Lung Volume and Ventilation Distribution After Bariatric Surgery-High-Flow Nasal Cannula Versus CPAP.

BACKGROUND: Patients with obesity are at increased risk of postoperative pulmonary complications. CPAP has been used successfully to prevent and treat acute respiratory failure, but in many clinical scenarios, high-flow nasal cannula (HFNC) therapy is emerging as a possible alternative. We aimed to compare HFNC and CPAP in a sequential study measuring their effects on gas exchange, lung volumes, and gas distribution within the lungs measured through electrical impedance tomography (EIT). METHODS: We enrolled 15 subjects undergoing laparoscopic bariatric surgery. Postoperatively they underwent the following oxygen therapy protocol (10 min/step): baseline air-entrainment mask, HFNC at increasing (40, 60, 80, and 100 L/min) and decreasing flows (80, 60, and 40 L/min), washout air-entrainment mask and CPAP (10 cm H2O). Primary outcome was the change in end-expiratory lung impedance (ΔEELI) measured by EIT data processing. Secondary outcomes were changes of global inhomogeneity (GI) index and tidal impedance variation (TIV) measured by EIT, arterial oxygenation, carbon dioxide content, pH, respiratory frequency, and subject's comfort. RESULTS: Thirteen subjects completed the study. Compared to baseline, ΔEELI was higher during 10 cm H2O CPAP (P = .001) and HFNC 100 L/min (P = .02), as well as during decreasing flows HFNC 80, 60, and 40 L/min (P = .008, .004, and .02, respectively). GI index was lower during HFNC 100 compared to HFNC 60increasing (P = .044), HFNC 60decreasing (P = .02) HFNC 40decreasing (P = .01), and during 10 cm H2O CPAP compared to washout period (P = .01) and HFNC 40decreasing (P = .03). TIV was higher during 10 cm H2O CPAP compared to baseline (P = .008). Compared to baseline, breathing frequency was lower at HFNC 60increasing, HFNC 100, and HFNC 80decreasing (P = .01, .02, and .03, respectively). No differences were detected regarding arterial oxygenation, carbon dioxide content, pH, and subject's comfort. CONCLUSIONS: HFNC at a flow of 100 L/min induced postoperative pulmonary recruitment in bariatric subjects, with no significant differences compared to 10 cm H2O CPAP in terms of lung recruitment and ventilation distribution.

Pre-operative body shape concerns moderate excess weight loss trajectory in bariatric surgery patients: a 2-year longitudinal study.

PURPOSE: The main research aim was to inspect whether pre-operative body shape concerns and discomfort as Body Shape Questionnaire (BSQ) scores moderate post-operative weight loss trajectory in bariatric patients. METHODS: Two studies were conducted. Study 1 analyzed cross-sectional data and verified the structural validity of the 34-item BSQ questionnaire on a sample of 327 candidates for bariatric surgery. Study 2 examined longitudinal data, with objective Body Mass Index (BMI) recorded every 6 months, from surgery intervention on, with 5 measurement occasions, from 111 patients who initially completed BSQ as bariatric surgery candidates and then underwent periodic medical post-operative follow-ups, over 2 years. RESULTS: In Study 1, confirmatory factor analysis of a single-dimension model yielded acceptable fit indices and high internal consistency levels. Study 2 showed that post-operative excess BMI reduction trend was not linear and pre-operative BSQ scores moderated it, with a higher risk of weight regain in patients who initially were less concerned with their body shape. CONCLUSIONS: The present findings support the structural validity of the BSQ questionnaire in bariatric candidates and call attention on the role of pre-operative body shape concerns on post-operative weight loss trajectories over 2 years, in accordance with a pathoplasty model. They suggest the need for systematic attention on perceived body image and psychological paths aimed to help bariatric patients regain positive attitudes towards their own body. Level of evidence III, well-designed cohort.

Liver Bacterial Colonization in Patients with Obesity and Gut Dysbiosis.

