Endoscopic Sleeve Gastroplasty: Practical Considerations, Current Techniques, and Troubleshooting

Endoscopic sleeve gastroplasty (ESG) has emerged as a safe and effective treatment for obesity over the past decade. This procedure, however, is technically challenging and requires frequent troubleshooting, even among experts. In this article the authors discuss current techniques, common pitfalls and adverse outcomes associated with ESG, how to avoid them, and how to address them if they occur.

Bikini line one-anastomosis gastric bypass (BLOGB): initial report

BACKGROUND

This study introduces a new access method for one-anastomosis gastric bypass (OAGB) by placing ports at the bikini line.

OBJECTIVE

To describe our initial experience and assess the feasibility, safety, and effectiveness of this novel access.

SETTING

University Hospital.

METHODS

This prospective case-control study included 72 patients: 42 were allocated to the bikini line one-anastomosis gastric bypass (BLOGB) group, and 30 were assigned to the control group. Exclusion criteria included a history of major abdominal surgery, hiatal hernia, extensive lower abdominal adhesions, or a body mass index (BMI) exceeding 55 kg/m2.

RESULTS

The mean preoperative BMI of the study sample was 40.01 ± 2.84. Weight loss was satisfactory, with the highest percent excess weight loss (%EWL) observed at 12 months: 90.88 ± 7.90 and 91 ± 7.11 (p = 0.474) in both groups, respectively. Both groups showed no significant differences in operative complications, hospital stay, weight loss, or resolution of obesity-associated diseases. However, the BLOGB patients had a longer mean operative time of 110.71 ± 17.72 min compared to 98 ± 18.27 min in the control group (p = 0.002). Moreover, they experienced less postoperative pain and reported greater satisfaction with the appearance of their scars.

CONCLUSION

BLOGB was found to be potentially feasible, safe, and effective, offering improved aesthetic outcomes and reduced postoperative pain. This approach may be suitable for a select group of patients concerned with scar appearance. However, large-scale studies are necessary to ensure that safety is not compromised in pursuit of aesthetic benefits.

Short-term gut microbiota's shift after laparoscopic Roux-en-Y vs one anastomosis gastric bypass: results of a multicenter randomized control trial

BACKGROUND

Roux-en-Y (RYGB) and one anastomosis gastric bypass (OAGB) represent two of the most used bariatric/metabolic surgery (BMS) procedures. Gut microbiota (GM) shift after bypass surgeries, currently understated, may be a possible key driver for the short- and long-term outcomes.

METHODS

Prospective, multicenter study enrolling patients with severe obesity, randomized between OAGB or RYGB. Fecal and blood samples were collected, pre- (T0) and 24 months postoperatively (T1). GM was determined by V3-V4 16S rRNA regions sequencing and home-made bioinformatic pipeline based on Qiime2 plugin and R packages.

OBJECTS

To compare OAGB vs RYGB microbiota profile at T1 and its impact on metabolic and nutritional status.

RESULTS

54 patients completed the study, 27 for each procedure. An overall significant variation was detected in anthropometric and serum nutritional parameters at T1, with a significant, similar decrease in overall microbial alpha and beta diversity observed in both groups. An increase in relative abundances of Actinobacteria and Proteobacteria and a reduction of Bacteroidetes, no significant changes in Firmicutes and Verrucomicrobia, with an increase of the Firmicutes/Bacteroidetes ratio were observed.

CONCLUSIONS

BMS promotes a dramatic change in GM composition. This is the first multicenter, RCT evaluating the impact of OAGB vs Roux-en-Y bypass on GM profile. The bypass technique per se did not impact differently on GM or other examined metabolic parameters. The emergence of slightly different GM profile postoperatively may be related to clinical conditions or may influence medium or long-term outcomes and as such GM profile may represent a biomarker for bariatric surgery's outcomes.

Novel Surgical Interventions for the Treatment of Obesity

Metabolic and bariatric surgery is widely recognized as the most effective and durable treatment for the disease of obesity and its associated comorbidities. In recent years, the field has seen significant advancements, introducing numerous innovative surgical options. This review aims to comprehensively examine these emerging surgical techniques, which have recently received endorsement from the American Society for Metabolic and Bariatric Surgery (ASMBS). Additionally, we will explore new technologies and methodologies supported by the latest scientific evidence. Our analysis will include a critical evaluation of the efficacy, safety, and long-term outcomes of these novel approaches, providing a detailed update on the current state of metabolic and bariatric surgery, highlighting key developments and their potential implications for clinical practice.

Significant and distinct impacts of sleeve gastrectomy and Roux-en-Y gastric bypass on esophageal acid exposure, esophageal motility, and endoscopic findings: a systematic review and meta-analysis

BACKGROUND

The lack of standardized objective assessment of esophageal physiology and anatomy contributes to controversies regarding the effects of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) on gastroesophageal reflux disease. This study aimed to investigate esophageal acid exposure, esophageal motility, and endoscopic findings before and after SG and RYGB.

METHODS

This was a systematic review and meta-analysis of studies reporting at least 1 objective measure of esophageal physiology and/or esophagogastroduodenoscopy (EGD) at baseline and after SG or RYGB. The changes in pH test, manometry, and EGD parameters were summarized.

RESULTS

Acid exposure time (AET) and DeMeester score (DMS) significantly increased after SG (mean difference [MD]: 2.1 [95% CI, 0.3-3.9] and 8.6 [95% CI, 2.0-15.2], respectively). After RYGB, both AET and DMS significantly decreased (MD: -4.2 [95% CI, -6.1 to -2.3] and -16.6 [95% CI, -25.4 to -7.8], respectively). Lower esophageal sphincter resting pressure and length significantly decreased after SG (MD: -2.8 [95% CI, -4.6 to -1.1] and -0.1 [95% CI, -0.2 to -0.02], respectively). There were no significant changes in esophageal manometry after RYGB. The relative risks of erosive esophagitis were 2.3 (95% CI, 1.5-3.5) after SG and 0.4 (95% CI, 0.2-0.8) after RYGB. The prevalence rates of Barrett esophagus changed from 0% to 3.6% after SG and from 2.7% to 1.4% after RYGB.

CONCLUSION

SG resulted in the worsening of all objective parameters, whereas RYGB resulted in the improvement in AET, DMS, and EGD findings. Determining the risk factors associated with these outcomes can help in surgical choice.

Banded versus non-banded Roux-en-Y gastric bypass: short, mid, and long-term surgical outcomes - a systematic review and meta-analysis

BACKGROUND

The Roux-en-Y gastric bypass (RYGB) is considered as one of the most effective treatments for people with obesity. A variant of this procedure, the banded-RYGB, may present several advantages over the standard technique. These potential benefits include enhanced weight loss, decreased recurrent weight gain, a lower incidence of dumping syndrome, and less distention of the jejunum below the gastrojejunostomy.

OBJECTIVES

The objective of this meta-analysis is to compare the surgical outcomes of RYGB procedures with a band (banded-RYGB) and without a band (RYGB) in the management of individuals with obesity.

SETTING

A systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Cochrane protocol (PROSPERO ID: CRD42023439874).

METHOD

The systematic review process led to the identification of 13 comparative studies involving 3230 patients who underwent banded-RYGB and 5302 who received RYGB, all of which were eligible for inclusion and meta-analysis.

RESULTS

Four studies reported data on 1-year postoperative percent excess weight loss (%EWL), demonstrating a significant increase of 6.03 %EWL in patients who underwent banded-RYGB. Four studies reported the 2-year postoperative %EWL, showing that patients who had banded-RYGB experienced a 5.32 greater %EWL compared to those who received RYGB, even if this was not statistically significant. For 5-year %EWL after bariatric surgery, 5 studies were included for continuous outcome meta-analysis. The average 5-years %EWL difference was 7.6 in favor of banded-RYGB. Patients who had banded-RYGB presented a nonsignificant 1.45 OR of developing postoperative complications compared to patients receiving RYGB.

CONCLUSION

This meta-analysis demonstrates that, compared to RYGB, patients who underwent banded-RYGB surgery showed a statistically significant increase in the %EWL at 1, 2, and 5 years postoperatively. Moreover, the banding procedure does not significantly increase the risk of postoperative complications.

Long Narrow Pouch Roux-en-Y Gastric Bypass (LN-RYGB) for Recurrent Weight Gain After Sleeve Gastrectomy

PURPOSE

Sleeve gastrectomy (SG) is the most performed metabolic and bariatric surgery (MBS). However, with the increase of SG in different regions, recurrent weight gain after SG is challenging for bariatric surgeons. We introduce a modified operation with a long, narrow pouch in RYGB (LN-RYGB) for weight regain after SG which enhanced the restrictive function in RYGB.

METHODS AND RESULTS

The LN-RYGB has a longer and narrow gastric pouch for 10 cm. The length of small Roux and biliopancreatic are the same as RYGB. As a revisional surgery, the post-1 year excess weight loss percentage (%EWL) was 63.1% and total weight loss percentage (%TWL) was 29.1% in 5 cases.

CONCLUSION

LN-RYGB is an optional treatment for recurrent weight gain after SG; a randomized control trial is needed to verify the long-term effect of LN-RYGB.

EFFICACY AND SAFETY OF ONE ANASTOMOSIS GASTRIC BYPASS IN SURGICAL TREATMENT OF OBESITY: SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

BACKGROUND

One anastomosis gastric bypass (OAGB) has gained prominence in the search for better results in bariatric surgery. However, its efficacy and safety compared to Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) remain ill-defined.

AIMS

To compare the efficacy and safety of OAGB relative to RYGB and SG in the treatment of obesity.

METHODS

We systematically searched PubMed, EMBASE, Cochrane Library, Lilacs, and Google Scholar databases for randomized controlled trials comparing OAGB with RYGB or SG in the surgical approach to obesity. We pooled outcomes for body mass index, percentage of excess weight loss, type-2 diabetes mellitus remission, complications, and gastroesophageal reflux disease. Statistical analyses were performed with R software (version 4.2.3).

