Multicenter retrospective cohort Italian study on elective laparoscopic cholecystectomy performed by the surgical residents.

PURPOSE: This retrospective multicenter cohort study aimed to evaluate the clinical outcomes (mortality rate, operative time, complications) of elective laparoscopic cholecystectomy (LC) when performed by a surgical resident in comparison to experienced consultant in the backdrop of Italian academic centers. METHODS: Retrospective review of all patients undergoing elective LC between January 2016 and January 2022 at six teaching hospitals across Italy was performed. Cases were identified using the Current Procedural Terminology (CPT) code 5123 (LC without cholangiogram). All cases of emergency surgery, ASA score > 3, or when cholecystectomy was performed with another surgical procedure, were excluded. All suitable cases were divided into 2 groups based on primary surgeon: consultant or senior resident. Main outcome was complication rates (intraoperative and peri/postoperative); secondary outcomes included operative time, the length of stay, and the rate of conversion to open. RESULTS: A total of 2331 cases (1425 females) were included, of which, consultants performed 1683 LCs (72%), while the residents performed 648 (28%) surgeries. The groups were statistically comparable regarding demographics, history of previous abdominal surgery, operative time, or intraoperative complications. The rate of conversion to open cholecystectomy was 1.42% for consultant and none for resident (p = 0.02). A statistically significant difference was observed between groups regarding the average length of stay (2.2 ± 3 vs 1.6 ± 1.3 days p = 0.03). Similarly, postoperative complications (1.7% vs 0.5%) resulted in statistically significant (p = 0.02) favoring resident group. CONCLUSIONS: Our study demonstrates that in selected patients, senior residents can safely perform LC when supervised by senior staff surgeons.

Colorectal cancer after bariatric surgery (Cric-Abs 2020): Sicob (Italian society of obesity surgery) endorsed national survey.

BACKGROUND: The published colorectal cancer (CRC) outcomes after bariatric surgery (BS) are conflicting, with some anecdotal studies reporting increased risks. The present nationwide survey CRIC-ABS 2020 (Colo-Rectal Cancer Incidence-After Bariatric Surgery-2020), endorsed by the Italian Society of Obesity Surgery (SICOB), aims to report its incidence in Italy after BS, comparing the two commonest laparoscopic procedures-Sleeve Gastrectomy (SG) and Roux-en-Y gastric bypass (GBP). METHODS: Two online questionnaires-first having 11 questions on SG/GBP frequency with a follow-up of 5-10 years, and the second containing 15 questions on CRC incidence and management, were administered to 53 referral bariatric, high volume centers. A standardized incidence ratio (SIR-a ratio of the observed number of cases to the expected number) with 95% confidence intervals (CI) was calculated along with CRC incidence risk computation for baseline characteristics. RESULTS: Data for 20,571 patients from 34 (63%) centers between 2010 and 2015 were collected, of which 14,431 had SG (70%) and 6140 GBP (30%). 22 patients (0.10%, mean age = 53 ± 12 years, 13 males), SG: 12 and GBP: 10, developed CRC after 4.3 ± 2.3 years. Overall incidence was higher among males for both groups (SG: 0.15% vs 0.05%; GBP: 0.35% vs 0.09%) and the GBP cohort having slightly older patients. The right colon was most affected (n = 13) and SIR categorized/sex had fewer values < 1, except for GBP males (SIR = 1.07). CONCLUSION: Low CRC incidence after BS at 10 years (0.10%), and no difference between procedures was seen, suggesting that BS does not trigger the neoplasm development.

Transhiatal Migration After Laparoscopic Sleeve Gastrectomy: Myth or Reality? A Multicenter, Retrospective Study on the Incidence and Clinical Impact.

