Robotic and laparoscopic Roux-en-Y gastric bypass after learning curve: 30-day and 12-month outcomes.

This study compares laparoscopic RYGB (L-RYGB) and robotic RYGB (R-RYGB) performed by the same team after the learning curve in both approaches. A retrospective cohort study was done, and the surgical outcome was analyzed in 30 days and 12 months for patients with similar characteristics and an equal number of cases in each group (233 cases). Four hundred and sixty-six patients were included in this study. Mean age was 46.8 ± 8.3 years and 2/3 were women. R-RYGB presented a longer operative time (150.7 versus 135.4 min; p < 0.001) with no differences in the length of hospital stay. The main 30-day complications were G-J stricture, leakage, and intraluminal bleeding. The reoperation rate was 1.6% by leakage (G-J anastomosis) and was higher in R-RYGB (2.1 versus 0.4; p = 0.108). The multivariate analysis identified that L-RYGB was the factor independently associated with a LOS longer than 2 days (odds ratio: 4.7, 95% CI: 2.6-8.2, p value < 0.001). At the FU time (12 months), no differences between the groups were found. The outcomes between the groups after the learning curve did not present differences in terms of 30 days and 12 months of FU when same preoperative characteristics and an equal number of cases in each group are considered. L-RYGB was the unique independent factor associated with long LOS.

Laparoscopic Versus Robot-Assisted Roux-en-Y Gastric Bypass: A Center of Excellence for the EAC-BC Experience.

Background: After the first laparoscopic Roux-en-Y gastric bypass (RYGB) in 1994 by Wittgrove, the introduction of robot-assisted procedures was the next step in the surgical race to reduce invasiveness. This breakthrough allowed us to perform bariatric surgery with less surgical trauma in obese patients with metabolic disorders, producing an exponential increase in procedures performed. Methods: This is a retrospective cohort study of a prospective database for patients who underwent RYGB during a 7-year period through two different approaches, laparoscopic and robotic. The robotic cases were performed by two generations of the da Vinci platform (S and Xi), and three groups were identified and compared (L-RYGB, RYGB-S, and RYGB-Xi). Results: A total of 495 patients underwent RYGB, of which 224 by laparoscopy (45.2%) and 271 by robotic approach (54.7%): 134 RYGB-S and 137 RYGB-Xi. The majority of the patients (71.1%) were females, with a mean age of 46.2 years and a mean body mass index of 44 kg/m2. The mean intraoperative time and intraoperative complication rate were higher in the robotic groups, especially in the RYGB-S group. Postoperative complications were higher in the same group, with a rate of 11.9%, where the main leakage occurred on the upper part of the gastric pouch and not in the hand-sewed robotic anastomosis (7.5%). General mortality was 0.6%. We found no significant differences at 1-year percentage of total weight loss (%TWL); at 2 years, the RYGB-Xi group had the lowest %TWL (25.24 ± 14.54, P ≤ .001). Conclusions: The present study reflects our experience during the robotic bariatric introduction and performance since 2011. Features of the da Vinci S platform along our learning curve may explain a higher complication rate. The patients who have been operated by the RYGB-Xi system had lower complications than the laparoscopic group. The robotic approach did not differ with laparoscopy in terms of weight loss and chronic complications after 24 months of follow-up.

A Comparison of Clinical Outcomes Between Two Different Models of Surgical Robots in Roux-en-Y Gastric Bypass.

Introduction: For the past 20 years, robotic surgical systems have been used for the Roux-en-Y gastric bypass (RYGB). The da Vinci Surgical System (Intuitive Surgical, Inc.) has been one of the most used robotic platforms. This study aims to retrospectively compare the performance of two models of surgical robots. Materials and Methods: A retrospective comparative study was conducted from a prospective database including all patients who underwent robotic RYGB (RRYGB) from 2011 to 2020. Results: Of a total of 277 patients included, 134 were in the RRYGB using the da Vinci S™ (RRYGB-S™) group and 143 were in the RRYGB using the da Vinci Xi™ (RRYGB-Xi™) group. The mean operative time in the RRYGB-S and RRYGB-Xi groups was 154 ± 28 and 151 ± 32 minutes, respectively (P = .510). The was no statistically significant difference in terms of intraoperative complications between the groups with regard to positive blue test, bleeding, and failure of stapler line. The readmission rate was higher in the RRGB-S group (14.1%) than in the RRYGB-Xi group (3.4%) (P = .004), and it was mainly due to major complications (P = .003) including pouch and gastrojejunostomy anastomotic leaks (P = .001). The nonsurgical complications were statistically significantly higher in the RRYGB-S group (7.4%) than in the RRYGB-Xi group (2.1%) (P < .05), as well as the surgical complications were higher in the RRYGB-S group (7.5%) than in the RRYGB-Xi group (0%) (P < .001). The mean percentage of the total weight loss at 1 and 2 years of follow-up did not show any statistically significant difference (P = .547). Conclusions: The higher complication rate in the S surgical system might be correlated with the initial learning curve and stressed the need for proper robotic surgical training and accurate strategies when introducing emerging technologies into the surgical practice.

