Omentopexy with Glubran®2 for reducing complications after laparoscopic sleeve gastrectomy: results of a randomized controlled study.

BACKGROUND: Gastric fistulas, bleeding, and strictures are commonly reported after laparoscopic sleeve gastrectomy (LSG), that increase morbidity and hospital stay and may put the patient's life at risk. We report our prospective evaluation of application of synthetic sealant, a modified cyanoacrylate (Glubran®2), on suture rime, associated with omentopexy, to identify results on LSG-related complications. METHODS: Patients were enrolled for LSG by two Bariatric Centers, with high-level activity volume. Intraoperative recorded parameters were: operative time, estimated intraoperative bleeding, conversion rate. We prospectively evaluated the presence of early complications after LSG during the follow up period. Overall complications were analyzed. Perioperative data and weight loss were also evaluated. A control group was identified for the study. RESULTS: Group A (treated with omentopexy with Glubran®2) included 96 cases. Control group included 90 consecutive patients. There were no differences among group in terms of age, sex and Body Mass Index (BMI). No patient was lost to follow-up for both groups. Overall complication rate was significantly reduced in Group A. Mean operative time and estimated bleeding did not differ from control group. We observed three postoperative leaks in Group B, while no case in Group A (not statistical significancy). We did not observe any mortality, neither reoperation. Weight loss of the cohort was similar among groups. In our series, no leaks occurred applying omentopexy with Glubran®2. CONCLUSION: Our experience of omentopexy with a modified cyanoacrylate sealant may lead to a standardized and reproducible approach that can be safeguard for long LSG-suture rime. TRIAL REGISTRATION: Retrospective registration on clinicaltrials.gov PRS, with TRN NCT03833232 (14/02/2019).

Gastroesophageal Reflux After Sleeve Gastrectomy: New Onset and Effect on Symptoms on a Prospective Evaluation.

BACKGROUND: Gastroesophageal reflux disease (GERD) is present in half of the obese candidates for bariatric surgery. Variability of symptoms and new onset of GERD are often debated. Prior studies have demonstrated that sleeve gastrectomy (SG) is associated with significant weight loss. OBJECTIVES: We prospectively evaluated the effect of a standardized SG technique on GERD symptoms in 104 patients. METHODS: All patients were surveyed on the presence of heartburn and/or regurgitation with a specific questionnaire (GERD-HRQL). Esophagogastroduodenoscopy (EGDS) was performed in the preoperative phase and after 12 months. RESULTS: All patients completed a 12-month follow-up. In the preoperative phase, 27.9% presented GERD symptoms (29 cases), while endoscopic findings were observed in 19.2% (20 cases). Preoperative GERD was ameliorated/solved in 65.5% of cases. The mean value of the GERD-HRQL score was significantly lower in postoperative evaluation (33.8 vs 19.4; p < 0.05). At 12-month EGDS, esophagitis was present in 13.5%, and GERD-HRQL symptoms were recorded in 10.6%. Considering patients treated until December 2015 (group 1, 44 patients) and those treated after December 2015 (group 2, 60 patients), all new clinical and endoscopic GERD diagnoses were observed in group 1; the majority of unsolved GERD cases was present in Ggoup 1 (8 vs 2; p < 0.05). CONCLUSION: Significant amelioration on preoperative GERD was confirmed after SG. New characteristics of reflux are emerging in SG patients, often asymptomatic. Standardization is necessary to define the real effect of SG on GERD.

Small bowel obstruction after gastric by-pass: Diagnostic limits and percutaneous drain. A paradigmatic case.

BACKGROUND: Obesity is showing a constant increase worldwide, making it the major public health problem. Bariatric surgery seems to be the best treatment for these to achieve a good excess weight loss. Gastric by-pass (GBP) is one the most important bariatric procedure, but there are a lot of complications as bowel obstruction for internal hernia, fistula and intussusception. CASE REPORT: We present a peculiar case report of a 53-years old woman that underwent to GBP. On the fourth postoperative day, she presented a bowel obstruction and underwent a second surgical intervention for incisional hernia. Another surgical revision was necessary because of dilatation of excluded stomach. Subsequent external drain of excluded stomach solved the paralytic ileum post bowel obstruction. CONCLUSION: Postoperative occlusion is more complex in bariatric patients, either for variety of etiology, either for choosing best approach to the new anatomy. In addition, post-surgery course may be different, because GBP may determine many modifications on gastrointestinal motility and clinical symptoms. An accurate knowledge of bariatric surgery is mandatory in these situations, obtaining the best management.

