Short-term Outcomes of Day-Case Stoma Closure: A Prospective, Observational Study.

BACKGROUND: Elective stoma closure is a common, standardized procedure in digestive surgery. OBJECTIVE: This study aimed to evaluate the feasibility of day-case surgery for elective stoma closure. DESIGN: This is a prospective, single-center, nonrandomized study of consecutive patients undergoing day-case elective stoma closure. SETTING: This study was performed at a French tertiary hospital between January 2016 and June 2018. PATIENTS: Elective stoma closure was performed by local incision with an ASA score of I, II, or stabilized III. OUTCOME MEASURES: The primary end point was the day-case surgery success rate in the overall population (all patients having undergone elective stoma closure) and in the per protocol population (patients not fulfilling any of the preoperative or perioperative exclusion criteria). The secondary end points (in the per protocol population) were the overall morbidity rate (according to the Clavien-Dindo classification), the major morbidity rate (Clavien score ≥3), and day-case surgery quality criteria (unplanned consultation, unplanned hospitalization, and unplanned reoperation). RESULTS: Between January 2016 and June 2018, 236 patients (the overall population; mean ± SD age: 54 ± 17; 120 men (51%)) underwent elective stoma closure. Fifty of these patients (21%) met all the inclusion criteria and constituted the per protocol population. The day-case surgery success rate was 17% (40 of 236 patients) in the overall population and 80% (40 of 50 patients) in the per protocol population. In the per protocol population, the overall morbidity rate was 30% and the major morbidity rate was 6%. Of the 40 patients with successful day-case surgery, the unplanned consultation rate and the unplanned hospitalization rate were both 32.5%. There were no unplanned reoperations. LIMITATIONS: This was a single-center study. CONCLUSION: In selected patients, day-case surgery for elective stoma closure is feasible and has acceptable complication and readmission rates. Day-case elective stoma closure can therefore be legitimately offered to selected patients. See Video Abstract at http://links.lww.com/DCR/B583. RESULTADOS A CORTO PLAZO DEL CIERRE DE ESTOMA AMBULATORIO UN ESTUDIO OBSERVACIONAL Y PROSPECTIVO: ANTECEDENTES:El cierre electivo de un estoma es un procedimiento común y estandarizado en cirugía digestiva.OBJETIVO:Evaluar la viabilidad de la cirugía ambulatoria para el cierre electivo de estomas.DISEÑO:Un estudio prospectivo, unicéntrico, no aleatorizado de pacientes consecutivos sometidos a cierre de estoma electivo ambulatorio.ESCENARIO:Un hospital terciario francés entre enero de 2016 y junio de 2018.PACIENTES:Cierre electivo de estoma realizado por incisión local con una puntuación de la American Society of Anesthesiologists de I, II o III estabilizado.PRINCIPALES MEDIDAS DE RESULTADO:El resultado principal fue la tasa de éxito de la cirugía ambulatoria en la población general (todos los pacientes habiendo sido sometidos a cierre de estoma electivo) y en la población por protocolo (pacientes que no cumplían con ninguno de los criterios de exclusión preoperatorios o perioperatorios). Los resultados secundarios (en la población por protocolo) fueron la tasa de morbilidad general (según la clasificación de Clavien-Dindo), la tasa de morbilidad mayor (puntuación de Clavien ≥ 3) y los criterios de calidad de la cirugía ambulatoria (consulta no planificada, hospitalización no planificada y reoperación no planificada).RESULTADOS:Entre enero de 2016 y junio de 2018, 236 pacientes (la población general; edad media ± desviación estándar: 54 ± 17; 120 hombres (51%)) se sometieron al cierre electivo del estoma. Cincuenta de estos pacientes (21%) cumplieron todos los criterios de inclusión y constituyeron la población por protocolo. La tasa de éxito de la cirugía ambulatoria fue del 17% (40 de 236 pacientes) en la población general y del 80% (40 de 50 pacientes) en la población por protocolo. En la población por protocolo, la tasa de morbilidad general fue del 30% y la tasa de morbilidad mayor fue del 6%. De los 40 pacientes con cirugía ambulatoria exitosa, la tasa de consultas no planificadas y la tasa de hospitalización no planificada fueron ambas del 32.5%. No hubo reoperaciones no planificadas.LIMITACIONES:Este fue un estudio de un solo centro.CONCLUSIÓN:En pacientes seleccionados, la cirugía ambulatoria para el cierre electivo de estoma es factible y tiene tasas aceptables de complicaciones y reingreso. Por lo tanto, se puede ofrecer legítimamente el cierre electivo ambulatorio de estoma a pacientes seleccionados. Consulte Video Resumen en http://links.lww.com/DCR/B583.

