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Background Bariatric surgery can influence the presentation, diagnosis, and management of gastrointestinal cancers. Oesophago-Gastric (OG) malignancies in patients who have had a prior bariatric procedure have not been fully characterised. Objective To characterise OG malignancies after bariatric procedures. Setting University Hospital, United Kingdom. Methods We performed a retrospective, multi-centre observational study of patients with OG malignancies after bariatric surgery to characterise this condition. Results This study includes 170 patients from 75 centres in 25 countries who underwent bariatric procedures between 1985 and 2020. At the time of the bariatric procedure, the mean age was 50.2 ± 10 years and the mean weight 128.8 ± 28.9 kg. Females comprised 57.3% (n=98) of the population. Most (n=64) patients underwent a Roux-en-Y Gastric Bypass (RYGB) followed by Adjustable Gastric Band (AGB) (n = 46) and Sleeve Gastrectomy (SG) (n = 43). Time to cancer diagnosis after bariatric surgery was 9.5 ± 7.4 years and mean weight at diagnosis was 87.4 ± 21.9 kg. The time lag was 5.9 ± 4.1 years after SG compared to 9.4 ± 7.1 years after RYGB and 10.5 ± 5.7 years after AGB. One-third of patients presented with metastatic disease. The majority of tumours were adenocarcinoma (82.9%). Approximately 1 in 5 patients underwent palliative treatment from the outset. Time from diagnosis to mortality was under one year for most patients who died over the intervening period. Conclusions The OGMOS (Oesophago-Gastric Malignancies after Obesity/ Bariatric Surgery) study presents the largest series to date of patients developing OG malignancies after bariatric surgery and attempts to characterise this condition.

BackgroundObesity is one of the most important health-related problems of the twenty-first century. Data on its prevalence in Austria remain scarce. Aim of this study was to determine current trends of overweight and obesity, associated comorbidities and socioeconomic status in all 18-year-old male Austrian citizens, and its potential impact on the demand for bariatric surgery in the future.MethodsData from compulsory military conscription examinations in all 18-year-old males from 2003 to 2018 were obtained from the Federal ministry of Defense’s database. Measurements of height, weight, and subsequent body mass index (BMI) calculations in 874, 220 adolescents were subdivided into yearly cohorts. Comorbidities, educational status, and nicotine abuse were evaluated.ResultsMean BMI increased from 22.0 ± 3.95 kg/m2in 2003 to 22.8 ± 4.69 kg/m2in 2018 (p p p p ConclusionsBMI and cardiovascular risk steadily increased over the last 15 years in Austrian male adolescents. A significant shift from normal weight to overweight was observed, while higher obesity classes doubled over this observational period. This study also revealed a significant association of BMI and lower educational status.Graphical AbstractTrends of overweight and obesity in male adolescents: prevalence, socio-economic status and impact on cardiovascular risk in a central European country

Surgery, like other fields of medicine, has not been spared by a number of unfortunate phenomena. Although our perception may point at recent times, some trends can actually be traced back to 1979. Cohen and Rothschild stated that even when medical progress is extraordinary, the path has too often been driven by overwhelming acceptance of popular albeit unproven ideas. These are referred to as bandwagons. Some of such ideas were eventually proven as valid, but more often were abandoned and/or replaced by new bandwagons. In the specific case of colorectal surgery, there are at least five currently ongoing bandwagons: 1) laparoscopic lavage of perforated colon; 2) laparoscopic ventral rectopexy; 3) stapled hemorrhoidopexy, also known as procedure for prolapse and hemorrhoids (PPH); 4) watch and wait; 5) transanal total mesorectal excision (taTME). Preventing bandwagons from taking off requires efforts at different levels: 1) innovators must constrain their self-interest of fame and rather recognize the need for establishing evidence to support their ideas; 2) new treatment modalities must be carefully weighed by sufficiently powered clinical trials prior to been implemented on patients; 3) the media should not mislead patients into the "best" treatment without reliable evidence; 4) physicians should keep in mind that the process of innovation in medicine is slow and disregard the temptation to accept at face value perhaps plausible, yet unproven ideas.

Gallbladder cancer is a rare, aggressive malignancy that has a poor overall prognosis. Effective treatment consists of early detection and surgical treatment. With the wide spread treatment of gallbladder disease with minimally invasive techniques, the rate of incidental gallbladder cancer has seen an equitable rise along with stage migration towards earlier disease. Although the treatment remains mostly surgical, newer modalities such as regional therapy as well as directed therapy based on molecular medicine has led to improved outcomes in patients with advanced disease. We aim to summarize the management of gallbladder cancer along with the newer developments in this formidable disease process.

Laparoscopic Roux-en-Y Gastric Bypass (RYGB) is a commonly used method in bariatric surgery that leads to sufficient long-term weight loss and consequently to improvement or resolution of obesity-associated diseases. The nadir weight is commonly reached between six months and two years after surgery. Despite this initially good weight loss, weight regain is observed in up to 20% of the patients. Besides intensive dietological evaluation, bariatric re-operation can be an option in these cases. Before the surgical reintervention, an intensive evaluation of the esophagus, pouch, anastomosis, and adjacent small bowel using upper GI-endoscopy and radiological examinations (X-ray and/or 3D-CT volumetry) is mandatory. In patients with a dilated pouch, pouch-resizing with a MiniMIZER® Gastric Ring (Bariatric Solutions GmbH, Stein am Rhein, Switzerland) could be an option to reestablish restriction in the long term. Currently, there is no gold standard for the choice of the weight regain procedure or for the technique used in the procedure itself. This article focuses on the standardized procedure of pouch resizing with implantation of a MiniMIZER® Gastric Ring for the surgical therapy of weight regain due to pouch dilatation and/or dilatation of the gastrojejunostomy and the adjacent small bowel (usually approximately the first 20cm), resulting in a huge neo-stomach after RYGB, as performed at the Medical University of Vienna. Further, indications for revisional surgery for weight regain, mandatory examinations, and recommended conservative therapy options prior to surgery will be described. Next, the fast-track concept and its advantages are explained. Lastly, the surgical procedure, including positioning of the patient, placement of trocars, the intraoperative process, and special advice, is presented. Exact planning of the procedure and postoperative follow-up are indispensable for a further long-term success after weight regain surgery. In conclusion, pouch-resizing and implantation of the MiniMIZER® Gastric Ring represent a practical and effective solution in patients with dilated pouch/anastomosis/adjacent small bowel with weight regain after RYGB, if conservative therapy, including dietitian counseling and new drugs (e.g., Semaglutide), has failed.

