Laparoscopic sleeve gastrectomy in a patient with situs viscerum inversus totalis: is the life easy upside-down?

INTRODUCTION: Obesity is an epidemic on the rise [1]. The number of bariatric procedures has increased worldwide. Laparoscopic sleeve gastrectomy (LSG) is a valid therapeutic option, leading to a sustained weight loss with a low complication rate [2]. Situs viscerum inversus totalis (SIT) is the complete transposition of all the abdominal organs, occurring in about 1 in 10,000 people [3]. Laparoscopic approach in SIT is challenging due to the mirror image anatomy. MATERIALS AND METHODS: We present the case of a 41-year-old man with a body mass index of 46.4 kg/m2 (131 kg; 1.68 m) previously diagnosed with SIT who has undergone LSG. RESULTS: In this video, we show a LSG performed in a patient with SIT. There were no changes in the technique compared to the "standard anatomy." The patient was placed on the operative table in anti-trendelenburg position with legs abducted. The surgeon stood between the legs while the assistant was on the right side of the patient and the scrub nurse on the opposite side. A 12-mm trocar was inserted with a direct technique in the right lateral flank. Carbon dioxide insufflation was done under vision. Other three trocars (12, 10, and 5 mm) were positioned in the left lateral flank, supraumbilical, and subxiphoid areas, respectively. Gastroepiploic dissection started at 5 cm from the pylorus up to the right crus. After the insertion of a 36-Fr boogie, an accurate stapling of the stomach was performed. The proximal side of the sleeve was reinforced with a non-absorbable suture. Titanium clips were placed leading to a complete haemostasis. The procedure lasted 45 min. The patient followed a "fast-track" protocol afterwards, with no changes in the perioperative workup compared to "standard anatomy" patients. He was discharged on day 2 postoperatively and no complication occured in the perioperative period. CONCLUSION: SIT is a rare condition leading to a mirror image that can be challenging for a laparoscopic surgeon. LSG is feasible and safe also for morbidly obese patients with SIT, not requiring any change in the surgical technique and perioperative management, as long as the surgeon is well beyond the learning curve.

Effects of biliopanceratic diversion on type 2 diabetes in patients with BMI 25 to 35.

OBJECTIVE: Biliopancreatic diversion (BPD) resolves type 2 diabetes in near totality of morbidly obeses [BMI (body mass index) ≥35 kg/m]. However, studies of BPD effect in BMI range 25.0 to 34.9 kg/m, including about 90% of diabetic patients, are lacking. MATERIALS AND METHODS: If BPD effects are independent of weight changes, they should be maintained in patients who, being mildly obese or overweight, will lose little or no weight after operation. Thirty type 2 diabetic patients with BMI 25 to 34.9 were submitted to BPD and monitored 12 months. Thirty-eight diabetic patients selected from a large database, kept 1 year on medical therapy, served as controls. RESULTS: Nineteen male and 11 female. Mean age 56.4 ± 7.4 years, weight 84.8 ± 11.1 kg, BMI 30.6 ± 2.9 kg/m, waist circumference 104 ± 9.4 cm, diabetes duration 11.2 ± 6.9 years, HbA1c 9.3±1.5. Twelve patients on insulin. Fifteen (2 F) with BMI < 30 (mean: 28.1). No mortality or major adverse events occurred. BMI progressively decreased, stabilizing around 25 since the fourth month, without excessive weight loss. One year after BPD, mean HbA1c was 6.3%±0.8, with 25 patients (83%) controlled (HbA1c≤7%) on free diet, without antidiabetics, and the remaining improved. Acute insulin response to intravenous glucose had increased from 1.2 ± 2.9 to 4.2 ± 4.4 µIU/mL. Diabetes resolution correlated positively with BMI. HbA1c decreased at 1 year in the control group, along with an overall increased amount of antidiabetic therapy. CONCLUSIONS: BPD improves or resolves diabetes in BMI 25 to 35 without causing excessive weight loss, its action being on insulin sensitivity and beta-cell function. The strikingly different response between morbidly obese and low BMI patients might depend on different beta-cell defect. ClinicalTrials.gov Identifier: NCT00996294.

