Two clues make a proof: EUS-directed transgastric ERCP in twice-surgically altered anatomy-Roux-en-Y gastric bypass conversion of a sleeve gastrectomy.

Video 1EUS-directed transgastric ERCP in twice-surgically-altered anatomy: Roux-en-Y gastric bypass conversion of a sleeve gastrectomy.

Sleeve Gastrectomy with Rossetti Fundoplication Increases Lower Esophageal Sphincter Tone Preventing Gastroesophageal Reflux Disease: High-Resolution Manometry Assessment.

Background: Laparoscopic sleeve gastrectomy (LSG) is associated with the long-term development of gastroesophageal reflux disease (GERD). Recent studies on LSG with fundoplication showed a lower rate of postoperative GERD than LSG alone; however, there is a lack of objective instrumental data in the literature. This study aimed to evaluate whether and how fundoplication associated with Sleeve Gastrectomy affects the esophagogastric physiology. Materials and Methods: This prospective observational study included 20 patients with morbid obesity, GERD, and lower esophageal sphincter (LES) hypotonia. All the patients underwent LSG with Rossetti fundoplication. High-resolution manometry was performed pre- and postoperatively. All the patients completed the 6 months follow-up. Results: The fundoplication increased LES tone in all patients. The increase in the LES tone was statistically significant (330% increase). The integrated relaxation pressure and the distal contractile integral both increased accordingly, indicating an increased esophageal effort to pass through the modified esophagogastric junction. Conclusion: Rossetti fundoplication associated with LSG increased LES tone and decreased the chance of developing long-term GERD after LSG.

Laparoscopic sleeve gastrectomy with Rossetti fundoplication: long-term (5-year) follow-up.

BACKGROUND: Gastroesophageal reflux disease (GERD), including erosive esophagitis, is highly prevalent in the obese population. Barrett's esophagus is the consequence of untreated GERD. Laparoscopic sleeve gastrectomy is one of the most frequently performed bariatric procedures. This study presents results after 5 years of follow-up of combined LSG and Rossetti fundoplication for the treatment of GERD, esophagitis, and Barrett's esophagus in patients with morbid obesity. OBJECTIVE: To evaluate long-term results after sleeve gastrectomy with Rossetti fundoplication. SETTING: Public university hospital in Italy. METHODS: Since January 2015, more than 450 patients with obesity underwent sleeve gastrectomy with a Rossetti fundoplication procedure as part of prospective studies underway at our center performed by 4 different expert bariatric surgeons. Currently, 127 patients have a follow-up of 5 years or more. RESULTS: Mean patient age was 42.9 ± 10.3 years, and mean body mass index was 42.4 ± 6.1 kg/m2. In total, 74.8% of patients were experiencing GERD before surgery. In 29 of 127 patients (22.8%), preoperative gastroscopy showed signs of esophagitis and/or Barrett's esophagus. In particular, 23 of 127 patients (18.1%) had grade A esophagitis, 2 of 127 (1.6%) had grade B, 2 of 127 (1.6%) had grade C, and 2 of 127 (1.6%) had Barrett's esophagus. Mean operative time was 51 ± 21 minutes. No intraoperative complications or conversions were reported. A regular postoperative course was seen in 91.3% of patients. Sixty months after surgery, more than 95% of patients did not experience any reflux symptoms. Percent total weight loss at follow-up was comparable with that with sleeve gastrectomy. Endoscopic follow-up demonstrated improvement of esophagitis lesions (including Barrett's esophagus) present in the preoperative setting. CONCLUSION: Laparoscopic sleeve gastrectomy with Rossetti fundoplication is well tolerated, feasible, and safe in patients with obesity, providing adequate weight loss results and complete resolution of clinical signs of GERD. We have recorded an improvement in esophagitis lesions present at preoperative gastroscopy and complete resolution of Barrett's esophagus within 5 years of follow-up.

Comparison of Laparoscopic Sleeve Gastrectomy Bleeding and Leakage Rates in Four Staple-Line Reinforcement Methods: A Prospective Observational Study.

Introduction: Staple-line bleeding and gastric leakage are the most serious complications of laparoscopic sleeve gastrectomy (LSG). Reinforcement of the staple line is reported to be a method to reduce these complications rates, but the question of which method is preferable is a matter of controversy in the literature. In this study, we compared different staple-line reinforcement methods to assess their efficiency in preventing staple-line bleeding and leakage. Materials and Methods: Two hundred patients eligible for LSG were enrolled in the study and randomized into five groups based on the reinforcement method used during surgery: no reinforcement, oversewing using 3-0 polydioxanone (PDS) suture, oversewing using 4-0 barbed absorbable closure device (V-Lock), fibrin sealant glue, and buttress material. Intraoperative and postoperative complications were recorded and analyzed. Differences were considered statistically significant for P < .05. Results: The no-reinforcement group showed higher bleeding rates (20%), although only 2.5% of the patients required reintervention. All groups using staple-line reinforcement showed better outcomes in bleeding rates (P < .05). No statistically significant differences were observed among the groups in terms of the leakage rate, reintervention rate, intraoperative complications, and operative times. Conclusion: The reinforcement of the staple line decreased the bleeding rate in sleeve gastrectomy but did not affect the gastric leakage rate.

