Metabolic Bariatric Surgery Across the IFSO Chapters: Key Insights on the Baseline Patient Demographics, Procedure Types, and Mortality from the Eighth IFSO Global Registry Report

INTRODUCTION

The International Federation for Surgery for Obesity and Metabolic Disorders (IFSO) Global Registry aims to provide descriptive data about the caseload and penetrance of surgery for metabolic disease and obesity in member countries. The data presented in this report represent the key findings of the eighth report of the IFSO Global Registry.

METHODS

All existing Metabolic and Bariatric Surgery (MBS) registries known to IFSO were invited to contribute to the eighth report. Aggregated data was provided by each MBS registry to the team at the Australia and New Zealand Bariatric Surgery Registry (ANZBSR) and was securely stored on a Redcap™ database housed at Monash University, Melbourne, Australia. Data was checked for completeness and analyzed by the IFSO Global Registry Committee. Prior to the finalization of the report, all graphs were circulated to contributors and to the global registry committee of IFSO to ensure data accuracy.

RESULTS

Data was received from 24 national and 2 regional registries, providing information on 502,150 procedures. The most performed primary MBS procedure was sleeve gastrectomy, whereas the most performed revisional MBS procedure was Roux-en-Y gastric bypass. Asian countries reported people with lower BMI undergoing MBS along with higher rates of diabetes. Mortality was a rare event.

CONCLUSION

Registries enable meaningful comparisons between countries on the demographics, characteristics, operation types and approaches, and trends in MBS procedures. Reported outcomes can be seen as flags of potential issues or relationships that could be studied in more detail in specific research studies.

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.

Hysteroscopy and weight loss in treatment of endometrial cancer: case report and literature review

Fertility-sparing treatments have become important for young women with atypical endometrial hyperplasia (AEH) or endometrial carcinoma (EC) who wish to preserve their reproductive potential. Evidence indicates a strong relationship between weight and EC and the effect of weight loss on reducing the risk of EC. We report the case of a young obese woman with a body mass index (BMI) of 46.6 kg/m2, diagnosed with grade 2 endometrial endometrioid adenocarcinoma, who underwent a combined fertility-sparing treatment with hysteroscopic resection followed by insertion of a levonorgestrel intrauterine system. After twelve months of failure to achieve a complete response, bariatric surgery was proposed to lose weight and improve the response to treatment. Histologic regression was achieved three months after surgery, with a weight loss of 30 kg and fifteen months after combined treatment of endometrial cancer. We reviewed the literature to summarize the evidence on the role of bariatric surgery and weight loss in modifying the oncologic and reproductive outcomes of women undergoing fertility-sparing treatment for atypical endometrial lesions.

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.

Current recommendations for procedure selection in class I and II obesity developed by an expert modified Delphi consensus

Metabolic and bariatric surgery (MBS) is widely considered the most effective option for treating obesity, a chronic, relapsing, and progressive disease. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued new guidelines on the indications for MBS, which have superseded the previous 1991 National Institutes of Health guidelines. The aim of this study is to establish the first set of consensus guidelines for selecting procedures in Class I and II obesity, using an Expert Modified Delphi Method. In this study, 78 experienced bariatric surgeons from 32 countries participated in a two-round Modified Delphi consensus voting process. The threshold for consensus was set at an agreement or disagreement of ≥ 70.0% among the experts. The experts reached a consensus on 54 statements. The committee of experts reached a consensus that MBS is a cost-effective treatment option for Class II obesity and for patients with Class I obesity who have not achieved significant weight loss through non-surgical methods. MBS was also considered suitable for patients with Type 2 diabetes mellitus (T2DM) and a body mass index (BMI) of 30 kg/m2 or higher. The committee identified intra-gastric balloon (IGB) as a treatment option for patients with class I obesity and endoscopic sleeve gastroplasty (ESG) as an option for patients with class I and II obesity, as well as for patients with T2DM and a BMI of ≥ 30 kg/m2. Sleeve gastrectomy (1) and Roux-en-Y gastric bypass (RYGB) were also recognized as viable treatment options for these patient groups. The committee also agreed that one anastomosis gastric bypass (OAGB) is a suitable option for patients with Class II obesity and T2DM, regardless of the presence or severity of obesity-related medical problems. The recommendations for selecting procedures in Class I and II obesity, developed through an Expert Modified Delphi Consensus, suggest that the use of standard primary bariatric endoscopic (IGB, ESG) and surgical procedures (SG, RYGB, OAGB) are acceptable in these patient groups, as consensus was reached regarding these procedures. However, randomized controlled trials are still needed in Class I and II Obesity to identify the best treatment approach for these patients in the future.

Abdominal Wall Hernias-State of the Art of Laparoscopic versus Robotic Surgery

Abdominal wall hernia repair, a common surgical procedure, includes various techniques to minimize postoperative complications and enhance outcomes. This review focuses on the comparison between laparoscopic and robotic approaches in treating inguinal and ventral hernias, presenting the ongoing situation of this topic. A systematic search identified relevant studies comparing laparoscopic and robotic approaches for inguinal and ventral hernias. Randomized control trials, retrospective, and prospective studies published after 1 January 2000, were included. Search terms such as hernia, inguinal, ventral, laparoscopy, robotic, and surgery were used. A total of 23 articles were included for analysis. Results indicated similar short-term outcomes for robotic and laparoscopic techniques in inguinal hernia repair, with robotic groups experiencing less postoperative pain. However, longer operative times and higher costs were associated with robotic repair. Robotic ventral hernia repair demonstrated potential benefits, including shorter hospital stay, lower recurrence and lower reoperation rates. While robotic surgery offers advantages such as shorter hospital stays, faster recovery, and less postoperative pain, challenges including costs and training requirements need consideration. The choice between laparoscopic and robotic approaches for abdominal wall hernias should be tailored based on individual surgeon expertise and resource availability, emphasizing a balanced evaluation of benefits and challenges.

Bariatric Surgery for Patients with Overweight/Obesity. A Comprehensive Grading Methodology and Network Metanalysis of Randomized Controlled Trials on Weight Loss Outcomes and Adverse Events

This study aims to compare different types of metabolic bariatric surgery (MBS) with lifestyle intervention/medical therapy (LSI/MT) for the treatment of overweight/obesity. The present and network meta-analysis (NMA) includes randomized trials. MBS was associated with a reduction of BMI, body weight, and percent weight loss, when compared to LSI/MT, and also with a significant reduction of HbA1c and a higher remission of diabetes. Meta-regression analyses revealed that BMI, a higher proportion of women, and a longer duration of trial were associated with greater effects of MBS. The NMA showed that all surgical procedures included (except greater curvature plication) were associated with a reduction of BMI. MBS is an effective option for the treatment of obesity. The choice of BMI thresholds for eligibility for surgery of patients with different complications should be performed making an evaluation of risks and benefits in each BMI category.

Bariatric Evaluation Through AI: a Survey of Expert Opinions Versus ChatGPT-4 (BETA-SEOV)

BACKGROUND

Recent advancements in artificial intelligence, such as OpenAI's ChatGPT-4, are revolutionizing various sectors, including healthcare. This study investigates the use of ChatGPT-4 in identifying suitable candidates for bariatric surgery and providing surgical recommendations to improve decision-making in obesity treatment amid the global obesity epidemic.

METHODS

We devised ten patient scenarios, thoughtfully encompassing a spectrum that spans from uncomplicated cases to more complex ones. Our objective was to delve into the decision-making process regarding the recommendation of bariatric surgery. From July 29th to August 10th, 2023, we conducted a voluntary online survey involving thirty prominent bariatric surgeons, ensuring that there was no predetermined bias in the selection of a specific type of bariatric surgery. This survey was designed to collect their insights on these scenarios and gain a deeper understanding of their professional experience and background in the field of bariatric surgery. Additionally, we consulted ChatGPT-4 in two separate conversations to evaluate its alignment with expert opinions on bariatric surgery options.

