Necrosis of the Nissen-Sleeve Gastrectomy (N-SG) Wrap

BACKGROUND

Sleeve gastrectomy (SG) is the highest performed bariatric procedure in the world. Gastro-oesophageal reflux disease (GERD) is widely debated topics after SG. Nissen-Sleeve gastrectomy (N-SG) technique was reported in 2016 as an alternative solution to this problem. They reported concern about valve ischaemia but did not report any such complication in the beginning of their experience. We would like to share video showing this complication and technique to manage it.

METHOD

Data was retrospectively analysed.

RESULTS

A 45-year-old female with BMI of 35.5 kg/m had an uneventful Nissen-SG. She had GERD treated with proton pump inhibitor (PPI). The preoperative gastroscopy showed peptic oesophagitis with hiatal hernia. On post-operative day (POD) 1, the patient complained of severe abdominal pain, tachycardia and fever. Inflammatory markers were raised. Diagnostic laparoscopy showed necrosis of the wrap. The wrap was carefully undone and resected with a stapler (with seamguard). Thorough wash with saline was performed. Drain was left near the new staple line. A CT scan with oral contrast 4 days later confirmed absence of a gastric leak. The patient was discharged 8 days after the revision on PPI and antibiotics. Two-years post-operatively, the patient is doing well and her GERD symptoms are controlled with PPI.

CONCLUSION

Wrap necrosis is a life-threatening complication after N-SG. This case is shared to raise awareness of this complication. This was successfully managed by prompt laparoscopy and wrap resection. Ideally such complications should be referred to experts or centers with high volume of bariatric surgery.

Surgical glue in laparoscopic sleeve gastrectomy: An initial experience and cost-effectiveness analysis

RATIONALE, AIMS, AND OBJECTIVES

Laparoscopic sleeve gastrectomy (LSG) is one of the most common bariatric procedures. Gastric leaks and bleeding are the most frequent complications, associated with a high clinical and economic burden. The best method of staple line reinforcement in LSG is debated. Surgical glue is one of the options available. The aim of this study was to assess the safety, efficiency, and relative cost-effectiveness of surgical glue used to perform LSG in morbid obese adults as compared with standard stapling.

METHODS

A prospective, observational, and comparative before-after study was conducted. All consecutive patients undergoing LSG at Montpellier University Hospital in 2011 and 2012 were included and treated according to 2 groups: standard stapling (n = 99, group 1) and surgical glue reinforcement (n = 94, group 2). Clinical and economic outcomes were measured after 6 months.

RESULTS

The duration of intervention was significantly shorter in group 2 (68 vs 82 minutes, P = .001). There was no significant difference regarding complications, but leaks in group 1 were more severe. Group 2 was also associated with a reduced initial length of stay (4.8 vs 5.2 days, P = .01). Six-month readmissions and total length of stay were also shorter in group 2 (5.5 vs 6.1 days, P = .003). Surgical glue use was associated with a significant reduction in the initial inpatient cost (€5488 vs €6152, P = .005) and in the 6-month total inpatient cost, including readmissions (€6006 vs €6754, P = .005). The incremental cost of glue to avoid a severe complication was -€5446.33 (95 confidence interval, -8202.01 to -2690.66).

CONCLUSIONS

Surgical glue might be a safe and cost-effective intervention in laparoscopic sleeve gastrectomy.

A multicentric prospective study evaluating the safety and efficacy of Kii® Fios® First Entry Trocar in laparoscopic bariatric surgery

INTRODUCTION

Laparoscopic surgery has evolved as an important field of surgery due to its clear benefits when compared to open laparotomy surgery. However, specific complications of laparoscopic surgery have been reported, of which the majority are complications associated with first entry to the abdominal cavity. The emergence of bariatric surgery, combined with the special considerations of the abdominal wall and cavity of obese patients, leads to seeking new modalities of access to the abdominal cavity in this specific population.Kii Fios First Entry Bladeless Trocar (Applied) is a new device that may allow surgeons to facilitate the creation of pneumoperitoneum. This prospective multicenter nonrandomized trial aims to evaluate the safety and efficacy of Kii Fios First Entry Bladeless Trocar in laparoscopic bariatric surgery.

