Staple Line Reinforcement During Laparoscopic Sleeve Gastrectomy: Absorbable Monofilament,Barbed Suture,Fibrin Glue,or Nothing? Results of a Prospective Randomized Study

Background

Laparoscopic sleeve gastrectomy (LSG) is associated with serious complications, such as staple line (SL) leaks and bleeding. In order to prevent the occurrence of these complications, surgeons have advocated the need to strengthen the staple line. The aim of this randomized controlled study was to compare the efficacy of three different ways of strengthening of the SL in LSG in preventing surgical post-operative complications.

Methods

Between April 2012 and December 2014, 600 patients (pts) scheduled for LSG were prospectively randomized into groups without SL reinforcement (group A) or with SL reinforcement including fibrin glue coverage (group B), or oversewn SL with imbricating absorbable (Monocryl?; group C) or barbed (V lock®) running suture (group D). Primary endpoints were post-operative leaks, bleeding, and stenosis, while secondary outcomes consisted of the time to perform the staple line reinforcement (SLR) and total operative time.

Results

Mean SLR operative time was lower for group B (3.4?±?1.3 min) compared with that for groups C (26.8?±?8.5 min) and D (21.1?±?8.4 min) (p?<?0.0001). Mean total operative time was 100.7?±?16.4 min (group A), 104.4?±?22.1 min (group B), 126.2?±?18.9 min (group C), and 124.6?±?22.8 (group D) (p?<?0.0001). Post-operative leaks, bleeding, and stenosis were recorded in 14 pts (2.3 %), 5 pts (0.8 %), and 7 pts (1.1 %), respectively, without statistical difference between the groups.

Conclusion

Our study suggests that SLR during LSG, with an imbricating or non-imbricating running suture or with fibrin glue, is an unrewarding surgical act with the sole effect of prolonging the operative time.

     

Cost analysis of leak after sleeve gastrectomy

Background

Leaks after laparoscopic sleeve gastrectomy (LSG) are serious complications of this procedure. The objective of the present study was to evaluate the costs of leaks after LSG.

Setting

Private hospital, France.

Methods

A retrospective analysis was conducted on a prospective cohort of 2012 cases of LSG between September 2005 and December 2014. Data were collected on all diagnostic and therapeutic measures necessary to manage leaks, ward, and intensive care unit (ICU) length of stay. Additional outpatient care was also analyzed.

Results

Twenty cases (0.99%) of gastric leak were recorded. Fifteen patients had available data for cost analysis. Of these, 13 patients were women (86.7%) with a mean age of 41.4 years (range 22–61) and mean BMI of 43.2 kg/m² (range 34.8–57.1). The leaks occurred after 7.4 days (±2.3) postoperatively. Only one gastric leak was recorded for the last 800 cases in which absorbable staple line reinforcement was used. Mean intra-hospital cost was 34398 € (range 7543–91,632 €). Prolonged hospitalization in ICU accounted for the majority of hospital costs (58.9%). Mean additional outpatient costs for leaks were 41,284 € (range 14,148–75,684€).

Conclusions

Leaks after LSG are an expensive complication. It is therefore important to take all necessary measures to reduce their incidence. Our data should be considered when analyzing the cost effectiveness of staple line reinforcement usage.

     

Reinforcing the Staple Line During Laparoscopic Sleeve Gastrectomy: Prospective Randomized Clinical Study Comparing Three Different Techniques

Background

Gastric leak and hemorrhage are the most important challenges after laparoscopic sleeve gastrectomy (LSG). In order to reduce these complications, the staple line can be reinforced by absorbable sutures or by the use of glycolide trimethylene carbonate copolymer onto the linear stapler (Gore Seamguard®; W.L. Gore &; Associates, Inc, Flagstaff, AZ). To our knowledge, there are no randomized studies showing the utility of staple line reinforcement during LSG. The purpose of this study was to randomly compare three techniques in LSG: no staple line reinforcement (group 1), buttressing of the staple line with Gore Seamguard® (group 2), and staple line suturing (group 3).

Methods

Between January 2008 and February 2009, 75 patients were prospectively and randomly enrolled in the three different techniques of handling the staple line during LSG. The patient groups were similar (NS).