Reversal to Normal Anatomy (With Sleeve Gastrectomy) for Severe Hypoglycemia.

Background. Laparoscopic Roux-en-Y gastric bypass (GBP) is an essential bariatric surgical procedure which is globally performed because of the associated effective weight loss and resolution of metabolic comorbidities, such as diabetes and dyslipidemia. Although some complications may occur, hypoglycemia is a rare complication, which can lead to lethal consequences. We aimed to describe the technical aspects and surgical results after reversal to normal anatomy (RNA). Methods. We conducted a retrospective data analysis including 16 patients who underwent laparoscopic RNA from 2011 to 2018. All data were archived in a prospective database. Previous bariatric surgery and postoperative outcomes were analyzed. Results. Sixteen patients underwent RNA, most of them after GBP, and 15 patients required sleeve gastrectomy. Among them, 80% were women; 5 patients presented with postoperative complications, such as colitis with intra-abdominal collection (n = 1), gastric leak (n = 2) treated with an endoprosthesis, mesenteric venous thrombosis (n = 1), and intra-abdominal bleeding (n = 1). Mean length of hospital stay was 5.93 (3-30). All patients recovered from their initial condition although 3 patients presented with mild hypoglycemia during follow-up. Seven patients regained weight (43.75%), and another 4 developed gastroesophageal reflux disease (25%). Conclusions. These laparoscopic RNA results are acceptable, indicating a clinical improvement in the hypoglycemic syndrome in all patients.

Intrathoracic sleeve gastrectomy migration with gastric volvulus treated with laparoscopic repair and conversion to gastric bypass.

A 43 years old female with laparoscopic sleeve gastrectomy (SG) and an 'anterior' hiatal hernia repair 11 years ago, presented with 3 years history dysphagia and heartburn. Upper gastrointestinal barium showed an almost complete intrathoracic migration of the SG with a partial organoaxial volvulus. Upper endoscopy revealed a 10 cm hiatal hernia with grade B esophagitis. Laparoscopic revision surgery with reduction of the gastric sleeve, standard posterior hiatal hernia repair, resection of the narrowed remnant of the SG and conversion to a gastric bypass was performed. No postoperative complications occurred. The patient is asymptomatic at 2 years of follow-up. We present the technical standards for the management and discuss the suspected pathophysiology of this rare but challenging condition.

Effectiveness of Laparoscopic Sleeve Gastrectomy in Super-obese and Non-Super-obese Patients.

OBJECTIVES: The primary aim of this study was to assess the effectiveness of sleeve gastrectomy (SG) in super-obese patients. The secondary aim was to identify patient characteristics associated with worse SG outcomes in this group. METHODS: A retrospective analysis was carried out of our electronic prospective bariatric surgery patient database, including all patients who underwent SG between January 2007 and January 2017. The sample was divided according to the initial body mass index (BMI) (> or <50 kg/m). The initial characteristics and results in terms of weight loss and comorbidity resolution between the groups were compared. A subanalysis of the variable distributions was carried out according to whether or not the final BMI in the super-obese group had reached <35 kg/m. Data analysis was carried out using STATA 13.1, with a P-value <0.05 considered to be significant. RESULTS: The mean initial BMI was 42.8 kg/m in group 1 (<50 kg/m) and 55 kg/m in group 2 (>50 kg/m). The median follow-up (FU) was 56.2 months. Maximum weight loss was attained at the 18-month FU in both groups (BMI: 28.8 and 34.7 kg/m, respectively). At the 5-year FU, percentage of total weight loss was higher in group 2 and percentage of excess weight loss was statistically higher in group 1 (29.6% vs. 33.1% and 67% vs. 59%, respectively). Outcomes for type 2 diabetes mellitus, hypertension, and dyslipidemia were similar in both groups. The variables associated with attaining a final BMI <35 kg/m in the super-obese group were lower initial BMI, absence of baseline weight-related conditions (type 2 diabetes mellitus, obstructive sleep apnea syndrome, home continuous positive airway pressure, arthropathy, heart disease), and absence of gastroesophageal reflux disease. CONCLUSIONS: We observed a statistically significant increase in poor outcomes in patients with a higher initial BMI and with weight-related comorbidities. These parameters could be considered to be potentially good predictors of less satisfactory outcomes in the super-obese patients.

Operative and Postoperative Complications of Laparoscopic Sleeve Gastrectomy in Super and Nonsuper Obese Patients: A Center of Excellence Experience Comparative Study.

