Ramadan fasting following laparoscopic sleeve gastrectomy: a prospective online survey cohort study in Egypt.

Purpose: This study aims to explore the feasibility and implications of Ramadan fasting for patients who have undergone laparoscopic sleeve gastrectomy (LSG), assessing impacts on hydration, nutrient intake, weight management, and gastrointestinal symptoms. Methods: A prospective online survey was conducted among 218 LSG patients and 83 control individuals with obesity who had not undergone surgery. Participants were surveyed before and after Ramadan, providing data on fasting practices, hunger and satiety levels, fluid and nutrient intake, and the occurrence of gastrointestinal symptoms. Statistical analysis was used to compare outcomes between fasting and non-fasting periods and between LSG patients and control participants. Results: A total of 70.2% of LSG patients completed the entire month of Ramadan fasting, with a significant correlation found between the duration post-surgery and the ability to fast. Fasting LSG patients reported decreased hunger, increased satiety, and significant reductions in fluid and nutrient intake during Ramadan. Weight loss was reported in 90.8% of fasting patients, with an average total weight loss of 7.2%. Gastrointestinal symptoms were mild and manageable. Conclusion: The majority of LSG patients can successfully fast during Ramadan with appropriate precautions, including adequate fluid and protein intake. The study highlights the need for patient education and tailored nutritional guidance to ensure safe and effective fasting post-LSG. In order to fast for the entire month, patients may be advised to consider postponing surgery for a few months after Ramadan, avoid overeating during non-fasting hours, and ensure sufficient fluid consumption and protein intake during fasting.

Bikini-line Hiatal Hernia Repair (BLHHR) During Sleeve Gastrectomy.

BACKGROUND: To preserve the aesthetic benefits achieved with Bikini line sleeve gastrectomy (BLSG), we have devised a novel approach for simultaneous hiatal hernia repair (HHR), known as bikini-line hiatal hernia repair (BLHHR). This manuscript presents our initial experience with BLHHR and assesses its feasibility and outcomes. METHODS: A prospective preliminary study was conducted on patients who underwent BLHHR between September 2020 and October 2022. Patient demographics, preoperative assessments, operative details, postoperative outcomes, and aesthetic evaluations were recorded. Feasibility and safety were assessed. RESULTS: Among 891 BLSG patients, 89 (9.9%) underwent BLHHR. The mean distances between the xiphoid process and the umbilicus, symphysis pubis, and anterior superior iliac spine (ASIS) were 28.8 ± 2.2, 33.9 ± 3.1, and 31.2 ± 1.8 cm, respectively. Optimal visualization and accessibility of the gastroesophageal junction (GEJ) were achieved without compromising HHR repair or sleeve gastrectomy. The mean operative time was 76.5 ± 11 min, longer than the 58 ± 10 min required for BLSG alone. Patient scar satisfaction ranged from 87.5 to 97.9%, and the mean pain score was 2.9 ± 0.8. No major complications were reported. At 6 months, %EWL (percentage of excess weight loss) was 53.3 ± 13.7%, GERD (gastroesophageal reflux disease) remission was achieved in 62.8% of patients and comorbidities were improved. CONCLUSION: BLHHR was potentially feasible and safe. Outcomes related to patient scar satisfaction, weight loss, improvement of associated comorbidities, and GERD symptoms were not compromised. The aesthetic benefits achieved by BLSG were maintained.

Feasibility and Efficacy of Laparoscopic Sleeve Gastrectomy as a Revisional Procedure After Failed Gastric Plication in Morbidly Obese Patients.

