Abdennaceur Dhahri

Is there a place for pigtail drains in the management of gastric leaks after laparoscopic sleeve gastrectomy

Laparoscopic sleeve gastrectomy (LSG) has a specific morbidity profile in which gastric leak (GL) is the main complication. With a view to defining a standardized protocol for GL management, the present retrospective study sought to describe the clinical patterns of post-LSG GL and treatment of the latter in our university medical center. From July 2004 to December 2010, 25 patients were included. GL was described in terms of clinical presentation, time to onset, and location in the staple line. Treatment of GL with pharmacologic, radiologic, endoscopic, and/or surgical procedures was always validated by a multidisciplinary care team. “Treatment success” was defined as the absence of contrast agent leakage on CT and endoscopy after removal of covered metallic stent or pigtail drains. Systemic inflammation and peritonitis were the main signs for early-onset GL (56%), whereas pulmonary symptoms and intra-abdominal abscesses revealed delayed-onset GL (44%). Surgery was always performed for early-onset GL. In the total study population, the median number of endoscopic procedures was five (range, 1–11) per patient, of covered SEMS was three (range, 1–8), and of pigtail drains was three (range, 1–4). Nine (36%) patients presented endoscopic-related complications. Four (16%) patients with treatment failure underwent radical surgery. The mortality rate was 4% (n=1). The management of post-LSG GL is challenging. Surgery was always performed for early-onset GL, whereas treatment of delayed-onset GL was based on endoscopy. Pigtail drains required fewer procedures per patient, were better tolerated, and had lower morbidity–mortality than covered SEMS.

Laparoscopic sleeve gastrectomy as day-case surgery (without overnight hospitalization).

BACKGROUND Day-case surgery (DCS) has boomed over recent years, as has laparoscopic sleeve gastrectomy (SG) for the treatment of morbid obesity. The objective of this study was to evaluate the safety and feasibility of day-case SG. METHODS This was a prospective, nonrandomized study of 100 patients undergoing day-case SG from May 2011 to July 2013. All patients met the criteria for DCS and for the treatment of morbid obesity. Standard surgical, anesthetic, and analgesic protocols were used. The primary study endpoint was the unplanned overnight admission rate. Secondary endpoints were standard DCS criteria, frequency and type of complications, and satisfaction rate of performing day-case SG. The short-term postoperative course of patients undergoing day-case and conventional SG also were compared. RESULTS A total of 416 patients were screened and 100 (24%) were included. There were 8 unplanned overnight admissions. Seven unexpected consultations, 7 hospital readmissions, and 5 major complications were recorded, including 3 cases of unexpected surgery for gastric leak. At follow-up, 96% of the patients were satisfied with day-case SG. The short-term postoperative course was similar among patients undergoing DCS and conventional management. CONCLUSION In selected patients, day-case SG is feasible with acceptable complication and readmission rates. The postoperative course was similar to that observed for standard SG.

Two lessons from a 5-year follow-up study of laparoscopic sleeve gastrectomy: Persistent, relevant weight loss and a short surgical learning curve

INTRODUCTION Like Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy (LSG) has been validated as a bariatric surgery procedure in its own right. However, the few studies of the long-term outcomes of LSG have only featured small patient populations. The objective of the present study was to evaluate weight loss 5 years after LSG and assess the surgical learning curve for this procedure. METHODS We performed a retrospective, single-center study of a prospective database including all consecutive patients having undergone LSG at Amiens University Medical Center between November 2004 and July 2007. Data (weight, body mass index [BMI], percentage of excess weight loss [EWL], percentage of excess BMI loss, and percentage weight loss [PWL]) were collected during follow-up (particularly after 5 years). RESULTS The study population comprised 118 patients (100 females [85%]; mean ± SD age, 40 ± 11 years; mean preoperative weight, 131 ± 22 kg; mean preoperative BMI, 47.7 ± 7 kg/m(2)). LSG was performed after failure of gastric banding in 23 cases (19%) and after failure of an intragastric balloon in 1 (0.8%). In all, 95 patients (81%) were analyzed ≥60 months after the LSG (mean follow-up period, 71 ± 9 months). The PWL and EWL were 25 ± 14% and 46 ± 26%, respectively. Eleven patients had undergone a second bariatric operation within 5 years of the LSG. Concerning the 84 patients in whom only LSG was the only operation, the PWL and EWL were 23 ± 14% and 43 ± 25%, respectively. The EWL was >50% in 35 of these 84 patients (42%) and between 25 and 50% in 30 cases (36%). Optimal weight results were achieved after only 28 LSG had been performed, which testifies to a shorter learning curve than for most other bariatric surgery techniques. CONCLUSION Isolated LSG is a quickly mastered bariatric surgery technique with a short learning curve. It enables a mean PWL of >25% and an EWL of >50% in >40% of cases.

