A systematic review and meta-analysis on GERD after OAGB: rate, treatments, and success.

INTRODUCTION: This review aims to investigate the gastroesophageal reflux disease (GERD) as one of the important concerns for both surgeons and patients after one anastomosis gastric bypass (OAGB). METHOD: PubMed, Scopus, Embase, Web of Science, and Cochrane were reviewed by the end of the 2021 with keywords relating to GERD, OAGB, and their equivalents. Data regarding OAGB, number of patients with GERD, treatment for GERD, endoscopy findings, the interval between GERD and OAGB were retrieved by two independent investigators. The primary effect/effect size measure was prevalence. RESULTS: 40 studies examining 17,299 patients were included revealing that 2% of patients experience GERD following OAGB. Reflux after revisional OAGB is six times higher than primary OAGB. Despite being unclear, medical and surgical treatments for GERD after OAGB were used in 60% and 41% of patients with estimated success rate of 85% and 100%, respectively. CONCLUSION: Based on how GERD was identified after OAGB, its rate ranged from 0 to 55%; the pooled rate of 2% is near to Roux-en-Y gastric bypass. GERD symptoms can be mild to be tolerated without medical treatment, moderate that respond to acid-reducing agents, or severe enough that are categorized as interactable and would need a surgical intervention.

Indications for upper gastrointestinal endoscopy before bariatric surgery: a multicenter study.

BACKGROUND: The role of preoperative upper gastrointestinal endoscopy before bariatric surgery is still debated, and a consensus among the international scientific community is lacking. The aims of this study, conducted in three different geographic areas, were to analyze data regarding the pathological endoscopic findings and report their impact on the decision-making process and surgical management, in terms of delay in surgical operation, modification of the intended bariatric procedure, or contraindication to surgery. METHODS: This is a multicenter cross-sectional study using data obtained from three prospective databases. The preoperative endoscopic reports, patient demographics, Body Mass Index, type of surgery, and Helicobacter pylori status were collected. Endoscopic findings were categorized into four groups: (1) normal endoscopy, (2) abnormal findings not requiring a change in the surgical approach, (3) clinically important lesions that required a change in surgical management or further investigations or therapy prior to surgery, and (4) findings that contraindicated surgery. RESULTS: Between 2006 and 2020, data on 643 patients were analyzed. In all of the enrolled bariatric institutions, preoperative endoscopy was performed routinely. A total of 76.2% patients had normal and/or abnormal findings that did not required a change in surgical management; in 23.8% cases a change or a delay in surgical approach occurred. Helicobacter pylori infection was detected in 15.2% patients. No patient had an endoscopic finding contraindicating surgery. CONCLUSIONS: The role of preoperative UGE is to identify a wide range of pathological findings in patients with obesity that could influence the therapeutic approach, including the choice of the proper bariatric procedure. Considering the anatomical modifications, the incidence of asymptomatic pathologies, and the risk of malignancy, we support the decision of performing preoperative endoscopy for all patients eligible for bariatric operation.

The evolution of surgical treatment for chronic leak following sleeve.

BACKGROUND: Leak is estimated to be the most severe complication of laparoscopic sleeve gastrectomy (LSG), with sporadic failure of endoscopic techniques. In such cases, an aggressive management with surgical reconstructive procedures can be proposed to patients in whom all the conservative endoscopic techniques failed. OBJECTIVES: The purpose of the present study was to report our experience with surgical approach for the treatment of chronic leak after LSG. SETTING: University hospital, France. METHODS: Between January 2013-December 2019, 21 consecutive patients underwent reconstructive surgery for the treatment of chronic leak after LSG. The initial intervention, the endoscopic approach, and the definitive surgical repair were carefully reviewed. RESULTS: Twenty-one patients (17 women) with a mean (standard deviation [SD]) age of 42.7 years (9.81) and a mean (SD) body mass index (BMI) of 27.3 (5.2) kg/m2 underwent reconstructive surgery for persistent fistula. Seventeen patients (81%) had their early LSG performed in another hospital. Endoscopic treatment was represented by the pigtail drain or stent in 9 cases each, ovesco in 8 cases, and glue for 2 patients. The reconstructive surgery was performed within 6 months in 8 cases; between 6-12 months in 6 cases; between 1-3 years in 4 cases, and >3 years in 3 cases. There were 14 fistulo-jejunostomy (66.7%), 5 Roux-en-Y gastric bypass (23.8%), and 2 total gastrectomies (9.5%). The operative time was between 99 minutes and 5.5 hours (mean = 216.2, median = 225 min). The hospital stay ranged from 5-30 days (mean = 12.67, median = 11 d) and the surgical reintervention rate was 23.8% (5/21 patients), including 1 case of recurrent hemorrhage requiring 3 surgical operations over 1 month of postoperative follow-up. No postoperative mortality was recorded. CONCLUSIONS: Surgery should be considered in case of failure of the endoscopic treatment of chronic leak after LSG. Further research is needed to clearly identify the appropriate treatment, but in our experience the fistulo-jejunostomy approach shows a low morbidity rate. (Surg Obes Relat Dis 2020;17:278-283.) © 2020 American Society for Metabolic and Bariatric Surgery. All rights reserved.

