Management of chronic proximal fistulas after sleeve gastrectomy by laparoscopic Roux-limb placement.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is an increasingly popular bariatric procedure. However, after LSG, leaks may occur that are difficult to treat and that can persist for months. Treatment is controversial and ranges from stent placement to total gastrectomy. We propose an alternative laparoscopic treatment. The aims of our study were to report on the incidence of chronic fistulas after LSG and the outcome of Roux-limb placement on these defects. The setting was a major teaching hospital in Belgium. METHODS: From January 1, 2002, to December 31, 2011, we performed LSG as a primary weight loss operation (PLSG) in 728 patients and as a corrective operation (CLSG) in 84 patients. A retrospective chart and database review was conducted. When a chronic leak persisted beyond 4 months, we performed a laparoscopic Roux-limb placement on the defect. RESULTS: Leaks occurred in 26 patients (3.6%) after PLSG and in 6 (7.1%) after CLSG. A leak persisted beyond 4 months in 7 patients (26.9%) after PLSG and in 2 patients (33.3%) after CLSG. Two patients with a chronic fistula after PLSG were referred to our hospital. In 11 patients, a Roux limb was laparoscopically sutured to the defect. The mean time for a chronic fistula to heal after Roux-limb placement was 12.5±10.2 days, and the mean length of hospital stay was 19.6± 14.2. CONCLUSION: Proximal leaks after LSG are relatively rare. However, a significant number become chronic. Laparoscopic placement of a Roux-limb on the defect is a safe treatment with an eventual succes rate of 100%.

Stent treatment for fistula after obesity surgery: results in 47 consecutive patients.

BACKGROUND: Leaks occurring after weight loss operations constitute a therapeutic challenge. There is no consensus as to what comprises state-of-the-art management of leaks after bariatric surgery. We sought to determine the efficacy and possible adverse effects of endoluminal stenting for leaks after bariatric surgery. METHODS: We report our experience with the stent treatment of consecutive bariatric patients with a leak (retrospective cohort study). Between October 2005 and July 2010, 47 patients presented an acute leak after a bariatric procedure (61 % primary procedures, 39 % revisions). Fifteen patients were initially approached laparoscopically, and 32 were treated by nonoperative techniques. After adequate drainage and resuscitation, all 47 patients were treated by the endoscopic placement of a partially covered metallic stent, and later of a plastic stent inside the metallic prosthesis to facilitate removal. Both stents were then ablated 1 week later. Primary outcome measurement concerned healing of the fistula, as evidenced by radiographic imaging. Secondary outcomes were length of hospital stay and occurrence of peri- and postprocedural complications. RESULTS: There was no mortality. 41 patients (87.23 %) healed with stent treatment alone; 5 of the 6 persisting leaks healed with laparoscopic intervention (intention-to-treat success rate 96 %). Complication rate was 28.7 %. Length of hospital stay was mean ± standard deviation 22.4 ± 19.38 days for the patients treated by stent alone, and 23.4 ± 18.4 days for the patients requiring additional surgery (P = NS). One patient developed a stricture and required endoscopic dilation, and one is still awaiting surgical treatment. CONCLUSIONS: Leaks after bariatric surgery can be treated safely and effectively by endoscopic stents. In cases of persisting leaks, laparoscopic intervention is successful in a majority of cases. Late strictures seldom occur.

Single-access laparoscopic adjustable gastric band removal: technique and initial experience.