RESULTS

In 40% of the scenarios, disparities were identified between the two conversations with ChatGPT-4. It matched expert opinions in 30% of cases. Differences were noted in cases like gastrointestinal metaplasia and gastric adenocarcinoma, but there was alignment with conditions like endometriosis and GERD.

CONCLUSION

The evaluation of ChatGPT-4's role in determining bariatric surgery suitability uncovered both potential and shortcomings. Its alignment with experts was inconsistent, and it often overlooked key factors, emphasizing human expertise's value. Its current use requires caution, and further refinement is needed for clinical application.

Comparing the safety and efficacy of sleeve gastrectomy versus Roux-en-Y gastric bypass in elderly (>60 years) with severe obesity: an umbrella systematic review and meta-analysis

BACKGROUND

Today, bariatric surgeons face the challenge of treating older adults with class III obesity. The indications and outcomes of Roux-en-Y gastric bypass (RYGB) versus sleeve gastrectomy (SG) also constitute a controversy.

METHODS

PubMed, Web of Science and Scopus were searched to retrieve systematic reviews/meta-analyses published by 1 March 2022. The selected articles were qualitatively evaluated using A Measurement Tool to Assess systematic Reviews (AMSTAR).

RESULTS

An umbrella review included six meta-analyses retrieved from the literature. The risk of early-emerging and late-emerging complications decreased by 55% and 41% in the patients underwent SG than in those receiving RYGB, respectively. The chance of the remission of hypertension and obstructive sleep apnoea, respectively increased by 43% and 6%, but type-2 diabetes mellitus decreased by 4% in the patients underwent RYGB than in those receiving SG. RYGB also increased excess weight loss by 15.23% in the patients underwent RYGB than in those receiving SG.

CONCLUSION

Lower levels of mortality and early-emerging and late-emerging complications were observed in the older adults undergoing SG than in those receiving RYGB, which was, however, more efficient in term of weight loss outcomes and recurrence of obesity-related diseases.

Long-Term Results of Laparoscopic Sleeve Gastrectomy: a Review of Studies Reporting 10+ Years Outcomes

Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure worldwide. Systematic search of Pubmed, Cochrane, and Embase was performed in order to find all the articles reporting 10+ years of LSG results. Eleven studies including 1020 patients met the inclusion criteria. Overall weighted mean %TWL was 24.4% (17-36.9%), and remission rates from TD2M to HTN were 45.6% (0-94.7%) and 41.4% (0-78.4%), respectively. De novo GERD had an overall prevalence of 32.3% (21.4-58.4%), and five cases (0.5%) of Barrett's disease were reported. Revisional surgery was required for 19.2% (1-49.5%) of patients, Roux-en-Y gastric bypass being the most common secondary procedure.

Dual docking technique for robotic repair of simultaneous inguinal and umbilical hernia: A preliminary single center experience

BACKGROUND

This study aimed to assess clinical results in terms of intraoperative outcomes, recovery and recurrence of our robotic technique for the treatment of patients affected by simultaneous inguinal and umbilical hernia, providing technical details to facilitate multiquadrant surgery in robotic hernia repair.

METHODS

Data from patients affected by simultaneous primary inguinal and umbilical hernia who underwent robotic repair with our dual docking technique was retrospectively analysed.

RESULTS

Fifteen patients were included. No intraoperative complications occurred. All patients achieved complete mobilisation within 7 h. The mean length of hospital stay was 21.6 h, with five patients discharged on the same day of surgery. There was no major complication and no recurrence within the median follow-up period of 673 days.

CONCLUSIONS

This surgical technique shows optimal postoperative outcomes, such as early mobilisation and short length of stay. Our study provides an aid to surgeons performing multiquadrant robotic surgery for the treatment of abdominal hernias.

Comment on Wijnia, J.W. A Clinician's View of Wernicke-Korsakoff Syndrome. J. Clin. Med. 2022, 11, 6755

We have read with great interest the article by Wijnia [...].

Propensity score matched analysis of postoperative nausea and pain after one anastomosis gastric bypass (MGB/OAGB) versus sleeve gastrectomy (SG)

The aim of our study was to assess and compare postoperative nausea and pain after one anastomosis gastric bypass (OAGB) and sleeve gastrectomy (LSG). Patients undergoing OAGB and LSG at our institution between November 2018 and November 2021 have been prospectively asked to report postoperative nausea and pain on a numeric analogic scale. Medical records were retrospectively reviewed to collect scores of these symptoms at the 6th and 12th postoperative hour. One-way analysis of variance (ANOVA) was used to evaluate effect of type of surgery on postoperative nausea and pain scores. To adjust for baseline differences between cohorts, a propensity score algorithm was used to match LSG patients to MGB/OAGB patients in a 1:1 ratio with a 0.1 tolerance. A total number of 228 (119 SGs and 109 OAGBs) subjects were included in our study. Nausea after OAGB was significantly less severe than after LSG both at the 6th and 12th hour assessment; pain was less strong after OAGB at the 6th hour but not after 12 h. Fifty-three individuals had a rescue administration of metoclopramide after LSG and 34 after OAGB (44.5% vs 31.2%, p = 0.04); additional painkillers were required by 41 patients after LSG and 23 after OAGB (34.5% vs 21.1%, p = 0.04). Early postoperative nausea was significantly less severe after OAGB, while pain was comparable especially at the 12th hour.

New techniques versus standard mapping for sentinel lymph node biopsy in breast cancer: a systematic review and meta-analysis

New tracers for sentinel lymph node biopsy (SLNB), as indocyanine green (ICG), superparamagnetic iron oxide (SPIO) and micro bubbles, have been recently introduced in clinical practice showing promising but variable results. We reviewed the available evidence comparing these new techniques with the standard tracers to evaluate their safety. To identify all available studies, a systematic search was performed in all electronic databases. Data regarding sample size, mean number of SLN harvested for patient, number of metastatic SLN and SLN identification rate of all studies were extracted. No significant differences were found in terms of SLNs identification rates between SPIO, RI and BD but with a higher identification rate with the use of ICG. No significant differences were also found for the number of metastatic lymph nodes identified between SPIO, RI and BD and the mean number of SLNs identified between SPIO and ICG versus conventional tracers. A statistically significant differences in favor of ICG was reported for the comparison between ICG and conventional tracers for the number of metastatic lymph nodes identified. Our meta-analysis demonstrates that the use of both ICG and SPIO for the pre-operative mapping of sentinel lymph nodes in breast cancer treatment is adequately effective.

Gastrointestinal bezoars: Review of the literature and report of a rare case of pumpkin seed rectal impaction

In science, bezoar is a mass of hair or undigested vegetable matter, found in a human or animal's intestines, similar to a hairball. Usually, it is found trapped in every part of the gastrointestinal system and must be distinguished by pseudobezoar which is an indigestive object voluntarily introduced into the digestive tract. The term Bezoar is from Arabic bāzahr, "bezoar" or ultimately from Middle Persian p'tzhl pādzahr, "antidote, bezoar"ægagropile o egagropile It should be a universal antidote that works against any poison, and could neutralize any poison. Otherwise, the name could derive from a kind of Turkish goat whose name is just bezoar. Authors report a case of fecal impaction by pumpkin seeds bezoar with abdominal pain: a difficulty to void with subsequent rectal inflammation and hemorrhoid enlargement was observed. The patient underwent a successful manual disimpaction. Guidelines do not require IRB approval Authors examined the literature about occlusion from bezoar The most common causes of occlusion from bezoar are: a previous gastric surgery such as a gastric band (for weight loss) or gastric bypass, a reduced stomach acid (hypochlorhydria) or decreased stomach size, a delayed gastric emptying, typically due to diabetes, autoimmune disorders, or mixed connective tissue disease. Seed bezoars are usually found in the rectum of patients without predisposing factors, causing constipation and pain. Rectal impaction is common after ingestion of seeds while a true occlusion is rare. Although several cases of phytobezoars composed of various types of seeds are reported in literature, bezoars of pumpkin seeds have rarely been reported.

