size. Subgroup analysis according to the distance between the starting point of gastric transection and pylorus was not possible (limitation). Odds ratio and control event rate across studies were used to calculate the number needed to treat (NNT) with OP/GP for an additional beneficial outcome (prevention of adverse outcome) to occur.

RESULTS

The initial search identified 442 records; 371 were found irrelevant after screening and were excluded. The remaining 71 reports were retrieved and assessed for eligibility. An additional 57 reports were excluded following an in-depth assessment. The remaining 14 studies were included in this meta-analysis; 8 were nonrandomized studies (NRSs) while 6 were randomized controlled trials. Most studies originated from a single country (limitation). A statistically significant decrease in favor of OP/GP was observed for all outcomes (bleeding, leaks, gastric twist/torsion, prolonged PONV 1 month postoperatively, and postoperative de novo GERD). Data was consistent across studies (low I2 ), and subgroup analysis according to bougie size revealed no subgroup differences. However, this study had 3 limitations that does not allow for strong conclusions.

CONCLUSIONS

Although the current literature lacks strong scientific evidence, this study suggests that omentopexy/gastropexy (OP/GP) may offer protection against bleeding and leaks as a staple line reinforcement method, as well as against gastric twist/torsion, prolonged postoperative nausea and vomiting (PONV), and de novo gastroesophageal reflux disease (GERD) as a staple line fixation method. Therefore, it is worthwhile to proceed with large-scale, multicenter, randomized controlled trials to reevaluate our findings. Furthermore, conducting a comparison between OP/GP and other staple line reinforcement techniques would be beneficial.

Decision regret up to 6 years after sleeve gastrectomy

BACKGROUND

Sleeve gastrectomy (SG) is one of the most popular types of weight loss surgery today but is neither risk-free nor universally effective. We previously demonstrated that 5% of Roux-en-Y gastric bypass (RYGB) patients and up to 20% of gastric banding patients report overall regret 4 years after surgery. This study explores patients' attitudes toward their decision to have SG and decision regret rates up to 6 years postoperatively.

METHODS

We surveyed 185 patients who were at least 6 months post-SG (response rate 30%). We used a modified version of the Decision Regret Scale developed by Brehaut et al. We converted responses to a 0-100 scale so that higher scores (> 50) reflect greater regret. We characterized patients who expressed having overall decision regret (score > 50) vs. those who did not (≤ 50). Demographic and preoperative clinical information was extracted from the online medical records.

RESULTS

Of 185 SG patients, only 13 (7%) reported regret scores > 50 (i.e. high decision regret). Mean time from SG to survey completion was 41 months (range 6-76 months). Unadjusted comparisons between the two groups revealed that patients with high regret scores had lower mean weight loss (32.1% vs. 48.9% EBMIL), and reported less improvement in quality-of-life (QoL), such as physical health (46.2% vs. 93.5% "somewhat" or "significantly" improved). The two groups were similar in short-term complications, but those reporting overall regret were more likely to report GI complaints such as bloating (61.5% vs. 30.4%). Finally, patients with regret scores > 50 were more likely to be further out from SG (median time since surgery 61.8 vs. 41.1 months).

CONCLUSION

In our study, very few patients reported regret (7%) up to 6 years postoperatively, in line with prior reports after RYGB. Those with regret reported poorer QoL.

Gastroesophageal reflux after sleeve gastrectomy: The dimension of the problem

Sleeve gastrectomy is a safe and effective bariatric surgery in terms of weight loss and longterm improvement or resolution of comorbidities. However, its achilles heel is the possible association with the development with the novo and/or worsening of pre-existing gastroesophageal reflux disease. The anatomical and mechanical changes that this technique induces in the esophagogastric junction, support or contradict this hypothesis. Questions such as «what is the natural history of gastroesophageal reflux in the patient undergoing gastric sleeve surgery?», «how many patients after vertical gastrectomy will develop gastroesophageal reflux?» and «how many patients will worsen their previous reflux after this technique?» are intended to be addressed in the present article.

Short-term outcomes of double omentopexy in one anastomosis gastric bypass surgery: A controlled clinical trial

Purpose

This study aims to assess the efficacy of implementing a novel technique of reinforcement of gastric pouch and remnant stomach staple line with Double Omentopexy (DO) in patients undergoing One-Anastomosis Gastric Bypass (OAGB) surgery and evaluate its impact in reducing the early postoperative complications.

Materials and Methods

The 123 patients were allocated into two groups: 61 in the standard OAGB group and 62 in OAGB with DO group. The primary outcomes are postoperative complications (including early postoperative bleeding, leakage, gastric twist, reflux, etc.) and hospital stay. The secondary outcome is excess body weight loss. Follow-up visits were planned after discharge: at two weeks, two months, and three months postoperatively.

Results

Postoperative complications were significantly lower, 3 (4.84%) in OAGB with DO compared with 10 (16.39%) in standard OAGB (P =0.037). There was no statistically significant difference in the incidence of early postoperative bleeding, deep vein thrombosis, biliary reflux, and gall bladder stone (P >.05). No patient had leakage in either group. The mean operative time was significantly longer (68.66 ± 6.68 min) in OAGB with the DO group when compared with the standard OAGB group (62.16 ± 7.54 min) (P <.001).

Conclusion

Applying the DO technique may be a good measure to be added during OAGB to decrease the incidence of potential postoperative complications, especially the rate and severity of bleeding.

Early Bowel Obstruction after Bariatric Surgery: An Analysis of the 2020-2021 MBSAQIP Database

BACKGROUND

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program evaluates 30-day outcomes of bariatric cases performed in the United States. The Participant Use File in 2020 introduced bowel obstruction (BO). We compared the rates of BO, risk factors, and postoperative outcomes after laparoscopic Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and duodenal switch (DS).

METHODS

Retrospective analysis of patients who underwent laparoscopic RYGB, SG, or DS obtained from the 2020-2021 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. Patients who underwent either as a primary procedure with a body mass index >35 kg/m 2 were selected. Baseline characteristics, operative details, and postoperative complications were collected. The outcome of interest was BO occurring within 30 days.

RESULTS

A total of 205,533 cases of which 148,944 were SG (72.4%), 54,606 were RYGB (26.5%), and 1983 were DS (1%). BO occurred in 0.74%, 0.4%, and 0.03% of patients who underwent an RYGB, DS, or SG, respectively. Patients with a BO in the RYGB group were more likely to be on immunosuppressive therapy (5.4% vs. 1.9%, P <0.001) with longer operative time (136.2 min±58.0 min vs. 117.4 min±53.6 min, P <0.001). SG patients with a BO were older (47.5±13.6 vs. 41.9±11.6, P =0.011) with longer operating times (98.6±63.8 vs. 68.9±33.4, P =0.002). Patients in the RYGB group with a BO had the highest rates of readmissions (71.9%) and reoperations (58.4%).

