Saeed Shoar

Portomesentric and splenic vein thrombosis (PMSVT) after bariatric surgery: a systematic review of 110 patients

BACKGROUND Portomesenteric and splenic vein thrombosis (PMSVT) is a rare but potentially serious complication after bariatric surgery. No study has systematically analyzed its incidence and risk factors. OBJECTIVES To pool the data regarding PMSVT after bariatric surgery and determine its incidence and risk factors. METHODS A meta-analysis and systematic review was conducted to retrieve studies on PMSVT after bariatric surgery. RESULTS A total of 41 eligible studies including 110 patients with postbariatric PMSVT were enrolled; the estimated incidence rate based on 13 studies was .4%. The use of oral contraception was reported in 35.4% of patients, previous surgery in 61.1%, smoking in 37.2%, and history of coagulopathy in 43%. PMSVT mostly occurred after sleeve gastrectomy (78.9%) and within the first postoperative month (88.9%). Pneumoperitoneum pressure was>15 mm Hg in 6% of patients. The portal vein was the most commonly affected vessel (41.5%). Prothrombin 20210 mutation and protein C/S deficiency were the most common thrombophilic conditions. Unfractionated heparin (59.1%), vitamin K antagonists (50.9%), and low molecular weight heparin (39.1%) were the most common treatments for PMSVT. The morbidity and mortality rates for postbariatric PMSVT were 8.2% and 3.6%, respectively. CONCLUSION PMSVT usually occurs within the first postoperative month and is mostly reported after sleeve gastrectomy. The portal vein is the most commonly involved vessel. A previous hypercoagulable state can be an important risk factor. Most patients can be treated with anticoagulation therapy. Further studies with comprehensive data review of patient information are required.

Bariatric manipulation of gastric arteries: A systematic review on the potential concept for treatment of obesity

BACKGROUND Gastric artery embolization (GAE) has recently received attention as a minimally invasive intervention in bariatric setting. AIMS The current systematic review aimed to gather and categorizes the existing data in the literature regarding bariatric gastric artery manipulation. This will highlight the importance of this potential concept as a therapeutic modality. METHODS A PubMed/Medline search was conducted to identify animal and human studies investigating the effect of gastric artery manipulation on weight, ghrelin, obesity, and tissue adiposity. RESULTS A total of 9 studies including 6 animal experiments with 71 subjects and 3 human studies with a total of 25 patients were retrieved. Animal subjects underwent chemical embolization while particle embolization was only used in human subjects. Five animal studies and 1 human study reported decreased ghrelin concentration. Three animal experiments and 2 human studies showed a significant weight change following GAE. There was no report regarding a serious adverse event requiring surgical or interventional management. CONCLUSION Currently, data regarding the potential role of gastric artery manipulation in decreasing the ghrelin and potential weight loss is scarce.

Comparison of two specimen retrieval techniques in laparoscopic sleeve gastrectomy: what is the role of endobag?

BackgroundLaparoscopic sleeve gastrectomy (LSG) has become a popular stand-alone treatment for morbid obesity. However, removal of the gastric specimen could be a challenging step due to its large size relative to the width of the trocar site.ObjectivesWe aimed to compare a simplified retrieval technique for extraction of the gastric specimen without an endobag with conventionally performed specimen retrieval using an endobag.MethodsA case-control study was conducted recruiting patients undergoing LSG. Patient’s demographics, preoperative characteristics, intra-operative, and postoperative variables were compared between the two groups according to the technique of gastric specimen removal.ResultsA total of 193 patients (60.6% female) were enrolled into case (n = 100) and control groups (n = 93). Mean ± SD age and BMI of patients were 35.64 ± 11.84 years and 47.28 ± 8.22 Kg/m2, respectively with no significant difference between groups. Median (25th, 75th inter-quartile), extraction time was significantly reduced in the non-endobag group compared to the endobag group (3.5 [2.5–4.5] min vs. 6.5 [3.4–8.2] min, p = 0.03).Patients of both groups had similar intra-operative and trocar site complications (hernia and wound infection) (3% for endobag group and 3.3 % for non-endobag group). The median (25–75% [IQR]) LOS was also comparable between endobag and non-endobag patients (3[2–3] vs. 3[2–4] days, p = 0.84). No difference was observed between the two groups for weight loss and comorbidity resolution.ConclusionNon-endobag technique for gastric specimen retrieval is safe and feasible with substantial saving in operative time and comparable intra-operative and postoperative outcomes to the conventional retrieval technique.

