Management of the staple line in laparoscopic sleeve gastrectomy: comparison of three different reinforcement techniques.

BACKGROUND: Nowadays, laparoscopic sleeve gastrectomy (LSG) is one of the most widely performed bariatric procedures. Different techniques have been described to reduce the rate of complications associated with the staple line, but no consensus has been reached. The aim of this study was to determine the incidence of surgical complications after LSG with three different approaches to the staple line. PATIENTS AND METHODS: A retrospective matched analysis was performed, comparing three groups of 100 patients each: partial oversewing of the staple line (PO group), complete oversewing of the staple line (CO group), and reinforcement with buttress material (BM group). Operative time, early surgical complications (superficial surgical site infection, leakage and hemorrhage), length of stay, weight evolution, and revisional surgery rates were analyzed. RESULTS: All three groups were comparable at baseline. All surgeries were performed laparoscopically. Operative time was significantly longer in the CO group (PO: 84.2 ± 22; CO: 104.7 ± 17; BM: 82.3 ± 22; PO vs CO, p = 0.021; BM vs CO, p = 0.011). There were no differences in length of stay, early surgical complications, and weight outcomes at 36 months between the groups. The need for a revisional surgery was significantly higher in the CO group compared to the PO group (PO: 3%; CO: 14%; BM: 9%; PO vs CO, p = 0.005). CONCLUSION: The CO group required a longer operative time. There were no differences in early surgical complications between the groups. The CO group had a higher need for revisional surgery than the PO group.

Effects of COVID-19 lockdown on a bariatric surgery waiting list cohort and its influence in surgical risk perception.

PURPOSE: The COVID-19 outbreak has forced a 2-month lockdown (LD) in Spain. We aimed to assess how that had affected our cohort of bariatric patients waiting for surgery. METHODS: A review of electronic records and a structured phone interview with each patient were conducted. Changes in severity of obesity were analyzed using the Obesity Surgery Score (OSS) and changes in health-related quality of life (HRQoL) using the validated EQ-5D questionnaire. Other miscellaneous questions about behavior modifications and surgical risk perception were also analyzed. RESULTS: All 51 patients fully answered the questionnaires. Mean age was 47 years and mean time on waiting list 91 days. Mean BMI increased during LD (42.7 vs 43.2; p < 0.001). Both OSS (2.84 vs 3; p = 0.011) and EQ-5D (69 vs 64; p < 0.001) mildly worsened during LD, mainly due to psychosocial issues. Twenty-seven patients (53%) thought that perioperative risks were higher under the current circumstances but they were as willing to undergo surgery as those who believed that the risks had not increased (74% vs 87%, p = 0.2). CONCLUSIONS: COVID-19 LD had a significant but mild effect on our cohort of bariatric surgery waiting list patients. Although perioperative risk perception had increased, patients were still willing to undergo their planned surgeries.

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.

Robotic Revisional Experience. Single Centre Prospective Cohort Study and Review of the Literature.

Background: Robotic bariatric surgery (RBS) has increased in recent years. Many doubts continue to exist regarding its utility in terms of postoperative complications, costs and technical aspects. RBS has increased its number and shows a more technical challenge associated with more post-operative complications compared to primary bariatric surgery. We herein present a single institution experience and review to describe its utility in revisional surgery. Methods: A retrospective review of our experience and a review of the literature has been conducted to evaluate the impact of robotic revisional surgery in the bariatric field. Results: A total of 17 patients (5 female and 12 male) were operated on. Most frequent surgery was conversion of sleeve gastrectomy to gastric bypass (n=9). No leaks were found nor severe complications. A systematic review showed similar results including a decreased number for complications when performing robotic revisional surgery. Conclusions: Revisional robotic surgery shows better results compared to standard laparoscopic revisional bariatric surgery in terms of efficacy, safety and hospital stay. No differences were seen in rates of mortality, morbidity and reintervention between both approaches. We encourage surgeons to learn to perform the robotic technique as part of the process of democratization and standardization of bariatric surgery.

SPECT/CT sentinel lymph node identification in papillary thyroid cancer: lymphatic staging and surgical management improvement.

