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The application of a robotic platform in the bariatric surgical field is intended to enhance the already established advantages of minimally invasive surgery in terms of both technical and clinical outcomes. These advantages are especially relevant for technically challenging multiquadrant operations such as Roux-en-Y Gastric Bypass (RYGB). Consequently, robotic-assisted surgery has emerged as a possible application for bariatric surgeries. The study attempts to assess feasibility and safety of the Hugo ™ -Robotic-Assisted Surgery System (Hugo ™ -RAS) platform compared to the DaVinci ® Surgical System (DaVinci ® -SS) with a focus on complication rates and operative times. We retrospectively reviewed bariatric procedures performed from January 2013 until December 2023. We included all robotic RYGBs performed using Hugo ™ -RAS and DaVinci ® -SS platforms. The study utilized Propensity Score Matching (PSM) analysis to address bias in selection, matching patients based on age, gender, body mass index, comorbidities and past abdominal operations. One hundred thirty-five patients were identified: 90 DaVinci ® -SS and 45 Hugo ™ -RAS procedures. After PSM, each group consisted of 45 patients. There was no discernible disparity observed in relation to early (≤ 30 days) postoperative complications rate (p = 1), mean operative time (for docking time, console time and total operative time: p = 0.176, p = 0.678, p = 0.229, respectively) and postoperative hospital stay (p = 0.052) between DaVinci ® -RSS and Hugo ™ -RAS procedures. Our results suggest that application of both Hugo ™ -RAS and DaVinci ® -SS robotic platforms to RYGB is related to comparable safety profiles. Although DaVinci ® -SS remains the most widely adopted platform in clinical practice, this study underscores the potential role of the Hugo ™ -RAS to provide effective solutions in robotic bariatric procedures., (© 2024. The Author(s).)

Purpose: Sleeve Gastrectomy (SG) is the most performed bariatric surgery, but a considerable number of patients may require revisional procedures for suboptimal clinical response/recurrence of weight (SCR/RoW). Conversion options include One-Anastomosis Gastric Bypass (OAGB) and Single Anastomosis Duodeno-Ileal Bypass (SADI). The study aims to compare SADI vs. OAGB as revisional procedures in terms of early and mid-term complications, operative time, postoperative hospital stay and clinical outcomes., Methods: All patients who underwent OAGB or SADI as revisional procedures following SG for SCR/RoW at three high-volume bariatric centers between January 2014 and April 2021 were included. Propensity score matching (PSM) analysis was performed. Demographic, operative, and postoperative outcomes of the two groups were compared., Results: One hundred and sixty-eight patients were identified. After PSM, the two groups included 42 OAGB and 42 SADI patients. Early (≤ 30 days) postoperative complications rate did not differ significantly between OAGB and SADI groups (3 bleedings vs. 0, p = 0.241). Mid-term (within 2 years) complications rate was significantly higher in the OAGB group (21.4% vs. 2.4%, p = 0.007), mainly anastomotic complications and reflux disease (12% of OAGBs). Seven OAGB patients required conversion to another procedure (Roux-en-Y Gastric Bypass-RYGB) vs. none among the SADI patients (p = 0.006)., Conclusions: SADI and OAGB are both effective as revisional procedures for SCR/RoW after SG. OAGB is associated with a significantly higher rate of mid-term complications and a not negligible rate of conversion (RYGB). Larger studies are necessary to draw definitive conclusions., (© 2024. The Author(s).)

