Laparoscopic sleeve gastrectomy as revisional surgery in a vertical gastroplasty with gastrogastric fistula: a simplified technique.

Gastrogastric fistula is one of the complications that can occur after vertical gastroplasty surgery for weight loss. We describe a novel sleeve gastrectomy technique to treat a proximal gastrogastric fistula after vertical gastroplasty.

Laparoscopic sleeve gastrectomy and left adrenalectomy with supragastric approach.

A female patient, 48-year-old, with morbid obesity (body mass index 42.5 kg/m2) complicated by hypertension, T2DM, and severe Obstructive Sleep Apnea Syndrome was candidated to bariatric surgery. During the preoperative work-up, an abdominal ultrasonography and an RMN showed an incidental left adrenal tumor with a diameter of 11 cm. The laboratory evaluation for the functional adrenal tumor was negative. A laparoscopic sleeve gastrectomy and left adrenalectomy with supragastric approach was successfully carried out. The minimally invasive treatment of coexisting abdominal pathologies such as morbid obesity and adrenal incidentalomas seem to be suitable and safe, providing several benefits in terms of surgical and anesthesiologic management and postoperative clinical outcomes. The supragastric approach may represent a valuable option for left adrenalectomy combined with laparoscopic sleeve gastrectomy.

A time-saving technique for specimen extraction in sleeve gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG), first intended as the first step of biliopancreatic diversion with duodenal switch (BPD-DS), is gaining popularity as a per-se procedure because of its effectiveness on weight loss and comorbidity resolution. The extraction of the gastrectomy specimen could be challenging and time-consuming. Different techniques have been described for specimen withdrawal. In this article we report the technique adopted in more than 250 LSGs performed in our department. METHODS: In the first 90 LSGs performed in our department from October 2002, the specimen was extracted in a retrieval bag using an endoloop. In the following 160 cases the technique has been simplified: the grasped specimen is withdrawn through the 15-mm trocar site without any additional device. RESULTS: We registered only two cases of wound infection (1.2%) with the simplified technique, both occurring in the initial cases. There were no cases of trocar site hernia formation. CONCLUSION: The technique described does not require any special devices and seems to be simpler, saves time, and is cost effective if compared with other techniques previously reported.

Early postoperative insulin-resistance changes after sleeve gastrectomy.

INTRODUCTION: Biliopancreatic diversion and gastric bypass are associated with a rapid improvement in insulin resistance few days after surgery. The purpose of this study was to evaluate the short-term effects in insulin resistance following sleeve gastrectomy (SG). MATERIALS AND METHODS: Between December 2007 and September 2008, 17 consecutive obese type 2 diabetes mellitus patients (three men, mean age 51.1 years, mean BMI 44.7 kg/m(2)) were submitted to laparoscopic SG. Fasting serum glucose, insulin concentration, and homeostatic model assessment for insulin resistance (HOMA IR) were drawn preoperatively and at 5, 15, 30, and 60 postoperative days. In seven of these patients insulin sensitivity was evaluated on postoperative days 1, 2, 3, and 4. Moreover a control group of three overweight and diabetic patients (one man, mean age 52.1 years and mean BMI 26.8 kg/m(2)) submitted to laparoscopic cholecystectomy and undergoing the same diet protocol was studied. RESULTS: In all obese patients, a sharp (5 days) and significant reduction of serum glucose and insulin concentration and HOMA IR values was observed after SG. In seven patients, serum glucose and insulin concentration and HOMA IR values were significantly lower at third postoperative day. At the 15th postoperative day both serum glucose and insulin concentration and HOMA IR remained significantly lower in the absence of significant weight modifications. At 30 and 60 postoperative days, these values remained substantially unchanged in spite of a greater weight loss. In the cholecystectomy patients group, at postoperative day 5, only the serum glucose concentrations were significantly reduced although with the higher values than normal in respect to the preoperative values. CONCLUSIONS: After SG the improvement of insulin action occurred rapidly and independently of EWL. The results of the present study confirm that a hormonal mechanism may contribute to changes in insulin resistance following SG.

