Endoscopic Administration of Combined Autologous Mesenchymal Stem Cells and Platelet-Rich Plasma for the Treatment of Gastric Staple Line Leaks After Sleeve Gastrectomy.

BACKGROUND: Gastric staple line leak treatment after laparoscopic sleeve gastrectomy (LSG) remains challenging. Regenerative medicine is gaining place in the accelerated treatment of damaged tissues. This study presents the first series of gastric leak treatment after LSG using endoscopic intragastric administration of combined autologous mesenchymal stem cells (MSC) and platelet-rich plasma (PRP). METHODS: MSC-PRP harvesting and endoscopic administration techniques are described in detail. Data were prospectively gathered and analyzed. Primary endpoints were morbidity/mortality rates and fistula closure time. RESULTS: Twelve patients (9 women, 3 men) were included. Median age was 41.5 years, median weight 105.5 kg and median BMI 38.9 kg/m2. Median time to gastric staple line leak detection was 10 days post-LSG. Median time between re-laparoscopy and MSC-PRP administration was 5 days. MSC-PRP endoscopic administration was successfully performed and tolerated by all patients, with median procedure duration of 27 min and minimal blood loss. Four postoperative complications were noted: two patients with increased tibial pain at tibial puncture site, one with tibial hematoma, and one with epigastric pain/dysphagia. Median length of hospital stay was 1 day. Gastric leak healing occurred after a median of 14 days, only two patients requiring a second MSC-PRP endoscopic injection. Median follow-up was 19 months, all patients being in good health at last contact. CONCLUSION: Endoscopic administration of combined autologous MSC-PRP seems to be a good option for treatment of gastric leaks after sleeve gastrectomy. It is a challenging procedure that should be performed in specialized bariatric centers by expert bariatric surgeons and endoscopists after meticulous patient selection.

Long-Term Results of Sleeve Gastrectomy and Roux-en-Y Gastric Bypass in Individuals Older Than 60 Years with Morbid Obesity.

PURPOSE: An increasing Pnumber of individuals with obesity over the age of 60 years require bariatric surgery to treat obesity and its related medical problems. Sleeve gastrectomy and Roux-en-Y gastric bypass have already proven their efficacy in this population, but literature lacks reports of long-term results. The aim of this study is to compare long-term results of sleeve gastrectomy and Roux-en-Y gastric bypass in individuals older than 60 years old. MATERIALS AND METHODS: This is a single-center, retrospective, comparative study of 204 patients undergoing either sleeve gastrectomy (123, 60.3%) or Roux-en-Y gastric bypass (81, 39.7%) for morbid obesity with a mean follow-up of 44.5 ± 19.1 months and 54.6 ± 17.9 months, respectively. RESULTS: Total weight loss was significantly increased for patients who underwent Roux-en-Y gastric bypass compared to sleeve gastrectomy from 12 to 48 months after surgery, while no significant difference was found after 60 (30.39% vs. 27.63%) and 72 (27.36% vs. 23.61%) months. Roux-en-Y gastric bypass was associated to a significant increased rate of early postoperative complications (22.2% vs. 4%; p < 0.0001), but no difference was found concerning late postoperative morbidity (6.2% vs. 1.6%). Both procedures were effective in obesity related medical problems. CONCLUSION: Roux-en-Y gastric bypass confers an increased weight loss than sleeve gastrectomy in patients over the age of 60 in the mid-term, but it is associated with more early postoperative complications. Sleeve gastrectomy can be considered a valid alternative as long-term weight loss results are superposable to those ensured by Roux-en-Y gastric bypass.

Laparoscopic Roux-en-Y fistulojejunostomy as a salvage procedure in patients with chronic gastric leak after sleeve gastrectomy.

