Robotic Vagus-Sparing Total Gastrectomy for CDH1 Gene Mutation Treatment.

Hereditary diffuse gastric cancer (HDGC) caused by the CDH1 gene mutation is an inherited cancer syndrome that increases the risk of diffuse gastric cancer and is nearly impossible to detect by screening gastroscopy. The recommended preventative treatment is a total gastrectomy. Robotic surgery facilitates the use of minimally invasive surgical (MIS) techniques for anastomoses and posterior vagus preservation to potentially reduce adverse functional outcomes. An asymptomatic 24 year old male with the CDH1 gene mutation proven by genetic testing and a family history of a brother having a total gastrectomy for HDGC was treated with this technique. This video case report demonstrates the techniques and pitfalls of robotic surgery in terms of the patient positioning and port placement, posterior vagus-preserving dissection, sutured esophagojejunostomy, jejunal pouch formation, and Roux-en-Y reconstruction with a staple-stapled jejunojejunostomy. While these techniques are demonstrated in the case of prophylactic gastrectomy, many of them can be applied to other benign and bariatric foregut and general surgery types.Robotic surgery can facilitate the foregut MIS technique, as described in this case of a vagus-sparing total gastrectomy.

A case of life-threatening, early postoperative refeeding syndrome in an obese young female undergoing laparoscopic sleeve gastrectomy.

Early complications after a laparoscopic sleeve gastrectomy (LSG) include bleeding, leaks, strictures and bowel obstructions. Patients post-LSG experience rapid but intended weight loss and may be on a restricted diet before and following surgery. Thus, many of these patients are in a malnourished state, placing them at a risk of developing potentially life-threatening refeeding syndrome (RFS). We describe the case of an 18-year-old female who developed RFS 2 weeks after LSG. We examine potential causes, review literature and discuss RFS pathophysiology as well as the guidelines that could help prevent RFS in bariatric surgery. Currently, not much is known about the risk of RFS in bariatric surgery and to our knowledge, this is the first report of RFS occurring in the early postoperative phase after LSG. A globally accepted definition of RFS should be established for guidelines to encompass wider patient groups.

Investigating the Prevalence of Copper and Zinc Abnormalities in Patients Pre and Post bariatric Surgery-an Australian Experience.

INTRODUCTION: Bariatric surgery predisposes patients to nutritional deficiencies. There are limited studies on zinc and copper abnormalities in this cohort. PURPOSE: The aim of this study was to identify the prevalence of these abnormalities in a cohort of Australian bariatric patients. Inflammatory markers, adherence to multivitamin supplementation (MVS) and the presence of gastrointestinal (GI) symptoms were also investigated. MATERIAL AND METHODS: Data was collected on all patients who attended a single clinic in Sydney, Australia, from August 2020 to August 2021. RESULTS: The study cohort consisted of 231 patients (76.2% female; mean pre-operative body mass index of 43.4 ± 7.1 kg/m2), most of whom underwent sleeve gastrectomy (78.8%). Data were collected preoperatively and then at ≤ 6 months, 1 and > 2 years postoperatively. Prior to surgery, low levels of zinc (2.1%) and copper (0.7%) were rare, but elevated copper levels were common (16.7%) and potentially related to an elevated C-reactive protein (CRP) (47.7%). Following surgery at > 2 years, the mean total weight loss (TWL) was 33.5 ± 12.4. CRP levels improved over time. Post operatively, low zinc (2.7-3.6%) and copper (1.5%) levels were rare. Patients with low levels in zinc and copper were a higher-risk group and generally exhibited GI symptoms, despite taking MVS. CONCLUSION: In the initial post-operative stages and with good adherence to MVS containing copper and zinc, abnormalities may not be a concern. Patients with GI symptoms appear to be at higher risk of abnormalities; increasing awareness, thorough screening, and more comprehensive supplementation are recommended.

Medium Term Outcomes of Revision Laparoscopic Sleeve Gastrectomy after Gastric Banding: A Propensity Score Matched Study.

