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Sleeve gastrectomy (SG) is the most frequently performed bariatric surgical intervention worldwide. Gastroesophageal reflux disease (GERD) is frequently observed after SG and is a relevant clinical problem. This prospective study investigated the gastroesophageal junction (GEJ) and pyloric sphincter by impedance planimetry (EndoFlip TM ) and their association with GERD at a tertiary university hospital center. Between January and December 2018, patients undergoing routine laparoscopic SG had pre-, intra-, and postoperative assessments of the GEJ and pyloric sphincter by EndoFlip TM . The distensibility index (DI) was measured at different volumes and correlated with GERD (in accordance with the Lyon consensus guidelines). Nine patients were included (median age 48 years, preoperative BMI 45.1 kg/m 2 , 55.6% female). GERD (de novo or stable) was observed in 44.4% of patients one year postoperatively. At a 40-ml filling volume, DI increased significantly pre- vs. post-SG of the GEJ (1.4 mm 2 /mmHg [IQR 1.1-2.6] vs. 2.9 mm 2 /mmHg [2.6-5.3], p VALUE=0.046) and of the pylorus (6.0 mm 2 /mmHg [4.1-10.7] vs. 13.1 mm 2 /mmHg [7.6-19.2], p VALUE=0.046). Patients with postoperative de novo or stable GERD had a significantly increased preoperative DI at 40 ml of the GEJ (2.6 mm 2 /mmHg [1.9-3.5] vs. 0.5 mm 2 /mmHg [0.5-1.1], p VALUE=0.031). There was no significant difference in DI at 40 mL filling in the preoperative pylorus and postoperative GEJ or pylorus. In this prospective study, the DI of the GEJ and the pylorus significantly increased after SG. Postoperative GERD was associated with a significantly higher preoperative DI of the GEJ but not of the pylorus., (© 2023. The Author(s).)

During upper gastrointestinal surgery, retraction of the liver plays an essential role in the visualization and creation of an optimal surgical field. Liver retraction may be problematic, particularly in obese patients. The use of conventional liver retractors requires additional skin incision and has the potential to cause pain as well as liver injuries. The present study is the first to evaluate the performance and safety of the LiVac Sling (Livac Pty Ltd, Melbourne, Australia) trocar-free retractor system in bariatric surgery patients. In this retrospective study, data from laparoscopic primary or revisional bariatric surgeries that were performed with the LiVac Sling system and a standard retractor between May 2017 and December 2017 were collected. Demographic data, body mass index, type of surgery, number and indication of LiVac Sling system used, surgery time, and complications were analyzed. In total, 51 procedures were included. Twenty Sling devices have been used in 17 patients (13 female; 75%). The distribution of baseline characteristics was similar between the standard retractor group and LiVac Sling retractor group. In the LiVac Sling group, the number of trocars used was significantly reduced over the study period. Within 30 days postoperatively, no complications could be identified, and no device-related adverse events were reported. In this bariatric population, the use of the LiVac Sling for liver retraction was safe. No device-related adverse events were registered, and compared with standard retraction, the number of trocars used could be reduced by one.

Hiatal hernia: Current evidence and controversies in treatment Abstract. A hiatal hernia describes an enlarged diaphragmatic hiatus esophageus, through which the gastroesophageal transition occurs. In its maximum variant, the entire stomach and other intestinal organs can be shifted thoracically. Symptoms of hiatal hernia are related to reflux disease, but also to intrathoracic compression symptoms due to the dislodgement of intrathoracic organs into the mediastinum, with the most dramatic presentation being ischemia of the herniated organs due to strangulation. The most common classification distinguishes four types of hiatus hernias according to their anatomical morphological characteristics (type I-IV). Treatment recommendation is guided by patients' symptoms, as no conservative treatment of a hiatal hernia is possible. High recurrence rates after surgical treatment of a hiatal hernia and antireflux surgery led to a discussion about diaphragm closure with or without mesh augmentation, and data seem to indicate that hiatal mesh augmentation reduces recurrence. Also, due to the high recurrence rates, re-do surgery is a valid option for symptomatic patients. Presently, no uniform recommendation for either surgical technique of hiatus closure or the use of a mesh inlay exists, and individual decision making is rather related upon the institutional experience with upper GI surgery.

