Improvement of Gastroesophageal Reflux Symptoms After Standardized Laparoscopic Sleeve Gastrectomy

Background

Gastroesophageal reflux disease (GERD) is present in half of morbidly obese patients. Published data reporting the results of laparoscopic sleeve gastrectomy (LSG) in patients with GERD are contradictory. We have shown in a previous study that symptoms of GERD can be reduced for up to 12 months after LSG with careful attention to surgical technique. The present study prospectively evaluated the effect of a standardized LSG technique on the incidence of postoperative GERD symptoms in a larger sample, and followed patients for up to 22 months.

Methods

This was a concurrent cohort study. All patients who underwent LSG at our center completed a standard multidisciplinary preoperative evaluation and were followed prospectively.

Results

A total of 382 patients underwent surgery. There were no cases of death or fistula. GERD was diagnosed in 170 patients (44.5 %) preoperatively, and hiatal hernia (HH) was detected in 142 patients (37.2 %) intraoperatively. Between 6 and 22 months postoperatively, 373 patients were completely evaluated. Ten (2.6 %) had GERD symptoms 6–22 months postoperatively, and 94 % of patients with preoperative GERD symptoms were asymptomatic at follow-up 6–22 months after LSG. Only 1 patient (0.5 %) of a subgroup of 174 without HH or esophagitis at preoperative evaluation had GERD at follow-up.

Conclusions

Our results confirm that, contrary to previous reports of LSG in the literature, careful attention to surgical technique can result in significantly reduced GERD symptoms up to 22 months postoperatively suggesting that LSG does not predispose patients to GERD during that period.     

Conversional Surgery: Single-Step Conversion of Laparoscopic Adjustable Gastric Band to Laparoscopic Sleeve Gastrectomy

Background

Although some patients attain good outcomes after adjustable gastric band (LAGB), a certain quantity have experienced complications and insufficient weight loss. The objective of this study is to assess the safety and outcome of laparoscopic sleeve gastrectomy (LSG) as a conversion surgery after a failed LAGB.

Methods

This is a retrospective analysis of 40 patients who received LSG as conversional surgery from 2009 to 2012 in Al Amiri Hospital, Kuwait. Data analyzed included percentage of excessive weight loss (EWL%), body mass index (BMI), and postoperative complications. Paired t test was utilized to evaluate total weight loss after both procedures.

Results

Among the 40 patients that underwent conversion surgery, the mean age was 36 years old, 34 (85 %) of which were females. Follow-up for LAGB was 1 to 11 years (median, 4.5 years) and 6 months to 3 years (median, 1 year) for LSG. Mean BMI before LAGB was 44 kg/m² (SD?=?7.2) and mean weight was 117.2 kg (SD?=?25.1). A percentage of 20 % achieved good outcomes and 7.5 % experienced complications and 60 % insufficient weight loss. Median EWL% achieved with LAGB was 11.5 %, and after LSG, a median EWL% of 56.9 % was recorded. After conversional surgery, a significant drop in BMI was noted with p value?Conclusions Laparoscopic conversion from LAGB to LSG may be considered as an alternative for patients with a failed LAGB procedure. However, a longer follow-up study is required to validate the results.     

Early Post-operative Complications: Incidence, Management, and Impact on Length of Hospital Stay. A Retrospective Comparison Between Laparoscopic Gastric Bypass and Sleeve Gastrectomy

Background

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are the most common obesity surgeries. Their early complications may prolong hospital stay (HS).

Methods

Data for patients who underwent LRYGB and LSG in our clinic from 2009 through August 2012 were collected. Early post-operative complications prolonging HS (>5 days) were retrospectively analyzed, highlighting their relative incidence, management, and impact on length of HS.