PURPOSE: Lymphadenectomy in papillary thyroid carcinoma (PTC) continues to be controversial. A better staging method is needed to provide adequate individual surgical treatment. SPECT/CT lymphoscintigraphy and sentinel lymph node (SLN) biopsy may improve lymphatic staging and surgical treatment. Our main objectives were to describe the lymphatic drainage of PTC using lymphoscintigraphy, to evaluate the lymphatic spread (comparing SLN and lymphadenectomy results) and to analyse the impact of SLN identification in surgery. METHODS: We prospectively studied 24 consecutive patients with PTC (19 women; mean age 52.7 years, range 22-81 years). The day before surgery, lymphoscintigraphy with ultrasound-guided intratumoral injection ((99m)Tc-nanocolloid, 148 MBq) was performed, obtaining planar and SPECT/CT images. All patients underwent total thyroidectomy, SLN biopsy (hand-held gamma probe) with perioperative analysis, central compartment node dissection, or laterocervical lymphadenectomy if perioperative stage N1b or positive SLNs in this lymphatic basin. RESULTS: Lymphoscintigraphy revealed at least one SLN in 19 of 24 patients (79 %) on planar and SPECT/CT images, and in 23 of 24 patients (96 %) during surgery using a hand-held gamma probe. Lymph node metastases were detected with classical perioperative techniques (ultrasound guidance and surgical inspection) in 3 of 24 patients, by perioperative SLN analysis in 10 of 23, and by definitive histology in 13 of 24. The false-negative (FN) ratio for SLN was 7.7 % (one patient with bulky lymph nodes). The FN ratio for perioperative frozen sections was 15.4 % (two patients, one with micrometastases, the other with bilateral SLN). Lymphatic drainage was only to the central compartment in 6 of 24 patients (3 of the 6 with positive SLNs for metastases), only to the laterocervical basin in 5 of 24 patients (all unilateral, 2 of 5 positive SLNs) and to the central and laterocervical compartments in 12 of 24 patients (6 of 12 and 3 of 12 positive SLNs, respectively). CONCLUSION: Lymphoscintigraphy reveals the lymph node drainage in a high proportion of patients. It detects laterocervical drainage in a significant percentage of patients, allowing the detection of occult lymph node metastases and improving the surgical management in PTC.

Laparoscopic repair of a postadrenalectomy left-sided diaphragmatic hernia complicated by chronic colon obstruction.

Iatrogenic diaphragmatic hernias are a rarely reported complication of abdominal surgery. We present a case of an iatrogenic diaphragmatic hernia diagnosed 2 years after an adrenalectomy. Corrective laparoscopic surgery was performed, and the postoperative course was uneventful. The patient remained asymptomatic 6 months after the repair. To our knowledge, this is the first such case to be reported.

Internet of things and bariatric surgery follow-up: Comparative study of standard and IoT follow-up.

INTRODUCTION: Follow-up of obese patient is difficult. There is no literature related to patient follow-up that incorporates the concept of Internet of Things (IoT), use of WiFi, Internet, or portable devices for this purpose. MATERIAL AND METHODS: This prospective observational study commenced in June 2011. Patients were prospectively offered to participate in the IoT study group, in which they received a WiFi scale (Withing®, Paris) that provides instant WiFi data to the patient and surgeon. Other patients were admitted to the standard follow-up group at the outpatient clinic. A total of 33 patients were included in our study (ten in the IoT group). RESULTS: Twelve patients did not have WiFi at home, ten lacked of computer knowledge, and seven preferred standard for follow-up. All patients underwent different surgical procedures. There were no complications. Excess weight loss (EWL) was similar in both groups. More than 90% of patients were satisfied. In the IoT group, patients considered it valuable in saving time, and considered seeing their evolution graphics extremely motivating. CONCLUSION: IoT technology can monitor medical parameters remotely and collect data. A WiFi scale can facilitate preoperative and follow-up. Standard follow-up in a classical outpatient clinic setting with the surgeon was preferred globally.

[Bariatric surgery in adolescents]. / Cirugía bariátrica en adolescentes.

The increased prevalence of obesity in children and adolescents is becoming a public health problem. As in adults, obesity is associated with other comorbidities and their risks. This systematic review aims to summarize the implications of morbid obesity in adolescents, and identify the currently accepted treatments for its management. Various treatments such as lifestyle changes, drug therapy, and surgery are the classical therapeutic triad. This review attempts to clarify the role of each of the major treatments in terms of safety and efficacy. Although obesity surgery in adolescents remains controversial for some aspects, there is evidence that the lack of effective treatment can lead to serious medical consequences in the future. Gastric bypass and gastric banding techniques remain of choice, but the role of other currently more popular techniques, such as sleeve gastrectomy should be clarified.

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.

Analysis of the Management of Cholelithiasis in Bariatric Surgery Patients: a Single-Center Experience.

PURPOSE: Cholelithiasis is an issue in bariatric surgery patients. The incidence of cholelithiasis is increased in morbidly obese patients. After bariatric surgery, the management maybe sometimes challenging. There is no consensus about how to deal with cholelithiasis prior to bariatric surgery. MATERIALS AND METHODS: A retrospective review from our prospectively collected bariatric surgery database. Primary bariatric procedures from 2009 to 2020 were included. Prevalence of cholelithiasis and its management prior to bariatric surgery and the incidence and management of postoperative biliary events were analyzed. RESULTS: Over 1445 patients analyzed, preoperatively cholelithiasis was found in 153 (10.58%), and 68 out of them (44.44%) were symptomatic. Seventy-six patients had a concomitant cholecystectomy. In those cases, the bariatric procedure did not show increased operative time, length of stay, morbidity, or mortality compared to the rest of primary bariatric procedures. Twelve patients (15.58%) with previous cholelithiasis and no concomitant cholecystectomy presented any kind of biliary event and required cholecystectomy. De novo cholelithiasis rate requiring cholecystectomy was 3.86%. Postoperative biliary events both in de novo and persistent cholelithiasis population did not show any difference between the type of surgery, weight loss, and other characteristics. CONCLUSIONS: Cholelithiasis was present in 10.58% of our primary bariatric surgery population. Concomitant cholecystectomy was safe in our series. Non-surgical management of asymptomatic cholelithiasis did not lead to a higher risk of postoperative biliary events. The global postoperative cholecystectomy rate was equivalent to the general population.