PURPOSE: Recently, the link between gut microbiota, liver inflammation, and obesity has become an interesting focus of research. The aim of this study is to show the possible relation between gut microbiota dysbiosis in patients with obesity and the presence of bacterial genomes in their liver biopsies. MATERIALS AND METHODS: A prospective study on patients undergoing bariatric surgery was carried out. Anthropometric and metabolic data, comorbidities, stool samples, and hepatic biopsies were collected and analyzed at the time of surgery. The V3-16S rRNA region was sequenced using the Ion Torrent new-generation sequencing platform. RESULTS: In each of the 23 patients enrolled, the bacterial population was analyzed both in the stools and liver. In eight patients (34.7%), Prevotella (62.5%), Bacteroides (50%), Streptococcus (12.5%), and Dalister (12.5%) were found in both samples, simultaneously; in 15 cases, the liver was free from colonization. The statistically significant difference between groups was a Roseburia intestinalis reduction in fecal samples of patients with liver biopsies colonized by bacteria (1% vs 3%; p = 0.0339). CONCLUSION: To the best of our knowledge, this is the first study reporting the presence of bacterial genome in a liver biopsy on bariatric patients, instead of the microbe-associated molecular patterns. Notably, in literature, the presence of Roseburia intestinalis in stool samples has been shown to prevent intestinal inflammation playing its role in the gut barrier integrity. In our population, the Roseburia reduction was associated with the presence of bacterial genome in the liver, probably related to a greater permeability of the gut and vascular barriers.

The potential role of omentin-1 in obesity-related metabolic dysfunction-associated steatotic liver disease: evidence from translational studies.

BACKGROUND: Obesity, characterized by visceral adipose tissue (VAT) expansion, is closely associated with metabolic dysfunction-associated steatotic liver disease (MASLD) and metabolic dysfunction-associated steatohepatitis (MASH). Recent research has highlighted the crucial role of the adipose tissue-liver axis in the development of MASLD. In this study, we investigated the potential role of omentin-1, a novel adipokine expressed by VAT, in obesity-related MASLD pathogenesis. METHODS: Through in silico analysis of differentially expressed genes in VAT from obese patients with and without MASH, we identified omentin-1 as a significant candidate. To validate our findings, we measured omentin-1 levels in VAT and plasma of lean controls and obese patients with biopsy-proven MASLD. Additionally, we assessed omentin-1 expression in the VAT of diet-induced mice MASLD model. In vitro and ex vivo studies were conducted to investigate the effects of omentin-1 on MASLD-related mechanisms, including steatosis, inflammation, endoplasmic reticulum (ER) stress, and oxidative stress. We also analyzed the impact of D-glucose and insulin on VAT omentin-1 levels ex vivo. RESULTS: Compared to the lean group, the obese groups exhibited significantly lower VAT and plasma levels of omentin-1. Interestingly, within the obese groups, omentin-1 is further decreased in MASH groups, independent of fibrosis. Likewise, VAT of mice fed with high-fat diet, showing histological signs of MASH showed decreased omentin-1 levels as compared to their control diet counterpart. In vitro experiments on fat-laden human hepatocytes revealed that omentin-1 did not affect steatosis but significantly reduced TNF-α levels, ER stress, and oxidative stress. Similar results were obtained using ex vivo VAT explants from obese patients upon omentin-1 supplementation. Furthermore, omentin-1 decreased the mRNA expression of NF-κB and mitogen-activated protein kinases (ERK and JNK). Ex vivo VAT explants showed that D-glucose and insulin significantly reduced omentin-1 mRNA expression and protein levels. CONCLUSIONS: Collectively, our findings suggest that reduced omentin-1 levels contribute to the development of MASLD. Omentin-1 supplementation likely exerts its beneficial effects through the inhibition of the NF-κB and MAPK signaling pathways, and it may additionally play a role in the regulation of glucose and insulin metabolism. Further research is warranted to explore omentin-1 as a potential therapeutic target and/or biomarker for MASLD.

Ischemic wound revascularization by the stromal vascular fraction relies on host-donor hybrid vessels.

