An alternative combined revision of Roux-en-Y gastric bypass: Cover all aspects (of failure)!

ABSTRACT: The revisional surgical techniques for managing weight regain after laparoscopic Roux-en-Y gastric bypass have lacked a clear gold standard. Various methods such as pouch minimising, gastroenterostomy narrowing and distalization have been described, but none have consistently achieved optimal success. This study introduces a combined revision technique that enables the reassessment of both alimentary limb and biliopancreatic limb lengths based on the individual patient's total bowel length. This approach aims to promote effective weight loss while minimising the pouch and gastroenterostomy.

Effect of Histopathological Findings of Gastric Specimens Resected During Laparoscopic Sleeve Gastrectomy on Weight Loss Success: A Retrospective Analysis of 599 Patients.

BACKGROUND: Even though there aren't enough studies on long-term outcomes, laparoscopic sleeve gastrectomy (LSG) is the most common procedure among weight loss surgeries. In this study, we aimed to evaluate the histopathological results of resected stomach specimens of patients who underwent LSG and to analyze the effect of histopathological results on weight loss success. METHODS: The patients were divided into two groups according to histopathological results of the pathology specimens: abnormal (chronic active gastritis, chronic inactive gastritis, neoplasias) and normal. If the excess weight loss percentage (EWL%) values were over 70% at the end of the first year following LSG, the patients were considered successful in terms of weight loss. The groups were compared in terms of age, gender, preoperative body mass index (BMI) value, as well as postoperative first-year BMI, EWL%, total weight loss percentage (TWL%), and successful patient percentage. RESULTS: A total of 599 patients were included in this study. When the patients were dichotomized according to their pathology results as normal or abnormal, 101 (%83.5) of the patients with normal pathology results had EWL% greater than 70%. On the contrary, 356 (74.5%) of the patients with abnormal pathology results had EWL% greater than 70%, and this difference was statistically significant (p=0.038). CONCLUSION: Patients with normal histopathologic examination results of resected gastric specimens after LSG are more successful than the patient population with abnormal histopathologic results in terms of the percentage of patients with EWL% above 70 at the end of the first postoperative year. We recommend routine histopathologic analysis of gastric specimens after LSG in severely obese patients.

Enhancing bariatric surgery safety for patients refusing blood transfusions: a specialized protocol with comprehensive technical measures.

Bariatric surgery has become a leading treatment for obesity, with techniques such as Laparoscopic Sleeve Gastrectomy (LSG) and Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) demonstrating notable success in sustained weight loss and improved quality of life. Technological advancements and improved techniques have enhanced the safety of these procedures. The surgical procedures of Jehovah's Witnesses, who refuse blood transfusions as part of their beliefs, pose unique challenges and have rarely been addressed in the context of bariatric surgery. This report aimed to investigate the safety of bariatric surgery in patients who refuse blood transfusion, with an established protocol to minimize the risk of bleeding. We examined the prospectively collected data of Jehovah's Witness patients who underwent bariatric surgery from 2019 to 2023. The surgeries were conducted following a protocol that included specific measures to prevent bleeding. Data were reviewed for demographics, anthropometrics, comorbidities, preoperative medications, operative time, blood loss, length of hospital stay, hemoglobin level, drainage volume, tranexamic acid use, and postoperative 30-day complications. Eleven Jehovah's Witness patients underwent bariatric surgery, including 10 LSG and 1 LRYGB. A patient with iron deficiency anemia underwent intravenous iron treatment before the surgery. There were no intraoperative complications or major postoperative complications. All patients maintained stable hemodynamics postoperatively. Only one patient encountered nausea-vomiting, classified as a minor complication. One patient experienced a small amount of hemorrhagic drainage, which transitioned to serous after tranexamic acid infusion. Bariatric surgery can be performed safely with established protocols in patients who refuse blood transfusions.

Effect of Laparoscopic Sleeve Gastrectomy on Thyroid Function Tests and Levothyroxine Doses in People With Obesity.

