Management and outcomes of gastric leak after sleeve gastrectomy: results from the 2010-2020 national registry / 中华医学杂志(英文版)

BACKGROUND@#Management of gastric leak after sleeve gastrectomy (SG) is challenging due to its unpredictable outcomes. We aimed to summarize the characteristics of SG leaks and analyze interventions and corresponding outcomes in a real-world setting.@*METHODS@#To retrospectively review of 15,721 SG procedures from 2010 to 2020 based on a national registry. A cumulative sum analysis was used to identify a fitting curve of gastric leak rate. The Kaplan-Meier method and log-rank tests were performed to calculate and compare the probabilities of relevant outcomes. The logistic regression analysis was conducted to determine the predictors of acute leaks.@*RESULTS@#A total of 78 cases of SG leaks were collected with an incidence of 0.5% (78/15,721) from this registry (6 patients who had the primary SG in non-participating centers). After accumulating 260 cases in a bariatric surgery center, the leak rate decreased to a stably low value of under 1.17%. The significant differences presented in sex, waist circumference, and the proportion of hypoproteinemia and type 2 diabetes at baseline between patients with SG leak and the whole registry population ( P = 0.005, = 0.026, <0.001, and = 0.001, respectively). Moreover, 83.1% (59/71) of the leakage was near the esophagogastric junction region. Leakage healed in 64 (88.9%, 64/72) patients. The median healing time of acute and non-acute leaks was 5.93 months and 8.12 months, respectively. Acute leak (38/72, 52.8%) was the predominant type with a cumulative reoperation rate >50%, whereas the cumulative healing probability in the patients who required surgical treatment was significantly lower than those requring non-surgical treatment ( P = 0.013). Precise dissection in the His angle area was independently associated with a lower acute leak rate, whereas preservation ≥2 cm distance from the His angle area was an independent risk factor.@*CONCLUSIONS@#Male sex, elevated waist circumference, hypoproteinaemia, and type 2 diabetes are risk factors of gastric leaks after SG. Optimizing surgical techniques, including precise dissection of His angle area and preservation of smaller gastric fundus, should be suggested to prevent acute leaks.

One anastomosis gastric bypass: recent global advancement / 中华消化外科杂志

Bariatric surgery is effective on obesity, which can significantly improve the metabolic diseases of obesity patients, especially the type 2 diabetes. However, the surgical proce-dures of bariatric and metabolic surgery are still evolving and in progress. One anastomosis gastric bypass (OAGB) is the latest bariatric surgery recognized by the international bariatric and metabolic surgery community. The authors review the relevant literatures at home and abroad, and introduce the development history, surgical skills, clinical efficacy, status quo and adaptability of OAGB.

