Long-term clinical evaluation of laparoscopic management of large hiatal hernias.

BACKGROUND: Large hiatal hernias (LHH) account for 5-10% of all hiatal hernias. Surgery of LHH should be associated with low rates of postoperative complications and recurrences, to guarantee a favorable quality of life (QoL). Data on long-term results of laparoscopic repair of LHH are lacking. The objective of our study is to evaluate the long-term clinical outcomes of laparoscopic LHH management in a high-volume experienced center. METHODS: Patients who had undergone elective laparoscopic repair of LHH between January 1992 and December 2008 at the Center of Minimally Invasive Surgery of the Department of Surgical Sciences, University of Turin, Italy were included. Preoperative and intraoperative data were collected from patients' charts. Patients were clinically evaluated at long-term postoperative follow-up to assess control of symptoms, degree of satisfaction with surgery, and QoL. RESULTS: At mean follow-up of 240 months (range 168-348), 81 patients were available for clinical evaluation. Severe heartburn was reported by six patients (7.4%), while severe post-prandial epigastric pain by three (3.7%). Recurrent coughing episodes were described by six patients (7.4%), while occasional mild episodes of transient dysphagia by 13 (16%). No gas bloat detected. Proton Pump Inhibitors were taken by 22 patients (27.2%) to control symptoms. The Modified Italian Gastroesophageal Reflux Disease-Health Related Quality of Life (MI-GERD-HRQL) score decreased significantly from 40 to 7 (P<0.0001) postoperatively. Satisfaction was achieved in 76 patients (93.8%) with an average satisfaction index of 8.6 (IQR 8-10). CONCLUSIONS: Laparoscopic LHH repair is effective when performed in a specialized center, with long-lasting significant improvements of symptoms and QoL.

Sleeve Volume and Preoperative Gastric Volume Assessment Using Three-dimensional MDCT Gastrography and Their Correlation to Short-term Post-Sleeve Gastrectomy Weight Loss.

PURPOSE: Several factors including preoperative stomach capacity and sleeve volume impact weight loss after laparoscopic sleeve gastrectomy (LSG). We aimed at measuring these volumes using multidetector computed tomography (MDCT) gastrography and correlating them with postoperative weight losses. MATERIALS AND METHODS: Morbidly obese patients prepared for LSG during 2018 were included in the study. MDCT gastrography was performed 1 week before, 6 and 12 months after LSG. Preoperative gastric volume and postoperative sleeve volumes were measured. Correlation with preoperative BMI and postoperative %TWL was performed. The change in sleeve volume at 6 and 12 months was assessed. RESULTS: A total of 98 patients (62 F) were included. Mean preoperative BMI was47 ± 7 kg/m2. Follow-up was achieved in 89 patients (91%) and 82 patients (83%) at 6 and 12 months, respectively. Mean %TWL was 24 ± 3 and 32.8 ± 3 at 6 and 12 months, respectively (p < 0.05). Preoperative gastric volume ranged from 800 to 1800 ml (mean ± SD, 1310 ± 307) and dropped significantly to range from 140 to 170 ml (158 ± 9) and from 165 to 210 ml (181 ± 12) at 6 and 12 months postoperatively, respectively. Pouch was not significantly dilated at 12 vs. 6 months postoperatively. Preoperative gastric volume was significantly correlated with preoperative BMI (p = 0.006*) but not with postoperative weight losses. Correlation between postoperative pouch volumes and weight losses at 6 and 12 months postoperatively showed no significance. CONCLUSION: Sleeve pouch is significantly smaller than preoperative stomach, but not significantly correlated to weight loss. Restriction is an important, but not the only factor controlling weight loss after LSG.

Feasibility and Efficacy of Laparoscopic Sleeve Gastrectomy as a Revisional Procedure After Failed Gastric Plication in Morbidly Obese Patients.

Background: Failure of adequate weight loss or weight regain has been reported after laparoscopic greater curve plication (LGCP). The primary aim of this retrospective study is to analyze weight loss outcome after revision of failed LGCP into laparoscopic sleeve gastrectomy (LSG). Patients and Methods: Patients who experienced failure (insufficient weight loss/weight regain) after LGCP performed in our center from 2009 to 2012 were included. LSG was performed for all patients. Results: Among 127 who underwent LGCP, 42 patients (33%) underwent revision. Mean body mass index (BMI) at time of LGCP was 44 ± 6 kg/m2. The highest % total weight loss (%TWL) after LGCP ranged from 11% to 34% (24.1 ± 5) (corresponding to % excess weight loss [%EWL] of 12%-47% [33.5 ± 12]). The time interval between LGCP and LSG ranged from 12 to 25 months (15.4 ± 3.8). After conversion, 2 patients (5%) experienced acute leakage managed by endoscopic stenting. After LSG, mean BMI (kg/m2) was 38, 32, 30, 28, 29, 30.2, and 30.4, while mean %TWL reached 9%, 19%, 24%, 29%, 25%, 25%, and 24% and mean %EWL reached 15%, 51%, 69%, 77%, 68%, 66%, and 64% at 1 month, 6 months, 1, 2, 3, 4, and 5 years, respectively. Except for results at 1 month, all results showed statistical significance (P ≤ .05). After LSG, the incidence of diabetes mellitus and hypertension dropped from 15 (35%) and 13 (30%) to 2 (5%) and 3 (7%) patients, respectively. No follow-up data (0%) were missed. Conclusion: LSG after failed LGCP has promising weight loss outcomes.

Impact of Laparoscopic Sleeve Gastrectomy on Obese Patients with Subclinical Hypothyroidism.

Background: This study aims to evaluate the incidence of subclinical hypothyroidism (SCH) among studied obese patients. The effects of laparoscopic sleeve gastrectomy (LSG) and loss of weight on thyroid hormones level and the impact of adding thyroxine treatment is described. Patients and Methods: Obese patients undergoing LSG at the university hospital between June 2016 and January 2018 were included. Weight loss and changes in body mass index (BMI), serum thyroid stimulating hormone (TSH), and FT4 were evaluated. SCH patients were randomly divided into group "A" received thyroxine treatment and group "B" received no treatment. Results: There were 554 patients studied (mean age 41 ± 12 years); the mean preoperative BMI, serum TSH, and FT4 were 45 ± 6.8 kg/m2, 3.91 ± 1 µU/mL, and 1.32 ± 1 ng, respectively. Incidence of SCH was 12.9%. Significant post-LSG decrease in BMI (30.8 ± 4.6 kg/m2) was associated with significant decrease in serum TSH (1.99 ± 1.1 µU/mL) in all patients; changes were more prominent in SCH group and in patients with higher BMI. SCH patients had normalization of mean serum TSH at 12 months post-LSG. Results of groups "A" and "B" were not significantly different. Conclusion: The incidence of SCH was 12.9%. The significant decrease in BMI was associated with a significant decrease in serum TSH after LSG; this was more evident in SCH and in patients with higher BMI. Complete resolution of SCH occurred at 12 months post-LSG. Adding thyroxine treatment in obese SCH patients did not improve outcome and should be reserved to specific clinical and laboratory indications.