Minimally invasive Mckeown esophagectomy with modified three-field lymphadenectomy in case of situs inversus totalis with carcinoma mid esophagus.

Performing complex surgical procedures in patients with situs inversus totalis is a challenge because of the need to orient to the completely mirror transposed abdominal and thoracic viscera. We report our experience in performing a three phase minimally invasive (thoracoscopic and laparoscopic) esophagectomy for carcinoma of the mid esophagus in a patient with situs inversus totalis. We believe that this is the first reported case of this kind.

Management of gastric leaks after laparoscopic sleeve gastrectomy for morbid obesity: A tertiary care experience and design of a management algorithm.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed 'standalone' bariatric procedure in India. Staple line gastric leaks occur infrequently but cause significant and prolonged morbidity. The aim of this retrospective study was to analyse the management of patients with a gastric leak after LSG for morbid obesity at our institution. PATIENTS AND METHODS: From February 2008 to 2014, 650 patients with different degrees of morbid obesity underwent LSG. Among these, all those diagnosed with a gastric leak were included in the study. Patients referred to our institution with gastric leak after LSG were also included. The time of presentation, site of leak, investigations performed, treatment given and time of closure of all leaks were analysed. RESULTS: Among the 650 patients who underwent LSG, 3 (0.46%) developed a gastric leak. Two patients were referred after LSG was performed at another institution. The mean age was 45.60 ± 15.43 years. Mean body mass index (BMI) was 44.79 ± 5.35. Gastric leak was diagnosed 24 h to 7 months after surgery. One was early, two were intermediate and two were late leaks. Two were type I and three were type II gastric leaks. Endoscopic oesophageal stenting was used variably before or after re-surgery. Re-surgery was performed in all and included stapled fistula excision (re-sleeve), suture repair only or with conversion to roux-en-Y gastric bypass or fistula jujenostomy. There was no mortality. CONCLUSION: Leakage closure time may be shorter with intervention than expectant management. Sequence and choice of endoscopic oesophageal stenting and/or surgical re-intervention should be individualized according to clinical presentation.

Comparison of weight loss outcomes 1 year after sleeve gastrectomy and Roux-en-Y gastric bypass in patients aged above 50 years.

INTRODUCTION: Safe, effective weight loss with resolution of comorbidities has been convincingly demonstrated with bariatric surgery in the aged obese. They, however, lose less weight than younger individuals. It is not known if degree of weight loss is influenced by the choice of bariatric procedure. The aim of this study was to compare the degree of weight loss between laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in patients above the age of 50 years at 1 year after surgery. MATERIALS AND METHODS: A retrospective analysis was performed of all patients more than 50 years of age who underwent LSG or LRYGB between February 2012 and July 2013 with at least 1 year of follow-up. Data evaluated at 1 year included age, sex, weight, body mass index (BMI), mean operative time, percentage of weight loss and excess weight loss, resolution/remission of diabetes, morbidity and mortality. RESULTS: Of a total of 86 patients, 54 underwent LSG and 32 underwent LRYGB. The mean percentage of excess weight loss at the end of 1 year was 60.19 ± 17.45 % after LSG and 82.76 ± 34.26 % after LRYGB (P = 0.021). One patient developed a sleeve leak after LSG, and 2 developed iron deficiency anaemia after LRYGB. The remission/improvement in diabetes mellitus and biochemistry was similar. CONCLUSION: LRYGB may offer better results than LSG in terms of weight loss in patients over 50 years of age.

Transumbilical endoscopic appendectomy in humans: on the road to NOTES: a prospective study.

BACKGROUND: Natural orifice translumenal endoscopic surgery (NOTES) is the newest technique emerging in the field of surgery. There are several techniques described in the literature, though there is no standardization yet. In this paper, we describe a transumbilical approach for the endoscopic appendectomy in humans. MATERIALS AND METHODS: Eight of 12 patients with uncomplicated appendicitis successfully underwent a transumbilical endoscopic appendectomy. Patients with a mass, abscessed or perforated appendix, previous lower abdominal surgeries, and conversion to laparoscopy (4 patients) were excluded. RESULTS: The average age of the patients was 32.5 years. The mean operating time was 95 minutes, and the conversion rate was 33.3%. Only 1 dose of intravenous analgesics was administered postoperatively. Hospital stay was 1-3 days. The follow-ups were scheduled at 7, 30, and 90 days and 8 months. Six patients completed all the follow-ups and experienced no problems. DISCUSSION: So far, this transumbilical approach to the appendectomy in humans has not been reported. We think that this method of approach is an effective technique by itself and an ideal "stepping stone" to NOTES, as well as helpful to train laparoscopic surgeons to make the transition to full-fledged NOTES. Unlike the transgastric or transvaginal approaches, the umbilical approach allows an easy maneuverability of the endoscope, though at the cost of an umbilical scar. The technical ease of the procedure and early outcome seem satisfactory. This technique may be considered as a "precursor" to NOTES.

