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 Table of Contents  
ABSTRACT
Year : 2018  |  Volume : 3  |  Issue : 1  |  Page : 44-56

SLS Congress Annual Meeting 2018


Date of Web Publication17-Aug-2018

Correspondence Address:
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2542-4629.239220

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How to cite this article:
. SLS Congress Annual Meeting 2018. Saudi J Laparosc 2018;3:44-56

How to cite this URL:
. SLS Congress Annual Meeting 2018. Saudi J Laparosc [serial online] 2018 [cited 2018 Dec 18];3:44-56. Available from: http://www.saudijl.org/text.asp?2018/3/1/44/239220


  SLS Congress Annual Meeting 2018: Seigo Kitano President, OITA University Japan Chairman, MESDA Chairman, UCDELSA Oita City, Japan Top



  JSES endoscopic surgical skill qualification system in Japan Top


Seigo Kitano

President, OITA University, Japan, Chairman, MESDA, Chairman, UCDELSA, Oita City, Japan

Just after laparoscopic gallbladder resection was first carried out in Japan, the skills and technical feasibility have been evaluated since its introduction in 1990. The requirements from the patients facilitated wider application of less invasive surgery to other types of surgery. Apparently, laparoscopic surgery developed in safe manner with training and education provided by JSES. Various new types of endo-surgical procedures have developed at active medical centers.

I would like to talk on an important role of skill qualification system for young surgeons to obtain good surgical skills in this field. JSES established Endoscopic Surgical Skill Qualification System in 2004. The purpose is to accredit the technique level with which one can conduct a safe and sufficient operation as well as an adequate teaching for the trainees.

In this symposium, I would like to summarize the current status of minimally invasive surgery for gastric cancer based on endoscopic surgical skill qualification system in Japan.


  Laparoscopic revisional sleeve gastrectomy and cholecystectomy in a super obese patient with failed gastric banding and cholelithiasis Top


Masayuki Ohta, Yuichi Endo, Kazuhiro Tada, Kunihiro Saga, Teijiro Hirashita, Hiroki Uchida, Yukio Iwashita, Masafumi Inomata, Seigo Kitano1

Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, Oita City, Japan

Introduction: Laparoscopic adjustable gastric banding (LAGB) had been the popular bariatric surgery in 2000's, and recently, the revisional procedures have been increased. We will show the techniques of laparoscopic revisional sleeve gastrectomy (SG) and cholecystectomy in a super obese patient with gallbladder (GB) stones.

Case: 30 years-old, male, 177 kg, BMI 72. He received LAGB 11 years ago. His weight fell down to 122kg 2 years after LAGB. However, afterward, he regained the weight due to no visit to our hospital and.had GB stones. Because laparoscopic SG has been only covered by Japanese health insurance, we planned to perform revisional SG (single-stage) with cholecystectomy after diet weight reduction until 160 kg (BMI 66).

Operative Techniques: After confirming no adhesion in the site of the first trocar by abdominal ultrasonography, the optical trocar was visually inserted into the peritoneal cavity. The other trocars were placed after pneumoperitoneum, and most of the trocars were shared for SG and cholecystectomy. After cholecystectomy, the band removal was not easy due to severe adhesion to the liver but finally completed. Single-stage SG was performed, and GB and resected stomach were removed from the trocar site.

Conclusion: Combination method of SG and cholecystectomy may be feasible even in super obese patients with failed gastric banding and cholelithiasis.


  Effects of sleeve gastrectomy on glucose and lipid metabolism in obese rat models Top


Masayuki Ohta, Yuichi Endo, Kiminori Watanabe, Kazuhiro Tada, Kunihiro Saga, Teijiro Hirashita, Hiroki Uchida, Yukio Iwashita, Masafumi Inomata, Seigo Kitano1

Department of Gastroenterological and Pediatric Surgery, Oita University, Faculty of Medicine, Oita City, Japan

Background/Aim: Laparoscopic sleeve gastrectomy (SG) is a typical restrictive bariatric procedure, but has additional metabolic effects compared to gastric banding (GB). The aims of study were to determine metabolic effects of SG comparing rat GB or diet models.

Methods: This study used Zucker rats. The SG model was compared with sham-operated (SO) control and GB or pair-fed (PF) control. Body weight change, cumulative food intake, serum metabolic parameters and hormones, serum bile acid level, OGTT, ITT, gastric emptying rate, small bowel transit, oral fat loading test, triglyceride (TG) contents of the liver, mRNA expression of FXR, SHR, and PPAR in the liver were examined

Results: The SG, GB, and PF groups showed significant decreases in weight, cumulative intake, and metabolic parameters compared with the SO control. The SG group had significantly higher gastric emptying rate, shorter small bowel transit time and lower TG level after oral fat loading than the other groups. The SG group also showed partial improvement of OGTT and ITT and higher levels of GLP-1 and bile acid compared with GB or PF group. In addition, the SG group had lower TG contents of the liver and higher expression of FXR, SHR and PAPR.

Conclusion: SG has additional effects on glucose and lipid metabolism.


  Predictive scoring systems of type 2 diabetes after sleeve gastrectomy: Comparison between ABCD and DiaRem scores Top


Masayuki Ohta, Yuichi Endo, Kazuhiro Tada, Kunihiro Saga, Teijiro Hirashita, Yukio Iwashita, Hiroki Uchida, Masafumi Inomata, Seigo Kitano1

Department of Gastroenterological and Pediatric Surgery, Oita University, Faculty of Medicine, Oita City, Japan

Background/Aim: The ABCD scoring system which Lee et al. have developed to predict remission of type 2 diabetes (T2DM) after gastric bypass and sleeve gastrectomy (SG) consists of age, BMI, c-peptide and duration of T2DM. DiaRem scoring system consists of age, HbA1c, insulin use and other diabetes medications. However, there have been no reports of comparison between the scoring systems after SG. The aim of this study was to investigate which is better to predict T2DM remission after SG among them.

Methods: This study enrolled 44 Japanese obese patients with T2DM who underwent SG and were followed for more than 1 year. Preoperative HbA1c was 7.9%, and 36 of the patients received T2DM treatment including oral medicine and insulin. ABCD score was calculated by Obes Surg 2013; 23:1020, and DiaRem score by Lancet Diabetes Endocrinol 2014; 2:38. Complete remission (CR) of T2DM was defined by <6.0% HbA1c without medication, and partial remission (PR) by <6.5% HbA1c without medication. Statistical analyses were performed using Receiver operating characteristic (ROC) curve, DeLong's test, and Fisher's exact test.

Results: We did not experience open conversion and serious complication. Weight loss and percent excess weight loss after 1 year were 36kg and 72%, respectively. HbA1c after 1 year was 5.7%, CR was achieved in 37 of the 44 patients (84%), and CR+PR in 41 (93%). The both scores were well correlated with T2DM remissions. Area under the curves from ROC curves were compared between the scores, but there were no significant differences in CR and CR+PR.

Conclusion: The both scoring systems may be useful tools for prediction of T2DM remissions after SG.


  Clinical significance of upper gastrointestinal endoscopy before laparoscopic bariatric procedures Top


Masayuki Ohta, Yuichi Endo, Kazuhiro Tada, Kunihiro Saga, Teijiro Hirashita, Yukio Iwashita, Hiroki Uchida, Masafumi Inomata, Seigo Kitano1

Department of Gastroenterological and Pediatric Surgery, Oita University, Faculty of Medicine, Oita City, Japan

Background/Aim: The routine endoscopy before bariatric surgery has remained controversial until now. We have routinely performed upper gastrointestinal endoscopy (UGE) before laparoscopic bariatric procedures, and here analyzed the clinical significance.

Methods: From August 2005 to September 2017, we have performed laparoscopic primary bariatric procedures in 155 consecutive Japanese patients. They were 93 females and 62 males with an average of 40 years old, and preoperative weight and BMI were 120kg and 45, respectively. We analyzed endoscopic findings, including gastroesophageal reflux disease (GERD), hiatal hernia (HH), Barrett's esophagus, gastritis, duodenitis, gastroduodenal ulcer, gastric cancer, and polyp.

Results: In 102 patients (66%), The preoperative UGE revealed abnormal findings, which included gastritis in 57 (37%), HH in 51 (32%), GERD in 27 patients (17%), benign gastric polyp in 16 patients (10%), duodenitis in 6 patients (4%), and Barrett's epithelium in 1 patients (0.6%) respectively. Two patients with definite HH were treated by concurrent crural repair at the time of the operation. Three of the 6 patients with duodenitis had a severe grade and were treated with a proton pump inhibitor before the operation. Eleven patients received eradication therapy for H. pylori before or after the operation. As a result, the preoperative UGE changed the perioperative management in 16 of the 155 patients (10%).

