Lipid-Associated Macrophages Control Metabolic Homeostasis in a Trem2-Dependent Manner.

Immune cells residing in white adipose tissue have been highlighted as important factors contributing to the pathogenesis of metabolic diseases, but the molecular regulators that drive adipose tissue immune cell remodeling during obesity remain largely unknown. Using index and transcriptional single-cell sorting, we comprehensively map all adipose tissue immune populations in both mice and humans during obesity. We describe a novel and conserved Trem2+ lipid-associated macrophage (LAM) subset and identify markers, spatial localization, origin, and functional pathways associated with these cells. Genetic ablation of Trem2 in mice globally inhibits the downstream molecular LAM program, leading to adipocyte hypertrophy as well as systemic hypercholesterolemia, body fat accumulation, and glucose intolerance. These findings identify Trem2 signaling as a major pathway by which macrophages respond to loss of tissue-level lipid homeostasis, highlighting Trem2 as a key sensor of metabolic pathologies across multiple tissues and a potential therapeutic target in metabolic diseases.

Endoscopic treatment of early leaks and strictures after laparoscopic one anastomosis gastric bypass.

BACKGROUND: Laparoscopic one anastomosis gastric bypass has become a prominent bariatric procedure. Yet, early and late complications, primarily leaks and strictures, are not uncommon. This study summarizes our experience with endoscopic treatment of laparoscopic one anastomosis gastric bypass complications. METHODS: This is a retrospective study of consecutive patients referred to our hospital from 2015 to 2017 with post laparoscopic one anastomosis gastric bypass complications. Therapy was tailored to each case, including fully covered self-expandable metal stents, fibrin glue, septotomy, internal drainage with pigtail stents, through-the-scope and pneumatic dilation. Success was defined as resuming oral nutrition without enteral or parenteral support or further surgical intervention. RESULTS: Nine patients presented with acute or early leaks: 5 (56%) had staple-line leaks, 3 (33%) had anastomotic leaks and 1 (11%) had both. All were treated with stents. Adjunctive endoscopic drainage was applied in 4 patients (44%). Overall 5 patients (56%) with acute/ early leaks recovered completely, including all 3 patients with anastomotic leak and the patient with both leaks but only 1/5 with staple line leak (20%). Complication rate in the leak group reached 22%. Eight patients presented with strictures, 7 at the anastomosis and one due to remnant stomach misalignment. All anastomotic strictures were dilated successfully. However, the patient with the pouch stricture required conversion to Roux-en-Y gastric bypass after 3 failed attempts of dilation. CONCLUSION: Endoscopic treatments of laparoscopic one anastomosis gastric bypass complications are relatively effective and safe. Anastomosis-related complications are more amenable to endoscopic treatment compared to staple line leaks.

Metabolic and bariatric surgery in vegetarians and vegans.

BACKGROUND: Vegetarianism is constantly increasing worldwide. However, the role of metabolic and bariatric surgery (MBS) in vegetarians/vegans is unclear as there is very limited data on this topic. The aim of this study was to evaluate MBS outcomes in vegetarians or vegans. METHODS: Retrospective analysis of a prospectively maintained database of a single-bariatric surgeon was carried out. All patients with a vegetarian or vegan lifestyle undergoing MBS were included. RESULTS: Eleven patients were included; none were lost to follow-up. Ten patients were women, the mean age and Body Mass Index (BMI) were 40.8±14 years and 43.5±4.9 kg/m2, respectively. Five patients (45%) were lacto-ovo-vegetarians, one (9%) was ovo-vegetarian, two (18%) were lacto-ovo-pesco-vegetarians, and three (27%) were vegans. Eight patients consumed vitamin supplements preoperatively, the mean albumin level was 4.1±0.2, 3/11 patients had vitamin D deficiency, 2/11 patients had vitamin-B12 deficiency, and 2/11 patients had iron deficiency. Eight patients (73%) underwent one anastomosis gastric bypass (OAGB), 2/11 patients (18%) underwent single anastomosis duodeno-ileal bypass with sleeve gastrectomy, and one patient (9%) underwent sleeve gastrectomy, the mean biliopancreatic limb length in OAGB was 225 cm. The median follow-up time was 17 months, the mean BMI and percentage of total weight loss during follow-up were 28.2±5 kg/m2 and 35.3±10.7%, respectively. The mean albumin level was 3.82±0.27, 3/11 patients had vitamin D deficiency, and 3/11 patients had iron deficiency. CONCLUSIONS: This study reports preliminary data on MBS outcomes in vegetarian/vegan patients. It was shown to be safe, effective, and an acceptable rate of nutritional deficiencies during follow-up. Further large cohort studies are required to clarify this data.