RESULTS

Data on 854 patients were extracted from 11 randomized controlled trials, of which 422 (49.4%) were submitted to OAGB with mean follow-up ranging from six months to five years. The meta-analysis revealed a significantly higher percentage of excess weight loss at 1-year follow-up and a significantly lower body mass index at 5-year follow-up in OAGB patients. Conversely, rates of type-2 diabetes mellitus remission, complications, and gastroesophageal reflux disease were not significantly different between groups. The overall quality of evidence was considered very low.

CONCLUSIONS

Our results corroborate the comparable efficacy of OAGB in relation to RYGB and SG in the treatment of obesity, maintaining no significant differences in type-2 diabetes mellitus remission, complications, and gastroesophageal reflux disease rates.

Weight Loss as Therapeutic Option to Restore Fertility in Obese Men: A Meta-Analytic Study

PURPOSE

Weight loss has been shown to significantly elevate testosterone serum levels, though the impact on semen analysis parameters and fertility remains incompletely understood. The objective of this study was to examine the influence of body weight loss on semen parameters in obese men.

MATERIALS AND METHODS

A meta-analysis was performed that included clinical trials in which a semen analysis before and after weight loss was evaluated. All strategies potentially available for weight loss were considered eligible. The primary outcome was the comparison of conventional semen analysis parameters before and after weight loss.

RESULTS

Twelve studies were considered including 345 subjects (mean age 37.6±7.9 years; mean baseline body mass index 45.4±6.0 kg/m²). Weight loss resulted in a significant increase of sperm concentration (effect size 0.495, standard error 0.251 [0.003, 0.986], p=0.049) and progressive motility (effect size 0.567, standard error 0.372 [0.370, 0.764], p<0.001). Moreover, a significant decrease of sperm DNA fragmentation index after weight loss (effect size -0.689, standard error 0.278 [-1.123, -0.255], p=0.002) was observed.

CONCLUSIONS

This meta-analytic analysis confirmed that body weight loss may improve qualitative and quantitative sperm characteristics providing evidence for suggesting weight loss to male partners with obesity and semen analysis alteration in couples attempting conception.

Bariatric surgery and diabetes: Current challenges and perspectives

Diabetes mellitus (DM) and obesity have become public issues of global concern. Bariatric surgery for the treatment of obesity combined with type 2 DM has been shown to be a safe and effective approach; however, there are limited studies that have systematically addressed the challenges of surgical treatment of obesity combined with DM. In this review, we summarize and answer the most pressing questions in the field of surgical treatment of obesity-associated DM. I believe that our insights will be of great help to clinicians in their daily practice.

The length of the biliopancreatic limb in one anastomosis gastric bypass

Introduction

The one-anastomosis gastric bypass (OAGB), first published by Dr Rutledge in 1997 is now a well-established procedure in the bariatric-metabolic armamentarium. This procedure based on a (single) loop gastro-jejunal anastomosis (the biliopancreatic limb or BPL) with a long narrow gastric pouch combines restriction with hypo-absorption. The biliopancreatic limb and in particular its length is held responsible for the degree of the hypo-absorptive effect but the most appropriate or "optimal" length of the BPL remains debatable.

Methods

The following text is based on a comprehensive and meticulous selection of the most recent literature in Cochrane, Pubmed and Google Scholar using the search terms "biliopancreatic limb", "biliopancreatic limb in one anastomosis gastric bypass" in an attempt to define not only the most common used biliopancreatic limb length but also to find out If there is an "ideal" limb length not only to optimize the outcomes of the OAGB in terms of weight loss and resolution of obesity-related diseases but also to reduce the potential side-effects in particular nutritional deficiencies.

Results

Until today there is no consensus about the "standard" or "ideal" length of the biliopancreatic limb in OAGB, a fixed length of 200 cm is still the most common used procedure although many reports and studies are in favour of shorter limb lengths adjusted to the BMI or the total small bowel length.

Conclusion

The "ideal" or "optimal" biliopancreatic limb length in OAGB still needs to be defined. There are different options and all of them have their credits, the question remains if a consensus can be reached regarding the best strategy to obtain the best outcome.

Effects of bariatric surgery on sexual function and fertility: A narrative review

Obesity has emerged as a prevalent global health concern, with its detrimental effects on the reproductive system and sexual function garnering increasing attention. Both men and women affected by obesity face a heightened risk of fertility challenges and sexual dysfunction. Although fertility and sexual function are distinct topics, they are intricately linked and mutually influential in both medical and societal contexts. Bariatric surgery (BS) has generated promising results in alleviating sexual dysfunction and enhancing fertility, results which are often gender specific. In men, improvements in sexual function can often be attributed to weight loss and subsequent optimizations in sex hormone levels. However, improving female sexual function may be related to a range of factors beyond weight loss. Bariatric procedures have shown limited benefits for male fertility; in fact, in some situations it can even be detrimental, leading to a decrease in sperm count and quality. Conversely, BS may positively impact female fertility, improving pregnancy and neonatal outcomes. Nevertheless, it is essential to consider the potential risks related to the adverse effects of malnutrition and rapid weight loss following BS, making it advisable to wait for 12-18 months before attempting pregnancy.

Does routine upper gastrointestinal swallow study after metabolic and bariatric surgery lead to earlier diagnosis of leak?

BACKGROUND

It is unclear whether routine upper gastrointestinal swallow study (SS) in the immediate postoperative period is associated with earlier diagnosis of gastrointestinal leak after bariatric surgery.

OBJECTIVE

To investigate the relationship between routine SS and time to diagnosis of postoperative gastrointestinal leak.

SETTING

MBSAQIP-accredited hospitals in the United States and Canada.

METHODS

We conducted an observational cohort study of adults who underwent laparoscopic primary Roux-en-Y gastric bypass (RYGB) (n = 82,510) and sleeve gastrectomy (SG) (n = 283,520) using the MBSAQIP 2015-2019 database. Propensity scores were used to match patient cohorts who underwent routine versus no routine SS. Primary outcome was time to diagnosis of leak. Median days to diagnosis of leak were compared. The Nelson-Aalen estimator was used to determine the cumulative hazards of leak.

RESULTS

In our study, 36,280 (23%) RYGB and 135,335 (33%) SG patients received routine SS. Routine SS was not associated with earlier diagnosis of leak (RYGB routine SS median 7 [IQR 3-12] days v. no routine SS 6 [2-11] days, P = .9; SG routine SS 15 [9-22] days v. no routine SS 14 [8-21] days, P = .06) or lower risk of developing leak (RYGB HR 1.0, 95%-CI .8-1.2; SG HR 1.1, 95%-CI 1.0-1.4). More routine SS patients had a length of stay 2 days or greater (RYGB 78.3% v. 61.1%; SG 48.6% v. 40.3%).

CONCLUSIONS

Routine SS was not associated with earlier diagnosis of leaks compared to the absence of routine SS. Surgeons should consider abandoning the practice of routine SS for the purpose of obtaining earlier diagnosis of postoperative leaks.

Primary Versus Revisional Bariatric and Metabolic Surgery in Patients with a Body Mass Index ≥ 50 kg/m2-90-Day Outcomes and Risk of Perioperative Mortality

BACKGROUND

Bariatric and metabolic surgery (BMS) is an effective treatment for patients with severe obesity. Patients with higher body mass index (BMI) and patients undergoing revisional surgery have a higher rate of major complications. This study purpose is to evaluate perioperative outcomes of patients with BMI ≥ 50 kg/m2.

MATERIALS AND METHODS

A retrospective analysis of patients with a BMI ≥ 50 kg/m2 undergoing BMS between 2015 and 2023 was conducted. A comparative analysis was performed between patients undergoing primary versus revisional surgery.

RESULTS

A total of 263 patients were included in the study. Primary procedures were performed in 220 patients (83.7%) and revisional procedures in 43 patients (16.3%). BMS included one anastomosis gastric bypass (n = 183), sleeve gastrectomy (n = 63), and other procedures (n = 17). Mean BMI was 54.6 with no difference between groups. There was no difference in baseline characteristics except the revisional group was older (44.8 ± 9.6 versus 39 ± 13 years; p = 0.006), had higher rates of gastroesophageal reflux disease (21% vs 7.3%; p = 0.005), and fatty liver disease (74% vs 55%; p = 0.02). There was perioperative mortality in three cases (1.1%) with no significant difference between groups. Leak rates were higher, and length of stay (LOS) was longer in the revisional group (4.6% vs 0.45%; p = 0.018 and 2.9 vs 3.7; p = 0.006, respectively).

CONCLUSION

Revisional BMS in patients with a BMI ≥ 50 kg/m2 is associated with increased leak rates and LOS. Mortality rate is 1.1% and is insignificantly different between groups. Further prospective and large-scale studies are needed to clarify the optimal surgical approach to patients with extreme BMI including revisional surgery.

Decision-making Considerations in Revisional Bariatric Surgery

OBJECTIVE

With drastic variations in bariatric practices, consensus is lacking on an optimal approach for revisional bariatric surgeries.

MATERIALS AND METHODS

The authors reviewed and consolidated bariatric surgery literature to provide specific revision suggestions based on each index surgery, including adjustable gastric band (AGB), sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch (BPD-DS), single anastomosis duodenal-ileal bypass with sleeve (SADI-S), one anastomosis gastric bypass (OAGB), and vertical banded gastroplasty (VBG).

RESULTS

AGB has the highest weight recurrence rate and can be converted to RYGB, SG, and BPD-DS. After index SG, common surgical options include a resleeve or RYGB. The RYGB roux limb can be distalized and pouch resized in context of reflux, and the entire anatomy can be revised into BPD-DS. Data analyzing revisional surgery after a single anastomosis duodenal-ileal bypass with sleeve was limited. In patients with one anastomosis gastric bypass and vertical banded gastroplasty anatomy, most revisions were the conversion to RYGB.

CONCLUSIONS

As revisional bariatric surgery becomes more common, the best approach depends on the patient's indication for surgery and preexisting anatomy.

