Roux-en-Y Gastric Bypass after Laparoscopic Sleeve Gastrectomy Failure: Could the Number of Previous Operations Influence the Outcome?

After a failed laparoscopic adjustable gastric band (LAGB), laparoscopic sleeve gastrectomy (LSG) has been proposed as revisional surgery. Those patients that receive a second restrictive procedure fall into a small subgroup of patients with more than one restrictive procedure (MRP). If also the second restrictive procedure fails, the correct surgical strategy is a challenge for the surgeon. Roux-en-Y gastric bypass (RYGB) may be an option but there is no evidence in the literature on whether the procedure is effective in treating failures after MRP. This study aims to evaluate the influence of the previous number of restrictive interventions (MRP vs single LSG) in the results of RYGB as revisional surgery. We have retrospectively analyzed patients who underwent conversion from laparoscopic sleeve gastrectomy (LSG), or from multiple restrictive procedures (MRP), to RYGB for weight regain (WR) or insufficient weight loss (IWL) between 2009 and 2019. The number of patients analyzed was 69 with conversion to RYGB after LSG and 44 after MRP. The reduction of excess weight (%TWL) at 3, 6, 12, 24 RYGB postoperative months was respectively of 11.03%, 16.39%, 21.43%, and 24.22% in the MRP group, and of 10.97%, 16.4%, 21.22%, and 22.71% in the LSG group. No significant difference was found in %TWL terms after RYGB for the MRP group and the LSG group with an overall %TWL, which was 11.00 ± 6.03, 16.40 ± 8.08, 21.30 ± 9.43, and 23.30 ± 9.91 respectively at 3, 6, 12, and 24 months. The linear regression model highlighted a positive relationship between the %EWL post-bypass at 24 months and the time elapsed only between the LSG and RYGB in the MRP group patients (p < 0.001). RYGB has proved to be a reliable technique with good results in terms of weight loss after failed bariatric surgery both in patients who previously underwent MRP and in those who underwent exclusively LSG. RYGB showed better results in patients who experienced WR than in those who had IWL from previous techniques.

Total Gastrectomy with Roux-en-Y Limb Reconstruction for Complex and Chronic Fistulas After Laparoscopic Sleeve Gastrectomy: Single-Center Experience.

PURPOSE: When a leak after laparoscopic sleeve gastrectomy (LSG) becomes a chronic fistula, the best surgical treatment remains controversial. The aim of study was to review our experience concerning the treatment of chronic and complex fistulas after LSG. MATERIALS AND METHODS: A retrospective analysis of patients with a gastric fistula following LSG who were treated at our center between January 2013 and December 2018 was performed. All patients included underwent a total gastrectomy with a Roux-en-Y reconstruction (TG) for LSG chronic fistula. RESULTS: During the period considered, 13 patients had a chronic fistula and were treated with open TG. The primary leak evolved to a gastro-cutaneos fistula in three patients (23%), to a gastro-splenic fistula in two patients (15.4%), to a gastro-pleural fistula in four patients (30.8%), and to a gastro-bronchial fistula in four patients (30.8%). During TG, a splenectomy and a spleno-pancreatectomy were needed in the two cases of gastro-splenic fistula. Five patients (38.5%) developed an early complication. Two patients developed an esophago-jejunal anastomotic leak treated with a conservative approach (15.4%). No patients needed hospitalization in the intensive care unit. Overall mean length of stay was 19 days (8-30 days). Mean BMI before LSG was 36 (± 5 kg/m2), mean BMI before TG was 30.3 (± 5.2 kg/m2), and mean BMI 2 years after TG was 23.5 (± 2.9 kg/m2). CONCLUSION: When a more conservative and less mutilating surgical option is not possible, open TG with esophago-jejunostomy remains a valuable salvage procedure in the case of complex and extensive fistulas after LSG.

Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass in patients with gastroesophageal reflux disease: results of a multicenter study.

