Enhanced Recovery After Surgery Promotes Recovery in Sleeve Gastrectomy: A Randomized Controlled Trial

Evaluation of Veress Needle as a Liver Retraction Technique in Laparoscopic Sleeve Gastrectomy

BackgroundLiver retraction management in laparoscopic sleeve gastrectomy (LSG) is challenging for surgeons, especially in patients with enlarged livers. Traditional methods, such as the Nathanson retractor (NR), often necessitate additional incisions, potentially increasing liver enzymes and increasing the risk of complications. The aim of this study was to evaluate the efficacy of the use of a Veress needle (VN), an alternative liver retraction technique, in LSG surgery compared with NR.Materials and MethodsThis study was conducted at a university-affiliated hospital between May 2022 and December 2022. Patients who underwent LSG were divided into two groups: one utilizing the NR and the other employing the VN for liver retraction. Parameters such as operation duration, retraction time, liver laceration, trocar-induced hemorrhage, subxiphoid trocar site infections, pain scores measured via the visual analog scale (VAS) at various time points, pre- and postoperative liver enzyme levels (AST, ALT, GGT, ALP) and CRP levels were analyzed.ResultsData from 151 patients were analyzed. The AST/ALT elevations (P < 0.001) were significantly lower in the VN group (73 patients) than in the NR group (78 patients), while there was no significant difference in GGT/ALP levels. Retraction-related bleeding was significantly greater in the NR group than in the VN group (6.4% vs 0%, P = 0.035). Postoperative infection rate was lower in the VN group but not statistically significant (0% vs 3.8%, P = 0.135). CRP differences were significant on the first postoperative day (P < 0.001). Postoperative VAS scores were significantly lower in the VN group at all measured time points except at the 48th hour and 10th day.ConclusionsThe VN technique in LSG significantly reduces liver enzyme elevation and the need for an extra trocar and incision, potentially lowering complication risk and enhancing patient outcomes.

A Comparative Analysis of the Liver Retraction with Long Surgical Gauze in Three-Port Sleeve Gastrectomy and the Four-Port Nathanson Retractor Technique

BACKGROUND

This study evaluated the long surgical gauze (SurG) technique as a liver retraction method in laparoscopic sleeve gastrectomy (LSG). Traditional methods involve the Nathanson retractor, associated with ischemia and necrosis complications. In addition, these techniques require an additional trocar with an incision that increases postoperative pain. Our aim, therefore, was to reduce such complications through the use of SurG and evaluate recovery and outcome implications.

METHODS

In this retrospective study, patients who underwent laparoscopic sleeve gastrectomy (LSG) between January and December 2023 were divided into two groups based on the liver retraction method used: NR or SurG. Demographic data, surgery times, postoperative liver enzyme levels (AST, ALT), C-reactive protein (CRP), pain scores, and analgesic use (VAS) were collected from medical records and statistically analyzed.

RESULTS

The SurG group demonstrated significantly lower postoperative pain scores and reduced analgesic use compared to the NR group (p < 0.001). Additionally, liver enzyme levels (AST, ALT, CRP) were lower in the SurG group, indicating less liver stress. Early mobilization was achieved more quickly in the SurG group, aligning with Enhanced Recovery After Surgery (ERAS) protocols. However, the SurG method showed some limitations during the dissection of the greater curvature due to the narrower field of view.

CONCLUSIONS

The long surgical gauze method provides a viable alternative to the Nathanson retractor, offering advantages such as less postoperative pain, reduced liver stress, and quicker mobilization. Despite some technical limitations, this method can improve patient outcomes in sleeve gastrectomy.

Comparison of the Grades of Fatty Liver Disease With Perioperative Risk Factors in Patients With Laparoscopic Sleeve Gastrectomy