Enhanced recovery after bariatric surgery (ERABS) in a high-volume bariatric center.

BACKGROUND: The growing demand for bariatric surgery has been accompanied by an expensive technological evolution and the need to contain healthcare costs and to increase the quality of care. The enhanced recovery after surgery (ERAS) protocols applied to the bariatric setting can be the answer to all these different issues. OBJECTIVES: Feasibility and safety of ERAS protocol in a single, high-volume bariatric center. SETTING: Humanitas Research Hospital, Rozzano MI, Italy. METHODS: Our ERAS bariatric protocol is based on the following 3 steps: (1) preoperative: optimization of all co-morbidities, counseling patients and family with information and education, and shortening fasting times (clear fluids up to 2 hr and solids up to 4 hr before induction of anesthesia); (2) intraoperative: premedication, parallel team work, awake patient positioning, standardized multimodal anesthesia and analgesia, noninvasive monitoring, video-laryngoscopy in reverse Trendelenburg position, short-acting anesthetic agents, and standardized laparoscopic surgery avoiding the nasogastric tube, catheter, and drain; and (3) postoperative: analgesia, early mobilization, early oral fluid, thromboprophylaxis, discharge planning, and follow-up telephone call. Clinical pathways were established and outcomes were retrospectively collected. RESULTS: Comparison between conventional care and ERAS protocol reveals a reduction of the length of hospital stay (from 4.7 to 2.1 d) and a low morbidity rate. From July 2015 to July 2018, a total of 2400 consecutive patients underwent primary or revisional bariatric surgery (2122 sleeve gastrectomies and 278 Roux-en-Y gastric bypasses [RYGB]). Mean body mass index was 44.9 kg/m2, mean age was 41.9 years, and the male to female ratio was 1:2.5. Total mean operative time was 85 minutes, with a surgical time of 65 minutes and an anesthesiologic/patient induction time of 4 minutes. Early complication rate was 3.5% with no perioperative mortality. Mean hospital stay was 2.1 days and the rate of readmission was .9%. CONCLUSIONS: This study demonstrates that our ERAS protocol is safe, feasible, and efficient. Patient preparation and multidisciplinary/parallel team work are crucial points.

Brachioplasty after bariatric surgery: personal technique.

BACKGROUND: A review of the results of the standard technique for "batwing" deformity after massive weight loss led to the need to optimize the cost/benefit ratio in terms of maximal correction/less visible scars. METHODS: Between 2001 and 2007, 29 patients were operated with a new technique based on a careful preoperative evaluation and markings, followed by an intraoperative skillful handling. This technique is not easy and needs plastic surgery experience and a long learning curve. RESULTS: The esthetic results are far better then those obtained with other techniques, especially the arm lower profile. CONCLUSION: The complication rate is similar to other techniques, even if a potential low risk for ulnar nerve damage is present.

Body contouring after biliopancreatic diversion.

BACKGROUND: From Nov 2001 to Mar 2006, 176 patients underwent body contouring plastic surgery after prior biliopancreatic diversion (BPD). Weight loss had varied from 30-100 kg. The plastic surgery targeted the arms (24 patients), breast (58), abdomen (62) and thighs (20), plus torsoplasty (12). METHODS: BPD is a "non-cosmetic" bariatric operation which results in malabsorption and subsequent major weight loss within 12 to 18 months. The typical "empty" aspect of the slimmed areas directed our surgical choices to specific techniques: brachioplasty, reduction mammaplasty and/or mastopexy (with or without prosthesis or "self-prosthesis" technique), thigh-lift, abdominoplasty and torsoplasty. We do not consider any liposuction technique suitable for this kind of patient, because of the specific histological changes caused by BPD. RESULTS: The metabolic discrepancies following BPD affect postoperative management of these patients. A higher incidence of complications has been reported, of both systemic and local nature; the local ones, common in the abdominal wall, convinced us to perform an arteriographic study preoperatively, to check anatomical alterations following the BPD. CONCLUSIONS: Although the characteristics of BPD patients limit the choices, we are satisfied with the results of cosmetic correction and quality of life. All the patients, without exception, noted a high rate of positive thinking and have undergone further body-contouring surgery (or plan to do so).