CONCLUSIONS

Early bowel obstruction is rare after bariatric surgery. It is more common after RYGB and least common after SG. Readmission and reoperation rates were highest in patients with BO in the RYGB group.

The Impact of Blood Pressure Switching (from Controlled Hypotension to Late Elevated Blood Pressure) During Laparoscopic Sleeve Gastrectomy: Controlled Clinical Trial

PURPOSE

Laparoscopic sleeve gastrectomy (LSG) is the most done bariatric procedure. Bleeding and leak are the most common associated complications. Elevation of systolic blood pressure (SBP) leads to discovering the bleeding sites but results in a bloody field and increases the operative time. Controlled hypotension shortens the operative time, reduces tissue edema, and improves field vision. We aimed to test controlled hypotension during LSG.

MATERIAL AND METHODS

This was a randomized controlled trial that included 200 patients who were operated by LSG, randomly assigned to 2 equal groups: group 1, operated with controlled hypotensive anesthesia, and group 2, operated with elevated SBP to 140 mmHg.

RESULTS

Of the patients, 162 (81%) were females, and 38 (19%) were male. The mean BMI was 45.7 kg/m2. The mean age was 41.7 years. The operative time was 36.43 ± 6.73 min in group 1 vs. 44.71 ± 5.47 min in group 2. The mean of total number of used gauzes and clips was 2.70 ± 3.49 in group 1 vs. 8.83 ± 3.15 in group 2. The mean amount of drain output was 37.65 ± 21.90 ml in group 1 vs. 74.00 ± 16.54 ml in group 2. The mean drop in the postoperative hematocrit was 0.08 in group 1 vs. 0.22 in group 2. The incidence of postoperative bleeding was 0% in group 1 vs. 1% in group 2.

CONCLUSIONS

Controlled hypotensive anesthesia in LSG reduces the operative time, reduces the intraoperative bleeding, and improves the operative field.

Management of gastropleural leak by video-assisted thoracoscopy after sleeve gastrectomy

Obesity is a major public health issue with various comorbidities. Sleeve gastrectomy has become a popular treatment for obesity, but it carries the risk of complications, particularly staple line leakage. This case study focused on a 32-year-old woman with grade II obesity and hiatal hernia who underwent laparoscopic sleeve gastrectomy. Four days after surgery, she presented with abdominal pain, revealing leakage from the gastric sleeve into the thoracic cavity. Diagnostic procedures and interventions were performed, including cavity lavage, drainage placement, and stent placement. The patient showed clinical improvement after video-assisted thoracoscopic surgery and a multidisciplinary approach involving nutrition support and antibiotics. Despite the challenges, the patient's clinical course improved, leading to discharge with no evidence of leakage on follow-up endoscopy. Careful monitoring and timely interventions are essential to manage complications in sleeve gastrectomy procedures and ensure optimal patient outcomes.

Bariatric surgery and liver transplantation, here we are now: A French nationwide retrospective study

At the time of the growing obesity epidemic worldwide, liver transplantation (LT) and metabolic syndrome are closely linked: non-alcohol-related fatty liver disease (NAFLD) is one of the leading indications for liver transplantation, and metabolic syndrome can also appear after liver transplantation, in relation to immunosuppressive medications and weight gain, whatever was the initial liver disease leading to the indication of LT. Therefore, the role of bariatric surgery (BS) is important due to its longer-lasting effect and efficacy. We performed a retrospective review of all 50 adult French liver transplant recipients who had a history of bariatric surgery, including 37 procedures before transplantation, and 14 after. There were three significantly different characteristics when comparing pre-and post-LT BS: patients were older (at the time of BS), presented more frequently arterial hypertension (at the time of LT), and the proportion of NAFLD as initial liver disease leading to LT was lower, in the post-LT group. Regarding pre-LT BS, in one case BS was complicated by liver failure leading to the rapid indication of LT; it was the single patient for whom the delay between BS and LT was less than 1 year; there was no patient who specifically underwent BS for the purpose of LT listing.

The Role Bariatric Surgery and Endobariatric Therapies in Nonalcoholic Steatohepatitis

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease worldwide. Disease spectrum varies from steatosis, steatohepatitis, fibrosis, cirrhosis, and hepatocellular carcinoma. Currently, there are no approved medical therapies, and weight loss through lifestyle modifications remains a mainstay of therapy. Bariatric surgery is the most effective therapy for weight loss and has been shown to improve liver histology. Recently, endoscopic bariatric metabolic therapies have also emerged as effective treatments for patients with obesity and NAFLD. This review summarizes the role of bariatric surgery and endoscopic therapies in the management of patients with NAFLD.

[Non-surgical treatment of staple-line suture leakage after redo sleeve gastrectomy]

Redo bariatric procedures are common. However, redo sleeve gastrectomy is not a frequent case of repeated bariatric surgery and can be performed rather as a necessary measure in difficult intraoperative conditions. We report a patient who underwent laparoscopic adjustable gastric band placement, its blockage and surgical removal, sleeve gastrectomy and redo sleeve gastrectomy. After that, staple-line suture failure developed that required endoscopic clipping.

Laparoscopic Roux-en-Y fistulojejunostomy as a salvage procedure in patients with chronic gastric leak after sleeve gastrectomy

BACKGROUND

The most common postoperative complication of laparoscopic sleeve gastrectomy (LSG) is staple-line leak. Even if its rate following LSG has been recently reduced, management of chronic leaks remains challenging.

OBJECTIVE

To present a series of patients treated with laparoscopic Roux-en-Y fistulojejunostomy (LRYFJ) for chronic gastric leak (>12 wk) post-LSG.

SETTING

University hospitals; specialized bariatric surgery units.

METHODS

Data were prospectively gathered and retrospectively analyzed. Parameters of interest were patient characteristics, perioperative data, and postoperative outcomes. Hemodynamically unstable patients and/or presentations of signs of severe sepsis were excluded. Surgical technique was standardized.

RESULTS

Fourteen patients underwent LRYFJ for chronic gastric leak (12 women, 2 men). The mean age was 49.2 years and the mean weight was 88.7 kg with a mean body mass index of 31.1 kg/m². All procedures were successfully performed by laparoscopy except 1 (7.1%) converted to open surgery. The mean operative time was 198 minutes, with a mean estimated blood loss of 135.7 mL and 2 patients necessitating transfusion (14.2%). Mortality was null. Five postoperative complications were noted (35.7%): 2 leaks of the fistulojejunostomy treated by antibiotherapy and endoscopic drainage; 1 perianastomotic hematoma treated by relaparoscopy and antibiotherapy; and 1 pleural effusion and 1 hematemesis both medically treated. The mean length of hospital stay was 14 days. The mean follow-up was 40 months, with all patients being in good health at last contact.

