Endoscopic vacuum therapy for treatment of rectal stump leakage.

BACKGROUND: Symptomatic rectal stump leakage (RSL) is a serious complication after discontinuity resection and requires immediate surgical, interventional, or endoscopic therapy. Re-operations are associated with high morbidity and mortality in these mostly very ill patients. Endoscopic vacuum therapy (EVT) has been established for management of anastomotic leakage; however, its effectiveness for RSL treatment has not been analyzed in detail yet. METHODS: A retrospective analysis of patients treated with EVT for RSL between 2001 and 2018 analyzing factors predicting therapy success and duration was carried out. RESULTS: Fifty-six patients with RSL at a median age of 66 years were included. Of these, 18 patients (32%) had been referred for EVT from external departments or institutions. RSL was associated with a relevant clinical deterioration in all patients, and 55 patients (98%) had been classified as ASA 3 and 4, preoperatively. In 9 patients (16%), additional surgical revision was necessary with initiation of EVT. In 47 patients (84%), EVT was successful and local control of the inflammatory focus was achieved. The median duration of therapy was 20 days. Two patients (4%) suffered from minor EVT-associated bleeding that was endoscopically controlled. Preoperative radiation of the pelvis was significantly associated with EVT failure (P = 0.035), whereas patient age represented a predictive factor for therapy length (P = 0.039). In 12 patients (21%), restoration of intestinal continuity was achieved in the further course. CONCLUSIONS: We present the first specific series on EVT for RSL. EVT for RSL was shown to be an effective and safe minimal-invasive treatment option, avoiding surgical revision in the majority of patients.

Banded gastric bypass - four years follow up in a prospective multicenter analysis.

BACKGROUND: The gastric bypass is the gold standard of bariatric surgery. Nevertheless some patients show insufficient weight loss or weight regain. Dilation of the pouch or the pouch outlet may be the cause. The banded gastric bypass tries to overcome dilation by placing an implant around the pouch or pouch outlet. In this study we describe our results using the GaBP™ ring system in banded gastric bypass operations in 3 bariatric centers. METHODS: 183 patients in 3 bariatric reference centers received a banded gastric bypass operation using the GaBP™ ring system. Up to 4 years follow up was evaluated including weight loss and complications. RESULTS: Mean EWL after 6 Months was 60% with a mean BMI of 30.1 kg/m2. After one year mean EWL reached 75.3% with a mean BMI of 27 kg/m2 (110 patients). After two and three years the EWL was 78.8% (n = 49) and 79.9% (n = 35). There was a mean EWL of 85% after 4 years. Thirteen patients finished a 4 year follow up period and mean BMI after 4 years was 25.2 kg/m2. In the perioperative and early postoperative period there was a low complication rate (4.3%). Stenosis or dysphagia was observed in only one patient. There was only one ring related complication. CONCLUSION: Banded gastric bypass using the GaBP™ ring system allows good weight loss with no regain of weight in a four year follow up. The complication rate is low. A randomized controlled trial is currently underway to compare banded and conventional gastric bypass.

Pylorus preserving loop duodeno-enterostomy with sleeve gastrectomy - preliminary results.

BACKGROUND: Bariatric operations mostly combine a restrictive gastric component with a rerouting of the intestinal passage. The pylorus can thereby be alternatively preserved or excluded. With the aim of performing a "pylorus-preserving gastric bypass", we present early results of a proximal postpyloric loop duodeno-jejunostomy associated with a sleeve gastrectomy (LSG) compared to results of a parallel, but distal LSG with a loop duodeno-ileostomy as a two-step procedure. METHODS: 16 patients underwent either a two-step LSG with a distal loop duodeno-ileostomy (DIOS) as revisional bariatric surgery or a combined single step operation with a proximal duodeno-jejunostomy (DJOS). Total small intestinal length was determined to account for inter-individual differences. RESULTS: Mean operative time for the second-step of the DIOS operation was 121 min and 147 min for the combined DJOS operation. The overall intestinal length was 750.8 cm (range 600-900 cm) with a bypassed limb length of 235.7 cm in DJOS patients. The mean length of the common channel in DIOS patients measured 245.6 cm. Overall excess weight loss (%EWL) of the two-step DIOS procedure came to 38.31% and 49.60%, DJOS patients experienced an %EWL of 19.75% and 46.53% at 1 and 6 months, resp. No complication related to the duodeno-enterostomy occurred. CONCLUSIONS: Loop duodeno-enterosomies with sleeve gastrectomy can be safely performed and may open new alternatives in bariatric surgery with the possibility for inter-individual adaptation.

Revisional Gastric Bypass Is Inferior to Primary Gastric Bypass in Terms of Short- and Long-term Outcomes-Systematic Review and Meta-Analysis.

