Metabolic and Bariatric Surgery in Patients with Obesity Class V (BMI > 60 kg/m2): a Modified Delphi Study

BACKGROUND

Metabolic and bariatric surgery (MBS) is the preferred method to achieve significant weight loss in patients with Obesity Class V (BMI > 60 kg/m2). However, there is no consensus regarding the best procedure(s) for this population. Additionally, these patients will likely have a higher risk of complications and mortality. The aim of this study was to achieve a consensus among a global panel of expert bariatric surgeons using a modified Delphi methodology.

METHODS

A total of 36 recognized opinion-makers and highly experienced metabolic and bariatric surgeons participated in the present Delphi consensus. 81 statements on preoperative management, selection of the procedure, perioperative management, weight loss parameters, follow-up, and metabolic outcomes were voted on in two rounds. A consensus was considered reached when an agreement of ≥ 70% of experts' votes was achieved.

RESULTS

A total of 54 out of 81 statements reached consensus. Remarkably, more than 90% of the experts agreed that patients should be notified of the greater risk of complications, the possibility of modifications to the surgical procedure, and the early start of chemical thromboprophylaxis. Regarding the choice of the procedure, SADI-S, RYGB, and OAGB were the top 3 preferred operations. However, no consensus was reached on the limb length in these operations.

CONCLUSION

This study represents the first attempt to reach consensus on the choice of procedures as well as perioperative management in patients with obesity class V. Although overall consensus was reached in different areas, more research is needed to better serve this high-risk population.

Endoscopic Revisional Gastroplasty After Bariatric Surgery with a Single-Channel Endoscope

BACKGROUND

Less invasive endoscopic bariatric procedures are under development for the management of recurrence of obesity. The purpose of the current manuscript was to evaluate the safety of the endoscopic revisional gastroplasty (ERG) for patients with recurrence of weight gain following different bariatric procedures.

MATERIALS AND METHODS

This is a retrospective single-center study over 22 patients using the ERG between January 2020 to July 2022 at Bouchard Private Hospital (Marseille, France). The demographic data, past surgical history, obesity complications, time interval between the surgical and endoscopic procedures, and intra and postoperative parameters and outcomes were analyzed.

RESULTS

A total of 22 patients underwent ERG: 19 female (86.4%) with a mean age of 34.2 years and a mean BMI of 32.9 kg/m2 (± 3.4). Average time between the revisional bariatric surgery and ERG was 14.4 months (range 5-36). There were 14 cases of LSG (77.8%), 9 cases of RYGBP (19.4%), and 3 cases with previous gastric band. All procedures were completed by endoscopy with no complication and a mean length of hospital stay of 1.1 days (± 0.9). The weight loss results at 1-year follow-up were available for 17 of the 22 patients: two patients were lost to follow-up (4%) and 3 patients had less than a 1-year follow-up from the ERG. The mean BMI, 1 year after ERG, was 28.7 kg/m2 (± 7.4); the mean BMI loss and %EWL were, respectively, 4.2 kg/m2 (± 4.7) and 53.1% (± 17).

CONCLUSION

Endoscopic revisional gastroplasty represents a safe minimal invasive approach that can be considered an effective and well-tolerated procedure for patients with previous bariatric surgery.

Classification of Slippage Following Laparoscopic BariClip Gastroplasty

INTRODUCTION

Laparoscopic BariClip gastroplasty (LBCG) is a new reversible gastric sleeve-like procedure without gastrectomy proposed to minimize the risk of severe complications. Still one of the possible complications described with LBCG is slippage. The purpose of the current manuscript is to analyze different cases of slippage and propose a classification of this complication.

METHODS

A number of 381 patients who underwent LBCG in 8 different centers were analyzed concerning the risk of slippage. All cases with documented slippage were carefully reviewed in terms of patients' symptomatology (presence of satiety, vomiting), history of weight loss, radiological data, and management of their slippage. A new classification was proposed depending on the anatomy, the symptomatology, and the time of occurrence.

RESULTS

We have identified a total of 17 cases (4.46%) of slippage following LBCG. In 11 patients, the slippage was symptomatic with repetitive vomiting and nausea, and in the remaining 6 patients, the slippage was identified by radiological studies for insufficient weight loss, weight regain, or routine radiological follow-up. Depending on the interval time, the slippage was classified as either immediate (in first 7 days) in 6 cases, early (in less than 90 days) in 4 cases, and late (after 3 months) in 7 cases. Evaluation of the radiological studies in these cases identified the following: anterosuperior displacement (type A) in 9 cases, posteroinferior displacement (type B) in 6 cases (one case after 3 months), and lateral displacement (type C) in the remaining 2 cases. The management of the slippage consisted of BariClip removal in 7 cases, repositioning in 5 cases, and conservative treatment in the remaining 5 cases. All patients with conservative treatment were recorded at the beginning of the experience.

CONCLUSIONS

Slippage is a possible complication after LBCG. This classification of the different types of slippage can benefit the surgeon in the management and treatment of this complication of LBCG.

