One Anastomosis Gastric Bypass after Sleeve Gastrectomy Failure: Does a Single Procedure Fit for all?

INTRODUCTION: Considering the multitude of bariatric procedures performed all over the world, the necessity of revisional surgery increased accordingly. Several authors argued that with the great diffusion of sleeve gastrectomy (SG), the number of patients who experienced a weight regain at long follow-up was congruous and physiologic, even if not negligible. Recent studies showed that one anastomosis gastric bypass (OAGB) was an effective and safe option also as redo surgery. The aim of the study was to evaluate effectiveness of OAGB as redo surgery after SG in term of anthropometric features and remission of comorbidities. METHODS: Bariatric patients experiencing weight regain and insufficient weight loss after SG and undergoing OAGB as redo surgery were retrospectively analyzed. During post-OAGB outpatient visit weight, %EWL, BMI, comorbidities, and vitamin deficiencies were evaluated. A further visit was scheduled for the evaluation of postoperative esophagitis/gastritis at upper endoscopy. RESULTS: Fifty-nine (Reviewer #3-1) patients underwent OAGB as redo-surgery consequently to the worsening of the bariatric outcomes at 29.42 ± 7.29 months from SG (mean weight, BMI and %EWL were 120.89 ± 16.79 kg, 43 ± 4.39 and 19.84 ± 30.29, respectively). Conversely, at a mean follow-up of 34.32 ± 1.71 months (Reviewer #3-3) after OAGB, no weight regain or insufficient weight loss cases were recorded (mean weight 71.25 ± 10.22 kg, mean BMI 24.46 ± 2.06 kg/m2, mean %EWL 69.49 ± 14.4, p < 0.0001) (Reviewer #3-2). CONCLUSION: OAGB is a safe and effective bariatric procedure in terms of morbidity, mortality, and %EWL also as revision surgery after SG. Further larger studies are needed to address this issue.

Does antrum size matter in sleeve gastrectomy? A prospective randomized study.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is a safe and effective bariatric procedure in terms of excess weight loss. Nevertheless, controversies still exist on several technical and operative aspects of LSG. The aim of this study is to evaluate variations in anthropometric features in subjects with a LSG gastric resection starting from 2 cm or 6 cm from the pylorus. Secondary aim was the evaluation of differences in morbidity, food tolerance, and GERD incidence studied with upper endoscopy (UE) and GERD Health-Related Quality-of-Life score. METHODS: Patients were prospectively randomized into 2 groups: Group A (at 2 cm proximally to the pylorus) and Group B (at 6 cm proximally to the pylorus). All patients were followed-up at 3, 6, 12, and 24 months. UE was performed in all patients at 12 or 24 months. RESULTS: One hundred and fifty met the inclusion criteria and were enrolled in the study. The anthropometric features (BMI, %EWL, %TWL) resulted statistically different in the first 12 months (24.2 ± 3.4 vs 27.5 ± 4.3, 63.7 ± 14.1 vs 59.6 ± 12.5 and 42.9 ± 7.4 vs 38.2 ± 6.2), in favor of group A. At 24 months the differences disappeared (25.2 ± 4.4 vs 26.2 ± 3.3, 62.8 ± 13.1 vs 61.6 ± 10.5 and 41.9 ± 7.4 vs 40.2 ± 6.2). An increased GERD was found in both groups postoperatively with a higher incidence in group A at 6-month follow-up. CONCLUSION: Performing the LSG with a radical antrectomy could improve weight loss at 12-month follow-up but expose to lower food tolerance and higher transitory GERD. The differences seem to be reduced to a 24-month.

Postoperative Clinical-Endoscopic Follow-up for GERD and Gastritis After One Anastomosis Gastric Bypass for Morbid Obesity: How, When, and Why.