Diagnosis and treatment of emergency inguinal hernia / 中华消化外科杂志

Objective:To investigate the diagnosis and treatment of emergency inguinal hernia.Methods:The retrospective cross-sectional study was conducted. The clinical data of 236 patients with emergency inguinal hernia who were admitted to the First Affiliated Hospital of Soochow University from January 2015 to May 2020 were collected. There were 194 males and 42 females, aged (69±30)years. Hospitalized patients received routine blood biochemistry test and imaging examinations for evaluation of characteristics of hernia contents and intestinal obstruction. Manual reduction and surgical treatment were selected according to the conditions of patients. Observation indicators: (1) treatment; (2) follow-up. Follow-up using outpatient examination and telephone interview was performed to detect hernia recurrence and late-onset mesh infection up to August 2020. Measurement data were described as M (range) or M ( P25, P75), and comparison between groups was analyzed using the Wilcoxon rank sum test. Count data were represented as absolute numbers, and comparison between groups was done using the chi-square test. Results:(1) Treatment: of the 236 patients, 106 cases had successful manual reduction, 124 cases underwent emergency operation, 6 cases refused surgery. ① For 106 cases with successful manual reduction (including 4 cases guided by B-ultrasonography), the manual reduction time was 5 minutes (2 minutes,7 minutes). Ninety-three of 106 patients underwent selective operation after manual reduction, including 89 cases with indirect hernia, 2 cases with direct hernia and 2 cases with compound hernia. The time to selective operation was 3 days(2 days,5 days) after manual reduction. Patients underwent mesh repair, of which the operation time, volume of intraoperative blood loss, time to postoperative first flatus, duration of postoperative hospital stay were 44 minutes (29 minutes, 66 minutes),10 mL(5 mL,20 mL), 1 day(1 day,2 days), 1 day(1 day,2 days), respectively. Eleven patients didn't undergo selective operation. Two patients with abdominal pain and fever after manual reduction were diagnosed with perforation of intestine by emergency surgical exploration, and then underwent partial intestinal resection combined with high ligation of hernial sac. ② There were 93 of 124 patients undergoing emergency operation with indirect hernia, 18 cases with femoral hernia, 6 cases with obturator hernia, 6 cases with compound hernia and 1 case with direct hernia. There were 54 of 124 patients undergoing open operation, including 21 cases with Bassini surgery, 18 cases with Lichtenstein surgery, 9 cases with Mc Vay surgery, 6 cases with high ligation of hernia sac. There were 70 patients undergoing laparoscopic operation, including 57 cases with laparoscopic transperitoneal preperitoneal hernia repair (TAPP), 10 cases with laparoscopic explora-tion + tissue repair and 3 cases with laparoscopic exploration + closure of inner inguinal ring. The operation time, volume of intraoperative blood loss, time to postoperative first flatus, cases with short-term postoperative complications were 60 minutes (50 minutes,76 minutes), 20 mL(14 mL,30 mL), 2 days(1 day,2 days), 15 cases for patients undergoing open surgery, respectively. The above indicators were 56 minutes (47 minutes,77 minutes), 20 mL(10 mL,25 mL), 2 days(1 day,2 days), 21 cases for patients under-going laparoscopic surgery. There was no significant difference in the above indicators between the two groups ( Z=?0.88, ?1.37, ?1.56, χ2=0.07, P>0.05). Cases with intraoperative placement of mesh and duration of hospital stay were 18 cases and 5 days(3 days,8 days) for patients undergoing open surgery, versus 57 cases and 3 days(2 days,5 days) for patients undergoing laparoscopic surgery, showing significant differences between the two groups ( χ2=29.50, Z=?4.32, P<0.05). (2) Follow-up: of 236 patients, 192 were followed up for 2?60 months, with a median follow-up time of 19 months. Seven patients had recurrence of hernia after emergency operation, including 3 with high ligation of the hernia sac, 2 with Bassini surgery, 1 with Lichtenstein surgery, and 1 with laparoscopic exploration + closure of inner inguinal ring. One patient with late-onset mesh infection after Lichtenstein surgery was improved after mesh removal. No long-term complications such as hernia recurrence or late-onset mesh infection occurred to the 184 patients. Conclusions:Emergency inguinal hernia had different state of illness, manual reduction is suitable for partial patients with incarceration. Surgery is the first choice, and the surgical procedure needs to be individually selected.

Day-case laparoscopic cholecystectomy: analysis of 59 consecutive patients / 国际外科学杂志

Objective To evaluate the feasibility and outcome of laparoscopic cholecystectomy as a overnight procedure in China.Methods The data of 59 consecutive patients who had undergone outpatient laparoscopic cholecystectomy between Januaiy 2013 and January 2015.All the patients were operated in the morning hours and discharged during 24 hours after operation.They were contacted by telephone 3 days subsequent to surgery and were seen in the outpatient unit 7 days after.Results Fifty-nine laparoscopic cholecystectomies were performed.No Conversion to open surgery case.The average operation time was 25 minutes,and restore semi-liquid diet 6 hours after the operation All the 59 patients were discharged during 24 hours after operations.None of the patients had an emergency readmission.None of the patients had complications 7 days after discharged.The average payment was 8 240 yuan.Conclusion These results suggest that laparoscopic cholecystectomy can be routinely performed as a overnight procedure.

Clinical efficacy of laparoscopic transabdominal preperitoneal hernia repair and risk analysis affecting postoperative complications / 中华消化外科杂志

