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Background: Obesity is a risk factor for gallstone formation, which can be exacerbated by bariatric surgery-induced rapid weight loss. Current guidelines do not recommend concomitant cholecystectomy (CC) for asymptomatic gallstones during the bariatric surgery procedure. However, long-term follow-up studies have shown that the incidence of post-bariatric surgery symptomatic gallstones necessitating therapeutic cholecystectomy increases to 40%. Therefore, some surgeons advocate simultaneous cholecystectomy during the bariatric surgery for asymptomatic individuals. This study aims to evaluate the safety of performing cholecystectomy for asymptomatic gallstones during the bariatric procedure. Methods: Data from a consecutive series of patients that underwent primary laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass (LRYGB) or conversion of LSG to a LRYGB with or without concomitant cholecystectomy for asymptomatic gallstones between Jan 2010 and Dec 2017 were retrieved from the database. The primary endpoint was the complication rate. Secondary endpoints were the surgical operating room time (ORT) and the length of hospital stay (LOS). Results: Out of the 2828 patients who were included, 120 patients underwent a concomitant cholecystectomy during their bariatric procedure (LSG or LRYGB) for asymptomatic gallbladder stones and were compared to the 2708 remaining patients who only had bariatric surgery. None of the concomitant cholecystectomy patients developed a gallbladder-related complication. There was no significant increase in the rate of minor or major complications between the CC groups and the non-CC groups (LSG: 6.7% vs. 3.2%, p=0.132; LRYGB: 0% vs. 2.3%, p =0.55; and conversion of LSG to LRYGB: 20% vs. 7.1%, p = 0.125, respectively). In addition, there was no significant increase in the length of hospital stay (1.85 ±4.19 days vs. 2.24 ±1.82, p=0.404) for LSG group and (1.75 ±2.0 vs. 2.3 ±2.1, p=0.179) for LRYGB group. Adding the cholecystectomy to the bariatric procedure only added an average of 23 min (min) (27 min when added to LSG and 18 min when added to LRYGB). Conclusion: As one of the largest series reviewing concomitant cholecystectomy in bariatric surgery, this study showed that in skilled laparoscopic bariatric surgical hands, concomitant cholecystectomy during bariatric surgery is safe and prevents potential future gallstone-related complications. Long-term large prospective randomized trials are needed to further clarify the recommendation of prophylactic concomitant cholecystectomy during bariatric surgery. [ABSTRACT FROM AUTHOR]

Purpose: Although the laparoscopic Roux-en-Y Gastric Bypass (LRYGB) is the gold-standard bariatric procedure, it remains uncertain what the optimal bowel limb lengths are to accomplish maximal weight loss while minimizing nutritional deficiencies and related gastro-intestinal complaints. The aim of this randomized controlled multicenter trial is to investigate the effect of significant lengthening of the length of the Roux limb (RL) at the cost of the length of the common channel (CC) while keeping the biliopancreatic limb (BPL) lengths the same on both study arms. Methods: Four hundred forty-four patients were randomized to receive either a Very Long Roux Limb LRYGB (VLRL-LRYGB) (variable RL length, BPL 60 cm, and CC 100 cm) or a Standard LRYGB (S-LRYGB) (RL 150 cm, BPL 60 cm, and a variable CC length). Results at 1-year follow-up for weight loss, effect on obesity-related comorbid conditions, complications, re-operation rate, malnutrition rate, and re-admission rate were investigated. Results: Weight loss at 1-year showed no significant differences for %EWL (84.3% versus 85.3%, p = 0.72) and %TWL (34.2% versus 33.6%, p = 0.359) comparing VLRL-LRYGB versus S-LRYGB. Malabsorption requiring surgical bowel length adjustment was observed in 1.4% in VLRL-LRYGB group versus 0.9% in S-LRYGB group (p = 0.316). Conclusion: Significant lengthening of the RL at the cost of the common channel seems to have no effect on the weight loss at 1-year follow-up, which supports the theory that absorption of nutrients also occurs in the RL. Nevertheless, long-term results of the VLRL-LRYGB have to be awaited to draw final conclusions as part of the discussion towards optimal limb length in LRYGB surgery. [ABSTRACT FROM AUTHOR]