Background: Failure of adequate weight loss or weight regain has been reported after laparoscopic greater curve plication (LGCP). The primary aim of this retrospective study is to analyze weight loss outcome after revision of failed LGCP into laparoscopic sleeve gastrectomy (LSG). Patients and Methods: Patients who experienced failure (insufficient weight loss/weight regain) after LGCP performed in our center from 2009 to 2012 were included. LSG was performed for all patients. Results: Among 127 who underwent LGCP, 42 patients (33%) underwent revision. Mean body mass index (BMI) at time of LGCP was 44 ± 6 kg/m2. The highest % total weight loss (%TWL) after LGCP ranged from 11% to 34% (24.1 ± 5) (corresponding to % excess weight loss [%EWL] of 12%-47% [33.5 ± 12]). The time interval between LGCP and LSG ranged from 12 to 25 months (15.4 ± 3.8). After conversion, 2 patients (5%) experienced acute leakage managed by endoscopic stenting. After LSG, mean BMI (kg/m2) was 38, 32, 30, 28, 29, 30.2, and 30.4, while mean %TWL reached 9%, 19%, 24%, 29%, 25%, 25%, and 24% and mean %EWL reached 15%, 51%, 69%, 77%, 68%, 66%, and 64% at 1 month, 6 months, 1, 2, 3, 4, and 5 years, respectively. Except for results at 1 month, all results showed statistical significance (P ≤ .05). After LSG, the incidence of diabetes mellitus and hypertension dropped from 15 (35%) and 13 (30%) to 2 (5%) and 3 (7%) patients, respectively. No follow-up data (0%) were missed. Conclusion: LSG after failed LGCP has promising weight loss outcomes.

Sleeve Volume and Preoperative Gastric Volume Assessment Using Three-dimensional MDCT Gastrography and Their Correlation to Short-term Post-Sleeve Gastrectomy Weight Loss.

PURPOSE: Several factors including preoperative stomach capacity and sleeve volume impact weight loss after laparoscopic sleeve gastrectomy (LSG). We aimed at measuring these volumes using multidetector computed tomography (MDCT) gastrography and correlating them with postoperative weight losses. MATERIALS AND METHODS: Morbidly obese patients prepared for LSG during 2018 were included in the study. MDCT gastrography was performed 1 week before, 6 and 12 months after LSG. Preoperative gastric volume and postoperative sleeve volumes were measured. Correlation with preoperative BMI and postoperative %TWL was performed. The change in sleeve volume at 6 and 12 months was assessed. RESULTS: A total of 98 patients (62 F) were included. Mean preoperative BMI was47 ± 7 kg/m2. Follow-up was achieved in 89 patients (91%) and 82 patients (83%) at 6 and 12 months, respectively. Mean %TWL was 24 ± 3 and 32.8 ± 3 at 6 and 12 months, respectively (p < 0.05). Preoperative gastric volume ranged from 800 to 1800 ml (mean ± SD, 1310 ± 307) and dropped significantly to range from 140 to 170 ml (158 ± 9) and from 165 to 210 ml (181 ± 12) at 6 and 12 months postoperatively, respectively. Pouch was not significantly dilated at 12 vs. 6 months postoperatively. Preoperative gastric volume was significantly correlated with preoperative BMI (p = 0.006*) but not with postoperative weight losses. Correlation between postoperative pouch volumes and weight losses at 6 and 12 months postoperatively showed no significance. CONCLUSION: Sleeve pouch is significantly smaller than preoperative stomach, but not significantly correlated to weight loss. Restriction is an important, but not the only factor controlling weight loss after LSG.

Outcome of idiopathic intracranial hypertension after laparoscopic sleeve gastrectomy.

BACKGROUND: Idiopathic intracranial hypertension (IIH) predominantly affects young, obese women and presents with signs and symptoms of increased intracranial pressure, such as headaches and visual impairment. OBJECTIVE: We aim to present our experience in the management of IIH. SETTING: University Hospital. METHODS: Obese IIH patients who had a laparoscopic sleeve gastrectomy during the study period (2 years) were included. Data were retrieved from prospectively collected database. Headaches, visual alterations, and medications or interventions used to treat are discussed. RESULTS: The study included 16 obese women with IIH. Mean age was 31 ± 2 years (range, 25-44 yr) and mean body mass index was 46 ± 4 kg/m2 (range, 42-53 kg/m2). Main symptoms and signs were chronic headaches (14), impaired vision (15), vision loss (1), papilledema (6), and field defects in 4 patients. Symptoms were present for a mean of 5 years (4-11). History of medical treatment with carbonic anhydrase inhibitor (acetazolamide) and thecoperitoneal shunting was present in 12 and 9 patients, respectively. Mean lumbar puncture opening pressure was 41.2 ± 21- (range, 30-64) cm water. At 12 months after laparoscopic sleeve gastrectomy, body mass index and percentage excess weight loss were 27.8 ± 1 kg/m2 and 75.2 ± 2%, respectively. Symptoms gradually improved with complete resolution in all but 2 patients (87.5%). CONCLUSION: The present work emphasizes the role of bariatric surgery in the management of obese patients with IIH. Larger, prospective, controlled studies are needed.