Conclusion: A routine UGE may be necessary before bariatric procedures in obese Japanese patients.


  Laparoscopic revisional procedure for failed gastric banding Top


Masayuki Ohta, Yuichi Endo, Kazuhiro Tada, Kunihiro Saga, Teijiro Hirashita, Hiroki Uchida, Yukio Iwashita, Masafumi Inomata, Seigo Kitano1

Department of Gastroenterological and Pediatric Surgery, Oita University, Faculty of Medicine, Oita City, Japan

Introduction: Laparoscopic adjustable gastric banding (LAGB) had been the popular bariatric surgery in 2000's, and recently, the revisional procedures have been increased. We will show the techniques of laparoscopic revisional sleeve gastrectomy (SG) and concomitant cholecystectomy in a super obese patient.

Case: Thirty-years-old, male, 177kg, BMI 72. He received LAGB 11 years ago. His weight fell down to 122kg 2 years after LAGB. However, afterward, he regained the weight due to no visit to our hospital and.also suffered from cholelithiasis. Because laparoscopic SG has been only covered by Japanese health insurance, we planned to perform revisional SG (single-stage) with concomitant cholecystectomy after diet weight reduction until 160kg (BMI 66).

Operative Techniques: Before the operation, we checked no adhesion in the first trocar site using abdominal ultrasonography. The optical trocar was visually inserted into the peritoneal cavity. The other trocars were placed after pneumoperitoneum, and most of the trocars were shared for SG and concomitant cholecystectomy. After cholecystectomy, the band removal was not easy due to severe adhesion to the liver but finally completed. Single-stage SG was performed, and GB and resected stomach were removed from the trocar site.

Conclusion: SG and concomitant cholecystectomy may be feasible even in super obese patients with failed gastric banding and cholelithiasis.


  “Pancreas-compressionless gastrectomy”: A novel laparoscopic approach for suprapancreatic lymph node dissection Top


Naoki Hiki

Department of Gastric Surgery, Gastroenterology Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan

Background: In radical operations for gastric cancer, a balance between the quality of lymph node dissection and safety of surgery must be ensured. During suprapancreatic lymphadenectomy in laparoscopic gastrectomy (LG), an adequate operative field should be safely and effectively established to reduce pancreas-related complications. We present a novel approach that avoids direct compression of the pancreas in LG and describe the surgical outcomes of this method.

Methods: We historically compressed the pancreas during suprapancreatic lymph node dissection in LG to obtain an adequate operative field but have since modified our operative technique. In our new method introduced in March 2016, the operative field is established by pulling and controlling the connective tissues along the inferior border of the pancreas and the nerves along the common hepatic and splenic arteries, instead of directly compressing the pancreas itself. We compared 51 patients in the compression group (January 2015–February 2016) and 45 patients in the compressionless group (March 2016–January 2017) in terms of surgical outcomes, including the amylase concentration in the drainage fluid and postoperative complications.

Results: The amylase concentrations in the compressionless group were significantly lower on postoperative days 1 and 3 (p\0.001 and p = 0.013, respectively) compared with the compression group. The rates of severe postoperative pancreatic fistula and intra-abdominal infectious complications decreased from 11.8 to 2.2% (p = 0.116) and from 17.6 and 2.2% (p = 0.018), respectively.

Conclusions: Our approach, termed ''pancreas-compression less gastrectomy,'' can be considered a safe and useful method to prevent postoperative infectious complications in LG.


  Role of prealbumin as a powerful and simple index for predicting postoperative complications after gastric cancer surgery Top


Naoki Hiki

Department of Gastric Surgery, Gastroenterology Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan

Background: Preoperative factors, including nutritional status, may have strong correlations with postoperative morbidities. The current study evaluated preoperative prealbumin concentrations as a predictor of postoperative complications after gastric surgery.

Methods: A retrospective study of 1798 patients who underwent gastrectomy for gastric adenocarcinoma was performed. Information was collected on basic patient characteristics, preoperative laboratory findings, and 30 day postoperative complications. The patients were divided into three groups based on prealbumin concentrations for analysis.

Results: The overall complication rate was 21.7 %, and the infection rate was 16 %. Subgroup analysis based on prealbumin concentrations showed that complication rates were markedly elevated with decreasing concentrations of prealbumin. Multivariate analysis using a logistic regression model showed that both overall and infectious complications were strongly associated with male gender, elevated C-reactive protein (CRP), and decreased prealbumin levels (p<0.05). Even in patients with a CRP level higher than 0.1 mg/dL, male gender and low prealbumin concentrations (<15 mg/dL) were significantly correlated with overall and infectious morbidities (p<0.05).

Conclusions: Preoperative prealbumin concentrations are useful predictors of short-term postoperative outcomes after gastrectomy.


  Outcomes of 552 laparoscopic fundoplication for gastroesophageal reflux disease in Japanese patients Top


Fumiaki Yano

Department of Surgery, Jikei University School of Medicine, Tokyo, Japan

Introduction: We introduced the first case of laparoscopic fundoplication (LF) for gastroesophageal reflux disease (GERD) in December 1994 and experienced 552 operations by December 2017. In this study, outcomes of LF for GERD in 552 patients at a single institution in Japan were evaluated.

Methods: Their mean age was 54.5±16.7 (15-87) years, 325 of them (59%) were men. Their clinical data were collected in a prospectively fashion and retrospectively reviewed. Their characteristics, preoperative clinical conditions, and the therapeutic outcomes of LF were assessed in terms of operative procedure, peri- and post-operative complications, and recurrence rate after surgery. Recurrence was defined as post-operative recurrence of erosive esophagitis and/or evident hiatal hernia.

Results: No operative mortality occurred. The mean follow-up period was 45.7±50.8 (range 2-260) months. Nissen procedure was performed for 98 patients (18%), Toupet procedure for 434 patients (79%), Collis-Nissen procedure for 13 patients (2%) and the others 7 patients (1%) underwent other surgeres. A total of 41 peri-operative complications were observed in 41 patients (7.4%), consisting of bleeding mainly from the spleen (0.9%), and injuries of the vagus nurve (3.2%), crus of the diaphragm (1.1%), stomach (0.9%), mediastinal pleura (0.5%), esophagus (0.4%), aorta (0.2%), or small intestine (0.2%), and one (aorta case) required conversion to open surgery. Post-operatively, 33 patients (6%) complained of moderate to severe post-operative dysphagia and 2 patient (0.4%) required re-do surgery (Nissen to Toupet). Recurrence was diagnosed in 69 patients (12.5%), and 13 of them (2.3%) required re-do surgery. The other 56 patients (10.2%) were treatable with acid suppressive medications. The mean time to recurrence was 67.0±54.0 (range 0-158) months. As patterns of recurrences, 55 patients had sliding hiatal hernia with or without erosive esophagitis, 5 patients had paraesophageal hiatal hernia, 4 patients each had a disrupted fundoplication, only erosive esophagitis, and 1 patient had mixed hiatal hernia.

Conclusion: Non-recurrence rate of LF were 87.5%. LF is a safe and secure procedure for treatment of GERD.

Surgical strategy of GERD, surgical outcomes


  Changes in surgical procedures and short-term outcomes for achalasia since the introduction of per-oral endoscopic myotomy (do patients need anti-reflux procedure?) Top


Fumiaki Yano

Department of Surgery, Jikei University School of Medicine, Tokyo, Japan

Background: In our institution, laparoscopic Heller-Dor procedure (LHD) has been the first-line surgical procedure for achalasia since the introduction in August 1994 and 576 patients underwent LHD until December 2017. In January 2016, per-oral endoscopic myotomy (POEM) was started, taking into patients' needs into consideration. Since then, treatment options have expanded to include balloon dilation, conventional LHD, LHD by reduced port surgery (RPS), LHD by needlescopic surgery (NS), and POEM. Here, we report changes we have observed in surgical procedures and short-term outcomes since the introduction of POEM.

Methods: The subjects were 77 patients (mean age 47.9±14.5 years, 40 men) who underwent surgery for achalasia from January 2016 to December 2017. After explaining the advantages and disadvantages, the choice of surgical procedure was left up to the patient.

Results: The breakdown of the surgical procedures was LHD (including 1 RPS and 31 NS):POEM=55:22. A total of 6 peri-operative complications were observed in 6 patients (8%), consisting of gastroesophageal mucosal injury (6%, LHD) and injuring of esophageal longitudinal muscles (2%, POEM), while dysphagia improved in all patients. Postoperative reflux esophagitis was observed in 9 patients with POEM (41%), which was significantly higher than 6 patients (11%) in LHD (p=0.0173).

