Low-Pressure Pneumoperitoneum During Laparoscopic Sleeve Gastrectomy: a Safety and Feasibility Analysis.

PURPOSE: Laparoscopy is advised under the lowest possible intra-peritoneal pressure. The aim of this study is to analyze the safety/feasibility of low pneumoperitoneum pressure (LPP) during laparoscopic sleeve gastrectomy (LSG). MATERIALS AND METHODS: All primary LSGs who completed a 3-month follow-up were included. Re-do operations and LSGs performed with concomitant procedures were excluded. All LSGs were performed by the senior author. Upon trocar insertions, pressure was set to 10 mmHg, and the procedure was started. The pressure was increased step-wise, according to the senior author's assessment of the quality of exposure. Doing so, three pressure groups were formed: groups 1 (10 mmHg), 2 (11-13 mmHg), and 3 (14 mmHg). All data was retrieved from our database. Statistical analysis was performed using one-way ANOVA/Tukey's HSD test/Chi-square test. P values < 0.05 were regarded as significant. RESULTS: Between February 2018 and October 2022, 708 consecutive/primary LSGs were studied. No mortality/conversion/thromboembolic event was observed. Groups 1, 2, and 3 comprised 376 (53.1%), 243 (34.3%), and 89 (12.6%) patients, respectively. Demographics, initial weight, duration of surgery, history for abdominoplasty, drain output, length of stay, and %total weight loss were evenly distributed among groups. Among 16 bleeding episodes, 14 occurred in the LPP group (p = 0.019). Including the only leak and stenosis, 8/9 of Clavien-Dindo 3b + 4 complications were observed in the LPP group (p = 0.092). CONCLUSIONS: LSG with LPP is feasible in about half of the patients. However, almost all potentially life-threatening complications occurred in the LPP group where a significantly higher rate of bleeding was observed. Our findings suggest caution for routinely using LPP during LSG.

Staple-line reinforcement using barbed sutures in 1008 sleeve gastrectomies.

PURPOSE: Among various staple-line reinforcement methods applied during sleeve gastrectomy (SG), although data on full-thickness-continuous-suturing (FTCS) is nearly nil, it has been considered as potentially harmful. The safety/efficacy profile of FTCS is assessed. METHODS: All consecutive SGs completing 3-month follow-up were studied. Data on peri-operative parameters, complications, and follow-up were prospectively recorded. All reinforcements were completed by FTCS utilizing barbed suture. Super-super obese, secondary SGs, SGs performed in patients with prior anti-reflux surgery, and SGs performed with additional concomitant procedures were evaluated as "technically demanding" SGs. Student's t/chi-square tests were used as appropriate. RESULTS: Between January 2012 and July 2020, 1008 SGs (941 "primary-standard," 67 "technically demanding") were performed without mortality/venous event. Single leak occurred in a patient with sleeve obstruction (0.1%). Thirteen bleedings, 4 requiring re-surgery (0.4%), and 17 stenoses (1.7%) were encountered. Four stenoses were treated with gastric bypass (1 emergency), 6 by dilatation(s), and one required parenteral nutrition. Six patients with stenosis chose not to have any treatment. No statistically significant difference was observed in postoperative complications between "primary-standard" and "technically demanding" SGs (p > 0.05). The median follow-up was 44 months. The excess weight loss % at 5th year was 80.1%. Suturing added 28.4 ± 6 minutes to the SG, 3 or fewer sutures were used to complete the reinforcement in > 95%. No mishap/complication occurred related to suturing. CONCLUSION: FTCS produced excellent result in terms of leakage/hemorrhage with an acceptable stenosis rate at a low cost with half-an-hour increase in the operating time. In contrast to previous allegations, no harm attributable to stitching itself occurred.

Eighty-Seven Consecutive Sleeve Gastrectomies Between the Two Peaks of the Covid-19 Pandemic. An Opening-Phase Experience.

