Predicting the Need for Surgery in Uncomplicated Adhesive Small Bowel Obstruction: A Scoring Tool.

INTRODUCTION: Nonoperative treatment can be attempted for uncomplicated adhesive small bowel obstruction (ASBO), but carries a risk of delayed surgery. Highlighting initial parameters predicting risk of failure of nonoperative management would be of great interest. METHODS: Patients initially managed conservatively for uncomplicated ASBO were retrospectively analyzed. Univariate and multivariate analysis were performed to identify predictive failure's factors. Based on the risk factors, a score was created and then prospectively validated in a different patients' population. RESULTS: Among 171 patients included, 98 (57.3%) were successfully managed conservatively. In a multivariate analysis, three independent nonoperative management failure's factors were identified: Charlson Index ≥4 (P = 0.016), distal obstruction (P = 0.009), and maximum small bowel diameter over vertical abdominal diameter ratio >0.34 (P = 0.023). A score of two or three was associated with a risk of surgery of 51.4% or 70.3% in the retrospective analysis and 62.2% or 75% in the validation cohort, respectively. CONCLUSIONS: This clinical-radiological score may help guide surgical decision-making in uncomplicated ASBO. A high score (≥2) was predictive of failure of nonoperative management. This tool could assist surgeons to determine who would benefit from early surgery.

Prevention of incisional hernia after single-port sleeve gastrectomy (PRISM): a prospective non-randomized controlled study.

BACKGROUND: SPSG carries a risk of incisional hernia, particularly in patients with high body mass index. Prophylactic mesh placement with either permanent or absorbable mesh could decrease the occurrence of incisional hernia, with uncertainty on other postoperative parietal complications. METHODS: This is a non-randomized monocentric single-blinded prospective study. High-risk patients (body mass index ≥ 45 kg/m2) underwent either 3 strategies of parietal closure (suture with or without permanent or absorbable mesh) during SPSG. The primary outcome was the occurrence of radiologically defined incisional hernia during the first postoperative year. Secondary outcomes included surgical site infection rates and postoperative pain. RESULTS: Between November 2018 and November 2019, 255 patients were included (85 in each group). All patients reached one-year postoperative follow-up. Significantly more incisional hernias were observed in the no mesh group in comparison with permanent and absorbable mesh groups, respectively (20% vs. 7.1% vs. 5.1%, P = 0.005). No difference was observed in mesh groups. No difference was observed regarding other parietal complications. One patient in the absorbable mesh group presented a superficial surgical site infection and required surgical drainage without mesh removal and one patient in the permanent mesh group presented a parietal hematoma and required surgical drainage with mesh removal. Twenty-six (92.8%) asymptomatic patients presented incisional hernia discovered on the one-year CT-scan. CONCLUSIONS: Prophylactic mesh placement during SPSG decreases the occurrence of postoperative incisional hernia. Routine permanent mesh placement could be proposed in high-risk patients.

Appendiceal endometriosis invading the sigmoid colon: a rare entity.

PURPOSE: We report an unusual case of endometriosis of the appendix with simultaneous invasion of the sigmoid colon. METHODS: Clinical, radiological, surgical, and histological data of the patient were reviewed, as well as the current literature on gastrointestinal endometriosis. RESULTS: A 41-year-old woman presented to the emergency department of our hospital with acute right lower quadrant pain, pronounced tenderness elevated white blood cell count, and increased C-reactive protein. Abdominal CT scan suggested a mucocele of the appendix. The patient was first treated with antibiotics, followed by en bloc resection of the appendix and of the sigmoid colon 2 months later. Histological examination revealed an endometriotic nodule of the appendix filling the appendiceal lumen and resulting in a mucocele which invaded the sigmoid colon wall. CONCLUSIONS: The diagnosis of gastrointestinal endometriosis can be challenging due to the variety of symptoms it can produce. Although extremely rare, a concomitant double gastrointestinal location of endometriosis may be possible and should be considered in women of reproductive age.

Cardiac remodeling in obese patients after laparoscopic sleeve gastrectomy.

