Development and Validation of a Predictive Model for Internal Hernia After Roux-en-Y Gastric Bypass in a Multicentric Retrospective Cohort: The Swirl, Weight Excess Loss, Liquid Score.

OBJECTIVE: The aim of this study was to develop and validate a prediction score for internal hernia (IH) after Roux-en-Y gastric bypass (RYGB). SUMMARY BACKGROUND DATA: The clinical diagnosis of IH is challenging. A sensitivity of 63% to 92% was reported for computed tomography (CT). METHODS: Consecutive patients admitted for abdominal pain after RYGB and undergoing CT and surgical exploration were included retrospectively. Potential clinical predictors and radiological signs of IH were entered in binary logistic regression analysis to determine a predictive score of surgically confirmed IH in the Geneva training set (January 2006-December 2014), and validated in 3 centers, Geneva (January 2015-December 2017) and Neuchâtel and Strasbourg (January 2012-December 2017). RESULTS: Two hundred twenty-eight patients were included, 80 of whom (35.5%) had surgically confirmed IH, 38 (16.6%) had a negative laparoscopy, and 110 (48.2%) had an alternate diagnosis. In the training set of 61 patients, excess body weight loss >95% (odds ratio [OR] 6.73, 95% confidence interval [CI]: 1.13-39.96), swirl sign (OR 8.93, 95% CI: 2.30-34.70), and free liquid (OR 4.53, 95% CI: 1.08-19.0) were independent predictors of IH. Area under the curve (AUC) of the score was 0.799. In the validation set of 167 patients, AUC was 0.846. A score ≥2 was associated with an IH incidence of 60.7% (34/56), and 5.3% (3/56) had a negative laparoscopy. CONCLUSIONS: The score could be incorporated in the clinical setting. To reduce the risk of delayed IH diagnosis, emergency explorative laparoscopy in patients with a score ≥ 2 should be considered.

Does the socio-demographic profile of patients limit access to bariatric surgery?

PURPOSE: Surgery remains the only treatment allowing for a significant and sustainable weight loss in case of severe obesity. Patients undergo a specific multidisciplinary preparation and selection before the operation. This study aims to correlate the psychosocial profile with the likelihood of undergoing bariatric surgery in patients enrolled in the preparation program of a Swiss reference center. METHODS: All patients referred to an obesity center between January 1, 2016, and June 30, 2017, seeking a first bariatric procedure were included. Socio-demographic data, BMI, preoperative psychological and dietary evaluations were collected. Usually, the preoperative process lasts 1 year. Patients who left the preparation or who had not undergone surgery after more than 2 years of follow-up were considered withdrawers. Surgery completion predictors were reviewed with bivariate analysis and socio-demographic clusters established using the K-means method. RESULTS: Out of a total of 221 patients, 99 (45%) patients had not undergone bariatric surgery 2 years after their first consultation. The patients were divided into four distinct socio-demographic clusters, among which a particularly deprived one. Criteria such as unfavorable psychological (p < 0.001) and dietary (p < 0.001) evaluations, and male gender (p < 0.05) were significantly associated with non-operation, unlike socio-demographic indicators and clusters (p > 0.1). CONCLUSION: Almost half of the patients starting a bariatric program are not operated on, which is related to an unfavorable psychological or dietary evaluation and to the male gender. This study also demonstrates that a significant share of patients combines several factors of social deprivation, without influencing the likelihood of surgery completion. LEVEL OF EVIDENCE: Level V: Descriptive study.

The GAMMA concept (gastrointestinal activity manipulation to modulate appetite) preliminary proofs of the concept of local vibrational gastric mechanical stimulation.

