30-day Morbidity and Mortality after Cholecystectomy for Benign Gallbladder Disease (AMBROSE): A Prospective, International Collaborative Cohort Study.

OBJECTIVE: This study aimed to assess 30-day morbidity and mortality rates following cholecystectomy for benign gallbladder disease and identify the factors associated with complications. SUMMARY BACKGROUND DATA: Although cholecystectomy is common for benign gallbladder disease, there is a gap in the knowledge of the current practice and variations on a global level. METHODS: A prospective, international, observational collaborative cohort study of consecutive patients undergoing cholecystectomy for benign gallbladder disease from participating hospitals in 57 countries between January 1 and June 30, 2022, was performed. Univariate and multivariate logistic regression models were used to identify preoperative and operative variables associated with 30-day postoperative outcomes. RESULTS: Data of 21,706 surgical patients from 57 countries were included in the analysis. A total of 10,821 (49.9%), 4,263 (19.7%), and 6,622 (30.5%) cholecystectomies were performed in the elective, emergency, and delayed settings, respectively. Thirty-day postoperative complications were observed in 1,738 patients (8.0%), including mortality in 83 patients (0.4%). Bile leaks (Strasberg grade A) were reported in 278 (1.3%) patients and severe bile duct injuries (Strasberg grades B-E) were reported in 48 (0.2%) patients. Patient age, ASA physical status class, surgical setting, operative approach and Nassar operative difficulty grade were identified as the five predictors demonstrating the highest relative importance in predicting postoperative complications. CONCLUSION: This multinational observational collaborative cohort study presents a comprehensive report of the current practices and outcomes of cholecystectomy for benign gallbladder disease. Ongoing global collaborative evaluations and initiatives are needed to promote quality assurance and improvement in cholecystectomy.

Early safety outcomes of laparoscopic one anastomosis gastric bypass in patients with class III, IV, and V obesity.

BACKGROUND: The extremely obese patient deserves special consideration: significant comorbidities, technical difficulties, and increased postoperative morbidity and mortality are all expected in this patient population. The study compared early postoperative complications (≤30-day) following one-anastomosis gastric bypass (OAGB) morbidity in patients with morbid obesity class IV obesity, body mass index (BMI) ≥50-59.9 kg/m2, and class V obesity, BMI ≥60 patients. METHODS: We retrospectively reviewed perioperative OAGB outcomes in three BMI groups. Operative time, length of stay (LOS), and overall early postoperative complication rates were studied. Patient-reported complications were ranked by Clavien-Dindo Classification (CDC). RESULTS: Between January 2017-December 2021, consecutive patients with obesity class III (n = 2950), IV (n = 256), and V (n = 23) underwent OAGB. BMI groups were comparable in sex, age, and associated comorbidities. Mean operative time was significantly longer in the higher BMI groups: class III (66.5 ± 25.6 min), IV (70.5 ± 28.7 min), and V (80.0 ± 34.7 min), respectively (p = 0.018); no difference in LOS. In respective BMI classes, ≤30-day complication rates were 3.2%, 3.5%, and 4.3% (p = 0.926). The respective number of patients with CDC grades of one to two were 45 (1.5%), 6 (2.3%), and 1 (4.3%), p = 0.500; and in grade ≥3a, 25 (0.8%), 1 (0.4%), 0 (0.0%), p = 0.669. There was 0.06% mortality (n = 2 in 3229), both in BMI class III. CONCLUSIONS: OAGB is a safe BS procedure in patients with class III, IV, and V obesity in the perioperative term with comparable ≤30-day morbidity in the three BMI groups.

Non-alcoholic fatty liver disease (NAFLD): a review of pathophysiology, clinical management and effects of weight loss.

