Ventral hernia repair with enhanced-view totally extraperitoneal technique after a massive weight loss by laparoscopic sleeve gastrectomy.

BACKGROUND: Ventral hernia repair (VHR) for obese patients is often associated with an increased risk of postoperative complications and hernia recurrences. Achieving preoperative weight loss is ideal before VHR; however, it is difficult to attain with medical treatment. Metabolic and bariatric surgery (MBS) offers the most effective and durable treatment for obesity. Therefore, massive weight loss occurring after MBS will improve the outcome of VHR. CASE PRESENTATION: A 49-year-old man (122.9 kg, BMI 39.1 kg/m2) presented to our hospital wishing to undergo laparoscopic sleeve gastrectomy and VHR. Physical examination revealed a tennis ball-sized lower midline defect. Computed tomography (CT) scans revealed a hernia orifice 5 cm in width and 10 cm in height. As the hernia orifice was large, mesh reinforcement was essential. We planned for him to undergo VHR after massive weight loss was achieved by MBS. VHR was performed using the enhanced-view totally extraperitoneal (eTEP) technique after weight loss of 38 kg was achieved 9 months following laparoscopic sleeve gastrectomy. His postoperative course was uneventful, and neither recurrence nor seroma was observed at 1 year follow-up. CONCLUSIONS: eTEP repair of a ventral hernia after massive weight loss following MBS would appear to be the best combination treatment for obese patients with ventral hernias. However, long-term follow-up is necessary to establish its safety and efficacy.

Oncologic outcomes after laparoscopic versus open multivisceral resection for local advanced colorectal cancer: A meta-analysis.

Laparoscopic (lap) colectomies for advanced colorectal cancer (CRC) often require resection of other organs. We systematically reviewed currently available literature on lap multi-visceral resection for CRC, with regard to short- and long-term oncological outcomes, and compared them with open procedures. We performed a systematic literature search in MEDLINE, EMBASE, Google Scholar and PubMed from inception to November 30, 2020. The aim of this study was to synthesize short-term and oncological outcomes associated with laparoscopic versus open surgery. Pooled proportions and risk ratios (RRs) were calculated using an inverse variance method. We included six observational cohort studies published between 2012 and 2020 (lap procedures: n = 262; open procedures: n = 273). Collectively, they indicated that postoperative complications were significantly more common after open surgeries than lap surgeries (RR: 0.53; 95% confidence interval [CI]: 0.39-0.72; P < 0.00001), but the two approaches did not significantly differ in positive resection margins (RR: 0.75; 95% CI: 0.38-1.50; P = 0.42), local recurrence (RR: 0.66; 95% CI: 0.28-1.62; P = 0.37), or (based on two evaluable studies) 5-year OS (RR: 0.70; 95% CI: 0.46-1.04; P = 0.08) or 5-year DFS (RR: 0.86; 95% CI: 0.67-1.11) for T4b disease. In conclusion, laparoscopic and open multi-visceral resections for advanced CRC have comparable oncologic outcomes. Although a randomized study would be ideal for further research, no such studies are currently available.

A case of sigmoid colon volvulus with transanal ileus tube placement and Sharon's operation performed safely.

Although endoscopic repair is often performed for sigmoid colon volvulus without intestinal necrosis, surgery is the common choice of treatment due to recurrence. With no established treatment, Hartmann's operation or sigmoid colon resection is often performed. We report a case of a 65-year-old man with transanal ileus tube placement before surgery for sigmoid colon volvulus to prevent recurrence and achieve intestinal decompression followed by Sharon's operation to achieve one-stage anastomosis. The patient showed good postoperative course, with no recurrence 3 months after surgery. This report discusses the usefulness of the transanal ileus tube and Sharon's operation for sigmoid colon volvulus without intestinal necrosis along with a review of the literature.

Initial entry via the left upper quadrant with an optical trocar in laparoscopic bariatric surgery.

