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Emanuele Soricelli, Giovanni Casella, Giorgio Di Rocco, Adriano Redler, Nicola BassoDepartment of Surgical Sciences, Policlinico Umberto I, Sapienza, University of Rome, ItalyAbstract: Since the early 2000s, laparoscopic sleeve gastrectomy has increasingly gained consensus in bariatric surgery, thanks to good to excellent results in terms of weight loss and comorbidity resolution, and to simpler technical aspects than in Roux-en-Y gastric bypass and biliopancreatic diversion. In yearly consensus summits, surgical indications, technical details, and management of complications, together with continuous update of data concerning clinical outcome, have been debated on the basis of increasing collective experience. In experimental studies and clinical trials, the pathophysiological mechanisms of weight loss and remission of cardiometabolic comorbidities subsequent to sleeve gastrectomy have been extensively discussed. The aim of this paper is to offer a review of state of the art laparoscopic sleeve gastrectomy and to focus attention on the currently most debated topics and future prospects of this procedure.Keywords: sleeve gastrectomy, type 2 diabetes mellitus, gastroesophageal reflux disease, revisional, quality of life

Purpose: The aim of this study was to evaluate the safety and efficacy of a new intragastric balloon (Elipse™ Balloon, Allurion Technologies, Natick, MA USA) not needing endoscopy. Materials and Methods: The balloon was swallowed under fluoroscopy in 38 consecutive patients (F/M 28/10, mean age 46.4 ± 10.6 years, mean weight 109.7 ± 21.9 kg, and mean body mass index (BMI) 38.6 ± 6.7 kg/m). After 4 months, the balloon spontaneously emptied and it was excreted through the digestive tract without upper endoscopy. Results: There were no complications during balloon passage. After 16 weeks, the mean weight loss was 12.7 kg, mean percent excess weight loss was 26%, and mean BMI reduction was 4.2 kg/m. Total body weight loss was 11.6%. There was a significant reduction in major co-morbidities related to metabolic syndrome: blood pressure ( p < 0.02), waist circumference ( p < 0.002), triglycerides ( p < 0.0001), blood glucose ( p < 0.001), and HOMA-IR index ( p < 0.001). At the end of the treatment, 37 balloons were naturally excreted in the stool, and one balloon was endoscopically removed. Conclusions: The results of this study on 38 consecutive patients demonstrate that the Elipse™ Balloon is safe, effective, and very well accepted by patients. [ABSTRACT FROM AUTHOR]

Gout is the most common form of inflammatory arthritis, and it is due to the deposition of monosodium urate crystals in the articular and extra-articular tissues. Body mass index is strongly correlated with elevated serum uric acid levels and gout is often associated with obesity and metabolic syndrome. Recommended nonpharmacological treatments for hyperuricemia and gout include dietary modifications and weight loss. Many studies have demonstrated that weight loss could reduce serum urate in patients with obesity and it is a commonly recommended treatment for gout. Bariatric surgery-induced weight loss exerts beneficial effects on hyperuricemia and gout, even if a possible raise of gout flares can be observed in patients with hyperuricemia early after surgery. The aim of this review is to systematically analyze all the studies published so far reporting a link between hyperuricemia and/or gout and bariatric surgery to obtain reliable figures on the incidence of this disease and describe the mechanisms underlying this association. Eleven studies accounting for 11,256 patients were included in the review. Mean preoperative prevalence of gout was 4.1%, while the preoperative prevalence of hyperuricemia ranged from 30.6% to 58%. After a mean follow-up of 8.5 months, postoperative prevalence of gout significantly decreased to 2.9% (p < .007). The incidence of gout flares after bariatric surgery was higher in the early postoperative phase and progressively decreased over time. Similarly, serum uric acid concentrations showed an increase within the first postoperative month, which was followed by a progressive decrease below the preoperative value., (© 2024. Italian Society of Surgery (SIC).)

Obesity is a chronic disease associated with increased morbidity and mortality and reduced quality of life. Pharmacotherapy can be associated with life style changes in increasing and maintaining weight loss and ameliorating obesity-related complications and comorbidities. In patients affected by obesity and uncontrolled obesity-associated complications or high degrees of BMI (> 40 Kg/m 2 ), metabolic bariatric surgery can be a valid therapeutic option. Many different types of surgical procedures have been developed in last decades, mainly performed via laparoscopic approaches. However, clinical indications for metabolic and bariatric surgery (MBS) and the choice of the most appropriate type of procedure have not been clarified so far.The Italian Society of Bariatric and Metabolic Surgery for Obesity (Società Italiana di Chirurgia dell'Obesità e delle Malattie Metaboliche-SICOB) decided to design and develop the updated version of the Italian guidelines aimed at assisting healthcare professionals in the choice of the surgical option for the treatment of obesity and related conditions. Between June and October 2022, a panel of 24 experts and an evidence review team (ERT, 10 members), participated in the definition of clinical questions, outcomes, and recommendations and collected and analyzed all the available evidence on the basis of pre-specified search strategies. GRADE methodology and PICO (Patient, Intervention, Comparison, Outcome) conceptual framework have been adopted for the development of the present guidelines. Aim of the present guideline is to verify indications to surgery with respect to the presence of comorbid conditions, evaluate the different types of surgical approaches and endoscopic bariatric procedure and revise indication to revision surgery and postoperative procedures., (© 2024. Italian Society of Surgery (SIC).)

