Surgical Intelligence Can Lead to Higher Adoption of Best Practices in Minimally Invasive Surgery.

OBJECTIVE: To examine the use of surgical intelligence for automatically monitoring critical view of safety (CVS) in laparoscopic cholecystectomy (LC) in a real-world quality initiative. BACKGROUND: Surgical intelligence encompasses routine, artificial intelligence-based capture and analysis of surgical video, and connection of derived data with patient and outcomes data. These capabilities are applied to continuously assess and improve surgical quality and efficiency in real-world settings. METHODS: Laparoscopic cholecystectomies conducted at 2 general surgery departments between December 2022 and August 2023 were routinely captured by a surgical intelligence platform, which identified and continuously presented CVS adoption, surgery duration, complexity, and negative events. In March 2023, the departments launched a quality initiative aiming for 75% CVS adoption. RESULTS: Two hundred seventy-nine procedures were performed during the study. Adoption increased from 39.2% in the 3 preintervention months to 69.2% in the final 3 months ( P < 0.001). Monthly adoption rose from 33.3% to 75.7%. Visualization of the cystic duct and artery accounted for most of the improvement; the other 2 components had high adoption throughout. Procedures with full CVS were shorter ( P = 0.007) and had fewer events ( P = 0.011) than those without. OR time decreased following intervention ( P = 0.033). CONCLUSIONS: Surgical intelligence facilitated a steady increase in CVS adoption, reaching the goal within 6 months. Low initial adoption stemmed from a single CVS component, and increased adoption was associated with improved OR efficiency. Real-world use of surgical intelligence can uncover new insights, modify surgeon behavior, and support best practices to improve surgical quality and efficiency.

Implementation of artificial intelligence-based computer vision model in laparoscopic appendectomy: validation, reliability, and clinical correlation.

BACKGROUND: Application of artificial intelligence (AI) in general surgery is evolving. Real-world implementation of an AI-based computer-vision model in laparoscopic appendectomy (LA) is presented. We aimed to evaluate (1) its accuracy in complexity grading and safety adherence, (2) clinical correlation to outcomes. METHODS: A retrospective single-center study of 499 consecutive LA videos, captured and analyzed by 'Surgical Intelligence Platform,' Theator Inc. (9/2020-5/2022). Two expert surgeons viewed all videos and manually graded complexity and safety adherence. Automated annotations were compared to surgeons' assessments. Inter-surgeons' agreements were measured. Since 7/2021 videos were linked to patients' admission numbers. Data retrieval from medical records was performed (n = 365). Outcomes were compared between high and low complexity grades. RESULTS: Low and high complexity grades comprised 74.8 and 25.2% of 499 videos. Surgeons' agreements were high (76.9-94.4%, kappa 0.77/0.91; p < 0.001) for all annotated complexity grades. Surgeons' agreements were also high (96.0-99.8%, kappa 0.78/0.87; p < 0.001) for full safety adherence, whereas agreement was moderate in partial safety adherence and none (32.8-58.8%). Inter-surgeons' agreements were high for complexity grading (kappa 0.86, p < 0.001) and safety adherence (kappa 0.88, p < 0.001). Comparing high to low grade complexity, preoperative clinical features were similar, except larger appendix diameter on imaging (13.4 ± 4.4 vs. 10.5 ± 3.0 mm, p < 0.001). Intraoperative outcomes were significantly higher (p < 0.001), including time to achieve critical view of safety (29.6, IQR 19.1-41.6 vs. 13.7, IQR 8.5-21.1 min), operative duration (45.3, IQR 37.7-65.2 vs. 25.0, IQR 18.3-32.7 min), and intraoperative events (39.4% vs. 5.9%). Postoperative outcomes (7.4% vs. 9.2%) including surgical complications, mortality, and readmissions were comparable (p = 0.6), except length of stay (4, IQR 2-5.5 vs. 1, IQR 1-2 days; p < 0.001). CONCLUSION: The model accurately assesses complexity grading and full safety achievement. It can serve to predict operative time and intraoperative course, whereas no clinical correlation was found regarding postoperative outcomes. Further studies are needed.

Rare Primary Retroperitoneal Neoplasms.

BACKGROUND: Primary retroperitoneal neoplasms (PRN) arise from diverse retroperitoneal tissues. Soft tissue sarcomas (STS) comprise the majority and are well studied. Other non-sarcomatous PRN are very rare and less familiar. OBJECTIVES: To evaluate the clinicopathologic and radiologic features of non-sarcomatous PRN, as well as the outcome of complete tumor resection (TR). METHODS: Retrospective data were collected on consecutive patients (June 2006 to January 2015) who underwent resection of retroperitoneal lesions at our department. Final pathology of non-sarcomatous PRN was included. RESULTS: The study population included 36 patients (26% with PRN). PRN were neurogenic (17%), fat-containing (3%), and cystic (6%). The preoperative diagnosis was correct in only 28%. All patients underwent TR via laparotomy (72%) or laparoscopy (28%), for mean operative time of 120 ± 46 minutes. En bloc organ resection was performed in 11%. Complete TR was achieved in 97%. Intra-operative spillage occurred in 8%. Intra-operative, 90-day postoperative complications, and mortality rates were 11%, 36%, and 0%, respectively. The mean length of stay was 6.5 ± 5.5 days. The median overall survival was 53 ± 4.9 months. CONCLUSIONS: Familiarity with radiologic characteristics of PRN is important for appropriate management. Counter to STS, other PRN are mostly benign and have an indolent course. Radical surgery is not required, as complete TR confers good prognosis. Expectant management is reserved for small, asymptomatic, benign neoplasms.

