Closure of mesenteric defects is associated with a higher incidence of small bowel obstruction due to adhesions after laparoscopic antecolic Roux-en-y gastric bypass: A retrospective cohort study.

INTRODUCTION: Small bowel obstruction (SBO) is a frequent complication after laparoscopic Roux-en-y gastric bypass (LRYGB). OBJECTIVES: We wanted to evaluate the effect of closure of the mesenteric defects on the incidence of SBO and postoperative complications after LRYGB. Furthermore, we wanted to identify possible risk factors for SBO. METHODS: This study was a retrospective cohort study of 1364 patients who underwent a LRYGB between July 2003 and October 2015. Cohort 1 contained 724 patients in whom mesenteric defects were not closed. Cohort 2 contained 640 patients in whom mesenteric defects were closed. Main outcome parameters were the incidence of SBO and postoperative complications as well as potential risk factors for SBO. RESULTS: Closure of the mesenteric defects was associated with a reduction in the incidence of SBO due to internal herniation (4.8% vs. 5.5, p = 0.02) but resulted in a higher incidence of SBO due to postoperative adhesions (4.8% vs. 1.7%, p = 0.004). Multivariate analysis identified smoking as a risk factor for SBO (p = 0.0187). We observed a higher incidence of late postoperative pain in cohort 2 (5.3% vs. 2.1%, p = 0.007). CONCLUSION: Although closure of the mesenteric defects is associated with a lower incidence of SBO due to internal herniation, this effect is countered by a higher incidence of SBO due to postoperative adhesions. Smoking is an independent risk factor for SBO after LRYGB. Closure of the mesenteric defects is associated with a higher incidence of late postoperative pain.

Laparoscopic parenchymal preserving hepatic resections in semiprone position for tumors located in the posterosuperior segments.

INTRODUCTION: All patients who underwent laparoscopic liver resections in the posterosuperior segments (LPSS) at our center were positioned in semiprone since August 2011. The aims of this study were to assess differences in perioperative outcomes between laparoscopic left lateral sectionectomies (LLLS) performed in supine position and LPSS in semiprone position. METHODS: We reviewed our prospectively collected database of all liver resections performed between January 2012 and January 2015. LLLS and LPSS were compared with respect to demographics and perioperative outcomes. RESULTS: Forty-five patients underwent LLLS (n = 20) or LPSS (n = 25). There were no differences in patient demographics or tumor diameter (p = 0.946). There were no conversions. Pringle maneuver was not used in both groups. There was no difference in peroperative central venous pressure (p = 0.511). The median operative time in the LLLS group was 100 min (60-260) and 160 min (95-270) in the LPSS group (p = 0.002) with median intraoperative blood loss in the LLLS group of 50 ml (0-550) versus a larger 150 ml (50-700) (p = 0.010) for patients receiving LPSS. No patients required transfusion. Intraoperative and postoperative complication rates were similar in both groups. Median hospital stay was 6 days in both groups (p = 0.554). CONCLUSION: LPSS in semiprone can be performed with similar clinical outcomes as a minor laparoscopic liver resection except for longer operative time and larger intraoperative blood loss without the need for transfusion.

SILS sigmoidectomy versus multiport laparoscopic sigmoidectomy for diverticulitis.

BACKGROUND AND OBJECTIVES: In this single-institution study, we aimed to compare the safety, feasibility, and outcomes of single-incision laparoscopic sigmoidectomy (SILSS) with multiport laparoscopic sigmoidectomy (MLS) for recurrent diverticulitis. METHODS: Between October 2011 and February 2013, 60 sigmoidectomies were performed by the same surgeon. Forty patients had a MLS and 20 patients had a SILSS. Outcomes were compared. RESULTS: Patient characteristics were similar. There was no difference in morbidity, mortality or readmission rates. The mean operative time was longer in the SILSS group (P=.0012). In a larger proportion of patients from the SILSS group, 2 linear staplers were needed for transection at the rectum (P=.006). The total cost of disposable items was higher in the SILSS group (P<.0001). No additional ports were placed in the SILSS group. Return to bowel function or return to oral intake was faster in the SILSS group (P=.0446 and P=.0137, respectively). Maximum pain scores on postoperative days 1 and 2 were significantly less for the SILSS group (P=.0014 and P=.047, respectively). Hospital stay was borderline statistically shorter in the SILSS group (P=.0053). SILSS was also associated with better cosmesis (P<.0011). CONCLUSION: SILSS is feasible and safe and is associated with earlier recovery of bowel function, a significant reduction in postoperative pain, and better cosmesis.

