Leak after sleeve gastrectomy with positive intraoperative indocyanine green test: Avoidable scenario?

BACKGROUND: The staple line gastric leak (GL) is estimated to be the most serious complication of the sleeve gastrectomy. The use of indocyanine green (ICG) has been introduced in minimally invasive surgery to show the vascularization of the stomach in real time and its application to the gastroesophageal junction (GE) during Laparoscopic Sleeve Gastrectomy (LSG) seems very promising. CASE PRESENTATION: We present the case of a 40-year-old female underwent laparoscopic sleeve gastrectomy. Intraoperative indocyanine green test showed a small dark area in the proximal third of the staple line reinforced with fibrin glue. Two weeks later the patient presented to the emergency room (ED) with abdominal pain, fever, vomiting, intolerance to oral intake and the evidence of a leak on the abdomen Computer Tomography (CT). The UIN for ClinicalTrial.gov Protocol Registration and Results System is: NCT05337644 for the Organization UFoggia. CONCLUSIONS: This case report shows that intraoperative ICG test can be helpful in determining which patients are at greater risk of the leak and, more importantly, the cause of the leak but further tests are needed to determine if the ICG predicts leak due to ischemia.

Management of post-bariatric complications. Our Center experience and literature review.

Bariatric surgery is recognized as the most effective treatment for morbid obesity, maintaining a stable weight reduction in the long term and reducing comorbidities, with a favorable impact on mortality. The aim of this study is to evaluate the complication rate and treatment techniques adopted in all patients undergoing bariatric surgery procedures in our center. From May 2017 to March 2020, 91 patients with morbid obesity are admitted to the Department of Medical and Surgical Science of the University Hospital of Foggia undergoing bariatric surgery. Seventyone patients underwent sleeve gastrectomy, nineteen gastric bypass and one mini-gastric bypass, five of these were redo operation procedures. Regarding postoperative complications (8,8%), there were 1 gastric leak (1,09%), 4 bleedings (4,39%) - 1 intraluminal bleeding and 3 intra-abdominal bleedings, 2 port-sites infections (2,19%) and 1 haemoperitoneum (1,09%). In our center we have also treated 3 cases of complications after bariatric surgery procedures performed in others centers. There were no deaths. Despite improvement in the performance of bariatric surgical procedures, complications are not uncommon. Flexible endoscopy has become an essential tool in managing bariatric surgery patients and offers the benefit of providing both diagnostic and therapeutic applications. KEY WORDS: Bariatric surgery, Bleeding post-bariatric surgery, Complications bariatric surgery, Gastric bypass, Leak post-sleeve gastrectomy, Mini invasive approach, Sleeve gastrectomy.

One-step versus two-step procedure for management procedures for management of concurrent gallbladder and common bile duct stones. Outcomes and cost analysis.

BACKGROUND: The management of cholelithiasis and choledocholithiasis combined is controversial. The more frequent approach is a two-stage procedure, with endoscopic sphincterotomy and stone removal from the bile duct followed by laparoscopic cholecystectomy. This study aims to demonstrate how, on the basis of the personal experience, the Rendez-vous technique, that combines the two techniques in a single-stage operation is better than the sequential treatment. METHODS: Between June 2017 to December 2019, 40 consecutive patients with cholelithiasis and choledocholithiasis combined were enrolled for the study: 20 were treated with the sequential treatment and 20 with the Rendez-vous method. The preoperative diagnostic work-up was similar in the two group. The endpoints of the study included incidence of endoscopic and surgical complications, rate of hospitalization and cost analysis. RESULTS: The study showed no difference in demographic parameters between the two groups, but the success rate of clearance of CBD was significantly smaller for sequential arm, with the need of additional procedures. We found a statistical reduction of postoperative acute pancreatitis, hospital stay and charges in Rendez-vous group, at the expense of a prolonged total operating time. CONCLUSIONS: The data of the study confirm the superiority of the Rendez-vous technique because it resolves cholelithiasis associated with choledocholithiasis in a single surgical act, with greater acceptance of the patient who avoids a second invasive surgical act, and with a reduction in complications; moreover, it requires shorter hospitalization, resulting in reduced costs. We propose this option in the management of cases where preoperative ERCP-ES has failed. KEY WORDS: Common bile duct stones, Cholecysto-choledocholithiasis, Endoscopic retrograde cholangiopancreatography, Endoscopic sphincterotomy, Laparoscopic cholecystectomy, Laparo-endoscopic Rendez-vous.

Right hemicolectomy: laparoscopic versus robotic approach.