BACKGROUND: Mechanical stimulation of the stretch receptors of the gastric wall can simulate the presence of indigested food leading to reduced food intake. We report the preliminary experimental results of an innovative concept of localized mechanical gastric stimulation. METHODS: In a first survival study, a biocompatible bulking agent was injected either in the greater curvature (n = 8) or in the cardia wall (n = 8) of Wistar rats. Six animals served as sham. Changes of bulking volume, leptin levels and weight gain were monitored for 3 months. In a second acute study, a micro-motor (n = 10; MM) or a size-paired inactive device (n = 10; ID) where applied on the cardia, while 10 additional rats served as sham. Serum ghrelin and leptin were measured at baseline and every hour (T0-T1-T2-T3), during 3 h. In a third study, 24 implants of various shapes and sizes were introduced into the gastric subserosa of 6 Yucatan pigs. Monthly CT scans and gastroscopies were done for 6 months. RESULTS: Weight gain in the CW group was significant lower after 2 weeks and 3 months when compared to the shame and GC (p = 0.01/p = 0.01 and p = 0.048/p = 0.038 respectively). Significant lower increase of leptin production occurred at 2 weeks (p = 0.01) and 3 months (p = 0.008) in CW vs. SG. In the MM group significant reduction of the serum ghrelin was seen after 3 h. Leptin was significantly increased in both MM and ID groups after 3 h, while it was significantly reduced in sham rats. The global device retention was 43.5%. Devices with lower profile and with a biocompatible coating remained more likely in place without complications. CONCLUSIONS: Gastric mechanical stimulation induced a reduced weight gain and hormonal changes. Low profile and coated devices inserted within the gastric wall are more likely to be integrated.

Fluorescence-enabled assessment of adrenal gland localization and perfusion in posterior retroperitoneoscopic adrenal surgery in a preclinical model.

BACKGROUND: The posterior retroperitoneoscopic adrenal access represents a challenge in orientation and working space creation. The aim of this experimental acute study was to evaluate the impact of computer-assisted quantitative fluorescence imaging on adrenal gland identification and assessment of intraoperative remnant perfusion for adrenal resection in the posterior retroperitoneoscopic approach. METHODS: Six pigs underwent simultaneous (n = 5) or sequential (n = 1) bilateral posterior retroperitoneoscopic adrenalectomy (n = 12). Fluorescence imaging was obtained via intravenous administration of 3 mL of Indocyanine Green (ICG) and by switching the camera systems to near-infrared mode (D-LIGHT P, KARL STORZ; Germany). Fluorescence-based visualization of adrenal glands before vascular division (n = 4), after the main vascular pedicle ligation (negative control, n = 1) or after adrenal resection (n = 7), was followed by completion adrenalectomy. The fluorescence signal intensity dynamics were recorded and analyzed using proprietary software. For each pixel, the slope of fluorescence signal intensity evolution over time was translated into a color-coded perfusion cartography, which was superimposed onto real-time images obtained with the corresponding left and right camera systems. Quantitative fluorescence signal analysis in the regions of interest (ROIs) served to assess adrenal remnant perfusion in divided adrenal glands. RESULTS: In the retroperitoneum, the vascular anatomy was illuminated in fluorescence imaging first. The adrenal glands were promptly highlighted after primary intravenous ICG administration (n = 9) or showed a fluorescence signal intensity increase upon reinjection (n = 3). Quantitative fluorescence analysis showed a statistically significant difference between perfused and ischemic segments in divided glands (p = 0.0156). CONCLUSIONS: Fluorescence imaging provides real-time guidance during minimally invasive adrenal surgery. Prior to dissection, it allows to easily discriminate the adrenal gland from surrounding retroperitoneal structures. After adrenal gland division, ICG injection associated with a computer-assisted quantitative analysis helps to distinguish between well-perfused and ischemic segments. Further studies are underway to establish the correlation between remnant perfusion and viability.

HYPerspectral Enhanced Reality (HYPER): a physiology-based surgical guidance tool.

BACKGROUND: HSI is an optical technology allowing for a real-time, contrast-free snapshot of physiological tissue properties, including oxygenation. Hyperspectral imaging (HSI) has the potential to quantify the gastrointestinal perfusion intraoperatively. This experimental study evaluates the accuracy of HSI, in order to quantify bowel perfusion, and to obtain a superposition of the hyperspectral information onto real-time images. METHODS: In 6 pigs, 4 ischemic bowel loops were created (A, B, C, D) and imaged at set time points (from 5 to 360 min). A commercially available HSI system provided pseudo-color maps of the perfusion status (StO2, Near-InfraRed perfusion) and the tissue water index. An ad hoc software was developed to superimpose HSI information onto the live video, creating the HYPerspectral-based Enhanced Reality (HYPER). Seven regions of interest (ROIs) were identified in each bowel loop according to StO2 ranges, i.e., vascular (VASC proximal and distal), marginal vascular (MV proximal and distal), marginal ischemic (MI proximal and distal), and ischemic (ISCH). Local capillary lactates (LCL), reactive oxygen species (ROS), and histopathology were measured at the ROIs. A machine-learning-based prediction algorithm of LCL, based on the HSI-StO2%, was trained in the 6 pigs and tested on 5 additional animals. RESULTS: HSI parameters (StO2 and NIR) were congruent with LCL levels, ROS production, and histopathology damage scores at the ROIs discriminated by HYPER. The global mean error of LCL prediction was 1.18 ± 1.35 mmol/L. For StO2 values > 30%, the mean error was 0.3 ± 0.33. CONCLUSIONS: HYPER imaging could precisely quantify the overtime perfusion changes in this bowel ischemia model.

