Results of sleeve gastrectomy conversion to Roux-en-Y gastric bypass on gastroesophageal reflux disease symptoms and proton pump inhibitors use evolution over time.

BACKGROUND: Although sleeve gastrectomy (SG) is associated with excellent results in the short term, it has been shown that it is plagued by weight regain and new onset or worsening of gastroesophageal reflux disease (GERD). These 2 clinical conditions are currently the 2 most frequent indications for revisional surgery. To date, only a few studies have focused exclusively on GERD. In a selected series of patients complaining of GERD symptoms after SG as a main complaint, we analyzed the efficacy of conversion to Roux-en-Y gastric bypass (RYGB), with a standardized surgical technique. METHODS: This is a retrospective study including all consecutive cases of SG to RYGB conversion for GERD not controlled by medical treatment. We excluded all patients undergoing conversion for weight regain without GERD. Quality of life and GERD symptoms were evaluated at outpatient's clinic visits before and after surgery with 2 standardized questionnaires (Gastroesophageal Reflux Disease Questionnaire and Simplified Form 6). RESULTS: This study showed that 70% of patients had complete resolution of GERD symptoms and 60% had completely discontinued proton pump inhibitors (PPIs). The conversion to RYGB resulted in a significant decrease in the rate of patients presenting daily symptoms of GERD and use of PPIs (10% and 16.6%, respectively; P < .019) and a dramatic increase in those without symptoms and no need for PPIs (70% and 60%, respectively; P < .001). CONCLUSION: Conversion to RYGB is a good option for GERD complications after SG providing a high rate of symptom remission and PPI discontinuation. Conversion to RYGB in the setting of GERD complications after SG improves postoperative outcomes decreasing GERD symptoms and improving quality of life.

Endoscopic Administration of Combined Autologous Mesenchymal Stem Cells and Platelet-Rich Plasma for the Treatment of Gastric Staple Line Leaks After Sleeve Gastrectomy.

BACKGROUND: Gastric staple line leak treatment after laparoscopic sleeve gastrectomy (LSG) remains challenging. Regenerative medicine is gaining place in the accelerated treatment of damaged tissues. This study presents the first series of gastric leak treatment after LSG using endoscopic intragastric administration of combined autologous mesenchymal stem cells (MSC) and platelet-rich plasma (PRP). METHODS: MSC-PRP harvesting and endoscopic administration techniques are described in detail. Data were prospectively gathered and analyzed. Primary endpoints were morbidity/mortality rates and fistula closure time. RESULTS: Twelve patients (9 women, 3 men) were included. Median age was 41.5 years, median weight 105.5 kg and median BMI 38.9 kg/m2. Median time to gastric staple line leak detection was 10 days post-LSG. Median time between re-laparoscopy and MSC-PRP administration was 5 days. MSC-PRP endoscopic administration was successfully performed and tolerated by all patients, with median procedure duration of 27 min and minimal blood loss. Four postoperative complications were noted: two patients with increased tibial pain at tibial puncture site, one with tibial hematoma, and one with epigastric pain/dysphagia. Median length of hospital stay was 1 day. Gastric leak healing occurred after a median of 14 days, only two patients requiring a second MSC-PRP endoscopic injection. Median follow-up was 19 months, all patients being in good health at last contact. CONCLUSION: Endoscopic administration of combined autologous MSC-PRP seems to be a good option for treatment of gastric leaks after sleeve gastrectomy. It is a challenging procedure that should be performed in specialized bariatric centers by expert bariatric surgeons and endoscopists after meticulous patient selection.

Outcomes of bariatric surgery in the setting of compensated advanced chronic liver disease associated with clinically significant portal hypertension: a multicenter, retrospective, cohort study on feasibility and safety.

BACKGROUND: The obesity epidemic has led to an increase in the proportion of patients with chronic liver disease due to metabolic associated steatosic liver disease and in the prevalence of obesity in patients with cirrhosis. Metabolic and bariatric surgery (MBS) has been proven to determine weight loss, obesity-related medical problems remission, and liver steatosis, inflammation, and fibrosis improvement. However, cirrhosis and portal hypertension are well-known risk factors for increased morbidity and mortality after surgery. The aim of this study is to evaluate the safety of MBS in patients with compensated advanced chronic liver disease (cALCD) and clinically significant portal hypertension (CSPH). MATERIAL AND METHODS: This is an international, multicentric, retrospective study on 63 individuals affected by obesity with cALCD and CSPH who underwent MBS in tertiary referral centers with experts hepatobiliary surgeons between January 2010 and October 2022. The primary endpoint was postoperative mortality at 90 days. The secondary endpoints included postoperative weight loss at last follow-up and postoperative complication rate. In addition, the authors performed subgroup analyses of Child-Pugh (A vs. B) score, MELD (≤9 vs. >9) score, and type of surgery. RESULTS: One patient (1.6%) experienced gastric leakage and mortality. There were three (5%) reported cases of portal vein thrombosis, two (3%) postoperative acute renal failure, and one (1.6%) postoperative encephalopathy. Child-Pugh score A resulted to be a protective factor for intraoperative bleeding requiring transfusion at univariate analysis (OR: 0.73, 95% CI: 0.55-0.97, P =0.046) but not at multivariate analysis. MELD>9 score and the type of surgery did not result to be a risk factor for any postoperative complication. CONCLUSION: MBS is safe in patients with cALCD and CSPH performed in tertiary bariatric referral centers with hepatobiliary expert surgeons. Larger, prospective studies with longer follow-up periods are needed to confirm these results.