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New Technologies and Expert Meeting (Part 1)
Introduction (and welcome address): Time for us to change!
Although the need for innovation remains a mantra in bariatrics, we felt that a different type of organization was requested starting effectively this year 2015, for several reasons:
- Some trends are moving so fast that sometimes "wait and see" seems the appropriate action, sometimes we have to confirm data that look brilliant and advise caution.
- New technologies can be divided into three groups: the current surgical techniques and their improvements; the endoscopic field; the adjacent fields (biology, smartsensing, etc.). Each of them is equally important, since we do not know from where the light will come in the near future. The surgical field is pretty much covered by more traditional meetings, even if a focus on them is necessary every now and then; the endoscopic field is also covered since the initiative of the Spanish leader Gontrand Lopez-Nava; innovations from "outside" require finesse and expertise to be sorted out.
Finally, we broke a deal with our friend Karl Miller who has organizes for a long time the very successful Austrian expert meeting. We agreed to host each other every other year, so that both our meetings represent innovation and state of the art expertise in the same time. This way we shall ensure more industry support, and a long-term capacity to deliver news in a friendly atmosphere and contribute to highlight this more than ever thrilling field... Long live to the International "New Technologies and Expert Meeting"!
Surgical techniques and surgical management: updates and upgrades
The experience with ERAS in laparoscopic bariatric surgery (Fast-track bariatric program) has been presented by two surgeons: The data of a high-volume center by Marie-Cécile BLANCHET (France-Lyon), and the lessons from a large experience by Paolo MILLO (Italy-Aosta).
Fast track programs (ERAS) in digestive surgery have been initiated by Henrik Kehlet in Sweden (1997). They involve minimal invasive surgical techniques, rapidly acting agents in anesthesia, optimal pain and anti-emetic control, preoperative carbohydrate loading, low molecular weight heparin, early mobilization, early oral nutrition and ambulation. Discharge criteria, as well as predictors of hospital stay beyond 3 days, must be defined before setting such a program. Bariatric surgery is important part of ERAS. Ambulatory procedure was chosen as a primary treatment modality since 2010 in Lyon for laparoscopic gastric banding. The rate of ambulatory surgical procedures has increased from 3.1% in 2010 to 92% in 2014 (932 patients). Call at day 1 was systematic, with a specific questionnaire. In the mean time, unplanned hospital admission and readmission rate has dropped to less than 1%.
While other publications have demonstrated the possibility of performing gastric bypass and sleeve gastrectomy in an ambulatory setting, other reports mention a possible increase in mortality (Morton, Ann Surg 2014). Caution is advised when post-operative complications may be uneasy to detect at an early stage. The Italian "Aosta experience of soft fast track" takes this into account, and favours early discharge rather than purely out-patient hospitalization.
Banding Sleeve Gastrectomy/Bypass or not: Karl MILLER (Austria) Vs Konrad KARCZ (Germany)
While K MILLER did not see any added value in banding a sleeve gastrectomy or a bypass, K KARCZ examined the arguments in favour of such a strategy, including data that have been collected till now. Is added risk placing a foreign body worth a hypothetical additional weight-loss? K MILLER disagrees with such a step, while K KARCZ assumes it is worthwhile in order to maximize the future benefit of such operations. Gastric bypass is a target for many years, following upon the steps of Mal FOBI’s operation. When it comes to sleeve gastrectomy, 3D-imagery assessment often shows in the long-term a stretching of tissues. K KARCZ deems useful an additional restriction with a band for patients with a BMI above 50, and presenting "big volume eating disorders". A review of the literature has demonstrated an erosion rate of 1.63% (48 cases out of 2949), which is acceptable. Optimization of weight-loss seems to be a key-benefit, as well as preventing weight-regain, although there are discrepancies in the literature. Banding could also decrease the incidence of “reactive hypoglycemia" after bypass.
Update on Robotic bariatric surgery: Paolo MILLO (Italy)
According to recent EAES consensus statements regarding digestive surgery, robotics may increase the rate of liver resection and distal pancreatectomy. It is not clear yet if the advantage is decisive when it comes to current bariatric techniques. In Aosta, 365 laparoscopic gastric bypass have been performed, 66 being robotic. Previous experience and literature have noticed an important added duration for the procedures. A hybrid type of operation remains possible: the gastrojejunal anastomosis is performed through the robotic approach, while the making of the pouch is performed via the standard laparoscopic approach. The alternative option is to select the cases for a totally robotic procedure.