Primary versus Revisional One Anastomosis Gastric Bypass: Outcomes of Patients with at Least 8-Year Follow-Up.

INTRODUCTION: One anastomosis gastric bypass (OAGB) prevalence is increasing worldwide and shows good mid- to long-term results. Data on long-term outcomes of revisional OAGB (rOAGB) is limited. This study's objective was to evaluate the long-term outcomes of patients undergoing primary OAGB (pOAGB) and rOAGB. METHODS: A retrospective analysis of a prospectively maintained patient registry at a single-tertiary center. Patients undergoing OAGB from January 2015 to May 2016 were included and grouped into pOAGB and rOAGB. RESULTS: There were 424 patients, of which 363 underwent pOAGB, and 61 underwent rOAGB. Baseline characteristics were insignificantly different between groups except for the type 2 diabetes (T2D) rate which was higher in pOAGB (26% vs. 11.5%, p = 0.01). The mean follow-up time was 98.5 ± 3.9 months, and long-term follow-up data were available for 52.5% of patients. The mean total weight loss (TWL) was higher in the pOAGB group (31.3 ± 14 vs. 24.1 ± 17.6, p = 0.006); however, TWL was comparable when relating to the weight at primary surgery for rOAGB. The rate of T2D and hypertension resolution was 79% and 72.7% with no difference between groups. Thirteen patients (5.9%) underwent OAGB revision during follow-up, with no difference between groups. Two deaths occurred during follow-up, both non-related to OAGB. CONCLUSION: OAGB is effective as a primary and as a revisional procedure for severe obesity with good long-term results in terms of weight loss and resolution of associated diseases. In addition, the revisional surgery rates and chronic complications are acceptable. Further large prospective studies are required to clarify these data.

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

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

Predictors of Poor Quality of Life in Patients with Gastroesophageal Reflux Disease Undergoing Sleeve Gastrectomy.

Background-Gastroesophageal reflux disease (GERD) is commonly diagnosed in patients with severe obesity. The outcomes of patients with preoperative GERD after sleeve gastrectomy (SG) are unclear, and some surgeons consider GERD a contraindication for SG. Methods-A retrospective analysis of a tertiary university hospital database was conducted. All patients with preoperative GERD undergoing SG between January 2012 and January 2020 and having at least two years of follow-up were included in the analysis. A validated GERD-associated quality of life questionnaire (GERD-HRQL) was completed by all patients. Results-During the study period, 116/1985 patients (5.8%) were diagnosed with GERD before SG. In total, 55 patients were available for a two-year follow-up and were included in the analysis. Median follow-up was 40 months (range 24-156 months). Mean total weight loss (TWL) was 24.0% ± 12.0%. On follow-up, 43 patients (78.1%) reported having GERD symptoms. In patients who underwent postoperative endoscopy, less than a third had esophagitis. The mean GERD-HRQL score was 25.2 ± 10.9. On univariable analysis, patients with poor GERD-HRQL had lower BMI at baseline (41.5 ± 12.4 vs. 44.9 ± 10.0 kg/m2, p = 0.03), were less commonly smokers at baseline (8.1% vs. 33.3%, p = 0.02), and had lower TWL at the end of the follow-up (22.2% ± 10.4% vs. 28.9% ± 13.7%, p = 0.05). On multivariable analysis, smoking status at baseline and TWL at last follow-up were independent predictors of better GERD-HRQL. Conclusions-In conclusion, most GERD patients after SG have a relatively high GERD-HRQL score, most patients still have GERD symptoms during the follow-up, and approximately a third of patients have endoscopic signs of esophagitis. There was an association between patients with higher TWL and smoking at baseline and better GERD-HRQL outcomes. The latter is potentially due to smoking cessation.