INTRODUCTION: The one anastomosis gastric bypass (OAGB) is a widely diffused surgical procedure for morbid obesity. Several studies considered OAGB at risk for biliary reflux and anastomotic ulcers. The aim of the study was to evaluate gastro-esophageal reflux disease (GERD) and esophagitis/gastritis rate after OAGB diagnosed by upper endoscopy (UE), comparing the results with GERD-Health-Related Quality of Life (HRQL) score. METHODS: From July 2014 to February 2019, patients underwent OAGB with at least 12-month follow-up were retrospectively evaluated. Clinical evaluation was associated with GERD-HRQL scoring. UE with a mucosal biopsy was also performed. A comparison among clinical scores and endoscopic findings was performed. RESULTS: Two hundred forty-one patients were analyzed in the study. Anthropometric features (BMI, %Excess weight loss, %Total weight loss) were significantly improved. Only 30% of patients with GERD-HQRL>30 showed esophagitis at UE: 11/181 (6.1%) showed grade A erosive esophagitis, 2/181 (1.1%) grade B esophagitis, whereas no patient resulted in grade C/D. Fifty-two patients (28.7%) showed endoscopic remnant gastritis of at least grade 1, with histological gastritis of at least mild grade in 70/181 patients (38.7%). CONCLUSION: OAGB is a feasible and effective procedure in terms of weight reduction and comorbidities control, but controversies remain about the long-term onset of GERD and bile reflux. The incidence of esophagitis was increased after OAGB. However, the severity and incidence were lower compared to sleeve gastrectomy. Conversely, the incidence of gastritis, ileo-gastric anastomotic inflammation, and HP positivity were not negligible, suggesting the potential benefits of endoscopic surveillance after OAGB.

The Role of Ursodeoxycholic Acid (UDCA) in Cholelithiasis Management After One Anastomosis Gastric Bypass (OAGB) for Morbid Obesity: Results of a Monocentric Randomized Controlled Trial.

INTRODUCTION: Bariatric surgery leads to rapid weight loss, a well-known risk factor for gallstone formation. Postoperative biliary complication rate requiring cholecystectomy is between 0.9 and 7.5% after laparoscopic sleeve gastrectomy and between 6 and 50% after laparoscopic gastric bypass. Several authors recommended ursodeoxycholic acid (UDCA) administration to reduce gallstone formation after diet-induced weight reduction. The aim of this randomized monocentric study is to evaluate gallstone incidence after prophylactic administration of UDCA in patients undergoing one anastomosis gastric bypass (OAGB). METHODS: Patients undergoing OAGB were prospectively randomized into 2 groups: the UDCA group receiving oral UDCA 600 mg/days for 6 months in the immediate postoperative days, and the control group not administered with UDCA. Each group included 95 patients. Abdominal ultrasound, clinical evaluation, and quality of life scoring with Gastrointestinal Quality of Life Index (GIQLI) were performed postoperatively in all patients at 3, 6, and 12 months. RESULTS: At 12 months of postoperative follow-up, 4 (4.2%) and 24 patients (25.2%) showed gallstones in the UDCA group and control group, respectively (p < 0.05). Among those who developed gallstones, 8 (28.6%) cases were symptomatic whereas 20 (71.4%) did not show any symptom. No statistically significant difference in GIQLI score between the two groups was found. CONCLUSION: OAGB, as other malabsorbent procedures, appears to have higher rate of cholelithiasis than purely restrictive procedures. In our prospective randomized controlled study, a regular postoperative UDCA intake during the first 6 months seems to significantly reduce cholelithiasis incidence after OAGB, with no case of intolerance reported. Further studies are needed to assess this issue.

Biliopancreatic Limb Length in One Anastomosis Gastric Bypass: Which Is the Best?