Laparoscopic Undo of Fundoplication with Roux-en-Y Gastric Bypass in a Morbidly Obese Patient with Prior Nissen's Fundoplication: A Video Report.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) may be a better option for morbidly obese patients with gastroesophageal reflux (GERD) for long-term reflux control. It is recommended after fundoplication if a patient is morbidly obese with GERD with failed fundoplication or if bariatric surgery is planned with a prior successful fundoplication (Kim et al., Am Surg 80(7):696-703, 2014; Kambiz Zainabadi, Surg Endosc. 22(12):2737-40, 2008). Complete takedown of the wrap to avoid stapling over the fundoplication creating an obstructed, septated pouch is needed (Kambiz Zainabadi, Surg Endosc. 22(12):2737-40, 2008). The aim of this video was to demonstrate the technical aspect of dissection and undo of Nissen's fundoplication followed by performance of a RYGB in a morbidly obese patient with GERD with prior successful Nissen's fundoplication opting for bariatric surgery after a year. METHODS: We present a case of a 50-year-old woman with a BMI of 36.14 with previous laparoscopic Nissen's fundoplication for severe GERD (controlled after surgery) and a prior laparoscopic intraperitoneal onlay mesh repair who presented for bariatric surgery 1 year after fundoplication. She was successfully treated by laparoscopic undo of the fundoplication with RYGB. RESULTS: In this multimedia high-definition video, we present step-by-step the laparoscopic undo of a Nissen's fundoplication followed by RYGB. The procedure included lysis of all adhesions between the liver and the stomach, dissection of the diaphragmatic crura, complete takedown of the wrap, repair of the hiatal hernia, creation of a gastric pouch, creation of an antecolic Roux limb, gastrojejunal anastomosis, and jejuno-jejunal anastomosis. CONCLUSION: Laparoscopic RYGB after fundoplication in morbidly obese patients with GERD is a technically difficult but feasible option.

Concomitant Bariatric Surgery with Laparoscopic Intra-peritoneal Onlay Mesh Repair for Recurrent Ventral Hernias in Morbidly Obese Patients: an Evolving Standard of Care.

BACKGROUND AND AIMS: Repair of recurrent ventral hernias (RVHs) has a high failure rate more so in the presence of obesity. The chronic increase in intra-abdominal pressure (IAP) associated with obesity might, in part, be an important implicating factor that needs to be addressed in these patients. Laparoscopic ventral hernia repair (LVHR) done with concomitant bariatric surgery in morbidly obese patients with RVHs may avoid multiple failures. We report our preliminary experience in treating RVHs in morbidly obese patients with laparoscopic intra-peritoneal onlay mesh (IPOM) repair and concomitant bariatric surgery. METHODS: A retrospective review of all patients with a RVH who underwent concomitant bariatric surgery and laparoscopic IPOM repair at our institution from 2009 to 2013 was performed. Demographic, operative, postoperative, and follow-up data were collected. RESULTS: There were 23 patients included in the study. The mean BMI was 43.24. Fifteen patients had a previous open mesh repair, and eight had a laparoscopic IPOM repair. The patients had a median of 2 previous repairs (range 1-5 repairs). A laparoscopic sleeve gastrectomy was performed in 22 patients, and a laparoscopic Roux-en-Y gastric bypass was performed in one. The mean operating time was 112 min (65-220 min). The mean hospital stay was 3.3 days (2-8 days). A seroma was noted in four patients. No mesh infection or recurrence was noted at a median follow-up of 3.3 years (9 months to 5.5 years). CONCLUSION: Laparoscopic IPOM repair done with concomitant bariatric surgery in morbidly obese patients with RVHs seems promising with a low rate of early recurrence.

Preliminary Evaluation of Acoustic Radiation Force Impulse Shear Wave Imaging to Detect Hepatic Fibrosis in Morbidly Obese Patients Before Bariatric Surgery.