Nonhealing wounds place a significant burden on both quality of life of affected patients and health systems. Skin substitutes are applied to promote the closure of nonhealing wounds, although their efficacy is limited by inadequate vascularization. The stromal vascular fraction (SVF) from the adipose tissue is a promising therapy to overcome this limitation. Despite a few successful clinical trials, its incorporation in the clinical routine has been hampered by their inconsistent results. All these studies concluded by warranting pre-clinical work aimed at both characterizing the cell types composing the SVF and shedding light on their mechanism of action. Here, we established a model of nonhealing wound, in which we applied the SVF in combination with a clinical-grade skin substitute. We purified the SVF cells from transgenic animals to trace their fate after transplantation and observed that it gave rise to a mature vascular network composed of arteries, capillaries, veins, as well as lymphatics, structurally and functionally connected with the host circulation. Then we moved to a human-in-mouse model and confirmed that SVF-derived endothelial cells formed hybrid human-mouse vessels, that were stabilized by perivascular cells. Mechanistically, SVF-derived endothelial cells engrafted and expanded, directly contributing to the formation of new vessels, while a population of fibro-adipogenic progenitors stimulated the expansion of the host vasculature in a paracrine manner. These data have important clinical implications, as they provide a steppingstone toward the reproducible and effective adoption of the SVF as a standard care for nonhealing wounds.

Inflammatory-nutritional scores in the diagnosis of NASH and liver fibrosis.

BACKGROUND: The aim of the present study was to investigate the possible correlation between various inflammation-nutritional scores to histological determined nonalcoholic steatohepatitis (NASH) and other liver injury suggestive for non-alcoholic fatty liver disease (NAFLD) in a bariatric population. METHODS: We consecutively and retrospectively evaluated all the patients referred to the Department of Bariatric Surgery in Trieste, Italy. Inflammation-nutritional scores were calculated starting from preoperative hematologic data. Liver biopsy was performed at the time of bariatric surgery (sleeve gastrectomy or gastric bypass) and pathological assessment was performed using Kleiner-Brunt staging system (NAS score). RESULTS: Glasgow Prognostic Score/modified Glasgow Prognostic Score (GPS/ mGPS) and Prognostic Index (PI) were associated to the diagnosis of NASH (P=0.024 and P=0.03 respectively). The presence of perisinusoidal and/or periportal fibrosis was correlated to Prognostic Nutritional Index (PNI) and platelet-to-lymphocyte ratio (PLR) values (P=0.02 and P=0.009 respectively). CONCLUSIONS: GPS/mGPS and PI are statistically associated to the histological diagnosis of NASH. Further studies on large series are needed to better understand the relationship between these serum markers and liver injury in obese patients.

Indications for upper gastrointestinal endoscopy before bariatric surgery: a multicenter study.

BACKGROUND: The role of preoperative upper gastrointestinal endoscopy before bariatric surgery is still debated, and a consensus among the international scientific community is lacking. The aims of this study, conducted in three different geographic areas, were to analyze data regarding the pathological endoscopic findings and report their impact on the decision-making process and surgical management, in terms of delay in surgical operation, modification of the intended bariatric procedure, or contraindication to surgery. METHODS: This is a multicenter cross-sectional study using data obtained from three prospective databases. The preoperative endoscopic reports, patient demographics, Body Mass Index, type of surgery, and Helicobacter pylori status were collected. Endoscopic findings were categorized into four groups: (1) normal endoscopy, (2) abnormal findings not requiring a change in the surgical approach, (3) clinically important lesions that required a change in surgical management or further investigations or therapy prior to surgery, and (4) findings that contraindicated surgery. RESULTS: Between 2006 and 2020, data on 643 patients were analyzed. In all of the enrolled bariatric institutions, preoperative endoscopy was performed routinely. A total of 76.2% patients had normal and/or abnormal findings that did not required a change in surgical management; in 23.8% cases a change or a delay in surgical approach occurred. Helicobacter pylori infection was detected in 15.2% patients. No patient had an endoscopic finding contraindicating surgery. CONCLUSIONS: The role of preoperative UGE is to identify a wide range of pathological findings in patients with obesity that could influence the therapeutic approach, including the choice of the proper bariatric procedure. Considering the anatomical modifications, the incidence of asymptomatic pathologies, and the risk of malignancy, we support the decision of performing preoperative endoscopy for all patients eligible for bariatric operation.