Is the Surgical Drainage Mandatory for Leak after Sleeve Gastrectomy?

INTRODUCTION

Despite the unanimous acknowledgement of the laparoscopic sleeve gastrectomy (LSG) worldwide, the leak remains its deficiency. For the last decade, the surgical treatment was practically considered mandatory for almost any collection following LSG. The aim of this study is to evaluate the need for surgical drainage for leak following LSG.

METHODS

All consecutive patients having gone through LSG from January 2017 to December 2020 were enrolled in our study. Once the demographic data and the leak history were registered, we analyzed the outcome of the surgical or endoscopic drainage, the characteristics of the endoscopic treatment, and the evolution to complete healing.

RESULTS

A total of 1249 patients underwent LSG and the leak occurred in 11 cases (0.9%). There were 10 women with a mean age of 47.8 years (27-63). The surgical drainage was performed for three patients and the rest of the eight patients underwent primary endoscopic treatment. The endoscopic treatment was represented with pigtails for seven cases and septotomy with balloon dilation for four cases. In two out of these four cases, the septotomy was anticipated by the use of a nasocavitary drain for 2 weeks. The average number of endoscopic procedures was 3.2 (range 2-6). The leaks achieved complete healing after an average duration of 4.8 months (range 1-9 months). No mortality was recorded for a leak.

CONCLUSIONS

The treatment of the gastric leak must be tailored to each patient. Although there is still no consensus for the endoscopic drainage of leaks after LSG, the surgical approach can be avoided in up to 72%. The benefits of pigtails and nasocavitary drains followed by endoscopic septotomy are undeniable, and they should be included in the armamentarium of any bariatric center.

Evolving Technique of Laparoscopic Vertical Gastric Clip Placement

INTRODUCTION

Laparoscopic BariClip gastroplasty (LBCG) will address a similar tubular restriction than the one achieved with the laparoscopic sleeve gastrectomy (LSG) at the level of the gastric fundus, while maintaining the advantage of simplicity and anatomic preservation. The purpose of the current study was to analyze the risk of slippage and to present the evolving technique by adding gastro-gastric plication of the gastric wall covering the BariClip at those areas where the gastric wall "slips" between the limbs of the clip.

METHODS

All patients undergoing LBCG with the evolving technique of gastric plication around the device associated with antral gastroplasty from January 2021 to May 2022 were included in the study group (group A). A control group (group B) was designed with patients who underwent previous LBCG technique between May 2017 and June 2019. This is a case-controlled group with patients matched by gender and BMI. We have analyzed the postoperative complications and more notably the slippage.

RESULTS

One hundred seventy-six patients (44 male and 132 female) with a mean age of 33 years (± 11) underwent evolving technique of LBCG. A control group of 67 patients who underwent previous technique of LBCG was included. All procedures were completed by laparoscopy with no intraoperative complication. For the study group, we have recorded a number of 5 slippages (2.8%). The diagnosis occurred during the first 6 months after the operation. The management consisted of repositioning-3 cases-and BariClip removal-2 cases. For the control group, we have recorded a number of 3 slippages (4.3%). All three patients underwent BariClip removal, with no repositioning.

CONCLUSIONS

We reported a new technique of placement of the BariClip with additional gastric plication anterior, posterior, and volume reduction in the antrum to potentially reduce the rate of slippage and improve weight loss outcomes.

The Reflux and BariClip: Initial Results and Mechanism of Action

INTRODUCTION

Laparoscopic BariClip Gastroplasty (LBCG) represents a new bariatric procedure that mimics the principle of the Laparoscopic Sleeve Gastrectomy (LSG), but using a completely reversible mechanism, which is essential for gastroesophageal reflux disease (GERD). The purpose of our study was to evaluate the evolution of GERD following the initial experience with LBCG.

METHODS

The first 43 obese patients who underwent LBCG performed by the same surgeon in two different medical centers in May 2018-December 2019 were included in the current study. Twelve patients had issues of reflux, regularly receiving PPIs (proton pump inhibitors) treatment in eight cases, and occasionally in four cases. Thirty-two patients completed the follow-up at one year and the GERD was evaluated using the PPI medications and the GerdQ.

RESULTS

The median preoperative GerdQ score was (14.58 ± 1.9). Three patients out of the twelve who had complained about preoperative GERD did not consent to the one year follow-up form. For the rest of nine patients, the median post-operative GerdQ score was (10.11 ± 3.2). The PPIs were used at one year follow-up in six patients: four with occasional use, one patient with regular use showing no improvement, and one who experienced de novo GERD symptomatology (3.1%). No statistically significant difference between the groups was recorded in terms of GERD. We recorded no intraoperative complications. No case of erosion occurred in the post-operative period, but we encountered two cases of slippage. One additional BariClip was removed at 14 months.

CONCLUSION

LBCG represents a new bariatric procedure that mimics the principle of the laparoscopic sleeve gastrectomy, but with a completely reversible mechanism. Even with limited cases, our experience reports several mechanisms of action that will be evaluated and discussed in further prospective clinical trials. After this preliminary clinical study, LBCG's effects on GERD and its safety are highly encouraging.