Indications, safety, and feasibility of conversion of failed bariatric surgery to Roux-en-Y gastric bypass: a retrospective comparative study with primary laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) is considered the "gold standard" revision procedure. The purpose of this study was to compare the surgical outcome of primary laparoscopic RYGB (pLRYGB) to revisional open or laparoscopic Roux-en-Y gastric bypass surgery (rRYGB). METHODS: A retrospective analysis of all patients who underwent pLRYGB or rRYGB from January 2003 to December 2009 has been performed. Demographics, indications for revision, and complications have been reviewed. The rRYGB and pLRYGB patients have been compared. RESULTS: Seventy-two patients underwent rRYGB, and 652 patients underwent pLRYGB. Mean follow-up was 35 and 45 months, respectively. Fifty-six rRYGB procedures were performed laparoscopically. The primary operations had consisted of laparoscopic gastric banding (n = 28), laparoscopic vertical banded gastroplasty (n = 19), laparoscopic sleeve gastrectomy (n = 6), laparoscopic RYGB (n = 3), and biliopancreatic diversion with duodenal switch (n = 16). Indications included weight regain (n = 29), malabsorption (n = 16), gastrogastric fistula (n = 5), band-associated problems (n = 3), and refractory stomal ulceration (n = 1). There was no significant difference in early or late postoperative complications when comparing rRYGB to pLRYGBP patients (11.1% vs. 5.52%, P = 0.069 and 19.4% vs. 24.2%, P = 0.465 respectively). Five rRYGB patients (7.04%) required reintervention (3 internal hernias, 1 ventral hernia, 1 laparoscopic exploration) compared with 101 pLRYGB patients (15.71%; P = 0.051). None of the patients died. Mean hospital stay was not significantly longer in the rRYGB group (5.38 vs. 4.95 days, P = 0.058). CONCLUSIONS: In our series, hospital stay, morbidity, and mortality of rRYGB were not significantly higher compared with pLRYGB. Furthermore, we believe that this type of revisional bariatric surgery should be performed in high-volume bariatric centers.

Prophylactic cholecystectomy, a mandatory step in morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass?

BACKGROUND: The aim of this study was to determine the incidence of symptomatic gallstone disease requiring cholecystectomy (CCE) after laparoscopic Roux-en-Y gastric bypass (LRYGBP) and to identify the peri-operative risk factors associated with postoperative symptomatic gallstone disease. METHODS: Between August 2003 and November 2009, 724 patients underwent LRYGBP at the Groeninge Hospital. Preoperative ultrasound was performed in 600 of 641 patients without history of CCE and 120 (20.0%) were diagnosed with cholecystolithiasis. RESULT: Six hundred twenty-five patients were included, 43(6.9%) developed delayed symptoms related to biliary disease. Of these 43 patients, 39 underwent post-LRYGBP CCE. Of these 39 patients, 9 (7.5%) had a positive ultrasound prior to LRYGBP. Multivariate analysis identified weight loss at 3 months post-LRYGB of more than 50% of excess weight [HR (95% CI), 2.04 (1.04-4.28); p = 0.037) as the sole significant independent predictor of delayed symptomatic cholecystolithiasis. CONCLUSIONS: Symptomatic gallstone disease occurred only in 6.9% of patients post-LRYGBP. Multivariate analysis identified weight loss at 3 months post-LRYGBP of more than 50% of excess weight as the sole significant independent predictor of delayed symptomatic cholecystolithiasis. Prophylactic CCE should not be recommended at the time of LRYGBP.

Small bowel obstruction after antecolic antegastric laparoscopic Roux-en-Y gastric bypass without division of small bowel mesentery: a single-centre, 7-year review.