PURPOSE: Revision bariatric surgery may be undertaken after weight loss failure and/or complications following primary bariatric surgery. This study aims to compare the efficacy and safety of revision laparoscopic sleeve gastrectomy (RLSG) after gastric banding (GB) to those of primary laparoscopic sleeve gastrectomy (PLSG). MATERIALS AND METHODS: A retrospective, propensity-score matched study was conducted to compare between PLSG (control) patients and RLSG after GB (treatment) patients. Patients were matched using 2:1 nearest neighbor propensity score matching without replacement. Patients were compared on weight loss outcomes and postoperative complications for up to five years. RESULTS: 144 PLSG patients were compared against 72 RLSG patients. At 36 months, PLSG patients had significantly higher mean %TWL than RLSG patients (27.4 ± 8.6 [9.3-48.9]% vs. 17.9 ± 10.2 [1.7-36.3]%, p < 0.01). At 60 months, both groups had similar mean %TWL (16.6 ± 8.1 [4.6-31.3]% vs. 16.2 ± 6.0 [8.8-22.4)]%, p > 0.05). Early functional complication rates were slightly higher with PLSG (13.9% vs. 9.7%), but late functional complication rates were comparatively higher with RLSG (50.0% vs. 37.5%). The differences were not statistically significant (p > 0.05). Both early (0.7% vs 4.2%) and late (3.5% vs 8.3%) surgical complication rates were lower in PLSG patients compared to RLSG patients but did not reach statistical significance (p > 0.05). CONCLUSION: RLSG after GB has poorer weight loss outcomes than PLSG in the short-term. Although RLSG may carry higher risks of functional complications, the safety of RLSG and PLSG are overall comparable.

The role of adjuvant pharmacotherapy with liraglutide for patients with inadequate weight loss following bariatric surgery.

PURPOSE: Despite the benefits of bariatric surgery for many patients, there are a proportion of patients who do not achieve adequate weight loss. We evaluate the role of liraglutide as adjuvant pharmacotherapy in those who respond poorly to weight loss surgery. MATERIALS AND METHODS: A non-controlled, prospective, open-label cohort study in which participants are prescribed liraglutide following inadequate response to weight loss surgery. The efficacy and tolerability of liraglutide was measured through measurement of BMI and monitoring of side effect profile. RESULTS: A total of 68 partial responders to bariatric surgery were included in the study, 2 participants were lost to follow-up. Overall 89.7% lost weight on liraglutide, with 22.1% showing a good response (>10% total body weight loss). There were 41 patients who discontinued liraglutide mainly due to cost. CONCLUSION: Liraglutide is efficacious in achieving weight loss and reasonably well tolerated in patients who have inadequate weight loss post-bariatric surgery.

Hiatal reconstruction is safe and effective for control of reflux after laparoscopic sleeve gastrectomy.

BACKGROUND: Gastroesophageal reflux is a known complication following laparoscopic sleeve gastrectomy (LSG) as anatomical changes predispose to reduced lower esophageal sphincter pressure and development of hiatus hernia. The mainstay of surgical management has been Roux-en-Y gastric bypass (RYGB) which is not without risk. Hiatus hernia repair (HHR) with surgical reattachment of the oesophagus to the crura, recreating the phreno-esophageal ligament is a simple procedure specifically targeting a number of anatomical changes responsible for reflux in this population. METHODS: We conducted a single centre retrospective analysis of adult patients with post-sleeve reflux refractory to medical treatment, managed with either HHR, RYGB or One-anastomosis Duodenal switch (OADS). PPI use and symptoms of reflux were assessed at early and mid-term time points via validated questionnaires. RESULTS: 99 patients were included, of these the surgical procedure was HHR alone in 58, RYGB in 29 and OADS in 12. At early follow-up control of reflux symptoms was achieved in 72.4% after HHR, 82.1% after RYGB and 100% after OADS with no significant difference between groups (p = 0.09). At mid-term followup (median 10 months IQR 7-21) there was no significant difference in the presence of symptomatic reflux as determined by post-op Visick score nor a difference in PPI use. The GerdQ score was significantly lower after OADS as compared to HHR and RYGB (4.6 ± 2.3 vs 7.7 ± 2.2 vs 8.7 ± 3.5, p = 0.006). CONCLUSION: HHR with reconstruction of the phreno-esophageal ligament is a safe and effective procedure for patients with reflux after LSG, that avoids more complex operations such as RYGB and OADS and their associated long-term sequelae.

Fertility, pregnancy and post partum management after bariatric surgery: a narrative review.

•Of the women who gave birth in Australia in 2018, 47% had overweight or obesity, with obesity being associated with both maternal and fetal complications. •Bariatric surgery improves fertility and some pregnancy-related outcomes. •Following bariatric surgery, pregnancy should be delayed by at least 12-18 months due to adverse pregnancy outcomes associated with rapid weight loss. •Contraception should be prescribed after bariatric surgery, although the effectiveness of the oral contraceptive pill may be reduced due to malabsorption and contraceptive devices such as intrauterine devices should be considered as first line therapy. •After bariatric surgery, women should undergo close monitoring for nutritional insufficiencies before, during and after pregnancy. Expert opinion recommends these women undergo dietary assessment and supplementation to prevent micronutrient deficiencies. •Bariatric surgeons, bariatric medical practitioners, bariatric dieticians, the patient's usual general practitioner, obstetricians, and maternity specialists should be involved to assist in the multidisciplinary management of these complex patients.