The Utility of Video Recording in Assessing Bariatric Surgery Complications

Introduction: Recording every procedure could diminish the postoperative complication rates in bariatric surgery. The aim of our study was to evaluate the correlation between recording every bariatric surgery and their postoperative analysis in relation to the early or late postoperative complications. Methods: Seven hundred fifteen patients who underwent a bariatric procedure between January 2018 and December 2019 were included in a retrospective analysis. There were: 589 laparoscopic sleeve gastrectomies (LSGs); 110 Roux-en-Y bypasses (RYGBs) and 16 gastric bands (LAGBs). The video recording was systematically used, and all patients were enrolled in the IFSO registry. Results: There were 15 patients (2.1%) with surgical postoperative complications: 5 leaks, 8 hemorrhages and 2 stenosis. Most complications were consequent to LSG, except for two, which occurred after RYGB. In four cases a site of active bleeding was identified. After reviewing the video, in three cases the site was correlated with an event which occurred during the initial procedure. Three out of five cases of leak following sleeve were treated purely endoscopically, and no potential correlated mechanism was identified. Two other possible benefits were observed: a better evaluation of the gastric pouch for the treatment of the ulcer post bypass and the review of one per operative incident. Two negative diagnostic laparoscopies were performed. The benefit of the systematic video recording was singled out in eight cases. All the other cases were completed by laparoscopy with no conversion. Conclusion: To record every bariatric procedure could help in understanding the mechanism of certain complications, especially when the analysis is performed within the team. Still, recording the procedure did not prevent the negative diagnostic laparoscopy, but it could play a significant role for the medico-legal aspect in the future.

Revisional Surgery from Vertical Banded Gastroplasty to Roux-en-Y Gastric Bypass with Gastric Resection

Introduction: Vertical banded gastroplasty (VBG) was a common bariatric procedure by laparotomy and or at the beginning of the laparoscopy, but nowadays it is almost an abandoned procedure. However, the young generation of bariatric surgeons should be aware about this procedure especially for revisional cases. Roux-en-Y gastric bypass (RYGB) is considered the procedure of choice for the revision of VBG. Materials and Methods: The evolution of revisional surgery to RYGB has known several technical steps. At the beginning, the procedure was performed with no gastric resection. Then a limited resection of the ancient staple line along with the fibrous tissue under the previous band or mesh was performed. The purpose of this article is to describe a simplified operative technique to simultaneously resect the ancient staple line and the calibration band. Results: After the initial viscrerolysis, an attempt to distinguish the course of the ancient section line of the stomach during the VBG is done. The dissection can become extremely challenging, with too much fibrosis and nonanatomical planes of dissection. At this point, we counsel to abandon the anterior direct dissection of the upper part of the stomach and to switch to a posterior dissection with the approach of greater curvature. Driven by the potential advantages (no risk of mucocele or gastrogastric fistula), for the past several years, we have changed the technique from resecting only the ancient staple line to perform a partial gastrectomy. The gastrectomy is larger and includes the complete resection of the gastric fundus, ancient staple line, the region with the mesh inside, and part of the gastric body. Once the stomach is extracted, the subsequent steps are similar to those of a primary RYGB. Conclusion: The procedure of choice for the revision of VBG is represented by RYGBP. Associating an atypical gastrectomy of the previous staple line with the region of mesh migration is a safe approach, eliminating the risk of mucocele.

Single Anastomosis Duodeno-ileal Bypass As a Revisional Procedure Following Sleeve Gastrectomy: Review of the Literature

Laparoscopic sleeve gastrectomies (LSGs) can experience weight-loss failure and conversion to another bariatric procedure. An analysis of the bariatric literature concerning the single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) as revisional surgery after LSG in terms of safety and efficacy identified 607 studies. Fifty-nine studies were analyzed for full content review and 9 primary studies (398 patients) were included. Revisional single anastomosis duodeno-ileal bypass (SADI) was performed in 294 patients at a mean interval of 37.7 months (range 11-179). Total weight loss (%) varies from 20.5% to 46.2%. Early complications after surgery occurred in 4.1% surgeries including leak (7 cases -1.9%). Mortality was nil. SADI after LSG, after failed sleeve gastrectomy or as a sequential procedure, offers a satisfactory weight loss result. Both early and late term complications are acceptable.

Leak After Sleeve Gastrectomy: Updated Algorithm of Treatment

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) is currently the most common procedure performed worldwide, and still the leak is considered the main limitation. After an initial enthusiasm for stents, the endoscopic treatment evolved including in the current management the septotomy with balloon dilatation and pigtails insertions. The aim of this study was to evaluate the updated algorithm of endoscopic treatment of leak following LSG including septotomy and balloon dilatation.

