Marius Nedelcu

Revised sleeve gastrectomy (re-sleeve)

BACKGROUND Laparoscopic sleeve gastrectomy (LSG) has rapidly become increasingly popular in bariatric surgery. However, in the long-term follow-up, weight loss failure and intractable severe reflux after primary LSG can necessitate further surgical interventions. OBJECTIVES To evaluate the safety and the efficiency of revisional sleeve gastrectomy (ReSG). SETTING Private hospital. METHODS From October 2008 to October 2014, 61 patients underwent ReSG. All patients with failure after primary LSG underwent radiologic evaluation, and an algorithm of treatment was proposed. RESULTS Sixty-one patients (54 women, 7 men; mean age 40.8 yr) with a body mass index (BMI) of 39.4 kg/m² underwent ReSG. The primary LSG was performed for mean BMI of 46.2 kg/m² (range 35.4-77.9). The mean interval time from the primary LSG to ReSG was of 37.5 months (9-80 mo). The indication for ReSG was insufficient weight loss in 28 patients (45.9%), weight regain in 29 patients (47.5%), and gastroesophageal reflux disease (GERD) in 4 patients. In 42 patients the gastrografin swallow results were interpreted as primary dilation and in the remaining 19 cases as secondary dilation. The computed tomography (CT) scan volumetry was obtained in 38 patients with mean gastric volume of 436.3 cc (275-1056 cc). All cases were completed by laparoscopy with no intraoperative incidents. The mean operative time was 39 minutes (range 29-70 min) and the mean hospital stay was 3.5 days (range 3-16 d). One perigastric hematoma and 2 cases of gastric stenosis were recorded. The mean BMI decreased to 29.2 kg/m(2) (range 20.2-37.5); the mean percentage of excess weight loss (%EWL) was 58.5% (±25.3) (P<.0004) for a mean follow-up of 20 months (range 6-56 mo). CONCLUSION The ReSG may be a valid option for failure of primary LSG. Further prospective clinical trials are required to compare the outcomes of ReSG with those of laparoscopic Roux-en-Y gastric bypass or duodenal switch for weight loss failure after LSG.

Laparoscopic sleeve gastrectomy as a revisional procedure for failed gastric banding: lessons from 300 consecutive cases

BACKGROUND Laparoscopic adjustable gastric banding (LAGB) is a common bariatric procedure associated with a high rate of weight loss failure and/or complications in the long term. The objective of this study was to test the hypothesis that the conversion of failed LAGB into laparoscopic sleeve gastrectomy (LSG) is not associated with an increased risk of postoperative complications and leads to weight loss results that are comparable to those obtained with a primary LSG. METHODS We retrospectively analyzed the results of a prospective series of 1360 LSG regarding patient demographics, the indication for revision morbidity, the percentage of excess weight loss, and the rate of postoperative complications. RESULTS The primary LSG group contained 1060 patients and the LAGB to LSG group contained 300 patients. The rate of postoperative complications was 4.5% in the primary LSG group and 2% in the LAGB to LSG group. Two patients died in the LSG group (1 pulmonary embolus, 1 myocardial infarction). There was no significant difference with respect to the rate of leak, which was 1% in the LAGB to LSG group and 1.6% in the primary LSG group. There was a greater weight loss after primary LSG, mean % excess weight loss of 75.9%±21.4 at a mean interval of 29±19.8 months, versus 62.6%±22.2 at a mean interval of 35±24 months after LAGB to LSG (P = .008). There were 72.1% and 59.2% of patients available for follow-up after primary LSG at 24 and 60 months respectively, versus 69.3% and 55.4% after LAGB to LSG. CONCLUSION This study indicates that the risk of leak after LSG was not increased after conversion failed LAGB into LSG when performed as a 2-step procedure.

What are the long-term results 8 years after sleeve gastrectomy?

BACKGROUND Laparoscopic sleeve gastrectomy (LSG) became the most frequent bariatric procedure performed in France (2011) and in the United States (2013), but studies reporting long-term results are still rare. SETTING Private hospital, France. METHODS This is a retrospective analysis of a prospective cohort of 168 patients who underwent LSG between 2005 and 2008. The objective of this study was to present the 8-year outcome concerning weight loss, modification of co-morbidities, and to report the revisional surgery after sleeve. RESULTS The preoperative mean body mass index was 42.8 kg/m2 (31.1-77.9), 35 patients were super obese, and 64 patients had a previous gastric band. For LSG as a definitive bariatric procedure, 8 years of follow-up data were available for 116 patients (follow-up: 69%). Of the remainder, 23 patients underwent revisional surgery and 29 were lost to follow-up. For the entire cohort, the mean excess weight loss (EWL) was 76% (0-149) at 5 years and 67% (4-135) at 8 years, respectively. Of the 116 patients with 8 years of follow-up, 82 patients had>50% EWL at 8 years (70.7%). Percentages of co-morbidities resolved were hypertension, 59.4%; type 2 diabetes, 43.4%; and obstructive sleep apnea, 72.4%. Twenty-three patients had revisional surgery for weight regain (n = 14) or for severe reflux (n = 9) at a mean period of 50 months (9-96). Twelve patients underwent resleeve gastrectomy, 6 patients underwent conversion to a bypass, and 5 patients to duodenal switch (1 single anastomosis duodeno-ileostomy). A total of 31% of patients reported gastroesophageal reflux symptoms at 8 years. CONCLUSIONS At 8 years postoperatively, the LSG as a definitive bariatric procedure remained effective for 59% of cases. The results appear to be more favorable especially for the non-super-obese patients and primary procedures. LSG is a well-tolerated bariatric procedure with low long-term complication rates.