Neuroendocrine neoplasms (NENs) of the gallbladder are very rare. As a result, the classification of pathologic specimens from gallbladder NENs, currently classified as gallbladder neuroendocrine tumors (GB-NETs) and carcinomas (GB-NECs), is inconsistent and makes nomenclature, classification, and management difficult. Our study aims to evaluate the epidemiological trend, tumor biology, and outcomes of GB-NET and GB-NEC over the last 5 decades. This is a retrospective analysis of the SEER database from 1973 to 2016. The epidemiological trend was analyzed using the age-adjusted Joinpoint regression analysis. Survival was assessed with Kaplan–Meier analysis and Cox regression was used to assess predictors of poor survival. A total of 482 patients with GB-NEN were identified. Mean age at diagnosis was 65.2 ± 14.3 years. Females outnumbered males (65.6% vs. 34.4%). The Joinpoint nationwide trend analysis showed a 7% increase per year from 1973 to 2016. The mean survival time after diagnosis of GB-NEN was 37.11 ± 55.3 months. The most common pattern of nodal distribution was N0 (50.2%) followed by N1 (30.9%) and N2 (19.2%). Advanced tumor spread (into the liver, regional, and distant metastasis) was seen in 60.3% of patients. Patients who underwent surgery had a significant survival advantage (111.0 ± 8.3 vs. 8.3 ± 1.2 months, p

Currently, 4.8% of bariatric operations worldwide are one-anastomosis gastric bypass (OAGB) procedures. If a hiatal hernia is detected in a preoperative gastroscopy, OAGB can be combined with hiatoplasty. Intrathoracic pouch migration (ITM) is common after bypass procedures because the fundus, a natural abutment, is separated from the pouch.The aim of this study was to find out whether OAGB or OAGB combined with hiatoplasty carries a higher risk of ITM and, therefore, also gastroesophageal reflux disease (GERD).University hospital.Fifty patients (group 1: 25× primary OAGB; group 2: 25× primary OAGB with hiatoplasty) were included in this study. History of weight, GERD, and quality of life were recorded in patient interviews and pouch volume and ITM were evaluated using 3-dimensional-computed tomography volumetry.There were no differences in terms of patient characteristics, history of weight, pouch volume, or quality of life between both groups. ITM was found in group 1 in 60% (n = 15) and group 2 in 76% (n = 19) of all patients (P = .152). The ITM mean length was significantly lower in group 1 with .9 ± 1.1 cm than in group 2 with 1.8 ± 1.2 cm (P = .007). Regarding GERD, there was no difference between both groups; nevertheless, significantly more patients with ITM (38.2%; n = 13) had GERD compared with patients without ITM (6.3%; n = 1).In primary OAGB, an additional hiatoplasty was not associated with higher rates of ITM or GERD; nevertheless, the length of ITM was higher after hiatoplasty. If ITM occurs, patients have a risk of developing GERD.

Laparoscopic Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S) is a bariatric/metabolic procedure that has been gaining popularity in recent years. SADI-S strongly affects the secretion of various gut hormones, adipocytokines and incretins. From a mechanistic point of view, the operation combines malabsorption and restriction, and has been shown to have a long-lasting and significant impact on weight loss and remission of comorbidities. With regard to the technique, first, a Sleeve is created and then the duodenum is tran-sected approximately 3-4cm after the pylorus at the level of the gastroduodenal artery (GDA). Next, 250-300cm of small bowel is measured from the caecum and a hand-sewn duo-deno-ileal anastomosis is performed. The length of the biliopancreatic limb is variable in this procedure. Because of the standardized common limb length in all patients, weight loss is very precise within a low range. Nevertheless, due to the complex hand-sewn anastomosis and the delicacy necessary when handling the duodenum, this procedure should be reserved for experienced bariatric surgeons in specialized centers. This article provides an overview of the standard surgical technique at the Department of Visceral Surgery at the Medical University of Vienna, as well as information about patient selection and pre- and postoperative care.

Purpose Since 2014, sleeve gastrectomy (SG) has been the most frequently performed bariatric-metabolic operation worldwide (2018: 386,096). There are only a few studies reporting a long-term follow-up (up to 11 years) available today. The aim of this study was to evaluate the long-term outcome of SG with a follow-up of at least 15 years regarding weight loss, remission of associated medical problems (AMP), conversions, and quality of life (QOL). Setting Multicenter cross-sectional study; university hospital. Methods This study includes all patients who had SG before 2005 at the participating bariatric centers. History of weight, AMP, conversions, and QOL were evaluated by interview at our bariatric center. Results Fifty-three patients met the inclusion criteria of a minimal follow-up of 15 years. Weight and body mass index at the time of the SG were 136.8kg and 48.7kg/m2. Twenty-six patients (49.1%) were converted to Roux-en-Y gastric bypass (RYGB) for weight regain and gastroesophageal reflux within the follow-up period. Total weight loss after 15 years was 31.5% in the non-converted group and 32.9% in the converted group. Remission rates of AMP and QOL were stable over the follow-up period. Conclusion Fifteen years after SG, a stable postoperative weight was observed at the cost of a high conversion rate. Patients converted to RYGB were able to achieve further weight loss and preserve good remission rates of AMP. SG in patients without the need of a conversion to another bariatric-metabolic procedure may be considered effective. Careful preoperative patient selection is mandatory when performing SG. Graphical abstract