BACKGROUND: Obesity is associated with high morbidity and represents an increasing health care problem worldwide. Laparoscopic sleeve gastrectomy (LSG) has been used effectively for weight loss and co-morbidity remission. In this retrospective study, we evaluated cardiac reverse remodeling at medium-term follow-up by echocardiography, the amount of cardiovascular medications, and the impact of co-morbidities after sleeve gastrectomy. METHODS: Altogether, 16 obese patients (4 men, 12 women; 46.4 ± 10.3 years) underwent complete clinical evaluation, laboratory tests, and color Doppler/tissue Doppler imaging echocardiography preoperatively and 12-20 months after bariatric surgery. RESULTS: Body weight (mean body mass index) was significantly reduced (from 44.8 ± 8.0 to 31.2 ± 7.8 kg/m2; p = 0.001). Lipid profile significantly improved: total cholesterol and triglycerides decreased (respectively: 215.5 ± 53.8 vs. 205.3 ± 46.6 mg/dl and 184.9 ± 109.3 vs. 116.1 ± 49.9 mg/dl, both p ≤ 0.05), and high-density lipoprotein increased (43.1 ± 10.9 vs. 51.4 ± 12.8 mg/dl, p = 0.005). Systolic blood pressure significantly decreased (from 133.0 ± 17.1 to 120.6 ± 13.7 mmHg; p = 0.04). Diabetes remission was complete in five of six patients (83%) and sleep apnea in four of five (80 %). Echocardiography showed significantly reduced interventricular septum and posterior wall thickness (11.3 ± 1.8 to 9.4 ± 2.1 mm and 10.4 ± 1.7 to 8.6 ± 1.9 mm, respectively; both p < 0.007) and reduced left ventricular mass (absolute value and indexed by height, respectively: 222.41 ± 78.2 to 172.75 ± 66.3 g (p = 0.003) and 55.9 ± 14.3 to 43.8 ± 17.2 g/m(2.7) (p = 0.0004). Antihypertensive drug intake was significantly reduced (p = 0.03), as shown by the 10-year Framingham Risk Score (from 14.2 ± 9.3 to 8.3 ± 9.5%, p = 0.003). CONCLUSIONS: Sleeve gastrectomy is associated with marked improvement in terms of weight loss, lipid profile, type 2 diabetes, sleep apnea, hypertension, and left ventricular hypertrophy, with a significantly reduced Framingham Risk Score.

Routine Early Computed Tomography Scanner After Laparoscopic Sleeve Gastrectomy in High-Risk Severely Obese Patients Is Effective for Bleeding or Hematoma Diagnosis but not for Staple-Line Leak Detection: a Prospective Study.

PURPOSE: Laparoscopic sleeve gastrectomy (LSG) is the most frequently performed bariatric procedure worldwide. Postoperative staple-line leak and intraabdominal hemorrhage can increase associated morbidity and mortality. The value of routine early computed tomography (CT) scanner examination in the early diagnosis of complications in high-risk severely obese patients undergoing LSG is studied. METHODS: This was a prospective, non-randomized study including all patients undergoing LSG in our department from 2014 to 2020. Patients presenting at least one potential risk factor for postoperative gastric leak and bleeding (as defined by the current literature) were included. Primary endpoint was the efficacy of postoperative day (POD) 2 CT-scanner examination in diagnosing these complications. RESULTS: One thousand fifty-one high-risk patients were included. Median age was 44 years. Early postoperative surgical complications occurred in 48 patients (4.5%): 25 (2.3%) intraabdominal hemorrhage and 23 (2.2%) staple-line leak. Early CT-scanner detected intraabdominal bleeding or hematoma in 22/25 patients, with 95.6% sensitivity (Youden's index = 0.95), while specificity was 100%, positive predictive value (PPV) 100%, and negative predictive value (NPV) 99.9%. Sensitivity of early postoperative CT-scanner was 43.4% (10/23 patients; Youden's index = 0.43) for staple-line leak detection, with specificity of 100%, PPV 100%, and NPV 98.7%. CONCLUSION: POD 2 CT-scanner in high-risk severely obese patients undergoing LSG is an excellent tool for early diagnosis of intraabdominal hemorrhage, but sensitivity remains low for staple-line leak detection. Close postoperative clinical follow-up of these patients is essential and any suspicion of postoperative surgical complication should motivate the performance of a CT-scanner.

Endoscopic internal drainage for the management of leak, fistula, and collection after sleeve gastrectomy: our experience in 617 consecutive patients.

