Value of Scintigraphy for Assessing Delayed Gastric Emptying After Pancreatic Surgery

Background

Delayed gastric emptying (DGE) occurs frequently after pancreatic surgery. Recently a consensus definition of DGE was introduced, and this grading system is currently widely used. The aim of this study was to compare results of gastric emptying scintigraphy with the grade of DGE after pancreatic surgery.

Methods

In 44 patients undergoing exploration for a pancreatic head or periampullary tumor, 28 pancreatoduodenectomies (PDs) and 16 double-bypass procedures were performed. All patients underwent preoperative and postoperative gastric emptying scintigraphy. We investigated whether the incidence of DGE was correlated with the results of gastric emptying scintigraphy.

Results

DGE occurred in 19 (43 %) patients. Clinically relevant DGE (grades B and C) prevailed in the PD group. Median postoperative residual activity at t = 2 h (%RA120) in these groups was 36 % (no DGE), 75 % (grade A), 93 % (grade B), and 95 % (grade C). DGE grade B or C was found in 7 of 10 patients with %RA120 of ≥94 % on postoperative day (POD) 7.

Conclusions

Postoperative %RA120 on scintigraphy is positively associated with severity of DGE. Gastric emptying scintigraphy on POD 7 can predict the severity of DGE. When postoperative gastric emptying scintigraphy shows high residual radioactivity, the likelihood of further progression to grade B or C DGE is high and warrants investigation for underlying causes.     

Diaphragmatic relaxing incisions during laparoscopic paraesophageal hernia repair

Background

Laparoscopic paraesophageal hernia (PEH) repair is associated with an objective recurrence rate exceeding 50 % at 5 years. Minimizing tension is a critical factor in preventing hernia recurrence. This study aimed to evaluate the outcomes of crural relaxing incisions in patients undergoing PEH repair.

Methods

Records were reviewed to identify patients who received a relaxing incision during laparoscopic PEH repair. The patients were followed by chest X-ray and videoesophagram at 3 months and then annually.

Results

From November 2010 to March 2013, 58 patients underwent PEH repair, and 15 patients received a relaxing incision to accomplish crural closure. The median age of the patients was 72 years (range 58–84 years). The relaxing incision was right-sided in 13 patients, left-sided in one patient, and bilateral in one patient. All the procedures were completed laparoscopically and included a fundoplication. Collis gastroplasty for a short esophagus was performed for 40 % of the patients. No major complications occurred. During a median follow-up period of 4 months, one patient had an asymptomatic mildly elevated left hemidiaphragm, and one patient had a trivial recurrent hernia, as shown on esophagogastroduodenoscopy (EGD).

Conclusion

Crural tension likely contributes to the high recurrence rate noted with laparoscopic PEH repair. Relaxing incisions are safe and allow crural approximation. Advanced laparoscopic surgeons should be aware of this option when faced with a large hiatus in a patient with PEH.     

Effect of laparoscopic cholecystectomy on gastric emptying and dyspepsia

Background

Laparoscopic cholecystectomy has become the gold standard for treatment of symptomatic gallstone disease. Nonresolution of dyspepsia postoperatively is of major concern nowadays. The present study was conducted to study the effect of laparoscopic cholecystectomy on gastric emptying in symptomatic gallstone disease using ^99mTc sulfur colloid scintigraphy. This pilot study sought to obtain preliminary data and to establish a base for further detailed study.

Methods

A total of 25 patients with a diagnosis of symptomatic gallstone disease scheduled for laparoscopic cholecystectomy were included in the study. All patients underwent gastric scintigraphic emptying study preoperatively and 2 weeks after laparoscopic cholecystectomy. Laparoscopic cholecystectomy was done as a day care procedure.

Results

Mean ± standard deviation preoperative gastric percentage clearance was 51.36 ± 12.67 %. Preoperative gastric emptying half-time was 62.72 ± 21.59 min. Forty percent of patients experienced dyspeptic symptoms before surgery. Twenty-four percent of patients had dyspeptic symptoms during postoperative follow-up at 2 weeks. Postoperative percentage gastric clearance was 49.92 ± 13.17 %. Postoperative gastric emptying half-time was 64.12 ± 19.13 min. Statistical analysis revealed no significant effect of laparoscopic cholecystectomy on gastric emptying parameters.