PURPOSE: During the Covid-19 pandemic, the outcome of symptomatic Covid-19 infection occurring early after elective operations is reportedly associated with fatalities. Incidence is unknown and data on bariatric practice is scarce. Covid-19 exposure status and outcomes of sleeve gastrectomy (SG) between the first two peaks of the pandemic are prospectively evaluated. MATERIAL AND METHODS: During our "opening-phase," candidates for SG were enrolled after written informed consent was obtained which specifically emphasized the additional risks of the Covid-19. Viral exposure history and swab/RNA testing were obtained from all. Preoperative antibody testing was also performed, once became available. Preoperative workout, definitions, and surgical technique were standard. Patients were followed up with video-calls. All perioperative data is prospectively recorded. RESULTS: Between June 23 and November 20, 87 consecutive SGs were performed without mortality and conversion with a 1.2% major early complication rate. Single complication was due to Covid-19, acutely becoming symptomatic one day following the SG. During the first year of the pandemic, a minimum of 13.8% of the patients had encountered the virus and the rate of developing postoperative symptomatic Covid-19 was 6.3% including a patient with full-blown Covid-19 pneumonia 1 day after SG. Results on weight loss matched expectations. CONCLUSION: Currently, differing from the first peak of pandemic, vaccines are underway although a more serious surge continues. Given the high rate of morbidity and mortality of Covid-19 infection early after elective operations, caution is warranted when balancing the expected benefit from an elective procedure against the risk of acquiring perioperative Covid-19 infection.

Inadvertent stapling of the orogastric tube during bariatric surgery: Report of 3 cases and a systematic review.

BACKGROUND: Entrapment of an orally introduced tube by stapling/stitching is an intra-operative complication of bariatric surgery with grave consequences. Incidence is unknown. No prevention/management strategy is available. A systematic review was performed to assess the absolute reported observed risk and incidence. Additionally, data on 3 cases during our entire sleeve gastrectomy (SG) experience is evaluated. METHODS: Literature is reviewed using PubMed/Web of science data-bases. Data was recorded prospectively. Videos of orally introduced tube staplings were re-watched, presentation/recognition/management were re-evaluated. A protocol ensuring the removal of the small caliber orogastric tube (OGT) by the surgeons direct inspection was introduced after the 3rd entrapment. RESULTS: Review revealed OGT as the most commonly entrapped tube following temperature probe and bougie. SG/stapling were the most common causative operation/reason, respectively. Leak rates over 20%, conversion, early-late re-operations and mortality were reported. During our 948 consecutive SGs, 3 OGT entrapments (0.32%), third one with double stapling, occurred. All were recognized/managed intraoperatively by freeing the entrapped-end of the OGT from the sleeve part of the staple-line. In doubly stapled case, second transected end could only be recognized when routine reinforcement suturing come in proximity. Defects were continuously stitched with barbed suture. No morbidity occurred. One-year excess-weight-loss was 82%. A pre-protocol incidence of 0.56% (n: 3/534) dropped to nil in the remaining 414. CONCLUSION: Iatrogenic stapling of the OGT during SG is rare, but morbid. It must be avoided by a strict protocol. Upon occurrence/recognition, stapling must immediately stop until the "entirety" of the tube, including the "specimen-part", is retrieved, to avoid double entrapment.

Sleeve gastrectomy in class 1 obesity: Assessment of operative outcomes.

BACKGROUND: The risk/benefit ratio of sleeve gastrectomy (SG), especially in patients without type 2 diabetes (T2D), is unknown for patients with class 1 obesity. OBJECTIVES: Assessment of operative outcomes of SG in class 1 obesity. SETTING: Private practice. METHODS: Candidates for a primary SG with body mass index 30-35 kg/m2 after 5 years of unsuccessful dieting were included after informed consent was obtained. Participants who did not complete 3-month follow-up and those who underwent modified SGs were excluded. Data and complications were recorded prospectively. Patients were followed up at 3, 6, and 12 months and yearly thereafter. Definition of presence and remission of T2D and insulin resistance were set according to guidelines. Effects on weight loss parameters were evaluated with Wilcoxon signed-rank test. RESULTS: Between 2012 and 2020, 143 consecutive SGs were performed in patients with class 1 obesity without conversion, leak, mortality, or a venous event. Two were lost to follow-up. In 141 participants, 2 bleedings and 1 colon perforation occurred (2.1% rate for acute life-threatening events). During a mean follow-up of 25.9 months; 1 case of functional stenosis and 4 cases of de novo symptomatic cholelithiasis clinically became evident in different patients, all requiring reoperation. Therefore a 5.6% rate of major complications were identified at 2 years. The benefit on weight loss was immediate and permanent (P < .001). T2D and insulin resistance were in remission in 100% and 98.1% of participants at 1 year, respectively. CONCLUSION: The 5.6% major complication rate reflects a minimum because more de novo symptomatic gallstones and stenosis are yet to occur or overlooked. Additionally, this excludes patients with de novo reflux and malnutrition, dissatisfaction issues, or recidivism. Caution is required to freely operate on patients with class 1 obesity with no co-morbidity. Evidence-based outcome data are lacking to balance the reported risks.

Risk of Alcohol Use Disorder After Sleeve Gastrectomy.

