Outcomes of laparoscopic proximal gastrectomy with esophagojejunal reconstruction for chronic staple line disruption after laparoscopic sleeve gastrectomy

Comparing the Efficacy of Robotic Versus Laparoscopic Sleeve Gastrectomy: A Systematic Review and Meta-Analysis

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has emerged as the predominant metabolic bariatric surgery. With a growing number of studies evaluating the feasibility of robotic sleeve gastrectomy (RSG), it becomes imperative to ascertain whether the outcomes of both techniques are comparable. This study endeavors to synthesize existing evidence and juxtapose the surgical outcomes of LSG and RSG.

METHODS

We collected articles comparing LSG and RSG published between 2011 and 2024. The compiled data included author names, study duration, sample size, average age, gender distribution, geographical location, preoperative body mass index (BMI), bougie diameter, duration of hospitalization, surgical duration, readmission rates, conversion rates, costs, postoperative percentage of excess weight loss (%EWL), postoperative BMI, mortality rates, and complications.

RESULTS

We incorporated 21 articles. Both the RSG and LSG cohorts exhibited comparable rates of readmission, conversion, mortality, and incidence of complications (p > 0.05). Moreover, the efficacy of weight loss was similar between RSG and LSG. Nonetheless, RSG was linked to longer operative duration (WMD, -27.50 minutes; 95% confidence interval [CI], -28.82 to -26.18; p < 0.0001), prolonged hospitalization (WMD, -0.15 days; 95% CI, -0.25 to -0.04; p = 0.006), and elevated expenses (WMD, -5830.9 dollars; 95% CI, -8075.98 to -3585.81; p < 0.0001).

CONCLUSIONS

While both RSG and LSG demonstrated positive postoperative clinical outcomes, RSG patients experienced extended hospital stays, longer operative times, and increased hospitalization costs compared to LSG patients. Using the robotic platform for sleeve gastrectomy (SG) in patients with obesity did not appear to offer any clear benefits.

Risk Factors and Management Approaches for Staple Line Leaks Following Sleeve Gastrectomy: A Single-Center Retrospective Study of 402 Patients

Sleeve gastrectomy (SG) has gained ever-increasing popularity among laparoscopic surgeons involved in bariatric surgery. This single-institution, retrospective cohort study aims to evaluate the prevalence of postoperative staple line leakage (PSLL) after LSG and identify risk factors for its development. We included patient data that underwent LSG at our institution for a span of 17 years-starting in January 2005 and ending in December 2022. We set the investigation of correlations of patient-related factors (age, weight, BMI, smoking status, presence of diabetes mellitus) with the occurrence of postoperative leaks. A total of 402 patients were included in our study. Of them, 26 (6.46%) developed PSLL. In total, 19 (73%) patients underwent percutaneous drainage and 14 patients (53.8%) were treated with intraluminal endoscopic stenting. Finally, five patients (19.2%) were treated with endoscopic clipping of the defect. Operative management was required in only one patient. There were no statistically significant differences in patient age, mean weight at the time of operation, and mean BMI. Abnormal drain amylase levels were associated with earlier detection of PSLL. More consideration needs to be given to producing a consensus regarding the management of PSLL, prioritizing nonoperative management with the combination of percutaneous drainage and endoscopic stenting as the safest and most efficient approach.

Management and outcomes of gastric leak after sleeve gastrectomy: results from the 2010-2020 national registry

BACKGROUND

Management of gastric leak after sleeve gastrectomy (SG) is challenging due to its unpredictable outcomes. We aimed to summarize the characteristics of SG leaks and analyze interventions and corresponding outcomes in a real-world setting.

METHODS

To retrospectively review of 15,721 SG procedures from 2010 to 2020 based on a national registry. A cumulative sum analysis was used to identify a fitting curve of gastric leak rate. The Kaplan-Meier method and log-rank tests were performed to calculate and compare the probabilities of relevant outcomes. The logistic regression analysis was conducted to determine the predictors of acute leaks.

