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BACKGROUND: Over the past 20 years, surgeons involved in soft tissue minimally invasive surgery have experienced the pros and cons of both conventional and tele-robotic laparoscopic approaches. The Maestro System, developed by Moon Surgical (Paris, France) aims to overcome the challenges inherent to both approaches thanks to a new concept that augments the surgeon's performance at the bedside during a laparoscopic procedure. METHODS: The current study aims to present the first human experience with laparoscopic cholecystectomy with the Maestro system on 10 patients. RESULTS: All ten procedures were completed successfully. No significant complications related to the use of the Maestro system werenoted. CONCLUSION: Our preliminary observations appear to support the benefits of the Maestro system in non-emergent laparoscopic cholecystectomies. It goes without saying that further research is necessary to demonstrate the safety of this approach in other procedures.
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Colecistectomia Laparoscópica , Laparoscopia , Robótica , Cirurgiões , Humanos , Colecistectomia Laparoscópica/métodos , Laparoscopia/métodos , Robótica/métodos , FrançaRESUMO
With the rise in obesity and bariatric procedures worldwide, there has been a surge in new and innovative procedures that has been increasingly offered to patients. In this position statement, IFSO highlights the importance of surgical ethics in innovation and when offering new procedures. Furthermore, the task force reviewed the current literature to describe which procedures can be offered as mainstream outside research protocols versus those that are still investigational and need further data.
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Cirurgia Bariátrica , Bariatria , Humanos , ObesidadeRESUMO
OBJECTIVE: To define "best possible" outcomes for secondary bariatric surgery (BS). BACKGROUND: Management of poor response and of long-term complications after BS is complex and under-investigated. Indications and types of reoperations vary widely and postoperative complication rates are higher compared to primary BS. METHODS: Out of 44,884 BS performed in 18 high-volume centers from 4 continents between 06/2013-05/2019, 5,349 (12%) secondary BS cases were identified. Twenty-one outcome benchmarks were established in low-risk patients, defined as the 75th percentile of the median outcome values of centers. Benchmark cases had no previous laparotomy, diabetes, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, thromboembolic events, BMI>â50âkg/m2 or age>â65âyears. RESULTS: The benchmark cohort included 3143 cases, mainly females (85%), aged 43.8â±â10âyears, 8.4â±â5.3âyears after primary BS, with a BMI 35.2â±â7âkg/m2. Main indications were insufficient weight loss (43%) and gastro-esophageal reflux disease/dysphagia (25%). 90-days postoperatively, 14.6% of benchmark patients presented ≥1 complication, mortality was 0.06% (n = 2). Significantly higher morbidity was observed in non-benchmark cases (OR 1.37) and after conversional/reversal or revisional procedures with gastrointestinal suture/stapling (OR 1.84). Benchmark cutoffs for conversional BS were ≤4.5% re-intervention, ≤8.3% re-operation 90-days postoperatively. At 2-years (IQR 1-3) 15.6% of benchmark patients required a reoperation. CONCLUSION: Secondary BS is safe, although postoperative morbidity exceeds the established benchmarks for primary BS. The excess morbidity is due to an increased risk of gastrointestinal leakage and higher need for intensive care. The considerable rate of tertiary BS warrants expertise and future research to optimize the management of non-success after BS.
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Cirurgia Bariátrica/normas , Benchmarking/normas , Procedimentos Cirúrgicos Eletivos/normas , Laparoscopia/normas , Obesidade Mórbida/cirurgia , Adulto , Feminino , Seguimentos , Humanos , Masculino , Estudos Prospectivos , ReoperaçãoRESUMO
INTRODUCTION: Sleeve gastrectomy (SG) is the commonest bariatric procedure worldwide. Yet there is significant variation in practice concerning its various aspects. This paper report results from the first modified Delphi consensus-building exercise on SG. METHODS: We established a committee of 54 globally recognized opinion makers in this field. The committee agreed to vote on several statements concerning SG. An agreement or disagreement amongst ≥ 70.0% experts was construed as a consensus. RESULTS: The committee achieved a consensus of agreement (n = 71) or disagreement (n = 7) for 78 out of 97 proposed statements after two rounds of voting. The committee agreed with 96.3% consensus that the characterization of SG as a purely restrictive procedure was inaccurate and there was 88.7% consensus that SG was not a suitable standalone, primary, surgical weight loss option for patients with Barrett's esophagus (BE) without dysplasia. There was an overwhelming consensus of 92.5% that the sleeve should be fashioned over an orogastric tube of 36-40 Fr and a 90.7% consensus that surgeons should stay at least 1 cm away from the angle of His. Remarkably, the committee agreed with 81.1% consensus that SG patients should undergo a screening endoscopy every 5 years after surgery to screen for BE. CONCLUSION: A multinational team of experts achieved consensus on several aspects of SG. The findings of this exercise should help improve the outcomes of SG, the commonest bariatric procedure worldwide, and guide future research on this topic.
