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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).)

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: 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).)

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.