Background: Laparoscopic sleeve gastrectomy (LSG) is now one of the most common surgical procedures worldwide. It was initially defined for staged procedures in super or super-super obese, or in very complex patients. The primary objective of the study was to assess the safety of LSG for morbid-obese (MO, body mass index [BMI] >40 kg/m2) and super-morbid-obese (SMO, BMI >50 kg/m2) patients in terms of operative and postoperative complication rate. Methods: This study involves a retrospective analysis of a prospective database that included data for patients who underwent LSG, between 2008 and 2017, in our institution. All LSG procedures were performed by the same two certified bariatric surgeons following a standardized surgical procedure. Data on operative and postoperative complications were collected for all the patients. Results: A total of 713 patients were included in the study 495 (61.42%) were MO (mean age 46.06 ± 11.98 years) and 218 (30.58%) were SMO (mean age 42.98 ± 11.17 years). There were no significant differences between both groups in terms of minor and major postoperative complications or long-term complications. Postoperative mortality was slightly higher in the MO group but without statistically significant differences (MO: 0.2%; SMO: 0%). Long-term reoperation rate and late complications were higher in the MO group 6.12% versus 4.04% and 17.43% versus 15.15%, respectively. Reoperation for gastroesophageal reflux disease was higher in MO patients compared to SMO and weight issues reoperation higher in the SMO. Conclusion: We found LSG as a safe procedure in both groups. Interestingly long-term reoperation and complications rates were higher in the MO group.

Laparoscopic Conversion from Single Anastomosis Duodeno-Jejunal Bypass with Sleeve Gastrectomy (SADJ-S) to Roux-en-Y Gastric Bypass (GBP): Improving Unsatisfactory Outcomes.

Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) can be considered as either a primary procedure or second stage procedure. Malnutrition is rare but could lead to a reversal of the SADI-S. The aim of this manuscript is to present the management and technique of weight regain after proximalization of a SADI-S by converting it to a gastric bypass.

Conversion of AspireAssist System® to Sleeve Gastrectomy: Technical Video Description.

PURPOSE: The AspireAssist System® (Aspire Bariatrics, Inc. King of Prussia, PA) is a new endoscopic procedure used to treat obese patients. The aim of this dedicated video is to present a case that required revision surgery due to failure of the AspireAssist System®, and to show how the cannula was removed from the abdomen, and why sleeve gastrectomy (SG) was a good option for revisional surgery in that patient. We aim to discuss technical aspects. PATIENT AND METHODS: A 43-year-old female patient who underwent a placement in 2016. Her initial BMI (body mass index) was 38 kg/m2, with a follow-up period of 26 months. A revisional surgery was performed including dissection of the previous gastric fistula and adhesiolysis from the previous AspireAssist System® placement. A complete dissection of the gastrostomy, including removal of all the system, was done. A decision was made, once the incisura angularis and the placement of a 40 Fch bougie showed that the transection could be performed. SG was done. Patients showed an uneventful postoperative course and 4 months follow-up with 45% EWL. CONCLUSION: In case of having the device in place, the surgeon must be aware to remove intraoperatively or endoscopically, the device. Surgeons should consider endoscopic removal of the AspireAssist System® before conversion to another procedure (SG or GBP) at least 6 months of the removal. Removal of the AspireAssist System® should be performed endoscopically but direct conversion to another bariatric procedure can be considered, either to SG or GBP depending on the technical intraoperative aspects.

Ligamentum Teres Cardiopexy as a Late Alternative for Gastroesophageal Reflux Disease in a Patient with Previous Reversal of Gastric Bypass to Sleeve Gastrectomy and Hiatal Hernia Repair.

An important percentage of the patient, undergoing primary or revisional bariatric surgery after sleeve gastrectomy, presents symptomatic gastroesophageal reflux disease (GERD). When and how surgical reinforcement of the lower esophageal sphincter should be performed to prevent acid reflux is still controversial. Here, we describe laparoscopic ligamentum teres cardiopexy, a surgical technique that reinforces the lower esophageal sphincter and restores its competence with a new valve, in patients with the previous conversion of gastric bypass to sleeve gastrectomy and hiatal hernia repair. We present the surgical technique performed on a patient with initial gastric bypass who underwent sleeve gastrectomy for hypoglycemia and hiatoplasty for severe GERD. Persistent GERD requested to undergo ligamentum teres cardiopexy. Ligamentum teres cardiopexy combined with the closure of the gastric crus is a late alternative treatment for GERD in patients with previous sleeve gastrectomy and hiatal hernia.

Giant rectal villous adenoma: Surgical approach with rectal eversion and perianal coloanal anastomosis.

INTRODUCTION: Colorectal cancer is an important cause of death. Most cases of colon and rectal cancer arise from a preexisting adenomatous polyp. However, if colorectal polyps are very large or not accessible for endoscopic ablation, or if they cannot be removed without an increased risk of perforation, surgical procedures are required. PRESENTATION OF CASE: The case of a patient with a giant villous adenoma of the rectum is described. The patient had diarrhea for 2 years associated with asthenia. Colonoscopy revealed a sessile lesion in the rectum measuring 14cm in the largest diameter. Rectal eversion technique was used, resecting the lesion under direct visibility and an external coloanal anastomosis was performed. Surgery was satisfactory and the resection margins were free. DISCUSSION: Removal of these polyps should be performed aiming to reduce the incidence of colorectal cancer, as well as to control local and systemic symptoms, such as diarrhea and fluid and electrolyte disorders, mainly in villous adenomas. Various surgical techniques are proposed, but in extensive circumferential lesions of the rectum they are difficult to apply. The rectal stump eversion technique was described by Maunsell (1892), for rectal cancer. CONCLUSION: Eversion of the rectal stump and external coloanal anastomosis may be a good surgical alternative for resecting giant rectal adenomas.