CONCLUSIONS

LRYFJ seems to be a good salvage option in selected patients for the treatment of chronic gastric leaks after LSG. However, it is a challenging procedure and should be performed in experienced bariatric centers by expert bariatric surgeons.

Psychosocial Aspects of Metabolic and Bariatric Surgeries and Endoscopic Therapies

Obesity is a prevalent progressive and relapsing disease for which there are several levels of intervention, including metabolic and bariatric surgery (MBS) and now endoscopic bariatric and metabolic therapies (EBMTs). Preoperative psychological assessment focused on cognitive status, psychiatric symptoms, eating disorders, social support, and substance use is useful in optimizing patient outcomes and minimizing risks in MBS. Very little is known about the psychosocial needs of patients seeking EBMTs, though these investigations will be forthcoming if these therapies become more widespread. As MBS and EBMT inherently alter the gastrointestinal (GI) tract, considerations for the longer-term GI functioning of the patient are relevant and should be considered and monitored.

The Impact of Bariatric-Surgery-Induced Weight Loss on Patients Undergoing Liver Transplant: A Focus on Metabolism, Pathophysiological Changes, and Outcome in Obese Patients Suffering NAFLD-Related Cirrhosis

Because of their condition, patients with morbid obesity develop several histopathological changes in the liver, such as non-alcoholic fatty liver disease (NAFLD), non-alcoholic steatohepatitis (NASH), cirrhosis, and end-stage liver disease (ESLD). Hence, a liver transplant (LT) becomes an opportune solution for them. Due to many challenges during the perioperative and postoperative periods, these patients are recommended to lose weight before the surgery. There are many proposals to achieve this goal, such as intragastric balloons and many different bariatric surgery (BS) procedures in combination with a preparation diet (very-low-calorie diet, ketogenic diet, etc.). All the interventions focus on losing weight and keeping the continuity and functionality of the digestive tract to avoid postoperative complications. Thus, this review analyzes recent publications regarding the metabolic and pathophysiological impacts of BS in LT patients suffering from NAFLD-related cirrhosis, the effect of weight loss on postoperative complications, and exposes the cost-effectiveness of performing BS before, after, and at liver transplantation. Finally, the authors recommend BS before the LT since there are many positive effects and better outcomes for patients who lose weight before the procedure. Nevertheless, further multicentric studies are needed to determine the generalizability of these recommendations due to their impact on public health.

Lactobacillus plantarum FRT4 alleviated obesity by modulating gut microbiota and liver metabolome in high-fat diet-induced obese mice

Background

Obesity has become a global epidemic recognized by the World Health Organization. Probiotics supplementation has been shown to contribute to improve lipid metabolism. However, mechanisms of action of probiotics against obesity are still not clear. Lactobacillus plantarum FRT4, a probiotic previously isolated from a kind of local yogurt, had good acid and bile salt tolerance and lowered cholesterol in vitro.

Objective

This study aimed to evaluate the effect of L. plantarum FRT4 on serum and liver lipid profile, liver metabolomics, and gut microbiota in mice fed with a high-fat diet (HFD).

Design

Mice were fed with either normal diet or HFD for 16 weeks and administered 0.2 mL of 1 × 10⁹ or 1 × 10¹⁰ CFU/mL dosage of L. plantarum FRT4 during the last 8 weeks of the diet. Cecal contents were analyzed by 16S rRNA sequencing. Hepatic gene expression and metabolites were detected by real-time quantitative polymerase chain reaction (PCR) and metabolomics, respectively.

Results

L. plantarum FRT4 intervention significantly reduced the HFD-induced body weight gain, liver weight, fat weight, serum cholesterol, triglyceride, and alanine aminotransferase (ALT) levels in the liver (P < 0.05). Liver metabolomics demonstrated that the HFD increased choline, glycerophosphocholine, and phosphorylcholine involved in the glycerophospholipid metabolism pathway. All these changes were reversed by FRT4 treatment, bringing the levels close to those in the control group. Further mechanisms showed that FRT4 favorably regulated gut barrier function and pro-inflammatory biomediators. Furthermore, FRT4 intervention altered the gut microbiota profiles and increased microbial diversity. The relative abundances of Bacteroides, Parabateroides, Anaerotruncus, Alistipes, Intestinimonas, Butyicicoccus, and Butyricimonas were significantly upregulated. Finally, Spearman's correlation analysis revealed that several specific genera were strongly correlated with glycerophospholipid metabolites (P < 0.05).

Conclusions

These findings suggested that L. plantarum FRT4 had beneficial effects against obesity in HFD-induced obese mice and can be used as a potential functional food for the prevention of obesity.

Bioabsorbable Glycolide Copolymer is Effective in Reducing Staple Line Bleeding in Sleeve Gastrectomy

BACKGROUND

Postoperative bleeding from the staple line after sleeve gastrectomy occurs in 2-8% of patients and it is associated with increased length and cost of hospitalization and may demand reoperation to gain hemostasis. Reinforced staplers are used by bariatric surgeons to reduce the incidence of postoperative leak but can have a role in avoiding bleeding. The aim of this study is to analyze the effects of reinforcement on the whole gastric staple line during sleeve gastrectomy on postoperative bleeding.

METHODS

Four hundred forty-eight consecutive patients undergoing sleeve gastrectomy from November 2012 to April 2019 were divided into two groups. In the Top-only group only the top staple shot was realized with reinforced material (GORE® SEAMGUARD®) while in the Bottom-to-Top group, patients received full staple line reinforcement. Statistical analysis focused on postoperative leak and bleeding, and length of stay; a propensity score matching analysis was performed to reduce between-group characteristics imbalance.

RESULTS

One hundred forty-five (Top-only) and 303 (Bottom-to-Top) patients were included. Four (2.8%) patients in the Top-only group and none in the Bottom-to-Top group experienced severe bleeding (p = 0.004); the difference was still significant after propensity score matching. Length of stay was significantly shorter for the Bottom-to-Top group before and after propensity score matching (4 vs. 5 days, p < 0.001).

CONCLUSIONS

Staple line buttressing reduces the incidence of severe postoperative bleeding when performed on the whole staple line, and it is associated with a shorter hospitalization.

Mechanism of Staple Line Leak After Sleeve Gastrectomy via Isobaric Pressurisation Concentrating Stress Forces at the Proximal Staple Line

Purpose

Staple line leak following sleeve gastrectomy is a significant problem and has been hypothesised to be related to hyperpressurisation in the proximal stomach. There is, however, little objective evidence demonstrating how these forces could be transmitted to the luminal wall. We aimed to define conditions in the proximal stomach and simulate the transmission of stress forces in the post-operative stomach using a finite element analysis (FEA).

Materials and Methods

The manometry of fourteen patients post sleeve gastrectomy was compared to ten controls. Manometry, boundary conditions, and volumetric CT were integrated to develop six models. These models delineated luminal wall stress in the proximal stomach. Key features were then varied to establish the influence of each factor.