Prof. Mannaerts also introduced and established a minimally invasive surgical oncology program at Tawam to further provide advanced training for young specialist surgeons, like UAE-national Dr. Fatima Jouhar. Prof. Mannaerts has spoken at numerous national and international meetings on bariatric surgery, ERABS, and OR fast-track logistics and is frequently invited as a surgeon trainer for bariatric teams in the Gulf region. Graph Professor Dr. Guido Mannaerts has influenced the practice of bariatric surgery with his long-standing interest in Enhanced Recovery After Bariatric Surgery (ERABS). [Extracted from the article]

Background: Although enhanced recovery after bariatric surgery (ERABS) has proven to be safe and cost-effective, this concept is relatively new in the Middle East. Methods: A retrospective analysis of consecutive registered cohorts of patients who underwent primary and purely laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) were compared before introduction of ERABS (2010–2014) and after ERABS (2015–2017) at Tawam Hospital/Johns Hopkins, the UAE. Results: A total of 462 eligible bariatric patients (LSG 414 and LRYGB 48) were operated on before and 1602 (LSG 1436 and LRYGB 166) after introduction of the ERABS. Significant improvements of mean patient time of the patient being within the OR for LSG (from 2:27 to 1:23 min, p = 0.000) and LRYGB (from 3:17 to 1:59 min, p = 0.000) were achieved when comparing pre-ERABS with after introduction of ERABS. Furthermore, there was a significant decrease in LOS in both LSG (from 3.2 to 1.5 days, p = 0.000) and in LRYGB (from 3.5 to 1.7 days, p = 0.000). Major (CD classification III–IV) complications decreased significantly in LSG (from 13.8 to 0.8%, p = 0.000) and were similar in LRYGB (from 4.2% to 3.0%, p = NS). The readmission rate for LSG (from 2.9 to 2.6%, p = NS) or LRYGB (from 0 to 4.8%, p = NS) and the reoperation rates after LSG (from 0.7 to 0.5%, p = NS) and LRYGB (from 0 to 2.4%, p = NS) did not differ between both groups following introduction of ERABS. Conclusions: Implementation of a standardized ERABS program in the Middle East is feasible and safe and leads to reduced LOS and OR times. [ABSTRACT FROM AUTHOR]

Background: Obesity is related to increased cardiovascular risk. It is unknown whether increasing levels of obesity also increase levels of cardiovascular risk factors and systemic inflammation. This study describes the relationship between classic cardiovascular risk factors and inflammatory markers with BMI in a group of obese and non-obese subjects.Materials and Methods: Obese subjects (BMI ≥ 30 kg/m2; n = 576; mean ± SD BMI 43.8 ± 7.58 kg/m2) scheduled for bariatric surgery were included. The reference population consisted of non-obese volunteers (BMI < 30 kg/m2; n = 377, BMI 25.0 ± 2.81 kg/m2). The relationship between BMI quintiles and the levels of cardiovascular risk factors was analyzed. Adipose tissue volumetry was performed in 42 obese subjects using abdominal CT scans.Results: The obese group included more women and subjects with type 2 diabetes mellitus, hypertension, and current smoking behavior. In obese subjects, HDL-C and triglycerides decreased with increasing BMI. Systolic and diastolic blood pressure, total cholesterol, LDL-C, and apoB were not related to BMI in the obese group, in contrast to the non-obese group. Inflammatory markers CRP, leukocyte count, and serum complement C3 increased with increasing BMI in the obese group, while these relations were less clear in the non-obese group. The subcutaneous adipose tissue surface was positively correlated to BMI, while no correlation was observed between BMI and visceral adipose tissue.Conclusions: Markers of inflammation are strongest related to BMI in obese subjects, most likely due to increased adipose tissue mass, while cardiovascular risk factors do not seem to deteriorate above a certain BMI level. Limited expansion capacity of visceral adipose tissue may explain these findings. [ABSTRACT FROM AUTHOR]