BACKGROUND: Endoscopy plays a pivotal role in the management of adverse events (AE) following bariatric surgery. Leaks, fistulae, and post-operative collection after sleeve gastrectomy (SG) may occur in up to 10% of cases. OBJECTIVES: To evaluate the efficacy and safety of endoscopic internal drainage (EID) for the management of leak, fistula, and collection following SG. SETTING: Retrospective, observational, single center study on patients referred from several bariatric surgery departments to an endoscopic referral center. METHODS: EID was used as first-line treatment for the management of leaks, fistulae, and collections. Leaks and fistulae were treated with double pigtail stent (DPS) deployment in order to guarantee internal drainage and second intention cavity obliteration. Collections were treated with endoscropic ultrasound (EUS)-guided deployment of DPS or lumen apposing metal stents. RESULTS: A total of 617 patients (83.3% female; mean age, 43.1 yr) were enrolled in the study for leak (n = 300, 48.6%), fistula (n = 285, 46.2%), and collection (n = 32, 5.2%). Median follow-up was 19.5 months. Overall clinical success was 84.7% whereas 15.3% of cases required revisional surgery after EID failure. Clinical success according to type of AE was 89.5%, 78.5%, and 90% for leak, fistula, and collection, respectively. A total of 10 of 547 (1.8%) presented a recurrence during follow-up. A total of 28 (4.5%) AE related to the endoscopic treatment occurred. At univariate logistic regression predictors of failure were: fistula (OR 2.012), combined endoscopic approach (OR 2.319), need for emergency surgery (OR 1.755), and previous endoscopic treatment (OR 4.818). CONCLUSION: Early EID for the management of leak, fistula, and post-operative collection after SG seems a safe and effective first-line approach with good long-term results.

Single-port Laparoscopic Surgery for the Treatment of Severe Obesity: Review and Perspectives.

This report aims to review current data on single-incision (single-port) laparoscopic surgery (SILS) for bariatric surgery. A comprehensive research of Pubmed database and Cochrane library on SILS bariatric surgery was conducted. Twenty-eight articles met inclusion criteria (3611 patients). Intraoperative and clinical outcomes for SILS sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and adjustable gastric banding (AGB) seem comparable to conventional laparoscopy. SILS for SG was safe and feasible with good outcomes. The same stands for RYGB but more studies are necessary for safe conclusions, while additional trocars are necessary to perform the procedure. AGB is feasible and safe by SILS but the declining number of annual procedures will probably limit the use of SILS. Major studies are unavailable for SILS and other bariatric procedures.

Submucosal Tunnel Endoscopic Resection of Gastric Lesion Before Obesity Surgery: a Case Series.

BACKGROUND: Submucosal tumors (SMTs) of the gastrointestinal tract are a rare pathological entity comprising a wide variety of neoplastic and non-neoplastic lesions. Even if most SMTs are benign tumors (e.g., leiomyomas), a smaller portion may have a malignant potential (e.g., gastrointestinal stromal tumor (GIST)). Preoperative diagnosis of SMT in bariatric patients may arise challenging clinical dilemmas. Long-term surveillance may be difficult after bariatric surgery. Moreover, according to SMT location, its presence may interfere with planned surgery. Submucosal tunneling endoscopic resection (STER) has emerged as an effective approach for minimally invasive en bloc excision of SMTs. This is the first case series of STER for SMTs before bariatric surgery. METHODS: Seven female patients underwent STER for removal of SMTs before bariatric surgery. All lesions were incidentally diagnosed at preoperative endoscopy. STER procedural steps comprised mucosal incision, submucosal tunneling, lesion enucleation, and closure of mucosal defect. RESULTS: En bloc removal of SMT was achieved in all cases. Mean procedural time was of 45 min (SD 18.6). No adverse event occurred. Mean size of the lesions was 20.6 mm (SD 5.8). Histological diagnoses were 5 leyomiomas, 1 lipoma, and 1 low grade GIST. Bariatric procedure was performed after a mean period of 4.1 months (SD 1.6) from endoscopic resection. CONCLUSION: STER is a safe and effective treatment for the management of SMT even in bariatric patients awaiting surgery. Preoperative endoscopic resection of SMTs has the advantages of reducing the need for surveillance and removing lesions that could interfere with planned surgery. STER did not altered accomplishment of bariatric procedures.

Endoscopic Internal Drainage Coupled to Prompt External Drainage Mobilization Is an Effective Approach for the Treatment of Complicated Cases of Sleeve Gastrectomy.