BACKGROUND: The most common postoperative complication of laparoscopic sleeve gastrectomy (LSG) is staple-line leak. Even if its rate following LSG has been recently reduced, management of chronic leaks remains challenging. OBJECTIVE: To present a series of patients treated with laparoscopic Roux-en-Y fistulojejunostomy (LRYFJ) for chronic gastric leak (>12 wk) post-LSG. SETTING: University hospitals; specialized bariatric surgery units. METHODS: Data were prospectively gathered and retrospectively analyzed. Parameters of interest were patient characteristics, perioperative data, and postoperative outcomes. Hemodynamically unstable patients and/or presentations of signs of severe sepsis were excluded. Surgical technique was standardized. RESULTS: Fourteen patients underwent LRYFJ for chronic gastric leak (12 women, 2 men). The mean age was 49.2 years and the mean weight was 88.7 kg with a mean body mass index of 31.1 kg/m2. All procedures were successfully performed by laparoscopy except 1 (7.1%) converted to open surgery. The mean operative time was 198 minutes, with a mean estimated blood loss of 135.7 mL and 2 patients necessitating transfusion (14.2%). Mortality was null. Five postoperative complications were noted (35.7%): 2 leaks of the fistulojejunostomy treated by antibiotherapy and endoscopic drainage; 1 perianastomotic hematoma treated by relaparoscopy and antibiotherapy; and 1 pleural effusion and 1 hematemesis both medically treated. The mean length of hospital stay was 14 days. The mean follow-up was 40 months, with all patients being in good health at last contact. CONCLUSIONS: LRYFJ seems to be a good salvage option in selected patients for the treatment of chronic gastric leaks after LSG. However, it is a challenging procedure and should be performed in experienced bariatric centers by expert bariatric surgeons.

Mesenchymal Stem Cells and PRP Therapy Favorize Leak Closure After Sleeve Gastrectomy in Zucker Rats.

INTRODUCTION: Sleeve gastrectomy (SG) is the most performed bariatric surgery but gastric leaks following SG occur in up to 2% of cases. Regenerative medicine is emerging as a promising field offering multiple possibilities in wound healing. We studied the efficiency of locally administered mesenchymal stem cells (MSCs) and platelet-rich plasma (PRP) on leak closure following SG in rats. METHODS: The amount of PRP and MSCs extracted from one rat was analyzed and a model of gastric leak was developed in 10-week-old male Zucker rats. Twenty-four rats underwent SG fashioned with a leak. After 24 h, a second surgery was performed. The control group was treated by peritoneal lavage and drainage only while the experimental group received an additional treatment of locally administered MSCs and PRP at the leak orifice. Analysis of the leak healing process was done by an anatomopathological examination of the stomach 1, 2, 3, and 4 weeks after SG. RESULTS: The extraction of MSCs and PRP from one rat was necessary for three recipients. Anatomopathological examination suggests that the closure of the leak orifice was faster in the experimental group. Statistical analysis revealed a significantly increased mucosae renewal and fibrosis score at the leak orifice after treatment with MSCs and PRP (p < 0.001). CONCLUSION: These results suggest that PRP and MSCs may accelerate the closure of leaks following SG in rats and may become a new tool in the treatment of human gastric leaks but more research on this topic is needed to confirm these findings.

Comparative analysis of robotic versus laparoscopic Roux-en-Y gastric bypass in severely obese patients.

Benefits of robotic surgery for Roux-en-Y gastric bypass (RYGB) are still debated. We aimed to compare conventional laparoscopic (L-RYGB) to robotic RYGB (R-RYGB) and evaluate safety, efficacy, advantages and drawbacks of each procedure. A prospective cohort study with a retrospective review approach was conducted to analyze results of L-RYGB and R-RYGB performed at a bariatric center of excellence. Patient demographics, perioperative data, weight loss, comorbidities evolution and cost were assessed. One hundred and sixty-one severely obese patients underwent R-RYGB and L-RYGB, respectively. Patient's characteristics were similar between groups. Intraoperative blood loss was similar (p = 0.91), with no requirement for blood transfusion. Median operative time was significantly reduced for R-RYGB (127 vs 160 min; p < 0.001). Seven patients (11.4%) in the L-RYGB group and 15 patients (15%) in the R-RYGB group had early postoperative complications (p = 0.63), with more anastomotic leaks and stenosis for R-RYGB during initial learning curve (p = NS). Mortality was null. Median length of hospital stay was similar (6 days; p = 0.20). Mean hospital cost was non-significantly increased for R-RYGB ($5730 vs. $4879; p = 0.34). Two years after surgery, median BMI and mean EWL% were similar for both groups (26.1 vs 26.5 kg/m2 and 89.9% vs 90.9% for L-RYGB and R-RYGB groups, respectively; p = 0.71 and 0.85, respectively), with no statistically significant difference in comorbidities between the two groups (p = 0.80). R-RYGB is feasible and safe within the reach of every laparoscopic surgeon. In our series, it was associated with shorter operative time and equivalent length of stay and weight loss outcomes compared to L-RYGB. Further well-designed randomized studies are necessary to draw safe conclusions.