BACKGROUND: The main side effect of long-term laparoscopic sleeve gastrectomy is the onset of severe gastroesophageal reflux disease (GERD). OBJECTIVES: The aim of this study was to evaluate the effectiveness of gastric bypass conversion in controlling postsleeve GERD. SETTING: University Hospital and Private Hospital, France and Private Hospital, Italy. METHODS: This retrospective multicenter study included patients who underwent laparoscopic sleeve gastrectomy and suffered from postoperative GERD, who did not respond to medical treatment and were converted to laparoscopic Roux-en-Y gastric bypass. The study involved 2 French university hospitals, 4 French private centers, and an Italian public hospital. RESULTS: A total of 80 patients were reviewed. Treatment of a hiatal hernia was performed during laparoscopic sleeve gastrectomy in 3 patients, while 19 patients were operated for hiatal hernia during conversion to bypass (P = .0004). Six months after surgery, 23 of 80 patients maintained reflux symptomatology with a daily frequency, for which continued proton pump inhibitor treatment was required. The persistence of GERD was significantly more frequent among patients with previous gastric banding (n = 19) compared with patients with no history of gastric banding (n = 4, P = .02). In other words, the likelihood of having poor clinical success from conversion of the sleeve to bypass because of intractable GERD was 3 times higher if the patient had a history of gastric banding (relative risk = 2.89, odds ratio = 3.69). CONCLUSION: The results of this study show that, despite the conversion, the symptomatology of GERD does not always disappear, especially in patients with previous gastric banding.

Two-step conversion surgery after failed laparoscopic adjustable gastric banding. Comparison between laparoscopic Roux-en-Y gastric bypass and laparoscopic gastric sleeve.

BACKGROUND: Despite its worldwide popularity, laparoscopic adjustable gastric banding (LAGB) requires revisional surgery for failures or complications, in 20-60% of cases. The purpose of this study was to compare in terms of efficacy and safety, the conversion of failed LAGB to laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy. (LSG). METHODS: The bariatric database of our institution was reviewed to identify patients who had undergone conversion of failed LAGB to LRYGB or to LSG, from November 2007 to June 2012. RESULTS: A total of 108 patients were included. Of these, 74 (68.5%) underwent conversion to LRYGB and 34 to LSG. All of the procedures were performed in 2-stage and laparoscopically. The mean follow-up for the LRYGB group was 29.1±17.9 months while for the LSG patients was 24.2±14.3 months. The mean body mass index (BMI) prior LRYGB and LSG was 45.6±7.8 and 47.5±5.6 (P = .09), respectively. Postoperative complications occurred in 16.2% of the LRYGB patients and in 2.9% of the LSG group (P = .04). Mean percentage of excess weight loss was 59.9%±16.2% and 70.2%±16.7% in LRYGB, and it was 52.2%±11.4% and 59.9%±14.4% in LSG at 12 months (P = .007) and 24 months (P = .01) after conversion. CONCLUSION: In this series, LRYGB and LSG are both effective and adequate revisional procedure after failure of LAGB. While LRYGB seems to ensure greater weight loss at 24 months follow-up, LSG is associated with a lower postoperative morbidity.

Use of a bioprosthetic mesh in complex hernia repair: early results from a French multicenter pilot study.

BACKGROUND: Implantation of synthetic meshes for reinforcement of abdominal wall hernias can be complicated by mesh infection, which often requires mesh explantation. The risk of mesh infection is increased in a contaminated environment or in patients who have comorbidities such as diabetes or smoking. The use of biological prostheses has been advocated because of their ability to resist infection. Initial results, however, have shown high hernia recurrence rates and wound occurrences. The objective of the present study is to evaluate early and mid-term outcomes in the largest French series that included 43 consecutive complex abdominal hernias repaired with biological prostheses. MATERIALS AND METHODS: Retrospective observational study of a prospective collected data bank. Patient demographics, history of previous repairs, intraoperative findings and degree of contamination, associated procedures, postoperative prosthetic-related complications, and long-term results were retrospectively reviewed. RESULTS: There were 25 (58%) incisional, 14 parastomal, and 4 midline hernia repairs. Hernias were considered "clean" (n = 5), "clean-contaminated" (n = 19), "contaminated" (n = 12), or "dirty" (n = 7). Wound-related morbidity occurred in 17 patients; 4 patients needed reoperation for cutaneous necrosis or abscess. Smoking was the only risk factor associated with wound complication (P = .022). No postoperative wound events required removal of the prosthesis. There were 4 hernia recurrences (9%). A previous attempt at repair (P = .018) and no complete fascia closure (P = .033) were associated with hernia recurrence. CONCLUSIONS: This study demonstrated that the use of bioprothesis in complex hernia repair allowed successful single-stage reconstruction. Wound-related complications were frequent. Cost-benefit analyses are important to establish the validity of these findings.