Development of the Italian clinical practice guidelines on bariatric and metabolic surgery, as well as design and methodological aspects., Background: Obesity and its complications are a growing problem in many countries. Italian Society of Bariatric and Metabolic Surgery for Obesity (Società Italiana di Chirurgia dell'Obesità e delle Malattie Metaboliche-SICOB) developed the first Italian guidelines for the treatment of obesity., Methods: The creation of SICOB Guidelines is based on an extended work made by a panel of 24 members and a coordinator. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology has been used to decide the aims, reference population, and target health professionals. Clinical questions have been created using the PICO (Patient, Intervention, Comparison, Outcome) conceptual framework. The definition of questions used the two-step web-based Delphi method, made by repeated rounds of questionnaires and a consensus opinion from the panel., Results: The panel proposed 37 questions. A consensus was immediately reached for 33 (89.2%), with 31 approved, two rejected and three which did not reach an immediate consensus. The further discussion allowed a consensus with one approved and two rejected., Conclusions: The areas covered by the clinical questions included indications of metabolic/bariatric surgery, types of surgery, and surgical management. The choice of a surgical or a non-surgical approach has been debated for the determination of the therapeutic strategy and the correct indications.

Introduction: Gastro-oesophageal reflux disease (GORD) after bariatric surgery is a debated topic. This study investigated the prevalence of GORD and associated oesophageal complications following bariatric procedures-namely, adjustable gastric banding (AGB), sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and one-anastomosis gastric bypass (OAGB)., Methods: This was a prospective multicentre study designed to evaluate the long-term effects of bariatric surgery on GORD. Patients were studied at baseline, at >10 years following AGB, SG, and RYGB, and at >3 years following OAGB (due to the more recent recognition of OAGB as a standard bariatric procedure). Patients were assessed by endoscopy and GORD symptom evaluation., Results: A total of 241 patients were enrolled. A minimum follow-up of 10 years was completed by 193 patients following AGB (57 patients), SG (95 patients), and RYGB (41 patients), and of >3 years by 48 subjects following OAGB. GORD symptoms increased following AGB and SG (from 14 to 31.6 per cent and from 26.3 to 58.9 per cent, respectively; P < 0.0001), improved following RYGB (from 36.6 to 14.6 per cent; P < 0.0001), and were unchanged following OAGB. The overall prevalence of erosive oesophagitis was greater in the SG group (74.7 per cent) than in the AGB (42.1 per cent), RYGB (22 per cent), and OAGB (22.9 per cent) groups (P < 0.0001). Barrett's oesophagus was found only in patients who had SG (16.8 per cent). Biliary-like gastric stagnation was found in a greater proportion of SG and OAGB patients (79.7 and 69.4 per cent, respectively) than in other treatment groups (P < 0.0001). The prevalence of biliary-type reflux into the oesophagus was higher in patients who underwent SG (74.7 per cent), compared with other treatment groups., Conclusion: Bariatric surgery leads to gastro-oesophageal complications of variable severity, particularly SG, which can result in a large proportion of patients developing Barrett's oesophagus., (© The Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Epidermoid cysts of the gastrointestinal tract are very uncommon and the published literature on this subject is anecdotal. We report the case of a 51-year-old man who was diagnosed with a cystic neoplasm located close to the cecum and the appendix. Given the strong suspicion of an appendiceal mucocele, the patient underwent a laparoscopic exploration. During the operation, a semisolid mass appearing to originate from the cecal wall was identified and a laparoscopic ileo-cecal resection was performed. The pathological diagnosis was an epidermoid cyst of the cecum. An epidermoid cyst of the cecum is a rare entity that usually has a mild and aspecific clinical picture. However, it should be included in the differential diagnosis of an occasionally diagnosed peri-cecal cystic lesion., (© 2021. Japanese Society of Gastroenterology.)

