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Comment on: Surgical Standardization to Prevent Gastric Stenosis after Laparoscopic Sleeve Gastrectomy
Author’s Accepted Manuscript Paired editorial for surgical standardization to prevent gastric stenosis after laparoscopic sleeve gastrectomy Marius Nedelcu, Patrick Noel www.elsevier.com/locate/buildenv
PII: DOI: Reference:
S1550-7289(16)30738-9 http://dx.doi.org/10.1016/j.soard.2016.09.039 SOARD2793
To appear in: Surgery for Obesity and Related Diseases Received date: 29 September 2016 Accepted date: 29 September 2016 Cite this article as: Marius Nedelcu and Patrick Noel, Paired editorial for surgical standardization to prevent gastric stenosis after laparoscopic sleeve gastrectomy, Surgery for Obesity and Related Diseases, http://dx.doi.org/10.1016/j.soard.2016.09.039 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Paired editorial for Surgical Standardization to Prevent Gastric Stenosis after Laparoscopic Sleeve Gastrectomy
Marius NEDELCU1,2, Patrick NOEL3 1
Sfantul Constantin Hospital, Brasov, Romania
2
Centre Hospitalier Universitaire Montpellier, France
3
The American Surgecenter, Abu Dhabi, UAE
Corresponding author: Marius NEDELCU Sfantul Constantin Hospital – Brasov Metabolic and Obesity Center Strada Iuliu Maniu 49, Brașov 500091, Romania [email protected] [email protected]
1
Laparoscopic sleeve gastrectomy (LSG) is generally considered a straightforward procedure, but the surgical technique is one of the major determinants of the postoperative complications. Besides the staple line leak, the other severe complication after LSG is represented by the gastric stenosis. Numerous manuscripts have been written about the different approaches to the management of gastric fistulas, but limited data and no standardization can be found concerning the treatment of gastric stenosis following LSG. The reported incidence of stenosis ranges from 0.1 to 3.9 % (1, 2). The authors are to be commended for reporting their experience with LSG and the standardization of the procedure in order to reduce its related complications (leak and stenosis). Professor Huang et al. provide us with an interesting contribution that reflects the critical role of the learning curve even for a straightforward procedure like LSG, as it relates to diminish the postoperative complication rates, both for stenosis (3) or for the leak (4). Even if we do not encourage the two technical particularities described by the authors regarding the innovating liver retractor and retroperitoneal fixation of the gastric tube, we respect the author experience and their outcomes. Probably a prospective randomized trial performed by the same team with the same technique will clarify the benefit of this retroperitoneal fixation. The authors did not bring significant data to support the fixation of the greater curvature site of the sleeve gastric tube with the retroperitoneal fat. We congratulate the authors for reporting their results after changing the technique to a “standardized” sleeve. Still, we think that the author should reconsider the whole endoscopic approach for the stenosis treatment following LSG. Surprisingly, the authors reported a failure of endoscopic approach in more than 88.9 %. According to our experience (5) and conviction, the surgery must be considered a really rescue option for stenosis following LSG. 2
I cannot agree more with you that the stents are very poorly tolerated by patients and that the cost might be considerate prohibitive, but in some cases of stenosis the benefit will exceed these two inconvenients and the stent must be a part of the algorithm of treatment of stenosis following LSG. We complement the authors for including in the discussion an additional paragraph of their more recent experience. Not only intolerance during endoscopic dilatation for LSG, but the relatively small-sized balloon dilator, instead of the achalasia balloon dilator, might lead to this unsatisfactory result in their experience. An improvement of the endoscopic approach is mandatory to improve the nonsurgical success rate of stenosis. The current manuscript emphasizes that a better endoscopic approach along with increased experience for surgical treatment will make possible a better treatment and prevention of gastric stenosis following LSG.
Refereences: 1. Boza C, Salinas J, Salgado N, et al. Laparoscopic sleeve gastrectomy as a stand-alone procedure for morbid obesity: Report of 1,000 cases and 3-year follow-up. Obes Surg. 2012;22:866–71. 2. Cottam D, Qureshi FG, Mattar SG, et al. Laparoscopic sleeve gastrectomy as an initial weight loss procedure for high-risk patients with morbid obesity. Surg Endosc. 2006;20:859–63. 3. Chang PC, Tai CM, Hsin MC, Hung CM, Huang IY, Huang CK. Surgical Standardization to Prevent Gastric Stenosis after Laparoscopic Sleeve Gastrectomy: A Case Series Surgery for Obesity and Related Diseases Published online: September 16, 2016 DOI: http://dx.doi.org/10.1016/j.soard.2016.09.014 3
4. Noel P, Nedelcu M, Gagner M. Impact of the Surgical Experience on Leak Rate After Laparoscopic Sleeve Gastrectomy. Obes Surg. 2016 Aug;26(8):1782-7. 5. Manos T, Nedelcu M, Gagner M, Noel P. How to treat stenosis after sleeve gastrectomy?
