Fluorescence-guided laparoscopic lymph node biopsy for lymphoma: the FLABILY study.

To date, no reports have indicated laparoscopic lymph node biopsies using Indocyanine green (ICG) in cases of lymphoproliferative disease. Preliminary data of patients undergoing fluorescence-guided laparoscopic lymph node biopsy (FGLLB) using ICG was retrospectively analysed from the multicentre registry FLABILY study. Between June 2022 and February 2024, 50 patients underwent FGLLB. The surgical biopsy aimed to re-stage lymphoproliferative disease for 25 patients and to establish a diagnosis in 25 patients. The median duration of the procedure was 65 ± 26.5 min. All the procedures were performed laparoscopically. One surgical conversion occurred due to bleeding. Median length of hospitalization was 1 ± 1.7 days. Two unrelated complications occurred in the immediate postoperative course. ICG was administrated preoperatively by means of an inguinal, perilesional, or intravenous injection according to the anatomical sites of the biopsy. Fluorescence was obtained in 43/50 (86%) of patients. A significant difference was highlighted in the appearance of fluorescence in sub-mesocolic lymph nodes compared to supra-mesocolic and mesenteric lymph nodes (41/49 (83.6%) vs. 13/22 (59%), p = 0,012). In 98% of cases, FGLLB provided the information necessary for the correct diagnosis. Fluorescence with ICG offers a simple and safe method for detecting pathological lymph nodes. FGLLB in suspected intra-abdominal lymphoma can largely benefit from this new opportunity which, to date, has not yet been tested. Further studies with a larger case series are needed to confirm its efficacy.

Laparoscopic Treatment of Gastroesophageal Reflux Disease. Outcomes and Quality of Life. A Long Term Follow-Up Study.

Background: This study evaluates the feasibility, efficacy, the complications rate, and the long-term results of laparoscopic treatment of gastroesophageal reflux disease (GERD) at a dedicated center. Materials and Methods: From 01/11/1993 to 01/12/2019, we performed 620 fundoplication surgeries by laparoscopic approach according to Rossetti technique and 160 according to Toupet technique, totally 780 procedures for gastroesophageal reflux disease. The average duration of surgery was 40 minutes (range 19 - 160) for Rossetti fundoplication, 50 (range 30 - 180), and for Toupet 60 (range 45 - 190). All patients were investigated by upper digestive tract radiography, esophagogastroscopy, 24h computerized pH-metry, manometry and scintigraphy to assess esophageal clearance and gastric emptying times. In the 180 (23 %) patients with associated hiatal hernia, direct hiatoplasty was performed in 108 cases, and hiatoalloplasty in the remaining 72. Results: There were no cases of perioperative mortality; the morbidity rate was 6.28 %. We had 16.7 % long-term failures, requiring reintervention in 46 cases (6.5 %). Thirty patients (3.84 %) had to resume occasional 40 mg PPI therapy and 48 patients (6.15 %) had to resume 40 mg PPI therapy continuously. Manometry in these patients revealed lower esophageal sphincter tone between 10- and 16-mm hg with complete and coordinated relaxations. Of the 44 patients who underwent redo surgery 26 were reoperated to repackage a tighter plastic. Six patients required reoperation for dysphagia. Twelve paraesophageal hernias were recorded in the group of patients in whom only hiatoplasty without prosthesis was performed. In all cases, a hiatoplasty with prosthesis was repackaged laparoscopically. Conclusions: We emphasize the importance of accurate morphologic and functional evaluation of the esophagus preoperatively for selection of the most appropriate intervention and postoperatively for evaluation of the causes of failures. In the presence of hiatal hernia, it is always advisable to perform hiatoplasty with the placement of a prosthesis.

Laparoscopic Sleeve Gastrectomy in Patients Over 60 Years Old: A Long-Term Follow-Up.