Given the increasing prevalence of diabetes and obesity worldwide, the deleterious effects of non-alcoholic fatty liver disease (NAFLD) are becoming a growing challenge for public health. NAFLD is the most common chronic liver disease in the Western world. NAFLD is closely associated with metabolic disorders, including central obesity, dyslipidaemia, hypertension, hyperglycaemia and persistent abnormalities of liver function tests.In general NAFLD is a common denominer for a broad spectrum of damage to the liver, which can be due to hepatocyte injury, inflammatory processes and fibrosis. This is normally seen on liver biopsy and can range from milder forms (steatosis) to the more severe forms (non-alcoholic steatohepatitis (NASH), advanced fibrosis, cirrhosis and liver failure). In these patients, advanced fibrosis is the major predictor of morbidity and liver-related mortality, and an accurate diagnosis of NASH and NAFLD is mandatory. Histologic evaluation with liver biopsy remains the gold standard to diagnose NAFLD. Diagnosis of NAFLD is defined as presence of hepatic steatosis, ballooning and lobular inflammation with or without fibrosis. Weight loss, dietary modification, and the treatment of underlying metabolic syndrome remain the mainstays of therapy once the diagnosis is established. Dietary recommendations and lifestyle interventions, weight loss, and the treatment of underlying metabolic syndrome remain the mainstays of therapy once the diagnosis is established with promising results but are difficult to maintain. Pioglitazone and vitamin E are recommended by guidelines in selected patients. This review gives an overview of NAFLD and its treatment options.

The many faces of diabetes. Is there a need for re-classification? A narrative review.

The alarming rise in the worldwide prevalence of obesity and associated type 2 diabetes mellitus (T2DM) have reached epidemic portions. Diabetes in its many forms and T2DM have different physiological backgrounds and are difficult to classify. Bariatric surgery (BS) is considered the most effective treatment for obesity in terms of weight loss and comorbidity resolution, improves diabetes, and has been proven superior to medical management for the treatment of diabetes. The term metabolic surgery (MS) describes bariatric surgical procedures used primarily to treat T2DM and related metabolic conditions. MS is the most effective means of obtaining substantial and durable weight loss in individuals with obesity. Originally, BS was used as an alternative weight-loss therapy for patients with severe obesity, but clinical data revealed its metabolic benefits in patients with T2DM. MS is more effective than lifestyle or medical management in achieving glycaemic control, sustained weight loss, and reducing diabetes comorbidities. New guidelines for T2DM expand the use of MS to patients with a lower body mass index.Evidence has shown that endocrine changes resulting from BS translate into metabolic benefits that improve the comorbid conditions associated with obesity, such as hypertension, dyslipidemia, and T2DM. Other changes include bacterial flora rearrangement, bile acids secretion, and adipose tissue effect.This review aims to examine the physiological mechanisms in diabetes, risks for complications, the effects of bariatric and metabolic surgery and will shed light on whether diabetes should be reclassified.

The first modified Delphi consensus statement on sleeve gastrectomy.

INTRODUCTION: Sleeve gastrectomy (SG) is the commonest bariatric procedure worldwide. Yet there is significant variation in practice concerning its various aspects. This paper report results from the first modified Delphi consensus-building exercise on SG. METHODS: We established a committee of 54 globally recognized opinion makers in this field. The committee agreed to vote on several statements concerning SG. An agreement or disagreement amongst ≥ 70.0% experts was construed as a consensus. RESULTS: The committee achieved a consensus of agreement (n = 71) or disagreement (n = 7) for 78 out of 97 proposed statements after two rounds of voting. The committee agreed with 96.3% consensus that the characterization of SG as a purely restrictive procedure was inaccurate and there was 88.7% consensus that SG was not a suitable standalone, primary, surgical weight loss option for patients with Barrett's esophagus (BE) without dysplasia. There was an overwhelming consensus of 92.5% that the sleeve should be fashioned over an orogastric tube of 36-40 Fr and a 90.7% consensus that surgeons should stay at least 1 cm away from the angle of His. Remarkably, the committee agreed with 81.1% consensus that SG patients should undergo a screening endoscopy every 5 years after surgery to screen for BE. CONCLUSION: A multinational team of experts achieved consensus on several aspects of SG. The findings of this exercise should help improve the outcomes of SG, the commonest bariatric procedure worldwide, and guide future research on this topic.