Pathological and immunohistochemical analysis of gastric mucosa after one anastomosis gastric bypass surgery

BACKGROUND

One anastomosis gastric bypass (OAGB) is now the third most common bariatric surgery worldwide. This procedure is garnering increasing attention, but its complication of bile reflux and the associated risk of gastric carcinogenesis remains controversial.

OBJECTIVE

The study aims to assess the impact of bile reflux on the gastric mucosa by comparing pathological and immunohistochemical results of gastric mucosa before and 2 years after OAGB surgery.

METHODS

This retrospective study analyzed gastric lesions observed in gastroscopy before and after OAGB surgery. Pathological examinations were conducted on mucosal samples from proximal, middle and distal part of stomach, with a particular focus on the expression of Ki-67, P53, and CDX2 in immunohistochemistry. Ki-67 indicates cellular proliferation, P53 is a tumor suppressor protein, and CDX2 is a marker for intestinal differentiation.

RESULTS

A total of 16 patients completed the follow-up. Regarding gastritis, presurgery nonerosive gastritis was found in two cases (12.5%), and postsurgery in six cases (37.5%). Erosive gastritis increased from one case (6.2%) presurgery to three cases (18.7%) postsurgery, totaling an increase from three to nine cases (p = .028). Bile reflux in the stomach increased from one case (6.2%) presurgery to three cases (18.7%) postsurgery. Most lesions in the proximal, middle, and distal part of stomach were relatively mild, with normal tissue states being predominant. Mild inflammation was found in all three areas, whereas moderate inflammation, intestinal metaplasia, and glandular atrophy were less common. No cases of severe inflammation were noted. The expression of gastric biomarkers CDX-2, Ki67, and P53 showed no significant statistical variation in different areas.

CONCLUSION

Bile reflux does occur after OAGB, but its incidence is not high. Based on the immunohistochemical and pathological results of the gastric mucosa 2 years post-OAGB, there seems to be no significant causal relationship between OAGB and oncogenic inflammation around the gastric tube.

Laparoscopic Roux-Y-gastric bypass versus laparoscopic one-anastomosis gastric bypass for obesity: clinical & metabolic results of a prospective randomized controlled trial

BACKGROUND

One anastomosis gastric bypass (OAGB) has been proposed as an effective alternative to the current standard procedure in Switzerland, Roux-en-Y gastric bypass (RYGB). Prospective data comparing both procedures are scarce. Therefore, we performed a non-inferiority randomized controlled trial assessing the effectiveness and safety of these 2 operative techniques.

METHOD

Eighty patients were randomized 1:1. OAGB consisted of a very long gastric pouch with a 200 cm biliopancreatic limb, RYGB of a 150 cm ante-colic alimentary and a 60 cm biliopancreatic limb, respectively. Primary endpoint was the percent excess weight loss (%EWL) at 12 months after surgery.

RESULTS

Mean %EWL at 12 months was 87.9% (SD24.4) in the RYGB group and 104.1% (SD24.6) in the OAGB group (p = 0.006). There was no mortality. The rate of marginal ulcers was higher in patients with OAGB compared to those with RYGB (p = 0.011), while the total number of late complications did not statistically differ between the two groups. Except for the remission of GERD, which was higher in the RYGB group compared to OAGB, there was no difference between the groups regarding the remission of comorbidities. OAGB showed improved glucose control compared to the RYGB after 1 year (p = 0.001). Furthermore, glucagon-like peptide-1 increase was significantly higher in OAGB at 6 weeks (p = 0.041) and 1 year after surgery (p = 0.029). Quality of life improved after both surgeries, without differences between the groups.

CONCLUSIONS

%EWL 1 year after surgery was higher in OAGB than in RYGB. A better glycemic control with a higher increase in GLP-1 was observed after OAGB compared to RYGB.

TRIAL REGISTRATION

This trial is registered on ClinicalTrials.gov under the identifier NCT02601092.

Comparison of Sleeve Gastrectomy with Loop Duodenojejunal Bypass Versus One Anastomosis Gastric Bypass for Type 2 Diabetes: The Role of Pylorus Preservation

BACKGROUND

One anastomosis gastric bypass (OAGB) is recognized as a standard procedure in metabolic surgery. However, concerns about postoperative bile reflux and nutritional risks are prevalent. Comparatively, sleeve gastrectomy with loop duodenojejunal bypass (SG + LoopDJB) bypasses an equivalent length of the foregut as OAGB while maintaining pyloric function. The role of pylorus function remains to be further elucidated regarding these metabolic procedures' therapeutic outcomes and side effects.

METHOD

A retrospective study was conducted in our center to compare the surgical safety and 1-year outcomes of OAGB and SG + LoopDJB regarding type 2 diabetes mellitus (T2DM) remission, weight loss, gastrointestinal disorders, and nutritional status in T2DM patients matched by gender, age, and BMI.

RESULTS

The baseline characteristics were comparable between groups. Compared with OAGB, SG + LoopDJB had longer operative time and length of stay (LOS) but similar major postoperative complications. At 1-year follow-up, OAGB has similar diabetes remission (both 91.9%), weight loss effect (28.1 ± 7.1% vs. 30.2 ± 7.0% for %TWL), and lipidemia improvement to SG + LoopDJB (P > 0.05). However, OAGB presented a higher incidence of hypoalbuminemia (11.9% vs. 2.4%, P = 0.026) but a low incidence of gastroesophageal reflux disease (GERD) symptoms (9.5% vs. 26.2%, P = 0.046) than SG + LoopDJB. There was no statistical difference regarding other gastrointestinal disorders and nutritional deficiencies between groups.

CONCLUSION

Both OAGB and SG + LoopDJB show comparable, favorable outcomes in weight loss, T2DM remission, and lipidemia improvement at the 1-year follow-up. Pylorus preservation, while increasing surgical difficulty and the risk of de novo GERD, may reduce the risk of postoperative hypoalbuminemia.

Revision/Conversion Surgeries After One Anastomosis Gastric Bypass-An Experts' Modified Delphi Consensus

PURPOSE

There is a lack of evidence for treatment of some conditions including complication management, suboptimal initial weight loss, recurrent weight gain, or worsening of a significant obesity complication after one anastomosis gastric bypass (OAGB). This study was designed to respond to the existing lack of agreement and to provide a valuable resource for clinicians by employing an expert-modified Delphi consensus method.

METHODS

Forty-eight recognized bariatric surgeons from 28 countries participated in the modified Delphi consensus to vote on 64 statements in two rounds. An agreement/disagreement among ≥ 70.0% of the experts was regarded to indicate a consensus.

RESULTS

A consensus was achieved for 46 statements. For recurrent weight gain or worsening of a significant obesity complication after OAGB, more than 85% of experts reached a consensus that elongation of the biliopancreatic limb (BPL) is an acceptable option and the total bowel length measurement is mandatory during BPL elongation to preserve at least 300-400 cm of common channel limb length to avoid nutritional deficiencies. Also, more than 85% of experts reached a consensus on conversion to Roux-en-Y gastric bypass (RYGB) with or without pouch downsizing as an acceptable option for the treatment of persistent bile reflux after OAGB and recommend detecting and repairing any size of hiatal hernia during conversion to RYGB.

CONCLUSION

While the experts reached a consensus on several aspects regarding revision/conversion surgeries after OAGB, there are still lingering areas of disagreement. This highlights the importance of conducting further studies in the future to address these unresolved issues.

Proximal Jejuno-Ileal Bypass as Revision of Roux-en-Y Gastric Bypass

INTRODUCTION

Bariatric surgery is established as a possibility for the treatment of obesity, allowing weight reduction and remission of obesity comorbidities. Reported suboptimal clinical response rates are as high as 30-60% (insufficient weight loss or gain, defined as BMI greater than 35 kg/m2 or excess weight loss less than 50%). Proximal jejuno-ileal bypass (PJIBP) is a promising option when re-intervention is required.

OBJECTIVES

To describe the standardization of a proprietary technique of modified PJIBP as a management procedure in patients with post-gastric bypass recurrent weight gain or insufficient post-intervention weight loss.

METHODS

This study evaluated a case series of 10 Latin American patients requiring post-bariatric re-intervention, between February 2018 and 2023, in a single-metabolic surgery center in Cali-Colombia.

RESULTS

Median age was 45 years (26-70 RIC), 60% female, and 40% male. Mean BMI at conversion was 36.7 kg/m2 (6.4 SD). Median follow-up was 22 months (RIC 16-30). Mean percentage of excess weight lost was 78% (22.4 SD). One hundred percent achieved glycemia control, only one patient persisted with dyslipidemia, and no patient presented hypoalbuminemia. At the end of follow-up, 100% received vitamin supplementation.

CONCLUSION

PJIBP could be an effective procedure, associated with positive results in relation to weight loss and resolution of obesity comorbidities. Deficiencies of fat-soluble vitamins and protein malnutrition represent the main concern in the long term, so multidisciplinary management and continuous follow-up are required.

Enhancing bariatric surgery safety for patients refusing blood transfusions: a specialized protocol with comprehensive technical measures

Bariatric surgery has become a leading treatment for obesity, with techniques such as Laparoscopic Sleeve Gastrectomy (LSG) and Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) demonstrating notable success in sustained weight loss and improved quality of life. Technological advancements and improved techniques have enhanced the safety of these procedures. The surgical procedures of Jehovah's Witnesses, who refuse blood transfusions as part of their beliefs, pose unique challenges and have rarely been addressed in the context of bariatric surgery. This report aimed to investigate the safety of bariatric surgery in patients who refuse blood transfusion, with an established protocol to minimize the risk of bleeding. We examined the prospectively collected data of Jehovah's Witness patients who underwent bariatric surgery from 2019 to 2023. The surgeries were conducted following a protocol that included specific measures to prevent bleeding. Data were reviewed for demographics, anthropometrics, comorbidities, preoperative medications, operative time, blood loss, length of hospital stay, hemoglobin level, drainage volume, tranexamic acid use, and postoperative 30-day complications. Eleven Jehovah's Witness patients underwent bariatric surgery, including 10 LSG and 1 LRYGB. A patient with iron deficiency anemia underwent intravenous iron treatment before the surgery. There were no intraoperative complications or major postoperative complications. All patients maintained stable hemodynamics postoperatively. Only one patient encountered nausea-vomiting, classified as a minor complication. One patient experienced a small amount of hemorrhagic drainage, which transitioned to serous after tranexamic acid infusion. Bariatric surgery can be performed safely with established protocols in patients who refuse blood transfusions.

