Occurrence of Dumping Syndrome After Esophageal Cancer Surgery: Systematic Review and Meta-analysis.

BACKGROUND: Dumping syndrome occurs frequently after esophageal cancer surgery, but the reported prevalence varied across previous studies. This systematic review and meta-analysis aimed to clarify the prevalence of dumping syndrome after esophageal cancer surgery, particularly exploring the sources of heterogeneity in previous studies. METHODS: A comprehensive literature search was conducted in PubMed, MEDLINE, Web of Science, Embase, and the Cochrane Library databases, supplemented by hand-search of reference lists, through March 2023. Random-effects meta-analysis estimated the average prevalence of dumping syndrome after esophageal cancer surgery. Heterogeneity across studies was examined by the I2 statistic and Cochran's Q test. RESULTS: Among the 2949 articles retrieved from the databases, 16 articles (15 cohort studies and 1 randomized controlled trial) met the inclusion criteria. The prevalence of dumping syndrome ranged 0-74% in these studies, showing high heterogeneity (I2 = 99%, P < 0.01), with the pooled prevalence of 27% (95% confidence interval [CI] 14-39%). The pooled prevalence in the three studies using specialized questionnaires was 67% (95% CI 60-73%), with reduced heterogeneity (I2 = 43%, P = 0.17). The prevalence also varied by year of publication, study population, and length and completeness of follow-up. CONCLUSIONS: Our findings revealed that dumping syndrome is common after esophageal cancer surgery. The varying prevalence across previous studies was probably owing to differences in measurement of dumping syndrome. Using specific patient reported outcome questionnaires is recommended for future investigations on dumping syndrome after esophageal cancer surgery.

Postbariatric surgery hypoglycemia: Nutritional, pharmacological and surgical perspectives.

Post-bariatric hypoglycaemia (PBH) is a metabolic complication of bariatric surgery (BS), consisting of low post-prandial glucose levels in patients having undergone bariatric procedures. While BS is currently the most effective and relatively safe treatment for obesity and its complications, the development of PBH can significantly impact patients' quality of life and mental health. The diagnosis of PBH is still challenging, considering the lack of definitive and reliable diagnostic tools, and the fact that this condition is frequently asymptomatic. However, PBH's prevalence is alarming, involving up to 88% of the post-bariatric population, depending on the diagnostic tool, and this may be underestimated. Given the prevalence of obesity soaring, and an increasing number of bariatric procedures being performed, it is crucial that physicians are skilled to diagnose PBH and promptly treat patients suffering from it. While the milestone of managing this condition is nutritional therapy, growing evidence suggests that old and new pharmacological approaches may be adopted as adjunct therapies for managing this complex condition.

Canagliflozin or acarbose versus placebo to ameliorate post-bariatric hypoglycaemia - The HypoBar I randomized clinical trial protocol.

INTRODUCTION: Post-bariatric hypoglycaemia (PBH) is a rare yet disabling clinical condition, mostly reported after Roux-en-Y gastric bypass (RYGB) surgery. RYGB is one of the most widely used and effective bariatric procedures. The pathophysiology of PBH remains unclear, and treatment options are limited in effectiveness and/or carry significant side effects. Acarbose slows carbohydrates digestion and absorption and is generally considered first-line pharmacological treatment for PBH but its gastrointestinal side effects limit patient compliance. Canagliflozin inhibits intestinal and renal sodium-dependent glucose absorption and reduces postprandial excursions of glucose, insulin and incretins after RYGB - effects that could be beneficial in ameliorating PBH. AIMS: The trial aims to investigate how blood glucose levels are affected during daily living in subjects with PBH during treatment with canagliflozin or acarbose compared with placebo, and to study the meal-induced entero-endocrine mechanisms implied in the treatment responses. METHODS: In a double-blinded, randomized, crossover clinical trial, HypoBar I will investigate the effectiveness in reducing the risk of PBH, safety, ambulatory glucose profile and entero-endocrine responses when PBH is treated with canagliflozin 300 mg twice daily during a 4-week intervention period, compared with acarbose 50 mg thrice daily or placebo. ETHICS AND DISSEMINATION: HypoBar I is approved by the Local regulatory entities. Results will be published in peer-reviewed journals. CONCLUSION: If effective, well-tolerated and safe, canagliflozin could be a novel treatment for people with PBH. HypoBar I might also unravel new mechanisms underlying PBH, potentially identifying new treatment targets. TRIAL REGISTRATION: EudraCT number 2022-000157-87.