An Unexpected High Rate of Internal Hernia in Our OAGB Experience as Revisional Surgery for Morbid Obesity.

Introduction: Internal hernia (IH) is a well-known complication of laparoscopic roux-en-y gastric bypass (LRYGB) with a reported incidence that ranges from 0% to 5%. In one anastomosis gastric bypass (OAGB), internal herniation is reported to be absent due to the lack of a jejuno-jejunostomy, which is present in LRYGB. Several papers reported large case series of patients undergoing OAGB with no IH through Petersen mesenteric defect. Consequently, there is no recommendation for routine closure of the mesenteric defects in OAGB. However, starting from 2015, some authors started reporting this complication in OAGB procedures. Material andMethods: The outcomes of 98 cases of revisional OAGB performed at our institution from 2014 were retrospectively collected. OAGB was secondary surgery following laparoscopic Sleeve Gastrectomy (LSG) in 96% of patients. The indications for secondary surgery were weight regain and/or severe Gastro-esophageal Reflux Disease (GERD). Outcomes of all OAGB procedures were collected at baseline and at 1, 3, 6, 12 and 24 months. Results: The rate of complications ( 30 days after discharge) requiring new surgery was 21.4% (21/98). The main causes of reintervention were the persistence of severe GERD/Biliary Reflux (14/21) and bowel obstruction due to Internal Hernia (4/21). IH was found in 4% of patients. Conclusion: Internal Hernia could be more common than reported in literature. The closure of mesenteric defects in OAGB should always be performed during revisional surgery for complicated IH.

Use of fibrin glue in bariatric surgery: analysis of complications after laparoscopic sleeve gastrectomy on 450 consecutive patients.

Laparoscopic Sleeve Gastrectomy (LSG) is one of the most performed surgical procedures in bariatric surgery. Staple line leak and bleeding are by far the two most feared complications after LSG. In this study, we retrospectively compared the efficacy of Fibrin Glue in preventing staple line leak and bleeding. From September 2019 to January 2020, 450 obese patients underwent elective LSG and were placed into groups with Fibrin Glue reinforcement (Group A) or without Fibrin Glue reinforcement (Group B). Primary endpoints were postoperative staple line leak and bleeding; while, secondary endpoints were reintervention rate, total operative time and mortality. Mean Body Mass Index (BMI) was 45.4 ± 7.9 kg/m2 (range: 35.1-81.8). Mean age was 43.3 ± 11.8 years (range: 18-65). No intraoperative complications or conversion to laparotomy were reported. Mean operative time was comparable between the groups (48 ± 18 min in Group A vs 48 ± 14 min in Group B; p > 0.05). No decrease in overall postoperative complications was found in Group A (5.1% vs 7.0%; p > 0.05), but after stratification according to Clavien-Dindo classification, we found a higher rate of Grade II (0.0% vs 1.6%; p < 0.05) and Grade IIIb (0.0% vs 1%; p < 0.05) complications in group B. Our study showed that Fibrin Glue as a reinforcement method during LSG is a reliable tool, without affecting the operative time of surgery and mortality. A significant reduction in complications (Clavien-Dindo grade II and grade IIIb) was observed in patients undergoing LSG with Fibrin Glue.

COVID-19 and Obesity: Is Bariatric Surgery Protective? Retrospective Analysis on 2145 Patients Undergone Bariatric-Metabolic Surgery from High Volume Center in Italy (Lombardy).

INTRODUCTION: On February 20, 2020, a severe case of pneumonia due to SARS-CoV-2 was diagnosed in northern Italy (Lombardy). Some studies have identified obesity as a risk factor for severe disease in patients with COVID-19. The purpose of this study was to investigate the incidence of SARS-CoV-2 infection and its severity in patients who have undergone bariatric surgery. MATERIAL AND METHODS: During the lockdown period (until May 2020), we contacted operated patients by phone and social networks (e.g., Facebook) to maintain constant contact with them; in addition, we gave the patients a dedicated phone number at which to call us for emergencies. We produced telemedicine and educational videos for obese and bariatric patients, and we submitted a questionnaire to patients who had undergone bariatric surgery in the past. RESULTS: A total of 2145 patients (313 male; 1832 female) replied to the questionnaire. Mean presurgical BMI: 44.5 ± 6.8 kg/m2. Mean age: 44.0 ± 10.0 year. Mean BMI after surgery: 29.3 ± 5.5 kg/m2 (p < 0.05). From February to May 2020, 8.4% of patients reported that they suffered from at least one symptom among those identified as related to SARS-CoV-2 infection. Thirteen patients (0.6%) tested positive for COVID-19. Six patients (0.3%) were admitted to the COVID Department, and 2 patients (0.1%) were admitted to the ICU. CONCLUSIONS: Although the reported rates of symptoms and fever were high, only 0.6% of patients tested positive for COVID-19. Among more than 2000 patients who underwent bariatric surgery analyzed in this study, only 0.1% needed ICU admission.