METHODS

In the period between December 2013 and June 2014, 588 patients were included by 18 surgeons from several French hospitals to undergo laparoscopic surgery using Kii Fios First Entry Trocar as a first-entry trocar. The surgeons filled out a questionnaire assessing the safety and efficacy of the trocar for every patient.

RESULTS

There were no mortality and no major complications. However, 11 cases (1.87%) of minor complications (liver and greater omentum injuries) were reported. The surgeons reported successful entry in less than 1 min for 70.58% of the cases.

CONCLUSIONS

Kii Fios First Entry Trocar (Applied) is a safe and efficient method to establish first entry in laparoscopic bariatric surgery when all the recommendations are followed and respected.

[Consequences and complications of bariatric surgery]

Consequences and complications of bariatric surgery. Bariatric surgery has a functional role (improvement of quality of life), a prevention role (increase in life expectancy, reduction of risk of cancer and cardiovascular disease) and a curative role (remission of diabetes mellitus, obstructive sleep apnea syndrome and arterial hypertension). The laparoscopic approach for bariatric surgery led to a major reduction of postoperative morbi-mortality and promotes its expansion with 49 000 procedures in 2015 (French PMSI data). Types and rates of complications after bariatric surgery vary according to the procedure. The efficiency of each technique is closely related to its morbi-mortality rate. This concept explains the disparity concerning the choice of the adequate procedure for the patient according to the bariatric team. The risk/benefits balance evaluation must be analyzed case-by-case by each specialist of the multidisciplinary bariatric staff and explained to the patients before final decision. This preoperative period (6-12 months) is crucial to select good candidates for bariatric surgery and contributes to the reduction of postoperative complications. A multidisciplinary surveillance for life is mandatory to prevent and treat late complications of bariatric surgery related to undernutrition.

Nissen Sleeve (N-Sleeve) operation: preliminary results of a pilot study

BACKGROUND

Sleeve gastrectomy (SG) is one of the most frequently performed bariatric procedures worldwide. Despite its impressive results, there is a growing concern about the relationship between SG and gastroesophageal reflux disease (GERD).

OBJECTIVES

We present our pilot study of patients operated with a Nissen anti-reflux valve added to a standard SG.

SETTING

University hospital in Montpellier, France.

METHODS

A prospective monocentric study including 25 consecutive patients operated with a laparoscopic Nissen-Sleeve (N-Sleeve) gastrectomy was carried out between September 2013 and March 2014. Inclusion criteria were indication for bariatric surgery for patients with GERD (Montreal's definition and classification). All patients were followed postoperatively for 1 year.

RESULTS

There were 13 (54%) females and 12 (46%) males with mean age of 41±12 (20-65) years. Mean body mass index was 42±4.8 (35-53) kg/m². Preoperatively, all patients had esophageal syndromes. Twenty-three (92%) patients had typical symptoms of GERD, but 2 were asymptomatic; however, they had esophageal injury. Esophagitis grade I-III presented in 10 (40%) patients and Barrett's esophagus in 8 (32%) cases. Two (8%) patients also had extraesophageal syndrome represented by asthma. Nineteen (76%) patients previously took proton pump inhibitors, regularly and 22 (88%) had experienced a hiatal hernia. There was no conversion to the open technique. Operative time was 84±13 (54-106) minutes. There were no deaths. Complications included one case of staple line bleeding and one Nissen valve perforation without recognized ischemia. No staple line failure was observed. Three months after N-Sleeve, 19 (76%) patients remained asymptomatic without proton pump inhibitor use. At 6 months and 1 year, 3 (12%) patients were still experiencing reflux. Excess weight loss at 1 year was 58±23%, total weight loss was 27±10%, and body mass index change was -11±4 kg/m².

CONCLUSION

The N-Sleeve seems to be a safe procedure that provides an adequate reflux control with no clear interference on the expected bariatric results of a standard SG.