Results

The sleeve gastrectomy cohort had a significantly higher peak intragastric isobaric pressures 31.58 ± 2.1 vs. 13.49 ± 1.3 mmHg (p = 0.0002). Regions of stress were clustered at the staple line near the GOJ, and peak stress was observed there in 67% of models. A uniform greater curvature did not fail or concentrate stress under maximal pressurisation. Geometric variation demonstrated that a larger triangulated apex increased stress by 17% (255 kPa versus 218 kPa), with a 37% increase at the GOJ (203kPA versus 148kPA). A wider incisura reduced stress at the GOJ by 9.9% (128 kPa versus 142 kPa).

Conclusion

High pressure events can occur in the proximal stomach after sleeve gastrectomy. Simulations suggest that these events preferentially concentrate stress forces near the GOJ. This study simulates how high-pressure events could translate stress to the luminal wall and precipitate leak.

Graphical Abstract

Changes in Food Choice, Taste, Desire, and Enjoyment 1 Year after Sleeve Gastrectomy: A Prospective Study

Obesity is a well-recognized global health problem, and bariatric surgery (BS)-induced weight reduction has been demonstrated to improve survival and obesity-related conditions. Sleeve gastrectomy (SG) is actually one of the most performed bariatric procedures. The underlying mechanisms of weight loss and its maintenance after SG are not yet fully understood. However, changes to the taste function could be a contributing factor. Data on the extent of the phenomenon are limited. The primary objective was to assess, through validated questionnaires, the percentage of patients who report an altered perception of post-SG taste and compare the frequency of intake of the different food classes before SG and after 1 year follow-up. The secondary objective was to evaluate the total body weight change. Materials and Methods: We prospectively investigated the changes in food choice and gustatory sensitivity of 52 patients (55.8% females) 12 months after SG. The mean initial weight and body mass index (BMI) were 130.9 ± 24.7 kg and 47.4 ± 7.1 kg/m2, respectively. The frequency of food intake was assessed by food-frequency questionnaire, while changes in taste perception were assessed using the taste desire and enjoyment change questionnaire. The change in total body weight was also assessed. Results: A significant decrease in the intake frequency of bread and crackers (p < 0.001), dairy products and fats (p < 0.001), sweets and snacks (p < 0.001) and soft drinks (p < 0.001), and a significant increase in the frequency of vegetable and fruit consumption (p < 0.001) were observed at 12 months after SG in both genders. On the contrary, we found no significant changes in the frequency of meat and fish intake in females (p = 0.204), whereas a significant change was found in males (p = 0.028). Changes in perceived taste intensity of fatty foods (p = 0.021) and tart foods (p = 0.006) for females and taste of bitter foods for females and males (p = 0.002; p = 0.017) were found. Regarding the change in food desire for both genders, there was a decrease in the desire for sweet, fatty, and salty foods, whereas there was an increasing trend in the desire for tart foods, especially for females. Significant reduction in total body weight and BMI was observed in both genders at the time of follow-up. Conclusions: Based on our findings, we are able to support the evidence that changes in taste, desire, and enjoyment of taste are very common after SG, with a reduced preference for food with high sugar and fat content and an increased postoperative preference for low-sugar and -fat foods. However, further investigation is needed to clarify this issue. The molecular, hormonal, and central mechanisms underlying these changes in taste perception need to be further elucidated, as they could identify new targets able to modify obesogenic eating behavior, opening up a novel personalized therapeutic approach to obesity.

Twisted Gastric Tube after Laparoscopic Sleeve Gastrectomy-An Unusual but Effective Surgical Approach to Achieve Full Recovery

Sleeve gastrectomy is at present the most practiced bariatric intervention for patients suffering from severe obesity. Although rare, post-operative complications such as leakages and strictures may represent a challenging issue for bariatric surgeons and cause impaired quality of life for patients. Gastric twist is even more rare. This complication is a functional obstruction rather than a stricture of the gastric remnant most likely due to technical mistakes at index surgery. If endoscopy usually allows diagnosis and constitutes the first-line treatment for this condition, surgery is mandatory when endoscopy is not successful. The conversion of the sleeve to a Roux-en-Y gastric bypass is the usually chosen intervention but a wide range of reconstruction has been proposed. In this report, we discuss the surgical technique we employed to achieve a full resolution of a gastric twist.

A Hub and Spoke Learning Program in Bariatric Surgery in a Small Region of Italy

Background

Metabolic and bariatric surgery (BS) are considered life-changing and life-saving treatments for obese patients. The Italian Society of Obesity Surgery (SICOB) requires at least 25 operations per year to achieve the standard of care in the field. Despite the increasing need to treat obese patients, some small southern regions of Italy, such as Molise, do not have enough experience in bariatric procedures to be allowed to perform them. Therefore, our aim was to run a Hub and Spoke Program with a referral center in BS to treat obese patients and provide a proper learning curve in BS in Molise.

Methods

In 2020, the “A. Cardarelli Hospital” in Campobasso, Molise, started a formal “Learning Model of Hub and Spoke Collaboration” with the Hub center “Ospedale Del Mare”, Naples. A multidisciplinary approach was achieved. Patients were supervised and operated under the supervision and tutoring of the referral center. We retrospectively reviewed our prospectively collected database from February 2020 to August 2021 in order to analyze the safety and effectiveness of our learning program.

Results

In total, 13 (3 men and 10 women) patients underwent BS with the mean age of 47.08 years and a presurgery BMI of 41.79. Seven (53.84%) patients were the American Society of Anesthesiologist (ASA) II, and 6 (46.16%) patients were ASA III. Twelve (92.31%) procedures were laparoscopic sleeve gastrectomies, 1 (7.69%) patient underwent endoscopic BioEnterics Intragastric Balloon (BIB) placement. One (8.33%) sleeve gastrectomy was associated to gastric band removal. Mean surgical time was 110.14 ± 23.54 min. The mean length of stay was 4.07 ± 2.40 days. No Clavien-Dindo ≥ III and mortality were reported. The follow-up program showed a mean decrease of 11.82 in terms of body mass index (BMI) value. The last 5 procedures were performed by the whole equips from “A. Cardarelli” under external tutoring without any impact on complication rate.

Conclusion

The setup of a proper Hub and Spoke Program may allow to perform BS to provide the standard of care. This approach may reduce health costs and related patient migration.

Impact of preoperative weight loss achieved by gastric balloon on peri- and postoperative outcomes of bariatric surgery in super-obese patients: a retrospective matched-pair analysis

Background

An intragastric balloon is used to cause weight loss in super-obese patients (BMI > 60 kg/m²) prior to bariatric surgery. Whether weight loss from intragastric balloon influences that from bariatric surgery is poorly studied.