ZusammenfassungAdipositas und damit einhergehende Komorbiditäten wie Diabetes mellitus Typ 2 (DMII), arterielle Hypertonie, Schlafapnoe, Erkrankungen des Bewegungsapparates usw. nehmen weltweit stetig zu. Bariatrische/metabolische Operationen stellen die bei Weitem effizienteste Methode dar, um langfristig Gewicht zu reduzieren und Komorbiditäten zu verbessern bzw. komplett in Remission zu bringen. Die Wirkungsmechanismen dieser Eingriffe umfassen neben Malabsorption und/oder Restriktion eine veränderte Ausschüttung verschiedener Hormone und Botenstoffe im Körper („gut hormones“, Adipozytokine usw.) sowie Veränderungen von Gallensäuren und des Mikrobioms. Die Indikation zu einer bariatrischen/metabolischen Operation (OP) kann ab einem BMI von ≥ 40 kg/m2 oder von ≥ 35 kg/m2 bei Bestehen mindestens einer der oben genannten Komorbiditäten gestellt werden. Gemäß den aktuellen Richtlinien der Amerikanischen Diabetesgesellschaft (ADA) kann auch schon bei einem BMI ≥ 30 kg/m2 eine OP in Erwägung gezogen werden, wenn bei bestehendem DMII kein suffizienter Gewichtsverlust oder keine glykämische Kontrolle auf konservative Art und Weise erreicht werden kann. Die derzeit am häufigsten durchgeführten bariatrischen/metabolischen Operationsmethoden sind die Sleeve-Gastrektomie (Schlauchmagen), der Y‑Roux-Magenbypass und der One-anastomosis-Magenbypass, wobei die Wahl der Operationsmethode von mehreren Faktoren abhängt und für jeden Patienten individuell entschieden werden sollte. Zur Evaluierung der passenden OP-Methode, zur Abschätzung des Risikos und zur individuellen Vorbereitung des Patienten müssen im Vorfeld der OP verschiedene Untersuchungen durchgeführt werden. Es konnte mittlerweile in vielen Studien gezeigt werden, dass die metabolische Chirurgie sehr sicher ist und die Lebenserwartung sowie die Lebensqualität des Patienten dadurch erheblich verlängert bzw. verbessert werden. Durch metabolische Chirurgie ist es im Langzeitverlauf möglich, neben Gewichtsverlust eine erhebliche Verbesserung/Remission von DMII, kardiovaskulären Erkrankungen, Erkrankungen des Bewegungs- und Stützapparats und Lebererkrankungen zu erreichen sowie das Risiko, an Karzinomen zu erkranken (bzw. daran zu versterben), erheblich zu reduzieren.

Purpose Long-term follow-up after sleeve gastrectomy (SG) revealed a high incidence of gastroesophageal reflux disease (GERD) frequently caused by preoperative silent pathologic reflux. We aimed to evaluate prevalence and phenotypes of GERD in asymptomatic patients with morbid obesity prior to metabolic surgery according to modern objective testing. Material and Methods Prospective collection of data including consecutive patients with morbid obesity (body mass index (BMI) ≥ 35 kg/m2) prior to metabolic surgery was applied for this study between 2014 and 2019. Patients underwent clinical examinations, endoscopy, pH metry, and high-resolution manometry and were analyzed according to the Lyon consensus. Results Of 1379 patients undergoing metabolic surgery, 177 (12.8%, females = 105) asymptomatic individuals with a median age of 42.6 (33.8; 51.6) years and a median BMI of 44.6 (41.3; 50.8) kg/m2 completed objective testing and were included during the study period. GERD was diagnosed in 55 (31.1%), whereas criteria of borderline GERD were met in another 78 (44.1%). GERD was mediated by a structural defective lower esophageal sphincter (p = 0.004) and highlighted by acidic (p = 0.004) and non-acidic (p = 0.022) reflux episodes. Esophageal motility disorders were diagnosed in 35.6% (n = 63) of individuals with a novel hypercontractile disorder found in 7.9% (n = 14) of patients. Conclusion GERD affects a majority of asymptomatic patients with morbid obesity prior to primary bariatric surgery. Future longitudinal trials will have to reveal the clinical significance of esophageal motility disorders in patients with morbid obesity.

The aim of this systematic review was to determine the rates of failure following nonoperative management for acute sigmoid diverticulitis complicated by abscess. Pubmed and Medline were systematically searched by two independent researchers. Studies reporting outcomes of nonoperative management of diverticulitis with abscess revealed on CT scan were included. The endpoint of the study was failure of nonoperative management which included relapse and recurrence. Relapse was defined as development of additional complications such as peritonitis or obstruction that required urgent surgery during index admission or readmission within 30 days. Recurrence was defined as development of symptoms after an asymptomatic period of 30–90 days following nonoperative management. Nonoperative management included nil per os, intravenous fluids and antibiotics, CT-guided percutaneous drainage, and/or total parenteral nutrition. Twenty-four of 844 studies yielded by literature search totaling 12,601 patients were eligible for inclusion. Pooled relapse rate was 18.9%. The pooled rate of recurrence of acute diverticulitis was found to be 25.5%. 60.9% of recurrences were complicated diverticulitis. Failure rate appeared to be significantly increased in patients undergoing percutaneous drainage for distant abscess as compared with pericolic abscess (51% vs. 18%; p = 0.0001). The rate of failure of nonoperative management was 44.4%. The rate of relapse at 30 days following nonoperative management was at 18.9%. Distant abscesses were associated with significantly increased rates of relapse compared with pericolic abscesses. The rate of recurrence following nonoperative management was 25.5% at the mean follow-up of 38 months.

