Background
The incidence of de novo gastroesophageal reflux disease (GERD) after LSG is substantial. However, an objective correlation with the structural gastric and EGJ changes has not been ...demonstrated yet. We aimed to prospectively evaluate the effects of laparoscopic sleeve gastrectomy (LSG) on the structure and function of the esophagogastric junction (EGJ) and stomach.
Methods
Investigations were performed before and after > 50% reduction in excess body weight (6–12 months after LSG). Subjects with GERD at baseline were excluded. Magnetic Resonance Imaging (MRI), high-resolution manometry (HRM), and ambulatory pH-impedance measurements were used to assess the structure and function of the EGJ and stomach before and after LSG.
Results
From 35 patients screened, 23 (66%) completed the study (age 36 ± 10 years, BMI 42 ± 5 kg/m
2
). Mean excess weight loss was 59 ± 18% after 7.1 ± 1.7-month follow-up. Esophageal acid exposure (2.4 (1.5–3.2) to 5.1 (2.8–7.3);
p
= 0.040 (normal < 4.0%)) and reflux events increased after surgery (57 ± 24 to 84 ± 38;
p
= 0.006 (normal < 80/day)). Esophageal motility was not altered by surgery; however, intrabdominal EGJ length and pressure were reduced (both
p
< 0.001); whereas the esophagogastric insertion angle (35° ± 11° to 51° ± 16°;
p
= 0.0004 (normal < 60°)) and esophageal opening diameter (16.9 ± 2.8 mm to 18.0 ± 3.7 mm;
p
= 0.029) were increased. The increase in reflux events correlated with changes in EGJ insertion angle (
p
= 0.010). Patients with > 80% reduction in gastric capacity (TGV) had the highest prevalence of symptomatic GERD.
Conclusion
LSG has multiple effects on the EGJ and stomach that facilitate reflux. In particular, EGJ disruption as indicated by increased (more obtuse) esophagogastric insertion angle and small gastric capacity were associated with the risk of GERD after LSG.
clinicaltrials.gov
:
NCT01980420
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Purpose
Long-term results on sleeve gastrectomy (SG) with more than 10 years report patients needing sleeve revision for weight loss failure, de novo gastroesophageal reflux (GERD), or sleeve ...complications. The aim of this study was to analyze the results of laparoscopic conversion of failed SG to Roux-en-Y gastric bypass (RYGB).
Materials and Methods
Retrospective review of a prospectively institutional maintained database to identify patients who underwent conversion of SG to RYGB between 2012 and June 2020.
Results
Sixty patients(50 females) underwent conversion to RYGB. Average time to conversion was 5.6 years (2–11). Mean %WL and TWL after SG were respectively 26±8.8% and 33.2±14.1kg. Mean BMI at the time of RYGB was 38.1±7.1 kg/m
2
. Mean follow-up was 30.4±16.8 months (6–84). Available patients at each time of follow-up: 1 year 59 (98.3%); 2 years 47 (78.3%); 3 years 39 (71.6%); and 5 years 33 (55%). Patients were divided according to indication for revision in weight regain/insufficient weight loss (30 patients) group 1 and GERD/complications (25 patients) group 2. Percentage of excess weight loss at 1, 3, and 5 years follow-up after bypass was for group 1 40.3±17.6, 34.3±19.5, and 23.2±19.4 and for group 2 90.4±37, 62.6±28.2, and 56±35.02. Total weight loss at last follow-up since sleeve was respectively 31kg in group 1 and 46.7kg in group 2 (
p
=0.002). No mortality was observed. Thirty-day complication rate was 3.3%.
Conclusion
RYGB after SG is a safe and effective revisional procedure to manage weight regain and de novo GERD, to address complications, and to improve comorbidities.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
Laparoscopic sleeve gastrectomy (LSG) is currently the most commonly performed bariatric procedure. Endoscopic sleeve gastroplasty (ESG) is a promising new bariatric technique which is ...less invasive in its approach. To date no study has compared quality of life (QoL) outcomes between LSG and ESG. The aim of this study is to compare QoL after ESG and LSG using a propensity score analysis.
Methods
QoL was evaluated by means of Gastrointestinal Quality of Life Index (GIQLI) questionnaire before and 6 months after the procedure. Patients were matched for age, sex, preoperative weight, and comorbidities.
Results
Propensity score matching resulted in 23 pairs of patients homogeneous for age (
p
= 0.3), preoperative BMI (
p
= 0.3), sex (
p
= 0.74), and comorbidities (
p
= 0.9). Post-ESG patients, despite a less important %EWL (39.9 (17.5–58.9)vs 54.9 (46.2–65);
p
= 0.01) and %TWL (13.4 (7.8–20.9) vs 18.8 (17.6–21.8);
p
= 0.03), presented better QoL (14 3–24 vs 13 (− 1–23) ΔGIQLI score;
p
= 0.79) with clear advantage for the gastrointestinal symptoms subdomain (66.5 (61–70.5) vs 59 (55–63);
p
= 0.001), while post-LSG patients presented a worsening of GERD symptoms (30.7% vs 0%) and an increased use of PPI therapy (
p
= 0.004). Resolution or improvement of comorbidities was similar (ESG 53% vs LSG 45.8%;
p
= 0.79) in both groups.
