Gastroesophageal Reflux Disease After Roux-en-Y Gastric Bypass: Pathophysiology and Management.

Introduction: Patients with obesity are often affected by gastroesophageal reflux disease (GERD). Roux-en-Y gastric bypass (RYGB) is considered the ideal operation for patients with severe obesity and GERD. Although the majority of patients improve their reflux with the operation, some might persist symptomatic and others can even develop de novo GERD. The aim of this study was to determine pathophysiologic factors involved in the development of GERD after RYGB surgery and define potential treatments for this condition. Materials and Methods: Studies including patients with GERD before and after RYGB and/or analyzing possible GERD therapies were analyzed by the authors. Searches were conducted in PubMed, Cochrane Library, and Embase databases. Results: GERD can persist, worsen, or develop after RYGB. There are certain technical elements of the operation identified as potential risk factors for GERD. Medical therapy is effective in the majority of patients. Both endoscopic and surgical procedures can also help resolving GERD after RYGB. Conclusions: Although the majority of patients with GERD after RYGB can be effectively managed with medical therapy, some may require endoscopic or surgical treatment. Critical technical elements of RYGB should be considered to reduce the risk of postoperative GERD.

Risk factors for major complications after surgical treatment of primary ileocecal Crohn's disease. A multicentric Latin American experience.

INTRODUCTION: Complications after ileocecal resection for Crohn's disease (CD) are frequent. The aim of this study was to analyze risk factors for postoperative complications after these procedures. MATERIALS AND METHODS: We conducted a retrospective analysis of patients treated surgically for Crohn's disease limited to the ileocecal region during an 8-year period at 10 medical centers specialized in inflammatory bowel disease (IBD) in Latin America. Patients were allocated into 2 groups: those who presented major postoperative complications (Clavien-Dindo > II), the "postoperative complication" (POC) group; and those who did not, the "no postoperative complication" (NPOC) group. Preoperative characteristics and intraoperative variables were analyzed to identify possible factors for POC. RESULTS: In total, 337 patients were included, with 51 (15.13%) in the POC cohort. Smoking was more prevalent among the POC patients (31.37 vs. 17.83; P = .026), who presented more preoperative anemia (33.33 vs. 17.48%; P = .009), required more urgent care (37.25 vs. 22.38; P = .023), and had lower albumin levels. Complicated disease was associated with higher postoperative morbidity. POC patients had a longer operative time (188.77 vs. 143.86 min; P = .005), more intraoperative complications (17.65 vs. 4.55%; P < .001), and lower rates of primary anastomosis. In the multivariate analysis, both smoking and intraoperative complications were independently associated with the occurrence of major postoperative complications. CONCLUSION: This study shows that risk factors for complications after primary ileocecal resections for Crohn's disease in Latin America are similar to those reported elsewhere. Future efforts in the region should be aimed at improving these outcomes by controlling some of the identified factors.

Laparoscopic approach for the treatment of acute complications after appendectomy: a systematic review.

INTRODUCTION: The significance of laparoscopy after appendectomy is still unclear, despite the fact that it is thought to be an appropriate technique for the detection and management of postoperative complications. We aimed to determine the incidence, risk factors, diagnosis, and laparoscopic approach for the treatment of acute complications after appendectomy performing a systematic review of the literature. EVIDENCE ACQUISITION: We performed systematic review of the PubMed/MEDLINE, Embase and GoogleScholar bibliographic databases between 1995 and 2022 regarding laparoscopic resolution of early postoperative complications after appendectomy. Demographics, peri-operative variables, and postoperative outcomes were analyzed. EVIDENCE SYNTHESIS: A total of 9 studies comprising 116 cases of laparoscopic resolution of early complications after appendectomy were included. The primary surgery showed a 60% of perforated or gangrenous appendicitis. Time elapse between the appendectomy and the diagnosis of the postoperative complication was from 2 to 15 days (median 5.8 days). The procedures performed at laparoscopy were as follows: laparoscopic washout and drainage of generalized peritonitis and intra-abdominal abscesses (95.6%), laparoscopic lysis of adhesions due to small bowel obstruction (1.7%), running suturing for unnoticed small bowel lesion (1.7%) and one patient required a right colectomy due to stump leakage (0.8%). Conversion to an open approach was necessary in 9 patients (7.8%). Postoperative complications after early re-laparoscopy washout were reported in 4 publications (15.5%). Finally, 15 (12.9%) patients required an additional intervention. The mean LOS was of 5 days. CONCLUSIONS: Infectious complications are not uncommon after appendectomy, but their incidence increases significantly in complicated appendicitis, with IAA being the most feared complication. When re-exploration is mandatory, the laparoscopic approach is a safe and highly effective tool for the diagnosis and treatment of these complications, adding the benefits of minimally invasive surgery.