Potential Application of Small Interfering RNA in Gastro-Intestinal Tumors.

Despite the progress made in the diagnoses and therapy of gastrointestinal cancers, these diseases are still plagued by a high mortality. Thus, novel therapeutic approaches are urgently required. In this regard, small interfering RNA (siRNA), double-stranded RNA molecules able to specifically target the mRNA of pathological genes, have the potential to be of therapeutic value. To be effective in the human body, siRNAs need to be protected against degradation. Additionally, they need to target the tumor, leaving the normal tissue untouched in an effort to preserve organ function. To accomplish these tasks, siRNAs have been formulated with smart delivery systems such has polymers and lipids. While siRNA protection is not particularly difficult to achieve, their targeting of tumor cells remains problematic. Here, after introducing the general features of gastrointestinal cancers, we describe siRNA characteristics together with representative delivery systems developed for gastrointestinal cancers. Afterward, we present a selection of research papers employing siRNAs against upper- and lower- gastrointestinal cancers. For the liver, we also consider papers using siRNAs to combat liver cirrhosis, a relevant risk factor for liver cancer development. Finally, we present a brief description of clinical trials employing siRNAs for gastrointestinal cancers.

SCL-90 empirical factors predict post-surgery weight loss in bariatric patients over longer time periods.

PURPOSE: This longitudinal study examined how pre-intervention psychological health helps predict bariatric surgery (BS) success as percentage of expected body mass index loss (%EBMIL) over shorter to longer periods. METHODS: Adult candidates for BS (N = 334, 67.4% females) completed the Symptoms Checklist 90 (SCL-90) questionnaire; on average, 11 months occurred between the pre-surgery psychological evaluations and the bariatric intervention. We explored the factor structure of the SCL-90 items and inspected how SCL-90 empirical factors compared with SCL-90 scales and general indices predicted %EBMIL at 3-6-month, 1-year, and 2-year follow-up occasions, adjusting for gender, pre-intervention use of antidepressants and actual and ideal BMIs. RESULTS: Factor analysis combined the 90 items into 8 factors, which partially replicated the expected item structure. The SCL-90 empirical factors (but not the SCL-90 scales and indices) contributed to predict BS success. In fact, the Relational Distress factor directly protected from weight regain at 1-year follow-up, indirectly via 1-year %EBMIL at the 2-year follow-up, when it further strengthened the impact of the empirical factor of Generalized Anxiety on the 2-year BS outcome. The results also evidenced a cascade effect of the pre-surgery actual BMI across time as well as unique and direct effects of pre-surgery use of antidepressants and perceived ideal BMI on the 2-year outcome. CONCLUSIONS: SCL-90 empirical factor scores for obese patients are more efficient in anticipating BS success compared with original scale scores. They reveal that relational distress and anxiety are risk factors for postoperative weight loss, in addition to pre-intervention actual BMI, antidepressant therapy, and perceived ideal BMI. LEVEL OF EVIDENCE: III, well-designed cohort.

Safety and efficacy of totally minimally invasive right colectomy in the obese patients: a multicenter propensity score-matched analysis.

Despite the well-known benefits of the minimally invasive approach for the right colon cancer treatment, less is known about its feasibility and advantages in morbid obese patients. The aim of this study is to compare the postoperative outcomes after totally minimally invasive right colectomy between the obese and non-obese population. Data derived from a prospectively maintained multicenter colorectal database were analysed, dividing the enrolled patients into two groups: obese (BMI > 29.99) patient group and non-obese patient group. Data about gender, age, American Society of Anesthesiologists (ASA) Score, tumor characteristics, operative time, anastomosis time, extraction site, incision length, intraoperative complications, postoperative complications, postoperative recovery, specimen length and retrieved nodes were taken to assess the achievement of the oncologic standards. After a propensity score matching, a total of 184 patients was included, 92 in each group. No differences were found in terms of demographic data and tumor characteristics. Intraoperative data showed a significant difference in terms of anastomosis time in favour of non-obese group (p < 0.0001). No intraoperative complications were recorded and no conversion was needed in both groups. No differences were found in terms of postoperative complications. There were no differences in terms of first mobilization (p = 0.745), time to first flatus (p = 0.241) time to tolerance to liquid and solid diet (p = 0.241 and p = 0.06) and length of hospital stay (p = 0.817). The analysis of oncologic outcomes demonstrated adequate results in both groups. The results obtained by our study confirmed the feasibility and safety of the totally minimally invasive approach even in obese population.