Purpose: This study analyzed the safety and effectiveness of laparoscopic sleeve gastrectomy (LSG) in patients over 60 years old, in a long-term follow-up, in a high-volume bariatric center. Methods: We retrospectively analyzed all patients older than 60 years who underwent LSG in our center from January 2009 to December 2018. A prospectively collected database of 4991 consecutive LSG cases was reviewed. Results: One hundred seventy-nine sleeve gastrectomy procedures were performed in patients older than 60 years, 135 were aged 60-65 years (group A) and 44 were older than 65 years (group B). We reported five cases (2.7%) of early complications: three postoperative hemorrhages, one cardial leakage, and one perigastric abscess. No thromboembolic events or mortality rates were reported. The mean follow-up period was 5.5 years (66 months). The follow-up loss rate was about 29%. At last follow-up, the mean body-mass index/body mass/percentage of excess weight loss values were, respectively, 33.7 ± 7/86.1 ± 21/60.4 ± 28.6 in group A and 32.4 ± 6.4/82.6 ± 18/61.8 ± 33 in group B. We reported 5 (4.0%) trocar site hernias, 1 (0.8%) cardial junction stenosis, and 22 (18%) new outbreaks of gastroesophageal reflux (GERD). There were 7 reinterventions (5.7%): 5 for weight regain and 2 for GERD not responding to medical therapy. There were no statistically significant differences between the two age groups. Conclusions: LSG is a safe and effective treatment for severe obesity in people over 60 years old. There are no differences in results of patients over 65 years and between 60 and 65 years old. Scales that include associated medical problems and the patient's general condition must be considered.

Could Glycated Hemoglobin be Leakage Predictor in Sleeve Gastrectomy? A Retrospective Observational Study on 4233 Patients.

PURPOSE: Diabetes increases the risks related to surgery. At the same time, bariatric surgery improves diabetes. Glycated hemoglobin (A1C) is an index of diabetes severity. The purpose of this study is to evaluate A1C as a possible predictor of postoperative complications after Sleeve Gastrectomy (SG), focusing on leakage. MATERIALS AND METHODS: Monocentric retrospective study considering all consecutive patients with obesity, with or without diabetes, who underwent bariatric surgical procedures, from January 2018 to December 2021. All patients had preoperative A1C values. RESULTS: 4233 patients were considered. 522 patients (12.33%) were diabetics (A1C ≥ 6.5%). Of these, 260 patients (6.14%) had A1C ≥ 7% and 59 (1.39%) A1C ≥ 8%. 1718 patients (40.58%) were in a pre-diabetic range (A1C 5.7%-6.5%). Higher A1C values were associated with older age, male gender, higher BMI and increased rate of comorbidities. A longer operative time was observed for patients with A1C ≥ 7%, p = 0.027 (53 ± 20 vs 51 ± 18 min). The frequency of leakage was significantly higher when A1C ≥ 7% (3.8% vs 2.0%, p = 0.026). The frequency of leakage further increased when A1C ≥ 8% (5.1%), although this difference did not reach statistical significance. CONCLUSION: Patients with obesity and A1C ≥ 7% need to be referred to a diabetologist to treat diabetes before surgery and consequently decrease the risk of leakage.

Role of Preoperative High-Resolution Manometry in the Identification of Patients at High Risk of Postoperative GERD Symptoms 1 Year After Sleeve Gastrectomy.

