Long-term outcomes of revisional one anastomosis gastric bypass post laparoscopic sleeve gastrectomy.

PURPOSE: Revisional bariatric surgeries following laparoscopic sleeve gastrectomy (LSG) have demonstrated a dramatic increase worldwide. Recently, one-anastomosis gastric bypass (OAGB) has become a contender as an appropriate revisional procedure; however, no long-term data currently exist on the effectiveness of it as a revisional surgery post-LSG. METHODS: A retrospective analysis was performed on all patients who underwent LSG at a public hospital in Kuwait from 2008 to 2017. A list was obtained of those who underwent revisional OAGB surgery after initial LSG, after which a phone survey was performed and demographics were analyzed. RESULTS: A total of 29 patients underwent revisional OAGB post-initial LSG, of which 89.7% were female. Prior to LSG, the mean weight of the patients was 127.5 kg, and the mean BMI was 49.0 kg/m2. The mean weight loss after initial LSG was 43.8 kg, while the average duration until patients underwent revisional OAGB was 5.3 years. The cause for revision was weight regain (86.2%) or inadequate weight loss (13.8%). Prior to undergoing revisional OAGB, the weight and BMI of the patients was 110.9 kg and 42.4 kg/m2, respectively. Revisional OAGB demonstrated a %excess weight loss of 14.5%, 31.9%, 48.0%, 56.3%, 57.2%, and 54.7% at 2 weeks, 3 months, 6 months, 1 year, 4 years, and 5 years, respectively. Twelve morbidities were reported during the follow-up period. CONCLUSION: Revisional bariatric surgery is technically demanding and may be associated with a high complication rate. However, OAGB as a revisional procedure has proven to be safe and effective in the long-term outcomes of revisional OAGB patients post-LSG.

Midterm results of revisional bariatric surgery postsleeve gastrectomy: resleeve versus bypass.

BACKGROUND: Bariatric surgery has been shown to produce the most predictable weight loss results, with laparoscopic sleeve gastrectomy (SG) being the most performed procedure as of 2014. However, inadequate weight loss may present the need for a revisional procedure. OBJECTIVES: The aim of this study is to compare the efficacy of laparoscopic resleeve gastrectomy (LRSG) and laparoscopic Roux-en-Y gastric bypass in attaining successful weight loss. SETTING: Public hospital following SG. METHODS: A retrospective analysis was performed on all patients who underwent SG from 2008-2019. A list was obtained of those who underwent revisional bariatric surgery after initial SG, and their demographic characteristics were analyzed. RESULTS: A total of 2858 patients underwent SG, of whom 84 patients (3%) underwent either a revisional laparoscopic Roux-en-Y gastric bypass (rLRYGB) or LRSG. A total of 82% of the patients were female. The mean weight and body mass index (BMI) before SG for the LRSG and rLRYGB patients were 136.7 kg and 49.9 kg/m2 and 133.9 kg and 50.5 kg/m2, respectively. The mean BMI showed a drop from 42.0 to 31.7 (P < .001) 1 year post revisional surgery for the LRSG group and 42.7 to 34.5 (P < .001) for the rLRYGB group, correlating to an excess weight loss (EWL) of 61.7% and 48.1%, respectively. At 5 years post revisional surgery, LRSG patients showed an increase in BMI to 33.8 (EWL = 45.3%), while those who underwent rLRYGB showed a decrease to 34.3 (EWL = 49.2%). Completeness of follow-up at 1, 3, and 5 years for rLRYGB and LRSG were 67%, 35%, and 24% and 45%, 21%, and 18%, respectively. CONCLUSIONS: Revisional bariatric surgery is a safe and effective method for the management of failed primary SG. LRSG patients tended to do better earlier on; however, it leveled off with those who underwent rLRYGB by 5 years.