Laparoscopic sleeve gastrectomy for the treatment of idiopathic intracranial hypertension in patients with severe obesity.

BACKGROUND: Severe obesity is a major risk factor for idiopathic intracranial hypertension (IIH). Data on the role of bariatric surgery for the treatment of this condition are scarce. OBJECTIVE: To evaluate the effectiveness of laparoscopic sleeve gastrectomy (LSG) on treating IIH in severely obese patients. SETTING: Two university bariatric surgery centers. METHODS: Prospectively collected data from consecutive patients undergoing LSG were retrospectively analyzed. Patients with IIH and referred by neuroophthalmologists for bariatric surgery were included in the analysis. RESULTS: Fifteen female patients with IIH underwent LSG (median age: 31 yr). Median preoperative body mass index was 42.1 kg/m2. Preoperatively, 14 patients (93.3%) had chronic headaches, 8 (53.3%) pulsatile tinnitus, and 1 (6.6%) epistaxis episodes. Ophthalmologic assessment showed bilateral papilledema in all patients, of whom 13 had visual symptoms. Median initial cerebrospinal fluid opening pressure was 31 cmH2 O (range: 25-50 cmH2 O); 4 patients required repeated decompressing lumbar punctures (1 ventriculoperitoneal shunt). LSG was successfully performed in all patients. No patients were lost to follow-up. Mean excess weight loss was and 87.4% and 88.1% 1 and 2 years after LSG, respectively. Headaches totally resolved in 13 patients (93.3%) and improved in 1 (P < .001). Pulsatile tinnitus (P = .013), epistaxis, visual symptoms (P < .001), and papilledema (P < .001) significantly resolved. Medication was stopped in 14 patients (93.3%). Two years after LSG, IIH outcomes for 7 patients reaching this time point remained unchanged. CONCLUSION: This study suggests that LSG is effective for severely obese patients with IIH, resulting in complete remission or significant improvement of their symptoms as well as medication discontinuation.

Midterm Outcomes of Gastric Pouch Resizing for Weight Regain After Roux-en-Y Gastric Bypass.

PURPOSE: Resizing of the gastric pouch, with eventually resizing of the gastrojejunal anastomosis, has been proposed as revisional procedure to treat weight regain after Roux-en-Y gastric bypass (RYGB), in patients with large gastric pouch and/or large gastrojejunal (GJ) anastomosis. The aim of this study is to determine the midterm results and the safety of laparoscopic resizing of the gastric pouch after RYGB in cases where gastric pouch is > 200 ml and/or GJ anastomosis > 20 mm. MATERIALS AND METHODS: All patients who underwent gastric pouch resizing between January 2009 and December 2016 were retrospectively reviewed from a prospective database. The gastric pouch was resized to a volume of 30-40 ml. RESULTS: A total of 48 patients had gastric pouch resizing after RYGB. The mean initial BMI was 42.9 ± 4.8 kg/m2. Perioperative morbidity was 8.3% in this series. Mean follow-up was 5.4 years. The mean BMI was 30.0 ± 7.3 kg/m2 at 1 year, 30.0 ± 6.0 kg/m2 at 3 years, and 30.9 ± 5.7 kg/m2 at 5 years. Mean %EBMIL at 1-, 3-, and 5-year follow-up was 51.9%, 55.1%, and 39%, respectively, in 48% follow-up rate. The obesity-related comorbidities disappeared in 67.3% of cases at maximum follow-up. CONCLUSIONS: In carefully selected patients with gastric pouch size > 200 ml and/or GJ anastomosis > 20 mm, and after extensive preoperative evaluation, gastric pouch resizing is a potentially effective option to treat weight regain due to anatomical factors after RYGB, with complication rate of 8%.