Introduction: Type 2 diabetes mellitus (T2DM) and obesity are both related to increased risk of cardiovascular disease and mortality. Early atherosclerotic vascular changes can be detected by non-invasive tests like carotid artery intima-media thickness (cIMT) and pulse wave velocity (PWV). Both cIMT and PWV are significantly impaired in T2DM patients and in obese patients, but the additional effect of T2DM on these vascular measurements in obese subjects has not been evaluated.Methods: Two hundred morbidly obese patients with or without T2DM were enrolled in a prospective cohort study and underwent extensive laboratory testing, including cIMT and PWV measurements. The cohort was divided into a group with and a group without T2DM.Results: Within this cohort, 43 patients (21.5%) were diagnosed with T2DM. These patients were older and had more often (a history of) hypertension as compared to patients without T2DM. HbA1c levels were significantly increased, while LDL cholesterol was significantly lower and the use of statins higher than in non-diabetic participants. cIMT and PWV were significantly increased in subjects suffering from T2DM. The variability in cIMT and PWV was related to differences in age and systolic blood pressure, but not to the presence of T2DM.Conclusion: While T2DM negatively affects the vasculature in morbid obesity, hypertension and age seem to be the major risk factors, independent from the presence of T2DM.Clinical Trial Registration: Dutch Trial Register NTR5172. [ABSTRACT FROM AUTHOR]

Background: Morbidly obese patients are at higher risk of complications after surgery. In bariatric surgery, pre- and intra-operative checklists are commonly used to identify high-risk patients preoperatively, to decrease the number of postoperative complications. This pilot study evaluates the effect of a postoperative checklist in bariatric surgery, addressing regularly measured parameters, on the occurrence and early recognition of complications. Methods: An in-house developed postoperative checklist was used on the first postoperative day after bariatric surgery and included information on nausea, pain, temperature, heart rate, and laboratory markers. Complications were scored using the Clavien-Dindo (CD) classification, and three groups were formed: no complications (CD0), minor complications (CD1 and 2), and major complications (≥CD3a). Differences between groups were analyzed using nonparametric tests. Results: Six hundred ninety-four subjects were included (79.5% female, age 42.6 ± 10.8 years, BMI 43.8 ± 5.8 kg/m). Twenty-nine subjects developed major complications within 30 days postoperatively. There were no significant differences in baseline characteristics between groups. Subjects with major complications were less willing to be discharged due to complaints, compared to subjects with no or minor complications (14.8 vs. 3.6 and 4.6%, respectively) and had a higher decrease of hemoglobin level (0.8 vs. 0.6 and 0.65 mmol/l, respectively). Conclusion: The patient's willingness for discharge, in combination with hemoglobin decrease, may be the best early predictors of major complications after bariatric surgery. This postoperative checklist may be an adequate instrument to identify patients who can be safely discharged home on the first postoperative day and thereby play a part in patient management after bariatric surgery. [ABSTRACT FROM AUTHOR]

Introduction: Bariatric surgery is the only treatment option that achieves sustained weight loss in obese patients and that also has positive effects on obesity-related comorbidities. Laparoscopic sleeve gastrectomy (LSG) seems to achieve equal weight loss as laparoscopic Roux-en-Y gastric bypass (LRYGB), but there is still much debate about the quality of life (QOL) after LSG, mainly concerning the association with gastroesophageal reflux. Our hypothesis is that QOL after LSG is comparable with QOL after LRYGB. Materials and Methods: Between February 2013 and February 2014, 150 patients were randomized to undergo either LSG or LRYGB in our clinic. Differences in QOL were compared between groups by using multiple QOL questionnaires at follow-up moments preoperatively and 2 and 12 months after surgery. Results: After 12 months of follow-up, 128 patients had returned the questionnaires. Most QOL questionnaires showed significant improvement in scores between the preoperative moment and after 12 months of follow-up. The Gastroesophageal Reflux Disease Questionnaire (GerdQ) score deteriorated in the LSG group after 2 months, but recovered again after 12 months. After 2 months of follow-up, the mean GerdQ score was 6.95 ± 2.14 in the LSG group versus 5.50 ± 1.49 in the LRYGB group ( p < 0.001). After 1 year, the mean GerdQ score was 6.63 ± 2.26 in the LSG group and 5.60 ± 1.07 in the LRYGB group ( p = 0.001). Conclusion: This randomized controlled trial shows that patients who underwent LSG have significantly higher GerdQ scores at both 2 and 12 months postoperatively than patients who underwent LRYGB, whereas overall QOL did not differ significantly. [ABSTRACT FROM AUTHOR]