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Derivação Gástrica , Obesidade Mórbida , Consenso , Técnica Delphi , Gastrectomia , Humanos , Obesidade Mórbida/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Redução de PesoRESUMO
BACKGROUND: Revisional bariatric surgery (RBS) constitutes a possible solution for patients who experience an inadequate response following bariatric surgery or significant weight regain following an initial satisfactory response. This paper reports results from the first modified Delphi consensus-building exercise on RBS. METHODS: We created a committee of 22 recognised opinion-makers with a special interest in RBS. The committee invited 70 RBS experts from 27 countries to vote on 39 statements concerning RBS. An agreement amongst ≥ 70.0% experts was regarded as a consensus. RESULTS: Seventy experts from twenty-seven countries took part. There was a consensus that the decision for RBS should be individualised (100.0%) and multi-disciplinary (92.8%). Experts recommended a preoperative nutritional (95.7%) and psychological evaluation (85.7%), endoscopy (97.1%), and a contrast series (94.3%). Experts agreed that Roux-Y gastric bypass (RYGB) (94.3%), One anastomosis gastric bypass (OAGB) (82.8%), and single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) (71.4%) were acceptable RBS options after gastric banding (84.3%). OAGB (84.3%), bilio-pancreatic diversion/duodenal switch (BPD/DS) (81.4%), and SADI-S (88.5%) were agreed as consensus RBS options after sleeve gastrectomy. lengthening of bilio-pancreatic limb was the only consensus RBS option after RYGB (94.3%) and OAGB (72.8%). CONCLUSION: Experts achieved consensus on a number of aspects of RBS. Though expert opinion can only be regarded as low-quality evidence, the findings of this exercise should help improve the outcomes of RBS while we develop robust evidence to inform future practice.
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Cirurgia Bariátrica/métodos , Consenso , Técnica Delphi , Adulto , Desvio Biliopancreático/métodos , Duodeno/cirurgia , Feminino , Gastrectomia/métodos , Derivação Gástrica/métodos , Humanos , Pessoa de Meia-Idade , Obesidade Mórbida/cirurgia , Cuidados Pré-Operatórios , ReoperaçãoRESUMO
OBJECTIVE: To define "best possible" outcomes for bariatric surgery (BS)(Roux-en-Y gastric bypass [RYGB] and sleeve gastrectomy [SG]). BACKGROUND: Reference values for optimal surgical outcomes in well-defined low-risk bariatric patients have not been established so far. Consequently, outcome comparison across centers and over time is impeded by heterogeneity in case-mix. METHODS: Out of 39,424 elective BS performed in 19 high-volume academic centers from 3 continents between June 2012 and May 2017, we identified 4120 RYGB and 1457 SG low-risk cases defined by absence of previous abdominal surgery, concomitant procedures, diabetes mellitus, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, anticoagulation, BMI>50âkg/m and age>65 years. We chose clinically relevant endpoints covering the intra- and postoperative course. Complications were graded by severity using the comprehensive complication index. Benchmark values were defined as the 75th percentile of the participating centers' median values for respective quality indicators. RESULTS: Patients were mainly females (78%), aged 38±11 years, with a baseline BMI 40.8â±â5.8âkg/m. Over 90 days, 7.2% of RYGB and 6.2% of SG patients presented at least 1 complication and no patients died (mortality in nonbenchmark cases: 0.06%). The most frequent reasons for readmission after 90-days following both procedures were symptomatic cholelithiasis and abdominal pain of unknown origin. Benchmark values for both RYGB and SG at 90-days postoperatively were 5.5% Clavien-Dindo grade ≥IIIa complication rate, 5.5% readmission rate, and comprehensive complication index ≤33.73 in the subgroup of patients presenting at least 1 grade ≥II complication. CONCLUSION: Benchmark cutoffs targeting perioperative outcomes in BS offer a new tool in surgical quality-metrics and may be implemented in quality-improvement cycle.ClinicalTrials.gov Identifier NCT03440138.