Combined Laparoscopic Revision of the Gastric Pouch and Distalization of the Roux Limb After Failure of Weight Loss Following Roux-en-Y Gastric Bypass.

PURPOSE: After failed Roux-en-Y gastric bypass (RYGB), the choice of a secondary procedure falls into many pathways: revision of the gastric pouch, distalization of the bypass (DRYGB), addition of an adjustable gastric band, and conversion to a duodenal switch (BPD/DS). MATERIAL AND METHODS: We present the case of a 54-year-old man with initial BMI of 51.5 kg/m2, who first underwent laparoscopic sleeve gastrectomy (SG) in 2010. In 2012, he underwent a RYGB procedure, and in 2015, a pouch resizing for weight regain. In 2018, he reached a BMI of 41.2 kg/m2. A 3D volumetric CT scan measured a gastric pouch volume of 220 cm3 and a gastrojejunal anastomosis diameter of 20 mm. RESULTS: As shown in the video, the patient underwent a combined revision of the gastric pouch and the gastrojejunal anastomosis associated to the distalization of the Roux limb. The gastrojejunal anastomosis is identified, and vertical division of the stomach is performed along a 36 French bougie, in order to create a 30 cm3 gastric pouch. Then, the jejunojejunal anastomosis is identified, and the Roux limb at the jejunojejunostomy is divided and transposed distally 100 cm to create a total alimentary length of 250 cm. The postoperative course was uneventful. At 1 year, his BMI was 31.2 kg/m2. No nutritional deficiencies were noted. CONCLUSION: Combined laparoscopic pouch resizing and distalization are safe and can lead to adequate weight loss. This technique allows the combination of an added restriction and malabsorption to the previous RYGB and could lead to an improved weight loss.

The Nissen-Sleeve (N-Sleeve): Results of a Cohort Study.

BACKGROUND: The Montpellier bariatric team has recently proposed some technical alternatives to decrease the rate of gastroesophageal reflux disease (GERD) after bariatric surgery and also to offer patients an alternative in case of contraindication to Roux-en-Y gastric bypass (RYGBP): the Nissen-Sleeve (N-Sleeve). OBJECTIVES: We present here the results from a cohort of patients that underwent an operation with this newly designed anti-reflux bariatric procedure N-Sleeve: Nissen valve added to a standard SG. METHODS: Data from a prospective, observational, and monocentric cohort. All consecutive patients presenting to the bariatric surgery department for a laparoscopic sleeve gastrectomy between 2016 and 2018 with GERD were included in the study. The fundus was stapled with a margin from the valve, and the valve was created with tissue at a distance from the greater curvature so as to avoid a double layer stapling of the stomach. RESULTS: A total of 70 patients were included in the study. Ninety percent of the cohort presented with a hiatal hernia at the time of surgery. No mortality was observed during the follow-up period. Concerning GERD, 76% of all patients had preoperative esophageal syndromes, whereas 21% were asymptomatic with associated esophagitis. Grade A-C esophagitis was present in 99% of the cohort, but no Barrett's esophagus was present. Fifty-six (80%) patients used PPIs regularly. At 1 year of follow-up, one patient was still symptomatic. CONCLUSIONS: Comparative trials remain necessary between N-Sleeve and standard bariatric procedures to refine the specific indications of each of them and determine the eventual role of the N-Sleeve.