Background Obesity is a global healthcare problem, and nonalcoholic fatty liver disease (NAFLD) is a commonly observed comorbid disease in the bariatric population. This study evaluated the relationship between NAFLD and various risk factors, including demographic, biochemical, and comorbid conditions in patients undergoing laparoscopic sleeve gastrectomy (LSG). Material and methods This retrospective data analysis study included patients who underwent LSG between August 2023 and 2024. Patient demographic data were collected, such as age, gender, weight, and body mass index (BMI), and NAFLD grade was determined by ultrasonography. Biochemical markers were recorded, including alanine aminotransferase (ALT), aspartate aminotransferase (AST), total cholesterol, triglyceride (TG), high-density lipoprotein (HDL), low-density lipoprotein (LDL), fasting blood glucose (FBG), HbA1c, and vitamin D. The presence of type II diabetes mellitus (T2DM) and hypertension (HT) was evaluated and compared with the grade of hepatosteatosis. Results The study included 436 patients, of whom 73.6% (n = 321) were female. The mean age was 37.23 ± 10.49 years, and the mean BMI value was 41.25 ± 6.11 kg/m2. Patients were classified and compared according to their NAFLD grade, revealing statistically significant differences in weight, BMI, ALT, AST, HDL, LDL, TG, total cholesterol, HbA1c, FBG, vitamin D, obesity class, DM, and HT (p < 0.05). HDL and vitamin D showed an inverse correlation with NAFLD. We observed no significant difference in the relationship of NAFLD with age and the presence of gallstone. Logistic regression analysis revealed that ALT, AST, LDL, total cholesterol, and FBG were statistically significantly associated with NAFLD in the multivariate model. Conclusion Hepatosteatosis, T2DM, and HT are frequent comorbid diseases that are common in bariatric patients. Our study shows that ALT, AST, LDL, FBG, and total cholesterol may be used as predictors of NAFLD.

Development and Validation of the GAASThyriC Model for Predicting Patients with Suboptimal Clinical Response After Laparoscopic Sleeve Gastrectomy and a Practical Calculator: A Retrospective Cohort Study

BACKGROUND

It might not be possible to achieve the desired outcome in every patient following bariatric surgery, even though every patient is thoroughly examined before surgery. This study aimed to develop a regression model based on parameters that affect weight loss success in patients scheduled for laparoscopic sleeve gastrectomy (LSG) and thus preoperatively predict whether the patients will have an optimal clinical response in terms of weight loss at the end of the first year.

MATERIALS AND METHODS

Between January 2018 and August 2022, patients who underwent LSG were analyzed retrospectively. Age, sex, comorbidities, smoking status, alcohol use status, preoperative weight, preoperative body mass index (BMI), preoperative laboratory data, weight, and total weight loss (TWL)% values at the end of the first year were recorded. At the end of the first year following LSG, patients with TWL% above 20% were defined as having an optimal clinical response in terms of weight loss. This study is designed, conducted, and reported regarding the "transparent reporting of a multivariable prediction model for individual prognosis or diagnosis" (TRIPOD) statement. The final model was used to construct an Excel-based calculator.

RESULTS

Four hundred thirty-eight patients underwent the sleeve gastrectomy procedure, and 38 of them were excluded from the study because of a lack of 1-year follow-up information, resulting in 400 eligible patients for our study. Age, glucose, thyroid stimulating hormone (TSH), alcohol consumption, systemic immune inflammation index (SII), and tobacco were the independent predictors of optimal clinical response ( P <0.001, P <0.001, P <0.001, P =0.011, P =0.039, P =0.045, respectively). The model was called the GAASThyriC score. When the final model was tested in the validation cohort, the AUC was 0.875 (95% CI, 0.742-0.999), the sensitivity was 83.3% (95% CI, 51.6-97.9), specificity was 86.4% (95% CI, 77.4-92.8), negative likelihood ratio was 0.19 (95% CI, 0.05-0.68), and accuracy was 86% (95% CI, 77.6-92.1) when the cutoff value was set to the optimal threshold (logit = 0.8451).

CONCLUSION

The GAASThyriC score can be used as an effective auxiliary tool to predict the patient population with suboptimal clinical response in terms of TWL% at the end of the first year after LSG.

Effect of Histopathological Findings of Gastric Specimens Resected During Laparoscopic Sleeve Gastrectomy on Weight Loss Success: A Retrospective Analysis of 599 Patients

BACKGROUND

Even though there aren't enough studies on long-term outcomes, laparoscopic sleeve gastrectomy (LSG) is the most common procedure among weight loss surgeries. In this study, we aimed to evaluate the histopathological results of resected stomach specimens of patients who underwent LSG and to analyze the effect of histopathological results on weight loss success.

METHODS

The patients were divided into two groups according to histopathological results of the pathology specimens: abnormal (chronic active gastritis, chronic inactive gastritis, neoplasias) and normal. If the excess weight loss percentage (EWL%) values were over 70% at the end of the first year following LSG, the patients were considered successful in terms of weight loss. The groups were compared in terms of age, gender, preoperative body mass index (BMI) value, as well as postoperative first-year BMI, EWL%, total weight loss percentage (TWL%), and successful patient percentage.