Technical Considerations in One Anastomosis Gastric Bypass-the Israeli Society of Metabolic and Bariatric Surgery Experience.

BACKGROUND: One anastomosis gastric bypass (OAGB) is gaining popularity worldwide due to its safety and effectiveness. OAGB is the most commonly performed metabolic bariatric surgery (MBS) in Israel. Israel is the only country where OAGB is the most prevalent MBS. Our aim is to address OAGB technical aspects using a national survey completed by members of the Israeli Society of Metabolic and Bariatric Surgery (ISMBS). MATERIALS AND METHODS: An online-survey composed of a 17-item-based questionnaire was sent to ISMBS members. All responses were collected and analyzed. RESULTS: A total of 47/64 (73.4%) ISMBS members participated in the survey. Most surgeons (74.5%) had > 10 years of MBS experience, and most (61.7%) performed > 100 MBS/year. The majority (78.7%) perform OAGB as their most common procedure. Most surgeons fashion a 10-15-cm pouch and use a 36-Fr bougie, (57.4% and 38.3%). Regarding bowel length measurement, 70% use visual estimation and 10.6% routinely measure total small bowel length (TSBL). The most common reasons for creating a longer biliopancreatic limb (BPL) were high body mass index (BMI) and revisional surgery (83.3% and 66%, respectively). In a primary procedure of a patient with a BMI = 40, most (76.6%) would create a 150-200-cm BPL. In patients with a BMI > 50 or revisional cases, most (70.2% and 68.0%) would create a 175-225-cm BPL. CONCLUSION: OAGB is the most prevalent MBS performed in Israel. This survey showed common preferences and variations among ISMBS members. Further studies are needed in order to standardize and build a consensus on OAGB technique.

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

BACKGROUND: Bariatric and metabolic surgery (BMS) is an effective treatment for patients with severe obesity. Patients with higher body mass index (BMI) and patients undergoing revisional surgery have a higher rate of major complications. This study purpose is to evaluate perioperative outcomes of patients with BMI ≥ 50 kg/m2. MATERIALS AND METHODS: A retrospective analysis of patients with a BMI ≥ 50 kg/m2 undergoing BMS between 2015 and 2023 was conducted. A comparative analysis was performed between patients undergoing primary versus revisional surgery. RESULTS: A total of 263 patients were included in the study. Primary procedures were performed in 220 patients (83.7%) and revisional procedures in 43 patients (16.3%). BMS included one anastomosis gastric bypass (n = 183), sleeve gastrectomy (n = 63), and other procedures (n = 17). Mean BMI was 54.6 with no difference between groups. There was no difference in baseline characteristics except the revisional group was older (44.8 ± 9.6 versus 39 ± 13 years; p = 0.006), had higher rates of gastroesophageal reflux disease (21% vs 7.3%; p = 0.005), and fatty liver disease (74% vs 55%; p = 0.02). There was perioperative mortality in three cases (1.1%) with no significant difference between groups. Leak rates were higher, and length of stay (LOS) was longer in the revisional group (4.6% vs 0.45%; p = 0.018 and 2.9 vs 3.7; p = 0.006, respectively). CONCLUSION: Revisional BMS in patients with a BMI ≥ 50 kg/m2 is associated with increased leak rates and LOS. Mortality rate is 1.1% and is insignificantly different between groups. Further prospective and large-scale studies are needed to clarify the optimal surgical approach to patients with extreme BMI including revisional surgery.

Long-Term Outcomes of Patients with Staple Line Leaks Following Sleeve Gastrectomy.