Cutaneous metastasis from primary gastric cancer: a case report and review of the literature.

Cutaneous metastases of internal neoplasms are uncommon. They can be metachronous or synchronous to the primary tumor and typically appear late in the course of advanced malignant disease. Gastric cancer rarely is reported as a cause of cutaneous metastasis; the most common metastatic sites are the liver, peritoneal cavity, and lymph nodes. We report a case of cutaneous metastasis from a primary gastric tumor that had been treated 6 years prior. There was no visceral invasion. The patient was treated successfully via a relaparotomy to exclude any macroscopic abdominal recurrence and complete excision of the lesion with a plastic flap to compensate for the tissue lost in the resection. Treatment plans vary depending on the diameter and number of lesions, the presence of visceral metastases, and the physical status of the patient. Therapy generally includes local excision, irradiation, or chemotherapy.

The effects of biliopancreatic diversion on type 2 diabetes mellitus in patients with mild obesity (BMI 30-35 kg/m2) and simple overweight (BMI 25-30 kg/m2): a prospective controlled study.

BACKGROUND: Beneficial effects of BPD on T2DM in BMI >35 kg/m(2) patients are far better than those in patients with BMI 25-35. This study was aimed at investigating if a similar difference exists between patients with mild obesity (OB, BMI 30-35) or simple overweight (OW, BMI 25-30). METHODS: Fifteen OB (six M) and 15 OW (13 M), diabetic for ≥ 3 years, with HbA1c ≥ 7.5% despite medical therapy, underwent BPD. OB/OW: age 55.1 ± 8.0/57.8 ± 6.7 years, BMI 33.1 ± 1.5/28.0 ± 1.3 kg/m(2), diabetes duration 11.6 ± 8.0/11.1 ± 6.1 years, insulin therapy 4/8 p. FSG and HbA1c were determined preoperatively and up to 2 years. Insulin resistance and beta-cell function were explored by means of HOMA-IR and IVGTT (AIR). Thirty-eight diabetic patients on medical therapy served as controls. RESULTS: Mean BMI stabilized around 27 since the 4th month in OB, and 24 since 1st month in OW. FSG in OB/OW preop, 1, 12, 24 months: 234 ± 76/206 ± 62 mg/dL, 154 ± 49/176 ± 75, 131 ± 32/167 ± 48, 134 ± 41/154 ± 41 (cross-sectional n.s. at all times); HbA1c: 9.5 ± 1.6/9.1 ± 1.3, 7.3 ± 1.1/7.3 ± 1.2, 5.9 ± 0.6/7.1 ± 1.1 (p < 0.01), 5.9 ± 0.9/6.9 ± 1.1 (p < 0.01). HOMA-IR, preoperatively 10.7 ± 5.8/7.5 ± 5.4, went below 3.0 at 1 month and remained such until 2 years in both groups. AIR, preoperatively 1.11 ± 3.17/1.27 ± 2.68 µIU/mL, in OB significantly increased at 4 months to 7.63 ± 5.79, maintained up to 2 years with 6.95 ± 3.19, whereas in OW, statistical significance was reached only at 2 years with 5.02 ± 4.87. CONCLUSIONS: Significantly different BPD effect, thus biological severity of T2DM, also exists between mildly obese and simply overweight patients. The rise of AIR allows hoping that an increase of beta-cell mass may occur in the long run.