Forensic Geochemistry Reveals International Ship Dumping as a Source of New Oil Spill in Brazil's Coastline (Bahia) in Late 2023.

In the present study, we applied forensic geochemistry to investigate the origin and fate of spilled oils like tarballs stranded at the beaches of Bahia, in northeastern Brazil, in September 2023, based on their fingerprints. Saturated and aromatic compounds were assessed by gas chromatography, and the oceanic surface circulation patterns were deciphered to determine the geographic origin of the spill. Contamination by petroleum represents an enormous threat to the unique, species-rich ecosystems of the study area. The geochemical fingerprint of the oil spilled in 2023 did not correlate with those of previous events, including the one in 2019, the one in early 2022 in Ceará, and an extensive spill across the Brazilian Northeast in late 2022. However, the fingerprint did correlate with crude oils produced by Middle Eastern countries, most likely Kuwait. The oil of the 2023 spill had a carbonate marine origin from early mature source rocks. These findings, together with the moderate weathering of the 2023 tarballs and the ocean circulation patterns at the time of the event, indicate that the oil was discharged close to the shore of Brazil, to the east or southeast of Salvador, by a tanker on an international route in the South Atlantic.

Disentangling the History of Deep Ocean Disposal for DDT and Other Industrial Waste Off Southern California.

Ocean disposal of industrial waste from technical DDT [mainly 1,1'-(2,2,2-trichloroethane-1,1-diyl)bis(4-chlorobenzene), or 4,4'-DDT] manufacture occurred historically in the Southern California Bight. However, the paucity of historical records highlights uncertainties as to the mode, location, and timing of disposal or ongoing ecological effects of these wastes. This study combines sampling, chemical analysis, and numerical modeling of deep San Pedro Basin sediments revealing substantial DDT contamination that extends at least 25 km from the mainland. These findings narrate bulk DDT waste disposal to the offshore that peaked in the 1950s, prior to the onset of formal regulations; was agnostic to later-designated disposal sites; and has experienced sluggish transformation. Our findings further indicate an attenuating secondary source for the DDT daughter product, 1-chloro-4-[2,2-dichloro-1-(4-chlorophenyl)ethenyl]benzene (4,4'-DDE), which still deposits into deep San Pedro Basin sediments. While demonstrating the severity of DDT contamination to the region, these findings further define the burial potential of DDT wastes and inform the past, present, and future contamination potential that is needed to understand and predict ecological consequences. This work also points firmly to bulk, not containerized, disposal of DDT waste and to potential alternative contents of collocated waste.

Exploring the hidden chemical landscape: Non-target and suspect screening analysis for investigating solid waste-associated environments.

Solid waste is an inevitable consequence of urbanization. It can be safely managed in municipal landfills and processing plants for volume reduction or material reuse, including organic solid waste. However, solid waste can also be discarded in (un-)authorized dumping sites or inadvertently released into the environment. Legacy and emerging contaminants have the potential to leach from solid waste, making it a significant pathway to the environment. Non-target screening (NTS) and suspect screening analysis (SSA) have become helpful tools in environmental science for the simultaneous analysis of a wide range of chemical compounds. However, the application of these analytical approaches to environmental samples related to Raw or Processed Solid Waste (RPSW) has been largely neglected so far. This perspective review examines the potential and policy relevance of NTS and SSA applied to waste-related samples (liquid, gaseous and solid). It addresses the hurdles associated with the chemical safety of solid waste accumulation, processing, and reuse, and the need for landfill traceability, as well as effectiveness of leachate treatments. We reviewed the current applications of NTS and SSA to environmental samples of RPSW, as well as the potential adaptation of NTS and SSA techniques from related fields, such as oilfield and metabolomics, to the solid waste domain. Despite the ongoing technical challenges, this review highlights the significant potential for the implementation of NTS and SSA approaches in solid waste management and related scientific fields and provides support and guidance to the regulatory authorities.

