Splenic and concomitant liver abscess after laparoscopic sleeve gastrectomy

Introduction: Laparoscopic sleeve gastrectomy (LSG) is a safe and effective procedure for losing weight and gaining control of obesity-related comorbidities. However, it is associated with postoperative complications such as bleeding, leak, and midgastric stenosis. Splenic and hepatic abscesses have been reported as unusual and rare complications after primary LSG. We report a case of splenic and concomitant hepatic abscesses after primary LSG, successful minimally invasive management, and midterm follow-up. Case Description: We report a complex case of splenic abscess with satellite hepatic abscess plus splenic thrombosis (0.1%) diagnosed 67 days after LSG. This unusual complication was managed by a minimally invasive approach (spleen sparing) with complete resolution after 35 days. After 18 months of follow-up, the patient showed complete resolution of the splenic and liver abscesses and progressive loss of excess weight. Conclusion: In high-volume centers, rare and life-threatening complications such as splenic and hepatic abscesses may be observed. The minimally invasive approach could represent an effective option of avoiding splenectomy in selected case

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

Transhiatal sleeve gastrectomy migration and GERD: laparoscopic hiatal hernia repair with reinforcement and conversion to R-en-Y gastric bypass

Background: Transhiatal sleeve migration, with consecutive gastroesophageal reflux disease (GERD) is a complication that leads to revisional surgery. Methods: A fifty-five years old, morbid obese female patient with BMI 45 kg/m2, hypertensive with OSAS and hypercholesterolemia, was operated by laparoscopic sleeve gastrectomy in 2010. She reached nadir in 2012 with BMI 28.7, with resolution of her comorbidities. From 2016 she complained from symptomatic GERD not responding to medical treatment, with evidence of transhiatal sleeve migration on radiological contrast study (Gastrografin), and on the CT scan of the hiatal area. Results: we present the video of conversion to laparoscopic R-en-Y gastric bypass LRYGB, associated with reinforced cruroplasty with bioabsorbable mesh, with marked improvement of GERD symptoms after reoperation. Conclusion: laparoscopic conversion from LSG to RYGB is feasible and useful for LSG complications

Salvation Gastric Bypass as Conversion from Failed, Open Banded Vertical Gastroplasty

Introduction: Vertical-banded gastroplasty used to be one of the most performed bariatric procedures, but it fallen out of interest due to other emerging procedures and non-satisfactory long-term results. Options for revision include conversion to sleeve gastrectomy, a Roux-en-Y gastric bypass (RYGB) or VBG reversal via gastrogastrostomy. Objectives: To evaluate the role of laparoscopic RYGBP in the treatment of a previous, failed open VBG. Methods: we present the video of a laparoscopic conversion from previous open, adjustable banded vertical gastroplasty. Patient was operated in other center in 1997 at a BMI of 55.3 kg/m2 and arrived a minimumof 30 kg/m2. In 2017 she presented for weight regain and reflux disease (BMI 41 kg/m2), requesting further attention. Intraoperative difficulties, adhesiolisys, band removal, unexpected situations are presented. Results: Conversion to laparoscopic RYGBP was safe and efficient, with no need for open surgery conversion, and further weight loss recorded. Postoperative prolonged respiratory problems registered, successfully treated conservatively. An important improvement of the patients’ symptoms and satisfaction was achieved 6 months postoperatively, with suspension of medical therapy, at a BMI of 35 kg/m2. Conclusions: Conversion of open VBG to RYGB is feasible and safe and can be performed with an acceptable complication rates, especially in experienced bariatric centers. It gives excellentweight loss results and relief of outlet obstruction

The impact of the surgical technique on stenosis after laparoscopic sleeve gastrectomy: a single center study on 5235 patients

Background: Laparoscopic Sleeve Gastrectomy (LSG) has gained worldwide popularity in the last 10 years as self alone bariatric procedure. Symptomatic Stenosis (SS) is a potential severe postoperative complication and it can be divided in organic stenosis (OS) and functional stenosis (FS). The aim of this paper is to propose a modified surgical technique to prevent FS. Methods: A retrospective review on 5235 LSG performed in Ponderas Academic Hospital between January 2011 and December 2019, searched FS in two consecutive patients groups, divided based on the modified surgical technique introduced in 2015, with fixation of the gastric tube to the pre-pancreatic fascia and stapler line's over-sewn running suture. Results: Group A (2011-2014) included 1332 LSG, 16 SS were registered (1.2%), 7 OS and 9 FS; 3903 LSG included in group B (2015-2019), counting for 37 SS (0.95%), 27 OS and 10 FS. A statistically significant difference between the 2 groups was observed for the FS incidence (p=0.03), while it was non-significant for the OS (p=0.52) and the total number of SS (p=0.43). The endoscopic approach was used in forty-eight SS (90.5%) with a successful rate of 83%, while specifically for the FS it was 100%; only one complication was registered during endoscopic treatment, that required further surgical solution. Conclusions: fixation of the gastric tube to the pre-pancreatic fascia and stapler line's over-sewn running suture during LSG, introduced lately, are beneficial in preventing the postoperative functional stenosis of the LSG, contributing to the improvement of the patient's quality of life