Second Laparoscopic Colorectal Resection: Safety and Feasibility.

BACKGROUND: As laparoscopic colorectal surgery continues increasing worldwide, the need of having a second laparoscopic colorectal resection (SLCR) might increase as well. Experience with this challenging procedure is scarce. The aim of this study was to evaluate the safety and feasibility of SLCR. METHODS: A retrospective analysis of a prospectively collected database of patients undergoing colorectal surgery who needed an SLCR during the period 2008-2020 was performed. Demographics, operative variables, and postoperative outcomes were analyzed. A propensity score matching with a control population undergoing a first elective colorectal resection was performed. RESULTS: A total of 1918 patients underwent colorectal surgery and 32 patients (1.7%) who required a SLCR were included for analysis; 17 (53.1%) were male, and the mean age was 71 (39 to 89) years. The median time between the first and second operations was 69 (6 to 230) months. At the second resection: The median operative time was 170 (90 to 380) minutes, there were 3 (9%) intraoperative complications and 2 (6%) conversions. Overall postoperative morbidity and major morbidity rates were 34% and 19%, respectively. Four patients (12.5%) required reoperation and 1 (3.1%) died of septic shock after an anastomotic leak. After propensity score matching, SLCR was more frequently performed by colorectal surgeons, and no differences in perioperative variables were observed compared with the control group. CONCLUSIONS: SLCR can be safely performed without jeopardizing perioperative outcomes. Further studies are needed to confirm the benefits of the minimally invasive approach in colorectal second resection and to elucidate the long-term outcomes.

Conversion from Laparoscopic to Open Appendectomy: Trends, Risk Factors and Outcomes. A 15-Year Single-Center Analysis of 2193 Adult Patients.

BACKGROUND: Laparoscopic appendectomy (LA) has become the standard of care for the management of acute appendicitis in adult patients. Despite the increasing experience in laparoscopy, conversion to open surgery might still occur. We aimed to identify preoperative and intraoperative risk factors for conversion and determine surgical outcomes in this population. METHODS: We performed a retrospective analysis of a consecutive series of patients undergoing LA during the period 2006-2020. The cohort was divided into two groups: patients who underwent a fully laparoscopic appendectomy (FLA) and patients who were converted to open appendectomy (CA). Demographics, perioperative variables and postoperative outcomes were compared between both groups. Independent risk factors for conversion were determined by logistic regression analysis. RESULTS: A total of 2193 patients were included for analysis; 2141 (98%) underwent FLA and 52 (2%) CA. Conversion rates decreased significantly over time (p = 0.006). Patients with CA had significantly higher overall postoperative morbidity rates (FLA 14.9% vs. CA 48.0%, p < 0.0001) and longer mean length of hospital stay (FLA 1.7 vs. CA 5 days). In the multivariate analysis, obesity (p < 0.001), previous abdominal operations (p = 0.013), peritonitis (p = 0.003) and complicated appendicitis (p < 0.001) were independent risk factor for conversion. CONCLUSIONS: Although conversion from laparoscopic to open appendectomy is infrequent and has decreased over time, it is associated with significantly higher postoperative morbidity. Patients with previous abdominal operations, obesity and complicated appendicitis should be thoroughly advised about the higher risk of conversion.

Transthoracic Esophagectomy: Hand-sewn Versus Side-to-side Linear-stapled Versus Circular-stapled Anastomosis: A Systematic Review and Meta-analysis.