Conclusions

Laparoscopic cholecystectomy does not alter gastric emptying or stomach percentage clearance in gallstone patients who have preoperative delayed gastric emptying on scintigraphy. Laparoscopic cholecystectomy has no effect on gastric emptying in symptomatic gallstone patients.     

Omental flap wrapping with fixation to the cut surface of the liver for reducing delayed gastric emptying after left-sided hepatectomy

Background

Delayed gastric emptying (DGE) is a common complication following left-sided hepatectomy. The goal of this study was to clarify the clinical implications of an omental flap wrapping procedure that includes fixation to the cut surface of the liver to reduce the incidence of DGE after left-sided hepatectomy.

Methods

The study included 50 consecutive patients who underwent left-sided hepatectomy between January 2000 and July 2011. Clinicopathologic risk factors for DGE after left-sided hepatectomy were identified using univariate and multivariate models. The incidence of DGE, digestive symptoms, and postoperative complications were compared between two groups: 25 patients treated with the omental flap wrapping and fixation procedure and 25 patients who did not receive such a flap.

Results

A univariate analysis revealed that a lack of the omental flap, the lymph node clearance, and use of left hemihepatectomy were associated with postoperative DGE. The multivariate analysis indicated that the lack of the omental flap was the only independent significant factor associated with the DGE (odds ratio, 21.23; p = 0.0002). There was a significant difference in the incidence of DGE between the patients with (4 %) and without an omental flap (36 %). The incidence of gastric distension and the use of prokinetic drugs were also significantly lower in patients with an omental flap than in patients without the flap, and patients with an omental flap resumed a solid diet significantly earlier.

Conclusions

This retrospective single-center study revealed that it was possible to reduce the incidence of DGE using a procedure involving omental flap wrapping with fixation to the cut surface of the liver after left-sided hepatectomy.     

Factors Influencing Clinically Significant Delayed Gastric Emptying After Subtotal Stomach-Preserving Pancreatoduodenectomy

Background

Subtotal stomach-preserving pancreatoduodenectomy (SSPPD), in which the pylorus ring is resected and most of the stomach is preserved, has been performed recently in Japan. This study was undertaken to clarify the incidence of delayed gastric emptying (DGE) after SSPPD at a high-volume hospital and to determine the independent factors that influence the development of DGE after SSPPD.

Methods

Between 2002 and 2011, 201 consecutive patients underwent standardized SSPPD. After SSPPD, DGE (defined according to the International Study Group of Pancreatic Surgery) was analyzed, and associated variables were assessed by univariate and multivariate analyses, retrospectively.

Results

Clinically significant DGE (grades B and C) occurred in 35 (17 %) of the 201 patients; 26 patients had other accompanying abdominal complications (secondary DGE), and pancreatic leakage was the sole risk factor for DGE (odds ratio 6.63, 95 % CI 2.86–15.74; p < 0.001). Only nine (4 % of all patients) of the 35 patients with clinically significant DGE were classified as having DGE that had arisen without any obvious etiology (primary DGE).

Conclusions

DGE after SSPPD is strongly linked to the occurrence of other postoperative intra-abdominal complications such as pancreatic fistula. The incidence rate of primary DGE after SSPPD was 4 %. Although the ISGPS classification of DGE is clearly applicable, the grades do not explain why DGE occurs. Primary and secondary DGE should therefore be defined separately.     

Long-term follow-up evaluation of revisional gastric bypass after failed adjustable gastric banding

Background

Disappointing long-term results, frequent band failure, and high rates of band-related complications increasingly necessitate revisional surgery after adjustable gastric banding. Laparoscopic conversion to gastric bypass has been recommended as the procedure of choice. This single-center retrospective study aimed to evaluate the long-term results of revisional gastric bypass after failed adjustable gastric banding.

Methods

The study included 108 consecutive patients who underwent laparoscopic conversion of gastric banding to gastric bypass from 2002 to 2012. Indications for surgery, operative data, weight development, morbidity, and mortality were analyzed. The median follow-up period was 3.4 years (maximum, 10 years).

