A practical port-sharing approach for concomitant cholecystectomy with laparoscopic sleeve gastrectomy: single-center experience.

Gallbladder disease is very common in obese patients. Concomitant cholecystectomy with laparoscopic sleeve gastrectomy (CC-LSG) may be necessary in such cases, and it has been proven safe when indicated. Herein, we presented an experience of our practical four-port-sharing technique for CC-LSG that can substitute the conventional trocar placement. A cohort study was conducted between January 2017 and March 2022 using a prospective database. Out of 238 patients with obesity who underwent bariatric surgery, 45 patients with gallbladder disease received CC-LSG using our four-port-sharing technique. The patients' demographic characteristics, intraoperative outcomes, and postoperative outcomes were examined. Of 45 obese patients with gallbladder disease undergoing CC-LSG, 18 patients with symptomatic cholelithiasis, 25 patients with asymptomatic cholelithiasis, and 2 patients with gallbladder polyps were identified. The mean age of these 45 patients (26 men and 19 women) was 38.3 years, and the mean body mass index was 41.8 kg/m2. There was no case of conversion to laparotomy. The mean operative time of LC and following LSG, the volume of blood loss, and hospital stay were 52.7 minutes and 95.2 minutes, 13.3 mL, and 3.8 days, respectively. No postoperative complications, including hemorrhage, bile leakage, staple leakage, pulmonary embolism, incisional hernia, and wound infection were noted. In CC-LSG, the application of our four-port-sharing technique is safe and feasible for obese patients with gallbladder diseases.

A Practically Modified Approach With Complete Posterior Mobilization for Three-port Sleeve Gastrectomy: Single-center Experience.

BACKGROUND: Although the procedure of laparoscopic sleeve gastrectomy (LSG) has been standardized either in conventional lateral to medial or medial to lateral approach, surgeons occasionally face the challenge of poor visualization of the His angle and difficulty in complete posterior mobilization in limited surgical field. This study aimed to introduce our novel details of modified approach to address these issues. METHODS: One hundred patients with obesity underwent modified approach- three-port laparoscopic sleeve gastrectomy. Herein, we demonstrated our method to ease the procedure of gastric fundus mobilization with extensive posterior mobilization (shown in video, Supplemental Digital Content 1, http://links.lww.com/SLE/A336 ). The demographic characteristics and perioperative data were reviewed. RESULTS: There was no case of conversion to open surgery. The mean operative time, volume of blood loss, and hospital stay were 72.5±22.7 minutes, 11.6±10.5 mL, and 4.3±2.1 days, respectively. One postoperative leakage was observed and it was successfully treated with metallic covered stent. The percentage of total weight loss at 6 months and 1 year were 20.3±8.4 and 29.8±9.2, respectively. CONCLUSIONS: Our experience showed that the modified technique is feasible and may help surgeons to accomplish a complete posterior mobilization, and better address the poor visualization of the the His angle-site owing to the interposition of floating omentum or bulging part of the stomach.

The Combination of Sleep Disorders and Depression Significantly Increases Cancer Risk: A Nationwide Large-Scale Population-Based Study.

Introduction: Sleep disorders, depression, and cancer have become increasingly prevalent worldwide. However, it is unknown whether coexistence of sleep disorders and depression influences the risk of cancer development. Therefore, we conducted a nationwide population-based study to examine this association among patients in Taiwan. Materials and Methods: A total of 105,071 individuals diagnosed with cancer and 420,284 age- and sex-matched patients without a diagnosis of cancer between 2000 and 2015 were identified from Taiwan's National Health Insurance Research Database. The underlying chronic diseases of patients that may developed cancer were gathered and studied as the predictor. A multivariate Cox proportional odds model was used to estimate the crude and adjusted odds ratios (aORs) with 95% confidence intervals (CIs) to estimate the interaction effect between sleep disorders and depression on the risk of cancer. Results: After adjusting for age, sex, comorbidities, and other covariates, the cancer group was associated with increased exposure to sleep disorders than the non-cancer group (aOR = 1.440, 95% CI = 1.392−1.489, p < 0.001). In addition, patients with both sleep disorders and depression were at an even higher risk for cancer than the general population (aOR = 6.857, p < 0.001). Conclusions: This retrospective cohort study shows that patients with both sleep disorders and depression are at a higher risk of cancer. Clinically, a meticulous cancer risk evaluation is recommended for patients with both sleep disorders and depression.

Combined Re-sleeve and Single Anastomosis Sleeve Ileal (SASI) Bypass as a Second Stage After Sleeve Gastrectomy (Video Report).