BACKGROUND AND AIMS: Acoustic Radiation Force Impulse (ARFI) shear wave imaging is a noninvasive method of assessment of the liver to detect fibrosis in patients with chronic hepatitis and nonalcoholic fatty liver disease (NAFLD). The aim of this retrospective study was to investigate whether noninvasive measurement of shear wave velocity (SWV) by ARFI shear wave imaging has a potential usefulness for detection of fibrosis secondary to NAFLD in patients with morbid obesity. METHODS: Twenty-eight morbidly obese patients were included in this study. NAFLD and fibrosis were classified according to the nonalcoholic steatohepatitis (NASH) Clinical Research Network NAFLD activity score. SWV was quantified by ARFI imaging. Component steatosis, inflammation and ballooning scores, and fibrosis staging were correlated with SWV, and diagnostic accuracy of ARFI for fibrosis was assessed. RESULTS: There was a decrease in mean SWV with increasing hepatic steatosis (P = .057). The SWV showed a significant negative correlation (r = -0.417, P = .011) with steatosis grade. The mean SWV was neither significantly different nor correlating with the obesity classes based on body mass index (BMI), steatosis grades, inflammation grades, ballooning grades, and fibrosis stages of NAFLD. Receiver operating characteristic analysis showed no significant area under curve for diagnosis of fibrosis using SWV. Valid SWV could be acquired in all subjects; however, only 21.42% fulfilled the interquartile range criterion. CONCLUSION: ARFI SWV values do not correlate with fibrosis on liver biopsy in morbidly obese patients and lack accuracy for diagnosis. Discordant values may be related to higher BMI and increasing hepatic steatosis.

Diagnostic Yield and Clinical Implications of Preoperative Upper Gastrointestinal Endoscopy in Morbidly Obese Patients Undergoing Bariatric Surgery.

BACKGROUND AND AIMS: Upper gastrointestinal (UGI) endoscopy in patients undergoing bariatric surgery is controversial. It is recommended routinely by some authors to detect benign or malignant pathology that mostly remains asymptomatic. Others recommend selective use, suggesting not much impact on surgical management of detected pathology, especially in asymptomatic patients. The aim of this study was to evaluate the diagnostic yield and impact of pathological findings on routine UGI endoscopy before bariatric surgery in a cohort of morbidly obese Indian patients. MATERIALS AND METHODS: We retrospectively reviewed preoperative screening UGI endoscopy reports of 283 patients who underwent bariatric surgery from February 2012 to August 2014. Data were collected on clinical information, UGI endoscopic findings, Helicobacter pylori testing, and management. RESULTS: Ten patients gave a history of gastroesophageal reflux, and the rest had no specific UGI complaints. Fifty-four had no abnormal findings. One hundred ninety-six had a lax lower esophageal hiatus, hiatal hernias of <5 cm, Grade I-II esophagitis, or mild to moderate gastritis or duodenitis that did not have an impact on surgery. Thirty-one had severe erosive gastritis or duodenitis, or polyposis that delayed surgery for treatment and review of biopsies. A large hiatal hernia >5 cm changed surgical plan to Roux-en-Y gastric bypass from a sleeve gastrectomy in 2 cases. None had varices or malignancy. CONCLUSIONS: Preoperative UGI endoscopy yielded a high proportion of endoscopic abnormalities even in asymptomatic patients. Surgery was delayed to treat severe mucosal lesions and to investigate polypoidal findings in the majority. A change in surgical approach and surveillance for malignancy was needed in a few cases.

Management of Type 1 Late Sleeve Leak with Gastrobronchial Fistula by Laparoscopic Suturing and Conversion to Roux-en-Y Gastric Bypass: Video Report.

BACKGROUND: Gastrobronchial fistula (GBF) is a rare but serious complication after laparoscopic sleeve gastrectomy (LSG). It commonly appears sometime after the primary LSG. (Alharbi Ann Thorac Med. 8(3):179-80, 2013; Albanopoulos et al. Surg Obes Relat Dis. 9(6):e97-9, 2013). Surgical approach is an effective treatment. (Rebibo et al. Surg Obes Relat Dis. 10(3):460-67, 2014). The aim of this video was to demonstrate the operative management of a gastrobronchial fistula after LSG by laparoscopic suturing and conversion to a Roux-en-Y gastric bypass (RYGB). METHODS: We present the case of a 53-year-old woman, with a BMI of 50.2 who presented with a left lower lobe consolidation 7 months after LSG. Imaging revealed a gastrobronchial fistula with left lower lobe consolidation and small sub-diaphragmatic collections. Endoscopy done revealed a fistulous opening beyond the oesophago-gastric junction and a trial of endoscopic stenting failed. RESULTS: In this multimedia high definition video, we present step-by-step the operative management of a late sleeve leak with gastrobronchial fistula by laparoscopic suturing and conversion to a RYGB. The procedure included mobilization of the gastric sleeve, identification and suturing of the fistulous opening, creation of a gastric pouch, creation of an ante-colic Roux limb, gastro-jejunal anastomosis and jejuno-jejunal anastomosis. Drainage of the fistula decreased with absence of a leak on imaging and pneumonia resolved in 15 days. This patient was diagnosed 7 months postoperatively with a gastric sleeve leak and the time to fistula closure from diagnosis was 2 months. CONCLUSION: GBF is a severe complication of bariatric surgery that usually presents late in the postoperative period. GBF after LSG can be treated by surgical fistula repair and conversion of the sleeve into a RYGB.