Sleeve gastrectomy: Technique and results

Sleeve gastrectomy (SG), sometimes also called longitudinal gastrectomy, is performedwith increasing frequency in the treatment of morbid obesity, second only to gastric bypass(GBP).SG is the natural offspring of other operations performed for morbid obesity, namely,calibrated vertical gastroplasty (CVG) (or Mason’s vertical banded gastroplasty), theMagenstrasse’s operation and Mill’s operation, mainly performed in the UK [1]. Hess andMarceau introduced the SG into the armamentarium of the bariatric surgeon in 1988 [2]as the restrictive part of the duodenal switch (DS). Gagner and Rogula [3] described thisoperation as the first of two stages of biliopancreatic diversion (BPD) with DS performed6 to 12 months later, in order to decrease the high mortality associated with this complexoperation in the super-obese. The SG was described as an isolated therapeutic modalityfor the first time in 1993 [1].As this procedure has been introduced only recently in bariatric surgery, the techniqueof SG has not yet been standardized in all its steps (the type of stapler, the size of thecalibration bougie, the size of the pouch, the type of staples, the number of firings as wellas whether or not to reinforce the staple line). This variability of technique, along withpoorselectionofcandidatesfortheprocedure(‘‘sweeteaters’’),arepossibleexplanationsfor the wide variations in outcome found in the different published series.Herein we describe the technique of SG, as performed in our unit since 2004 (230interventions—oral communication). Based on the literature and our midterm results wealso report the main complications and their management.

Management of gastrobronchial fistula after laparoscopic sleeve gastrectomy

BACKGROUND Gastric fistula (GF) is a serious complication after laparoscopic sleeve gastrectomy (LSG). Furthermore, gastrobronchial fistula (GBF) may appear some time after a primary LSG. The objective of this study was to characterize GBF after LSG and establish standardized treatment procedures. METHODS All patients undergoing surgery for GBF after LSG at a public university medical center in France between November 2004 and January 2013 were included in this study. Surgical and perioperative care was standardized. The primary efficacy criterion was the complication rate. Secondary efficacy criteria were the mortality rate, surgical data, types of complications, and the length of stay (LOS) in hospital. RESULTS Six patients were treated for GBF after LSG: 2 presented GBF after primary LSG performed in our institution and 4 had been referred by tertiary centers. The median (range) time to onset of GBF after LSG was 136 days (99-238 d). Preoperative refeeding was performed in 5 cases. The median time interval between the discovery of GBF and its surgical treatment was 31 days (7-137 d). Five patients underwent simultaneous abdominal and thoracic procedures. The abdominal procedures consisted of total gastrectomy (n = 1) and 60-cm Roux-en-Y gastrojejunal anastomosis (n = 6). There were no postoperative mortalities. Four postoperative complications occurred (66.6%), 2 of which were postoperative fistulas (33.3%) requiring revisional surgery. The median time to oral refeeding was 10 days (8-65 d) and the median LOS was 14 days (13-25 d). CONCLUSIONS Our treatment of GBF is based on effective drainage with endoscopic procedures, allowing optimal preoperative refeeding before combined abdominal and thoracic surgery. For the abdominal procedure, we prefer a 60-cm Roux-en-Y gastrojejunal anastomosis to total gastrectomy, because the former is simpler and minimizes the long-term risk of postoperative malabsorption.

Efficiency of laparoscopic sleeve gastrectomy on metabolic syndrome disorders: two years results.