BACKGROUND: The use of one anastomosis gastric bypass (OAGB) is rapidly spreading. Concerns about biliary reflux and malabsorption with consequent nutritional deficits exist, so studies on biliopancreatic limb (BPL) adequate length in OAGB are required to balance excess weight loss in percentage (% EWL), resolution of comorbidities, and nutritional deficit. The purpose was to evaluate, at 2 years after OAGB, the effects of BPL length on weight loss, resolution of comorbidity, and nutritional deficiencies in patients. METHODS: From January 2015 to January 2017, 180 patients were collected into three groups based BPL length: group A, 150 cm; group B, 180 cm; and group C, 200 cm. Aims were to compare %EWL, co-morbidity resolution rates, nutritional parameters, and morbidity/mortality in the three groups. RESULTS: The total number of patients was 180: 60 for each group. One hundred seventy-two (95%) patients attended the 1-year follow-up (group A = 58; group B = 58, group C = 56). One hundred fifty-seven (87%) patients attended the 2-year follow-up (group A = 52 (87%); group B = 53 (88%); group C = 52 (87%)). There was no statistically significant difference in %EWL, %TWL, T2DM, and hypertension resolution rates among the groups. About vitamin deficiency, differences were not statistically significant. Iron and ferritin deficiency rate were statistically significant only between A and C groups. CONCLUSIONS: According to our evidence, standardization of BPL length shorter than 200 cm is suggested, potentially minimizing malnutrition-related outcomes. Our study seems to show that a BPL of 150-180 cm is safe and effective in terms of EWL and comorbidity improvement with low malnutrition effects even in BMI > 50.

Safety and efficacy of prophylactic resorbable biosynthetic mesh in loop-ileostomy reversal: a case-control study.

Loop ileostomy (LI) is a widely used temporary stoma technique. Reversal of LI is generally considered a minor and safe procedure, with very low short-term postoperative mortality and morbidity rates. Complications include incisional hernia (IH), carrying a high probability of surgical repair. Clinical measures to reduce the IH rate warrant consideration. Recent researches suggest the use of a prophylactic non-absorbable mesh to reduce IH rate; however, surgeons are reluctant to implant a permanent foreign material in contaminated operative fields, because of a higher risk of mesh-related complications, infection, seroma, and pain. The aim of the present study is to assess feasibility, potential benefits, and safety of a prophylactic biosynthetic mesh placed during LI reversal. From January 2016 to December 2018, 26 consecutive patients underwent LI reversal positioning a resorbable biosynthetic mesh in an on-lay position [mesh group (MG)]. The mesh used was a GORE BIO-A tissue reinforcement, a biosynthetic mesh composed of a bioabsorbable polyglycolide-trimethylene carbonate copolymer. The MG was matched with 58 patients [control group (CG)], undergoing LI reversal without mesh placement from January 2013 to December 2018. To detect IH, abdominal wall was studied according to clinical and ultrasonographic criteria. Primary endpoint was IH rate on LI site, at 6 and 12 months after stomal reversal. Secondary endpoints included incidence of wound events. Thirty-day morbidity was classified according to Clavien-Dindo score; mortality and length of hospital stay were also collected. Mean follow-up was 15.4 ± 2.3 months (range 12.4-22.0) for MG vs 37.2 ± 26.9 (range 24.9-49.7) for. CG. At 1 year of follow-up, IH rate was lower in MG (n = 1/26 [3.8%]) vs CG (n = 19/58 [32.7%]; P < 0.05). A clinically evident IH was less frequent in MG (n = 0 [0%]) vs CG (n = 13 [68%]; P < 0.05). A radiologic IH was less frequent in MG (n = 1 [3%]) vs CG (n = 6 [31%]; P < 0.05). Stoma site hernia was repaired in 9/19 patients (47%) in CG; no patient of MG has hernia repaired. Incarcerated IH was observed in one patient of CG. No postoperative mortality was reported. Overall postoperative morbidity showed no difference comparing MG and MG (n = 5 [17%] vs n = 15 [19%], respectively; P > 0.05). Surgical site infections (SSI) were treated with antibiotic therapy, no debridement was necessary. Seroma occurred in two patients, one for each group. No statistically significant difference for surgical outcomes was found between the two groups at 30 days. Early results of the present study suggest that an on-lay prophylactic placement of GORE BIO-A tissue reinforcement might lower IH rate at LI site. The procedure seems to be safe and effective, even long-term results and further studies are needed.