Objective To explore the clinical efficacy of laparoscopic transabdominal preperitoneal (TAPP) hernia repair and risk factors affecting postoperative complications.Methods The retrospective casecontrol study was conducted.The clinical data of 595 patients who received laparoscopic TAPP hernia repair in the First Affiliated Hospital of Soochow University from February 2008 to August 2016 was collected.Operations were performed by the same doctors' team.Observation indicators:(1) surgical situations;(2) postoperative situations;(3) follow-up situations;(4) risk factors affecting complications after laparoscopic TAPP hernia repair.Follow-up using outpatient examination and telephone interview was performed to detect the recovery time of non-restricted activity,postoperative complications and hernia recurrence up to February 2017.Measurement data with normal distribution were represented as (x)±s.The univariate analysis and multivariate analysis were done using the chi-square test and Logistic regression model.Results (1) Surgical situations:595 patients underwent laparoscopic TAPP hernia repair using the heavy meshes.Overall operation time and overall volume of blood loss were (55±25) minutes and (7±5)mL,including operation time of (50±20)minutes in 502 unilateral hernias and operation time of (81 ± 29)minutes in 93 bilateral hernias.Of 595 patients,34 had incarcerated hernia,the contents of hernia:greater omentum,small intestine and sigmoid colon were detected in 21,11 and 2 patients,respectively,with an incarcerated time of 2-21 hours;4 with incarcerated hernia induced small intestinal necrosis received laparoscopy-assisted small intestinal resection ± anastomosis,1 with sigmoid colon necrosis received necrotic sigmoid canal resection ± sigmoidostomy and 29 received repair after the contents restoration of hernia.Operation time and volume of intraoperative blood loss in 34 patients with incarcerated hernia were (84 ± 39)minutes and (12±6) mL.Thirteen of 595 patients (10 with indirect hernia and 3 with direct hernia) had recurrent hernia,and operation time and volume of intraoperative blood loss were (75±-26)minutes and (10± 5)mL.(2) Postoperative situations:time to initial exsufflation of 595 patients was (19± 12)hours.Of 595 patients,590 took fluid diet at 6 hours postoperatively and 5 undergoing enterectomy took fluid diet at 24 hours postoperatively.The pain score at 1 day postoperatively and duration of hospital stay were respectively 2.5± 1.4 and (2.1± 1.9)days.(3) Follow-up situations:of 595 patients,593 recovered non-restricted activity at 2 weeks postoperatively and 2 didn't recover non-restricted activity at 2 weeks postoperatively.Of 595 patients,542 were followed up for 6-60 months,with a median time of 31 months.Fifty-seven,25,13 and 1 patients were respectively complicated with seroma,surgical pain,urinary retention and enteroparalysis,they were improved by symptomatic treatment,and the same patient can have multiple complications.There were no severe complications which needed surgical intervention,such as vascular injury,damnify of intestinal canal and poke hole hernia.Of 2 patients with recurrence of hernia,1 with right indirect hernia had recurrence of direct hernia and then received Lichtenstein tension-free hernia repair,and 1 received treatment in other hospital.(4) Risk factors affecting complications after laparoscopic TAPP hernia repair:results of univariate analysis showed that age,diameter of hernia sac,incarcerated hernia,recurrent hernia,operation time and volume of intraoperative blood loss were related factors affecting complications after laparoscopic TAPP hernia repair (x2 =6.657,55.296,44.305,5.253,117.461,100.722,P＜0.05).Results of multivariate analysis showed that diameter of hernia sac ≥ 4 cm,incarcerated hernia,operation time ≥ 100 minutes and volume of intraoperative blood loss ≥ 10 mL were independent risk factors affecting complications after laparoscopic TAPP hernia repair (OR =3.610,11.315,12.401,7.346,95％ confidence interval:2.009-6.486,3.579-35.772,5.408-28.437,3.739-14.434,P＜ 0.05).Conclusion Laparoscopic TAPP approach for inguinal hernia is safe and effective,and diameter of hernia sac ≥4 cm,incarcerated hernia,operation time ≥ 100 minutes and volume of intraoperative blood loss ≥ 10 mL are independent risk factors affecting complications after laparoscopic TAPP hernia repair.

Prevention and management of complications after laparoscopic gastric bypass operation / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the prevention and management of complications after laparoscopic gastric bypass (LRYGB) operation.</p><p><b>METHODS</b>Clinical data of 82 cases (9 cases of simple obesity, 55 of obesity complicated with type 2 diabetes, 18 of non-obesity simple type 2 diabetes) undergoing LRYGB in our hospital between May 2010 to May 2013 were retrospectively analyzed. Cause of complication was explored and experience was summarized in order to provide reference to clinical practice.</p><p><b>RESULTS RESULTS</b>There was no mortality and re-admission within 30 days after procedures. Nine patients developed complications. Punctural injury occurred in 1 patient(1.2%) and laparotomy surgery was performed to stop bleedind. Hemorrhage was observed in 4 patients(4.9%, one patients had concurrent anastomotic ulcer) and was cured by either gastrolavage with solution of epinephrine and normal saline or cautery under gastroscope. Anastomotic leakage occurred in one patient(1.2%) which was cured by placing nose-gastro tube immediately after diagnosis of leakage and total enteral nutrition for one month. Anastomotic stricture occurred in 1 patient(1.2%), general peritonitis occurred after balloon dilation and laparoscopic repair was performed to repair the perforation due to dilation. Gastroplegia occurred in two patients(2.4%) and was cured after fasting, gastrointestinal decompression, usage of gastrointestinal prokinetic medications and enteral nutrition. All complications were cured at last. BMI of all patients dropped in vary extent after a follow up of 19.0-35.0(29.1±5.4) months.</p><p><b>CONCLUSIONS</b>Complication after LRYGB operation may be prevented by active preoperative preparation, surgical precision, and intensive postoperative care. Even complications occur, the corresponding treatments are effective.</p>

