Revisional Surgery After One Anastomosis/Minigastric Bypass: an Italian Multi-institutional Survey

Background Efficacy and safety of OAGB/MGB (one anastomosis/mini gastric bypass) have been well documented both as primary and as revisional procedures. However, even after OAGB/MGB, revisional surgery is unavoidable in patients with surgical complications or insufficient weight loss. Methods A questionnaire asking for the total number and demographics of primary and revisional OAGB/MGBs performed between January 2006 and July 2020 was e-mailed to all S.I.C. OB centres of excellence (annual caseload > 100; 5-year follow-up > 50%). Each bariatric centre was asked to provide gender, age, preoperative body mass index (BMI) and obesity-related comorbidities, previous history of abdominal or bariatric surgery, indication for surgical revision of OAGB/MGB, type of revisional procedure, pre- and post-revisional BMI, peri- and post-operative complications, last follow-up (FU). Results Twenty-three bariatric centres (54.8%) responded to our survey reporting a total number of 8676 primary OAGB/MGBS and a follow-up of 62.42 ± 52.22 months. A total of 181 (2.08%) patients underwent revisional surgery: 82 (0.94%) were suffering from intractable DGER (duodeno-gastric-esophageal reflux), 42 (0.48%) were reoperated for weight regain, 16 (0.18%) had excessive weight loss and malnutrition, 12 (0.13%) had a marginal ulcer perforation, 10 (0.11%) had a gastro-gastric fistula, 20 (0.23%) had other causes of revision. Roux-en-Y gastric bypass (RYGB) was the most performed revisional procedure (109; 54%), followed by bilio-pancreatic limb elongation (19; 9.4%) and normal anatomy restoration (19; 9.4%). Conclusions Our findings demonstrate that there is acceptable revisional rate after OAGB/MGB and conversion to RYGB represents the most frequent choice. Graphical abstract

P-L05 Enterohepatic migration of ingested fishbone resulting in hepatic abscess- Case report and review of literature

Background Ingestion of foreign bodies is common, particularly in children. In adults, most foreign body ingestions are related to food bolus or bone. The majority present with pharyngeal symptoms. Most foreign bodies exit the gastrointestinal tract without complication. However, around 1% result in perforation. Patients may have a delayed presentation with nonspecific symptoms and pose a diagnostic dilemma. We report a rare case of silent migration of a fishbone into the liver and a review of the literature. Methods We present the case of a 56 year old man who presented with a liver abscess second to an ingested fishbone. We conducted a PUBMED search and reviewed the published data over a period of thirty years. We identified 52 similar cases and compared the presentation, site of perforation and location of the fish bone. We observed the different approaches in presentation and management of such patients. Results A 56-year-old man presented to his local hospital with dull epigastric pain and raised inflammatory markers. CT scan revealed a 4 cm abscess in the left lobe of the liver, with a linear radio-dense body within. The patient was given antibiotics and the abscess was aspirated. The patient was transferred to our Hepatopancreaticobiliary unit for further management. Laparoscopy was performed. The left lateral segment of the liver was adherent to the gastric antrum. The hepato-gastric fistula was disconnected. The fishbone was retrieved from the liver. The abscess was drained and wash out performed. The patient was discharged the following day. Conclusions Left lobe liver abscess should raise suspicion of foreign body. Although antibiotic treatment may be effective in the short term, there is no long-term data regarding recurrence. We believe that laparoscopic drainage of the abscess and extraction of the foreign body offer control of the source of sepsis and reduces the risk of recurrence.

Management of sleeve gastrectomy leakage: case report

Treatment of postoperative gastric fistula complicated by local and systemic infection is difficult and controversial, particularly when treating obese patients with multiple prior surgical procedures. A 41-year-old male patient was transferred to our hospital to be admitted in the Intensive Care Unit with respiratory failure and postoperative sepsis, after being submitted to bariatric surgery. He had been through four subsequent surgical procedures: 1- a laparoscopic sleeve gastrectomy; 2- an exploratory laparotomy for unproven suspected subphrenic abscess; 3- a laparotomy with splenectomy and peritoneal drainage for splenic and peri-splenic abscess; 4-celiotomy and lavage for purulent peritonitis. Due to persistent clinical and analytical deterioration, and suspicion of left subphrenic abscess and digestive fistula, we proceeded to: identification and drainage of the abscess, adhesiolysis, identification of fistula orifice at the cardiac incisure (methylene blue and perioperative endoscopy), placement of a Pezzer tube for directed and controlled fistulization, Shirley’s drain in the subphrenic space for continuous lavage, jejunostomy for enteral nutrition. Under clinical and imaging control (esophageal transit, fistulography and computed tomography with water-soluble contrasts) he was started on a water diet 2 months after and the Shirley’s drain was later removed. Patient was discharged two and a half months after the intervention, maintaing the Pezzer tube and under enteral nutrition by jejunostomy. Oral feeding started in the 3rd postoperative month and jejunostomy and Pezzer probes were removed. Patient was asymptomatic at seven-month postoperative outpatient appointment.

Multi-layer endoscopic suturing: a novel method of gastric fistula closure

Background and study aims Current endoscopic methods of treating gastric fistulas are either too complex or have high rates of recurrence. We aimed to provide a novel endoscopic method for robust fistula closure. Patients and methods This was a single-center, retrospective study of five patients who underwent multi-layer endoscopic suturing for closing of a chronic fistula (> 4 weeks). Devitalization of the fistula tract was achieved with argon plasma coagulation, followed by endoscopic suturing of the fistula. Then, endoscopic suturing of the gastric wall surrounding the fistula was performed, creating an overlay of healthy gastric mucosa around the fistula. Results Technical success (fistula closure on the day of the procedure) was achieved in all five patients, with no complications. After a median follow up of 5 months (range 2–23 months), there was a 100 % clinical success rate (no fistula recurrence). Conclusions Our single-operator method of multi-layer endoscopic suturing provides a robust fistula closure with minimal to no risk of recurrence. In light of limitations of current fistula closure methods, further investigations are warranted to better define long-term outcomes with it compared to alternative methods.

Staged surgical treatment of the patient with chronic pancreatitis

A clinical case of successful surgical treatment of a patient with chronic pancreatitis, complicated by suppuration of a postnecrotic cyst and the formation of a cysto-gastric fistula. As a result of the conservative and minimally invasive treatment, the pseudocyst was drained, and the cystogastric fistula was closed. The staged treatment was completed by resection of the head of the pancreas with the formation of an anastomosis.