SERPINE-1 Gene Methylation and Protein as Molecular Predictors of Laparoscopic Sleeve Gastrectomy Outcome.

BACKGROUND: Body weight is subjected to genetic and epigenetic modifiers that might affect the success of weight loss interventions. Because of its possible complications and disparity in patients' response, identification of predictors to the outcome of bariatric surgery is indispensable. OBJECTIVES: This prospective study aims to investigate serpin peptidase inhibitor type 1 (SERPINE-1) protein and gene methylation as molecular predictors to the outcome of bariatric surgery. PATIENTS AND METHODS: One hundred participants were enrolled and divided to control group (n = 50) and obese patients who underwent laparoscopic sleeve gastrectomy (LSG) (n = 50). Anthropometric measurements were assessed and blood samples were collected preoperatively and 6 months postoperatively for assessment of SERPINE-1 protein and gene methylation, C-reactive protein (CRP), and homeostatic model assessment of insulin resistance (HOMA-IR). Moreover, subjects were followed for 2 years for weight loss parameters. RESULTS: Patients with obesity showed high baseline SERPINE-1 protein and gene hypermethylation where LSG was followed by a drop in SERPINE-1 protein level but not gene hypermethylation. Baseline SERPINE-1 gene methylation was negatively related to postoperative weight loss and was the independent predictor to weight loss after LSG. Likewise, postoperative SERPINE-1 protein was negatively related to weight loss with independent expression from its gene methylation state. Furthermore, postoperative SERPINE-1 gene methylation correlated to CRP and HOMA-IR. CONCLUSION: Baseline SERPINE-1 gene methylation might be a predictor of weight loss after LSG. Meanwhile, postoperative SERPINE-1 protein could be a predictor to weight loss maintenance after LSG. Lastly, postoperative SERPINE-1 gene methylation might serve as an index to postoperative changes in obesity-related comorbidities.

Weight Loss and Diabetes Control Following Laparoscopic Sleeve Gastrectomy.

Background: Data following laparoscopic sleeve gastrectomy (LSG) for type 2 diabetes mellitus obese patients are extremely variable and we herein present our results. Methods: The data of 320 (90 diabetic) obese patients who had LSG were retrieved from prospectively collected database. Postoperative weight loss and glycemic control were evaluated during 24 months follow-up. Results: Diabetic patients had a significantly higher percentage excess weight loss (%EWL) (60.21 ± 11 and 72.9 ± 13) than nondiabetics (53.4 ± 12 and 62.5 ± 29) at 12 and 24 months post LSG, respectively. Diabetic patients with body mass index (BMI) >40 kg/m2 had significantly higher %EWL (64.17 ± 13 and 75.2 ± 16) than patients with BMI ≤40 at 12 and 24 months, respectively. The mean glycated hemoglobin and fasting blood glucose were 6.6% ± 1.4%, 6.1% ± 1.1%, 5.9% ± 1.2%, 5.8% ± 0.5%, and 110 ± 1.6 mg/dL, 106.7 ± 1.8 mg/dL, 99.2 ± 1.9 mg/dL, and 98.1 ± 1.2 mg/dL at 1, 6, 12, and 24 months, respectively. All patients had complete diabetes remission at 12 months, and this was maintained at 24 months. Conclusion: Diabetic obese patients with BMI >40 kg/m2, had a better %EWL compared with nondiabetics and to diabetics with lower BMI. Diabetes remission started early at 1 month. At 12 months, all diabetics had complete diabetes remission and this was maintained at 24 months. Our results need to be validated in a larger study, which evaluates impact of gastrointestinal motility on diabetes control.

Impact of Laparoscopic Sleeve Gastrectomy on Obese Patients with Subclinical Hypothyroidism.