Reported incidence of small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass varies between 1.5% and 3.5%. It has been suggested that the antecolic antegastric laparoscopic Roux-en-Y gastric bypass (AA-LRYGB) is associated with a low incidence of internal herniation (IH). Therefore we routinely did not close mesenteric defects. The records of 652 consecutive patients undergoing primary AA-LRYGB from January 2003 to December 2009 in a single institution were retrospectively reviewed to determine the incidence, etiology, clinical symptoms, radiologic diagnostic accuracy and operative outcomes of SBO. Of the 652 patients, 63 (9.6%) developed SBO. The majority (6.9%, 45 patients) had a SBO due to IH. In 41 (91%) cases, the IH was at the jejunojejunostomy (JJ), four cases had an IH at Petersen's space. Adhesions and ventral hernia were found in 14 (2.1%) and four (0.6%) cases, respectively. Twenty-nine out of 63 cases had negative computed tomography (CT) findings and IH was diagnosed on CT in only 33% (14/45) of patients with IH. All patients underwent diagnostic laparoscopy. No bowel resections had to be performed. In contrast to previous reports, a high incidence of SBO with a high rate of IH at the JJ site was found in our series. Accuracy of CT is low and diagnostic laparoscopy is mandatory when SBO is suspected. Since 2010 we have started closing the JJ site, and data on SBO are collected prospectively. We believe that closing of the mesenteric defects is a mandatory step, even in an AA-LRYGB.

Treatment of small-bowel fistulae in the open abdomen with topical negative-pressure therapy.

BACKGROUND: An open abdomen (OA) can result from surgical management of trauma, severe peritonitis, abdominal compartment syndrome, and other abdominal emergencies. Enteroatmospheric fistulae (EAF) occur in 25% of patients with an OA and are associated with high mortality. METHODS: We report our experience with topical negative pressure (TNP) therapy in the management of EAF in an OA using the VAC (vacuum asisted closure) device (KCI Medical, San Antonio, TX). Nine patients with 17 EAF in an OA were treated with topical TNP therapy from January 2006 to January 2009. Surgery with enterectomy and abdominal closure was planned 6 to 10 weeks later. RESULTS: Three EAF closed spontaneously. The median time from the onset of fistulization to elective surgical management was 51 days. No additional fistulae occurred during VAC therapy. One patient with a short bowel died as a result of persistent leakage after surgery. CONCLUSIONS: Although previously considered a contraindication to TNP therapy, EAF can be managed successfully with TNP therapy. Surgical closure of EAFs is possible after several weeks.

Laparoscopic sleeve gastrectomy as a single-stage procedure for the treatment of morbid obesity and the resulting quality of life, resolution of comorbidities, food tolerance, and 6-year weight loss.

BACKGROUND: This retrospective study evaluated long-term weight loss, resolution of comorbidities, quality of life (QoL), and food tolerance after laparoscopic sleeve gastrectomy (LSG). METHODS: Between January 2003 and July 2008, 102 patients underwent LSG as a sole bariatric operation. A retrospective review of a prospectively collected database was performed. Demographics, complications, and percentage of excess weight loss (%EWL) were determined. Quality of life was measured using Medical Outcomes Survey Short Form 36 (SF-36) and Bariatric Analysis and Reporting Outcome System (BAROS) questionnaires, which were sent to all patients. The food tolerance score (FTS) was determined and compared with that of nonobese subjects. RESULTS: A total of 83 patients (81.4%) were eligible for follow-up evaluation. Their mean initial body mass index (BMI) was 39.3 kg/m(2). No major complications occurred. At a median follow-up point of 49 months (range, 17-80 months), the mean %EWL was 72.3% ± 29.3%. For the 23 patients who reached the 6-year follow-up point, the mean %EWL was 55.9% ± 25.55%. The mean BAROS score was 6.5 ± 2.1, and a "good" to "excellent" score was observed for 75 patients (90.4%). In the comparison of patients with a %EWL greater than 50% and those with a %EWL of 50% or less, the SF-36 scores were statistically different only for "physical functioning" and "general health perception." The mean FTS was 23.8, and 95.2% of the patients described their food tolerance as acceptable to excellent. CONCLUSION: Laparoscopic sleeve gastrectomy is a safe and effective bariatric procedure, although a tendency for weight regain is noted after 5 years of follow-up evaluation. Resolution of comorbidity is comparable with that reported in the literature. The LSG procedure results in good to excellent health-related QoL. Food tolerance is lower for patients after LSG than for nonobese patients who had no surgery, but 95.2% described food tolerance as acceptable to excellent.