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Índice de Massa Corporal , Gastrectomia/métodos , Derivação Gástrica/métodos , Laparoscopia/métodos , Obesidade Mórbida/cirurgia , Qualidade de Vida , Centros Médicos Acadêmicos , Adulto , Fatores Etários , Benchmarking , Estudos de Coortes , Feminino , Gastrectomia/efeitos adversos , Derivação Gástrica/efeitos adversos , Saúde Global , Hospitais com Alto Volume de Atendimentos , Humanos , Internacionalidade , Laparoscopia/efeitos adversos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Obesidade Mórbida/diagnóstico , Obesidade Mórbida/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores Sexuais , Redução de PesoRESUMO
BACKGROUND: There is a paucity on literature data related to conversion of Omega anastomosis gastric bypass (OAGB) to Roux-en-Y gastric bypass (RYGB). METHODS: This is a retrospective study. Records of all patients who underwent this conversion were analyzed. Additionally, patients were contacted to answer a questionnaire on their current clinical condition. RESULTS: Twenty-eight patients underwent laparoscopic conversion between September 2007 and June 2016. Indications were peritonitis in 7 patients (leaks after OAGB in 5, perforated marginal ulcer (MU) and blow-out remnant with concomitant leak in one patient each), anastomotic bleeding in one, bile reflux in 6, recalcitrant MU in 4, afferent loop syndrome in 6, postprandial vomiting in 2 (related to anastomotic stenosis and perianastomotic diverticulum, one each), and malnutrition and hypoglycemia both in 1. Thirty-day mortality was zero, complication rate (Clavien-Dindo grade III or more) 5% ((N = 1/20), abscess) when conversion was elective and 50.0% ((N = 4/8), all persisting leaks) when conversion was urgent. All 4 leaks persisting after conversion were successfully treated by endoscopic stenting, despite stent migration in 2 patients. Follow-up was available in 92.9%, for a mean time of 64.5 ± 30.1 months. Successful symptom relief (Likert score 4 or more) was noted for bile reflux and postprandial vomiting. Additionally, malnutrition was corrected. CONCLUSIONS: When indicated, conversion of OAGB to RYGB is a safe treatment strategy. In case conversion is performed for leak after OAGB, persisting subclinical leaks are frequent but can be efficiently addressed by endoscopic stenting.
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Derivação Gástrica/métodos , Laparoscopia/efeitos adversos , Adulto , Idoso , Anastomose em-Y de Roux/efeitos adversos , Anastomose Cirúrgica/métodos , Fístula Anastomótica/etiologia , Fístula Anastomótica/cirurgia , Refluxo Biliar , Feminino , Derivação Gástrica/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/cirurgia , Úlcera Péptica/etiologia , Peritonite/etiologia , Estudos Retrospectivos , Adulto JovemRESUMO
BACKGROUND: Endoscopic sleeve gastroplasty is a safe and feasible treatment for obesity. This study is focused on our technique modification which suggests a different suturing pattern in order to distribute suture tension more evenly. METHODS: A retrospective study of 148 patients (121 women) who underwent this procedure and were monitored for 12 months was conducted. The average age was 41.53 ± 10 years. The average BMI was 35.11 ± 5.5 kg/m2 with the average initial weight being 98.7 ± 17 kg. A subgroup of the first 72 patients (60 women) were monitored for 18 months. A new running "Z" stitch pattern was used to provide gastric cavity reduction by means of 4 parallel suture rows. The stitch pattern was intended to provide a homogenous distribution of the disruptive force on the suture among all stitch points. RESULTS: %TWL was 17.53 ± 7.57 in 12 months and 18.5 ± 9% in 18 months indicating durability of the procedure. Patients with a BMI < 35 benefited most from an endoscopic gastroplasty. Leptin did not predict a response to endoscopic gastroplasty and decreased in all patients. In just one case there was a mild bleeding (0.67%) at the insertion point of the helix, which was resolved by sclerotherapy. CONCLUSIONS: Endoscopic gastroplasty offers a real choice for obese patients. This single-center experience with a modified suturing pattern provides a successful technique for weight loss.