Results

Sixty-six patients (4.9 %) after 1,345 LRYGB operations vs. 49 patients (7.14 %) after 686 LSG operations developed early complications. This difference is statistically significant (p?=?0.039). Male gender percentage was significantly higher in complicated LSG group vs. complicated LRYGB group [23 patients (46.9 %) vs. 16 patients (24.2 %)] (p?=?0.042). Mean BMI was significantly higher in the complicated LSG group (54.2?±?8.3) vs. complicated LRYGB group (46.8?±?5.7; p?=?0.004). Median length of HS was not longer after complicated LSG compared with complicated LRYGB (11 vs. 10 days; p?=?0.287). Leakage and bleeding were the most common complications after either procedure. Leakage rate was not higher after LSG (12 patients, 1.7 %) compared with LRYGB (22 patients, 1.6 %; p?=?0.304). Bleeding rate was significantly higher after LSG (19 patients, 2.7 %) than after LRYGB (10 patients, 0.7 %; p?=?0.004). Prolonged elevation of inflammatory markers was the most common presentation for complications after LSG (18 patients, 36.7 %) and LRYGB (31 patients, 46.9 %).

Conclusions

LSG was associated with more early complications. This may be attributed to higher BMI and predominance of males in LSG group.     

Sleeve Gastrectomy Severe Complications: Is It Always a Reasonable Surgical Option?

Background

Laparoscopic sleeve gastrectomy (LSG) is widely adopted but exposes serious complications.

Methods

A retrospective database analysis was done to study LSG staple line complications in a tertiary referral university center with surgical ICU experienced in treatment of morbid obesity and complications. Twenty-two consecutive patients were referred between January 2004 and February 2012 with postoperative gastric leak or stenosis after LSG. Interventions consisted in the control of intra-abdominal and general sepsis; restoration of staple line continuity or revision of LSG; nutritional support; treatment of associated complications. Main outcome measures concerned success rates of therapeutic strategies, morbidity and mortality rates, LOS, and time to cure.

Results

Thirteen patients (59 %) were referred after failure of reoperation (seven fistula repairs were attempted). Three patients received emergency surgery in our center with transorificial intubation and jejunostomy formation. An endoscopic stent was tried in nine patients but failed in 84.6 % of cases within 20 days (1–161). Seven patients (32 %) necessitated total gastrectomy within 217 days (0–1,915 days) for conservative treatment failure. Procedures under general anesthesia were required in 41 % of cases, organ failure was found in 55 % of cases, and central venous device infection in 40 %. Mortality rate was 4.5 % (n?=?1). Patients with unfavorable evolution of LSG complications (death or additional gastrectomy) had more previous bariatric procedure (82 % vs. 18 %, p?=?0.003). Median time to cure was 310 days (9–546 days).

Conclusions

LSG exposes severe complications occurring in patients with benign condition. Endoscopic stents entail high failure rate. Total gastrectomy is required in one third of the cases.     

Nine-year objective and subjective follow-up of the ultra-lateral anterior repair for cystocele

Introduction and hypothesis

The aim of this study was to determine the long-term objective and subjective outcomes of the native tissue ultra-lateral anterior repair for cystocele.

Methods

An observational study of patients from a single tertiary centre was carried out from January 1994 to December 2006. Patients who underwent an ultra-lateral anterior repair during this period were sent the Pelvic Floor Distress Inventory (PFDI) questionnaire and invited to return for a POP-Q examination. Symptoms of prolapse, stage of cystocele recurrence and reoperation rate were assessed at follow-up.

Results

Of the 135 patients recruited, 53 also had a POP-Q examination. Mean follow-up was 9.25 years (SD 3.2). The anatomical recurrence rate was 45 % at 9.25 years, but only 26 % of patients had recurrent prolapse symptoms. Most recurrences (43 %) occurred at between 1 and 5 years. The reoperation rate for cystocele was 7.4 %.

Conclusion

Despite these rates of anatomical and symptomatic recurrence, only 7.4 % of patients underwent repeat cystocele surgery. Thus, symptomatic/anatomical recurrence of prolapse often does not mandate surgical correction. Considering that mesh complications require surgical management in approximately 10–15 %, this study supports the notion that the use of mesh in anterior vaginal repairs to reduce the risk of “recurrence” needs careful discussion with each patient.     

Comparison of short-term outcomes between laparoscopic greater curvature plication and laparoscopic sleeve gastrectomy

Background

Laparoscopic greater curvature plication (LGCP) is an emerging restrictive bariatric procedure that successfully reduces the gastric volume by plication of the gastric greater curvature. The aim of this prospective nonrandomized study was to compare short-term outcomes and associated complications between LGCP and laparoscopic sleeve gastrectomy (LSG).