PURPOSE: The long-term outcomes of patients with staple line leaks (SLL) after SG are under-reported. The purpose of this study is to evaluate the long-term outcomes of patients with SLL after SG. MATERIALS AND METHODS: A retrospective analysis of a maintained patient registry of patients undergoing SG between January 2012 and December 2020 in a single bariatric center was analyzed and included patients with SLL. Outcomes were compared to a group without SLL. RESULTS: During this period, 1985 patients underwent SG of which 61 patients (3.1%) developed leak. 26 patients (1.3%) had overt SLL and the rest had organ space infection around the staple line. The mean age and body mass index (BMI) were 39.8 ± 11.3 and 41.5 ± 4.7, respectively. 7 patients (11.4%) underwent concomitant surgery and 12 patients (19.7%) had intraoperative complications. Leak was complicated by Clavien-Dindo ≥ 3 in 31 patients (50.8%). Reoperation rate was 27.8% (n = 17). ≥ 2 interventions were required in 26% of patients (n = 16). Two patients died during hospitalization due to septic complications. Long-term follow-up of median 121 months was available in 78% of the cohort (n = 48). The median total weight loss and BMI were 27% and 30.1 kg/m2, respectively. Weight loss outcomes were higher in comparison to patients without SLL. Seven patients (14.6%) underwent SG revision. All associated medical problems improved during follow-up except for gastroesophageal reflux which was found in 50% of cohort. CONCLUSION: Long-term outcomes of SG patients with SLL are satisfactory in terms of weight loss, resolution of comorbidities, and requirement for surgical revision.

Conversion of sleeve gastrectomy to Roux-en-Y laparoscopic gastric bypass: a comprehensive 14-year follow-up study on efficacy and outcomes.

BACKGROUND: Failed sleeve gastrectomy (SG), defined by inadequate weight loss or weight regain and by reflux and structural complications, can be treated by a laparoscopic conversion to Roux-en-Y gastric bypass (RYGB). OBJECTIVES: To examine the efficacy and outcomes of conversion surgery over a 14-year follow-up period. SETTING: Government and private medical centers in university settings. METHODS: We conducted a cohort study of 58 patients who underwent conversion of SG to RYGB for 2 indications: invalidating reflux or weight recurrence during 2009-2023. Weight dynamics analysis was performed with 2 references of weight: before SG (with intention to treat) and before conversion. RESULTS: At conversion surgery, the mean weight, body mass index (BMI), percentage of excess weight loss (%EWL), and percentage of total weight loss (%TWL) (calculated with intention to treat, from the weight before SG) were 92.2 ± 25.2 kg, 34.3 ± 8.0 kg/m2, 55.2% ± 39.9%, and 22.8% ± 15.2%, respectively. Mean nadir weight, BMI, %EWL, and %TWL after conversion (calculated from the weight before SG) were 71.1 ± 18.4 kg, 26.7 ± 5.5 kg/m2, 96.5% ± 30.5%, and 40.2% ± 10.6%, respectively. At follow-up, the mean weight, BMI, %EWL, and %TWL (calculated from the weight before SG) were 80.4 ± 17.7 kg, 29.6 ± 5.4 kg/m2, 78.9% ± 26.8%, and 33.3% ± 11.2%, respectively. The mean percentages of %EWLio and %TWLio (calculated from the weight before conversion = EWL from index operation) at nadir were 73.2% ± 92.7% and 20.1% ± 12.2% after conversion, respectively, and decreased to 41.9% ± 94.0% and 13.2% ± 15.2% at last follow-up (mean 6.6 yr), respectively. CONCLUSIONS: SG to RYGB conversion provides moderate to low complementary weight loss in the short term. By 3-4 years, there is a clear trend toward weight gain.

Revision of restrictive bariatric procedures in elderly patients: results at a 5-year follow-up.

Revisional Bariatric Surgery (RBS) is increasing in popularity. Elderly patients (> 65 years old) are sometimes referred for RBS evaluation. The aim of this study is to evaluate outcomes of elderly patients undergoing RBS. A retrospective analysis of a cohort from a single-tertiary bariatric center. All elderly patients undergoing RBS after restrictive procedures between 2012 and 2022 were included. Thirty Nine patients undergoing RBS were included in the comparative analysis - 23 patients (57.5%) after adjustable gastric banding (s/p LAGB) and 16 patients (40%) after Sleeve Gastrectomy (s/p SG). The mean age and body mass index (BMI) of patients were comparable (67.2 ± 2.8 years and 38.3 ± 7.4, respectively). There was no difference in associated medical problems except reflux which was higher in s/p SG (68% vs. 13%; p < 0.001). The mean time interval between surgeries was 8.7 ± 5.1 years. The surgeries included One anastomosis gastric bypass (n = 22), SG (n = 8) and Roux-en-y gastric bypass (n = 9). Early major complication rates were comparable (4.3% and 12.5%; p = 0.36), and readmission rate was higher in patients s/p SG (p = 0.03). Ninety percent of patients were available to a follow-up of 59.8 months. The mean BMI and total weight loss was 29.2 and 20.3%, respectively with no difference between groups. The rate of patients with associated medical problems at last follow-up was significantly reduced. Five patients (12.5%) underwent revisional surgery due to complications during follow-up. In conclusion, RBS in the elderly is associated with a reasonable complication rate and is effective in terms of weight loss and improvement of associated medical problems in a 5-year follow-up.