PURPOSE: Only anecdotally reported, intrathoracic migration (ITM) represents an unacknowledged complication after sleeve gastrectomy (LSG) contributing to gastroesophageal reflux disease (GERD) development, both recurrent and de novo. The primary endpoint of this study was to evaluate the incidence of postoperative ITM ≥ 2 cm; the secondary endpoint was to determine the relationships between ITM, GERD, endoscopic findings, and percentage of patients requiring surgical revision. MATERIALS AND METHODS: A retrospective, multicenter study on prospective databases was conducted, analyzing LSGs performed between 2013 and 2018. Inclusion criteria consisted of primary operation; BMI ranging 35-60 kg/m2; age 18-65 years; minimum follow-up 24 months; and postoperative UGIE, excluding concomitant hiatal hernia repair. Esophageal manometry and 24-h pH-metry were indicated, based on postoperative questionnaires and UGIE; patients with GERD due to ITM, and non-responders to medical therapy, were converted to R-en-Y gastric bypass (RYGB). RESULTS: An ITM ≥ 2cm was postoperatively diagnosed in 94 patients (7% of 1337 LSGs), after mean 24.16 ± 13.6 months. Postoperative esophagitis was found in 29 patients vs. 15 initially (p=0.001), while GERD was demonstrated in 75 (vs. 20 preoperatively, p< 0.001). Fifteen patients (16%) underwent revision to RYGB with posterior cruroplasty. Seventeen patients with severe GERD presented improvement of endoscopic findings and clinical symptoms as a result of conservative therapy. CONCLUSIONS: ITM after LSG is not a negligible complication and represents an important pathogenic factor in the development or worsening of GERD. Postoperative UGIE plays a fundamental role in the diagnosis of esophageal mucosal lesions.

Concomitant hiatal hernia repair during bariatric surgery: does the reinforcement make the difference?

BACKGROUND: Hiatal hernia repair (HHR) is still controversial during bariatric procedures, especially in case of laparoscopic sleeve gastrectomy (LSG). AIMS: to report the long-term results of concomitant HHR, evaluating the safety and efficacy of posterior cruroplasty (PC), simple or reinforced with biosynthetic, absorbable Bio-A® mesh (Gore, Flagstaff, AZ, USA). Primary endpoint: PC's failure, defined as symptomatic HH recurrence, nonresponding to medical treatment and requiring revisional surgery. METHODS: The prospective database of 1876 bariatric operations performed in a center of excellence between 2011-2019 was searched for concomitant HHR. Intraoperative measurement of the hiatal surface area (HSA) was performed routinely. RESULTS: A total of 250 patients undergone bariatric surgery and concomitant HHR (13%). Simple PC (group A, 151 patients) was performed during 130 LSG, 5 re-sleeves and 16 gastric bypasses; mean BMI 43.4±5.8 kg/m2, HSA mean size 3.4±2 cm2. Reinforced PC (group B) was performed in 99 cases: 62 primary LSG, 22 LGB and 15 revisions of LSG; mean BMI 44.6±7.7 kg/m2, HSA mean size 6.7±2 cm2. PC's failure, with intrathoracic migration (ITM) of the LSG was encountered in 12 cases (8%) of simple vs. only 4 cases (4%) of reinforced PC (P=0.23); hence, a repeat, reinforced PC and R-en-Y gastric bypass (LRYGB) was performed laparoscopically in all cases. No mesh-related complications were registered perioperatively or after long-term follow-up (mean 50 months). One case of cardiac metaplasia without goblet cells was detected 4 years postoperatively; conversion to LRYGB, with reinforced redo of the PC was performed. The Cox hazard analysis showed that the use of more than four stitches for cruroplasty represents a negative factor on recurrence (HR=8; P<0.05). CONCLUSIONS: An aggressive search for and repair of HH during any bariatric procedure seems advisable, allowing a low HH recurrence rates. Additional measures, like mesh reinforcement of crural closure with biosynthetic, absorbable mesh, seem to improve results on long term follow-up, especially in case of larger hiatal defects. In our experience, reinforcement of even smaller defects seems advisable in obese population.