Accuracy of High-Resolution Manometry in Hiatal Hernia Diagnosis in Primary and Revision Bariatric Surgery.

PURPOSE: There is a complex association between obesity, hiatal hernia (HH), and reflux. There is a deficiency of literature on the accuracy of preoperative high-resolution manometry (HRM) in detecting HH before both primary and revision bariatric surgery. MATERIALS AND METHODS: A retrospective analysis of a prospective database of all HRM performed before bariatric surgery from 2014 to 2019. An electronic medical records review was conducted. Sensitivity, specificity, and global diagnostic test accuracy were calculated. RESULTS: Sixty-seven patients with HRM (mean age of 44.0 ± 11.3 years, body mass index 40.8 ± 6.9 kg/m2) were eligible. Intraoperative diagnosis of HH was made in 37 patients (55.2% prevalence). The HRM sensitivity was 48.7% (95% confidence interval (CI) 31.9-65.6%), specificity 90.0% (95% CI 73.5-97.9%), and accuracy was 67.2% (95% CI 54.6-78.2%). Comparing primary (28) and revision (39) surgery, the sensitivity (37.5% vs 57.1%), specificity (75.0% vs 100%), and diagnostic accuracy (54.3% vs 76.3%) were comparable, with overlapping 95% CI. Endoscopy performed in 30 patients had a sensitivity of 25.5% (95% CI 6.8-49.9%), specificity of 100% (95% CI 75.3-100%), and accuracy of 57.8% (95% CI 38.5-75.5%) and was comparable to HRM. CONCLUSION: High-resolution manometry for the detection of HH before bariatric surgery has a high specificity and maintains a high accuracy in both primary and revision bariatric surgery.

Barrett's Oesophagus and Bariatric/Metabolic Surgery-IFSO 2020 Position Statement.

The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) has been playing an integral role in educating both the metabolic surgical and the medical community at large about the importance of surgical and/or endoscopic interventions in treating adiposity-based chronic diseases. The occurrence of chronic conditions following bariatric/metabolic surgery (BMS), such as gastro-oesophageal reflux disease (GERD) and columnar (intestinal) epithelial metaplasia of the distal oesophagus (also known as Barrett's oesophagus (BE)), has long been discussed in the metabolic surgical and medical community. Equally, the risk of neoplastic progression of Barrett's oesophagus to oesophageal adenocarcinoma (EAC) and the resulting requirement for surgery are the source of some concern for many involved in the care of these patients, as the surgical alteration of the gastrointestinal tract may lead to impaired reconstructive options. As such, there is a requirement for guidance of the community.The IFSO commissioned a task force to elucidate three aspects of the presenting problem: First, to determine what the estimated incidence of Barrett's oesophagus is in patients presenting for BMS; second, to determine the frequency at which Barrett's oesophagus may develop following BMS (with a particular focus on the laparoscopic sleeve gastrectomy (LSG)); and third, to determine if regression of Barrett's oesophagus may occur following BMS given the close relationship of obesity and the development of BE/EAC. Based on these findings, a position statement regarding the management of this pathology in the context of BMS was developed. The following position statement is issued by the IFSO Barrett's Oesophagus task force andapproved by the IFSO Scientific Committee and Executive Board. This statement is based on current clinical knowledge, expert opinion and published peer-reviewed scientific evidence. It will be reviewed regularly.

High-resolution impedance manometry and 24-hour multichannel intraluminal impedance with pH testing before and after sleeve gastrectomy: de novo reflux in a prospective series.