Results

The most common indications for band removal were band migration, insufficient weight loss, and pouch dilation. The median interval between gastric banding and gastric bypass was 6.6 years. In 52 % of the cases, band removal and gastric bypass surgery were performed simultaneously as a single-stage laparoscopic procedure. The early postoperative morbidity rate was 10.2 %. The body mass index before gastric banding (43.3 kg/m²) decreased significantly to 37.9 kg/m² before gastric bypass and to 28.8 kg/m² 5 years after gastric bypass.

Conclusions

This is the first report on the long-term outcome after conversion of failed adjustable gastric banding to gastric bypass. Findings have shown revisional gastric bypass to be a feasible bariatric procedure particularly for patients with insufficient weight loss that guarantees a constant and long-lasting weight loss.     

Incidence, mechanisms, and outcomes of esophageal and gastric perforation during laparoscopic foregut surgery: a retrospective review of 1,223 foregut cases

Background

Intraoperative perforation is a potentially major complication of laparoscopic (lap) foregut surgery. This study analyzed the incidence, mechanism, and outcomes of intraoperative perforations during these procedures in a large institutional experience.

Methods

All patients who underwent lap foregut surgery including laparoscopic antireflux surgery (LARS), paraesophageal hernia (PEH) repair, Heller myotomy, and reoperative hiatal hernia (redo HH) repair at the authors’ institution from August 2004 to September 2012 were reviewed retrospectively. Perforation events and postoperative outcomes were analyzed, and complications were graded by the modified Clavien system. All data are expressed as means ± standard deviations or as medians. Statistical analysis was performed using Fisher’s exact test and the Mann–Whitney U test.

Results

In this study, the repairs for 1,223 patients were analyzed (381 LARS procedures, 379 PEH repairs, 313 Heller myotomies, 150 redo HH repairs). Overall, 51 patients (4.2 %) had 56 perforations resulting from LARS (n = 4, 1 %), PEH repair (n = 7, 1.8 %), Heller myotomy (n = 18, 5.8 %), and redo HH repair (n = 22, 14.6 %). Redo HH was significantly more likely to result in perforations than LARS or PEH repair (p < 0.001). The locations of the perforations were esophageal in 13 patients (23.6 %), gastric in 40 patients (72.7 %), and indeterminate in 2 patients (3.6 %). The most common mechanisms of perforations were suture placement for LARS (75 %) and traction for PEH repair (43 %) and for Heller myotomy during the myotomy (72 %). The most redo HH perforations resulted from dissection/wrap takedown (73 %) and traction (14 %). Perforations were recognized and repaired intraoperatively in 43 cases (84 %) and postoperatively in eight cases (16 %). Perforations discovered postoperatively were more likely to require reoperation (75 vs 2 %; p < 0.001), to require more gastrointestinal and radiologic interventions (50 vs 2 %; p = 0.004), and to have higher morbidity (88 vs 26 %; p = 0.004) than perforations recognized intraoperatively.

Conclusions

In a high-volume center, intraoperative perforations are the most frequent with reoperative HH repair. If perforations are recognized and repaired intraoperatively, they require minimal postoperative intervention. Unrecognized perforations usually require reoperation and result in significantly greater morbidity.     

A population-based analysis of emergent versus elective paraesophageal hernia repair using the Nationwide Inpatient Sample

Background

As the life expectancy in the United States continues to increase, more elderly, sometimes frail patients present with sub-acute surgical conditions such as a symptomatic paraesophageal hernia (PEH). While the outcomes of PEH repair have improved largely due to the proliferation of laparoscopic surgery, there is still a defined rate of morbidity and mortality. We sought to characterize the outcomes of both elective and emergent PEH repair using a large population-based data set.

Methods

The Nationwide Inpatient Sample was queried for primary ICD-9 codes associated with PEH repair (years 2006–2008). Outcomes were in-hospital mortality and the occurrence of a pre-identified complication. Multivariate analysis was performed to determine the risk factors for complications and mortality following both elective and emergent PEH repair.

Results

A total of 8,462 records in the data, representing 41,723 patients in the US undergoing PEH repair in the study interval, were identified. Of these procedures, 74.2 % was elective and 42.4 % was laparoscopic. The overall complication and mortality rates were 20.8 and 1.1 %, respectively. Emergent repair was associated with a higher rate of morbidity (33.4 vs. 16.5 %, p < 0.001) and mortality (3.2 vs. 0.37 %, p < 0.001) than elective repair. Emergent repair patients were more likely to be male, were older, and more likely to be minority. Logistic modeling revealed that younger age, elective case status, and a laparoscopic approach were independently associated with a lower probability of complications and mortality.