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Endoscopia/métodos , Gastroplastia/métodos , Obesidade/cirurgia , Técnicas de Sutura , Adulto , Índice de Massa Corporal , Feminino , Humanos , Leptina/sangue , Masculino , Estudos Retrospectivos , Redução de PesoRESUMO
OBJECTIVE: The aim of the study was to report 10+ year outcome of laparoscopic biliopancreatic diversion with duodenal switch (LDS), with special focus on quality of life. BACKGROUND:: Reports on long-term morbidity and quality of life after LDS are rare. METHODS: Records of all patients who underwent LDS 10+ years ago were analyzed. Patients were contacted to answer a questionnaire based on Bariatric Analysis and Reporting Outcome System. Blood work was reported when performed within the past year. RESULTS: Of the 153 patients who underwent LDS, follow-up was available for 113 patients (78.5%). Mean follow-up was 130.2â±â4.6 months. Percentage total weight loss was 40.7â±â10.8%. Weight loss was greatest in the super obese category (BMI > 50âkg/m). Remission rate for type 2 diabetes was 87.5% (21/24) and for arterial hypertension 80.9% (38/47). Dyslipidemia remission rates were 93.3% (28/30) for total cholesterol, 89.7% (26/29) for triglycerides, and 95.0% (19/20) for low-density lipoprotein cholesterol. However, 42.5% of the patients needed reoperation, including 10.6% for correction of protein malnutrition, the latter exclusively in non-super obese individuals. Most common deficiencies concerned vitamin A and D, iron, and zinc. De novo gastroesophageal reflux disease was reported in 43.8%. The Bariatric Analysis and Reporting Outcome System score was good at 4.9â±â2.2, and 82.3% of participants would choose the procedure again. CONCLUSIONS: LDS is a very effective metabolic procedure, at the cost of occasional protein and other nutritional deficiencies. Outcome in the long term is best in super obese patients. Overall quality of life is good. The high reoperation rate and incidence of gastroesophageal reflux disease are concerning.
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Desvio Biliopancreático/métodos , Duodeno/cirurgia , Laparoscopia , Obesidade Mórbida/cirurgia , Qualidade de Vida , Adulto , Feminino , Refluxo Gastroesofágico/epidemiologia , Humanos , Entrevistas como Assunto , Masculino , Complicações Pós-Operatórias/epidemiologia , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Inquéritos e Questionários , Resultado do Tratamento , Redução de PesoRESUMO
BACKGROUND: We propose a new minimally invasive technique by laparoscopic approach which minimizes parietal damage and allows precise location of the fistula, hence reduces blind dissection. METHODS: Ten consecutive patients suffering from a HRVF benefited from the described technique. Location and time frame were east of the Democratic Republic of Congo and September 2012 through January 2014. By laparoscopy, dissection of the mesorectum in the "holy plane" is taken posteriorly as distally on the sacrum as possible. Dissection subsequently continues laterally beyond the fistula in an effort to maximally circumvene the fistulous area where no plane of cleavage can be found. If the cleavage plane beyond the fistula addresses a healthy rectum, a suture of vaginal and rectal defect is performed. If the cleavage plane beyond the fistula involves significant laceration of the rectum, while leaving at least 2 cm of healthy rectum above the sphincter, rectal resection and colorectal anastomosis are performed. If the rectal laceration involves the distal 2 cm but halts short of the sphincter (large fistula), the pull-through technique is performed. RESULTS: Of ten participants, four had large HRVF and two presented significant fibrosis. Three underwent simple suture of rectal and vaginal defect, one rectal resection and six a "pull-through" technique. The median procedure time was 1h50 (1h00-3h30). There was no morbidity. None of the patients required protective ileostomy or colostomy. Nine patients were declared clinically cured with a median follow-up of 14.3 months (11-36). The Cleveland Clinic Incontinence Score was 20 in all patients before the treatment and was significantly (p = 0.004) reduced to 2.6 [0-20] after the treatment. CONCLUSIONS: This minimally invasive technique allowed us to treat HRVF, including complex ones in ten patients without significant morbidity. Clinical success with a median follow-up of 14.3 months was 90%.
