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.

Small Bowel Obstruction After Laparoscopic Roux-en-Y Gastric Bypass Caused by Hemobezoar: A Case Series and Review of Literature.

BACKGROUND: The development of an intraluminal blood clot (hemobezoar), represents a rare cause (0.05% to 1.9%) of small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass (LRYGB). We present a case series of 6 cases of SBO caused by hemobezoar. METHODS: A retrospective analysis of a prospective database including patients who underwent LRYGB from January 2010 to December 2019 has been performed. All the patients who underwent reoperation because of an SBO caused by an intraluminal blood clot were included in the present study. RESULTS: Six of 843 LRYGB patients developed an hemobezoar (0.71%). Primary LRYGB was uneventful in all cases. SBO symptoms developed after a mean interval of 26.6 hours from the primary procedure. All reoperations were performed with the laparoscopic approach. In all cases, the hemobezoar was located at the level of the jejunojejunal anastomosis (JJA) and was removed through an enterotomy performed at the distal end of the biliopancreatic stump. Three postoperative complications occurred: 1 ab-ingestis pneumonia, 1 leak of the JJA requiring further reoperation, and 1 pelvic abscess treated with radiologic drainage. The mean hospital stay was 11 days. DISCUSSION: SBO due to hemobezoar is a rare but worrisome early complication after LRYGB. It almost always affects the JJA and requires a prompt diagnosis to avoid dreadful sequelae. In the absence of anastomotic leak or stenosis, surgical management may consist of the removal of the blood clot without refashioning the anastomosis and it may be accomplished with the laparoscopic approach.

Laparoscopic Management of Internal Hernia After One Anastomosis Gastric Bypass (OAGB).

Among the advantages of the One Anastomosis Gastric Bypass (OAGB) are the lack of jejuno-jejunal anastomosis and a supposed lower incidence of internal hernia (IH), with only a few cases reported until now. However, the incidence of IH after OAGB is not null. We present a video of the laparoscopic management of an IH that occurred after an OAGB. The patient was a 49-year-old female who had undergone a laparoscopic revisional OAGB 2 years previously after a failed laparoscopic adjustable gastric banding. She was referred to our Unit for recurrent postprandial colicky pain. She lost a total of 50 kg and her body mass index (BMI) dropped from 38 to 19 kg/m2. A CT scan with intravenous contrast showed a swirl of the mesentery around the superior mesenteric artery, without small bowel obstruction. A laparoscopic exploration was performed, confirming the suspicion of IH at the Petersen's space. An anticlockwise derotation of the whole common limb was performed, and the Petersen's space was eventually closed with a running non-absorbable suture.

Seminal but not Serum Levels of Holotranscobalamin are Altered in Morbid Obesity and Correlate with Semen Quality: A Pilot Single Centre Study.

Vitamin B12 (cobalamin) is an essential cofactor in the one-carbon metabolism. One-carbon metabolism is a set of complex biochemical reactions, through which methyl groups are utilised or generated, and thus plays a vital role to many cellular functions in humans. Low levels of cobalamin have been associated to metabolic/reproductive pathologies. However, cobalamin status has never been investigated in morbid obesity in relation with the reduced semen quality. We analysed the cross-sectional data of 47-morbidly-obese and 21 lean men at Careggi University Hospital and evaluated total cobalamin (CBL) and holotranscobalamin (the active form of B12; holoTC) levels in serum and semen. Both seminal and serum concentrations of holoTC and CBL were lower in morbidly obese compared to lean men, although the difference did not reach any statistical significance for serum holoTC. Seminal CBL and holoTC were significantly higher than serum levels in both groups. Significant positive correlations were observed between seminal holoTC and total sperm motility (r = 0.394, p = 0.012), sperm concentration (r = 0.401, p = 0.009), total sperm number (r = 0.343, p = 0.028), and negative correlation with semen pH (r = -0.535, p = 0.0001). ROC analysis supported seminal holoTC as the best predictor of sperm number (AUC = 0.769 ± 0.08, p = 0.006). Our findings suggest that seminal rather than serum levels of holoTC may represent a good marker of semen quality in morbidly obese subjects.