PURPOSE: Sleeve gastrectomy (SG) has become the most common bariatric procedure, but it is often characterized by the onset of postoperative gastroesophageal reflux disease (GERD). High-resolution manometry (HRM) is a useful tool to detect risk factors for GERD. The aim of this study was to evaluate preoperative manometric parameters as possible predictors of postoperative GERD. MATERIALS AND METHODS: This was a monocentric retrospective study. We analyzed 164 patients, with preoperative esophagitis/GERD symptoms who underwent preoperative HRM and were submitted to SG (July 2020-February 2022). RESULTS: Postoperative GERD was observed in 60 patients (36.6%): 41 of them (68%) already had preoperative GERD symptoms, whereas the remaining 19 patients (32%) developed postoperative symptoms. Female patients developed postoperative GERD in a significantly higher fraction of cases as compared to male patients (82% versus 18%; p < 0.001). DCI (distal contractile integral) was identified as the only HRM parameter correlating with the presence of GERD. Patients with DCI ≤ 1623 mmHg*cm*s developed postoperative GERD in 46% of cases (n = 43/94), as compared to 24% of cases (n = 17/70) among patients with DCI > 1623 mmHg*cm*s (p = 0.005). At multivariable analysis, female sex (OR 3.402, p = 0.002), preoperative GERD symptoms (OR 2.489, p = 0.013), and DCI ≤ 1623 mmHg*s*cm (OR 0.335, p = 0.003) were identified as independent determinants of postoperative GERD. CONCLUSION: All the patients with preoperative risk factors for reflux, such as GERD symptoms or esophagitis on EGDS (esophagogastroduodenoscopy), should be considered for an HRM. Moreover, when a DCI ≤ 1623 mmHg*s*cm is found, a bariatric procedure different from SG might be considered.

Re-sleeve gastrectomy: weight loss, comorbidities and gerd evaluation in a large series with 5 years of follow-up.

INTRODUCTION: Laparoscopic sleeve gastrectomy (SG) has rapidly become one of the most commonly performed procedures in bariatric surgery. Weight regain and insufficient weight loss are the most common causes for surgical failure. Re-sleeve gastrectomy (ReSG) can represent an option when there is evidence of a dilated gastric tube. OBJECTIVES: The aim of the study is to evaluate safety, efficacy and rate of gastro-esophageal reflux disease (GERD) after ReSG in one of the largest series present in literature with long-term follow up. METHODS AND STUDY DESIGN: Retrospective study design. From February 2010 to August 2018, 102 patients underwent ReSG at our Centre. We divided patients into two groups, according to the main reason for surgical failure: insufficient weight loss or progressive weight regain. RESULTS: One hundred-two patients (78 women, 24 men) with BMI 38 ± 6 kg/m2 underwent ReSG (mean age 44 years). Rate of postoperative complications was 3.9% (4/102). After a mean follow-up of 55 months, mean BMI decreased to 30,4 kg/m2 and the mean percentage of excess weight loss (%EWL) was 51 ± 38.6. Symptoms of GERD were present in 35/102 patients (34.3%) and the need for a new operation occurred in six patients. Forty-five patients were submitted to ReSG for progressive weight regain (group A) and 57 for insufficient weight loss (group B). No differences were found in terms of postoperative BMI and %EWL. CONCLUSION: ReSG is a feasible procedure after primary SG failure in selected patients, but its efficacy in reducing the BMI under 30 kg/m2 is still unclear. In addition, over 30% of patients suffer from long-term gastro-esophageal reflux.

Laparoscopic sleeve gastrectomy with Rossetti fundoplication: long-term (5-year) follow-up.

BACKGROUND: Gastroesophageal reflux disease (GERD), including erosive esophagitis, is highly prevalent in the obese population. Barrett's esophagus is the consequence of untreated GERD. Laparoscopic sleeve gastrectomy is one of the most frequently performed bariatric procedures. This study presents results after 5 years of follow-up of combined LSG and Rossetti fundoplication for the treatment of GERD, esophagitis, and Barrett's esophagus in patients with morbid obesity. OBJECTIVE: To evaluate long-term results after sleeve gastrectomy with Rossetti fundoplication. SETTING: Public university hospital in Italy. METHODS: Since January 2015, more than 450 patients with obesity underwent sleeve gastrectomy with a Rossetti fundoplication procedure as part of prospective studies underway at our center performed by 4 different expert bariatric surgeons. Currently, 127 patients have a follow-up of 5 years or more. RESULTS: Mean patient age was 42.9 ± 10.3 years, and mean body mass index was 42.4 ± 6.1 kg/m2. In total, 74.8% of patients were experiencing GERD before surgery. In 29 of 127 patients (22.8%), preoperative gastroscopy showed signs of esophagitis and/or Barrett's esophagus. In particular, 23 of 127 patients (18.1%) had grade A esophagitis, 2 of 127 (1.6%) had grade B, 2 of 127 (1.6%) had grade C, and 2 of 127 (1.6%) had Barrett's esophagus. Mean operative time was 51 ± 21 minutes. No intraoperative complications or conversions were reported. A regular postoperative course was seen in 91.3% of patients. Sixty months after surgery, more than 95% of patients did not experience any reflux symptoms. Percent total weight loss at follow-up was comparable with that with sleeve gastrectomy. Endoscopic follow-up demonstrated improvement of esophagitis lesions (including Barrett's esophagus) present in the preoperative setting. CONCLUSION: Laparoscopic sleeve gastrectomy with Rossetti fundoplication is well tolerated, feasible, and safe in patients with obesity, providing adequate weight loss results and complete resolution of clinical signs of GERD. We have recorded an improvement in esophagitis lesions present at preoperative gastroscopy and complete resolution of Barrett's esophagus within 5 years of follow-up.