Background: Laparoscopic bariatric surgery provides many benefits including lower postoperative pain scores, reduced opioid consumption, shorter hospital stays, and improved quality of recovery. However, the anaesthetic management of obese patients requires caution in determining postoperative risk and in planning adequate postoperative pathways. Currently, there are no specific indications for intensive care unit (ICU) admission in this surgical population and most decisions are made on a case-by-case basis. The aim of this study is to investigate whether Obesity Surgery Mortality Risk Score (OS-MRS) is able to predict ICU admission in patients undergoing laparoscopic bariatric surgery (LBS). Methods : We retrospectively reviewed data of patients who underwent LBS during a 2-year period (2017-2019). The collected data included demographics, comorbidities and surgery-related variables. Postoperative ICU admission was decided via bariatric anaesthesiologists' evaluations, based on the high risk of postoperative cardiac or respiratory complications. Anaesthesia protocol was standardized. Logistic regression was used for statistical analysis. Results: ICU admission was required in 2% ( n = 15) of the 763 patients. The intermediate risk group of the OS-MRS was detected in 84% of patients, while the American Society of Anaesthesiologists class III was reported in 80% of patients. A greater OS-MRS ( p = 0.01), advanced age ( p = 0.04), male gender ( p = 0.001), longer duration of surgery ( p = 0.0001), increased number of patient comorbidities ( p = 0.002), and previous abdominal surgeries ( p = 0.003) were predictive factors for ICU admission. Conclusions: ICU admission in obese patients undergoing LBS is predicted by OS-MRS together with age, male gender, number of comorbidities, previous abdominal surgeries, and duration of surgery., Competing Interests: The authors declare no conflicts of interest.

The increased operative time and costs represent the main limitations of robotic technology application to bariatric surgery. Robotic platforms may help the surgeon to overcome the technical difficulties in super-obese (SO, BMI ≥ 50 kg/m 2 ) patients, in which multi-quadrant operations could be challenging. We aimed to evaluate the effect of robot-assisted (R) versus laparoscopic (L) approaches in Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S) and Roux-en-Y Gastric Bypass (RYGB) in SO and Super-Super Obese (SSO, BMI ≥ 60 kg/m 2 ) patients in terms of outcomes and cost-effectiveness. Bariatric procedures performed from 2012 to 2023 were retrospectively reviewed. The inclusion criteria were BMI ≥ 50 kg/m 2 , primary SADI-S or RYGB. Operative time (OT), early complications, post-operative stay (POS), overall costs and follow-up data were analyzed. A subgroup analysis for surgical procedures and SSO patients was also performed. Among 4596 patients, 174 RYGB and 91 SADI-S in BMI ≥ 50 kg/m 2 patients were selected. After Propensity Score Matching analysis, two groups of patients were identified (laparoscopic and robot-assisted), each one composed of 18 RYGB and 26 SADI-S. Intraoperative and post-operative complication rates and POS were comparable. Mean OT was longer in robotic procedures compared with laparoscopy (199.1 ± 65.7 and 109.5 ± 39.1 min, respectively, p < 0.001). The difference in OT was eliminated after only SSO patients were included in the analysis (172.7 ± 24.1 vs 152.6 ± 26.2 min for R-SADI-S and L-SADI-S, respectively, p = 0.107). Robotic surgeries were associated with higher costs (8134.6 ± 1886.7 and 2386.7 ± 388.2 € in R-RYGB and L-RYGB, respectively; 7996.6 ± 873.1 and 3954.6 ± 631.1 € in R-SADI-S and L-SADI-S). Despite increased costs, robotic approach may represent an added value in more complex cases such as SSO patients., (© 2024. The Author(s).)

Robotic assisted surgery is a rapidly developing field in bariatric surgery. Its wide diffusion has led to the development and standardisation of robotic assisted approaches for various bariatric operations. However, further application has been limited thus far due to issues of cost-effectiveness and accessibility. The introduction of new robotic platforms may help overcome those obstacles. In this study, we present the first fifteen cases of Roux-en-Y Gastric Bypass (RYGB) operations performed with the new Hugo™ RAS system (Medtronic, Minneapolis, MN, USA). From January to March 2023, consecutive patients scheduled for minimal invasive Roux-en-Y-Bypass were randomly selected and underwent the procedure robotic-assisted with the new platform. No exclusion criteria were applied. Seven female and eight male patients with a median BMI of 42 (range: 36-50) and obesity-related comorbidities in eight cases underwent RYGB. The median docking time was 7 min (range: 6-8.5) and the median console time was 100 min (range: 70-150). Procedures were performed without intraoperative complications and no conversion to laparoscopy or open surgery was noted. Operative times were indicative of a steep learning curve. No early post-operative complications were observed. Based on our initial experience, RYGB with the Hugo™ RAS system is promising and may be integrated in established robotic programmes without requiring a long adaptation period., (© 2023. The Author(s).)