Comparison of sleeve gastrectomy and Roux-en-Y gastric bypass after failure of gastric banding: a two-center study with a propensity score-matched analysis.

BACKGROUND: Few studies on series comparing sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) after failure of gastric banding (GB) are available. The objective of this study was to compare the short- and medium-term outcomes of SG and RYGB after GB. MATERIALS AND METHODS: Between January 2006 and December 2017, patients undergoing SG (n = 186) or RYGB (n = 107) for failure of primary GB were included in this two-center study. Propensity-score matching was performed based on preoperative factors with a 2:1 ratio. Primary endpoint was the weight loss at 2 years between the SG and RYGB groups. Secondary endpoints were overall mortality and morbidity, reoperation, correction of comorbidities and the rate of adverse events at 2 years follow-up. RESULTS: In our propensity score matching analysis, operative time was significantly less in the SG group (95 min vs. 179 min; p < 0.001). Post-operative complications were lower in the SG group (9.5% vs. 35.4%; p = 0.003). At 2 years follow-up, the mean EWL was similar as same as comorbidities. There was a significant difference in favor of SG concerning the rate of adverse events at 2 years follow-up (p < 0.001). CONCLUSION: Revision of GB by SG or RYGB is feasible, with a higher rate of early post-operative complications for RYGB. Weight loss at 2 years follow-up is similar; however, RYGB appears to result in a higher rate of adverse events than SG.

Short-term outcomes of single-port versus conventional laparoscopic sleeve gastrectomy: a propensity score matched analysis.

BACKGROUND: Sleeve gastrectomy (SG) has become a frequent bariatric procedure. Single-port sleeve gastrectomy (SPSG) could reduce parietal aggression however its development has been restrained due to fear of a complex procedure leading to increased morbidity and suboptimal sleeve construction. The aim of this study was to compare the short-term outcomes of SPSG versus conventional laparoscopic sleeve gastrectomy (CLSG) with regards to morbidity, weight loss, and co-morbidity resolution. METHODS: Between January 2015 and December 2016, data from all consecutive patients that underwent SPSG and CLSG in two institutions performing exclusively one or the other approach were retrospectively analyzed. Propensity score adjustment was performed on the factors known to influence the choice of approach. RESULTS: During the study period, 1122 patients underwent SG in both institutions (610 SPSG and 512 CLSG). From each group, 314 patients were successfully matched. A 15-min increase in operative time was observed during SPSG (P < 0.001). Postoperative morbidity was similar with a minor increase after SPSG (8.6 vs. 6.7%, P = 0.453). No differences in incisional hernia rates were observed (1.6 (SPSG) vs. 0.3% (CLSG), P = 0.216). Percentage of total weight loss was 31.1% and 28.2% in the CLSG and SPSG 12 months after surgery, respectively (P = 0.321). Co-morbidities resolution 12 months following the procedure was similar. CONCLUSIONS: SPSG can be performed safely with similar intraoperative and postoperative morbidity compared to CLSG. Weight loss and co-morbidities resolution at 1 year are equivalent. A 15-min longer operative time was the only negative side of SPSG.

Effectiveness of Fibrin Sealant Application on the Development of Staple Line Complications After Sleeve Gastrectomy: A Prospective Randomized Trial.