Laparoscopic diverted one-anastomosis gastric bypass (D-OAGB) is a bariatric procedure combining the principles of restriction, malabsorption, and other factors to induce weight loss. It is achieved by creating a narrow, long gastric pouch and bypassing a part of the small bowel (biliopancreatic limb). D-OAGB was first described by Dr. Ribero in 2013 and is technically a variation of the very heterogeneous group of Roux-en-Y gastric bypass operations. There are different technical variants to perform D-OAGB and to organize pre- and postoperative care. The following article is based on the approach to bariatric surgery as taken at the Department of General Surgery at the Medical University of Vienna. This article focuses on patient preparation before bariatric/metabolic surgery with mandatory and optional preoperative examinations to find the surgical procedure best suited for each individual patient and to decrease the patient’s risk. The surgical technique of D-OAGB itself, including positioning of the patient and related technical highlights, as well as the specifics of the postoperative course, are described. D-OAGB is an effective procedure for patients with symptomatic gastroesophageal reflux for adequate weight loss and remission of comorbidities with a low risk of malnutrition. For D-OAGB to be successful, important technical steps, such as creating a narrow, long pouch, exact length of the biliopancreatic and alimentary limb, and additional hiatoplasty (if necessary), should be taken. In terms of the postoperative course, regular checkups are vital to ensure desirable outcome in the long-term follow up and early detection of adverse developments.

The implementation of high-resolution manometry (HRM) and the Lyon Consensus statement facilitate evaluation of gastroesophageal reflux disease and motility disorders in morbidly obese patients. Therefore, we aimed to investigate prevalence and phenotype of (borderline) GERD and esophageal motility disorders in this population. Consecutive morbidly obese (BMI ≥ 35 kg/m2) patients were offered evaluation by means of HRM, ambulatory 24-h pH impedance monitoring, endoscopy, and a clinical examination at our tertiary academic center. Data were collected prospectively. Out of 448 eligible individuals, 147 patients (females = 75, 51%) with a median age of 41.6 (33.4; 52.3) years and a BMI of 44 (40.9; 49.4) kg/m2 were included during the study period. The Chicago Classification revealed motility disorders in 50 (34%) patients, dominated by outflow obstruction (18.4%, n = 27) and a novel disorder (7.5%, n = 11), nicknamed jackhammer esophagus (JE). According to the Lyon Consensus, 52 (35.4%) patients had evidence of true GERD, whereas borderline GERD was noted in another 60 (40.8%). Hypersensitive esophagus was observed in 6.8% (n = 10). Sensitivity and specificity of symptoms for GERD were 53.8% and 68.4%, respectively. The current gold standard of assessment revealed that the prevalence of esophageal motility disorders and (borderline) GERD is high in the morbidly obese population. Further longitudinal data are needed to delineate the natural course of novel motility disorders like JE in obesity and to identify risk factors for adverse outcomes following bariatric surgery.

Objective: Sleeve gastrectomy (SG) has recently become the most commonly applied bariatric procedure worldwide. Substantial regaining of weight or severe reflux might compromise quality of life (QOL) after SG in the long-term follow-up. Long-term data on patients’ QOL is limited, even though the persistent improvement in QOL is one of the aims of bariatric surgery. The objective of this study was to present patients’ QOL 10 years after SG. Methods: Of 65 SG patients with a follow-up of ≥10 years after SG who were asked to fill out the Bariatric Quality of Life Index (BQL) and Short Form 36 (SF36) questionnaires, 48 (74%) completed them. This multicenter study was performed in a university hospital setting in Austria. Results: The BQL score revealed nonsignificant differences between the patients with > 50% or < 50% excess weight loss (EWL). It did show significant differences between patients with and without any symptoms of reflux. Patients with < 50% EWL scored significantly lower in 3/8 categories of SF36. Patients suffering from reflux had significantly lower scores in all categories. Conclusions: EWL and symptomatic reflux impair patients’ long-term QOL after SG.

Background One-anastomosis gastric bypass (OAGB) is a well-established treatment method in patients with morbid obesity. Its long-term impact on de novo reflux, anastomotic complications, and malnutrition needs further evaluation. Roux-en-Y gastric bypass (RYGB) is a technically feasible procedure in revisional bariatric surgery. This study presents our institutional data on conversion from OAGB to RYGB. Objective To determine the reasons for conversion, preoperative endoscopic findings, and feasibility of revisional bariatric surgery after OAGB. Setting University hospital in Austria METHODS: Retrospective analysis of a prospectively fed database. All patients undergoing OAGB between January 2012 and December 2019 were included. Screening was carried out for all patients needing conversion to RYGB. Percent total weight loss, percent excess weight loss, time to conversion, postoperative complications, and reasons for conversion were assessed. Results Eighty-two of 1,025 patients who underwent OAGB were converted laparoscopically to RYGB. Seven patients were converted early because of anastomotic/gastric tube leakage. Median time to late conversion was 29.1 ± 24.3 months, mean percent excess weight loss was 86.6% ± 33.1% and percent total weight loss was 35.1% ± 13.5%. Forty-two patients were converted because of reflux, 11 because of persistent marginal ulcers, 10 because of anastomotic stenosis, 9 because of malnutrition, and 3 because of weight regain. Seven patients showed Barrett's metaplasia in biopsies at the gastroesophageal junction before conversion. Conclusion Laparoscopic conversion from OAGB to RYGB is technically feasible with a moderate rate of postoperative complications. Severe (bile) reflux is a serious long-term complication after OAGB, with 4.1% of patients needing conversion to RYGB. Endoscopy after OAGB in patients showing clinical symptoms of gastroesophageal reflux disease is strongly advised to detect underlying pathologic changes.