BACKGROUND: Single-access laparoscopy (SAL) has gained significant interest in recent years. Potential benefits, beyond cosmetic outcomes, could be reduction of abdominal trauma, decreased risk of incisional hernia and diminished postoperative pain. Technique and initial experience in patients submitted to laparoscopic adjustable gastric band removal (LAGBR) through SAL is reported here. METHODS: Between December 2009 and March 2012, 14 patients (9 females, 5 males) underwent LAGBR through SAL. Indications for operation were band intolerance (11), pouch dilatation (2) and insufficient weight loss (1). The mean age was 40.3 ± 9.1 years (range 26-57), and the mean interval time between LAGB placement and removal was 94.7 ± 41.9 months (range 37-157). The mean weight and the mean body mass index at the time of LAGBR were 89.3 ± 17.6 kg (range 65-119) and 30.6 ± 4.5 kg/m(2) (range 25.3-36.7), respectively. Technically, the previous port site scar was used as the single-access site to the abdominal cavity. An 11-mm reusable trocar was adopted for a 10-mm regular scope, besides curved reusable instruments. RESULTS: No patients required conversion to open surgery and none necessitated additional trocars. The mean laparoscopic time was 24.6 ± 7.9 min (range 13-37), and the mean final scar length was 3.6 ± 0.3 cm (range 3-4). Two patients experienced early postoperative complications. The mean hospital stay was 1.3 ± 1.1 days (range 1-5). The mean follow-up time was of 18 ± 9.8 months (range 3-30), and there were no late complications. CONCLUSIONS: LAGBR can be safely performed through SAL. Thanks to this technique, the laparoscopic working triangulation is established as well as the ergonomic positions of the surgeon. Due the use of only reusable material, the cost of this SAL remains similar to multiport laparoscopy.

International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is an emerging surgical approach, but 1 that has seen a surge in popularity because of its perceived technical simplicity, feasibility, and good outcomes. An international expert panel was convened in Coral Gables, Florida on March 25 and 26, 2011, with the purpose of providing best practice guidelines through consensus regarding the performance of LSG. The panel comprised 24 centers and represented 11 countries, spanning all major regions of the world and all 6 populated continents, with a collective experience of >12,000 cases. It was thought prudent to hold an expert consensus meeting of some of the surgeons across the globe who have performed the largest volume of cases to discuss and provide consensus on the indications, contraindications, and procedural aspects of LSG. The panel undertook this consensus effort to help the surgical community improve the efficacy, lower the complication rates, and move toward adoption of standardized techniques and measures. The meeting took place at on-site meeting facilities, Biltmore Hotel, Coral Gables, Florida. METHODS: Expert panelists were invited to participate according to their publications, knowledge and experience, and identification as surgeons who had performed >500 cases. The topics for consensus encompassed patient selection, contraindications, surgical technique, and the prevention and management of complications. The responses were calculated and defined as achieving consensus (≥70% agreement) or no consensus (<70% agreement). RESULTS: Full consensus was obtained for the essential aspects of the indications and contraindications, surgical technique, management, and prevention of complications. Consensus was achieved for 69 key questions. CONCLUSION: The present consensus report represents the best practice guidelines for the performance of LSG, with recommendations in the 3 aforementioned areas. This report and its findings support a first effort toward the standardization of techniques and adoption of working recommendations formulated according to expert experience.

Transumbilical single-access laparoscopic perforated gastric ulcer repair.

INTRODUCTION: In patients presenting with peritonitis, laparoscopy offers the possibility of diagnosis as well as treatment, with less abdominal trauma, reduced postoperative pain, and shorter hospital stay. CASE REPORT: A 30-year-old woman, presenting with diffuse abdominal pain and free pneumoperitoneum, was submitted to transumbilical single-access laparoscopy. The procedure was performed using a standard 11-mm reusable trocar in the umbilicus and curved reusable instruments inserted transumbilically without trocars. The cavity exploration showed a perforated gastric ulcer at the anterior surface of the prepyloric area. A gastric suture repair, omentoplasty, and lavage of the cavity were performed. RESULTS: The umbilical incision was 15 mm and laparoscopy lasted 86 minutes. Use of painkillers was minimal, and the patient was discharged on the fifth postoperative day. After 6 months, the umbilical scar was no visible. CONCLUSIONS: Transumbilical single-access laparoscopy can be proposed in selected patients presenting perforated gastric ulcer, with the main advantage of improved cosmetic results.