Methods

From January 2011 to November 2011, a total of 39 patients were allocated to undergo either LGCP (n = 19) or LSG (n = 20). Data on the operative time, complications, hospital stay, overall cost of LSG and LGCP, body mass index loss (BMIL), percentage of excess weight loss (%EWL), loss of appetite and improvement of comorbidities were collected during the follow-up examinations.

Results

All procedures were completed laparoscopically. The mean operative time was 95.0 ± 17.4 minutes for the LGCP group and 85.5 ± 18.4 minutes for the LSG group (P = 0.107). No patient required reoperation due to an early complication. One patient in the LSG group was readmitted because of gastric stenosis. The mean hospital stay was 4.2 ± 1.9 days in the LGCP group and 3.9 ± 1.7 days in the LSG group (P = 0.595). The total cost of LSG was $7,826 ± 537 compared to LGCP ($3,358 ± 264) (P < 0.001). One year after surgery, the mean %EWL was 58.8 ± 16.7 % (n = 11) in the LGCP group and 80.0 ± 26.8 % (n = 11) in the LSG group (P = 0.038). Loss of feeling of hunger was reported in 27.3 % LGCP patients and 72.7 % LSG patients (P = 0.033) at 1 year after surgery. The comorbidities, including diabetes, sleep apnea and hypertension, were markedly improved in both groups 6 months after surgery.

Conclusions

The short-term outcomes of our study demonstrate that compared with LSG, LGCP is inferior as a restrictive procedure for weight loss, despite its significantly smaller cost. Longer follow-up and prospective comparative trials are needed to confirm the long-term outcomes of this novel procedure and make definitive conclusions.     

Laparoscopic Roux-en-Y Gastric Bypass Versus Laparoscopic Sleeve Gastrectomy for the Treatment of Morbid Obesity. A Prospective Study with 5 Years of Follow-Up

Background

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most widely used bariatric procedures today, and laparoscopic sleeve gastrectomy (LSG) is becoming increasingly popular. The aim of this study was to compare mid-term results of both procedures.

Methods

From January 2008 to December 2008, 117 obese patients were assigned by patient choice after informed consent to either a LRYGB procedure (n?=?75) or a LSG procedure (n?=?42). We determined operative time, length of stay, morbidity, comorbidity outcomes, failures, and excess weight loss at 5 years.

Results

Both groups were comparable in demographic characteristics and comorbidities at baseline. No significant statistical differences were found in length of stay and early major morbidity, but mean operative time was shorter in LSG group, p?p?>?0.05. Five years after surgery, the percentage of excess weight loss was similar in both groups (69.8 % for LRYGB and 67.3 % for LSG, p?>?0.05). Failures were more common for LSG group, 22.2 versus 12.7 % for LRYGB group, but this difference was not significant, p?>?0.05.

Conclusions

Both techniques are comparable regarding safety and effectiveness after 5 years of follow-up, so not one procedure is clearly superior to the other.     

Carpal tunnel release in patients with diabetes result in poorer outcome in long-term study

Background

The aim of this prospective study was to compare the results of surgical decompression of carpal tunnel syndrome (CTS) in patients with diabetes mellitus with those with idiopathic CTS.

Methods

The results of surgical decompression of CTS in 27 patients with diabetes mellitus were compared with 42 patients with idiopathic CTS. All patients underwent surgical release of transverse carpal ligament by the mini-incision of palm technique. Patient self-administered Boston Questionnaire (BQ) for the assessment of severity of CTS symptoms and hand functional status was evaluated before and 6 months and 10 years after surgery.

Results

After surgical release, all the patients of both groups reported an absence of pain, disappearance or reduction of paresthesia, and improvement in hand function. Six months after surgery, there was a significant improvement of symptomatic and functional BQ scores compared with preoperative state in both groups. Ten years after surgery, there was statistical difference in preoperative and postoperative 10th year functional BQ score between DM (?) and DM (+) (p < 0.01). DM status affected statistically functional BQ score between preoperative and postoperative 10th year.