Results

Mean operative time to perform the stomach sectioning was 15.9?±?5.9 min (group 1), 20.8?±?8.1 min (group 2), and 30.8?±?10.1 min (group 3) (p?p?=?0.02). Mean blood loss during stomach sectioning was 19.5?±?21.3 mL (group 1), 3.6?±?4.7 mL (group 2), and 16.7?±?23.5 mL (group 3) (p?p?=?0.03). Mean number of stapler cartridges used was 5.6?±?0.7 (group 1), 5.7?±?0.7 (group 2), and 5.8?±?0.6 (group 3) (NS). Postoperative leak affected one patient (group 1), two patients (group 2), and one patient (group 3) (NS). Mean hospital stay was 3.6?±?1.4 days (group 1), 3.9?±?1.5 days (group 2), and 2.8?±?0.8 days (group 3) (p?=?0.01).

Conclusions

In LSG, buttressing the staple line with Gore Seamguard® statistically reduces blood loss during stomach sectioning as well as overall blood loss. No staple line reinforcement statistically decreases the time to perform stomach sectioning and the total operative time. No significant difference is evidenced in terms of postoperative leak between the three techniques of LSG.

     

Early Weight Recidivism Following Laparoscopic Sleeve Gastrectomy: A Prospective Observational Study

Background

Although weight loss following laparoscopic sleeve gastrectomy (LSG) can be substantial, weight recidivism is still a major concern. The aim of our work is to study early weight recidivism following LSG and to evaluate the role of gastric computed tomography volumetry (GCTV) in the assessment of patients experiencing early weight regain.

Methods

One-hundred and one morbidly obese patients undergoing LSG were prospectively studied. Patients were followed up for 2 years. Those who presented with weight recidivism were counseled for dietary habits and assessed for the amount of weight regain. Patients who regained weight were scheduled for GCTV.

Results

Twelve patients were excluded from the study. Weight recidivism was reported in 9/89 patients (10.1 %) [weight loss failure (n?=?1), weight regain (n?=?8)] and was almost always first recognized 1½–2 years after LSG. The amount of weight regain showed negative correlations with preoperative body weight and body mass index (r?=??0.643, P?=?0.086 and r?=??0.690, P?=?0.058; respectively) and positive correlations with the distance between the pylorus and the beginning of the staple line (r?=?0.869, P?=?0.005), as well as with the residual gastric volume (RGV) on GCTV 2 years after LSG (r?=?0.786, P?=?0.021).

Conclusions

In the small group of patients who regained weight, a longer distance between the pylorus and the beginning of the staple line, as well as a higher RGV on GCTV 2 years after LSG, were both associated with increased weight regain. Gastric computed tomography volumetry with RGV measurement holds promise as a useful research tool after LSG.

     

Impact of the Surgical Experience on Leak Rate After Laparoscopic Sleeve Gastrectomy

Introduction

Laparoscopic sleeve gastrectomy (LSG) has become one of the most commonly performed bariatric procedures, largely due to several advantages it carries over more complex bariatric procedures. LSG is generally considered a straightforward procedure, but one of the major concerns is a staple line leak.

Objective

The objectives of this study are to evaluate the correlation between surgeon’s experience and leak rate and to assess the different risk factors for developing a gastric leak after LSG.Setting: Private hospital, France.

Methods

The analysis of a single surgeon’s yearly leak rate since the introduction of LSG for possible risk factors was done.

Results

A total of 2012 LSGs were performed in between September, 2005 and December, 2014. Twenty cases (1 %) of gastric leak were recorded. Of these, 17 patients were women (94.4 %) with a mean age of 39.4 years (range 22–61) and mean body mass index (BMI) 41.2 kg/m² (range 34.8–57.1). On a yearly basis, the leak rate was 4.8 % (2006), 5.7 % (2007), 0 (2008), 2.6 % (2009), 2 % (2010), 0.8 % (2011), 0.6 % (2012), 0.2 % (2013), and 0 (2014). In the first 1000 cases (group A), there were 18 cases of gastric leak and in the last 1000 cases, there were 800 with GORE® SEAMGUARD® Bioabsorbable Staple Line Reinforcement (group B) 2 cases of gastric leak (p?=?0.009). A revisional LSG, 395 patients after gastric banding and 61 patients re-sleeve gastrectomy, was performed in 456 cases (22.7 %). There were 3 cases of leak (0.65 %). There were two deaths.