Conclusion
LSG may significantly affect QoL and results in worsening of gastrointestinal symptoms including GERD. ESG is a promising less invasive bariatric endoscopic procedure that demonstrated a positive impact on both QoL and comorbidities, which could lead to greater patient acceptance earlier in their disease or at a younger age.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
This prospective study applied magnetic resonance imaging (MRI) to assess the effect of laparoscopic sleeve gastrectomy (LSG) on gastric structure and function. The impact of these changes ...on patient outcomes was analyzed.
Method
Obese patients without gastrointestinal symptoms referred for bariatric surgery were recruited prospectively. Pre-operative assessment included (i) high-resolution manometry and pH-impedance monitoring and (ii) magnetic resonance imaging (MRI) measurement of gastric capacity, accommodation, and emptying with the 400 ml liquid Nottingham test meal (NTM). Studies were repeated 6–7 months after LSG. Weight loss and changes in the Gastrointestinal Quality of Life Index (GIQLI) assessed patient outcomes.
Results
From 35 patients screened, 23 (66%) completed the study (17 females, age 36 ± 10 years, BMI 42 ± 5 kg/m2). Mean excess weight loss was 59 ± 18% at follow-up. Total gastric volume (capacity) after the meal was 467 mL (455–585 ml) before and 139 mL (121–185 ml) after LSG (normal reference 534 (419–675) mL), representing a mean 70% reduction (
p
< 0.0001). Similar findings were present for gastric content volume indicating rapid early-phase gastric emptying (GE) post-LSG. Conversely, late-phase GE was slower post-LSG (2.5 ± 1.0 vs. 1.4 ± 0.6 mL/min;
p
< 0.0001; (reference
1
.5(1.4–4.9) mL/min)). Patients with ≥ 80% reduction in gastric capacity had greater weight loss (
p
= 0.008), but worse gastrointestinal outcomes (
p
= 0.023).
Conclusions
MRI studies quantified the marked reduction in gastric capacity after LSG. The reduction in capacity was associated with rapid early- but slow late-phase GE after surgery. These changes were associated with weight loss; however, reductions in gastric capacity ≥ 80% were linked to increased acid reflux and impacted on gastrointestinal quality of life.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
In patients with persistent symptoms after Heller myotomy (HM), treatment options include repeat HM, pneumatic dilation, or peroral endoscopic myotomy (POEM). We evaluated the efficacy and safety of ...POEM in patients with achalasia with prior HM vs without prior HM.
We conducted a retrospective cohort study of 180 patients with achalasia who underwent POEM at 13 tertiary centers worldwide, from December 2009 through September 2015. Patients were divided into 2 groups: those with prior HM (HM group, exposure; n = 90) and those without prior HM (non-HM group; n = 90). Clinical response was defined by a decrease in Eckardt scores to 3 or less. Adverse events were graded according to criteria set by the American Society for Gastrointestinal Endoscopy. Technical success, clinical success, and rates of adverse events were compared between groups. Patients were followed up for a median of 8.5 months.
POEM was technically successful in 98% of patients in the HM group and in 100% of patients in the non-HM group (P = .49). A significantly lower proportion of patients in the HM group had a clinical response to POEM (81%) than in the non-HM group (94%; P = .01). There were no significant differences in rates of adverse events between the groups (8% in the HM group vs 13% in the non-HM group; P = .23). Symptomatic reflux and reflux esophagitis after POEM were comparable between groups.
POEM is safe and effective for patients with achalasia who were not treated successfully by prior HM. Although the rate of clinical success in patients with prior HM is lower than in those without prior HM, the safety profile of POEM is comparable between groups.
Background
In laparoscopic cholecystectomy (LC), achievement of the Critical View of Safety (CVS) is commonly advocated to prevent bile duct injuries (BDI). However, BDI rates remain stable, probably ...due to inconsistent application or a poor understanding of CVS as well as unreliable reporting. Objective video reporting could serve for quality auditing and help generate consistent datasets for deep learning models aimed at intraoperative assistance. In this study, we develop and test a method to report CVS using videos.
Method
LC videos performed at our institution were retrieved and the video segments starting 60 s prior to the division of cystic structures were edited. Two independent reviewers assessed CVS using an adaptation of the doublet view 6-point scale and a novel binary method in which each criterion is considered either achieved or not. Feasibility to assess CVS in the edited video clips and inter-rater agreements were evaluated.
Results
CVS was attempted in 78 out of the 100 LC videos retrieved. CVS was assessable in 100% of the 60-s video clips. After mediation, CVS was achieved in 32/78(41.03%). Kappa scores of inter-rater agreements using the doublet view versus the binary assessment were as follows: 0.54 versus 0.75 for CVS achievement, 0.45 versus 0.62 for the dissection of the hepatocystic triangle, 0.36 versus 0.77 for the exposure of the lower part of the cystic plate, and 0.48 versus 0.79 for the 2 structures connected to the gallbladder.