Long-term results after transoral outlet reduction (TORe) of the gastrojejunal anastomosis for secondary weight regain and dumping syndrome after Roux-en-Y gastric bypass.

BACKGROUND: Bariatric surgery has been proven to be the most effective therapy for obesity and Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed procedure. However, weight regain and dumping syndrome occur over time. The transoral outlet reduction (TORe) procedure using an endoscopic suturing device may be an option to treat these conditions. We aimed to analyze outcome parameters and long-term results for this endoscopic technique. METHODS: A retrospective data analysis of patients who underwent TORe using an endoscopic suturing system at our institution from January 2015 to December 2020 was performed. A total of 71 subjects were included. Forty-five patients received the intervention for weight regain, 9 for dumping syndrome and 17 for both. The primary endpoint was weight stabilization or weight loss for subjects with weight regain, and resolution of symptoms for those with dumping syndrome. Secondary endpoints were intraoperative complications, procedure time, length of hospital stay and diameter of gastrojejunal anastomosis 1 year post-intervention. RESULTS: The median size of the gastrojejunal anastomosis was estimated at 30 mm before intervention, and after performing a median of 3 endoscopic sutures, the median estimated gastrojejunal anastomosis width was reduced to 9.5 mm. Eight perioperative complications occurred. Overall mean follow-up was 26.5 months. All interventions achieved weight stabilization or weight loss or resolution of dumping symptoms within the first 3 months, 98.2% at 12 months, 91.4% at 24 months and 75.0% at 48 months. In 22/26 subjects a persisting improvement of dumping syndrome was achieved. CONCLUSIONS: TORe is a safe and effective procedure in the treatment of patients with dumping syndrome after laparoscopic RYGB, the effect on weight stabilization is less significant. A prospective randomized trial should be conducted to compare the effects of TORe with other surgical methods like banding the gastrojejunal anastomosis.

Is Sigstad's score really capable of detecting post-surgical late dumping syndrome?

BACKGROUND: This clinical trial explores the Sigstad score for late dumping syndrome in postoperative patients who have undergone sleeve gastrectomy (SG) or One Anastomosis Gastric Bypass (OAGB). The aims of this study are to investigate the correlations with late dumping syndrome, to evaluate the reliability and validity of the Sigstad score and to discuss a modified scoring system. METHODS: The study was conducted at the Obesity Center of the Westküstenklinikum Heide and included 271 patients. Data collection involved conducting interviews, diet diaries and measuring blood glucose levels. Non-parametric tests, logistic regression and McDonald's Omega were the selected statistical approaches. RESULTS: Body Mass Index (BMI) decreased over time (-9.67 kg/m2 at 4 months, -15.58 kg/m2 at 12 months). Preoperatively, the Sigstad score exhibited the highest value, and no occurrences of late dumping syndrome were observed. No significant differences were found in BMI concerning late dumping syndrome or Sigstad score among postoperative patients. Postoperative patients experienced an increase in gastrointestinal symptoms. The reliability test showed a McDonald's omega value of 0.509. The analysis conducted through binary logistic regression indicated dizziness as a significant predictor of late dumping syndrome; however, this finding did not hold up after performing Bonferroni correction. CONCLUSION: The Sigstad score is not a reliable or valid method for detecting late dumping syndrome after surgery for obesity and metabolic disorders. It is necessary to have alternatives that use objective measures and assess the quality of life, and that these alternatives be validated in large patient cohorts.

Factors influencing illegal dumping of hazardous waste in China.