Hepatic endometrioma: a case report and review of the literature: report of a case.

Hepatic endometriosis has an extremely rare occurrence characterized by the presence of ectopic endometrium in the liver. A diagnosis of hepatic endometriosis is established after surgery. A 51-year-old multiparous female was referred to our unit for investigation of a liver tumor. The patient reported a 6-month history of epigastric pain and vomiting. She had undergone conservative hysterectomy for uterine leiomyomas several years earlier. The results of liver function tests and the levels of tumor markers (CA 19.9, CEA, CA125, αFP) were normal. Radiological imaging (USS, CT and MRI) suggested the presence of liver cystadenoma, liver cystadenocarcinoma or cystic metastasis of the liver in the left liver lobe extending to the diaphragm with left hepatic vein compression. Laparotomy was performed. The intraoperative frozen sections suggested a diagnosis of endometriosis. Anatomical resection was performed, including left lobectomy with diaphragm resection. The final histology confirmed the presence of hepatic endometrioma without malignant transformation. Fourteen cases of hepatic endometrioma have been described in the medical literature. We herein report the 15th case. Making a preoperative diagnosis of hepatic endometriosis is very difficult, despite conducting a complete investigation, in the absence of clinical and radiological characteristics. The diagnosis is made according to a histological examination of the whole surgical sample.

Ileocolic intussusception due to a cecal endometriosis: case report and review of literature.

UNLABELLED: Cecal endometriosis and ileocolic intussusception due to a cecal endometriosis is extremely rare. We report a case of a woman who presented an ileocecal intussusception due to a cecal endometriosis. The patient gave two months history of chronic periombilical pain requiring regular hospital admission and analgesia. The symptoms were not related to menses. A laparotomy was performed and revealed an ileocolic intussusception. The abdominal exploration did not find any endometriosis lesion. Ileocaecal resection was performed. Microscopic examination showed a cystic component, lined by a regular cylindric epithelium. Foci of endometrial tissue were observed in the cecal subserosa and muscularis mucosal, with irregular endometrial glands lined by cylindric epithelium without atypia immunostained with CK7, and characteristic endometrial stroma immunostained with CD10. Cecal endometriosis and ileocolic intussusception due to a cecal endometriosis is extremely rare. Diagnose of etiology remains challenging due to the absence of clinical and radiological specific characteristics. VIRTUAL SLIDE: The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/2975867306869166.

Prevalence of and risk factors for morbidity after elective left colectomy: cancer vs noncomplicated diverticular disease.

HYPOTHESIS: Independent risk factors for postoperative morbidity after colectomy are most likely linked to disease characteristics. DESIGN: Retrospective analysis. SETTING: Twenty-eight centers of the French Federation for Surgical Research. PATIENTS: In total, 1721 patients (1230 with colon cancer [CC] and 491 with diverticular disease [DD]) from a databank of 7 prospective, multisite, randomized trials on colorectal resection. INTERVENTION: Elective left colectomy via laparotomy. MAIN OUTCOME MEASURES: Preoperative and intraoperative risk factors for postoperative morbidity. RESULTS: Overall postoperative morbidity was higher in CC than in DD (32.4% vs 30.3%) but the difference was not statistically significant (P = .40). Two independent risk factors for morbidity in CC were antecedent heart failure (odds ratio [OR], 3.00; 95% confidence interval [CI], 1.42-6.32) (P = .003) and bothersome intraluminal fecal matter (2.08; 1.42-3.06) (P = .001). Three independent risk factors for morbidity in DD were at least 10% weight loss (OR, 2.06; 95% CI, 1.25-3.40) (P = .004), body mass index (calculated as weight in kilograms divided by height in meters squared) exceeding 30 (2.05; 1.15-3.66) (P = .02), and left hemicolectomy (vs left segmental colectomy) (2.01; 1.19-3.40) (P = .009). CONCLUSIONS: Patients undergoing elective left colectomy for CC or for DD constitute 2 distinct populations with completely different risk factors for morbidity, which should be addressed differently. Improving colonic cleanliness (by antiseptic enema) may reduce morbidity in CC. In DD, morbidity may be reduced by appropriate preoperative nutritive support (by immunonutrition), even in patients with obesity, and by preference of left segmental colectomy over left hemicolectomy. By decreasing morbidity, mortality should be lowered as well, especially when reoperation becomes necessary.