INTRODUCTION: We investigated how laparoscopic sleeve gastrectomy (LSG) affected serum levels of thyroid-stimulating hormone (TSH), free thyroxine (FT4), and free triiodothyronine (FT3) in obese patients with hypothyroidism. We additionally examined whether the dose of levothyroxine decreases as a result of weight loss in this study. MATERIALS AND METHODS: Fifty-one people with obesity who received levothyroxine treatment for hypothyroidism and underwent LSG between January 2017 and January 2023 were retrospectively examined. Weight, body mass index (BMI), TSH, FT4, FT3, weekly levothyroxine dose changes, and weight-adjusted levothyroxine doses before surgery and the sixth month after surgery were compared. RESULTS: Among the 51 patients included in this study, 50.98% ceased the use of levothyroxine, and nearly half (41.18%) required an adjustment of their levothyroxine dose during the follow-up period (sixth month). Notably, the total weekly dose of levothyroxine (mcg) decreased in the sixth month following surgery (p<0.001). The weekly weight-adjusted dose (mcg/kg) decreased during the same time frame (p<0.001). The preoperative total weekly dose of levothyroxine, EWL% and absence of hyperlipidemia were found to be the independent predictors of the weight-adjusted weekly levothyroxine dose change (p<0.001, p=0.038, and p=0.044, respectively). CONCLUSIONS: Thyroid function tests in people with obesity can show improvement after LSG. LSG may reduce the weight-adjusted dose of levothyroxine at six months postoperatively and therefore patients should be monitored for possible levothyroxine dose readjustments based on weight loss.

Effectiveness of the Modified Hemoglobin, Albumin, Lymphocyte, and Platelet Score in Predicting Weight Loss After Laparoscopic Sleeve Gastrectomy.

Introduction: The overexpression of proinflammatory cytokines in obesity has suggested an association between obesity and inflammation. In this study, we aimed to predict the success of weight loss at the end of the first year of patients who underwent laparoscopic sleeve gastrectomy (LSG) for morbid obesity using hemoglobin, albumin, lymphocyte, and platelet (HALP) score and modified HALP (m-HALP) score. Materials and Methods: Patients were divided into two groups according to the success of weight loss. The groups were compared in terms of HALP score, m-HALP score, demographic parameters, and preoperative laboratory tests. The diagnostic performance measurements of the m-HALP score were calculated. In addition, logistic regression analysis was performed for the factors affecting weight loss in the first year after LSG. Results: Seventy-two patients were evaluated. The median m-HALP score of the patients with an excess weight loss percentage (EWL%) <60 threshold was 562 (416.6-891.9), the median m-HALP score of the patients with an EWL% above the 60 threshold was 394.3 (347.9-543), and the difference between the outcome groups was significant (P = .002).The accuracy of m-HALP score in identifying the patients whose EWL would be <60% 1 year after the surgery was 63.9 (95% confidence interval = 51.7-74.9). Conclusion: This study showed that the m-HALP score is effective in predicting weight loss after bariatric surgery.

Comparison of Laparoscopic Sleeve Gastrectomy and Single Anastomosis Sleeve Ileal Bypass in Type 2 Diabetes Mellitus Remission Using International Criteria.

Introduction: Single anastomosis sleeve ileal (SASI) bypass procedure is recommended in the treatment of patients with obesity, who have comorbidities such as type 2 diabetes mellitus (T2DM). Meanwhile, laparoscopic sleeve gastrectomy (LSG) has become the most preferred contemporary bariatric procedure. Research comparing these two techniques are scarce in the literature. In this study, we aimed to compare LSG and SASI procedures in terms of weight loss and diabetes remission. Materials and Methods: Thirty patients, who underwent LSG and 31 patients, who underwent SASI, with a body mass index (BMI) of 35 and above, and under unsuccessful medical treatment, in terms of T2DM, were included in the study. Patients' demographic data were recorded. Oral antidiabetic drugs and insulin use, HbA1c and fasting blood glucose values, and BMI values were recorded preoperatively, at thd sixth month and at first year. According to these data, patients were compared in terms of primarily diabetes remission and secondarily weight loss. Results: At the sixth month and first year, the mean excess weight loss (EWL) values of the SASI group were 55.2% ± 12.45% and 71.67% ± 15.75%, respectively, while EWL values of the LSG group were 57.41% ± 16.22% and 69.73% ± 16.65%, respectively (P > .05). T2DM evaluations revealed that in the SASI group, 25 (80.65%) patients at the sixth month and 26 (83.87%) patients at the first year had either clinical improvement or remission, whereas 23 (76.67%) patients at the sixth month and 26 (86,67%) patients at the first year in the LSG group had the same outcomes (P > .05). Conclusion: The short-term comparison of LSG and SASI procedures revealed similar results in terms of weight loss and T2DM remission. Hence, LSG can be considered as the first-step treatment of morbid obesity accompanied by T2DM, since it is a simpler surgical procedure.