Short-Term Results of Revisional Single-Anastomosis Gastric Bypass After Sleeve Gastrectomy for Weight Regain.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) has become the most performed bariatric procedure as of 2015. However, inadequate weight loss may present the need for revisional procedures. OBJECTIVES: The objective of this study was to analyze the efficacy of single-anastomosis gastric bypass (SAGB) in attaining successful weight loss following an initial LSG. METHODS: A retrospective analysis was performed on all patients who underwent LSG at Amiri Hospital, Kuwait from 2008 to 2017. A list was obtained of those who underwent revisional SAGB surgery after initial LSG, and their demographics were analyzed. RESULTS: A total of 31 patients underwent revisional SAGB bariatric surgery after initial LSG, of which 87.1% were female. Prior to LSG, the mean weight of the patients was 127.5 kg and the mean BMI was 49.0 kg/m2. The mean weight loss after initial LSG was 43.8 kg, while the average duration until patients underwent revisional SAGB was 5.1 years. The cause for revision was weight regain (86.2%), inadequate weight loss (10.3%), or the development of a complication (reflux) (6.5%). Prior to undergoing revisional SAGB, the weight and BMI of the patients were 110.9 kg and 42.6 kg/m2, respectively. This demonstrated a %excess weight loss of 14.5, 31.9, 48.0, and 58.9% 2 weeks, 3 months, 6 months, and 1-year post-SAGB, respectively. Three (10.3%) morbidities were reported and thereafter successfully resolved. CONCLUSION: Revisional SAGB bariatric surgery is a safe and effective method in the short-term basis for the management of inadequate primary LSG.

The safety and efficacy of the procedureless intragastric balloon.

BACKGROUND: Obesity is on a continuous rise worldwide, and with it, novel bariatric procedures have emerged. The introduction of gastric balloons has opened up a nonsurgical option for patients opting for it. However, they still require some form of sedation and endoscopy for insertion and/or removal. OBJECTIVES: The Elipse balloon is a novel creation that has managed to bypass both these procedures; therefore, the investigation into its effectiveness is of importance. SETTING: Royale Hayat, Sabah, and Amiri Hospitals, Kuwait. METHODS: This is a multicenter, prospective analysis of all patients who underwent the Elipse balloon insertion. For the duration of 4 months, weight, body mass index, and the occurrence of adverse events was documented. RESULTS: A total of 135 patients were included, with a mean age of 33.5 years. At the 4-month mark, the mean weight of the patients showed a drop of 13.0 kg (P = .000), and the mean body mass index showed a drop of 4.9 units (P = .000). The mean percent total weight loss was 15.1%. All patients reported nausea in the first day of insertion; however, 69.6% reported complete resolution by the third day. Two patients (1.5%) vomited the balloon early, 3 patients (2.2%) had to have the balloon removed early due to intolerance, 3 patients (2.2%) experienced early deflation, 18 (13.3%) patients reported episodes of diarrhea around the time of deflation, and 29 (21.5%) patients experienced colicky abdominal pain in the week of balloon deflation. One patient experienced small bowel obstruction after which the balloon was removed via laparoscopic enterotomy. CONCLUSION: This study aimed to evaluate the safety and effectiveness of the Elipse balloon in the largest population studied as of date. It was also able to demonstrate that it can be safely and successfully swallowed, filled, imaged, and passed. In addition, it effectively aided in weight loss, showing promising results.

Laparoscopic management of a small bowel obstruction secondary to Elipse intragastric balloon migration: A case report.

INTRODUCTION: The Elipse™ intragastric balloon (IGB) for weight loss is a swallowable capsule that is filled with 550mL of fluid and resides in the stomach for four months before being excreted from the gastrointestinal tract. Although initial data showed that use of this device is safe and free from serious complications, we report for the first time the successful management of an Elipse™ IGB-related adverse event. PRESENTATION OF CASE: A 41-year-old woman presented to our emergency department following two days of abdominal pain, vomiting, and constipation. Her medical history included four caesarean sections and insertion of the Elipse™ IGB 16 weeks prior to presentation. The patient was vitally stable at presentation and abdominal examination revealed a mildly distended abdomen. Plain X-ray revealed a small bowel obstruction (SBO), and a double contrast computed tomography scan showed a dilated small bowel with mild free fluid proximal to a transition zone at the distal jejunum. Laparoscopic enterotomy was performed just proximal to the obstruction site, and the balloon was visualized and extracted after it had been incised and emptied. The enterotomy incision was closed with an intracorporeal continuous absorbable suture. The patient's recovery was uneventful and she was discharged on postoperative day 4. DISCUSSION: We discuss the possible etiologies of SBO following Elipse™ IGB insertion, and present a brief literature review regarding surgical and nonsurgical management options for such cases. CONCLUSION: Although initial data showed the Elipse™ IGB to be safe, complications can occur and be managed successfully.

