Roux-en-Y Gastric Bypass after Laparoscopic Sleeve Gastrectomy Failure: Could the Number of Previous Operations Influence the Outcome?

After a failed laparoscopic adjustable gastric band (LAGB), laparoscopic sleeve gastrectomy (LSG) has been proposed as revisional surgery. Those patients that receive a second restrictive procedure fall into a small subgroup of patients with more than one restrictive procedure (MRP). If also the second restrictive procedure fails, the correct surgical strategy is a challenge for the surgeon. Roux-en-Y gastric bypass (RYGB) may be an option but there is no evidence in the literature on whether the procedure is effective in treating failures after MRP. This study aims to evaluate the influence of the previous number of restrictive interventions (MRP vs single LSG) in the results of RYGB as revisional surgery. We have retrospectively analyzed patients who underwent conversion from laparoscopic sleeve gastrectomy (LSG), or from multiple restrictive procedures (MRP), to RYGB for weight regain (WR) or insufficient weight loss (IWL) between 2009 and 2019. The number of patients analyzed was 69 with conversion to RYGB after LSG and 44 after MRP. The reduction of excess weight (%TWL) at 3, 6, 12, 24 RYGB postoperative months was respectively of 11.03%, 16.39%, 21.43%, and 24.22% in the MRP group, and of 10.97%, 16.4%, 21.22%, and 22.71% in the LSG group. No significant difference was found in %TWL terms after RYGB for the MRP group and the LSG group with an overall %TWL, which was 11.00 ± 6.03, 16.40 ± 8.08, 21.30 ± 9.43, and 23.30 ± 9.91 respectively at 3, 6, 12, and 24 months. The linear regression model highlighted a positive relationship between the %EWL post-bypass at 24 months and the time elapsed only between the LSG and RYGB in the MRP group patients (p < 0.001). RYGB has proved to be a reliable technique with good results in terms of weight loss after failed bariatric surgery both in patients who previously underwent MRP and in those who underwent exclusively LSG. RYGB showed better results in patients who experienced WR than in those who had IWL from previous techniques.

Multiple odontogenic keratocysts in a patient with Lowe syndrome: a first case report and literature review.

Lowe syndrome (LS) is a rare disease (1:500,000) with X-linked recessive inheritance involving the kidneys, eyes, and nervous system. A Mexican 25-year-old male patient presented for diagnosis of multiple radiolucent lesions observed on routine radiographic examination. General aspects revealed cognitive delay, eye alterations, and kidney involvement, which support the diagnosis of LS. Radiolucent well-delimited lesions were observed in both mandibular angle and symphysis. Under general anesthesia, incisional biopsy and decompression were performed. Histological aspects led to diagnosing odontogenic keratocyst (OKC) for all lesions. The lesions in the right and left mandibular angles were decompressed, and the symphyseal lesion was enucleated. A 2-month follow-up shows the bone healing process. There are few reports detailing oral findings in LS. Here, we reported the first case of multiple OKC in a patient with LS. In addition, we performed a literature review on odontogenic lesions in patients affected by LS.

Total Gastrectomy with Roux-en-Y Limb Reconstruction for Complex and Chronic Fistulas After Laparoscopic Sleeve Gastrectomy: Single-Center Experience.

PURPOSE: When a leak after laparoscopic sleeve gastrectomy (LSG) becomes a chronic fistula, the best surgical treatment remains controversial. The aim of study was to review our experience concerning the treatment of chronic and complex fistulas after LSG. MATERIALS AND METHODS: A retrospective analysis of patients with a gastric fistula following LSG who were treated at our center between January 2013 and December 2018 was performed. All patients included underwent a total gastrectomy with a Roux-en-Y reconstruction (TG) for LSG chronic fistula. RESULTS: During the period considered, 13 patients had a chronic fistula and were treated with open TG. The primary leak evolved to a gastro-cutaneos fistula in three patients (23%), to a gastro-splenic fistula in two patients (15.4%), to a gastro-pleural fistula in four patients (30.8%), and to a gastro-bronchial fistula in four patients (30.8%). During TG, a splenectomy and a spleno-pancreatectomy were needed in the two cases of gastro-splenic fistula. Five patients (38.5%) developed an early complication. Two patients developed an esophago-jejunal anastomotic leak treated with a conservative approach (15.4%). No patients needed hospitalization in the intensive care unit. Overall mean length of stay was 19 days (8-30 days). Mean BMI before LSG was 36 (± 5 kg/m2), mean BMI before TG was 30.3 (± 5.2 kg/m2), and mean BMI 2 years after TG was 23.5 (± 2.9 kg/m2). CONCLUSION: When a more conservative and less mutilating surgical option is not possible, open TG with esophago-jejunostomy remains a valuable salvage procedure in the case of complex and extensive fistulas after LSG.

Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass in patients with gastroesophageal reflux disease: results of a multicenter study.

BACKGROUND: The main side effect of long-term laparoscopic sleeve gastrectomy is the onset of severe gastroesophageal reflux disease (GERD). OBJECTIVES: The aim of this study was to evaluate the effectiveness of gastric bypass conversion in controlling postsleeve GERD. SETTING: University Hospital and Private Hospital, France and Private Hospital, Italy. METHODS: This retrospective multicenter study included patients who underwent laparoscopic sleeve gastrectomy and suffered from postoperative GERD, who did not respond to medical treatment and were converted to laparoscopic Roux-en-Y gastric bypass. The study involved 2 French university hospitals, 4 French private centers, and an Italian public hospital. RESULTS: A total of 80 patients were reviewed. Treatment of a hiatal hernia was performed during laparoscopic sleeve gastrectomy in 3 patients, while 19 patients were operated for hiatal hernia during conversion to bypass (P = .0004). Six months after surgery, 23 of 80 patients maintained reflux symptomatology with a daily frequency, for which continued proton pump inhibitor treatment was required. The persistence of GERD was significantly more frequent among patients with previous gastric banding (n = 19) compared with patients with no history of gastric banding (n = 4, P = .02). In other words, the likelihood of having poor clinical success from conversion of the sleeve to bypass because of intractable GERD was 3 times higher if the patient had a history of gastric banding (relative risk = 2.89, odds ratio = 3.69). CONCLUSION: The results of this study show that, despite the conversion, the symptomatology of GERD does not always disappear, especially in patients with previous gastric banding.

Laparoscopic Sleeve Gastrectomy Learning Curve: Clinical and Economical Impact.

BACKGROUND: The results in the literature regarding the learning curve (LC) of laparoscopic sleeve gastrectomy (LSG) are scarce and non-definitive. The purpose of the study was to evaluate the correlation between the LSG learning curve and intraoperative parameter variation, postoperative morbidity, weight loss results, and economic impact. METHODS: The first 99 obese patients undergoing LSG surgery by the same surgeon from March 2013 to April 2016 were included in the present study. Patients were equally distributed among three groups (A, B, C) based on case sequence. RESULTS: The three study groups were homogeneous with respect to age, BMI, gender, and comorbidities. There was a significant reduction in operative time among the groups (p < 0.00001), with a difference of approximately 40 min between the first and third groups. The decrease in operative time was associated with a decrease in the number of stapler firings used per LSG. Conversely, there was no statistical correlation between intraoperative blood loss, intraoperative complications, or weight loss 1-year postsurgery and the LSG learning curve. In addition, the increase in experience with LSG was also associated with a significant reduction (p < 0.00001) in the length of hospital stay. With respect to postoperative complications, a statistically significant difference was recorded between groups B and C (p = 0.02). Finally, a patient undergoing surgery at the end of the LC had an estimated reduction in economic impact of approximately 2700 Euros compared with a patient undergoing surgery at the beginning of the LC. CONCLUSION: Approximately 60 cases are required to reach proficiency in reducing postoperative complications and costs of LSG.

Resolution of type 2 diabetes after sleeve gastrectomy: a 2-step hypothesis.