INTRODUCTION: Despite advances in treating gastric staple line leaks after bariatric surgical procedures, chronic leaks have been reported. Failure of their treatment frequently leads to radical surgery. We aimed to describe a strategy for preventing occurrence of chronic gastric leaks after complicated sleeve gastrectomy in patients necessitating relaparoscopy and external drainage as a first step of gastric leak management. METHODS: Data from 14 consecutive patients admitted for gastric leak after laparoscopic sleeve gastrectomy were prospectively collected and retrospectively analyzed. Patients included underwent relaparoscopy and external drainage as first step of management. RESULTS: Median time to gastric leak detection was 4 days. Emergency relaparoscopy allowed peritoneal lavage and external drainage placement next to the leak. Median time between surgery and endoscopic internal drainage (EID) was 4 days. Progressive external drainage mobilization started after 2 days. Control endoscopy was performed every 4 weeks until healing. A median interval of 112 days was necessary before healing in 13 patients. Thirteen patients (92.8%) had no gastric leak recurrence at 1 year. In one patient, EID was considerably delayed and external drainage mobilization prolonged, leading to chronic gastric leak and total gastrectomy after 18 months. CONCLUSION: This study reports for the first time a well-standardized protocol of early EID after relaparoscopy coupled to rapid external drainage removal for effectively treating complicated cases of sleeve gastrectomy. Bariatric surgeons should be aware of such therapeutic strategies and include them in their arsenal against postoperative gastric staple line leaks in severely obese patients.

Safety and short-term outcomes of laparoscopic sleeve gastrectomy for patients over 65 years old with severe obesity.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is a widely accepted, stand-alone bariatric operation. Data on elderly patients undergoing LSG are scarce. OBJECTIVES: The aim of this study was to demonstrate that LSG is safe and effective for patients>65 years old with severe obesity. SETTING: Department of Minimally Invasive Digestive Surgery, Antoine-Beclere Hospital, AP-HP, Paris-Saclay University, France. METHODS: Prospectively collected data from consecutive patients undergoing LSG were retrospectively analyzed. Patients with>1-year follow-up were included in the analysis for weight loss and co-morbidities evaluation. Quality of life was evaluated using the Short-Form 36 questionnaire. RESULTS: Fifty-four patients>65 years old (range, 65-75 yr) underwent LSG. Median weight was 119 kg, and median body mass index was 43 kg/m2. Median duration of surgery was 86.5 minutes. Two patients (3.7%) suffered a gastric staple-line leak, 1 treated by pure endoscopic internal drainage and 1 by relaparoscopy with subsequent endoscopic internal drainage. Mortality was null. Median length of hospital stay was 5 days. Six, 12, and 24 months after LSG, median body mass index decreased significantly to 35, 32.9, and 30.7 kg/m2, respectively (P<.0001), with mean excess weight loss of 76.3% at 2 years. Type 2 diabetes, hypertension, dyslipidemia, obstructive sleep apnea syndrome, and arthralgia showed statistically significant remission at 1- and 2-year follow-up, while 6 of 8 SF-36 scale scores of quality of life assessment improved significantly. CONCLUSIONS: This study suggests that LSG is effective for patients>65 years old, resulting in significant weight loss, co-morbidities remission, and quality of life improvement. Careful patient selection after adequate risk versus benefit evaluation by an expert multidisciplinary team is essential for patient safety and optimal results.

Endoscopic Fistula-jejunostomy for Chronic Gastro-jejunal Fistula After Sleeve Gastrectomy.

INTRODUCTION: Proximal gastric leak is one of the most common complications after laparoscopic sleeve gastrectomy (LSG). Endoscopy is the gold standard treatment for acute staple-line leaks. Surgery is the most effective treatment modality in case of chronic fistula. MATERIAL AND METHODS: A 55-year- old man presented an acute leak after LSG. The leak was treated with metal stent deployment with temporary closure. After 6 months, he presented leak recurrence with general sepsis, perigastric-infected collection, and gastro-jejunal fistula. RESULTS: Endoscopic internal drainage (EID) was performed; however, due to fistula persistence, a surgical procedure was proposed. The patient refused revisional surgery; therefore, endoscopic salvage procedure was decided. A fully covered metal stent was deployed in order to bypass the perigastric collection creating an endoscopic gastro-jejunal anastomosis. CONCLUSION: Revisional surgery is the gold standard treatment for chronic fistula after SG. Endoscopic treatment with SEMS deployment may be a sound option in selected cases especially after failure of other endoscopic techniques or refusal of revisional surgery.