Reoperative bariatric surgery after primary laparoscopic gastric plication for morbid obesity: a systematic review and meta-analysis.

BACKGROUND: Laparoscopic gastric plication (LGP) often requires reoperative bariatric surgery (RBS) due to complications and insufficient weight loss. The aim of our study was to assess perioperative morbidity and weight loss during follow-up in patients undergoing RBS after primary LGP for morbid obesity. METHODS: A search of PubMed, Web of Science, Cochrane Library, and Google Scholar was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using ("conversion"OR "revision*""OR "reoperat*")AND("gastric"OR "curvatur*")AND "plication." Studies were deemed eligible if data on RBS after LGP were provided. For each study, data were extracted and analyzed. RESULTS: In the literature review, 291 articles were screened and 7 included. The studies covered a total of 367 patients, of whom 119 received a sleeve gastrectomy (SG), 85 a Roux-en-y gastric bypass (RYGB), 75 a one anastomosis-gastric bypass (OAGB), 45 a re-LGP, and 25 a jejuno-ileal bypass. After RBS, excess weight loss was 50.8 ± 6.5% at 6 months, 71.0 ± 7.7% at 12 months, and 89.0 ± 7.8% at 24 months. Operative time was 101.3 ± 14.6 min. Postoperatively, 18/255 patients (7.1%) had a complication, and leakage and reoperations were reported in 6/255 (2.4%) and 5/255 (2.0%) patients, respectively. Length of hospital stay was 3.1 ± 2.4 days. The quality of evidence was rated as "very low." CONCLUSIONS: Despite limitations, this systematic review and meta-analysis showed that RBS after LGP has an acceptable rate of complications and is effective in terms of excess weight loss during follow-up. No specific operation (e.g., SG, RYGB, OAGB) can be suggested over another due to the lack of evidence.

Assessment of gastric pouch blood supply with indocyanine green fluorescence in conversional and revisional bariatric surgery: a prospective comparative study.

Our study aimed to evaluate the usefulness of indocyanine green (ICG) angiography during conversional or revisional bariatric surgery. We prospectively enrolled all patients scheduled for reoperative bariatric surgery with gastric pouch resizing and ICG assessment and we compared them with a retrospective series of similar patients who did not receive ICG. The primary outcome was the rate of intraoperative change in the surgical strategy due to the ICG test. We included 32 prospective patients receiving intraoperatively an ICG perfusion test and 48 propensity score-matched controls. The mean age was 50.7 ± 9.7 years, 67 (83.7%) patients were female, and the mean BMI was 36.8 ± 5.3 kg/m2. The patient characteristics were similar in both groups. The ICG angiography was successfully conducted in all patients, and no change of the surgical strategy was necessary. Postoperative complications were similar in both groups (6.2% vs. 8.3%, p = 0.846), as well as operative time (125 ± 43 vs. 133 ± 47 min, p = 0.454) and length of hospital stay (2.8 ± 1.0 vs. 3.3 ± 2.2 days, p = 0.213). Our study suggested that ICG fluorescence angiography might not have been useful for assessing the blood supply of the gastric pouch in patients who underwent reoperative bariatric surgery. Therefore, it remains uncertain whether the application of this technique is indicated.

Laparoscopic-Assisted Transversus Abdominis Plane (TAP) Block Versus Port-Site Infiltration with Local Anesthetics in Bariatric Surgery: a Double-Blind Randomized Controlled Trial.

BACKGROUND: The transversus abdominis plane (TAP) block has shown great potential usefulness in the management of postoperative pain; however, there is lacking evidence regarding its use in bariatric surgery. This randomized double-blind trial was aimed at comparing the effectiveness of the TAP block and port-site infiltration (PSI) in patients undergoing bariatric surgery. METHODS: We included patients ≥ 18 years old undergoing bariatric surgery. From July 2020 to July 2021, all eligible patients were randomized to receive either laparoscopic-assisted TAP block or PSI. Demographic and clinical data were collected and analyzed. RESULTS: During the study period, we included 113 patients. Fifty-one were allocated to the TAP block group and 62 to the PSI group. The mean age was 47.9 ± 11.2 years, 88 (77.9%) patients were female, and mean BMI was 40.5 ± 5.9 kg/m2. Operative time was 110 ± 42 min vs. 114 ± 41 min in the TAP block and PSI groups (p = 0.658). At 24 h after surgery, pain on the VAS was 2.5 ± 2.6 vs. 2.3 ± 2.1 (p = 0.661). No significant difference between the groups was noted at 3, 6, 12, and 18 h. Also, opioid and antiemetic consumption, the length of stay (3.4 ± 1.5 days vs. 3.2 ± 1.1 days, p = 0.392), and satisfaction score (154 ± 10 pts vs. 154 ± 16 pts, p = 0.828) were similar in the two groups. CONCLUSIONS: Patients undergoing bariatric surgery and receiving either the TAP block or the PSI had similar postoperative pain, nausea, length of stay, and satisfaction. As PSI is technically easier and more reproducible, it might be the first choice for postoperative multimodal analgesia in bariatric surgery.

