A narrative review on bariatric ERAS

Bariatric/metabolic surgery (BMS) is the most effective treatment of morbid obesity, while Enhanced Recovery After Surgery (ERAS) after BMS represents a multimodal perioperative protocol designed to achieve early recovery for patients with peculiar characteristics. The aim of the current narrative review is to summarize and discuss the current role, the application, and the future developments of ERAS protocols in the field of BMS

25th International Congress of the European Association for Endoscopic Surgery (EAES) Frankfurt, Germany, 14-17 June 2017 : Oral Presentations

Introduction: Ouyang has recently proposed hiatal surface area (HSA) calculation by multiplanar multislice computer tomography (MDCT) scan as a useful tool for planning treatment of hiatus defects with hiatal hernia (HH), with or without gastroesophageal reflux (MRGE). Preoperative upper endoscopy or barium swallow cannot predict the HSA and pillars conditions. Aim to asses the efficacy of MDCT’s calculation of HSA for planning the best approach for the hiatal defects treatment. Methods: We retrospectively analyzed 25 patients, candidates to laparoscopic antireflux surgery as primary surgery or hiatus repair concomitant with or after bariatric surgery. Patients were analyzed preoperatively and after one-year follow-up by MDCT scan measurement of esophageal hiatus surface. Five normal patients were enrolled as control group. The HSA’s intraoperative calculation was performed after complete dissection of the area considered a triangle. Postoperative CT-scan was done after 12 months or any time reflux symptoms appeared. Results: (1) Mean HSA in control patients with no HH, no MRGE was cm2 and similar in non-complicated patients with previous LSG and cruroplasty. (2) Mean HSA in patients candidates to cruroplasty was 7.40 cm2. (3) Mean HSA in patients candidates to redo cruroplasty for recurrence was 10.11 cm2. Discussion. MDCT scan offer the possibility to obtain an objective measurement of the HSA and the correlation with endoscopic findings and symptoms. The preoperative information allow to discuss with patients the proper technique when a HSA[5 cm2 is detected. During the follow-up a correlation between symptoms and failure of cruroplasty can be assessed. Conclusions: MDCT scan seems to be an effective non-invasive method to plan hiatal defect treatment and to check during the follow-up the potential recurrence. Future research should correlate in larger series imaging data with intraoperative findings

Laparoscopic splenectomy in the management of benign and malignant hematologic diseases

Objectives: The use of laparoscopy to treat malignant hematological diseases is not completely accepted. Our aim was to analyze operative and postoperative results of laparoscopic splenectomy performed for benign versus malignant hematological disorders. Methods: Between 1994 and 2003, 76 consecutive patients underwent laparoscopic splenectomy. The first 38 cases were performed by using an anterior approach, whereas in the remaining 38 cases a semilateral position was used. Results: Baseline characteristics showed that patients with malignant diseases were significantly older (56.9 vs 32.6 years, P 0.001). Seventy-two (94.7%) procedures were completed laparoscopically. Conversion was required in 4 cases (5.2%). Mean operative time was 138.5 minutes for benign and 151.0 minutes for malignant diseases, (P 0.05, ns). The hand-assisted technique was used in 3 patients with massive splenomegaly. Pathologic features showed that spleen volume was higher in patients with malignant diseases (mean interpole diameter 18.1 cm vs 13.7 cm, P 0.001). Massive splenomegaly (interpole diameter over 20 cm, weight over 1000 g) was present in 13 patients (17.1%); 9 had malignant diseases. Overall perioperative mortality was 1.3% and major postoperative complications occurred in 6 patients (7.8%). Postoperative splenoportal partial thrombosis was identified in 9.7% of patients. Conclusions: Laparoscopic splenectomy is a well-accepted, less-invasive procedure for hematological disorders. Neoplastic diseases or splenomegaly, or both, do not seem to limit the indications for a minimally invasive approach after the learning curve

Effect of BMI on safety of bariatric surgery during the COVID-19 pandemic, procedure choice, and safety protocols - An analysis from the GENEVA Study

It has been suggested that patients with a Body Mass Index (BMI) of > 60 kg/m2 should be offered expedited Bariatric Surgery (BS) during the Coronavirus Disease-2019 (COVID-19) pandemic. The main objective of this study was to assess the safety of this approach

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

Evaluation of the histopathological modifications induced by the positioning of autologous platelet-rich plasma vs. biosynthetic, absorbable mesh as reinforcement of the cruroplasty: a study on an animal model