Introduction: Although long-term results of sleeve gastrectomy (LSG) remain scarce in the literature, its popularity as a stand-alone procedure has accounted for a global increase in LSG performance. In this retrospective study, the authors present 5 to 8-year follow-up results in terms of weight loss, failure/revision rate, and comorbidity resolution from a single center. Materials and Methods: A prospectively maintained database was reviewed for patients who underwent LSG between 2007 and 2010. Data analysis on weight loss, comorbid conditions, revision surgery, and mortality was conducted. Results: Median percentage excess BMI loss (%EBMIL) was 59.0, and 53.9 %, and median percentage total weight loss (%TWL) was 25.1, and 22.9 % at 5 and 8 years, respectively. Revision to gastric bypass due to insufficient weight loss or gastroesophageal reflux disease (GERD) was performed in 42 patients (15.2 %). Resolution of comorbid condition was achieved in 91 % of patients with obstructive sleep apnea syndrome (OSAS), 68 % of patients with type 2 diabetes (T2DM), 53 % of patients with hypertension, and 25 % of patients with dyslipedemia. Loss to follow-up rate was 45 % at 5 years, 28 % at 6 years, 23 % at 7 years, and 13 % at 8 years. Conclusion: This study adds to the currently available data confirming the LSG to be a safe and effective procedure at long term. Data from high-volume studies are needed to establish the definite role of the LSG in the spectrum of bariatric procedures. [ABSTRACT FROM AUTHOR]