Conclusion

LSG can be performed with a low complication rate. This large series of a single surgeon’s experience demonstrated that the leak rate after LSG could be significantly decreased over time with changes in techniques.

     

Proximal Leakage After Laparoscopic Sleeve Gastrectomy: an Analysis of Preoperative and Operative Predictors on 1738 Consecutive Procedures

Background

The purpose of this paper was to search for predictive factors for proximal leakage after laparoscopic sleeve gastrectomy (LSG) in a large cohort from a single referral center.

Materials and Methods

One thousand seven hundred and thirty-eight patients, collected in a prospectively held database from 2008 to 2016, were retrospectively analyzed. The correlation between postoperative leakage and both preoperative (age, gender, height, weight, BMI, and obesity-related morbidities) and operative variables (the distance from pylorus at which the gastric section was started, operative time, experience of surgeons who performed the LSG, and the surgical materials used) was analyzed. The experience of the surgeons was calculated in the number of LSGs performed. The surgical materials considered were stapler, cartridges, and reinforcement of the suture.

Results

Proximal leakage was observed in 45 patients out of 1738 (2.6%). No correlation was found between leakage and the preoperative variables analyzed. The operative variables that were found to be associated with lower incidence of leakage at the multivariate analysis (p < 0.05) were the reinforcement of the staple line (or overriding suture or buttressing materials) and the experience of the surgeons. A distance of less than 2 cm from the pylorus resulted to be significantly related to a higher incidence of fistula at the univariate analysis.

Conclusions

In this large consecutive cohort study of LSG, proximal staple line reinforcement (buttress material or suture) reduced the risk of a leak. The risk of a proximal leak was much higher in the surgeons first 100 cases, which has implications for training and supervision during this “learning curve” period.

     

Portion Control Eating—a Determinant of Bariatric Outcomes

Introduction

Bariatric surgery leads to significant weight loss but the results vary. Application of dietary principles like portion-controlled eating leads to greater weight loss and fewer complications.

Aims

To evaluate the improvement in weight loss outcomes by incorporating portion-controlled eating behavior in postbariatric patients.

Methods

All patients who underwent bariatric surgery from January 2012 to December 2013 were included in the study. Portion-controlled eating behavior was incorporated in the post-bariatric nutritional protocol. Their demographic, preoperative, and postoperative data were prospectively maintained on Microsoft Office Excel and analyzed statistically.

Results

Three hundred and seventy-two (89.6%) underwent laparoscopic sleeve gastrectomy (LSG), while 43 (10.4%) underwent laparoscopic Roux-en-Y gastric bypass (RYGB). In the LSG group, lowest (nadir) BMI was 28.99?±?5.6 kg/m² and % Excess weight loss (EWL) was 87.3?±?27.2%, achieved between 1 and 2 years. In the RYGB group, lowest (nadir) BMI was 27.5?±?12.09 kg/m and % EWL was 94.32?±?33.12%. Surgical failure (less than 50% EWL) were 10 (3.27%) in the LSG group and 1 (3%) in the RYGB group. There were no leaks reported in our study.

Conclusion

Our study highlights the importance of postoperative nutritional interventions like portion-controlled eating for successful bariatric outcome.

     

Staple Line Bleeding in Sleeve Gastrectomy—a Simple and Cost-Effective Solution

Background

Staple line bleeding (SLB) is a common intraoperative complication following resection in laparoscopic sleeve gastrectomy (SG). Opinion is divided on the best measure to deal with SLB which includes expensive reinforcement strategies, suturing the staple line or diathermy. Tranexemic acid is a relatively inexpensive drug known to reduce bleeding in trauma and surgery. The aim of this study was to evaluate whether intraoperative tranexemic acid reduces staple line bleeding.