PURPOSE: Although Roux-en-Y gastric bypass (RYGB) is the main primary bariatric procedure, it has also been utilized as revisional bariatric surgery. Our aim is to compare revisionary gastric bypass with primary gastric bypass through systematic review with meta-analysis. METHODS: Available literature was searched for eligible studies up to December 2017. Inclusion criteria were reports on morbidity, %EWL, or diabetes remission. Secondary outcomes involved mortality, anastomotic leakage, operative time, and length of hospital stay. Random effect meta-analyses were undertaken. RESULTS: Initial search yielded 1164 references. Final meta-analysis involved 21 studies and revealed significant differences in terms of morbidity (RR1.54, p < 0.001) and EWL (WMD-19.9, p < 0.001). There were no differences in diabetes remission. CONCLUSION: Revisionary RYGB has worse weight loss effect with greater morbidity rate than primary RYGB.

Minimally Invasive Surgery for the Treatment of Colorectal Cancer.

BACKGROUND: Reduction in operative trauma along with an improvement in endoscopic access has undoubtedly occupied surgical minds for at least the past 3 decades. It is not at all surprising that minimally invasive colon surgery has come a long way since the first laparoscopic appendectomy by Semm in 1981. It is common knowledge that the recent developments in video and robotic technologies have significantly furthered advancements in laparoscopic and minimally invasive surgery. This has led to the overall acceptance of the treatment of benign colorectal pathology via the endoscopic route. Malignant disease, however, is still primarily treated by conventional approaches. METHODS AND RESULTS: This review article is based on a literature search pertaining to advances in minimally invasive colorectal surgery for the treatment of malignant pathology, as well as on personal experience in the field over the same period of time. Our search was limited to level I and II clinical papers only, according to the evidence-based medicine guidelines. We attempted to present our unbiased view on the subject relying only on the evidence available. CONCLUSION: Focusing on advances in colorectal minimally invasive surgery, it has to be stated that there are still a number of unanswered questions regarding the surgical management of malignant diseases with this approach. These questions do not only relate to the area of boundaries set for the use of minimally invasive techniques in this field but also to the exact modality best suited to the treatment of every particular case whilst maintaining state-of-the-art oncological principles.

Modification of internal hernia classification system after laparoscopic Roux-en-Y bariatric surgery.

INTRODUCTION: The occurrence of internal hernia is not an uncommon late complication following the laparoscopic bariatric Roux-en-Y gastric bypass procedure. In some instances, it can be life threatening if not treated in a timely manner. Although there are numerous publications in the literature addressing internal hernia, they are mostly retrospective, and focus mainly on describing the different reconstructive orientation as far as the bowel is concerned. AIM: Our study aim is to address the relationship between the three basic elements of internal hernia, namely: intestinal mesentery defect, the involved intestine and herniated loop direction. Although a developed and widely accepted classification system of internal hernia has not been established yet, we hope this study can help the system to be established. MATERIAL AND METHODS: We studied all patients who underwent revision bariatric operations in the Freiburg and Lübeck University Hospitals (2007-2013). A single surgeon performed and documented all revision procedures for internal hernia. The post-operative follow-up period is up to 6 years. All patients with internal hernias were included whether their primary surgery was performed in our center or performed in other institutions, being referred to our center for further management. The presence of hernia defect, the type of herniated intestinal loop and the direction by which the herniated intestinal loop migrated were analyzed. RESULTS: Twenty-five patients with internal hernia were identified; in 2 patients more than one hernia type coexisted. The most frequent constellation of internal hernias was BP limb herniation into the Brolin space and migrating from left to right direction (28%). The highest incidence of internal hernia was found to be following Roux-en-Y gastric bypass (68%); the biliopancreatic limb (BP) limb was the most commonly involved intestine (51.9%). The incidence of Petersen hernia was the highest (59.3%), and left-right direction was more common. The most common hernia direction of the biliopancreatic limb was from left to right (92.6%), but alimentary limb (AL; 57.1%) and common channel (CC; 66.7%) often favor the other course. CONCLUSIONS: There are existing different types of internal hernias after bariatric operations including separate mesenterial spaces, various intestine parts and herniation direction. Our SDL classification system may offer a useful pathway that facilitates the understanding, and systematic approach to internal hernia, which can be used by bariatric quality registers.

To band or not to band--early results of banded sleeve gastrectomy.