A prospective pilot study of the efficacy and safety of Elipse intragastric balloon: A single-center, single-surgeon experience.

BACKGROUND: Elipse™ is the least invasive IGB for weight loss that needs no sedation or endoscopy. It is a swallowable capsule filled with 550 mL of fluid, which stays in the stomach for 16 weeks and is excreted from the gastrointestinal tract. Kuwait is one of the first countries to start using Elipse™ as a weight loss device. This study aims to evaluate the efficacy and safety of Elipse™ intragastric balloon (IGB). MATERIALS AND METHODS: This is a single-center prospective pilot study of 51 Elipse™ insertions at our clinic. The patients were followed for 4 months to monitor their weight and body mass index (BMI) at 1, 2, and 4 months. Total weight loss, % excess weight loss (%EWL), % total body weight loss (%TBWL), and change in BMI and waist circumference (WC) were recorded at the end of the study. A short survey was administered to evaluate symptoms, complications, and overall satisfaction. RESULTS: Fifty-one patients participated, of which five had Elipse™ removed because of intolerance. One case vomited the balloon; one had early deflation. The total weight loss was 8.84 kg, %TBWL 10.44%, %EWL 40.84%, change in BMI 3.42 kg/m2, and the total WC reduction 8.62 cm. Symptoms after insertion were severe, whereas those during excretion were mild and self-limiting. No serious complications were recorded, and the overall satisfaction was above average. CONCLUSION: Our data proves that Elipse™ is a safe and effective device for weight loss. Nevertheless, some limitations were observed that need to be overcome for better outcomes. Larger studies are needed to support our findings.

Giant gastric lipoma presenting as GI bleed: Enucleation or Resection?

INTRODUCTION: Gastric lipomas are unusual benign lesions and account for less than 1% of all tumours of the stomach and 5% of all gastrointestinal lipomas (Thompson et al.2003; Fernandez et al. 1983 [1,2]). Although predominantly asymptomatic and indolent; they may present with gastric outlet obstruction and upper gastrointestinal (GI) bleeding owing to size and ulceration. Only a few cases have been reported, presenting large in size with massive GI bleeding (Alcalde Escribano et al. 1989; Johnson et al. 1981 [3,4]). PRESENTATION OF CASE: We report the case of a 62-year-old gentleman who presented to the emergency department with massive upper GI hemorrhage. He was initially resuscitated and stabilized. Later gastroscopy showed a large submucosal tumour (Fig. 1). Biopsy revealed adipose tissue. Computed tomography (CT) scan of the abdomen and pelvis showed a huge well defined oval soft tissue lesion measuring about 16×8×8cm. The mass noted a homogenous fat density arising from the posterior wall of stomach with no extramural infiltration (Fig. 2). The tumour was completely enucleated through an explorative gastrotomy incision (Fig. 4). DISCUSSION AND CONCLUSION: Massive bleeding secondary to a giant gastric lipoma is a rare finding of a rare disease. The majority of cases in the literature result in major gastric resection. Familiarity with its radiological findings and a high index of suspicion can lead to proper diagnosis in the acute setting. If malignancy is carefully ruled out, stomach preserving surgery is an optimal treatment option.

Approach to Poor Weight Loss After Laparoscopic Sleeve Gastrectomy: Re-sleeve Vs. Gastric Bypass.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is increasing worldwide; however, long-term follow-up results included insufficient weight loss and weight regain. This study aims at assessing the outcomes of converting LSG to laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic re-sleeve gastrectomy (LRSG). METHODS: A total of 1300 patients underwent LSG from 2009 to 2012, of which 12 patients underwent LRYGB and 24 patients underwent LRSG in Al-Amiri Hospital alone. Data included length of stay, percentage excessive weight loss (EWL%), and body mass index (BMI). RESULTS: Twenty-four patients underwent conversion from LSG to LRSG, and 12 patients underwent conversion from LSG to LRYGB due to insufficient weight loss and weight regain. Eighty-five percent were females. The mean weight and BMI prior to LSG for the LRYGB and LRSG patients were 136.5 kg and 52, and 134 kg and 50, respectively. The EWL% after the initial LSG was 37.9 and 43 %, for LRYGB and LRSG, respectively. There were no complications recorded. Results of conversion of LSG to LRYGB involved a mean EWL% 61.3 % after 1 year (p value 0.009). Results of LRSG involved a mean EWL% of 57 % over interval of 1 year (p value 0.05). Comparison of the EWL% of LRYGB and LRSG for failed primary LSG was not significant (p value 0.097). CONCLUSION: Following our algorithm, revising an LSG with an LRSG or LRYGB for poor weight loss is feasible with good outcomes. Larger and longer follow-up studies are needed to verify our results.