Background: The development of an intraluminal blood clot (hemobezoar), represents a rare cause (0.05% to 1.9%) of small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass (LRYGB). We present a case series of 6 cases of SBO caused by hemobezoar., Methods: A retrospective analysis of a prospective database including patients who underwent LRYGB from January 2010 to December 2019 has been performed. All the patients who underwent reoperation because of an SBO caused by an intraluminal blood clot were included in the present study., Results: Six of 843 LRYGB patients developed an hemobezoar (0.71%). Primary LRYGB was uneventful in all cases. SBO symptoms developed after a mean interval of 26.6 hours from the primary procedure. All reoperations were performed with the laparoscopic approach. In all cases, the hemobezoar was located at the level of the jejunojejunal anastomosis (JJA) and was removed through an enterotomy performed at the distal end of the biliopancreatic stump. Three postoperative complications occurred: 1 ab-ingestis pneumonia, 1 leak of the JJA requiring further reoperation, and 1 pelvic abscess treated with radiologic drainage. The mean hospital stay was 11 days., Discussion: SBO due to hemobezoar is a rare but worrisome early complication after LRYGB. It almost always affects the JJA and requires a prompt diagnosis to avoid dreadful sequelae. In the absence of anastomotic leak or stenosis, surgical management may consist of the removal of the blood clot without refashioning the anastomosis and it may be accomplished with the laparoscopic approach., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Sleeve gastrectomy (SG) leads to esophageal mucosal damage in an elevated percentage of cases, configuring a clinical condition of Barrett's esophagus (BE) in a proportion as high as 15-18.8%. BE may rarely evolve into esophageal adenocarcinoma (EAC)., Objectives: To raise awareness of BE as a precancerous lesion which may progress toward malignancy after this popular bariatric procedure., Setting: Bariatric referral centers, Italy., Methods: All patients referred to our bariatric center who developed an EAC after SG between 2012 and 2019 were reviewed and consecutively included in this study. The available scientific literature regarding this complication is additionally reviewed., Results: The 3 male patients comprised in this case series underwent laparoscopic SG between 2012 and 2015 in different bariatric referral centers. Age and body mass index at baseline ranged from 21-54 years and 43.1-75.6 kg/m 2 , respectively. All patients were lost to follow-up early after surgery (3.7 ± 1.4 months), and were diagnosed with EAC at a mean of 27.3 ± 7.6 months after SG. The 4 reported cases in the scientific literature developed an EAC at a mean of 32.5 ± 23 months from SG. Overall, a diagnosis of EAC was made approximately 30.3 ± 17.1 months postoperatively, which seems relatively and worryingly early after surgery., Conclusion: Although the rate and probability of progression from BE to EAC is still not well defined, assuming that the rising popularity and execution of SG leads to a growth in the BE incidence, then the preoperative identification and stratification of cancer risk factors in this subset of patients is strongly encouraged. Clinical and endoscopic follow-ups are essential to allow for prevention and early diagnosis and for epidemiologic data collection purposes., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Among the advantages of the One Anastomosis Gastric Bypass (OAGB) are the lack of jejuno-jejunal anastomosis and a supposed lower incidence of internal hernia (IH), with only a few cases reported until now. However, the incidence of IH after OAGB is not null. We present a video of the laparoscopic management of an IH that occurred after an OAGB. The patient was a 49-year-old female who had undergone a laparoscopic revisional OAGB 2 years previously after a failed laparoscopic adjustable gastric banding. She was referred to our Unit for recurrent postprandial colicky pain. She lost a total of 50 kg and her body mass index (BMI) dropped from 38 to 19 kg/m 2 . A CT scan with intravenous contrast showed a swirl of the mesentery around the superior mesenteric artery, without small bowel obstruction. A laparoscopic exploration was performed, confirming the suspicion of IH at the Petersen's space. An anticlockwise derotation of the whole common limb was performed, and the Petersen's space was eventually closed with a running non-absorbable suture.

Background: It is generally accepted that the efficacy with an intragastric balloon decreases after the first 4 months of treatment. Aim of this study is to evaluate if the association of a very low-calorie ketogenic diet (VLCKD) can improve the results in terms of weight loss parameters and co-morbidities, as compared to usually prescribed low-calorie diet (LCD)., Methods: For the present study (January 2016-June 2017), 80 patients (20 M/60 F, mean age 37.8 ± 6.1 years; excess weight 56 ± 10 kg; mean BMI 37.2 ± 3.8 kg/m 2 ) underwent Orbera positioning. After 4 months, they were randomized into two groups according to the type of treatment: group A (Bioenterics intragastric balloon - Orbera + VLCKD) (n = 40), and group B (Orbera + LCD) (n = 40)., Results: All patients completed the study with good adherence to diet therapy treatment allocation. After the 6-month treatment period, at time of Orbera removal, mean weight loss was 19 kg and 12 kg in groups A and B respectively (p < 0.05). Mean BMI was 28.9 ± 2.8 and 31.6 ± 3.1 kg/m 2 (p < 0.05), and %EWL was 33.1 ± 3.3 and 21.1 ± 2.9 (p < 0.05) in groups A and B respectively. During the last 2 months in group A, the mean weight loss was 8 kg, while in Group B, the main weight loss was 3 kg (p < 0.001). The VLCKD treatment induced a more significant reduction of major comorbidities related to metabolic syndrome., Conclusions: This study clearly indicates the efficacy of the prescription of very low-calorie ketogenic diet improving the efficacy of intragastric balloon positioning.