Conclusion: While almost 30% of patients underwent POEM, reflux esophagitis occurred at a higher rate in POEM as compared to LHD. Over 70% of patients needed anti-reflux procedure to prevent from post-operative reflux esophagitis.

Topics: LHD vs. POEM, Patients' needs, anti-reflux procedure


  What makes an excellent bariatric surgeon? Top


Kazunori Kasama

Weight Loss and Metabolic Surgery Center, Yotsuya Medical Cube, Tokyo, Japan

The author have tried to find the factors to be an excellent bariatric surgeon for long time. He interviewed some world well known excellent bariatric surgeons about their philosophy for bariatric and metabolic surgery and would like to present them to young surgeons who eager to be excellent.


  Bariatric and metabolic surgery in Asia Top


Kazunori Kasama

Weight Loss and Metabolic Surgery Center, Yotsuya Medical Cube, Tokyo, Japan

Bariatric surgery is now well developed in western countries, even its starting was not too late in Asia, and the development has been slow. One of the reasons is the ratio of obesity is not high in comparison with western countries. However, recent progress of bariatric and metabolic surgery in Asia is outstanding because the number and ratio of diabetes are high in Asia. For Asian population, diabetes is bigger burden than obesity. Metabolic surgery is defined as surgery intentionally treats metabolic disorders such as diabetes, hypertensions, dyslipidemia and so on. The purpose of metabolic surgery is deferent from that of bariatric surgery. As the purpose is different, of course, selection criteria should be different.

Gastric bypass is known to be superior to sleeve gastrectomy in terms of remission of diabetes, even sleeve gastrectomy is the most frequently performed procedures worldwide. However, in some Asian countries, gastric cancer is still one of the biggest issue to be concerned after gastric bypass.

Recently, so called “Sleeve plus” procedures, including Sleeve DJB, Sleeve PJB and SAID are being performed in Asia in order to achieve better glycemic control and to avoid the risk of remnant gastric cancer.

In Asia, bariatric surgery move toward metabolic surgery and Sleeve gastrectomy and “Sleeve plus” procedure will be performed frequently.


  Bariatric surgery for Asian patients with body mass index less than 35 Top


Kazunori Kasama, Yosuke Seki

Weight Loss and Metabolic Surgery Center, Yotsuya Medical Cube, Tokyo, Japan

Introduction: Demands for metabolic surgery as a treatment modality for mild obese DM patients in Asia is increasing. Laparoscopic sleeve gastrectomy with duodenojejunal bypass (LSG-DJB) is a combination of sleeve gastrectomy and proximal intestinal bypass through duodenal exclusion. This technique has shown excellent weight loss and anti-diabetic effects in severely obese patients. In this retrospective study, we examined the clinical effects of LSG-DJB on mildly obese patients (BMI <35 kg/m 2) with type 2 diabetes mellitus (T2DM)

Methods: Seventy-two consecutive Japanese patients with T2DM with a body mass index (BMI) <35 kg/m 2, underwent LSG-DJB in a single institution from September 2007 to March 2015 were included for the study. Weight loss, safety and the impact on T2DM and metabolic syndrome were examined at 1 year after surgery when weight loss reaches an expected plateau. In addition, pre and post- operative factors between those who achieved diabetes remission (remitters) and non-remitters were compared.

Results: The follow up rate at 1 year after surgery was 93%. The mean percent total weight loss (%TWL) was 31.6 ± 8.8 % and the mean glycosylated hemoglobin (HbA1c) dropped from 8.9 ± 1.5 % to 6.4 ± 1.0 %. There were 4 early and 7 late severe complications (Grade III-A or more based on the Clavien-Dindo classification), which account for the 1-year morbidity rate of 15%. There was no mortality. The complete (HbA1c <6% without diabetes medication) and partial (HbA1c <6.5% without diabetes medication) remission of T2DM was achieved in 31% and 49% of the patients, respectively. Positive impacts were also observed on hypertension and dyslipidemia. Consequently, the ratio of those who achieved the composite endpoint (HbA1c <7%, low-density lipoprotein cholesterol <100 mg/dL, systolic blood pressure <130 mmHg) significantly increased from 4.2% to 22% (p=0.003).

Conclusions: LSG-DJB for T2DM patients with a BMI <35 kg/m2 is a feasible and effective surgical method in achieving moderate weight loss and excellent improvement of glycemic control, metabolic syndrome and cardiovascular risk although the T2DM remission rate was lower compared to severely obese individuals. Proper patient selection for candidates of the procedure is imperative to effectively predict poor responders.


  Surgical techniques for laparoscopic Roux en Y gastric bypass for morbid obesity with hand- sewn gastorojejunal anastomosis Top


Susumu Inamine MD

Department of Surgery, Okinawa Red Cross Hospital, Naha, Okinawa, Japan

Under general anesthesia, the patient was laid down in a supine position with legs open. A skin incision was made on the middle clavicular line, just below the left costal arch. Then 12 mm in diameter trocar was inserted with optical method. After pneumoperitoneum at a pressure of 15 mmHg, a laparoscopic telescope with 30 degree was inserted into the peritoneal cavity. Observing the peritoneal cavity, the ports were inserted at the most appropriate position. We use 5 ports usually. We always use Nathanson's liver retractor for retraction of the left lobe of the liver. We performed a peritoneal incision around the Angle of His using an ultrasonic device, and dissected the tissues sufficiently wide until the left crus of the diaphragm was exposed. Using an ultrasonic device, we incise the gastrocolic ligament, then entered the lesser sac, and observed the posterior wall of the stomach. If there were adhesions, we tried to do adhesiolysis. If possible, we did tunneling from the dorsal side of the stomach to anterior through the Angle of His. After flipping up the omentum and transverse colon to the cephalad, we confirm that there is no adhesion in the small intestine to be used for bypass. We transected jejunum 50 cm distal from ligamentum of Treitz with Endo-GIA 45 mm Camel. Jejuno-jejunal anastomosis was performed using EndoGIA45mm Camel after measuring as Roux limb in 150 cm. The entry hole of the stapler was closed by full thickness running sutures using 3-0 absorbable threads. Closure of the defect of mesentery was done by continuous sutures with 2-0 non- absorbable sutures.

Using an ultrasonic device, we created a hole for passing through the Roux limb on the left side of the transverse mesocolon. The next step was to create a gastric pouch. Using an ultrasonic device, a small tunnel was created about 2 cm wide along the stomach wall in the middle of small curvature, and then the tunnel leading to the posterior wall of the stomach was created. Transection of stomach about 4cm was done in the small curvature side stomach using an Endo- GIA 45 mm purple. Then, along the 36 Fr bogie placed in the gastric lumen, gastrotomy was performed toward the Angle of His using Endo-GIA 60mm purple to complete the gastric pouch. Gastrojejunostomy was performed by two-layer continuous suturing. First of all, seromuscular layer continuous suturing was performed with 3-0 absorbable thread in the gastric pouch and jejunum. Next, an ultrasonic device was used to create a hole of about 2 cm at the distal end of the gastric puch and another hole of the same size was mede in the jejunumon the contralateral side. We perform full-thickness continuous suturing of the stomach and jejunum using separate 3-0 absorbsble sutures on the posterior wall and anterior one. After passing 36Fr bougie through the anastomotic stoma, the two threads were tied. Finally, the anastomosis was completed by performing a sero-muscular layer continuous suturing of the anterior walls. The defect of transverse mesocolon and the so-called Petersen's space were sutured with 2-0 non-absorbable sutured. All working ports were removed under laparoscopic observation. We have never done any fascial suture at port site. We believe it is not necessary.


  Laparoscopic hand-sewn single-anastomosis duodenojejunal bypass with sleeve gastrectomy: Initial results of the novel procedure Top


Susumu Inamine MD

Department of Surgery, Okinawa Red Cross Hospital, Naha, Okinawa, Japan

Purpose: Laparoscopic duodenojeunal bypass with sleeve gastrectomy (DJB-SG) was introduced by Kasama et al. as a novel type of bariatric and metabolic surgery for morbid obesity with type 2 diabetes. Recently, a simpler procedure, “laparoscopic single anastomosis duodenal-jejunal bypass with sleeve gastrectomy (SADJB- SG)” was introduced by Lee et al. We performed this new procedure as a type of metabolic surgery. The surgical procedure and early outcomes of SADJB-SG are described herein.

