Routine Upper Gastrointestinal Fluoroscopy Before Laparoscopic Sleeve Gastrectomy: Is It Necessary?

BACKGROUND: Controversy exists regarding the clinical utility of routine preoperative upper gastrointestinal (GI) fluoroscopy in morbid obese patients undergoing laparoscopic sleeve gastrectomy (LSG). The aim of our study was to determine the efficacy of these studies in detecting hiatal hernias (HH). METHODS: The institution's prospectively maintained, IRB-approved database was retrospectively queried to identify all consecutive patients who underwent LSG between 2011 and 2017. All patients underwent routine preoperative upper GI fluoroscopy. Reports from all imaging studies were retrospectively reviewed and compared to the presence of an intraoperative HH. RESULTS: During the study period, a total of 1810 patients (854 males, 956 females) underwent LSG at our institution. Mean age was 40.95 ± 13 years (range 11-75), and mean BMI was 42.8 ± 5 kg/m2 (range 30-86). The overall prevalence of HH was 11.1% (201 patients). All HHs detected were repaired. Considering the intraoperative identification of HH the gold standard for diagnosis, the sensitivity and specificity of preoperative UGI fluoroscopy for HH detection were 32% (66/201) and 94% (1512/1609), respectively. The median operative time was significantly longer when concomitant LSG and HH repair was performed compared to LSG alone (76 min vs. 55 min, p < 0.001, respectively). The foreknowledge of HH had no influence on the median operative times (77 min vs. 75 min, predicted vs. incidental, respectively, p = 1.34). HH repair did not affect the complication rate (p = 0.3). CONCLUSION: Routine preoperative upper GI fluoroscopy holds a low sensitivity for HH detection. Health policy regulators should consider omitting this exam from routine preoperative evaluation for bariatric patients.

Results of conversion of gastric banding to gastric bypass in patients between 50 and 60 years of age are similar to those observed in younger patients.

BACKGROUND: The effect of age and gender on outcomes of revisional bariatric surgery has not been assessed. METHODS: A retrospective analysis of patients undergoing revision from laparoscopic adjustable gastric banding (LAGB) to laparoscopic roux en Y gastric bypass (LRYGB) between 2007 and 2017 was performed. Patients were divided according to gender and age (<50 and ≥ 50 years), and the outcomes of the subgroups were compared. RESULTS: During the study period, 161 revisional LRYGBs were performed. Postoperative percentage of total body weight loss was comparable between the subgroups. No significant difference was observed between the groups in the improvement/resolution of comorbidities. Overall early complication rates were comparable, however major postoperative bleeding was more common in older patients (6.7 vs. 0.9%, p = 0.03). More late complications were demonstrated in females when compared to males (14.3 vs. 2.0%, p = 0.02). CONCLUSIONS: Revisional LRYGB after failed LAGB yields acceptable results, regardless of patient gender and age.

A comparison between one- and two-stage revisional gastric bypass.

BACKGROUND: The safety of performing a one-stage revision from laparoscopic adjustable gastric banding (LAGB) to laparoscopic Roux-en-Y gastric bypass (LRYGB) has been questioned. The objective of this study was to compare safety and outcomes of one-stage versus two-stage revisional LRYGB performed after failed LAGB. METHODS: A retrospective analysis of all patients undergoing revisional LRYGB after failed LAGB between January 2007 and March 2017 was performed. Patients undergoing one- and two-stage revisions were compared. The primary outcome assessed was the early complication rate, while secondary outcomes included late complications, weight loss, and improvement of comorbidities. RESULTS: During the study period, 161 revisional LRYGB's were performed, including 121 one-stage and 40 two-stage procedures. Baseline demographic data, BMI and presence of comorbidities were similar between the groups. In patients undergoing a two-stage procedure, band slippage, port infection, and erosion were more commonly cited as indications for revision. Similar early complication rates were demonstrated between the groups. However, late complications were more common in the two-stage group (20.0% vs. 7.4%, P = 0.03), including higher rates of gastro-gastric fistula (5.0% vs. 0%, P = 0.01) and anemia (10.0% vs. 1.1%, P = 0.02). Three-fourths of the cohort had a follow-up of more than 6 months, and the two groups demonstrated similar weight loss results and improvement/resolution of comorbidities. CONCLUSION: The performance of one-stage revisional LRYGB after failed LAGB seems to be a safe procedure, with noninferior outcomes when compared to a two-stage revisional procedure. It is a valid option, except in cases of mechanical and infectious band complications.

Not All Leaks Are Created Equal: a Comparison Between Leaks After Sleeve Gastrectomy and Roux-En-Y Gastric Bypass.