Hybrid fluorescent magnetic gastrojejunostomy: an experimental feasibility study in the porcine model and human cadaver.

BACKGROUND: Laparoscopic gastrojejunostomies are time consuming and require a specific training. Alternatively, sutureless anastomosis can be achieved using endoscopically delivered magnetic rings. Our aim was to assess the feasibility and reproducibility of an endo-laparoscopic gastrojejunostomy technique, using a pair of magnets coated with a near-infrared fluorescent biocompatible polymeric material. METHODS: Five pigs (3 acute and 2 survival models) and one human anatomical specimen were included. In the survival models, the distal ring was inserted into the duodenum endoscopically, and it was fixed to a thread clipped to the gastric mucosa. Twenty-four hours later, a two-port laparoscopy was performed using a near-infrared (NIR) laparoscope. The magnet position in the jejunum was detected with the transluminal fluorescence of the dye. Magnetic interaction with the metallic tip of the laparoscopic grasper allowed to capture the ring and bring the bowel loop to the future anastomotic site on the gastric wall. The proximal magnet was inserted into the stomach endoscopically and released when magnetic interaction started, allowing for a precise connection with the distal ring. The animals were followed up for 12 days and underwent control endoscopies and radiograms. In the acute animals, the anastomotic procedure was repeated 24 times. Finally, the procedure was performed in the human anatomical specimen. RESULTS: There were no technical problems, and magnetic connection could be precisely directed at both the anterior and posterior gastric walls. No complications occurred during the survival period and the anastomoses were patent on day 5. Transluminal fluorescence enabled a rapid detection of the magnet. CONCLUSIONS: Hybrid-reduced port magnetic gastrojejunostomy using a pair of fluorescently coated magnetic rings was feasible, reproducible, and easy to perform in both porcine and cadaver models.

Correction to: Discrimination between arterial and venous bowel ischemia by computer-assisted analysis of the fluorescent signal.

In the original version, Ines Gockel was omitted as a coauthor. The complete author listing is corrected here.

Discrimination between arterial and venous bowel ischemia by computer-assisted analysis of the fluorescent signal.

BACKGROUND: Arterial blood supply deficiency and venous congestion both play a role in anastomotic complications. Our aim was to evaluate a software-based analysis of the fluorescence signal to recognize the patterns of bowel ischemia. METHODS: In 18 pigs, two clips were applied on the inferior mesenteric artery (group A: n = 6) or vein (group V: n = 6) or on both (group A-V: n = 6). Three regions of interest (ROIs) were identified on the sigmoid: P = proximal to the first clip; C = central, between the two clips; and D = distal to the second clip. Indocyanine Green was injected intravenously. The fluorescence signal was captured by means of a near-infrared laparoscope. The time-to-peak (seconds) and the maximum fluorescence intensity were recorded using software. A normalized fluorescence intensity unit (NFIU: 0-to-1) was attributed, using a reference card. The NFIU's over-time variations were computed every 10 min for 50 min. Capillary lactates were measured on the sigmoid at the 3 ROIs. Various machine learning algorithms were applied for ischemia patterns recognition. RESULTS: The time-to-peak at the ischemic ROI C was significantly longer in group A versus V (20.1 ± 13 vs. 8.43 ± 3.7; p = 0.04) and in group A-V versus V (20.71 ± 11.6 vs. 8.43 ± 3.7; p = 0.03). The maximal NIFU at ROI C, was higher in the V group (1.01 ± 0.21) when compared to A (0.61 ± 0.11; p = 0.002) and A-V (0.41 ± 0.2; p = 0.0005). Capillary lactates at ROI C were lower in V (1.3 ± 0.6) than in A (1.9 ± 0.5; p = 0.0071), and A-V (2.6 ± 1.5; p = 0.034). The K nearest neighbor and the Linear SVM algorithms provided both an accuracy of 75% in discriminating between A versus V and 85% in discriminating A versus A-V. The accuracy dropped to 70% when the ML had to identify the ROI and the type of ischemia simultaneously. CONCLUSIONS: The computer-assisted dynamic analysis of the fluorescence signal enables the discrimination between different bowel ischemia models.