Timing of Bariatric Surgery and COVID-19 Vaccination: Experience From a High-volume Single Center

BACKGROUND

During the last year, there was a large COVID-19 vaccination campaign in Italy. Concurrently, metabolic bariatric surgery (MBS) restarted after a long period of discontinuity. No data are currently available on the best timing of COVID-19 vaccination for MBS candidates. The aim of this study was to report MBS outcomes in relation to the timing of COVID-19 vaccine administration.

MATERIALS AND METHODS

A prospectively maintained database was utilized to locate patients undergoing MBS between January 1 and December 31, 2021. Patients were divided into 2 groups: patients receiving a vaccine dose within 30 days before or after surgery (Group±30); and patients with a longer time interval of vaccine dose before or after surgery (Group>±30). Postoperative outcomes were recorded and compared.

RESULTS

A total of 108 patients were included: 33 (30.6%) of whom were in Group±30 and 74(69.4%) in Group>30. Baseline characteristics were comparable between the 2 groups. Findings revealed that postoperative outcomes (ie, 30-d complications and length of stay postoperatively) were comparable between groups. Two patients in the ±30 group had mesenteric vein thrombosis after sleeve gastrectomy (SG); however, the rate of thrombosis events was comparable between groups ( P =0.09). Thrombosis between SG patients were not significantly different between the 2 groups.

CONCLUSIONS

COVID-19 vaccination within 30 days of MBS does not impact complication rates and length of stay. COVID-19 vaccination may have a negative impact on venous thrombosis after SG, but this study is underpowered to draw this conclusion. Larger studies should be conducted to replicate current study findings.

Evolution of Bariatric Surgery in Italy in the Last 11 Years: Data from the SICOB Yearly National Survey

BACKGROUND

Bariatric surgery (BS) is a relatively novel surgical field and is in continuous expansion and evolution.

PURPOSE

Aim of this study was to report changes in Italian surgical practice in the last decade.

METHODS

The Società Italiana di Chirurgia dell'Obesità (SICOB) conducted annual surveys to cense activity of SICOB centers between 2011 and 2021. Primary outcome was to detect differences in frequency of performance of adjustable gastric banding (AGB), sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), one anastomosis gastric bypass (OAGB), bilio-pancreatic diversion (BPD), and gastric plication (GP). Secondary outcome was to detect differences in performance of main non-malabsorptive procedures (AGB + SG) and overall bypass procedures (RYGB + OAGB). Geographical differences were also investigated.

RESULTS

Median response rate was 92%. AGB declined from 36% of procedures in 2011 to 5% in 2021 (p < 0.0001). SG increased from 30% in 2011 to 55% in 2021 (p < 0.0001). RYGB declined from 25 to 12% of procedures (p < 0.0001). OAGB rose from 0% of procedures in 2011 to 15% in 2021 (p < 0.0001). BPD underwent decrease from 6.2 to 0.2% in 2011 and 2021, respectively (p < 0.0001). Main non-malabsorptive procedures significantly decreased while overall bypass procedures remained stable. There were significant differences among regions in performance of SG, RYGB, and OAGB.

CONCLUSIONS

BS in Italy evolved significantly during the past 10 years. AGB underwent a decline, as did BPD and GP which are disappearing and RYGB which is giving way to OAGB. The latter is rising and is the second most-performed procedure after SG which has been confirmed as the preferred procedure by Italian bariatric surgeons.

Micronutrients Deficiencies in Candidates of Bariatric Surgery: Results from a Single Institution over a 1-Year Period

BACKGROUND

Micronutrient deficiencies represent a common condition after bariatric surgery (BS). The prevalence of these nutritional disorders before BS is still debated. The aim of our study was to retrospectively evaluate the prevalence of micronutrient deficiencies in candidates for BS.

METHODS

A prospectively maintained database of our institution was searched to find all patients who underwent surgery between January and December 2021. The following data were collected: age, gender, body mass index (BMI), obesity-associated diseases, and preoperative serum levels of vitamin B12, folate, and vitamin D.

RESULTS

A total of 174 patients were included in our study. Mean age and BMI were 39.2 ± 11.4 years and 44.3 ± 7.1 kg/m², respectively. One hundred and thirty-nine patients (79.9%) had at least one preoperative micronutrient disorder, with vitamin D deficiency being the most common (116, 66.7%), followed by a deficit of folate (76, 43.7%) and vitamin B12 (10, 5.7%). Forty-seven (27%) individuals had insufficient levels of vitamin D. Comparison of deficiencies between sexes showed that vitamin B12 < 20 ng/ml was significantly more frequent in women (p = 0.03). DLP showed a mild significant effect on folate levels (p = 0.01), while the association of HNT and T2DM had a mild significant effect on vitamin B12 (p = 0.02).

CONCLUSIONS

Preoperative micronutrient deficiencies were frequently found in candidates for BS. Approximately 90% of patients had deficient or insufficient serum levels of vitamin D preoperatively. Almost half of the patients had a preoperative deficit of folate, and vitamin B12 deficiency was significantly more frequent in the female population. It is mandatory to screen all patients undergoing BS for vitamin deficiencies before surgery.

Safety and efficacy of OAGB/MGB during the learning curve: setting a benchmark in a bariatric center of excellence

Very little has been published on the learning curve (LC) of the One Anastomosis /Mini Gastric Bypass (OAGB/MGB). Aim of this study was to compare perioperative outcomes of OABG/MGBs performed during the LC of an experienced laparoscopic surgeon to global benchmark cut-offs. First 200 patients undergoing OAGB/MGB at our university hospital from 2010 to 2016 were retrospectively included in this study. LC of the surgeon was divided in two groups of 100 consecutive patients each and perioperative outcomes were compared to abovementioned global benchmarks for LSG and RYGB. A cumulative sum (CUSUM) analysis was performed for operative time and hospital stay. Uneventful postoperative recovery was recorded in 95% of patients. All benchmark values for RYGB were met in group 2. Comparison with cut-offs for LSG showed longer hospital stay and operative time in both groups but postoperative rate of complications resulted lower even for Group 1. CUSUM graph of the operative time runs randomly above the predetermined limit till the 40th cases but reaches the plateau after the 115th operation. CUSUM curve of the hospital stay reaches the plateau after the 57th case. OAGB/MGB confirms to be a feasible procedure, which can be safely and effectively performed during the learning curve. However, at least 100 hundred cases are required to reduce operative time and hospital stay.

Minimally Invasive Repair of Recurrent Inguinal Hernia: Multi-Institutional Retrospective Comparison of Robotic Versus Laparoscopic Surgery

Introduction: Inguinal hernia repair is one of the most commonly performed surgical procedures in general surgery. Despite surgical advances, recurrence and chronic pain are still major issues after this intervention. Aim of our study was to retrospectively assess and compare outcomes of robotic versus laparoscopic repair of recurrent inguinal hernia. Methods: All patients who underwent recurrent inguinal hernia repair between 2014 and 2021 in five different institutions were included in our study. Baseline data on age, gender, body mass index, comorbidities, smoking habit, and anticoagulant therapy were retrospectively collected from prospectively maintained databases. Operative time, length of stay, and early and late complications were compared between the robotic and the laparoscopic approach. Results: Forty-eight patients underwent recurrent inguinal hernia repair between January 2014 and December 2021. Twenty-three patients underwent a robotic procedure, whereas 25 were submitted to the laparoscopic intervention. Overall mean follow-up was 26.2 months. There was no significant difference in the baseline characteristics of the two groups. Acceptable and comparable rates of peri- and postoperative outcomes were recorded. However, postoperative visual analog scale score and incidence of chronic pain were lower after the robotic rather than after the laparoscopic approach. (2.9 versus 3.8 P = .002; 20% versus 0%; P = .02, respectively). Conclusions: Minimally invasive repair of recurrent inguinal hernia is safe and feasible; robotic surgery is associated with low rate of postoperative and chronic pain without a significant increase in operative time.

