Is simultaneous bariatric surgery and ventral hernia repair a safe and effective approach?

BACKGROUND: There is currently a lack of consensus regarding the timing of ventral hernia repair relative to bariatric surgery. OBJECTIVES: To compare outcomes between patients undergoing simultaneous and selectively deferred ventral hernia repair and bariatric surgery. SETTING: High volume UPPER gastrointestinal and Bariatric Unit. Sydney, Australia. METHODS: A retrospective case series from a single institution's prospectively collected database (2003-21) was performed to determine the characteristics and outcomes in patients having simultaneous and deferred hernia repair relative to their bariatric surgery. RESULTS: In our patient cohort (N = 134), 111 patients underwent simultaneous repair and 23 had a deferred procedure. Of the simultaneous patients, 95 (85.6%) underwent resection bariatric surgery. The median operative time in the simultaneous versus deferred groups was 155 versus 287 minutes and the length of stay was 3 versus 7 days. There has been one (.9%) mesh infection requiring explant, in an open, simultaneous repair undertaken in a gastric band patient, 3 (2.8%) infected seromas, 1 (.9%) surgical site infection, and 8 (7.5%) hernia recurrences in the simultaneous group. The deferred group has had no mesh infections, no hernia recurrence, and 2 (9.5%) infected seromas to date. There was 1 mortality in the simultaneous cohort (simultaneous gastric bypass group), from a massive Pulmonary Embolism (<30 days postoperatively) and one in the deferred group from an interval small bowel obstruction. CONCLUSIONS: Simultaneous ventral hernia repair with bariatric surgery had a low rate of infection and a low mesh explant rate, even when coupled with resection bariatric surgery in this series. A combined approach may be safe, even in the clean-contaminated surgical context.

Investigating the prevalence of nutritional abnormalities in patients prior to and following bariatric surgery.

AIMS: Bariatric surgery remains an effective treatment for the condition of obesity. However it predisposes patients to nutritional deficiencies and related complications. The aim of this study was to identify nutritional abnormalities, weight loss, adherence to supplements, and presence of gastrointestinal symptoms in a cohort of bariatric surgical patients. METHODS: An analysis of the electronic medical records of patients attending a multidisciplinary private clinic in Sydney, Australia from August 2020 to August 2021 was conducted. Data on anthropometric measures, nutritional indices, adherence to supplements and gastrointestinal symptoms preoperatively and then at ≤6 months, 1 and 2 years or more postoperatively were collected. RESULTS: A total of 231 patients were included in the study. The majority of patients were female (76.2%), with a sleeve gastrectomy (78.8%). Average preoperative BMI was 43.4 ± 7.1 kg/m2 . Weight loss ≥2 years postsurgery was 33.5 ± 12.4 kg. The most common abnormalities preoperatively were: C-reactive protein (47.7%), vitamin D (39%), B12 (31%), parathyroid hormone (27.6%) and ferritin (12.7%). Vitamin B12 (23.2%), parathyroid hormone (23%), vitamin D (17.7%) and ferritin (15.9%) remained common abnormalities postoperatively. Adherence to multivitamins was 90% in the first year following surgery, declining to 77% at ≥2 years. Gastrointestinal symptoms were predominantly present in the initial stages following surgery, manifesting thiamin deficiency in 6.5% of patients. CONCLUSIONS: Despite achieving durable weight loss, nutritional and related abnormalities remain an ongoing challenge for bariatric surgery. Adherence to nutrient supplements, gastrointestinal symptoms and related complications are important considerations in addressing the problem.

Changes in Anthropometric Measures, Nutritional Indices and Gastrointestinal Symptoms Following One Anastomosis Gastric Bypass (OAGB) Compared with Roux-en-y Gastric Bypass (RYGB).

PURPOSE: Bariatric surgery is an effective treatment for obesity with new procedures emerging. However, despite comparable weight loss and improvements in metabolic outcomes, research on nutritional and gastrointestinal symptoms remains limited. Here we compare clinical data on weight, nutritional disorders and gastrointestinal symptoms of patients before and following one anastomosis gastric bypass (OAGB) and Roux-en-Y gastric Bypass (RYGB). MATERIALS AND METHODS: In this retrospective study, data on anthropometry, nutritional indices, dietary intake and gastrointestinal symptoms were retrieved in cohorts of patients up to 2 years following OAGB and RYGB. RESULTS: Seventy-three patients had either a RYGB (28) or an OAGB (45), with 71% seeking these as a revisional procedure. Significant and higher weight loss was observed in the OAGB cohort at 1 year (%TWL 33.0 ± 8.5 vs. 26.6 ± 12.4), albeit comparable at 2 years postoperatively (%TWL 29.0 ± 11.1 vs. 34.1 ± 11.2). Disorders such as vitamin D, active B12, folate, homocystein (Hcy) and hyperparathyroidism were present following both surgeries. Levels of vitamin D, ferritin and total protein significantly worsened over time. Gastrointestinal symptoms of diarrhoea, steatorrhoea and reflux were higher in the OAGB cohort while the RYGB cohort reported more dumping syndrome (DS). CONCLUSION: Significant and similar weight loss results are seen following both OAGB and RYGB. Nutritional disorders were common in both cohorts and increased over time. However, the OAGB patients reported more gastrointestinal side effects, which may contribute to poor quality of life and nutritional consequences. Prospective and longer-term studies investigating the nutritional and gastrointestinal health of patients undergoing OAGB is recommended.