Introduction: Intussusception represents an uncommon cause of intestinal obstruction after Rouxen-Y gastric bypass. Symptoms are not specific and clinical presentation may vary from acute intestinal obstruction with or without bowel necrosis to intermittent or chronic pain. CT scan is the diagnostic test of choice., Materials and Methods: A 38-year-old woman who had undergone RYGBP 5 months prior was admitted to our Emergency Department with acute abdominal pain, alimentary and bilious vomiting, and fever. A CT scan revealed an intussusception after the anastomosis and dilatation of the biliopancreatic limb and the gastric remnant. An emergency laparoscopic exploration was performed., Results: The patient undergoes an explorative laparoscopy. A bowel intussusception starting distally at the jejunojejunostomy and involving the latter is discovered. The common channel is divided first, and after that, the alimentary limb is resected. The biliary limb is identified, marked, and finally divided. A side-to-side jejunojejunal anastomosis is created between the alimentary limb and the common limb. Finally, the anastomosis between the common limb and the biliopancreatic limb is fashioned about 30 cm distally from the latter anastomosis. The total operative time was 130 min. Postoperative course was uneventful, and the patient was discharged on the fifth postoperative day., Conclusion: Although rare, intussusception after RYGBP must be considered as a possible cause of intestinal obstruction. In case of a small bowel intussusception, a surgical resection is recommended. A laparoscopic approach to treat bowel intussusception after RYGBP is safe and feasible.

Background: The postoperative development or worsening of gastroesophageal reflux disease (GERD) represents the major drawback of laparoscopic sleeve gastrectomy (SG). A GERD diagnosis is often based only on symptoms and proton pump inhibitors (PPI) intake, while objective tests like esophagogastroduodenoscopy and pH measurements are performed less frequently., Objectives: To evaluate the association between reflux symptoms and GERD-related esophageal lesions., Settings: University hospital, Rome, Italy., Methods: A comprehensive clinical control entailing GERD symptoms, PPI intake, and esophagogastroduodenoscopy was proposed to all patients who underwent SG between June 2007 and February 2011, irrespective of the presence of GERD symptoms. One hundred forty-four of 219 patients agreed to take part in the study (follow-up rate: 65.8%)., Results: After a mean follow-up of 66 months, GERD symptoms and PPI intake were recorded in 70.2% and 63.9% of patients, respectively. Mean visual analogue scale score was 2.9 ± 3.3. The overall frequency of erosive esophagitis was 59.8%, while nondysplastic Barrett's esophagus was detected in 13.1%. The frequency of esophageal biliary reflux was 68%. GERD symptoms and visual analogue scale score were not significantly associated with the development of erosive esophagitis and Barrett's esophagus and the severity of the esophageal lesions. Moreover, the frequency of erosive esophagitis and Barrett's esophagus in patients consuming PPI were similar to that of patients without PPI., Conclusion: Symptoms investigation alone is not a reliable tool to diagnose GERD after SG. The use of objective diagnostic tests, such as esophagogastroduodenoscopy, should be carefully considered in the postoperative follow-up schedule of SG patients., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

The present video shows the laparoscopic management of an acute small bowel obstruction (ASBO) after a Roux-en-Y Gastric Bypass (RYGBP), due to the development of an intraluminal hemobezoar involving the jejuno-jejunostomy (j-j). On the first postoperative day (POD), the patient presented persistent abdominal pain, sense of fullness, nausea, and vomiting with traces of blood. The abdominal tube drained a small amount of serous fluid, while blood tests revealed a mild leukocytosis and a slight decrease of the hemoglobin. A CT scan showed the dilation of the excluded stomach, duodenum, and both the alimentary and biliopancreatic limbs. The transition point was located in the common limb, just beyond the j-j, which was dilated by a fluid collection with the radiological aspect of a blood clot. The patient underwent an emergency laparoscopy which confirmed the preoperative radiological findings. An enterotomy was performed at the biliopancreatic stump, and the blood clot was pulled out by suction. The enterotomy was then closed by means of a linear stapler. Postoperative course was uneventful, except for the development of low-grade pneumonia. The patient was discharged on POD 8. ASBO is a worrisome postoperative complication of RYGBP. Although rare, the development of intraluminal hemobezoar should always be considered as a possible cause of ASBO. Laparoscopic management is feasible and effective and does not necessarily entail the complete revision of the j-j.