Response to the “Letter to the Editor Concerning the Publication: Efficacy of First-Time Intragastric Balloon in Weight Loss: a Systematic Review and Meta-Analysis of Randomized Controlled Trials”

We appreciate the opportunity of replying to the editorial comment on our published study entitled BEfficacy of Firsttime Intra-gastric Balloon in Weight Loss: a Systematic Review and Meta-analysis of Randomized Controlled Trials^. The aforementioned BLetter to the Editor^ has commented on our study regarding the mixed inclusion of randomized controlled trial (RCT) on air-filled and fluidfilled IGBs. Moreover, the authors mentioned that 289 patients have undergone insertion of the historical IGBs accounting for 24% of the whole population included in metaanalysis. Additionally, the letter speculates that the comparison of air-filled and fluid-filled IGBs is indeed a comparison between the modern and historical IGBs. Our meta-analysis has clearly stratified the two groups of IGB to perform a sub-group analysis to compare the weight loss outcome and complication rate between air-filled and fluid-filled IGBs. Moreover, most of the time, it is not feasible to implement a very strict criteria in the systematic literature reviews to exclude studies based on a historical basis. On the other words, although we agree that the new generation of airfilled IGBs has evolved over the last decades, these types of balloons have been continuously used as an alternative option for fluid-filled IGBs as a temporary treatment of obesity. That being said, exclusion of air-filled IGBs which have been concurrently evolved to shape the current generation of IGBs, does not seem practical. To provide an example, a recent RCT comparing fluid-filled IGBs and air-filled IGBs identified similar weight loss outcome between the two types of balloons [1]. However, it demonstrated a longer extraction time, higher deflation rate, and patient discomfort for air-filled IGB probably due to its difficult passage through the cardia and the lower pharynx. The results of this recent RCT sheds light on the fact that despite the improvement in IGBs design and shape which resulted in similar weight loss outcome, the modern air-filled balloons still require modification to avoid the spontaneous deflation and ameliorate the patient tolerance. This is in the same direction with our study finding which emphasizes on the comparable weight loss outcome of airfilled and fluid-filled IGBs but warning a higher complication rate for air-filled balloons. Excluding the study of Gliebter et al. which has used a fluid-filled type of IGB [2], it should be noted that the total number of patients pertinent to an air-filled IGB is 249 (20%) not 289 (24%). Nevertheless, such a subdivision of patients becomes meaningful only when the whole included population is pooled together in a single analysis. But, as our metaanalysis clearly shows, different sub-group analysis based on weight loss measurement unit and IGB type dilutes the weight of such a calculated sub-population. We appreciate that Geliebter et al. have used an IGBs which is made out of breast implant [2] and this type of IGBs have been abandoned long time ago by FDA. However, it is noteworthy that not all the available IGBs in the market are FDA-approved as they are mostly manufactured in the European and South American countries [3]. Furthermore, we should revoke the aim of our metaanalysis to be the comparison of IGBs versus conservative medical treatment in weight loss. With that in mind, comparison of air-filled IGBs against fluid-filled IGBs was not within the main scope of our study. In fact, the sub-group analysis based on the IGB type was for the sake of clarity of the effect of the IGB type in the weight loss outcome. * Alan A. Saber saber6231@gmail.com

Laparoscopic sleeve gastrectomy in patients with abdominoplasty: a case-control study

BACKGROUND Abdominoplasty is increasingly performed after weight loss surgery. However, performing a laparoscopic sleeve gastrectomy (LSG) after abdominoplasty poses technical challenges. OBJECTIVE The present study aimed to compare operative events and postoperative outcomes between LSG patients with and without a history of prior abdominoplasty. SETTING University hospital, Qatar. METHODS A case-control study was conducted on 2 groups of patients with (n = 33) and without (n = 69) prior abdominoplasty who underwent LSG. Patient demographics, baseline characteristics, as well as operative and postoperative events were compared between the 2 groups. RESULTS A total of 102 patients with an average age of 39.6±7.7 years and body mass index (BMI) of 42.8±5.9 kg/m2 were included. There were no significant differences between the 2 groups in terms of demographic characteristics, preoperative BMI, and co-morbidities. The number of ports required was significantly higher in the LSG patients with a history of prior abdominoplasty than in the nonabdominoplasty patients. The operation time was also significantly longer in the abdominoplasty patients than in the nonabdominoplasty patients (90.3±36.7 minutes versus 57.1±17.7 minutes; P<.0001). However, no significant differences were observed in terms of postoperative complications, length of hospital stay, and weight loss results. CONCLUSION LSG after abdominoplasty is associated with longer operative times and the need for additional port placement to overcome the decreased working space. However, operative strategies should be considered to overcome the technical challenges during LSG in patients who underwent a prior abdominoplasty.