The Impact of Blood Pressure Switching (from Controlled Hypotension to Late Elevated Blood Pressure) During Laparoscopic Sleeve Gastrectomy: Controlled Clinical Trial.

PURPOSE: Laparoscopic sleeve gastrectomy (LSG) is the most done bariatric procedure. Bleeding and leak are the most common associated complications. Elevation of systolic blood pressure (SBP) leads to discovering the bleeding sites but results in a bloody field and increases the operative time. Controlled hypotension shortens the operative time, reduces tissue edema, and improves field vision. We aimed to test controlled hypotension during LSG. MATERIAL AND METHODS: This was a randomized controlled trial that included 200 patients who were operated by LSG, randomly assigned to 2 equal groups: group 1, operated with controlled hypotensive anesthesia, and group 2, operated with elevated SBP to 140 mmHg. RESULTS: Of the patients, 162 (81%) were females, and 38 (19%) were male. The mean BMI was 45.7 kg/m2. The mean age was 41.7 years. The operative time was 36.43 ± 6.73 min in group 1 vs. 44.71 ± 5.47 min in group 2. The mean of total number of used gauzes and clips was 2.70 ± 3.49 in group 1 vs. 8.83 ± 3.15 in group 2. The mean amount of drain output was 37.65 ± 21.90 ml in group 1 vs. 74.00 ± 16.54 ml in group 2. The mean drop in the postoperative hematocrit was 0.08 in group 1 vs. 0.22 in group 2. The incidence of postoperative bleeding was 0% in group 1 vs. 1% in group 2. CONCLUSIONS: Controlled hypotensive anesthesia in LSG reduces the operative time, reduces the intraoperative bleeding, and improves the operative field.

How Good is Stratification and Prediction Model Analysis Between Primary and Revisional Roux-en-Y Gastric Bypass Surgery? A Multi-center Study and Narrative Review.

INTRODUCTIONS: Revision surgery because of weight recurrence is performed in 2.5-33% of primary vertical banded gastroplasty (VBG), laparoscopic sleeve gastrectomy (LSG), and gastric band (GB) cases. These cases qualify for revisional Roux-en-Y gastric bypass (RRYGB). METHODS: This retrospective cohort study analyzed data from 2008 to 2019. A stratification analysis and multivariate logistic regression for prediction modeling compared the possibility of sufficient % excess weight loss (%EWL) ≥ 50 or insufficient %EWL < 50 between three different RRYGB procedures, with primary Roux-en-Y gastric bypass (PRYGB) as the control during 2 years of follow-up. A narrative review was conducted to test the presence of prediction models in the literature and their internal and external validity. RESULTS: A total of 558 patients underwent PRYGB, and 338 underwent RRYGB after VBG, LSG, and GB, and completed 2 years of follow-up. Overall, 32.2% of patients after RRYGB had a sufficient %EWL ≥ 50 after 2 years, compared to 71.3% after PRYGB (p ≤ 0.001). The total %EWL after the revision surgeries for VBG, LSG, and GB was 68.5%, 74.2%, and 64.1%, respectively (p ≤ 0.001). After correcting for confounding factors, the baseline odds ratio (OR) or sufficient %EWL ≥ 50 after PRYGB, LSG, VBG, and GB was 2.4, 1.45, 0.29, and 0.32, respectively (p ≤ 0.001). Age was the only significant variable in the prediction model (p = 0.0016). It was impossible to develop a validated model after revision surgery because of the differences between stratification and the prediction model. The narrative review showed only 10.2% presence of validation in the prediction models, and 52.5% had external validation. CONCLUSION: Overall, 32.2% of all patients after revisional surgery had a sufficient %EWL ≥ 50 after 2 years, compared to PRYGB. LSG had the best outcome in the revisional surgery group in the sufficient %EWL group and the best outcome in the insufficient %EWL group. The skewness between the prediction model and stratification resulted in a partially non-functional prediction model.

Surgical Management Algorithm for Intrathoracic Sleeve Migration: A Retrospective Series and Literature Review.