Background: Morbidly obese patients are affected by gastroesophageal reflux disease (GERD) and hiatal hernia (HH) more frequently than lean patients. Because of conflicting results, the indication to sleeve gastrectomy (SG) in patients with GERD is still debated., Objectives: To evaluate the incidence of GERD on the basis of clinical, endoscopic, and histologic data in patients undergoing SG., Settings: University hospital, Rome, Italy., Methods: From July 2007 to January 2010, 162 patients underwent primary SG. Preoperatively all patients underwent visual analogue scale (VAS) evaluation of GERD symptoms, proton pump inhibitors (PPIs) consumption recording, and esophagogastroduodenoscopy (EGD). Stomach resection started 6 cm from pylorus on a 48Fr bougie. Staple line was reinforced by an oversewing suture. A postoperative clinical control with VAS evaluation, PPI consumption, and EGD was proposed to all patients. Three patients were excluded because of the occurrence of major postoperative complications., Results: A total of 110 patients accepted to take part in the study (follow-up rate: 69.1%). At a mean 58 months of follow-up, incidence of GERD symptoms, VAS mean score, and PPI intake significantly increased compared with preoperative values (68.1% versus 33.6%: P<.0001; 3 versus 1.8: P = .018; 57.2% versus 19.1%: P<.0001) At EGD, an upward migration of the "Z" line and a biliary-like esophageal reflux was found in 73.6% and 74.5% of cases, respectively. A significant increase in the incidence and in the severity of erosive esophagitis (EE) was evidenced, whereas nondysplastic Barrett's esophagus (BE) was newly diagnosed in 19 patients (17.2%). No significant correlations were found between GERD symptoms and endoscopic findings., Conclusion: In the present series the incidence of EE and of BE in SG patients was considerably higher than that reported in the current literature, and it was not related to GERD symptoms. Endoscopic surveillance after SG should be advocated irrespective of the presence of GERD symptoms., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Metabolic surgery improves insulin resistance and type 2 diabetes possibly because of weight loss. We performed a novel sleeve gastrectomy in rats that resects ∼80% of the glandular portion, leaving the forestomach almost intact (glandular gastrectomy [GG]) and compared subsequent metabolic remodeling with a sham operation. GG did not affect body weight, at least after 10 weeks; improved hepatic and peripheral insulin sensitivity likely through increased Akt, glycogen synthase kinase 3, and AMPK phosphorylation; and reduced ectopic fat deposition and hepatic glycogen overaccumulation. Body adipose tissue was redistributed, with reduction of intraabdominal fat. We found a reduction of circulating ghrelin levels, increased GLP-1 plasma concentration, and remodeling of gut microbiome diversity characterized by a lower relative abundance of Ruminococcus and a higher relative abundance of Lactobacillus and Collinsella These data suggest that at least in rat, the glandular stomach plays a central role in the improvement of insulin resistance, even if obesity persists. GG provides a new model of the metabolically healthy obese phenotype., (© 2016 by the American Diabetes Association.)

Background: Since the great diffusion of laparoscopic treatment of obesity, there is a growing interest concerning the learning process for those surgeons who undertake the bariatric activity. However, papers analyzing the learning curve (LC) for sleeve gastrectomy (SG) are still scarce. This study aims to investigate whether the LC for SG of a novice bariatric surgeon might be positively influenced by the training in a high-volume bariatric center (HVBC)., Methods: Between October 2010 and January 2014, 128 patients underwent SG by the same young surgeon who previously attended a 2-year training in a HVBC. His LC has been divided into three consecutive periods: in the first period (1st-47th SGs) he operated in the HVBC, while in the second (48th-88th SGs) and third period (89th-128th SGs) he moved to a novel department where surgical and ancillary staff were initially not confident with bariatric procedures but progressively owned the proper experience. Preoperative characteristics, operative data, complications and postoperative results of the three periods were compared., Results: Mean follow-up was 1 year. Preoperative patients' characteristics were homogeneous. No significant differences have been registered among the three periods concerning operative data, mortality, intra- and post-operative complications, weight loss outcomes and comorbidities' resolution. Post-operative follow-up rates at 6 and 12 months were 98.4 and 92.1 %, respectively., Conclusions: Long-lasting fellowship in a HVBC might allow the novel bariatric surgeon to safely and proficiently overcome the LC for SG, even in a new established bariatric setting.