OBJECTIVES: Evaluate the effectiveness of the use of fibrin sealant (FS) for preventing the development of staple line complications (SLCs) after sleeve gastrectomy (SG). BACKGROUND: There is no consensus on the best means of preventing SLCs after SG. METHODS: This was a prospective, intention-to-treat, randomized, 2 center study of a group of 586 patients undergoing primary SG (ClinicalTrials.gov identifier: NCT01613664) between March 2014 and June 2017. The 1:1 randomization was stratified by center, age, sex, gender, and body mass index, giving 293 patients in the FS group and 293 in the control group (without FS). The primary endpoint (composite criteria) was the incidence of SLCs in each of the 2 groups. The secondary criteria were the mortality rate, morbidity rate, reoperation rate, length of hospital stay, readmission rate, and risk factors for SLC. RESULTS: There were no intergroup differences in demographic variables. In an intention-to-treat analysis, the incidence of SLCs was similar in the FS and control groups (1.3% vs 2%, respectively; P = 0.52). All secondary endpoints were similar: complication rate (5.4% vs 5.1%, respectively; P = 0.85), mortality rate (0.3% vs 0%, respectively; P = 0.99), GL rate (0.3% vs 1.3%, respectively; P = 0.18), postoperative hemorrhage/hematoma rate (1% vs 0.7%, respectively; P = 0.68), reoperation rate (1% vs 0.3%, respectively; P = 0.32). Length of stay was 1 day in both groups (P = 0.89), and the readmission rate was similar (5.1% vs 3.4%, respectively; P = 0.32). No risk factors for SLCs were found. CONCLUSION: The incidence of postoperative SLCs did not appear to depend on the presence or absence of FS.

Gastropancreatic ligament: Description, incidence, and involvement during laparoscopic sleeve gastrectomy.

During laparoscopic sleeve gastrectomy (LSG), adhesions between the stomach and the pancreas are sometimes found, forming a "gastropancreatic ligament" (GPL). However, the GPL has only been described once in the literature, in 1985. The objective of this study was to determine the incidence of the GPL during LSG, describe this structure and assess its effect on the surgical technique. All patients undergoing primary LSG in our institution (n = 240) and patients referred for gastric fistula (GF) after primary LSG (n = 18) between January 2015 and December 2015 were included. The primary endpoint was the incidence of a GPL during primary LSG. The secondary endpoints were the postoperative complication rate, the postoperative GF rate, and the presence of this ligament during reoperation for GF. Among the 240 patients, a GPL was visible in 49 cases (20.4%) and was described as thin in 34 of these (69.4%). Twelve postoperative complications (5%) were observed, including seven major (2.9%). The GF rate was 2% (n = 5), not requiring reoperation. The gastric stenosis rate was 0.4% (n = 1). The GPL had been previously sectioned in one of the five patients (20%) with postoperative GF. During the study period, 18 patients were referred for GF and 14 were reoperated. A non-sectioned GPL, not described in the operating report, was observed in four patients (28.5%). A GPL was identified in 20.4% of cases. Identification of a GPL could be important in the context of LSG, as section of the ligament allows tension-free stapling to be performed and can therefore possibly reduce the risk of postoperative complications, particularly GF. Clin. Anat. 30:336-341, 2017. © 2017 Wiley Periodicals, Inc.

Laparoscopy-assisted open cystogastrostomy and pancreatic debridement for necrotizing pancreatitis (with video).

INTRODUCTION: Pancreatic pseudocysts and walled-off necrosis are well-known complications, described in 10% of cases of acute pancreatitis. Open cystogastrostomy is usually proposed after failure of minimally invasive drainage or in the presence of septic shock. The objective of this study was to evaluate the feasibility and efficacy of laparoscopy-assisted open cystogastrostomy for treatment of symptomatic pancreatic pseudocyst with pancreatic necrosis. MATERIALS AND METHODS: Between January 2011 and October 2014, all patients with pseudocyst and pancreatic necrosis undergoing open cystogastrostomy were included. Surgical procedure was standardized. The primary efficacy endpoint was the feasibility and efficacy of laparoscopy-assisted open cystogastrostomy as treatment of symptomatic pancreatic pseudocyst. Secondary endpoints included demographic data, preoperative management, operative data, postoperative data and follow-up. RESULTS: Laparoscopy-assisted open cystogastrostomy was performed in 11 patients [six men (54%)], with a median age of 61 years (45-84). Nine patients received preoperative radiological or endoscopic management. First-line open cystogastrostomy was performed in two cases. Median operating time was 190 min (110-240). There was one intraoperative complication related to injury of a branch of the superior mesenteric vein. There were no postoperative deaths and two postoperative complications (18%) including one major complication (postoperative bleeding). The median length of hospital stay after surgery was 16 days (7-35). The median follow-up was 10 months (2-45). One patient experienced recurrence during follow-up. CONCLUSION: Open cystogastrostomy for necrotizing pancreatitis promotes adequate internal drainage with few postoperative complications and a short length of hospital stay. However, this technique must be performed very cautiously due to the risk of vascular injury which can be difficult to repair in the context of severe local inflammation related to pancreatic necrosis.