Ficolin-2 Plasma Level Assesses Liver Fibrosis in Non-Alcoholic Fatty Liver Disease.

Fibrosis is the strongest predictor for disease-specific mortality in non-alcoholic fatty liver diseases (NAFLD), but the need for liver biopsy limits its diagnosis. We assessed the performance of plasma ficolin-2 (FCN-2) as a biomarker of fibrosis identified by an in silico discovery strategy. Two hundred and thirty-five morbidly obese (MO) subjects with biopsy-proven NAFLD stratified by fibrosis stage (F0, n = 44; F1, n = 134; F2, n = 46; F3/F4, n = 11) and 40 cirrhotic patients were enrolled. The cohort was subdivided into discovery (n = 76) and validation groups (n = 159). The plasma level of FCN-2 and other candidate markers was determined. FCN-2 was inversely correlated with the stage of liver fibrosis (ρ = −0.49, p < 0.001) independently of steatosis (p = 0.90), inflammation (p = 0.57), and ballooning (p = 0.59). In the global cohort, FCN-2 level decreased significantly in a stepwise fashion from F0/F1 (median 4753 ng/mL) to F2−F3−F4 (2760 ng/mL) and in cirrhotic subjects (1418 ng/mL). The diagnostic performance of FCN-2 in detecting F ≥ 2 was higher than other indexes (APRI, FIB-4) (AUROC 0.82, 0.68, and 0.6, respectively). The accuracy improved when combined with APRI score and HDL values (FCNscore, AUROC 0.85). Overall, the FCN-2 plasma level can accurately discriminate liver fibrosis status (minimal vs. moderate/advanced) significantly improving the fibrosis diagnostic algorithms.

Long-term efficacy of lipoprotein apheresis and lomitapide in the treatment of homozygous familial hypercholesterolemia (HoFH): a cross-national retrospective survey.

BACKGROUND: Homozygous familial hypercholesterolemia (HoFH) is a rare life-threatening condition that represents a therapeutic challenge. The vast majority of HoFH patients fail to achieve LDL-C targets when treated with the standard protocol, which associates maximally tolerated dose of lipid-lowering medications with lipoprotein apheresis (LA). Lomitapide is an emerging therapy in HoFH, but its place in the treatment algorithm is disputed because a comparison of its long-term efficacy versus LA in reducing LDL-C burden is not available. We assessed changes in long-term LDL-C burden and goals achievement in two independent HoFH patients' cohorts, one treated with lomitapide in Italy (n = 30) and the other with LA in France (n = 29). RESULTS: The two cohorts differed significantly for genotype (p = 0.004), baseline lipid profile (p < 0.001), age of treatment initiation (p < 0.001), occurrence of cardiovascular disease (p = 0.003) as well as follow-up duration (p < 0.001). The adjunct of lomitapide to conventional lipid-lowering therapies determined an additional 58.0% reduction of last visit LDL-C levels, compared to 37.1% when LA was added (padj = 0.004). Yearly on-treatment LDL-C < 70 mg/dl and < 55 mg/dl goals were only achieved in 45.5% and 13.5% of HoFH patients treated with lomitapide. The long-term exposure to LDL-C burden was found to be higher in LA than in Lomitapide cohort (13,236.1 ± 5492.1 vs. 11,656.6 ± 4730.9 mg/dL-year respectively, padj = 0.002). A trend towards fewer total cardiovascular events was observed in the Lomitapide than in the LA cohort. CONCLUSIONS: In comparison with LA, lomitapide appears to provide a better control of LDL-C in HoFH. Further studies are needed to confirm this data and establish whether this translates into a reduction of cardiovascular risk.