Conversion from laparoscopic adjustable gastric banding (LAGB) and laparoscopic sleeve gastrectomy (LSG) to one anastomosis gastric bypass (OAGB): preliminary data from a multicenter retrospective study.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure, while laparoscopic adjustable gastric banding (LAGB) has been for a decade one of the most popular interventions for weight loss. After LSG and LAGB, some patients may require a second surgery due to weight regain or late complications. One anastomosis gastric bypass (OAGB) is a promising bariatric procedure, which provides effective long-term weight loss and has a favorable effect on type 2 diabetes. OBJECTIVES: To retrospectively analyze data from 10 Italian centers on conversion from LAGB and LSG to OAGB. SETTING: High-volume centers for bariatric surgery. METHODS: Prospectively collected data from 10 high-volume centers were retrospectively reviewed. Body mass index (BMI), percentage of excess BMI loss, reasons for redo, remission from co-morbidities (hypertension, diabetes, gastroesophageal reflux, and dyslipidemia), and major complications were recorded. RESULTS: Three hundred patients were included in the study; 196 patients underwent conversion from LAGB to OAGB and 104 were converted from LSG. BMI was 45.1 ± 7 kg/m2 at the time of first intervention, 41.8 ± 6.3 kg/m2 at redo time, and 30.5 ± 5.5 kg/m2 at last follow-up appointment. Mean percentage of excess BMI loss was 13.2 ± 28.2 at conversion and 73.4 ± 27.5 after OAGB. Remission rates from hypertension, diabetes, gastroesophageal reflux, and dyslipidemia were 40%, 62.5%, 58.7% and 52%, respectively. Mean follow-up was 20.8 (range, 6-156) months and overall complications rate was 8.6%. CONCLUSION: Our data show that OAGB is a safe and effective revisional procedure after failed restrictive bariatric surgery.

Intussusception After Roux-en-Y Gastric Bypass: Laparoscopic Management.

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

Massive Weight Loss Obtained by Bariatric Surgery Affects Semen Quality in Morbid Male Obesity: a Preliminary Prospective Double-Armed Study.

OBJECTIVES: The aim of this study is to evaluate the effect of massive weight loss on the seminal parameters at 6 months from bariatric surgery. DESIGN: Two-armed prospective study performed in 31 morbidly obese men, undergoing laparoscopic roux-en-Y-gastric bypass (n = 23) or non-operated (n = 8), assessing sex hormones, conventional (sperm motility, morphology, number, semen volume), and non-conventional (DNA fragmentation and seminal interleukin-8), semen parameters, at baseline and after 6 months from surgery or patients' recruitment. RESULTS: In operated patients only, a statistically significant improvement in the sex hormones was confirmed. Similarly, a positive trend in the progressive/total sperm motility and number was observed, though only the increase in semen volume and viability was statistically significant (Δ = 0.6 ml and 10%, P < 0.05, respectively). A decrease in the seminal interleukin-8 levels and in the sperm DNA fragmentation was also present after bariatric surgery, whereas these parameters even increased in non-operated subjects. Age-adjusted multivariate analysis showed that the BMI variations significantly correlated with the changes in the sperm morphology (ß = -0.675, P = 0.025), sperm number (ß = 0.891, P = 0.000), and semen volume (r = 0.618, P = 0.015). CONCLUSION: The massive weight loss obtained with bariatric surgery was associated with an improvement in some semen parameters. The correlations found between weight loss and semen parameter variations after surgery suggest that these might occur early downstream of the testis and more slowly than the changes in the sex hormones.

Large Hemobezoar Causing Acute Small Bowel Obstruction After Roux-en-Y Gastric Bypass: Laparoscopic Management.

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

Healthcare usage and economic impact of non-treated obesity in Italy: findings from a retrospective administrative and clinical database analysis.

OBJECTIVES: Investigate the prevalence of obesity in Italy and examine its resource consumption and economic impact on the Italian national healthcare system (NHS). DESIGN: Retrospective, observational and real-life study. SETTING: Data from three health units from Northern (Bergamo, Lombardy), Central (Grosseto, Tuscany) and Southern (Naples, Campania) Italy. PARTICIPANTS: All patients aged ≥18 years with at least one recorded body mass index (BMI) measurement between 1 January 2009 and 31 December 2012 were included. INTERVENTIONS: Information retrieved from the databases included primary care data, medical prescriptions, specialist consultations and hospital discharge records from 2009-2013. Costs associated with these data were also calculated. Data are presented for two time periods (1 year after BMI measurement and study end). PRIMARY AND SECONDARY OUTCOME MEASURES: Primary-to estimate health resources consumption and the associated economic impact on the Italian NHS. Secondary-the prevalence and characteristics of subjects by BMI category. RESULTS: 20 159 adult subjects with at least one documented BMI measurement. Subjects with BMI ≥30 kg/m2 were defined as obese. The prevalence of obesity was 22.2% (N=4471) and increased with age. At the 1-year observation period, obese subjects who did not receive treatment for their obesity experienced longer durations of hospitalisation (median length: 5 days vs 3 days), used more prescription drugs (75.0% vs 57.7%), required more specialised outpatient healthcare (mean number: 5.3 vs 4.4) and were associated with greater costs, primarily owing to prescription drugs and hospital admissions (mean annual cost per year per patient: €460.6 vs €288.0 for drug prescriptions, €422.7 vs € 279.2 for hospitalisations and €283.2 vs €251.7 for outpatient care), compared with normal weight subjects. Similar findings were observed for the period up to data cut-off (mean follow-up of 2.7 years). CONCLUSIONS: Untreated obesity has a significant economic impact on the Italian healthcare system, highlighting the need to raise awareness and proactively treat obese subjects.