Patients and Methods: We performed SADJB-SG in three morbidly obese patients with type 2 diabetes (male/female 2:1; age 48±3.3 years; BMI 44.6±3.5 kg/m 2). The operating time, blood loss, peri-operative complications, and anti- diabetic effects were evaluated.

Surgical Techniques: Under general anesthesia, the procedure was done in the lithotomy position with a six-port laparoscopic technique. The whole greater omentum was dissected along the stomach wall with an ultrasonic coagulating device and/or a vessel sealer system. A vertical gastric sleeve with 36-Fr boogie was created with linear staplers from 5 cm proximal to the pylorus to the angle of His. The staple line was routinely reinforced by continuous invaginating suturing with absorbable sutures. The dissection was then prolonged to the first portion of the duodenum above the gastroduodenal artery. The duodenum was divided 2 cm distal to the pylorus by linear stapler with preservation of the right gastric artery and supra- duodenal vessels. The ligamentum of Treitz was identified and measured downwards. End-to-side duodenojejunal anastomosis was then performed with a 200-cm biliopancreatic limb in an ante-colic fashion. The anastomosis was carried out by two-layer hand sewing with continuous sutures under laparoscopy. An air leak test was done, and a closed suction drain was left.

Results: In all these patients, the procedure was successfully performed. The operating time was 207.3±10.3 min. The blood loss was 86.7±98.7 ml. The duration of hospital stay after surgery was 7±2 days. There were no perioperative complications. In all of these patients, anti-diabetes drugs, including insulin, were no longer needed by two months after surgery. One case required revision surgery (re-sleeve and converted RY) due to insufficient weight loss and bile reflux symptoms 1 year after primary surgery.

Conclusions: Our initial results show that SADJB-SG is feasible, safe, and effective as bariatric and metabolic surgery.


  “Back to the suture”: How can we make it as easy as possible to perform needle driving and knot-tying during laparoscopic bariatric surgery? Top


Susumu Inamine MD,

Okinawa Red Cross Hospital, Naha, Okinawa, Japan

Aims: Laparoscopic gastrointestinal surgery often requires the reconstruction of the GI tract. In laparoscopic surgery, it is believed that hand-sewn suturing using a needle and thread is difficult to carry out as a result of limitations in the access angle to the suture targets due to the use of fixed surgical ports. Using staplers is one solution, but when encountering difficult situations, hand-sewn suturing with a needle and thread is often safer than using staplers. We have so far performed hundreds of laparoscopic hand-sewn anastomoses such as esophagojejunostomy, gastroduodenostomy, esophagogastrostomy, gastrogastrostomy, duodenojejunostomy for gastric malignancies and bariatric and metabolic surgeries without the occurrence of any anastomotic leakage.

Methods: There are various techniques for performing laparoscopic hand-sewn sutures, but we will herein share two of these important techniques to facilitate the performance of laparoscopic gastrointestinal anasotomosis based on our own experience. Results. “The touch and go technique “; in laparoscopic surgery, there are two important angles between the suturing target and the surgical port in three dimensions. Namely, the “Azimuths angle”, which is the angle in the horizontal direction and the “Depression angle”, which is the angle in the vertical direction. Generally, the smaller these angles are the easier it is to drive and manipulate needles. In order to carry out needle driving in the proper direction, it is necessary to cancel these important angles in laparoscopic surgery. One solution is to hold the needle with a needle holder at an appropriate angle. Then we can sew the suture lines on the gut at almost all angles in an appropriate direction quickly with one action maneuver named “Touch and go needle drive”. “The intentional slip knot technique”; basically, this is a square knot using “over wrap “and “under wrap” techniques. First of all, we intentionally create a loose square knot and then convert it to a slip knot quickly without releasing the thread, and finally we can bring the gut wall together with the most appropriate strength without any loosening.

Conclusions: Using the “Touch and go technique” and the “Intentional slip knot technique” laparoscopic gastrointestinal anastomosis / sutures can be easily, quickly, and accurately performed.


  Who would have thought it? laparoscopic hand-sewn esophagojejunal anastomosis provides to be the easiest, safest and cheapest way of reconstruction after total gastrectomy Top


Susumu Inamine MD,

Okinawa Red Cross Hospital, Naha, Okinawa, Japan

Background: Esophageal jejunostomy is an essential procedure not only for reconstruction after gastric cancer surgery but also for revision surgery for obesity surgery. But making an esopagojejunal anastomosis under laparoscopy is very challenging. Several techniques using circular stapler or a linear staplers for the anastomosis have been reported. But the methods using staplers are not easy enough to perform safely. Therefore, we developed a hand-sewn esophagojenunal anastomosis (HSEJA) technique under laparoscopically without the need for a mini laparotomy. To date, we have performed 43 laparoscopic HESDJA procedures. The aim of this study was to confirm the technical feasibility and short and long-term safety of the technique.

Materials and Methods: From June 2010 to Dec 2017, 43 consecutive patients were underwent laparoscopic total gastrectomies by single surgeon.

Surgical Technique: The abdominal esophagus was mobilized and transected with an endolinear stapler. Then the cut end of the abdominal esophagus was opened with laparoscopic coagulating shears (LCS), and a 2.5 cm hole was made at antemesenteric side of the jejunum for anastomosis using the LCS. Finally, an end-to-side esophagojejunal anastomosis was made with hand-sewn single layer interrupted sutures using 3-0 absorbable sutures.

Results: The totally laparoscopic Roux en Y reconstructions with HSEJA were performed successfully in all of the patients. The median suturing time for the HSEJA was 37 minutes (range, 26-85 min), and the median number of stitches was 17 (range, 13-24). No anastomotic leakge occurred. All patients were discharged uneventfully. Endoscopic studies revealed four cases (9.3%) of anastomotic stenosis.

Conclusions: Laparoscopic HSEJA after total gastrectomy is feasible, safe and inexpensive.


  Laparoscopic surgery for advanced gastric cancer Top


Takahiro Kinoshita

Division of Gastric Surgery, National Cancer Center Hospital East, Kashiwa, Japan

Laparoscopic radical gastrectomy has penetrated worldwide, but its applicability to advanced cancer disease (stage II/III) is still controversial. Several large-scale randomized studies have shown surgical safety in short-term outcomes analyses, however final conclusion regarding oncological validity is still pending. In advanced cancer, some oncological concerns can be raised, such as cancer cell spillage owing to inappropriate intraoperative manipulation with long surgical instruments without enough tactile feedback. In this video presentation, laparoscopic management of node-metastatic case, or voluminous tumor cases will be demonstrated. The most important matter is to follow oncological principle of surgery. Tumor or metastatic nodes should not be traumatically grasped by the forceps. In cooperation with assistant surgeons, clear operative fields should be exposed. With the maximum use of gauze or pre-tied loop suture, operative fields can be exposed without touching the tumor directly. Resection margin is recommended to be maintained in 3 cm in localized type and 5 cm in diffuse type according to the latest guidelines. Due to loss of tactile feedback, in laparoscopic surgery intraoperative peroral endoscopy and frozen section pathological diagnosis should be prepared. Omentectomy is basically done in T3/T4 tumors, but bursectomy is not performed any more according to the results of JCOG 1001 trial. Splenectomy is also not necessary unless the tumor invades the greater curvature according to the results of JCOG 0110 trial.


  Robotic surgery for gastric cancer Top


Takahiro Kinoshita

Division of Gastric Surgery, National Cancer Center Hospital East, Kashiwa, Japan

Background: Laparoscopic surgery for gastric cancer has been well recognized universally as an effective surgical intervention, however its technical difficulty is hampering its wider penetration. This technical difficulty seems to be derived from limitation of the straight instrument's movement. Additionally, inappropriate compression by the straight instruments to the pancreas are likely to be a cause of postoperative pancreatic fistula as pointed out by several articles. Robotic surgery is one of the most promising solution to compensate the shortcoming of conventional laparoscopic surgery.

Methods: We have introduced robotic gastrectomy in 2014. Clinical records of these patients undergoing robotic gastrectomy for stomach cancer were reviewed.

Results: In total 61 patients (Male/Female=33/28) received robotic gastrectomy. Median age was 64 y.o. (42-83) with median BMI of 22.4%, and operative procedure included 47 distal, 8 total, and 6 proximal gastrectomy. Median operation time was 326 minutes (247-462), and blood loss was 15 g (3-176). Postoperative complication with grade 3 or more occurred in 2 patients (3.2%).

Conclusion: Robotic surgery for stomach cancer can be safely performed in selected patients with low postoperative morbidity rate. However, still prolonged operation time and expensive cost compared with conventional laparoscopic surgery seem problematic which should be solved.