Methods

In this prospective matched comparative study of SG, one cohort of patients was administered tranexemic acid (1 g) after induction and compared to a control group. The primary outcome compared the number of staple line bleeding points requiring intervention intra-operatively. Secondary outcomes included estimated blood loss and operating time. The anaesthetic and thromboprophylaxis protocols were uniform. Operative technique and stapling equipment were identical in all patients.

Results

Twenty-five patients were allocated to both the control and treatment arms. Patient characteristics in both groups were similar in age (median 34 vs 43 years), body mass index (median 54.7 vs 52 kg/m²), gender distribution (female:male?=?20:5) and co-morbidities. The treatment group receiving tranexemic acid, required significantly less number of haemostatic stitches for staple line bleeding (19 vs 46, p?<?0.05), incurred less intraoperative blood loss (p?<?0.01) and had quicker operating times (median 66 vs 80 min, p?<?0.05). There was no difference in morbidity or mortality in both groups.

Conclusion

Intraoperative prophylactic tranexemic acid use is a simple and economical option for effectively reducing staple line bleeds leading to significant decrease in operating times.

     

Clinical and Economic Evaluation of Absorbable Staple Line Buttressing in Sleeve Gastrectomy in High-Risk Patients

Background

Gastric leaks and bleeding are the most important complications after laparoscopic sleeve gastrectomy (LSG). The use of absorbable membranes as staple line reinforcement may decrease this risk. On the other hand, these materials bring additional costs and their economic impact is not well known. The purpose of this study was to assess the clinical and economic performance of one of the commercially available buttressing absorbable materials when treating a high-risk population.

Methods

A retrospective, observational, and comparative study was conducted at Montpellier University Hospital, France, between July 2013 and September 2014. Patients undergoing LSG, who were at a high risk for leaks and bleeding, were included and treated according to two groups: no buttressing (July 2013 to January 2014) and buttressing (February 2014 to September 2014). Clinical and economic outcomes were measured throughout the first 6 months.

Results

Two hundred two patients were included in the study: 116 during the no stapling reinforcement period and 86 during the buttressing period. Baseline characteristics were similar. There was no significant difference between the two groups regarding gastric leaks. However, buttressing reduced hemorrhagic complications (0 vs 8.6 %, p?=?0.005) and decreased average total hospital costs for the first hospitalization (5768 vs 6025 €, p?<?0.001), as well as 6-month total inpatient cost (5944 vs. 6246 €, p?<?0.001).

Conclusions

Staple line reinforcement with absorbable material reduces bleeding in high-risk population. Therefore, this type of material can also result in cost-savings.

     

Metabolic Parameters,Weight Loss,and Comorbidities 4 Years After Roux-en-Y Gastric Bypass and Sleeve Gastrectomy

Background

Sleeve gastrectomy (LSG) is now the predominant bariatric surgery performed, yet there is limited long-term data comparing important outcomes between LSG and Roux-en-Y gastric bypass (RYGB). This study compares weight loss and impact on comorbidities of the two procedures.

Methods

We retrospectively evaluated weight, blood pressure, hemoglobin A1c, cholesterol, and medication use for hypertension, diabetes, and hyperlipidemia at 1–4 years post-operatively in 380 patients who underwent RYGB and 334 patients who underwent LSG at the University of Michigan from January 2008 to November 2013. Follow-up rates from 714 patients initially were 657 (92%), 556 (78%), 507 (71%), and 498 (70%) at 1–4 years post-operatively.

Results

Baseline characteristics were similar except for higher weight and BMI in LSG. There was greater weight loss with RYGB vs. LSG at all points. Hemoglobin A1c and total cholesterol improved more in RYGB vs. LSG at 4 years. There was greater remission of hypertension and discontinuation of all medications for hypertension and diabetes with RYGB at 4 years.

Conclusions

Weight loss, reduction in medications for hypertension and diabetes, improvements in markers of diabetes and hyperlipidemia, and remission rates of hypertension were superior with RYGB vs. LSG 4 years post-operatively. Choice of bariatric procedures should be tailored to surgical risk, comorbidities, and weight loss goals.

