Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition.

PURPOSE: Malnutrition after mini-gastric bypass (MGB) is a rare and dreaded complication with few data available regarding its surgical management. We aim to report the feasibility, safety, and results of laparoscopic reversal of MGB to normal anatomy (RMGB) in case of severe and refractory malnutrition syndrome after intensive nutritional support (SRMS). METHODS: A 10-year retrospective chart review was performed on patients who underwent RMGB (video included) for SRMS following MGB. RESULTS: Twenty-six of 2934 patients underwent a RMGB at a mean delay of 20.9 ± 13.4 months post-MGB. At presentation, mean body mass index (BMI), excess weight loss (%EWL), and albumin serum level were 22 ± 4.4 kg/m2, 103.6 ± 22.5%, and 25.5 ± 3.6 gr/L, respectively. Seventeen (63.5%) patients had at least one severe malnutrition related complication including severe edema in 13 (50%), venous ulcers in 2 (7.7%), infectious complications in 7 (27%), deep venous thrombosis in 5 (19.2%), and motor deficit in 5 (19.2%) patients. At surgical exploration, 8 of 12 (66.5%) patients had a biliary limb longer than 200 cm and 9 (34.6%) had bile reflux symptoms. Overall morbidity was 30.8% but lower when resecting the entire previous gastrojejunostomy with creation of a new jejunojejunostomy (8.3 vs 50%, p = 0.03). After a mean follow-up of 8 ± 9.7 months, all patients experienced a complete clinical and biological regression of the SRMS after the RMGB despite a mean 13.9 kg weight regain in 16 (61.5%) patients. CONCLUSIONS: Post-MGB SRMS and its related comorbidities are rare but dreaded conditions. Although burdened by a significant postoperative morbidity and weight regain, RMGB remains an effective option to consider, when intensive nutritional support fails.

Long-Term Results of One Anastomosis Gastric Bypass: a Single Center Experience with a Minimum Follow-Up of 10 Years.

PURPOSE: The purpose of this study was to evaluate the efficacy and safety of the OAGB at least 10 years after surgery. MATERIAL AND METHODS: We retrospectively reviewed our prospectively collected data on consecutive morbid patients with obesity receiving OAGB from January 2005 to December 2007. RESULTS: A total of 385 patients met the inclusion criteria. The mean follow-up was 149 months. Of all patients, 52% underwent OAGB as a primary procedure and 48% as a revisional procedure. At the 10-year follow-up, the mean body mass index (BMI) was 30.7 ± 11.8, the mean %TWL was 33.4 ± 10.6, and the mean %EWL was 64.1 ± 24.6. We did not find a significant statistical difference in terms of weight loss between primary OAGB and secondary OAGB. In total, 43% of patients achieved a %EWL greater than 75%, while 29% of the patients had an EWL% that was below 50%. All of the comorbidities related to obesity showed a high improvement or fully resolved. Early complications occurred in 9 patients (2.3%), while the overall rate of late complications was 17.1%. Nineteen patients (4.9%) developed an ulcer at the gastrojejunal anastomosis level, nine patients (2.3%) were re-hospitalized for major malnutrition, thirty-eight patients (9.8%) showed a postoperative biliary reflux, and five patients (2.7%) experienced severe anemia, which required several hospitalizations for iron I.V. supplementation. CONCLUSION: According to results of the present study, we believe that OAGB has shown to be a technique with a reasonable balance between long-term efficacy and undesirable sequelae.

Presentation and surgical management of leaks after mini-gastric bypass for morbid obesity.

BACKGROUND: Few data exist about the characteristics and management of enteric leaks after mini-gastric bypass (MGB). OBJECTIVES: We aimed to describe the incidence, presentation, and surgical management of enteric leaks in patients who underwent laparoscopic MGB for morbid obesity. SETTING: Private practice. METHODS: An 8-year, 9-month retrospective chart review was performed on patients who had enteric leak requiring reoperation after MGB at a single institution. RESULTS: Thirty-five of 2321 patients were included. Ninety-seven percent had symptoms. Arterial hypertension and heavy smoking were predicting factors of leaks occurrence post-MGB (P<.01). Enteric leak was diagnosed by systematic upper gastrointestinal series in 4 pts (11.4%) and by computed tomography with oral water soluble contrast in 4 of 31 pts (13%). In the other 27 patients, diagnosis of the leak was made intraoperatively. Eleven patients (32%) had leak arising from the gastric stapler line (type 1), 4 (11%) from the gastrojejunal anastomosis (type 2), and 20 (57%) from undetermined origin. The most common presentation was intra-abdominal abscess in type 1 and leaks of undetermined origin and generalized peritonitis in type 2. One third of the patients who underwent reoperation developed well-drained chronic fistula into the irrigation-drainage system, with complete healing in all patients without any further procedure. The mean hospital stay was 19 days with no mortality reported. CONCLUSION: Enteric leak leading to intra-abdominal sepsis post-MGB is rare (1.5%) An operative aggressive management based on clinical symptoms is the treatment of choice allowing no postoperative leak-related mortality and complete healing.

Prognostic factor analysis in advanced gastric cancer patients treated with hydroxyurea, leucovorin, 5-fluorouracil, and cisplatin (HLFP regimen).

This study was performed to determine the prognostic factors of 102 nonresectable locally advanced or metastatic gastric cancer patients prospectively treated with a multimodulation of 5-fluorouracil (5FU), hydroxyurea, leucovorin, and cisplatin. Response rate in 85 patients with measurable disease was 62.4% (95% confidence interval 51.9% to 72.9%). A weight increase (5% or more) was observed in 47% of patients, performance status improved in 70.6%, and symptoms disappeared in 69%. Median times for progression-free survival and overall survival were eight and 11 months, respectively. Liver metastases, more than two involved sites, and increased carcinoembryonic antigen (CEA) were found to be univariate adverse prognostic factors for survival. In a multivariate analysis, only the presence of liver metastasis was found to be an independent prognostic factor. Response rate and survival in patients with gastric linitis or diffuse forms were in the same range as in patients with intestinal forms of gastric adenocarcinoma.

Long-term survival with consolidation intraperitoneal chemotherapy for patients with advanced ovarian cancer with pathological complete remission.

OBJECTIVES: The goal of this study was to evaluate the long-term outcome after consolidation intraperitoneal (IP) chemotherapy in patients with a negative second-look laparotomy (SLL) following first-line intravenous chemotherapy for advanced ovarian cancer. METHODS: This study included patients with FIGO stage III-IV ovarian cancer who entered into four prospective trials (1984-1995) including intravenous chemotherapy based on cisplatin (six cycles) and anthracycline, early debulking surgery after three cycles of chemotherapy in the case of initial residual disease >2 cm, SLL, and IP consolidation chemotherapy. Among 218 patients, 68 with biopsy-negative SLL received every 4 weeks three consolidation cycles of IP chemotherapy (mitoxantrone, cisplatin, etoposide) via a totally implantable port. Long-term outcome of these patients is reported. RESULTS: Mean age was 56 years (33-72 years). Overall, 51% of the patients had at least a grade 3 or 4 toxic effect. Main toxic effects were leukopenia, abdominal pain related to the catheter, and nausea and vomiting. Only 13 patients (19%) did not receive the full three cycles. The median progression-free survival (PFS) for the whole population is 34 months, 34% of the patients being estimated to be free of disease at 5 years. The median overall survival is 73 months, and the 5-year survival is 58%. CONCLUSIONS: In this selected population treated with IP consolidation chemotherapy, prolonged survival was observed. However, the occurrence of late relapses in this most favorable patient category underlines the need to improve the consolidation therapy options in ovarian cancer.