P-267 A continuous culture medium with a lower concentration of lactate has a pronounced effect on the percentage of usable blastocysts on day 5

Study question

Does Continuous Single Culture Medium NX, an embryo culture medium containing 1mM lactate, support increased blastocyst development over high lactate Vitrolife G1/G2 Series sequential culture?

Summary answer

There is a statistically significant increase in day 5 usable blastocysts in low lactate culture medium compared to the one with high lactate medium.

What is known already

Studies have shown that day 5 is the most desirable day to obtain blastocysts that are of an expansion, grade and quality to be utilized for transfer and/or vitrification procedures as those result in the highest success of clinical pregnancy,as compared to day 6/ 7 blastocysts, that do not meet criteria. Moreover, recent studies have indicated that there is an increase in chromosomal correctness of embryos cultured in a 1mM lactate environment as opposed to the higher 6-10mM lactate concentrations that have historically been believed necessary for successful blastocyst culture and resulting pregnancy.

Study design, size, duration

A prospective split sibling oocytes study was performed on 50 ICSI and IMSI cycles from October 2020 through April 2021. Oocytes were divided into the low lactate medium and high lactate gradient medium immediately following ICSI/IMSI and thereafter cultured in those medium until the final day of blastocyst culture. All patient ages were included in the sample population.

Participants/materials, setting, methods

This study was carried out in a private clinic. All patient stimulation protocol information and diagnosis’ were recorded; however, there was no restriction on participation. The endpoint was to analyse the resulting usable blastocyst rates on day 5 and day 6 in both arms of the study, using a denominator of normal 2PN fertilization. If a blastocyst was transferred or cryopreserved on day 5 or day 6, it was determined to be usable.

Main results and the role of chance

The resulting data was stratified not only by day 5 and day 6 usable blastocyst rates but also by patient age. It illustrates a statistically significant improvement in day 5 usable blastocysts for patients &lt;35 in CSCM-NXC vs G1/G2 at 56% and 42%, respectively, a 14% increase (p &lt; .05). The overall day 5 usable blastocyst rate was also statistically significant in CSCM-NXC (47%) as compared to G1/G2 (36%), (p &lt; .05) with all ages considered. Additionally, on day 5, there was a higher percentage of usable blastocysts demonstrated in low lactate vs high in patients aged 35-37 (65% vs 42%, respectively) and 41-42 (41% vs 15%). Statistical significance was reversed in patients &lt;35 on day 6, with G1/G2 having 24% usable blasts and CSCM-NXC 10% (p &lt; .05). Interestingly, though not significant, G1/G2 had an increase in usable blastocyst percentage on day 5 in patients &gt;42 (20% vs 11%), but overall, CSCM-NXC saw an increase in that same age group by 16%.

Limitations, reasons for caution

Though statistical significance was found in this study, a greater number will help to bolster the statistical power of the observations. Additionally, more studies are needed in order to ascertain if low lactate has an effect on the development prior to ICSI and resulting culture.

Wider implications of the findings

The mechanism of action that leads to the successful embryo development in low lactate embryo culture medium is vastly unknown, so further studies are required in order to understand the complexities and the impact of the observations provided.

Trial registration number

not applicable.

P-260 Study of kinetic parameters using KIDscoreTMDay5 version 3.0 in euploid, mosaic and aneuploid blastocysts

Study question

Do kinetic parameters change among euploid, mosaic and aneuploid blastocysts? Is the KIDscoreTMDay5 version 3.0 (KS-5.3) correlated to preimplantation genetic testing for aneuploidies (PGT-A) results?

Summary answer

The KS-5.3 differs in embryo ploidy classes. The analysis of the kinetic variables showed that the aneuploid embryos were significantly slower than euploid and mosaic.

What is known already

Chromosomal abnormalities affect more than 50% of embryos in women with &gt;35 years of age and PGT-A is the best way to predict embryo’s ploidy status decreasing implantation failure and miscarriage. However, this procedure is not always possible due to social or moral issues. So, the use of the non-invasive time lapse monitoring could be helpful to determine the morphokinetic characteristics in the different ploidy classes. KS-5.3 (vitrolife,Sweden) is a scoring model based on morphokinetic data, developed to predict the pregnancy rate of day-5 blastocysts. Recent publications showed differences in kinetic parameters between euploid and aneuploid embryos.

Study design, size, duration

This retrospective study analyzed 728 blastocysts with PGT-A results obtained at Villa Mafalda Clinic from May 2020 to June 2021. Embryos were cultured in EmbryoScope+ time-lapse system (Vitrolife) at 37 °C, 6%CO2, and 5% O2. The PGT-A was performed using next-generation sequence (NGS) technology on the trophectoderm biopsy sample on day 5/6/7. Automatic annotations for division times and quality gradings were performed by senior embryologists and all kinetic values were reported in hours post microinjection.

Participants/materials, setting, methods

728 blastocysts were classified in: (E) euploid (n = 172), (M) mosaicism (n = 171) and (A) aneuploid (n = 385). In this study, they were considered KS-5.3 and the following kinetic variables: the time to reach 2 cells (t2), 3 cells (t3), 4 cells (t4), 5 cells (t5), and the blastocyst formation (TB). Continuous variables were reported as the median and interquartile range (IQR). For the statistical analysis, nonparametric tests were performed and p &lt; 0.05 was considered statistically significant.

Main results and the role of chance

KS5.3 was significantly different between groups [E = 6.6(4.6-7.9) vs M = 5.3(2.9-7.2) vs A = 4.0(2.5-6.6), p &lt; 0.0001]. It was significantly higher in euploid than in mosaic and aneuploid (EvsM p = 0.0007, EvsA p  &lt;0.0001, MvsA p = 0.0077). A significant delay in t2,t3,t4 and tb was showed in aneuploid embryos compared to euploid and mosaic, whereas there was no significant difference between euploid and mosaic: [t2: E = 25.80 (24.56-28.09), M = 25.99 (24.49-28.91), A = 27.02 (25.30-29.47), EvsA p  &lt;0.0001, AvsM p = 0.03, EvsM p = 0.32]; [t3: E = 37.08 (34.74-39.34), M = 36.69 (34.55-40.02), E = 38.45 (35.93-41.14), EvsA p = 0.0003, MvsA p = 0.002, EvsM p &gt;0.99]; [t4: E = 38.28 (35.63-41.19), M = 38.49 (35.47-42.13), A 39.72 (37.25-43.31), EvsA p = 0.0001, MvsA p = 0.02, EvsM p = 0.65]; [tb: E = 107.70 (102.20-114.30), M = 110.10 (103.60-116.80), A = 113.7 (106.80-122.70), EvsA p  &lt;0.0001, MvsA p  &lt;0.0001, EvsM p = 0.42]. As for t5, there were no differences among the groups. Longer cell cycles in aneuploid embryos could be associated with activated DNA repair mechanism or during chromosome segregation. Instead, regarding the mosaics, there was a significant difference with euploid embryos only in KS5.3. The age was similar between euploid and mosaic [E = 36.29 (33.42-39.00) vs M = 36.71 (34.00-39.33) p = 0.99], whereas that was significantly higher in aneuploid embryos [A = 39.11(36.01-42.27), EvsA/EvsM p  &lt;0.0001].

Limitations, reasons for caution

All these findings have to be validated in a larger sample size. Furthermore, for the retrospective nature of this study, there were some confounding factors, such as protocol of stimulation, female age, and malefactor. This research did not consider the importance of every single kinetic parameter.

Wider implications of the findings

A further study is needed to verify if there is a correlation between morphology and ploidy status. This could clarify the difference in KS-5.3 between euploid and mosaic. In order to decrease age bias, we should enlarge the sample size to analyze a subgroup of patients with higher maternal age.