Conclusions

Patients undergoing emergent PEH repair in the United States tend to be older, more likely a racial minority, and less likely to undergo laparoscopic repair. Elective repair, younger age, and a laparoscopic approach are associated with improved outcomes. Considering all of the above, we recommend that patients consider elective repair with a surgeon experienced in the laparoscopic approach, especially when symptoms related to the hernia are present.     

Laparoscopic repair of giant hiatus hernia: prosthesis is not required for successful outcome

Background

Giant hiatus hernia (GHH) are difficult to manage effectively. This study reports a laparoscopic, prosthesis-free technique to repair of GHH.

Methods

Retrospective analysis of a prospectively populated database of a single surgeon’s experience of GHH (>30 % intrathoracic stomach) repair using a novel, uniform technique was performed. Routine postoperative endoscopy, quality of life (QOL), and Visick scoring was conducted.

Results

Surgery was conducted in 100 patients (70F, 30 M). Mean (standard deviation [SD]) age was 69.1 (±11.4), median (interquartile range) ASA was 2 (range, 2–3), and mean (SD) body mass index (BMI) was 29.1 (±4.5). Mean follow-up was 574.1 (±240.5) days. One (1 %) patient was converted to an open procedure due to technical issues. Median stay was 2.5 days (range, 2–4). One postoperative death occurred secondary to respiratory sepsis. Eight (8 %) patients had perioperative complications: 4 major (PE, non-ST elevation MI, postoperative bleed managed conservatively, infected mediastinal fluid collection); and 4 minor (pneumothorax, asymptomatic troponin leak, subacute small bowel obstruction, and urinary retention). Ninety-nine (99 %) patients had objective screening for recurrence at 3–6 months. Two (2 %) patients have had symptomatic recurrence of their hiatus hernia; both involved a recurrent fundal herniation. Another seven (7 %) had small (<2 cm), asymptomatic recurrences diagnosed only on routine follow-up. Seven (7 %) patients have required reintervention for dysphagia with endoscopic dilatation conducted to good effect in all cases. Two (2 %) patients have required revisional surgery: one for a symptomatic recurrence at 3 months and a second for recurrent mediastinal collection. The Visick score fell from a mean (SD) of 3 (±1.1) to 1.7 (±0.8) postoperatively (p < 0.0001). The mean (SD) QOL preoperatively was 87.8 (±24) versus 109.1 (±22.3) postoperatively (p < 0.0001).

Conclusions

GHH can be managed safely and effectively laparoscopically, without the use of a prosthesis.     

Iron-Deficiency Anemia Is a Common Presenting Issue with Giant Paraesophageal Hernia and Resolves Following Repair

Background

A significant percentage of patients with paraesophageal hernia (PEH) will have a co-existing diagnosis of iron-deficiency anemia which will resolve following surgical repair.

Methods

Between 2000 and 2010, 270 patients underwent operative repair of PEH. Of this group, 123 patients (45.6 %) reported a preexisting diagnosis of iron-deficiency anemia. The study group consisted of 77 patients with a documented preoperative hemoglobin level (Hb) consistent with iron-deficiency anemia and a follow-up level at least 3 months following surgery.

Results

Of the 77 patients included, 72 underwent elective repair, median age was 75 (39–91) years, and 65 % were female. Cameron erosions were identified preoperatively in 32 %. Mean preoperative hemoglobin was 9.6 (4.4–13.6) g/dl and postoperative hemoglobin was 13.2 (10.7–17) g/dl at 3–12 months and 13.6 (9.7–17.2) g/dl at more than 1 year. Ninety percent of patients had a rise in postoperative hemoglobin level by at least 1 g/dL. Anemia resolved in 55 (71 %) patients, more often in women and younger patients (<70 years). Twenty-nine of 40 (73 %) patients on iron therapy discontinued this postoperatively.

Conclusion

A significant number of patients who present with giant PEH will present with iron-deficiency anemia. Elective repair will result in resolution of the anemia in more than 70 % of patients. PEH is underappreciated as a source of iron-deficiency anemia, and appropriate patients should be considered for elective repair.     