Methods

In this retrospective, single-center study, the effects of intragastric balloon in 26 patients (BMI 69.26 ± 6.81) on weight loss after bariatric surgery (primary endpoint), postoperative complications within 30 days, hospital readmission, operation time, and MTL30 (secondary endpoints) were evaluated. Fifty-two matched-pair patients without intragastric balloon prior to bariatric surgery were used as controls.

Results

Intragastric balloon resulted in a weight loss of 17.3 ± 14.1 kg (BMI 5.75 ± 4.66 kg/m²) with a nadir after 5 months. Surgical and postoperative outcomes including complications were comparable between both groups. Total weight loss was similar in both groups (29.0% vs. 32.2%, p = 0.362). Direct postoperative weight loss was more pronounced in the control group compared to the gastric balloon group (29.16 ± 7.53% vs 23.78 ± 9.89% after 1 year, p < 0.05 and 32.13 ± 10.5% vs 22.21 ± 10.9% after 2 years, p < 0.05), who experienced an earlier nadir and started to regain weight during the follow-up.

Conclusion

A multi-stage therapeutic approach with gastric balloon prior to bariatric surgery in super-obese patients may be effective to facilitate safe surgery. However, with the gastric balloon, pre-treated patients experienced an attenuated postoperative weight loss with an earlier nadir and earlier body weight regain. This should be considered when choosing the appropriate therapeutic regime and managing patients’ expectations.

Stent Management of Leaks After Bariatric Surgery: a Systematic Review and Meta-analysis

BACKGROUND

Despite the low rates of complications of bariatric surgery, gastrointestinal leaks are major adverse events that increase post-operative morbidity and mortality. Endoscopic treatment using self-expanding stents has been used in the therapeutic management of these complications with preliminary good results.

METHODS

We performed a systematic review and meta-analysis of self-expanding stents placement for the management of gastrointestinal leaks after obesity surgery. Overall proportion of successful leak closure, stent migration, and reoperation were analysed as primary outcomes. Secondary outcomes were patients' clinical characteristics, duration and type of stent, other stent complications, and mortality.

RESULTS

A meta-analysis of studies reporting stents was performed, including 488 patients. The overall proportion of successful leak closure was 85.89% (95% CI, 82.52-89.25%), median interval between stent placement and its removal of 44 days. Stent migration was noted in 18.65% (95% CI, 14.32-22.98%) and the overall proportion of re-operation was in 13.54% (95% CI, 9.94-17.14%). The agreement between reviewers for the collected data gave a Cohen's κ value of 1.0. No deaths were caused directly by complications with the stent placement.

CONCLUSIONS

Endoscopic placement of self-expanding stents can be used, in selected patients, for the management of leaks after bariatric surgery with a high rate of effectiveness and low mortality rates. Nevertheless, reducing stent migration and re-operation rates represents an important challenge for future studies.

Application of the Caprini Risk Assessment Model to Select Patients for Extended Thromboembolism Prophylaxis After Sleeve Gastrectomy

BACKGROUND

The Caprini risk assessment model is a well-validated tool that identifies patients who would benefit from extended venous thromboembolism (VTE) prophylaxis beyond hospital discharge. VTE, particularly portal mesenteric vein thrombosis (PMVT), is a potentially devastating complication of laparoscopic sleeve gastrectomy (LSG); therefore, we sought to examine whether the model can be safely applied to LSG patients. We hypothesized that its use can minimize the incidence of postoperative VTE, including PMVT, without increasing the likelihood of bleeding complications.

MATERIALS AND METHODS

We conducted a retrospective chart review of those patients who underwent LSG at our institution from 2010 and 2018, at which time the Caprini risk assessment model was already our institutional standard. We determined the patients' Caprini scores at the time of discharge and whether patients at high risk of VTE were discharged from hospital on extended courses of VTE prophylaxis. We also recorded if bleeding complications or VTE events occurred in the first 180 days after LSG.

RESULTS

Six hundred thirty-eight patients underwent LSG, including 521 (81.7%) women, with an average preoperative body mass index (BMI) of 44.4 kg/m² (SD 6.8). One hundred fifty-eight (24.8%) patients had Caprini scores that warranted extended courses of VTE prophylaxis beyond hospital discharge. Three patients (0.47%) developed a postoperative VTE, but no patient developed PMVT. No bleeding complications were observed among patients who received extended VTE prophylaxis.

CONCLUSION

The Caprini risk assessment model can effectively identify patients after LSG who might benefit from extended courses of VTE prophylaxis. Extended VTE prophylaxis does not seem to confer increased bleeding risk in this patient population.

Foreign body reaction to spilled gastric contents mimicking peritoneal metastasis of colorectal cancer

Colorectal cancer represents the third most common cancer worldwide. The presence of peritoneal metastasis of colorectal cancer indicates Stage 4 disease with poor prognosis. We report a case of a foreign body reaction to plant material spilled during previous surgery, which mimicked peritoneal metastases. A 62-year-old male was found to have recto-sigmoid adenocarcinoma on colonoscopy. At the time of resection, peritoneal nodules were identified throughout the peritoneal cavity with the appearance of metastases. The resection was aborted, a diverting colostomy was fashioned and biopsies of the nodules were taken. The histology showed a foreign body reaction to plant material that was spilled during a sleeve gastrectomy that was performed 4 years prior. The patient subsequently underwent anterior resection with anastomosis and has recovered from surgery.

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.

Amylase Is Not a Useful Indicator for Leakage Detection Following Sleeve Gastrectomy: A Prospective Study

Introduction. Gastric leak after laparoscopic sleeve gastrectomy (LSG) is a severe complication that may lead to sepsis and even death. Early diagnosis and treatment are critical. The aims of this prospective study are to establish normal amylase levels and investigate elevated amylase levels, especially in the drain, for detecting anastomotic leakage following LSG. Material and Methods. One hundred sixty-one patients who underwent LSG during 1 year at Rambam Health Care Campus were included prospectively in the study. Demographic and medical background, peri- and postoperative complications, and laboratory data including amylase levels in blood, urine, and drain were evaluated. Univariate and multivariate analyses were performed to examine independent variables that can predict increases in amylase values. Results. Thirty-five (21.8%) patients had high levels of amylase in blood, urine, and/or drain and 126 (78.2%) normal values of amylase until discharge. No significant differences were found in operation duration, length of hospitalization, or occurrence of complications. One patient had a staple-line leak diagnosed in the third postoperative day that was treated conservatively with endoscopic approach. His amylase levels in the blood and drain were normal, with only a slight hyperamylasuria. Conclusions. High amylase levels after LSG does not necessarily indicate a major complication such as staple-line leak, and in the vast majority of cases, it seems to have no clinical relevancy. Therefore, it should not automatically lead to a full investigation in the absence of further clinical signs. It is suggested that there is no clinical justification to test amylase routinely after LSG.