Background: Laparoscopic sleeve gastrectomy (SG) has gained great popularity as a stand-alone bariatric procedure because short- and mid-term outcomes in terms of weight loss and resolution of co-morbidities have been very positive. However, long-term results from large series still are sparse., Objectives: To evaluate the long-term clinical outcomes of SG in a large series of patients undergoing SG as a stand-alone procedure., Setting: University hospital in Italy., Methods: A retrospective analysis of prospectively collected data from 182 patients undergoing SG between 2006 and 2008 in the authors' institution. Long-term outcomes at 6 and 7 years were analyzed in terms of weight loss and co-morbidities resolution., Results: Mean initial body mass index (BMI) was 45.9±7.3 kg/m(2). Major postoperative complications occurred in 8 patients (5.4%): 4 leaks, 2 bleeding, 1 abdominal collection, and 1 dysphagia. All complications were managed conservatively. One hundred forty-eight patients (81.4%) completed the 72-month (6-year) follow-up. Thirty-seven patients (25%) reached a follow-up of 84 months. At year 6 follow-up the mean BMI and the mean percentage of excess weight loss (%EWL) were 30.2 kg/m(2) and 67.3%, respectively. Mean total body weight loss was 44.9 kg, while a %EWL >50 was registered in 123 patients (83.1%). Preoperative BMI did not significantly influence postoperative %EWL. Remission of type 2 diabetes mellitus, arterial hypertension, obstructive sleep apnea syndrome, and gastroesophageal reflux disease symptoms occurred in 83.8%, 59.7%, 75.6%, and 64.7% of patients, respectively., Conclusion: %EWL and resolution of co-morbidities appear to be sustained 6 and 7 years after SG. Preoperative BMI is not predictive for weight loss outcomes., (Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Aims: Reinforcement of the staple line is one of the most debated technical aspects concerning laparoscopic sleeve gastrectomy (LSG). Different buttressing methods have been proposed and demonstrated to be effective in reducing the incidence of staple line bleeding, although data concerning their effort on staple line leakage are not consistent. The aim of this study was to ascertain the technical feasibility and to report the preliminary outcomes of laparoscopic use of platelet-rich plasma (PRP) to reinforce the staple line during sleeve gastrectomy., Patients and Methods: From March 2012 to May 2012, 20 patients were prospectively enrolled (10 females; mean age, 44.6 ± 11 years; mean body mass index, 42.3 ± 5.45 kg/m(2)). Type 2 diabetes mellitus was present in 4 patients, obstructive sleep apnea syndrome in 3, and hypertension in 6. LSG was performed using a 48-French bougie and gold cartridges; reinforcement of the staple lines with buttressed materials or oversewing the suture was performed excluding the last cranial cartridge. PRP was prepared by separating the platelets from autologous blood withdrawn on the same day of surgery, in order to obtain a membrane with cylindrical shape (2×5 cm) formed by fibrin and active platelets. The membrane is introduced through the 10-mm trocar and placed at the upper portion of the staple line. The overall cost for the preparation of PRP is about €15., Results: No intraoperative complications and conversions have been recorded during the surgical procedures. No deaths occurred. The mean operative time was 85 ± 31 minutes, which was not significantly increased compared with the operative time of the surgeon's overall personal series (750 cases). At 12 months of follow-up the abdominal ultrasound was negative for collections, and upper contrast showed no images indicating gastric leaks. In no case did PRP induce symptoms of rejection, infection, or adverse events., Conclusions: The use of PRP during LSG is feasible, does not increase significantly the operative time, does not require any special devices, and is cost effective. A larger cohort of patients is needed to ascertain the potential effectiveness of PRP in the prevention of postoperative staple line complications.