Conclusion

Diabetes mellitus was a risk factor for poor outcome of surgical decompression of CTS. Patients with diabetes had worse surgical outcome compared with patients with idiopathic CTS in long-term follow-up.     

Initial Experience with Laparoscopic Sleeve Gastrectomy by a Novice Bariatric Team in an Established Bariatric Center—A Review of Literature and Initial Results

Background

Laparoscopic sleeve gastrectomy (LSG) is a highly successful approach to morbid obesity with low incidence of complications. The literature suggests a learning curve of 50–100 cases for attaining proficiency and reducing the complication rates for laparoscopic bariatric surgery. The aims of this paper were to review the literature of initial cases by bariatric surgeons worldwide and to report the experience of initial 50 cases of LSG by a novice bariatric team in a single center. The objective was to evaluate the outcomes for laparoscopic bariatric surgery in the first 50 patients by a novice team of bariatric surgeons in an already established bariatric surgery program with short-term follow-up.

Methods

All surgeries were done by a new bariatric team who underwent laparoscopic fellowship training under a bariatric team with an experience of over 600 bariatric procedures. Fifty consecutive patients from March 2010 to January 2012 were offered LSG and followed up for a minimum of 6 months. Weight loss and comorbidity resolution were tabulated and assessed.

Results

Mean preoperative and postoperative BMIs were 46.6 and 35.7 kg/m², respectively. There were no life threatening postoperative complications or mortality. The median percent excess weight loss was 50.3 % at the end of 6 months. Comorbidity resolution values were 96 % for obstructive sleep apnea, 89 % for diabetes mellitus, and 87 % for joint pains, among the most common comorbidities.

Conclusion

LSG is effective in achieving weight loss and in improving comorbidities with minimal complications even at the hands of novice bariatric surgeons with good laparoscopic skills and adequate bariatric training.     

Evaluation of clinical outcomes of cementless total hip arthroplasty in patients under 30 years of age

Background

Historically, performing a successful hip joint replacement in patients aged fewer than 30 years has been an orthopedic challenge. The newer generation of prostheses and surgical techniques has the potential to increase the longevity of implants. The purpose of this study was to evaluate the outcomes of cementless hip arthroplasty in patients aged fewer than 30 years.

Materials and methods

In this cross-sectional study, 41 patients (46 hips) were studied with a mean age of 24, 4 (from 17 to 30 years) of whom underwent cementless metal–polyethylene hip arthroplasty from 2004 to 2007. The Harris hip score (HHS) was used to assess the functional consequences. Patients were followed up in terms of early complications (thrombophlebitis of the lower limbs, dislocation, hematoma and infection) and late complications (aseptic loosening, dislocation and reoperation) at weeks 3 and 6, at 3 and 6 months, 1 year after surgery and annually thereafter.

Results

Patients were followed for an average of 5 years and 2 months (from 51 to 82 months). One early complication (symptomatic thrombophlebitis) and one late dislocation (2.2 %) were observed. There were no cases of aseptic loosening or osteolysis at the end of follow-up. The preoperative HHS was 59.6 (from 41 to 76), which rose to 82 and 83.5 after the 1-year and final follow-up, respectively, which was a significant increase.

Conclusions

Hip arthroplasty using a new generation of cementless proximal porous prosthesis with resistant polyethylene to cover the joint surfaces in patients aged fewer than 30 years is satisfactory and is accompanied by low complications.     

Postoperative complications in bariatric surgery using age and BMI stratification: a study using ACS-NSQIP data

Background

Bariatric surgery results in long-term weight loss and significant morbidity reduction. Morbidity and mortality following bariatric surgery remain low and acceptable. This study looks to define the trend of morbidity and mortality as it relates to increasing age and body mass index (BMI) in patients undergoing bariatric surgery.

Methods

We queried the ACS/NSQIP 2010–2011 Public Use File for patients who underwent elective laparoscopic adjustable banding (LAGB), sleeve gastrectomy (LSG) and gastric bypass (LGBP). Total morbidity and 30-day mortality were evaluated. Logistic regression models were created to estimate the effect of increasing age and BMI on morbidity for these bariatric procedures.