Transanal minimally invasive surgery (TAMIS) can be performed robotically assisted (R-TAMIS) for easier rectal defect suture closure particularly on the anterior rectal wall. The surgical technique described in this technical note emphasizes three safety points: 1) decreased likelihood for rectal injury when the ports are inserted into the GelPOINT® Path Transanal Access Platform (Applied Medical, Rancho Santa Margarita, California) on the back table rather than being inserted into the rectum; 2) decreased external collision between ports when using ports of different length; and 3) increased stabilization of pneumorectum when insufflating with an AirSeal™ port (Intelligent Flow System, ConMed, Utica, New York). Although R-TAMIS can be safely performed with the da Vinci® Si® or Xi® (Intuitive Surgical Inc., Sunnyvale, California) patient cart, the following differences are noteworthy: a) the Si® vertically-mounted arms design forces the patient in an uncomfortable position with asymmetrical hip flexion as opposed to the Xi® boom-mounted horizontal arm design; b) the 28cm circumference of each Si® patient cart arms operating between the patient’s legs offer decreased maneuvering freedom as opposed to the 19cm circumference of the Xi® counterparts; and c) the abduction pattern of movement of the Si® arms potentially increases the risk of external collision with the patient’s legs as opposed to the Xi® “jack-knife” pattern of movement.

The aim of this meta-analysis was to evaluate whether robotic pancreaticoduodenectomy (PD) may provide better clinical and pathologic outcomes compared to its open counterpart. The Pubmed, EMBASE, and Cochrane Library were systematically searched. Overall postoperative morbidity and resection margin involvement rate were the primary endpoints. Secondary endpoints included operating time, estimated blood loss (EBL), incisional surgical site infection (SSI) rate, length of hospital stay (LOS), and number of lymph nodes harvested. Twenty-four studies totaling 12,579 patients (2,175 robotic PD and 10,404 open PD were included. Overall postoperative mortality did not significantly differ [OR (95%CI) = 0.86 (0.74, 1.01); p = 0.06]. Resection margin involvement rate was significantly lower in robotic PD [15.6% vs. 19.9%; OR (95%CI) = 0.64 (0.41, 1.00); p = 0.05; NNT = 23]. Operating time was significantly longer in robotic PD [MD (95%CI) = 75.17 (48.05, 102.28); p

AIM: There is not sufficient evidence about whether stool DNA methylation tests allow prioritizing patients to colonoscopy. Due to the COVID-19 pandemic, there will be a wait-list for rescheduling colonoscopies once the mitigation is lifted. The aim of this meta-analysis was to evaluate the accuracy of stool DNA methylation tests in detecting colorectal cancer. METHODS: The PubMed, Cochrane Library and MEDLINE via Ovid were searched. Studies reporting the accuracy (Sackett phase 2 or 3) of stool DNA methylation tests to detect sporadic colorectal cancer were included. The DerSimonian-Laird method with random-effects model was utilized for meta-analysis. RESULTS: Forty-six studies totaling 16 149 patients were included in the meta-analysis. The pooled sensitivity and specificity of all single genes and combinations was 62.7% (57.7%, 67.4%) and 91% (89.5%, 92.2%), respectively. Combinations of genes provided higher sensitivity compared to single genes (80.8% [75.1%, 85.4%] vs. 57.8% [52.3%, 63.1%]) with no significant decrease in specificity (87.8% [84.1%, 90.7%] vs. 92.1% [90.4%, 93.5%]). The most accurate single gene was found to be SDC2 with a sensitivity of 83.1% (72.6%, 90.2%) and a specificity of 91.2% (88.6%, 93.2%). CONCLUSIONS: Stool DNA methylation tests have high specificity (92%) with relatively lower sensitivity (81%). Combining genes increases sensitivity compared to single gene tests. The single most accurate gene is SDC2, which should be considered for further research.

Laparoscopic One-Anastomosis Gastric Bypass (OAGB) is a bariatric procedure that combines the principles of restriction and malabsorption, which are achieved by creating a long and narrow gastric pouch and bypassing part of the small bowel (duodenum and part of the jejunum). It is currently the third most common bariatric procedure worldwide; more than19,000 operations (4.8%) are performed per year. OAGB is synonymous with "Mini Gastric Bypass" and "Omega Loop Gastric Bypass". There are numerous technical variants for performing OAGB and organizing pre- and postoperative care. This article is based on the approach to bariatric surgery at the Department of General Surgery at Vienna Medical University. We focus on patient preparation before a bariatric/metabolic procedure with mandatory and optional examinations to decrease the patient's risk and find the procedure best suited for each individual patient. Next, the surgical technique itself is described, including positioning of the patient, positioning of the trocars and related tips, tricks, and technical highlights, as well as the specifics of the postoperative course. OAGB is an effective procedure for weight loss and remission of comorbidities with a low risk of malnutrition for patients with good compliance. For OAGB to be successful, important technical steps such as a long and narrow pouch, exact length of the biliopancreatic limb and hiatoplasty, if necessary, should be taken. In terms of post-operative care, regular check-ups are vital to ensure a positive outcome in long-term follow-up and the early detection of adverse developments.

Sporadic medullary thyroid cancer (MTC) can occur anytime in life although they tend to present at a later age (&ge, 45 years old) when the tumors are more easily discernible or become symptomatic. We aimed to identify the factors affecting the survival in patients &ge, 45 years of age diagnosed with MTC. We analyzed the Surveillance, Epidemiology, and End Results (SEER) registry from 1973&ndash, 2016 focusing on patients &ge, 45 years of age with MTC as an isolated primary. A total of 2533 patients aged &ge, 45 years with MTC were identified. There has been a statistically significant increase of 1.19% per year in the incidence of MTC for this group of patients. The disease was more common in females and the Caucasian population. Most patients had localized disease on presentation (47.6%). Increasing age and advanced stage of presentation were associated with worse survival with HR 1.05 (p &lt, 0.001) and HR 3.68 (p &lt, 0.001), respectively. Female sex and surgical resection were associated with improved survival with HR 0.74 (p &lt, 0.001) and 0.36 (p &lt, 0.001), respectively. In conclusion, the incidence of MTC in patients &ge, 45 years of age is increasing. Patients should be offered surgical resection at an early stage to improve their outcomes.