Introduction: Robotic assisted surgery is a rapidly developing field of minimally invasive bariatric surgery in the last 20 years. Its wide diffusion has led to the development and standardization of robotic assisted approaches for bariatric operations. In this study, we present the first four Roux-en-Y Gastric Bypass (RYGB) operations performed with the new Hugo™ RAS system (Medtronic, Minneapolis, MN, USA)., Methods: In January and February 2023, 4 consecutive patients scheduled for minimal invasive Roux-en-Y-Bypass were selected and underwent the procedure robotic-assisted with the new platform. No exclusion criteria were applied., Results: Four patients, two females and two males, underwent RYGB with a median BMI of 40 Kg/m 2 (range: 36-46) and diabetes mellitus in two cases. The median docking time was 8 min (range: 7-8.5) and the median console time was 127.5 min (range: 95-150). A description of the operating theatre, robotic arms and docking setup is provided. Procedures were performed without intraoperative complications and no conversion to laparoscopy or open surgery was noted. No additional ports were needed to be placed. System's function and docking were uneventful. No early post-operative complications were observed., Conclusions: Based on our initial experience, RYGB with the Hugo™ RAS system is feasible. This study provides the configurations necessary to perform RYGB with the Hugo™ RAS system as well as general information and insights from our preliminary experience., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Raffaelli, Voloudakis, Pennestrì, Gallucci, Modesti, Salvi, Greco and Ciccoritti.)

Introduction: Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy (SADI-S), like other hypoabsorptive procedures, could be burdened by long-term nutritional deficiencies such as malnutrition, anemia, hypocalcemia, and hyperparathyroidism., Objectives: We aimed to report our experience in terms of mid-term (2 years) bariatric, nutritional, and metabolic results in patients who underwent SADI-S both as a primary or revisional procedure., Methods: One hundred twenty-one patients were scheduled for SADI-S as a primary or revisional procedure from July 2016 to February 2020 and completed at least 2 years of follow-up. Demographic features, bariatric, nutritional, and metabolic results were analyzed during a stepped follow-up at 3 months, 6 months, 1 year and 2 years., Results: Sixty-six patients (47 female and 19 male) were included. The median preoperative BMI was 53 (48-58) kg/m 2 . Comorbidities were reported in 48 (72.7%) patients. At 2 years, patients had a median BMI of 27 (27-31) kg/m 2 ( p < 0.001) with a median %EWL of 85.3% (72.1-96.1), a TWL of 75 (49-100) kg, and a %TWL of 50.9% (40.7-56.9). The complete remission rate was 87.5% for type 2 diabetes mellitus, 83.3% for obstructive sleep apnea syndrome and 64.5% for hypertension. The main nutritional deficiencies post SADI-S were vitamin D (31.82%) and folic acid deficiencies (9.09%)., Conclusion: SADI-S could be considered as an efficient and safe procedure with regard to nutritional status, at least in mid-term (2 years) results. It represents a promising bariatric procedure because of the excellent metabolic and bariatric outcomes with acceptable nutritional deficiency rates. Nevertheless, larger studies with longer follow-ups are necessary to draw definitive conclusions.

