Long-term results of laparoscopic gastric sleeve: the importance of follow-up adherence.

OBJECTIVE: This study was conducted to assess the long-term results of the Laparoscopic Sleeve Gastrectomy (LSG) in patients not compliant with follow-up, and in patients who completed a postoperative follow-up program. PATIENTS AND METHODS: The data concerning LSG patients operated from February 2011 to December 2013 were retrospectively reviewed basing on a single center database. The patients with complete long-term follow-up were scheduled in Group A, while patients who failed to attend controls for more than two years were scheduled in Group B. Long-term results (weight loss, comorbidity improvement and late complications) were compared between the two groups. RESULTS: The study population consisted of 285 patients. Of these, 101 had a complete follow-up with a mean duration of 71 ± 7.6 months (Group A). The remaining 184 patients (Group B) were not compliant with follow-up and, consequently, the mean duration of follow-up was 5.5 ± 7.3 months (p < 0.00001). A higher number of patients with insufficient weight loss was recorded in Group B with respect to Group A (78 vs. 23; p = 0.001). The number of patients with results below 25% EWL was significantly higher in Group B than in Group A (24 vs. 5; p = 0.04). In the long-term, the rate of patients with symptomatic reflux requiring medical treatment was two-fold higher in Group B than in Group A. CONCLUSIONS: The adherence to a long-term follow-up plan after LSG seems to decrease the number of patients experiencing insufficient weight loss and those at risk for developing a gastro-esophageal reflux disease.

Gastric Bypass after multiple restrictive procedures: Roux-en-Y or One Anastomosis? A retrospective multicentric study.

OBJECTIVE: When restrictive surgery fails, conversion to more malabsorptive techniques is frequently proposed. The aim of this study is to evaluate the weight loss figures between Roux-en-Y Gastric Bypass (RYGB) and One Anastomosis Gastric Bypass (OAGB) in patients who have already undergone Multiple Restrictive Procedures (MRP). PATIENTS AND METHODS: All patients who underwent conversion of Laparoscopic Sleeve Gastrectomy (LSG) to RYGB or OAGB between 2010 and 2019 were retrospectively analyzed. Only patients who had conversion for Weight Regain (WR) or Insufficient Weight Loss (IWL) after both Laparoscopic Gastric Banding (LGB) and LSG entered the study population. Finally, 44 patients underwent conversion to RYGB, and 24 patients to OAGB. RESULTS: Concerning Excess Weight Loss (%EWL) at 3, 6, 12, 24 postoperative months, the results for RYGB were 33.7%, 47.95%, 61.8%, 61.8%, while for OAGB were 38.3%, 51.9%, 63.75%, 79.45%. A significant difference was recorded in favor of OAGB at 3 (p=0.03) and 24 (p=0.046) postoperative months. % EWL at 24 months in the case of IWL was 57.8% for RYGB, while for OAGB was 72.7% (p=0.047). No significant difference was found considering patients with WR (80.9% and 80.5%; p= 0.999). Patients with better results at 24 months after surgery had a significantly longer time between sleeve and bypass than those with a lower % EWL. CONCLUSIONS: The results of the present study seem to show that both techniques give good results at 24 months in patients who have undergone MRP. However, OAGB shows overall better results, particularly in patients with IWL.

Alterations of digestive motility after bariatric surgery.

Bariatric surgery can induce changes in digestive motility that are de novo or secondary to an improvement or aggravation of previous disorders due to obesity. Alterations of digestive motility are frequently part of the mechanism of action and a result of surgery. They are not rare and they are not always associated with an increase in weight loss but can lead to the negative consequences on quality of life, which are more or less reversible as a real surgical complication. Knowledge of these complications has become essential, especially in this period when bariatric surgery often concerns patients who have already undergone an operation. Thus, the changes in digestive motility after bariatric surgery and the complications that may result from them must be known and considered to adapt surgical techniques to each patient, both in the case of a first intervention and in the case of a reoperation, which is becoming more and more frequent. The objective of this review is to synthesize alterations of esophageal and gastro-intestinal motility secondary to bariatric surgical procedures.

The role of antral resection in sleeve gastrectomy. An observational comparative study.

OBJECTIVE: The role of antral resection (AR) in laparoscopic sleeve gastrectomy (LSG) is still a greatly debated topic in the literature. The aim of this study was to evaluate the results and complications of AR in LSG. PATIENTS AND METHODS: In this observational comparative study, 101 patients who underwent LSG were divided into two groups based on the extent of antral resection: 1 cm from the pylorus (1-DP group), or 6 cm from the pylorus (6-DP group). The %EWL (%Excess weight loss), resolution of T2D (Type 2 Diabetes Mellitus) and GLP-1 were investigated 48 hours before surgery and 3, 6 and 12 months after LSG. Postoperative complications in the first 30 days after surgery were also compared between the two groups using the Clavien-Dindo (CD) score. RESULTS: A significant difference in %EWL was observed at 3 and 6 months in favor of the 1-DP group (38.9% and 57.8%, respectively) compared to the 6-DP group (31.4% and 49.7%, respectively). No difference in T2D resolution was observed between two groups during the follow-up period, with similar changes in GLP-1. Statistically significant differences were found between 1-DP and 6-DP group for the reintervention rate (CD III, 7.7% and 1.9%, respectively; p = 0.02) and life-threatening complications requiring intensive care unit management (CD IV, 3.8% and 0%, respectively, p = 0.03). CONCLUSIONS: In LSG, sparing the antrum is associated with a significant reduction in the rate of postoperative complications, but the metabolic and weight results are comparable to those for antrum resection.

