Laparoscopic Clip Gastroplasty with the BariClip.

Having the advantages of the reversibility by clipping and not cutting the stomach, the BariClip procedure reproduces the effect of the SG [1, 2] without adding the risk of leaks, and minimizes the occurrence of postoperative GERD by decreasing the intragastric pressure [3]. We present an edited video on the placement of a BariClip with the main steps of the procedure for a female patient with a BMI 41 kg/sqm. A 36 F bougie is placed to calibrate the size of the pouch. Using a laparoscopic approach, the BariClip is placed into the peritoneal cavity through a 12 mm trocar. The BariClip is then closed around the stomach parallel to the lesser curvature, creating a small medial pouch and an excluded large lateral segment. To prevent slippage (rate is approximately 3%), the BariClip is sutured to the gastric wall both anteriorly and posteriorly at various levels of the stomach, as shown in the video. Despite the possibility to suture on either side of the BariClip, the left indentations are preferred in order to avoid vessels of the lesser curvature which are closer to the right indentations. The recovery was uneventful, and 4 h after the surgery, the patient was tolerating liquids. She was discharged the following day with a prescription of PPI (pantoprazole 40 mg) for 30 days and of clexane 0.4 IM for 5 days. As with most bariatric procedures, she was started on 2 weeks of liquids, followed by 2 weeks of soft diet, before experiencing solid food. At 1 month after surgery, the patient had lost 10% of her TBW, and at 1-year follow-up, she had lost 31% of her TBW. She had no reflux, pain, or any other complaints and was very happy. The closing of the BariClip has been designed to be a low-pressure system, and in addition, it has a wide inferior outlet (2.5 cm), which does not create high intraluminal pressure. Both of these factors result in a low risk of erosion and of GERD. The rate of erosion in the original series was 1.3% with up to a 7-year history of implantation. The most common complication encountered at the beginning of our experience has been a slippage of the BariClip, and with the learning curve, this rate dropped to 3%. The QOL has been studied on a first series of patients and showed good results comparable with those given with the LSG and the RYGB [4]. In conclusion, the BariClip accomplishes almost similar weight loss as a SG, without a gastrectomy, without risks of leaks, and without causing reflux, and at the same ,time the BariClip is reversible [5].

Laparoscopic Banded Resleeve Gastrectomy.

Introduction: The recurrence of the morbid obesity disease after laparoscopic sleeve gastrectomy is a well-known complication. The banded resleeve gastrectomy (ReSG) is considered an innovative procedure and an alternative restrictive option to other malabsorptive procedures. Materials and Methods: We present an edited video on the placement of a MIDCAL™ (MID, Dardilly, France) ring during a revised sleeve gastrectomy with the main steps of the procedure. The subject is a male patient with a body mass index of 44 kg/m2. After the fundus resection, the MIDCAL is placed and fixed to the stomach by two sutures. Results: We present the steps of the operation. The intervention is performed by posterior approach using a three-port technique. The dissection of the previous staple line of the sleeve was continued upward with the visualization of the left crura. The gastric tube was calibrated with a 36F bougie. The restapling of the previous sleeve was carried out by respecting the incisura angularis. The dissection of the pars flaccida allowed the posterior passage of the MIDCAL ring, which was locked and then fixed to the gastric wall with two nonabsorbable sutures. The operative outcome was favorable. The total body weight loss was 9% at 1 month and 27% at 2 years follow-up. Conclusion: Banded ReSG is a safe procedure with acceptable results at short term. Other comparative studies are suitable to provide with long-term follow-up results.