Expected Values of Esophageal Transit and Gastric Emptying Scintigraphy Post-uncomplicated Sleeve Gastrectomy

PURPOSE

Sleeve gastrectomy (SG) results in significant anatomical and physiological alterations of the esophagus and stomach, including food tolerance. Currently, there is no consensus on the parameters of abnormal esophageal transit and gastric emptying in this population. We describe standardized esophageal transit and gastric emptying protocols, and define expected values following an uncomplicated SG.

MATERIALS AND METHODS

In 43 asymptomatic post-SG patients with optimal weight loss, a standardized liquid and semi-solid (oatmeal) esophageal transit study, plus a 90-min semi-solid gastric emptying study with dynamic 5-s image acquisition to assess gastroesophageal reflux, was performed. Gastric emptying half-time and retention rate was calculated. Esophageal transit and reflux were graded by visual inspection of images.

RESULTS

Thirty-one female and 12 male patients participated: mean age 49.0±10.7 years, pre-operative BMI 47.6±7.0 kg/m², excess weight loss 58.8±26.0% at median follow-up of 7.4 months. The standardized semi-solid meal and liquid preparations were well tolerated. Delays in esophageal transit of liquid and semi-solid boluses were infrequent (7.0% and 16.3% respectively). Deglutitive reflux of both semi-solids and liquids was common (48.8% and 32.6%). The median semi-solid gastric emptying half-time was 21.0 min. A large proportion of substrate transited into the small bowel on initial image acquisition (median 39.1%). Reflux events during gastric emptying were common (median 5.0 events, 12.7% of image acquisition time).

CONCLUSIONS

Rapid gastric emptying with asymptomatic deglutitive and post-prandial gastroesophageal reflux events are common following SG. We have defined the expected values of standardized esophageal transit and gastric emptying scintigraphy specifically tailored to SG patients.

Indications and Long-Term Outcomes of Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass

PURPOSE

Long-term results on sleeve gastrectomy (SG) with more than 10 years report patients needing sleeve revision for weight loss failure, de novo gastroesophageal reflux (GERD), or sleeve complications. The aim of this study was to analyze the results of laparoscopic conversion of failed SG to Roux-en-Y gastric bypass (RYGB).

MATERIALS AND METHODS

Retrospective review of a prospectively institutional maintained database to identify patients who underwent conversion of SG to RYGB between 2012 and June 2020.

RESULTS

Sixty patients(50 females) underwent conversion to RYGB. Average time to conversion was 5.6 years (2-11). Mean %WL and TWL after SG were respectively 26±8.8% and 33.2±14.1kg. Mean BMI at the time of RYGB was 38.1±7.1 kg/m². Mean follow-up was 30.4±16.8 months (6-84). Available patients at each time of follow-up: 1 year 59 (98.3%); 2 years 47 (78.3%); 3 years 39 (71.6%); and 5 years 33 (55%). Patients were divided according to indication for revision in weight regain/insufficient weight loss (30 patients) group 1 and GERD/complications (25 patients) group 2. Percentage of excess weight loss at 1, 3, and 5 years follow-up after bypass was for group 1 40.3±17.6, 34.3±19.5, and 23.2±19.4 and for group 2 90.4±37, 62.6±28.2, and 56±35.02. Total weight loss at last follow-up since sleeve was respectively 31kg in group 1 and 46.7kg in group 2 (p=0.002). No mortality was observed. Thirty-day complication rate was 3.3%.

CONCLUSION

RYGB after SG is a safe and effective revisional procedure to manage weight regain and de novo GERD, to address complications, and to improve comorbidities.

Surgical Management of a Chronic Sleeve Gastrocolic Fistula with Near Total Gastrectomy and Roux-en-Y Reconstruction

BACKGROUND

Management of the leak is determined by the duration of the leak from the initial surgery. Acute leaks occurring less than 72 hours after surgery are best managed with reoperation and primary repair. Intermediate leaks, greater than 72 hours but less than 12 weeks, can be managed with non-operative management in non-septic patients. When non-operative management fails beyond 12 weeks the leak is considered a chronic fistula which are best treated with definitive operative management. Sub-total gastrectomy with Roux-En-Y reconstruction with gastrojejunostomy, has been reported with resolution of the fistula in over 90% of cases.

OBJECTIVES

To demonstrate the operative management of chronic sleeve gastrectomy leaks.

METHODS

A 37-year-old male with a history of a sleeve gastrectomy, developed a chronic fistula between the distal gastric staple line and the transverse colon. After non-operative management failed the patient was taken to the operating room for a diagnostic laparoscopy with plans to perform a revision. A fistula between the distal sleeve staple line and the transverse colon was identified. The gastroesophageal junction was dissected and inspected, there was no fistula at the angle of His. A near total gastrectomy was then performed leaving a small gastric pouch. The colonic side of the fistula was oversewn. Roux-En-Y reconstruction was then performed.

RESULTS

No leak identified at four-month follow-up.

CONCLUSION

Leak after sleeve gastrectomy can be difficult to manage. Chronic leaks do not respond well to non-operative management. Partial gastrectomy with Roux-En-Y reconstruction is a technically challenging option with good results.

Laparoscopic Sleeve Gastrectomy with Omentopexy: Is It Really a Promising Method?-A Systematic Review with Meta-analysis

Purpose

Laparoscopic sleeve gastrectomy (LSG) is one of the most commonly performed bariatric procedure worldwide. Omentopexy during LSG is a novel variation of this well-established technique. There are no clear conclusions on indications for this procedure, safeness, and effects of such a method. We aimed to compare the outcomes of laparoscopic sleeve gastrectomy (LSG) with omentopexy (OP) and without omentopexy.

Materials and Methods

We searched the Medline, EMBASE, and Scopus databases up-to June 2020. Full-text articles and conference abstracts were included for further analysis. This review follows the PRISMA guidelines.

Results

Of initial 66 records, only 4 studies (N = 1396 patients) were included in the meta-analysis. Our findings showed that LSG with omentopexy had significantly lowered overall morbidity compared to LSG without omentopexy (RR = 0.38; 95% CI [0.15, 0.94]; p=0.04). Gastric leakage rate (RR = 0.17; 95% CI [0.04, 0.76]; p = 0.02) was also significantly lower in LSG with omentopexy. There were no significant differences between groups in length of hospital stay.

Conclusions

Our meta-analysis showed that LSG with omentopexy may be a feasible procedure for decreasing morbidity and gastric leak rate. However, despite promising results, the procedure needs to be researched more in randomized controlled studies to draw solid conclusions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-021-05327-8.

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.

Diagnostic Criteria for Gastro-esophageal Reflux Following Sleeve Gastrectomy

Background

Gastro-esophageal reflux disease (GERD) post-sleeve gastrectomy (SG) is a controversial issue and diagnostic dilemma. Strong heterogeneity exists in the assessment of reflux post-SG, and better diagnostic tools are needed to characterize symptomatic reflux. We aimed to determine the discriminant factors of symptomatic reflux and establish diagnostic thresholds for GERD following SG.