Opioid-Free Anesthesia in Bariatric Surgery: a Propensity Score-Matched Analysis.

PURPOSE: Patients undergoing bariatric surgery are at particular high risk of postoperative nausea and vomiting (PONV). Few studies have shown the superiority of opioid-free anesthesia (OFA) over general anesthesia with opioids in bariatric surgery. The aim was to investigate the potential advantages of the OFA in bariatric surgery. MATERIALS AND METHODS: This is a retrospective study on a prospectively collected database that included bariatric patients over a 3-year period. All patients who underwent bariatric surgery at our institution were included and divided into opioid-free or standard anesthesia. The primary endpoint was the length of hospital stay. Data was collected and analyzed using a propensity score. RESULTS: We included 344 patients, of these 209 (60.8%) received opioid-free and 135 (39.2%) received a standard anesthesia. Mean age was 46.2 ± 11.2 years, 265 (77.0%) patients were female, and 238 (69.2%) had at least one associated medical problem. The two groups were similar in terms of age, gender, BMI, associated medical problems, and type of operations. Postoperatively, we observed no significant difference in opioid requirement, while significantly less doses of antiemetics were administered in the OFA group at postoperative day 1 (0.4 ± 0.7 vs. 0.7 ± 1.0 doses, p = 0.006) and 2 (0.1 ± 0.4 vs. 0.2 ± 0.6 doses, p = 0.022). Length of stay was significantly shorter in the OFA group (2.8 ± 0.9 vs. 3.5 ± 2.0 days, p < 0.001) both in the overall and in the propensity score-matched analyses. CONCLUSION: OFA is effective for patients undergoing bariatric surgery. Perioperative outcomes are similar, while OFA patients required less antiemetics and were discharged earlier from hospital.

Robotic-Assisted Versus Laparoscopic Revisional Bariatric Surgery: a Systematic Review and Meta-analysis on Perioperative Outcomes.

This systematic review and meta-analysis investigated the role of robotic-assisted surgery in patients undergoing revisional bariatric surgery (RBS). According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a literature search of PubMed, Cochrane Library, Web of Science, and Google Scholar was performed: (("sleeve"AND "gastr*")OR "bariatric"OR "gastric bypass")AND("robot*"OR "DaVinci"OR "Da Vinci")AND("revision*"OR "conversion*"). In this review, six studies with 29,890 patients were included (2459 in the robotic group). No difference in postoperative complications (RR 1.070, 95%CI 0.930-1.231, p = 0.950), conversions to open surgery (RR 1.339, 95%CI 0.736-2.438, p = 0.339), length of stay (SMD - 0.041, 95%CI - 0.420-0.337, p = 0.831) or operative time (RR 0.219, 95%CI - 0.539-0.977, p = 0.571) was found. This systematic review and meta-analysis showed no significant advantage of robotic-assisted RBS; on the other hand, it showed a non-inferior efficacy compared to standard laparoscopy.

Three-dimensional laparoscopic Roux-en-Y gastric bypass with totally hand-sewn anastomoses for morbid obesity. A single center experience.

PURPOSE: To assess the impact of three-dimensional (3D) vision use on operative time (OT) in laparoscopic Roux-en-Y gastric bypass (LRYGB) with hand-sewn anastomoses. METHODS: We analyzed a prospectively collected database of patients who underwent LRYGB. We included all patients operated on with either 2D or 3D vision. Demographics and clinical characteristics, operative time, hospital stay and 30-day postoperative complications were collected for all patients and analyzed. RESULTS: During the study time, out of 143 patients who underwent LRYGB for morbid obesity, 111 were considered eligible. Seventy-eight patients were operated with 2D vision and 33 patients with 3D vision. Demographics and clinical characteristics were not different among groups. Mean OT was 203±51 and 167±32 minutes in the 2D and 3D groups respectively (p<0.001). Multivariate analyses showed that increasing age and BMI were independently related to prolonged OT, while 3D vision (OR 6.675, 95% CI 2.380-24.752, p<0.001) was strongly associated with shorter OT. CONCLUSIONS: The use of 3D vision in LRYGB significantly reduced the OT, though intra- and postoperative complication rates and the length of hospital stay were not affected. Despite its limitations, our study supports the value of 3D vision laparoscopy in bariatric surgery.