A case of de Garengeot hernia: the feasibility of laparoscopic transabdominal preperitoneal hernia repair.

INTRODUCTION: de Garengeot hernia is described as the presence of an appendix in a femoral hernia. This rare hernia usually presents with both diagnostic and therapeutic dilemmas. PRESENTATION OF CASE: We report a case of a 59 year-old woman with a one-year history of a right irreducible femoral hernia. She underwent diagnostic laparoscopy with an intraoperative diagnosis of de Garengeot hernia. This was followed by a laparoscopic transabdominal preperitoneal (TAPP) approach for hernia repair. DISCUSSION: The long-standing presentation of de Garengeot hernia is seldomly reported in literature. There has been no standard approach of treatment for de Garengeot hernias described, possibly due to the rarity of this condition. The unusual presentation of the hernia prompted us to undergo a diagnostic laparoscopy first, during which the appendix was seen incarcerated in a femoral hernia sac. We were easily able to proceed for a laparoscopic TAPP approach for hernia repair without the need for conversion to an open repair. CONCLUSION: We were able to obtain an accurate diagnosis of an appendix within a long-standing irreducible femoral hernia through diagnostic laparoscopy followed by transabdominal preperitoneal (TAPP) approach for hernia repair. We would like to underline the usefulness of laparoscopy as a valuable tool in the diagnosis and treatment of this unusual presentation of groin hernias.

A case of acute mesentero-axial gastric volvulus in a patient with a diaphragmatic hernia: experience with a laparoscopic approach.

Gastric volvulus is an uncommon but serious surgical condition mandating an early diagnosis and surgical intervention. It may present either acutely or chronically with epigastric pain, retching and vomiting. There are two types of gastric volvulus: organo-axial and mesentero-axial. We report a case of a mesentero-axial gastric volvulus in a 49-year-old woman with a left-sided diaphragmatic hernia. She presented with a significant epigastric pain and vomiting. A flexible upper endoscopy, a barium meal and a contrast-enhanced computed tomography imaging had confirmed the diagnosis. She was treated with a laparoscopic mesh repair of the diaphragmatic defect followed by a gastropexy. She had an uneventful postoperative course and was asymptomatic thereafter.

A case of a colocutaneous fistula: A rare complication of mesh migration into the sigmoid colon after open tension-free hernia repair.

INTRODUCTION: The Lichtenstein technique is commonly used in inguinal hernia repair and a polypropylene mesh is the most frequently used mesh. Mesh migration into the colon has been rarely reported in the literature. Here we report a case of a colocutaneous fistula that developed following delayed mesh migration into the sigmoid colon. PRESENTATION OF CASE: A 52-year-old man undergone Lichtenstein repair for left direct inguinal herniain 2008. Three years later, he presented complaining of rectal bleeding and concurrent bloody discharge from the hernia repair scar. Colonoscopy identified an internal fistulous orifice with intraluminal extrusion of the polypropylene mesh. Furthermore, abdominal ultrasound revealed a fistulous tract extending from the sigmoid colon to the anterior abdominal wall, and a fistulogram confirmed the findings. Open sigmoidectomy and resection of the abdominal wall with the fistula tract was performed, and BIO-A(®) tissue reinforcement meshwas placed. His postoperative course was unremarkable and was discharged on postoperative day 3. DISCUSSION: Mesh migration after mesh inguinal hernia repair is unpredictable. A previous report has presented complications related to prosthetics in hernia repair, such as infection, contraction, rejection, and, rarely, mesh migration.Mesh migration may occur as an early or late complication after hernioplasty. CONCLUSION: During hernia repair, the surgeon should carefully check for a sliding hernia, which may contain the sigmoid colon within the sac, because failure to identify this hernia may lead to direct contact between the mesh and the colon, which may cause pressure necrosis and fistula formation followed by mesh migration.