Ten-Year Results of Laparoscopic Sleeve Gastrectomy: a Retrospectively Designed Study of a Single Tertiary Center.

PURPOSE: Laparoscopic sleeve gastrectomy (SG) is the most popular bariatric surgery. Nonetheless, only a few studies have reported its long-term outcomes. This study aimed to evaluate changes in weight and body mass index (BMI) parameters, resolution of comorbidities, and frequency of re-operations in a follow-up period of at least 10 years. MATERIALS AND METHODS: Data was available from 180 patients' records who underwent SG between 2008 and 2011 in the Tel Aviv Sourasky Medical Center. Eighty patients agreed to partake in a follow-up assessment that was completed via a phone call questionnaire and hospital computed registry. RESULTS: Patients' mean preoperative BMI was 43.86 ± 6.36 kg/m2 which was significantly higher when compared to mean nadir BMI and last follow-up BMI (29.44 ± 7.12 and 36.34 ± 9.7; p < 0.001). Mean percentage of excess weight loss (%EWL) at 10 years was 42.65 ± 36.02% and mean percentage of total weight loss was 19.33 ± 16.73%. Twenty-eight patients (35%) maintained at least 50% EWL. Twenty-seven (33.75%) patients underwent at least one surgical procedure following SG. Eleven patients (13.75%) underwent a conversion to Roux-en-Y gastric bypass and six patients (7.5%) underwent conversion to one anastomosis gastric bypass. Resolution of type 2 diabetes (T2D), hypertension, and hypercholesterolemia occurred in 47%, 43.7%, and 48.4%, respectively. De-novo cases of gastroesophageal reflux (GERD) were present in 40%. CONCLUSION: SG shows high long-term failure rates. One of every three patients will undergo another surgical procedure within a 10-year period.

Long Term Effects of Metabolic and Bariatric Surgery on Idiopathic Intracranial Hypertension.

BACKGROUND: Idiopathic Intracranial Hypertension (IIH) is a rare disorder, linked to severe obesity. The study aimed to evaluate long-term effects of metabolic and bariatric surgery (MBS) on IIH outcomes. METHODS: Retrospective study of patients with IIH and severe obesity who underwent MBS. Data were retrieved from prospectively maintained databases of two bariatric surgeons. RESULTS: Thirteen patients were included, of them 12 women. Median age was 36 (interquartile range;IQR 21,47) years and body mass index (BMI) was 40.4 (IQR 37.8,41.8) kg/m2. All patients had visual disturbances,12/13 had headaches, and 6/13 had tinnitus. The mean opening pressure on lumbar puncture was 45 cmH2O, and 11/13 patients had papilledema. Medications for IIH were consumed by 11/13 patients, and 2/13 patients had prior surgical intervention for IIH. MBS types included sleeve gastrectomy (n=7), adjustable gastric banding (n=2), roux-en-y gastric bypass (n=2), one anastomosis gastric bypass (n=1), duodenal switch (n=1). At a median follow-up of 10 years (IQR 8,13), the median BMI and total weight loss were 29.7 kg/m2 and 27%, respectively. Remission of symptoms was achieved in 9/13 patients. CONCLUSIONS: MBS results in significant and sustainable weight loss, with subsequent resolution or improvement of IIH. It may be considered as a preventive measure for IIH in patients with severe obesity.

Revisional Surgery of One Anastomosis Gastric Bypass for Severe Protein-Energy Malnutrition.