Persistent fistula after sleeve gastrectomy: a chronic dilemma

Nu există limită de timp în ceea ce priveşte apariţia fistulelor după sleeve gastrectomy LSG, iar cele cu debut tardiv pot evolua către fistule persistente, cronice. Scopul acestui studiu retrospectiv a fost de a analiza incidenţa, tratamentul şi urmările după acestea, tratate într-un Centru de Excelenţă de chirurgie bariatrică şi de a dezvolta un tratament standard. Materiale şi Metode: între 2011-2018, 9 cazuri de fistule postoperatorii au apărut după un număr total de 1365 LSG (0,65%), 7 prezentând debut tardiv (minim 10 zile de la operaţie). Au fost identificate şi analizate fistulele cronice, persistente, inclusiv o fistulă gastro-bronhială şi una gastro-cutanată. Rezultate: prezentăm 3 cazuri particulare de fistule foarte tardive, cronice de tip III (fistule complexe), cu debut variind de la 6 până la 84 luni după LSG, şi tratamentul acestora (conservativ, radiologie şi/sau endoscopie intervenţională, chirurgical). Concluzii: managementul fistulelor tardive, cronice de tip III, este variabil, nestandardizat şi ar trebui planificat pe baza evoluţiei clinice, momentul diagnosticului, resursele disponibile şi expertiza locală. Un centru bariatric de excelenţă poate garanta un diagnostic şi tratament mai adecvat, pe baza resurselor şi a posibilităţilor existente.Background: There is no time limit for the occurrence of leaks after sleeve gastrectomy LSG, and very late ones might evolve versus persistent, chronic fistulas. The aim of this retrospective study was to analyze the incidence, treatment and outcomes of persistent, chronic fistulas occurred or treated in a bariatric Center of Excellence IFSO-EC (CoE) and to establish a standardized approach. Materials Methods: between 2011-2018, nine cases of postoperative leaks occurred on a total of 1365 LSG performed (0.65%), 7 of them having late presentations (onset over 10 days postoperative). Chronic, persistent fistulas were identified and analyzed, including one gastro-bronchial and one gastro-cutaneous fistulas. Results: We present three peculiar cases of very late, chronic type III fistulas, with onset at 6-84 months after primary LSG and their management, including conservative, interventional radiology and endoscopy and surgical therapies. Conclusions: the management of late, chronic type III fistula is variable, with no standard algorithm to follow, but it should be planned based on the clinical evaluation, time of diagnosis, available resources, multidisciplinary approach and expertise. This emphasises again the necessity of a bariatric CoE that can guarantee a better diagnose and treatment, based on the use of wide, available resources, both professional and material

Low Rate of Oral Human Papillomavirus (HPV) Infection in Women Screened for Cervical HPV Infection in Southern Italy: A Cross-Sectional Study of 140 Immunocompetent Subjects

Even though the natural history of cervical and oral human papillomavirus (HPV) infection has been investigated intensely, the possibility that HPV may infect both sites in the same subject is not well documented. This study investigated the frequency of concurrent oral and cervical HPV infection in southern Italian women, in the light of some selected socio-behavioral variables. One hundred forty women (mean age: 36 years), with known cervical HPV status, were analyzed for oral HPV. Age, smoking/drinking habits, clinical and socio-behavioral history were assessed by personal interviews. Oral mucosal cells were collected by oral brushing and HPV DNA was sought by the use of nested PCR amplification followed by direct DNA sequencing and the commercial assay INNOLiPA HPV Genotyping (Innogenetics N.V., Ghent, Belgium). The data were analyzed by using the chi-square test and a logistic regression (logit) model (P<0.05 statistically significant). Oral HPV infection was detected in 2/140 (1.4%) cases, being present in 2/ 76 (2.6%) women with cervical HPV infection and 0/64 uninfected women (P¼0.19). A lack of typespecific concordance in thetwo patients with concurrent infection was observed. In the sample of population examined, HPV cervical infection does not seemto predispose to oral transmission, even in the presence of oral–genital sexual habits, thus suggesting the independence of infection at the two mucosal sites.Even though the natural history of cervical and oral human papillomavirus (HPV) infection has been investigated intensely, the possibility that HPV may infect both sites in the same subject is not well documented. This study investigated the frequency of concurrent oral and cervical HPV infection in southern Italian women, in the light of some selected socio-behavioral variables. One hundred forty women (mean age: 36 years), with known cervical HPV status, were analyzed for oral HPV. Age, smoking/drinking habits, clinical and socio-behavioral history were assessed by personal interviews. Oral mucosal cells were collected by oral brushing and HPV DNA was sought by the use of nested PCR amplification followed by direct DNA sequencing and the commercial assay INNOLiPA HPV Genotyping (Innogenetics N.V., Ghent, Belgium). The data were analyzed by using the chi-square test and a logistic regression (logit) model (P < 0.05 statistically significant). Oral HPV infection was detected in 2/140 (1.4%) cases, being present in 2/76 (2.6%) women with cervical HPV infection and 0/64 uninfected women (P = 0.19). A lack of type-specific concordance in the two patients with concurrent infection was observed. In the sample of population examined, HPV cervical infection does not seem to predispose to oral transmission, even in the presence of oral-genital sexual habits, thus suggesting the independence of infection at the two mucosal site

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 &gt;= 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 &gt;= 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&lt; 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