Aim: Several studies demonstrated increased alcohol intake after gastric bypass but not for laparoscopic sleeve gastrectomy (LSG). The purpose of this study is to determine whether there is an increased risk of developing alcohol use disorder after LSG. Materials and Methods: LSG patients with at least 1-year follow-up who completed the alcohol use disorder identification test (AUDIT) preoperatively, and at their control visit, were the subjects. AUDIT was applied to the patients who were followed up from 1 to 6 years postoperatively. Patients were divided into two groups as those who were followed for 1-3 years and 4-6 years. AUDIT scores and risk categories were compared. According to the AUDIT results, score intervals between 0-7, 8-15, 16-19 and 20-40 identified patients with low, moderate, high risk, and alcoholism, respectively. Results: There were 183 LSG patients eligible for inclusion. An AUDIT score of 2.79 before LSG showed prominent reduction in alcohol use in the first 3 years after LSG with a score of 2.27 (P = .033). At 4-6 years follow-up, AUDIT scores showed significant increase from 3.06 to 4.04, suggesting an increase in alcohol use in the long term (P = .042). In addition, the increase of risk after surgery in pre-LSG moderate-risk category (n = 21) turned out to be higher than pre-LSG low-risk category (n = 162). Conclusions: This study showed reduction in AUDIT scores in the first 3-year follow-up after LSG and increase in the 4-6 years follow-up. High pre-LSG AUDIT score, a potential risk for future alcohol use disorder, was one of the key findings of our study. Screening of LSG candidates before and after surgery by AUDIT scoring according to risk categories with larger samples will provide useful input for relevant guidelines.

Screening Esophagogastroduodenoscopy Before Laparoscopic Sleeve Gastrectomy: Results in 819 Patients.

Aim: The routine use of esophagogastroduodenoscopy (EGD) during the preoperative evaluation of surgical weight loss candidates is controversial. The aim of this study is to evaluate the findings of preoperative EGD in patients who are scheduled for a primary laparoscopic sleeve gastrectomy (LSG). The probable effect of these findings on the medical and surgical strategy that was followed is assessed. Methods: Findings of EGD obtained from consecutive LSG candidates and all data were prospectively recorded and retrieved from the database. Results: A total of 819 patients underwent EGD successfully. Mean age and body mass index were 38 ± 11.3 and 43.17 ± 7.2 kg/m2, respectively. Fifty-eight percent were female. EGD of 263 (32.1%) patients was normal and 687 (84%) patients were asymptomatic. At least one abnormal finding was detected in 65% of the asymptomatic patients. Abnormal findings that did not change the surgical strategy were found in 550 patients (67.2%). Findings such as gastritis or duodenitis that changed the medical management before surgery were found in 309 patients (38.2%). Helicobacter pylori was positive in 218 (26.6%) patients but eradication treatment was not applied in the preoperative period. No pathology was detected that would create absolute contraindication or change the type of surgery in any patient. Only technical modifications were required in 13% due to hiatal hernia. The timing of the planned surgery has changed in only 6 patients (0.74%) (early stage neuroendocrine tumor, leiomyoma, severe ulcer). Conclusions: Routine EGD performed before LSG did not change the planned bariatric option in any patient, but led to 13% rate of technical modifications due to the presence of hiatal hernia. At least one abnormal finding was detected in 65% of asymptomatic patients. Due to endoscopic findings, the rate of patients who started medical acid-suppression treatment in the preoperative period was 38%.

Mesh Repair of a Giant Para-Esophageal Hernia + Sleeve Gastrectomy. Combined Treatment of Intra-Thoracic Stomach and Morbid Obesity: a Video Case Presentation.

Concurrent surgical treatment of an intra-gastric stomach + morbid obesity is demonstrated. Video footage on diagnosis (gastroscopy and upper GI series) and surgical steps, as well as 2-year outcome (upper GI series), is presented. Although controversy exists regarding the best bariatric option when concomitantly repairing a giant para-esophageal hernia, in the light of recent reports and our own experience, sleeve gastrectomy may be the procedure of choice if reflux is no issue.

Cholelithiasis After Sleeve Gastrectomy and Effectiveness of Ursodeoxycholic Acid Treatment.