An Unexpected High Rate of Internal Hernia in Our OAGB Experience as Revisional Surgery for Morbid Obesity.

Introduction: Internal hernia (IH) is a well-known complication of laparoscopic roux-en-y gastric bypass (LRYGB) with a reported incidence that ranges from 0% to 5%. In one anastomosis gastric bypass (OAGB), internal herniation is reported to be absent due to the lack of a jejuno-jejunostomy, which is present in LRYGB. Several papers reported large case series of patients undergoing OAGB with no IH through Petersen mesenteric defect. Consequently, there is no recommendation for routine closure of the mesenteric defects in OAGB. However, starting from 2015, some authors started reporting this complication in OAGB procedures. Material andMethods: The outcomes of 98 cases of revisional OAGB performed at our institution from 2014 were retrospectively collected. OAGB was secondary surgery following laparoscopic Sleeve Gastrectomy (LSG) in 96% of patients. The indications for secondary surgery were weight regain and/or severe Gastro-esophageal Reflux Disease (GERD). Outcomes of all OAGB procedures were collected at baseline and at 1, 3, 6, 12 and 24 months. Results: The rate of complications ( 30 days after discharge) requiring new surgery was 21.4% (21/98). The main causes of reintervention were the persistence of severe GERD/Biliary Reflux (14/21) and bowel obstruction due to Internal Hernia (4/21). IH was found in 4% of patients. Conclusion: Internal Hernia could be more common than reported in literature. The closure of mesenteric defects in OAGB should always be performed during revisional surgery for complicated IH.

Laparoscopic Treatment of Incisional and Ventral Hernia.

BACKGROUND AND OBJECTIVES: Although several large studies regarding patients undergoing minimally invasive repair of incisional hernia are currently available, the results are not particularly reliable as they are based on heterogeneous groups, different surgical techniques, different mesh types, or with a too short follow period. METHODS: We conducted a retrospective observational trial, collecting data from patients who underwent laparoscopic repair of a primary abdominal wall or an incisional hernia using the laparoscopic Intraperitoneal Onlay Mesh technique and a single mesh type, i.e., a composite polyester mesh with a hydrophilic film (Parietex CompositeTM mesh - Medtronic, Minneapolis, MN - USA). All patients signed an informed consent. RESULTS: One thousand seven hundred seventy-seven patients were enrolled. The median surgery time was 50 minutes and the median length of hospital stay was 2 days. Intraoperative complications occurred in 12 patients (0.7%), while early postoperative surgical complications occurred in 115 (6.5%); during follow-up, bulging mesh was diagnosed in 4.5% of cases and hernia recurred in 4.3% of patients. An overlap equal or greater than 4 cm resulted as a significant protective factor, while the use of absorbable fixing devices was a risk factor for recurrence (odds ration: 9.06, p < 0.001, 95% confidence interval: 4.19 - 19.57). CONCLUSIONS: Minimally invasive treatment of primary and postincisional abdominal wall hernias is a safe, effective, and reproducible procedure. An overlap equal or greater than 4 cm, the use of nonabsorbable fixing devices and a postoperative care and follow-up regime are crucial in order to obtain good results and low recurrence rates.