Laparoscopic Ventral Hernia Repair in Bariatric Patients: the Role of Defect Size and Deferred Repair.

PURPOSE: To analyze the safety of laparoscopic ventral hernia delayed repair in bariatric patients with a composite mesh. MATERIALS AND METHODS: This retrospective single-center observational trial analyzed all bariatric/obese patients with concomitant ventral hernia who underwent laparoscopic abdominal hernia repair before bariatric surgery (group A) and laparoscopic delayed repair after weight loss obtained by the bariatric procedure (group B). RESULTS: Group A (30 patients) had a mean BMI of 37.8 ± 5.7 kg/m2 (range: 34.0-74.2 kg/m2); group B (170 patients) had a mean BMI of 24.6 ± 4.5 kg/m2 (range 19.0-29.8 kg/m2) (p < 0.05). Mean operative time: group A, 51.7 ± 26.6 min (range 30-120); group B 38.9 ± 21.5 min (range 25-110) (p < 0.05). Average length of stay: group A, 2.0 ± 2.7 days (range 1-5) versus group B, 2.8 ± 1.9 days (range 1-4) (p > 0.5). Recurrent hernia group A 1/30 (3.3%) versus recurrent hernia group B 4/170 (2.3%) (p > 0.5). Bulging: group A, 3/30 (10.0%) versus group B, 0/170 (0%) (p = 0.23). CONCLUSION: The present study demonstrates the safety of performing LDR in patient candidates for bariatric surgery in cases of a large abdominal hernia (W2-W3) with a low risk of incarceration or an asymptomatic abdominal hernia. In the case of a small abdominal hernia (W1) or strongly symptomatic abdominal hernia, repair before bariatric surgery, along with subsequent bariatric surgery and any revision of the abdominal wall surgery with weight loss, is preferable.

Modified laparoscopic sleeve gastrectomy with Rossetti antireflux fundoplication: results after 220 procedures with 24-month follow-up.

BACKGROUND: Gastroesophageal reflux disease (GERD), including erosive esophagitis, is highly prevalent in the obese population. Laparoscopic sleeve gastrectomy (LSG) is one of the most frequently performed bariatric procedures. The relationship between LSG and GERD has gained increasing attention. This retrospective study aimed to assess the effectiveness of combined LSG and modified Rossetti antireflux fundoplication for the treatment of GERD on morbidly obese patients after bariatric surgery. OBJECTIVES: To assess the effectiveness, on morbid obese patients, of combined SG and Rossetti fundoplication for the treatment of GERD in obese patients. SETTING: Public Hospital, Italy. METHODS: From January 2015 to May 2018, 220 obese patients (167 female; 53 male) underwent LSG and modified Rossetti antireflux fundoplication procedure, performed by 4 different expert bariatric surgeons. Data have been collected in an Excel file and processed by XLStat to perform statistical analyses. We analyzed short-term complications and medium-term results with 24-month follow-up in terms of weight loss, remission of co-morbidities, and resolution of GERD. RESULTS: Mean BMI was 42.58 ± 5.93 kg/m2 (range, 31.70-63.16). Patients suffering from GERD before surgery were 137 of 220 (62.3%). No intraoperative complications or conversion were reported. Regular postoperative course was recorded in 90% of patients (198 of 220 patients). Gastric perforation has always occurred on the fundoplicated portion of the stomach. This perforation, which is different from the well-known post-LSG gastric fistula, may be because of incorrect gastric fundus manipulation. Rate of reoperation was 14 of 220 (6.4%). A good sense of repletion without episodes of vomiting, nausea, or dysphagia was reported in 95% of the analyzed patients. Of patients, 98.5% did not suffer from reflux symptoms and did not take proton pump inhibitors. A decrease in BMI and percent of total weight loss at follow-up were comparable with LSG. Endoscopic follow-up is still ongoing. Improvement in esophagitis was observed in 63 of 65 (96.92%) patients and all 4 patients shows improvement in Barrett's esophagus. CONCLUSIONS: LSG and modified Rossetti antireflux fundoplication procedure is a tolerated and feasible procedure in obese patients, with good postoperative weight loss results and improvement in GERD.

