Concomitant hiatal hernia repair during bariatric surgery: does the reinforcement make the difference?

Background: Hiatal hernia repair (HHR) is still controversial during bariatric procedures, especially in case of laparoscopic sleeve gastrectomy (LSG). Aims: to report the long-term results of concomitant HHR, evaluating the safety and efficacy of posterior cruroplasty (PC), simple or reinforced with biosynthetic, absorbable Bio-A® mesh (Gore, USA). Primary endpoint: PC's failure, defined as symptomatic HH recurrence, nonresponding to medical treatment and requiring revisional surgery. Methods: the prospective database of 1876 bariatric operations performed in a center of excellence between 2011-2019 was searched for concomitant HHR. Intraoperative measurement of the hiatal surface area (HSA) was performed routinely. Results: A total of 250 patients undergone bariatric surgery and concomitant HHR (13%). Simple PC (group A, 151 patients) was performed during 130 LSG, 5 re-sleeves and 16 gastric bypasses; mean BMI 43.4 ± 5.8 kg/m2, HSA mean size 3.4 ± 2 cm2. Reinforced PC (group B) was performed in 99 cases: 62 primary LSG, 22 LGB and 15 revisions of LSG; mean BMI 44.6 ± 7.7 kg/m2, HSA mean size 6.7 ± 2 cm2. PC's failure, with intrathoracic migration (ITM) of the LSG was encountered in 12 cases (8%) of simple vs. only 4 cases (4%) of reinforced PC (p=0.23); hence, a repeat, reinforced PC and R-en-Y gastric bypass (LRYGB) was performed laparoscopically in all cases. No mesh-related complications were registered perioperatively or after long-term follow-up (mean 50 months). One case of cardiac metaplasia without goblet cells was detected 4 years postoperatively; conversion to LRYGB, with reinforced redo of the PC was performed. The Cox hazard analysis showed that the use of more than four stitches for cruroplasty represents a negative factor on recurrence (HR = 8; p < 0.05). Conclusions: An aggressive search for and repair of HH during any bariatric procedure seems advisable, allowing a low HH recurrence rates. Additional measures, like mesh reinforcement of crural closure with biosynthetic, absorbable mesh, seem to improve results on long term follow-up, especially in case of larger hiatal defects. In our experience, reinforcement of even smaller defects seems advisable in obese population

Colorectal cancer after bariatric surgery (Cric-Abs 2020): Sicob (Italian society of obesity surgery) endorsed national survey

Background The published colorectal cancer (CRC) outcomes after bariatric surgery (BS) are conflicting, with some anecdotal studies reporting increased risks. The present nationwide survey CRIC-ABS 2020 (Colo-Rectal Cancer Incidence-After Bariatric Surgery-2020), endorsed by the Italian Society of Obesity Surgery (SICOB), aims to report its incidence in Italy after BS, comparing the two commonest laparoscopic procedures-Sleeve Gastrectomy (SG) and Roux-en-Y gastric bypass (GBP). Methods Two online questionnaires-first having 11 questions on SG/GBP frequency with a follow-up of 5-10 years, and the second containing 15 questions on CRC incidence and management, were administered to 53 referral bariatric, high volume centers. A standardized incidence ratio (SIR-a ratio of the observed number of cases to the expected number) with 95% confidence intervals (CI) was calculated along with CRC incidence risk computation for baseline characteristics. Results Data for 20,571 patients from 34 (63%) centers between 2010 and 2015 were collected, of which 14,431 had SG (70%) and 6140 GBP (30%). 22 patients (0.10%, mean age = 53 +/- 12 years, 13 males), SG: 12 and GBP: 10, developed CRC after 4.3 +/- 2.3 years. Overall incidence was higher among males for both groups (SG: 0.15% vs 0.05%; GBP: 0.35% vs 0.09%) and the GBP cohort having slightly older patients. The right colon was most affected (n = 13) and SIR categorized/sex had fewer values < 1, except for GBP males (SIR = 1.07). Conclusion Low CRC incidence after BS at 10 years (0.10%), and no difference between procedures was seen, suggesting that BS does not trigger the neoplasm development

Leak after sleeve gastrectomy. How long do we have to be worried?

