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Graphical Abstract The angiotensin-converting enzyme 2 (ACE2) is the receptor for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It is highly expressed in adipose tissue, possibly associated with progression to severe coronavirus disease 2019 (COVID-19) in obese subjects. We searched the Gene Expression Omnibus (GEO) and reanalyzed the GSE59034 containing microarray data from subcutaneous white adipose tissue (sWAT) biopsies from 16 women before and 2 years after RYGB, and 16 controls matched by sex, age, and BMI. After RYGB, there was a significant decrease in sWAT ACE2 gene expression (logFC=-0.4175, P=0.0015). Interestingly, after RYGB the sWAT ACE2 gene expression was significantly lower than in non-obese matched controls (LogFC=-0.32875, P=0.0014). Our data adds to the well-known benefits of RYGB, a potential protective mechanism against COVID-19.

One of the roles of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) is to provide guidance on the management of patients seeking surgery for adiposity-based chronic diseases. The role of endoscopy around the time of endoscopy is an area of clinical controversy. In 2018, IFSO commissioned a task force to determine the role of endoscopy before and after surgery for the management of adiposity and adiposity-based chronic diseases. The following position statement is issued by the IFSO Endoscopy in Bariatric/Metabolic Surgery Taskforce. It has been approved by the IFSO Scientific Committee and Executive Board. This statement is based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence. It will be reviewed regularly.

Two randomized controlled trials (RCTs) from Europe recently showed similar weight loss and rates of type 2 diabetes (T2D) remission following laparoscopic gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). However, results from observational studies in the United States (US) have discordant results. We compared 1-year weight loss and T2D remission between LRYGB and LSG in a heterogeneous patient cohort from the US, albeit with similar inclusion and exclusion criteria to the European RCTs. Logistic regression was used to propensity match LSG and LRYGB patients according to age, gender, race, preoperative BMI, and T2D. Inclusion and exclusion criteria were adopted from the two European RCTs. Demographic, anthropometric, weight outcomes, and comorbidities prevalence were compared at baseline and 1-year follow-up. We included 278 patients (139 LSG and 139 RYGB; median age 42 years, 89% female, 57% black race, 22% with public health insurance, and 25% with T2D). One year after surgery, mean %EWL was 77.3 ± 19.5% with LRYGB and 63.1 ± 21% with LSG (P < 0.001). Mean %TWL was 34.2 ± 7.3% after LRYGB and 28.1 ± 8.2% after LSG, (P < 0.001). The proportion of patients who achieved T2D remission was comparable between surgeries (LRGYB: 68.6% vs. LSG: 66.7%, P = 0.89). LSG, older age, black race, and higher preoperative BMI were independently associated with lower %EWL. Independent correlates of weight loss were different for LRYGB and LSG. Weight loss, but not the likelihood of T2D remission, was greater with LRYGB than LSG in a diverse patient cohort in the US. Further research efforts connecting population diversity to discordant results across studies is needed to better counsel patients with regards to expected postoperative outcomes.

Gastric bypass has profound effects on glycemic control in adults with type 2 diabetes mellitus. The goal of this study was to examine the long-term rates and clinical predictors of diabetes remission and relapse among patients undergoing gastric bypass.We conducted a retrospective cohort study of adults with uncontrolled or medication-controlled type 2 diabetes who underwent gastric bypass from 1995 to 2008 in three integrated health care delivery systems in the USA. Remission and relapse events were defined by diabetes medication use and clinical laboratory measures of glycemic control. We identified 4,434 adults with uncontrolled or medication-controlled type 2 diabetes who had gastric bypass.Overall, 68.2 % (95 % confidence interval [CI], 66 and 70 %) experienced an initial complete diabetes remission within 5 years after surgery. Among these, 35.1 % (95 % CI, 32 and 38 %) redeveloped diabetes within 5 years. The median duration of remission was 8.3 years. Significant predictors of complete remission and relapse were poor preoperative glycemic control, insulin use, and longer diabetes duration. Weight trajectories after surgery were significantly different for never remitters, relapsers, and durable remitters (p = 0.03).Gastric bypass surgery is associated with durable remission of type 2 diabetes in many but not all severely obese diabetic adults, and about one third experience a relapse within 5 years of initial remission. More research is needed to understand the mechanisms of diabetes relapse, the optimal timing of surgery in effecting a durable remission, and the relationship between remission duration and incident microvascular and macrovascular events.

Background Heterozygous mutations in melanocortin-4 receptor (MC4R) are the most frequent genetic cause of obesity. Bariatric surgery is a successful treatment for severe obesity. The mechanisms of weight loss after bariatric surgery are not well understood. Methods Ninety-two patients who had Roux-en-Y gastric bypass (RYGB) surgery were screened for MC4R mutations. We compared percent excess weight loss (%EWL) in the four MC4R mutation carriers with that of two control groups: 8 matched controls and with the remaining 80 patients who underwent RYGB. Results Four patients were heterozygous for functionally significant MC4R mutations. In patients with MC4R mutations, the %EWL after RYGB (66% EWL) was not significantly different compared to matched controls (70% EWL) and non-matched controls (60% EWL) after 1 year of follow-up. Conclusions This study suggests that patients with heterozygous MC4R mutations also benefit from RYGB and that weight loss may be independent of the presence of such mutations.