METHODS

All consecutive patients treated by endoscopy between January 2018 and March 2020 for leak following LSG were included in the current study. After recording the demographic and the leak history, we have analyzed the number of endoscopic sessions, the duration of treatment, and the healing rate of endoscopic treatment for 3 groups: A, small orifice (< 10 mm); B, large orifice (> 10 mm) and acute leak; and group C with large orifice and late leak.

RESULTS

A total of 53 patients received endoscopic treatment for leak following LSG. The leaks achieved complete healing after average duration of 3.2 months (range 1-7 months), 2.3 months for group A, 4.2 months for group B, and 3.7 months for group C. The average number of endoscopic procedures was 2.8 (range 2-6) and was required for general population: for group A, 2.3 sessions; in group B, 3.4 sessions; and in group C, 2.7 sessions. Two out of 53 patients (3.8%) required additional treatment outside of the current algorithm, one in group A and another in group B. One patient was transferred for pulmonary abscess, and for another patient, the leak was considered chronic after a total of 14 months, and a laparoscopic fistula-jejunostomy was performed with favorable outcomes.

CONCLUSIONS

Although there is still no consensus for endoscopic management of leaks after LSG, the benefits of pigtails and the septotomy are undeniable, and it should be included in the armamentarium of any bariatric endoscopic service.

Bariatric surgery in patients with previous COVID-19 infection

Background

The process of reintroducing bariatric surgery to our communities in a COVID-19 environment was particular to each country. Furthermore, no clear recommendation was made for patients with a previous COVID-19 infection and a favorable outcome who were seeking bariatric surgery.

Objectives

To analyze the risks of specific complications for patients with previous COVID-19 infection who were admitted for bariatric surgery.

Setting

Eight high-volume private centers from 5 countries.

Methods

All patients with morbid obesity and previous COVID-19 infection admitted for bariatric surgery were included in the current study. Patients were enrolled from 8 centers and 5 countries, and their electronic health data were reviewed retrospectively. The primary outcome was to identify early (<30 d) specific complications related to COVID-19 infection following bariatric surgery, and the secondary outcome was to analyze additional factors from work-ups that could prevent complications.

Results

Thirty-five patients with a mean age of 40 years (range, 21–68 yr) and a mean body mass index of 44.3 kg/m² (±7.4 kg/m²) with previous COVID-19 infection underwent different bariatric procedures: 23 cases of sleeve (65.7 %), 7 cases of bypass, and 5 other cases. The symptomatology of the previous COVID-19 infection varied: 15 patients had no symptoms, 12 had fever and respiratory signs, 5 had only fever, 2 had digestive symptoms, and 1 had isolated respiratory signs. Only 5 patients (14.2 %) were hospitalized for COVID-19 infection, for a mean period of 8.8 days (range, 6–15 d). One patient was admitted to an intensive care unit and needed invasive mechanical ventilation. The mean interval time from COVID-19 infection to bariatric surgery was 11.3 weeks (3–34 wk). The mean hospital stay was 1.7 days (±1 d), and all patients were clinically evaluated 1 month following the bariatric procedure. There were 2 readmissions and 1 case of complication: that case was of a gastric leak treated with laparoscopic drainage and a repeated pigtail drain, with a favorable outcome. No cases of other specific complications or mortality were recorded.

Conclusion

Minor and moderate COVID-19 infections, especially the forms not complicated with invasive mechanical ventilation, should not preclude the indication for bariatric surgery. In our experience, a prior COVID-19 infection does not induce additional specific complications following bariatric surgery.

The first modified Delphi consensus statement on sleeve gastrectomy

INTRODUCTION

Sleeve gastrectomy (SG) is the commonest bariatric procedure worldwide. Yet there is significant variation in practice concerning its various aspects. This paper report results from the first modified Delphi consensus-building exercise on SG.

METHODS

We established a committee of 54 globally recognized opinion makers in this field. The committee agreed to vote on several statements concerning SG. An agreement or disagreement amongst ≥ 70.0% experts was construed as a consensus.

RESULTS

The committee achieved a consensus of agreement (n = 71) or disagreement (n = 7) for 78 out of 97 proposed statements after two rounds of voting. The committee agreed with 96.3% consensus that the characterization of SG as a purely restrictive procedure was inaccurate and there was 88.7% consensus that SG was not a suitable standalone, primary, surgical weight loss option for patients with Barrett's esophagus (BE) without dysplasia. There was an overwhelming consensus of 92.5% that the sleeve should be fashioned over an orogastric tube of 36-40 Fr and a 90.7% consensus that surgeons should stay at least 1 cm away from the angle of His. Remarkably, the committee agreed with 81.1% consensus that SG patients should undergo a screening endoscopy every 5 years after surgery to screen for BE.

CONCLUSION

A multinational team of experts achieved consensus on several aspects of SG. The findings of this exercise should help improve the outcomes of SG, the commonest bariatric procedure worldwide, and guide future research on this topic.