Technical Variations and Considerations around OAGB in IFSO-APC and IFSO-MENAC Chapters, an Expert Survey

OBJECTIVE

This study aimed to evaluate the technical variations of one-anastomosis gastric bypass (OAGB) among IFSO-APC and MENAC experts.

BACKGROUND

The multitude of technical variations and patient selection challenges among metabolic and bariatric surgeons worldwide necessitates a heightened awareness of these issues. Understanding different perspectives and viewpoints can empower surgeons performing OAGB to adapt their techniques, leading to improved outcomes and reduced complications.

METHODS

The scientific team of IFSO-APC, consisting of skilled bariatric and metabolic surgeons specializing in OAGB, conducted a confidential online survey. The survey aimed to assess technical variations and considerations related to OAGB within the IFSO-APC and IFSO-MENAC chapters. A total of 85 OAGB experts participated in the survey, providing their responses through a 35-question online format. The survey took place from January 1, 2024, to February 15, 2024.

RESULTS

Most experts do not perform OAGB for children and adolescents younger than 18 years. Most experts create the gastric pouch over a 36-40-F bougie and prefer to create a gastrojejunostomy, at the posterior wall of the gastric pouch. An anti-reflux suture during OAGB is performed in all patients by 51.8% of experts. Most experts set a common limb length of > 4 m in revisional and conversional OAGBs to prevent nutritional complications.

CONCLUSION

The ongoing debate among metabolic and bariatric surgeons regarding the technical variations and patient selection in OAGB remains a significant point of discussion. This survey demonstrated the variations in technical aspects and patient selection for OAGB among MBS surgeons in the IFSO-APC and IFSO-MENAC chapters. Standardizing the OAGB technique is crucial to ensure optimal safety and efficacy in this procedure.

Periprocedural Changes of Serum Biomarkers in Predicting Complications Following Bariatric Surgery for Obesity: Systematic Review and Meta-analysis

Bariatric surgery is an effective treatment for severe obesity, but complications and peri-operative monitoring are important considerations. We conducted a comprehensive review of studies assessing pre-operative biomarkers and complications in patients undergoing bariatric surgery. A total of 14 studies were included. Gastric leak, infections, bleeding, obstruction or stenosis, hypoglycemia, and hypoalbuminemia were the most common complications observed. Our analysis showed a significant association between lower pre-operative albumin levels and complications (SMD [95%CI] =  - 0.21 [- 0.38; - 0.04]). However, other biomarkers did not have a significant impact on complication occurrence. Changes in C-reactive protein, neutrophil-lymphocyte ratio, and white blood cell levels were observed in certain peri-operative time points and complication subgroups. These findings suggest the potential use of pre-operative biomarkers and peri-operative changes of biomarker's levels for predicting complications.

Effects of bariatric surgery on renal function: a retrospective cohort study comparing one-year outcomes between one-anastomosis gastric bypass and Roux-en-Y gastric bypass

BACKGROUND

Evidence on the effect of one-anastomosis gastric bypass (OAGB) on renal function is limited.

OBJECTIVE

To compare the evolution of estimated renal function observed 1 year after OAGB and Roux-en-Y gastric bypass (RYGB) in individuals with obesity.

DESIGN AND SETTING

Observational, analytical, and retrospective cohort study. Tertiary-level university hospital.

METHODS

This study used a prospectively collected database of individuals who consecutively underwent bariatric surgery. Renal function was assessed by calculating the estimated glomerular filtration rate (eGFR), according to the Chronic Kidney Disease Epidemiology Collaboration. The one-year variation in the eGFR was compared between the procedures.

RESULTS

No significant differences in age, sex, obesity-associated conditions, or body mass index were observed among individuals who underwent either OAGB or RYGB. OAGB led to a significantly higher percentage of total (P = 0.007) and excess weight loss (P = 0.026). Both OAGB and RYGB led to significantly higher values of eGFR (103.9 ± 22 versus 116.1 ± 13.3; P = 0.007, and 102.4 ± 19 versus 113.2 ± 13.3; P < 0.001, respectively). The one-year variation in eGFR was 11 ± 16.2% after OAGB and 16.7 ± 26.3% after RYGB (P = 0.3). Younger age and lower baseline eGFR were independently associated with greater postoperative improvement in renal function (P < 0.001).

CONCLUSION

Compared with RYGB, OAGB led to an equivalent improvement in renal function 1 year after the procedure, along with greater weight loss.

Marginal Ulcer Perforation after One Anastomosis Gastric Bypass: Surgical Treatment and Two-Year Outcomes

Background: Marginal ulcer (MU) perforation is a chronic complication after One-anastomosis Gastric Bypass (OAGB). This study's purpose was to analyze patients undergoing OAGB revision due to MU perforation and describe the two-year outcomes. Methods: A retrospective analysis of a database in a single-tertiary hospital. All patients undergoing surgical revision due to MU perforation were included. Results: During the study period, 22 patients underwent OAGB revision due to MU perforation. The rate of MU perforation was 0.98%. The median age was 48 years and there were 13 men (59%). The median time from OAGB to MU perforation was 19 months with a median total weight loss of 31.5%. Nine patients (41%) were smokers. Omental patch (±primary closure) was performed in 19 patients (86%) and three patients (14%) underwent conversion to Roux-en-Y gastric bypass (RYGB). At a median follow-up of 48 months, three patients (14%) had recurrent MU diagnosis, of which one had a recurrent MU perforation. Four patients (18%) underwent conversion to RYGB during follow-up. Conclusions: MU perforation is a chronic complication after OAGB. In this cohort, most patients were men and likely to be smokers. Omental patch was effective in most cases. Recurrent MU rates at two years follow-up were acceptable.

Comparison of adrenalectomy with conservative treatment on mild autonomous cortisol secretion: a systematic review and meta-analysis

Objective

This systematic review and meta-analysis was conducted to compare the benefits of adrenalectomy and conservative treatment for comorbidities associated with mild autonomous cortisol secretion (MACS) in patients diagnosed with MACS.

Background

MACS is the most common benign hormone-secreting functional adrenal incidentaloma. Overproduction of cortisol is observed in MACS patients, resulting in a variety of long-term health issues, including arterial hypertension (HTN), diabetes mellitus (DM), dyslipidemia, obesity, and osteoporosis; however, the classic clinical manifestations of Cushing's syndrome (CS) are not present.

Methods

A systematic search was conducted using MEDLINE, Embase, Web of Sciences, and Scopus databases on December, 2023. Two reviewers independently extracted data and assessed the quality of the included articles. A meta-analysis was performed to compare the beneficial effects of adrenalectomy versus conservative management for MACS-related comorbidities.

Results

Fifteen articles were included in this study, which evaluated 933 MACS patients (384 Adrenalectomy and 501 Conservative treatment, and 48 excluded due to incomplete follow-up duration). MACS diagnosis criteria were different among the included articles. All studies, however, stated that there must be no overt CS symptoms. Meta-analysis demonstrates the overall advantage of adrenalectomy over conservative treatment for MACS-related comorbidities (Cohen's d = -0.49, 95% CI [-0.64, -0.34], p = 0.00). Subgroup analysis indicated that the systolic blood pressure (pooled effect size = -0.81, 95% CI [-1.19, -0.42], p = 0.03), diastolic blood pressure (pooled effect size = -0.63, 95% CI [-1.05, -0.21], p = 0.01), and BMD (pooled effect size = -0.40, 95% CI [-0.73, -0.07], p = 0.02) were significantly in favor of adrenalectomy group rather than conservative treatment but no significant differences between the two treatment groups in other MACS-related comorbidities were reported.

Conclusion

Despite the limited and diverse data, this study demonstrates the advantage of adrenalectomy over conservative treatment for MACS-related comorbidities.

Effect of anti-reflux suture on gastroesophageal reflux symptoms after one anastomosis gastric bypass: a randomized controlled trial

PURPOSE

Gastroesophageal reflux disease (GERD) is an issue after one anastomosis gastric bypass (OAGB) and modification of OAGB with adding an anti-reflux system may decrease the incidence of postoperative GERD. This study aimed to compare the efficacy of the anti-reflux mechanism to treat preoperative GERD and prevent de novo GERD.

METHODS

A prospective randomized clinical trial study was conducted on patients with a body mass index of 40 and more from August 2020 to February 2022. Patients undergoing one anastomosis gastric bypass with and without anti-reflux sutures (groups A and B, respectively). These patients had follow-ups for one year after the surgery. GERD symptoms were assessed in all the patients using the GERD symptom questionnaire.

RESULTS

The mean age was 39.5 ± 9.8 years and 40.7 ± 10.2 years in groups A and B respectively. GERD symptoms remission occurred in 76.5% and 68.4% of patients in groups A and B, respectively. The incidence of de novo GERD symptoms was lower in group A, compared to group B (6.2% and 16.1% in groups A and B respectively), without any statistically significant difference (p-value: 0.239).

CONCLUSION

GERD symptoms and de novo GERD after OAGB seems to be under-reported after OAGB. This study suggests that applying an anti-reflux suture can decrease de novo GERD symptoms.

Laparoscopic sleeve gastrectomy vs one-anastomosis gastric bypass 5-year follow-up: a single-blinded randomized controlled trial

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is the most performed bariatric procedure worldwide, whereas one-anastomosis gastric bypass (OAGB) is the third most performed procedure. Both procedures have reported good weight loss (WL) and low complications. However, should both have differences in the durability of WL and malnutrition?