The impact of the surgical technique on stenosis after laparoscopic sleeve gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has gained worldwide popularity in the last 10 years as self alone bariatric procedure. Symptomatic stenosis (SS) is a potential severe postoperative complication and it can be divided in organic stenosis (OS) and functional stenosis (FS). The aim of this paper is to propose a modified surgical technique to prevent FS. METHODS: A retrospective review on 5235 LSG performed in Ponderas Academic Hospital between January 2011 and December 2019, searched FS in two consecutive patients groups, divided based on the modified surgical technique introduced in 2015, with fixation of the gastric tube to the prepancreatic fascia and stapler line's over-sewn running suture. RESULTS: Group A (2011-2014) included 1332 LSG, 16 SS were registered (1.2%), 7 OS and 9 FS; 3903 LSG included in group B (2015-2019), counting for 37 SS (0.95%), 27 OS and 10 FS. A statistically significant difference between the 2 groups was observed for the FS incidence (P=0.03), while it was non-significant for the OS (P=0.52) and the total number of SS (P=0.43). The endoscopic approach was used in forty-eight SS (90.5%) with a successful rate of 83%, while specifically for the FS it was 100%; only one complication was registered during endoscopic treatment, that required further surgical solution. CONCLUSIONS: Fixation of the gastric tube to the prepancreatic fascia and stapler line's over-sewn running suture during LSG, introduced lately, are beneficial in preventing the postoperative functional stenosis of the LSG, contributing to the improvement of the patient's quality of life.

Persistent Fistula after Sleeve Gastrectomy: A Chronic Dilemma.

Background: There is no time limit for the occurrence of leaks after sleeve gastrectomy LSG, and very late ones might evolve versus persistent, chronic fistulas. The aim of this retrospective study was to analyze the incidence, treatment and outcomes of persistent, chronic fistulas occurred or treated in a bariatric Center of Excellence IFSO-EC (CoE) and to establish a standardized approach. Materials Methods: between 2011-2018, nine cases of postoperative leaks occurred on a total of 1365 LSG performed (0.65%), 7 of them having late presentations (onset over 10 days postoperative). Chronic, persistent fistulas were identified and analyzed, including one gastro-bronchial and one gastro-cutaneous fistulas. Results: We present three peculiar cases of very late, chronic type III fistulas, with onset at 6-84 months after primary LSG and their management, including conservative, interventional radiology and endoscopy and surgical therapies. Conclusions: the management of late, chronic type III fistula is variable, with no standard algorithm to follow, but it should be planned based on the clinical evaluation, time of diagnosis, available resources, multidisciplinary approach and expertise. This emphasises again the necessity of a bariatric CoE that can guarantee a better diagnose and treatment, based on the use of wide, available resources, both professional and material.

Histopathology Findings in Patients Undergoing Laparoscopic Sleeve Gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has gained popularity in the last 10 years for its good results in weight loss and comorbidity control. However, guidelines on the pathological examination of the specimen are lacking. The aim of this retrospective study was to determine the usefulness of the routine specimen examination when presurgery endoscopy (upper gastrointestinal endoscopy, UGIE) and multiple gastric biopsies are part of the preoperative work-up. METHODS: A retrospective review of records of the patients submitted to LSG between January 2012 and August 2017 was carried out. Sex, age, histopathology findings in the presurgery endoscopy biopsies and surgical specimen, and the prevalence of Helicobacter pylori infection were analyzed. RESULTS: A total of 925 patients entered the study group (mean age = 44.1 years, Females = 80.3%, BMI = 44.58 kg/m2). The most common histopathology pattern in the endoscopy biopsies and in the surgical specimens was inactive chronic gastritis (64.4 and 55.6%, respectively). Helicobacter pylori infection was 24.6 and 2.48%, respectively. Ninety-nine percent (n 796) of patients with non-significant endoscopy biopsy findings showed the same patterns in specimen analysis. Only three patients (0.3%) who had intestinal presurgery metaplasia were positive in the specimen analysis, and two cases of gastric stromal neoplasms (gastrointestinal stromal tumor and gastric leiomyoma) were found intraoperatively. CONCLUSION: Most of the findings are non-significant and can be predicted if UGIE plus multiple biopsies is routinely included in the bariatric work-up with significant cost reduction. In those patients who had a significant finding prior to the surgery or intraoperatively, the pathological examination of the specimen is recommended.