Background: Local excision, as an alternative to radical resection for patients with pathological complete response (ypT0) after preoperative chemoradiation, is under investigation., Objective: The aim of the present study was to evaluate the long-term clinical outcome of a selected group of patients with ypT0 rectal cancer who underwent local excision with transanal endoscopic microsurgery as a definitive treatment., Patients: Between 1993 and 2013, 43 patients with rectal adenocarcinoma underwent complete full-thickness local excision with a transanal endoscopic microsurgery procedure after a regimen of chemoradiation. In all patients, rectal wall penetration was preoperatively assessed by endorectal ultrasound and/or magnetic resonance. Chemoradiation and transanal endoscopic microsurgery were indicated in patients refusing radical procedures or patients unfit for major abdominal procedures., Main Outcome Measures: Patient characteristics, operative record, pathology report, and tumor recurrence were analyzed at a median follow-up of 81 months. The potential prognostic factors for recurrence, screened in univariate analysis, were analyzed by multivariate analysis by using the Cox regression model., Results: Thirteen patients (30.2%), without residual tumor in the surgical specimen (ypT0), were treated with transanal endoscopic microsurgery only. In this ypT0 group, 2 patients (15.4%) had postoperative complications: 1 bleeding and 1 suture dehiscence. Postoperative mortality was nil. No local and distal recurrences were observed, and no tumor-related mortality occurred. In 30 patients (69.8%), partial tumor chemoradiation response or the absence of tumor chemoradiation response was observed. In this group, recurrence occurred in 17 patients (56.7%)., Limitations: The study was limited by its retrospective nature, different protocols of chemoradiation and preoperative staging over time, and the small sample size., Conclusions: Local excision with transanal endoscopic microsurgery can be considered a definitive therapeutic option in patients with rectal cancer treated with preoperative chemoradiation, when no residual tumor is found in the specimen. In this selected group, local excision offers excellent results in terms of survival and recurrence rates. In the presence of residual tumor, transanal endoscopic microsurgery should be considered as a large excisional biopsy (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A157).

Background: Laparoscopic sleeve gastrectomy (LSG) is an approved primary procedure for morbid obesity, but it is associated with serious complications, such as staple line leaks and bleeding. The objective of this study was to assess the effectiveness of staple line reinforcement (SLR) in reducing leaks and bleeding after LSG., Methods: A total of 1162 patients underwent LSG (305 males, 857 females). The mean age was 43.7 years and the mean body mass index was 48 kg/m(2). The patients were divided into 6 groups based on the type of SLR, including a no-SLR control group, with evaluation of leaking and bleeding risk and correlation of patients' characteristics with complications., Results: A total of 189 patients underwent LSG without reinforcement. The SLR method was oversewing in 476 patients, bovine pericardium in 312, synthetic polyester in 76, glycolide/trimethylene copolymer in 63, and thrombin matrix in 46. The overall leak frequency was 2.8%; higher with synthetic polyester (7.8%), 4.8% with no reinforcement, and lower with bovine pericardium strips (.3%; P<.01). Postoperative hemorrhage occurred in 35 patients (3%), with a higher frequency being observed without SLR (13.7%; P = .02). Only diabetes was a risk-factor for a leak (P< .01)., Conclusion: SLR with bovine pericardium strips significantly reduced the leak risk. Postoperative bleeding was significantly lower with all SLR-methods, although there was no significant difference among the various techniques. Patients with type II diabetes had a higher risk of staple line leak after LSG. Further randomized, controlled studies are needed to improve our understanding of the efficacy of SLR during LSG., (© 2013 American Society for Bariatric Surgery Published by American Society for Metabolic and Bariatric Surgery All rights reserved.)

Background: The aim of this study was to evaluate the long-term effects of laparoscopic sleeve gastrectomy (LSG) on type 2 diabetes mellitus (T2DM) and other related co-morbidities in severely obese patients., Methods: From May 2003 to July 2008, 33 morbidly obese diabetic patients (20 with body mass index [BMI]>50 kg/m(2)) underwent LSG. A total of 23 females and 10 males participated, with a mean age of 49.3±8 years, mean preoperative BMI of 52.1±8.5 kg/m(2), mean fasting plasma glucose (FPG) of 143.2±47.9 mg/dL, mean glycosylated hemoglobin (HbA1c) of 7.3%±1.4%, and a mean T2DM duration of 7 years. All patients had a 36-month follow-up, and 13 had a 60-month follow-up., Results: Twenty-nine patients (87.8%) discontinued antidiabetic medications 3 months after LSG, (mean BMI of 42.8±7.8 kg/m(2); FPG of 104.5±22.1 mg/dL; HbA1c of 5.3%±.4%). At 36 months, 22 of 26 LSG patients (84.6%) had normal FPG and HbA1c values without antidiabetic therapy. At the 60-month follow-up, 10 of 13 patients (76.9%) had normal FPG and HbA1c values without antidiabetic therapy. The Framingham risk score decreased significantly from 9.7% preoperatively to 4.7% postoperatively. No new diabetic retinopathy occurred during the whole period of observation., Conclusions: This study confirms the efficacy of LSG in the treatment of T2DM and indicates that, at both 36- and 60-month follow-ups, LSG can provide a significant percentage of treated patients with a prolonged remission of T2DM, with diminished cardiac risk factors and no development of diabetic retinopathy. These results compare favorably with those reported after standard medical therapy., (Copyright © 2013 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Gastroesophageal reflux disease (GERD) with or without hiatal hernia (HH) is now recognized as an obesity-related co-morbidity. Roux-en-Y gastric bypass has been proved to be the most effective bariatric procedure for the treatment of morbidly obese patients with GERD and/or HH. In contrast, the indication for laparoscopic sleeve gastrectomy (SG) in these patients is still debated. Our objective was to report our experience with 97 patients who underwent SG and HH repair (HHR). The setting was a university hospital in Italy., Methods: From July 2009 to December 2011, 378 patients underwent a preoperative workup for SG. In 97 patients, SG was performed with HHR. The clinical outcome was evaluated considering GERD symptom resolution or improvement, interruption of antireflux medications, and radiographic evidence of HH recurrence., Results: Before surgery, symptomatic GERD was present in 60 patients (15.8%), and HH was diagnosed in 42 patients (11.1%). In 55 patients (14.5%), HH was diagnosed intraoperatively. The mean follow-up was 18 months. GERD remission occurred in 44 patients (73.3%). In the remaining 16 patients, antireflux medications were diminished, with complete control of symptoms in 5 patients. No HH recurrences developed. "De novo" GERD symptoms developed in 22.9% of the patients undergoing SG alone compared with 0% of patients undergoing SG plus HHR., Conclusion: SG with HHR is feasible and safe, providing good management of GERD in obese patients with reflux symptoms. Small hiatal defects could be underdiagnosed at preoperative endoscopy and/or upper gastrointestinal contrast study. Thus, a careful examination of the crura is always recommended intraoperatively., (Copyright © 2013 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