Aortic Injuries Following Stent Deployments in Bariatric Surgery-Review of Literature

Introduction: Consecutive to an increase in the number of bariatric surgeries worldwide, the number of articles reporting complications have also increased. The most dreadful bariatric complication is represented by the leak, and the endoscopic stent is still the standard treatment for some bariatric teams despite the poor quality of life and associated complications. The purpose of this review was to identify the very rare cases of aortic injuries associated with stent use in bariatric surgery. Methods: Aortic injuries related to stent use was the main criteria to summarize the literature by a careful assessment of PubMed/MEDLINE databases. Leak characteristics, primary endoscopic treatment, and the outcome of endoscopic complication were retrieved and categorized from each eligible article. Results: Thirty-five articles were selected for analysis. After abstract analysis, 22 studies were excluded, and 13 articles were reviewed in full-text version. Four articles were confirmed with aortic injury following stent use for complications after different bariatric procedures. These contained one retrospective case series and three retrospective case reports. There were 4 patients involved with complications following bariatric surgery: Roux-en-Y Gastric Bypass-3 cases and laparoscopic sleeve gastrectomy-1 case. The reported mortality of the aorto-esophageal fistula was 50%. Conclusions: Using stents in the treatment of leaks following bariatric surgery could be an efficient treatment, despite the poor quality of life and the stent migration. Even though it is rare, the aortic injury is a dreaded complication related to stent use and associated with high mortality rates.

Laparoscopic Clip Gastroplasty with the BariClip

Having the advantages of the reversibility by clipping and not cutting the stomach, the BariClip procedure reproduces the effect of the SG [1, 2] without adding the risk of leaks, and minimizes the occurrence of postoperative GERD by decreasing the intragastric pressure [3]. We present an edited video on the placement of a BariClip with the main steps of the procedure for a female patient with a BMI 41 kg/sqm. A 36 F bougie is placed to calibrate the size of the pouch. Using a laparoscopic approach, the BariClip is placed into the peritoneal cavity through a 12 mm trocar. The BariClip is then closed around the stomach parallel to the lesser curvature, creating a small medial pouch and an excluded large lateral segment. To prevent slippage (rate is approximately 3%), the BariClip is sutured to the gastric wall both anteriorly and posteriorly at various levels of the stomach, as shown in the video. Despite the possibility to suture on either side of the BariClip, the left indentations are preferred in order to avoid vessels of the lesser curvature which are closer to the right indentations. The recovery was uneventful, and 4 h after the surgery, the patient was tolerating liquids. She was discharged the following day with a prescription of PPI (pantoprazole 40 mg) for 30 days and of clexane 0.4 IM for 5 days. As with most bariatric procedures, she was started on 2 weeks of liquids, followed by 2 weeks of soft diet, before experiencing solid food. At 1 month after surgery, the patient had lost 10% of her TBW, and at 1-year follow-up, she had lost 31% of her TBW. She had no reflux, pain, or any other complaints and was very happy. The closing of the BariClip has been designed to be a low-pressure system, and in addition, it has a wide inferior outlet (2.5 cm), which does not create high intraluminal pressure. Both of these factors result in a low risk of erosion and of GERD. The rate of erosion in the original series was 1.3% with up to a 7-year history of implantation. The most common complication encountered at the beginning of our experience has been a slippage of the BariClip, and with the learning curve, this rate dropped to 3%. The QOL has been studied on a first series of patients and showed good results comparable with those given with the LSG and the RYGB [4]. In conclusion, the BariClip accomplishes almost similar weight loss as a SG, without a gastrectomy, without risks of leaks, and without causing reflux, and at the same ,time the BariClip is reversible [5].

The First Modified Delphi Consensus Statement for Resuming Bariatric and Metabolic Surgery in the COVID-19 Times

The purpose of this study was to achieve consensus amongst a global panel of expert bariatric surgeons on various aspects of resuming Bariatric and Metabolic Surgery (BMS) during the Coronavirus Disease-2019 (COVID-19) pandemic. A modified Delphi consensus-building protocol was used to build consensus amongst 44 globally recognised bariatric surgeons. The experts were asked to either agree or disagree with 111 statements they collectively proposed over two separate rounds. An agreement amongst ≥ 70.0% of experts was construed as consensus as per the predetermined methodology. We present here 38 of our key recommendations. This first global consensus statement on the resumption of BMS can provide a framework for multidisciplinary BMS teams planning to resume local services as well as guide future research in this area.

Laparoscopic Banded Resleeve Gastrectomy

Introduction: The recurrence of the morbid obesity disease after laparoscopic sleeve gastrectomy is a well-known complication. The banded resleeve gastrectomy (ReSG) is considered an innovative procedure and an alternative restrictive option to other malabsorptive procedures. Materials and Methods: We present an edited video on the placement of a MIDCAL™ (MID, Dardilly, France) ring during a revised sleeve gastrectomy with the main steps of the procedure. The subject is a male patient with a body mass index of 44 kg/m². After the fundus resection, the MIDCAL is placed and fixed to the stomach by two sutures. Results: We present the steps of the operation. The intervention is performed by posterior approach using a three-port technique. The dissection of the previous staple line of the sleeve was continued upward with the visualization of the left crura. The gastric tube was calibrated with a 36F bougie. The restapling of the previous sleeve was carried out by respecting the incisura angularis. The dissection of the pars flaccida allowed the posterior passage of the MIDCAL ring, which was locked and then fixed to the gastric wall with two nonabsorbable sutures. The operative outcome was favorable. The total body weight loss was 9% at 1 month and 27% at 2 years follow-up. Conclusion: Banded ReSG is a safe procedure with acceptable results at short term. Other comparative studies are suitable to provide with long-term follow-up results.