Taste perception and expression in stomach of bitter taste receptor tas2r38 in obese and lean subjects.

Differences in taste perception have been related to eating behavior, nutritional status, and diseases. Recently, taste receptors have been identified in several extra-oral tissues, such as the gastrointestinal tract, where they seem to influence processes like digestion, sense of satiety as well as energy balance and intraluminal changes occurring in obesity. Our study aims to analyze differences in taste perception among 42 obese patients (OB) and 41 normal-weight subjects (LEAN). Polymorphisms in the gene codifying for the bitter taste receptor TAS2R38 and its expression on the surface of the gastric mucosa were tested and compared among OB and LEAN. Taste intensity of PROP (6-n-propylthiouracil), quinine, sucrose, citric acid and NaCl were measured on a labeled magnitude scale. DNA from peripheral whole blood was extracted and three polymorphisms in the TAS2R38 gene (rs713598, rs1726866, rs10246939) analyzed. Gastric biopsies were collected during bariatric surgery in OB and during endoscopy in LEAN. RNA was extracted and TAS2R38 gene expression assessed by RT-Real-Time qPCR. Anamnestic and anthropometric data were recorded in all participants during baseline visits. Logistic regression analysis showed that OB perceives sweet (sucrose) and bitter (PROP or 6-n-propylthiouracil) taste more intensely than LEAN (p-value = 0.02 and p-value = 0.005, respectively). While polymorphisms in TAS2R38 gene did not differ among OB and LEAN, we observed a significant increase of TAS2R38 mRNA levels in the stomach of OB compared to LEAN (p = 0.01). Our results provide new evidence of a link between obesity and altered taste perception as well as TAS2R38 expression in the stomach.

Effect of SARS-CoV-2 (COVID-19) Pandemic and Lockdown on Body Weight, Maladaptive Eating Habits, Anxiety, and Depression in a Bariatric Surgery Waiting List Cohort.

PURPOSE: On January 30, 2020, the World Health Organization declared COVID-19 as a "public health emergency of international concern." The primary aim of the study was to evaluate weight and food habit changes during COVID-19 outbreak. The secondary endpoint was to explore the psychological factors, arising during the pandemic, influencing weight and dietary variations. MATERIALS AND METHODS: A survey composed of four different items was conducted by telephone interview: (1) anthropometric data and type of procedure, (2) Hospital Anxiety and Depression Scale (HADS), (3) maladaptive eating behaviors, and (4) personal feelings moved by the COVID-19 spread and lockdown. RESULTS: Fifty-six patients were enrolled. No significant changes in weight, BMI, and maladaptive eating habits were observed. A significant reduction in the anxiety index score was observed. In 17.8% of cases, a change in obesity class was reported, and among these patients, a substantial modification in bariatric procedures was planned (60%). CONCLUSION: This study showed no effect on weight and BMI nor on rates of maladaptive eating habits associated with quarantine/social isolation among severely obese individuals waiting for the bariatric surgery. At the end of lockdown, a considerable proportion of patients modified their initial obesity class, and in selected cases, it could represent a criteria for rearrangement of the planned bariatric procedure. In obese patients, the lockdown and social distancing generated a reduction of fear of confronting and being negatively judged by others. This psychological aspect was assessed with the reduction of the HADS score.