Laparoscopic sleeve gastrectomy: Effect on long-term remission for morbidly obese patients with type 2 diabetes at 5-year follow up.

BACKGROUND: In the short-term, laparoscopic sleeve gastrectomy has been shown to be effective for the treatment of the type 2 diabetes in patients with severe obesity. There are few data with greater follow-up. Our aim was to evaluate the results of laparoscopic sleeve gastrectomy on the control of type 2 diabetes in patients with severe obesity at 5 years at the University Hospital, France. METHODS: From a total of 355 patients with severe obesity operated between January 2006 and June 2010, 52 (15%) had a diagnosis of type 2 diabetes before undergoing laparoscopic sleeve gastrectomy. RESULTS: There were 31 females (60%) and 21 males (40%), with a mean age of 51 ± 10 years (range 27-67) with a mean body mass index of 48 ± 10 kg/m2 (range 35-82). The mean duration of type 2 diabetes was 10.8 ± 10.8 years before bariatric operation. The preoperative glycated hemoglobin was 8 ± 2% (range 5.9-12.8) in 45 patients; 17 patients (38%) had levels of glycated hemoglobin ≥9%. Three patients (6%) required insulin alone, 4 (8%) were taking oral antidiabetic medicine and insulin, and the remaining 45 patients (87%) were taking only oral antidiabetic medicines. The complete data regarding weight loss at 5-year follow-up were obtained for 46 patients, yielding an overall follow-up rate of 89%. The prolonged remission of type 2 diabetes achieved at 1 year that persisted at 5 years of follow-up was present in 9 patients (17%). No patient with complete remission of their type 2 diabetes required insulin preoperatively. Improvement of type 2 diabetes was observed in 30 patients (58%) at 1 year, which was maintained for 27 patients (52%) at 5-year follow-up. CONCLUSION: Laparoscopic sleeve gastrectomy has demonstrated a moderate efficacy in the treatment morbidly obese patients with type 2 diabetes. Markedly increased preoperative glycated hemoglobin levels, older age, and preoperative need for insulin treatment may be the factors predicting failure of complete remission of type 2 diabetes after laparoscopic sleeve gastrectomy.

Multicenter prospective randomized study comparing the technique of using a bovine pericardium biological prosthesis reinforcement in parietal herniorrhaphy (Tutomesh TUTOGEN) with simple parietal herniorrhaphy, in a potentially contaminated setting.

The use of parietal synthetic prosthetic reinforcement material in potentially contaminated settings is not recommended, as there is a risk that the prosthesis may become infected. Thus, simple parietal herniorrhaphy, is the conventional treatment, even though there is a significant risk that the hernia may recur. Using new biomaterials of animal origin presently appears to offer a new therapeutic solution, but their effectiveness has yet to be demonstrated. The purpose of this multicenter prospective randomized single-blind study was to compare the surgical treatment of inguinal hernia or abdominal incisional hernia by simple parietal herniorrhaphy without prosthetic reinforcement (Group A), with Tutomesh TUTOGEN biological prosthesis reinforcement parietal herniorrhaphy (Group B), in a potentially contaminated setting. We examined early postoperative complications in the first month after the operation, performed an assessment after one year of survival without recurrence and analyzed the quality of life and pain of the patients (using SF-12 health status questionnaire and Visual Analog Pain Scale) at 1, 6, and 12 months, together with an economic impact study. Hundred and thirty four patients were enrolled between January 2009 and October 2010 in 20 French hospitals. The groups were comparable with respect to their enrollment characteristics, their history, types of operative indications and procedures carried out. At one month post-op, the rate of infectious complications (n(A) = 11(18.33%) vs. n(B) = 12(19.05%), p = 0.919) was not significantly different between the two groups. The assessment after one year of survival without recurrence revealed that survival was significantly greater in Group B (Group A recurrence: 10, Group B: 3; p = 0.0475). No difference in the patients' quality of life was demonstrated at 1, 6, or 12 months. However, at the 1 month follow-up, the "perceived health" rating seemed better in the group with Tutomesh (p = 0.022). No significant difference between the two parietal repair groups was observed during the follow-ups with respect to the criterion of pain (using a visual analog scale). There was a significant difference between the two parietal repair groups with regard to the number of days spent in intensive care unit, in favor of the Tutomesh technique (p = 0.010). The use of a Tutomesh bioprosthesis for hernia repair or postincisional hernia in a potentially contaminated workplace reduces the risk of short-term recurrence without increasing overall comorbidity.

Laparoscopic sleeve gastrectomy for late adolescent population.