Endoscopic Gastroplasty. Initial Experience

Introduction: Less invasive endoscopic bariatric procedures are under development for the management of class I of obesity. The purpose of our study is to evaluate endoscopic gastroplasty (EG) using a suturing method, as well as the perioperative care and outcomes, during one-year period. Methods: This is a prospective single-center study over 17 patients using the EG under general anesthesia with overnight inpatient observation. The analyzed variables were: change in body weight; and adverse effects. In order to analyze correlations between BMI , and identify predictors for better weight loss after EG, we created 2 groups of patients: Group A (with BMI 35 and primary obesity - 10 patients) and Group B (with BMI 35 , or previous gastric balloon or bariatric surgery - 7 cases). Results: A total of 17 patients underwent endoscopic procedures for primary obesity or weight regain. All patients were female with a mean age of 38.7 years. The mean BMI was 34.8 kg/m2 (range: 30.8 - 44.1). There were no major intra-procedure adverse events or during the follow up. All patients were discharged on the 1st or 2nd day following the procedure and in the future the procedure will be proposed in ambulatory setting. Four patients (23.5 %) were complaining of moderate postprocedural pain for a mean period of time of 7.75 days (range 2-15 days) and two other patients complained about nausea and vomiting alleviated by the intravenous drugs. Of the 17 initial patients, 4 were available for 3-month of follow-up, 7 for 6-month, 3 for 9-month, and 3 completed the 12-month assessment with the mean EWL of 46.1 %. According to ASGE definition, 70.6 % (n= 12) of the 17 patients reached 25% of EWL. All patients in group A reached a successfully weight loss and the mean EWL was 72.4 %, but 5 out 7 patients in group B failed to achieve an EWL 25 %. Moreover, all patients who underwent previous bariatric surgery failed to achieve any results in term of weight loss following EG. Conclusions: Endoscopic gastroplasty represent a safe minimal invasive approach that can be considered as an effective and well tolerated procedure especially for primary obesity treatment. For patients with previous bariatric surgical procedures or with severe obesity the results are less favorable.

The Interest of Enhanced Recovery After Surgery in a New Bariatric Center

Background: With the creation of a new bariatric center in Abu Dhabi, United Arab Emirates (UAE) and the organization of this bariatric department according to the international guidelines, a new activity of bariatric surgery started in January 2015. The surgeon had 20 years of experience in this field and he had performed over 5000 major laparoscopic bariatric procedures before starting this new bariatric program. The concept of enhanced recovery after bariatric surgery (ERABS) was applied from the beginning of the program. We decided to analyze the first 2 years of ERAS activity after having split them in two different periods: the 1st year of activity included restrictive procedures and the 2nd year associated malabsorptive surgeries. Materials and Methods: The results of the use of a fast-track program could be measured by different parameters like operative time, length of hospital stay, rate of complications, and rate of readmission and reoperation. Results: Between January and December 2015, 116 patients underwent a bariatric procedure. The mean age was 34.6 years (16-61) and average body mass index (BMI) was 41.7 kg/sqm (32-72.2). Sixty percent of patients were women and 37% of patients had at least one comorbidity (diabetes type 2, high blood pressure, hyperlipidemia, or sleep apnea). Ninety-four percent of the procedures were laparoscopic sleeve gastrectomy (LSG), 2.6% were laparoscopic Roux-en-Y gastric bypass, and 3.4% band removal. The mean operative time was 20 minutes for an LSG (14-45 minutes) and the average hospital stay was 1.2 days (standard deviation [SD]: 0.9-3.3). The rate of complications was 1.7% with 1 postoperative hematoma drained by CT scan on day 14 after the surgery and 1 relative stenosis endoscopically dilated on postoperative day 45. No reoperation was done. No leak was observed. At 1 year, the mean excess weight loss (EWL) was 64% (47-124) in 89 patients with a 76% rate of follow-up. For the 2nd year of activity in 2016, 142 patients went in the program. The mean age was 32.7 years (17-64) and average BMI was 42.3 kg/sqm (31-68). Seventy-two percent were women and 41% of the patients had one comorbidity or more. The majority of surgeries performed were LSG for 83.1% of the patients. RYGB was realized in 4.2% of cases, resleeve gastrectomy in 4.2%, and band removal in 1.4%. Some malabsorptive surgeries were performed as well, such as one anastomosis gastric bypass for 3 patients (4.2%), and single anastomosis duodeno-ilelal in 2 cases (2.8%). The average hospital stay was 1.5 days (SD: 0.9-3.5). No complication was observed. No reoperation was done. Two patients (1.4%) came back to the hospital on postoperative day 2 and 8 after a LSG for one or several episodes of vomiting without further complication. At 1 year, the mean EWL was 68% (49-154) in 98 patients with a 69% rate of follow-up. Conclusions: This new program of bariatric surgery in two steps using fast-track protocols, respecting international guidelines and with an experienced surgeon showed on its 1st year of implementation a 1.7% rate of readmission on 116 patients without reoperation or major complication and a hospital stay of 1.2 days. For the 2nd year of implementation with the inclusion of malabsorptive procedures only 2 patients (1.4%) were readmitted for a short episode of vomiting and the hospital stay was 1.5 days.