Modifications of IGF2 and EGFR plasma protein concentrations in NAFLD patients after bariatric surgery.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is strictly associated with the epidemic of obesity and is becoming the most prevalent liver disease worldwide. In severe obesity, bariatric surgery (BS) is the most effective treatment not only for obesity but also for the associated metabolic co-morbidities, NAFLD, among others. To date, noninvasive diagnostic/prognostic methods cannot evaluate hepatic improvements following surgery. OBJECTIVES: We aimed to measure plasma level of insulin-growth factor-2 protein (IGF2) and epithermal growth factor receptor (EGFR), and to assess their relationship with clinical and biochemical parameters during the 12 months follow-up. METHODS: Demographic, clinical-biochemical data, and plasma IGF2 and EGFR were measured in 69 patients preoperatively (T0) and 6 and 12 months (T6M and T12M, respectively) after BS. Liver biopsy was performed at T0. Relationships between IGF2, EGFR, and several biochemical parameters were performed using Pearson or Spearman correlation analysis. RESULTS: IGF2 plasma level increases during follow-up, passing from 2.5 (1.8-15.5) at baseline to 13.3 (8.6-19.1) at T12M, p < 0.001. Conversely, EGFR showed a not significant reduction. At T12M, the plasma level of both markers was comparable to those of lean subjects. The clinical-biochemical parameters (BMI, glycated hemoglobin, HOMA-IR) also return to the normal range at T12M. Correlation analysis demonstrated that IGF2 was significantly associated with total bilirubin, direct bilirubin, and albumin at T0 while with blood glucose, ALT, GGT, and AST/ALT ratio at T6M and T12M. CONCLUSIONS: IGF2 plasma levels increase after bariatric surgery, and these changes are associated with the modification of hepatic biochemical parameters, even if other clinic or metabolic improvements cannot be excluded.

Ileocecal valve syndrome and vitamin b12 deficiency after surgery: a multicentric prospective study.

Patients undergoing colon resection are often concerned about their functional outcomes after surgery. The primary aim of this prospective, multicentric study was to assess the intestinal activity and health-related quality-of-life (HRQL) after ileocecal valve removal. The secondary aim was to evaluate any vitamin B12 deficiency. The study included patients undergoing right colectomy, extended right colectomy and ileocecal resection for either neoplastic or benign disease. Selected items of GIQLI and EORTC QLQ-CR29 questionnaires were used to investigate intestinal activity and HRQL before and after surgery. Blood samples for vitamin B12 level were collected before and during the follow-up period. The empirical rule effect size (ERES) method was used to explain the clinical effect of statistical results. Linear mixed effect (LME) model for longitudinal data was applied to detect the most important parameters affecting the total score. A total of 158 patients were considered. Applying the ERES method, the analysis of both questionnaires showed clinically and statistically significant improvement of HRQL at the end of the follow-up period. Applying the LME model, worsening of HRQL was correlated with female gender and ileum length when using GIQLI questionnaire, and with female gender, open approach, and advanced cancer stage when using the EORTC QLQ-CR29 questionnaire. No significant deficiency in vitamin B12 levels was observed regardless of the length of surgical specimen. In our series, no deterioration of HRQL and no vitamin B12 deficiency were found during the follow-up period. Nevertheless, warning patients about potential changes in bowel habits is mandatory. In our series, no deterioration of HRQL and no vitamin B12 deficiency were found during the follow-up period. Nevertheless, warning patients about potential changes in bowel habits is mandatory.

Multidimensional Prognostic Index (MPI) score has the major impact on outcome prediction in elderly surgical patients with colorectal cancer: The FRAGIS study.

BACKGROUND: This study aims (I) to evaluate whether the Multidimensional Prognostic Index (MPI) score is associated with postoperative outcomes and (II) to develop a prognostic model for individual complication-risk prediction following colorectal cancer (CRC) surgery. METHOD: This is a prospective multicentric cohort study. Consecutive ≥75-year-old candidates for elective CRC surgery were enrolled from October 2017 to August 2019. Patients underwent standardized preoperative geriatric assessment including the MPI. Patients with MPI score > 0.33 were classified as frail. Logistic regression models were employed to evaluate variables associated with major postoperative complications and mortality, using 10-fold cross-validated LASSO (least absolute shrinkage and selection operator) for model selection. RESULTS: In all, 104 patients were included, 34 (33%) had MPI score > 0.33. Major postoperative complications occurred in 52% of frail versus 16% of fit (MPI score ≤ 0.33) patients (p < .01). Both 30-day (9% vs. 0%; p = .033) and 90-day mortality (18% vs. 1%; p < .01) were higher among frail patients. In multivariate analysis, MPI score was associated with adverse outcomes. A final postoperative complication predictive model was created, including MPI score, gait-speed test, ASA (American Society of Anesthesiology) score, surgical approach, and stoma creation. CONCLUSION: MPI score is strongly associated with postoperative major complications in CRC elderly patients and it is a primary component of an individual prediction model.

