Eleni Zachari

Influence of the Learning Curve on Safety and Efficiency of Laparoscopic Sleeve Gastrectomy

BackgroundLaparoscopic sleeve gastrectomy (LSG) is a relatively new bariatric procedure, and data regarding the learning curve are scarce. The aim of this study is to assess how the procedure can be safely implanted in a newly established bariatric unit and to define the learning curve.MethodsProctorship and mentorship in bariatric surgery were attended by two surgeons who were previously experienced in advanced laparoscopic surgery. The first consecutive 102 patients who underwent LSG in our newly established bariatric center were included. Patients were divided into three groups of 34 (groups 1, 2, and 3) according to case sequence. Data on demographics, operative time, conversion rate, hospital stay, morbidity, mortality, and excess weight loss (EWL) over time were compared between the groups.ResultsThe operative time was significantly lower in groups 2 (p = 0.016) and 3 (p = 0.003) compared to group 1. The learning curve was flat up to the 68th case. A significant decrease in hospital stay was noted for group 3 compared to groups 1 (p < 0.001) and 2 (p = 0.002). The conversion rate, mortality and morbidity rates, and EWL did not differ significantly between the groups. Mortality was 0.98% and procedure-related morbidity was 7.8%.ConclusionsLSG can be safely and efficiently performed in a newly established bariatric center following a mentorship procedure. Proficiency seems to require 68 cases. The operative time and hospital stay may significantly decrease with experience early in the learning curve, as opposed to mortality and morbidity rates, conversion rate, and EWL.

Laparoendoscopic rendezvous versus preoperative ERCP and laparoscopic cholecystectomy for the management of cholecysto-choledocholithiasis: interim analysis of a controlled randomized trial.

Background:Although the ideal management of cholecysto-choledocholi-thiasis is controversial, the 2-stage approach [endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy, and common bile duct (CBD) clearance followed by laparoscopic cholecystectomy] remains the standard way of management worldwide. One-stage approach using the so-called laparoendoscopic rendezvous (LERV) technique offers some advantages, mainly by reducing the hospital stay and the risk of post-ERCP pancreatitis. Objective:To compare the LERV 1-stage approach with the standard 2-stage approach consisting of preoperative ERCP followed by laparoscopic cholecystectomy for the treatment of cholecysto-choledocholithiasis. Setting:Controlled randomized trial, University/Teaching Hospital. Methods:Patients with cholecysto-choledocholithiasis were randomized either to LERV or to the 2-stage approach. Both elective and emergency cases were included in the study. Primary endpoint was to detect difference in overall hospital stay, whereas secondary endpoints were (i) to detect differences in morbidity (especially post-ERCP pancreatitis) and (ii) success of CBD clearance. This is an interim analysis of the first 100 randomized patients. Results:Hospital stay was significantly shorter in the LERV group; median 4 (2–19) days versus 5.5 (3–22) days, P = 0.0004. There was no difference in morbidity and success of CBD clearance between the 2 groups. Post-ERCP amylase value was found significantly lower in the LERV group: median 65 (16–1159) versus 91 (30–1846), P = 0.02. Conclusions:Interim analysis of the results suggests the superiority of the LERV technique in terms of hospital stay and post-ERCP hyperamylasemia.

Complicated Gallstones after Laparoscopic Sleeve Gastrectomy

Background. The natural history of gallstone formation after laparoscopic sleeve gastrectomy (LSG), the incidence of symptomatic gallstones, and timing of cholecystectomy are not well established. Methods. A retrospective review of prospectively collected database of 150 patients that underwent LSG was reviewed. Results. Preoperatively, gallbladder disease was identified in 32 of the patients (23.2%). Postoperatively, eight of 138 patients (5.8%) became symptomatic. Namely, three of 23 patients (13%) who had evident cholelithiasis preoperatively developed complicated cholelithiasis. From the cohort of patients without preoperative cholelithiasis, five of 106 patients (4.7%) experienced complicated gallstones after LSG. Total cumulative incidence of complicated gallstones was 4.7% (95% CI: 1.3–8.1%). The gallbladder disease-free survival rate was 92.2% at 2 years. No patient underwent cholecystectomy earlier than 9 months or later than 23 months indicating the post-LSG effect. Conclusion. A significant proportion of bariatric patients compared to the general population became symptomatic and soon developed complications after LSG, thus early cholecystectomy is warranted. Routine concomitant cholecystectomy could be considered because the proportion of patients who developed complications especially those with potentially significant morbidities is high and the time to develop complications is short and because of the real technical difficulties during subsequent cholecystectomy.