Stapled haemorrhoidopexy: correlation among histology, intraoperative morphology and interindividual anatomic variability in muco-haemorrhoidal prolapse.

PURPOUSE: The Authors correlated intraoperative mucohaemorrhoidal prolapse morphology, specimen histology, anal canal length and purse-string height. METHODS: Between September-November 2010, 18 patients (9 grade III; 9 grade IV haemorrhoids) underwent stapled haemorrhoidopexy. Mean age was 54 years (range 38-78).Proctoscopic prolapse morphology, anal canal length, pursestring height and external component were evaluated intraoperatively and specimens sent for histology. RESULTS: Intraoperative findings were as follows: 2/18 patients showed no procidentia, 2/18 'haemorrhoid type' prolapse, 14/18 'rectal type' prolapse. Mean anal canal lenght was 3.5 cm (range 2.5-4.5); mean purse-string height was 4.5 cm from the dentate line (range 3.5-5.5); 10/18 patients carried external component. Histology showed mucosa/submucosa in 4/18 cases, muscolaris propria in 9/18, perivisceral fat in 5/18. No procidentia/'haemorrhoid type' prolapse showed only mucosa/submucosa at histolgy; a 'rectal type' morphology showed at least the muscolaris propria. An anal canal > 3.5 cm related to 'haemorrhoid type' prolapse, a pursestring ≤ 4 cm and mucosa/submucosa at histology. An anal canal ≤ 3.5 cm related to 'rectal type' prolapse, a purse string > 4 cm from dentate line and at least the muscolaris propria. One patient required analgesics for >7 days. At three months, 1/18 patient presented urgency, 2/18 stool clustering. In 1/18 patient a moderate grade of external component persisted. DISCUSSION: A possible correlation among anoscopic phenotype, specimen histology, pursestring height, might exist and influence clinical outcomes. CONCLUSIONS: A positive correlation between specimen thickness, purse-string height and 'rectal type' morphology was found. Patients with higher anal canal showed haemorrhoidal pattern of prolapse, a lower purse-string and mucosa/submucosa at histology.Intraoperative prolapsing tissue morphology could represent a further criteria for surgical decision.

Double incision laparoscopic cholecystectomy (DILC) with routinary intra-operative cholangiography (IOC) : less trauma, same safety. Report on 30 consecutive non-selected cases.

Laparoscopic approach for cholecystectomy is, actually, the gold standard for gallbladder surgical benign diseases. Single transumbilical incision can further reduce abdominal wall trauma. Two main related issues are still to be enlighten: difficulty in obtaining a clear exposure of the Calot's triangle and routinely use of intra-operative cholangiography (IOC). A standardized technique of double incision laparoscopic cholecystectomy (DILC) with routine IOC is described. Between January and May 2012, 30 consecutive patients scheduled for elective cholecystectomy underwent DILC with IOC. Exclusion criteria were: clinical and/or radiological suspect of gallbladder malignancy/acute cholecystitis (AC)/common duct stones; ASA > 3; previous extensive abdominal surgery. Follow-up was performed at 7, 30 and 60 days postoperatively. Three 5-mm trocars through the umbilicus and one 3-mm subcostally on the right are used, along with a 30° laparoscopic camera. IOC is performed through the 3-mm channel. Median age was 49.5 years (range 24-78); female/male was 21/9. Median BMI was 27.4 (range 16.2-38.9). AC was encountered in five cases (17 %). Synchronous AC and choledocolithiasis occurred in one case (3 %), requiring conversion to laparoscopic choledocolithotomy. Additional ports were required in these latter five patients (17 %). IOC was routinely attempted in all patients, succeeding in 26 (86 %). Median operative 'skin to skin' time was 47.8 min (range 25-75). In the subgroup not receiving IOC, median operative time was 35 min (range 25-45); 51.5 min as median time (range 25-75) was reported for the subgroup undergone the entire planned procedure. No intraoperative complications occurred. Median length of stay was 1.51 days (range 1-5). Postoperative minor complications occurred in three patients (10 %) and wound umbilical infection occurred in one (3.4 %). DILC with the routine use of IOC seems to be repeatable and safe. Even if DILC seems more easily learnt, further studies are needed to address this issue.

