Zinc deficiency after gastric bypass for morbid obesity: a systematic review

The final publication is available at Springer via http://dx.doi.org/10.1007/s11695-016-2474-8 Up to 50% of patients have zinc deficiency before bariatric surgery.Roux-en-Y gastric bypass (RYGB) is the commonest bariatric procedure worldwide. It can further exacerbate zinc deieciency by reducing intake as well as absorption. The British Obesity and Metabolic Surgery Society therefore, recommends that zinc level should be monitored routinely following gastric bypass. However the American guidance does not recommend such monitoring for all RYGB patients and reserves it for patients with 'specific findings' This review concludes that clinically relevant zinc deficiency is rare after RYGB Routine monitoring of zinc levels is hence unnecessary for asymptomatic patients after RYGB and should be reserved for patients with skin lesions, hair loss, pica, disgeusia, hypogonadism, or erectile dysfunction in male patients and unexplained iron deficiency anaemia

Portomesenteric venous thrombosis after laparoscopic sleeve gastrectomy: A case report and a call for prevention

Postoperative portomesenteric venous thrombosis (PMVT) is being increasingly reported after bariatric surgery. It is variable and often a nonspecific presentation along with its potential for life-threatening and life-altering outcomes makes it imperative that it is prevented, detected early and treated optimally. We report the case of a 50-year-old morbidly obese man undergoing a laparoscopic sleeve gastrectomy who developed symptomatic PMVT two weeks postsurgery, which was successfully treated by anticoagulant therapy. We provide postulates to the etiopathological mechanism for this thrombotic entity. The growing recognition that obesity and bariatric surgery create a procoagulant state regionally and systemically provides impetus for designing the ideal protocol for PMVT prophylaxis, which could be more common than currently believed. We support the early screening for PMVT in the postbariatric surgical patient with unexplainable or intractable abdominal symptoms. The role of routine surveillance and the ideal duration of post-PMVT anticoagulation is yet to be elucidated

Double rolling and center hitch technique for laparoscopic ventral hernia repair

Background: Intraperitoneal onlay mesh repair is an established modality to treat large ventral hernias. Various techniques of laying the mesh are utilized. We present the Double Rolling and Center Hitch technique to lay a large intraperitoneal onlay mesh. Objective: The aim of the study is to devise and adopt a method to reduce the difficulty in manoeuvring a large mesh inside the peritoneal cavity. It should also help in correct placement of mesh and decrease the operative time. Materials and Methods: The DRACH technique was used in eighteen patients with large ventral hernias between May 2010 and September 2011. The Mesh size used was 15x20cm and more (considered to be large mesh). Results: All the procedures were completed successfully. Mesh handling was significantly easier with the DRACH technique. The average mesh deployment time (MDT) was 15mins. In all cases the mesh was adequately centred with a margin of 3-5cm from the defect. Conclusion: The DRACH technique can be employed to lay large intraperitoneal meshes in order to reduce the handling difficulties associated with large meshes, and to aid in better placement of meshes so as to centered over the defect

Review of contemporary role of robotics in bariatric surgery

With the rise in a number of bariatric procedures, surgeons are facing more complex and technically demanding surgical situations. Robotic digital platforms potentially provide a solution to better address these challenges. This review examines the published literature on the outcomes and complications of bariatric surgery using a robotic platform. Use of robotics to perform adjustable gastric banding, sleeve gastrectomy, roux-en-y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch and revisional bariatric procedures (RBP) is assessed. A search on PubMed was performed for the most relevant articles in robotic bariatric surgery. A total of 23 articles was selected and reviewed in this article. The review showed that the use of robotics led to similar or lower complication rate in bariatric surgery when compared with laparoscopy. Two studies found a significantly lower leak rate for robotic gastric bypass when compared to laparoscopic method. The learning curve for RYGB seems to be shorter for robotic technique. Three studies revealed a significantly shorter operative time, while four studies found a longer operative time for robotic technique of gastric bypass. As for the outcomes of RBP, one study found a lower complication rate in robotic arm versus laparoscopic and open arms. Most authors stated that the use of robotics provides superior visualisation, more degrees of freedom and better ergonomics. The application of robotics in bariatric surgery seems to be a safe and feasible option. Use of robotics may provide specific advantages in some situations, and overcome limitations of laparoscopic surgery. Large and well-designed randomised clinical trials with long follow-up are needed to further define the role of digital platforms in bariatric surgery

Global benchmarks in primary robotic bariatric surgery redefine quality standards for Roux-en-Y gastric bypass and sleeve gastrectomy

Background: Whether the benefits of the robotic platform in bariatric surgery translate into superior surgical outcomes remains unclear. The aim of this retrospective study was to establish the 'best possible' outcomes for robotic bariatric surgery and compare them with the established laparoscopic benchmarks. Methods: Benchmark cut-offs were established for consecutive primary robotic bariatric surgery patients of 17 centres across four continents (13 expert centres and 4 learning phase centres) using the 75th percentile of the median outcome values until 90 days after surgery. The benchmark patients had no previous laparotomy, diabetes, sleep apnoea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, history of thromboembolic events, BMI greater than 50 kg/m2, or age greater than 65 years. Results: A total of 9097 patients were included, who were mainly female (75.5%) and who had a mean(s.d.) age of 44.7(11.5) years and a mean(s.d.) baseline BMI of 44.6(7.7) kg/m2. In expert centres, 13.74% of the 3020 patients who underwent primary robotic Roux-en-Y gastric bypass and 5.9% of the 4078 patients who underwent primary robotic sleeve gastrectomy presented with greater than or equal to one complication within 90 postoperative days. No patient died and 1.1% of patients had adverse events related to the robotic platform. When compared with laparoscopic benchmarks, robotic Roux-en-Y gastric bypass had lower benchmark cut-offs for hospital stay, postoperative bleeding, and marginal ulceration, but the duration of the operation was 42 min longer. For most surgical outcomes, robotic sleeve gastrectomy outperformed laparoscopic sleeve gastrectomy with a comparable duration of the operation. In robotic learning phase centres, outcomes were within the established benchmarks only for low-risk robotic Roux-en-Y gastric bypass. Conclusion: The newly established benchmarks suggest that robotic bariatric surgery may enhance surgical safety compared with laparoscopic bariatric surgery; however, the duration of the operation for robotic Roux-en-Y gastric bypass is longer.</p