A female patient, 48-year-old, with morbid obesity (body mass index 42.5 kg/m2) complicated by hypertension, T2DM, and severe Obstructive Sleep Apnea Syndrome was candidated to bariatric surgery. During the preoperative work-up, an abdominal ultrasonography and an RMN showed an incidental left adrenal tumor with a diameter of 11 cm. The laboratory evaluation for the functional adrenal tumor was negative. A laparoscopic sleeve gastrectomy and left adrenalectomy with supragastric approach was successfully carried out. The minimally invasive treatment of coexisting abdominal pathologies such as morbid obesity and adrenal incidentalomas seem to be suitable and safe, providing several benefits in terms of surgical and anesthesiologic management and postoperative clinical outcomes. The supragastric approach may represent a valuable option for left adrenalectomy combined with laparoscopic sleeve gastrectomy.

Background: The prevalence of gastroesophageal reflux disease (GERD) and/or hiatal hernia (HH) is significantly increased in morbidly obese patients. Laparoscopic bariatric procedures such as gastric banding (LGB) and Roux-en-Y gastric bypass have been shown to improve both obesity and reflux symptoms. The aim of this paper is to evaluate the effectiveness of laparoscopic sleeve gastrectomy (LSG) and hiatal hernia repair (HHR) for the treatment of obesity complicated by HH., Methods: From October 2008, six patients underwent HHR in addition to LSG. Clinical outcomes have been evaluated in terms of GERD symptoms improvement or resolution, interruption of antireflux medication, and X-ray evidence of HH recurrence., Results: Symptomatic HH was diagnosed preoperatively in four patients. In two additional patients, HH was asymptomatic and it was diagnosed intraoperatively. Prosthetic reinforcement of crural closure was performed in two symptomatic cases with a HH >5 cm. Mortality was nil and no complications occurred. After a mean follow-up of 4 months, GERD symptoms resolution occurred in three patients, while the other patient reported an improvement of reflux. Body mass index had fallen from 43.4 to 36.2 kg/m(2). A small recurrence in the patient with persistence of reflux symptoms has been radiologically reported., Conclusions: Laparoscopic crural closure in addition to LSG could represent a valuable option for the synchronous management of morbid obesity and HH, providing good outcomes in terms of weight loss and GERD symptoms control.

Background: Laparoscopic sleeve gastrectomy (LSG), first intended as the first step of biliopancreatic diversion with duodenal switch (BPD-DS), is gaining popularity as a per-se procedure because of its effectiveness on weight loss and comorbidity resolution. The extraction of the gastrectomy specimen could be challenging and time-consuming. Different techniques have been described for specimen withdrawal. In this article we report the technique adopted in more than 250 LSGs performed in our department., Methods: In the first 90 LSGs performed in our department from October 2002, the specimen was extracted in a retrieval bag using an endoloop. In the following 160 cases the technique has been simplified: the grasped specimen is withdrawn through the 15-mm trocar site without any additional device., Results: We registered only two cases of wound infection (1.2%) with the simplified technique, both occurring in the initial cases. There were no cases of trocar site hernia formation., Conclusion: The technique described does not require any special devices and seems to be simpler, saves time, and is cost effective if compared with other techniques previously reported.