Background: With the increase in utilization of laparoscopic sleeve gastrectomy (LSG), intrathoracic sleeve migration (ITSM) has introduced a novel challenge for bariatric surgeons. Despite being an underreported complication, effective and safe solutions for ITSM are being sought. The aim of this study is to present our center's experience as well as a comprehensive review of the literature on ITSM. Accordingly, we propose an algorithm for the surgical management of ITSM. Methods: We conducted a retrospective chart review of 4000 patients who underwent LSG at our center. ITSM was clinically suspected with gastroesophageal reflux disease (GERD) symptoms and/or epigastric pain resistant to proton pump inhibitors. Diagnosis of ITSM was confirmed in all patients by three-dimensional computed tomography (3D-CT) volumetry. Several corrective procedures were offered based on the findings of the 3D-CT volumetry, esophagogastroduodenoscopy, and the diaphragmatic pillars' condition: cruroplasty with gastropexy, one anastomosis gastric bypass (OAGB), or Roux-en-Y gastric bypass (RYGB) with or without re-sleeve gastrectomy, omentopexy, or ligamentum teres augmentation. We conducted a literature review of ITSM using several databases. Results: Fifteen patients were diagnosed with postoperative ITSM. The most common presenting complaint was severely worsened GERD symptoms not responding to medical treatment. The mean time interval between the primary operation and diagnosis of ITSM was 38.8 ± 29.1 months. Three patients had re-sleeve gastrectomy and gastropexy, 5 patients had OAGB, and 7 patients had RYGB. The mean postoperative body mass index was 31.2 ± 4.9 kg/m2. No case of recurrent ITSM was detected during follow-up. Our electronic database search yielded 19 studies to be included in our review, which included 201 patients. Conclusion: A high index of suspicion is required to diagnose ITSM. CT volumetry with 3D reconstruction may be the most sensitive diagnostic modality. ITSM management should depend on the results of the diagnostic workup and the condition of the diaphragmatic pillars during surgery.

Religious Fasting of Muslim Patients After Metabolic and Bariatric Surgery: a Modified Delphi Consensus.

BACKGROUND: Fasting during Ramadan is one of the five pillars of the Muslim faith. Despite the positive effects of fasting on health, there are no guidelines or clear recommendations regarding fasting after metabolic/bariatric surgery (MBS). The current study reports the result of a modified Delphi consensus among expert metabolic/bariatric surgeons with experience in managing patients who fast after MBS. METHODS: A committee of 61 well-known metabolic and bariatric surgeons from 24 countries was created to participate in the Delphi consensus. The committee voted on 45 statements regarding recommendations and controversies around fasting after MBS. An agreement/disagreement ≥ of 70.0% was regarded as consensus. RESULTS: The experts reached a consensus on 40 out of 45 statements after two rounds of voting. One hundred percent of the experts believed that fasting needs special nutritional support in patients who underwent MBS. The decision regarding fasting must be coordinated among the surgeon, the nutritionist and the patient. At any time after MBS, 96.7% advised stopping fasting in the presence of persistent symptoms of intolerance. Seventy percent of the experts recommended delaying fasting after MBS for 6 to 12 months after combined and malabsorptive procedures according to the patient's situation and surgeon's experience, and 90.1% felt that proton pump inhibitors should be continued in patients who start fasting less than 6 months after MBS. There was consensus that fasting may help in weight loss, improvement/remission of non-alcoholic fatty liver disease, dyslipidemia, hypertension and type 2 diabetes mellitus among 88.5%, 90.2%, 88.5%, 85.2% and 85.2% of experts, respectively. CONCLUSION: Experts voted and reached a consensus on 40 statements covering various aspects of fasting after MBS.

Pattern of Retinal Vasculitis in an Egyptian Cohort.