Impact of Laparoscopic Sleeve Gastrectomy on Gastrointestinal Motility

Objective Laparoscopic sleeve gastrectomy (LSG) was considered mainly as a restrictive procedure due to anatomic alterations in the upper gastrointestinal tract. Additionally, due to neurohormonal alterations, LSG modifies the gastrointestinal motility, which controls appetite and feeling of satiety. Aim The aim of the study was to review the impact of laparoscopic sleeve gastrectomy on gastrointestinal motility. Material and Methods A search of the medical literature was undertaken in Pubmed, Web of Science, and Cochrane library. Esophageal, gastric, bowel motility were assessed separately. Results Nine studies assessed esophageal motility. The data remain debatable attributing to the heterogeneity of follow-up timing, surgical technique, bougie size, and distance from pylorus. The stomach motility was assessed in eighteen studies. Functionally, the sleeve was divided into a passive sleeve and an accelerated antrum. All scintigraphic studies revealed accelerated gastric emptying after LSG except of one. Patients demonstrated a rapid gastroduodenal transit time. The resection of the gastric pacemaker had as a consequence aberrant distal ectopic pacemaking or bioelectrical quiescence after LSG. The bowel motility was the least studied. Small bowel transit time was reduced; opposite to that the initiation of cecal filling and the ileocecal valve transit was delayed. Conclusion Laparoscopic sleeve gastrectomy has impacts on gastrointestinal motility. The data remain debatable for esophageal motility. Stomach and small bowel motility were accelerated, while the initiation of cecal filling and the ileocecal valve transit was delayed. Further pathophysiological studies are needed to evaluate the correlation of motility data with clinical symptoms.

The use of over-the-scope clip in the treatment of persistent staple line leak after re-sleeve gastrectomy: Review of the literature

Staple line leak after sleeve gastrectomy (SG) is a severe complication associated with increased mortality rates and the potential need for reoperation. We report the successful management of a re-SG staple line leak with the use of an endoscopic over-the-scope clip.

Complicated Cholelithiasis: An Unusual Combination of Acute Pancreatitis and Bouveret Syndrome

Bouveret syndrome is a rare form of gallstone ileus. The purpose of the present study was to present the unusual case of a female patient with complicated cholelithiasis manifested as a combination of acute pancreatitis and concomitant Bouveret syndrome. A 61-year-old female patient was admitted to the emergency department complaining of mid-epigastric and right upper quadrant abdominal pain radiating band-like in the thoracic region of the back as well as repeated episodes of vomiting over the last 24 h. The initial correct diagnosis of pancreatitis was subsequently combined with the diagnosis of Bouveret syndrome as a computed tomography scan revealed the presence of a gallstone within the duodenum causing luminal obstruction. After failure of endoscopic gallstone removal, a surgical approach was undertaken where gallstone removal was followed by cholecystectomy and restoration of the anatomy by eliminating the fistula. The concomitant pancreatitis complicated the postoperative period and prolonged the length of hospital stay. However, the patient was discharge on the 45th postoperative day. Attempts for endoscopic removal of the impacted stone should be the initial therapeutic step. Surgery should be reserved for cases refractory to endoscopic intervention and when definite treatment is the actual challenge.

Current knowledge and perception of bariatric surgery among Greek doctors living in Thessaly

The purpose of this study was to assess doctors’ knowledge, current conceptions, and clinical practice regarding obesity and bariatric surgery.