  Laparoscopic surgery for esophago-gastric junction cancer Top


Takahiro Kinoshita

Division of Gastric Surgery, National Cancer Center Hospital East, Kashiwa, Japan

Background: Esophago-gastric junction cancer (EGJ cancer) is defined as tumors whose epicenter is located within 2 cm from EGJ and invading the esophagus in the latest UICC TNM 8th classification. Optimal surgical procedures for EGJ cancer is still debatable universally, and there are the difference between the East and the West. In Japan, if the esophageal invasion is 3 cm or less, transhiatal approach is basically chosen according to the results of JCOG 9502 trial. On the other hand, in western countries, thoraco-abdominal approach seems to be major. In our hospital, we have introduced laparoscopic transhiatal approach to EGJ cancer with 3cm or less esophageal invasion since 2011.

Methods: Clinical records of patients with EGJ cancer who underwent laparoscopic transhiatal approach between 2011 and 2016 were reviewed.

Results: In total, 45 patients (Male/Female=33/12) were enrolled. Median age was 68 y.o. (37-80). Median tumor size was 20 mm (10-70), and 38 patients received proximal gastrectomy and 7 received total gastrectomy. Median operation time was 256 minutes (200-370), and blood loss was 11 g (7-69). Additional resection of the esophagus was required in 2 patients (4.4%). Postoperative morbidity was recorded in 6 patients (13%), including 2 anastomotic leakage (4.4%), 1 abdominal abscess (2.2%) and 2 pancreatic leakage (4.4%). There was no mortality.

Conclusion: Laparoscopic transhiatal resection for EGJ cancer is technically challenging, but appears feasible and safe in technical or short-term oncological aspects when performed by an experienced surgical team. A largescale prospective study is needed to evaluate long-term outcomes.


  Minimally invasive esophagectomy for esophageal cancer Top


Hiroya Takeuchi

Department of Surgery, Hamamatsu University School of Medicine, Shizuoka, Japan

Background: In this study, we focused on the comparison of minimally invasive esophagectomy (MIE) such as thoracoscopic esophagectomy and open esophagectomy (OE) objectively by propensity score matching using a Japanese nationwide database.

Methods: The National Clinical Database (NCD) which commenced in 2011, is a nationwide project that is linked to the surgical board certification system in Japan. Propensity score matching was performed to compare the MIE with the OE by use of the 2011-2012 NCD database.

Results: Esophagectomy for 9584 patients with thoracic esophageal cancer were categorized into MIE (n = 3589) with OE (n = 5995) in the NCD 2011-2012 database. Preoperative background factors of the patients compared were quite different between the two groups. In general, OE was preferred to be chosen for patients with worse overall health condition. Propensity score matching created a matched cohort of 3515 pairs of patients. The operative time was significantly longer in the MIE group than in the OE group, whereas blood loss was markedly lesser in the MIE group than in the OE group. There was no significant differences in overall morbidity between the two groups. The incidence of the patients who needed prolonged respiratory ventilation more than 48 hours after surgery was significantly less in the MIE group than the OE group (P = 0.006). However, the incidence of postoperative recurrence laryngeal nerve palsy was significantly more in the MIE group than in the OE group (10.3% vs. 8.1%, P = 0.002). Moreover, the incidence of gastric conduit necrosis also tended to be higher in the MIE group compared with the OE group (0.8% vs. 0.4%, P = 0.087). The reoperation rate within 30 days was significantly higher in the MIE group than in the OE group (7.0% vs 5.3%, P = 0.004). There were no significant differences in 30-day or operative mortality rates between the MIE and OE groups.

Conclusions: Our results suggest that MIE is comparable with conventional OE in terms of short-term outcome after surgery. Based on this observational study, we started a randomized controlled trial, JCOG1409, which compare the short- and long-term outcomes between the two procedures in Japan.


  Minimally invasive surgery for esophagogastric junction cancer Top


Hiroya Takeuchi

Department of Surgery, Hamamatsu University School of Medicine, Shizuoka, Japan

The location of the tumor epicenter, T factor and tumor esophageal invasion should be considered when we decide surgical strategy for esophagogastric junction (EGJ) carcinoma. In general, patients except a selected group (≥ T2 and tumor epicenter located above the EGJ or below the EGJ with ≥ 3 cm esophageal invasion) should be performed transhiatal approach to retrieve lower mediastinal lymph node (LN) dissection for EGJ cancer.

When radical resection via a laparoscopic transhiatal approach is planned, abdominal LN dissection is performed first and transhiatal lower LN dissection follows laparoscopically. We start by detaching the esophagus up to the head, to mobilize its lower part, and pull the esophagus as far down as possible into the abdominal cavity. On the anterior side of the esophagus, we exfoliate the tissue along the rear of the pericardium (#111 supradiaphragmatic LNs). The cranial extent of the excision is the lower pulmonary vein and the lateral margins are the pleural surfaces. At the back of the esophagus, LN dissection proceeds along the anterior surface of the aorta (#112ao thoracic para-aortic LNs). When lower mediastinal LN dissection is required, it is easiest to detach the tissue from the rear of the pericardium, where the connective tissue is loose. We strip back the pericardial layer on both the right and left sides to expose a semicircle of the anterior surface of the esophagus. When the tumor has not invaded the pleura, we try to keep both sides of the pleura intact. Also it is important to prevent damage to the azygos vein and thoracic duct.

As reconstruction procedures via a laparoscopic transhiatal approach, double tract reconstruction is essentially preferred as an easy and secure procedure. Prior to the reconstruction, we perform intra-operative gastric endoscopy to check the tumor location, and divide the esophagus 2-3 cm to the oral side of the tumor, using a linear stapler. For double tract reconstruction, the jejunum is divided 20 cm distal to the Treitz ligament and a jejunojejunosotomy (JJ) is created 40 cm distal to the esophagojejunostomy. Rapid intra- operative pathological diagnosis is used to check that the surgical margins are negative. Then, esophagojejunostomy (EJ), gastrojejunostomy (GJ) and JJ are completed using an linear staplers. GJ is performed 10-12 cm distal to the EJ using the posterior side of the jejunum and the anterior wall of the remnant gastric body; the JJ is performed 40 cm distal to the EJ. We may perform laparoscopic proximal gastrectomy with esophagogastrostomy (Kamikawa's double-flap method) on cases who meet both of the following conditions: 1) Esophagogastrostomy can be anastomosed in the abdominal cavity, not in the mediastinal cavity; and, 2) the remnant gastric body after gastrectomy is ≥ 50% that of the original.


  Minimally invasive function-preserving gastrectomy based on the sentinel node concept in gastric cancer Top


Hiroya Takeuchi

Department of Surgery, Hamamatsu University School of Medicine, Shizuoka, Japan

Background: Clinical application of sentinel node (SN) mapping for early gastric cancer had been controversial for years. However, single institutional results of SN mapping for these cancers are almost acceptable in terms of detection rate and accuracy to determine lymph node status. SN mapping may play a key role to obtain individual metastatic information and allows modification of the surgical procedures for early gastric cancer.

Results: The Japan Society of Sentinel Node Navigation Surgery conducted a prospective multicenter trial of SN mapping for early gastric cancer by a dual tracer method with radioactive colloid and blue dye. SN mapping had been performed for 397 patients with early gastric cancer at 12 comprehensive hospitals including our institution. As results, detection rate of hot and/or blue node was 98%. The sensitivity to detect metastasis based on SN status was 93%, and accuracy of metastatic status based on SN was 99%. Based on these results, minimized gastrectomy such as partial gastrectomy, and segmental gastrectomy with individualized selective and modified lymphadenectomy for early gastric cancer with negative SN has been performed as an ongoing multicenter trial in Japan. More recently the combination of endoscopic resection with SN biopsy also appears attractively.

Conclusions: Our results suggested that SN concept for cN0 early gastric cancer could be validated, and modified esophagectomy or gastrectomy with individualized minimally invasive surgery which might retain the patients' quality of life should be established as the next surgical challenge.


  Laparoscopic partial gastrectomy with sentinel node mapping for early gastric cancer Top


Hiroya Takeuchi

Department of Surgery, Hamamatsu University School of Medicine, Shizuoka, Japan

In current function-preserving surgeries, such as laparoscopic local resection or segmental gastrectomy, the approach of gastrectomy is usually from the outside of the stomach, in which the demarcation line of the tumor cannot be visualized at the phase of resection. Therefore, surgeons cannot avoid a wider resection of the stomach than desired to prevent a positive surgical margin. Recently, a new technique called Nonexposed endoscopic wall-inversion surgery (NEWS) has been developed, involving full-thickness partial resection, which can minimize the extent of gastric resection using endoscopic and laparoscopic surgeries without transluminal access mainly designed to treat gastric cancer. In the clinical trial, we have been accumulating cases of NEWS with laparoscopic SN biopsy for early gastric cancer with the risk of lymph node metastasis.