BACKGROUND: Morbid obesity prevalence is rapidly increasing among adolescents worldwide. Evidence is mounting that bariatric surgery is the only reliable method for substantial and sustainable weight loss; however, the debate continues with regard to the optimal surgical procedure for adolescents and to the age limit when bariatric surgery should be proposed. METHODS: A retrospective multicenter review included all late adolescent patients (<20 years old) who underwent sleeve gastrectomy from 2005 to 2012 in three French bariatric centers: Montpellier University Hospital, Casamance Private Hospital, and Noumea Regional Hospital. Collected data included age, sex, body mass index (BMI), intraoperative complications, length of hospital stay, operative morbidity, the need for reoperation, and percentage of excess weight loss (% EWL) at 6 months, 1 year, and 2 years postoperatively. RESULTS: A total of 61 adolescent patients have undergone sleeve gastrectomy. Of these, 42 were women and 19 were men. The mean preoperative weight was 132.8 kg (range 90-217 kg) with a BMI of 46.7 (range 35.5-68.7). Seventeen patients (27.9%) were superobese (BMI > 50), and seven patients (11.5%) were supersuperobese (BMI > 60). All the procedures were performed by laparoscopy with no intraoperative complications. The mean hospital stay was 4.6 days. Four major complications were recorded: one staple line leak, two hematomas, and one case of pneumonia. No mortality was recorded. The % EWL at 6 months, 1 year, and 2 years postoperatively was 48.1% (±17.9%), 66.7% (±19.5%), and 78.4% (±16.8%), respectively, for a follow-up of 93.4, 81.9, and 52.4%, respectively. There were 18 patients (29.5%) with identified comorbid conditions: 10 cases of sleep apnea, 7 cases of hypertension, and 1 case of type 2 diabetes, with a resolution rate of 77.8%. CONCLUSIONS: Laparoscopic sleeve gastrectomy may be advantageous for this age group, since it involves neither foreign body placement nor lifelong malabsorption. Laparoscopic sleeve gastrectomy represents an attractive bariatric procedure for adolescent patients, more efficient than gastric banding and with less morbidity compared to gastric bypass.

Laparoscopic approach for retrorectal tumors.

BACKGROUND: Retrorectal tumors are uncommon and may represent a surgical challenge. Laparoscopic excision has been reported in very few papers. We present our experience of nine cases operated by a transabdominal laparoscopic approach, between 2005 and 2011. METHODS: There were two males and seven females with a mean age of 35 years (range 19-48). The tumors were discovered incidentally in four cases or because of nonspecific clinical signs. All patients have had an MRI preoperatively. RESULTS: Only one patient required open conversion due to a huge tumor >7 cm of diameter. Postoperative mortality was nil. One patient developed a hematoma in the pelvic area. The median hospital stay was 4.7 days (range 4-8). Final diagnostic were as follows: four schwannomas, one ganglioneuroma, two tailgut cysts, one anterior meningocele, and one paragangliomas. During the follow-up showed no recurrences, but four of nine patients developed neurologic complications as parenthesis and sciatic pain and one patient developed retrograde ejaculation. CONCLUSIONS: Our case series shows that the laparoscopic approach is a feasible and safe option. It reduces surgical trauma and offers an excellent tool for perfect visualization of the deep structures in the presacral space to minimize the vascular and neurological injuries.

Surgical management of chronic fistula after sleeve gastrectomy.

BACKGROUND: There is no clear definition of the chronic leak after sleeve gastrectomy. There are several endoscopic approaches, including endoprothese, endoscopic clips, endoscopic sealing glue, or balloon dilation. In case of failure of the endoscopic treatment, a definitive surgical approach can be attempted. The objective was to evaluate the surgical treatment of chronic leak after sleeve gastrectomy. METHODS: From November 2010 through March 2012, 8 patients with chronic gastric fistula after laparoscopic sleeve gastrectomy had definitive surgical repair. The initial intervention, the diagnosis and management of the fistula, and the endoscopic approach were carefully reviewed. RESULTS: Five patients had their original laparoscopic sleeve gastrectomies performed at another hospital, while 3 had laparoscopic sleeve gastrectomy at our institution. The mean period of time from the diagnosis of the fistula to definitive surgical treatment was 14.4 months (range 5-44 months). Seven patients initially had surgical drainage by laparoscopy (5) and by laparotomy (2), with concomitant feeding jejunostomy in 6 patients. The endoscopic treatment consisted of endoprothese in 4 patients, endoscopic sealing glue in 2 patients, and sequential approach with glue and prosthesis in 2 other patients. One patient was treated exclusively by endoscopic approach with no surgical drainage. The surgical procedures performed for chronic fistula were gastrojejunal lateral anastomosis (4), Roux-en-Y gastric bypass (2), and gastrectomy with esojejunal anastomosis (2). Four patients presented with postoperative fistula, with a mean healing time of 32 days (range 22-63 days). No mortality was recorded. CONCLUSION: In chronic forms of fistulas with no improvements by endoscopic approach, the surgical treatment can be a solution. It remains a difficult procedure with a high percentage of leakage, but this type of fistula is more easily tolerated by the patient and heals faster.