The first consensus statement on revisional bariatric surgery using a modified Delphi approach.

BACKGROUND: Revisional bariatric surgery (RBS) constitutes a possible solution for patients who experience an inadequate response following bariatric surgery or significant weight regain following an initial satisfactory response. This paper reports results from the first modified Delphi consensus-building exercise on RBS. METHODS: We created a committee of 22 recognised opinion-makers with a special interest in RBS. The committee invited 70 RBS experts from 27 countries to vote on 39 statements concerning RBS. An agreement amongst ≥ 70.0% experts was regarded as a consensus. RESULTS: Seventy experts from twenty-seven countries took part. There was a consensus that the decision for RBS should be individualised (100.0%) and multi-disciplinary (92.8%). Experts recommended a preoperative nutritional (95.7%) and psychological evaluation (85.7%), endoscopy (97.1%), and a contrast series (94.3%). Experts agreed that Roux-Y gastric bypass (RYGB) (94.3%), One anastomosis gastric bypass (OAGB) (82.8%), and single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) (71.4%) were acceptable RBS options after gastric banding (84.3%). OAGB (84.3%), bilio-pancreatic diversion/duodenal switch (BPD/DS) (81.4%), and SADI-S (88.5%) were agreed as consensus RBS options after sleeve gastrectomy. lengthening of bilio-pancreatic limb was the only consensus RBS option after RYGB (94.3%) and OAGB (72.8%). CONCLUSION: Experts achieved consensus on a number of aspects of RBS. Though expert opinion can only be regarded as low-quality evidence, the findings of this exercise should help improve the outcomes of RBS while we develop robust evidence to inform future practice.

Low Incidence of Postoperative Leaks When Using Small-Diameter Calibrated Bougies During Laparoscopic Sleeve Gastrectomy: A Retrospective Cohort Study.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is a well-established bariatric procedure. A staple line leak is a recognized complication of LSG. Bougie size has been suggested to impact leak rates. In this study, we evaluate the impact of using 32-34F bougie sizes with LSG on early postoperative outcomes including staple line leaks within our practice. METHODS: This is a retrospective cohort analysis of a prospectively maintained database of all LSG procedures performed between January 2012 and December 2018 at a single medical center. Data collected and analyzed included bougie size, postoperative leak rate, need for re-operation, 12-month excess weight loss, and 30-day morbidity and mortality. RESULTS: During the study period, 3153 patients underwent LSG, of whom 1977 (62.7%) were female. Mean age and body mass index (BMI) were 42.9 ± 12.2 years (range 15-76 years) and 42.4 ± 5.2 kg/m2 (range 27-73), respectively. No intraoperative complications or mortality occurred. There was one case of perioperative mortality due to bleeding (0.03%). Early postoperative adverse events occurred in 131 patients (4.1%): 17 leaks (0.5%), 75 bleeds (2.4%), and 39 (1.2%) other. CONCLUSION: The use of smaller-sized (32-34F) bougies had no impact on staple line leaks in the hands of experienced bariatric surgeons at a high-volume center.

Obesity-related acetylcholinesterase elevation is reversed following laparoscopic sleeve gastrectomy.