Trial registration number

not applicable

Patient Selection in One Anastomosis/Mini Gastric Bypass-an Expert Modified Delphi Consensus

PURPOSE

One anastomosis/mini gastric bypass (OAGB/MGB) is up to date the third most performed obesity and metabolic procedure worldwide, which recently has been endorsed by ASMBS. The main criticisms are the risk of bile reflux, esophageal cancer, and malnutrition. Although IFSO has recognized this procedure, guidance is needed regarding selection criteria. To give clinicians a daily support in performing the right patient selection in OAGB/MGB, the aim of this paper is to generate clinical guidelines based on an expert modified Delphi consensus.

METHODS

A committee of 57 recognized bariatric surgeons from 24 countries created 69 statements. Modified Delphi consensus voting was performed in two rounds. An agreement/disagreement among ≥ 70.0% of the experts was considered to indicate a consensus.

RESULTS

Consensus was achieved for 56 statements. Remarkably, ≥ 90.0% of the experts felt that OAGB/MGB is an acceptable and suitable option "in patients with Body mass index (BMI) > 70, BMI > 60, BMI > 50 kg/m² as a one-stage procedure," "as the second stage of a two-stage bariatric surgery after Sleeve Gastrectomy for BMI > 50 kg/m² (instead of BPD/DS)," and "in patients with weight regain after restrictive procedures. No consensus was reached on the statement that OAGB/MGB is a suitable option in case of resistant Helicobacter pylori. This is likely as there is a concern that this procedure is associated with reflux and its related long-term complications including risk of cancer in the esophagus or stomach. Also no consensus reached on OAGB/MGB as conversional surgery in patients with GERD after restrictive procedures. Consensus for disagreement was predominantly achieved "in case of intestinal metaplasia of the stomach" (74.55%), "in patients with severe Gastro Esophageal Reflux Disease (GERD)(C,D)" (75.44%), "in patients with Barrett's metaplasia" (89.29%), and "in documented insulinoma" (89.47%).

CONCLUSION

Patient selection in OAGB/MGB is still a point of discussion among experts. There was consensus that OAGB/MGB is a suitable option in elderly patients, patients with low BMI (30-35 kg/m²) with associated metabolic problems, and patients with BMIs more than 50 kg/m² as one-stage procedure. OAGB/MGB can also be a safe procedure in vegetarian and vegan patients. Although OAGB/MGB can be a suitable procedure in patients with large hiatal hernia with concurrent hiatal hernia, it should not be offered to patients with grade C or D esophagitis or Barrett's metaplasia.

Linear Versus Circular Laparoscopic Gastrojejunal Anastomosis of Roux-en-Y Gastric Bypass: Systematic Review and Meta-Analysis of 22 Comparative Studies

PURPOSE

To compare the rate of complications of linear versus circular gastrojejunal anastomosis of laparoscopic Roux-en-Y gastric bypass.

METHODS

A systematic search of PubMed, Embase, and the Cochrane Library databases was carried out using the terms "laparoscopic," "circular," "linear," "anastomosis," "gastric bypass" in accordance to PRISMA guidelines. Only original articles in English language comparing linear versus circular anastomosis were included. No temporal interval was set. Outcome measures were wound infection, bleeding, marginal ulcer, leak, and stricture. Pooled odds ratio (OR) with a 95% confidence interval (CI) was calculated. Heterogeneity was assessed using the I2 statistic. Funnel plots were used to detect publication bias.

RESULTS

Twenty-two articles (7 prospective and 15 retrospective) out of 184 retrieved papers were included in this study. The pooled analysis showed a reduced odd of wound infection and bleeding after linear anastomosis. Likelihood of marginal ulcer, leak, and stricture was similar after the 2 techniques. Wound infection was reported in 15 studies (OR, 0.17; 95% CI, 0.06-0.45; P=0.0003; I2=91), bleeding in 9 (OR, 0.45; 95% CI, 0.34-0.59; P=0.00001; I2=6) marginal ulcer in 11 (OR, 0.61; 95% CI, 0.26-1.41; P=0.25; I2=65), leaks in 15 (OR, 0.61; 95% CI, 0.21-1.67; P=0.34; I2=83) and stricture in 18 (OR, 0.48; 95% CI, 0.23-1.00; P=0.05; I2=68).

CONCLUSION

Laparoscopic RYGB can be safely performed both with circular and linear staplers. Rates of wound infection and bleeding were significantly lower after linear gastrojejunal anastomosis.

Topical hemostatic application on staple line in laparoscopic sleeve gastrectomy: a single-surgeon experience

BACKGROUND

Laparoscopic Sleeve Gastrectomy (LSG) is a common bariatric procedure with low complication rates. Several hemostatic agents have been used to reduce staple line bleeding, but its impact is unclear. The primary endpoint of this study was to compare the early (30-day) complications comparing oxidized regenerated cellulose (ORC) and fibrin sealant (FS) application on the staple line. The secondary endpoints were to compare the need for postoperative blood transfusion, postoperative blood work values of Hemoglobin (Hb), white blood cell (WBC), C-reactive protein (CRP), drain output volume and hospital length of stay (LOS).

METHODS

A retrospective analysis of all patients who underwent LSG between January and October 2021 was performed. Subjects were divided into two groups according to the use of ORC versus FS on the staple line. Early postoperative complications, Hb level, WBC count, and drain output volume were compared between groups.

RESULTS

A total number of 77 patients were included: 27 in the ORC-group and 50 in the FS-group. No major complication was recorded in both groups. There was no significant difference in the need for blood transfusion, Hb value, and drain output volume on postoperative day (POD) 1 and 2. There was a significantly higher WBC count in the ORC-group on POD 1 and 2. There was no difference in hospital LOS between the groups.

CONCLUSIONS

The use of FS and ORC was associated with a comparable low rate of bleeding. ORC causes an increased WBC count postoperatively, but this showed no clinical relevance.

New endoscopic capsule vs upper gastrointestinal endoscopy in preoperative work-up of obese candidate for bariatric surgery: Relevance of a pilot study in the COVID-19 era

Background and study aims  Obesity represents a major health concern; bariatric surgery is the most effective treatment reducing and maintaining weight loss. The role of a routine esophagogastroduodenoscopy (EGD) prior bariatric surgery is still debated. Moreover, in this scenario of COVID-19 pandemic, EGD is even more questionable due to the procedural risk of viral transmission. A new model of video-endoscopic capsule (VEC) recently has been introduced as a good alternative to the EGD. The aim of this study was to determine if this new capsule is an adequate diagnostic alternative to EGD in the work-up of patients selected for bariatric surgery, particularly in the setting of COVID-19. Patients and methods  From January to November 2020, 27 patients selected for bariatric surgery were enrolled in this pilot study to assess for noninferiority of VEC compared to EGD in detection of upper gastrointestinal disease. Results  VEC had sensitivity, specificity, and positive and negative predictive values in identification of significant lesions of 91.3 %, 83.33 %, 98.01 %, and 51.57 %, respectively, compared with EGD as the standard criterion. The accuracy was 90.51 % (95 % CI, 73.75 %-98.18 %) and the chi-square statistic is 0.1153 ( P  = 0.73). Conclusions  Our report confirms the diagnostic noninferiority of VEC in preoperative work-up of patients selected for bariatric surgery, compared to EGD. This is very important, particularly during the COVID-19 pandemic, given the high risk of contamination with EGD. Larger multicenter studies are required to confirm our preliminary results.

The first survey addressing patients with BMI over 50: a survey of 789 bariatric surgeons

Background

Bariatric surgery in patients with BMI over 50 kg/m² is a challenging task. The aim of this study was to address main issues regarding perioperative management of these patients by using a worldwide survey.

Methods

An online 48-item questionnaire-based survey on perioperative management of patients with a BMI superior to 50 kg/m² was ideated by 15 bariatric surgeons from 9 different countries. The questionnaire was emailed to all members of the International Federation of Surgery for Obesity (IFSO). Responses were collected and analyzed by the authors.

