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.

A Narrative Review on Bariatric ERAS.

Introduction: Bariatric/metabolic surgery (BMS) is the most effective treatment of morbid obesity, while Enhanced Recovery After Surgery (ERAS) after BMS represents a multimodal perioperative protocol designed to achieve early recovery for patients with peculiar characteristics. The aim of the current narrative review is to summarize and discuss the current role, the application, and the future developments of ERAS protocols in the field of BMS. Methods: A literature search for studies published up to June 30, 2022, with no restrictions on language or publication period, was performed on Medline and Embase, using the keywords "ERAS" OR "enhanced recovery after surgery" AND "bariatric surgery" OR "metabolic surgery". Postoperative length of hospital stay LOS, overall and major morbidity and mortality, readmission rates, postoperative nausea or vomit PONV, opioids and antiemetics use, hospital costs, ERAS in specific health care settings, barriers to ERAS and further developments were analyzed. Results/Conclusions: The results were presented with a narrative review, using tabulation to summarize the results of meta-analyses and RCTs: 6 articles reporting guidelines, 5 metaanalyses, 9 randomized controlled trials, and 48 observational studies. ERAS protocols are feasible and safe in the setting of BMS, and associated to reduced LOS, PONV and postoperative pain, reduced opioid and antiemetic use and reduced costs. Postoperative mortality and readmission rates are similar between patients receiving standard care and those with ERAS protocols. Furthermore, increase of ERAS application may be useful in health care systems dealing with epidemic infectious diseases and implemented by technological advancements.

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.

Short-term outcomes of sleeve gastrectomy conversion to R-Y gastric bypass: multi-center retrospective study.

INTRODUCTION: The outcomes of failed laparoscopic sleeve gastrectomies (LSG) converted to laparoscopic standard R-Y gastric bypass (LRYGB) in case of insufficient weight loss (IWL), weight regain (WR), and/or severe gastro-esophageal reflux disease (GERD) are scanty. PURPOSE: To evaluate incidence, indications, and short-term outcomes of LSG conversion to LRYGB in three bariatric centers. METHODS: Patients operated between January 2012 and December 2016 by primary LSG, with mean follow-up of 24 months and converted to LRYGB for IWL, WR, and/or GERD, were retrospectively analyzed for demographics, operative details, perioperative complications, comorbidities evolution, and further WL. RESULTS: Thirty patients (2.76%, 7 M/23 F, mean age 41 ± 10.1 years, initial mean BMI 46.9 ± 6.3 kg/m2) were successfully converted after a mean period of 33 ± 27.8 months for severe GERD (15 patients, 50%), GERD and IWL/WR (3 patients, 10%), and IWL/WR (12 patients, 40%). Surgical complications occurred in three patients (10%). Mean BMI at revision time was 36 ± 9 kg/m2, and 30.8 ± 5.2, 28 ± 4.9, and 28 ± 4.3 kg/m2 after 6, 12, and 24 months, respectively. Resolution of GERD was achieved in 83% of cases. Overall, postoperative satisfaction was reported by 96% of the cases, after mean follow-up of 24 ± 8.9 months. CONCLUSIONS: In high-volume centers, where strict criteria for patients' selection for LSG are applied, the expected incidence of reoperations for "non-responder" (IWL/WR) or de novo or persistent severe GERD non-responder to medical treatment is low (< 3%). Conversion of "non-responder" LSG to LRYGB is effective for further WL and GERD remission at short term (2 years follow-up); however, a high postoperative complication rate was observed. Long-term multidisciplinary follow-up is mandatory to confirm data on WL durability and comorbidity control.

Long-term outcomes of sleeve gastrectomy as a revisional procedure after failed gastric band: a multicenter cross-matched cohort study.