Conclusions
The present study is the first to formalize a reproducible method for objective video reporting of CVS in LC. Minute-long video clips provide information on CVS and binary assessment yields a higher inter-rater agreement than previously used methods. These results offer an easy-to-implement strategy for objective video reporting of CVS, which could be used for quality auditing, scientific communication, and development of deep learning models for intraoperative guidance.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
Although it has been proven that various volatile organic compounds (VOCs) are produced during surgery, there have been no studies focusing specifically on endoscopy. Therefore, we aimed ...to investigate VOCs produced during endoscopic submucosal dissection (ESD).
Methods
Thirty-one patients scheduled for ESD were enrolled in this study. Sorbent tubes were installed to collect gas at two sites: one in a suction bottle and the other at the level of the endoscopists’ upper chest. Gas collections were performed for up to 30 min during submucosal dissection. Quantitative analysis of the VOCs in gas samples was performed using gas chromatography and mass spectrometry. Concentrations of fifteen VOCs were measured. The total concentration of volatile organic compounds (TVOC) was also calculated.
Results
Among the five carcinogens—benzene, ethylbenzene, formaldehyde, tetrachloroethylene, and trichloroethylene (TCE)—measured, excess life-time risks of cancer for benzene and TCE were interpreted as unacceptable based on the New Jersey Department of Environmental Protection Division of Air Quality and the Environmental Protection Agency guidelines (5 × 10
–4
and 7 × 10
–5
, respectively). Among the non-carcinogenic VOCs, the mean concentration of toluene was much higher than the reference value (260 μg/m
3
) in the Japanese guidelines for indoor air quality (IAQ) (1323.7 ± 2884.0 μg/m
3
from the air at the upper chest level of endoscopists and 540.9 ± 1345.4 μg/m
3
from the suction bottle). Mean TVOCs were at least 10 times higher than the reference value (400 μg/m
3
) issued by the Japanese guidelines for IAQ.
Conclusions
Various carcinogenic and non-carcinogenic VOCs were detected at levels higher than the reference “safe” values during the submucosal dissection step of ESD. Implementation of counter measures is essential to protect medical personnel who are involved in ESD surgeries.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
8.
Endoscopy in surgery Rodríguez-Luna, María Rita; Perretta, Silvana
Frontiers in gastroenterology (Lausanne, Switzerland),
11/2023, Volume:
2
Journal Article
Peer reviewed
Open access
The expanding role of flexible endoscopy (FE) has helped to establish better diagnostic strategies and fewer invasive therapies within the lumen of the gastrointestinal (GI) tract. Endoscopic skills ...represent critical tools for surgeons since they markedly impact perioperative outcomes. Although it is widely recognized that endoscopy plays a key role in digestive surgery, endoscopic curricula and syllabi may vary depending on geographical regions, which have their own standardized guidelines such as the United States and countries with numerous disparities such as Western Europe. Such heterogeneous practices represent a call for action, particularly as surgical societies aim to expand cutting-edge endoscopy within surgery. This article outlines the crucial role of intraoperative endoscopy in commonly performed digestive surgeries and stresses the need to develop standardized endoscopic training curricula in surgery, particularly in Europe.
Background
As flexible endoscopy offers many advantages to patients, access to training should be aggressively encouraged. In 2014, the IRCAD-IHU-Strasbourg launched a year-long university diploma ...using advanced education methods to offer surgeons and gastroenterologists high-quality, personalized training in flexible endoscopy. This paper describes and critically reviews the first 5 years of the University Diploma in Surgical Endoscopy (UDSE).
Methods
The UDSE aims to progressively transmit theoretical knowledge, clinical judgment, and practical skills on basic and advanced flexible endoscopy. The 300-h year-long curriculum is composed of 100 h of online lectures with tests, 150 h of clinical rotations and 50 h of hands-on sessions. The hands-on training is delivered through validated mechanical simulators, virtual reality simulators, and specifically designed
ex vivo
and in vivo animal models. Participants’ demographics, training, and clinical experience were recorded. Trainees’ evaluations of each online lecture, hands-on training, and clinical rotations were assessed using a Likert scale from 1 (not satisfactory) to 5 (outstanding). Trainees’ skill progression was evaluated using the Global Assessment of Gastrointestinal Endoscopic Skills (GAGES) proficiency test. Finally, clinical uptake was surveyed.
Results
162 (79.01% males) trainees from 38 countries enrolled and successfully completed the first 5 courses. The vast majority of the trainees were surgeons and 19.14% were gastroenterologist. Sixty-nine (42.59%) participants were residents and 97 (56.79%) had no prior experience in flexible endoscopy. The online lectures, on-site sessions, and clinical rotations were highly appreciated receiving an overall average score of 4.33/5, 4.56/5, 4.43/5, respectively. Trainees’ endoscopic skills improved significantly (16.68 vs. 20.53 GAGES scores;
p
= 0.016). At an average of 18.83 months following the course, 31 alumni (77.50% of repliers) started to use a flexible endoscope in their practice.
Conclusions
Over its 5-year evolution, the UDSE has proven to be a valid means to ease access to the fundamental knowledge, practical skills, and clinical judgment necessary to achieve proficiency in surgical endoscopy.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
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