Surgery
for
Obesity
and
Related
Diseases
DOI:10.1016/
j.soard.2016.08.491
4
PII: DOI: Reference:
S1550-7289(16)30738-9 http://dx.doi.org/10.1016/j.soard.2016.09.039 SOARD2793
To appear in: Surgery for Obesity and Related Diseases Received date: 29 September 2016 Accepted date: 29 September 2016 Cite this article as: Marius Nedelcu and Patrick Noel, Paired editorial for surgical standardization to prevent gastric stenosis after laparoscopic sleeve gastrectomy, Surgery for Obesity and Related Diseases, http://dx.doi.org/10.1016/j.soard.2016.09.039 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Paired editorial for Surgical Standardization to Prevent Gastric Stenosis after Laparoscopic Sleeve Gastrectomy
Marius NEDELCU1,2, Patrick NOEL3 1
Sfantul Constantin Hospital, Brasov, Romania
2
Centre Hospitalier Universitaire Montpellier, France
3
The American Surgecenter, Abu Dhabi, UAE
Corresponding author: Marius NEDELCU Sfantul Constantin Hospital – Brasov Metabolic and Obesity Center Strada Iuliu Maniu 49, Brașov 500091, Romania [email protected] [email protected]
1
Laparoscopic sleeve gastrectomy (LSG) is generally considered a straightforward procedure, but the surgical technique is one of the major determinants of the postoperative complications. Besides the staple line leak, the other severe complication after LSG is represented by the gastric stenosis. Numerous manuscripts have been written about the different approaches to the management of gastric fistulas, but limited data and no standardization can be found concerning the treatment of gastric stenosis following LSG. The reported incidence of stenosis ranges from 0.1 to 3.9 % (1, 2). The authors are to be commended for reporting their experience with LSG and the standardization of the procedure in order to reduce its related complications (leak and stenosis). Professor Huang et al. provide us with an interesting contribution that reflects the critical role of the learning curve even for a straightforward procedure like LSG, as it relates to diminish the postoperative complication rates, both for stenosis (3) or for the leak (4). Even if we do not encourage the two technical particularities described by the authors regarding the innovating liver retractor and retroperitoneal fixation of the gastric tube, we respect the author experience and their outcomes. Probably a prospective randomized trial performed by the same team with the same technique will clarify the benefit of this retroperitoneal fixation. The authors did not bring significant data to support the fixation of the greater curvature site of the sleeve gastric tube with the retroperitoneal fat. We congratulate the authors for reporting their results after changing the technique to a “standardized” sleeve. Still, we think that the author should reconsider the whole endoscopic approach for the stenosis treatment following LSG. Surprisingly, the authors reported a failure of endoscopic approach in more than 88.9 %. According to our experience (5) and conviction, the surgery must be considered a really rescue option for stenosis following LSG. 2
I cannot agree more with you that the stents are very poorly tolerated by patients and that the cost might be considerate prohibitive, but in some cases of stenosis the benefit will exceed these two inconvenients and the stent must be a part of the algorithm of treatment of stenosis following LSG. We complement the authors for including in the discussion an additional paragraph of their more recent experience. Not only intolerance during endoscopic dilatation for LSG, but the relatively small-sized balloon dilator, instead of the achalasia balloon dilator, might lead to this unsatisfactory result in their experience. An improvement of the endoscopic approach is mandatory to improve the nonsurgical success rate of stenosis. The current manuscript emphasizes that a better endoscopic approach along with increased experience for surgical treatment will make possible a better treatment and prevention of gastric stenosis following LSG.
Refereences: 1. Boza C, Salinas J, Salgado N, et al. Laparoscopic sleeve gastrectomy as a stand-alone procedure for morbid obesity: Report of 1,000 cases and 3-year follow-up. Obes Surg. 2012;22:866–71. 2. Cottam D, Qureshi FG, Mattar SG, et al. Laparoscopic sleeve gastrectomy as an initial weight loss procedure for high-risk patients with morbid obesity. Surg Endosc. 2006;20:859–63. 3. Chang PC, Tai CM, Hsin MC, Hung CM, Huang IY, Huang CK. Surgical Standardization to Prevent Gastric Stenosis after Laparoscopic Sleeve Gastrectomy: A Case Series Surgery for Obesity and Related Diseases Published online: September 16, 2016 DOI: http://dx.doi.org/10.1016/j.soard.2016.09.014 3
4. Noel P, Nedelcu M, Gagner M. Impact of the Surgical Experience on Leak Rate After Laparoscopic Sleeve Gastrectomy. Obes Surg. 2016 Aug;26(8):1782-7. 5. Manos T, Nedelcu M, Gagner M, Noel P. How to treat stenosis after sleeve gastrectomy?
Surgery
for
Obesity
and
Related
Diseases
DOI:10.1016/
j.soard.2016.08.491
4