Laparoscopic Management of Internal Hernia After Roux-en-Y Gastric Bypass.

INTRODUCTION: Internal hernia (IH) represents the most common cause of small-bowel obstruction after laparoscopic RYGBP. The anatomic changes resulting from RYGBP, the use of laparoscopy, and the postoperative weight loss all account for the high incidence of IH after this procedure. As the symptoms may be very vague, the interpretation of the clinical picture may result difficult. Moreover, laparoscopic treatment of IH could be very challenging for surgeons not familiar with the modified intestinal anatomy of the RYGBP. METHODS: The video shows the management of an IH at the Petersen's defect. A 51-year-old female was assessed for recurrent abdominal pain 3 years after a RYGBP. A CT scan showed the mesenteric swirl sign, so a diagnostic laparoscopy was performed. The video first shows the identification of the herniated bowel through the mesenteric defect. Then, complete reduction of the IH and the closure of the Petersen's defect are shown. RESULTS: The total operative time was 35 min. The postoperative stay was uneventful and the patient was discharged in postoperative day one. CONCLUSION: In case of clinical suspicion of IH, even in case of normal laboratory and radiological findings, a surgical exploration is indicated.

Laparoscopic Conversion of One Anastomosis Gastric Bypass to Roux-en-Y Gastric Bypass for Chronic Bile Reflux.

BACKGROUND: One anastomosis gastric bypass (OAGB) demonstrated similar results to traditional Roux-en-Y procedures. A possible concern is how to manage a chronic bile reflux when medical therapy results ineffective. Revision of the gastro-jejunal anastomosis, obtaining a Roux-en-Y reconstruction, has already been proposed, but technical details have not been elucidated yet. This video shows how to revise a 200-cm OAGB to treat chronic bile reflux, by converting the procedure to Roux-en-Y, having a short gastric pouch and a long efferent limb. METHODS: A 51-year-old patient complained of recurrent heartburns 2 months after OAGB. A gastroscopy witnessed the presence of a 6-cm long gastric pouch with pouchitis and bile reflux in esophagus. Specific medications were ineffective. He underwent a revisional laparoscopic procedure. The efferent limb was measured and consisted of 650 cm. The afferent limb was then divided next to the previous gastro-jejunal anastomosis and a jejuno-jejunal anastomosis was performed distally at 70 cm on the alimentary limb. RESULTS: Total operative time was 50 min. The postoperative stay was uneventful and the patient was discharged in postoperative day four. At 6 months follow-up he is still free of medications without symptoms. CONCLUSIONS: The ideal scenario for the presented technique is the finding of a long efferent limb, in order to fashion a Roux-en-Y limb without the risk of postoperative malabsorption. To reach this goal, we suggest the measurement of the whole small bowel intra-operatively, in order to assess the length of the common channel left in place.

Laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography (ERCP) after Roux-en-Y gastric bypass: technical features.

BACKGROUND: Laparoscopic gastric bypass is one of the most performed bariatric operations worldwide. The exclusion of stomach and duodenum after this operation makes the access to the biliary tree, in order to perform an endoscopic retrograde cholangiopancreatography (ERCP), very difficult. This procedure could be more often required than in overall population due to the increased incidence of gallstones after bariatric operations. Among the different techniques proposed to overcome this drawback, laparoscopic access to the excluded stomach has been described by many authors with a high rate of success reported. METHODS: We herein describe our technique to perform laparoscopic transgastric ERCP. A gastrotomy on the excluded stomach is performed to introduce a 15-mm trocar. Two stitches are passed through the abdominal wall and placed at the two sides of the gastrotomy for traction. The intragastric trocar is used to pass a side-viewing endoscope to access the biliary tree. CONCLUSION: In patients with a past history of Roux-en-Y gastric bypass (RYGB), the present technique allows us a standardized, safe, and reproducible access to the major papilla and the biliary tree using a transgastric access. This will lead to simplify the procedure and reduce the risk of peritoneal contamination.