     

Incidence,Indications, and Predictive Factors for ICU Admission in Elderly,High-Risk Patients Undergoing Laparoscopic Sleeve Gastrectomy

Background

Obesity affects the elderly, leading to increased prevalence of age- and obesity-associated comorbidities. There are no guidelines for indications and risk assessment for the elderly undergoing bariatric surgery.

Objectives

To determine the incidence, indications, and outcomes of planned ICU admission in elderly, high-risk patients after laparoscopic sleeve gastrectomy (LSG) and to assess if preoperative risk factors for planned postoperative ICU admission in elderly patients undergoing LSG could be predicted preoperatively.

Methods

Retrospective review of prospectively collected data for all patients aged ≥?60 years who underwent LSG (2011–2016) at Hamad General Hospital in Qatar.

Results

We followed up 58 patients aged 60–75 years for 28?±?17 months. About 77.6% of patients were in the intermediate-risk group of the Obesity Surgery Mortality Risk Score (OS-MRS). Fourteen patients (24%) required ICU admission for 2?±?1.2 days; all patients belonged to the American Society of Anesthesiologists (ASA) III class and intermediate to high risk on OS-MRS. There were no reported mortalities. The mean body mass index (BMI) decreased from 49?±?10.6 to 37.6?±?10.1 kg/m². The number of patient comorbidities (OR, 1.43; 95% CI, 1.03–1.99) and the diagnosis of obstructive sleep apnea (OSA; OR, 7.8; 95% CI, 1.92–31.68) were associated with planned ICU admission.

Conclusion

Elderly patients undergoing LSG usually have excellent postoperative course despite the associated high risk and the required ICU admission. The number of comorbidities, diagnosis of OSA, and ASA score are possible clinically significant predictive factors for the need of post-LSG ICU admission.

     

Fully Ambulatory Laparoscopic Sleeve Gastrectomy: 328 Consecutive Patients in a Single Tertiary Bariatric Center

Background

Laparoscopic sleeve gastrectomy (LSG) is becoming one of the most popular bariatric procedures because of its short operative time, good resolution of comorbidities, excellent weight loss, and low complications rate. However, the safety of LSG as a day-surgery procedure has not yet been widely documented.

Methods

A retrospective analysis of a prospectively collected bariatric database, in a single institution, between August 2012 and February 2015, yielded 980 patients who underwent LSG; 328 patients (33.5 %) responded to established criteria and were operated on a 1-day surgery basis (length of stay?<?12 h).

Results

There were 258 (78 %) primary LSG and 70 revisional LSG (22 %) performed on 284 females and 44 males, with a mean age (±SD) of 38?±?9 years. Mean (±SD) preoperative body mass index (BMI) was 45?±?6 kg/m². Operative time was 68?±?17 min (mean?±?SD). There were no deaths. A total of 322 patients (98.2 %) were discharged home the day of surgery. There were 6 (1.8 %) unplanned overnight hospitalization, and 28 patients (8.5 %) were readmitted between days 1 and 30. Most patients (25/34, 73 %) were hospitalized for minor problems, such as pain, nausea, and/or vomiting. There were two cases of (0.6 %) gastric staple line leaks, three (0.9 %) of intra-abdominal hematomas, two (0.6 %) of pneumonia, one (0.3 %) of acute pancreatitis, and one (0.3 %) of urinary tract infection. All patients recovered well.

Conclusions

LSG can be performed as an outpatient procedure in selected patients, with acceptable results in terms of retention, readmission, and complication rates.

     

Approach to Poor Weight Loss After Laparoscopic Sleeve Gastrectomy: Re-sleeve Vs. Gastric Bypass

Background

Laparoscopic sleeve gastrectomy (LSG) is increasing worldwide; however, long-term follow-up results included insufficient weight loss and weight regain. This study aims at assessing the outcomes of converting LSG to laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic re-sleeve gastrectomy (LRSG).

Methods

A total of 1300 patients underwent LSG from 2009 to 2012, of which 12 patients underwent LRYGB and 24 patients underwent LRSG in Al-Amiri Hospital alone. Data included length of stay, percentage excessive weight loss (EWL%), and body mass index (BMI).