Background: With the increasing prevalence of morbid obesity and healthcare costs in general, interest is shown in safe, efficient, and cost-effective bariatric care. This study describes an Enhanced Recovery After Bariatric Surgery (ERABS) protocol and the results of implementing such protocol on procedural times, length of stay in hospital (LOS), and the number of complications, such as readmissions and reoperations. Methods: Results of implementing an ERABS protocol were analyzed by comparing a cohort treated according to the ERABS protocol (2012-2014) with a cohort treated before implementing ERABS (2010-2012). Differences between both cohorts were analyzed using independent t tests and chi-squared tests. Results: A total of 1.967 patients (mean age 43.3 years, 80 % female) underwent a primary bariatric procedure between 2010 and 2014, of which 1.313 procedures were performed after implementation of ERABS. A significant decrease of procedural times and a significantly decreased LOS, from 3.2 to 2.0 nights ( p < 0.001), were seen after implementation of ERABS. Significantly more complications were seen post-ERABS (16.1 vs. 20.7 %, p = 0.013), although no significant differences were seen in the number of major complications. Conclusion: Implementation of ERABS can result in shorter procedural times and a decreased LOS, which may lead to more efficient and cost-effective bariatric care. The increase in complications was possibly due to better registration of complications. The main goal of an ERABS protocol is efficient, safe, and evidence-based bariatric care, which can be achieved by standardization of the total process. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic adjustable gastric band (LAGB), laparoscopic sleeve gastrectomy (LSG), and laparoscopic Roux-en-Y gastric bypass (LRYGB) are the most performed procedures worldwide (92 %) nowadays. However, comparative clinical trials are scarce in literature. The objective of this study was to compare the effectiveness and safety of the three most performed bariatric procedures. Methods: A multicenter, retrospective, matched cohort study was conducted. Patients were eligible for analysis when a primary procedure was performed between 2007 and 2010 in one of the two specialized bariatric centers. Primary outcome was weight loss, expressed in the percentage excess weight loss (%EWL). Secondary outcome parameters are hospital stay, complication rate, and revisional surgery. Results: In total, 735 patients, 245 in each group, were included for analysis. The groups were comparable for age and gender after matching. Mean postoperative follow-up was 3.1 ± 1.2 years. LAGB patients showed less %EWL compared to LSG and LRYGB at all postoperative follow-up visits. LRYGB showed a %EWL of 71 ± 20 % compared to LSG (76 ± 23 %; p = 0.008) after 1-year follow-up; thereafter, no significant difference was observed. After 3 years of follow-up, LAGB showed a higher complication rate compared to LSG and LRYGB ( p < 0.05). Revisional surgery after LAGB was needed in 21 %, while 9 % of the LSG underwent conversion to RYGB. Conclusions: LRYGB is a safe and effective treatment in morbid obese patients with good long-term outcomes. LSG seems to be an appropriate alternative as a definitive procedure, in terms of weight reduction and complication rate. LAGB is inferior to both LRYGB and LSG. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: The objective of this study was to correlate dynamic magnetic resonance imaging (MRI) with Pelvic Organ Prolapse Quantification (POP-Q) measurements and pelvic floor symptoms in order to determine the value of dynamic MRI for evaluating vaginal vault prolapse both before and 6 months after laparoscopic sacrocolpopexy. Methods: This was a prospective, single-center cohort study in 43 patients who underwent a modified laparoscopic sacrocolpopexy/hysteropexy operation using bone-anchor fixation and synthetic mesh. The study included dynamic MRI, POP-Q staging, and validated questionnaires before and 6 months after laparoscopic sacrocolpopexy. To assess MRI data, the pubococcygeal reference line and specifically defined anatomical landmarks for the separate compartments were used. Differences between pre- and postoperative measurements were evaluated with the Wilcoxon signed-rank test, and correlations at the 0.05 level were considered to be significant (Pearson correlation, two tailed). Results: At 6 months, a statistically significant improvement was seen in POP-Q staging for all compartments. Dynamic MRI measurements only revealed a significant improvement after surgery for the apical compartment. The correlation between (changes in) MRI measurements, POP-Q measurements, and validated questionnaires was poor. Conclusions: The value of dynamic MRI for evaluating and documenting changes in vaginal vault support and position after laparoscopic sacrocolpopexy is limited due to the poor correlation with both POP-Q staging and pelvic floor symptoms. [ABSTRACT FROM AUTHOR]

Purpose: With current diagnostic methods, the majority of patients with symptomatic colorectal anastomotic leakage (CAL) is identified approximately 1 week after operation. The aim of this study is to determine whether real-time polymerase chain reaction (RT-PCR) for detection of Escherichia coli and Enterococcus faecalis on drain fluid can serve as a screening test for CAL in the early postoperative phase. Methods: All patients included in this multicenter prospective observational study underwent left-sided colorectal resection for both malignant and benign diseases with construction of an anastomosis. In all patients, an intra-abdominal drain was placed during operation. During the first five postoperative days, drain fluid was processed for RT-PCR. The quantitative results of the RT-PCR on days 2 to 5 were compared to the results of day 1 in order to detect concentration changes. Results: In total, 243 patients, with both benign and malignant diseases, were included of whom 19 (7.8 %) developed symptomatic CAL. An increase in E. coli concentration was found in significantly more patients with CAL on day 4 and 5 [ p = 0.0004; diagnostic odds ratio (DOR) 7.9]. For E. faecalis, this result was found for days 2, 3, and 4 ( p < 0.003) with highest DOR on day 3 (31.6). Sensitivity and negative predictive values were 92.9 and 98.7 %, respectively, virtually ruling out CAL in case of negative test results on the third postoperative day. Conclusion: Quantitative PCR for E. faecalis performed on drain fluid may be an objective, affordable and fast screening tool for symptomatic colorectal anastomotic leakage. [ABSTRACT FROM AUTHOR]

