Is the Surgical Drainage Mandatory for Leak after Sleeve Gastrectomy?

Septotomy; Sleeve gastrectomy; Surgical drainageSeptotomía; Gastrectomía en manga; Drenaje quirúrgicoSeptotomia; Gastrectomia en màniga; Drenatge quirúrgicIntroduction: 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

Endoscopic Gastric Band Removal

Complication; Endoscopy; Laparoscopic adjustable gastric bandComplicación; Endoscopia; Banda gástrica ajustable laparoscópicaComplicació; Endoscòpia; Banda gàstrica ajustable laparoscòpicaBackground: Laparoscopic adjustable gastric band (LAGB) procedures have declined worldwide in recent years. A known complication is the intraluminal erosion of the prosthetic material. The endoscopic management of gastric band erosion represents the recommended approach nowadays, and it avoids any additional trauma to the gastric wall already damaged by the migration. The purpose of our study was to assess the feasibility of endoscopic management for intraluminal gastric band erosion following LAGB. Methods: From January 2009–December 2020, a total of 29 patients were retrospectively reviewed after undergoing endoscopic gastric band removal. The study included all consecutive patients who underwent endoscopic gastric band removal in this period. No patients were excluded from the study. Data on patient demographic characteristics, case history, operative details (procedural time, adverse events), and complications were reviewed retrospectively. Results: Twenty-nine patients underwent endoscopic gastric band removal: 22 women (75.8%) with a mean age of 45 years (range: 28–63) and mean Body Mass Index (BMI) of 31 ± 4.7 kg/m2 (range: 24–41). The average time to the identification of erosion after LAGB was 42 months (range: 28–137). The initial upper endoscopy found a migrated band of more than half of the diameter in 21 cases, less than a half but more than a third in seven cases and in one case, less than a third (use of a stent). Twenty-seven patients were successfully treated with endoscopic removal, and in two cases, the endoscopic approach failed, and laparoscopy was further performed. Conclusions: The endoscopic management of intraluminal erosion after LAGB can be safe and effective and should be considered the procedure of choice when treating this complication. The percentage of the band migration is important for the timing of the endoscopic removal

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 futur

Transient hepatic attenuation difference (THAD) or fat sparing? Aberrant right gastric vein (ARGV) determining a pseudolesion at the border of the IInd/IIIrd liver segments. Review of developmental concepts

The aberrant right gastric vein (ARGV) is a rare anatomical variation. It can be responsible for unexplained hyperdensities in the hepatic parenchyma on CT scans, also known as third inflow effects. We present two cases sharing similar vascular pattern and slightly different imagistic findings on ultrasound and computer-tomography performed studies. Both ultrasonographies showed a nodular-geographic hypoechoic area within a hyperechogenic fatty liver. Further CT evaluation showed in both cases a hyperattenuating homogenous area clearly visible on all four phases at the border of the IInd/IIIrd hepatic segment, that enhance especially on the portal venous phase, with no slow-fill, wash-out, central scar or rim-like features. The areas were considered to be focal fat sparing areas in diffuse fatty liver or a perfusion disorder due to the presence of an aberrant right gastric vein. The aim of this paper is to discuss the embryological aspects which are the groundwork for this vascular anomaly and to correlate the findings with imagistic aspects. These two ARGV produced pseudolesions, understood as focal fat sparing areas within diffuse fatty livers. These pseudolesions mimic liver tumours, therefore it is important to look for such an aberrant vessel in order to rule out other diagnoses

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

Laparoscopic sleeve gastrectomy in the South Pacific. Retrospective evaluation of 510 patients in a single institution

International audienceINTRODUCTION:The South Pacific has a high prevalence of obesity and super-obesity. We reviewed our experience with laparoscopic sleeve gastrectomy (LSG) to evaluate its efficacy and safety.METHODS:A retrospective review of a prospectively collected database of LSGs carried out by one surgeon in one center. The percentage of excess weight loss and the rate of resolution or improvement of comorbidities reflected efficacy, and major complications or mortalities reflected safety.RESULTS:From January 2008 to February 2013, we performed 510 surgeries and included 494 consecutive patients (367 females) (45.5 ± 11.2 years) in our study. LSG was the primary procedure in 384 patients, 6 patients had redo bariatric surgery after failure of initial LSG, 57 patients had a history of gastric banding with insufficient weight loss or band-related complications, and 46 super-obese patients had an intragastric balloon placed before LSG. Average starting body mass index was 47.8 kg m(-2). Mean percent excess weight loss was 64.3% at 1 year; 67.3% at 2 years and 66.4% at 3 years. The percentages of resolved comorbidities were as follows: hypertension: 48.3%, type 2 diabetes mellitus: 72.5%, dyslipidemia: 61.0%, and obstructive sleep apnea: 77.8%. The mortality rate was 1/494. The postoperative morbidity included gastric fistula in 3.0%, hemorrhaging in 2.4%, and postoperative gastroesophageal reflux in 9.4%.CONCLUSIONS:In the South Pacific, LSG is a safe and effective means of treating morbid obesity with sustained weight loss and resolution of comorbid medical conditions

Considerations on the Remuneration System of the Public Administration – an Analysis on Electoral Cycles and Scenarios Development

The paper aims to identify trends in the characteristics of the number of employees and the average salary in public administration in the last two election cycles in the period 2000-2008 compared with other sectors and proposes a series of three scenarios for the evolution of salaries in public administration. Within the three scenarios we estimate a number of variables such as average salary in the public administration, the number of employees, the ratio between the number of employees in the public administration and other sectors, the ratio between the average salary in the public administration and other sectors. The results obtained from the analysis of the three scenarios allow us to formulate the hypotheses for the development of a new scenario: the average salary will increase each year by 15% and the number of employees will decrease each year by 9%. At the end of the paper we proposed a series of recommendations to define a new remuneration law for civil servants in the immediately following period