Biliopancreatic diversion with duodenal switch and single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) are technically demanding hypo-absorptive bariatric procedures. They are often indicated in superobese patients (BMI ≥ 50 kg/m 2 ), as robotic platform could improve ergonomics against a thick abdominal wall, preventing bending of instruments and simplifying hand-sewn anastomoses. We aimed to report our experience with robotic SADI-S (R-group) and to compare outcomes with the laparoscopic (L-group) approach. Among 2143 patients who underwent bariatric procedures at our institution between July 2016 and June 2021, 116 (5.4%) consenting patients were scheduled for SADI-S as primary or revisional procedure: 94 L-group, 22 R-group. R-group and L-group patients were matched using PSM analysis to overcome patients selection bias. Postoperative complications, operative time (OT), post-operative stay (POS) and follow-up data were compared. After PSM, 44 patients (22 patients for each group) were compared (Chi-square 0.317, p = 0.985). Median age, gender, median BMI, preoperative rates of comorbidities, previous abdominal bariatric and non-bariatric surgeries and type of surgical procedures (SADI-S/SADI) were comparable. Median OT was shorter in the L-group (130 Vs 191 min, p < 0.001). 30-days' re-operative complications and late complications rates were comparable. At 25-months' mean follow-up, the median Percentage Excess Weight Loss (72%) was comparable between the groups (p = 0.989). L-group and R-group were comparable in terms of re-operative complication rate and short-term outcomes. The robotic platform may increase the rate of single step procedure in challenging cases. Larger studies with longer follow-up and cost-analysis are necessary to draw definitive conclusions., (© 2022. The Author(s).)

Aim: To investigate the prevalence of biopsy-proven non-alcoholic steatohepatitis (NASH) in a cohort of patients with morbid obesity and with or without type 2 diabetes (T2D) and to find non-invasive predictors of NASH severity., Methods: We evaluated a cohort of 412 subjects (age 19-67 years, body mass index-BMI: 44.98 kg/m 2 ), who underwent fine-needle liver biopsy during bariatric surgery. Thirty-six percent of the subjects were affected by T2D. Liver biopsies were classified according to the Kleiner's NAFLD Activity Score (NAS). NAFLD Fibrosis Score (NFS), AST/ALT ratio, AST to Platelet ratio (APRI), fibrosis-4 score (FIB4) were calculated. A neural network analysis (NNA) was run to predict NASH severity., Results: The prevalence of biopsy-proven NASH was 63% and 78% in subjects with obesity and without or with T2D, respectively. T2D doubled the risk of NASH [OR 2.079 (95% IC=1.31-3.29)]. The prevalence of NAFL increased with the increase of BMI, while there was an inverse correlation between BMI and NASH (r=-0.145 p=0.003). Only mild liver fibrosis was observed. HOMA-IR was positively associated with hepatocyte ballooning (r=0.208, p<0.0001) and fibrosis (r=0.159, p=0.008). The NNA highlighted a specificity of 77.3% using HDL-cholesterol, BMI, and HOMA-IR as main determinants of NASH., Conclusions: Our data show a higher prevalence of NASH in patients with morbid obesity than reported in the literature and the pivotal role of T2D among the risk factors for NASH development. However, the inverse correlation observed between BMI and biopsy-proven NASH suggests that over a certain threshold adiposity can be somewhat protective against liver damage. Our model predicts NASH presence with high specificity, thus helping identifying subjects who should promptly undergo liver biopsy., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Purpose: Biliopancreatic diversion with duodenal switch and single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) are technically demanding hypo-absorptive bariatric procedures generally indicated in super-obese patients (BMI ≥ 50 kg/m 2 ). Data from the literature prove the procedure to be safe and effective, with promising bariatric and metabolic effects. Anyway, international societies support the creation of multicentric national and international registries to obtain more homogeneous data over the long period. We aimed to report our experience with this procedure., Methods: Among 2313 patients who underwent bariatric procedures at our institution, between July 2016 and August 2021, 121 (5.2%) consenting patients were scheduled for SADI-S as primary (SADIS) or revisional procedure after sleeve gastrectomy (SADI) (respectively 87 and 34 patients). Early and late post-operative complications, operative time, post-operative stay, and follow-up data were analyzed., Results: Overall, the median preoperative BMI was 52.3 (48.75-57.05) kg/m 2 with a median age of 44 (39-51) years, the median operative time was 120 (100-155) min. Complications at 30th-day post-op were registered in 4 (3.3%) patients and late complications in 4 (3.3%) patients. At a median follow-up of 31 (14-39) months, the median percentage excess weight loss was 79.8 (55.15-91.45)%, and the median total weight loss was 57.0650 (43.3925-71.3475)%., Conclusion: Our data, coherently with the literature, confirm that SADI-S is a safe, effective procedure with acceptable complications rate. Larger studies with longer follow-ups are necessary to draw definitive conclusions., (© 2022. The Author(s).)