New approach to Laparoscopic Greater Curve Plication, partially or fully stapled plication: Martin FRIED (Czech Republic). Initiated by Talebpour in Iran, and popular in many countries because supposedly cheaper than sleeve gastrectomy and less dangerous, this operation remains a challenge to many surgeons who are not convinced by the technique and the results. A variation, suggested by M FRIED, could make it more reliable and simpler. Stapled plication seems to increase the durability of the plication, its reproducibility (every 3 cm), its standardization (with a more symetrical pattern), and the strength of tissue invagination. The EMS stapler (hernia stapler) has been used, it is designed for "tissue approximation". One could fear that such a use would be dangerous for gastric tissues, but it was not the case in the Czech experience. This can be combined with a running suture, making it a partially stapled plication.
Technical improvements to Laparoscopic Greater Curve Plication, prevention of leaks and other complications : Karin DOLEZAVOLA (Czech Republic).
In the same team in Prague, K DOLEZAVOLA reviewed the cumulative experience of a 2000 cases series, and stated that rules can be established in order to improve the outcomes. The plication should stop 2cm below the angle of His to preserve the anti-reflux mechanism, as well as the vascularization and suspension of the fundus; preserving the fundus also avoids intermittent obstruction. The stomach should not be rotated. The dissection should stop 3-5 cm away from the pylorus, and stay away (1 cm) from the gastric wall when dividing the greater curve. An adequate interval between the stitches should be kept (1.5-2 cm). In this series, 5 leaks have been reported out of 670 patients (0.79%). Critical areas for endangered blood supply are pointed out, e.g. the upper third of the stomach in case of previous surgery.
A fight of concepts : Endoplication Vs Surgical plication Vs Sleeve Gastrectomy, can we achieve the same goals ? Round table : Gontrand LOPEZ-NAVA (Spain) Vs Martin FRIED (Czech Republic)Vs Patrick NOEL (Abu-Dhabi)
During this round table, comparisons have been made between Laparoscopic Vertical Gastric Plication and Sleeve Gastrectomy, in terms of postoperative complications and short-term outcomes. Although these procedures seem totally different, they share the same goal of a "longitudinal restriction". Is the simplest way the best? Moreover, can this be replicated through endoscopic channels or does endoscopic plication represent a different concept?
Laparoscopic sleeve gastrectomy (LSG) is nowadays the most popular bariatric procedure around the world. Laparoscopic vertical gastric plication (LVGP) is presented as an alternative for LSG with theoretical advantages including a lower postoperative morbidity, a higher efficiency, and reversibility. Some papers suggest that LSG and LVGP are comparable in terms of short and medium weight-loss. Nevertheless, most national or international societies have deemed that this procedure was still investigational; additional data and comparative studies with long-term follow-up are required.
Patrick NOEL has advocated the sleeve gastrectomy as a solid and well established operation. He claims that the effects on ghrelin and PYY owing to fundus resection, transforms this, operation it in a metabolic one, at least not a purely restrictive one. Bioabsorbable material reinforcing the staple line have decreased the rate of leakage to 2%. A few comparative (and randomized) studies versus surgical plication have been published and the results seem contradictory.
The similarities between surgical plication and endoscopic plication have also been pointed out. Yet some factors could influence less interesting results, for instance the lack of strength or long-term resistance of endoscopic "bites" for plication, and/or the fact that endoscopy does not suppress blood supply to the greater curve (M FRIED). Nevertheless and according to G LOPEZ-NAVA, endoscopic plication represents an important step towards minimal aggressiveness. The method can be repeated upon demand, and it fits into a "treatment gap" for obese patients, being a bridge to other surgical options. The endoscopic sleeve gastroplasty reduces the gastric lumen into a tubular configuration, with the greater curvature replaced by a line of sutured plications. General anesthesia with endotracheal intubation is needed. An endoscopic suturing system requiring a double channel endoscope delivers full-thickness sets of running sutures from the antrum to the fundus. Post procedure outpatient care includes diet instruction with intensive follow-up by a multidisciplinary team. Voluntary oral contrast and endoscopy studies are scheduled to assess the gastroplasty at 3 months, 6 and 12 months. Mean procedure duration was 66 minutes during which 6-8 sutures on average were placed. All patients were discharged in less than 24 hours. There were no major intra-procedural, early, or delayed adverse events. Post-discharge pain was controlled with oral analgesia (2-4 days) and nausea (1 day) occurred in 20% of the patients. Weight loss parameters were satisfactory (57.0 % of %EWL at 1 year) and oral contrast studies and endoscopy revealed sleeve gastroplasty configuration until one year of follow-up.