Background Emergency surgery is often required for fulminant Clostridium difficile colitis. Total abdominal colectomy has been the treatment of choice despite high morbidity and mortality. Objective The aim of this meta-analysis was to evaluate postoperative mortality and morbidity after total abdominal colectomy and loop ileostomy with colonic lavage in patients with fulminant C difficile colitis. Data sources Studies comparing total abdominal colectomy to loop ileostomy for fulminant C difficile colitis were identified by a systematic search of PubMed, Cochrane Library, MEDLINE, and CINAHL. Study selection Relevant records were detected and screened using a cascade system (title, abstract, and/or full text article). Intervention(s) Total abdominal colectomy (rectal-sparing resection of the entire colon with end ileostomy) was compared to loop ileostomy (exteriorization of an ileal loop not far from the ileocecal junction for colonic lavage). Main outcomes measures This meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guidelines. Primary outcome was postoperative mortality, defined as death occurring within 30 days after the intervention. Secondary end points were the rates of ostomy reversal, deep venous thrombosis/embolism, surgical site infection, urinary tract infection, respiratory complications, reoperations, and adverse events. Mantel-Haenszel method with random-effects model was used for meta-analysis. Results Five observational studies (3 cohort and 2 database analysis studies) totaling 3683 patients were included. Postoperative mortality rate was 31.3% after total abdominal colectomy and 26.2% after loop ileostomy (OR = 1.36 (95% CI, 0.83-2.24); p = 0.22; number needed to treat/harm = 20; I = 55%). Ostomy reversal rate was both statistically and clinically significantly higher after loop ileostomy as compared with total abdominal colectomy (80% vs 25%; OR = 0.08 (95% CI, 0.02-0.30); p = 0.002; number needed to treat/harm = 2) with low heterogeneity (I = 0%). Limitations A limitation is the observational nature of the included studies introducing an overall high risk of selection bias. Conclusions This meta-analysis suggests that loop ileostomy with colonic lavage for fulminant C difficile colitis may be associated with similar survival and decreased surgical site infection rates as compared with total abdominal colectomy. Although loop ileostomy with colonic lavage was associated with higher ostomy reversal rates, this finding was based on the data from only 2 studies.

Introduction/Purpose Weight regain and weight loss failure after bariatric surgery are important issues that may require a weight regain procedure. Three-dimensional-computed tomography (3D-CT) is a well-established method allowing exact measurements of pouch volume. The aims of this study were to prove the applicability of swallow MRI as a non-ionizing procedure and compare it to 3D-CT in patients after weight regain procedures following RYGB. Materials and Methods Twelve post-RYGB patients who had a follow-up operation for weight regain before 12/2017 were included in this prospective study. Swallow MRI and 3D-CT were performed in each patient to evaluate the size of the anastomosis, pouch volume, and intrathoracic pouch migration (ITM). Results Mean pouch volume in swallow MRI and 3D-CT were 40.4 ± 21.0 ml and 43.5 ± 30.2 ml, respectively (p = 0.83), and pouch diameter at the maximal distention was 35.3 ± 5.9 ml (MRI) and 31.0 ± 10.0 ml (CT) (p = 0.16). The rate of ITM was 75% in both examinations (p = 1.0). Conclusion Swallow MRI is a valid method for the assessment of pouch volume in different phases of the swallowing process and is comparable to 3D-CT. The diagnosis of ITM using swallow MRI was equal to 3D-CT.

Purpose Bariatric-metabolic surgery in superobese patients (BMI > 50 kg/m2) is very challenging indeed with little room for error. In many cases, a two-step procedure is required, since more complex primary bariatric procedures can be technically demanding and bearing a relevant risk for the patient. At our institution, laparoscopic sleeve gastrectomy (SG) is the preferred primary procedure, followed by a conversion to either SADI-S or Roux-en-Y gastric bypass (RYGB) after initial weight loss is achieved [1, 2]. This video aims at demonstrating the conversion from primary SG to RYGB due to an adverse event in a 45-year-old superobese female patient (weight, 170 kg; BMI, 73 kg/m2). Methods An intraoperative laparoscopic video has been anonymized and edited to demonstrate the course of the operation on the patient mentioned above. Results The start of the procedure was uneventful. After a successful mobilization of the greater curvature, the stomach was resected with an electronic stapling device guided by a firm 36-french bougie (Rüsch, Germany) towards the angle of His. Due to a limited view, a stapler was placed over the bougie, which resulted in the stomach being subtotally transected, the staples attaching the bougie to the sleeve about 5 cm from the gastroesophageal junction. Salvage surgery after removing the remnants of the bougie was a conversion to RYGB. Conclusion When performing a bariatric-metabolic surgery in superobese patients, an extended skill level is required to provide a solution, should anything go wrong. Therefore, we suggest bariatric-metabolic surgery in superobese patients to be performed solely and specifically at high-volume centres. Electronic supplementary material The online version of this article (10.1007/s11695-020-04790-z) contains supplementary material, which is available to authorized users.