Laparoscopic sleeve gastrectomy (LSG) is the procedure with the fastest growing numbers worldwide. Although excellent weight loss can be achieved, one major obstacle of LSG is weight regain due to sleeve dilatation. Banded sleeve gastrectomy (BLSG) has been described as an option to counteract sleeve dilatation and ameliorate weight loss over time. In a retrospective study, we analysed 25 patients who underwent BLSG using a MiniMizer® ring. Twenty five patients who had previously undergone a conventional LSG were selected for matched-pair analysis. Patient follow-up was 12 months in both groups. Mean preoperative BMI was 56.1 ± 7.2 kg/m(2) for BLSG and 57.0 ± 6.3 kg/m(2) for LSG, P = 0.522. Operative time was significantly shorter for BLSG (53 ± 27 min vs. 68 ± 20 min, P = 0.0025). Excess weight loss (%EWL) was equal in both groups with %EWL at 12 months of 58.0 ± 14.6 % for BSLG patients vs. 58.4 ± 19.2 % for LSG patients. There was no procedure-related mortality in either group. At 12 months postoperative, vomiting was significantly increased in BSLG patients (OR 6.75, P = 0.035). New onset reflux was equal in both groups (OR 0.67, P = 0.469). Ring implantation does not increase the duration of surgery or early surgical complications. Weight loss in the first follow-up year is not influenced, but the incidence of vomiting is raised after 12 months when patients start to increase eating volume.

Systematic ileal transposition in Zucker rats shows advantage for long segment distal transposition.

INTRODUCTION: The possibility of achieving diabetes remission through bariatric surgery has dramatically changed treatment options for this disease. Ileal transposition (IT), specifically designed to provoke diabetes remission, has so far shown great success in rodent studies. However, it remains uncertain which combination of ileal length and origin produces best results. METHODS: Forty male Zucker rats underwent transposition of 25% distal, 50% distal, and 50% proximal ileum or sham surgery. Glucose control, insulin, and glucagon-like peptide (GLP)-1 serum levels were analyzed after 1, 3, and 6 months. Body weight was recorded weekly. RESULTS: In relation to sham-operated animals, the 50% distal IT presented with improved glucose tolerance after 1, 3, and 6 months (2-way analysis of variance [ANOVA]: P < .05, < .0001, and < .0001, respectively). The 25% distal and 50% proximal IT only showed improved glucose control after 3 months, suggesting a fading effect in long-term observation (2-way ANOVA: P < .0001 for both). Glucose-stimulated GLP-1 levels were steadily elevated only in the 2 distal IT groups (Mann-Whitney sham versus 50% distal, P < .01, < .01, and < .05; sham versus 25% distal, P < .01, = .001, < .05 for 1, 3, and 6 months, respectively). IT had no impact on serum insulin levels. CONCLUSION: The current study restates the findings of improved glucose tolerance and GLP-1 stimulation after IT, but is the first to demonstrate a fading glycemic effect in long-term observation. Systematic comparison of length and ileal origin revealed that long and distal transposition delivers best results.

Duodeno-enteral omega switches - more physiological techniques in metabolic surgery.

INTRODUCTION: In bariatric surgery, still new surgical techniques are developed. On the one hand, the Roux-en-Y gastric bypass (RYGB) is one of the most common procedures used. However, many patients experience dumping syndrome or pain due to bile reflux. On the other hand, revisions after gastric banding are frequent and may be technically challenging. AIM: To create a new bariatric procedure counterbalancing the drawbacks of conventional RYGB, also suitable as a redo option after gastric banding. MATERIAL AND METHODS: To diminish the complication rate and pathophysiological disadvantages in reoperations after gastric banding, we primarily combined a gastric plication (GP) with a single anastomosis duodeno-ileal omega switch (DIOS), bypassing 2/3 of the total bowel length. Further on, in patients with lower body mass index we combined a GP or LSG and laparoscopic sleeve gastrectomy with a duodeno-jejunal omega switch (DJOS), performing an end-to side anastomosis after 1/3 of the total bowel length. RESULTS: The DIOS and DJOS techniques restrict food intake and bypass the duodenum and part (DJOS) or the whole (DIOS) jejunum. Restriction is achieved either through gastric plicature or conventional sleeve gastrectomy. CONCLUSIONS: Similar bariatric and metabolic effects to proximal RYGB are expected in the case of DJOS, or to a conventional duodenal switch when performing a DIOS procedure. Performing a gastric plicature will reduce the risk of gastric leak when revising patients after failed gastric banding.

[Malnutrition after biliopancreatic diversion--postoperative management and complications]. / Malnutrition nach biliopankreatischer Teilung--postoperative Maßnahmen und Komplikationen.

The biliopancreatic diversion is currently the maximum variant of bariatric surgery. It presents several opportunities of typical surgical complications, beside the risks generally prevailing in bariatric surgery. In addition, there is the procedure-immanent risk of development of nutritional deficiencies in the long-term process, at significant percentages. These deficiencies can, to a great extent, be avoided by consistent supplementation within the scope of a structured follow-up program; they can also be corrected by a substitution therapy. In the future, the risk of malnutrition can possibly be lowered by technically modified procedures with equal bariatric effectiveness. Considering the very good long-term results with regard to stable weight reduction in connection with a high recovery rate of the comorbidities, combined with a consistent postal-surgical management, the problem of malnutrition appears to be of minor importance. However, an appropriate compliance of the patient is also required.