Management of Leak after Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy.

The single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) has been introduced in the past few years for the treatment of morbid obesity. SADI-S has shown good results in terms of long-term results and short-term complications. However, the management of patients undergoing SADI-S and suffering from a leak is a great challenge for surgeons. We present an extensive review of the currently available literature on the management of leak after SADI in morbid obese (MO) patients. We aim at providing objective information regarding the optimal management, including diagnosis, technical options for the different strategies that have been proposed, to facilitate the selection of the best individual approach for each MO patient.

The Panoramic View of Revisional Bariatric Surgery.

Introduction: Obesity remains a major public chronic disease, and the multifactorial components of its relapse in many patients remain inevitable. Methods: This article provides a panoramic view of the most commonly performed revisional bariatric surgery (RBS). RBS is a complex procedure; thus, primary procedures should be well chosen and performed to avoid the increasing number of RBS cases. Results: Bariatric surgery is the only successful long-term treatment for obesity. However, a proportion of primary bariatric surgeries has failed during the follow-up period. In recent decades, the solution for these complications is by performing RBS. It is mandatory to understand obesity as a chronic disease to appropriately treat patients. Treatment strategies are needed to determine the indications for revision. RBS requires a meticulous evaluation to facilitate good long-term results. Conclusions: Treatment strategies will be a fundamental pillar to wisely determine the indications for revision and identify the factors influencing failure by prudently and rationally evaluating the revisional procedure that the patient will benefit from and acquiring a high level of surgical skills.

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.

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.

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.

Abdominal Wall Hernia and Metabolic Bariatric Surgery.

The management of morbidly obese patients with a concomitant ventral hernia (VH) is a great challenge for surgeons. There is controversy over the optimal strategy to tackle both health problems, requiring an individualized approach. Obese patients have a higher recurrence rate after hernia repair, and bariatric surgery in the presence of a VH can be difficult. As morbid obesity is related with severe comorbidities, including increased cardiovascular and anesthetic risks, some advocate for a single-stage strategy. A primary hernia repair carried out during the bariatric surgery, however, may increase morbidity without definitively solving the problem. Biological meshes are expensive and also have a high recurrence rate. The laparoscopic placement of a synthetic mesh offers good results, but it is worrisome because bariatric surgery is a clean-contaminated procedure. Moreover, there is a great chance that a plastic surgery would be necessary after completing the weight-loss process, and the abdominal wall surgery could be performed at that point. There are many arguments, but the evidence is weak. We present an extensive review of the currently available literature on the management of VH in morbidly obese patients. We aim to provide objective information regarding the pros and cons of the different strategies that have been proposed, to facilitate the selection of the best approach to individual morbidly obese patients with abdominal wall hernias precising both of surgical repair.

Massive necrotizing fasciitis: a life threatening entity.

Necrotizing fasciitis (NF) is a complicated soft tissue infection frequently associated with severe sepsis if an early medical and surgical treatment is not performed. We report two postoperative cases of severe NF after oophorectomy and colorectal resection. Because of the similarity with more benign skin infections at the early steps, clinical suspicion is crucial. Surgical exploration and resection will provide both the diagnosis confirming necrotizing infection of the fascia with vessels and treatment. Also, empirical broad-spectrum antibiotics must be initiated as soon as possible. Regardless of the presence of risk factors, NF is a condition with a high mortality rate and only an expeditious and undelayed treatment may improve the patient's outcome. Surgical focus control requires wide and repeated resections, and planned reconstructive plastic surgery might be necessary.

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.

Seasonal variation of body weight loss after bariatric surgery.

Seasonal variations have been described in humans in several variables such as sleep, mood, appetite, food preferences, or body weight. We hypothesized that these variations could also influence the decrease in body weight rate in patients submitted to body weight loss interventions. Thus, here we tested the variations of weight loss according to the time of the year the surgery took place in a group patients (n = 1322) submitted to bariatric surgery in the Hospital Universitari de la Vall d'Hebron in Barcelona (geographical coordinates: 41°25'41″N 2°8'32″E). For the analysis, the percentage of total body weight loss (%TWL), excess body weight loss (%EWL) and percentage of body mass index loss (%BMIL) were calculated at 3 (n = 1255), 6 (n = 1172), 9 (n = 1002), and 12 months (n = 1076) after surgery. For %EWL and %BMIL a statistically significant seasonal variation was detected when the variables were calculated at 3 months, but not at the other times, with more weight loss in summer-fall. However, seasonal variations were not detected for %TWL (p = 0.09). The mean amplitude of the seasonal rhythm for %EWL was of 1.8%, while for the rhythm of %BMIL was 0.7%. Moreover, a second peak was detected in January-February modulating the seasonal rhythm of the two variables. Results confirm seasonal variations in humans and indicate that short term responses to weight loss can be modulated by the time of year.