Major hepatectomy for the treatment of complex bile duct injury.

BACKGROUND: Postcholecystectomy complex bile duct injuries involving the hilar confluence, which are often associated with vascular injuries and liver atrophy, remain a considerable surgical challenge. The aim of this study is to report our experience of major hepatectomy with long-term outcome in these patients. METHODS: From January 1987 to January 2002, 18 patients underwent a major hepatectomy for complex bile duct injuries. The hilar confluence was involved in all cases and was associated with vascular injuries in 13 (72%), including arterial injuries in 11, and partial liver atrophy in 15 (83%). The average time interval between the initial cholecystectomy and hepatectomy was 43 +/- 63 months and 16 (88%) patients had previously undergone an average of 2 (range 1-3) surgical repairs. RESULTS: Major liver resection included a right hepatectomy in 14 (78%) patients, a left hepatectomy in 3, and a left trisectionectomy in one. There was no postoperative mortality, but severe postoperative morbidity was experienced in 11 (61%) patients, including biliary fistula in 7 (39%), prolonged ascites in 8 (44%) and hemorrhage requiring reoperation in one. With a median follow-up time of 8 years (range 3 to 12), 17 (94%) patients have excellent or good results, including 13 patients without symptoms. CONCLUSION: This study shows that salvage major hepatectomy is an efficient treatment for patients with complex hilar bile duct injuries and should be considered before liver transplantation or recourse to metallic stents.

Laparoscopic two-stage left colonic resection for patients with peritonitis caused by acute diverticulitis.

PURPOSE: Purulent or fecal peritonitis is one of the most serious complications of acute diverticulitis. Up to one-fourth of patients hospitalized for acute diverticulitis require an emergent operation for a complication, including abscess, peritonitis, or stenosis. Open Hartmann's procedure has been the operation of choice for these patients. The advantages of laparoscopy could be combined with those of the primary resection in selected patients with peritonitis complicating acute diverticulitis. However, because of technical difficulties and the theoretic risk of poorly controlled sepsis, laparoscopic Hartmann's procedure has been seldom reported for such patients. METHODS: Data were prospectively collected from 2003 to 2005 in a single referral center specialized in abdominal emergencies. Laparoscopic Hartmann's procedure (Stage 1) was performed in selected patients with peritonitis complicating acute diverticulitis. Secondarily, Hartmann's reversal (Stage 2) also was performed laparoscopically. RESULTS: Thirty-one patients were studied. The median Mannheim Peritonitis Index score was 21 (+/-5; range, 12-32). The conversion rate was 19 and 11 percent for Stage 1 and Stage 2, respectively. There was no perioperative uncontrolled sepsis. Overall operative 30-day mortality and morbidity rates were 3 and 23 percent for Stage 1, and 0 and 15 percent for Stage 2, respectively. Stoma reversal was possible in 90 percent of patients. CONCLUSIONS: The results of this small series demonstrated that the indications of laparoscopy in diverticulitis could be extrapolated to selected patients with peritonitis. The technical feasibility and safety of laparoscopic Hartmann's procedure in selected patients seem acceptable. However, larger-scale, controlled studies are needed to define more accurately the role of laparoscopy in complicated diverticulitis.

[Cystic teratoma of the pancreas]. / Tératome kystique du pancréas.

The preoperative diagnosis of cystic tumours of the pancreas can be difficult. It is usually based on morphological and biological (i.e., cyst fluid content of tumour markers) data. However, the latter can be misinterpreted in case of exceptional cystic tumours, other that cystadenomas. We report here the case of a 45-year old woman who was operated on for a benign cystic mature teratoma with endocrine component and high concentrations in cyst fluid CEA and CA 72.4 which was evocative of a malignant mucinous cystadenoma.