BACKGROUND: Impaired sympathetic/parasympathetic response, expressed by elevated Acetylcholinesterase (AChE) is associated with obesity, metabolic syndrome and inflammation. However, the association between morbid obesity and AChE and the changes in cholinergic tone following bariatric laparoscopic sleeve gastrectomy (LSG) surgery-induced weight reduction were never analyzed. METHODS: Two studies are presented; the first (the "apparently healthy cohort") was a cross-sectional study and the second (the "LSG cohort") was a prospective-cohort study with 12 months of follow-up. The "apparently healthy cohort" included 1450 apparently healthy participants who volunteered to the Tel-Aviv Medical Center Inflammation Survey (TAMCIS) during a routine annual checkup visit. The "LSG cohort" included 77 morbid obese patients before and at 3, 6, and 12 months following LSG surgery. Main outcomes included anthropometric measurements, Hemoglobin A1c (HbA1C), serum AChE, insulin test and Homeostasis Model Assessment (HOMA). RESULTS: Among the TAMCIS participants, serum AChE activity increased with BMI in a dose-dependent manner until it reached a peak level at BMI of 30-35 kg/m², followed by a plateau. Following LSG, a significant decrease in AChE activity between baseline and 12 months post-surgery was found for men, but not for women (-122.2 ± 135.3, P < 0.001 vs. -21.8 ± 120.5, P = 0.258 nmol substrate hydrolyzed/min per ml, respectively). The reduction in AChE activity was negatively correlated with %excess weight loss (EWL) and positively correlated with %body fat reduction at 12 months post-surgery among women (r = -0.329, P = 0.034 and r = 0.350, P = 0.023, respectively). In men, AChE activity reduction was positively correlated with the HOMA reduction (r = 0.358, P = 0.048). CONCLUSIONS: Obesity-related AChE resistance phenotype may be reversed following LSG and correlates with metabolic outcomes. Further long-term studies will be needed to validate and evaluate the beneficial effect of AChE reduction post bariatric surgery.

Conversion for failed adjustable gastric banding warrants hiatal scrutiny for hiatal hernia.

BACKGROUND: Failure or complications following laparoscopic adjustable gastric banding (LAGB) may necessitate band removal and conversional surgery. Band position and band-induced chronic vomiting create ideal conditions for de novo hiatal hernia (HH) formation. HH presence impedes and complicates conversional surgery by obscuring crucial anatomical landmarks and hindering precise gastric sleeve or pouch formation. The aim of this study was to evaluate the incidence of a HH in patients with an LAGB undergoing conversion compared to patients undergoing primary bariatric surgery (BS). METHODS: Retrospective review of consecutive BS performed between 2010 and 2015. Data collected included demographics, anthropometrics, comorbidities, previous BS, preoperative and intra-operative HH detection, operation time, perioperative complications and length of hospital stay. RESULTS: During the study period, 2843 patients (36% males) underwent BS. Of these, 2615 patients (92%) were "primary" (no previous BS-control group), 197 (7%) had a previous LAGB (study group), and 31 (1%) had a different previous BS and were excluded. Reasons for conversion included weight regain, band intolerance and band-related complications. Mean age and body mass index were similar between the study and the control groups. HH was preoperatively diagnosed by upper gastrointestinal (UGI) fluoroscopy in 9.1% and 9.0% of the LAGB and control groups (p = NS), respectively. However, HH was detected intra-operatively in 20.3% and 7.3%, respectively (p < 0.0001). CONCLUSIONS: Preoperative diagnosis of a HH by UGI fluoroscopy for patients who have undergone LAGB is unreliable. Intra-operative hiatal exploration is highly recommended in all cases of conversional BS after LAGB.

[DIAGNOSIS, TREATMENT AND PREVENTION OF GASTROINTESTINAL DISEASES PRE AND POST BARIATRIC SURGERY PROCEDURES].