BACKGROUND: Minimally invasive surgery for colorectal cancer has been demonstrated to have the same oncological results as open surgery, with better clinical outcomes. Robotic surgery is an evolution of minimally invasive technique. This study aims to evaluate surgical and oncological short-term outcomes of robotic right colon resection in comparison with the laparoscopic approach. METHODS: Between January 2014 and May 2017, fifteen laparoscopic right hemicolectomies were compared to seven robotic ones. The primary data points included operation time, length of hospital stay, extraction site incision length, complications, and conversions. When malignancy was the indication for surgery, additional data points have been added. RESULTS: The study showed no difference in parameters between the two groups, but estimated blood loss was significantly smaller for Robotic arm. We found a prolonged total operative room time in the robotic arm, while the surgical time is similar in two groups. The data collected about specimen length and number of lymph nodes suggest that robotic procedure is oncologically similar to laparoscopic one. CONCLUSIONS: Robotic approach allows performance of adequate dissection of the right colon with radical lymphadenectomy as in laparoscopic surgery, confirming the safety and oncological efficacy of this technique, with acceptable results and short-term outcomes. KEY WORDS: Da Vinci surgery, XI, Laparoscopic colorectal surgery, Right hemicolectomy, Robot.

Antegrade cholecystectomy before ligating the elements. A technique that reduces complications.

BACKGROUND: In open surgery, the most common approach is Retrograde approach ("fundus first"), while is less frequent in laparoscopic cholecystectomy. Antegrade access, is obtained by putting in traction the infundibulum and reaching up to the fundus right before clipping the cystic. Our study analyzes a number of surgical procedures performed by surgeons with long experience in laparoscopy. METHODS: From 2002 to 2017, 2020 laparoscopic cholecystectomies were performed at our Institution. The operative technique used since 2002 is the following: incision of the visceral peritoneum from the infundibulum away from Calot's triangle along the gallbladder bed up to the fundus and then to the infundibulum. RESULTS: No bile duct injuries happened. Average operative time was 38 min. 30 conversions to an open procedure (1.5%) occurred, in patients with cholecystitis and cirrhosis Postoperative stay was mean 2 days with no delayed complications on follow up. CONCLUSIONS: Gallbladder antegrade dissection for laparoscopic cholecystectomy may be an easier approach and may reduce the time of surgery. So it may be used as the standard procedure and not only be used for complicated cholecystectomies. KEY WORDS: Difficult cholecystectomy, Laparoscopy, Antegrade dissection, Cholecystectomy, Cholecystitis, Fundus first.

Endoscopy for treating minor post-cholecystectomy biliary fistula A review of the literature.

AIM: Laparoscopic cholecystectomy for gallstone disease is the most common surgical procedures performed in Western countries and bile leaks remain a significant cause of morbidity. A recognized treatment for minor biliary injury is internal biliary decompression by endoscopic retrograde cholangiopancreatography. The aim of this study was to assess the effectiveness of endoscopic strategy in the management of minor biliary injuries. MATERIAL OF STUDY: Twenty-two patients with a bile leak following laparoscopic cholecystectomy were recorded consecutively between 2007 and 2017 and they were all treated with endoscopic approach, with ERCP in order to confirm the nature of the injury and decompress the bile duct with sphincterotomy, stent insertion, or the placement of nasobiliary drains. In 15 patients, the leak was diagnosed by persistent bile drainage, in the other 7 patients without a drain the biliary leak was suspected because of symptoms in the immediate postoperative period. RESULTS: Controlled biliary fistulae were established in all 22 patients (100%), without further intervention. A complete cholangiogram was obtained in all patients (100%). The most common sites of minor leak were the cystic duct stump and the Luschka duct, but in one patients the site of the leak was unclear. DISCUSSION: Early in the series, sphincterotomy alone or nasobiliary tube placement was performed. Subsequently patients underwent sphincterotomy with stent insertion, in order to promote preferential drainage of bile into the duodenum. The median time to resolution after successful ERCP was 4 days. Two patients underwent ERCP complicated by mild pancreatitis. The median hospital stay was 15 days (range, 10-31 days) post-laparoscopic cholecystectomy. ERCP was performed 4-6 weeks later to document healing of the leaking point and to remove the stent. Routine follow was at median 50 days. CONCLUSIONS: This review confirms that postoperative minor biliary injuries can be successful managed by endoscopic ERCP biliary decompression. KEY WORDS: Bile leak, Bile duct injury, Biliary fistula, Endoscopy, ERCP, Laparoscopic cholecystectomy.