Aim: Few adverse effects may occur after bariatric surgery, one being the formation of gallstones. The aim of this study is to determine the incidence of cholelithiasis after laparoscopic sleeve gastrectomy (LSG) and whether ursodeoxycholic acid (UDCA) treatment reduces gallstone formation. Materials and Methods: Gall bladders of all patients planned for LSG were preoperatively checked by ultrasonography (USG). Patients who had no documented gallbladder pathology before LSG and who had USG at 12th month and 2 years follow-up after LSG were included in the study. The incidences of newly developed cholelithiasis, cholecystectomy, and endoscopic retrograde cholangiopancreatography (ERCP) requirement in patients who did not receive any UDCA treatment (pre-2015 protocol, n = 128) was compared with the corresponding numbers in patients who regularly used 500 mg/day oral UDCA for 6 months after the LSG (post-2015 protocol, n = 152). Results: Between January 2012 and October 2018, 717 LSGs were performed in two centers and after exclusions, 280 patients were eligible for evaluation. Sixty-four of 280 (23%) patients developed cholelithiasis after LSG and cholecystectomy was performed in 24 patients (8.6%) for symptomatic cholelithiasis. In the non-UDCA group, 48 patients developed cholelithiasis (n = 48/128, 37.5%) compared with 16 patients in the UDCA group (n = 16/152, 10.5%) (P < .001). Compared with 5 patients in the UDCA group, 19 patients underwent cholecystectomy (39.6%) in the non-UDCA group due to symptomatic cholelithiasis (P = .55) and 5 of these patients also required an ERCP. No ERCP became necessary in the UDCA group (P = .2). Conclusions: An almost fourfold decrease in the rate of new gall stone formation with 500 mg daily UDCA treatment was impressive and may suggest routine UDCA treatment after LSG. Given the rate of exclusions and follow-up differences among the groups, certainly, randomized trials, with less exclusion are needed to provide conclusive evidence.

Sleeve gastrectomy in patients with previous antireflux surgery. Preliminary results of the "no-touch to posterior wrap" technique.

BACKGROUND: Reported morbidity of Roux-en-Y gastric bypass in patients with previous antireflux surgery warrants caution, and data on sleeve gastrectomy (SG) are unexpectedly scarce. OBJECTIVES: To evaluate the safety and efficiency of SG in patients who previously underwent an antireflux procedure. A new technique to preserve intact fundoplication is described. SETTING: Private practice, bariatric center of excellence, Turkey. METHODS: The following data were retrieved from our prospective data base: (1) details of previous repair; (2) clinical/endoscopic reflux status, body mass index (kg/m2), and presence of metabolic syndrome (MetS) and type 2 diabetes (T2D) before SG; (3) duration of SG, length of stay, complications; and (4) percent excess weight loss, MetS/T2D resolution, and reflux status at follow-up. RESULTS: Fifteen consecutive SGs were performed without conversion or major complications. The first case is excluded from the analysis because complete wrap unfolding was abandoned in favor of the described technique. Among 14, 10 had MetS, 4 had T2D, and 1 had a proven reflux recurrence before SG. Mean operating time was 118.5 minutes. All were discharged on the third postoperative day. Apart from 1 functional stenosis, no complications occurred. At 12 months, percent excess weight loss rate was 82.2, MetS resolved in 9 of 10, and T2D was in complete (n = 2) or partial remission (n = 1). No de novo reflux became evident, and absence of reflux was proved by pHmeter in 3. CONCLUSIONS: SG is feasible in patients who previously had antireflux repair with negligible morbidity and percent excess weight loss rates similar to that with regular sleeves. Results in reflux control needs further confirmation.

Iatrogenic cardiac tamponade as a mortal complication of peri-hiatal surgery. Analysis of 30 published cases.

Iatrogenic cardiac tamponade (ICT) is a dreadful complication of peri-hiatal surgery and vast majority occur during a hernia repair. Strikingly, against all warnings, the incidents and related deaths seem to be increasing. The aim of this review is to provide insight on how to prevent and challenge ICT. PubMed search identified 30 distinct ICTs with 10 deaths (33.3%) due to peri-hiatal procedures. Twenty-nine operations were mechanical repairs and laparoscopic anti-reflux surgery was the primary cause (n:18). Graft fixation (n:23) and helical tacks (n:13) were the main offenders. Initial symptom was hypotension affecting 92%. Seven ICTs were only identified at autopsy. All treated patients except one underwent a drainage. Almost all ICTs were caused by injury to the diaphragmatic dome, anterior to hiatus. In conclusion, peri-hiatal surgery-related ICT is extremely fatal. ICT mainly occurs during the repair of a hernia, a benign condition and therefore must be prevented. Graft fixation, around the ante-hiatal diaphragmatic dome must be abandoned. If mesh-augmentation is absolutely necessary, meticulous stitching must be preferred instead of fixators. Persistent hypotension during or following a peri-hiatal operation is an alarming sign of ICT. Increased awareness is mandatory for prevention and survival.