In recent years, illegal dumping of hazardous waste (IDHW) in China has become a recurring problem. Effective identification and exploration of the factors influencing illegal dumping are crucial for incident prevention and hazardous waste management, but its analysis has rarely been reported. Thus, this study focused on 568 cases of IDHW officially reported by the government. Through regular expressions, the categories of dumped wastes and the provinces where the incidents occurred were extracted. Furthermore, a comprehensive set of influencing factors was constructed by text mining for the case content and by the integration from the existing literature. On this basis, the unstructured and structured data were integrated using a Boolean dataset to respectively explore the association rules of influencing factors for the overall IDHW and for major waste categories, in conjunction with the extracted province information. Subsequently, a Bayesian network was constructed by utilizing the results of association rules mining and the key factors were identified through corresponding analysis. The findings of this study reveal a close connection between various influencing factors, with distinct key factors identified for different categories of hazardous waste. Among them, law-enforcement emerges as a crucial factor in most IDHW cases, while the factor of public monitoring for metallic hazardous waste and the factor of government supervision for distillation residue waste and other waste play a key role in their respective cases of illegal dumping. These findings offer a fresh research perspective for investigating the factors influencing IDHW and present helpful insights for developing effective strategies to prevent and control such incidents.

Impact of solid waste dumping on soil quality and its potential risk on human health and environment.

The soil, comprising minerals, organic matter, and living organisms, serves as a critical component of our environment. However, anthropogenic activities, such as uncontrolled sewage disposal and industrial waste, have led to pervasive soil pollution, impacting ecosystems and human health. This comprehensive study scrutinizes the intricate dynamics of soil pollution resulting from open waste dumping, specifically examining its impact on the health of local communities and the environment in Haridwar municipality. In this study, four solid waste dumping sites were meticulously surveyed, with soil samples analyzed for 19 parameters through statistical tools like one-way ANOVA, Kruskal-Wallis tests, soil pollution indices, and potential health risk assessment. The Geo-accumulation Index (Igeo) and contamination factor (CF) followed the heavy metals in the order of Zn > Mn > Fe > Cu in all selected sites. Additionally, a potential health risk assessment considered ingestion, inhalation, and dermal exposure pathways, revealing a high non-carcinogenic risk of metals (Mn > Fe > Zn > Cu) for both children and adults. In the ingestion pathway, the hazard quotient indicated a high risk of metals for both children and adults in the range of 1192.73 to 2066.94 for child and 191.98 to 312.16 for adults. Crucially, the HQ revealed potential health risks, emphasizing the urgency of addressing metal contamination. However, the findings indicate that dumping sites directly or indirectly affects the local people of Haridwar municipality. Therefore, this study provides a baseline framework for minimizing the impact of dumping sites on local population and the environment.

Consideration of hotspots in the selection of supervision schemes to reduce illegal dumping of construction and demolition waste.

Illegal dumping of construction and demolition waste continues to be a problem hindering circular economy efforts. Controlling illegal dumping necessitates establishing an effective surveillance scheme and investigating the proper penalty value. This problem has previously been described as a game theory problem, with the government and construction contractors as the players. Taking into account illegal dumping hotspots, which can often be identified through topographical and geographical characteristics, is also important when establishing supervision strategies. This study develops an evolutionary game-theoretic model that can assist in devising effective supervision strategies to control the spread of illegal dumping, while taking into consideration hotspots. In specific, this study investigates the suitability of two alternative strategies: police patrols and hybrid monitoring through both patrols and the installation of closed-circuit television cameras in hotspots. The model was applied to two case studies, using parameters informed by real-world contexts, to demonstrate its potential for selecting suitable strategies according to local situations. The results suggest that nine possible scenarios govern the stable evolutionary strategies of game players, with five scenarios in which contractors converge to adopt legal dumping. Accordingly, based on the parameters of the region (hotspot areas, cost of supervision, efficiency of patrols, penalties, etc.), governments would be able to assess which of the strategies would lead to long-term compliance of contractors while also increasing their payoffs. Further analysis allowed to determine the minimum efficiency required, and simulations were performed to demonstrate the influence of different supervision efficiencies and penalties on the evolutionary strategies.