Techniques of intragastric laparoscopic surgery

Benign or pre-cancerous lesions and foreign bodies of the stomach not amendable to endoscopic removal often require extensive surgery to address a process that does not necessitate lymph node sampling or formal gastrectomy. These lesions are particularly difficult to address endoscopically when located at the esophagogastric junction as a retroflexed view is needed. From its first description in 1995, intragastric laparoscopic surgery has evolved with respect to both technological advancements and tactical innovations. Here we report the development of four distinct techniques of laparoscopic intragastric surgery which we have developed over time and applied in 11 patients. These techniques consist of a (1) combined gastroscopic/laparoscopic approach when minimal manipulation of the lesion is needed, (2) multiport resection which provides optimal triangulation and allows for resection of more complex lesions, (3) stapled removal of broad-based lesions, and (4) single access technique with the device placed directly through the abdominal wall into the stomach. The techniques expand the surgeon’s armamentarium to address more complex intragastric processes safely, while the typical postoperative benefits of minimal access surgery such as fast recovery time and less pain are preserved. As we gain greater experience with intragastric laparoscopic surgery, this technique holds the promise of becoming a standard surgical technique for benign lesions for which it is oncologically safe to perform a limited resection.

How to treat stenosis after sleeve gastrectomy

BACKGROUND Laparoscopic sleeve gastrectomy (LSG) has increasingly gained worldwide acceptance among bariatric surgeons during the past 10 years. Numerous articles have been written about the different approaches to the management of gastric fistulas, but limited data can be found concerning gastric stenosis after LSG. SETTING Private hospital, France. METHODS A total of 18 patients received endoscopic treatment for stenosis after LSG between May 2007 and June 2015. Stenosis was classified according to the endoscopic findings as functional (the passage of the endoscope was possible, but the sleeve was twisted with various degrees of rotation) or mechanical (the passage of the endoscope was very difficult or impossible). RESULTS This study included 13 women and 5 men, with an average age of 37.2±8.4 years and an average body mass index of 41.6±8.7 kg/m2. The average number of endoscopic procedures was 1.3 (range, 1-4). No patient had stent migration. The successful rate of endoscopic approach for stenosis of LSG was 94.4%, with one patient requiring conversion to Roux-en-Y gastric bypass. The mean time from the LSG to the first endoscopic intervention was 28.2 days. All patients presented with midsleeve stricture, located near the incisura angularis, and no patient showed a stenosis in the upper part of the gastric tube. CONCLUSIONS The treatment of stenosis after LSG must be tailored to the clinical status of the patient and endoscopic findings. Both balloon dilation and stent deployment are useful and safe tools and must be used when appropriate.

Gastrobronchial Fistula: A Serious Complication of Sleeve Gastrectomy. Results of a French Multicentric Study

BackgroundGastrobronchial fistula (GBF) is a complication of esophageal, splenic, or antireflux surgeries and was recently described as a complication of bariatric surgery. Our aim was to study all cases of GBF after laparoscopic sleeve gastrectomy (LSG) managed in five French university bariatric centers in order to establish the incidence and to evaluate the different treatments of this complication.MethodsWe retrospectively studied 13 patients which developed GBF after LSG performed between March 2007 and August 2012. Patients were separated into two groups: patients who had early gastric fistula which has evolved into a GBF (group 1) and patients who had a late gastric fistula, either directly GBF or a late gastric fistula evolved in GBF (group 2).ResultsGroup 1 consisted of five patients and group 2 of eight patients. All patients were undernourished at diagnosis. Management of GBF was a combined thoraco-abdominal surgery with gastrojejunal anastomosis (n = 5) or total gastrectomy (n = 1), multiple endoscopic treatment and thoracic surgery (n = 3), an endobronchial valve (n = 1), total gastrectomy and thoracic drainage (n = 1), and transorificial intubation with thoracic surgery or drainage (n = 2). There was no mortality. All GBF healed.ConclusionsGBF after LSG is a serious complication which is not anecdotal. Most of the early gastric fistulas occuring after LSG become chronic and can evolve into a GBF. Surgical approach is an effective treatment. Endobronchial valve is a novel alternative.