Results

A total of 20,308 laparoscopic bariatric procedures were reviewed (11617 LGBP, 3069 LSG and 5622 LAGB). Overall mortality and morbidity rates were 0.11 and 3.84 %, respectively. The odds of postoperative complications increased by 2 % with each additional year of age (OR 1.02, 95 % CI 1.02–1.03) and every point increase in BMI (OR 1.02, 95 % CI 1.01–1.03). Multiple logistic regression identified COPD, Diabetes, Hypertension, and Dyspnea as major risk factors for postoperative morbidity. Postoperative complications were three times more likely after LGBP (OR 2.87, 95 % CI 2.31–3.57) and two times more likely after LSG (OR 2.06, 95 % CI 1.57–2.72) when compared to patients undergoing LAGB.

Conclusion

Morbidity and mortality increase on a predictable trend with increasing age and BMI. There is increased risk of morbidity for stapling procedures when compared to gastric banding, but this must be considered in context of surgical efficacy when choosing a bariatric procedure. These data can be used in preoperative counseling and evaluation of surgical candidacy of bariatric surgical patients.     

Impact of Laparoscopic Sleeve Gastrectomy on Upper Gastrointestinal Symptoms

Background

Altered gastric anatomy following laparoscopic sleeve gastrectomy (LSG) is likely to induce upper gastrointestinal (GI) symptoms. Published studies, however, have focused mainly on gastroesophageal reflux disease (GERD). This study aims to evaluate LSG's impact on the prevalence of upper GI symptoms and to assess the effects of time from surgery, weight loss, and proton pump inhibitor (PPI) therapy.

Methods

The validated Rome III Criteria symptom questionnaire for upper GI symptoms, including quality of life items, has been self-administered to 97 patients who underwent LSG. Symptoms were analyzed either separately or altogether to classify patients in GERD or dyspepsia, subdivided in epigastric pain (EPS) and post-prandial distress (PDS) syndromes.

Results

Before LSG, 52.7 % of the patients were asymptomatic, 27.0 % had GERD, and 8.1 % had dyspepsia (2.7 % EPS, 5.4 % PDS). After a median follow-up of 13 months, 91.9 % of the patients complained of upper GI symptoms, the most prevalent being PDS (59.4 %). GERD prevalence did not differ before and after LSG. The only symptom strongly related to LSG was dysphagia (OR 4.7, 95 % CI 1.3–20.4, p?=?0.015), which was present in 19.7 % of the patients and mainly associated with PDS rather than GERD. GI symptoms, however, did not have a great impact on quality of life. Time from surgery, weight loss after surgery, as well as concomitant PPI, did not influence the symptoms.

Conclusions

After a median follow-up of 13 months, PDS-like dyspepsia, rather than GERD, was the main complaint, both poorly responding to PPI therapy. A longer follow-up will be necessary to evaluate their future persistency.     

Does longitudinal sleeve gastrectomy have a family “halo effect”? A case-matched study

Introduction

Some researchers have suggested that the weight loss of a patient who has undergone bariatric surgery could be influenced by his or her family environment. Indeed, some people decide to undergo surgery after another family member has had the operation. This study aimed to evaluate the results of longitudinal sleeve gastrectomy (LSG) performed for several members of a family compared with to a control group of unrelated individuals.

Material and methods

On the basis of preoperative data, 78 LSG patients from 39 families (the LSG-family group) were matched 1:1 with 78 LSG patients selected from among 550 LSG patients whose family members had undergone no bariatric surgery (the LSG group). Within the LSG-family group, a distinction was drawn between family members who had undergone surgery before their relation (the LSG-family 1 subgroup) and those who had undergone surgery after their relation (the LSG-family 2 subgroup).

Results

The median preoperative body mass index (BMI) in each of the two groups was 48.1 kg/m². The LSG-family and LSG groups 24 months after surgery had respective mean BMIs of 28.6 and 32.5 kg/m² (p ≤ 0.01), excess weight losses (EWLs) of 83.5 % and 71.4 % (p ≤ 0.01), and missed consultation rates of 13.1 % and 25.9 % (p = 0.04). A comparison of the LSG-family 1 and family 2 subgroups 24 months after surgery showed respective mean BMIs of 30.0 and 27.5 kg/m² (p = 0.12), EWLs of 80.2 % and 86.2 % (p = 0.32), and missed consultation rates of 14.1 % and 12.1 % (p = 0.22).