Feasibility of Laparoscopic Re-resection for Patients with Recurrent Hepatocellular Carcinoma

Background

Repeated resection via an open approach is an effective treatment for post-operative recurrent hepatocellular carcinoma (HCC). However, there are limited data on the application of laparoscopic approach for recurrent HCC in patients with prior liver resections. The aim of this study was to review our experience of laparoscopic re-resection in patients with postoperative tumor recurrence.

Materials and methods

A total of 11 patients received laparoscopic re-resections for postoperative tumor recurrence in our center. Data were reviewed for demographics, tumor characteristics, and perioperative outcomes. Case-match analysis with the open approach was performed in a 1:2 ratio.

Results

Six patients had their first liver resection carried out via the open approach and the remaining five patients received the laparoscopic approach. The recurrent tumor size was 20 mm (12–50 mm) and ten patients had a solitary recurrence. Two patients had laparoscopic left lateral sectionectomy and the remaining nine patients had sub-segmentectomies. There was no significant difference in patient characteristics, preoperative liver function, and tumor features between the laparoscopic and open groups. Perioperative blood loss was significantly reduced in the laparoscopic group (100 vs. 314 mL; p = 0.014) but the morbidity rate (18.2 vs. 4.5 %; p = 0.199) and length of hospitalization were comparable (6 vs. 5 days; p = 0.831). The 3-year overall survival rates for the laparoscopic and open groups were 60.0 and 89.3 %, respectively (p = 0.279).

Conclusion

Our study showed that laparoscopic re-resection for recurrent HCC was feasible with satisfactory postoperative and oncological outcomes, even in patients with previous major liver resections.     

Closure versus non-closure of hernia defect during laparoscopic ventral hernia repair with mesh

Purpose

Laparoscopic ventral hernia repair with mesh versus laparoscopic ventral hernia defect closure with mesh reinforcement. The primary end-point was recurrence.

Methods

Retrospective review of patients who underwent laparoscopic ventral hernia repair for small- and medium-sized hernias between July 2000 and September 2011. These patients were divided: (1) repair with mesh alone (non-closure group) and (2) those with hernia defect closure and mesh reinforcement (closure group). The closure group was further divided by technique: percutaneous versus intracorporeal closure of the defect.

Results

128 patients were studied: 93 patients (72.66 %) in the non-closure group and 35 patients (27.34 %) in the closure group. Follow-up was available in 105 patients (82.03 %) at a mean of 797.2 days (range 7–3,286 days). In the non-closure group there were 14 patients (15.05 %) with postoperative complications and 8 patients (22.86 %) in the closure group, four of which were seromas. Fourteen patients (19.18 %) developed recurrent hernias in the non-closure group with an average time to presentation of 23.17 months (range 5.3–75.3). Two patients (6.25 %) developed recurrent hernias in the percutaneous group with an average time to presentation of 12.95 months (range 9.57–16.33). There have been no recurrences in patients whose defect was closed intracorporeally.

Conclusion

Although our study demonstrated a difference in recurrence rates of 19.18 % in the non-closure group versus 6.25 % in the closure group, the difference did not reach statistical significance. A larger series with longer follow-up may demonstrate clinical significance.     

Assessment of delayed gastric emptying after major hepatectomy using a 13C-acetic acid breath test

Purposes

Delayed gastric emptying (DGE) after hepatectomy affects the quality of life of patients, although the causes and related conditions have not been investigated. This study evaluated the relationship between hepatectomy and DGE by the objective assessment of gastric emptying (GE).

Methods

Nineteen patients who underwent major hepatectomy were prospectively enrolled in the study. Their GE was studied using the ¹³C-acetic acid breath test before and after hepatectomy. The results of the GE analysis were correlated with the postoperative course after hepatectomy.

Results

Clinically evident DGE, which was defined as the inability to take in an appropriate amount of solid food orally by postoperative day 14, was not found in these patients, but the gastric half-emptying times before and after hepatectomy were 20.2?±?9.7 and 28.6?±?12.2?min, respectively (P?=?0.01). The GE time was significantly delayed in patients aged ≥41?years, or who underwent right hemihepatectomy.

Conclusions

Gastric emptying was significantly inhibited in patients who underwent major hepatectomy, and aging and a right-sided hemihepatectomy may be related to the development of DGE.     