BACKGROUND: One anastomosis gastric bypass (OAGB) is safe and effective. Its strong malabsorptive component might cause severe protein-energy malnutrition (PEM), necessitating revisional surgery. We aimed to evaluate the safety and outcomes of OAGB revision for severe PEM. METHODS: This was a single-center retrospective analysis of OAGB patients undergoing revision for severe PEM (2015-2021). Perioperative data and outcomes were retrieved. RESULTS: Ten patients underwent revision for severe PEM. Our center's incidence is 0.63% (9/1425 OAGB). All patients were symptomatic. Median (interquartile range) EWL and lowest albumin were 103.7% (range 57.6, 114) and 24 g/dL (range 19, 27), respectively, and 8/10 patients had significant micronutrient deficiencies. Before revision, nutritional optimization was undertaken. Median OAGB to revision interval was 18.4 months (range 15.7, 27.8). Median BPL length was 200 cm (range 177, 227). Reversal (n = 5), BPL shortening (n = 3), and conversion to Roux-en-Y gastric bypass (RYGB) (n = 2) were performed. One patient had anastomotic leak after BPL shortening. No death occurred. Median BMI and albumin increased from 22.4 kg/m2 (range 20.6, 30.3) and 35.5 g/dL (range 29.2, 41), respectively, at revision to 27.5 (range 22.2, 32.4) kg/m2 and 39.5 g/dL (range 37.2, 41.7), respectively, at follow-up (median 25.4 months, range 3.1, 45). Complete resolution occurs after conversion to RYGB or reversal to normal anatomy, but not after BPL shortening. CONCLUSIONS: Revisional surgery of OAGB for severe PEM is feasible and safe after nutritional optimization. Our results suggest that the type of revision may be an important factor for PEM resolution. Comparative studies are needed to define the role of each revisional option.

Anastomotic Ulcer Perforation Following One Anastomosis Gastric Bypass.

PERFORATED ANASTOMOTIC ULCER AFTER ONE ANASTOMOSIS GASTRIC BYPASS: BACKGROUND: One anastomosis gastric bypass (OAGB) is a common bariatric metabolic surgery. Anastomotic ulcer (AU) perforation is a delayed complication, liable to cause sepsis and death. We present a cohort of twelve patients who underwent emergent surgery due to AU perforation. MATERIALS AND METHODS: A retrospective analysis of a single center database of patients operated for AU perforation after OAGB (January 2015 to December 2021). Data retrieved included perioperative characteristics and postoperative outcomes. RESULTS: The incidence of AU perforation among 1425 OAGB patients is 0.7%. AU perforation occurred after OAGB at a median time interval of 13 months (interquartile range (IQR) 5, 23). Eight patients had at least one risk factor for AU perforation. All patients presented with acute abdominal pain. Pneumoperitoneum was evident in ten patients on imaging studies. Surgery was laparoscopic in eleven patients, with one conversion to laparotomy. Operative findings were AU perforation, with a median perforation size of 5 mm (IQR 1.1, 18.7). Laparoscopic omentopexy ± primary AU repair, open omentopexy ± primary AU repair, and laparoscopic conversion to Roux-en-Y gastric bypass were performed (n = 9, 2, 1 patients, respectively). Median length of stay was 7.5 days (IQR 5, 11.5). No major complications occurred. All patients are doing well at a median follow-up of 11.5 months (IQR 2.2, 19.2). Four out of seven smoking patients still smoke. CONCLUSION: AU perforation after OAGB mandates a high index of suspicion, prompt diagnosis, and surgical treatment. Laparoscopic omentopexy ± primary AU repair is feasible in most cases, safe, and confers good outcomes.

Early effects of gastric bypass on endothelial function, inflammation, and cardiovascular risk in obese patients.