Extending the length of the Roux limb (RL) in gastric bypass (GBP) may improve weight loss in super obese patients (body mass index [BMI]50 kg/m(2)), but no consensus exists about the optimal length of the RL. We sought to determine the impact of RL length on weight loss in super obese patients 1 year after GBP.One-year weight loss outcomes were analyzed in all super obese patients who underwent consecutive and primary laparoscopic or open GBP between January 2003 and June 2006. Patients were divided into two groups according to RL length (100 vs. 150 cm). The RL length was at the discretion of the attending surgeon. Baseline and follow-up data were collected prospectively. Multiple linear regression was used to adjust for potential confounders in the weight loss outcomes.Twelve-month follow-up data were available in 137 (85%) of 161 patients with a BMIor= 50 who underwent GBP during the study period. An RL of 100 or 150 cm was used in 102 (74.5%) and 35 patients (25.5%), respectively. In multivariate analysis, patients with the 150-cm RL lost more weight (68.5 vs. 55.3 kg, p0.01), had a greater change in BMI (25 vs. 21 kg/m(2), p = 0.01), and had greater excess weight loss (64 vs. 53%, p0.01).A 150-cm RL provides better weight loss outcomes in super obese patients at 1-year follow-up.

Intestinal malrotation is a congenital anomaly occurring in one of 500 live births. It typically presents during the first months of life, but in rare instances, it can persist undetected into adulthood when it is identified during a radiographic or surgical procedure. We present a case of intestinal malrotation discovered at the time of laparoscopic Roux-en-Y gastric bypass (LRYGBP), detail the technical aspects needed to be incorporated to complete the operation, followed by a literature review of this rare clinical scenario. Incomplete malrotation is not a contraindication to performing a LRYGBP for morbid obesity.

The aims of this study were to determine the rate of gastrojejunostomy (GJ) stricture following Roux-en-Y gastric bypass (RYGBP), the independent predictors of stricture, and clinical outcomes with and without a stricture. Univariate and multivariate analysis of peri-operative and outcomes data were prospectively collected from 379 morbidly obese patients who underwent consecutive open or laparoscopic RYGBP from January 2003 to August 2006. Predictors studied were age, gender, BMI, co-morbidities, surgical technique (hand-sewn vs linear stapler vs 21-mm vs 25-mm circular stapler; open vs laparoscopic; retrocolic retrogastric vs antecolic antegastric Roux limb course, and Roux limb length), and surgeon experience. Outcomes studied consisted of occurrence of GJ strictures, technical details and outcomes after endoscopic therapy, and excess weight loss (EWL) at 12 months. 15 patients (4.1%) developed a GJ stricture. The use of a 21-mm circular stapler was identified as the only independent predictor of a GJ stricture (odds ratio 11.3; 95% CI 2.2-57.4, P = 0.004). Endoscopic dilation relieved stricture symptoms in all patients (60% one dilation only). There was no significant difference in %EWL at 12 months between the patients with a stricture (median EWL 54%, IQR 49 – 63) vs those without a stricture (median EWL 61%, IQR 49-73, P = 0.33). The rate of GJ strictures is 4.1%. The use of a 21-mm circular stapler is the only independent predictor of GJ stricture. Endoscopic dilation relieved symptoms in all patients.Weight loss is independent of the anastomotic technique used and occurrence of a GJ stricture.

A higher incidence of gastrojejunal (GJ) anastomotic strictures has been reported following laparoscopic gastric bypass (LRYGB) with the 21 mm compared to 25 mm circular stapler. We hypothesized that the rate of stricture formation is affected by route of anvil insertion and its position relative to the gastric pouch staple line [trans‐gastric above staple line (trans‐gastric) vs. trans‐oral through staple line (trans‐oral)] following LRYGB. Retrospective review of consecutive patients who underwent LRYGB with circular stapled GJ studied in four groups: trans-gastric‐21 mm, trans-gastric‐25 mm, trans-oral‐21 mm, and trans-oral-25 mm. Primary outcome studied was GJ stricture; secondary outcomes were results with endoscopic therapy and weight loss at 12 months. Predictors studied were age, gender, body mass index (BMI), comorbidities, and operative technical factors including anvil size and insertion route. Regression analyses were performed to identify predictors of GJ stricture. Eight hundred seventy-six patients underwent LRYGB. Seventy-six (8.7 %) developed a GJ stricture. The highest stricture rate occurred in the trans-gastric‐21 mm group (17 %, p