Pylorus-Resecting Pancreaticoduodenectomy Offers Long-Term Outcomes Similar to Those of Pylorus-Preserving Pancreaticoduodenectomy: Results of a Prospective Study

Background

We showed in a previous study that pylorus-resecting pancreaticoduodenectomy (PrPD), which divides the stomach adjacent to the pylorus ring, preserves more than 95 % of the stomach and significantly reduced the incidence of delayed gastric emptying (DGE) compared with pylorus-preserving pancreaticoduodenectomy (PpPD). However, long-term outcomes of PrPD and the adverse effect of early postoperative DGE on long-term outcomes remain unclear.

Methods

A total of 130 patients enrolled in a previous study were followed for 24 months after surgery. Primary endpoint was whether PrPD is a better surgical procedure than PpPD regarding long-term outcomes.

Results

Weight loss > grade 2 (Common Terminology Criteria for Adverse Events, Version 4.03) at 24 months after surgery was significantly better in group PrPD (16.2 %) than in group PpPD (42.2 %) (p = 0.011). Nutritional status and late postoperative complications were similar for the two groups. The incidence of weight loss > grade 2 at 24 months was 63.6 % in DGE patients with DGE and 25.3 % in non-DGE patients (p = 0.010). T _max (time to peak ¹³CO₂ content in ¹³C-acetate breath test) at 24 months in DGE patients was significantly delayed compared with that in non-DGE patients (27.9 ± 22.7 vs. 16.5 ± 10.1 min, p = 0.023). Serum albumin level at 24 months was higher in non-DGE patients than in those with DGE (3.7 ± 0.6 vs. 4.1 ± 0.4 g/dl, p = 0.013).

Conclusions

PrPD offers long-term outcomes similar to those of PpPD. DGE may be associated with weight loss and poor nutritional status in patients with long-term outcomes.     

Impact of the Reconstruction Method on Delayed Gastric Emptying After Pylorus-Preserving Pancreaticoduodenectomy: A Prospective Randomized Study

Background

Delayed gastric emptying (DGE) is of considerable concern in patients undergoing pylorus-preserving pancreaticoduodenectomy (PPPD). Prolonged hospital stay, increased cost, and decreased quality of life add on to interventions needed to treat DGE. This study was conducted to determine if performing duodenojejunostomy via the antecolic rather than the retrocolic route improved incidence of DGE.

Methods

Patients undergoing PPPD between April 2007 and November 2009 were randomized for either antecolic or retrocolic reconstruction of the duodenojejunostomy. DGE was then assessed by clinical criteria on postoperative day (POD) 10. A paracetamol absorption test was also administered with a liquid meal, and serial plasma levels of intestinal peptides were measured.

Results

Overall, 64 patients were amenable for analysis: 36 in the antecolic group and 28 in the retrocolic group. The incidences of DGE on POD 10 were 17.6 and 23.1 % (antecolic vs. retrocolic, respectively) (p = 0.628). The two groups did not differ in regard to their median (interquartile range) postoperative hospital length of stay [13.0 (10.0–17.5) vs. 12.5 (11.0–17.0) days; p = 0.446], time to regular diet [5 (5–7) vs. 5 (4–6) days; p = 0.353], or morbidity (52.9 vs. 50.0 %; p = 0.777). The median length of nasogastric tube decompression was similar in the two groups [4 (3–7) vs. 3 (3–5) days; p = 0.600]. Levels of paracetamol and glucagon-like peptide-1 were markedly decreased in patients with DGE.

Conclusions

Antecolic reconstruction after PPPD does not improve the occurrence/the incidence of DGE and is similar to retrocolic reconstruction with regard to secondary outcome parameters.     

Laparoscopic inguinal hernioplasty after radical prostatectomy: is it safe? Prospective clinical trial

Introduction

Despite inguinal hernia repair being one of the most common elective operations performed in general surgical practice, there are many controversies including indications for repair and selection of the surgical technique. In recent years, laparoscopic repair has gained wider acceptance because it is associated with fewer postoperative complications and less chronic pain when compared with conventional approaches with similar recurrence rate. However, patients with lower abdominal surgery are contraindicated for laparoscopic approach. There are few studies that evaluated whether patients who have been subjected to radical prostatectomy might be subjected to laparoscopic hernia repair with the same benefits as those without previous radical prostatectomy.