INTRODUCTION: Laparoscopic bariatric surgery (BS) is not readily performed in Japan. To facilitate safe initial access to the abdominal cavity, we insert an optical viewing trocar at a unique site in the left upper quadrant (LUQ). Herein, we describe the technique, its advantages, and outcomes. MATERIALS AND SURGICAL TECHNIQUE: Briefly, the optical trocar is inserted just below the left subcostal margin, 8 cm from the midline. On insertion, layers of the abdominal wall are visualized on the monitor. Depending on the angle of insertion, five, seven, or eight layers are seen. DISCUSSION: In assessing our initial entry technique, used in 21 obese patients undergoing laparoscopic sleeve gastrectomy, we found median insertion time to be 25 seconds. There were no related complications. In nearly all (20/21) patients, the abdominal wall was visualized as seven layers: subcutaneous fat, anterior rectus sheath, rectus abdominis muscle, posterior rectus sheath, transverse abdominis muscle, transversalis fascia, and peritoneum. Understanding the layers of the abdominal wall visualized during optical trocar insertion in the LUQ will provide for safe and rapid initial entry in patients undergoing laparoscopic BS and can further the widespread acceptance of laparoscopic BS.

Successful one-stage laparoscopic procedure for de Garengeot hernia: a totally extraperitoneal repair-first approach.

The de Garengeot hernia is a femoral hernia in which the appendix migrates into the hernia sac. It is usually diagnosed intraoperatively due to its rarity and lack of clinical presentation typical to acute appendicitis. Although most cases need emergency operation due to incarceration, no standard procedure exists. We report the case of a 49-year-old woman who was diagnosed with a de Garangeot hernia preoperatively by contrast-enhanced computed tomography. She underwent one-stage laparoscopic surgery via a totally extraperitoneal approach followed by laparoscopic appendectomy. She recovered uneventfully and was discharged on postoperative Day 3. Generally, hernioplasty and appendectomy are required for the de Garengeot hernia treatment. Avoiding a peritoneal incision around the herniation and performing a mesh repair prior to appendectomy is expected to carry a lower infectious risk than other laparoscopic procedures. With accurate diagnosis, this procedure could be a useful modality for de Garengeot hernia.

Prevalence of reflux esophagitis in obese Japanese undergoing bariatric surgery.

BACKGROUND: Currently, the data on the relationship between obesity and gastroesophageal reflux disease (GERD) in Asian populations are scarce. METHODS: The aim of this study is to investigate the prevalence of reflux esophagitis (RE) among obese Japanese patients in each body mass index (BMI) range group. In addition, we aim to investigate the risk factors for RE in obese Japanese patients. The present retrospective cohort study included 674 obese Japanese patients who underwent bariatric surgery between January 2003 and April 2016. The patients were stratified into five groups based on BMI range. RESULTS: The mean BMI was 42.7 ± 9.24 kg/m2. The prevalence of RE among each of the groups was as follows: Group 1 (BMI 30-34.9) = 20.7%; Group 2 (BMI 35-39.9) = 24.0%; Group 3 (BMI 40-44.9) = 25.2%; Group 4 (BMI 45-49.9) = 26.7%; and Group 5 (BMI ≥50) = 24.8%. Overall, the prevalence of RE was 24.2% in our study. Furthermore, no significant difference in BMI was noted between the RE and non-RE groups (43.4 ± 9.3 kg/m2 and 42.5 ± 10.2 kg/m2, respectively; p = 0.24). According to the multivariate logistic regression model, gender, Helicobacter pylori infection status, GERD-related symptoms, and hiatal hernia were significantly correlated with RE. CONCLUSION: Our study shows that the prevalence of RE in severely obese Japanese patients was significantly higher than the average prevalence of RE in Japan. However, the prevalence of RE did not increase with BMI in our cohort.

Five-Year Outcomes of Laparoscopic Sleeve Gastrectomy in Japanese Patients with Class I Obesity.