Wide-Area Debris Field and Seabed Characterization of a Deep Ocean Dump Site Surveyed by Autonomous Underwater Vehicles.

Disposal of industrial and hazardous waste in the ocean was a pervasive global practice in the 20th century. Uncertainty in the quantity, location, and contents of dumped materials underscores ongoing risks to marine ecosystems and human health. This study presents an analysis of a wide-area side-scan sonar survey conducted with autonomous underwater vehicles (AUVs) at a dump site in the San Pedro Basin, California. Previous camera surveys located 60 barrels and other debris. Sediment analysis in the region showed varying concentrations of the insecticidal chemical dichlorodiphenyltrichloroethane (DDT), of which an estimated 350-700 t were discarded in the San Pedro Basin between 1947 and 1961. A lack of primary historical documents specifying DDT acid waste disposal methods has contributed to the ambiguity surrounding whether dumping occurred via bulk discharge or containerized units. Barrels and debris observed during previous surveys were used for ground truth classification algorithms based on size and acoustic intensity characteristics. Image and signal processing techniques identified over 74,000 debris targets within the survey region. Statistical, spectral, and machine learning methods characterize seabed variability and classify bottom-type. These analytical techniques combined with AUV capabilities provide a framework for efficient mapping and characterization of uncharted deep-water disposal sites.

Transoral gastric outlet reduction for post-prandial hypoglycemia after Roux-en-Y gastric bypass.

BACKGROUND: Post-prandial hypoglycemia is an uncommon but disabling late complication of Roux-en-Y gastric bypass (RYGB). Most patients can be treated with dietary interventions and medications; however, some patients develop refractory hypoglycemia that may lead to multiple daily episodes and seizures. While RYGB reversal surgery is an effective treatment, complication rates are high, and patients inevitably experience weight regain. Transoral gastric outlet reduction (TORe) is a minimally invasive treatment that is effective for early and late dumping syndrome. However, prior studies have not distinguished the effectiveness of TORe specifically for patients with post-prandial hypoglycemia. This study aims to describe a single institution's experience of TORe for treating post-prandial hypoglycemia. METHODS: This is a case series of patients with prior RYGB complicated by post-prandial hypoglycemia who underwent TORe from February 2020 to September 2021. Pre-procedural characteristics and post-procedural outcomes were obtained. Outcomes assessed included post-prandial hypoglycemia episodes, dumping syndrome symptoms, and weight change. RESULTS: A total of 11 patients underwent TORe from 2020 to 2021 for post-prandial hypoglycemia. Three (27%) patients had a history of seizures due to hypoglycemia. All had been advised on dietary changes, and ten patients (91%) were on medications for dumping. All patients reported a reduction in post-prandial hypoglycemic events as well as the majority of dumping syndrome symptoms during an average follow-up time of 409 ± 125 days. Ten patients (91%) had experienced weight regain from their post-RYGB nadir weight. For these patients, the average total body weight loss 12 months post-TORe was 12.4 ± 12%. There were no complications requiring hospitalization. One patient experienced post-TORe nausea and vomiting requiring dilation of the gastrojejunal anastomosis with resolution in symptoms. CONCLUSION: TORe is a safe and effective treatment for post-prandial hypoglycemia and weight regain after RYGB in patients with symptoms refractory to medications and dietary changes.

Severity of post-Roux-en-Y gastric bypass dumping syndrome and weight loss outcomes: is there any correlation?

PURPOSE: The present research was conducted to evaluate the effect of the severity of dumping syndrome (DS) on weight loss outcomes after Roux-en-Y gastric bypass (RYGB) in patients with class III obesity. METHODS: The present retrospective cohort study used the dumping symptom rating scale (DSRS) to evaluate the severity of DS and its correlation with weight loss outcomes in 207 patients 1 year after their RYGB. The patients were assigned to group A with mild-to-moderate DS or group B with severe DS. RESULTS: The mean age of the patients was 42.18 ± 10.46 years and their mean preoperative BMI 42.74 ± 5.59 kg/m2. The total weight loss percentage (%TWL) in group B was insignificantly higher than that in group A, but besides that was not significantly different in the two groups. CONCLUSION: The present findings suggested insignificant relationships between the presence and severity of DS after RYGB and adequate postoperative weight loss.