The gentamicin-collagen sponge for surgical site infection prophylaxis in colorectal surgery: a prospective case-matched study of 606 cases.

PURPOSE: Surgical site infection (SSI) is a major concern in colorectal surgery (CRS). It accounts for 60 % of all postoperative complications and has an incidence of between 10 and 30 %. The gentamicin-collagen sponge (GCS) was developed to help avoid SSI. The aim of this study was the evaluation of the efficacy of a GCS in preventing SSI after CRS. METHOD: This study was a retrospective analysis of data collected in a prospective database. Six hundred six CRS patients were enrolled in the study and prospectively assigned to one of two groups. From January 2007 to December 2008, all procedures were performed without the use of GCS (forming the non-GCS group). From January 2009 to July 2011, all procedures included a GCS (forming the GCS group). The primary endpoint was the presence or absence of SSI at postoperative day 30. RESULTS: The incidence of SSI was 29.7 and 20.8 % in the non-GCS and GCS groups, respectively (p = 0.019). By using a stepwise logistic regression, the predictors of SSI were found to be ASA grade (p < 0.001), operating time (log-transformed value, p < 0.001), gender (p = 0.021), and GCS use (p < 0.001). By adjusting on these variables, a mean reduction in postoperative hospitalization of 8.3 days was found in the GCS group. The proportions of Clavien IIIB-V were 16.6 and 8.9 % for the non-GCS and GCS groups, respectively (p = 0.041). CONCLUSIONS: This study provides additional evidence of the efficacy of the GCS in reducing SSI rates and shortening hospitalization after CRS.

Does longitudinal sleeve gastrectomy have a family "halo effect"? A case-matched study.

INTRODUCTION: Some researchers have suggested that the weight loss of a patient who has undergone bariatric surgery could be influenced by his or her family environment. Indeed, some people decide to undergo surgery after another family member has had the operation. This study aimed to evaluate the results of longitudinal sleeve gastrectomy (LSG) performed for several members of a family compared with to a control group of unrelated individuals. MATERIAL AND METHODS: On the basis of preoperative data, 78 LSG patients from 39 families (the LSG-family group) were matched 1:1 with 78 LSG patients selected from among 550 LSG patients whose family members had undergone no bariatric surgery (the LSG group). Within the LSG-family group, a distinction was drawn between family members who had undergone surgery before their relation (the LSG-family 1 subgroup) and those who had undergone surgery after their relation (the LSG-family 2 subgroup). RESULTS: The median preoperative body mass index (BMI) in each of the two groups was 48.1 kg/m². The LSG-family and LSG groups 24 months after surgery had respective mean BMIs of 28.6 and 32.5 kg/m² (p ≤ 0.01), excess weight losses (EWLs) of 83.5 % and 71.4 % (p ≤ 0.01), and missed consultation rates of 13.1 % and 25.9 % (p = 0.04). A comparison of the LSG-family 1 and family 2 subgroups 24 months after surgery showed respective mean BMIs of 30.0 and 27.5 kg/m² (p = 0.12), EWLs of 80.2 % and 86.2 % (p = 0.32), and missed consultation rates of 14.1 % and 12.1 % (p = 0.22). CONCLUSION: The outcome for LSG in terms of weight loss and postoperative follow-up care was better in the family group than in the control group. This may have been due to better postoperative follow-up care for the patients in the LSG-family group. Within a family, the patients who had surgery after their relation showed a trend toward greater weight loss and better postoperative follow-up care.

Gastrointestinal bleeding complication of gastric fistula after sleeve gastrectomy: consider pseudoaneurysms.