Methods

Between March 2010 and March 2013, 20 consecutive patients, who had been subjected to prior radical prostatectomy, underwent laparoscopic transabdominal inguinal repair and were followed prospectively. Surgical procedure was performed using a standard technique.

Results

Mean operative time was 67.5 min. There was only one (5 %) intraoperative minor complication, an injury to the inferior epigastric vessels, which was managed by clipping of the vessels. There were no major postoperative complications. After 24 h and on the seventh postoperative day, 85 and 90 % of patients had no pain or only complained of discomfort, respectively. Nine patients (45 %) did not need any analgesics postoperatively. The mean time to return to leisure activities and to work was 3.1 and 5.6 days, respectively. There was no conversion to open surgery. All patients were discharged within 24 h. After a mean follow-up of 14 months, none of the patients presented recurrence.

Conclusion

TAPP after prostatectomy is safe and effective. It seems that patients undergoing laparoscopic repair after radical prostatic resection have the same benefits as those without prostatectomy.     

Laparoscopic Removal of Poor Outcome Gastric Banding with Concomitant Sleeve Gastrectomy

Background

Laparoscopic adjustable gastric banding (LAGB) has a significant incidence of long-term failure, which may require an alternative revisional bariatric procedure to remediate. Unfortunately, there is few data pinpointing which specific revisional procedure most effectively addresses failed gastric banding. Recently, it has been observed that laparoscopic sleeve gastrectomy (LSG) is a promising primary bariatric procedure; however, its use as a revisional procedure has been limited. This study aims to evaluate the safety and efficacy of LSG performed concomitantly with removal of a poor-outcome LAGB.

Methods

A retrospective review was performed on patients who underwent LAGB removal with concomitant LSG at King Saud University in Saudi Arabia between September 2007 and April 2012. Patient body mass index (BMI), percentage of excess weight loss (%EWL), duration of operation, length of hospital stay, complications after LSG, and indications for revisional surgery were all reviewed and compared to those of patients who underwent LSG as a primary procedure.

Results

Fifty-six patients (70 % female) underwent conversion of LAGB to LSG concomitantly, and 128 (66 % female) patients underwent primary LSG surgery. The revisional and primary LSG patients had similar preoperative ages (mean age 33.5?±?10.7 vs. 33.6?±?9.0 years, respectively; p?=?0.43). However, revisional patients had a significantly lower BMI at the time of surgery (44.4?±?7.0 kg/m² vs. 47.9?±?8.2; p?<?0.01). Absolute BMI postoperative reduction at 24 months was 14.33 points in the revision group and 18.98 points in the primary LSG group; similar %EWL was achieved by both groups at 24 months postoperatively (80.1 vs. 84.6 %). Complications appeared in two (5.5 %) revisional patients and in nine (7.0 %) primary LSG patients. No mortalities occurred in either group.

Conclusions

Conversion of LAGB by means of concomitant LSG is a safe and efficient procedure and achieves similar outcomes as primary LSG surgery alone.     

Revisional versus primary Roux-en-Y gastric bypass: a case-matched analysis

Background

Laparoscopic adjustable gastric banding (LAGB) has been a widely performed bariatric procedure. Unfortunately, revisional surgery is required in 20–30 % of cases. Data comparing revisional and primary gastric bypass procedures are scarce. This study compared revisional malabsorptive laparoscopic very very long limb (VVLL) Roux-en-Y gastric bypass (RYGB) with primary VVLL RYGB and tested the hypothesis that one-stage revisional laparoscopic VVLL RYGB is an effective procedure after failed LAGB.

Methods

In this study, 48 revisional VVLL RYGBs were matched one-to-one with 48 primary VVLL RYGBs. The outcome measures were operating time, conversion to open surgery, excess weight loss (EWL), and early and late morbidity.

Results

Surgical and medical morbidities did not differ significantly. No conversions occurred. The revisional group showed an EWL of 41.8 % after 12 months of follow-up evaluation and 45.1 % after 24 months based on the pre-revisional weight. The total EWL based on the weight before the LAGB was calculated to be 54.3 % after 12 months and 57.2 % after 24 months. The EWL in the primary RYGB group was significantly higher for both types of calculation: 41.8 %/54.3 % versus 64.1 % (p < 0.001 and <0.01) after 12 months and 45.1 %/57.2 % versus 70.4 % (p < 0.001 and <0.002) after 24 months.