Environmental damage compensation for illegal solid waste dumping in China.

China aims to improve its system for pursuing environmental damage compensation environmental violation cases. To hold violators accountable, China has an effective system for the identification and assessment (I&A) of environmental damage. This study selected a typical case of the illegal dumping of solid waste (IDSW) in China to analyze the causes, the degree, and characteristics of environmental damage, focusing on components such as the physical quantification and valuation of damage. The findings were as follows: (1) Compensation claimants and obligors consider baseline damage confirmation and causality analysis key components of I&A. (2) The I&A process for a specific case needs to focus on key nodes such as the type, location, and duration of IDSW. (3) Restraining IDSW requires accurately quantifying the physical and value-related losses caused by solid waste dumping. (4) In the selected case study, the damage from environmental contamination caused by the IDSW incident amounted to 3938,990 yuan, including an environmental damage value of 3651,990 yuan and a transaction cost of 287,000 yuan. Both parties accepted the I&A calculation process in this case, and the desired punishment effect was achieved. Hence, the case study demonstrated that accurate I&A is the technical basis for environmental damage compensation. Thus, in the future, more attention should be paid to the role of scientific and technological means and knowledge reserves in the I&A of environmental damage.

Exploring in vitro solubility of lamotrigine in physiologically mimetic conditions to prospect the in vivo dissolution in pediatric population.

Pediatric drugs knowledge still leaves several gaps to be filled, all the while many biopharmaceutic properties applied to adults do not work in pediatrics. The solubility in many cases is extrapolated to pediatrics; however, sometimes it may not represent the real scenario. In this context, the aim of this study was to assess the possibility of the extrapolation of the solubility data assumed for adults to children aged 2-12 years using lamotrigine (LTG) as a model. LTG showed that its solubility is dependent on the pH of the medium, no precipitate formation was seen, and biomimetic media showed a greater capacity to solubilize it. Based on the dose number (D0 ) in adults, the LTG was soluble in acidic pH media and poorly soluble in neutral to basic. Similar behavior was found in conditions which mimic children aged 10-12 years at a dose of 5 and 15 mg/kg. The D0 for 5-year-old children at a dose of 15 mg/kg showed different behaviors between biorelevant and pharmacopeial buffers media. For children aged 2-3 years, LTG appeared to be poorly soluble under both gastric and intestinal conditions. Solubility was dependent on the volume of fluid calculated for each age group, and this may impact the development of better pharmaceutical formulations for this population, better pharmacokinetic predictions in tools as PBPK, and physiologically-based biopharmaceutics modeling, greater accuracy in the justifications for biowaiver, and many other possibilities.

Community identified characteristics related to illegal dumping; a mixed methods study to inform prevention.

Illegal dumping is a public health burden for communities suffering from historical disinvestment. We conducted a mixed methods study to answer: 1) What are stakeholder perspectives on social/environmental determinants of illegal dumping? and 2) Do these or other characteristics predict known locations of illegal dumping? We employed an exploratory sequential design in which we collected and analyzed in-depth interviews (n=12) with service providers and residents and subsequently collected and analyzed data from multiple secondary sources. Stakeholders endorsed nine determinants of illegal dumping: Economic Decline, Scale of Vacancy, Lack of Monitoring, Poor Visibility, Physical Disorder, Illegal Activity, Norms, Accessibility, and Seclusion. Results demonstrate important community-identified, modifiable, social, and environmental characteristics related to illegal dumping with the potential to inform effective prevention.

Geochemical distribution and environmental risk assessment of trace metals in groundwater released from e-waste management activities in Lahore, Pakistan.