Laparoscopic adjustable gastric band (LAGB) is the bariatric procedure most likely subject to revisional surgery. Both laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (LRYGB) represent viable options, but the long-term results are still lacking. In 2014, we published the 2-year follow-up of our multicenter cohort of revisional LSG after failed LAGB. Evaluate the long-term follow-up (median 9.3 years) of the same cohort of patients. University and primary-care hospitals, Italy. We retrospectively examined a prospectively maintained database of the previously published multicenter cohort of 56 patients who underwent LSG after failed LAGB between 2008-2011. The control group included cross-matched non-revisional LSGs. The primary endpoint was weight loss, secondary endpoints co-morbidities, and the need for further bariatric surgery. The study group included 44 patients and the control group 56. We found %EWL 53% Vs. 67% (p = .021), %EBMIL (54 Vs. 68%, p = .018), %TWL (26 Vs. 34%, p = .002). We also found more severe GERD (gastroesophageal reflux disease) symptoms in the revisional than in the primary group (9.0 vs. 1.8% mild and 23.0 vs. 3.0% severe). Ten patients from the revisional group (22.7%) vs. eight in the primary group (13%) underwent further bariatric surgery (LRYGB). Our results showed less favorable weight loss in revisional than primary LSG after LABG, higher prevalence of GERD, and a more frequent need for further revisional surgery. Despite the study's limitations, the present data suggest that the long-term outcomes may offset the possible reduced short-term complication rate after revisional sleeve gastrectomy for a failed LABG.

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.

Characterization of gut microbiota in patients with metabolic syndrome candidates for bariatric/metabolic surgery: Preliminary findings of a multi-center prospective study.

INTRODUCTION: gut microbiota (GM) seems to be involved in the pathophysiology and progression of both metabolic syndrome (MS) and obesity. The aim was to investigate GM's composition in patients with severe obesity, candidates for bariatric/metabolic surgery BMS. MATERIALS AND METHODS: Multicentre, prospective, cohort study, enrolling 84 patients with BMI 40-55 kg/m2, divided bymetabolic status (MS) inhealthy(group A), pre-MS (B), or MS (C). RESULTS: No differences were foundregarding anthropometric,nutritional parameters, except for vitamin D.As a whole the alpha and beta diversity examinations showed no statistical differences in GM profile. A total of 5/7 phyla with relative frequencies were identified above 0.1% (Actinobacteria,Bacteroidetes,Firmicutes,Proteobacteria,Verrucomicrobia).FusobacteriaandPatescibacteriarepresented the less abundant. There were no significant differences in the top ten genera.Data onBacteroidetes(inversely related to triglycerides and LDL and directly related to HDL levels) and onFirmicutes(opposite trend) relative abundances suggest no differences among the three conditions.No correlation between the relative abundance of themain phylaand plasmatic glucose levels was observed. CONCLUSIONS: In a selected cohort of patients with obesity, MS did not affect the preoperative GM's profile. Severe obesity, per se, seems to be an independent condition affecting GM.

Long-Term Results After Laparoscopic Sleeve Gastrectomy with Concomitant Posterior Cruroplasty: 5-Year Follow-up.

BACKGROUND: Hiatal hernia (HH) repair during laparoscopic sleeve gastrectomy (LSG) has been advocated to reduce the incidence of postoperative gastroesophageal reflux disease (GERD) and/or intrathoracic migration (ITM). The necessity of intraoperative repair in asymptomatic patients is still controversial. Previous, mid-term results of a prospective, comparative study evaluating posterior cruroplasty concomitant with LSG (group A 48 patients with simple vs. group B 48 reinforced with bioabsorbable mesh) confirmed the safety and effectiveness of simultaneous procedures. Present aim was to report the 60 months follow-up update, evaluating GERD and esophageal lesions' incidence and HH's recurrence. RESULTS: Follow-up was completed in 87.5% of the patients. Recurrent GERD was registered in 6/38 (15.7%, group A) and in 9/46 (19.5%, group B) (p = 1.0000). Grade A esophagitis and GERD was shown in 2 patients (5.2%), respectively 2 (4.3%) of each group (p = 1.0000), and recurrent HH was confirmed subsequently by contrast study and CT scan. Neither Barrett's lesions nor de novo GERD was found in any patient. Failure of the cruroplasty with ITM was recorded in 7 patients from group A (18.4%) and 2 patients from group B (4.3%) p < 0.05; hence, a repeat posterior, reinforced cruroplasty was performed in all cases. A total of 12 patients (14.2%, 8 respective 4) were converted within 5 years for persistent/recurrent GERD, with only 1 case of de novo (group B). CONCLUSIONS: Accurate patient selection and proper sleeve technique, combined with posterior cruroplasty (simple or reinforced) ensure effectiveness, with a rate of failure (HH recurrence) at 5 years of 10.7%.