INTRODUCTION: It is commonly stated in bariatric surgical forums that leaks following laparoscopic sleeve gastrectomy (LSG) are more difficult to manage than those following laparoscopic roux-en-Y gastric bypass (LRYGB). However, no previous study has provided a thorough comparison of leak management following these two operations. METHODS: Our database was retrospectively reviewed to identify patients with leak following LSG and LRYGB performed between January 2007 and December 2017. RESULTS: Postoperative leak was diagnosed in 16/2132 (0.75%) LSG and 9/595 (1.5%) LRYGB patients. More of the LRYGB leaks had undergone revisional surgeries (66.7 vs. 6.3%, p < 0.001), and were diagnosed in the index admission (77.8 vs. 18.7%, p = 0.002). The mean time between the bariatric operation and the diagnosis of leak was 6.0 days in LRYGB and 26.2 days in LSG patients (p = 0.097). Approximately two thirds of each group were initially treated with laparoscopic exploration and drainage. Subsequent endoscopy was utilized more commonly in LSG patients (87.5 vs. 22.2%, p < 0.001). Drainage alone (laparoscopic or percutaneous) eventually led to leak resolution in more LRYGB patients (66.7 vs. 18.8%, p = 0.02), while endoscopic intervention led to resolution in more LSG patients (37.5 vs. 0%, p = 0.04). The mean time between leak diagnosis and its resolution was 57.8 and 44.2 days, for LSG and LRYGB patients, respectively. CONCLUSION: The diagnosis of leak tends to be earlier in LRYGB patients. Endoscopic therapies are more frequently required in the management of leaks following LSG, while in those following LRYGB, drainage alone leads to resolution of leak in the majority of cases.

Outcomes of Sleeve Gastrectomy in Septuagenarians.

BACKGROUND: Few previous studies have assessed the safety of bariatric surgery in septuagenarians. METHODS: A retrospective analysis of all patients 70 years or older who underwent laparoscopic sleeve gastrectomy at our institution between 2012 and 2017 was performed. This group was compared to a matched cohort of younger LSG patients (18-50 years) who were operated during the same time period. RESULTS: Thirty septuagenarian LSG patients were compared to 60 younger patients. Gender distribution, preoperative weight, and preoperative body mass index (BMI) were comparable, although patients in the older age group suffered from more preoperative comorbidities (100 vs. 51.7%, p < 0.001). Operative time was longer (77.2 vs. 57.3 min, p = 0.005) and more hiatal hernias were repaired (46.7 vs. 8.3%, p < 0.001) in the older age group. Intraoperative complications occurred more in the older age group (6.7 vs. 0%, p = 0.04) but the overall complication rate (13.3 vs. 5.0%, p = 0.17) and the postoperative complication rate (10.0 vs. 5.0%, p = 0.38) were comparable. After a mean follow-up period of 31.3 and 33.5 months, the percentage of total body weight loss was 24.6 and 28.3% for the older and younger patients, respectively (p = 0.11). Rates of improvement/remission of comorbidities were comparable between the groups. CONCLUSIONS: In a carefully selected group of severely obese patients ≥ 70 years old, LSG may be safe, with acceptable postoperative complication rates, weight loss results, and improvement in comorbidities.

Conversion of Laparoscopic Adjustable Gastric Banding to Gastric Bypass: a Comparison to Primary Gastric Bypass.

INTRODUCTION: Laparoscopic adjustable gastric banding (LAGB) has a considerable failure rate. Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the rescue options. This study aims to compare the complication rates and outcomes between LAGB converted to LRYGB and primary LRYGB. MATERIALS AND METHODS: A retrospective analysis was performed in all patients converted from LAGB to LRYGB between January 2007 and March 2017. This group was compared to a matched cohort of primary LRYGB patients operated during the same period. Early and late complications, weight loss, and improvement of comorbidities were analyzed. RESULTS: One hundred sixty-one revisional LRYGB patients were compared to a similar number of primary LRYGB patients. Preoperative age, gender distribution, weight, and BMI were comparable. Mean operative time was longer in the revisional group (137.7 vs. 112.7 min, respectively, P < 0.001). The overall early complication rates were comparable between the groups (7.5 vs. 11.8%, P = 0.16), including postoperative leak rate (0.62%). Follow-up of at least 6 months was attained in 78% of the patients. Revisional cases demonstrated less weight loss (61.5 vs. 73.5%EWL, respectively, P = 0.004) and slightly less improvement of comorbidities (75.0 vs. 85.7%, respectively, P = 0.09). The late complication rate was comparable (8.1 vs. 8.1%, P = 1.0). CONCLUSION: Albeit longer operating time, revision of LAGB to LRYGB is a safe procedure, with similar complication rates when compared to primary LRYGB. Although revisional LRYGB does result in less weight loss than primary LRYGB, the procedure's safety makes it a very plausible option as a rescue operation for failed LAGB.