Physiological reno-portal bypass in liver transplantation with non-tumorous portal vein thrombosis.

Reno-portal anastomosis (RPA) in presence of spleno-renal shunts (SRS) is a physiological option to restore blood flow in liver transplantation with portal vein thrombosis (PVT). Diffuse splanchnic venous system thrombosis (complex PVT) is its main indication but RPA proved to be useful in selected cases of less extensive thrombosis (non-complex PVT). Up until now only two monocentric and one multicentric case series has been published on this topic in addition to few anecdotal reports. After 2014, we introduced RPA in our institution to manage some cases of complex PVT in presence of SRS. Here, we present the evolution of indication to RPA. From 2014 to 2020, we performed ten RPA: nine patients presented non-complex and one complex PVT. Overall early and late complication rates were 66.6% and 50%, respectively. Two patients developed RPA stenosis, treated by interventional radiology. Self-resolving acute kidney injury (AKI) was observed in three cases. No re-transplantation was necessary. RPA was patent in all patients, with a mean follow-up of 41.9 months. The overall patient survival was 70% at 1 year and 60% at 3 and 5 years. Four patients died at 1, 2, 3 and 20 months from LT. Causes of deaths were, respectively, stroke, cerebral infection, sepsis (MOF) and sudden variceal bleeding in sinusoidal obstruction syndrome. The relative simplicity and effectiveness of RPA in presence of SRS allowed us to rely more and more often on this technique in liver transplantation with challenging non-complex PVT.

Dor versus Toupet fundoplication after Laparoscopic Heller Myotomy: Systematic review and Bayesian meta-analysis of randomized controlled trials.

Laparoscopic Heller Myotomy (LHM) with partial fundoplication has become the treatment of choice for esophageal achalasia. However, the choice of the partial fundoplication is debated. The aim of this study was to compare outcomes for Dor and Toupet fundoplication after LHM. A systematic search of randomized controlled trials comparing Dor and Toupet fundoplication was performed using PubMed, EMBASE and Web of Science. Three studies met the inclusion criteria. Overall, 174 patients were included in the analysis. The postoperative abnormal acid reflux [pooled Risk Ratio 0.98 (95% HPD 0.54-1.80)] and dysphagia [pooled Risk Ratio 1.03 (95% HPD 0.51-2.05)] were similar comparing Dor and Toupet fundoplication. The % total time pH ≤ 4 [estimated pooled mean difference -0.08 (95% HPD -1.04-0.90)] and DeMeester score [estimated pooled mean difference 0.51 (95% HPD -0.90-1.94)] were comparable. Additionally, the operative time [estimated pooled mean difference 0.02 (95% HPD -0.53-0.52)] and iatrogenic esophageal perforation [pooled Risk Ratio 1.05 (95% HPD 0.52-2.10)] were similar in the two groups. Dor and Toupet fundoplication after laparoscopic Heller myotomy seem comparable in term of postoperative abnormal acid exposure and dysphagia. The choice of the partial fundoplication should be left to surgeon experience and tailored on each patient.

Roux-en-Y gastric bypass: systematic review and Bayesian network meta-analysis comparing open, laparoscopic, and robotic approach.

The Roux-en-Y gastric bypass (RYGB) is performed via an open (OpenRYGB), laparoscopic (LapRYGB), or robotic (RoRYGB) approach. Previous review evidence is limited to pairwise meta-analysis, and RoRYGB versus OpenRYGB comparison is lacking. The aim of this network meta-analysis was to globally compare short-term outcomes within the open, laparoscopic, and robotic surgical approaches to RYGB. PubMed, EMBASE, and Web of Science databases were consulted. A fully Bayesian network meta-analysis was performed to compare OpenRYGB, LapRYGB, and RoRYGB. Nineteen studies, for a total of 276,732 patients, were included. Overall, 28.8% of the patients underwent OpenRYGB, 67.3% LapRYGB, and 3.9% RoRYGB. The 30-day mortality was significantly lower for both LapRYGB and RoRYGB versus OpenRYGB (risk ratio [RR] = .64, 95% credible interval [CrI] .46-.97, and RR = .49, 95% CrI .24-.99, respectively). The overall complication rate was significantly lower for both LapRYGB and RoRYGB versus OpenRYGB (RR = .63, 95% CrI .42-.91, and RR = .60, 95% CrI .33-.95, respectively). Anastomotic leak rate was similar for LapRYGB and RoRYGB versus OpenRYGB (RR = 1.10, 95% CrI .67-1.81, and RR = .95, 95% CrI .45-2.12, respectively). Surgical site infection (RR = .42, 95% CrI .30-.75, and RR = .24; 95% CrI .13-.58, respectively) and pulmonary complications (RR = .57, 95% CrI .45-.77, and RR = .42; 95% CrI .25-.76, respectively) were significantly lower for LapRYGB and RoRYGB versus OpenRYGB. No differences were found when postoperative bleeding, thromboembolic complication, 30-day reoperation, and 30-day hospital readmission were considered. This network meta-analysis suggests that both LapRYGB and RoRYGB appear to be safer compared to OpenRYGB with regard to 30-day mortality, overall complication rate, surgical site infection rate, and pulmonary complication rate. The surgical management of morbid obesity through RYGB is evolving, and the adoption of innovative minimally invasive techniques may improve patient outcomes.