The use of fibrin sealant to prevent major complications following laparoscopic gastric bypass: results of a multicenter, randomized trial.

BACKGROUND: Published interim results have shown that fibrin sealant (Tissucol/Tisseel Baxter AG, Vienna, Austria) may be effective in preventing anastomotic leaks and internal hernias following laparoscopic Roux-en-Y gastric bypass (LRYGBP). We report the final results of a multicenter, randomized clinical trial evaluating the use of fibrin sealant in LRYGBP. METHODS: Between January 2004 and December 2005, 340 patients aged 21-65 years with a body mass index (BMI) of 40-59 kg/m(2) undergoing LRYGBP were randomized (1:1) to two treatment groups: fibrin sealant group (applied to gastrojejunal and jejunojejunal anastomoses and over mesenteric openings), and control group (no fibrin sealant; suture of the mesenteric openings). Operative time, early and late complications, reinterventions, time to oral diet initiation, and length of stay were assessed. RESULTS: Overall, 320 patients were included into the study: 160 in the control group and 160 in the fibrin sealant group. All patients completed follow-up assessments at 6 and 12 months, and 60.9% completed assessments at 24 months. There were no significant differences between groups with respect to demographics, operative time, oral diet initiation, hospital stay, and BMI reduction at 6, 12, and 24 months. The incidence of anastomotic leak was numerically, but not significantly, greater in the control group. The overall reintervention rate for specific early complications (<30 days) was significantly higher in the control group (p = 0.016). No deaths or conversions to open laparotomy occurred. CONCLUSION: The use of fibrin sealant in laparoscopic RYGBP may be beneficial in reducing the reintervention rate for major perioperative (<30 days) complications. Larger studies are needed.

Laparoscopic splenectomy in the management of benign and malignant hematologic diseases.

OBJECTIVES: The use of laparoscopy to treat malignant hematological diseases is not completely accepted. Our aim was to analyze operative and postoperative results of laparoscopic splenectomy performed for benign versus malignant hematological disorders. METHODS: Between 1994 and 2003, 76 consecutive patients underwent laparoscopic splenectomy. The first 38 cases were performed by using an anterior approach, whereas in the remaining 38 cases a semilateral position was used. RESULTS: Baseline characteristics showed that patients with malignant diseases were significantly older (56.9 vs 32.6 years, P < 0.001). Seventy-two (94.7%) procedures were completed laparoscopically. Conversion was required in 4 cases (5.2%). Mean operative time was 138.5 minutes for benign and 151.0 minutes for malignant diseases, (P > 0.05, ns). The hand-assisted technique was used in 3 patients with massive splenomegaly. Pathologic features showed that spleen volume was higher in patients with malignant diseases (mean interpole diameter 18.1 cm vs 13.7 cm, P < 0.001). Massive splenomegaly (interpole diameter over 20 cm, weight over 1000 g) was present in 13 patients (17.1%); 9 had malignant diseases. Overall perioperative mortality was 1.3% and major postoperative complications occurred in 6 patients (7.8%). Postoperative splenoportal partial thrombosis was identified in 9.7% of patients. CONCLUSIONS: Laparoscopic splenectomy is a well-accepted, less-invasive procedure for hematological disorders. Neoplastic diseases or splenomegaly, or both, do not seem to limit the indications for a minimally invasive approach after the learning curve.