Laparoscopic Roux-en-Y Double Fistulo-Jejunostomy for Chronic Gastric Leaks After Converted Vertical Banded Gastroplasty to Sleeve Gastrectomy.

BACKGROUND: As laparoscopic sleeve gastrectomy (LSG) is becoming the most popular bariatric procedure worldwide, treatment options for managing complications, in particular gastric leaks, are also emerging. Staple line leak is a major short-term complication of the procedure. Patients with persistent gastric leaks after failure of endoscopic and radiologic management are candidates for salvage surgery. Laparoscopic Roux-en-Y fistulo-jejunostomy (RYFJ) represents a surgical option to treat persistent gastric leak post-LSG. METHODS: We present the case of a 55-year-old woman undergoing laparoscopic double RYFJ for persistent gastric leaks after complicated bariatric surgery. The patient developed two chronic gastric leaks (gastro-esophageal and cardial localizations) following conversion to sleeve gastrectomy for failed vertical banded gastroplasty. With the two leaks being refractory to endoscopic treatment 6 months later after laparoscopic sleeve gastrectomy, salvage surgery was proposed. Surgery was performed laparoscopically, the gastric leak orifices were identified after careful dissection, and a double RYFJ was successfully completed. RESULTS: Postoperative course was uneventful. The patient remains in good health 6 months after surgery. CONCLUSIONS: Double LRYFJ for chronic leaks after complicated bariatric procedures seems safe with good postoperative outcomes. However, it remains a challenging procedure and should be reserved for selected patients in specialized bariatric centers.

An Alternative Technique of Reversal of Roux-en-Y Gastric Bypass: the Small Bowel Limb Transposition.

Roux-en-Y gastric bypass (RYGB) is recently the second most frequent operation worldwide and is only preceded by sleeve gastrectomy. We present an alternative technique of reversal of RYGB. There is no need to dissect or resect the gastrojejunal anastomosis. This dissection might be difficult as the gastrojejunal anastomosis might be adherent to the residual stomach. The 2 anastomoses performed are technically easy and done on healthy non-inflammatory tissue.

Treatment of complex recurrent fistula-in-ano by surgery combined to autologous bone marrow-derived mesenchymal stroma cells and platelet-rich plasma injection.

PURPOSE: We report a case of successful management of complex recurrent cryptoglandular fistula-in-ano by surgery combined with autologous bone marrow-derived mesenchymal stroma cells (MSCs) and platelet-rich plasma (PRP) injection. METHODS: Clinical, radiological, and surgical data of the patient were reviewed, as well as the current literature on complex fistula-in-ano. RESULTS: A 37-year-old man with a recurrent cryptoglandular perianal fistula was addressed to our department. Inflammatory bowel disease was excluded by clinical history, endoscopy, and blood tests. Physical examination and MRI showed an anterior external orifice on the midline, 5 cm from the anal verge, with an internal orifice on the same line. Surgery combined to injection of MSC-PRP solution was successfully performed. MSC-PRP solution was prepared while the patient was under general anesthesia: bone marrow MSCs were obtained by centrifugation of a tibial puncture specimen and PRP from a peripheral whole blood sample of the patient. There were no adverse events post-operatively. Clinical and MRI examination 4 months after treatment confirmed the absence of perianal fistula. More than 2 years after surgery, there has been no recurrence. CONCLUSIONS: Treatment of complex recurrent cryptoglandular fistula-in-ano by surgery combined to autologous bone marrow-derived MSCs and PRP injection seems safe in selected patients, allowing long-term healing. This procedure seems promising but further evaluation by clinical trials is warranted.

Impact of Mesenteric Defect Closure During Laparoscopic Roux-en-Y Gastric Bypass (LRYGB): a Retrospective Study for a Total of 2093 LRYGB.