METHODS

A single-blinded, randomized controlled trial of 300 patients was conducted to compare the outcomes of LSG and OAGB over a 5-year follow-up. The primary endpoint was WL in percentages of total WL (%TWL) and excess WL (%EWL). The secondary endpoints were complications, gastroesophageal reflux disease (GERD), associated medical problems, bariatric analysis and reporting outcome system (BAROS) assessment, and weight recurrence (WR).

RESULTS

Overall, 201 patients (96 in the LSG group and 105 in the OAGB group) completed 5 years of follow-up. OAGB had significantly higher %TWL and %EWL than those of LSG throughout the follow-up. LSG had significantly higher WR and GERD. Both procedures had significant improvement in associated medical problems and BAROS scores compared with baseline, with no significant difference. WR was associated with higher relapse of associated medical conditions after initial remission and with lower BAROS scores regarding WL scores.

CONCLUSION

OAGB had significantly higher WL, less WR, and less GERD. However, it had a higher incidence of bile reflux. Both procedures had comparable complication rates, excellent remissions in associated medical problems, and improved quality of life. WR was associated with significantly more relapse of associated medical problems and significantly lower BAROS scores.

Risk of Esophageal Adenocarcinoma After Bariatric Surgery: A Meta-Analysis of Retrospective Studies

PURPOSE

This study aims to systematically review and meta-analyze the evidence on the risk of esophageal adenocarcinoma (EAC) following metabolic and bariatric surgery (MBS).

MATERIALS AND METHODS

A systematic literature search was conducted on the China National Knowledge Infrastructure (CNKI), Wanfang, EMBASE, MEDLINE, Web of Science, The Cochrane Library, and PubMed databases. Meta-analysis utilized odds ratios (ORs) and 95% confidence intervals (CIs) to analyze the correlation between MBS and the risk of EAC. Meta-analysis was performed using STATA software (version 12.0).

RESULTS

Fourteen studies involving patients with obesity undergoing bariatric surgery and control groups receiving conventional treatment were included. The meta-analysis indicated a reduction in the overall incidence of esophageal cancer after bariatric surgery (OR = 0.69, 95% CI: 0.51-0.95, P = 0.022). Subgroup analysis results demonstrated a decreased risk of EAC in European patients with obesity undergoing MBS treatment (OR: 0.60, 95% CI: 0.38-0.95, P = 0.028). In studies with a sample size greater than or equal to 100,000 patients, the risk of EAC in patients with obesity undergoing MBS was significantly lower than the non-surgery group (OR: 0.59, 95% CI: 0.42-0.83, P = 0.003). Articles published before 2020 and those published in 2020 or earlier showed a significant difference in the incidence of EAC between the surgery and non-surgery groups (OR: 0.57, 95% CI: 0.43-0.75, P < 0.001). The risk of EAC in patients with obesity with a follow-up time of less than 5 years was statistically significant (OR: 0.46, 95% CI: 0.25-0.82, P = 0.009).

CONCLUSION

Our meta-analysis results suggest a reduced risk of esophageal cancer in patients with obesity after bariatric surgery.

PROSPERO REGISTRATION

CRD 42024505177.

A novel method of tunneling retroperitoneoscopic adrenalectomy: a prospective study

BACKGROUND

To introduce the surgical technique and our team's extensive experience with tunnel method in laparoscopic adrenalectomy.

METHODS

From July 2019 to June 2022, we independently designed and conducted 83 cases of " Tunnel Method Laparoscopic Adrenalectomy," a prospective study. There were 45 male and 38 female patients, ages ranged from 25 to 73 years(mean: 44.6 years).The cases included 59 adrenal cortical adenomas, 9 pheochromocytomas, 6 cysts, 4 myelolipomas, 1 ganglioneuroma, and 4 cases of adrenal cortical hyperplasia. In terms of anatomical location, there were 39 cases on the left side, 42 on the right side, and 2 bilateral cases. Tumor diameters ranged from 0.6 to 5.9 cm(mean: 2.9 cm). Utilizing ultrasound monitoring, percutaneous puncture was made either directly to the target organ or its vicinity, and the puncture path was manually marked. Then, under the direct view of a single-port single-channel laparoscope, the path to the target organ in the retroperitoneum or its vicinity was further delineated and separated. This approach allowed for the insertion of the laparoscope and surgical instruments through the affected adrenal gland, thereby separating the surface of the target organ to create sufficient operational space for the adrenalectomy.

RESULTS

All 83 surgeries were successfully completed. A breakdown of the surgical approach reveals that 51 surgeries were done using one puncture hole, 25 with two puncture holes, and 7 with three puncture holes. The operation time ranged from 31 to 105 min (mean: 47 min), with a blood loss of 10 to 220mL (mean: 40 mL). Notably, there were no conversions to open surgery and no intraoperative complications. Postoperative follow-up ranged from 6 to 28 months, during which after re-examination using ultrasound, CT, and other imaging methods, there were no recurrences or other complications detected.

CONCLUSIONS

The completion of the tunnel method laparoscopic adrenalectomy represents a breakthrough, transitioning from the traditional step-by-step separation of retroperitoneal tissues to reach the target organ in conventional retroperitoneoscopic surgery. This method directly accesses the target organ, substantially reducing the damage and complications associated with tissue separation in retroperitoneoscopic surgery, As a result, it provides a new option for minimally invasive surgery of retroperitoneal organs and introduces innovative concepts to retroperitoneoscopic surgery.

Multimodal approach utilising a weight management programme prior to bariatric surgery in patients with BMI ≥50 kg/m2: A propensity score matching retrospective cohort study

We evaluated preoperative weight loss and days from initial consult to surgery in patients with BMI ≥50 kg/m2 who were and were not enrolled in medical weight management (MWM) prior to laparoscopic sleeve gastrectomy. We retrospectively identified patients with BMI ≥50 kg/m2 who had primary sleeve gastrectomy between 2014 and 2019 at two bariatric surgery centres in our healthcare system. Patients presenting after 2017 that received preoperative MWM (n = 28) were compared to a historical cohort of non-MWM patients (n = 118) presenting prior to programme initiation in 2017 on preoperative percent total body weight loss (%TBWL) and days from initial consult to surgery. A total of 151 patients (MWM, 33; non-MWM, 118) met inclusion criteria. BMI was significantly greater in MWM versus non-MWM (p = .018). After propensity score matching, median BMI at initial consult in non-MWM versus MWM no longer differed (p = .922) neither were differences observed on the basis of weight, age, sex, race or ethnicity. After PSM, MWM had significantly lower BMI at surgery (p = .018), lost significantly more weight from consult to surgery (p < .001) and achieved significantly greater median %TBWL from consult to surgery (p < .001). We noted no difference between groups on 6-month weight loss (p = .533). Days from initial consult to surgery did not differ between groups (p < .863). A preoperative MWM programme integrated into multimodal treatment for obesity in patients with a BMI ≥50 kg/m2 resulted in clinically significant weight loss without prolonging time to surgery.

One-Anastomosis Gastric Bypass (OABG) vs. Single Anastomosis Duodeno-Ileal Bypass (SADI) as revisional procedure following Sleeve Gastrectomy: results of a multicenter study

PURPOSE

Sleeve Gastrectomy (SG) is the most performed bariatric surgery, but a considerable number of patients may require revisional procedures for suboptimal clinical response/recurrence of weight (SCR/RoW). Conversion options include One-Anastomosis Gastric Bypass (OAGB) and Single Anastomosis Duodeno-Ileal Bypass (SADI). The study aims to compare SADI vs. OAGB as revisional procedures in terms of early and mid-term complications, operative time, postoperative hospital stay and clinical outcomes.

METHODS

All patients who underwent OAGB or SADI as revisional procedures following SG for SCR/RoW at three high-volume bariatric centers between January 2014 and April 2021 were included. Propensity score matching (PSM) analysis was performed. Demographic, operative, and postoperative outcomes of the two groups were compared.

RESULTS

One hundred and sixty-eight patients were identified. After PSM, the two groups included 42 OAGB and 42 SADI patients. Early (≤ 30 days) postoperative complications rate did not differ significantly between OAGB and SADI groups (3 bleedings vs. 0, p = 0.241). Mid-term (within 2 years) complications rate was significantly higher in the OAGB group (21.4% vs. 2.4%, p = 0.007), mainly anastomotic complications and reflux disease (12% of OAGBs). Seven OAGB patients required conversion to another procedure (Roux-en-Y Gastric Bypass-RYGB) vs. none among the SADI patients (p = 0.006).

CONCLUSIONS

SADI and OAGB are both effective as revisional procedures for SCR/RoW after SG. OAGB is associated with a significantly higher rate of mid-term complications and a not negligible rate of conversion (RYGB). Larger studies are necessary to draw definitive conclusions.

American Society for Metabolic and Bariatric Surgery position statement on one-anastomosis gastric bypass

The following position statement is issued by the American Society for Metabolic and Bariatric Surgery in response to inquiries made to the society by patients, physicians, society members, hospitals, health insurance payors, and others regarding one-anastomosis gastric bypass as a treatment for obesity and metabolic disease. This statement is based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence available at this time. The statement may be revised in the future as more information becomes available.

Efficacy of LigaSure Versus Harmonic Devices in Laparoscopic Sleeve Gastrectomy: A Systematic Review and Meta-Analysis

Our goal is to conduct a thorough systematic review and meta-analysis of comparative studies to evaluate the efficacy of LigaSure (Valleylab, Boulder, CO) compared with Harmonic (Ethicon Endo-Surgery, Inc., Cincinnati, OH) devices in patients undergoing laparoscopic sleeve gastrectomy (LSG). Our search strategy, from inception until March 1, 2024, involved multiple databases, including the Cochrane Controlled Register of Trials (CENTRAL), Web of Science (WOS), PubMed, Scopus, and Google Scholar. We evaluated randomized clinical trials using the Cochrane Risk of Bias tool for randomized trials (RoB-2) tool and non-randomized studies using the Risk of Bias In Non-randomized Studies for Interventions (ROBINS-I) tool. The primary outcomes assessed were operative time, mean length of hospital stay, and the rates of intraoperative complications such as bleeding, organ injury, leakage, and hematoma formation. Additionally, we collected data on postoperative complications, including bleeding, abscess formation, leakage, fever (>38°C), and reoperation rates. Data were analyzed using random-effects models and reported as mean difference (MD) or risk ratio (RR) with a 95% confidence interval (CI) using Review Manager software (RevMan, version 5.4 for Windows, The Cochrane Collaboration, 2020). Four studies, comprising two randomized clinical trials (RCTs) and two retrospective cohort studies, involving a total of 692 patients, were included in the analysis. Both the operative time and length of hospital stay did not significantly differ between the LigaSure and Harmonic groups (p>0.05). The pooled analysis also revealed no significant difference between the LigaSure and Harmonic groups in terms of intraoperative and postoperative complications (p>0.05). In conclusion, our systematic review and meta-analysis found no significant statistical or clinical differences between LigaSure and Harmonic devices in terms of operative outcomes and complication rates in patients undergoing LSG.