Pigtails Internal Drainage for 2-cm Gastric Leak After Sleeve Gastrectomy Prolongs Healing

We would like to thank Donatelli et al. for the opportunity to comment on his complicated case report of a leak after laparoscopic sleeve gastrectomy (LSG) with a 2-cm-long dehiscence. We would like to make some remarks. In the selected case presented, a dehiscence of 2 cm is unusual and the technique used for the initial laparoscopic sleeve gastrectomy (LSG) must be questionable. A description of the initial procedure is suitable, describing the technique of dissection, the bougie size, the type of stapling, and the reinforcement used. Such a large defect can be explained by necrosis which occurred after dissection, by mischoice of stapling device, or/and poor choice of reinforcement type. The gastric leak healed by pigtails approach (although some may re-opened at a later date), but no details about the presence of gastric stenosis was mentioned. A twisted, poorly constructed sleeve will add insult to the injury and it necessitates the deployment of an endoscopic stent. Still the patient needed seven endoscopic sessions and 206 days to close the leak. In our proposed algorithm [1], for patients with gastric stenosis treated with tailored approach and endoscopic stent, the leaks achieved complete healing after an average duration of 118 days (a 75 % reduction in time). This difference of the healing time is increasing cost and patients’ sufferance unnecessarily. The occurrence of a gastropleural fistula could also be explained by the presence of a concomitant hiatal hernia misrecognized during the initial procedure. If this was the case, it should have been operated contemporaneously and the gastropleural fistula could have been avoided. The OVESCO® clip (OTSC®; Ovesco Endoscopy GmbH, Tübingen, Germany) in this sett ing was, in fact, contraindicated. The authors Bbelieve^ that in their experience, the stents will increase the local ischemia and subsequently increase leak in size. We do not agree with the statement that stents cause ischemia, as no recent data in the literature [2, 3] supports it. The debate on the algorithm regarding the leak size when no stenosis is associated will remain open. Most centers are proposing, for all types of leaks after LSG, an endoscopic stent [4, 5]. The main purpose of the algorithm with our early experience of 19 cases was to change this dogma and to offer patients with this dreaded complication after LSG, a tailored approach.We remain unconvinced that pigtail drains represent a solution for all the types of leak, irrespective of leak size, and we are waiting for a new updated manuscript with all 200 cases from the authors.

Paired editorial: Evolution of Endoscopic Treatment of Sleeve Gastrectomy Leaks: From Partially Covered to Long Fully Covered Stents

Laparoscopic sleeve gastrectomy (LSG) has become the most frequently performed bariatric procedure worldwide. Even if some of the advantages of this procedure are indisputable (e.g., lower long-term complication rate, the simplicity of the technique), the most feared complication remains gastric leak. The advent of new, longer endoscopic stents represents a new starting point in the endoscopic management of leaks after LSG. We appreciate the manuscript by Garofalo et al. in which the authors report their initial successful experience with the Megastent (Taewoong Medical Industries, South Korea). We commend the authors for offering consistent and clear information necessary to understand why the novel stent seems to have certain advantages in the treatment of LSG leaks. They emphasize the following 3 aspects:

Additional tools to improve the follow up after bariatric surgery

Bariatric surgery has proved its efficiency versus medical treatment when referring to long-term results [1]. Despite technical advancements in bariatric surgery that have improved the patient’s safety the last decade, there are still many limitations and deficiencies in the standard of care for patients with morbid obesity. Barriers to providing quality healthcare include the slow acknowledgment among practitioners that obesity requires long-term management; inadequate physician training in nutrition and obesity; limited reimbursement for the full range of treatments and wide variety in different countries; general misperception of increased cost of bariatric surgery; and limited referral of patients with severe obesity to experienced surgeons, even though bariatric surgery is a level A health-improving treatment option (i.e., with improvement based on data from multiple randomized trials or meta-analyses) [2]. The current letter approaches 2 main deficiencies in our daily practice (insufficient preoperative evaluation and follow-up) and proposes an innovative idea to perfect our activity, increasing patients’ satisfaction and improving the long-term results. The first problem we discuss is insufficient preoperative evaluation. All accredited bariatric centers have a multidisciplinary approach, with nutritional, psychological, and endocrinology support, but only few have additional tools like support groups or different workshops for the patients (i.e., cooking, self-affirmation, hypnosis, reading food labels) with the aim to enhance patients’ involvement and determination. The second is represented by the patient’s adherence to a bariatric program. “Why has bariatric surgery failed?” has

Minimally Invasive Intragastric Surgery

As the peritoneal cavity represents the operating space for laparoscopic surgeons, they have imagined directly working in the stomach by following the same principles: insufflation to create a new operating space, introduction of surgical instruments through working ports, and performance of a surgical procedure by using various techniques of dissection. We aim to describe the technical principles of this new approach as it offers a valuable option for surgeons in the management of gastric tumors and early cancer. It may preclude major surgical procedures, especially for the management of lesions located at the esophagogastric junction. Selected indications can be identified due to adequate preoperative workup including endoscopy, endoscopic ultrasonography, and conventional imaging studies (CT scan and MRI). When all inclusion criteria and technical principles are respected, this new minimally invasive approach offers major benefits for patients. It combines the preservation of an almost normal anatomy by respecting the stomach and the gastroesophageal junction with a simple postoperative course.