Materials and Methods

Patients post-SG were categorized into asymptomatic and symptomatic cohorts and completed validated symptom questionnaires. All patients underwent stationary esophageal manometry and 24-h ambulatory pH monitoring. Univariate and multivariate analyses were conducted to determine the strongest discriminant factors for GERD.

Results

Baseline characteristics of the asymptomatic cohort (n = 48) and symptomatic cohort (n = 76) were comparable. The median post-operative duration was 7.3 (14.1) vs 7.5 (10.7) months (p = 0.825). The symptomatic cohort was more female predominant (90.8 vs 72.9%, p = 0.008). Reflux scores were significantly higher in the symptomatic group (36.0 vs 10.5, p = 0.003). Stationary manometry parameters were similar, including hiatus hernia prevalence and impaired esophageal motility. The symptomatic cohort had significantly higher total acid exposure, especially while supine (11.3% vs 0.6%, p < 0.001). Univariate and multivariate regressions delineated reflux score and supine acid exposure as discriminant factors for symptomatic reflux. The thresholds for distinguishing symptomatic reflux are as follows: reflux score of 11.5 (sensitivity 84.0%, specificity 68.2%) and supine acid exposure of 2.65% (sensitivity 67.1%, specificity 70.8%).

Conclusion

A reflux score of 11.5 or more or supine acid exposure of 2.65% or more should be considered diagnostic in defining symptomatic reflux following SG.

A 4-tier Protocolized Radiological Classification System for Leaks Following Sleeve Gastrectomy

OBJECTIVES

To develop and validate a classification of sleeve gastrectomy leaks able to reliably predict outcomes, from protocolized computed tomography (CT) findings and readily available variables.

SUMMARY OF BACKGROUND DATA

Leaks post sleeve gastrectomy remain morbid and resource-consuming. Incidence, treatments, and outcomes are variable, representing heterogeneity of the problem. A predictive tool available at presentation would aid management and predict outcomes.

METHODS

From a prospective database (2009-2018) we reviewed patients with staple line leaks. A Delphi process was undertaken on candidate variables (80-20). Correlations were performed to stratify 4 groupings based on outcomes (salvage resection, length of stay, and complications) and predictor variables. Training and validation cohorts were established by block randomization.

RESULTS

A 4-tiered classification was developed based on CT appearance and duration postsurgery. Interobserver agreement was high (κ=0.85, P<0.001). There were 59 patients, (training: 30, validation: 29). Age 42.5±10.8 versus 38.9±10.0 years (P=0.187); female 65.5% versus 80.0% (P=0.211), weight 127.4±31.3 versus 141.0±47.9 kg, (P=0.203). In the training group, there was a trend toward longer hospital stays as grading increased (I=10.5 d; II=24 d; III=66.5 d; IV=72 d; P= 0.005). Risk of salvage resection increased (risk ratio grade 4=9; P=0.043) as did complication severity (P=0.027). Findings were reproduced in the validation group: risk of salvage resection (P=0.007), hospital stay (P=0.001), complications (P=0.016).

CONCLUSION

We have developed and validated a classification system, based on protocolized CT imaging that predicts a step-wise increased risk of salvage resection, complication severity, and increased hospital stay. The system should aid patient management and facilitate comparisons of outcomes and efficacy of interventions.

Gastric Fistula After Sleeve Gastrectomy: Clinical Features and Treatment Options

PURPOSE

To trace the clinical profile of fistula cases after sleeve gastrectomy (SG) and evaluate the efficacy and safety of endoscopic treatments and the admission costs of these patients.

METHODS

This is a retrospective study of patients who developed gastric fistulas after SG. All patients were submitted to surgical and/or endoscopic interventions (self-expandable stent, septotomy, and balloon dilation). The main studied variables were need for reoperation, number of endoscopic procedures, endoscopic complications, time until fistula diagnosis, fistula location, time until resolution, length of hospital stay, and health costs.

RESULTS

The sample was mainly female (76.2%) with a mean age of 39.5 years and a BMI of 39.6 kg/m². In 90.5% of cases, the fistula occurred in the topography of the His angle. Thirteen patients required surgical intervention. Of the patients who underwent endoscopic interventions, it was necessary to place more than one self-expandable stent of a maximum duration of 4 weeks. Six patients underwent more than two sessions of septotomy. There was one case of bleeding after septotomy. Dilatation was required in 71.4% of patients and an average of two sessions (1-5) per patient. The diagnosis of fistula occurred 14.4 days after surgery. The average time to resolve fistulas was 50.6 days. The average hospital stay was 75.8 days. The total cost of hospitalization was on average US$ 75,180.00.

CONCLUSION

The surgical and endoscopic treatment of gastric fistulas after SG was safe and effective. There was a very low rate of complications. The time of onset of fistulas was not decisive for patient improvement.

A review of commonly performed bariatric surgeries: Imaging features and its complications

Obesity is a disease that has achieved the level that can be considered an epidemic. According to the National Center for Health Statistics data, the prevalence of obesity has increased from 30.5% in 1999-2000 to 42.4% in 2017-2018. During the same period, severe obesity has increased from 4.7% to 9.2%. With the growing prevalence of obesity, related conditions such as coronary artery disease, diabetes, and strokes have also become more prevalent. In the past few years, the need for bariatric surgeries such as laparoscopic Roux-en-Y gastric bypass, sleeve gastrectomy, and laparoscopic adjustable gastric banding has increased considerably. With an increasing number of bariatric surgeries, multiple postoperative complications have become common. In this review, we have attempted to describe normal postsurgical anatomical findings after bariatric surgeries and pictorial review of a few common postoperative complications.

Endoscopic Management of Postoperative Complications

Gastrointestinal surgery is increasingly being performed. Despite improving technology and outcomes, complications are not completely avoidable. Frequently, surgical complications require invasive procedures for management. However, with increasing availability of flexible endoscopy and a wider array of tools, more often these complications can be managed with an endolumenal approach. This article is an in-depth review of endoscopic management of surgical complications.

Gastric Fistula in the Chest After Sleeve Gastrectomy: a Systematic Review of Diagnostic and Treatment Options

This study aimed to establish the optimal diagnostic and treatment algorithm for the management of gastric fistula in the chest (GFIC) after sleeve gastrectomy (SG) through a systematic review of published cases. A multi-database search was performed, which produced 1182 results, of which 26 studies were included in this systematic review. The initial presentation included subphrenic collections, leaks, or (recurrent) pneumonia with associated symptoms such as persistent cough, fever, and/or dyspnea. Computed tomography (CT) scan in combination with either upper gastrointestinal (UGI) series or an esophagogastroduodenoscopy (EGD) was used to adequately diagnose the fistulas. Initial treatment was either with clips and/or clips and stents that were placed endoscopically. When unsuccessful in the majority of the cases, the surgical treatment consisted of total gastrectomy and Roux-en-Y esophagojejunostomy in a laparoscopic or open fashion.