Efficacy and safety of one anastomosis gastric bypass versus Roux-en-Y gastric bypass at 5 years (YOMEGA): a prospective, open-label, non-inferiority, randomised extension study

BACKGROUND

The multicentre randomised trial YOMEGA (NCT02139813) comparing the one anastomosis gastric bypass (OAGB) with the Roux-en-Y gastric bypass (RYGB) confirmed the non-inferiority of OAGB on weight loss outcomes at 24 months. We aimed to report weight loss, metabolic, and safety outcomes at 5 years.

METHODS

YOMEGA is a prospective, open-label, non-inferiority, randomised trial conducted at nine centres in France. Inclusion criteria were BMI of 40 kg/m2 or more, or 35 kg/m2 or more with comorbidities. Key exclusion criteria were severe gastro-oesophageal reflux disease or Barrett's oesophagus and previous bariatric surgery. Patients were randomly assigned (1 :1) to OAGB (one gastrojejunal anastomosis with a 200 cm biliopancreatic limb) or RYGB (with a 150 cm alimentary limb and a 50 cm biliary limb), stratified by centre, with blocks of variable size. The primary endpoint of this extension study was percentage excess BMI loss and was analysed in the per-protocol population, including patients with data who were operated on with the technique randomly assigned to them and excluding patients with major deviations from the protocol during the follow-up (change of surgical technique, death, or withdrawal of consent). Non-inferiority was concluded for the primary endpoint if the upper bound of the CI was less than the non-inferiority limit (7 percentage points). YOMEGA is registered with ClinicalTrials.gov, NCT02139813, and the 5-year follow-up of YOMEGA is registered with ClinicalTrials.gov, NCT05549271.

FINDINGS

Between May 13, 2014, and March 2, 2016, 253 patients were randomly assigned to OAGB (n=129) or RYGB (n=124), and from these patients 114 in the OAGB group and 118 in the RYGB group were included in the per-protocol analysis. In the per-protocol population, at baseline, mean age was 43·0 years (SD 10·8), mean BMI was 44·0 kg/m2 (5·6), 54 (23%) patients were male and 178 (77%) were female; 55 (27%) of 207 patients had type 2 diabetes. After 5 years, mean percentage excess BMI loss was -75·6% (SD 28·1) in the OAGB group versus -71·4% (SD 29·8) in the RYGB group, confirming non-inferiority (mean difference -4·1% [90% CI -12·0 to 3·7], p=0·0099). Remission of type 2 diabetes was similar in both groups. Nutritional status did not differ; the most common adverse event was clinical gastro-oesophageal reflux disease, occurring in 27 (41%) of 66 patients in the OAGB group versus 14 (18%) of 76 patients in the RYGB group (p=0·0030). Among serious adverse events, ten (8%) of 127 patients converted from OAGB to RYGB. 171 (68%) of 253 patients were followed up.

INTERPRETATION

OAGB was not inferior to RYGB regarding percentage excess BMI loss at 5 years with similar metabolic outcomes. The high rate of clinical gastro-oesophageal reflux disease after OAGB raises questions about its long-term consequences, which need to be further investigated.

FUNDING

Medtronic.

Time to Flip the Approach: Retroperitoneoscopic Adrenalectomy

INTRODUCTION

Retroperitoneoscopic adrenalectomy (RPA) has gained increasing popularity with its excellent perioperative outcomes and direct surgical access compared to other adrenalectomy approaches. We review perioperative outcomes of RPA by a specialized endocrine surgeon before and after expert intensive trainings (EITs), and to that of other laparoscopic adrenalectomy approaches at our center over a 9-year period, aiming to ascertain if RPA is worth the steep learning curve.

MATERIAL AND METHODS

One hundred twenty one adrenalectomies were performed between January 2014 to June 2022. Patient demographic, tumor characteristics, and perioperative outcomes were retrospectively reviewed. The primary endpoints included procedure duration, complications, and length of stay. Part I of the study examined the effect of EITs on RPA's learning curve, and part II compared these outcomes with that of the alternative approach, transabdominal lateral adrenalectomy (TLA).

RESULTS

Both procedure duration and days in hospital markedly decreased after the two EITs for RPA. RPA resulted in a shorter procedure duration and hospital stay compared to TLA, and had lesser and milder intraoperative and postoperative complications compared to TLA.

CONCLUSIONS

RPA results in safe and excellent outcomes, and offers additional benefit of direct surgical access, feasibility in patients with previous abdominal surgery, high body mass index, and multiple comorbidities. The steep learning curve can be overcome and shortened by EITs, motivating centers with specialized endocrine surgery to integrate RPA training into its curriculum, given its foreseeable rewarding outcomes.

Biliopancreatic diversion for severe obesity: long-term weight maintenance and occurrence of nutritional complications are two facets of the same coin

BACKGROUND

Despite the widespread clinical use of hypoabsorptive metabolic bariatric surgery, very long-term outcomes are still lacking. The aim of the study was to assess the long-term safety and efficacy of biliopancreatic diversion at 30 years in patients with class 3 obesity (BMI over 40 kg/m2).

METHODS

This retrospective single-centre study used data from a prospectively collected database on a sample of consecutive patients submitted to biliopancreatic diversion with a minimum follow-up of 30 years. Outcomes assessed included overall survival, long-term weight loss and weight maintenance, remission of obesity-related co-morbidities, and short- and long-term surgical and/or nutritional or metabolic complications.

RESULTS

Among 199 consecutive patients (136 female, 63 male) who had surgery between November 1992 and April 1994, the mean age at operation was 38 (range 14-69) years and mean preoperative BMI was 48.7 (32.0-74.3) kg/m2. At baseline, 91 of 199 patients (45.7%) had type 2 diabetes. At 20 and 30 years, 122 (61%) and 38 (19%) of the 199 patients respectively were available for follow-up. At 30 years, the overall mortality rate was 12% (23 of 199). Surgical complications were concentrated in the short-term follow-up, whereas nutritional or metabolic complications increased progressively over time. A nutritional complication was diagnosed in 73 of 122 patients (60%) at 20 years and 28 of 38 (74%) at 30 years. Weight loss and glycaemic control were maintained throughout the follow-up; mean % total weight loss was 32.8 (range 14.1-50.0) at 1 year and 37.7 (range 16.7-64.8) at 30 years. One patient presented with recurrence of type 2 diabetes at 20 and 30 years; there were no patients with new-onset type 2 diabetes.

CONCLUSION

Biliopancreatic diversion leads to good and sustained weight maintenance up to 30 years with low perioperative risk, but at the cost of a high long-term prevalence of nutritional complications.

Metabolic and Bariatric Surgery in Patients with Obesity Class V (BMI > 60 kg/m2): a Modified Delphi Study

BACKGROUND

Metabolic and bariatric surgery (MBS) is the preferred method to achieve significant weight loss in patients with Obesity Class V (BMI > 60 kg/m2). However, there is no consensus regarding the best procedure(s) for this population. Additionally, these patients will likely have a higher risk of complications and mortality. The aim of this study was to achieve a consensus among a global panel of expert bariatric surgeons using a modified Delphi methodology.

METHODS

A total of 36 recognized opinion-makers and highly experienced metabolic and bariatric surgeons participated in the present Delphi consensus. 81 statements on preoperative management, selection of the procedure, perioperative management, weight loss parameters, follow-up, and metabolic outcomes were voted on in two rounds. A consensus was considered reached when an agreement of ≥ 70% of experts' votes was achieved.

RESULTS

A total of 54 out of 81 statements reached consensus. Remarkably, more than 90% of the experts agreed that patients should be notified of the greater risk of complications, the possibility of modifications to the surgical procedure, and the early start of chemical thromboprophylaxis. Regarding the choice of the procedure, SADI-S, RYGB, and OAGB were the top 3 preferred operations. However, no consensus was reached on the limb length in these operations.

CONCLUSION

This study represents the first attempt to reach consensus on the choice of procedures as well as perioperative management in patients with obesity class V. Although overall consensus was reached in different areas, more research is needed to better serve this high-risk population.

Revisional One-Step Bariatric Surgical Techniques After Unsuccessful Laparoscopic Gastric Band: A Retrospective Cohort Study with 2-Year Follow-up

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) has high reported rates of revision due to poor weight loss (WL) and high complication rates. Yet, there is yet to be a consensus on the best revisional procedure after unsuccessful LAGB, and studies comparing different revisional procedures after LAGB are still needed.

METHODS

This was a retrospective cohort study that compared the outcomes of one-step revisional Roux-en-Y gastric bypass (rRYGB), one-anastomosis gastric bypass (rOAGB), or laparoscopic sleeve gastrectomy (rLSG) after LAGB. WL, complications, resolution of associated medical conditions, and food tolerance were assessed with a post hoc pairwise comparison one-way analysis of variance (ANOVA) throughout a 2-year follow-up.