Optimization of Point-Shear Wave Elastography by Skin-to-Liver Distance to Assess Liver Fibrosis in Patients Undergoing Bariatric Surgery.

BACKGROUND: Obesity is a primary limiting factor in liver stiffness measurement (LSM). The impact of obesity has always been evaluated in terms of body mass index (BMI), without studying the effects of skin-to-liver distance (SLD) on LSM. We studied the impact of SLD on LSM in a cohort of obese patients undergoing bariatric surgery and intra-operatory liver biopsy. MATERIALS AND METHODS: 299 patients underwent LSM by point-shear wave elastography (ElastPQ protocol), with two different ultrasound machines. SLD was measured as the distance between the skin and the liver capsule, perpendicular to where the region of interest (ROI) was positioned. We used the following arbitrary cut-offs: <5.7 kPa, F0-1; 5.7-7.99 kPa, F2; ≥8 kPa, F3-4. RESULTS: We developed two logistic regression models using elastography-histology agreement (EHA) as the dependent variable and SLD as the independent variable. The model based on the second machine showed strongly more performant discriminative and calibration metrics (AIC 38.5, BIC 44.2, Nagelkerke Pseudo-R2 0.894, AUROC 0.90). The SLD cut-off value of 34.5 mm allowed a correct EHA with a sensitivity of 100%, a specificity of 93%, negative predictive value of 100%, positive predictive value of 87%, an accuracy of 96%, and positive likelihood ratio of 3.56. CONCLUSION: The impact of SLD is machine-dependent and should be taken into consideration when interpreting LSM. We believe that our findings may serve as a reference point for appropriate fibrosis stratification by liver elastography in obese patients.

Correction to: Ileocecal valve syndrome and vitamin b12 deficiency after surgery: a multicentric prospective study.

One of the co-author Eliana Cagnazzo has been incorrectly published. The correct co-author name has been copied below.

Occult hepatitis B virus infection predicts non-alcoholic steatohepatitis in severely obese individuals from Italy.

BACKGROUND & AIMS: Obesity is associated with non-alcoholic fatty liver (NAFL), which may progress towards non-alcoholic steatohepatitis (NASH), cirrhosis and hepatocellular carcinoma (HCC). Occult hepatitis B virus infection (OBI) may contribute to hepatic damage in patients with chronic liver disease of different aetiologies (eg HCV, alcohol). However, information on the prevalence and clinical impact of OBI in obese individuals is lacking. The aims of this study were to investigate NASH prevalence and risk factors in obese people who underwent bariatric surgery. METHODS: Two-hundred and twenty-six subjects (160 females; mean age 42.9 years ±10.8 SD) without evidence of any further cause of liver disease consecutively underwent bariatric surgery in two Italian liver centers. During surgery, all patients underwent liver biopsy for histological evaluation and molecular studies. Liver DNA extracts were tested for PNPLA3, TM6SF2, MBOAT7, IRGM polymorphisms and for OBI. Univariate and multivariate analyses were used to identify predictors of NASH. RESULTS: Histology showed NASH in 115 (50.9%) and NAFL in 111 cases (49.1%). Twenty-nine/226 (12.8%) cases had OBI, 24 (82.8%) of whom had NASH and 5 (17.2%) NAFL, whereas among the 197 OBI-negative cases, 91 (46.2%) had NASH and 106 (53.8%) NAFL (P = .0002). Multivariate analysis showed that older age (P = .03, OR 1.034), alanine aminotransferase values (P = .005, OR 1.023), insulin resistance/diabetes (P = .02, OR 2.257), TM6SF2 polymorphism (P = .04, OR 3.168) and OBI (P = .004, OR 5.503) were independent predictors of NASH. CONCLUSION: NASH is highly prevalent in obese individuals undergoing bariatric surgery. OBI is one of the strongest risk factors of NASH in these patients.