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Laparoscopia/métodos , Fístula Retovaginal/cirurgia , Adulto , Incontinência Fecal/etiologia , Incontinência Fecal/cirurgia , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Complicações do Trabalho de Parto/cirurgia , Gravidez , Estudos Prospectivos , Estupro , Reto/cirurgia , Índice de Gravidade de DoençaRESUMO
BACKGROUND: In the technique used in our department, Roux-en-Y gastric bypass (RYGB) anatomically only differs from the mini- or omega loop gastric bypass (OLGB) by the incorporation of an isolated alimentary limb, called the Roux limb. The metabolic consequences of the incorporation of a Roux limb are unknown. OBJECTIVES: To evaluate differences in glucose and insulin dynamics between RYGB and OLGB in normoglycemic patients, by submitting them to a glucose challenge after stabilization of their weight. METHODS: Nondiabetic patients who had undergone OLGB 4 years earlier were matched with nondiabetic patients who had undergone RYGB around the same time and with healthy controls. Participants underwent oral (OGTT) and intravenous glucose tolerance test (IVGTT). Endpoints of the study were: progression of plasma glucose and insulin, changes in their concentration [calculated by area under the curve (AUC)] at OGTT and IVGTT, incretin effect and incidence of hypoglycemia. RESULTS: Each of the three groups comprised 14 participants. At OGTT, plasma glucose and insulin incremental values were comparable after OLGB and RYGB, and substantially higher than in controls. Overall glucose concentration, however, did not vary across the three groups. Thirty-minute and overall insulin plasma concentration, indicators of early and total insulin secretion, respectively, was significantly higher in both bypass groups than in controls, and was greatest in OLGB. Severe hypoglycemia occurred in one out of two patients in both bypass groups. At IVGTT, no differences were registered across the three groups and no participant experienced hypoglycemia. The incretin effect was higher after OLGB than after RYGB, but the difference was not statistically significant. CONCLUSIONS: The incorporation of a Roux limb in a loop gastric bypass appears to create a statistically nonsignificant tendency toward reducing insulin hypersecretion observed at OGTT after OLGB, and consequently toward tapering the incretin effect.
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Glicemia/metabolismo , Derivação Gástrica/métodos , Teste de Tolerância a Glucose , Hipoglicemia/sangue , Obesidade Mórbida/cirurgia , Adulto , Feminino , Seguimentos , Humanos , Insulina/sangue , Resistência à Insulina , Masculino , Obesidade Mórbida/metabolismoRESUMO
OBJECTIVE: To describe the technical aspects of a laparoscopic Roux limb placement for the management of chronic proximal fistulas after laparoscopic sleeve gastrectomy (LSG). Laparoscopic Roux limb placement has been proposed as corrective strategy after LSG proximal leak. METHOD: A retrospective chart and database review was conducted in our institution. From January 1, 2002 to May 30, 2013, 18 patients underwent a laparoscopic Roux limb placement on the defect for the treatment of a proximal chronic fistula. The aim of this article was to present the operative technique. RESULTS: Eighteen patients who underwent laparoscopic Roux limb placement had undergone previous treatments including percutaneous drainage, endoscopic stenting of the fistula, and even percutaneous glue treatment. These patients had a chronic fistula and were admitted for a Roux limb placement of the fistula. The mean time for a chronic fistula to heal alter Roux limb placement was 13.5 ± 10.3 days, and the mean length of hospital stay was 18.4 ± 13.2. 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. An accurate surgical technique should be done.