BACKGROUND: Gastric fistula (GF) is the most serious complication after longitudinal sleeve gastrectomy (LSG), with an incidence ranging from 0 to 5 %. In this context, concomitant upper gastrointestinal bleeding (UGIB) has never been described. Here, we describe our experience of this situation and suggest a procedure for the standardized management of this life-threatening complication. METHODS: We retrospectively analyzed all patients having been treated for post-LSG UGIB in our university medical center between November 2004 and February 2012. Data on GF and UGIB (time to onset, diagnosis and management) were assessed. RESULTS: Forty patients were treated for post-LSG GF in our institution, 18 of whom (45 %) had been referred by tertiary centers. Four patients presented UGIB (10 %): two had undergone primary LSG, one had undergone simultaneous gastric band removal and LSG, and one had undergone repeat LSG. The median time interval between GF and UGIB was 15 days. The four cases of UGIB included three pseudoaneurysms (75 %, with two affecting the left gastric artery and one affecting the upper pole of the splenic artery) and one case of bleeding related to stent-induced gastric ulceration. Computed tomography enabled diagnosis of the pseudoaneurysm in all cases. Two of the four patients (50 %) were treated with selective embolization during arteriography, and two (50 %) were treated surgically with arterial ligation. One of the surgically treated patients died during follow-up. CONCLUSIONS: UGIB after LSG was investigated in the context of a postoperative GF and was found to have been caused by a pseudoaneurysm in 75 % of cases. When looking for a pseudoaneurysm, a primary angiography should be preferred to endoscopy allowing selective arterial embolization in hemodynamically stable patients, whereas surgery should be reserved for treatment failures or hemodynamically instability.

Gastric leak after sleeve gastrectomy: risk factors for poor evolution under conservative management.

BACKGROUND: Gastric leak (GL) is the most highly feared early postoperative complication after sleeve gastrectomy (SG), with an incidence of 1% to 2%. This complication may require further surgery/endoscopy, with a risk of management failure that may require additional surgery, including total gastrectomy, leading to a risk of mortality of 0% to 9%. OBJECTIVES: Assess the impact of factors that may lead to a poorer evolution of GL. SETTING: University Hospital, France, public practice. METHODS: This was a retrospective, single-center study of a group of patients managed for GL after SG between November 2004 and January 2019 (n = 166). Forty-three patients were excluded. The population study was divided into 2 groups: patients with easy closing of the GL (n = 73) and patients with difficult closing of the GL or failure to heal (n = 50). Patients were allocated to 1 of 2 groups depending on the time to heal (median time of 84 days). The study's primary efficacy endpoint was to determine the risk factors for a poorer evolution of GL. RESULTS: Among 123 patients included in this study, 103 patients had undergone primary SG (83.7%). The mean time to the appearance of GL was 15.1 days (range, 1-156 d). Seventy-four patients underwent a reoperation (60%). The mean number of endoscopies per patient was 2.7 (range, 2-7 endoscopies). The mean time to healing was 89.5 days (range, 18-386 d). There were 8 cases of healing failure (6.5%). Multivariate analysis identified body mass index (>47 kg/m2), time to referral (>2 d), and serum prealbumin level (<.1 g/dL) to be independent risk factors for a poorer evolution of GL. CONCLUSION: Improvement of nutritional status before SG and early referral for GL could reduce the risk of delayed closure or the need for further surgery.

Technique of open laparoscopy for supramesocolic surgery in obese patients.

BACKGROUND: Incidence of obesity and related diseases are increasing in the world. Visceral surgeons are more often confronted with laparoscopic surgery in obese patients. Besides validated surgery procedures, such as cholecystectomy and gastroesophageal reflux surgery, bariatric procedures are increasingly performed. In obese patients, the thickness of adipose panicle makes open laparoscopy hazardous. METHODS: In our department, we use systematically a technique of open laparoscopy in obese patients for supramesocolic surgery, which is safe, reproducible, and permits good closure of the abdominal wall. RESULTS: The surgical technique consists of opening the abdominal wall through the rectus abdominis. Helped by specific retractors called Descottes (Medtronic Laboratory), both fascias are charged by sutures separately. Incision in the fascias is made safely by pooling on sutures. Introduction of port-site is made under view control. At the end of laparoscopy, closure of both fascias is easily done. CONCLUSIONS: We present a technique of open laparoscopy in obese patients, systematically used, for supramesocolic surgery. This technique is safe, reproducible, and permits an efficient closure of the abdominal wall.