Results

Twenty-four patients underwent conversion from LSG to LRSG, and 12 patients underwent conversion from LSG to LRYGB due to insufficient weight loss and weight regain. Eighty-five percent were females. The mean weight and BMI prior to LSG for the LRYGB and LRSG patients were 136.5 kg and 52, and 134 kg and 50, respectively. The EWL% after the initial LSG was 37.9 and 43 %, for LRYGB and LRSG, respectively. There were no complications recorded. Results of conversion of LSG to LRYGB involved a mean EWL% 61.3 % after 1 year (p value 0.009). Results of LRSG involved a mean EWL% of 57 % over interval of 1 year (p value 0.05). Comparison of the EWL% of LRYGB and LRSG for failed primary LSG was not significant (p value 0.097).

Conclusion

Following our algorithm, revising an LSG with an LRSG or LRYGB for poor weight loss is feasible with good outcomes. Larger and longer follow-up studies are needed to verify our results.

     

Comparison of Outcomes Between Laparoscopic Roux-en-Y Gastric Bypass and Sleeve Gastrectomy in a Lebanese Bariatric Surgical Practice

Purpose

Long-term studies on the outcomes of bariatric surgery are still limited in the Middle East. The aim of this study is to compare the outcomes of laparoscopic Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (LSG) up to 5 years of follow-up.

Materials and Methods

A retrospective analysis of patients who underwent LRYGB and LSG was performed. The primary outcome was weight loss. Postoperative complications, operative time, and hospital length of stay were secondary outcomes.

Results

Four hundred patients underwent primary LSG and 175 patients underwent LRYGB between 2008 and 2013. Follow-up rates at 5 years were around 60%. Percent total weight loss was similar after 3, 4, and 5 years in both groups, averaging around 28%. Mean percentage of excess weight loss (%EWL) at 5 years was 72.0 ± 31.0% in the LSG group vs. 63.0 ± 21.0% in the LRYGB group (p = 0.03). Patients undergoing LRYGB had a significantly longer operative time as well as a longer hospital stay. No significant difference was found in the rates of short- and long-term complications between the two groups. However, patients undergoing LRYGB were more likely to develop small intestinal obstruction and iron-deficiency anemia.

Conclusions

Both LSG and LRYGB result in satisfactory weight loss within 5 years. Patients’ comorbidities and potential risks must be included in the choice of the appropriate bariatric procedure. LSG appears to give durable weight loss with less risk of major long-term complications.

     

The Effects of Laparoscopic Sleeve Gastrectomy on Obesity-Related Hypertriglyceridemia-Induced Acute Pancreatitis

Background

Hypertriglyceridemia-induced acute pancreatitis (HTG-AP) is a significant clinical problem and is characterized by high recurrence rate compared with non-HTG-AP. The objective of this study was to investigate the effects of laparoscopic sleeve gastrectomy (LSG) on obesity-related HTG-AP.

Methods

Twenty-nine patients with obesity-related HTG-AP were admitted to our hospital and treated with the conventional therapy or LSG surgery according to the wishes of patients. Clinical data and the recurrence rate of AP were collected at baseline and at four different time points (3, 6, 9, and 12 months) after the treatments for all patients.

Results

Of the 29 patients, 28 patients (19 patients with conventional therapy and 9 patients with LSG surgery) completed the 12-month follow-up. Clinical data and the severity scores of AP were comparable at baseline when the patients were admitted to the intensive care unit. The LSG group experienced a large weight loss (percent total weight loss, 26.87?±?1.44%; percent excess weight loss, 79.56?±?1.37%) and triglyceride reduction (from 15.77?±?1.02 to 1.36?±?0.09 mmol/L), and no recurrence was observed at 12 months after the surgery. In the conventional treatment group, however, body weight was not changed although triglyceride was significantly decreased (from 17.34?±?1.29 to 8.25?±?1.12 mmol/L), and more importantly, 47.4% of the patients had at least one recurrence of AP in 12 months after the treatment.

Conclusions

LSG might be an effective way to cure obesity-related HTG-induced AP since it prevents the recurrence of this disease. Further randomized studies will be needed to standardize this way of treatment.