Sleeve gastrectomy-induced endocrine changes in the remnant stomachs of premenopausal and postmenopausal rats: role of the estrogen receptors

BACKGROUND

Although alterations in the plasma levels of leptin, glucagon-like peptide-1, and gastrin were linked with bariatric surgery outcomes, gastric production of these peptides was not elucidated before.

OBJECTIVE

The aim was to evaluate the impact of estrogen depletion and estrogen receptors (ERs) on sleeve gastrectomy (SG)-induced alterations in gastric hormone production, gastric mucosal integrity, and bone mass.

SETTING

Physiology Research Lab at the University.

METHODS

Female Sprague-Dawley rats underwent ovariectomy or sham operation (control), and 2 months later SG or sham SG was performed. Rats received either nonselective agonist 17 β, ER-α agonist, ER-β agonist, or vehicle for 3 weeks. Trunk blood and gastric tissues were collected for biochemical measurements, while histopathologic examination was performed in gastric and femur samples.

RESULTS

In the presence of intact ovaries, SG-induced weight loss was accompanied by reductions in the gastric synthesis of leptin and gastrin, while gastric glucagon-like peptide-1 was additionally decreased when SG was performed at the postmenopausal state. SG elevated the depleted serum estradiol levels of menopause, implicating a beneficial effect, but the occurrence of severe gastric mucosal injury was triggered. On the other hand, using ER agonists upregulated gastrin-expressing cells, ameliorated gastric injury, and improved bone loss.

CONCLUSIONS

SG, either at premenopausal or postmenopausal state, resulted in considerable loss in bone mass, along with reductions in the gastric levels of gastrin and leptin. Functional status of the ovaries needs to be taken into consideration when monitoring the outcomes of SG, and ER agonists could be of value in controlling SG-induced complications.

Comparing patterns of care and outcomes after operative management of complications after bariatric surgery at MBSAQIP accredited bariatric centers and non-bariatric facilities

BACKGROUND

Many operations for complications after bariatric surgery are performed by surgeons without bariatric expertise at centers without teams who routinely care for bariatric patients. This study sought to evaluate whether bariatric expertise affects patterns of care and perioperative outcomes among patients undergoing operative intervention for complications after bariatric surgery.

METHODS

Administrative claims data from the Kentucky Office of Health Policy were queried for inpatients undergoing operative intervention for complications related to bariatric surgery between 2015 and 2018. Patients were stratified with respect to whether or not they underwent surgery at a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) accredited bariatric surgery center (BCE) or not (non-BCE). Groups were compared with respect to demographic, procedural, and outcome variables.

RESULTS

BCE patients were more often Caucasian than non-BCE patients (p < 0.001) and have either private insurance or Medicare coverage (p = 0.02). Regarding operative approach, operations were more likely to be performed laparoscopically in BCE (88.5% BCE vs. 80.9% non-BCE, p = 0.007). Length of stay was significantly shorter for BCE patients (median 2 days BCE vs. 3 days non-BCE, p < 0.001), and BCE patients were more likely to be discharged home (85.4% BCE vs. 78.5% non-BCE, p = 0.02). Inpatient mortality and average total charges per patient did not differ significantly between the two groups CONCLUSIONS: Surgical management of complications after bariatric surgery at BCE is associated with greater utilization of minimally invasive techniques, shorter hospital stay, and increased likelihood of routine home discharge. These findings should prompt a review and standardization of care patterns for patients with complications after bariatric surgery aimed at optimizing outcomes and improving value.

Laparoscopic Sleeve Gastrectomy with T-Shaped Omentoplasty: Impact on the Early Postoperative Outcomes

PURPOSE

Laparoscopic sleeve gastrectomy (LSG) is an effective bariatric procedure, yet can be followed by complications such as staple line leak and bleeding, vomiting, and gastroesophageal reflux disease (GERD). Various attempts have been described in the literature to improve the early outcome of LSG through various measures. This study aimed to assess the impact of adding T-shaped omentoplasty to LSG on the short-term outcome of the procedure.

METHODS

This was a retrospective cohort study on patients with morbid obesity who underwent LSG in the period of November 2015 to November 2018. The outcome of patients with morbid obesity who underwent LSG combined with T-shaped omentoplasty (group I) was compared with that of a similar number of patients who underwent classical LSG without staple line fixation (group II). The main outcome measures were the rates of staple line bleeding and leak, postoperative nausea and vomiting (PONV), GERD, gastric axial rotation, other complications, and weight loss.

RESULTS

The study included 106 patients of a mean BMI of 49.8 kg/m². Group II had significantly higher PONV) scale at 1 week and 1 month than group I. Group I had significantly lower rates of staple line bleeding (0 vs 9.6%, p = 0.02) and GERD (3.7% vs 17.3%, p = 0.02) than group II. Both groups had similar rates of staple line leak and comparable operation time.

CONCLUSION

Staple line fixation using the T-shaped omentoplasty technique was associated with lower incidence of significant PONV, staple line bleeding, and GERD as compared with classical LSG.

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.

Bifidobacterium animalis subsp. lactis A6 Alleviates Obesity Associated with Promoting Mitochondrial Biogenesis and Function of Adipose Tissue in Mice

Probiotics are widely known for their health benefits. Mitochondrial dysfunction is related to obesity. The aim of this study was to illuminate whether Bifidobacterium animalis subsp. lactis A6 (BAA6) could improve obesity due to increased mitochondrial biogenesis and function of adipose tissues. Four-week-old male C57BL/6 mice were fed with a high-fat diet (HFD) for 17 weeks. For the final eight weeks, the HFD group was divided into three groups including HFD, HFD with BAA6 (HFD + BAA6 group), and HFD with Akkermansia muciniphila (AKK) (HFD + AKK group as positive control). The composition of the microbiota, serum lipopolysaccharides (LPS), and mitochondrial biosynthesis and function of epididymal adipose tissues were measured. Compared with the HFD group, body weight, relative fat weight, the relative abundance of Oscillibacter and Bilophila, and serum LPS were significantly decreased in the HFD + BAA6 and HFD + AKK groups (p < 0.05). Furthermore, the addition of BAA6 and AKK increased the expression of peroxisome proliferator-activated receptor γ coactivator 1α (PGC-1α) (by 21.53- and 18.51-fold), estrogen-related receptor α (ERRα) (by 2.83- and 1.24-fold), and uncoupling protein-1 (UCP-1) (by 1.51- and 0.60-fold) in epididymal adipose tissues. Our results suggest that BAA6 could improve obesity associated with promoting mitochondrial biogenesis and function of adipose tissues in mice.