Sleeve gastrectomy as a rescue of failed gastric banding: comparison of 1- and 2-step approaches.

BACKGROUND: Series comparing gastric banding (GB) removal and sleeve gastrectomy (SG) when procedures are performed as a 1- or a 2-step approach are contradictory in their outcomes. No series comparing these approaches with midterm weight loss is available. OBJECTIVES: Compare the outcomes and weight loss of SG performed as 1- and 2-step approaches as a revisional procedure for GB failure. SETTING: University Hospital, France, public practice. METHODS: Between February 2006 and January 2017, all patients undergoing SG with a previous history of implementation of GB (n = 358) were included in this 2-center, retrospective, observational study. Revisional surgery was proposed in patients with insufficient excess weight loss (excess weight loss ≤50%) or weight regain after GB. A 1-step (1-step group, n = 270) or 2-step (2-step group, n = 88) approach was decided depending on patient's choice and/or surgeon's preference. The primary efficacy endpoint was the comparison of weight loss in the 1- and 2-step groups at the 2-year follow-up. The secondary efficacy endpoints were short-term outcomes (overall mortality and morbidity at postoperative day 30, specific morbidity, reoperation, length of hospital stay, and readmission). RESULTS: In the 1-step group, the mean preoperative body mass index before SG was 40.5 kg/m2 (27.0-69.0), while in the 2-step group, the mean preoperative body mass index was 43.5 kg/m2 (31.5-61.7). Mean operating time was 109 minutes (50-240) in the 1-step group and 78.7 minutes (40-175) in the 2-step group (P = .22). In the 1-step group, 6 conversions to laparotomy occurred, while in the 2-step group, 2 conversions to laparotomy occurred (P = .75). One death (.2%, in the 2-step group) and 39 complications (30 in the 1-step group [11.1%] and 9 in the 2-step group [10.2%]) also occurred. The mean length of hospital stay was 6.2 days in the 1-step group and 4.1 days in the 2-step group. At 2-year follow-up, mean body mass index was 32.4 kg/m2 in the 1-step group and 33.2 kg/m2 in the 2-step group (P = .15), representing excess weight losses of 61.9 and 50.1 (P = .05), respectively. The rates of revisional surgery were .7% and 2.2%, respectively. CONCLUSIONS: SG after previous GB is efficient with similar outcomes depending on the 1- or 2-step approach. The 1-step approach seems to have increased weight loss compared with the 2-step approach.

[Bariatric surgery in the treatment of severe obesity]. / Place de la chirurgie dans la prise en charge de l'obésité morbide.

Over the past ten years, the treatment of severe obesity has radically changed through the benefits of bariatric surgery not only on weight loss significant and lasting, but also on reducing mortality, correction of metabolic disorders, reduction of cardiovascular risk and improving the quality of life. Its indication should be multidisciplinary. Laparoscopy has become the rule, reducing the postoperative morbimortality. Four types of intervention are regularly performed in France. We report their principle, their results and major complications.

Laparoscopic sleeve gastrectomy as day-case surgery: a case-matched study.