Is an Early Resumption of a Regular Diet After Laparoscopic Roux-en-Y Gastric Bypass Safe?

BACKGROUND: Return to a normal diet is a crucial step after bariatric surgery. Proximal anastomosis is a source of concern for early feeding as the passage of solid food through a recent anastomosis could well increase pressure and the risk of leakage. This study aims to assess the safety of an early normal diet after a laparoscopic Roux-en-Y gastric bypass (LRYGB). MATERIALS AND METHODS: All consecutive patients undergoing primary LRYGB between January 2015 and December 2020 were included prospectively. Three postoperative pureed diets were compared at 4 weeks, 2 weeks, and 1 week. All-cause morbidity at 90 days was the main outcome. Overall complications, severe complications (Clavien-Dindo ≥ grade 3a), length of hospital stay, number of emergency, and unplanned consultations during the 3 postoperative months were recorded for each group. RESULTS: Three hundred and sixty-seven patients with a mean BMI of 42.10 kg/m2 (± SD: 4.78) were included. All-cause morbidity at 90 days was 11.7% (43/367) and no significant difference was observed between the 3 groups. Adjustment for patients and operative cofounders did not demonstrate any increased risk of postoperative complications between the 3 groups, with an odds ratio of 1, 1.23(95% CI [0. 55-2.75]), and 1.14 (95% CI [0.49, 2.67]) for groups 1, 2, and 3 respectively. Severe complications (Clavien-Dindo ≥ grade 3a) and emergency or unplanned consultations were also similar in the 3 groups. CONCLUSION: Return to a normal diet 1 week after LRYGB did not increase short-term morbidity and unplanned consultations. It may be safe and contribute to patient comfort.

Global Benchmark Values for Laparoscopic Roux-en-Y-Gastric Bypass: a Potential New Indicator of the Surgical Learning Curve.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a technically demanding procedure. The learning curve of LRYGB is challenging and potentially associated with increased morbidity. This study evaluates whether a general laparoscopic surgeon can be safely trained in performing LRYGB in a peripheral setting, by comparing perioperative outcomes to global benchmarks and to those of a senior surgeon. METHODS: All consecutive patients undergoing primary LRYGB between January 2014 and December 2017 were operated on by a senior (A) or a trainee (B) bariatric surgeon and were prospectively included. The main outcome of interest was all-cause morbidity at 90 days. Perioperative outcomes were compared with global benchmarks pooled from 19 international high-volume centers and between surgeons A and B for their first and last 30 procedures. RESULTS: The 213 included patients had a mean all-cause morbidity rate at 90 days of 8% (17/213). 95.3% (203/213) of the patients were uneventfully discharged after surgery. Perioperative outcomes of surgeon B were all within the global benchmark cutoffs. Mean operative time for the first 30 procedures was significantly shorter for surgeon A compared with surgeon B, with 108.6 min (± 21.7) and 135.1 min (± 28.1) respectively and decreased significantly for the last 30 procedures to 95 min (± 33.7) and 88.8 min (± 26.9) for surgeons A and B respectively. CONCLUSION: Training of a new bariatric surgeon did not increase morbidity and operative time improved for both surgeons. Perioperative outcomes within global benchmarks suggest that it may be safe to teach bariatric surgery in peripheral setting.

Gastrojejunal Anastomosis Complications and Their Management after Laparoscopic Roux-en-Y Gastric Bypass.

BACKGROUND: Complications at the gastrojejunal anastomosis after laparoscopic Roux-en-Y gastric bypass (LRYGB) are challenging in terms of diagnosis, therapy, and prevention. This study aims at identifying these complications and discussing their management. METHODS: Data of 228 patients who underwent a LRYGB between October 2008 and December 2011 were reviewed retrospectively to evaluate the frequency and treatment of complications such as stenoses, marginal ulcers, perforated marginal ulcers, or anastomotic leaks related to the operation. RESULTS: Follow-up information was available for 209 patients (91.7%) with a median follow-up of 38 months (range 24-62 months). Of these patients 16 patients (7.7%) experienced complications at the gastrojejunostomy. Four patients (1.9%) had stenoses and 12 patients (5.7%) marginal ulcers, one of them with perforation (0.5%). No anastomotic leaks were reported. One case with perforated ulcer and one with recurrent ulcers required surgical revision. CONCLUSION: Gastrojejunal anastomotic complications are frequent and occur within the first few days or up to several years after surgery. Stenoses or marginal ulcers are usually successfully treated nonoperatively. Laparoscopic repair, meanwhile, is an appropriate therapeutic option for perforated ulcers.