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Anastomose em-Y de Roux/métodos , Fístula Esofágica/cirurgia , Junção Esofagogástrica/cirurgia , Gastrectomia/efeitos adversos , Laparoscopia/métodos , Obesidade Mórbida/cirurgia , Doença Crônica , Drenagem/métodos , Fístula Esofágica/diagnóstico , Fístula Esofágica/etiologia , Feminino , Seguimentos , Gastrectomia/métodos , Humanos , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Reoperação/métodos , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
BACKGROUND: In laparoscopic surgery, telerobotic systems such as Da Vinci™ were developed, among other things, to give back exposure and vision control to the operating surgeon. However, new limitations such as the separation of the operating surgeon from the operating table, cost, and size were unveiled. A new device, Maestro™, appears promising in addressing these limitations. The current work evaluates the feasibility, safety, and surgeon satisfaction with the assistance provided by the Maestro System. METHODS: Non-consecutive patients who were candidates for laparoscopic digestive surgery were enrolled in a descriptive prospective, monocentric study. Case selection was solely based on the availability of the device, but not on the patient's characteristics. Surgery was performed by a leading surgeon with the help of one less experienced surgeon. Feasibility was defined by the maintenance of the initial surgical plan. Safety was assessed by the absence of serious adverse events related to the device and surgeon satisfaction was evaluated by a questionnaire following the intervention. RESULTS: All 50 procedures were completed without conversion in laparotomy and without adjustment of the surgical team. Four complications were recorded during the study; however, none related to the use of the Maestro System. In 92% of the cases, the surgeon was satisfied with the assistance provided by the Maestro System. CONCLUSIONS: In standard elective digestive procedures by laparoscopy, the use of the Maestro System is feasible and safe. It is beneficial to the surgeon and operative room organization by limiting the size of the surgical team.
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INTRODUCTION: The International Federation for Surgery for Obesity and Metabolic Disorders (IFSO) Global Registry aims to provide descriptive data about the caseload and penetrance of surgery for metabolic disease and obesity in member countries. The data presented in this report represent the key findings of the eighth report of the IFSO Global Registry. METHODS: All existing Metabolic and Bariatric Surgery (MBS) registries known to IFSO were invited to contribute to the eighth report. Aggregated data was provided by each MBS registry to the team at the Australia and New Zealand Bariatric Surgery Registry (ANZBSR) and was securely stored on a Redcap™ database housed at Monash University, Melbourne, Australia. Data was checked for completeness and analyzed by the IFSO Global Registry Committee. Prior to the finalization of the report, all graphs were circulated to contributors and to the global registry committee of IFSO to ensure data accuracy. RESULTS: Data was received from 24 national and 2 regional registries, providing information on 502,150 procedures. The most performed primary MBS procedure was sleeve gastrectomy, whereas the most performed revisional MBS procedure was Roux-en-Y gastric bypass. Asian countries reported people with lower BMI undergoing MBS along with higher rates of diabetes. Mortality was a rare event. CONCLUSION: Registries enable meaningful comparisons between countries on the demographics, characteristics, operation types and approaches, and trends in MBS procedures. Reported outcomes can be seen as flags of potential issues or relationships that could be studied in more detail in specific research studies.