Purpose: To describe the clinical experience with retinal vasculitis at 4 Egyptian tertiary eye centers. Methods: A multicenter retrospective chart review of all patients with retinal vasculitis encountered at 4 ocular inflammation referral clinics in Egypt between February 2013 and February 2018. Results: The study included 618 patients (327 males and 291 females). Of these, 284 patients had isolated retinal vasculitis, whereas 233 patients had an associated systemic inflammatory disease, the most frequent being Behçet's disease, followed by sarcoidosis. In 101 patients, retinal vasculitis could be attributed to an infectious etiology, and among this category, the most common was tuberculosis, followed by toxoplasmosis. Conclusion: In our Egyptian cohort, more than half the patients had their retinal vasculitis as part of a serious systemic disease, or as part of an infectious process, as tuberculosis. And in view of the significant potential morbidity of these conditions, the local ophthalmologists need to be aware of these entities when faced with patients presenting with retinal vasculitis.

Pattern of Scleritis in an Egyptian Cohort.

Purpose: To report the clinical experience with scleritis at four Egyptian tertiary care eye centers. Methods: Multicenter retrospective chart review of all patients with scleritis visiting four ocular inflammation referral clinics in Egypt between January 2013 and October 2017. Results: A total of 303 scleritis patients were enrolled. These included 76 male and 227 female patients. The most frequent subtype of scleritis was nodular anterior scleritis (44.9%). Rheumatoid arthritis and Wegener granulomatosis were the 2 most common systemic associations among our cohort. Eyes with necrotizing scleritis with inflammation had the lowest mean initial and final BCVA. Conclusion: The visual prognosis of an eye with scleritis varies with the subtype of scleral inflammation. In our cohort, it was found to be poorer in eyes with necrotizing scleritis with inflammation compared to other subtypes.

Single Anastomosis Sleeve Ileal Bypass: New Step in the Evolution of Bariatric Surgeries.

PURPOSE: Single anastomosis sleeve ileal bypass (SASI) procedure appears as a new metabolic and bariatric surgery based on Santoro's operation, in which a sleeve gastrectomy is followed by a side-to-side gastroileal anastomosis. The study is aimed to evaluate the short-term outcomes of laparoscopic single anastomosis sleeve ileal bypass with respect to postoperative weight loss and metabolic and nutritional effects on patients. METHODS: Forty-five morbidly obese patients with a mean age of 31.2 years and a mean body mass index (BMI) of 43.2 kg/m2 underwent SASI bypass. Postoperatively, all patients were followed up at 1, 3, 6, and 12 months, and during each visit data about their BMI, obesity-related comorbidities, and nutritional status were collected. RESULTS: One year after the surgery, mean BMI decreased to 29.1 kg/m2 and there was significant decrease in plasma level of fasting blood glucose, insulin, and low-density lipoprotein. On the other hand, there was significant increase in high-density lipoprotein plasma level, whereas hemoglobin and albumin plasma level remained normal. Six months after the surgery, calcium plasma level showed mild decrease in two cases, which was improved with multivitamin tablets. In 93% of our patients, multivitamin supplements were stopped after six months of surgery. CONCLUSIONS: Laparoscopic SASI bypass has been shown to be an effective, safe, and simple procedure for the treatment of morbid obesity and its associated metabolic consequences. Moreover, it results in minimal postoperative nutritional complications in comparison to other bariatric procedures.

Redo Surgery after Failed Open VBG: Laparoscopic Minigastric Bypass versus Laparoscopic Roux en Y Gastric Bypass-Which Is Better?

Background. Long-term studies have reported that the rate of conversion surgeries after open VBG ranged from 49.7 to 56%. This study is aiming to compare between LMGB and LRYGB as conversion surgeries after failed open VBG with respect to indications and operative and postoperative outcomes. Methods. Sixty patients (48 females and 12 males) presenting with failed VBG, with an average BMI of 39.7 kg/m(2) ranging between 26.5 kg/m(2) and 53 kg/m(2), and a mean age of 38.7 ranging between 24 and 51 years were enrolled in this study. Operative and postoperative data was recorded up to one year after the operation. Results. MGB is a simple procedure that is associated with short operative time and low rate of complications. However, MGB may not be applicable in all cases with failed VBG and therefore RYGB may be needed in such cases. Conclusion. LMGB is a safe and feasible revisional bariatric surgery after failed VBG and can achieve early good weight loss results similar to that of LRYGP. However, the decision to convert to lap RYGB or MGB should be taken intraoperatively depending mainly on the actual intraoperative pouch length.