Laparoscopic Abdominal Wall Hernia Repair.

BACKGROUND AND OBJECTIVES: The aim of this retrospective monocentric study was to evaluate results and recurrence rate with long-term follow-up after laparoscopic incisional/ventral hernia repair. METHODS: This was a retrospective, single-center, observational trial, collecting data from patients who underwent laparoscopic incisional/ventral abdominal hernia repair using the open intraperitoneal onlay mesh technique and a single mesh type. All patients signed an informed consent form before surgery. RESULTS: A total of 1,029 patients were included. The median surgery time was 40 min (range 30-55) and the median length of hospital stay was 2 d (range 2-3). Intraoperative complications occurred in two of 1,029 patients (0.19%), whereas early postoperative surgical complications (within 30 d) occurred in 50 patients (4.86%). Postoperative complications according to Clavien-Dindo classification were as follows: I, 3.30% (34 of 1,029); II, 0.97% (10 of 1,029); IIIB, 0.58% (six of 1,029); IV, 0.00% (none of 1,029); and V, 0.00% (none of 1,029). During follow-up, bulging mesh was diagnosed in 58 of 1,029 patients (5.6%), and hernia recurred in 40 of 1,029 patients (3.9%). A mesh overlap equal to or greater than 4 cm appeared to be a significant protective factor for hernia recurrence (P < .001); a mesh overlap equal or greater than 5 cm appeared to be a significant protective factor for bulging (P < .001), whereas the use of resorbable fixing devices was a significant risk factor for hernia recurrence (odds ratio, 111.53, P < .001, 95% confidence interval, 21.53-577.67). CONCLUSION: This study demonstrates that laparoscopic repair of ventral/incisional abdominal wall hernias is a safe, effective, and reproducible procedure. Identified risk factors for recurrence are an overlap of less than 4 cm and the use of resorbable fixation means.

Low-dose interleukin-2 administered pre-operatively to patients with gastric cancer activates peripheral and peritumoral lymphocytes but does not affect prognosis.

BACKGROUND: There is evidence that cancer is immunogenic under certain situations. IL-2 is described to stimulate an effective antitumor immune response in vitro and in vivo. The ability of cancer patients to undergo surgical resection is still the most important prognostic factor for many solid tumors, including gastric adenocarcinoma. The host immune system may be further compromised by surgical procedures leading to a generalized state of immunodepression in the post-operative period. The aim of this randomized case-control study is to evaluate the effects of pre-operative low-dose IL-2 treatment on patients with gastric adenocarcinoma who undergo surgery. METHODS: Sixty-eight patients with gastric adenocarcinoma were enrolled in the study and randomized in two groups: 36 patients were pre-treated with IL-2 and 32 underwent surgery without any treatment. Total peripheral WBC, neutrophils, CD3(+) T, CD4(+) T, CD8(+) T and NK cells were obtained before and after surgery, at different times. Peritumoral infiltration was analyzed on all surgical specimens. Overall survival and relapse-free survival were studied with a median follow-up of 51 months. RESULTS: Low-dose IL-2 treatment resulted in an increase peritumoral lymphocytic and eosinophilic infiltrations and in a minor decrease in CD3(+) T and CD4(+) T cells after surgery (P < 0.05). A stepwise multivariate analysis revealed that overall survival and relapse-free survival were affected only by stage of tumor and age of patients. CONCLUSIONS: According to our data low-doses of IL-2 administered pre-operatively to patients with gastric cancer activate peripheral and peri-tumoral lymphocytes but did not affect prognosis.

Case report of a hepatic angiomyolipoma.

Angiomyolipoma (AML) is a benign mesenchymal tumor that has been frequently reported in the kidney but rarely in the liver. Hepatic AML may be clinically, radiologically and morphologically difficult to distinguish from hepatocellular carcinoma or other hepatic lesions, even though the number of cases has been increasing recently due to improved imaging techniques. Histologically it consists of smooth muscle cells, adipose cells and abnormal blood vessels. It is commonly diagnosed following abdominal pain but may also be asymptomatic, has a predominant female predilection, highly variable size and occurs in subjects with a wide age range. The right lobe is the most common site, and multicentricity has been reported. Here we report a case of the myomatous variant of AML, accidentally discovered in a young woman with no clear features on radiographic examination, which was diagnosed by means of fine needle aspiration biopsy (FNAB) and then surgically removed. Although careful observation with serial radiological follow-up is an option in these cases, we chose the surgical approach because of the risk of rupture due to the large size of the lesion and the risk of malignant behavior or transformation. In case of the myomatous variant composed of irregular cells with epithelioid appearance, hepatocellular carcinoma with fatty changes or the possibility of other malignant tumors must be ruled out by immunohistochemistry (HMB-45), even in biopsy specimens.