Comparison between endoscopy and laparoscopy in resection of gastric stromal tumor / 中华消化内镜杂志

Objective To compare the feasibility and safety of endoscopy with laparoscopy and without for gastric stromal tumor.Methods A retrospective and comprehensive analysis was made based on the clinical data of endoscopic (53 cases) and laparoscopic (39 cases) resection for gastric stromal tumor (diameter ＜ 3 cm with clear boundary),by comparing the operation time,intraoperative blood loss,indwelling time of postoperative gastric tube,recovery time of bowel functions,postoperative complications,hospitalization time,metastasis,recurrence rate.Results Compared with the laparoscopic group,the endoscopic group required shorter operation time [50(48-58) min VS 70 (50-95) min,U =1575.00,P ＜ 0.01],less intraoperative blood loss [10 (5-15) ml VS 20 (20-30) ml,U =1794.00,P ＜ 0.01],earlier recovery of bowel functions [18 (8-36) h VS 24 (20-40) h,U =1666.00,P ＜ 0.01],hospitalization time,indwelling time of the postoperative gastric tube and postoperative complications showed no statistical difference (P ＞ 0.05).The postoperative follow-up time were (27 + 15) and (24 + 11) months in the endoscopic and laparoscopic group,respectively (t =0.3084,P ＞ 0.05).During the follow-up,no tumor recurrence or distant metastasis was discovered,nor was death of gastric stromal tumor.Conclusion Endoscopy without the assist of laparoscopy for the gastric stromal tumor,whose diameter is less than 3 cm with clear boundary,is safe and less invasive,and leads to quick recovery.

The impact of virtual hepatectomy and computer-assisted risk analysis on surgical planning and intraoperative strategy for major hepatic resection / 中华肝胆外科杂志

Objectives To evaluate the impact of virtual hepatectomy and computer-assisted risk analysis on surgical planning and intraoperative strategy for major hepatectomy.Methods Twentytwo consecutive patients (17 males and 5 females) were admitted to the hospital from January to December in 2010 for complicated major hepatectomy.CT scanning was performed with 64-MSCT.All the data of imaging were transferred to the Myrian(R) XP-Liver system (IntrasenseR,France).The following steps were undertaken by a radiologist and a surgeon majoring in liver surgery: step 1,image analysis and 3-D reconstruction; step 2,virtual resection and liver volumetry; step 3,computer-assisted risk analysis for hepatic dysfunction,followed by adjustment of the operative planning.Results The three-dimensional reconstruction models of the liver by the Myrian(R) XP-Liver system were visualized.The ideal simulation effect was achieved comparing the virtual imaging with the actual operation.Of the 22 patients who underwent complicated major hepatectomy,complete tumor removal (R0 resection) was achieved in 20 patients.There were 2 patients who received a R1 resection as microscopic tumor cells were found at the cutting margin of the right portal vein and bile duct.No patient died during the hospital stay.After computer-assisted risk analysis,the operative planning and surgical strategies were changed in 6 patients.Conclusions The application of the hepatic three-dimensional reconstruction and virtual hepatectomy using the Myrian(R) XP-Liver system provided important preoperative data for good preoperative planning and intraoperative strategy in complex hepatectomy.

Surgical management of unsuspected gallbladder carcinoma after laparoscopic cholecystectomy / 中国医师进修杂志

Objective To investigate the surgical management of unsuspected gallbladder carcinoma (UGC) after laparoscopic cholecystectomy ( LC ). Method The clinical data of 11 cases of UGC incidently found after LC from October 2003 to August 2009 were retrospectively analyzed. Results According to Nevin staging, 2 cases were stage Ⅰ , 6 cases were stage Ⅱ , 2 cases were stage Ⅲ and 1 case was stage Ⅳ.Four cases were treated by LC,including 2 cases with stage Ⅰ and 2 cases with stage Ⅱ ;another 7 cases were treated by radical resection after LC. All patients were followed up for 1-66 months after operation, 2 cases with stage Ⅰ were observed alive up; 2 cases with stage Ⅱ treated by LC died less than 3 years after operation, 3 of the 4 cases with stage Ⅱ treated by radical resection were alive up, only 1 died in 21 months after operation; 2 cases with stage Ⅲ died in 8 months and 10 months respectively, 1 case with stage Ⅳ died in 1 month after operation. Conclusions It is difficult to diagnose the UGC preoperatively. LC is sufficient for patients with Nevin stage Ⅰ , radical resection after LC is required for patients with stage Ⅱ or more advanced stage. If tumors are located in the neck of gallbladder, radical resection is required regardless of their stage.