BACKGROUND: Three anastomotic techniques are mostly used to create an esophagogastric anastomosis in a transthoracic esophagectomy: hand-sewn (HS), side-to-side linear-stapled (SSLS), and circular-stapled (CS). The aim of this study was to compare surgical outcomes after HS, SSLS, and CS intrathoracic esophagogastric anastomosis. MATERIALS AND METHODS: A systematic review using the MEDLINE database was performed to identify original articles analyzing outcomes after HS, SSLS, and CS esophagogastric anastomosis. The main outcome was an anastomotic leakage rate. Secondary outcomes included overall morbidity, major morbidity, and mortality. A meta-analysis of proportions and linear regression models were used to assess the effect of each anastomotic technique on the different outcomes. RESULTS: A total of 101 studies comprising 12,595 patients were included; 8835 (70.1%) with CS, 2532 (20.1%) with HS, and 1228 (9.8%) with SSLS anastomosis. Anastomotic leak occurred in 10% [95% confidence interval (CI), 6%-15%], 9% (95% CI, 6%-13%), and 6% (95% CI, 5%-7%) of patients after HS, SSLS, and CS anastomosis, respectively. Risk of anastomotic leakage was significantly higher with HS anastomosis (odds ratio=1.73, 95% CI: 1.47-2.03, P<0.0001) and SSLS (odds ratio=1.68, 95% CI: 1.36-2.08, P<0.0001), as compared with CS. Overall morbidity (HS: 52% vs. SLSS: 39% vs. CS: 35%) and major morbidity (HS: 33% vs. CS: 19%) rates were significantly lower with CS anastomosis. Mortality rate was 4% (95% CI, 3%-6%), 2% (95% CI, 2%-3%), and 3% (95% CI, 3%-4%) after HS, SSLS, and CS anastomosis, respectively. CONCLUSION: HS and SSLS intrathoracic esophagogastric anastomoses are associated with significantly higher rates of an anastomotic leak than CS anastomosis.

Open versus hybrid versus totally minimally invasive Ivor Lewis esophagectomy: Systematic review and meta-analysis.

BACKGROUND: Hybrid and minimally invasive approaches have emerged as less invasive alternatives to open Ivor Lewis esophagectomy. The aim of this study was to compare surgical outcomes between open (OE), hybrid (HE), and totally minimally invasive esophagectomy (TMIE). METHODS: A systematic literature search was performed to analyze outcomes after OE, HE, and TMIE with intrathoracic anastomosis. Main outcomes included anastomotic leak rate, overall morbidity, and 30-day mortality. A meta-analysis of proportions was used to assess the effect of each approach on different outcomes. RESULTS: A total of 130 studies comprising 16,053 patients were included for analysis; 8081 (50.3%) underwent OE, 1524 (9.5%) HE, and 6448 (40.2%) TMIE. The risk of anastomotic leak was lower after OE (odds ratio [OR], 0.71; 95% CI, 0.62-0.81; P < .0001). Overall morbidity rate was 45% (95% CI, 38%-52%) after OE, 40% (95% CI, 25%-59%) after HE, and 37% (95% CI, 32%-43%) after TMIE. Risk estimation showed higher odds of postoperative mortality after OE (OR, 2.22; 95% CI, 1.76-2.81; P < .0001) and HE (OR, 1.93; 95% CI, 1.32-2.81; P < .001), compared with TMIE. Median length of hospital stay (LOS) was 14.1 (range, 8-28), 12.5 (range, 8-18), and 11.9 (range, 7-30) days after OE, HE and TMIE, respectively (P = .003). CONCLUSIONS: HE and TMIE are associated with lower rates of overall morbidity, reduced postoperative mortality, and shorter LOS, compared with OE. TMIE is associated with lower mortality rates and shorter LOS than HE. Further efforts are needed to widely embrace TMIE in a safe manner.

Surgical outcomes after totally minimally invasive Ivor Lewis esophagectomy. A systematic review and meta-analysis.