OBJECTIVES There are very few studies evaluating the efficacy of sleeve gastrectomy on the metabolic syndrome, truly a worldwide pandemic. The main objective of this study was to retrospectively determine the evolution of the metabolic syndrome and its associated comorbidities (type 2 diabetes, arterial hypertension, and dyslipidemia) at 24 months after sleeve gastrectomy. The secondary objective was to determine the predictive factors for resolution of this syndrome. MATERIAL AND METHODS Between July 2004 and February 2008, 241 patients with morbid obesity (males: 17%) underwent sleeve gastrectomy in our center. Patients were seen in combined medical and surgical outpatient postoperative follow-up consultation at 3, 6, 12 and 24 months. Patients were classed as responders or not, according to whether or not the metabolic syndrome (as defined according to the National Cholesterol Education Program-Adult Treatment Panel III [NCEP-ATPIII]) disappeared at 24 months follow-up. RESULTS Thirty-six patients (15% of all patients, 30% of males) presented initially with metabolic syndrome. Twenty-six patients (72%) still had metabolic syndrome at 6 months, 17 patients (47%) at 12 months, and 13 patients (36%) at 24 months. The main parameters that regressed after sleeve gastrectomy were type 2 diabetes and hypertriglyceridemia. In univariate analysis, only one parameter (systolic blood pressure) appeared to be a factor of non-resolution of the metabolic syndrome at 24 months. CONCLUSION Our study showed that sleeve gastrectomy reduced the incidence of the metabolic syndrome and several of its components.

Laparoscopic sleeve gastrectomy in patients with NASH-related cirrhosis: A case-matched study

BACKGROUND Laparoscopic sleeve gastrectomy (SG) is a validated procedure for the surgical treatment of morbid obesity. Cirrhosis is often considered a relative contraindication to elective extrahepatic surgery. The objective of this study was to evaluate the morbidity related to SG performed in cirrhotic patients compared with noncirrhotic patients. METHODS Between March 2004 and January 2013, we included all patients with cirrhosis undergoing SG (13 patients). These patients (SG-cirrhosis group) were matched in terms of preoperative data (age, gender, body mass index, and co-morbidities) on a 1:2 basis, with 26 noncirrhotic patients (SG group) selected from a population of 750 patients. Cirrhosis was diagnosed postoperatively on histologic exam. The primary endpoint was the overall postoperative complication rate. Secondary endpoints were operating time, revisional surgery rate, gastric fistula and bleeding rates, postoperative mortality, and weight loss over a 24-month period. RESULTS The SG-cirrhosis group consisted of 13 patients with a median age of 52 years. All patients in the SG-cirrhosis group were Child A. Etiology of cirrhosis was related to NASH in 93.3%. Median operating time in the SG-cirrhosis group and SG group was 75 minutes versus 80 minutes (P = .59). No postoperative mortality was observed in either group. The overall postoperative complication rate was 7.7% versus 7.7% (P = 1). The major complication rate was 0% versus 7.7% (P = .22), and the postoperative gastric fistula rate was 0% versus 3.8% (P = .47). No complications related to cirrhosis were reported. CONCLUSION SG can be performed in Child A cirrhosis with no increased risk of postoperative complications and no specific complications related to cirrhosis. Weight loss for patients with cirrhosis undergoing SG is similar to that observed in noncirrhotic patients.

Persistent gastric fistula after sleeve gastrectomy: an analysis of the time between discovery and reoperation

BACKGROUND Gastric leak (GL) represents one of the main early-onset postoperative complication of sleeve gastrectomy (SG). Most studies of GL featured short series and no data on the time to reoperation for persistent GL. OBJECTIVES Characterize the time between discovery of persistent post-SG GL and the implementation of reoperation. SETTING University hospital, France, public practice. METHODS All patients treated for post-SG GL between November 2004 and December 2013 were included. The primary efficacy criterion was the time interval between discovery of a persistent GL and reoperation. The secondary efficacy criteria were demographic, surgical, and endoscopic data; mortality rate; time to GL healing; treatment success rate; and risk factors for failure treatment. RESULTS Eighty-six patients were treated for post-SG GL. Forty patients (46.5%) had early-onset GL (postoperative day ≤ 7). Two patients (2.3%) presented primary gastrobronchial fistula. Fifty-six patients (70%) underwent immediate reoperation. Endoscopic treatment was required to treat the GL in 92.7% of the cases (n = 77). The mortality rate was 1.2% (n = 1). The treatment success rate was 89.1%. The median time to healing GL was 84 days (14-423 d). Eighty percent of the GLs had healed 120 days after discovery. After 120 days, the incidence of complications related to GL increased and few additional GLs healed. The only identified risk factor for treatment failure was large retained gastric fundus (P ≤ .05). CONCLUSIONS Most cases of GL can be adequately treated by incorporating endoscopic stenting. Surgery for persistent GL should be performed within 120 days of discovery; after this cut-off, the incidence of GL-related complications increases. Large retained gastric fundus is a risk factor for treatment failure and may prompt the surgeon to consider earlier reoperation.