INTRODUCTION: In the last decade, the number of bariatric surgery procedures increased dramatically in Israel similar to what has occurred worldwide. Bariatric surgery procedures have a proven efficacy in the treatment of morbid obesity. However, post-operative complications that involve the gastrointestinal tract may occur. Beyond the importance of early diagnosis and treatment, it is crucial to understand that we may decrease and prevent some of the complications by selecting the bariatric procedure according to the patient's medical background. This review addresses diagnosis, treatment and prevention of gastrointestinal diseases pre- and post-bariatric surgery procedures. Recommended pre-operative diagnostic procedures are listed including the eradication of helicobacter pylori and the protective effect of proton pump inhibitors. We reviewed the effect of specific bariatric procedures on gastroesophageal reflux disease and on intestinal motility. Prevention and treatment of nutritional deficits and metabolic complications are also discussed. Finally, this document was written by a panel of experts representing the attitudes of the Israeli Societies for Metabolic and Bariatric Surgery (ISMBS), Pharmaceutical (PSI), Study of Obesity and the Israeli Gastroenterology and Liver Diseases Association, all endorsed by the Institute for Quality in Medicine of the Israeli Medical Association (IMA).

Outcome of Delayed Cholecystectomy after Percutaneous Cholecystostomy for Acute Cholecystitis.

BACKGROUND: Recent studies have suggested that urgent cholecystectomy is the preferred treatment for acute cholecystitis. However, initial conservative treatment followed by delayed elective surgery is still common practice in many medical centers. OBJECTIVES: To determine the effect of percutaneous cholecystostomy on surgical outcome in patients undergoing delayed elective cholecystectomy. METHODS: We conducted a retrospective analysis of all patients admitted to our medical center with acute cholecystitis who were treated by conservative treatment followed by delayed cholecystectomy between 2004 and 2013. Logistic regression was calculated to assess the association of percutaneous cholecystostomy with patient characteristics, planned surgical procedure, and the clinical and surgical outcomes. RESULTS: We identified 370 patients. Of these, 134 patients (36%) underwent cholecystostomy during the conservative treatment period. Patients who underwent cholecystostomy were older and at higher risk for surgery. Laparoscopic cholecystectomy was offered to 92% of all patients, yet assignment to the open surgical approach was more common in the cholecystostomy group (16% vs. 3%). Cholecystostomy was associated with significantly higher conversion rates to open approach (26% vs. 13%) but was not associated with longer operative time, hemorrhage, surgical infections, or bile duct or organ injuries. CONCLUSIONS: Treatment with cholecystostomy is associated with higher conversion rates but does not include other major operative-related complications or poorer clinical outcome.

Assessment of perioperative complications following primary bariatric surgery according to the Clavien-Dindo classification: comparison of sleeve gastrectomy and Roux-Y gastric bypass.

BACKGROUND: Laparoscopic Roux-Y gastric bypass (LRYGBP) is the gold-standard procedure for the treatment of morbid obesity. It has been reported to be somewhat more efficient and durable than laparoscopic sleeve gastrectomy (LSG). However, it is considered more invasive and, therefore, more hazardous. There is a lack of unity in complication reporting following bariatric surgery. Thus, there is a possible misconception regarding the relative safety of the two major bariatric procedures performed worldwide. This may have contributed to a shift in practice with LSG gaining momentum "at the expense" of LRYGBP. The aim of this study was to evaluate the relative safety of primary LSG and LRYGBP according to the Clavien-Dindo complication grading system. METHODS: A total of 2651 and 554 patients underwent primary LSG and LRYGBP, respectively at three high-volume centers. Thirty-day perioperative complications were recorded and graded. Length of hospital stays (LOS) and readmission rates were collected as well. RESULTS: Complications occurred in 110 (3.7%) and 24 (4.3%) patients following LSG and LRYGBP, respectively (p = 0.9). No significant difference was found between the groups regarding overall and complication-grade-specific rates. Individual complication types were unevenly distributed, but not significantly so. Patients with complications were older than those without (47 and 43 years, respectively; p = 0.01). Gender was not a risk factor for complication. Median LOS and readmission rates were not significantly different. CONCLUSIONS: LSG and LRYGBP are equally safe, at least in the perioperative period. Acknowledging and conveying this finding to surgeons and patients alike is important and might cause a pendulum shift in the distribution of bariatric procedures performed.

Concomitant cholecystectomy during laparoscopic sleeve gastrectomy.