A New Endovascular Radiofrequency Device for Dilatation of Vascular Stenosis in a Rabbit Model

ABSTRACT Purpose: To investigate the use of a new endovascular radiofrequency (RF) device, the Habib™ VesCoag™ Catheter, to induce vascular remodeling and dilatation of arterial stenosis in a rabbit model. Materials and Methods: RF was used to induce arterial stenosis in 10 rabbits and this was confirmed by angiography and color Doppler ultrasound. Two groups of five animals were then subjected to (1) balloon dilatation of the stenosis (intervention group), (2) no intervention (control group). Two rabbits from each group were sacrificed following the procedures to investigate vessel histopathology. At six weeks, the remaining six rabbits underwent follow-up angiogram and color Doppler ultrasound to assess vessel patency. They were then sacrificed and the vessels prepared for histopathological analysis. Three-dimensional images with confocal microscopy of the arterial lumen were also acquired. Results: In the intervention group, stenosis was reversed and patency confirmed by angiography and color Doppler ultrasound six weeks later in all surviving rabbits. Histopathology revealed degenerative changes of elastic fibers, focal losses of elastica lamella, disorganization of myocytes and extensive hyalinization of the tunica adventitia. Focal elastin changes of the arterial elastic lamella were also shown by three-dimensional confocal microscopy images. Conclusion: We have developed a novel endovascular RF catheter that can be safely and effectively used to induce vascular remodeling and dilatation of arterial stenosis in an experimental rabbit model.

Comparison of glucose homeostasis parameters between patients with high and low risk of diabetes at 6 weeks and 6 months after sleeve gastrectomy

BACKGROUND The changes in glucose homeostasis after sleeve gastrectomy (SG) for patients with high (HRD) and low risk (LRD) of developing diabetes have not been investigated. OBJECTIVE To compare the glucose homeostasis parameters between patients with HRD and LRD after SG. SETTING University hospital in Greece. METHODS Thirteen patients were categorized as HRD (9 females, mean body mass index 46.3±1.6 kg/m2) and 10 as LRD (8 females, mean body mass index 45.4±1.7 kg/m2) based on a preoperative 2-hour oral glucose tolerance test (OGTT). OGTT was repeated 6 weeks and 6 months postoperatively. OGTT-derived indices of insulin secretion, insulin sensitivity, and β-cell function (oral disposition index [ODI]) were calculated. RESULTS Preoperatively, in the HRD group, fasting and postload glucose levels were higher and the ODIs were lower compared with those in the LRD group. Six weeks postoperatively, glucose levels and ODIs were not different between the 2 groups. However, 6 months postoperatively, the HRD group had demonstrated higher postload glucose levels and lower ODI (0-30) and ODI (0-120) compared with the LRD group. Six weeks postoperatively, insulin levels, early insulin secretion, and insulin resistance indices were decreased compared with preoperative levels only in the HRD group. Six months postoperatively, ODIs and insulin sensitivity indices improved in both groups compared with baseline. CONCLUSION Six months after SG, glucose levels and ODIs improved for both HRD and LRD patients; however, postprandial glucose levels and ODI (0-30) and ODI (0-120) in HRD patients did not return to LRD levels. Moreover, during the first 6 postoperative weeks, the changes in glucose homeostasis parameters compared with preoperative levels were different for HRD and LRD patients.

Venous Thromboembolism in Bariatric Surgery

Deep venous thrombosis (DVT) and pulmonary embolism (PE) constitute clinical presentations of the same vascular disease, known as venous thromboembolism (VTE). VTE is responsible for hospitalization of >250000 Americans annually. It is associated with high morbidity and mortality and represents a primary cause of preventable death. There is strong evidence that obesity is an independent risk factor for DVT and PE. Bariatric surgery is proven to be an effective means in the therapy of morbid obesity and its related comorbidities, thus its prevalence is rapidly increasing. Well established and widely performed procedures include laparoscopic adjustable gastric band (LAGB), Roux-en-Y gastric bypass (RYGBP), biliopancreatic diversion (BPD, with or without duodenal switch) and sleeve gastrectomy (SG). LAGB is a purely restrictive method, while RYGBP and BPD are considered as mainly malabsorbptive procedures. SG was performed as a bridge to further by-pass surgery, however nowadays is performed as a single stage procedure. The risk of VTE in patients undergoing elective bariatric surgery is high, attributable to obesity, intraoperating factors and the lack of an established guidance describing optimal VTE prophylaxis. Overall incidence of VTE in this population is reported to be 1-3%. Diagnosis of PE postoperatively in obese patients can be difficult due to physical limitations and consequently may be underdiagnosed. Furthermore, although VTE is usually diagnosed as immediate postoperative complication, PE can occur in nonhospitalized patients, within the first month after surgery, despite pharmacologic prophylaxis.