Background: Thyroid lobectomy is the preferred option for small, unifocal papillary thyroid carcinoma. Involvement of the central neck lymph nodes is an indication for total thyroidectomy plus central neck dissection. We aimed to verify if frozen section examination of ipsilateral central neck nodes can identify the subgroup of patients scheduled for thyroid lobectomy intraoperatively who could benefit of more extensive initial operative treatment., Methods: Ninety-four consenting patients with clinically unifocal cN0 papillary thyroid carcinoma underwent thyroid lobectomy plus ipsilateral central neck dissection with frozen section examination. If the frozen section examination was positive for metastases, a completion thyroidectomy and a bilateral central neck dissection were accomplished during the same procedure., Results: Frozen section examination identified occult nodal metastases in 25 of the 94 patients who then underwent immediate completion thyroidectomy and bilateral central neck dissection. Overall, central neck node metastases were found at final histology in 35 cases: occult micrometastases were observed in additional 9 patients and nodal metastases ≥2 mm in additional 1 patient., Conclusion: Intraoperative assessment of nodal status obtained with ipsilateral central neck dissection and frozen section examination is able to change the extent of thyroidectomy in about one-fourth of patients scheduled for thyroid lobectomy. Frozen section examination appears a safe and effective strategy to decrease the need of a second-step completion procedure and, theoretically, the risk of recurrence., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Internal hernia (IH) represents a delayed complication of the laparoscopic Roux-en-Y gastric bypass (LRYGB) and it is historically difficult to identify preoperatively. Numerous CT signs were considered suggestive of IH but none of them is pathognomonic. In this study, we aim to evaluate the accuracy of CT in diagnosing IH, differentiating from non-specific abdominal pain. This can lead to a way of personalized medicine and improve the outcome of anti-obesity treatments. We retrospectively reviewed CT scans of 50 patients previously subjected to LRYGB procedure, with a clinical suspicion of IH. 3 groups of patients were identified: IH group (21 patients with a surgical confirmed IH), negative group (12 patients in whom IH was not confirmed at surgery), and control group (17 patients who were not surgically explored because of low/no suspicion of IH). We divided CT signs into three groups: "bowel loop signs", "vessel signs", and "venous congestion/stasis signs". The accuracy of CT in detecting IH was tested by comparing each sign, either individually or in combination, with the surgical findings. Statistical analysis showed that "vessel signs" (swirl sign, superior mesenteric vein beaking, mesenteric arteries, and veins branches inversion) present the highest distribution in patients with IH demonstrated at surgery, with a higher accuracy in case of simultaneous presence of two or three signs. CT imaging is highly accurate in diagnosing IH. Despite no single sign being pathognomonic, the combination of two or more signs, especially among the "vessels signs", can suggest the IH, even in pauci-symptomatic patients.

Concerns still exist regarding the role of early routine upper gastrointestinal contrast study (UGI) after bariatric procedures for detection of early complications. We reviewed our database to identify patients who underwent laparoscopic primary or redo surgery (previously placement of adjustable gastric banding), between January 2012 and December 2017. All the patients underwent UGI within 48 h after surgery. Among 1094 patients, early UGI was abnormal in 5 patients: in 4 cases a leak (one false positive) and in one case stenosis (one true positive) were suspected. In this clinical setting, five leaks were observed and required surgical re-exploration: 3 correctly identified and 2 not detected at UGI. Overall, 3 patients developed anastomotic stenosis. Our data suggest that early routine UGI after bariatric procedures has limited utility.