BACKGROUND: The prevalence of cholelithiasis in morbidly obese individuals is 19-45%. Laparoscopic sleeve gastrectomy (LSG) has become one of the most performed procedures worldwide. The management of gallstones at the time of LSG is under debate. We herein report our experience with concomitant LSG and cholecystectomy. METHODS: Patients undergoing LSG, between 2006 and 2014 with symptomatic cholelithiasis (SC), underwent concomitant cholecystectomy (SGC), and were compared to those who had LSG alone. Gender, age, and BMI were noted. Preoperative ultrasonography was performed for all patients and gallstone presence was recorded. Operative time, intraoperative mishaps, perioperative complications, length of hospital stay (LOS), and the incidence of subsequent symptomatic gallbladder disease were collected as well. RESULTS: SC was present in 180 patients who underwent SGC. LSG was performed in 2,383, of whom 43 (2%) had asymptomatic cholelithiasis (AC). SGC patients had a higher percentage of females and were older (79% and 46 years vs. 62% and 43 years, respectively). BMI, LOS, and complications were similar. Operative time was prolonged by 35 min in SGC. Two patients with SGC had bile leakage. Of patients with AC, 9.3% required cholecystectomy during the first post-operative year after LSG due to evolution of symptoms, compared to only 2.7% of those with normal preoperative gallbladders. Presenting symptoms and severity of the disease were worse in the first group. CONCLUSIONS: For SC, LSC is safe and warranted. Prophylactic cholecystectomy when gallstones are absent is unnecessary. Management of AC at the time of LSG is still debatable.

Adenocarcinoma of the Gallbladder: Incidental Finding in Patients following Laparoscopic Sleeve Gastrectomy and Cholecystectomy.

BACKGROUND: Gallbladder (GB) cancer is rare. Most cases are incidentally found in specimens after a cholecystectomy. Cholelithiasis is almost always present when this diagnosis is made. Obesity is a known risk factor for gallstone formation and thus may be related to GB cancer. OBJECTIVES: To highlight the importance of evaluating the gallbladder before surgery, resecting the gallbladder whenever required, and screening the resected tissue for malignancy. METHODS: We retrospectively searched a prospectively maintained database of all bariatric procedures during the last 8 years for cases of concomitant laparoscopic sleeve gastrectomy (LSG) and laparoscopic cholecystectomy (LC). Pathologic reports of the gallbladders were reviewed. Demographic data and perioperative parameters were documented. RESULTS: Of 2708 patients reviewed, 1721 (63.55%) were females and 987 (36.45%) males. Excluded were 145 (5.35%) who had a previous cholecystectomy. Of the remaining 2563, 180 (7.02%) had symptomatic gallbladder disease and underwent LSG with LC. Of these, two females (BMI 53 kg/m2 and 47 kg/m2, both age 60) were found by histological examination to have adenocarcinoma in their GB specimens (1.11%). Both were reoperated, which included partial hepatectomy of the GB bed, resection of the cystic stump, lymph node dissection, and resection of the port sites. One patient is doing well, with no evidence of disease at a postoperative follow-up of 4 years. The second patient had recurrent disease with peritoneal spread and ascites 20 months post-surgery and died 18 months later. CONCLUSIONS: GB cancer is a rare finding in cholecystectomy specimens. The incidence of this entity might be higher in obese older females owing to the higher incidence of cholelithiasis in these patients.

Concomitant bariatric and ventral/incisional hernia surgery in morbidly obese patients.