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Cirurgia Bariátrica , Derivação Gástrica , Doenças Metabólicas , Obesidade Mórbida , Humanos , Obesidade Mórbida/cirurgia , Cirurgia Bariátrica/métodos , Obesidade/cirurgia , Derivação Gástrica/métodos , Doenças Metabólicas/cirurgia , Sistema de Registros , Gastrectomia/métodos , DemografiaRESUMO
Background: The efficacy and safety of opioid-free anaesthesia during bariatric surgery remain debated, particularly when administering multimodal analgesia. As multimodal analgesia has become the standard of care in many centres, we aimed to determine if such a strategy coupled with either dexmedetomidine (opioid-free anaesthesia) or remifentanil with a morphine transition (opioid-based anaesthesia), would reduce postoperative morphine requirements and opioid-related adverse events. Methods: In this prospective double-blind study, 172 class III obese patients having laparoscopic gastric bypass surgery were randomly allocated to receive either sevoflurane-dexmedetomidine anaesthesia with a continuous infusion of lidocaine and ketamine (opioid-free group) or sevoflurane-remifentanil anaesthesia with a morphine transition (opioid-based group). Both groups received at anaesthesia induction a bolus of magnesium, lidocaine, ketamine, paracetamol, diclofenac, and dexamethasone. The primary outcome was 24-h postoperative morphine consumption. Secondary outcomes included postoperative quality of recovery (QoR40), incidence of hypoxaemia, bradycardia, and postoperative nausea and vomiting (PONV). Results: Eighty-six patients were recruited in each group (predominantly women, 70% had obstructive sleep apnoea). There was no significant difference in postoperative morphine consumption (median [inter-quartile range]: 16 [13-26] vs 15 [10-24] mg, P=0.183). The QoR40 up to postoperative day 30 did not differ between groups, but PONV was less frequent in the opioid-free group (37% vs 59%, P=0.005). Hypoxaemia and bradycardia were not different between groups. Conclusions: During bariatric surgery, a multimodal opioid-free anaesthesia technique did not decrease postoperative morphine consumption when compared with a multimodal opioid-based strategy. Quality of recovery did not differ between groups although the incidence of PONV was less in the opioid-free group. Clinical trial registration: NCT05004519.
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BACKGROUND: Metabolic and bariatric surgery (MBS) is the preferred method to achieve significant weight loss in patients with Obesity Class V (BMI > 60 kg/m2). However, there is no consensus regarding the best procedure(s) for this population. Additionally, these patients will likely have a higher risk of complications and mortality. The aim of this study was to achieve a consensus among a global panel of expert bariatric surgeons using a modified Delphi methodology. METHODS: A total of 36 recognized opinion-makers and highly experienced metabolic and bariatric surgeons participated in the present Delphi consensus. 81 statements on preoperative management, selection of the procedure, perioperative management, weight loss parameters, follow-up, and metabolic outcomes were voted on in two rounds. A consensus was considered reached when an agreement of ≥ 70% of experts' votes was achieved. RESULTS: A total of 54 out of 81 statements reached consensus. Remarkably, more than 90% of the experts agreed that patients should be notified of the greater risk of complications, the possibility of modifications to the surgical procedure, and the early start of chemical thromboprophylaxis. Regarding the choice of the procedure, SADI-S, RYGB, and OAGB were the top 3 preferred operations. However, no consensus was reached on the limb length in these operations. CONCLUSION: This study represents the first attempt to reach consensus on the choice of procedures as well as perioperative management in patients with obesity class V. Although overall consensus was reached in different areas, more research is needed to better serve this high-risk population.
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Cirurgia Bariátrica , Obesidade Mórbida , Tromboembolia Venosa , Humanos , Obesidade Mórbida/cirurgia , Técnica Delphi , Anticoagulantes , Índice de Massa Corporal , Obesidade/complicações , Obesidade/cirurgia , Cirurgia Bariátrica/métodos , Redução de PesoRESUMO
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.