Purpose: Chylorrhea resulting from injury of the lymphatic system during neck dissection is a well-known complication. It is an uncommon occurrence in spinal surgery, and only one case after right anterior cervical spine surgery has been described so far. Despite its rarity, chylous leakage deserves a particular attention since it may become a serious and occasionally fatal complication if not detected early and managed appropriately., Methods: We report the case of a 42-year-old man who underwent a standard anterior cervical discectomy and fusion according to Cloward approach for a C6-C7 disk herniation. The patient developed a delayed prevertebral chyle collection on postoperative day 5, presenting with mild breathing and swallowing difficulties., Results: He was managed with conservative care, including bed rest, low-fat diet and drainage pouch positioning, which led to the complete resolution of the fluid collection., Conclusions: Knowledge of the normal anatomy of the lymphatic system and of its variations is essential when planning an anterior spinal procedure, and represents the first measure to be adopted in order to avoid such complication. The prompt identification of a postoperative chylous fistula and the applicability of an individually based management's protocol may help in the majority of the cases to reduce the potential morbidity, without significant long-term effects.

The use of barbed sutures for constructing an anastomosis is favoured by a few bariatric surgeons as compared to conventional sutures. The aim of this study is to assess safety and efficacy of barbed sutures to close the gastric pouch-jejunal anastomosis (GPJA) in laparoscopic gastric bypass (Roux-en-Y gastric bypass-RYGB, and One-Anastomosis gastric bypass-OAGB) using propensity score-matching (PSM) analysis. A retrospective analysis of patients who underwent primary laparoscopic gastric bypasses between January 2012 and December 2017 was performed. Patients were divided into two different groups (RYGB-G and OAGB-G). PSM analysis was performed to minimize patient selection bias between the two types of sutures (barbed-BS and conventional-CS) in each group. A total of 808 patients were reviewed. After PSM, 488 (244 BS vs 244 CS) patients in RYGB-G and 48 in OAGB-G (24 BS vs 24 CS) patients were compared. Median operative time was significantly shorter (p < 0.001) for BS in RYGB-G. In OAGB-G, BS were associated with a shorter operative time, although no significant difference was observed (p = 0.183). Post-operative hospital stay was significantly shorter for BS in both the groups (p < 0.001). Post-operative 30th-day complications were comparable: no leakage or bleeding of GPJA was observed in BS groups. At median follow-up of 28.78 months, no late complications were observed. Barbed sutures appear to be effective to close GPJA during gastric bypass and as safe as conventional suture. Further studies are necessary to draw definitive conclusions.

Background: Several authors have demonstrated the safety and feasibility of laparoscopy in selected cases of abdominal emergencies. The aim of the study was to analyse the current Italian practice on the use of laparoscopy in abdominal emergencies and to evaluate the impact of the 2012 national guidelines on the daily surgical activity., Methods: Two surveys (42 closed-ended questions) on the use of laparoscopy in acute abdomen were conducted nationwide with an online questionnaire, respectively, before (2010) and after (2014) the national guidelines publication. Data from two surveys were compared using Chi-square or Fisher's exact test, and data were considered significant when p < 0.05., Results: Two-hundred and one and 234 surgical units answered to the surveys in 2010 and 2014, respectively. Out of 144,310 and 127,013 overall surgical procedures, 23,407 and 20,102, respectively, were abdominal emergency operations. Respectively 24.74 % (in 2010) versus 30.27 % (in 2014) of these emergency procedures were approached laparoscopically, p = 0.42. The adoption of laparoscopy increased in all the considered clinical scenarios, with statistical significance in acute appendicitis (44 vs. 64.7 %; p = 0.004). The percentage of units approaching Hinchey III acute diverticulitis with laparoscopy in 26-75 % of cases (14.0 vs. 29.7 %; p = 0.009), those with >25 % of surgeons confident with laparoscopic approach to acute diverticulitis (29.9 vs. 54 %; p = 0.0009), the units with >50 % of surgeons confident with laparoscopic approach to acute appendicitis, cholecystitis and perforated duodenal ulcer, all significantly increased in the time frame. The majority of respondents declared that the 2012 national guidelines influenced their clinical practice., Conclusions: The surveys showed an increasing use of laparoscopy for patients with abdominal emergencies. The 2012 national guidelines profoundly influenced the Italian surgical practice in the laparoscopic approach to the acute abdomen.