Introduction: Symptomatic hiatal hernia’s (HH) incidence, associated with gastroesophageal reflux disease (GERD), ranges between 10-20% in the general population. Laparoscopic suture of the diaphragmatic crura (posterior cruroplasty PC) during the HH’s surgical treatment determines good long-term results in the majority of cases, without cancelling the risks of recurrences or surgical revisions. Based on anatomical, physiological, morphological and evolution of certain diseases, the use of porcine model became one of the most important research fields, including laparoscopic implant of prosthetic materials. Cruroplasty’s reinforcement is widely used in large hiatal defects for recurrences’ reduction with no consensus on type or shape of mesh. The use of autologous platelet-rich plasma (PRP) concentrate, simple and cheap prepared, might be an alternative option. Aims: finding new solutions for the laparoscopic treatment of symptomatic HH, in particular comparing a biosynthetic, absorbable mesh, vs. autologous PRP in a porcine model, in order to determine local histopathological (HP) changes and complications. Rationale: the literature lacks on comparative studies on the use of PRP for the reinforcement of hiatal defects repair. Materials and methods: Prospective, randomized study on 12 pigs. The laparoscopic procedure consisted in creation of a hiatal defect, then sutured PC, reinforced with absorbable mesh (group A) or PRP positioning (group B). Blood withdrawal was made prior to surgery for autologous concentrate’s preparation in group B. The animals survived the procedure and professional care was taken for the next 7 months. Second procedure was performed afterwards, consisting in euthanasia, laparoscopy, and laparotomy for specimen retrieval (whole hiatal area). HP examination was performed, evaluating 4 main components: proliferative fibroblast – fibrocyte – collagen neoformation; vascular; inflammatory; and dystrophic. A semiquantative HP scoring of tissue reaction was elaborated. Expected Results: direct consequences on the public health for the management of the HH/GERD, definition of the technical indications, avoiding costly materials loss. Results: animals survived 7 months of postoperative care, with normal growth and without complications related to the surgical procedures. There were no complications, local or general, in both groups, with more intense adherential process in group A at the gross examination. Complete resorption of both products was demonstrated on gross and HP examination. Both reinforcements determined inflammatory infiltrates predominantly mononuclear, with induced local collagen production and tissue neo-vascularization. Animals in the mesh group had increased mean chronic inflammation score (2.66 vs. 1.83, p = 0.908) compared to the PRP group. Vascular network did not differ between groups (p = 0.3061), although there was an increased trend toward mean collagen fibers in the mesh group (score 2.83±0.4) compared to PRP (2.33±0.81), p=0.248. Conclusions: Our laparoscopic, animal model of hiatal hernia repair was reliable, feasible and reproductible. The comparative study of both materials, autologous and biosynthetic, did not show any specific complications, with no residual material found after 7 months. The mesh group showed a more important score of sclerotic collagenising process. PRP was shown to be an autologous source of pro-regenerative growth factors and chemokines suited to hiatal area wound healing, enhanced angiogenesis, myofibroblast recruitment and tissue ingrowth and less severe peritoneal adhesions. The novelty of the study and the histopathological results suggest the use of combined products, so autologous PRP could find a clinical application in the surgical treatment of the hiatal defects, as a promising co-adjuvant to local remodeling and healing in this animal model. Next studies should verify that the use of PRP could improve the crura’s weakness

Chirurgia bariatrică în tratamentul sindroamelor obstructive în somn (Sleep disturbances and bariatric surgery)

Chirurgia bariatrica se adreseaza unei populatii reduse de obezi, adica pacientii cu obezitate 2 si 3, la care tratamentul conservator are sanse de reusita redusa. Reprezinta o solutie care, chiar invaziva, non-fiziologica si grevata de riscuri, ofera rezultate bune chiar si la distanta la majoritatea pacientilor. Introducerea tehnicilor laparoscopice si a noilor tipuri de tehnici si tehnologii, a determinat progresiv acceptarea si dezvoltarea acestei optiuni viabile. Chirurgia bariatrica, indiferent de procedura aleasa, are efecte favorabile pe tulburarile de somn, determinand rezolutia sau imbunatirea acestora. Diferentele de eficacitate intre diversele proceduri bariatrice pot fi explicate doar prin efecte metabolice, independente de scaderea ponderala68. Imbunatirea dramatica a OSAS in marea majoritate a pacientilor obezi supusi chirurgiei bariatrice, tradusa prin reducerea indexului apnee-hipopnee cu 33.9 episoade/ora (17,5-50,2 episoade/ora) si o rezolutie a apneei de somn in medie de 85,7% sunt argumente suficiente pentru a recomanda chirurgia bariatrica la aceasta categorie de pacienti

Gastric bypass is redemption after failed bariatric procedures. A video report on a complicated sleeve gastrectomy in a multiple operated patient

Introduction: Laparoscopic sleeve gastrectomy is the most performed bariatric procedure, but complications might interfere with patient’s long-term evolution based on patient’s compliance and tolerance, surgical attitude and unpredictable evolution. Materials: We present the case of a female obese patient, with impaired type II diabetes mellitus and other comorbidities, with multiple, sequential bariatric minimally-invasive interventions: sleeve gastrectomy in 2012 complicated by postoperative acute gastric dilation and later by mediogastric stenosis, with endoscopic gastric dilations; reoperated for viscerolysis and cholecystectomy; initially converted to functional one anastomosis gastric bypass (200 cm limb), with a non-adjustable gastric ring positioned instead of stapled division. The last operation was complicated 12 months after by persistent biliary gastro-esophageal reflux, chronic abdominal pain, and gas bloat syndrome. In 2018 the patient underwent conversion to laparoscopic R-en-Y gastric bypass, with gastro-enteral anastomosis resection, band removal and viscerolysis. Results: Conversion to R-en-Y was complicated by biliary leakage post-viscerolysis, treated with laparoscopic approach in the 9thpo day. After multiple surgical and endoscopic interventions, the patient presents short-term favorable outcomes, with no reflux or abdominal pain, with further weight loss and diabetes improvement. Conclusion: Bariatric surgery has unpredictable evolution in same cases, and conversion to R-en-Y seems to be the best solution

Letter in reply: Long-term results after laparoscopic sleeve gastrectomy with concomitant posterior cruroplasty: five-year follow-up

Dear Authors Thank you for your letter and for the interest you showed for our study. We are glad to make the required clarifications in order to make our results more legitimate and reliable