Conclusion

The outcome for LSG in terms of weight loss and postoperative follow-up care was better in the family group than in the control group. This may have been due to better postoperative follow-up care for the patients in the LSG-family group. Within a family, the patients who had surgery after their relation showed a trend toward greater weight loss and better postoperative follow-up care.     

Analysis of the Five-Year Outcomes of Sleeve Gastrectomy and Mini Gastric Bypass: A Report from the Indian Sub-Continent

Background

Few reports have compared laparoscopic sleeve gastrectomy (LSG) to laparoscopic Roux-en-Y procedure (LRNY). This study aims at comparing the 5-year follow-up results of mini gastric bypass (MGB or omega gastric bypass (OGB)) and LSG in terms of weight loss, weight regain, complications, and resolution of co-morbidities.

Methods

A retrospective analysis of the prospectively collected database was done from the start of our bariatric practice from February 2007 to August 2008 (minimum 5-year follow-up). During this period, 118 patients underwent LSG. These patients were matched in age, gender, preoperative weight, and BMI to 104 patients who underwent MGB in the same time period. The results were compared.

Results

Follow-up was achieved in 72 MGB vs 76 LSG patients up to 5 years. The mean BMI for the MGB and LSG group was 44?±?3.1 and 42?±?5.2 kg/m², respectively (P?P?=?0.166), respectively. Post-op gastro-esophageal reflux disease (GERD) was seen in 2.8 % MGB patients and marginal ulcer was diagnosed in 1 MGB patient (1.4 %). GERD was seen in 21 % post-LSG patients.

Conclusions

Both MGB and LSG are safe, short, and simple operations. Weight loss is similar in MGB and LSG in the first years, but lesser %EWL with LSG at 5 years (68 % in MGB vs 51 % in LSG). Post-op GERD is more common after LSG.     

Laparoscopic sleeve gastrectomy versus intragastric balloon: a case-control study

Aim

To compare the efficacy of laparoscopic sleeve gastrectomy (LSG) and BioEnterics intragastric balloon (BIB^®) to lose weight and comorbidities after 12 months of follow-up before a more invasive bariatric procedure.

Methods

From January 2004 to December 2006, 40 patients underwent laparoscopic sleeve gastrectomy (LSG) as a first step in biliopancreatic diversion with duodenal switch. Controls (n = 80) were selected based on charts of patients who, during the same period, underwent BioEnterics intragastric balloon therapy. In both groups we considered: length of procedure, hospital stay, intraoperative or endoscopic complications, postoperative or postendoscopic complications, comorbidities at baseline, after 6 months (time of BIB removal), and after 12 months from baseline, and weight loss parameters [weight in kg, percentage excess weight less (%EWL), body mass index (BMI), and percentage excess BMI loss (%EBL)]. Results are expressed as mean ± standard deviation.

Results

Mortality, intra- and postoperative complications (in LSG group), and intra- and postendoscopic complications (in BIB group) were absent. Mean operative time in the LSG group was 120 ± 40 (range 60–200) min. Mean positioning time for BIB was 15 ± 5 (range 10–25) min. BMI at baseline was 54.1 ± 2.9 (range 45.1–55.9) kg/m² and 54.8 ± 2.5 (range 45.1–56.2) kg/m² in BIB and LSG groups, respectively. At 6-month follow-up, mean BMI was 46.2 ± 3.5 and 45.3 ± 5.5 kg/m² in the BIB and LSG patients, respectively [p = not significant (ns)]. After 12 months BIB patients regained BMI, even if strictly followed with a diet regimen, while LSG patients continued to lose weight. Significant differences between groups were absent for the comorbidities considered.

