Diagnosis and Management of Postoperative Complications After Sleeve Gastrectomy

Nissen sleeve gastrectomy: 5-year follow-up results

BACKGROUND

Nissen sleeve gastrectomy is a new bariatric procedure based on the combination of 2 well-known surgical techniques (vertical sleeve gastrectomy and Nissen fundoplication). It was conceived as a means to prevent the major drawback of the sleeve gastrectomy (SG), the gastroesophageal reflux disease (GERD), while preserving the advantages of SG in terms of weight loss, and remission of obesity-related comorbidities.

OBJECTIVES

The objectives of this study are to present the long-term (5 years) follow-up results on weight loss, evolution of GERD and other comorbidities, and the complication rate of the Nissen sleeve gastrectomy.

SETTING

Montpellier University Hospital, France.

METHODS

This is a prospective analysis of patients who underwent Nissen sleeve gastrectomy as a first-line bariatric procedure between January 2018 and February 2019. A subgroup analysis of patients with no further surgery during follow-up was also performed.

RESULTS

A total of 144 patients underwent Nissen sleeve gastrectomy: After adjusting for exclusion criteria, 133 patients comprised the initial study population, 81.9% of whom had complete follow-up for weight and GERD clinical symptom outcomes at 5 years. The mean total weight loss (TWL%) was 22 (±12.3)% and the mean excess weight loss percentage (EWL%) was 59.4% (±34.2)%. Of the 63 patients with preoperative clinical symptoms of GERD, we observed an 85.5% 5-year clinical remission rate; however, only 25 patients had a gastroscopy at 5 years. The cumulative short- and long-term reoperation rate was 8.1% and the mortality rate was zero.

CONCLUSIONS

The Nissen sleeve gastrectomy achieves a satisfactory long-term TWL% and a significant improvement in comorbidities, particularly regarding the incidence of GERD. The rate of complications requiring surgical reoperation is low.

Bariatric surgery for treatment of morbid obesity in adults

Morbid obesity requires active intervention, with treatment options including lifestyle modification, pharmacotherapy, and surgery. As the prevalence of obesity continues to rise in Korea, it is crucial for specialists and general practitioners to have a comprehensive understanding of obesity and its management. Bariatric surgery is the most effective treatment modality for obesity, leading to significant weight loss and metabolic benefits. It involves surgical alterations of normal anatomical structures to improve overall health. Therefore, selecting the appropriate procedure based on the individual characteristics of patients is crucial. This review highlights the two most commonly performed bariatric procedures worldwide, including in Korea: sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). Furthermore, it provides a comprehensive overview of the surgical techniques involved in SG and RYGB, addresses potential complications, and presents findings from key studies on the weight loss and metabolic outcomes of these surgeries. Additionally, to support clinical application, the review provides outcome data for these procedures based on studies conducted in Korean populations. In addition to SG and RYGB, this review briefly introduces other surgical and endoscopic options, as well as pharmacological treatments that are currently available or may become viable options in the near future.

Endoscopic management of complications after sleeve gastrectomy: a narrative review

Sleeve gastrectomy (SG) has become the most widely performed bariatric procedure globally due to its technical simplicity and proven efficacy. However, complications following SG, including bleeding, leakage, fistulas, stenosis, gastroesophageal reflux disease (GERD), and hiatal hernia (HH), remain a significant concern. Endoscopic interventions have emerged as valuable minimally invasive alternatives to traditional surgical approaches for managing these complications. This review aims to provide a comprehensive overview of the endoscopic management strategies available for addressing the various complications encountered after SG, emphasizing their critical role in optimizing patient outcomes.

Endoscopic Management of Post-Sleeve Gastrectomy Complications

Obesity is associated with several chronic conditions including diabetes, cardiovascular disease, and metabolic dysfunction-associated steatotic liver disease and malignancy. Bariatric surgery, most commonly Roux-en-Y gastric bypass and sleeve gastrectomy, is an effective treatment modality for obesity and can improve associated comorbidities. Over the last 20 years, there has been an increase in the rate of bariatric surgeries associated with the growing obesity epidemic. Sleeve gastrectomy is the most widely performed bariatric surgery currently, and while it serves as a durable option for some patients, it is important to note that several complications, including sleeve leak, stenosis, chronic fistula, gastrointestinal hemorrhage, and gastroesophageal reflux disease, may occur. Endoscopic methods to manage post-sleeve gastrectomy complications are often considered due to the risks associated with a reoperation, and endoscopy plays a significant role in the diagnosis and management of post-sleeve gastrectomy complications. We perform a detailed review of the current endoscopic management of post-sleeve gastrectomy complications.

Awareness of Bariatric Sleeve Gastrectomy Complications Among the General Population of Saudi Arabian Regions

Sleeve gastrectomy (SG) is a type of procedure called bariatric surgery that provides large weight loss and has a positive impact on diseases associated with obesity. However, it has brought several complications that have an impact on those undergoing surgery, which are classified into intraoperative and postoperative issues. The study's goal is to assess the Saudi Arabian population's awareness of SG consequences. This study assessed the general population's knowledge in Saudi Arabia in 2023 using a cross-sectional approach. The total number of participants was 1,013, the majority of whom were individuals between the ages of 18 and 25 (471, 46%), and females (692, 68%). A total of 692 (68%) participants showed awareness of BMI; in addition, 987 (97%) were aware of gastric sleeve surgery, and 538 (53%) understood its indications correctly. Regarding SG complications, approximately 821 (81%) of participants showed awareness. There were significant associations between knowledge of gastric sleeve surgery and residence in the northern region of Saudi Arabia. In conclusion, our study indicated that the general population is aware of the complications of gastric sleeve surgery, but it found a deficiency in their knowledge about BMI.