Assuntos
Fístula Anastomótica/cirurgia , Cirurgia Bariátrica/efeitos adversos , Endoscopia Gastrointestinal/métodos , Fístula Intestinal/cirurgia , Obesidade Mórbida/cirurgia , Stents , Adulto , Fístula Anastomótica/etiologia , Cirurgia Bariátrica/instrumentação , Broncopatias/etiologia , Broncopatias/fisiopatologia , Broncopatias/cirurgia , Feminino , Humanos , Fístula Intestinal/etiologia , Fístula Intestinal/fisiopatologia , Laparoscopia/métodos , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/fisiopatologia , Desenho de Prótese , Reoperação , Fístula do Sistema Respiratório/etiologia , Fístula do Sistema Respiratório/fisiopatologia , Fístula do Sistema Respiratório/cirurgia , Estudos Retrospectivos , Gastropatias/etiologia , Gastropatias/fisiopatologia , Gastropatias/cirurgia , Cicatrização/fisiologia , Adulto JovemRESUMO
OBJECTIVE: This study was designed to describe and analyze the outcomes after laparoscopic reversal to normal anatomy (NA) with or without concomitant "sleeve gastrectomy" (SG), after Roux-en-Y gastric bypass (RYGB). Reversal has been proposed as corrective strategy after RYGB. METHODS: We propose a retrospective analysis of a prospectively kept database. RESULTS: From January 2005 to October 2012, 20 female patients underwent laparoscopic reversal after RYGB for one or more of the following conditions: hypoglycaemic syndrome (nine patients), weight regain (six patients), severe dumping (six patients), and cachexia (two patients). Preoperative BMI was 28.0 (19.2-40.3) kg/m². Reversal was performed to NA in ten patients and included a SG procedure in another ten. Postoperative complications included one bleeding and three leaks (15%; all in SG patients). Mean hospital stay was 7 days. Mortality was 0. With a mean follow-up of 11.5 months, all but one patient recovered from their initial condition. However, three developed severe gastroesophageal reflux disease (GERD) symptoms and three had chronic diarrhoea. CONCLUSIONS: Outcomes of laparoscopic reversal of RYGB are good, but complications may occur when SG is added. The surgical alterations caused by the reversal may explain the GERD or diarrhoea experienced by some patients.
Assuntos
Gastrectomia/métodos , Derivação Gástrica/métodos , Laparoscopia , Obesidade Mórbida/cirurgia , Estômago/anatomia & histologia , Adulto , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Single-incision laparoscopy (SIL) has gained significance recently. The umbilicus has been the preferred access site for SIL. Suprapubic access site (SAS) can be an alternative, especially for a right hemicolectomy (RH). METHODS: Between November 2011 and July 2012, 7 consecutive patients underwent suprapubic SIL RH (SSILRH). The median age was 53 years, and the median body mass index was 23.9 kg/m2. Indications for surgery included appendicular tumor (1) and adenocarcinoma of the right colon (6). Three reusable trocars were used, and the resection was performed through the SAS. An intracorporeal linear stapled anastomosis was performed, the mesenteric defect was closed, and the access site was used for specimen extraction. RESULTS: No patient required additional trocars or conversion to an open surgery. The median laparoscopic time was 222 minutes, and the median final incision length was 50 mm. The median Visual Analogue Scale score (0-10) at 6, 18, 30, 42, 54, 66, and 78 postoperative hours was 6, 6, 2, 2, 2, 2, and 2, respectively. The median hospital stay was 4 days. CONCLUSIONS: SSILRH is useful because the SAS can be enlarged for extraction of the specimen without compromising the cosmetic outcome. The mesocolic and mesenteric dissections are on the same axis as the access site. The intracorporeal anastomosis can be performed without traction. Finally, positioning of the operative table improves exposure of the operative field and allows the surgeon to maneuver the colon and small bowel intracorporeally.
Assuntos
Anastomose Cirúrgica/instrumentação , Anastomose Cirúrgica/métodos , Colectomia/instrumentação , Colectomia/métodos , Laparoscopia/instrumentação , Laparoscopia/métodos , Adulto , Idoso , Anastomose Cirúrgica/efeitos adversos , Colectomia/efeitos adversos , Colo/cirurgia , Feminino , Humanos , Íleo/cirurgia , Laparoscopia/efeitos adversos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias/etiologiaRESUMO
MAJOR UPDATES TO 1991 NATIONAL INSTITUTES OF HEALTH GUIDELINES FOR BARIATRIC SURGERY: Metabolic and bariatric surgery (MBS) is recommended for individuals with a body mass index (BMI) >35 kg/m2, regardless of presence, absence, or severity of co-morbidities.MBS should be considered for individuals with metabolic disease and BMI of 30-34.9 kg/m2.BMI thresholds should be adjusted in the Asian population such that a BMI >25 kg/m2 suggests clinical obesity, and individuals with BMI >27.5 kg/m2 should be offered MBS.Long-term results of MBS consistently demonstrate safety and efficacy.Appropriately selected children and adolescents should be considered for MBS.(Surg Obes Relat Dis 2022; https://doi.org/10.1016/j.soard.2022.08.013 ) © 2022 American Society for Metabolic and Bariatric Surgery. All rights reserved.