Remnant Gastric Cancer After Roux-en-Y Gastric Bypass: Narrative Review of the Literature.

BACKGROUND: The Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed procedures for surgical weight loss. It has been shown that overweight may be associated with an increased risk of gastric cancer. However, the risk of remnant gastric cancer after RYGB has not been defined yet and the development of neoplasm in the excluded stomach remains a matter of concern. METHODS: PubMed, EMBASE, and Web of Science databases were consulted. Articles that described the diagnosis and management of remnant gastric cancer after RYGB were considered. RESULTS: Seventeen patients were included. The age of the patient population ranged from 38 to 71 years. The most commonly reported symptoms were abdominal pain, nausea/vomiting, and anemia. Abdominal computed tomography was used for diagnosis in the majority of patients. The neoplasm was located in the antrum/pre-pyloric region in 70% of cases and adenocarcinoma was the most common tumor histology (80%). An advanced tumor stage (III-IV) was diagnosed in almost 70% of patients and 40% were considered unresectable. Gastrectomy with lymphadenectomy was performed in 9 cases (53%). Post-operative morbidity was 12%. The follow-up ranged from 3 to 26 months and the overall disease-related mortality rate was 33.3%. CONCLUSION: The development of remnant gastric cancer after RYGB is rare. Surgeons should be aware of this potential event and the new onset of epigastric pain, nausea, and anemia should raise clinical suspicion. Further epidemiologic studies are warranted to deeply investigate the post-RYGB-related risk of remnant gastric cancer development in high-risk populations.

Management of Esophageal Achalasia after Roux-en-Y Gastric Bypass: Narrative Review of the Literature.

INTRODUCTION: The development of achalasia after Roux-en-Y gastric bypass (RYGB) is rare. Heller myotomy (HM) is the gold standard treatment while peroral endoscopic myotomy (POEM) is an emerging technique with promising results. The aim of this narrative review was to summarize the current knowledge on the treatment of esophageal achalasia after RYGB. METHODS: PubMed, EMBASE, and Web of Science databases were consulted. All articles that described the management of achalasia after RYGB were included in this narrative review. RESULTS: Twelve studies for a total of 28 patients were included. The age of the patient population ranged from 44 to 70 years old and 80% were females. Overall, 61.5% underwent laparoscopic RYGB while 38.5% underwent open RYBG. The elapsed time from the RYGB to myotomy ranged from 14 months to 14 years. Dysphagia (64%) and regurgitation (60.7%) were the most commonly reported symptoms; type I achalasia was diagnosed in 50% of patients. Surgical HM was performed in 17 patients (61%) while POEM was performed in 11 patients (39%). Postoperative morbidity was 3.6% with no differences comparing surgical HM and POEM (6% vs. 0%, p = 0.43). The follow-up time ranged from 1 to 43 months. The overall recurrence rate requiring reoperation was 7% with no differences comparing surgical HM and POEM (12% vs. 0%; p = 0.25). CONCLUSION: Both HM and POEM seem feasible, safe, and effective in the management of achalasia after RYGB. The role of POEM in the management algorithm of these patients should be further evaluated.

Utility of C-reactive protein as predictive biomarker of anastomotic leak after minimally invasive esophagectomy.

BACKGROUND: Early detection of anastomotic leakage after esophagectomy has the potential to reduce morbidity and mortality. Prompt suspicion of leak may help to exclude patients from fast-track protocols, thereby avoiding early oral feeding and early hospital discharge which could aggravate the prognosis of a clinically occult leak. PATIENTS AND METHODS: Observational retrospective cohort study. Patients with diagnosis of esophageal cancer who underwent elective minimally invasive esophagectomy were included. The following data were collected: age, gender, BMI, comorbidities, ASA score, tumor histology, TNM staging, use of neo-adjuvant therapy, type of operation, operative time, morbidity, and 90-day mortality. A panel of biomarkers including C-reactive protein (CRP), procalcitonin (PCT), white blood cells (WBC), and percentage of neutrophils (PN) were measured at baseline and on postoperative days 3, 5, and 7. RESULTS: Two hundred forty-three patients operated between 2012 and 2017 were included in the study. Anastomotic leakage occurred in 29 patients. There was a statistical association over time between anastomotic leakage and CRP (p < 0.001), PCT (p < 0.001), WBC (p = 0.019), and PN (p = 0.007). The cut-off value of CRP on POD 5 was 8.3 mg/dL, AUC = 0.818, negative LR = 0.176. CONCLUSIONS: Increased serum CRP, PCT, WBC, and PN after minimally invasive esophagectomy are associated with anastomotic leakage. A CRP value lower than 8.3 mg/dL, combined with reassuring clinical and radiological signs, may be useful to exclude leakage on postoperative day 5.