BACKGROUND: Weight loss (WL) and altered gut hormonal levels are involved in glucose homeostasis after laparoscopic sleeve gastrectomy (LSG). OBJECTIVES: The aim of this study was to evaluate the time-related effects of WL, ghrelin, and glucacon-like peptide-1 (GLP-1) plasma concentrations on type 2 diabetes resolution after LSG. SETTING: University hospital, Italy. METHODS: Ninety-one patients who underwent LSG were investigated. Insulin secretion (insulinogenic index [IGI]), insulin resistance, plasma glucose level and percentage glycated hemoglobin using the oral glucose tolerance test were assessed before surgery, on postoperative day 3, and then at 6, 12, 24, and 36 months after LSG. At the same time points, WL, ghrelin, and GLP-1 levels were determined. RESULTS: During follow-up, the resolution rate of type 2 diabetes was 9.4%, 42.3%, 71.8%, 81.2%, and 91.8%, respectively. Ghrelin plasma concentrations decreased significantly after LSG (271.5 ± 24.5 pg/mL versus 122.4 ± 23.4 pg/mL, P = .04). GLP-1 plasma concentrations increased significantly after LSG (1.7 ± 2.6 pg/mL versus 2.5 ± 3.4 pg/mL, P = .04). The percentage of excess weight loss and IGI presented a positive linear correlation (r) at all follow-up time points with a strong positive correlation at 12 and 24 months. A strong negative correlation between ghrelin and IGI was recorded during the first 3 days after LSG (r = -.9). GLP-1 and IGI presented a strong positive correlation at day 3 and 6 months (i.e., .8 and .8, respectively). CONCLUSION: LSG may affect glucose homeostasis by 2 different time-related modes: a first step in which the hormonal changes play a predominant role in glucose homeostasis and a second step in which the percentage excess weight loss determines the metabolic results.

Correction to: Establishing a Reproducible Murine Animal Model of Single Anastomosis Duodenoileal Bypass with Sleeve Gastrectomy (SADl-S).

The first and last names of the authors were inverted in the original article. They are displayed correctly here.

Gastrosplenic Fistula with Gastrointestinal Bleeding: a Rare and Potentially Fatal Complication After Sleeve Gastrectomy.

BACKGROUND: Although the surgical technique is safe and standardized, laparoscopic sleeve gastrectomy (LSG) is associated with serious and potentially life-threatening complications, such as gastric leak and bleeding. METHODS: In this retrospective study, three French university hospitals reviewed their experience with LSG. Between September 2014 and May 2016, three cases of gastrosplenic fistula complicated by massive upper gastrointestinal hemorrhage (UGIH) were recorded. RESULTS: Patient number 1 experienced a massive UGIH 2 months after LSG. After blood transfusion, a transcatheter embolization of the splenic artery branch was successfully performed. Patient number 2 was admitted to the emergency department for massive UGIH 5 years after LSG. After several unsuccessful endoscopic attempts, she underwent a midline laparotomy, and an "en bloc" staple line resection and splenectomy was performed. Patient number 3 arrived at the hospital with an unstable hemodynamic status 16 days after the LSG and was given emergency surgery. She died as a consequence of hemorrhagic shock. CONCLUSIONS: Post-LSG gastrosplenic fistula (GSF) is a rare and dreaded complication necessitating emergency management. Angiography with arterial embolization seems to be the treatment of choice for GSF following SG, allowing diagnosis and treatment when hemodynamic stability is warranted. In a life-threatening situation, hemostatic splenectomy remains the treatment of choice.

Laparoscopic Sleeve Gastrectomy in Kidney Transplant Candidates: a Case Series.

BACKGROUND: Patients with a body mass index (BMI) >35 kg/m2 who need kidney transplant present with increased postoperative mortality and reduced kidney graft survival compared to patients with a lower BMI. For this reason, obese patients are often excluded from the transplantation waiting list. The aim of this study was to evaluate the feasibility and the results of laparoscopic sleeve gastrectomy (LSG) for obese patients awaiting a kidney transplant. METHODS: This was a retrospective study on patients with dialysis-dependent renal failure (DDRF) operated on at two first-level bariatric centers in Paris (France). All the patients were contraindicated for kidney transplantation due to the presence of morbid obesity. RESULTS: Nine DDFR patients with a mean BMI of 45.9 kg/m2 underwent LSG for the treatment of obesity. Furthermore, all patients presented with hypertension and sleep apnea and six out nine were diabetics. In the immediate postoperative period, all patients were transferred to the intensive care unit (mean stay of 2.1 days). The only major adverse event was a delayed weaning from mechanical ventilation in one patient. The mean hospital stay was 5.5 days (3-12). The total weight loss (TWL) was 27.1, 33.6, and 39.5 kg at 6, 12, and 18 months, respectively. One patient underwent renal transplantation 18 months after LSG, and the other five patients were actively listed for kidney transplantation. CONCLUSIONS: According to the results of this small sample series, LSG seems to be an effective and safe procedure in DDRF patients with concomitant obesity and can increase access to transplantation.