Laparoscopic gastric banding outcomes do not depend on device or technique. long-term results of a prospective randomized study comparing the Lapband® and the SAGB®.

BACKGROUND: Gastric banding still represents one of the most widely used bariatric procedures. It provides acceptable weight loss in many patients, but has frequent long-term complications. Because different types of bands may lead to different results, we designed a randomized study to compare the Lapband® with the SAGB®. We hereby report on the long-term results. METHODS: Between December 1998 and June 2002, 180 morbidly obese patients were randomized between Lapband® or SAGB®. Weight loss, long-term morbidity, and need for reoperation were evaluated. RESULTS: Long-term weight loss did not differ between the two bands. Patients who maintained their band had an acceptable long-term weight loss of between 50 and 60 % EBMIL. In both groups, about half the patients developed long-term complications, with about 50 % requiring major redo surgery. There was no difference in the overall rates of long-term complications or failures between the two groups, but patients who had a Lapband® were significantly more prone to develop band slippage/pouch dilatation (13.3 versus 0 %, p < 0,001). CONCLUSIONS: Although in the absence of complication, gastric banding leads to acceptable weight loss; the long-term complication and major reoperation rates are very high independently from the type of band used or on the operative technique. Gastric banding leads to relatively poor overall long-term results and therefore should not be considered the procedure of choice for the treatment of morbid obesity. Patients should be informed of the limited overall weight loss and the very high complication rates.

Laparoscopic gastric banding: a prospective, randomized study comparing the Lapband and the SAGB: early results.

OBJECTIVE: The objective of this study was to evaluate the results of laparoscopic gastric banding using 2 different bands (the Lapband [Bioenterics, Carpinteria, CA] and the SAGB [Swedish Adjustable Gastric Band; Obtech Medical, 6310 Zug, Switzerland]) in terms of weight loss and correction of comorbidities, short-and long-term complications, and improvement of quality of life in morbidly obese patients SUMMARY BACKGROUND DATA: During the past 10 years, gastric banding has become 1 of the most common bariatric procedures, at least in Europe and Australia. Weight loss can be excellent, but it is not sufficient in a significant proportion of patients, and a number of long-term complications can develop. We hypothesized that the type of band could be of importance in the outcome. METHODS: One hundred eighty morbidly obese patients were randomly assigned to receive the Lapband or the SAGB. All the procedures were performed by the same surgeon. The primary end point was weight loss, and secondary end points were correction of comorbidities, early- and long-term complications, importance of food restriction, and improvement of quality of life. RESULTS: Initial weight loss was faster in the Lapband group, but weight loss was eventually identical in the 2 groups. There was a trend toward more early band-related complications and more band infections with the SAGB, but the study had limited power in that respect. Correction of comorbidities, food restriction, long-term complications, and improvement of quality of life were identical. Only 55% to 60% of the patients achieved an excess weight loss of at least 50% in both groups. There was no difference in the incidence of long-term complications. CONCLUSIONS: Gastric banding can be performed safely with the Lapband or the SAGB with similar short- and midterm results with respect to weight loss and morbidity. Only 50% to 60% of the patients will achieve sufficient weight loss, and close to 10% at least will develop severe long-term complications.

[Pelvic and abdominal actinomycosis. Case report and review of the literature]. / L'actinomycose abdominopelvienne. Présentation d'un cas et revue de la littérature.

Pelvic and abdominal actinomycosis is a chronic suppurating granulomatosis caused by a Gram positive gem, Actinomyces Israelii. Manifestations of this rare disease may mimic cancer, inflammatory bowel disease, or diverticulitis. These syndromes lead to surgical exeresis. The diagnosis is obtained from the pathology report. We report the case of a 56 years old woman with large bowel obstruction secondary to extensive pelvic and abdominal actinomycosis. A review of the literature shows that the abdominal-pelvic form has been increasing over the past 10 years secondary to the increased and prolonged use of the intrauterine device. Treatment of this condition consists of a combination of antibiotics and surgery to achieve complete recovery.