Laparoscopic bariatric surgery is safe during phase 2-3 of COVID-19 pandemic in Italy: A multicenter, prospective, observational study.

BACKGROUND: Sars-Cov-2 epidemic in Italy caused one of the greatest 2020 European outbreaks, with suspension of elective bariatric/metabolic surgery (BMS). From May 2020 a significant decline of the epidemic has been observed (phase 2); National Health Service protocols permitted elective BMS' resumption. A new, more severe COVID-19 surge, the "second wave", started on October 2020 (phase 3). AIM: The primary end point was to analyze the outcomes of any Sars-Cov-2 infection and related morbidity/mortality within 30 POD after laparoscopic BMS during phase 2-3; secondary end points were readmission and reoperation rates. METHODS: Study design prospective, multicenter, observational. SETTING: Eight Italian high-volume bariatric centers. All patients undergoing BMS from July 2020 through January 2021 were enrolled according to the following criteria: no Sars-Cov-2 infection; primary procedures; no concomitant procedure; age > 18 < 60 years; compensated comorbidities; informed consent including COVID-19 addendum; adherence to specific admission, in-hospital and follow-up protocols. Data were collected in a prospective database. Patients undergone BMS during July-December 2019 were considered a control group. RESULTS: 1258 patients were enrolled and compared with 1451 operated on in 2019, with no differences for demographics, complications, readmission, and reintervention rates. Eight patients (0·6%) tested positive for Sars-Cov-2 infection after discharge, as well as and 15 healthcare professionals, with no related complications or mortality. CONCLUSIONS: Introduction of strict COVID-19 protocols concerning the protection of patients and health-care professionals guaranteed a safe resumption of elective BMS in Italy. The safety profile was, also, maintained during the second wave of outbreak, thus allowing access to a cure for the obese population.

Use of fibrin glue in bariatric surgery: analysis of complications after laparoscopic sleeve gastrectomy on 450 consecutive patients.

Laparoscopic Sleeve Gastrectomy (LSG) is one of the most performed surgical procedures in bariatric surgery. Staple line leak and bleeding are by far the two most feared complications after LSG. In this study, we retrospectively compared the efficacy of Fibrin Glue in preventing staple line leak and bleeding. From September 2019 to January 2020, 450 obese patients underwent elective LSG and were placed into groups with Fibrin Glue reinforcement (Group A) or without Fibrin Glue reinforcement (Group B). Primary endpoints were postoperative staple line leak and bleeding; while, secondary endpoints were reintervention rate, total operative time and mortality. Mean Body Mass Index (BMI) was 45.4 ± 7.9 kg/m2 (range: 35.1-81.8). Mean age was 43.3 ± 11.8 years (range: 18-65). No intraoperative complications or conversion to laparotomy were reported. Mean operative time was comparable between the groups (48 ± 18 min in Group A vs 48 ± 14 min in Group B; p > 0.05). No decrease in overall postoperative complications was found in Group A (5.1% vs 7.0%; p > 0.05), but after stratification according to Clavien-Dindo classification, we found a higher rate of Grade II (0.0% vs 1.6%; p < 0.05) and Grade IIIb (0.0% vs 1%; p < 0.05) complications in group B. Our study showed that Fibrin Glue as a reinforcement method during LSG is a reliable tool, without affecting the operative time of surgery and mortality. A significant reduction in complications (Clavien-Dindo grade II and grade IIIb) was observed in patients undergoing LSG with Fibrin Glue.

COVID-19 and Obesity: Is Bariatric Surgery Protective? Retrospective Analysis on 2145 Patients Undergone Bariatric-Metabolic Surgery from High Volume Center in Italy (Lombardy).