RESULTS

The final analysis included 102 (rRYGB), 80 (rOAGB), and 70 (rLSG) patients. After 2 years, an equal percentage of excess weight loss was observed in rOAGB and rRYGB (both >90%; p=0.998), significantly higher than that in rLSG (83.6%; p<0.001). In our study, no leaks were observed. rRYGB had higher complication rates according to the Clavien-Dindo classification (10.8% vs. 3.75% and 5.7% in rOAGB and rLSG, respectively, p=0.754), and re-operations were not statistically significant. Food tolerance was comparable between rOAGB and rRYGB (p = 0.987), and both had significantly better food tolerance than rLSG (p<0.001). The study cohorts had comparable resolution rates for associated medical problems (p>0.60).

CONCLUSION

rOAGB and rRYGB had better outcomes after LAGB than rLSG regarding WL, feasibility, food tolerance, and safety. rOAGB had significantly higher rates of nutritional deficiencies.

Conversion of one-anastomosis gastric bypass (OAGB) to Roux-en-Y gastric bypass (RYGB) for gastroesophageal reflux disease (GERD): who is more at risk? A multicenter study

BACKGROUND

Although gastroesophageal reflux disease (GERD) affects 0.6% to 10% of patients operated on for one-anastomosis gastric bypass (OAGB), only about 1% require surgery to convert to Roux-en-Y gastric bypass (RYGB) [3-5]. The aim of the present study was to analyze the characteristics of OAGB patients converted to RYGB for GERD not responding to medical treatment.

METHODS

This retrospective multicenter study included patients who underwent conversion from OAGB to RYGB for severe GERD. The conversion was performed with resection of the previous gastro-jejunal anastomosis and the use of the afferent loop as a new biliary loop.

RESULTS

A total of 126 patients were included in the study. Of these patients, 66 (52.6%) had a past medical history of bariatric restrictive surgery (gastric banding, sleeve gastrectomy). A hiatal hernia (HH) was present in 56 patients (44.7%). The association between previous restrictive surgery and HH was recorded in 33 (26.2%) patients. Three-dimensional gastric computed tomography showed an average gastric pouch volume of 242.4 ± 55.1 cm3. Conversion to RYGB was performed on average 60 ± 35.6 months after OAGB. Seven patients (5.5%) experienced an early postoperative complication (4 patients grade IIIb and 3 grade IIb), and 3 (2.4%) a late complication. Patients showed further weight loss after RYGB conversion and an average of 24.8 ± 21.7 months after surgery, with a mean % of total weight loss (%TWL) of 6.9 ± 13.6 kg. From a clinical point of view, the problem of GERD was definitively solved in more than 90% of patients.

CONCLUSIONS

Situations that weaken the esogastric junction appear to be highly frequent in patients operated on for OAGB and converted to RYGB for severe reflux. Similarly, the correct creation of the gastric pouch could play an important role in reducing the risk of conversion to RYGB for GERD.

Variation in HbA1c in Patients with Obesity and type 2 Diabetes Mellitus 12 months after Laparoscopic One-Anastomosis Gastric Bypass and Laparoscopic Roux-en-Y Gastric Bypass: a Retrospective Matched Cohort Study

BACKGROUND

Glycemic control is an important goal of bariatric surgery in patients with type 2 diabetes mellitus (T2DM) and obesity. The laparoscopic one-anastomosis gastric bypass (OAGB) has potential metabolic benefits over the laparoscopic Roux-en-Y gastric bypass (RYGB). Aim of this study is to examine whether RYGB or OAGB grants better glycemic control 12 months post-surgery.

METHODS

For this retrospective cohort study, patients with T2DM and obesity, who underwent primary OAGB between 2008 and 2017 were reviewed. For each OAGB patient, three primary RYGB patients were matched for age, gender and body mass index (BMI). Glycemic control was expressed by the glycated hemoglobin (HbA1c), which was measured pre- and 12 months post-operatively. Weight loss was reported in percentage total weight loss (%TWL).

RESULTS

A total of 152 patients, of whom 38 had OAGB and 114 RYGB, were included. Mean (standard deviation (SD)) HbA1c was 7.49 (1.51)% in the OAGB group and 7.56(1.23)% in the RYGB group at baseline. Twelve months after surgery the mean (SD) HbA1c dropped to 5.73 (0.71)% after OAGB and 6.09 (0.76)% after RYGB (adjusted p = 0.011). The mean (SD) BMI was reduced from 42.5(6.3) kg/m2 to 29.6(4.7) kg/m2 after OAGB and 42.3(5.8) kg/m2 to 29.9 (4.5) kg/m2 after RYGB; reflecting 30.3 (6.8) %TWL post-OAGB and 29.0 (7.3) %TWL post-RYGB (p = 0.34).

CONCLUSION

This study indicates that OAGB leads to lower HbA1c one year after surgery compared to RYGB, without a difference in weight loss. Prospective (randomized) studies are needed to ascertain the most optimal metabolic treatment for patients with obesity and T2DM.

[Personalized treatment of pheochromocytoma]

BACKGROUND

Pheochromocytoma is a rare but severe disease of the adrenal glands. The aim of this study is to present and discuss recent developments in the diagnosis and treatment of pheochromocytoma.

MATERIAL AND METHODS

A narrative review article based on the most recent literature is presented.

RESULTS AND DISCUSSION

The proportion of pheochromocytomas as tumors of adrenal origin is about 5% of incidentally discovered adrenal tumors. The classical symptomatic triad of headaches, sweating, and palpitations occurs in only about 20% of patients, while almost all patients show at least 1 of these symptoms. To diagnose pheochromocytoma, levels of free plasma metanephrines or alternatively, fractionated metanephrines in a 24‑h urine collection is required in a first step. In the second step an imaging procedure, computed tomography (CT) or magnetic resonance imaging (MRI), is performed to localize the adrenal tumor. Functional imaging is also recommended to preoperatively detect potential metastases. Genetic testing should always be offered during the course of treatment as 30-40% of pheochromocytomas are associated with genetic mutations. The dogma of preoperative alpha blockade is increasingly being questioned and has been controversially discussed in recent years. Minimally invasive removal of the adrenal tumor is the standard surgical procedure to cure patients with pheochromocytoma. The transabdominal and retroperitoneal laparoscopic approaches are considered equivalent. The choice of the minimally invasive procedure depends on the expertise and experience of the surgeon and should be tailored accordingly. Individualized and regular follow-up care is important after surgery.

Transabdominal and retroperitoneal adrenalectomy: comparative study

BACKGROUND

Laparoscopic adrenalectomy is recognized as the "gold standard" approach for benign adrenal tumors. The majority of surgeons opt for laparoscopic transabdominal adrenalectomies (LTA), while retroperitoneoscopic adrenalectomies (RPA) in the prone position have certain advantages for patients. The aim of this study was to compare the effectiveness and safety of the transabdominal and retroperitoneoscopic laparoscopic adrenalectomies.

MATERIALS AND METHODS

Between 2000 and 2021, our clinic performed 472 laparoscopic adrenalectomies. The age ranged from 19 to 79 years, with a mean age of 50.5 ± 10.2 years. The patient pool consisted of 315 women and 157 men. Tumor sizes ranged from 1 to 10 cm.

RESULTS

In a study of 316 patients undergoing LTA versus 156 with RPA, the TLA averaged 82.5 min (70-98), while the RPA took 56.4 min (46-62) (P < 0.001). Intraoperative blood loss was 110 cc for the LTA group and 80 cc for the RPA group (P < 0.05) Conversion rates stood at 2.5% for transabdominal and 4.5% for retroperitoneoscopic procedures (P = 0.254). At 24 h post-operation, pain scores were 3.6 and 1.6, respectively (P < 0.001). Time to resume solid oral intake was 15.2 h for TLA and 8 h for RPA, with hospital stays at 4.5 days and 3 days respectively (P < 0.001). Short-term complications occurred in 8.9% of transabdominal and 12.2% of retroperitoneoscopic patients (P = 0.257).

CONCLUSIONS

For small tumors, RPA offers advantages over the transabdominal method in surgery time, blood loss, post-op pain, and recovery. These benefits are enhanced for patients with prior abdominal surgeries. However, large tumors present challenges in the retroperitoneal approach due to limited space and anatomical orientation. If complications emerge, surgeons can seamlessly switch to the LTA.

Comparison of revisional surgeries after OAGB versus RYGB: Results from the multicenter Polish Revision Obesity Surgery Study (PROSS)

<br><b>Introduction:</b> Roux-en-Y gastric bypass (RYGB) is a leading bariatric surgery globally. One-anastomosis gastric bypass (OAGB), a modification of RYGB, ranks as the third most common bariatric procedure in Poland. While clinical trials show that OAGB outcomes are comparable to those of RYGB regarding weight loss, remission of comorbidities, and hormonal impact, there is limited data on long-term outcomes and complications.</br><br><b>Aim:</b> The aim of the study was to compare the outcomes of revisional surgeries conducted after OAGB <i>versus</i> RYGB.</br> <br><b>Material and methods:</b> This retrospective study analyzed patients undergoing revisional bariatric surgeries from January 2010 to January 2020 across 12 Polish centers. The inclusion criteria were an age of at least 18 years and prior OAGB or RYGB surgery. Those with incomplete primary surgery data and follow-up post-revision were excluded. Data were collected regarding parameters for anthropometrics, comorbidities, and perioperative details. The patients were categorized based on their initial surgery: OAGB or RYGB. The primary endpoints were the reasons for and types of revisional surgery and weight changes; the secondary endpoints were postoperative complications and length of hospital stay (LOS).</br> <br><b>Results:</b> In total, 27 patients participated, with a mean age of 38.18 7 years. Differences between the OAGB (13 patients) and RYGB (14 patients) groups included median initial body weight (100 kg <i>vs.</i> 126 kg, p<0.016), number of postoperative complications (9 <i>vs.</i> 3, p = 0.021), and median LOS (3 <i>vs.</i> 4.5 days, p = 0.03). GERD was the primary reason for OAGB revisions (69.2%), whereas insufficient weight loss led to the most RYGB revisions (42.9%).</br><br><b>Conclusions:</b> The RYGB patients commonly needed revisions due to weight issues, whereas reoperations in the OAGB patients were conducted due to postoperative complications. The postoperative complications and LOS were similar between the groups.</br> <br><b>The importance of research for the development of the field:</b> The results may influence clinical surgeons' choice of surgical technique.</br>.