What Value of Sixth Month Excess Weight Loss (Postsleeve Gastrectomy) Is Necessary for Better Sleep Quality?

BACKGROUND: Obesity, caused by caloric intake over output, is a global health problem. The relationship between sleep and obesity is discussed in the literature. Little is known about the compliance of sleep quality and patients' weight loss. This study aimed to review how sleep quality is affected by bariatric surgery, assess whether compliance with sleep quality can be predicted after bariatric surgery, and establish its correlation with excess weight loss. METHODS: A cross-sectional study was conducted for patients undergoing bariatric surgery (laparoscopic sleeve gastrectomy). Sleep quality was assessed with the Pittsburgh sleep quality index (PSQI) scale preoperatively and in the sixth postoperative month. A PSQI global score above 5 indicated poor sleep quality. Participants were divided into 2 groups: good and poor sleep quality. Receiver operating characteristics and logistic regression analysis were also performed to predict sleep quality. RESULTS: The questionnaire was completed by 100 subjects. All PSQI components, except the sixth (sleep medication) component, improved in patients at the sixth postoperative month versus baseline values. In the receiver operating characteristic analysis to test the availability of excess weight loss (EWL%) cutoff values relative to predict successful sleepers, 65.1 of the sixth month EWL% was found for the diagnosis of successful sleeper patients with 72.6% sensitivity and 63% specificity (area under the curve: 0.706, P =0.002, 95% CI, 0.586 to 0.825). CONCLUSIONS: For patients undergoing weight loss surgery, while assessing the sixth postoperative month, the EWL% value over 65.1 was recommended for better sleep quality.

Correct Stapling Technique in Laparoscopic Sleeve Gastrectomy: Are We Increasing the Bleeding? A Prospective Cohort Study.

Introduction: Laparoscopic sleeve gastrectomy (LSG) has become the most common bariatric surgery procedure. Bleeding is the most common complication of this surgery and mostly occurs from the staple line. The aim of this study was to evaluate whether waiting between compression and firing during the stapling phase reduces the postoperative bleeding. Methods: A total of 325 patients who underwent LSG between April and July 2022 were analyzed prospectively. In terms of postoperative bleeding, the two groups, which we waited 30 seconds between staple firings and the no wait group, were compared. Results: The mean age of patients was 37.36 (±11.12) years and mean body mass index was 45.18 (±3.1) kg/m2. Eleven patients needed transfusion. The rate of haemorrhagic complications was 3.38% (Group 1% 6.21 and Group 2% 1.11) (P = .012). The duration of surgery was ∼10 minutes longer in the study group, which we waited (P = .0001). Conclusions: During the stapling stage in LSG, waiting between compression and firing can help reduce postoperative bleeding.

Enhanced Recovery After Surgery Promotes Recovery in Sleeve Gastrectomy: A Randomized Controlled Trial.