INTRODUCTION: On February 20, 2020, a severe case of pneumonia due to SARS-CoV-2 was diagnosed in northern Italy (Lombardy). Some studies have identified obesity as a risk factor for severe disease in patients with COVID-19. The purpose of this study was to investigate the incidence of SARS-CoV-2 infection and its severity in patients who have undergone bariatric surgery. MATERIAL AND METHODS: During the lockdown period (until May 2020), we contacted operated patients by phone and social networks (e.g., Facebook) to maintain constant contact with them; in addition, we gave the patients a dedicated phone number at which to call us for emergencies. We produced telemedicine and educational videos for obese and bariatric patients, and we submitted a questionnaire to patients who had undergone bariatric surgery in the past. RESULTS: A total of 2145 patients (313 male; 1832 female) replied to the questionnaire. Mean presurgical BMI: 44.5 ± 6.8 kg/m2. Mean age: 44.0 ± 10.0 year. Mean BMI after surgery: 29.3 ± 5.5 kg/m2 (p < 0.05). From February to May 2020, 8.4% of patients reported that they suffered from at least one symptom among those identified as related to SARS-CoV-2 infection. Thirteen patients (0.6%) tested positive for COVID-19. Six patients (0.3%) were admitted to the COVID Department, and 2 patients (0.1%) were admitted to the ICU. CONCLUSIONS: Although the reported rates of symptoms and fever were high, only 0.6% of patients tested positive for COVID-19. Among more than 2000 patients who underwent bariatric surgery analyzed in this study, only 0.1% needed ICU admission.

Surgical Outcomes of Laparoscopic Right Colectomy with Complete Mesocolic Excision.

BACKGROUND AND OBJECTIVES: Literature demonstrates that colorectal cancer is nowadays one of the most common malignancies. Laparoscopy and robotic surgery are progressively gaining popularity in the treatment of colorectal tumors. Complete mesocolic excision and central vascular ligation have been widely adopted with encouraging results in terms of an improvement of overall survival, but some studies in the literature seem to demonstrate a higher morbidity rate. METHODS: We conducted a retrospective study from 01/01/2010 to 30/04/2019 on a series of 250 patients, 155 males (62%) and 95 females (38%) who underwent right colectomy with minimally invasive approach, complete mesocolic excision, central vascular ligation, and intracorporeal anastomosis. RESULTS: No perioperative mortality occurred. Postoperative morbidity rate was 6%, including 10 cases of anastomotic leak (5%). Conversion rate was 2.5%. Mean hospital stay was 6 days (range, 4-25 days). Mean operative time was 70 minutes (range, 50-130 minutes). No cases of duodenal or pancreatic damages, no chronic pain or diarrhea, and no severe alteration of bowel function were recorded. We observed only 3 cases of transient delayed gastric emptying. CONCLUSIONS: Laparoscopic right colectomy with complete mesocolic excision, central vascular ligation and intracorporeal anastomosis leads to encouraging oncological mid- and long-term outcomes with low complications rates.

Laparoscopic Ventral Hernia Repair in Bariatric Patients: the Role of Defect Size and Deferred Repair.

PURPOSE: To analyze the safety of laparoscopic ventral hernia delayed repair in bariatric patients with a composite mesh. MATERIALS AND METHODS: This retrospective single-center observational trial analyzed all bariatric/obese patients with concomitant ventral hernia who underwent laparoscopic abdominal hernia repair before bariatric surgery (group A) and laparoscopic delayed repair after weight loss obtained by the bariatric procedure (group B). RESULTS: Group A (30 patients) had a mean BMI of 37.8 ± 5.7 kg/m2 (range: 34.0-74.2 kg/m2); group B (170 patients) had a mean BMI of 24.6 ± 4.5 kg/m2 (range 19.0-29.8 kg/m2) (p < 0.05). Mean operative time: group A, 51.7 ± 26.6 min (range 30-120); group B 38.9 ± 21.5 min (range 25-110) (p < 0.05). Average length of stay: group A, 2.0 ± 2.7 days (range 1-5) versus group B, 2.8 ± 1.9 days (range 1-4) (p > 0.5). Recurrent hernia group A 1/30 (3.3%) versus recurrent hernia group B 4/170 (2.3%) (p > 0.5). Bulging: group A, 3/30 (10.0%) versus group B, 0/170 (0%) (p = 0.23). CONCLUSION: The present study demonstrates the safety of performing LDR in patient candidates for bariatric surgery in cases of a large abdominal hernia (W2-W3) with a low risk of incarceration or an asymptomatic abdominal hernia. In the case of a small abdominal hernia (W1) or strongly symptomatic abdominal hernia, repair before bariatric surgery, along with subsequent bariatric surgery and any revision of the abdominal wall surgery with weight loss, is preferable.