Results

789 bariatric surgeons from 73 countries participated in the survey. Most surgeons (89.9%) believed that metabolic/bariatric surgery (MBS) on patients with BMI over 50 kg/m² should only be performed by expert bariatric surgeons. Half of the participants (55.3%) believed that weight loss must be encouraged before surgery and 42.6% of surgeons recommended an excess weight loss of at least 10%. However, only 3.6% of surgeons recommended the insertion of an Intragastric Balloon as bridge therapy before surgery. Sleeve Gastrectomy (SG) was considered the best choice for patients younger than 18 or older than 65 years old. SG and One Anastomosis Gastric Bypass were the most common procedures for individuals between 18 and 65 years. Half of the surgeons believed that a 2-stage approach should be offered to patients with BMI > 50 kg/m², with SG being the first step. Postoperative thromboprophylaxis was recommended for 2 and 4 weeks by 37.8% and 37.7% of participants, respectively.

Conclusion

This survey demonstrated worldwide variations in bariatric surgery practice regarding patients with a BMI superior to 50 kg/m². Careful analysis of these results is useful for identifying several areas for future research and consensus building.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08979-w.

HIV screening in patients with anal condylomatosis. An overview about ethical and legal issues

Although there is a strong evidence of prevalence of condylomata in the HIV-positive population, literature on HIV prevalence in HIV-unscreened population diagnosed with condylomata is still unconclusive. Our aim is to review literature about HIV screening and diagnosis of anal condylomata in order to evaluate medical aspects, ethical and legal issues concerning the management of this disease. We undertook an online search on Pubmed for the keywords "HIV", "screening" and "anal condylomata" and 23 papers were analysed, 2 being randomized controlled trial, 11 comparative studies and 10 reviews. A total of 1270 patients were reviewed. All authors strongly recommend HIV testing in patients with clinical evidence of anal condylomata. In undeveloped countries with high prevalence of HIV, a proctological evaluation could be a could represent an unexpected therapeutic option for HIV infected male patients to prevent anal cancer. Clinical trials and prospective studies are necessary to validate this interesting hypothesis. KEY WORDS: Anal condylomatosis, HIV screening, Papilloma virus.

Preoperative Localization in Colonic Surgery (PLoCoS Study): a multicentric experience on behalf of the Italian Society of Colorectal Surgery (SICCR)

The aim of this prospective multicentric study was to compare the accurate colonic lesion localization ratio between CT and colonoscopy in comparison with surgery. All consecutive patients from 1st January to 31st December 2019 with a histologically confirmed diagnosis of dysplastic adenoma or adenocarcinoma with planned elective, curative colonic resection who underwent both colonoscopy and CT scans were included. Each patient underwent conventional colonoscopy and CT to stage the tumour, and the localization results of each procedure were registered. CT and colonoscopic localization were compared with surgical localization, adopted as the reference. Our analysis included 745 patients from 23 centres. After comparing the accuracy of colonoscopy and CT (for visible lesions) in localizing colonic lesions, no significant differences were found between the two preoperative tools (510/661 vs 499/661 correctly localized lesions, p = 0.518). Furthermore, after analysing only the patients who underwent complete colonoscopy and had a visible lesion on CT, no significant difference was observed between conventional colonoscopy and CT (331/427 vs 340/427, p = 0.505). Considering the intraoperative localization results as a reference, a comparison between colonoscopy and CT showed that colonoscopy significantly failed to correctly locate the lesions localized in the descending colon (17/32 vs 26/32, p = 0.031). We did not identify an advantage in using CT to localize colonic tumours. In this setting, colonoscopy should be considered the reference to properly localize lesions; however, to better identify lesions in the descending colon, CT could be considered a valuable tool to improve the accuracy of lesion localization.

Ten-Year Results of Laparoscopic Sleeve Gastrectomy: Retrospective Matched Comparison with Laparoscopic Adjustable Gastric Banding-Is There a Significant Difference in Long Term?

Background

The laparoscopic sleeve gastrectomy (LSG) is the most common bariatric procedure performed worldwide while the laparoscopic adjustable gastric banding (LAGB) has been almost abandoned. Aim of this study was to retrospectively assess 10-year outcomes of LSG through a matched comparison with LAGB.

Materials and Methods

Retrospective search of prospectively maintained database of our university was carried out to find all patients that underwent LSG before December 2010. Each subject with LSG was matched one-to-one with a patient that had undergone LAGB in the same period with correspondent preoperative age, BMI, and sex.

Results

A total of 76 patients underwent LSG before 2010 and were all included in this study; a matched group of 76 out of 178 LAGB patients with 10-year follow-up was retrieved from our database. Comparison between the two groups showed better outcomes after LSG at 1 and 5 years but weight loss was comparable with the LAGB group at 10 years (%TWL 22.2 ± 13 vs 21.2 ± 16.1; p = 0.89). No significant difference was found in conversion/removal rate (15.8% vs 18.4%; p = 0.67).

Conclusion

LSG is an effective stand-alone bariatric procedure with better outcomes than LAGB in medium term, but results are comparable at 10 years. Subjects undergoing LSG should be informed that conversion to RYGB or OAGB may be necessary to achieve further weight loss or to treat reflux.

Graphical abstract

Characterization of gut microbiota in patients with metabolic syndrome candidates for bariatric/metabolic surgery: Preliminary findings of a multi-center prospective study

INTRODUCTION

gut microbiota (GM) seems to be involved in the pathophysiology and progression of both metabolic syndrome (MS) and obesity. The aim was to investigate GM's composition in patients with severe obesity, candidates for bariatric/metabolic surgery BMS.

MATERIALS AND METHODS

Multicentre, prospective, cohort study, enrolling 84 patients with BMI 40-55 kg/m², divided bymetabolic status (MS) inhealthy(group A), pre-MS (B), or MS (C).

RESULTS

No differences were foundregarding anthropometric,nutritional parameters, except for vitamin D.As a whole the alpha and beta diversity examinations showed no statistical differences in GM profile. A total of 5/7 phyla with relative frequencies were identified above 0.1% (Actinobacteria,Bacteroidetes,Firmicutes,Proteobacteria,Verrucomicrobia).FusobacteriaandPatescibacteriarepresented the less abundant. There were no significant differences in the top ten genera.Data onBacteroidetes(inversely related to triglycerides and LDL and directly related to HDL levels) and onFirmicutes(opposite trend) relative abundances suggest no differences among the three conditions.No correlation between the relative abundance of themain phylaand plasmatic glucose levels was observed.

CONCLUSIONS

In a selected cohort of patients with obesity, MS did not affect the preoperative GM's profile. Severe obesity, per se, seems to be an independent condition affecting GM.

30-Day Morbidity and Mortality of Bariatric Surgery During the COVID-19 Pandemic: a Multinational Cohort Study of 7704 Patients from 42 Countries

BACKGROUND

There are data on the safety of cancer surgery and the efficacy of preventive strategies on the prevention of postoperative symptomatic COVID-19 in these patients. But there is little such data for any elective surgery. The main objectives of this study were to examine the safety of bariatric surgery (BS) during the coronavirus disease 2019 (COVID-19) pandemic and to determine the efficacy of perioperative COVID-19 protective strategies on postoperative symptomatic COVID-19 rates.

METHODS

We conducted an international cohort study to determine all-cause and COVID-19-specific 30-day morbidity and mortality of BS performed between 01/05/2020 and 31/10/2020.

RESULTS

Four hundred ninety-nine surgeons from 185 centres in 42 countries provided data on 7704 patients. Elective primary BS (n = 7084) was associated with a 30-day morbidity of 6.76% (n = 479) and a 30-day mortality of 0.14% (n = 10). Emergency BS, revisional BS, insulin-treated type 2 diabetes, and untreated obstructive sleep apnoea were associated with increased complications on multivariable analysis. Forty-three patients developed symptomatic COVID-19 postoperatively, with a higher risk in non-whites. Preoperative self-isolation, preoperative testing for SARS-CoV-2, and surgery in institutions not concurrently treating COVID-19 patients did not reduce the incidence of postoperative COVID-19. Postoperative symptomatic COVID-19 was more likely if the surgery was performed during a COVID-19 peak in that country.