Financial Impact of Anastomotic Leakage in Colorectal Surgery.

BACKGROUND: Anastomotic leakage after colorectal surgery is a complication that requires additional treatments strongly affecting the economic outcomes. We evaluated the use of resources and the economic burden associated with anastomotic leaks following colorectal surgery. METHODS: Between January 2015 and December 2016, we retrospectively evaluated patients who underwent colorectal surgery with primary anastomosis. We compared the medical resource utilization and the DRG-based reimbursement of cases with uncomplicated surgery and cases complicated by anastomotic leakage. RESULTS: Of the 95 patients included in the study, 87 (92%) presented an uneventful postoperative course and 8 patients (8%) developed an anastomotic leakage requiring surgery. The statistical analysis showed no significant differences in terms of demographics, risks factor, and operative results, except the length of hospital stay (9.7 vs. 29.1 days, p < 0.01). The cost for 87 uncomplicated cases was 1,535,297 EUR (average cost of 17,647 EUR), whereas the cost of the 8 patients with anastomotic leakage was 575,822 EUR (average cost of 71,978 EUR) (p < 0.01). For each patient, the hospital had 542 EUR profit in the uncomplicated group and a 12,181 EUR loss in the anastomotic leakage group (p < 0.01). The multiple R-squared line regression analysis showed that factors independently related to costs were age (p = 0.05) and length of hospital stay (p = 0.01). CONCLUSIONS: In terms of economic impact, the occurrence of an anastomotic leakage has a large negative influence on medical resource utilization, so that, despite the complication-related increase of DRG-reimbursement, every complicated case represents a financial burden for the hospital.

Laparoscopic treatment of an infected urachalcyst and diverticulum in a young adult: Presentation of a case and review of the literature.

INTRODUCTION: A urachal remnant is a rare anomaly in adults, with a heterogeneous presentation. We report a case of an infected urachal cyst associated with a urachal diverticulum. PRESENTATION OF CASE: We report the case of a 16-year-old male who presented to our hospital with lower abdominal pain without any other signs of general infection. A physical examination revealed umbilical erythema with associated tenderness. All laboratory tests were normal. An ultrasound scan revealed an urachal cyst near the umbilicus and a second cyst near the bladder dome. We decided on a staged treatment with antibiotic administration followed by surgical excision of the urachus during laparoscopy. The patient was discharged on day 10 without complications. Pathology revealed chronic inflammatory tissue without signs of malignancy. DISCUSSION: Urachus is a fibrous remnant of the allantois that progressively obliterates after birth, forming the median umbilical ligament. Incomplete regression of the urachal lumen results in several anomalies. These anomalies require treatment when discovered because of an increased risk of infection and neoplastic differentiation. A urachal cyst is the most common type of anomaly, and infection is the usual mode of presentation. Surgical intervention with complete excision of the urachus is the treatment of choice. A staged approach with antibiotic administration followed by surgery is recommended if signs of infection are present. CONCLUSION: Urachal anomalies in adulthood are rare, with a nonspecific presentation. However, identifying a urachal anomaly is important because of the increased risk for infection and neoplastic differentiation. The laparoscopic approach is safe and patients recover rapidly.

Development of a model for laparoscopic cholecystectomy video assisted training. A randomized study.

PURPOSE: To identify the surgical trainee benefits through the use of video assisted training (VAT). METHODS: Twelve cases of uncomplicated laparoscopic cholecystectomy (LC) were selected. Edited video segments focused on essential intra-operative anatomical structure identification and critical surgical steps. Evaluation of these videos was constructed on a scoring system based on pre and post-teach tests. RESULTS: The mean value of the pre-teach score was 33.2 ± 18.0 points and in the post-teach test the mean value was 66.7 ± 9.7 points. A statistically significant difference was seen when comparing pre and post-teach results (p<.00001). CONCLUSION: The widespread and the systematic use of video assisted learning may be a useful and economic tool in adjunct to the surgical training techniques practiced until now throughout the surgical community.