BACKGROUND: Laparoscopic sleeve gastrectomy (SG) is increasingly popular but concern regarding its effect on gastroesophageal reflux disease remain. The current literature is conflicting, and there have been little objective data. OBJECTIVES: To objectively and more accurately assess the impact of SG on esophago-gastric physiology. SETTING: Centre of Excellence in Metabolic and Bariatric Surgery, Private Hospital, Australia. METHODS: Prospective cohort study of 31 patients undergoing SG with high-resolution impedance manometry (HRM), 24-hour multichannel intraluminal impedance combined with pH testing (MII-pH), and Gastroesophageal Reflux Disease Symptom Assessment Scale (GSAS) questionnaire 1 month before and 6 months after SG. RESULTS: There were 31 patients that underwent SG, 20 with synchronous hiatal repair and fixation, and 6 that were excluded. HRM demonstrated significantly increased intragastric pressures (15.5-29.6 mm Hg) and failed swallows (3.1-7.5%) but no other change in esophageal motility. MII-pH did not demonstrate significant changes in acid exposure time (8.5%-7.5%) or number of reflux episodes, although the numbers of long reflux episodes (2.3-4.7) and weak acid reflux episodes were significantly increased (15.4-55.2). DeMeester and GSAS scores were not significantly changed. There was no significant difference in patients with preexisting reflux. However, for patients without preexisting reflux, acid exposure time increased significantly (1.3%-6.7%), as did DeMeester scores (5.8-24.5) and the numbers of long reflux episodes (.1-4.4) and weakly acidic episodes (22.1-89.2). CONCLUSION: SG was associated with increased intragastric pressures, without changes in esophageal motility or acid exposure. For patients without preexisting reflux, there were increases in acid exposure time, long reflux episodes, weakly acidic reflux episodes, and DeMeester score.

Accuracy of hiatal hernia diagnosis in bariatric patients: Preoperative endoscopy versus intraoperative reference.

BACKGROUND AND AIM: Obesity is becoming increasingly prevalent in Asia. Bariatric surgery in the region is growing in popularity to reflect increasing demand. Hiatal hernia (HH) is common among the obese population. There is a lack of evidence comparing preoperative endoscopy against intraoperative findings as a standard of reference for HH diagnosis. METHODS: This was a retrospective analysis of a bariatric procedure database from a single tertiary teaching hospital and high-volume endoscopy center. Electronic medical records were reviewed. Endoscopy results were compared to intraoperative findings, and subgroup analysis of >2 cm hernias was performed. Sensitivity, specificity, predictive values, likelihood ratios, and global diagnostic test accuracy were calculated. RESULTS: A total of 434 patients were eligible for this study, of which HH was detected in 37 patients (prevalence rate 8.55%). Mean age was 41.51 ± 11.07 years, and body mass index was 39.37 ± 5.67 kg/m2. Endoscopy sensitivity was 75.68% (95% confidence interval, 58.80-88.23%) and specificity 91.44% (88.24-94.00%). Positive likelihood ratio was 8.53 (6.11-12.79) and negative likelihood ratio 0.27 (0.15-0.47). Positive predictive value was 45.16% (36.27-54.38%) and negative predictive value 97.58% (95.80-98.62%). Accuracy of endoscopy for preoperative HH diagnosis was 90.09% (86.89-92.74%). CONCLUSION: Endoscopy can have a high diagnostic accuracy of preoperative HH diagnosis in obese Asian patients using intraoperative diagnosis as the reference standard.

Minimally invasive Venetian blinds ventral hernia repair with botulinum toxin chemical component separation.

BACKGROUND: Laparoscopic ventral repair is safe, with lower wound infection rates compared with open repair. 'Venetian blinds' technique of plication in combination with mesh reinforcement, is totally intra-corporeal, with hernia defect and sac plication to reduce seroma formation. While laparoscopic suturing of the abdominal wall can represent a technical challenge, pre-operative botulinum toxin A (BTA) injections as an adjunct can assist. This study aims to demonstrate feasibility and efficacy of this technique in abdominal wall hernia repair, with BTA adjunct in midline hernias. METHODS: A single-centre case series was conducted using minimally invasive 'Venetian blinds' technique for repair of complex ventral abdominal hernias. Twelve patients (seven midline, five non-midline) underwent repair (11 laparoscopic; one robotic). Midline hernias received BTA (200-300 units Botox) 4-6 weeks prior to surgery. Repairs were mesh-reinforced following fascial closure. RESULTS: Twelve (10 female, two male) patients, with a median age 72 years (range 31-83) and body mass index of 27.3 kg/m2 (range 22.8-61.7) were included. The median length of operation was 133 min (range 45-290) and length of hospital stay 3 days (range 1-28). To date there has been no recurrence of hernia. A single symptomatic seroma was treated with antibiotics and did not require mesh removal. One patient developed hospital-acquired pneumonia and pseudomembranous colitis. CONCLUSION: Minimally invasive 'Venetian blinds' technique has promising early results with both midline and non-midline ventral hernias. The addition of BTA is a novel and feasible combination for repair of midline ventral hernias.

Subspecialty approach for the management of acute cholecystitis: an alternative to acute surgical unit model of care.