Staple Line Reinforcement During Laparoscopic Sleeve Gastrectomy: Absorbable Monofilament, Barbed Suture, Fibrin Glue, or Nothing? Results of a Prospective Randomized Study.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is associated with serious complications, such as staple line (SL) leaks and bleeding. In order to prevent the occurrence of these complications, surgeons have advocated the need to strengthen the staple line. The aim of this randomized controlled study was to compare the efficacy of three different ways of strengthening of the SL in LSG in preventing surgical post-operative complications. METHODS: Between April 2012 and December 2014, 600 patients (pts) scheduled for LSG were prospectively randomized into groups without SL reinforcement (group A) or with SL reinforcement including fibrin glue coverage (group B), or oversewn SL with imbricating absorbable (Monocryl™; group C) or barbed (V lock®) running suture (group D). Primary endpoints were post-operative leaks, bleeding, and stenosis, while secondary outcomes consisted of the time to perform the staple line reinforcement (SLR) and total operative time. RESULTS: Mean SLR operative time was lower for group B (3.4 ± 1.3 min) compared with that for groups C (26.8 ± 8.5 min) and D (21.1 ± 8.4 min) (p < 0.0001). Mean total operative time was 100.7 ± 16.4 min (group A), 104.4 ± 22.1 min (group B), 126.2 ± 18.9 min (group C), and 124.6 ± 22.8 (group D) (p < 0.0001). Post-operative leaks, bleeding, and stenosis were recorded in 14 pts (2.3 %), 5 pts (0.8 %), and 7 pts (1.1 %), respectively, without statistical difference between the groups. CONCLUSION: Our study suggests that SLR during LSG, with an imbricating or non-imbricating running suture or with fibrin glue, is an unrewarding surgical act with the sole effect of prolonging the operative time.

Varicose vein stripping vs haemodynamic correction (CHIVA): a long term randomised trial.

OBJECTIVES: To compare the long-term results of stripping vs. haemodynamic correction (Ambulatory Conservative Haemodynamic Management of Varicose Veins, CHIVA) in the treatment of superficial venous incompetence resulting in chronic venous disease (CVD). DESIGN: Randomised comparative trial. PATIENTS: 150 patients affected by CVD, CEAP clinical class 2-6, were randomised to saphenous stripping or to CHIVA. METHODS: The clinical outcome was assessed by an independent observer who recorded the Hobbs clinical score for treated limbs. A subjective report of the outcome was provided by the patients. Recurrence of varices was assessed by both clinical examination and duplex ultrasonography. RESULTS: The mean follow-up was 10 years, 26 patients were lost to follow-up. The Hobbs score similar in the stripping and CHIVA groups. However recurrence of varicose veins was significantly higher in the stripping group (CHIVA 18%; stripping 35%, P<0.04 Fisher's exact test), without significant differences in the rate of recurrences from the sapheno-femoral junction. The associated risk of recurrence at ten years was doubled in the stripping group (OR 2.2, 95% CI 1-5, P=0.04). CONCLUSIONS: Recurrent varices occurred more frequently following saphenous stripping than after CHIVA treatment. The deliberate preservation of the saphenous trunk as a route of venous drainage in the CHIVA group may have been a factor reducing the recurrence rate.

The "T" vein of the leg.

BACKGROUND: We frequently observe a tributary of the saphenous vein with the origin in the saphenous compartment of the medial aspect of the upper third of the leg. It runs transversally in the interfascial compartment toward the lateral aspect of the leg. Constantly it feeds by reflux varicose veins clinically visible in the paratibial region and/or in the lateral aspect of the leg. For the peculiarity of its anatomical shape as well as duplex appearance, we defined it as the "T" vein. OBJECTIVES: To assess how frequently the "T" vein of the leg is involved in varicose networks. METHODS: A total of 218 consecutive patients affected by primary varicose veins have been evaluated by the means of duplex scanning. We assessed both the presence of the above-mentioned tributary and the frequency of its hemodynamic involvement in the varicose network. RESULTS: In 15 of 218 cases (7%) we demonstrated the above-mentioned tributary with an interfascial length ranging between 5 and 12 cm involved in varicose networks. CONCLUSIONS: The anterior tributary of the saphenous vein of the anterolateral aspect of the leg is a neglected clinical entity, whose existence is important to know for the treatment of varicose veins of the lateral aspect of the leg.

Minimally invasive surgical management of primary venous ulcers vs. compression treatment: a randomized clinical trial.

OBJECTIVES: to compare minimally invasive surgical haemodynamic correction of reflux (CHIVA) with compression in the treatment of venous ulceration. DESIGN: prospective randomised study. MATERIALS AND METHODS: from a cohort of 80 patients with 87 venous leg ulcers, 47 were randomised to either surgery or compression. RESULTS: at a mean follow-up of 3 years, healing was 100% (31 days) in the surgical and 96% (63 days), in the compression group (p<0.02). The recurrence rate was 9% in the surgical and 38% in the compression group (p<0.05). In the surgical group, all plethysmographic parameters except ejection fraction, had improved significantly at 6 months in the surgical group, and at 3 years residual volume fraction remained in the normal range. Finally, quality of life significantly improved in the operated group. CONCLUSIONS: this study supports the effectiveness of surgical therapy for leg ulceration secondary to superficial venous reflux.