Is the Morbidity Increased for Gastric Band Removal When the Band Is Placed Around the Esophagus?

Introduction: Laparoscopic adjustable gastric band (LAGB) procedures declined worldwide in the recent years. In the majority of the national registers, the numbers of gastric band removal and revisions following LAGB have surpassed the implants. Still a good knowledge of different techniques is important for young bariatric surgeons to diminish the morbidity of revisional surgery. Methods: From January 2015 to December 2016, a total of 139 patients were retrospectively reviewed after undergoing a gastric band removal. The study included all consecutive patients who underwent a gastric band removal in this period of time with no exclusion criteria. Sixteen patients (18.8%) received the perigastric technique, 57 patients (67.1%) received the pars flaccid technique, 54 patients (38.8%) received bands with periesophageal technique, and for 12 patients (14.1%), the operative reports did not allow to identify the techniques used. In the present study, the operative times and the reported complications of the three main bands techniques were compared. Results: There were 124 women (89.2%) and 15 men (10.8%), with a median age of 44 years (range: 24-71). The overall mean preoperative body mass index was 34 ± 7.6 kg/m² (range: 22-52 kg/m²), and the mean preoperative weight was 93.7 ± 24.9kg (range: 49-165 kg). One hundred and seventeen patients (84.2%) had procedures performed on an out-patient basis. The overall mean operative time was 23.9 ± 13.7 minutes (range: 7-83 minutes). We recorded three cases of bleeding with one conversion to laparotomy. The overall percentage of complications in the entire series was 6.5%. No mortality was recorded. Conclusions: Our study regarding the band removal revealed that no correlation was found for operative morbidity among the three different types of bands. The only proven difference was the operative time, which was greater for periesophageal approach. For the latter one, a particular attention should be paid to the risk of injury for diaphragmatic or left suprahepatic vein.

Operative morbidity of laparoscopic sleeve gastrectomy in subjects older than age 65

BACKGROUND

Continuous developments in healthcare have led to an increase in average life expectancy. Obesity in aged persons is increasing and is more clearly associated with an increased risk of diabetes, cardiovascular disease, lipid abnormalities, mobility-limited problems, and other co-morbidities in this category of age.

OBJECTIVES

The aim of the present study was to report the outcomes of laparoscopic sleeve gastrectomy in patients >65 years of age.

SETTING

Private hospital, France.

METHODS

A retrospective review was performed from patients aged >65 years who had undergone laparoscopic sleeve gastrectomy (June 2011-December 2017). The data analyzed included age, co-morbidities, preoperative body mass index, length of hospital stay, and postoperative complications.

RESULTS

A total of 93 patients were included with a mean age of 68.8 years (range, 65-78); 73 were female (78.5 %), and the mean preoperative body mass index was 43.6 ± 5.4 kg/m². Revisional surgery was well represented in 34.4% of cases. Thirty-two patients had a previous gastric band converted to laparoscopic sleeve gastrectomy, with 12 cases of 1-step revision (37.5%). Eleven patients (11.8%) had concomitant cholecystectomy. All procedures were performed laparoscopically with no peroperative complications. The median hospital stay was 3.1 days (1-6 d). Complications included 1 hematoma treated conservatively. The 30-day mortality rate was 0%. The mean excess weight loss at 1 year postoperatively was 67.1% (range, 34%-107%) with a follow-up rate of 78.1%. Resolution or improvement was observed in 65% of patients presenting with diabetes, in 72.5% of patients presenting with HTA, in 47.1% of patients presenting with dyslipidemia, and in 63.6% of patients presenting with sleep apnea.

CONCLUSIONS

Sleeve gastrectomy in elderly patients seems to be safe in terms of complications. Surgery is associated with a low-morbidity profile. Sleeve gastrectomy is our preferred procedure in this category of patients.

Highly Efficient Spin-to-Charge Current Conversion in Strained HgTe Surface States Protected by a HgCdTe Layer

We report the observation of spin-to-charge current conversion in strained mercury telluride at room temperature, using spin pumping experiments. We show that a HgCdTe barrier can be used to protect the HgTe from direct contact with the ferromagnet, leading to very high conversion rates, with inverse Edelstein lengths up to 2.0±0.5  nm. The influence of the HgTe layer thickness on the conversion efficiency is found to differ strongly from what is expected in spin Hall effect systems. These measurements, associated with the temperature dependence of the resistivity, suggest that these high conversion rates are due to the spin momentum locking property of HgTe surface states.