A Comparative Study Evaluating the Incidence of Colorectal Neoplasia(s) in Candidates for Bariatric Surgery by Screening Colonoscopy, 40-49 Versus 50-65 Years Old: a Preliminary Study.

INTRODUCTION: Obesity and metabolic syndrome (MetS) are associated with colorectal neoplasia (CRN) and carcinoma (CRC). Whether such subjects must undergo screening colonoscopy (SC) earlier, is unknown. Incidences of CRNs in 40-49- versus 50-65-year-old bariatric patients were compared by SC. No prospective data on SC is available in morbidly obese/MetS. MATERIAL AND METHODS: Surgical weight loss candidates over 39 years of age, asymptomatic, and average-risk for CRC offered SC. Those giving written informed consent were enrolled. Colonoscopies were done by the same surgeon. Smoking/drinking history, fasting blood glucose (FBG), insulin, C-peptide, triglyceride, high density lipoprotein, vitamin D, HbA1c, and insulin resistance parameters were recorded. CRN rate and the distribution of variables in patients 40-49 years of age were compared with 50-65. Student's t and Chi-square tests were used as appropriate. P < 0.05 was regarded as statistically significant. RESULTS: Among 168 SCs, 47 had CRNs (27.9%). Including carcinoma, 15 had an advanced CRN (aCRN) (8.9% aCRN and 0.6% CRC). CRN rate was 35.6% in ≥ 50 years old whereas 22.1% in 40-49 (p = 0.053). aCRN rates (8.4% in 40-49 versus 9.6% in 50-65) were similar (p = 0.792). Metabolic parameters and smoking-drinking history were equally distributed between the groups except FBG and HbA1c as their mean levels were slightly higher in the 50-65 age group (p < 0.05). CONCLUSIONS: Presented results warrant routine SC in the 40-49-year-old morbidly obese and/or MetS patient population with average risk, and in aged > 50, it certainly must be enforced and included in the preoperative check-list if not done before.

A Simple Method to Aid Safe Resection Margin During Sleeve Gastrectomy in Patients With Incidental Gastric Lesions.

In contrast to colonic tattooing, data on dye-marking before gastric operations are scarce. A simple method of gastric tattooing before sleeve gastrectomy (SG) is presented. SG, under tattoo guidance has never been reported. Submucosa of the lesion is injected with 1 to 2 mL of carbon particles (Spot, PA) 24 hours before SG. At surgery, serosal dye stain is identified and stapling achieved with care to remove all dye-stained segment. Dye spread on the serosal surface differed significantly. However, as all the dye-stained segments were avoidable during stapling, 2 neuroendocrine tumors, 2 leiomyomas, and 1 benign ulcer were resected with clear histologic margins. The method presented herein may decrease the need for operative gastroscopy, mucosal resection, or laparoscopic gastrotomy in a number of patients. Because of the problem of the dye spreading, its utilization may be inappropriate in lesions that are closer to the minor curvature and incisura angularis in particular.

Cardiac Tamponade as a Life-Threatening Complication of Laparoscopic Antireflux Surgery: The Real Incidence and 3D Anatomy of a Heart Injury by Helical Tacks.

BACKGROUND: Cardiac tamponade (CT) is a dreadful complication of laparoscopic antireflux surgery (LARS) with unknown incidence, and preventive measures are yet to be defined. Incidence during LARS with respect to usage/configuration of graft deployment is analyzed. Three-dimensional (3D) analysis of tack distribution provided anatomical insight to prevent cardiac injury. MATERIALS AND METHODS: Data regarding the usage and configuration of graft deployment are retrieved from the prospective database. Grafting was "posterior" or "posterior + anterior." Incidence of CT in all hiatoplasties is calculated. Tomography is reconstructed in 3D, showing the spatial distribution of the tacks. Tacks are numbered in the surgical video. Corresponding numbering is applied to the tacks in any particular tomography slice, utilizing the 3D images as an interface. A numbering-blinded radiologist is asked to identify the offending and the nonoffending tacks as the cause of tamponade. Tack-to-pericardium distances are recorded. Tacks having no measurable distance from the pericardium are regarded as offensive. RESULTS: One CT occurred in 1302 consecutive LARS (0.076%). The incidence is 0% when "no" (379) or "posterior" (880) graft is used as opposed to 2.3% rate in "posterior + anterior" (43) grafting. The distribution of "offensive," "nonoffensive but nearest," and "safe" tacks followed a pattern. All offensive tacks belonged to the anterior graft fixation, which we referred as the critical zone. CONCLUSION: CT during LARS is rare, and associated with graft fixation anterior to the hiatal opening. Avoiding graft fixation to the critical zone may prevent cardiac injury.