Modified laparoscopic sleeve gastrectomy with Rossetti antireflux fundoplication: results after 220 procedures with 24-month follow-up.

BACKGROUND: Gastroesophageal reflux disease (GERD), including erosive esophagitis, is highly prevalent in the obese population. Laparoscopic sleeve gastrectomy (LSG) is one of the most frequently performed bariatric procedures. The relationship between LSG and GERD has gained increasing attention. This retrospective study aimed to assess the effectiveness of combined LSG and modified Rossetti antireflux fundoplication for the treatment of GERD on morbidly obese patients after bariatric surgery. OBJECTIVES: To assess the effectiveness, on morbid obese patients, of combined SG and Rossetti fundoplication for the treatment of GERD in obese patients. SETTING: Public Hospital, Italy. METHODS: From January 2015 to May 2018, 220 obese patients (167 female; 53 male) underwent LSG and modified Rossetti antireflux fundoplication procedure, performed by 4 different expert bariatric surgeons. Data have been collected in an Excel file and processed by XLStat to perform statistical analyses. We analyzed short-term complications and medium-term results with 24-month follow-up in terms of weight loss, remission of co-morbidities, and resolution of GERD. RESULTS: Mean BMI was 42.58 ± 5.93 kg/m2 (range, 31.70-63.16). Patients suffering from GERD before surgery were 137 of 220 (62.3%). No intraoperative complications or conversion were reported. Regular postoperative course was recorded in 90% of patients (198 of 220 patients). Gastric perforation has always occurred on the fundoplicated portion of the stomach. This perforation, which is different from the well-known post-LSG gastric fistula, may be because of incorrect gastric fundus manipulation. Rate of reoperation was 14 of 220 (6.4%). A good sense of repletion without episodes of vomiting, nausea, or dysphagia was reported in 95% of the analyzed patients. Of patients, 98.5% did not suffer from reflux symptoms and did not take proton pump inhibitors. A decrease in BMI and percent of total weight loss at follow-up were comparable with LSG. Endoscopic follow-up is still ongoing. Improvement in esophagitis was observed in 63 of 65 (96.92%) patients and all 4 patients shows improvement in Barrett's esophagus. CONCLUSIONS: LSG and modified Rossetti antireflux fundoplication procedure is a tolerated and feasible procedure in obese patients, with good postoperative weight loss results and improvement in GERD.

Management of 69 Gastric Leakages after 4294 Consecutive Sleeve: The Experience of a High Volume Bariatric Center.

PURPOSE: To propose an algorithm of treatment for leakage after laparoscopic sleeve gastrectomy (LSG). MATERIALS AND METHODS: Sixty-nine patients who developed gastric leakage out of 4294 patients who underwent LSG from 2010 to 2018 were considered in this study. Patients' outcomes in terms of incidence of resolution and time to leakage resolution were compared by leakage characteristics and type of treatment. Three patients were lost to follow up. RESULTS: Leakage occurred in a median of 6 days from surgery, and for majority of patients (80.3%), it was in the upper part of the sleeve. The median dimension of leakage was 6.5 mm. Low level leakage resulted in a lower time of resolution (p < 0.001). Patients with clinical leakage were treated with surgery or endoscopic placement of a self-expandable metal stent (SEMS). The median time of leakage resolution was 42 days. The hospitalization time for SEMS was shorter with a 68.3% of complete resolution compared with the 29.4% of surgery. In patients with subclinical and small leakage, a conservative treatment was successful in 87.5%. Overall 39.4% of patients needed a second line treatment after that the first failed. CONCLUSION: Leakage could be treated conservatively if subclinical and < 5 mm. Surgery is mandatory if a perigastric collection is present or an organ lesion is suspected. SEMS seems to be the best option to treat high level leakage.