Outpatient laparoscopic sleeve gastrectomy: first 100 cases

STUDY OBJECTIVE The development of outpatient surgery was one of the major goals of public health policy in 2010. The purpose of this observational prospective study was to evaluate the feasibility of laparoscopic sleeve gastrectomy (SG) in an ambulatory setting. DESIGN Study design was a prospective prospective observational, nonrandomized study, registered (ClinicalTrials.gov identifier: NCT01513005), with institutional review board approval and written informed consent. SETTING Amiens University Medical Center. PATIENTS Patients undergoing SG who were preselected by inclusion ambulatory criteria. INTERVENTIONS All patients operated on for obesity by laparoscopic SG, from May 2011 through July 2013. MEASUREMENTS We collected outcomes data on 100 patients including incidence of postoperative nausea and vomiting, maximum and average pain scores, and the overall satisfaction rate. MAIN RESULTS Of the 100 obese patients, 93% were women. The mean age was 36 years (22-55 years). The mean preoperative body mass index was 42.4 kg/m(2). The mean operating time was 60 minutes (range, 30-95 minutes). The overall satisfaction rate was 93% (n = 93). When leaving the postoperative care unit, 94% of patients felt no or mild pain. Eighty-two percent had no postoperative postoperative nausea and vomiting, and 7 patients needed treatment using ondasetron. CONCLUSIONS Laparoscopic SG in an ambulatory setting is feasible with a dedicated anesthesiological approach and an expert surgical team. Appropriate patient selection is important for ensuring safety and quality of care within the outpatient program.

Is sleeve gastrectomy still contraindicated for patients aged≥60 years? A case-matched study with 24 months of follow-up

BACKGROUND Current guidelines consider that bariatric surgery is relatively contraindicated in elderly adults (aged≥60 years). The objective of this study was to evaluate obesity-related morbidity after sleeve gastrectomy (SG) according to whether patients were aged≥60 years or<60 years. METHODS Forty-two patients aged≥60 years (the elderly group) were matched 1:2 with 84 patients aged<60 (the control group). The primary objective was to compare weight change and the remission rate of co-morbidities in the 2 groups after 24 months of follow-up. The secondary endpoints were short-term and midterm postoperative outcomes (operating time, the frequency of conversion to laparotomy, the length of hospital stay, postoperative complications, mortality, and the SG failure rate). RESULTS No significant differences were observed between the elderly and control groups in terms of the mean operating time (83 minutes in both groups; P = .90), length of stay (3.2 versus 3.4 days, respectively; P = .51), morbidity rate (4.7% versus 9.5%, P = .35), or mortality rate (0% in both groups). The mean excess weight loss was significantly lower in the elderly group than in the control group at 12 months (56.2% versus 71.4%, respectively; P<.01) and 24 months (51.8% versus 73.5%, P<.01). Similar statistically significant differences were observed between the elderly group and control group for remission of metabolic syndrome (95% versus 90%, respectively; P = .55), type 2 diabetes mellitus (87% versus 71%, respectively; P = .13), hypertension (81% versus 77%, respectively; P = .71), and dyslipidemia (94% versus 74%, respectively; P = .09) at 24 months after SG. CONCLUSION Results support the safety and efficacy of SG for morbid obesity in patients aged≥60 years. In contrast to weight loss, the long-term morbidity rate and remission of obesity-related co-morbidities were similar in the participants aged≥60 years and those aged<60 years.