BACKGROUND: In comparison with purely restrictive procedures, combined restrictive and malabsorptive procedures seem to produce better weight loss and comorbidity control in patients with morbid obesity. Two-stage bariatric surgery is popular and is a safe and efficient strategy for patients with super obesity (BMI > 50 kg/m2) and super-super obesity (BMI > 60 kg/m2). METHODS: The patient in this video was a 36-year-old man with an initial BMI of 53.2 kg/m2. Two-stage bariatric surgery was planned. The patient underwent the first stage, laparoscopic sleeve gastrectomy, in 2018. Eighteen months after surgery, his lowest BMI was 38.8 kg/m2, and his excess weight loss was 50.9%. In 2021, he regained weight and reached a BMI of 42.4 kg/m2. Then, a second-stage bariatric surgery was performed. RESULTS: As shown in the video, combined re-sleeve and single anastomosis sleeve ileal (SASI) bypass constituted the second stage of bariatric surgery. During the operation, adhesiolysis was first performed, and the stomach was mobilized through a lateral-to-medial approach. Gastric transection was performed with a 36-Fr bougie. Then, the ileocecal junction was identified, and a location 250 cm from the cecum was selected as the anastomosis site. Gastro-ileal anastomosis (3 cm in diameter) was established with a stapler, and the two-layer suture method was used to close the defect. The postoperative period was uneventful, and the patient was discharged 5 days after surgery. CONCLUSIONS: Combined re-sleeve and SASI bypass has a few surgical morbidities and is promising as an alternative to second-stage duodenal switch in patients with super obesity.

Combined Nissen Fundoplication and Single Anastomosis Sleeve Ileal Bypass (N-SASI) as a Practical Modality of Bariatric Surgery (Video Report).

Sleeve gastrectomy is one of the most common bariatric procedures because of its simplicity and effectiveness. Gastro-esophageal reflux disease (GERD) symptoms and weight regain after SG are common issues. Roux-en-Y gastric bypass (RYGB) is currently the most promising approach to achieve satisfying weight loss and GERD remission; however, remnant gastric cancer is still a major concern for patients. We present a video case that individualized procedure of Nissen fundoplication, and SASI bypass (N-SASI) was designed and applied to the patient with class III obesity and severe GERD. This is a 37-year-old man with obesity (BMI: 41.8 kg/m2, categorized as class III obesity) and associated disease of stage 1 hypertension, hyperlipidemia, obstructive sleep apnea syndrome, and non-alcoholic steatohepatitis as well as severe symptoms of GERD. Esophageal-gastro-duodenal scope revealed GERD grade C, hiatal hernia, and duodenal ulcer. He refused RYGB recommended initially due to serious concern about remnant gastric cancer. We therefore performed Nissen fundoplication for his GERD symptoms and adapted SASI bypass instead of RYGB as the individualized bariatric surgery to achieve the optimal surgical outcome. The postoperative course was smooth, and the patient was discharged on postoperative day 8.

Revisional Single Anastomosis Sleeve Ileal (SASI) Bypass for Failed Gastric Clipping and Proximal Jejunal Bypass (GC-PJB) (Video Report).

BACKGROUND: Bariatric surgery, the most effective strategy to manage morbid obesity, has increased rapidly in the face of expanding obese population in the twenty-first century. Hence, it is reasonable to expect a rise in the need for revisional bariatric surgery (RBS), especially due to weight recidivism. METHOD: In this video report, the patient was a 28-year-old Asian female with an initial BMI of 42.6 kg/m2 and underwent primary bariatric surgery of laparoscopic gastric clipping with proximal jejunal bypass (GC-PJB) in January 2018. She had the nadir BMI of 35.2 kg/m2 in August 2019. However, she regained weight and her BMI rebounded to 43.7 kg/m2 at the time of consultation for RBS in 2021. After a multidisciplinary team evaluation, laparoscopic procedures of removal of gastric clip and single anastomosis sleeve ileal (SASI) bypass with preservation of previous jejunojejunal anastomosis were performed. RESULTS: The operative time was 216 min and blood loss was 25 ml. There were no intraoperative or postoperative complications. The patient had an uneventful postoperative course and was discharged 4 days after surgery. At the 3-month follow-up after RBS, the patient had lost 25 kg (weight dropped from 119 to 94 kg), and the corresponding BMI was 34.5 kg/m2. CONCLUSION: Laparoscopic removal of gastric clip and SASI bypass with preservation of previous jejunojejunal anastomosis is technically feasible and promising as a revisional procedure for failed GC-PJB.