BACKGROUND: A transthoracic esophagectomy is associated with high rates of morbidity. Minimally invasive esophagectomy has emerged to decrease such morbidity. The aim of this study was to accurately determine surgical outcomes after totally minimally invasive Ivor-Lewis Esophagectomy (TMIE). METHODS: A systematic literature search was performed to identify original articles analyzing patients who underwent TMIE. Main outcomes included overall morbidity, major morbidity, pneumonia, arrhythmia, anastomotic leak, chyle leak, and mortality. A meta-analysis was conducted to estimate the overall weighted proportion and its 95% confidence interval (CI) for each analyzed outcome. RESULTS: A total of 5619 patients were included for analysis; 4781 (85.1%) underwent a laparoscopic/thoracoscopic esophagectomy and 838 (14.9%) a robotic-assisted esophagectomy. Mean age of patients was 63.5 (55-67) years and 75.8% were male. Overall morbidity and major morbidity rates were 39% (95% CI, 33%-45%) and 20% (95% CI, 13%-28%), respectively. Postoperative pneumonia and arrhythmia rates were 10% (95% CI, 8%-13%) and 12% (95% CI, 8%-17%), respectively. Anastomotic leak rate across studies was 8% (95% CI, 6%-10%). Chyle leak rate was 3% (95% CI, 2%-5%). Mortality rate was 2% (95% CI, 2%-2%). Median ICU stay and length of hospital stay were 2 (1-4) and 11.2 (7-20) days, respectively. CONCLUSIONS: Totally minimally invasive Ivor-Lewis esophagectomy is a challenging procedure with high morbidity rates. Strategies to enhance postoperative outcomes after this operation are still needed.

Synthetic Mesh in Contaminated Abdominal Wall Surgery: Friend or Foe? A Literature Review.

INTRODUCTION: The use of synthetic mesh in contaminated fields is controversial. In the last decade, published data have grown in this matter suggesting favorable outcomes. However, multiple variables and scenarios that influence the results still make difficult to obtain convincing recommendations. METHODS: We performed a review of relevant available data in English regarding the use of synthetic meshes in contaminated abdominal wall surgery using the Medline database. Articles including patients undergoing ventral hernia in contaminated fields were included for analysis. RESULTS: Most studies support the use of synthetic meshes for ventral hernia repair in contaminated fields, as they have shown lower recurrence rate and similar wound morbidity. Although no mesh seems ideal in this setting, most surgeons advocate for the use of reduced-in-weight polypropylene mesh. Sublay location of the prosthesis associated with complete fascial closure appears to offer better results in these patients. In addition, current evidence suggests that the use of prophylactic synthetic mesh when performing a stoma or for stoma reversal incisional hernias might be beneficial. CONCLUSION: A better understanding of surgical site occurrences and its prevention, as well as the introduction of new reduced-in-weight meshes have allowed using synthetic meshes in a contaminated field. Although the use of mesh has indeed shown promising results in these patients, the surgical team should still balance pros and cons at the time of placing synthetics in contaminated fields.

Indocyanine green (ICG) fluorescence imaging for prevention of anastomotic leak in totally minimally invasive Ivor Lewis esophagectomy: a systematic review and meta-analysis.

BACKGROUND: Indocyanine green (ICG) fluorescence imaging is an emerging technology that might help decreasing anastomotic leakage (AL) rates. The aim of this study was to determine the usefulness of ICG fluorescence imaging for the prevention of AL after minimally invasive esophagectomy with intrathoracic anastomosis. METHODS: A systematic literature review of the MEDLINE and Cochrane databases was performed to identify all articles on totally minimally invasive Ivor Lewis esophagectomy. Studies were then divided into two groups based on the use or not of ICG for perfusion assessment. Primary outcome was anastomotic leak. Secondary outcomes included operative time, ICG-related adverse reactions, and mortality rate. A meta-analysis was conducted to estimate the overall weighted proportion and its 95% confidence interval (CI) for main outcomes. RESULTS: A total of 3,171 patients were included for analysis: 381 (12%) with intraoperative ICG fluorescence imaging and 2,790 (88%) without ICG. Mean patients' age and proportion of males were similar between groups. Mean operative time was also similar between both groups (ICG: 354.8 vs. No-ICG: 354.1 minutes, P = 0.52). Mean ICG dose was 12 mg (5-21 mg). No ICG-related adverse reactions were reported. AL rate was 9% (95% CI, 5-17%) and 9% (95% CI, 7-12%) in the ICG and No-ICG groups, respectively. The risk of AL was similar between groups (odds ratio 0.85, 95% CI 0.53-1.28, P = 0.45). Mortality was 3% (95% CI, 1-9%) in patients with ICG and 2% (95% CI, 2-3%) in those without ICG. Median length of hospital stay was also similar between groups (ICG: 13.6 vs. No-ICG: 11.2 days, P = 0.29). CONCLUSION: The use of ICG fluorescence imaging for perfusion assessment does not seem to reduce AL rates in patients undergoing minimally invasive esophagectomy with intrathoracic anastomosis.