INTRODUCTION: Ventral hernias are not uncommon in the bariatric population. Their management is technically demanding and remains controversial. Hernia complications can be lethal after bariatric surgery (BS). We herein report our experience with concomitant BS and ventral hernia repair (VHR). METHODS: We performed a retrospective analysis of a prospectively maintained database queried for combined procedures. Hernias were repaired after complete reduction (when the defect was not empty) using a dual mesh fixed to the abdominal wall with absorbable tackers. Data collected included demographics, anthropometrics, co-morbidities, peri-operative course, and intermediate weight loss and co-morbidity status. RESULTS: Between 2007 and 2012, a total of 54 patients (34 females, mean body mass index 44.2 kg/m(2)) underwent concomitant BS and VHR. The vast majority of procedures were laparoscopic sleeve gastrectomies (N = 48; 89 %). Others included laparoscopic Roux-en-y gastric bypass (RYGB), open RYGB, and laparoscopic gastric banding (two each). Six patients had complications (11 %): three leaks, two abdominal wall hematomas, and one pulmonary embolism. Hernia recurrence was noted in one patient (1.8 %). Average excess weight loss post-surgery was 49.9 ± 10.3 and 57.7 ± 9.2 % at 6 and 12 months, respectively. The total number of pre-operative co-morbidities was 110. At 12-month follow-up, 50 % (N = 56) were completely resolved and 38 % (N = 42) were improved. CONCLUSION: Concomitant BS and VHR is feasible and safe, obviating the need for two separate procedures while not hampering the outcome of either. Complication rates for the combined surgery do not seem to be adversely affected.

Advantages of minimal incision laparoscopic cholecystectomy.

BACKGROUND: Modifications to conventional laparoscopic cholecystectomy (CLC) are aimed at decreasing abdominal wall trauma and improving cosmetic outcome. Although single-incision laparoscopic surgery (SILS) provides excellent cosmetic results, the procedure is technically challenging and expensive compared to the conventional laparoscopic approach. OBJECTIVES: To describe a novel, hybrid technique combining SILS and conventional laparoscopy using minimal abdominal wall incisions. METHODS: Fifty patients diagnosed with symptomatic cholelithiasis were operated using two reusable 5 mm trocars inserted through a single 15 mm umbilical incision and a single 2-3 mm epigastric port. This technique was clubbed "minimal incision laparoscopic cholecystectomy" (MILC). RESULTS: MILC was completed in 49 patients (98%). In five patients an additional 3 mm trocar was used and in 2 patients the epigastric trocar was switched to a 5 mmtrocar. The procedure was converted to CLC in one patient. Mean operative time was 29 minutes (range 18-60) and the average postoperative hospital stay was 22 hours (range 6-50). There were no postoperative complications and the cosmetic results were rated excellent by the patients. CONCLUSIONS: MILC is an intuitive, easy-to-learn and reproducible technique and requires small changes from CLC. As such, MILC may be an attractive alternative, avoiding the cost and complexity drawbacks associated with SILS.

Mid-term follow-up after laparoscopic sleeve gastrectomy in obese adolescents.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is gaining credibility as a simple and efficient bariatric procedure with low surgical risk. Since surgical treatment for morbid obesity is relatively rare in adolescents, few results have bten accumulated so far. OBJECTIVES: To prove the safety and efficacy of LSG turgery in an adolescent population METHODS: Data were prospectively collected regarding adolescent patients undergoing LSG. All patients underwent pre- and postoperative medical and professional evaluation by a multidisciplinary team. RESULTS: Between the years 2006 and 2011, 32 adolescents underwent LSG in our center (20 females and 12males). Mean age was 16.75 years (range 14-18 years), mean weight was 121.88 kg (83-178 kg), and mean body mass index 43.23 (35-54). Thirty-four comorbid conditions were identified. LSG was the primary bariatric procedure in all the patients. Mean operative time was 60 minutes (range 45-80 min). Tiere were two complications (6.25%): an early staple line leak and a late acute cholecystitis. There were no deaths. Mean percent excess weight loss at 1, 3, 6, 9,12, 24, 36, 48, and 60 months post-surgery was 27.9%, 41.1%, 62.6%, 79.2%, 81.7%, 71%, 75%, 102.9% and 101.6%, respectively. Comorbidities were completely resolved or ameliorated within 1 year folllowing surgery in 82.4% and 17.6%, respectively. CONCLUSIONS: LSG is feasible and safe in morbidly obese adolescents, achieving efficient weight loss and impressive resolution of comorbidities. Further studies are required to evaluate the long-term results of this procedure as well as its place among other bariatric options.