Background Surgery for obesity and metabolic diseases has been evolved in the light of new scientific evidence, long-term outcomes and accumulated experience. EAES has sponsored an update of previous guidelines on bariatric surgery. Methods A multidisciplinary group of bariatric surgeons, obesity physicians, nutritional experts, psychologists, anesthetists and a patient representative comprised the guideline development panel. Development and reporting conformed to GRADE guidelines and AGREE II standards. Results Systematic review of databases, record selection, data extraction and synthesis, evidence appraisal and evidence-to-decision frameworks were developed for 42 key questions in the domains Indication; Preoperative work-up; Perioperative management; Non-bypass, bypass and one-anastomosis procedures; Revisional surgery; Postoperative care; and Investigational procedures. A total of 36 recommendations and position statements were formed through a modified Delphi procedure. Conclusion This document summarizes the latest evidence on bariatric surgery through state-of-the art guideline development, aiming to facilitate evidence-based clinical decisions.

Background Roux-en-Y gastric bypass (RYGB) is the second most frequently performed bariatric procedure worldwide. While pouch migration is a common phenomenon after sleeve gastrectomy (SG), it has hardly been documented after RYGB so far. Objectives The aim of this study was to correlate the diagnostic performance of gastroscopy of the gastroesophageal junction with 3-dimensional (3D) computed tomography (CT) during postoperative care of patients revised due to weight regain after RYGB, with particular attention to intrathoracic pouch migration (ITM) and pouch volume. Setting University Hospital Setting, Austria Material and Methods Thirty RYGB patients that were revised due to weight regain (median age 37.5 years) before 12/2017 were included in this prospective study. CT findings were correlated with gastroscopy regarding pouch size and ITM. Pouch distension was achieved with both oral contrast and effervescent granules. All patients had CT and gastroscopy on the same day. In addition, patients were evaluated for reflux disease based on clinical history. Results ITM was found in 20/30 (66.7%) patients in CT whereas gastroscopy did not correctly identify any herniation. In 16/28 (57.1%) subjects pouch measurements at gastroscopy and CT showed a difference smaller than 40%. In two patients, pouch distension was not sufficient for CT volumetry. The intraclass correlation coefficient (ICC) proved to be 0.594. Symptomatic reflux was present in 10/30 (33.3%) patients, five of whom had ITM. Conclusion ITM is an underreported finding after revised RYGB and missed in gastroscopy. In terms of pouch volume, 3D-CT volumetry demonstrated only moderate agreement with gastroscopy.

Background Laparoscopic sleeve gastrectomy (SG) is the most frequently performed bariatric procedure today. While an increasing number of long-term studies report the occurrence of Barrett’s esophagus (BE) after SG, its treatment has not been studied, yet. Objectives The aim of this study was to evaluate Roux-en-Y gastric bypass (RYGB) as treatment for BE and reflux after SG. Setting University hospital setting, Austria Methods This multi-center study includes all patients (n = 10) that were converted to RYGB due to BE after SG in Austria. The mean interval between SG and RYGB was 42.7 months. The follow-up after RYGB in this study was 33.4 months. Gastroscopy, 24 h pH-metry, and manometry were performed and patients were asked to complete the BAROS and GIQLI questionnaires. Results Weight and BMI at the time of SG was 120.8 kg and 45.1 kg/m2. Eight patients (80.0%) went into remission of BE after the conversion to RYGB. Two patients had RYGB combined with hiatoplasty. The mean acid exposure time in 24 h decreased from 36.8 to 3.8% and the mean DeMeester score from 110.0 to 16.3. Patients scored 5.1 on average in the BAROS after conversion from SG to RYGB which denotes a very good outcome. Conclusions RYGB is an effective therapy for patients with BE and reflux after SG. Its outcomes in the current study were BE remission in the majority of cases as well as a decrease in reflux activity. Further studies with larger cohorts are necessary to confirm these findings.

Sleeve gastrectomy (SG) has been the most frequently performed bariatric procedure worldwide since 2014. Therefore, it is vital to look at its outcomes in a long-term follow-up based on a large patient collective. Main points of discussion are weight regain, reflux, and patients’ quality of life at 10+ years after the procedure. The aim of this study is to present an update of data that have been published recently and, thus, achieve more conclusive results. The number of patients has been doubled, and the length of the follow-up is still 10+ years. Multi-center study, medical university clinic, Austria This study includes all patients who had SG before December 2006 at the participating bariatric centers. At 10+ years, non-converted patients (67%) were examined using gastroscopy, manometry, 24-hour pH-metry, and questionnaires. Patients’ history of weight, comorbidities, and reflux were established through interviews. At 10+ years after SG, the authors found a conversion rate of 33%, an %EWL in non-converted patients of 50.0 ± 22.5, reflux in 57%, and Barrett’s metaplasia in 14% of non-converted patients. Gastroscopies revealed that patients with reflux were significantly more likely to have de-novo hiatal hernia. A significantly lower quality of life was detected through GIQLI and BAROS in patients with reflux. The authors recommend gastroscopies at 5-year intervals after SG to detect the possible sequelae of reflux at an early stage. Conversion to Roux-en-Y-gastric bypass (RYGB) works well to cure patients from reflux but may not be as efficient at treating weight regain.

Laparoscopic sleeve gastrectomy (SG) has become the most frequently performed bariatric procedure worldwide. De novo reflux might impact patients’ quality of life, requiring lifelong proton pump inhibitor medication. It also increases the risk of esophagitis and formation of Barrett’s metaplasia. Besides weight regain, gastroesophageal reflux disease (GERD) is the most common reason for conversion to Roux-en-Y gastric bypass. We performed 24-h pH metries, manometries, gastroscopies, and questionnaires focusing on reflux (GIQLI, RSI) in SG patients with a follow-up of more than 10 years who did not suffer from symptomatic reflux or hiatal hernia preoperatively. From a total of 53 patients, ten patients after adjustable gastric banding were excluded. From the remaining 43, six patients (14.0%) were converted to RYGB due to intractable reflux over a period of 130 months. Ten out of the remaining non-converted patients (n = 26) also suffered from symptomatic reflux. Gastroscopies revealed de novo hiatal hernias in 45% of the patients and Barrett’s metaplasia in 15%. SG patients suffering from symptomatic reflux scored significantly higher in the RSI (p = 0.04) and significantly lower in the GIQLI (p = 0.02) questionnaire. This study shows a high incidence of Barrett’s esophagus and hiatal hernias at more than 10 years after SG. Its results therefore suggest maintaining pre-existing large hiatal hernia, GERD, and Barrett’s esophagus as relative contraindications to SG. The limitations of this study—its small sample size as well as the fact that it was based on early experience with SG—make drawing any general conclusions about this procedure difficult.