RESULTS

A total of 78 cases of SG leaks were collected with an incidence of 0.5% (78/15,721) from this registry (6 patients who had the primary SG in non-participating centers). After accumulating 260 cases in a bariatric surgery center, the leak rate decreased to a stably low value of under 1.17%. The significant differences presented in sex, waist circumference, and the proportion of hypoproteinemia and type 2 diabetes at baseline between patients with SG leak and the whole registry population ( P = 0.005, = 0.026, <0.001, and = 0.001, respectively). Moreover, 83.1% (59/71) of the leakage was near the esophagogastric junction region. Leakage healed in 64 (88.9%, 64/72) patients. The median healing time of acute and non-acute leaks was 5.93 months and 8.12 months, respectively. Acute leak (38/72, 52.8%) was the predominant type with a cumulative reoperation rate >50%, whereas the cumulative healing probability in the patients who required surgical treatment was significantly lower than those requring non-surgical treatment ( P = 0.013). Precise dissection in the His angle area was independently associated with a lower acute leak rate, whereas preservation ≥2 cm distance from the His angle area was an independent risk factor.

CONCLUSIONS

Male sex, elevated waist circumference, hypoproteinaemia, and type 2 diabetes are risk factors of gastric leaks after SG. Optimizing surgical techniques, including precise dissection of His angle area and preservation of smaller gastric fundus, should be suggested to prevent acute leaks.

Completion Gastrectomy with Esophagojejunostomy for Management of Complications of Benign Foregut Surgery

BACKGROUND

With the worldwide epidemic of obesity, an increasing number of bariatric operations and antireflux fundoplications are being performed. Despite low morbidity of the primary foregut surgery, completion gastrectomy may be necessary as a definitive procedure for complications of prior foregut surgery; however, the literature evaluating outcomes after completion gastrectomy with esophagojejunostomy (EJ) for benign diseases is limited. We present our experience of completion gastrectomy with Roux-en-Y EJ in the setting of benign disease at a single tertiary center.

METHODS AND PROCEDURES

All patients who underwent total, proximal, or completion gastrectomy with EJ for complications of benign foregut surgery from January 2006 to December 2015 were retrospectively identified. All cancer operations were excluded.

RESULTS

There were 23 patients who underwent gastrectomy with EJ (13 laparoscopic EJ [LEJ] and 10 open EJ). The index operations included 12 antireflux, 9 bariatric, and 2 peptic ulcer disease surgeries. Seventy-eight percent of patients had surgical or endoscopic interventions before EJ, with a median of one prior intervention and a median interval from the index operation to EJ of 25 months (interquartile range 9-87). The 30-day perioperative complication rate was 30% with 17% classified being major (Clavien-Dindo ≥ III) and no 30-day perioperative mortality. Comparing laparoscopic and open approaches showed similar operative times, estimated blood loss, and overall complication rate. LEJ was associated with a shorter length of stay (LOS) (P < .001), fewer postoperative ICU days (P = .002), fewer 6-month complication rates (P < .007), and decreased readmission rate (P = .024).

CONCLUSION

Our series demonstrates that EJ is a reasonable option for reoperative foregut surgery. The laparoscopic approach appears to be associated with decreased LOS and readmissions.

Staple Line Reinforcement in Laparoscopic SleeveGastrectomy: Experience in 1023 Consecutive Cases

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) is one of the most frequently performed bariatric procedures performed worldwide. However, staple line-related complications have become a major challenge for bariatric surgeons. The aim of this study was to evaluate the morbidity in a cohort of patients who underwent LSG with imbricated oversewing of the staple line at a single high-volume center.

MATERIALS AND METHODS

We retrospectively reviewed prospectively collected data for all patients who underwent LSG to treat obesity at our institution from January 2010 to September 2016. All practitioners had undergone training with a single senior bariatric surgeon using oversewing as staple line reinforcement (SLR).

RESULTS

In total, 1023 LSGs were performed (female, 67.3%; mean age, 40.6 ± 10.8 years; median preoperative body mass index, 37 ± 4.5 kg/m²). The mean operative time was 67.6 ± 23.4 min (range, 30-150 min). The rate of conversion to open surgery was 0.3%. Early complications were noted in 18 patients (1.8%), including 5 cases of bleeding (0.5%). No leaks, stenosis, or mortality occurred.