The Relationship Between Bariatric Surgery and Diet Quality: a Systematic Review.

BACKGROUND: Bariatric surgery is currently the most effective treatment for morbid obesity. These procedures change the gastrointestinal system with the aim of reducing dietary intake. Improving diet quality is essential in maintaining nutritional health and achieving long-term benefits from the surgery. The aim of this systematic review was to examine the relationship between bariatric surgery and diet quality at least 1 year after surgery. METHODS: A systematic search of five databases was conducted. Studies were included that reported diet quality, eating pattern, or quality of eating in adult patients who had undergone laparoscopic-adjusted gastric banding (LAGB), Roux-en-Y gastric bypass (RYGB), and sleeve gastrectomy (SG) procedures. Data was extracted to determine the relationship between having had bariatric surgery and subsequent diet quality. RESULTS: A total of 34 study articles (described in 36 articles) met the inclusion criteria. The majority of studies were observational in nature and showed a reduction in energy intake following surgery, as well as inadequate intakes of micronutrients and protein, and an excessive intake of fats. There was evidence of nutrient imbalances, suboptimal compliance with multivitamin and mineral supplementation, and limited follow-up of patients. CONCLUSION: The current evidence base suggests that despite being effective in reducing energy intake, bariatric surgery can result in unbalanced diets, inadequate micronutrient and protein intakes, and excessive intakes of fats. In combination with suboptimal adherence to multivitamin and mineral supplementation, this may contribute to nutritional deficiencies and weight regain. There is a need for high-quality nutrition studies, to identify optimal dietary compositions following bariatric surgery.

Management of Zenker's diverticulum using flexible endoscopy.

BACKGROUND AND AIMS: Zenker's diverticulum is a false diverticulum through Killian's dehiscence. Symptoms include halitosis, dysphagia, regurgitation, cough, and aspiration pneumonia. Treatment options include open transcervical cricopharyngeal myotomy, trans-oral rigid endoscopic stapling, and minimally invasive endoscopic myotomy. Although open surgical techniques have historically been the criterion standard for treatment, endoscopic options have become increasingly used. We propose the use of flexible endoscopy in the management of Zenker's diverticulum. METHODS: We present a retrospective case series of 9 patients undergoing endoscopic cricopharyngeal myotomy from 2014 to 2018 using our endoscopic technique. RESULTS: We demonstrate that endoscopic technique provided adequate symptomatic relief in 7 of 9 patients, with no operative adverse events. CONCLUSIONS: Cricopharyngeal myotomy using flexible endoscopy is a safe and effective technique for the management of Zenker's diverticulum. Potential benefits of this approach include shorter operative times, shorter postoperative admissions, and earlier progression of diet. Initial treatment with endoscopic technique does not preclude future open repairs.

Simultaneous ventral hernia repair in bariatric surgery.

BACKGROUND: Obesity is a significant risk factor in abdominal hernia occurrence and recurrence. In patients having bariatric surgery, there are no clear guidelines as to whether repair should be done simultaneously, especially if procedures involve division or resection of part of the gastrointestinal tract. METHODS: A retrospective case series review over a 6-year period to December 2012 from a prospective database was conducted. As per existing practice for bariatric procedures, patients were followed up indefinitely. Short- and long-term outcomes were analysed. RESULTS: Forty-five patients underwent combined laparoscopic bariatric surgery and abdominal wall hernia repair. Of these, 36 had resection procedures (gastric bypass or sleeve gastrectomy) and 9 had non-resection procedures (gastric banding). The mean operative time was 151 min and the mean length of stay was 3 days. Two patients developed post-operative mesh seroma infections. To date, there have been no mesh removals or recurrent hernias. There was no mortality in this series. DISCUSSION: This study demonstrated a low rate of mesh infection (4.44%) at a median follow-up of 13 months, even when a resectional procedure was performed (5.56%). These results suggest the possible viability and reasonable short-/long-term outcomes of simultaneous laparoscopic abdominal wall hernia repair during bariatric surgical procedures, even if the surgery involved division or resection of part of the gastrointestinal tract. This topic is an area of clinical research that warrants further study.

Reduced use of drains following axillary lymphadenectomy for breast cancer.

BACKGROUND: Axillary dissection is frequently performed during the treatment of operable breast cancer, and is associated with certain morbidities. Accumulation of axillary fluid, otherwise known as a seroma, is a frequent complication that appears to be related to the degree of dissection. Based on empirical evidence, surgeons have attempted to reduce the occurrence and duration of seromas by using suction drainage, but this concept has been challenged by several authors. OBJECTIVES: To determine if the natural history of seroma fluid accumulation after axillary surgery is altered by the duration of suction drainage or non-placement of a drain. METHODS: Ninety consecutive patients having axillary dissection for breast cancer had either prolonged suction drainage (mean 9.6 days), short duration drainage (2 days), or had no drain placed. Seromas were aspirated and the time to cessation of fluid accumulation determined, as well as any other wound complications. RESULTS: There was no difference in the number of wound complications or the duration of fluid accumulation between the three groups, being 26.6, 25.7, and 27.9 days, respectively. Patients having no drains placed required more frequent aspirations. CONCLUSIONS: The duration of seroma fluid accumulation is not altered by the placement of a suction drain following axillary lymphadenectomy.