Five-year results after resleeve gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has become increasingly popular in bariatric surgery. However, in the long-term follow-up, weight loss failure and intractable severe acid reflux after primary LSG can necessitate further interventions. OBJECTIVES: The aim of our study was to evaluate long-term results 5 years after resleeve gastrectomy (ReSG). SETTING: Private hospital, France. METHODS: The study included all patients with failure after LSG who underwent ReSG between October 2008 and January 2014. The patients underwent radiologic evaluation, and an algorithm of treatment was proposed. We analyzed the 5-year outcomes concerning weight loss and long-term complications after ReSG. RESULTS: A total of 52 patients (46 women; mean age 40.2 yr) with a mean body mass index (BMI) of 39.4 kg/m2 underwent ReSG. The mean interval time from the primary LSG to ReSG was of 27.8 months (11-72 mo). The indication for ReSG was inadequate weight loss (28 patients; 53.8%), weight regain (22 patients; 42.3%), and gastroesophageal reflux disease (2 patients; 3.8%). In 35 cases the contrast agent (diatrizoate meglumine/diatrizoate sodium solution [Gastrografin]) swallow results were interpreted as primary dilation and in the remaining 17 cases as secondary dilation. One patient died from gynecologic cancer. Of the remainder, 3 patients underwent single-anastomosis duodenoileal bypass, 5 patients underwent Roux-en-Y gastric bypass, and 1 patient underwent a second ReSG for reflux. A total of 39 of 42 patients with ReSG as definitive procedure had available data at 5-year follow-up. The mean percentage of excess BMI loss was 63.7%. Of the 39 patients, 28 (71.8%) had >50% excess BMI loss at 5 years. Eight of the 11 patients with weight loss failure (<50% excess BMI loss) after ReSG were diagnosed with secondary or diffuse dilation on preoperative imaging; the remaining 3 patients had been operated in our early initial experience with the resleeve procedure. All cases were completed by laparoscopy with no intraoperative incidents. In terms of complications, we recorded 1 leak, 2 stenoses, and 2 cases of bleeding with no mortality. CONCLUSIONS: At 5 years postoperative, the ReSG as a definitive bariatric procedure remained effective for 53.8%. The results appear to be more favorable especially for the non-super-obese patients and for those with primary dilation. ReSG is a well-tolerated bariatric procedure with a low long-term complication rate. Further prospective clinical trials are required to compare the outcomes of ReSG with those of Roux-en-Y gastric bypass or single-anastomosis duodenoileal bypass for weight loss failure after LSG.

The Interest of Enhanced Recovery After Surgery in a New Bariatric Center.

Background: With the creation of a new bariatric center in Abu Dhabi, United Arab Emirates (UAE) and the organization of this bariatric department according to the international guidelines, a new activity of bariatric surgery started in January 2015. The surgeon had 20 years of experience in this field and he had performed over 5000 major laparoscopic bariatric procedures before starting this new bariatric program. The concept of enhanced recovery after bariatric surgery (ERABS) was applied from the beginning of the program. We decided to analyze the first 2 years of ERAS activity after having split them in two different periods: the 1st year of activity included restrictive procedures and the 2nd year associated malabsorptive surgeries. Materials and Methods: The results of the use of a fast-track program could be measured by different parameters like operative time, length of hospital stay, rate of complications, and rate of readmission and reoperation. Results: Between January and December 2015, 116 patients underwent a bariatric procedure. The mean age was 34.6 years (16-61) and average body mass index (BMI) was 41.7 kg/sqm (32-72.2). Sixty percent of patients were women and 37% of patients had at least one comorbidity (diabetes type 2, high blood pressure, hyperlipidemia, or sleep apnea). Ninety-four percent of the procedures were laparoscopic sleeve gastrectomy (LSG), 2.6% were laparoscopic Roux-en-Y gastric bypass, and 3.4% band removal. The mean operative time was 20 minutes for an LSG (14-45 minutes) and the average hospital stay was 1.2 days (standard deviation [SD]: 0.9-3.3). The rate of complications was 1.7% with 1 postoperative hematoma drained by CT scan on day 14 after the surgery and 1 relative stenosis endoscopically dilated on postoperative day 45. No reoperation was done. No leak was observed. At 1 year, the mean excess weight loss (EWL) was 64% (47-124) in 89 patients with a 76% rate of follow-up. For the 2nd year of activity in 2016, 142 patients went in the program. The mean age was 32.7 years (17-64) and average BMI was 42.3 kg/sqm (31-68). Seventy-two percent were women and 41% of the patients had one comorbidity or more. The majority of surgeries performed were LSG for 83.1% of the patients. RYGB was realized in 4.2% of cases, resleeve gastrectomy in 4.2%, and band removal in 1.4%. Some malabsorptive surgeries were performed as well, such as one anastomosis gastric bypass for 3 patients (4.2%), and single anastomosis duodeno-ilelal in 2 cases (2.8%). The average hospital stay was 1.5 days (SD: 0.9-3.5). No complication was observed. No reoperation was done. Two patients (1.4%) came back to the hospital on postoperative day 2 and 8 after a LSG for one or several episodes of vomiting without further complication. At 1 year, the mean EWL was 68% (49-154) in 98 patients with a 69% rate of follow-up. Conclusions: This new program of bariatric surgery in two steps using fast-track protocols, respecting international guidelines and with an experienced surgeon showed on its 1st year of implementation a 1.7% rate of readmission on 116 patients without reoperation or major complication and a hospital stay of 1.2 days. For the 2nd year of implementation with the inclusion of malabsorptive procedures only 2 patients (1.4%) were readmitted for a short episode of vomiting and the hospital stay was 1.5 days.