CONCLUSIONS

BS can be performed safely during the COVID-19 pandemic with appropriate perioperative protocols. There was no relationship between preoperative testing for COVID-19 and self-isolation with symptomatic postoperative COVID-19. The risk of postoperative COVID-19 risk was greater in non-whites or if BS was performed during a local peak.

30-Day Morbidity and Mortality of Bariatric Surgery During the COVID-19 Pandemic: a Multinational Cohort Study of 7704 Patients from 42 Countries

BACKGROUND

There are data on the safety of cancer surgery and the efficacy of preventive strategies on the prevention of postoperative symptomatic COVID-19 in these patients. But there is little such data for any elective surgery. The main objectives of this study were to examine the safety of bariatric surgery (BS) during the coronavirus disease 2019 (COVID-19) pandemic and to determine the efficacy of perioperative COVID-19 protective strategies on postoperative symptomatic COVID-19 rates.

METHODS

We conducted an international cohort study to determine all-cause and COVID-19-specific 30-day morbidity and mortality of BS performed between 01/05/2020 and 31/10/2020.

RESULTS

Four hundred ninety-nine surgeons from 185 centres in 42 countries provided data on 7704 patients. Elective primary BS (n = 7084) was associated with a 30-day morbidity of 6.76% (n = 479) and a 30-day mortality of 0.14% (n = 10). Emergency BS, revisional BS, insulin-treated type 2 diabetes, and untreated obstructive sleep apnoea were associated with increased complications on multivariable analysis. Forty-three patients developed symptomatic COVID-19 postoperatively, with a higher risk in non-whites. Preoperative self-isolation, preoperative testing for SARS-CoV-2, and surgery in institutions not concurrently treating COVID-19 patients did not reduce the incidence of postoperative COVID-19. Postoperative symptomatic COVID-19 was more likely if the surgery was performed during a COVID-19 peak in that country.

CONCLUSIONS

BS can be performed safely during the COVID-19 pandemic with appropriate perioperative protocols. There was no relationship between preoperative testing for COVID-19 and self-isolation with symptomatic postoperative COVID-19. The risk of postoperative COVID-19 risk was greater in non-whites or if BS was performed during a local peak.

Effect of bariatric surgery on in vitro fertilization in infertile men with obesity

BACKGROUND

Obesity has previously been related to reduced female fertility, with prolonged waiting time to pregnancy among women with a body mass index (BMI) >35 kg/m² but there are few studies investigating the relationship between high BMI, bariatric surgery, and male fertility.

OBJECTIVES

The primary objective of this article was to investigate the effect of bariatric surgery on in vitro fertilization (IVF) outcomes in a cohort of men with morbid obesity who underwent sleeve gastrectomy (SG).

SETTING

University hospital, bariatric surgery unit.

METHODS

Pre- and postsurgery data on patient age, body mass index (BMI), and variables related to male fertility (semen volume, concentration, progressively motile sperm count, and sperm morphology) were collected; assisted reproductive technology outcomes before and after bariatric surgery were measured by the number of metaphase II oocytes; the number of top-quality oocytes and embryos; the number of fertilized oocytes; the number of transferred embryo; the implantation rate; the pregnancy rate; the live birth rate and the miscarriage rate.

RESULTS

Thirty-five men with obesity and idiopathic infertility were included in this study. We found a significant increase, after bariatric surgery, in semen volume, total sperm concentration, progressively motile sperm count, and sperm morphology. Considering IVF outcomes, mean number of top-quality oocytes, mean number of fertilized oocytes, mean number of embryos obtained, and top-quality embryos were significantly increased after bariatric procedure.

CONCLUSION

Bariatric surgery is confirmed to be safe and effective in increasing the outcomes of assisted reproductive technology treatment also in case of infertile men with obesity, both in terms of pregnancy and live birth rate.

Robotic Colorectal Cancer Surgery. How to Reach Expertise? A Single Surgeon-Experience

The complexity associated with laparoscopic colorectal surgery requires several skills to overcome the technical difficulties related to this procedure. To overcome the technical challenges of laparoscopic surgery, a robotic approach has been introduced. Our study reports the surgical outcomes obtained by the transition from laparoscopic to robotic approach in colorectal cancer surgery to establish in which type of approach the proficiency is easier to reach. Data about the first consecutive 15 laparoscopic and the first 15 consecutive robotic cases are extracted, adopting as a comparator of proficiency the last 15 laparoscopic colorectal resections for cancer. The variables studied are operative time, number of harvested nodes, conversion rate, postoperative complications, recovery outcomes. Our analysis includes 15 patients per group. Our results show that operative time is significantly longer in the first 15 laparoscopic cases (p = 0.001). A significantly lower number of harvested nodes was retrieved in the first 15 laparoscopic cases (p = 0.003). Clavien Dindo I complication rate was higher in the first laparoscopic group, but without a significant difference among the three groups (p = 0.09). Our results show that the surgeon needed no apparent learning curve to reach their laparoscopic standards. However, further multicentric prospective studies are needed to confirm this conclusion.

Learning curve and global benchmark values of laparoscopic sleeve gastrectomy: results of first 100 cases of a newly trained surgeon in an Italian center of excellence

To evaluate whether the learning curve for sleeve gastrectomy could be completed after 50 cases. First 100 patients undergoing LSG under a newly trained laparoscopic surgeon were included in this study and divided into two groups of 50 consecutive patients each. Perioperative outcomes were compared to recently introduced global benchmarks. Short-term weight loss was calculated as Total Weight Loss Percent (%TWL) and complications were classified in accordance with the Clavien–Dindo classification. CUSUM analysis was performed for operative time and hospital stay. Mean preoperative age and BMI were 41.8 ± 10.3 years and 42.9 ± 5.4 kg/m², respectively. Demographics and rate of patients with previous surgery were comparable preoperatively in the two groups. Mean operative time was 92.1 ± 19.3 min and hospital stay was 3.4 ± 0.6 days as per our standard protocol of discharge. Uneventful postoperative course was recorded in 93% of patients and only one case of staple line leak was registered in the first 50 cases (group 1). No statistical difference in BMI and %TWL was found between the two groups at any time of follow-up. Comparison between two groups showed a significant reduction in hospital stay and operative time after the first 50 LSGs (p < 0.05). LSG can be performed by newly trained surgeons proctored by senior tutors. At least 50 cases are needed to meet global benchmark cut-offs and few more cases may be required to reach the plateau of the learning curve.

Barbed suture in gastro-intestinal surgery: A review with a meta-analysis

BACKGROUND

The laparoscopic approach is a very popular technique for many gastrointestinal operations and barbed sutures may improve the difficulties of intracorporeal anastomosis by eliminating the need for knot tying. The aim of this systematic review with a meta-analysis is to explore literature to establish the security profile of barbed suture compared with conventional laparoscopic sutures.

MATERIALS AND METHODS

A systematic search was performed in all electronic databases (PubMed, Web of Science, Scopus, EMBASE) and 12 studies were included in the analysis, involving 27,133 patients, whereof 3372 cases (patients undergone barbed suture usage) and 23,761 controls (patients undergone conventional suture usage). We found 3 studies discussing differences between barbed and conventional sutures in colorectal surgery and 8 studies presenting results in bariatric surgery, both in Roux-en-y gastric bypass and Mini Gastric/One Anastomosis Gastric Bypass.

RESULTS

We found comparable rate of leaks, bleedings and stenosis. The meta-regression analysis demonstrated that, both in case of bariatric and colorectal surgery, the demographic characteristic of patients and the oncological features of neoplasms did not impact of these findings. As expected, operative time is significantly shorter when barbed suture is used.

CONCLUSION

Our analysis on current literature define an acceptable security profile for barbed suture with effective results particularly in terms of shorter operative time.