Non-sustainable e-waste recycling and dumping activities release trace metals into the ambient environment where they may threaten the biological communities and human health. A total of 45 groundwater and 21 leachate samples were collected from seven recycling, seven dumping, and one reference site in Lahore, Pakistan, and analyzed for Cu, Pb, Zn, Cd, Mn, and Fe in atomic absorption spectrophotometer. Comparing the results with the World Health Organization (WHO) standards of drinking water, only the concentrations of Cu, Zn, Mn, and Fe at all sites were found to be within the permissible limits, i.e., 2, 3, 0.5, and 1 mg/L, respectively. In leachates, only Cd and Mn at one site (0.204 and 8.636 mg/L, respectively) exceeded the allowable limits of National Environmental Quality Standards of Municipal and Liquid industrial effluents. Geo-accumulation index, contamination factor, contamination degree, and pollution load index values showed no to moderate contamination. The ecological risk index did not exceed 150, depicting low risk to nearby biological communities. The non-carcinogenic health risk assessment showed a hazard index value greater than 1 at all sites for children (2.04) and adults (1.52), with Pb being the major contributor to adverse health impacts via ingestion and dermal route. Children (1.21 × 10-4) were at a more significant threat of carcinogenic risk from Pb and Cd as compared to adults (8.10 × 10-5). Therefore, there is a dire need to introduce sustainable e-waste recycling and managing techniques to reduce further groundwater contamination via the percolation of trace metals and to reduce the current contamination level.

Transoral Outlet Reduction (TORe) for the Treatment of Weight Regain and Dumping Syndrome after Roux-en-Y Gastric Bypass.

Obesity is a chronic relapsing disease of global pandemic proportions. In this context, an increasing number of patients are undergoing bariatric surgery, which is considered the most effective weight loss treatment for long-term improvement in obesity-related comorbidities. One of the most popular bariatric surgeries is the Roux-en-Y gastric bypass (RYGB). Despite its proven short- and long-term efficacy, progressive weight regain and dumping symptoms remain a challenge. Revisional bariatric surgery is indicated when dietary and lifestyle modification, pharmaceutical agents and/or psychological therapy fail to arrest weight regain or control dumping. However, these re-interventions present greater technical difficulty and are accompanied by an increased risk of peri- and postoperative complications with substantial morbidity and mortality. The endoscopic approach to gastrojejunal anastomotic revision, transoral outlet reduction (TORe), is used as a minimally invasive treatment that aims to reduce the diameter of the gastrojejunal anastomosis, delaying gastric emptying and increasing satiety. With substantial published data supporting its use, TORe is an effective and safe bariatric endoscopic technique for addressing weight regain and dumping syndrome after RYGB.

"The rich will always be able to dispose of their waste": a view from the frontlines of municipal failure in Makhanda, South Africa.

A significant proportion of South African municipalities, who hold the mandate for providing solid waste management (SWM) services for millions of South Africans, appear to be on the brink of collapse. On the frontlines of municipal failure, the city of Makhanda, following two decades of poor governance and mismanagement, has found itself unable to fulfil its mandate, with the state retreating on SWM service provision, and disruptions to waste management services becoming a daily reality. Drawing on embedded, qualitative fieldwork, this article examines how differently placed residents have experienced disruptions to SWM services. This work explores how residents of Makhanda's two halves: the affluent and predominantly white neighbourhoods in the west, and the poor, non-white townships in the east, have (or have not) adapted to manage and dispose of their own waste during periods of disruption. Findings suggest that disruptions to waste management service provision have been broadly experienced by residents. However, the consequences of interruptions to municipal collection have not been evenly borne, as more resourced, western residents have been more successful at managing their own waste disposal, while the residents of Makhanda's townships are less capable of coping, with affected communities coming to resemble a dumping ground, and residents having to adopt unsafe or environmentally harmful disposal practices. These findings are important because they shed light on the challenges of creating cleaner, more equal communities without healthy municipal participation in waste management services, while raising important considerations for a South Africa facing the possibility of widespread municipal collapse.