RESULTS

A total of 599 patients were included in this study. When the patients were dichotomized according to their pathology results as normal or abnormal, 101 (%83.5) of the patients with normal pathology results had EWL% greater than 70%. On the contrary, 356 (74.5%) of the patients with abnormal pathology results had EWL% greater than 70%, and this difference was statistically significant (p=0.038).

CONCLUSION

Patients with normal histopathologic examination results of resected gastric specimens after LSG are more successful than the patient population with abnormal histopathologic results in terms of the percentage of patients with EWL% above 70 at the end of the first postoperative year. We recommend routine histopathologic analysis of gastric specimens after LSG in severely obese patients.

Effectiveness of the Modified Hemoglobin, Albumin, Lymphocyte, and Platelet Score in Predicting Weight Loss After Laparoscopic Sleeve Gastrectomy

Introduction: The overexpression of proinflammatory cytokines in obesity has suggested an association between obesity and inflammation. In this study, we aimed to predict the success of weight loss at the end of the first year of patients who underwent laparoscopic sleeve gastrectomy (LSG) for morbid obesity using hemoglobin, albumin, lymphocyte, and platelet (HALP) score and modified HALP (m-HALP) score. Materials and Methods: Patients were divided into two groups according to the success of weight loss. The groups were compared in terms of HALP score, m-HALP score, demographic parameters, and preoperative laboratory tests. The diagnostic performance measurements of the m-HALP score were calculated. In addition, logistic regression analysis was performed for the factors affecting weight loss in the first year after LSG. Results: Seventy-two patients were evaluated. The median m-HALP score of the patients with an excess weight loss percentage (EWL%) <60 threshold was 562 (416.6-891.9), the median m-HALP score of the patients with an EWL% above the 60 threshold was 394.3 (347.9-543), and the difference between the outcome groups was significant (P = .002).The accuracy of m-HALP score in identifying the patients whose EWL would be <60% 1 year after the surgery was 63.9 (95% confidence interval = 51.7-74.9). Conclusion: This study showed that the m-HALP score is effective in predicting weight loss after bariatric surgery.

Enhanced Recovery After Surgery (ERAS) in Saudi Arabian Surgical Practice: A Comprehensive Analysis of Surgical Outcomes, Patient Satisfaction, and Cost-Effectiveness

Introduction Surgical procedures present substantial healthcare costs, patient discomfort, and potential adverse outcomes. In response, enhanced recovery after surgery (ERAS) protocols have emerged as comprehensive, evidence-based preoperative care pathways designed to optimize preoperative, intra-operative, and postoperative management. These protocols incorporate various interventions, such as preoperative education, nutritional optimization, minimally invasive techniques, multimodal pain management, early mobilization, and patient engagement. Despite their global success and growing popularity, the adoption and influence of ERAS protocols in Saudi Arabia have not been extensively explored. This study aims to assess the ERAS effects on surgical outcomes and evaluate its relationship with patient satisfaction, considering factors such as cost-effectiveness and compliance in the Saudi context. Methods This cross-sectional study encompassed data collection from 1,452 patients who underwent surgical procedures such as bariatric surgery and cholecystectomy, employing systematic random sampling across multiple healthcare facilities in Saudi Arabia. Data were gathered through structured questionnaires, medical records, and cost-effectiveness analysis within the period spanning from January to August 2023. The relationship between ERAS protocol implementation, surgical outcomes, patient satisfaction, and cost-effectiveness was analyzed using statistical tests, including correlation, regression analysis, and chi-square tests. A statistical significance threshold was set at p < 0.05, and Statistical Product and Service Solutions (SPSS, version 28.0) (IBM SPSS Statistics for Windows, Armonk, NY) was used for data analysis. Results Among the 1,452 respondents, 1,152 (79.3%) reported the implementation of ERAS protocols during their surgical procedures. Those receiving ERAS protocols exhibited significantly lower rates of surgical complications, readmissions, and reduced dependency on pain medication (p < 0.001). Additionally, participants subjected to ERAS protocols reported significantly higher satisfaction levels based on the mean satisfaction scale score, with a p-value of less than 0.001. Conclusion The results highlight substantial improvements associated with the implementation of ERAS protocols, particularly in terms of reduced surgical site infections, shortened hospitalization periods, and decreased pain management-related complications. Moreover, ERAS protocol implementation demonstrated enhanced surgical outcomes, increased postoperative satisfaction, and overall improved recovery experiences. These findings underscore the potential benefits of integrating ERAS protocols into the surgical practices of Saudi Arabia. This research contributes to a better understanding of the advantages offered by ERAS protocols and their potential for enhancing healthcare delivery in the region.