Background: This study aims to evaluate the incidence of subclinical hypothyroidism (SCH) among studied obese patients. The effects of laparoscopic sleeve gastrectomy (LSG) and loss of weight on thyroid hormones level and the impact of adding thyroxine treatment is described. Patients and Methods: Obese patients undergoing LSG at the university hospital between June 2016 and January 2018 were included. Weight loss and changes in body mass index (BMI), serum thyroid stimulating hormone (TSH), and FT4 were evaluated. SCH patients were randomly divided into group "A" received thyroxine treatment and group "B" received no treatment. Results: There were 554 patients studied (mean age 41 ± 12 years); the mean preoperative BMI, serum TSH, and FT4 were 45 ± 6.8 kg/m2, 3.91 ± 1 µU/mL, and 1.32 ± 1 ng, respectively. Incidence of SCH was 12.9%. Significant post-LSG decrease in BMI (30.8 ± 4.6 kg/m2) was associated with significant decrease in serum TSH (1.99 ± 1.1 µU/mL) in all patients; changes were more prominent in SCH group and in patients with higher BMI. SCH patients had normalization of mean serum TSH at 12 months post-LSG. Results of groups "A" and "B" were not significantly different. Conclusion: The incidence of SCH was 12.9%. The significant decrease in BMI was associated with a significant decrease in serum TSH after LSG; this was more evident in SCH and in patients with higher BMI. Complete resolution of SCH occurred at 12 months post-LSG. Adding thyroxine treatment in obese SCH patients did not improve outcome and should be reserved to specific clinical and laboratory indications.

Bikini Line Sleeve Gastrectomy: Initial Report.

BACKGROUND/INTRODUCTION: Several reports have discussed the potential for reducing port access in laparoscopic sleeve gastrectomy (LSG); however, each approach had its innate setbacks. Aiming at improving the aesthetic outcome, we report a novel approach to the LSG where we place the trocars at the bikini line in what we described as bikini line sleeve gastrectomy (BLSG). METHODS: The present work is a prospective, pilot study on the use of BLSG in patients, during the period between April and October 2016. Exclusion criteria included the following: large hiatal hernia, upper abdominal surgery, and xiphi-umbilical, xiphi-symphysis pubis, and xiphi-anterior superior iliac spine distances of > 25,36 and 33 cm, respectively. Four trocars were used: one at the umbilicus and three at the bikini line. All laparoscopic graspers were bariatric length instruments (43 cm). However, camera telescope, endoscopic stapler, and bipolar dissectors were standard length. RESULTS: Twenty eight patients underwent BLSG. The mean age was 34.6 ± 3.7 years with a mean BMI of 42.46 kg/m2 ± 3. There were no major intra- or postoperative complications and no conversion to conventional port site placement. Patient's scar satisfaction was favorable. The mean postoperative BMI and weight at 6 m were 28.5 ± 1 kg/m2 and 79.8 kg ± 2, respectively. The mean percentage excess weight loss at 3, 6, and 12 months were 39.5 ± 4.6, 64.5 ± 5, and 69.8 ± 6%, respectively. CONCLUSION: BLSG was found to be potentially safe, feasible, and effective with a favorable aesthetic outcome; it could possibly be offered to a select group of patients that are conscious about their scar appearance.

Management modalities in slipped gastric band.

BACKGROUND: Gastric band slippage is one of the possible complications of the laparoscopic gastric band (LGB). Band slippage can present as an emergency and have drastic consequences. We herein report the different treatment modalities of slipped gastric band. MATERIAL AND METHODS: A retrospective study of all patients presenting with slipped gastric band between May 2013 and January 2015 at our University hospital is described. All patients were evaluated at the time of presentation by radiological studies and upper gastrointestinal endoscopy. On diagnosis, all bands were deflated in an attempt to relieve symptoms. After patient counseling and band position evaluation, patients were consented for either removal or repositioning of the band. RESULTS: This study included 100 patients. Gastric band slippage rate was 8%. All patients presented with signs of gastric obstruction and expressed a long history of intermittent vomiting attacks. All patients were subjected to a complete gastric band deflation on presentation. Band deflation successfully relieved symptoms and reversed band slippage in 2 patients. However, both patients returned with band reslippage within the same month. The other 6 patients had persistent band slippage despite complete band deflation. Three of the 8 patients had a successful band repositioning, and the rest had their gastric bands removed. CONCLUSION: Gastric band slippage can be a serious LGB complication. Repeated vomiting can be a significant risk factor for band slippage. Moreover, band repositioning can be a well-tolerated and feasible option in the management of slipped gastric band.

Computed tomographic scan mapping of gastric wall perfusion and clinical implications.