Conclusions

Revisional laproscopic VVLL RYGB can be performed as a one-stage procedure by experienced bariatric surgeons but shows less effective EWL than primary RYGB procedures.     

Laparoscopic Sleeve Gastrectomy (LSG)—A Good Bariatric Option for Failed Laparoscopic Adjustable Gastric Banding (LAGB): A Review of 90 Patients

Background

Laparoscopic adjustable gastric banding (LAGB) is one of the most frequently performed bariatric surgeries. Even with a high failure rate, revisional procedures such as re-banding or laparoscopic Roux-en-Y gastric bypass (LRYGB) were commonly performed. Recently, conversions of LAGB to laparoscopic sleeve gastrectomy (LSG) were reported. We will review our experience on this conversion.

Methods

Between February 2007 and January 2012, 800 patients underwent LSG, with 90 as a revisional procedure for failed LAGB. A retrospective review of a prospectively collected database was performed. Data were collected through routine follow-up and weight loss data were also obtained through self-reporting via the Internet. Demographics, complications, and percentage of excess weight loss (%EWL) were determined.

Results

A total of 90 patients underwent LSG as a revisional procedure, comprising of 77 women and 13 men with a mean age of 41 years (22 to 67), a mean body mass index of 42 kg/m² (26 to 58). Among them, 15.5 % had diabetes mellitus, 35.5 % had hypertension, 20.0 % had hyperlipidemia, and 18.8 % had obstructive sleep apnea. The mean operative time was 112 min (50 to 220) and mean hospital stay was 4.2 days (1 to 180). Operative complications included 5.5 % leak and 4.4 % hemorrhage or gastric hematoma. There was no postoperative mortality. The mean postoperative %EWL was 51.8 % (n?=?82), 61.3 % (n?=?60), 61.6 % (n?=?45), 53.0 % (n?=?30), 55.3 % (n?=?20), and 54.1 % (n?=?10) at 6, 12, 18, 24, 36, and 48 months, respectively.

Conclusions

LSG after LAGB yields a positive outcome with higher complication rates than for primary LSG. We advocate this procedure as a good bariatric option for failed LAGB.     

Revisional surgery after failed laparoscopic adjustable gastric banding: a systematic review

Background

Laparoscopic adjustable gastric banding (LAGB) has emerged as one of the most commonly performed bariatric procedures worldwide. Unfortunately, revisional surgery is required in 20–30 % of cases. Several revisional strategies have been proposed, but there is no consensus regarding the best surgical option. This systematic review was designed to determine which revisional surgery (laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, or laparoscopic biliopancreatic diversion with duodenal switch) is best suited to enhance weight loss following failed LAGB due to complications or inadequate weight loss.

Methods

EMBASE, MEDLINE, PsycINFO, and Cochrane Clinical Trials were searched using the most comprehensive timeline for each database. A total of 24 relevant articles were identified. Two investigators independently extracted data, and differences were resolved by consensus. The weighted means were calculated for weight loss measurements.

Results

A total of 106, 514, and 71 patients underwent conversion from LAGB to laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass (LRYGB), and laparoscopic biliopancreatic diversion and duodenal switch (BPDDS), respectively. Before revisional surgery, the weighted mean body mass index (BMI) was 38.8 (6.9), 43.3 (8.1), and 41.3 (7.2) kg/m² for the LSG, LRYGB, and BPDDS groups, respectively. The majority of data was reported at 12–24 months follow-up. The mean BMI within this interval was 28 (10.5), 32.2 (6.4), and 33 (5.7) kg/m² for the LSG, LRYGB, and BPDDS groups, respectively. In addition, the mean excess weight loss (EWL) was 22 % (2.8), 57.8 % (11.7), 47.1 % (14) for the LSG, LRYGB, and BPDDS groups, respectively. The EWL reached 78.4 % (35) in the BPPDS group after 2-year follow-up.

Conclusions

Failed LAGB is best managed with conversion to another bariatric procedure. Stable weight loss occurs with salvage LRYGB. Although results for revisional BPPDS appear promising, additional research, with higher methodological quality, is needed.