Management of Type 2 Late Sleeve Leak by Laparoscopic Suturing and Conversion to Roux-en-Y Gastric Bypass: Video Report.

BACKGROUND: Laparoscopic sleeve forming gastrectomy (SFG) is a commonly performed bariatric procedure for the surgical management of morbid obesity. Staple line gastric leaks occur infrequently but are the most feared complication causing prolonged morbidity (Burgos et al., Obes Surg 19(12):1672-7, 2009; Márquez et al., Obes Surg 20(9):1306-11, 2010). Roux-en-Y diversion is an accepted management (Baltasar et al., Surg Obes Relat Dis 4(6):759-63, 2008). The aim of this video was to demonstrate the operative management of a late sleeve leak by laparoscopic suturing & conversion to a RYGB. METHODS: We present the case of an 18-year-old woman with a BMI of 44.68 kg/m(2) with hypothyroidism and polycystic ovarian disease who underwent laparoscopic sleeve gastrectomy and presented with a leak on postoperative day 13. She was diagnosed to have a type 2, late leak just beyond the esophagogastric junction (Csendes et al., Hepatogastroenterology 37 Suppl 2:174-7, 1990) RESULTS: In this multimedia high-definition video, we present step-by-step the operative management of a late sleeve leak by laparoscopic suturing and conversion to a RYGB. Procedure included mobilization of the gastric sleeve, identification and suturing of the fistulous opening, creation of a gastric pouch, creation of an ante-colic Roux limb, gastrojejunal anastomosis and jejuno-jejunal anastomosis. Drainage of fistula gradually decreased with absence of a leak on imaging in 12 days. This patient was diagnosed with a gastric sleeve leak on the 13th postoperative day, and the time to fistula closure from diagnosis was 1 month. CONCLUSIONS: Sleeve leak fistula repair with conversion to a RYGB aids healing by providing surgical decompression and better drainage. It may be considered as an alternative management technique in sleeve leaks.

Prevalence and Predictors of Non-Alcoholic Fatty Liver Disease in Morbidly Obese South Indian Patients Undergoing Bariatric Surgery.

BACKGROUND: Numerous studies worldwide have identified a high prevalence of non-alcoholic fatty liver disease (NAFLD) among morbidly obese subjects. Several predictors have been found to be associated with NAFLD and its histological high-risk components. Similar data from India is lacking. We aimed to determine the prevalence and the predictors of NAFLD and its histological high-risk components in a cohort of Indians with morbid obesity undergoing bariatric surgery. Safety of a routine intraoperative liver biopsy was also assessed. METHODS: There were 134 morbidly obese patients who underwent bariatric surgery with concomitant liver biopsy. These were assessed for NAFLD and its histological high-risk components. Clinical, biochemical, and histological features were evaluated, and predictors of NAFLD, non-alcoholic steatohepatitis (NASH), fibrosis, and advanced fibrosis were identified. RESULTS: Mean BMI was 44.66 ± 9.81. Eighty-eight (65.7 %) showed NAFLD. Forty-five (33.6 %) showed NASH and 42 (31.3 %) showed fibrosis both not mutually exclusive. Nineteen (14.1 %) showed advanced fibrosis. Higher alanine aminotransferase (ALT) independently predicted NAFLD and was significantly associated with NASH and fibrosis. Type 2 diabetes mellitus (T2DM) and the metabolic syndrome were significantly associated with fibrosis. Systemic hypertension (HT) independently predicted NASH and fibrosis. There were no intraoperative or postoperative complications related to the liver biopsy. CONCLUSIONS: NAFLD has a high prevalence among morbidly obese patients. Elevated ALT, HT, T2DM, and the metabolic syndrome are predictors for NAFLD and its high-risk histological components. Routine intraoperative liver biopsy is safe in morbidly obese undergoing bariatric surgery for diagnosing NAFLD.