Three-dimensional laparoscopic Roux-en-Y gastric bypass with totally hand-sewn anastomoses for morbid obesity. A single center experience

Abstract Purpose To assess the impact of three-dimensional (3D) vision use on operative time (OT) in laparoscopic Roux-en-Y gastric bypass (LRYGB) with hand-sewn anastomoses. Methods We analyzed a prospectively collected database of patients who underwent LRYGB. We included all patients operated on with either 2D or 3D vision. Demographics and clinical characteristics, operative time, hospital stay and 30-day postoperative complications were collected for all patients and analyzed. Results During the study time, out of 143 patients who underwent LRYGB for morbid obesity, 111 were considered eligible. Seventy-eight patients were operated with 2D vision and 33 patients with 3D vision. Demographics and clinical characteristics were not different among groups. Mean OT was 203±51 and 167±32 minutes in the 2D and 3D groups respectively (p<0.001). Multivariate analyses showed that increasing age and BMI were independently related to prolonged OT, while 3D vision (OR 6.675, 95% CI 2.380-24.752, p<0.001) was strongly associated with shorter OT. Conclusions The use of 3D vision in LRYGB significantly reduced the OT, though intra- and postoperative complication rates and the length of hospital stay were not affected. Despite its limitations, our study supports the value of 3D vision laparoscopy in bariatric surgery.

Development of a model for laparoscopic cholecystectomy video assisted training. A randomized study

Abstract Purpose: To identify the surgical trainee benefits through the use of video assisted training (VAT). Methods: Twelve cases of uncomplicated laparoscopic cholecystectomy (LC) were selected. Edited video segments focused on essential intra-operative anatomical structure identification and critical surgical steps. Evaluation of these videos was constructed on a scoring system based on pre and post-teach tests. Results: The mean value of the pre-teach score was 33.2 ± 18.0 points and in the post-teach test the mean value was 66.7 ± 9.7 points. A statistically significant difference was seen when comparing pre and post-teach results (p<.00001). Conclusion: The widespread and the systematic use of video assisted learning may be a useful and economic tool in adjunct to the surgical training techniques practiced until now throughout the surgical community.

Clinical effects of laparotomy with perioperative continuous peritoneal lavage and postoperative hemofiltration in patients with severe acute pancreatitis.

BACKGROUND: The elevated serum and peritoneal cytokine concentrations responsible for the systemic response syndrome (SIRS) and multiorgan failure in patients with severe acute pancreatitis lead to high morbidity and mortality rates. Prompted by reports underlining the importance of reducing circulating inflammatory mediators in severe acute pancreatitis, we designed this study to evaluate the efficiency of laparotomy followed by continuous perioperative peritoneal lavage combined with postoperative continuous venovenous diahemofiltration (CVVDH) in managing critically ill patients refractory to intensive care therapy. As the major clinical outcome variables we measured morbidity, mortality and changes in the Acute Physiology and Chronic Health Evaluation (APACHE II) score and cytokine concentrations in serum and peritoneal lavage fluid over time. METHODS: From a consecutive group of 23 patients hospitalized for acute pancreatitis, we studied 6 patients all with Apache II scores >/=19, who underwent emergency surgery for acute complications (5 for an abdominal compartment syndrome and 1 for septic shock) followed by continuous perioperative peritoneal lavage and postoperative CVVDH. CVVDH was started within 12 hours after surgery and maintained for at least 72 hours, until the multiorgan dysfunction syndrome improved. Samples were collected from serum, peritoneal lavage fluid and CVVDH dialysate for cytokine assay. Apache II scores were measured daily and their association with cytokine levels was assessed. RESULTS: All six patients tolerated CVVDH well, and the procedure lasted a mean 6 days (range, 3-12). Five patients survived and one died of Acinetobacter infection after surgery (mortality rate 16.6%). The mean APACHE II score was >/= 19 (range 19-22) before laparotomy and decreased significantly during peritoneal lavage and postoperative CVVDH (P = 0.013 by matched-pairs Students t-test). The decrease in cytokine concentrations in serum and lavage fluid was associated with the decrease in APACHE II scores and high interleukin 6 (IL-6) and tumor necrosis factor (TNF) concentrations in the hemofiltrate. CONCLUSION: In critically ill patients with abdominal compartment syndrome, septic shock or high APACHE II scores related to severe acute pancreatitis, combining emergency laparotomy with continuous perioperative peritoneal lavage followed by postoperative CVVHD effectively reduces the local and systemic cytokines responsible for multiorgan dysfunction syndrome thus improving patients' outcome.