Laparoscopic vertical clip gastroplasty - quality of life.

BACKGROUND: Over the last decade, several techniques have emerged and the bariatric trends have changed. A new bariatric procedure that has been proposed is laparoscopic vertical clip gastroplasty (LVCG), which mimics the principle of laparoscopic sleeve gastrectomy, but with a completely reversible mechanism. The introduction of a new procedure in the bariatric armamentarium necessitated a period of preclinical and clinical studies and a validation of the procedure concerning the quality of life. SETTING: Private hospital, Dominican Republic. OBJECTIVES: The purpose of this manuscript was to evaluate patient satisfaction, measured by various questionnaires after LVCG. METHODS: From November 2012 to February 2017, 138 patients underwent LVCG and demographic data were collected prospectively. A total of 82 were evaluated for quality of life with a minimum follow-up of 6 months after the procedure. The quality of life was also analyzed regarding the complications and resolution of different medical conditions included in the Bariatric Analysis and Reporting Outcome System score. RESULTS: Eighty-five patients (73.9%) agreed to participate in the study and a total of 82 patients completed the questionnaires at all points in time. Seventy-one patients were female, with an average age of 34 (19-38). Mean body mass index before operation was 42.4 kg/m2 and declined significantly in both the first and second year postoperatively to 33.7 kg/m2 (1-year follow-up) in 65 patients and 34.3 kg/m2 (2-year follow-up) in 37 patients. The results showed failure for 1.2% of patients and were fair for 6.1% of cases. Quality of life was assessed as good for 26 patients (31.8%), as very good for 39 patients (47.5%), and as excellent for 11 patients (13.4%). CONCLUSIONS: LVCG represents a new bariatric procedure that mimics the principle of laparoscopic sleeve gastrectomy, but with a completely reversible mechanism. The procedure consists of a nonadjustable clip that is vertically placed parallel to the lesser curvature. After >3 years of clinical use, the weight loss results seem to be encouraging and up to 92.7% of patients have an improved quality of life.

What are the long-term results 8 years after sleeve gastrectomy?