Minimally invasive Ivor Lewis esophagectomy: Robot-assisted versus laparoscopic-thoracoscopic technique. Systematic review and meta-analysis.

BACKGROUND: Evidence comparing conventional minimally invasive esophagectomy (CMIE) via laparoscopy and thoracoscopy with robot-assisted minimally invasive esophagectomy (RAMIE) is scarce. The aim of this meta-analysis was to compare surgical outcomes after CMIE and RAMIE with an intrathoracic anastomosis. METHODS: A systematic literature search was performed to identify original articles analyzing outcomes after CMIE and RAMIE. Main surgical outcomes included operative time, intraoperative blood loss, anastomotic leak rates, pneumonia, overall morbidity, length of stay (LOS), and 30-day mortality. Oncologic outcomes included lymph node yield and R0 resections rates. A meta-analysis of proportions and linear regression models were used to assess the effect of each procedure on the different outcomes. RESULTS: A total of 6,249 patients were included for analysis; 5,275 (84%) underwent CMIE and 974 (16%) RAMIE. Robotic esophagectomy had longer operative time and less intraoperative blood loss. Anastomotic leakage rates were similar with both approaches. Patients undergoing RAMIE had significantly lower rates of postoperative pneumonia (OR 0.46, 95% CI 0.35-0.61, P < .0001) and overall morbidity (OR 0.67, 95% CI 0.58-0.79, P < .0001). Median LOS was similar in both procedures (RAMIE: 12.1 versus CMIE: 11.9 days, P = .64). Similar mortality rates were found after RAMIE and CMIE (OR 0.69, 95% CI 0.34-1.38, P = .29). Lymph node yield was similar in both procedures, but RAMIE was associated with higher rates of R0 resection (OR 2.84, 95% CI 1.53-5.26, P < .001). CONCLUSION: Patients undergoing robotic esophagectomy have less intraoperative blood loss, lower rates of postoperative pneumonia, reduced overall morbidity, and higher rates of R0 resections, as compared with those undergoing a laparoscopic-thoracoscopic esophageal resection.

Laparoscopic resection and primary anastomosis for perforated diverticulitis: with or without loop ileostomy?

BACKGROUND: Evidence is growing about the benefits of laparoscopic resection with primary anastomosis (RPA) in perforated diverticulitis. However, the role of a diverting ileostomy in this setting is unclear. The aim of this study was to analyze the outcomes of laparoscopic RPA with or without a proximal diversion in Hinchey III diverticulitis. METHODS: This is a retrospective analysis of patients undergoing laparoscopic sigmoidectomy for perforated Hinchey III diverticulitis during the period 2000-2019. The sample was divided into two groups: RPA without diversion (G1) and RPA with protective ileostomy (G2). Primary outcomes of interest were 30-day overall morbidity, mortality, length of hospital stay (LOS), and urgent reoperation rates. Secondary outcomes of interest included operative time, readmission, and anastomotic leak rates. RESULTS: Laparoscopic RPA was performed in 94 patients: 76 without diversion (G1) and 18 with proximal loop ileostomy (G2). Mortality (G1: 1.3% vs. G2: 0%, p = 0.6), urgent reoperation (G1: 7.9% vs. G2: 5.6%, p = 0.73), and anastomotic leak rates (G1: 5.3% vs. G2: 0%, p = 0.32) were comparable between groups. Higher overall morbidity (G1: 27.6% vs. G2: 55.6%, p = 0.02) and readmission rates (G1: 1.3% vs. G2: 11.1%, p = 0.03), and longer LOS (G1: 6.3 vs. G2: 9.2 days, p = 0.02) and operative time (G1: 182.4 vs. G2: 230.2 min, p = 0.003) were found in patients with proximal diversion. CONCLUSION: Laparoscopic RPA had favorable outcomes in selected patients with Hinchey III diverticulitis. The addition of a proximal ileostomy resulted in increased morbidity, readmissions, and length of stay. Further investigation is needed to establish which patients might benefit from proximal diversion.