BACKGROUND: Bariatric surgery is being recognized increasingly as an effective treatment for obesity and related comorbidities. In Japan, the cost of laparoscopic sleeve gastrectomy (LSG) is covered by the national health insurance for adults with a body mass index (BMI) ≥ 35 kg/m2 and specific comorbidities (type 2 diabetes mellitus (T2DM), hypertension (HT), dyslipidemia (DL), and obstructive sleep apnea syndrome (OSAS)). However, only 0.6% of the adult population have a BMI ≥ 35 kg/m2. In contrast, 4.3% have class I obesity (a BMI of 30-34.9 kg/m2). The BMI of Asians with central obesity-induced diabetes and other metabolic disorders is much lower than that of Westerners. OBJECTIVES: To evaluate the medium-term (up to 5 years) outcomes of LSG performed in Japanese patients with class I obesity. METHODS: One hundred eighteen consecutive patients with class I obesity treated by LSG at our center between August 2007 and December 2018 were included in a retrospective study. Mean preoperative body weight (BW) and BMI were 88.6 ± 10.3 kg and 32.8 ± 1.6 kg/m2, respectively. Weight loss, comorbidity status, and adverse events were assessed. RESULTS: Mean BW/BMI at 1, 3, and 5 years after LSG decreased significantly to 66.6 ± 11.2 kg/24.6 ± 2.8 kg/m2, 68.0 ± 14.0 kg/25.4 ± 4.0 kg/m2, and 69.1 ± 12.9 kg/26.5 ± 3.0 kg/m2, respectively. Mean total weight loss at 1, 3, and 5 years was 24.7 ± 8.2%, 21.8 ± 12.1%, and 18.5 ± 9.7%, respectively. Metabolic disorders such as T2DM, HT, and DL improved significantly. There was no mortality. CONCLUSION: LSG is safe, yields excellent weight loss, and improves obesity-related comorbidities in Japanese patients with class I obesity.

Revisional Bariatric Surgery for Insufficient Weight Loss and Gastroesophageal Reflux Disease: Our 12-Year Experience.

INTRODUCTION: Although bariatric surgery is increasing in Japan, revision surgery is uncommon. To clarify indications for the various revision surgeries available, we retrospectively assessed perioperative/postoperative outcomes of revisional weight loss surgeries performed at our medical center between July 2006 and July 2017. METHODS: The study group comprised patients treated for insufficient weight loss (IWL group, n = 15) or intractable postoperative gastroesophageal reflux disease (GERD group, n = 9). Clinical characteristics and perioperative/postoperative outcomes were assessed for the total patients, per patient group, and per type of revision surgery performed. RESULTS: In the IWL group, BMI decreased from 47.3 ± 9.2 kg/m2 at the time of revision surgery to 36.9 ± 7.4 kg/m2 1 year later, and excess weight loss (%EWL) reached 62.7 ± 14.6%. Among patients whose primary surgery was laparoscopic sleeve gastrectomy, %EWL and total weight loss (%) were greater after laparoscopic biliopancreatic diversion with duodenal switch (LBPD/DS) or duodenojejunal bypass (DJB) than after other revision surgeries. Complete or partial remission of the GERD was achieved in all GERD group patients (9/9, 100%), and six (6/9, 66.7%) were able to discontinue proton pump inhibitor therapy. Serious complications occurred in four patients (4/24, 16.7%) following laparoscopic Roux-en-Y gastric bypass (LRYGB): stump leakage in one, gastrojejunal leak in one, and gastrojejunal stricture in two. CONCLUSION: LBPD/DS or DJB as revision surgery appears to be effective for further weight loss in the medium term, and LRYGB appears to be effective for GERD remission. Bariatric surgeons should bear in mind, however, that the post-LRYGB complication rate appears to be relatively high.

Laparoscopic transabdominal preperitoneal hernioplasty for recurrent obturator hernia: A case report.