Background: Obesity is associated with respiratory symptoms and impaired pulmonary function, which could increase the risk of complications after bariatric surgery. The purpose of this study is to assess the relationship between pulmonary function parameters before, and the risk of complications after, laparoscopic bariatric surgery. Methods: This prospective study included patients (age 18-60, BMI >35 kg/m), who were eligible for bariatric surgery. Spirometry was performed in all patients. Complications up to 30 days after bariatric surgery were recorded. Results: Four hundred eighty-five patients were included (304 laparoscopic sleeve gastrectomy, 181 laparoscopic gastric bypass). There were 53 complications (8 pulmonary, 27 surgical, 14 infectious, 4 other) in 50 patients (10 %). There were 35 re-admissions (7.2 %), and 17 re-laparoscopies (3.5 %). Subjects with and without complications did not differ significantly with respect to demographics, weight, BMI, abdominal circumference or fat percentage. Subjects with complications had a significantly lower mean FEV (mean 86.9 % predicted) and FVC (95.6 % predicted) compared to patients without complications (95.9 % predicted, p = 0.005, and 100.1 % predicted, p = 0.045, respectively). After adjustment for age, gender, BMI, and smoking, abnormal spirometry value remained the single predictive covariable of postoperative complications: FEV/FVC <70 % adjusted OR 3.1 (95%CI 1.4-6.8, p = 0.006) and ΔFEV ≥12 % adjusted OR 2.9 (95 %CI 1.3-6.6, p = 0.010). Conclusions: The risk of pulmonary complications after laparoscopic bariatric surgery is low. However, subjects with abnormal spirometry test results have a threefold risk of complications after laparoscopic bariatric surgery. Preoperative pulmonary function testing might be useful to predict the risk of complications of laparoscopic bariatric surgery. [ABSTRACT FROM AUTHOR]

The surgical treatment of vaginal vault prolapse can either be performed by the vaginal or the abdominal (laparoscopic) route. The objective of this study was to compare the laparoscopic sacral colpopexy (LSC) and total vaginal mesh (TVM) for vaginal vault prolapse. This study compared a prospective cohort of LSC with bone-anchor fixation and mesh limited to the apex to a prospective cohort of TVM as treatment modalities in patients with a symptomatic vaginal vault prolapse (pelvic organ prolapse-quantification (POP-Q) point C ≥ −3). Primary outcome was failure in the apical compartment after 6 month follow-up, defined as POP-Q stage ≥ II with prolapse complaints or re-treatment in apical compartment. Based on an overall failure in all compartments of 23 % in the LSC group and 57 % in the TVM group, 29 patients would be needed in each group with a power of 80 % and alpha 0.05. Ninety-seven women were included, 45 LSC and 52 TVM. The failure rate of symptomatic vault prolapse was 1 (2 %) in each group ( p = 0.99). The failure rate (POP stage ≥ II) in any compartment was 23 (51 %) in the LSC group and 11 (21 %) in the TVM group ( p = 0.002). Each technique had its own type of complications. Short-term failure rates in the apical compartment after TVM and LSC were similar. In case of anterior or posterior prolapsed, additional mesh insertion or additional vaginal colporrhaphy is indicated in LSC surgery. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: The aim of this study was to evaluate short-term anatomic and functional outcomes and safety of laparoscopic sacrocolpopexy with bone anchor fixation. Methods: A prospective cohort study of women undergoing laparoscopic sacrocolpopexy between 2004 and 2009. Anatomic outcome was assessed using the pelvic organ prolapse quantification score (POP-Q). Functional outcomes were assessed using the Urogenital Distress Inventory, Defecatory Distress Inventory, and the Incontinence Impact Questionnaire preoperatively and at 6 months postoperatively. The Wilcoxon signed rank test was used to test differences between related samples. Results: Forty-nine women underwent laparoscopic sacrocolpopexy. The objective success rate in the apical compartment was 98%, subjective success rate was 79%. One mesh exposure (2%) was found. One conversion was necessary due to injury to the ileum. Conclusions: Laparoscopic sacrocolpopexy with bone anchor fixation is a safe and efficacious treatment for apical compartment prolapse. It provides excellent apical support and good functional outcome 6 months postoperatively. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic sleeve gastrectomy (LSG) is becoming increasingly popular as a stand-alone procedure for the treatment of morbidly obese patients. A direct posterior approach to the angle of His was developed at our department to improve visualization of the difficult dissection of the short gastric vessels and to facilitate proper mobilization of the stomach around the left crus enabling safe realization of a tight sleeve. The technique and its preliminary results are described. Methods: LSG by posterior approach was performed in a consecutive series of 445 (110 male/335 female, age 18-63 years, mean body mass index 46 kg/m (range 35-76)) patients between 2007 and 2010. Results: Weight loss defined as mean percent excess weight loss (%EWL) was 71% (±26%) at 1 year, 69% (±25%) at 2 years, and 55% (±27%) at 3 years. Sixteen patients (4%) developed postoperative intra-abdominal hematoma, 8 patients (2%) anastomotic leakage, and 6 patients intra-abdominal abscess (1%), requiring reoperation in 20 patients (4%). Five patients (1%) had pulmonary embolism. Thirty-day mortality rate was 0.2%. Conclusions: LSG by the posterior approach is a safe and effective procedure, enabling a tight sleeve formation leading to satisfactory %EWL results. Since long-term results of LSG are unknown, further studies are needed to define the exact place of the LSG as a stand-alone bariatric procedure. [ABSTRACT FROM AUTHOR]