BACKGROUND: Few series have demonstrated the feasibility of laparoscopic sleeve gastrectomy (SG) as day-case surgery (DCS). OBJECTIVE: Compare the outcomes and healthcare costs of SG performed as DCS or as an inpatient procedure. SETTING: University Hospital, France, public practice. METHODS: This was a prospective, nonrandomized study of 250 consecutive patients undergoing day-case SG from May 2011 to June 2017. Each patient in the DCS group (n = 250) was manually paired by sex, age, body mass index, preoperative co-morbidities, and year of surgery with 1 patient undergoing SG as an inpatient procedure (SG control group, n = 250). Patients in the SG control group were excluded from DCS on the basis of DCS criteria. The primary endpoint of this study was the clinical and economic impact of performing SG as DCS compared with inpatient management. The secondary endpoints were related to DCS, DCS satisfaction rate, comparison of outcomes and costs between DCS and inpatient procedures, and the changing modalities of SG as DCS in our institution (by comparing the first 100 patients to the last 150 patients). RESULTS: A total of 1573 patients underwent SG during the period, 250 patients underwent SG as DCS (15.9%) and 554 patients were excluded on the basis of DCS criteria. No postoperative deaths, 19 overnight admissions (7.6%), 16 unscheduled consultations (6.4%), and 12 unscheduled hospitalizations (4.8%) were observed in the DCS group. No significant differences were observed in postoperative complications. Readmission was higher in the DCS group (5.6% versus 4%; P < .001), while the length of rehospitalization was shorter in the DCS group (5.8 versus 10.8 d; P < .001). Overall cost and cost per patient were significantly lower in the DCS group (P < .001). CONCLUSION: Day-case SG on selected patients was not associated with increased morbidity and mortality rates and was cost-effective due to the low cost of management of postoperative complications.

Impact of Routine 12 mm Epigastric Trocar Site Closure on Incisional Hernia After Sleeve Gastrectomy: a Prospective Before/After Study.

BACKGROUND: Recent studies have reported trocar site hernia (TSH) rates after bariatric surgery ranging from 0 to 45.2% based on imaging assessment. The objective of this study was to evaluate the TSH rate after sleeve gastrectomy (SG) comprising routine 12 mm epigastric trocar site closure (TSC). MATERIAL: Prospective observational study with retrospective control cohort of a group of patients undergoing primary SG with routine 12 mm epigastric TSC. The "before" group (control group) was a previously published group of patients without 12 mm epigastric TSC and the "after" group (closure group) concerned patients with routine 12 mm epigastric TSC. Primary endpoint was the TSH rate after routine epigastric TSC. Secondary endpoints were comparison of the TSH rate, TSC feasibility and causes of failure, TSC-related morbidity, evaluation of TSC time and its course, and identification of risk factors for TSH. RESULTS: One hundred twenty-three patients were analyzed during the study period. Feasibility of epigastric TSC was 97.3% without related morbidity. Mean epigastric TSC time was 44.2 s (18-150). Epigastric TSC time was always less than 60 s after 10-15 procedures. At 1 year, 10 patients presented TSH (8.1%): epigastric in 6.5% (n = 8) cases and after open laparoscopy in 1.6% (n = 2) cases. Comparison of the two groups revealed a lower TSH rate in the closure group (8.1% vs. 17.0%; p = 0.02), due to a lower epigastric TSH rate (6.5% vs. 14.8%; p = 0.02). Routine epigastric TSC was a protective factor for TSH (p = 0.03; relative risk of 0.43). CONCLUSION: Routine epigastric TSC during SG is rapid and provides effective prevention of TSH.

Comparison of Repeat Sleeve Gastrectomy and Roux-en-Y Gastric Bypass in Case of Weight Loss Failure After Sleeve Gastrectomy.

BACKGROUND: Few series are available on the results of repeat sleeve gastrectomy (re-SG) and Roux-en-Y gastric bypass (RYGB) performed to manage the failure of primary sleeve gastrectomy (SG). The objective of this study was to compare the short- and medium-term outcomes of re-SG and RYGB after SG. MATERIAL & METHODS: Between January 2010 and December 2017, patients undergoing re-SG (n = 61) and RYGB (n = 83) for failure of primary SG were included in this study. Revisional surgery was proposed for patients with insufficient excess weight loss (EWL ≤ 50%) or weight regain. The primary endpoint was the comparison of weight loss in the re-SG group and the RYGB group at the 1-year follow-up. The secondary endpoints were overall mortality and morbidity, specific morbidity, length of stay, weight loss, and correction of comorbidities. RESULTS: The mean interval between SG and re-SG was 41.5 vs. 43.2 months between SG and RYGB (p = 0.32). The mean operative time was 103 min (re-SG group) vs. 129.4 min (RYGB group). One death (1.7%; re-SG group) and 25 complications (17.4%; 9 in the re-SG group, 16 in the RYGB group) were observed. At the 1 year, mean body mass index was 31.6 in the re-SG group and 32.5 in the RYGB group (p = 0.61) and excess weight loss was 69.5 vs. 61.2, respectively (p = 0.05). CONCLUSION: Re-SG and RYGB as revisional surgery for SG are feasible with acceptable outcomes and similar results on weight loss on the first postoperative year.