BACKGROUND: Obesity is associated with a chronic low-grade inflammatory state, insulin resistance, and endothelial dysfunction, all of which contribute to increased risk of cardiovascular disease. We hypothesized that gastric bypass would produce rapid improvements in endothelial function, reduce inflammation, and lead to a decrease in cardiovascular risk. METHODS: We performed a prospective study of morbidly obese patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGB). Clinical data, biochemical markers of inflammation, and parameters indicative of cardiovascular risk were collected preoperatively and at 3 and 6 months postoperatively. Metabolic and inflammatory mediators that were quantified included C-reactive protein, fibrinogen, PAI-1, IL-6, IL-10, IL-1Ra, adiponectin, leptin, triglycerides, total cholesterol, HDL, LDL, glucose, insulin, and HbA1c. Brachial artery reactivity testing (BART) was performed to assess peripheral arterial endothelial function, and Framingham cardiovascular risk score (FRS) was calculated on all study participants pre- and postoperatively. RESULTS: Fifteen patients (11 female) were enrolled (age = 49.2 ± 10.4 years; BMI = 48.1 ± 5.3 kg/m(2)). Six months post RYGB, mean BMI decreased to 35.4 ± 4.5, corresponding to 51.7% excess weight loss (P < 0.001). Mean waist circumference decreased significantly from 132 cm at baseline to 110 cm at 3 months (P = 0.003) and 107 cm at 6 months (P < 0.001). Six months after RYGB, weight loss led to significant improvements in clinical parameters indicative of cardiovascular disease or risk, including brachial artery diameter, endothelial independent vasodilation, and FRS. Favorable improvements in the proinflammatory markers CRP (P = 0.01) and leptin (P = 0.005), the anti-inflammatory mediator adiponectin (P = 0.002), and insulin sensitivity (HOMA-IR, P = 0.007) were evident at 3 months. At 6 months, improvements in CRP, leptin, and fasting insulin were maintained and fibrinogen levels also decreased (P = 0.047). Adiponectin continued to increase at 6 months (P = 0.004). CONCLUSION: Gastric bypass is associated with early reversal of endothelial dysfunction, a more favorable inflammatory milieu, and, most importantly, a reduction in cardiovascular risk.

Totally Laparoscopic Ileocolic Resection for Complex Enterovisceral Fistulas in Crohn's Disease: A Comparative Study.

INTRODUCTION: In primary Crohn's disease (CD), laparoscopic ileocolic resection has been shown to be both feasible and safe, and is associated with improved outcomes in terms of postoperative morbidity and length of hospital stay. However, it is unclear whether the laparoscopic approach can be routinely proposed as a safe procedure for patients with complex enterovisceral fistulas.The aim of this study is to assess the feasibility and safety of laparoscopic surgery for complex enterovisceral fistulas, and compare it with CD patients who underwent primary laparoscopic ileocolic resection. PATIENTS AND METHODS: All patients who underwent laparoscopic primary ileocolic resection (LICR) for complex enterovisceral fistulas between July 2006 and July 2017 were included. They were compared with all consecutive patients who underwent LICR for nonfistulizing CD in the same period of time. Patients with previous bowel resections or recurrent disease were excluded. RESULTS: Nineteen patients with 20 enterovisceral fistulas (group I) were compared with 61 patients who underwent LICR for nonfistulizing disease (group II). There were no differences between the groups in age, sex, preoperative body mass index, nutritional status, and American Society of Anesthesiology score. There was no conversion to open surgery in both groups.There were no significant differences between groups in terms of operative time [120 (range: 65 to 232) vs. 117 (range: 62 to 217) min, P=0.7], hospital stay [6 (5 to 8) vs. 7 (5 to 65) days, P=0.56], overall morbidity 26.3% versus 16.4% (P=0.33), major morbidity (Clavien-Dindo >3) 15.7% versus 10% (P=0.66) and reoperation rates 5.3% versus 4.9% (P=0.9). There was no mortality in both groups. CONCLUSIONS: Our experience shows that the laparoscopic approach for complex enterovisceral fistulas in selected CD patients is both feasible and safe in the hands of experienced inflammatory bowel disease surgeons with extensive expertise in laparoscopic surgery. Larger study cohorts are needed to confirm these findings.