Currently, laparoscopic sleeve gastrectomy (LSG) is the most popular procedure for the treatment of morbid obesity in USA and Europe. Minor complications have an overall incidence of 11 % while major l complications constitute about 5 % in large series. The mean incidence of leak is 2.1 % . According to the time of onset, Csendes et al. classified leakage as early when diagnosed within 4 days posteratively, intermediate within days 5–9 and late when occurring after the 10th postoperative day. Leak is the second most common cause of death with an overall reported mortality rate of 0.4 %. It remains unusual and unexplainable to see very late leaks occurring several months after LSG (6-7- months) as those reported in this paper

Transhiatal Migration After Laparoscopic Sleeve Gastrectomy: Myth or Reality? A Multicenter, Retrospective Study on the Incidence and Clinical Impact

Purpose Only anecdotally reported, intrathoracic migration (ITM) represents an unacknowledged complication after sleeve gastrectomy (LSG) contributing to gastroesophageal reflux disease (GERD) development, both recurrent and de novo. The primary endpoint of this study was to evaluate the incidence of postoperative ITM >= 2 cm; the secondary endpoint was to determine the relationships between ITM, GERD, endoscopic findings, and percentage of patients requiring surgical revision.Materials and Methods A retrospective, multicenter study on prospective databases was conducted, analyzing LSGs performed between 2013 and 2018. Inclusion criteria consisted of primary operation; BMI ranging 35-60 kg/m(2); age 18-65 years; minimum follow-up 24 months; and postoperative UGIE, excluding concomitant hiatal hernia repair. Esophageal manometry and 24-h pH-metry were indicated, based on postoperative questionnaires and UGIE; patients with GERD due to ITM, and non-responders to medical therapy, were converted to R-en-Y gastric bypass (RYGB).Results An ITM >= 2cm was postoperatively diagnosed in 94 patients (7% of 1337 LSGs), after mean 24.16 +/- 13.6 months. Postoperative esophagitis was found in 29 patients vs. 15 initially (p=0.001), while GERD was demonstrated in 75 (vs. 20 preoperatively, p< 0.001). Fifteen patients (16%) underwent revision to RYGB with posterior cruroplasty. Seventeen patients with severe GERD presented improvement of endoscopic findings and clinical symptoms as a result of conservative therapy.Conclusions ITM after LSG is not a negligible complication and represents an important pathogenic factor in the development or worsening of GERD. Postoperative UGIE plays a fundamental role in the diagnosis of esophageal mucosal lesions

Conversion to gastric bypass and revision of cruroplasty due to persistent gastroesophageal reflux disease after initial sleeve gastrectomy and cruroplasty

Introduction: recently, dramatically increased numbers of bariatric procedures worldwide are followed by an increased incidence of revision surgeries, due to complications or failures. Objectives: To evaluate the role of laparoscopic gastric bypass in the treatment of gastroesophageal reflux disease after sleeve gastrectomy. Methods: A morbid obese, female patient, 55 years old, BMI 39 kg/m2, with concomitant HTA, hyperinsulinemia and 3 cm, non-complicated hiatal hernia, was operated in 2013 by laparoscopic sleeve gastrectomy (LSG) and concomitant hiatal hernia repair by posterior cruroplasty. 30 months afterwards a resolution of obesity and comorbidity was obtained, with BMI of 25.7 kg/m2. Meantime, symptomatic, persistent gastroesophageal reflux disease, resistant to medical treatment, with radiological confirmed hiatal hernia, was registered. Results: we present the video of laparoscopic conversion of gastric sleeve to R-en-Y gastric bypass (GBP), with concomitant revision of the posterior cruroplasty. An important improvement of the patient’s symptoms was achieved 3 months postoperatively, with suspension of medical therapy, maintained one year after intervention. Conclusions: conversion in GBP is actually the best option of treatment in case of reflux disease after LSG

Multicenter retrospective cohort Italian study on elective laparoscopic cholecystectomy performed by the surgical residents

PurposeThis retrospective multicenter cohort study aimed to evaluate the clinical outcomes (mortality rate, operative time, complications) of elective laparoscopic cholecystectomy (LC) when performed by a surgical resident in comparison to experienced consultant in the backdrop of Italian academic centers.MethodsRetrospective review of all patients undergoing elective LC between January 2016 and January 2022 at six teaching hospitals across Italy was performed. Cases were identified using the Current Procedural Terminology (CPT) code 5123 (LC without cholangiogram). All cases of emergency surgery, ASA score > 3, or when cholecystectomy was performed with another surgical procedure, were excluded. All suitable cases were divided into 2 groups based on primary surgeon: consultant or senior resident. Main outcome was complication rates (intraoperative and peri/postoperative); secondary outcomes included operative time, the length of stay, and the rate of conversion to open.ResultsA total of 2331 cases (1425 females) were included, of which, consultants performed 1683 LCs (72%), while the residents performed 648 (28%) surgeries. The groups were statistically comparable regarding demographics, history of previous abdominal surgery, operative time, or intraoperative complications. The rate of conversion to open cholecystectomy was 1.42% for consultant and none for resident (p = 0.02). A statistically significant difference was observed between groups regarding the average length of stay (2.2 +/- 3 vs 1.6 +/- 1.3 days p = 0.03). Similarly, postoperative complications (1.7% vs 0.5%) resulted in statistically significant (p = 0.02) favoring resident group.ConclusionsOur study demonstrates that in selected patients, senior residents can safely perform LC when supervised by senior staff surgeons