     

Role of Percutaneous Glue Treatment After Persisting Leak After Laparoscopic Sleeve Gastrectomy

Background

Over the years, many treatment modes have been attempted for gastrocutaneous fistula (GCF) after laparoscopic sleeve gastrectomy (LSG). Minimally invasive techniques for GCF treatment include stent placement and radiological percutaneous glue treatment (GT).

Material and Method

Ten patients underwent a radiological acrylate mixed with contrast medium GT combined or not with other treatment strategies such as relaparoscopy, ultrasound, or computerized tomography scan (CT scan)-guided drain and endoscopic stent placement.

Results

Ten patients (mean age 47.1 years, range 64–29) were treated by percutaneous injection of glue after LSG leak. Body mass index (BMI) was 42.2 kg/m²?±?6.7 at the time of LSG surgery. Mean time between LSG and leak diagnosis was 12 days (range 4–31 days). GT was only effective when performed after endoscopic stent placement (80 % resolution). With this regimen, five patients required a laparoscopic Roux limb placement. All fistulas eventually healed a mean of 75 days (range 29–293 days) after GCF diagnosis.

Conclusions

Percutaneous glue treatment alone does not seem to provide adequate results. Stenting previous to the glue treatment allows for better results.

     

Gastric Stenosis After Laparoscopic Sleeve Gastrectomy: Diagnosis and Management

Purpose

The use of laparoscopic sleeve gastrectomy (LSG) is increasing worldwide. Although post-LSG gastric stenosis (GS) is less frequent, it has not been well defined and lacks standardized management procedures. The objective of the present study was to describe a series of patients with GS symptoms after LSG and to develop a standardized management procedure for this complication.

Methods

We performed a retrospective analysis of a prospective database of patients presenting with GS after LSG procedures performed between January 2008 and March 2014. The primary efficacy criterion was the frequency of post-LSG GS. GS was classified as functional (i.e. a gastric twist) or organic. The secondary efficacy criteria included the time interval between LSG and diagnosis of GS, the type of stenosis, the type of management, and the follow-up data.

Results

During the study period, 1210 patients underwent primary or secondary LSG. Seventeen patients had post-operative symptoms of GS (1.4 %); one patient had achalasia that had not been diagnosed preoperatively and thus was excluded from our analysis. The median time interval between LSG and diagnosis of GS was 47.2 days (1–114). Eleven patients had organic GS and six had functional GS. Seven patients required nutritional support. Endoscopic treatment was successful in 15 patients (88.2 %) after balloon dilatation (n?=?13) or insertion of a covered stent (n?=?2). Two of the 15 patients required conversion to Roux-en-Y gastric bypass (11.8 %).

Conclusion

GS after LSG is a rare complication but requires standardized management. Most cases can be treated successfully with endoscopic balloon dilatation.

     

Morbidity Rates and Weight Loss After Roux-en-Y Gastric Bypass,Sleeve Gastrectomy,and Adjustable Gastric Banding in Patients Older Than 60 Years old: Which Procedure to Choose?

Background

As life expectancy increases, more elderly patients fit into the criteria for bariatric procedures. The aim of our study is to evaluate and compare the safety and efficacy of Roux-en-Y gastric bypass (RYGB), laparoscopic sleeve gastrectomy (LSG), and laparoscopic adjustable gastric banding (LAGB) in patients older than 60.

Material and Methods

Between January 2005 and December 2013, 68 LAGB, 73 LSG, and 212 RYGB patients were 60 years or older at the time of primary procedure. A retrospective review was performed in these patients.