Introduction: The most popular approach for treating obesity is laparoscopic sleeve gastrectomy (LSG). The enhanced recovery after surgery (ERAS) protocol aims to reduce the patient's surgical stress response, optimize their physiological function, and facilitate recovery. The purpose of this study was to investigate the efficacy and safety of the ERAS protocol in patients who have undergone LSG. Methods: Between January 2020 and March 2021, a single-center randomized controlled study with patients undergoing LSG was planned. Patient demographics, duration of surgery and anesthetic induction, postoperative nausea-vomiting (PONV) and pain scores, length of hospital stay, and emergency room readmissions within the first 30 days were also documented. Patients were divided into two groups: those who followed the ERAS protocol and those who did not. The senior surgeon was blinded for the preoperative and postoperative period, whereas the other surgeon was not. The groups were compared in terms of length of hospital stay, duration of surgery, visual analog scale (VAS) scores, PONV effect scores, and emergency service admissions within the first 30 days after surgery. Results: A total of 96 patients were included in this study. Of these, 49 were in the ERAS protocol group and 47 were in the traditional treatment group. The mean age of the patients in the ERAS and traditional treatment groups were 37.47 ± 10.11 years and 35.77 ± 9.62 years, respectively. While the ERAS group patients were hospitalized for a mean of 30.46 ± 11.26 hours, the traditional group patients were hospitalized for 52.02 ± 6.63 hours (P: .001). There was no difference between the groups in terms of the first 30-day readmission to the emergency department (P: .498). Both VAS and PONV effect scores at the 2nd and 12th hours of the ERAS group patients were lower (P: .001, .002, .001, .001, respectively). Conclusions: When compared with the conventional method, the ERAS protocol reduced patient hospitalization time, decreased postoperative nausea, vomiting, and pain scores, and did not vary in postoperative emergency department readmissions. In patients receiving LSG, the ERAS protocol can be employed safely and successfully. Clinical Trial Registration number: NCT04442568.

Sleeve gastrectomy in situsinversustotalis case.

Laparoscopic sleeve gastrectomy surgery is a procedure that has become more common in the past 10 years. Situsinversustotalis is an extremely rare condition. SG can be performed safely in SIT patients. However, pre-operative multidisciplinary evaluation is very important. In this article, we present a 25-year-old female patient with a body mass index of 47.6 who had no idea that she had SIT until pre-operative tests revealed it. The patient was discharged on the 3rd post-operative day without any problem. We would like to emphasize the importance of imaging even if the patient does not have any disease or risk before bariatric surgery. We believe that more studies should be done with SIT and bariatric surgery.

Acute Intrathoracic Migration With Incarceration of Laparoscopic Sleeve Gastrectomy Due to Incomplete Hiatal Hernia Repair.

Concomitant hiatal hernia repair during laparoscopic sleeve gastrectomy (LSG) is recommended if it is detected. Intrathoracic sleeve migration (ITSM) is a sliding hiatal hernia that develops after LSG. In this article, we present an early ITSM due to an incomplete repair of a hiatal hernia. An obese patient had hiatal hernia in the preoperative endoscopy. After LSG, the defect was repaired with anterior cruroplasty. Vomiting attacks were observed after the operation. Based on clinical signs and radiological findings, laparoscopic exploration was indicated. During the reoperation, an acute entrapment of the upper portion of the sleeve was observed, which had migrated through the hiatus. This suture was undone. There was no gastric ischemia. No additional hiatal repair was attempted. The operation was sufficient to alleviate the symptoms. The patient was discharged on the second postoperative day uneventfully. Until the most recent follow-up, the patient has progressed with adequate weight loss, without complaints of reflux and without proton pump inhibitors ITSM with incarceration is a complication that can occur after incomplete hiatal repair. Failure to perform hiatal repair with proper technique can be attributed to this complication.

Incidental detection of gastrointestinal stromal tumors during laparoscopic sleeve gastrectomy. What to do?

INTRODUCTION: We evaluated and characterized the incidental GISTs during laparoscopic sleeve gastrectomy in our clinic. METHODS: All GISTs identified during laparoscopic sleeve gastrectomy between January 2015 and December 2017 were evaluated. Typical demographic, clinicopathologic, treatment, location, resection margins, immunohistochemistry (CD 34, CD 117, ASMA, desmin and S100) and criteria for oncological aggressiveness (tumor size, number of mitoses, presence or absence of tumor necrosis) data were recorded. RESULTS: Within the 800 bariatric surgeries at our institution, 7 GISTs were identified (0.87%). The median age of the patients was 32 years (age range: 24-42 years). The mean BMI was found to be 40.66 kg/m2 (range: 35-44 kg/m2). All GIST cases were found in the stomach samples. All tumors were not larger than 20 mm. All tumors were found close to the greater curvature of the stomach; in five cases, tumors were located in a single focus, while in 1 case, it was located both in the corpus and fundus. CD117 and CD34 were found to be positive in the pathological examination of all parts. In addition, desmin, smooth muscle actin (SMA) and S-100 were also positively stained. No complications or mortality were observed in this series. CONCLUSION: Tumor resection with a negative surgical margin may be considered complete oncologic treatment in case of presence of very low or low risk classification of postoperative GIST recurrence. After GIST resection, all patients should remain under long-term postoperative care. KEY WORDS: Bariatric surgery, Incidental gastrointestinal stromal tumors, Obesity, Sleeve gastrectomy.