Postsurgery activation of dormant liver micrometastasis: a case report and review of literature.

BACKGROUND: We present the case of a 55-year-old woman who underwent a Whipple procedure for pancreatic adenocarcinoma. The preoperative work-up showed no signs of liver metastasis and confirmed the patient's operability, but at less than 40 days postoperatively there were diffuse liver metastasis present on CT. This rapid evolution raises the question whether current staging systems are adequate in determining a patient's operability. It also suggests an interaction between the primary tumor and the host and the existence of disseminated tumor cells. DISCUSSION: In this article, we give an explanation for the clinical evolution presented in our case using the "integrated organ" and the "concomitant resistance" hypotheses. We believe that, if these theories continue to prove their viability, the search for disseminated tumor cells will be essential for good clinical practice in this type of pathology.

Can a short course of prophylactic low-dose proton pump inhibitor therapy prevent stomal ulceration after laparoscopic Roux-en-Y gastric bypass?

BACKGROUND: The purpose of this retrospective analysis was to determine if a short course of prophylactic proton pump inhibitor (PPI) therapy can prevent stomal ulceration after laparoscopic Roux-en-Y gastric bypass (LRYGBP). METHODS: Four hundred forty-nine consecutive patients who underwent LRYGBP and had a minimum of 6 months follow-up were included. Patients were categorized in two groups: patients with Helicobacter pylori at preoperative endoscopy (HP group) and patients without H. pylori (non-HP group). All patients in the HP group were medically treated prior to surgery. In both groups, almost half of the patients received low-dose proton pump inhibitors (omeprazole 20 mg daily) for 1 month following LRYGBP. RESULTS: The incidence of stomal ulceration in the HP group was not statistically different from the incidence in the non-HP group (7/86, 8.14% vs. 41/363, 11.29%; p = 0.559). When comparing the patients who did receive PPI therapy with the patients who did not receive PPI therapy within the non-HP group, there was no significant reduction in development of stomal ulceration (18/169, 10.65% vs. 23/194, 11.86%; p = 0.743). When comparing the patients who did receive PPI therapy with the patients who did not receive PPI therapy within the HP group, there is a significant reduction in development of stomal ulceration (0/41, 0% vs. 7/45, 15.56%; p = 0.0123). CONCLUSION: Development of stomal ulceration in patients tested positive for H. pylori prior to LRYGBP can be prevented by prophylactic low-dose PPI therapy following surgery.

Laparoscopic solution for early gastric cancer in a morbidly obese patient.

During preoperative work-up for laparoscopic gastric bypass in a morbidly obese female, gastroscopy visualized two small ulcers in the antrum. Biopsies diagnosed adenocarcinoma of the diffuse type. Staging was performed, and endoscopic ultrasonography showed early gastric cancer. A laparoscopic neartotal gastrectomy with D1 resection and perigastric lymph node dissection and full omentectomy in combination with a gastric bypass, was peformed. This approach respects the oncologic and bariatric principles and gives a combined solution for the patient.

Gastrogastric fistula after gastric bypass--is surgery always needed?

Because of regain of weight to BMI 37.1 kg/m(2) 6 years after a VBG, a 41-year-old female now underwent revision to divided Roux-en-Y gastric bypass, performed laparoscopically. 12 days postoperatively, she started bleeding from the main stomach, and CT scan revealed that the bypassed stomach was distended with clot. She was treated conservatively and stopped bleeding. Upper GI series 2 weeks postoperatively revealed a large gastrogastric fistula between the tiny pouch and the bypassed stomach. We initially planned to close the fistula. However, upper GI series 2 months and 4 months postoperatively showed no sign of gastrogastric fistula, and proton pump inhibitors were stopped. At 1 year after gastric bypass, our patient has had good weight loss.