Briefly, after placing mucosal markings, ICG was endoscopically injected into the submucosa around the lesion to examine the SNs. The SN basin, including hot or stained SNs, was dissected, and intraoperative pathological diagnosis confirmed that no metastasis had occurred. Subsequently, NEWS was performed for the primary lesion. Serosal markings were laparoscopically placed, submucosal injection was endoscopically administered, and circumferential seromuscular incision and suturing were laparoscopically performed, with the lesion inverted toward the inside of the stomach. Finally, the circumferential mucosal incision was endoscopically performed, and the lesion was perorally retrieved.

NEWS combined with laparoscopic SN biopsy can minimize not only the area of lymphadenectomy but also the extent of gastric resection as full-thickness partial gastrectomy for patients with SN-negative metastasis. Furthermore, NEWS does not require intentional perforation, which enables us to apply this technique for treating cancers without the risk of iatrogenic dissemination. The combination of NEWS and laparoscopic SN biopsy is expected to become a promising, ideal minimally invasive, function-preserving surgery to cure cases of cN0 early gastric cancer.


  Gastrogastric fistula: A possible complication of gastric bypass Top


Ahmed Nasser Al-Garzaie1,2

1The Owner of Dr. Fakhry and Dr. Ahmed AlGarzaie Hospital in Alkhobar, Eatern Province of Saudi Arabia, 2Director of (Somna-Care) Center of Excellence in Bariatric and Metabolic Surgery and Advance Minimal Invasive Surgery, Procare Hospital, AlKhobar, Saudi Arabia

Background: Gastrogastric fistula is a communication between the proximal gastric pouch and the distal gastric remnant, rarely described in the realm of bariatric procedures, different theories exist for fistula formation: (1) it is a technical complication derived from the incomplete division of the stomach during the creation of the pouch, and (2) it occurs after a staple-line failure, developing a leak with an abscess, which then drains into the distal stomach forming the fistula (3) foreign body as a mish or band used migrated in banded gastric bypass. Diagnosis is based on radiologic study, upper endoscopy and computed tomography.

Methods: We report tow cases will be presented in a video the first is a case post mini gastric bypass with gastrogastric fistula due to incomplete division of the stomach. The second a case past banded Roux en-Y gastric bypass with a proline mish migrated into the remnant stomach forming gastrogastric fistula.

Conclusions: Gastrogastric fistula is a possible complication of gastric bypass and its laparoscopic treatment is feasible.


  Conversion from sleeve gastrectomy to gastric bypass Top


Ahmed Nasser Al-Garzaie1,2

1The owner of Dr. Fakhry and Dr. Ahmed AlGarzaie Hospital in Alkhobar, Eatern Province of Saudi Arabia,2 Director of (Somna-Care) Center of Excellence in Bariatric and Metabolic Surgery and Advance Minimal Invasive Surgery, Procare Hospital, AlKhobar, Saudi Arabia

Background: Due to excellent weight loss success in the short-time follow-up, sleeve gastrectomy (SG) has gained popularity as sole and definitive bariatric procedure. In the long-term follow-up, weight loss failure and intractable severe reflux can necessitate further surgical intervention or treatment of leak complication.

Methods: A retrospective analysis of laparoscopic conversions from SG to gastric bypass either Roux-Y (RYGB) or mini gastric bypass was performed to assess the efficacy for reflux relief and weight loss success.

Results: A total of twenty tow underwent conversion Sleeve to Gastric bypass for severe reflux (n=7) or weight regain (n=13) and one case a leaked sleeve, one case sever stenosis after a median interval of 33 months following laparoscopic sleeve gastrectomy. In one of the patients. In both groups, conversion to RYGB or mini GB was successful, as proton pump inhibitor medication could be discontinued in all patients presenting with severe reflux, and a significant weight loss could be achieved in the patients with weight regain within a median follow-up of 30 months.

Conclusion: Conversion to Gastric bypass is an effective treatment for weight regain or intractable reflux symptoms following SG. Thus, SG can be performed, intended as sole and definitive bariatric intervention, with conversion from SG to Gastric bypass as an exit strategy for these complications.


  Revision of the R-Y gastric bypass for the weight regain Top


Ahmed Nasser Al-Garzaie1,2

1The owner of Dr. Fakhry and Dr. Ahmed AlGarzaie Hospital in Alkhobar, Eatern Province of Saudi Arabia,2 Director of (Somna-Care) Center of Excellence in Bariatric and Metabolic Surgery and Advance Minimal Invasive Surgery, Procare Hospital, AlKhobar, Saudi Arabia

Background: Laparoscopic Roux-en-Y gastric bypass (RYGB) is an effective treatment modality for severe obesity. Failure of weight loss and/or weight regain due to lack of restriction has been reported in long-term follow-up studies. The aim of this study is to determine the safety and effectiveness of reestablishing the restrictive component of the operation by resizing the pouch and/or anastomosis for pouch and excising the enlarged blind intestinal end and / or adding fobi's band and/or identifying and treating the gastro-gastric fistula if exist and/or increase the length of the Ray limb using a laparoscopic approach.

Methods: We retrospectively reviewed our prospectively collected database for all patients that underwent revisional surgery of RYGB for weight regain or failure of weight loss. Percent excess weight loss (%EWL) and BMI loss (BMIL) were characterized into the following three time periods: Post- operative follow-up was at 6, 12, 18, 24, 36, and 48 months.

Results: Between 2012 and 2017, a total of 21 patients in the database underwent revision of RYGB. All patients underwent trimming of the pouch and decreasing the gasto-jejunal anastomosis size (TPA)., and 7 TPA with Fobi's Band, 1 cases TPA with excising the gasto-gastric fistula, and 8 cases with elongation of the Ray limb by redo the jejuna-jejunal anastomosis. All cases exploring and closing the potential areas for the internal hernias. Mean follow-up period was 26.1 months. The post-revision mean %EWL was 38%, and the BMI loss was 7 kg/m (2). In the pre-revision to 48 months post-revision time period, mean %EWL and BMIL were 40.6% and 7.5 kg/m (2) in the TPA- only group, 52% and 9,1 kg/m (2) in the TPA with conversion to banded gastric bypass group,60% and 11 kg/m (2) in the resizing and elongation of the malabsorbtive limb respectively. One patient (4.3%) developed a stenosi treated with a endoscoic diltation.. There was no mortality in this series.

Conclusion: Trimming of the pouch and anastomosis appears to be a safe and effective revisional modality for patients with insufficient weight loss or weight regain after gastric bypass in the hands of experienced surgeons and the initial results by TPA and conversion to banded gastric bypass give more in weight reduction.


  Totally extraperitoneal inguinal hernia repair Top


Dr. Hussam Adi, MD, MMAS (UK), FACS

Consultant Laparoscopic Surgeon, Director of Resident Training Program, King Salman Armed Forces Hospital, Tabuk, Kingdom of Saudi Arabia

Background: Totally extraperitoneal repair (TEP) of inguinal hernia is a procedure that requires steep learning curve.

Technique: We are demonstrating our technique step by step with or without space maker balloon. The anatomical landmarks are illustrated. Tricks to overcome intraoperative difficulties are shown.

Conclusion: TEP is not an easy procedure to teach. A complete awareness of anatomy and pitfalls should be recognized.


  Management of ventral hernia in morbidly obese patients Top


Dr. Hussam Adi, MD, MMAS (UK), FACS

Consultant Laparoscopic Surgeon, Director of Resident Training Program, King Salman Armed Forces Hospital, Tabuk, Kingdom of Saudi Arabia

Background: There is no consensus for the management of ventral hernia. Therefore, appropriate management of ventral hernia in morbidly obese patients is not straightforward decision.

Methods: We are presenting our protocol for approaching morbidly obese patients with ventral hernia whether primary or incisional one. This approach depends on available published data.

Results: Our patients are divided into favorable and unfavorable anatomy which are subdivided into symptomatic or asymptomatic. The favorable anatomy includes gynecoid fat distribution, BMI < 50 kg/m2, upper abdominal location, defect < 8cm in diameter and abdominal wall thickness < 4cm. In case of favorable anatomy and symptomatic patient, laparoscopic hernia repair (LHR) is done firstly followed by the bariatric surgery. If patient is asymptomatic, we proceed with concomitant LHR and bariatric surgery. A program of low calorie diet is the initial step of management before LHR for symptomatic patients and unfavorable anatomy, then bariatric surgery is performed. Bariatric surgery is firstly planned followed by LHR for asymptomatic patients with unfavorable anatomy.