Reports of recurrence after obturator hernia repair are few. We describe the case of an 89-year-old woman who presented to us with a thrice recurrent obturator hernia. She had undergone open non-mesh repair twice and then laparoscopic non-mesh repair. She was readmitted to our hospital 6 months after the laparoscopic repair. Manual reduction was successful, paving the way for elective transabdominal preperitoneal repair. During the endoscopic repair, surgical mesh was placed extraperitoneally over the hernia defect and then fixed to Cooper's ligament with absorbable tacks. The patient was discharged on postoperative day 2 without complications. In the 2 months that have passed since the surgery there has been no sign of recurrence, but the patient will be carefully followed up. Repair of a recurrent obturator hernia is technically challenging; however, the transabdominal preperitoneal approach seems to be reliable and safe.

Reduced-Port Sleeve Gastrectomy for Morbidly Obese Japanese Patients: a Retrospective Case-Matched Study.

BACKGROUND: Reduced-port laparoscopic surgery remains controversial due to technical challenges that can lead to suboptimal outcomes, and data pertaining to operative and clinical outcomes of reduced-port sleeve gastrectomy (RPSG) vs. conventional laparoscopic sleeve gastrectomy (CLSG) are lacking. AIMS: This retrospective case-matched study aimed to compare midterm (2-year) outcomes of RPSG and of CLSG. METHODS: Patients included in the study had undergone laparoscopic bariatric surgery at our center between 2010 and 2017. Thirty-one consecutive female patients who underwent RPSG were compared to a sex-, age-, body mass index-matched group of 31 patients who underwent CLSG. Outcomes were evaluated and compared between groups. RESULTS: Estimated blood loss volume, incidences of intraoperative and postoperative complications, and length of postoperative hospital stay did not differ significantly between the 2 groups. Operation time was significantly greater in the RPSG group than in the CLSG group (148.7 ± 22.6 vs. 120.2 ± 25.9 min, respectively; p < 0.001). Excess weight loss at 1 year was 105.9% and 109.7%, respectively (p = 0.94) and at 2 years was 101.1% and 105.3%, respectively (p = 0.64). One RPSG patient required placement of additional trocars because of bleeding from short gastric vessels, but conversion to open surgery was not required. CONCLUSIONS: RPSG is feasible in carefully selected bariatric patients and results in midterm outcomes comparable to those observed after CLSG. Good cosmesis is a potential benefit of RPSG.

Portomesenteric vein thrombosis after laparoscopic sleeve gastrectomy in patient with liver cirrhosis.

Laparoscopic sleeve gastrectomy (LSG) has become the dominant bariatric procedure because of its reliable weight loss and low complication rate. Portomesenteric vein thrombosis (PMVT) after LSG is an infrequent complication that can lead to serious consequences. Here, we report a patient who presented with abdominal pain 11 days after LSG for the treatment of morbid obesity. Contrast CT of the abdomen revealed PMVT. The patient had liver cirrhosis, which is a major risk factor for PMVT. When LSG is performed on an obese patient with liver cirrhosis, careful attention must be paid to the onset of PMVT.

Comparison of three software programs for three-dimensional graphic imaging as contrasted with operative findings.

OBJECTIVES: Several types of practical three-dimensional (3D) imaging software programs are available, including those attached to computed tomographic devices. Three different software programs (Advantage Workstation Volume Share 4, OsiriX and CTTRY) were used to generate 3D images on the basis of imaging data obtained by 64-slice multidetector-row computed tomography in the same patient. METHODS: Surgery was then performed referring to these 3D images in five patients. The characteristics, advantages, disadvantages and utility in the operative field of the images generated with each software program were compared with respect to actual operative findings. RESULTS: There were no marked differences in vascular images at the segmental level among the software programs, and all three were considered useful for surgery. However, vascular images at the subsegmental level differed among the three programs. CONCLUSIONS: The depiction of blood vessels at the subsegmental level lacked accuracy when compared with operative findings.