Laparoscopic splenectomy in the management of benign and malignant hematologic diseases.

OBJECTIVES: The use of laparoscopy to treat malignant hematological diseases is not completely accepted. Our aim was to analyze operative and postoperative results of laparoscopic splenectomy performed for benign versus malignant hematological disorders. METHODS: Between 1994 and 2003, 76 consecutive patients underwent laparoscopic splenectomy. The first 38 cases were performed by using an anterior approach, whereas in the remaining 38 cases a semilateral position was used. RESULTS: Baseline characteristics showed that patients with malignant diseases were significantly older (56.9 vs 32.6 years, P < 0.001). Seventy-two (94.7%) procedures were completed laparoscopically. Conversion was required in 4 cases (5.2%). Mean operative time was 138.5 minutes for benign and 151.0 minutes for malignant diseases, (P > 0.05, ns). The hand-assisted technique was used in 3 patients with massive splenomegaly. Pathologic features showed that spleen volume was higher in patients with malignant diseases (mean interpole diameter 18.1 cm vs 13.7 cm, P < 0.001). Massive splenomegaly (interpole diameter over 20 cm, weight over 1000 g) was present in 13 patients (17.1%); 9 had malignant diseases. Overall perioperative mortality was 1.3% and major postoperative complications occurred in 6 patients (7.8%). Postoperative splenoportal partial thrombosis was identified in 9.7% of patients. CONCLUSIONS: Laparoscopic splenectomy is a well-accepted, less-invasive procedure for hematological disorders. Neoplastic diseases or splenomegaly, or both, do not seem to limit the indications for a minimally invasive approach after the learning curve.

Accuracy of laparoscopy in the diagnosis and staging of lymphoproliferative diseases.

Laparoscopy seems to be playing an emerging role in the management of lymphoproliferative diseases. The aim of this study was to prospectively analyze personal experience evaluating the role and limits of laparoscopy in the management of lymphomas. From July 1993 to December 2000, 131 consecutive patients were referred to our institution for primary diagnosis (group A, n = 70), suspected relapse (reassessment) (group B, n = 54), or staging/restaging of lymphoproliferative diseases (group C, n = 7). Diagnostic and/or operative laparoscopy was performed in all patients. To assess the accuracy of laparoscopy, the results were analyzed according to the indications for surgery. In all, 128 procedures were completed laparoscopically (95.5%). Conversion was required in 7 cases (5.1%). Causes of the conversions were severe obesity (body mass index 62.5), uncontrolled intraoperative bleeding (HIV+), nondiagnostic tissue sampling (2 cases), perisplenic inflammation and perisplenic abscesses (3 cases). The results of this study highlight the safety of diagnostic and staging laparoscopy and laparoscopic splenectomy in patients with lymphoproliferative diseases (major complications 2.9%, perioperative mortality 0%). In all, 96.4% of patients from group A and 100% of patients from group B were treated on the basis of laparoscopic findings. No false negative diagnosis occurred. Laparoscopy may become the "gold standard" in the management of lymphoproliferative disease in the following settings: for the differential diagnosis of hepatic and/or splenic focal lesions; when percutaneous needle biopsy fails and/or genetic analysis is needed for therapeutic decision; for the primary diagnosis and abdominal staging of patients with diffuse retroperitoneal lymphadenopathy in the absence of peripheral lymphadenopathy; for cases of abdominal restaging after concurrent chemoradiotherapy and in cases of suspected relapse when percutaneous biopsy is not technically possible; and for patients with lymphoproliferative disease when splenectomy is required. Marked splenomegaly with perisplenic inflammatory reaction and lymphadenopathy in HIV+ patients should be considered possible causes of failure of the laparoscopic approach.