Relationship between monocyte-to-high-density lipoprotein cholesterol ratio and excess weight loss in laparoscopic sleeve gastrectomy.

Aim: The present study evaluates the relationship between the monocyte-to-high-density lipoprotein cholesterol ratio (MHR) and the percentage of excess weight loss (%EWL) in patients undergoing laparoscopic sleeve gastrectomy. Method: This prospective cohort study evaluated 125 patients who underwent laparoscopic sleeve gastrectomy. The MHR before and at 6 months after surgery were compared in patients with <50 and ≥50 %EWL. Results: The MHR was lower in patients with a %EWL of <50 than in patients with a %EWL of ≥50 (p = 0.019). The decrease in the MHR at postoperative 6 months was more remarkable in patients with a %EWL of ≥50 (p < 0.001). Conclusion: The present study suggests that MHR decreased more remarkably at postoperative 6 months in patients with high %EWL, predicting a decrease in cardiovascular risk.

Lay abstract The primary focus of laparoscopic sleeve gastrectomy is to achieve sufficient weight loss to reduce cardiovascular events while minimizing surgical morbidity. The present study found a significant relationship between the percentage of excess weight loss and monocyte-to-high-density lipoprotein cholesterol ratio (MHR), the decrease in MHR being more remarkable with increasing excess weight loss and mostly attributable to the monocyte component. MHR can be used as a marker of atherosclerosis to monitor patients if they have achieved a reduction in cardiovascular risks. Monocyte count can be used as a simple substitute in conditions where MHR is not readily available.

Is the increased incidence of pathologically proven acute appendicitis more likely seen in elderly patients? A retrospective cohort study.

AIM: Although appendicitis is a disease of the young, it has been speculated that its incidence has increased among the elderly people. In this study, it was aimed to evaluate annual changes of appendicitis seen in older patients (≥60 years) throughout a 10-year period. METHODS: All adult patients who were surgically treated for acute appendicitis were retrospectively analyzed with respect to pathological analysis, gender, age and proportion of the patients aged 60 or over in an annual base. Variability in the mean age and proportion of the older patients aged 60 or over throughout the study years were regarded as the main outcomes. RESULTS: There were 3296 patients with a mean age of 30.42 ± 12 years. Distribution of gender was similar (p = 0.636). There was a significant positive correlation in the mean age of the patients throughout the study years (p = 0.043). Stratification by the age of 60 yielded a significant increase in percent of the older patients, from 0.93% at 2007 to 4.28% at 2016 (p = 0.019). CONCLUSIONS: The mean age of the patients with acute appendicitis is going to increase. Therefore, it is expected that all surgeons are more likely to be confronted with elderly patients with appendicitis in the near-future.

Biopsy Techniques for Skin Disease and Skin Cancer: A New Approach.

Skin biopsies provide physicians with valuable information in the evaluation of many dermatologic diseases. It becomes increasingly important for physicians to be proficient at performing skin biopsies because of the prevalence of skin malignancies and other dermatologic diseases in general population. The most common techniques include the punch, shave, excisional, and incisional biopsies. Each procedure has advantages and disadvantages, depending on the dermatologic diseases. The choice of biopsy type depends on the suspected disease's pathology and lesion location. Performing time-saving and economically convenient techniques is more favorable for both physicians and patients. For this purpose, for the past 10 years, we used a technique that provides hemostasis and substitute suturing without using any suture material for patients who are suitable for punch and incisional biopsies. We aim to share this easy, cheap, and time-saving procedure.