Laparoscopic management of foramen of Winslow incarcerated hernia.

Foramen of Winslow hernia (FWH) is a rare and often overlooked diagnosis with a high mortality rate. Widespread availability of cross-sectional imaging allows early diagnosis and prompt management. In this setting, before ischemia occurs, explorative laparoscopy would be the most suitable approach. Experience, however, remains sparse, and technical difficulties may be encountered. This is the case of a 38-year-old Caucasian woman who presented to the emergency department for a sudden epigastric pain. Physical exam was unremarkable, and routine blood tests were within normal range. An abdominal computed tomography (CT) scan confirmed the diagnosis of ileocaecal herniation through the foramen of Winslow. Under urgent laparoscopy, the caecum appeared viable but incarcerated in the lesser sac. Caecal puncture was the key to achieving atraumatic reduction of the hernia and bowel salvage.

Laparoscopic Gastric Plication (LGP) as an Alternative to Laparoscopic Sleeve Gastrectomy (LSG) in Patients with Morbid Obesity: A Preliminary, Short-Term, Case-Control Study.

BACKGROUND: Based on short-term outcome, gastric plication (LGP) could be considered as an alternative to sleeve gastrectomy (LSG) in patients with severe obesity. However, long-term follow-up of weight loss and comorbidity are yet to be available. Theoretical advantages include reduced fistula rate, no implantable device, preservation of the alimentary pathway, and no gastric resection. We report a case-control study comparing short-term outcome in two groups of patients who had either LGP or LSG, respectively. METHODS: From January 2012 to June 2013, 40 patients had LGP, matched with 40 patients who had LSG. RESULTS: No postoperative mortality was observed. Overall morbidity rate reached 22.5 % in the LGP Group and 10 % in the LSG Group (P = 0.04). The most common complication was nausea and vomiting occurring in 20 % of patients with LGP and 5 % of patients with LSG, respectively (P < 0.001). No clinical or radiological leak occurred. Mean operative time was 91.5 ±18.6 min in the LGP group and 81 min ±16.8 min in the LSG group, respectively (P = 0.104). Mean hospital stay was 3.4 ±1.1 days in the LGP Group and 3.2 ±1.2 days the LSG group, respectively (P = 0.614). Average total operating room (OR) cost was 1736 euros for LGP as compared to 2842 euros for LSG, respectively (P < 0.001). At 18-month follow-up, mean excess weight loss (EWL) was 56.5 % +9.8 in LGP patients and 71.3 % +10.4 in patients who had LSG (P = 0.041). CONCLUSIONS: LGP for patients with severe obesity is safe and feasible with low rates of serious complications. As compared to LSG, LGP is associated to higher postoperative rate of nausea, lower operative cost, and lower EWL at 18-month follow-up (P = 0.041).

Incarcerated hernia in a trocar site following laparoscopic gastric bypass.

This paper reports a case of small bowel occlusion due to the herniation of an ileal ansa at the site of the insertion of a 12-mm trocar. A 28-year-old obese female patient underwent laparoscopic surgery for gastric bypass, the skin incisions of the trocar insertion sites were closed with absorbable sutures. Small bowel occlusion occurred on post-operative day 6 and the patient again underwent laparoscopic surgery. Laparoscopic exploration confirmed the suspected presence of the incarcerated hernia of an ileal ansa at the site of the trocar insertion which was freed without any need for bowel resection. The fascial defect was successfully closed under direct vision with the use of a special system of fascial sutures.