CONCLUSIONS

LSG is a safe technique, but staple line-associated complications can be life-threatening. In this series, no leaks occurred from the very beginning of the surgeons' experience in LSG. Imbricated oversewing of the staple line, proper mentoring, and performance of surgery in appropriate settings are good approaches to decreasing complications.

Novel oesophago-gastro-duodenal stenting for gastric leaks after laparoscopic sleeve gastrectomy

The management of gastric leak after laparoscopic sleeve gastrectomy (LSG) can be complex and challenging. Whilst operative interventions are mostly complicated and reserved for unstable or refractory cases, endoscopic self-expandable metal stenting (SEMS) is increasingly preferred as a safer treatment option. Yet, SEMS carries the problems of frequent stent migration and inconsistent healing as ordinary SEMS is designed mainly for stenotic disease. We hereby present two cases of early and chronic post-LSG leakage that were respectively failed to be treated by surgery and ordinary SEMS but were successfully managed by a dedicated extra-long oesophago-gastro-duodenal stent. In oesophago-gastro-duodenal stenting, the characteristics of extra-long stent length allow total gastric exclusion between the mid-oesophagus and the first part of duodenum to prevent stent migration and to equalise high pressure gradient within the gastric sleeve to promote fistula healing.

Changing trends in bariatric surgery

BACKGROUND AND AIMS

Bariatric surgery is considered the only long-lasting treatment for morbid obesity. Techniques and procedures have changed dramatically. We report on some of the major changes in the field.

MATERIALS AND METHODS

We reviewed some of the major changes in trends in bariatric surgery based on some landmark paper published in the literature.

RESULTS

We identified three major phases in the evolution of bariatric surgery. The pioneer phase was mostly characterized by discovery of weight loss procedures serendipitously from procedures done for other purposes. The second phase can be identified with the advent of laparoscopic techniques. This is considered the phase of greatest expansion of bariatric surgery. The metabolic phase derives from the improved understanding of the mechanisms of actions of the bariatric operations at the hormonal and molecular level.

CONCLUSIONS

Bariatric surgery has changed significantly over the years. The safety of the laparoscopic approach, along with the better understanding of the metabolic changes obtained postoperatively, has led to a more individualized approach and also an attempt to expand the indications for these procedures.

Management of staple line leaks following sleeve gastrectomy

BACKGROUND

Leaks after laparoscopic sleeve gastrectomy (LSG) are not very frequent but are a difficult complication that can become chronic. Various treatment options have been suggested but no definitive treatment regimen has been established. The aim of our study is to report leak complications after LSG, their management, and outcomes.

METHODS

Between June 2008 and October 2013, a total of 539 patients underwent laparoscopic and robot-assisted laparoscopic sleeve gastrectomy at our institution. A retrospective review of a prospectively collected database was performed for all LSG patients, noting the outcomes and complications of the procedure.

RESULTS

Fifteen (2.8%) patients presented with a leak after LSG. The diagnosis was made at a mean of 27.2±29.9 days (range, 1-102) after LSG. Eight (53.3%) patients underwent conservative treatment initially and 6 (75.0%) of these patients required stenting as secondary treatment. Although leaks from 3 patients resolved with stenting, the other 3 required restenting and 2 eventually underwent conversion to gastric bypass. Five (33.3%) patients underwent endoscopic intervention, closing the leak with fibrin glue (n=3) or hemoclips (n=2). Two (13.3%) patients who were diagnosed with a leak immediately after LSG before discharge had their leak oversewn laparoscopically with an omental patch. Leaks in 9 (60.0%) patients did not heal after the first intervention, and the mean number of intervention required was 2.3±1.7 times (range, 1-7) for the treatment of this condition.

CONCLUSION

Management of leaks after LSG can be challenging. Early diagnosis and treatment is important in the management of a leak. However, it can be treated safely via various management options depending on the time of diagnosis and size of the leak.