Importance: Sleeve gastrectomy is increasingly used in the treatment of morbid obesity, but its long-term outcome vs the standard Roux-en-Y gastric bypass procedure is unknown., Objective: To determine whether there are differences between sleeve gastrectomy and Roux-en-Y gastric bypass in terms of weight loss, changes in comorbidities, increase in quality of life, and adverse events., Design, Setting, and Participants: The Swiss Multicenter Bypass or Sleeve Study (SM-BOSS), a 2-group randomized trial, was conducted from January 2007 until November 2011 (last follow-up in March 2017). Of 3971 morbidly obese patients evaluated for bariatric surgery at 4 Swiss bariatric centers, 217 patients were enrolled and randomly assigned to sleeve gastrectomy or Roux-en-Y gastric bypass with a 5-year follow-up period., Interventions: Patients were randomly assigned to undergo laparoscopic sleeve gastrectomy (n = 107) or laparoscopic Roux-en-Y gastric bypass (n = 110)., Main Outcomes and Measures: The primary end point was weight loss, expressed as percentage excess body mass index (BMI) loss. Exploratory end points were changes in comorbidities and adverse events., Results: Among the 217 patients (mean age, 45.5 years; 72% women; mean BMI, 43.9) 205 (94.5%) completed the trial. Excess BMI loss was not significantly different at 5 years: for sleeve gastrectomy, 61.1%, vs Roux-en-Y gastric bypass, 68.3% (absolute difference, -7.18%; 95% CI, -14.30% to -0.06%; P = .22 after adjustment for multiple comparisons). Gastric reflux remission was observed more frequently after Roux-en-Y gastric bypass (60.4%) than after sleeve gastrectomy (25.0%). Gastric reflux worsened (more symptoms or increase in therapy) more often after sleeve gastrectomy (31.8%) than after Roux-en-Y gastric bypass (6.3%). The number of patients with reoperations or interventions was 16/101 (15.8%) after sleeve gastrectomy and 23/104 (22.1%) after Roux-en-Y gastric bypass., Conclusions and Relevance: Among patients with morbid obesity, there was no significant difference in excess BMI loss between laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass at 5 years of follow-up after surgery., Trial Registration: clinicaltrials.gov Identifier: NCT00356213.

Background: Morbid obesity and its associated co-morbidities are risk factors for the development of abdominal hernias, add complexity to their repair, and increase perioperative risk. Repair of hernias with loss of domain (LoD) is further complicated by risk of abdominal compartment syndrome. A staged concept with an initial weight loss procedure might enable a reposition of the herniated viscera, improve co-morbidities for, and prohibit abdominal compartment syndrome in the subsequent repair., Objective: To evaluate a multistep treatment strategy that entails initial laparoscopic sleeve gastrectomy (LSG) followed by open repair in the treatment of complex hernias with LoD in morbidly obese patients SETTING: University hospital METHODS: Retrospective analysis of all patients (n = 15) with morbid obesity and hernias with LoD treated in a staged concept between April 2010 and December 2015 RESULTS: Median initial body mass index was 45 kg/m 2 . All hernias were recurrent incisional hernias with≥2 failed repairs. No major complications occurred during or after LSG. After a median of 185 days, the second stage at a median body mass index of 33.6 kg/m 2 was performed. No bowel resections were needed. The only major perioperative complication was pneumonia in 2 patients (13%). Within 24 months (6-68) after the second step, there were 3 reoperations (small recurrence [7%], infected seroma [7%], and infected mesh [7%]). One patient (7%) was lost to follow-up after 2 years., Conclusion: A 2-step approach to treat massive hernias with LoD in morbidly obese patients is safe and effective. LSG as initial weight loss procedure addresses LoD successfully without a need for further preoperative measures to condition for hernia repair., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Morbidly obese patients with excessive concomitant disease carry a significantly increased perioperative risk. Although they may benefit most from a bariatric intervention, they are often denied surgery. Laparoscopic sleeve gastrectomy (LSG), as it is less complication-prone than other bariatric procedures, suits the needs of those patients., Objective: To review the short-term outcome of LSG for high-risk patients SETTING: University hospital, Switzerland., Methods: A total of 110 patients with high perioperative risk undergoing LSG between January 2008 and December 2014 were prospectively recorded. Patients were defined as "high-risk" if they met 2 of the following criteria: American Society of Anesthesiologists physical status score (ASA)>III, Obesity Surgery Mortality Risk Score (OS-MRS)≥4, Revised Cardiac Risk Index (RCRI) class IV, Obstructive Sleep Apnea-Severity Index (OSA-SI)≥5, renal insufficiency chronic kidney disease ≥3, liver cirrhosis, or history of life-threatening perioperative events., Results: Of the patients, 59 (54%) were male. Median age was 49 years (range: 18-69), and median BMI was 51.7 kg/m 2 (38.7-89.2). Median operating time was 65 minutes (27-260). Eighty-six patients (78%) were classified as ASA IV, 65 (59%) as RCRI class IV, 51 (46%) as OS-MRS≥4 and 63 (57%) as OSA-SI≥5. Eighty-nine (81%) had type 2 diabetes, 70 (64%) were under antiplatelet and or anticoagulant therapy. Four patients (4%) were converted to open. Length of stay was 5 days (1-70). Major complications occurred in 12 patients (11%), including 1 mortality (1%)., Conclusion: "High-risk"-patients identified using a combination of established obesity- and co-morbidity-related risk scores profit from LSG as part of a uniform treatment pathway. Given the severity of co-morbidities, LSG can be performed safely. (Surg Obes Relat Dis 2016;X:XXX-XXX.) © 2016 American Society for Metabolic and Bariatric Surgery. All rights reserved., (Copyright © 2016. Published by Elsevier Inc.)