Detection of colo-rectal liver metastases: prospective comparison of contrast enhanced US, multidetector CT, PET/CT, and 1.5 Tesla MR with extracellular and reticulo-endothelial cell specific contrast agents.

BACKGROUND: To compare contrast-enhanced US (CE-US), multidetector-CT (MDCT), 1.5 Tesla MR with extra-cellular (Gd-enhanced) and intracellular (SPIO-enhanced) contrast agents and PET/CT, in the detection of hepatic metastases from colorectal cancer. MATERIALS AND METHODS: A total of 34 patients with colo-rectal adenocarcinoma underwent preoperatively CE-US, MDCT, Gd- and SPIO-enhanced MR imaging (MRI), and PET/CT. Each set of images was reviewed independently by two blinded observers. The ROC method was used to analyze the results, which were correlated with surgical findings, intraoperative US, histopathology, and MDCT follow-up. RESULTS: A total of 57 hepatic lesions were identified: 11 hemangiomas, 29 cysts, 1 focal fatty liver, 16 metastases (dimensional distribution: 5/16 < 5 mm; 3/16 between 5 mm and <10 mm; 8/16 ≥ 10 mm). Six of 34 patients were classified as positive for the presence of at least one metastasis. Considering all the metastases and those ≥ 10 mm, ROC areas showed no significant differences between Gd- and SPIO-enhanced MRI, which performed significantly better than the other modalities (P < 0.05). Considering the lesions <10 mm, ROC areas showed no significant differences between all modalities; however MRI presented a trend to perform better than the other techniques. Considering the patients, ROC areas showed no significant differences between all the modalities; however PET/CT seemed to perform better than the others. CONCLUSIONS: Gd- and SPIO-enhanced MRI seem to be the most accurate modality in the identification of liver metastases from colo-rectal carcinoma. PET/CT shows a trend to perform better than the other modalities in the identification of patients with liver metastases.

PET/CT colonography in patients with colorectal polyps: a feasibility study.

PURPOSE: To examine: (1) the feasibility of PET/CT colonography (PET/CTc) in patients with colorectal polyps; (2) the impact of metabolic information on CTc interpretation and, conversely, the impact of morphological information on PET characterisation of focal colorectal uptake. METHODS: Ten patients with colorectal polyps underwent PET/CTc, followed within 3 h by therapeutic conventional colonoscopy (CC). A radiologist and a nuclear medicine physician analysed the PET/CTc images. The agreement of morphological and metabolic information in the colon and rectum was evaluated. The sensitivity and specificity of PET, CT and PET/CT were calculated for colorectal polyps. RESULTS: Seventeen polypoid lesions were identified at CC: six< or =5 mm, six between 6 and 9 mm, and five > or =10 mm (four hyperplastic polyps, 11 tubular adenomas, one adenocarcinoma and one submucosal lipoma). A total of 20 scans (supine and prone) were performed in the ten patients: the agreement of morphological and metabolic information was excellent in 17 scans, good in two and moderate in one. PET/CTc showed a sensitivity of 91% for lesions > or =6 mm and a specificity of 100%. The metabolic information did not disclose any further polyps missed on CTc. The morphological information permitted correct classification of all eight instances of focal radiotracer uptake. CONCLUSION: PET/CTc is a feasible study. Adding a colonographic protocol to PET/CT images seems to allow correct characterisation of all cases of colorectal focal radiotracer uptake. The metabolic information does not seem to increase the accuracy of CTc.