Impact of COVID-19 Lockdown on Short-term Weight Loss in a Single Italian Institution

Italy was the first European country to have a major outbreak of COVID-19. Bariatric procedures were stopped and telemedicine had to be implemented. A large percentage of patients struggled to follow postoperative diet and to start physical activity due to social restrictions. We have compared short-term outcomes of patients who had bariatric procedures prior to lockdown with subjects that had undergone obesity surgery in the same period of the previous year at our institution. A total number of 63 patients were included in this study. Weight loss at 1, 3 and 6 postoperative months in the 2019 group was significantly higher at any point of follow-up when compared to 2020. Social limitations and nonattendance of clinical appointments may have compromised early results.

Evaluation of reflux following sleeve gastrectomy and one anastomosis gastric bypass: 1-year results from a randomized open-label controlled trial

Background

Recent reports have demonstrated that de novo reflux and worsening of pre-existing symptoms occur after SG; concerns are still expressed about the risk of symptomatic biliary reflux gastritis and oesophagitis. The aim of our study was to investigate and compare the rate of postoperative acid and non-acid reflux following Mini-/One anastomosis gastric bypass (MGB/OAGB) and laparoscopic sleeve gastrectomy (LSG).

Study design

A prospective randomized open-label, controlled trial registered on clinicaltrial.gov (NCT number: NCT02987673) has been carried out to evaluate esophagogastric junction exposure to reflux in the first year after MGB/OAGB and LSG using high impedance manometry, endoscopy, and a validated questionnaire.

Results

A total of 58 individuals were eventually enrolled in this trial and represented the per-protocol population (n = 28 MGB/OAGB, n = 30 LSG). No difference was found between the two groups in terms of demographic characteristics, PAGI-SYM score, acid exposure time percent of the esophagus (AET%), esophagitis, and other HRiM and MII-pH data at baseline. Comparing MII-pH outcomes of the two groups, AET% resulted significantly higher after LSG at 12 months. Endoscopic findings showed a significant increase of esophagitis ≥ B in the LSG group after 1 year; postoperative esophagitis ≥ B resulted also significantly worsened after LSG when compared to MGB/OAGB.

Conclusion

Since AET% and rate of esophagitis are significantly higher after LSG when compared to MGB/OAGB, this procedure should be preferred in case of preoperative subclinical reflux or low grade (A) esophagitis.

Small bowel obstruction secondary to adipose tissue herniation through gastric band tubing loop. An unusual case presentation

BACKGROUND

Laparoscopic adjustable gastric band complications like oesophageal dilatation, intractable nausea and vomiting, band migration, late slippages, and port problems with a cumulative rate of 19.2%. Rarely, LAGB complications may be related to the connection tube system and in this case the clinical presentation and the effects of the problem can generate difficulties in diagnosis.

METHODS

A 47 years old woman who had a LAGB placed 2 years before the symptoms was admitted in our centre with nausea, vomit, leukocytosis and distended abdomen with a generalized tenderness. Computed tomography images showed an anomalous course of banding tube and a contemporary compression of a small bowel tract secondary to the traction exerted by an adipose tissue band attracted by the tube.

RESULTS

A laparoscopic exploration of the abdominal cavity showed a tight loop of LAGB tubing causing a small bowel obstruction with an ischemic damage, so surgeons provided to LAGB removal and a 50 cm ileum resection CONCLUSIONS: Small bowel obstruction resulting from LAGB tubing is an uncommon complication which was reported in few cases. Although bariatric surgery currently represents the best treatment option for morbid obesity and its related- diseases, peri- and post-operative complications have always to be taken into account.

KEY WORDS

Adjustable gastric band complications, Bariatric surgery, Bowel obstruction, CT scan, LAGB tube.

Endoscopic Approach to Recurrent Pilonidal Sinus: A Retrospective Analysis

Background: The aim of this study is to report short- and long-term results using video-assisted ablation of pilonidal sinus (PS) technique to treat recurrent PS. Methods: We included all consecutive patients with a recurrent PS disease operated on with endoscopic approach since 1st January 2014 to 31st December 2018. Analyzed outcomes were recurrence rate at 1, 3, and 5 years, time off work, time to sitting on toilet and to walk without pain, time to wound healing, rate of incomplete wound healing and postoperative infection, postoperative pain at 6 hours, 1 day, and 1 week, and patients' satisfaction after 1 month. Demographic and sinuses' data were recorded. To adjust for all the variables, multivariate analyses were performed with outcomes as dependent variables, and with patients' and sinuses' characteristics as independent variables. Results: Sixty-three patients were included in the analysis. Recurrence rate at 1-year follow-up was 4.7% (3 patients on 63), at 3-year follow-up was 11.7% (4 on 34), and at 5-year follow-up was 23.07% (3 on 13). A 3- and 5-year follow-up was completed by 34 and 13 patients, respectively. The mean time off work was 3.5 ± 1.5 days, time to sitting on toilet without pain was 1.5 ± 1.1 days, and time to walk without pain was 1.3 ± 0.9 days. The mean time to wound healing was 27.9 ± 10.3 days, with a rate of incomplete wound healing of 4.7%. Postoperative infection rate was 7.9%. The mean postoperative pain was 1 ± 0.9 at 6 hours after the procedure, 0.6 ± 0.6 at 1 day and 0.1 ± 0.3 at 1 week. Patients' satisfaction was good in 98.5% of patients. After the multivariate analysis, no parameters showed an influence on the postoperative outcomes. Conclusions: Our results encouraged to adopt an endoscopic approach even in case of recurrent PS.

Role of Preoperative Adrenergic Blockade with Doxazosin on Hemodynamic Control during the Surgical Treatment of Pheochromocytoma: A Retrospective Study of 48 Cases

Authors evaluated the effects of selective adrenergic blockade by means of doxazosin on blood pressure in 48 patients operated on for pheochromocytoma by a multicenter retrospective study. Age, tumor size, surgical approach, and operative time were analyzed as predictive factors of intraoperative hypertensive crises. Forty-eight patients underwent adrenalectomy—four open surgery and 44 laparoscopic surgery—for pheochromocytoma of adrenal glands from 1998 to 2008 after preoperative administration of doxazosin. Perioperative cardiovascular status modifications and surgical medium- and long-term outcomes were analyzed. There was no mortality, conversion rate was 4.5 per cent, and morbidity rate was 8.3 per cent. Intraoperative hypertensive crises (180/ 90 mmHg or higher) were observed in 14.5 per cent (seven of 48) of patients and were treated pharmacologically with no aftermath. None of the examined variables influenced the occurrence of intraoperative hypertensive episodes. Postoperative hypotension (lower than 90/60 mmHg) was observed in four of 48 patients (8.3%) and was treated by crystalloids and hydrocortisone. In the surgical treatment of pheochromocytoma, the preoperative adrenergic blockade by doxazosin does not prevent intraoperative hypertensive crises. Nevertheless, in our series, they were of short duration and were not associated with major cardiovascular complications. Perioperative hemodynamic instability was managed bypreoperative pharmacological treatment, allowing low morbidity.

Bariatric surgery and the COVID-19 pandemic: SICOB recommendations on how to perform surgery during the outbreak and when to resume the activities in phase 2 of lockdown

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its related disease, coronavirus disease 2019 (COVID-19), has been rapidly spreading all over the world and is responsible for the current pandemic. The current pandemic has found the Italian national health system unprepared to provide an appropriate and prompt response, heavily affecting surgical activities. Based on the limited data available in the literature and personal experiences, the Società Italiana di Chirurgia dell’OBesità e Malattie Metaboliche (SICOB) provides recommendations regarding the triage of bariatric surgical procedures during the COVID-19 pandemic defining a dedicated path for surgery in morbidly obese patients with known or suspected COVID-19 who may require emergency operations. Finally, the current paper delineates a strategy to resume outpatient visits and elective bariatric surgery once the acute phase of the pandemic is over. Models developed during the COVID-19 crisis should be integrated into hospital practices for future use in similar scenarios. Surgeons are presented with a golden opportunity to embrace systemic change and to drive their professional future.