The aim of this study was to review our experience with laparoscopic end colostomy closure. A retrospective review of a prospectively entered database was performed. Proportions and continuous variables were compared using the Fisher's exact and the Mann-Whitney U tests, respectively. Within the study period, 53 patients underwent closure of end colostomies. The main reasons for the colonic resections were perforated diverticulitis (52.7%) and neoplasms (20.8%). In 28 patients (53%), laparoscopic closure (LC) was attempted. Demographics did not differ between the attempted LC and the primary open closure (OC) group. The conversion rate from an LC to an OC was 50 per cent (14 of 28), mostly as a result of adhesions (71.4%). Hospital length of stay (HLOS) was significantly longer for the OC than with the attempted LC group (15.4 ± 11.9 days vs 11.3 ± 8.5 days, P = 0.046). The overall complication rate was not different between the completed LC and the OC groups (43 vs 56%, P = 0.634). The majority of complications detected (91.1%) were minor and could be treated conservatively. The role of laparoscopy to close end colostomies is questionable, because the conversion rate is high. However, a shorter HLOS can be expected when laparoscopy is successful. To reduce morbidity resulting from prolonged operation times, it is crucial to convert early and pre-emptively if hostile adhesions are found.

Background: Laparoscopic sleeve gastrectomy (LSG) has become the most frequently performed bariatric procedure to date. However, LSG is known to worsen pre-operative and result in de novo gastroesophageal reflux disease (GERD). Pre-operative evaluation reveals a high percentage of silent GERD of so far unknown influence on post-operative GERD.Methods: Prospective data of patients undergoing primary LSG between 01/2012 and 12/2015 were evaluated. Pre-operative GERD-specific evaluation consisted of validated questionnaires, upper endoscopy, 24 h-pH-manometry, and esophagograms. Patients were followed-up with questionnaires every 6 months, upper endoscopies after 1 year and 24 h-pH-metry after 2 years. Silent GERD was defined as esophagitis grade > B and/or abnormal esophageal acid exposure in absence of symptoms. LSG was performed over a 32F bougie, hiatal hernias > 1 cm were addressed with posterior hiatoplasty. Excluded were patients with hiatal hernias > 4 cm, patients with incorrect anatomy (stenosis, fundus too large) and conversion to RYGB for early leaks.Results: 222 patients were included. Mean follow-up was 32 ± 16 months, mean preoperative body mass index 49.6 ± 7.2 kg/m2. 116 patients (52%) presented with post-operative GERD-symptoms, of which 85 (73%) had de novo symptoms. Of those, 48 (of 85, 56%) had no preoperative GERD and 37 (of 85, 44%) silent GERD. 57 patients (26%) had neither pre- nor post-operative GERD, 7 (3%) had silent pre-operative and no postop GERD, and in 19 patients (9%) GERD was cured with LSG. 31 patients (14%) stayed symptomatic. Of 56 patients (25%) with pre-operative silent GERD, 37 (of 54, 66%) became symptomatic.Conclusion: LSG leads to a considerable rate of post-operative GERD. De novo-GERD consist of around half of pre-operative silent GERD and completely de novo-GERD. Most patients with pre-operative silent GERD became symptomatic. [ABSTRACT FROM AUTHOR]

Background: Re-sleeve gastrectomy (re-SG) is a possible option to increase weight loss after biliopancreatic diversion with duodenal switch (BPD-DS). We report the feasibility, efficacy and safety of re-SG in patients presenting with long-term weight regain after BPD-DS.Methods: From October 2010 to December 2013, a total of 17 patients (12 female, 5 male) with a mean age of 42.1 ± 19.4 years underwent re-SG, mainly because of weight regain after BPD-DS. Re-SG was performed laparoscopically over a 32 French stomach tube.Results: At the time of BPD-DS, the mean weight and BMI of all patients were 130.1 ± 17.9 kg and 46.1 ± 6.5 kg/m(2), respectively. The mean time interval between BPD-DS and re-SG was 63.1 ± 20.3 months. At the time of re-SG, the mean weight and BMI were 115.4 ± 14.2 kg and 39.8 ± 5.3 kg/m(2), and the %EWL after BPD-DS was 22.9 ± 17.4 %. Three conversions (17.6 %) to open surgery were required. No mortality occurred. One patient (5.9 %) developed a leak within the first week after re-SG that was treated conservatively with an endoluminal stent. The mean follow-up was 37.2 ± 7.1 months after re-SG. One- and three-year follow-up showed a mean weight, BMI, and cumulative %EWL of 96.0 ± 17.1 kg, 33.8 ± 7.3 kg/m(2), and 53.1 ± 18.3 % (17/17 patients; 100 %), and 100.3 ± 21.1 kg, 35.1 ± 8.3 kg/m(2), and 47.2 ± 19.7 % (13/17 patients; 76 %) after re-SG, respectively.Conclusions: This study shows that re-SG in patients with weight regain after BPD-DS is a feasible, effective and safe option as a revisional bariatric procedure. However, patients have to be carefully considered for revisional surgery since re-SG is associated with the potential risk of surgical complications. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented which discusses the case of a 36-year-old woman with a total excess weight loss (EWL) and additional case of late perforation at the jejuno-jejunal (JJ) anastomosis after initial exploratory laparoscopy was performed.