BACKGROUND: Internal hernia is a rare but a potentially fatal complication of laparoscopic Roux-En-Y gastric bypass (LRYGB). The aims of this study are to determine the impact of mesenteric defects closure on the incidence of internal hernia after LRYGB and to determine the symptoms, characteristics, and management of internal hernias after LRYGB. METHODS: A retrospective study for a total of 2093 LRYGB was carried out from 1998 to December 2013. Four hundred twenty-one patients were operated without closure of the mesenteric defects (group A). From January 2005 to December 2013, 1672 patients were operated with closure of the mesenteric defects at Petersen defect (PD) and at jejunojejunal anastomosis (J-J) defect (group B). The incidence of internal hernias was compared between the two periods. RESULTS: Out of the 2093 patients who underwent LRYGB, 20 patients (0.95%) developed a symptomatic internal hernia that required primary surgical intervention; 7 patients (1.66%) in group A all at J-J DEFECT versus 13 patients (0.78%) in (group B) 6 at (J-J DEFECT), 5 at PD, and 2 at PD, J-J DEFECT. This incidence was significantly lower in (group B) (p = 0.0021). The median interval between LRYGB and reoperation was 53 months in group A and 26 months in group B. A CT scan was performed in 8 patients, 40%, and showed signs of occlusion in all cases. CONCLUSIONS: The closure of mesenteric defects during LRYGB is recommended because it is associated with a significant reduction in the incidence of internal hernia.

Laparoscopic Roux-En-Y Fistulo-Jejunostomy, a Preferred Technique after Failure of Endoscopic and Radiologic Management of Fistula Post Sleeve Gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy represents the most performed bariatric procedure in France. Staple line leak is the major short-term complication of the procedure. Patients with persistent fistula after sleeve gastrectomy, after failure of endoscopic and radiological treatment, are candidates for salvage surgery. Laparoscopic fistulo-jejunostomy (LRYFJ) represents a surgical option to treat persistent fistula post sleeve. METHODS: The case of a 46-year-old woman, with persistent fistula after sleeve gastrectomy, undergoing laparoscopic fistula-jejunostomy is presented. The patient developed an abdominal abscess 2 months after sleeve gastrectomy, treated with radiological drainage. Upper gastrointestinal endoscopy was performed for pigtail insertion. Three months later, the fistula was persistent and salvage surgery was proposed. At surgery, the pigtail drain and the fistula orifice were identified with careful dissection. Then a manual Roux-en-Y fistula-jejunal anastomosis and a mechanical jejuno-jejunal anastomosis are performed. RESULTS: The postoperative course was uneventful. CONCLUSIONS: LRYFJ for chronic fistula after sleeve gastrectomy is safe and effective. However, it remains a challenging procedure and should be reserved for specialized centers.

Revisional But Not Conversional Gastric Bypass Surgery Increases the Risk of Leaks: Review of 176 Redo out of 932 Consecutive Cases.

INTRODUCTION: Nowadays, surgeons are dealing more and more with patients experiencing failure of a previous bariatric procedure after the worldwide exponential increase of bariatric surgery. Only a few and contradictory studies investigated both outcomes and complications risk factors in this subset population of bariatric patients. We aimed to study a homogeneous population of patients undergoing redo bariatric surgery (REDO-BS) resulting in bypass anatomy to evaluate early postoperative outcomes and identify risk factors of postoperative complications and mortality. MATERIAL AND METHODS: In this study, we compared the outcomes of patients undergoing REDO-BS from another former bariatric procedure into Roux-en-Y gastric bypass (RYGP) to those undergoing primary RYGP. Data were extracted from a prospectively maintained database. RESULTS: One hundred thirty-eight conversional bariatric surgery (CBS) cases resulting in RYGP anatomy and 38 RBS cases of pouch resizing (PR) were compared with 756 primary RYGP. There were no statistical significant difference in outcomes between the primary and CBS groups but patients undergoing PR had a significant higher risk of developing a leak than others. CBS complication risk factors were age (OR = 1.05; p = 0.04), operative time, and T2DM (OR = 4.11; p = 0.03). CONCLUSIONS: CBS is safe and leads to similar early postoperative outcomes as primary RYGP whereas the indication for revisional surgery such as PR should be carefully evaluated as it is associated with an increased risk of leak.