Background: Anastomotic leakage is a major complication in colorectal surgery. This study investigates a new method for reducing anastomotic failure using antitraction sutures. Methods: In 2007, the authors began routine placement of three sutures at every one-third of the circular end-to-end anastomosis to reduce traction. Before the start of the new protocol, 76 patients received laparoscopic colorectal left sided surgery, 21 (28%) of whom received a defunctioning stoma. After the start of the new protocol, 77 patients received laparoscopic colorectal surgery, 6 (8%) of whom received a defunctioning stoma. Results: Placement of a defunctioning stoma was significantly reduced ( n = 21 vs. 6; P = 0.01). Only one patient (1%) in the sutured group experienced anastomotic leakage compared with six patients in the control group ( P = 0.025). Other anastomosis-related complications during the follow-up period, including anastomotic stenosis and intraabdominal abscess, occurred more frequently in the control group, although the difference did not reach significance. Conclusion: The use of antitraction sutures to support the anastomosis seems to reduce the occurrence of anastomotic leakage in laparoscopic left colorectal surgery. A prospective randomized trial is necessary to prove the decreasing effect of antitraction sutures on anastomotic leakage as well as the major decreasing effect on the necessity of placement of defunctioning stomas. [ABSTRACT FROM AUTHOR]

Background: Several minimal invasive, mainly laparoscopic-assisted, techniques for reversal of Hartmann's procedure (HP) have been published. The purpose of this pilot study was to assess a minimal invasive procedure through the stomal site that may compare favorably with open or laparoscopic-assisted procedures in terms of operative time, hospital stay and postoperative complications.Methods: HP reversal through the stomal side was attempted in 13 consecutive patients. Lysis of intra-abdominal adhesions was done manually through an incision at the formal stoma side, without direct vision between thumb and index finger. The rectal stump was identified intra-abdominally using a transanal rigid club. A manually controlled stapled end-to-end colorectal anastomosis was created.Results: Mean duration of operation was 81 min (range 58-109 min); mean hospital stay was 4.2 days (range 2-7 days). In two patients the procedure was converted because of strong adhesions in the lower pelvic cavity around the rectal stump that could not be lysed manually safely. No complications occurred in the patients in whom reversal was completely done through the stomal site.Conclusions: In our opinion, restoration of intestinal continuity through the stomal side after HP is a feasible operation, without need for additional incisions. In the hands of a specialist gastrointestinal surgeon this technique can be attempted in all patients, as conversion to a laparoscopic-assisted or an open procedure can be performed when necessary. [ABSTRACT FROM AUTHOR]