Conclusions

Laparoscopic sleeve gastrectomy and BioEnterics intragastric balloon are two valid options for producing weight loss as a first-step procedure. LSG has all the related risks of general anesthesia, laparoscopic surgery, and digestive anastomosis, whereas BIB presents a very low rate of minor complications, such as psychological intolerance. For all these reasons, at this time, BIB is considered a better option than LSG as a first-step procedure in the short term (12 months).     

Three-dimensional stomach analysis with computed tomography after laparoscopic sleeve gastrectomy: sleeve dilation and thoracic migration

Background

Laparoscopic sleeve gastrectomy (LSG) is frequently performed as a definitive bariatric procedure today. Quantitative data on the detailed anatomy of the stomach after LSG are yet sparse.

Methods

Thirty-two multislice computed tomography (MSCT) data sets acquired in 27 LSG patients (22 female, 5 male) with a dedicated examination protocol and post-processing were evaluated for gastric volume, stomach length, sleeve length, antrum length, staple line length, and maximum cross-sectional sleeve area. Obtained parameters were compared to time after surgery, weight loss, and the occurrence of postsurgical regurgitation.

Results

Mean gastric volume was 186.5?±?88.4?ml. Gastric volume correlated significantly with the time interval after surgery. Sleeve sizes of 105.3?±?30.2?ml during early follow-up confirmed correct primary sizing of the sleeve, whereas marked dilation to 196.8?±?84.3?ml was found in patients with a follow-up of 6?months and longer (p?=?0.038). Sleeve area and staple line length were also positively correlated with time after surgery. No correlation was found between gastric volume and excess weight loss. In ten patients an intrathoracic migration of the staple line could be noted, with four of these patients developing persistent regurgitation after LSG. Regurgitation was present in only 2 of 17 patients without sleeve herniation.

Conclusion

Multislice computed tomography allows for a comprehensive and quantitative evaluation of the anatomy after LSG and thus provides new insights in the process of sleeve dilation. Intrathoracic migration of the staple line could be identified as a possible cause of persistent regurgitation.     

Follow-up of mesh complications using the IUGA/ICS category–time–site coding classification

Introduction

The International Urogynecological Association (IUGA) and the International Continence Society (ICS) developed a complication classification to facilitate international comparison and to improve our understanding of complications. This code was applied to surgical cases for the analysis of complications after mesh insertion.

Methods

The study included patients who had undergone vaginal prolapse repair with a trocar-guided polypropylene mesh between 2006 and 2010 in a Dutch peripheral hospital. Complications were assessed at secondary follow-up and classified using category (C), timing (T), and site (S) components (CTS).

Results

Of the 107 women included, 84 returned for secondary follow-up (response rate 80 %, median time after surgery 36 months, range 12–64). In 45 patients no complications occurred. In the remaining 39 patients, 43 complication codes were established. Six of the seven categories of complications were found at all different time codes. Concerning the site of the complication codes S1, S2, and S3 were applicable. Perioperative complications (6 %) included hemorrhage and bladder perforation. Six patients were reoperated for symptomatic mesh exposure or local pain. At secondary follow-up exposure was diagnosed in another 4 patients (12 %). In 36 % mesh wrinkling or shrinkage was discovered, although without complaints in most. Eight women had daily complaints or dyspareunia. Eighty-two percent of patients indicated strong improvement after surgery. Several limitations of the classification are discussed.

Conclusions

Despite limitations, the IUGA/ICS code is demonstrated to be useful in describing mesh complications. We advise the use of the CTS code at follow-up consultations after a minimum of 2 years for improved insight into and knowledge on the occurrence of complications.     

Preceptorship and Proctorship as an Effective Way to Learn Laparoscopic Sleeve Gastrectomy

Background

Laparoscopic sleeve gastrectomy has rapidly gained popularity as a procedure for morbidly obese patients. The goal of this project is to evaluate a training program for the laparoscopic sleeve gastrectomy (LSG), given to a group of surgeons by a specialized consultant in bariatric surgery.

Methods

The training process is divided in two parts. First, bringing the trainee surgeons to a specialized bariatric center to observe and take part in bariatric procedures with an experienced bariatric surgeon (preceptorship). Second, the consulting surgeon offers on-site training to all surgeons within their own hospital (proctorship). The support personnel (bariatric nurse, OR nurse, nutritionist) accompany the surgeon and are included in the training process. Finally, preoperative, intraoperative and postoperative data are compiled and analyzed.