BACKGROUND: Several postoperative gastrointestinal complications are attributed to ischemia. We herein evaluate the gastric wall perfusion using computed tomography (CT) scan perfusion index on trial to address the etiology of ischemic complication after sleeve gastrectomy. METHODS: A retrospective study of 205 patients undergoing CT scan of the abdomen to evaluate the pattern of gastric vascular perfusion was performed. The perfusion index of the gastric mucosa was measured at 5 gastric points using CT perfusion scanning. RESULTS: Gastric perfusion at the angle of His (AOH) (53.51 ± 14.38) was statistically significantly lower (P < .001) than that at the other gastric points studied: fundus, greater curvature, lesser curvature, incisura angularis, and mid gastric points (76.16 ± 15.21, 73.27 ± 16.55, 76.12 ± 16.12, and 75.24 ± 14.9, respectively). Gastric perfusion was significantly lower at all the gastric points (and especially so at the AOH) among obese patients (33 cases) compared with nonobese patients (18 cases). Gastric perfusion at all the points studied showed a decrease as the body mass index increases. Hypertensive patients had a better gastric perfusion compared with nonhypertensive patients. CONCLUSIONS: Gastric wall perfusion is statistically significantly decreased at the AOH and gastric fundus compared with perfusion at other gastric points. Gastric perfusion at all the gastric points studied decreased with the increase in body mass index. Gastric leakage in obese patients following sleeve gastrectomy could be attributed to a decrease in the blood supply at AOH.

Laparoscopic gastric greater curvature plication versus laparoscopic sleeve gastrectomy: early outcome in 140 patients.

BACKGROUND: Laparoscopic gastric greater curvature plication (LGGCP) is a novel bariatric procedure. Its outcome as a standalone procedure has been studied in the literature. We herein describe a comparative study between LGGCP versus laparoscopic sleeve gastrectomy (LSG). The objective of this study was to analyze %excess weight loss (%EWL), co-morbidity improvement and complication rate in both groups at 1, 3, 6, 12 months follow-up. METHODS: Retrospective study of 140 patients undergoing LGGCP and LSG between July 2011 and March 2012 at University of Alexandria, Egypt. Data on patient demography, operative time, length of stay, body mass index (BMI) were collected. RESULTS: Baseline characteristics were similar for both groups, except for preoperative BMI that was higher among the LSG group. Follow up rate was 98% (n = LGCCP: 68 - LSG: 69) at 6 months and 81% (n = LGGCP: 54 - LSG: 60) at 1 year. The mean operative time and mean length of stay were longer in the LSG group (P = .03) and (P = .02), respectively. There were 4 (6.5%) readmissions and 2 (3.2%) reoperations in the LGGCP group compared to 3 (3.8%) readmission and 2 (2.6%) reoperations in the LSG group. At 6 months follow-up the mean %EWL for LGGCP and LSG was 40.4±11.9% and 47.1±13.9% (P<.001), while at 1 year it was 52.1±15.1% and 68.1±15.8% (P<.001), respectively. Both techniques showed similar results in co-morbidity improvement at 1 year. CONCLUSION: In the short term, both techniques were comparable as regards to co-morbidity resolution. However, LSG appears to have achieved a higher weight loss.

Gastric plication for morbid obesity: a systematic review.

BACKGROUND: Gastric plication is a new bariatric procedure. Controversies exist regarding this emerging surgery. We herein present a comprehensive review of the literature regarding gastric plication approach. METHODS: Advanced Pub Med search combining the MeSH terms "Gastric plication", OR "Gastric greater curvature plication" yielded 213 abstracts. Abstracts were screened for articles in English and articles on human subjects yielding 130. Further searches revealed 121 titles to be unrelated to gastric plication. The remaining nine abstracts were analyzed for their full texts. Two articles were excluded because, one was a commentary on another article, and the other was a released ASMBS policy on gastric plication. In the end, there were seven articles published on gastric plication. RESULTS: A total of 307 patients had undergone gastric plication. The mean operative time range was 40 to 150 min. The median length of hospital stay ranged between 1.3 and 1.9 days. In respect to excess weight loss (EWL), at 6 months, it ranged from 54 to 51 %, while at 12 months 67-53.4 %. The longest follow-up was 3 years with a mean of 57 % EWL. CONCLUSION: Laparoscopic gastric plication is still in its infancy. Prospective randomized studies comparing gastric plication to other well established bariatric procedures are needed to prove the reliability and metabolic effectiveness of such new procedure.