Conclusion: Our algorithm for management of ventral hernia in morbidly obese patient has been helpful for the time and selection of hernia repair.


  Laparoscopic highly selective vagotomy: Is it still valid procedure? Top


Dr. Hussam Adi, MD, MMAS (UK), FACS

Consultant Laparoscopic Surgeon, Director of Resident Training Program, King Salman Armed Forces Hospital, Tabuk, Kingdom of Saudi Arabia

Background: Laparoscopic Highly selective vagotomy (LHSV) was common procedure for peptic ulcer diseases (PUD). However, it is dropped of the algorithms over the world in favor of new medications.

Methods: We are reviewing the literature and presenting in which cases, we still performing LHSV. We include demonstration of our technique.

Results: Indications for LHSV include development of complications of PUD despite continuous medical treatment, non-compliant patients and those who are on life-long ulcerogenic medicines. Laparoscopic approach has added more feasible and safer option for the above-mentioned group of patients. Proper surgical technique is essential for adequate vagotomy.

Conclusion: LHSV should be in the algorithm of management of PUD. However, in order to be done efficiently, training of the procedure is an issue for junior surgeons.


  Conversion of vertical banded gastroplasty: RY gastric bypass versus minigastric/single anastomosis bypass Top


Dr. Hussam Adi, MD, MMAS (UK), FACS

Consultant Laparoscopic Surgeon, Director of Resident Training Program, King Salman Armed Forces Hospital, Tabuk, Kingdom of Saudi Arabia

Background: Long term results of vertical banded gastroplasty (VBG) show more than 50% conversion rate due to weight regain or complications.

Methods: We present our technique and approach of conversion of VBG into RY gastric bypass (RYGB) and minigastric/ Single anastomosis bypass (MGB/ SAGB) in King Salman Armed Forces Hospital, Tabuk, Saudi Arabia. We review the available data that compare conversion of VBG to RYGB or MGB/ SAGB.

Results: Conversion of VBG to MGB/ SAGB is an easier procedure that can be considered in case of weight regain. However, in case of gastroesophageal reflux or stricture, RYGB is more suitable option to address such complications.

Conclusion: Although conversion of VBG to RYGB has been the gold standard practice, conversion of VBG to MGB/ SAGB is a safe option in selected cases.


  The management of post-bariatric surgery complications Top


Salman Alsabah, MD, MBA, FRCS(c), FACS

Laparoscopic and Bariatric Surgeon, Amiri Hospital, Kuwait

Background: Obesity today is a leading cause of global morbidity and mortality, and bariatric surgeries such as laparoscopic sleeve gastrectomy (LSG) are increasingly playing a key role in its management. Such operations, however, carry many difficult and sometimes fatal complications. This study aimed at evaluating possible options for the management of post-LSG complications.

Methods: A retrospective study was conducted on the patients who were admitted with post-LSG complication development at Al-Amiri Hospital Kuwait from January 2007 and December 2016. 17 patients presented with leak and were stented endoscopically with self-expandable metal stent (SEMS). Self-expandable plastic stent (SEPS) was used to facilitate stent removal; 30 with post-LSG fistula and were managed with Roux-en-Y fistulo-jejunostomy (RYFJ); 26 with sleeve gastrectomy stenosis (SGS), and were treated with endoscopic balloon dilatation; two patients that developed post-LSG reflux were managed with cardiopexy with ligamentum teres; while nine patients were diagnosed with portomesenteric vein thrombosis (PMVT).

Results:

76% of the 17 patients that presented with post-LSG leaks had successful treatment of their gastric leak, as shown by gastrograffin swallow 1 week post SEMS placement and SEPS-assisted retrieval. 30 patients had RYFJ for post-SG fistula. Endoscopic and radiologic assessment revealed no persistent fistula and no residual collections after a mean follow-up period of 22months. The 26 patients that presented with SGS were followed for a mean duration of 156±20 days from the last endoscopic balloon dilatation, with 88.5% reporting complete resolution of their symptoms. The 2 patients that were treated for post-LSG reflux were followed up for 6 months. Both patients had no hiatal hernia or reflux on barium swallow, no symptoms of reflux, no proton pump inhibitor usage, and a manometric measurement of over 12 mm Hg at the 6 months period. For the 9 patients that were diagnosed with PMVT, 8 were managed with anti- coagulation therapy, while 1 underwent urgent laparotomy. The details of the cases are further discussed in our publications found in Surgical Endoscopy, Obesity Surgery and Surgery for Obesity and Related Diseases.

Conclusions: With the increase in popularity of LSG's, more is being understood about the potentially serious complications that may arise subsequently to it. Therefore, a need for efficacious as well as innovative techniques to deal with such complications is of major importance.


  Revisional bariatric surgery after initial laparoscopic sleeve gastrectomy: What to choose Top


Salman Alsabah, MD, MBA, FRCS(c), FACS

Laparoscopic and Bariatric Surgeon, Amiri Hospital, Kuwait

Introduction: Bariatric surgery has been shown to produce the most predictable weight loss results, with laparoscopic sleeve gastrectomy (LSG) being the most performed procedure as of 2014. However, inadequate weight-loss may present the need for a revisional procedure. The aim of this study is to compare the efficacy of laparoscopic re-sleeve gastrectomy (LRSG), laparoscopic Roux-en-Y gastric bypass (LRYGB) and gastric mini-bypass surgery (MGBP) in attaining successful weight loss following initial LSG.

Methods: A retrospective analysis was performed on all patients who underwent LSG at Amiri and Royale Hayat Hospital, Kuwait from 2008-2017. A list was obtained of those who underwent revisional bariatric surgery after initial LSG, and their demographics were analyzed.

Results: A total of 107 patients underwent revisional bariatric surgery, of which 38.3% underwent LRYGB, 34.6% underwent LRSG, and 27.1% underwent MGBP. 85% of the patients were female. The mean weight and BMI prior to LSG for the LRSG, LRYGB and MGBP patients were 137.1 Kg and 49.9 Kg/m2, 135.2Kg and 50.5 Kg/m2, and 127.5 Kg and 49.0 Kg/m2 respectively. The mean BMI showed a drop from 42.03 to 31.7 (p=0.000) 1-year post revisional surgery for the LRSG group, 42.7 to 34.7 (p=0.000) for the LRYGB group, and from 42.4 to 32.2 in the MGBP group, correlating to an excess weight loss (EWL) of 62.1%, 47.18% and 58.9% respectively. At 2 years post- revisional, LRSG patients showed an increase in BMI to 32.85 (EWL=57.11%), while those that underwent LRYGB continued to show a decrease to 30.83 (EWL=67.16%).

Conclusion: Revisional bariatric surgery is a safe and effective method for the management of failed primary LSG. Revisional bariatric surgery has also shown to help with the management of comorbidities associated with obesity.


  Approach to surgical failure: Weight regain and inadequate weight loss after bariatric surgery Top


Nasreen AlFaris, MD, MPH

Endocrinogy Diabetes and Metabolism/Obesity Medicine, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia

Bariatric surgery is the most effective treatment modality for individuals with Class II (BMI 35–39.9) and Class III obesity (BMI ≥40). Unfortunately, there is often inadequate weight loss or weight regain after bariatric surgery. Studies that have been conducted in the bariatric surgery population show that significant weight regain (≥15% gain of initial weight loss post bariatric surgery) occurs in 25% -35% of persons who undergo surgery 2–5 years after their initial surgical date. Concomitantly, there is often a reemergence of co-morbidities that initially improved after bariatric surgery.

During my talk I will discuss possible causes of inadequate weight loss and weight regain after bariatric surgery. Additionally, while revisional bariatric surgery has been employed in this patient population, they are ineffective long-term. Endoscopic pouch plications, stoma reductions, and sclerotherapy have also been utilized to treat inadequate weight loss and weight regain in bariatric surgery patients, but this too has proven ineffective long term.

I will discuss the utility of pharmacologic treatment for treatment of inadequate weight loss and weight regain after surgery and the options available in the region.