Background Bariatric metabolic surgery is a well-established treatment option associated with significant weight loss and an improvement of metabolic co-morbidities. However, the changes in gastrointestinal anatomy frequently result in nutritional deficiencies. Objective To evaluate the impact of biliopancreatic limb length in one-anastomosis gastric bypass (OAGB) on micronutrient and protein deficiencies. Setting University hospital, Austria. Methods All patients that were (1) undergoing OAGB between 2012 and 2014, and (2) had at least 3 postoperative follow-up visits were retrospectively analyzed. Systemic levels of parathyroid hormone, vitamins (A, D, E, and B12), folic acid, magnesium, calcium, iron, albumin, and ferritin were correlated to biliopancreatic limb length as follows: short limb (150 cm), intermediate limb (200 cm), and long limb (250 cm). Results A total of 155 patients fulfilled inclusion criteria (female/male: n = 111/44). OAGB led to a mean percent excess weight loss of 79.9 (±24.2) and a reduction of mean body mass index from 45.4 kg/m2 (±6.1 kg/m2) at baseline to 30.2 kg/m2 (±9.9 kg/m2). Preoperative deficiencies were seen in 25-hydroxy-vitamin D (93.8%), folic acid (27.6%), ferritin (4.1%), vitamin A (5.5%), and vitamin B12 (2.3%). In patients with long limb, systemic folic acid levels were significantly lower after 24 months postoperatively compared with short and intermediate limb (P Conclusion Nutritional deficiencies were common after OAGB without severe deficiencies in biliopancreatic limb lengths ranging from 150 to 250 cm. A trend can be observed with more pronounced deficiencies with intermediate and long limb lengths without significant differences for most micronutrients.

The number of obese individuals worldwide continues to increase every year, thus, the number of bariatric/metabolic operations performed is on a constant rise as well. Beside exclusively restrictive procedures, most of the bariatric operations have a more or less malabsorptive component. Several different bypass procedures exist alongside each other today and each type of bypass is performed using a distinct technique. Furthermore, the length of the bypassed intestine may differ as well. One might add that the operations are performed differently in different parts of the world and have been changing and evolving over time. This review evaluates the most frequently performed bariatric bypass procedures (and their variations) worldwide: Roux-en-Y Gastric Bypass, One-Anastomosis Gastric Bypass, Single-Anastomosis Duodeno-Ileal Bypass + Sleeve Gastrectomy, Biliopancreatic Diversion + Duodenal Switch and operations due to weight regain. The evaluation of the procedures and different limb lengths focusses on weight loss, remission of comorbidities and the risk of malnutrition and deficiencies. This narrative review does not aim at synthesizing quantitative data. Rather, it provides a summary of carefully selected, high-quality studies to serve as examples and to draw tentative conclusions on the effects of the bypass procedures mentioned above. In conclusion, it is important to carefully choose the procedure and small bowel length excluded from the food passage suited best to each individual patient. A balance has to be achieved between sufficient weight loss and remission of comorbidities, as well as a low risk of deficiencies and malnutrition. In any case, at least 300 cm of small bowel should always remain in the food stream to prevent the development of deficiencies and malnutrition.

Background With promising short-term results, laparoscopic sleeve gastrectomy (SG) has become the second most frequently performed bariatric procedure worldwide. Aside from a growing number of reports covering up to 10 years of follow-up, only limited data have been published so far on long-term results. Objectives The aim of the study was to present a 10-year follow-up for SG. Setting University hospital setting, Austria. Methods We present the first complete 10-year follow-up of 53 consecutive patients who underwent SG before 2006. In this multicenter study, weight loss success, weight regain, and revisional surgery were analyzed beside Bariatric Analysis and Reporting Outcome System (BAROS) scores. Results A mean maximum percent excess weight loss of 71±25% (percent total weight loss: 28±15%) was reached at a median of 12 (range 12–120) months after SG. At 10 years, a mean percent excess weight loss of 53±25% was achieved by 32 patients, corresponding to a percent total weight loss of 26.3±13.4%. Nineteen of the 53 patients (36%) were converted to Roux-en-Y gastric bypass (n = 18) or duodenal switch (n = 1) due to significant weight regain (n = 11), reflux (n = 6), or acute revision (n = 2) at a median of 36 months. Two patients died at 3 and 101 months postoperatively, unrelated to SG. A total of 31 patients (59%) suffered from weight regain of 10 kg or more, among them 24 patients (45%) with 15 kg or more, 16 patients (30%) with 20 kg or more, and 7 patients (13%) with 25 kg or more weight regain from nadir. Mean BAROS score was 2.4±2.2 at 10 years follow-up, classifying SG as "fairly efficient." Conclusion Within a long-term follow-up of 10 years or more after SG, a high incidence of both significant weight regain and intractable reflux was observed, leading to conversion, most commonly to Roux-en-Y gastric bypass.

Frail patients with malignant tumors of the rectum may be candidates for palliative robotic transanal surgery, given increased risks for perioperative morbidity and mortality. We, herein, described the surgical technique of robotic transanal surgery and attempted to provide readers with a concise insight into the current state of this procedure.