One Anastomosis Gastric Bypass vs. Sleeve Gastrectomy in the Remission of Type 2 Diabetes Mellitus: A Retrospective Analysis on 3 Years of Follow-Up

Background. Obesity is a prevalent condition associated with various comorbidities, impacting mortality, fertility, and quality of life. Its relationship with type 2 diabetes mellitus (DMII) is well established, with nearly 44% prevalence. Bariatric surgery has proven crucial for treating both obesity and DMII. The comparison between surgical techniques, such as sleeve gastrectomy (SG) and one anastomosis gastric bypass (OAGB), remains controversial in terms of glycemic control efficacy. This retrospective study aimed to assess DMII remission efficacy between SG and OAGB after 36 months. Methods. From January 2016 to September 2020, 201 patients who underwent SG and OAGB for morbid obesity associated with DMII were accurately followed-up with for 36 months, focusing on %HbA1c, DMII remission, anthropometric results, and nutrient deficiency. Results. Although DMII remission did not exhibit statistical significance between the groups (82% vs. 93%, SG vs. OAGB, p = 0.051), OAGB demonstrated a more robust association with glycemic control (Odds Ratio 0.51) throughout the entire follow-up and yielded superior anthropometric outcomes. Notably, nutrient deficiencies, excluding cholecalciferol, iron, and riboflavin, did not show significant intergroup differences. Conclusions. This study contributes valuable insights into the extended-term efficacy of SG and OAGB in DMII remission. The nuanced findings underscore the multifaceted nature of metabolic outcomes, suggesting that factors beyond weight loss influence diabetes resolution. Larger comparative studies are warranted to comprehensively address this issue.

One Anastomosis Gastric Bypass as Revisional Surgery Following Sleeve Gastrectomy: A Systematic Review and Meta-Analysis

BACKGROUND

Although sleeve gastrectomy (SG) is the most performed metabolic and bariatric surgery (MBS) worldwide, some patients require conversional procedures due to weight recurrence or late complications. Recently, one-anastomosis gastric bypass (OAGB) gained popularity as a viable option to address those problems. The aim of this meta-analysis is to assess the safety and efficacy of conversional OAGB after primary SG in the management of patients with obesity.

METHODS

Cochrane, Embase, PubMed, Scopus, and Web of Science were searched for articles from their inception to February 2023 by two independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) system. The review was registered prospectively with PROSPERO (CRD42023403528).

RESULTS

From 1,117 studies screened, twenty studies met the eligibility criteria, with a total of 1,057 patients with obesity undergoing conversional OAGB after primary SG. The mean age ranged from 28.2 to 49.5 years, and 744 patients (75.2%) were women. At one year after revisional OAGB, the pooled mean percent excess weight loss (%EWL) was 65.2% (95%CI: 56.9, 73.4, I2 = 97%). The pooled mean %EWL after conversional OAGB was 71.1% (95%CI: 62.2, 80.0, I2 = 90%) at two years and 71.6% (95%CI: 61.0, 82.2, I2 = 50%) at five years. Additionally, resolution rates of diabetes and hypertension were 65.4% (95%CI: 0.522, 0.785, I2 = 65%) and 58.9% (95%CI: 0.415, 0.762, I2 = 89%), respectively.

CONCLUSIONS

Our meta-analysis demonstrated OAGB as an effective conversional procedure after primary SG in terms of weight loss and obesity-associated medical problems for selected patients. Despite the promising results, further randomized controlled studies with larger sample sizes and more extended follow-up periods are necessary to determine if the OAGB is the best conversional surgery after SG.

ReSleeve or revisional one anastomosis gastric bypass for failed primary sleeve gastrectomy with dilated gastric tube: a retrospective study

BACKGROUND

Revisional bariatric surgery (RBS) has been increasingly performed due to weight loss failure (WLF). Many revisional procedures have been proposed after primary laparoscopic sleeve gastrectomy (pLSG) failure, including ReSleeve gastrectomy (ReLSG), and laparoscopic one anastomosis gastric bypass (LOAGB). Choosing the RBS post-pLSG failure represents a challenge. WLF without gastric tube (GT) dilation is undoubtedly converted to a malabsorptive procedure, but the presence of GT dilation makes it more difficult to select a RBS. This study aimed to compare two relatively simple revisional procedures after pLSG failure with dilated GT to help decision making on which procedure better done to which patient.

METHODS

Data of 52 patients who completed one year follow-up (FU) after their RBS (ReLSG: 27 or LOAGB: 25) for their failed pLSG were collected, assessed, correlated to weight loss (WL) and compared.

RESULTS

Mean operative time was 97 ± 18.4 min. with revisional LOAGB (RLOAGB) and 62 ± 11 min. with ReLSG. Six patients (11.5%) had seven postoperative procedure-specific complications. Significant hemorrhage occurred in three patients. Two cases of leakage were encountered with each procedure. LOAGB Patients had lower mean final weight (76.2 ± 10.5 vs 85.3 ± 13), lower mean Final BMI (26.4 ± 2.5 vs 29.7 ± 2.9) and higher mean percentage of excess weight loss (EWL%) (83.6 ± 13.5% vs 60.29 ± 14.6%). All RLOAGB patients and 77.8% of ReLSG patients had EWL% > 50%. RLOAGB patients had higher EWL% compared to ReLSG (p < 0.001). Insufficient WL (IWL) patients had higher EWL% compared to weight regain (WR) patients (p = 0.034).

CONCLUSION

Both procedures (RLOAGB and ReLSG) were relatively safe and effective in terms of WL. RLOAGB led to higher WL compared to ReLSG in all types of patients despite higher Caloric intake. IWL patients had more WL compared to WR patients. WL was not related to GT dilation type. Large-scale longer-FU studies are still needed.

TRIAL REGISTRATION

PACTR202310644487566 (retrospectively registered).

A cadaveric anatomical study of the adrenals: vascular relationship

The adrenal gland is a retroperitoneal organ with intimate relationships with neighboring organs but also with the large retroperitoneal vessels. Our aim was to study the vascular relationships of the adrenal gland with the large abdominal vessels. Our work is an anatomical dissection of 80 fresh cadaveric adrenals. The subjects didn't have a history of retroperitoneal surgery. Dissection conditions were similar to those in the living. All measurements were made in situ. On the right side, the average distance between the adrenal gland and the renal vein (DR) was 13 mm (0-20). In one case, the adrenal gland laid directly on the right renal vein (DR = 0). The average length L, over which the right adrenal gland entered behind the inferior vena cava (IVC), was 8 mm (0-12). In 4 cases, the right adrenal was lateral to the IVC and in 6 cases the length L exceeded 10 mm. On the left side, the mean distance DL, separating the adrenal gland from the left renal vein was 8 mm with extremes ranging from 0 mm to 18 mm. In eleven cases, the adrenal gland laid directly on the left renal vein. The right adrenal gland has a close relationship with the IVC and is often located behind it. This close relationship helps to explain the increased incidence of IVC lesions during surgery. The left adrenal gland has an intimate relationship with the left renal vein and often lies on top of it. This explains the risk of injury to the left renal pedicle during left adrenal surgery.

Frequency, morbidity and equity - the case for increased research on male fertility

Currently, most men with infertility cannot be given an aetiology, which reflects a lack of knowledge around gamete production and how it is affected by genetics and the environment. A failure to recognize the burden of male infertility and its potential as a biomarker for systemic illness exists. The absence of such knowledge results in patients generally being treated as a uniform group, for whom the strategy is to bypass the causality using medically assisted reproduction (MAR) techniques. In doing so, opportunities to prevent co-morbidity are missed and the burden of MAR is shifted to the woman. To advance understanding of men's reproductive health, longitudinal and multi-national centres for data and sample collection are essential. Such programmes must enable an integrated view of the consequences of genetics, epigenetics and environmental factors on fertility and offspring health. Definition and possible amelioration of the consequences of MAR for conceived children are needed. Inherent in this statement is the necessity to promote fertility restoration and/or use the least invasive MAR strategy available. To achieve this aim, protocols must be rigorously tested and the move towards personalized medicine encouraged. Equally, education of the public, governments and clinicians on the frequency and consequences of infertility is needed. Health options, including male contraceptives, must be expanded, and the opportunities encompassed in such investment understood. The pressing questions related to male reproductive health, spanning the spectrum of andrology are identified in the Expert Recommendation.

One Anastomosis Gastric Bypass versus Roux-en-Y Gastric Bypass: A Randomized Prospective Trial

Background and Objectives: One anastomosis gastric bypass (OAGB) and Roux-en-Y gastric bypass (RYGB) surgeries are effective methods used in bariatric surgery. There are limited randomized studies comparing these procedures over more than 2 years. Here, we aimed to compare the 3-year results of two bariatric procedures. Materials and Methods: Patients included in this randomized prospective study were compared in OAGB and RYGB groups. A total of 55 patients, aged between 18 and 65, were eligible for the study. Thirteen patients who did not accept randomization were excluded. Patients were evaluated at 6, 12, 24, and 36 months postoperatively. Results: Three patients were excluded from the study due to loss of communication during the clinical follow-up and one due to death by amyotrophic lateral sclerosis, which started in the eighth month after surgery. The study was completed with a total of 38 patients (OAGB; n = 20, RYGB; n = 18). Patients in the two groups were similar in terms of age, gender, body mass index (BMI), and obesity-related comorbidities. At the end of 3-year follow-up, BMI in the OAGB and RYGB groups was 28.80 ± 4.53 kg/m2 and 29.17 ± 5.36 kg/m2, respectively (p = 0.822). Percentage total weight loss (TWL%) was similar. No significant differences were found between the groups regarding percentage excess weight loss (EWL%). Remission of comorbidities was similar. De novo refluxes developed in four OAGB patients; there were no occurrences of these in RYGB patients (p = 0.066). Conclusions: Both OAGB and RYGB are effective in the treatment of morbid obesity. The two procedures are similarly successful in terms of obesity-related comorbidities.