  Sleeve gastrectomy and gastroesophageal reflux disease Top


Abdullah Al-Zahrani, MD

Consultant Upper GI and Bariatric Surgery Division, Department of Surgery, Prince Sultan Military Medical City, Riyadh, Kingdom of Saudi Arabia

Surgical weight reduction is considered to be the most durable option for the treatment of obesity and its co-morbidities. Laparoscopic sleeve gastrectomy (LSG) has established popularity as a single, definitive procedure for weight loss based on its success, ease of technique, and low complication profile.LSG also appears well tolerated in the longer term, with a lower risk of adverse nutritional consequences and surgical complications.

The he effect of LSG on gastro- esophageal reflux disease (GERD) is unknown, and some studies have proposed that anatomic changes associated with LSG and the variety of techniques adopted by surgeons may increase GERD symptoms or result in the development of denovo GERD.

Several variables have been studied and found to attribute to the persistence or development of GERD post sleeve gastrectomy.

Several modifications and additional procedures have been described to reduce the incidence of post sleeve gasterectomy during the initial procedure and further procedure have described to treat post sleeve gastrectomy GERD.

This presentation will explore all the etiologies and treatment options to reduce and treat post sleeve gastrectomy GERD.


  Evidence of objective endoscopic gastroesophageal reflux post sleeve gastrectomy Top


Ali Molhammad Ali AlMontashary

Department of Surgery, King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia

Background: Sleeve Gastrectomy (LSG) has emerged as the most commonly performed bariatric surgical procedure due to its technical simplicity, safety profile and efficacy (1). Development of gastro- esophageal reflux disease (GERD) following SG is a concern as both obesity and GERD are associated with Barrett's esophagus and esophageal adenocarcinoma. However, the literature is conflicting and results inconsistent on the relationship of GERD and SG. The studies done are heterogeneous, varied in design and approach to the diagnosis of GERD. Endoscopic detection of esophagitis is the most robust objective evidence for the presence of GERD.

Aim: Primary Aim: To look objectively for endoscopic evidence of oesophagitis (EE) post SG.

Secondary Aim: To look for factors associated with EE post SG.

Materials and Methods: Setting: This study was done in King Abdullah Medical City (KAMC), a tertiary referral center for Bariatric surgery and Gastroenterology for the western region of Kingdom of Saudi Arabia.

Study Population: All patients who had SG done in KAMC and had endoscopy done were included.

Study Design: A single centre retrospective review of patients who have had SG.

Results:

  • Five hundred sixty two (out of 1180 LSG) patients who had a gastroscopy post LSG and finished minimum 1- year post LSG were included. Median age of patients was 35 years (range 18-65) with 59% females and 48 % had hypertension, diabetes mellitus and/or hyperlipidemia. The median post SG endoscopy interval was 16 months (range 12–33)
  • EE was detected in 23 % with 64%, 31% and 5% having grade A, B and C respectively. None had hiatus hernia and one of them had a 5cm Barrett's oesophagus (BE)
  • 19 % were positive for helicobacter pylori (HP) and 23 % of these had oesophagitis. Compared to those without HP, the prevalence of oesophagitis was not significantly different (P = 1.00). In addition, gender, BMI ≥50 and age > 50 had no significant correlation with EE post SG.
Figure 1: Esophagitis post SG with grade

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Figure 2: Correlation of EE with gender, BMI, age and HP

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Discussion:

  • Endoscopic oesophagitis was prevalent in nearly a quarter of our study population who had SG
  • The development of EE maybe denovo posy SG with the potential to evolve into BE
  • There was correlation between development of EE post SG and gender, BMI, age or presence of HP
  • Our study has limitations as it is retrospective in nature and included a small sample size
  • Further studies with prospective follow up are underway and could pave the way for a better and more generalizable outcome.


Reference

Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg 2013;23:427-36.


  KAMC's experience of IVC filter placement prior to bariatric surgery in extremely high risk patients for thromboembolic events Top


Ali Almontashery

Department of Surgery, King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia

Background: Nowadays, bariatric surgery is widely used to treat morbidly obese patients in the Kingdom of Saudi Arabia. This study aims to describe KAMC's experience in using of IVC filter for patients of bariatric surgery.

Design and Methods: A retrospective hospital file review of all patients for the pre-operative, operative and post- operative information was done. Caprini score was retrospectively calculated for all patients and their outcome was reported.

Results: Out of 1550 patients who underwent bariatric surgery in the period from March 2013 to Feb 2018 at KAMC, 7 had IVC filter placement. There were 5 (83.3%) female patients and patients' ages ranged from 30.6 to 62.2 (median: 53.9) years. Pre-operative BMI ranged from 32.3 to 51.1 (median: 42.8) kg/m2 and Caprini score ranged from 7 to 9. Five patients underwent laparoscopic sleeve gastrectomy and one underwent laparoscopic bypass. The operation time ranged from 1.4 to 4.9 (median: 2.1) hours. Three cases used Opt Ease Filter brand and the other three used other types of filters. Hospital stay ranged from 2 to 29 days. Three cases were admitted to the ICU, only one case developed DVT, and for two patients clots were found on filters. No filter migration or breakage was reported.

Conclusion: IVC filter is used in less than 1 % of patients who underwent bariatric surgery and no complications were reported with its use.


  Techniques in SLIS using GelPort Top


Dr. Hanan M. AlGhamdi, MBBS, MD

Asst. Prof. Hepatobiliary & Multiorgan Transplant & Laparoscopic Surgeon, Outpatient & Emergency Services Medical Director, University of Dammam & King Fahad Hospital of the University, AlKhobar, Saudi Arabia

Describing the technique steps in using Gel Port in SLIS including: port modification, incision, appropriate instrument, and sleeve technique and incision closure to prevent incision complication.


  Hemostasis in SLIS Top


Dr. Hanan M. AlGhamdi, MBBS, MD

Asst. Prof. Hepatobiliary & Multiorgan Transplant & Laparoscopic Surgeon, Outpatient & Emergency Services Medical Director, University of Dammam & King Fahad Hospital of the University, AlKhobar, Saudi Arabia

A continuous challenge for laparoscopic surgeon especially in narrow field for maneuvers as in SLIS and the commonest cause of conversion to open is to keep the surgical field almost bleeding- free. Moreover, blood absorbs light causing darkness and suboptimal intraabdominal working field and it is difficult to control bleeding by laparoscopic means as compared to open. Subsequently, massive bleeding allows no opportunity for the open approach maneuver efficient-application, as an example direct compression or tying. Several techniques and devices introduced to prevent and decrease bleeding including energy devices, hemostatic material and staple line buttressing materials, the cons and pros of these will be reviewed.


  MGB “one anastomsis gastric bypass” as a redo procedure and the use of virtual gastroscopy for preoperative evaluation Top


Prof. Mohamed Mahmoud Abouzeid

Ass. Prof. Ain Shams University, Consultant Bariatric and Laparoscopic Surgery, Member of the Royal College of Surgeons MRCS, Registered in UK General Medical Council "GMC" Executive Board member of Pan Arab Society of Metabolic and Bariatric Surgery, Cairo, Egypt

Background: OAGB is gaining popularity throughout the world, in 2017 we published the results of our first 1500 cases and it was promising and now we need to spotlight the Benifit of OAGB as a redo procedure. On the other hand Virtual Gastroscopy is a revolution in Assessment of Redo Cases before final decision to do second operation.

Introduction: Adjustable gastric band was more popular 10 years ago with more patients needing revisions for weight regain nowadays. The concept of transforming restrictive procedure to a malabsorptive one is adopted by many surgeons.

Objectives: To present our experience in converting adjustable gastric banding to OAGB as one step procedure

Methods: From March 2014 to January 2017, 100 cases of failed gastric banding where converted to OAGB, 16 of them males and 84 females. Mean age 36.6 (20-56), and preoperative body mass index 46.2 kg/m2 (37-68). Period of band appliction was 5.5 years (2-11). Type 2 DM affected 23 patients, hypertension 28. Mean follow up 22 months (12 to 32). Upper endoscopy used Preoperative to exclude perfi preoperative to exlude perforation.

Results: All procedures were completed laparoscopically. Mean operative time was 74 minutes (58-112). Mean length of hospital stay 36 hours (24-96). No conversion to open surgery or mortality. One intra-operative complication. Peri-operative morbidity 2 cases. All patients experienced excess weight loss (EWL) with mean 76% (35%-95%) and 6% of patients had less than 50% EWL. Hypertension resolution 85.7 (24 of 28) and T2DM remission 91% (21 of 23) No record of weight regain to date. Symptomatic bile reflux 2 patients (2%)

Conclusion: With a relatively lax pouch OAGB is a good option after Band, complications are few. Longer follow-up is required.




    Figures

  [Figure 1], [Figure 2]



 

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