Results

This study included 31 patients operated for LSG by the two newly trained surgeons after proctorship. Median age was 43 and mean BMI was 45.9. No leak, stricture, or mortality was found after the surgery. Mean surgical time was 94 min, and mean hospital length of stay was 3.9 days. Minor complications were seen during the follow-up at 1 to 3–6 months with excessive weight loss (EWL) of 62 % at 6 month.

Conclusions

This study showed the effectiveness of training provided through preceptorship/proctorship with a specialized consulting surgeon. The low complication rate and the weight loss achieved in only 6 months demonstrate the safety and efficacy of this learning method.     

C-reactive protein, white blood cells, and neutrophils as early predictors of postoperative complications in patients undergoing laparoscopic sleeve gastrectomy

Background

Early detection and treatment of complications after laparoscopic sleeve gastrectomy (LSG) are mandatory. This study aimed to evaluate C-reactive protein (CRP), white blood cell (WBC) count, and neutrophil (NEU) count in relation to the early diagnosis of major surgical complications after LSG.

Methods

A prospective study of 177 patients who underwent LSG during 2008–2011 was performed. Measurements of WBC, NEU, and CRP performed on postoperative days 0, 1, 3, 5, 7, 9, 11, 13, and 30 were correlated with postoperative surgical complications.

Results

Both WBC and NEU were correlated with leak or abscess on postoperative days 3, 5, 7, 9, and 11, whereas on day 1, only NEU was significantly increased. Elevated CRP was correlated with leak or abscess on all the days (p < 0.001). The parameters measured were not correlated with postoperative bleeding unless leak or abscess coexisted. According to receiver operating characteristic (ROC) analysis, CRP detected leak or abscess with remarkably higher sensitivity and specificity than WBC or NEU on all the days. Moreover, the area under the curve (AUC) of CRP was higher than the AUC of WBC or NEU, suggesting important statistical significance. On day 1, WBC and NEU achieved 77.8 and 78.3 % sensitivity, respectively, and an even lower specificity (68.4 and 52.6 %), whereas a CRP cutoff at 150 mg/l achieved 83.2 % sensitivity and 100 % specificity. On day 3, the sensitivity and specificity of CRP reached 100 % (cutoff level, 200 mg/l), and on day 5, CRP achieved 83.2 % sensitivity and 100 % specificity (cutoff level, 150 mg/l), whereas for WBC and NEU, specificity was high (>92 %), but sensitivity did not exceed 78.2 %.

Conclusion

Because CRP detected leak or abscess after LSG with remarkably higher sensitivity and specificity than WBC or NEU, CRP seems to be a more accurate market for the early detection of these complications.     

Early neurological recovery course after surgical treatment of cervical spondylotic myelopathy: a prospective study with 2-year follow-up using three different functional assessment tests

Purpose

Though surgical decompression is today a common option for treatment of cervical spondylotic myelopathy (CSM), little is known about the exact postoperative early neurological recovery course. The purpose of this study was to analyze the functional recovery, its dynamics, its intensity and its pattern, in the early postoperative period after surgical decompression for CSM.

Methods

A prospective non-controlled observational study was performed from March 2006 to July 2008, and included consecutive patients with CSM who underwent surgical decompression. Functional assessments were done before the operation, at 1 month, 6, 12, 18 and 24 months after surgery using three tests: the Japanese Orthopaedic Association (JOA) test, the nine-hole peg test (9HPT) and the Crockard walking test.

Results

Sixty-seven patients were included (mean age of 61 years). The global JOA score improved after surgery, reaching statistical significance at 1 month (from 11.5 ± 2.6 to 13.6 ± 2.0 points, p = 0.0078), then settling to a plateau till the end of follow-up at 24 months (12.7 ± 2.6 points). The 9HPT and the Crockard test did not show any significant improvement after surgery.

Conclusions

Neurological recovery after surgical decompression has been proved to be very fast during the first month, but stabilizes afterwards. The JOA score is the best assessment to reveal neurological improvement in the early recovery course.