Laparoscopic Abdominal Wall Hernia Repair.

BACKGROUND AND OBJECTIVES: The aim of this retrospective monocentric study was to evaluate results and recurrence rate with long-term follow-up after laparoscopic incisional/ventral hernia repair. METHODS: This was a retrospective, single-center, observational trial, collecting data from patients who underwent laparoscopic incisional/ventral abdominal hernia repair using the open intraperitoneal onlay mesh technique and a single mesh type. All patients signed an informed consent form before surgery. RESULTS: A total of 1,029 patients were included. The median surgery time was 40 min (range 30-55) and the median length of hospital stay was 2 d (range 2-3). Intraoperative complications occurred in two of 1,029 patients (0.19%), whereas early postoperative surgical complications (within 30 d) occurred in 50 patients (4.86%). Postoperative complications according to Clavien-Dindo classification were as follows: I, 3.30% (34 of 1,029); II, 0.97% (10 of 1,029); IIIB, 0.58% (six of 1,029); IV, 0.00% (none of 1,029); and V, 0.00% (none of 1,029). During follow-up, bulging mesh was diagnosed in 58 of 1,029 patients (5.6%), and hernia recurred in 40 of 1,029 patients (3.9%). A mesh overlap equal to or greater than 4 cm appeared to be a significant protective factor for hernia recurrence (P < .001); a mesh overlap equal or greater than 5 cm appeared to be a significant protective factor for bulging (P < .001), whereas the use of resorbable fixing devices was a significant risk factor for hernia recurrence (odds ratio, 111.53, P < .001, 95% confidence interval, 21.53-577.67). CONCLUSION: This study demonstrates that laparoscopic repair of ventral/incisional abdominal wall hernias is a safe, effective, and reproducible procedure. Identified risk factors for recurrence are an overlap of less than 4 cm and the use of resorbable fixation means.

Laparoscopic Surgery of Gastric Cancer with D2 Lymphadenectomy and Omentum Preservation: Our 10 Years Experience.

Introduction: The debate is still open about laparoscopic treatment of gastric cancer. The aim of this retrospective study is to analyze our short-, medium-, and long-term surgical and oncological results in laparoscopic treatment of gastric cancer with D2 lymphadenectomy and omentum preservation. Materials and Methods: From January 2010 to June 2018, after >150 surgical procedures for gastric cancer performed by minimally invasive approach, we performed 100 laparoscopic subtotal gastrectomies and 38 total gastrectomies, both for early gastric cancer (EGC) and advanced gastric cancer (AGC). We always made a D2 lymphadenectomy or higher. As often as possible, we performed omentum-preserving technique. Primary outcomes analyzed included incidence of medical and surgical complications. Secondary outcomes analyzed were survival probability and incidence of relapse. Every patient read and signed informed consent before surgery. Results: Mean operative time: 2.4 ± 0.7 hours (range 1.2-4.7 hours). Rate of conversions: 14.5% (20/138); intraoperative complications: 1.4% (2/138) and positive resection margins: 6.5% (9/138). Overall incidence of duodenal fistula: 3.6% (5/138). Rate of reoperation was 7.3% (10/138). Postoperative complications according to Clavien-Dindo classification: I 3.6% (5/138); II 13.0% (18/138); III 5.8% (8/138); III B 0.7% (1/138); V 1.4% (2/138). Overall survival with 60 months follow-up was 58%. Overall 60 months incidence of relapse was 44%. Patients with omentum preservation had a lower incidence of relapse than patients with omentectomy (40% versus 57% P = .002). Conclusions: Laparoscopic treatment of gastric cancer with D2 lymphadenectomy and omentum preservation is safe and feasible, both for EGC and for AGC. Although this study has limitations, omentum-preserving technique was associated with a statistically lower recurrence rate.