Compression pre-stapler firing and post-ignition wait during sleeve gastrectomy: a prospective randomized trial

BACKGROUND

Insufficient research exists on the stapling technique in and duration of laparoscopic sleeve gastrectomy (LSG).

OBJECTIVES

This study aimed to assess the clinical outcomes using a 30-second precompression and post-firing waiting time without extra support for the stapling line.

DESIGN AND SETTINGS

Randomized controlled prospective study at a university hospital.

METHODS

This study included 120 patients treated between January 2022 and February 2023. The patients were divided into the non-waiting group (T0) and waiting group (T1), each with 60 patients. Perioperative complications were analyzed using statistical tests.

RESULTS

The waiting group (T1) showed a significant reduction in the number of intraoperative bleeding points requiring intervention compared with the non-waiting group (T0) (81 versus 134, P < 0.05). In T0, postoperative C-reactive protein (CRP) levels increased (P < 0.05) and hemoglobin levels decreased significantly (P <0.05). The study recorded 22 postoperative complications, accounting for 18.3% of all cases during the 30-day postoperative period.

CONCLUSIONS

The study concluded that the 30 sec + 30 sec stapling technique reduces perioperative bleeding, length of stay, and serious complication rates and is practical and effective for LSG.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov with registration code NCT05703035; link: https://clinicaltrials.gov/ct2/show/NCT05703035.

Long-term follow-up of a cohort with post sleeve gastrectomy leaks: results of endoscopic treatment and salvage surgery

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) is the most performed bariatric procedure worldwide. The most challenging postoperative complication is gastric leak. The objectives of this study are to examine the efficacy and morbidity of different therapeutic strategies addressing leakage, and the long-term outcomes of a cohort of LSG leaks.

METHODS

A retrospective review of patients treated for LSG leaks between September 2014 and January 2023 at our high-volume bariatric surgery center was performed.

RESULTS

The charts of 37 patients (29 women and 8 men) were reviewed, with a mean age of 43 years and a median follow-up of 24 months. The mean preoperative body mass index was 45.1 kg/m2. Overall, 30/37 (81%) patients were successfully treated with endoscopic management, and 7/37 (19%) ultimately underwent salvage surgery. If the leak was diagnosed earlier than 6 weeks, endoscopic treatment had a 97% success rate. The median number of endoscopic procedures was 2 per patient, and included internal pigtails, stents, septoplasty, endoluminal vacuum therapy and over-the-scope clips. Complications included stent-related ulcers (10), esophageal stenosis requiring endoscopic dilatations (4), stent migrations (2) and kinking requiring repositioning (1), and internal pigtail migration (3). Revisional surgery consisted of proximal gastrectomy and Roux-en-Y esophago-jejunal anastomosis, Roux-en-Y fistulo-jejunostomy or classic Roux-en-Y gastric bypass proximal to the gastric stricture. In 62% of the cases, the axis/caliber of the LSG was abnormal. Beyond 4 attempts, endoscopy was unsuccessful. The success rate of endoscopic management dropped to 25% when treatment was initiated more than 45 days after the index surgery.

CONCLUSIONS

Purely endoscopic management was successful in 81% of cases; with 97% success rate if diagnosis earlier than 6 weeks. After four failed endoscopic procedures, a surgical approach should be considered. Delayed diagnosis appears to be a significant risk factor for failure of endoscopic treatment.

ASSESSMENT OF THE EFFICIENCY OF ANALGETIC ACTION OF LAPAROSCOPICALLY ASSISTED TAP BLOCK AS A COMPONENT OF PERIOPERATIVE MULTIMODAL ANALGESIA PLAN IN OBESE PATIENTS UNDERGOING METABOLIC SURGERY

OBJECTIVE

The aim: To assess the effectiveness and feasibility of laparoscopically assisted TAP block utilization in the system of multimodal analgesia by comparing the severity of pain and associated postoperative recovery indicators in obese patients after laparoscopic sleeve gastrectomy.

PATIENTS AND METHODS

Materials and methods: The retrospective study included 39 patients, who underwent metabolic surgery from 2013-2022. All patients were divided into 2 groups depending on the chosen perioperative analgesia protocol. Group 1 included 19 patients who prior to skin incision a local infiltration of the trocar puncture areas of the abdominal wall. Group 2 included 20 patients, whom in addition to the above-described anaesthesia procedure after completion of the main stage of surgery, a laparoscopically assisted bilateral subcostal TAP block was additionally performed.

RESULTS

Results: The need to use opioid analgesics in the rescue analgesia mode arose in 17.6% (3/17) of patients of the first group, and 5% (1/20) of patients in the second group Average duration of postoperative hospitalization in group 1 was 7.2±1.1 days, and in group 2 it was 6.2±1.4 days (P <0.05).

CONCLUSION

Conclusions: Subcostal TAP block in obese patients is a safe and effective method of regional anaesthesia. Further study of this option of regional anaesthesia is required in order to be able to form clearer recommendations for its routine use in clinical practice.