Evaluation of anti-Müller hormone AMH levels in obese women after sleeve gastrectomy.

INTRODUCTION: The link between obesity epidemic in fertile age and fertility reduction, in relation with BMI increase, has been demonstrated. An inverse proportionality between BMI and anti-Müller hormone (AMH) has been investigated. This hormone is strictly related to ovarian function. It has been demonstrated that it is significantly decreased in obese women. SCOPE: The aim of this study was evaluation of AMH levels in 53 obesity women with BMI >35, at 3 and 6 months after laparoscopic sleeve gastrectomy (LSG). Specific evaluation of comorbidities and of gynecological effects of weight loss was also evaluated. RESULTS: Cohort of 53 women was considered, treated with LSG. A progressive increase of AMH levels after LSG was confirmed, with statistically significant results at followup of 6 months. In these patients, we also observed an improvement in the menstrual cycle and resolution of dysmenorrhea. All considered comorbidities were ameliorated at both followup. CONCLUSION: LSG determined a significant increase of AMH level in women, at early followup, with a comprehensive amelioration of gynecological status. Larger cohorts and a better evaluation of ovarian function after LSG will lead to more powerful results of the effect of weight loss on women.

Giant mucinous ovarian borderline tumor. A good lesson from an asymptomatic case.

INTRODUCTION: Cases of giant mucinous ovarian tumors are rarely described in literature, with different clinical manifestations. Compressive symptoms or visible abdominal mass are the most frequent observations, with higher surgical risks and life-threatening complications. PRESENTATION OF CASE: We report a case of a 69-year-old female with a giant borderline ovarian mucinous tumor, with peculiarity of absence of clinical manifestation, in front of a mass of over 6500 g. The patient underwent exploratory laparotomy where a giant cystic mass with solid lesions measuring more than 50 cm was found. It originated from the left ovary and extended up to mesocolon. Excision of the tumor intact wall, without fluid aspiration, abdominal hysterectomy with bilateral ooforectomy was performed. No hemodynamic and cardiac intraoperative modifications were observed. There were no significant early or late postoperative complications. Patient was well 12 months after surgery. The pathological examination showed a giant cystic neoplasm measuring 60 × 50 × 40 cm, weighing 6500 g. This histological study showed a mucinous neoplasm of borderline malignancy, with epithelial cells mainly of endocervical type with focal development of intestinal epithelium with goblet cells. DISCUSSION: Giant ovarian lesions are often related with compressive symptoms and need resection with high-risk of mortality. Although optimal imaging evolution, rarely rapid growth and abnormal mucina production can determine giant evolution. CONCLUSION: Our case report is paradigmatic for absence of symptoms at diagnosis, although dimension of lesion, for borderline mucinous histotype, that determined a good prognosis in this patient, and for safe operative treatment.

Metabolic effects, safety, and acceptability of very low-calorie ketogenic dietetic scheme on candidates for bariatric surgery.

BACKGROUND: Previous studies have demonstrated significant advantages from a preoperative dietetic regimen for candidates to bariatric procedure. OBJECTIVES: Evaluation of safety, efficacy, and acceptability of a very low-calorie ketogenic diet in patients before bariatric surgery. SETTING: University Hospital. METHODS: A standardized 30-day sequential preoperative diet regimen has been analyzed, optimizing metabolic response with gradual carbohydrate reintroduction. Patients were given a dedicated KetoStationkit, for use during the first 10 days of the scheme, followed by a hypocaloric scheme for 20 days. The study group underwent routine laboratory tests and anthropometric measurements (percent weight loss, body mass index, waist circumference) at enrollment (T0), after 10 days (T1), and after 30 days (T2). Ketone body levels were measured in the plasma and urine. RESULTS: Between January 2015 and September 2015, 119 patients were included in the study. Mean body mass index was 41.5 ± 7.6 kg/m2. Weight, body mass index, and waist circumference at T0 and T1, T0 and T2, and T1 and T2 decreased significantly (P<.05). A bioelectrical impedance assay determined a significant reduction in visceral fat at T1 and T2. We observed a significant (P<.05) improvement in several clinical parameters, including glycemic and lipid profile parameters. We also observed a mean 30% reduction in liver volume. The majority of patients declared satisfied or very satisfied. The adverse effects were mild, of short duration, and not clinically relevant. CONCLUSION: Our results confirm the acceptability, safety, and significant advantage of a very low-calorie ketogenic diet for reducing weight and liver volume of patients in preparation for bariatric surgery.