Endoscopic treatment for sleeve gastrectomy leaks/ Pigtail drainage: Gianfranco DONATELLI (France) and Jean-Marc CATHELINE (France)
Leaks are considered one of the major complications of Laparoscopic Sleeve Gastrectomy (LSG) with a reported rate up to 7 %. Drainage of the collection combined with stent deployment is the most frequent treatment, but success is variable and burdened by high morbidity and some mortality. A new approach by Endoscopic Internal Drainage (EID) for the management of leaks is suggested. Methods: Since March 2013, 62 patients presenting a leak following LSG were treated with a double pigtail plastic stents across the orifice leak, positioning one end inside the collection and the other end in the remnant stomach. The aim of EID is to drain internally the collection and in the same time ensure leak healing. Results: Double pigtails stent were successfully delivered in 61 out of 62 patients (98.4 %). 42 patients were cured by EID after a mean delay of 58.2 days and an average of 3.65 endoscopic sessions. 2 died of a non related event. 3 were lost to follow up. 13 are still under treatment and there was1 failure. Six patients developed stenosis and were treated endoscopically. Conclusions: EID proved to be a valid, efficient and safe minimally invasive approach for treatment of leaks following SG. EID achieved complete drainage of perigastric abscesses and stimulated mucosal growth over the stent. It was well tolerated, allowed early re-alimentation and had fewer complications than other techniques. Long-term follow-up confirmed good outcomes with no motility or feeding alterations.
Update of new Ethicon Stapling devices (GST): Charles RENAULT (France)
A new stapling device has been presented, involving linear staplers such as used for a sleeve gastrectomy. The GST system (Gripping Surface Technology), has a unique feature that decreases tissue slippage when misalignment occurs. It is already available and should enhance the quality of stapling.
In vivo instrumentation and micro-robots for bariatrics : Antonello FORGIONE (Italy)
A new flexible platform has been initiated at the AIMS Academy Milan. MAGS= Magnetically Activated Guidance Systems, trocarless instrumentation for laparoscopy have been developed. They involve magnetic positioning of the camera inside the abdomen. These "In vivo tools" are equivalent to virtual ports. Multiple camera may increase the surgical vision inside the abdominal cavity and permit extra-access to various organs while facilitating the use of regular instruments.
Sleeve Gastrectomy with Ileal Transposition : Alper CELIK (Turkey)
This controversial operation has been developed to gain additional metabolic effect while benefiting from the effects of a sleeve gastrectomy. The translocation of the proximal jejunum and the distal ileum seems technically feasible and does not require extra surgical skills. Ileum is supposed to be the key target in order to provide satiety in a bariatric operation. Therefore A CELIK calls it a "functional restriction". Rationale: remission of ghrelin levels, activation of both foregut and hindgut hypothesis, through sleeve gastrectomy, duodenal exclusion and ileal transposition. The term "functional" means that the activation of anorexigenic hormones of distal ileal origin occurs. This operation prevents a severe malabsorption: only the duodenum and a 50 cm segment of the proximal jejunum are bypassed. The series (364 patients) had a 6.1% complication rate, 1 early death, 2 late deaths, 8 leaks (2.2%). 94% of the patients did not need vitamin and mineral supplements after one year FU.
A simple liver-retractor for bariatric surgery, the Versalifter : Vincent MALHERBE (Belgium)
A device that allows the left lobe of the liver to be retracted without trocar has been presented. It is simple and light, and hooked to the diaphragm on one end, to the umbilical ligament on the other end. It has been proven useful for typical bariatric procedures (lap-banding, sleeve gastrectomy, gastric bypass).