Cost analysis of leak after sleeve gastrectomy

BACKGROUND

Leaks after laparoscopic sleeve gastrectomy (LSG) are serious complications of this procedure. The objective of the present study was to evaluate the costs of leaks after LSG.

SETTING

Private hospital, France.

METHODS

A retrospective analysis was conducted on a prospective cohort of 2012 cases of LSG between September 2005 and December 2014. Data were collected on all diagnostic and therapeutic measures necessary to manage leaks, ward, and intensive care unit (ICU) length of stay. Additional outpatient care was also analyzed.

RESULTS

Twenty cases (0.99%) of gastric leak were recorded. Fifteen patients had available data for cost analysis. Of these, 13 patients were women (86.7%) with a mean age of 41.4 years (range 22-61) and mean BMI of 43.2 kg/m² (range 34.8-57.1). The leaks occurred after 7.4 days (±2.3) postoperatively. Only one gastric leak was recorded for the last 800 cases in which absorbable staple line reinforcement was used. Mean intra-hospital cost was 34398 € (range 7543-91,632 €). Prolonged hospitalization in ICU accounted for the majority of hospital costs (58.9%). Mean additional outpatient costs for leaks were 41,284 € (range 14,148-75,684€).

CONCLUSIONS

Leaks after LSG are an expensive complication. It is therefore important to take all necessary measures to reduce their incidence. Our data should be considered when analyzing the cost effectiveness of staple line reinforcement usage.

What are the long-term results 8 years after sleeve gastrectomy?

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) became the most frequent bariatric procedure performed in France (2011) and in the United States (2013), but studies reporting long-term results are still rare.

SETTING

Private hospital, France.

METHODS

This is a retrospective analysis of a prospective cohort of 168 patients who underwent LSG between 2005 and 2008. The objective of this study was to present the 8-year outcome concerning weight loss, modification of co-morbidities, and to report the revisional surgery after sleeve.

RESULTS

The preoperative mean body mass index was 42.8 kg/m2 (31.1-77.9), 35 patients were super obese, and 64 patients had a previous gastric band. For LSG as a definitive bariatric procedure, 8 years of follow-up data were available for 116 patients (follow-up: 69%). Of the remainder, 23 patients underwent revisional surgery and 29 were lost to follow-up. For the entire cohort, the mean excess weight loss (EWL) was 76% (0-149) at 5 years and 67% (4-135) at 8 years, respectively. Of the 116 patients with 8 years of follow-up, 82 patients had>50% EWL at 8 years (70.7%). Percentages of co-morbidities resolved were hypertension, 59.4%; type 2 diabetes, 43.4%; and obstructive sleep apnea, 72.4%. Twenty-three patients had revisional surgery for weight regain (n = 14) or for severe reflux (n = 9) at a mean period of 50 months (9-96). Twelve patients underwent resleeve gastrectomy, 6 patients underwent conversion to a bypass, and 5 patients to duodenal switch (1 single anastomosis duodeno-ileostomy). A total of 31% of patients reported gastroesophageal reflux symptoms at 8 years.

CONCLUSIONS

At 8 years postoperatively, the LSG as a definitive bariatric procedure remained effective for 59% of cases. The results appear to be more favorable especially for the non-super-obese patients and primary procedures. LSG is a well-tolerated bariatric procedure with low long-term complication rates.

How to treat stenosis after sleeve gastrectomy?

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has increasingly gained worldwide acceptance among bariatric surgeons during the past 10 years. Numerous articles have been written about the different approaches to the management of gastric fistulas, but limited data can be found concerning gastric stenosis after LSG.

SETTING

Private hospital, France.

METHODS

A total of 18 patients received endoscopic treatment for stenosis after LSG between May 2007 and June 2015. Stenosis was classified according to the endoscopic findings as functional (the passage of the endoscope was possible, but the sleeve was twisted with various degrees of rotation) or mechanical (the passage of the endoscope was very difficult or impossible).

RESULTS

This study included 13 women and 5 men, with an average age of 37.2±8.4 years and an average body mass index of 41.6±8.7 kg/m². The average number of endoscopic procedures was 1.3 (range, 1-4). No patient had stent migration. The successful rate of endoscopic approach for stenosis of LSG was 94.4%, with one patient requiring conversion to Roux-en-Y gastric bypass. The mean time from the LSG to the first endoscopic intervention was 28.2 days. All patients presented with midsleeve stricture, located near the incisura angularis, and no patient showed a stenosis in the upper part of the gastric tube.

CONCLUSIONS

The treatment of stenosis after LSG must be tailored to the clinical status of the patient and endoscopic findings. Both balloon dilation and stent deployment are useful and safe tools and must be used when appropriate.