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) became the most frequent bariatric procedure performed in France (2011) and in the United States (2013), but studies reporting long-term results are still rare. SETTING: Private hospital, France. METHODS: This is a retrospective analysis of a prospective cohort of 168 patients who underwent LSG between 2005 and 2008. The objective of this study was to present the 8-year outcome concerning weight loss, modification of co-morbidities, and to report the revisional surgery after sleeve. RESULTS: The preoperative mean body mass index was 42.8 kg/m2 (31.1-77.9), 35 patients were super obese, and 64 patients had a previous gastric band. For LSG as a definitive bariatric procedure, 8 years of follow-up data were available for 116 patients (follow-up: 69%). Of the remainder, 23 patients underwent revisional surgery and 29 were lost to follow-up. For the entire cohort, the mean excess weight loss (EWL) was 76% (0-149) at 5 years and 67% (4-135) at 8 years, respectively. Of the 116 patients with 8 years of follow-up, 82 patients had>50% EWL at 8 years (70.7%). Percentages of co-morbidities resolved were hypertension, 59.4%; type 2 diabetes, 43.4%; and obstructive sleep apnea, 72.4%. Twenty-three patients had revisional surgery for weight regain (n = 14) or for severe reflux (n = 9) at a mean period of 50 months (9-96). Twelve patients underwent resleeve gastrectomy, 6 patients underwent conversion to a bypass, and 5 patients to duodenal switch (1 single anastomosis duodeno-ileostomy). A total of 31% of patients reported gastroesophageal reflux symptoms at 8 years. CONCLUSIONS: At 8 years postoperatively, the LSG as a definitive bariatric procedure remained effective for 59% of cases. The results appear to be more favorable especially for the non-super-obese patients and primary procedures. LSG is a well-tolerated bariatric procedure with low long-term complication rates.

Cost analysis of leak after sleeve gastrectomy.

BACKGROUND: Leaks after laparoscopic sleeve gastrectomy (LSG) are serious complications of this procedure. The objective of the present study was to evaluate the costs of leaks after LSG. SETTING: Private hospital, France. METHODS: A retrospective analysis was conducted on a prospective cohort of 2012 cases of LSG between September 2005 and December 2014. Data were collected on all diagnostic and therapeutic measures necessary to manage leaks, ward, and intensive care unit (ICU) length of stay. Additional outpatient care was also analyzed. RESULTS: Twenty cases (0.99%) of gastric leak were recorded. Fifteen patients had available data for cost analysis. Of these, 13 patients were women (86.7%) with a mean age of 41.4 years (range 22-61) and mean BMI of 43.2 kg/m2 (range 34.8-57.1). The leaks occurred after 7.4 days (±2.3) postoperatively. Only one gastric leak was recorded for the last 800 cases in which absorbable staple line reinforcement was used. Mean intra-hospital cost was 34398 € (range 7543-91,632 €). Prolonged hospitalization in ICU accounted for the majority of hospital costs (58.9%). Mean additional outpatient costs for leaks were 41,284 € (range 14,148-75,684€). CONCLUSIONS: Leaks after LSG are an expensive complication. It is therefore important to take all necessary measures to reduce their incidence. Our data should be considered when analyzing the cost effectiveness of staple line reinforcement usage.

How to treat stenosis after sleeve gastrectomy?

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has increasingly gained worldwide acceptance among bariatric surgeons during the past 10 years. Numerous articles have been written about the different approaches to the management of gastric fistulas, but limited data can be found concerning gastric stenosis after LSG. SETTING: Private hospital, France. METHODS: A total of 18 patients received endoscopic treatment for stenosis after LSG between May 2007 and June 2015. Stenosis was classified according to the endoscopic findings as functional (the passage of the endoscope was possible, but the sleeve was twisted with various degrees of rotation) or mechanical (the passage of the endoscope was very difficult or impossible). RESULTS: This study included 13 women and 5 men, with an average age of 37.2±8.4 years and an average body mass index of 41.6±8.7 kg/m2. The average number of endoscopic procedures was 1.3 (range, 1-4). No patient had stent migration. The successful rate of endoscopic approach for stenosis of LSG was 94.4%, with one patient requiring conversion to Roux-en-Y gastric bypass. The mean time from the LSG to the first endoscopic intervention was 28.2 days. All patients presented with midsleeve stricture, located near the incisura angularis, and no patient showed a stenosis in the upper part of the gastric tube. CONCLUSIONS: The treatment of stenosis after LSG must be tailored to the clinical status of the patient and endoscopic findings. Both balloon dilation and stent deployment are useful and safe tools and must be used when appropriate.