[The relationship between attention deficit hyperactivity disorders (ADHD) and obesity].

The obesity epidemic has been recognized as a worldwide problem. More than 1/3 of the adults and about 15% of children and adolescents are overweight. In the search for the reasons for obesity and refractory obesity, some research efforts have recently been directed into the relationship between obesity and attention deficit hyperactivity disorder (ADHD). This link can be explained by two theoretical approaches: ADHD leads to obesity because of the impulsive behavior of ADHD patients; both obesity and ADHD originate from a similar psycho-pathological mechanism. ADHD is usually diagnosed in childhood with symptoms of hyperactivity, impulsivity, and distraction, often continuing into adulthood with symptoms of disorganization, frustration, and excessive emotional reaction. Treatment of ADHD requires a multidisciplinary approach of medication, psychological treatment, occupational therapy (in children) and nutritional assistance. Most studies of the association between ADHD and obesity were performed on subjects seeking help for obesity problems. In this population (both children and adults), the percentage of ADHD was found to be significantly higher than the prevalence of ADHD in the general population. Overweight subjects with ADHD, who were treated with medications, showed improved patterns of weight loss and maintenance. In addition, patients diagnosed with ADHD had lower compliance with follow-up visits after bariatric surgery. It seems that the problem is in the correct diagnosis of ADHD in obese patients, followed by medical as well as cognitive behavioral treatment, that can turn the impulsivity into an advantage, driving patients to positive pathways such as physical activity.

Early outcomes of one-anastomosis gastric bypass in the elderly population at high-volume bariatric centers.

The increasing rate of obesity and life expectancy will lead to increasing numbers of bariatric procedures in the elderly. We aim to report the early (≤ 30 days) adverse events of One-Anastomosis Gastric Bypass (OAGB) in this patient population. Assuta Bariatric Centers in Israel. Retrospective review of perioperative OAGB outcomes between elderly group (≥ 65 years) and non-elderly group (18-64 years) at high-volume bariatric centers between January 2017-December 2021. Operative time, length of stay (LOS), and overall ≤ 30 days complication rates, as ranked by the Clavien-Dindo Classification (CDC) were compared. There were 6618 patients (non-elderly group) and 104 (elderly group) who underwent OAGB. Gender and preoperative BMI were comparable between the two age groups. The elderly group had significantly higher rate of ischemic heart disease and chronic renal failure. The number of patients with LOS ≥ 3 days was significantly higher in the elderly group [19.4% (n = 20) vs. 6.6% (n = 331), respectively; p < 0.001]. The total early adverse events were higher in the elderly group with no statistical significance [7.7% (n = 8) vs. 3.8% (n = 250), respectively; p = 0.062]. The rate of minor and major adverse events and reoperation rate was comparable between the two groups. The rate of readmissions was significantly higher in the elderly group 5.8% (n = 6) vs. 1.9% (n = 124), respectively p = 0.015. There was 0.06% mortality (n = 2) in the non-elderly group. OAGB is a relatively safe metabolic and bariatric surgery for elderly obese patients with early (≤ 30 days) morbidity rates similar to the non-elderly population.

Laparoscopic Conversion of Gastric Plication to One Anastomosis Gastric Bypass.

Laparoscopic gastric plication (LPG) is a restrictive procedure to reduce the size of the stomach by folding and suturing the stomach to decrease its capacity. LGP has a high revision rate, mostly to sleeve gastrectomy. To the best of our knowledge, this is the first such report on the bariatric population that has been never described before.The purpose of this video was to show the feasibility and safety, as well as the main technical aspects, of a laparoscopic conversion of gastric plication to One Anastomosis Gastric Bypass.