Sleeve Gastrectomy Failure-Revision to Laparoscopic One-Anastomosis Gastric Bypass or Roux-n-Y Gastric Bypass: a Multicenter Study.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) is the most popular bariatric procedure performed worldwide. However, many patients undergo secondary surgery due to either weight-related and complication-related reasons or both. Conversional options vary with one-anastomosis gastric bypass (OAGB) and Roux-n-Y gastric bypass (RYGB) being the most common. The aim of the study was to assess the safety and efficacy of converting failed LSG to either OAGB or RYGB, and compare weight-related results and post-conversion complications. METHODS: Retrospective review of hospital records of patients who underwent conversion from LSG to either RYGB or OAGB due to insufficient weight loss or weight regain in 7 bariatric centers between 2013 and 2019. Data retrieved included demographics, anthropometrics, comorbidities, indication for conversion, conversion type, complications, and weight loss. RESULTS: During the study period, 396 patients were included in the study. Eighty-four (21%) patients were lost to follow-up. RYGB and OAGB were performed in 119 and 144 patients, respectively. Mean age and body mass index (BMI) at revision were 44.2 years (range 19-72) and 40.6 ± 5.9 kg/m2 (range 35-71), respectively. Of these, 191 (73%) were female. Percent total body weight loss (%TWL) was 16% ± 1% for the RYGB group vs. 23% ± 12% for the OAGB group (p = 0.0007) at a median follow-up of 29 months (range 7-78 months) following conversion. Gastroesophageal reflux disease (GERD) was significantly higher 1 year following conversion to OAGB vs. RYGB occurring in 25 (17.4%) and 9 (7.6%) patients, respectively (p = 0.018). CONCLUSIONS: Conversion of LSG to OAGB, compared to RYGB, results in increased weight loss but a higher rate of GERD and potential nutritional deficiencies.

Sleeve Gastrectomy Is Associated with a Greater Reduction in Plasma Liver Enzymes Than Bypass Surgeries-A Registry-Based Two-Year Follow-Up Analysis.

Bariatric surgeries may lead to an improvement in metabolic fatty liver disease, and a reduction in the levels of the hepatic enzyme Alanine Aminotransferase (ALT). We compared the effects of Sleeve Gastrectomy (SG), Roux en Y Gastric Bypass (RYGB) and One Anastomosis Gastric Bypass (OAGB) on the levels of ALT by analysis of two-year follow-up data from 4980 patients in the Israeli Bariatric Registry that included laboratory tests and demographic information. Pre-operative characteristics of patients, and particularly levels of liver enzymes, were similar across surgery types. Regression modeling and retrospective matching showed that SG was superior to RYGB and OAGB in reducing ALT levels, and in reducing the fraction of patients with abnormally high ALT levels. Two-year post-surgery, an increase in ALT levels from normal to abnormal levels was observed in 5% of SG patients, and in 18% and 23% of RYGB and OAGB patients. In conclusion, SG leads to a greater reduction in ALT levels compared with bypass surgeries and a lower incidence of post-surgical elevation of ALT levels. Further studies are required to identify the cause for the rise in liver enzymes, and to determine whether ALT levels correlate with liver pathology especially following bariatric surgery.

Endoscopic Management of Sleeve Stenosis.

PURPOSE: Sleeve gastrectomy is one of the most popular bariatric procedures performed. A complication of this surgery is sleeve stenosis, causing significant morbidity and the need for corrective intervention. Endoscopic treatment using pneumatic dilation has evolved as an effective, and minimally invasive, technique to successfully treat this complication. Here we report our experience with endoscopic management of sleeve stenosis at a tertiary bariatric center. MATERIAL AND METHODS: We identified all patients that underwent endoscopic management of sleeve stenosis at a tertiary bariatric center from 2010. We reviewed patient demographics, operative data, interval to endoscopic treatment, and outcomes of pneumatic dilations. RESULTS: Sixty seven patients underwent 130 endoscopic dilations. The majority of these patients were female (71%), and at the time of sleeve gastrectomy average age was 43.3 years (range 18-68 years) and average BMI was 41.5 kg/m2 (range 31-63 kg/m2). The time interval to first endoscopic procedure was 7.2 months (range 0.75-53 months), with an average of 2 procedures per patient. During the follow-up period, the success rate of endoscopic dilatation was 76.1%, while the remaining 16 patients underwent conversion to gastric bypass. Two patients underwent emergency conversion to gastric bypass for sleeve perforation during the procedure (1.5%). There was a modest weight gain of 3 kg (4.2% total body weight) after sleeve dilatation. CONCLUSIONS: Endoscopic management of sleeve stenosis is safe and effective, with a success rate of over 75%. During endoscopic management, there was a 1.5% risk of sleeve perforation requiring emergency surgery. Mild weight regain occurred following endoscopic sleeve dilation.