Results

Mean age and body mass index (BMI) was 62.7?±?2.2, 64.1?±?2.9, and 62.6?±?2.3 years and 42.7?±?5.6, 44.0?±?7.0, and 45.2?±?6.7 kg/m² for LAGB, LSG, and RYGB at the time of procedure, respectively.Seven (10.3 %) patients from the LAGB, 3 (4.1 %) from the LSG, and 29 (13.8 %) from the RYGB group required readmissions. Reoperation rate was 10.3, 1.4, and 9.5 % in LAGB, LSG, and RYGB, respectively. The difference in reoperation rates was statistically significant (p?<?0.03) while that in readmission rates was not (p?>?0.58). Procedure-related mortality rate was 1.4 % in the RYGB group, while no mortality was observed in LSG and LAGB groups. At 6, 12, and 18 months postoperatively, mean percentage of excess weight loss were highest in the RYGB group, followed by LSG and LAGB group (p?<?0.01). Mean number of comorbidities at the last follow-up significantly decreased in LSG and RYGB patients.

Conclusions

LSG showed the lowest readmission and reoperation rate, and RYGB patients had the highest mortality rate. Weight loss and comorbidity resolution were effectively achieved in RYGB and LSG patients.

     

Sugar Detection Threshold After Laparoscopic Sleeve Gastrectomy in Adolescents

Introduction

Obesity in young people is one of the most serious public health problems worldwide. Moreover, the mechanisms preventing obese adolescents from losing and maintaining weight loss have been elusive. Laparoscopic sleeve gastrectomy (LSG) is successful at achieving long-term weight loss in patients across all age groups, including children and adolescents. Anecdotal clinical observation as well as evidence in rodents suggests that LSG induces a shift in preference of sugary foods. However, it is not known whether this shift is due to a change in the threshold for gustatory detection of sucrose, or whether LSG induces behavioral change without affecting the gustatory threshold for sugar.

Aims

The objective of this study was to determine whether adolescents who undergo LSG experience a change in their threshold for detecting sweet taste.

Methods

We studied the sucrose detection threshold of 14 obese adolescents (age 15.3 ± 0.5 years, range 12–18) who underwent LSG 2 weeks before surgery and at 12 and 52 weeks after surgery. Matched non-surgical subjects were tested on two occasions 12 weeks apart to control for potential learning of the test that may have confounded the results. Seven sucrose concentrations were used and were tested in eight blocks with each block consisting of a random seven sucrose and seven water stimuli. The subjects were asked to report whether the sample contained water or not after they tasted 15 ml of the fluid for 10 s.

Results

The bodyweight of the LSG group decreased from 136.7 ± 5.4 to 109.6 ± 5.1 and 86.5 ± 4.0 kg after 12 and 52 weeks, respectively (p < 0.001). There was no significant difference after surgery in taste detection threshold of patients after LSG (p = 0.60), and no difference was observed comparing the taste detection threshold of the LSG group with the non-surgical controls (p = 0.38).

Conclusion

LSG did not affect the taste detection threshold for sucrose, suggesting that the shift in preference for sugary foods may be due to factors other than fundamental changes in taste sensitivity.

     

Goal-Directed Fluid Therapy on Laparoscopic Sleeve Gastrectomy in Morbidly Obese Patients

Background

In bariatric surgery, there are no guidelines available for intraoperative fluid administration. Goal-directed fluid therapy (GDFT) is a new concept of perioperative fluid management that has been shown to improve the prognosis of patients undergoing abdominal surgery. The aim of our study is to assess the impact of the implementation of a GDFT protocol in morbidly obese patients who underwent laparoscopic sleeve gastrectomy (LSG).

Methods

A before-after intervention study, in morbidly obese patients who underwent LSG, was conducted at the Obesity Unit of the General University Hospital Elche. Data from the GDFT implementation group (January 2014 to December 2015) were prospectively collected and compared with a preimplementation group (January 2012 to December 2013).

Results

Baseline demographic and comorbidity data between the two groups of patients were similar. The length of stay in the hospital was significantly shortened in GDFT group from 4.5 to 3.44 days (p?<?0.001). Intraoperative fluid administration was significantly lower in the GDFT group (1002.4 vs 1687.2 ml in preimplementation group, p?<?0.001). In the postoperative period, there was a statistically significant reduction in postoperative nausea and vomiting (PONV) after GDFT implementation (48 to 14.3 %, p?<?0.001).

Conclusions

Implementation of GDFT protocols can prevent intraoperative fluid overload in patients undergoing bariatric surgery. It could improve outcomes, for example decreasing PONV or even hospital stay.