Repeat sleeve gastrectomy: optimization of outcomes by modifying the indications and technique.

BACKGROUND: Few series are available concerning repeat sleeve gastrectomy (re-SG), and series have reported contradictory results concerning morbidity rates, with limited data concerning weight loss. OBJECTIVE: Evaluate the short- and medium-term outcomes of re-SG. SETTING: University hospital, France, public practice. METHODS: Between June 2007 and March 2016, all patients undergoing re-SG (n = 46 patients) were included. Re-SG was proposed for patients with insufficient excess weight loss (EWL) (≤50%) or renewed weight gain with excessively high residual gastric volume (>250 mL and/or large gastric pouch). The primary efficacy endpoint was the overall complication rate of re-SG. The secondary efficacy endpoints were operative data, evaluation of weight loss, and correction of co-morbidities, risk factors for gastric leak (GL), by comparing 2 periods (period 1, January 2004-December 2013: blue/green or purple staplers without reinforcement; period 2, after December 2013: black staplers with reinforcement) and comparison of weight loss according to the indication for re-SG. RESULTS: The re-SG group consisted of 46 patients (35 women, mean age: 47.5 yr). The mean body mass index (BMI) before SG was 47.2 kg/m² (35-63.6). The mean time interval between SG and re-SG was 73 months (11-106). The BMI before re-SG was 41.2 kg/m² (29-54.7). Indications for surgery were insufficient weight loss in 25 patients (54.3%) and weight regain in 21 patients (45.7%). A large gastric pouch was visible in 4 patients (8.6%). The mean operating time was 97.6 minutes (45-220). One death (2.1%) and 7 complications (15.2%) were observed. The mean length of hospital stay was 3.6 days (1-30). At last follow-up, mean BMI was 32.1 kg/m2 (20.3-41.3) and mean EWL was 62.3% (18-127.2). When analyzing risk factors for GL, residual gastric volume between 250 and 350 mL was associated with a higher GL rate compared with a volume ≥350 mL, and re-SG performed during period 1 was associated with a higher GL rate than re-SG performed during period 2 (17.4% versus 0%; P = .13). Re-SG performed for weight regain was associated with a significantly higher additional weight loss compared with re-SG performed for insufficient weight loss (mean additional EWL of 45.9%; P = .06). CONCLUSION: Re-SG is feasible, but it requires adaptation of the surgical procedure to decrease complications. Results on weight loss are acceptable, but the best indications for re-SG were a gastric volume>350 mL and in the case of weight regain with the exception of technical failure of the primary SG.

Identifying Patients Eligible for a Short Hospital Stay After Stoma Closure.

INTRODUCTION: The implementation of enhanced recovery programmes after elective colorectal surgery has dramatically reduced the length of stay. The objective of this study was to assess the selection of good candidates for short post-operative stay (GCSS) in the context of stoma closure. METHODS: Between January 2011 and December 2014, 222 patients were included in the present retrospective, single-center study. The primary endpoint was the proportion of GCSS. We also identified factors associated with GCSS status and built a predictive score. RESULTS: The study population was predominantly male (n = 122, 55%). 60% of the patients had undergone ileostomy and 85% had undergone hand-sewn anastomosis. The postoperative ileus rate was 5% and the readmission rate was 3.5%. 41% (n = 92) of the study population were considered to be GCSS. In a multivariate analysis, age under 50 (odds ratio (OR) [95% confidence interval (CI)] = 2.8 [1.2-5.6], p = 0.008), the absence of vascular comorbidities (OR [95%CI] = 3.2 [1.3-12.3]; p = 0.006) and stapled anastomosis (OR: 4.2, 95%CI: 1.1-17.3, p = 0.03) were associated with GCSS status. Predictive scores of 0, 1, 2, and 3 were associated with GCSS rates of 20%, 18%, 44%, and 62%, respectively (p < 0.001). CONCLUSION: In the context of stoma closure, 41% of patients were GCSS.