BACKGROUND: Acute cholecystitis is a common condition. Recent studies have shown an association between creation of an acute surgical unit (ASU) and improved outcomes. This study aimed to evaluate the outcomes of a subspecialty based approach to the management of acute cholecystitis as an alternative to the traditional 'generalist' general surgery approach or the ASU model. METHOD: A 6-year retrospective analysis of outcomes in patients admitted under a dedicated upper gastrointestinal service for acute cholecystitis undergoing emergency laparoscopic cholecystectomy. RESULTS: Seven hundred emergency laparoscopic cholecystectomies were performed over this time. A total of 486 patients were available for analysis. The median time to operation was 2 days and median length of operation was 80 min. A total of 86.9% were performed during daylight hours. Eight cases were converted to open surgery (1.6%). Intra-operative cholangiography was performed in 408 patients. The major complication rate was 8.2%, including retained common bile duct stones (2.3%), sepsis (0.2%), post-operative bleeding (0.4%), readmission (0.6%), bile leak (2.1%), AMI (0.4%), unscheduled return to theatre (0.6%) and pneumonia (0.8%). There were no mortalities and no common bile duct injuries. CONCLUSION: Over a time period that encompasses the current publications on the ASU model, a subspecialty model of care has shown consistent results that exceed established benchmarks. Subspecialty management of complex elective pathologies has become the norm in general surgery and this study generates the hypothesis that subspecialty management of patients with complex emergency pathologies should be considered a valid alternative to ASU. Access block to emergency theatres delays treatment and prolongs hospital stay.

A histologic evaluation of the laparoscopic adjustable gastric band capsule by tissue sampling during sleeve gastrectomy performed at different time points after band removal.

BACKGROUND: Laparoscopic sleeve gastrectomy (SG) is gaining popularity as a revision option after failed laparoscopic adjustable gastric banding (LAGB). Data have shown that single stage revisions may be associated with a higher complication rate. A histologic basis for this observation has not been studied. The objective of this study was to document the histologic properties of the LAGB capsule across the gastric staple line after SG at various time points after LAGB removal. METHODS: Gastric sleeve specimens of all LAGB to SG revisions were identified from January to May 2013 and underwent histologic evaluation of the LAGB capsule. Single blinded pathologist interpretation was performed, with inflammation, fibrosis, neovascularization, foreign body (FB) reaction, and wall thickness assessed semi-quantitatively and scored from 0-3. Based on combined features, an attempt was made to predict the timing of revision surgery. RESULTS: The study identified 19 revisions performed for inadequate excess weight loss or weight regain. The mean age for revision was 44 (19-65). The minimum time to revision was 42 days, the longest 1,188 days. There were no surgical complications. Varying degrees of inflammation and fibrosis were common features at all times. Angiogenesis, neovascularization and FB reaction were prominent in revisions performed before 80 days. The gastric wall was thicker during early revision. The optimal time to perform revision was difficult to determine. CONCLUSIONS: LAGB caused varying degrees of inflammatory and FB reaction that time did not fully resolve. The lower leak rates observed with delayed revisions do not appear to be attributable to gastric histology.

Efficacy of surgery in the management of obesity-related type 2 diabetes mellitus.

BACKGROUND: It is estimated that up to 80% of persons with diabetes mellitus type 2 are overweight and in these patients it is recognized that effective weight control can lead to improvement or even resolution of their diabetes (Colagiuri et al.). All currently carried out operations for morbid obesity have been shown to improve diabetes, but there appears to be a variable response to surgery depending on several surgical and patient factors. METHODS: In this prospective review, we analysed the change in the diabetic status in 72 patients undergoing three different bariatric procedures in a single institution over 30 months. A review of the published work comparing the efficacy of the various procedures in achieving improvement or resolution of diabetes was also carried out and correlated to our findings. RESULTS: At an average follow up of 13 months, 50% of patients who had placement of laparoscopic adjustable gastric band had an improvement or resolution of their diabetes, compared with 95% of patients who had had laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass. Two of 12 (17%) laparoscopic adjustable gastric band patients had normal blood glucose levels off all diabetic medications compared with 7 of 21 (33%) laparoscopic sleeve gastrectomy and 27 of 39 (69%) Roux-en-Y gastric bypass patients. There was no significant association between the amount of weight lost and the return to euglycaemia. CONCLUSION: Direct comparison has shown a significant difference in the effects of different forms of bariatric surgery on type 2 diabetes, this is in keeping with evidence that surgery can lead to improvement in diabetes additional to that obtained by weight loss alone.