Weight Regain Following Roux-en-Y Gastric Bypass: Etiology and Surgical Treatment.

BACKGROUND: The Roux-en-Y gastric bypass (RYGB) surgery helps patients achieve excellent excess weight loss, with subsequent improvement or resolution of co-morbidities. However, up to 20% of all RYGB patients, and 40% of the super morbidly obese, experience significant weight regain. The etiology of weight regain is multifactorial; hence, multidisciplinary management is mandatory. Revision options for failed conservative and medical management include resizing the restrictive component of the bypass or intensifying malabsorption. While improvement of restriction generally has limited efficacy, intensifying malabsorption achieves significant long-term excess weight loss. The optimal surgical option should be personalized, considering eating behavior and psychological issues, surgical anatomy of the bypass, and anesthetic and surgical risks.

Cytoreduction surgery with hyperthermic intraperitoneal chemotherapy in recurrent ovarian cancer improves progression-free survival, especially in BRCA-positive patients- a case-control study.

BACKGROUND: Approximately 70% of women diagnosed with advanced-stage ovarian cancer experience disease recurrence. Survival data were compared between a group of recurrent epithelial ovarian cancer (rEOC) patients treated by cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC) and a matched group of rEOC patients treated by systemic chemotherapy only (without surgery). Treatment outcome in relation to the patients' BRCA status was compared. METHODS: Twenty-seven rEOC patients treated by cytoreduction and HIPEC were selected from our database and matched (1:3) with 84 rEOC patients treated with chemotherapy only. Progression-free survival (PFS) and overall survival (OS) in the two groups were analyzed and compared. RESULTS: The estimated median PFS was 15 months in the HIPEC group and 6 months in the systemic chemotherapy group (P = 0.001). The median OS following HIPEC treatment has not been reached, since more than 70% of the women were alive at the time of analysis. The 5-year survival rate was significantly higher in the HIPEC treated patients compared to that of the controls (79% vs. 45%, P = 0.016). BRCA status did not affect PFS. CONCLUSIONS: HIPEC after surgical cytoreduction in patients with rEOC appears beneficial compared to systemic chemotherapy treatment alone. The benefit is even greater in BRCA mutation carriers.

Implementation of Artificial Intelligence-Based Computer Vision Model for Sleeve Gastrectomy: Experience in One Tertiary Center.

INTRODUCTION: Sleeve gastrectomy (SG) is the most common metabolic and bariatric procedure performed. Leveraging artificial intelligence (AI) for automated real-time data structuring and annotations of surgical videos has immense potential of clinical applications. This study presents initial real-world implementation of AI-based computer vision model in sleeve gastrectomy (SG) and external validation of accuracy of safety milestone annotations. METHODS: A retrospective single-center study of 49 consecutive SG videos was captured and analyzed by the AI platform (December 2020-August 2023). A bariatric surgeon viewed all videos and assessed safety milestones adherence, compared to the AI annotations. Patients' data were retrieved from the bariatric unit registry. RESULTS: SG total duration was 47.5 min (interquartile range 36-64). Main steps included preparation (12.2%), dissection of the greater curvature (30.8%), gastric transection (28.5%), specimen extraction (7.2%), and final inspection (14.4%). Out of body time comprised 6.9% of the total video. Safety milestones components and AI-surgeon agreements included the following: bougie insertion (100%), distance from pylorus ≥ 2 cm (100%), parallel to lesser curvature (98%), fundus mobilization (100%), and distance from esophagus ≥ 1 cm (true-100%, false-13.6%; kappa coefficient 0.2, p = 0.006). Intraoperative complications included notable hemorrhage (n = 4) and parenchymal injury (n = 1). CONCLUSIONS: The AI model provides a fully automated SG video analysis. Outcomes suggest its accuracy in four of five safety milestone annotations. This data is valuable, as it reflects objective performance measures which can help us improve the surgical quality and efficiency of SG. Larger cohorts will enable SG standardization and clinical correlations with outcomes, aiming to improve patients' safety.

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.

Esophagogastric cancer surgery characteristics and outcomes in bariatric patients, compared with non-bariatric patients.

BACKGROUND: The association between bariatric surgery and esophagogastric cancer (EGC) is debated. This study aimed to assess EGC characteristics and surgery outcomes comparing bariatric and non-bariatric patients. METHODS: Single-center retrospective analysis of prospective EGC surgery database. RESULTS: EGC-surgery was performed in 269 patients, classified as bariatric (N.=10, 3.3%), and non-bariatric (N.=259, 96.6%) groups. Non-bariatric group was sub-classified into body mass index (BMI) <35 kg/m2 (N.=244) and >35 kg/m2 (N.=15). BMI was 35.3±5.6 vs. 25.7±16.1 and 37.8±8.7 kg/m2 in bariatric vs. non-bariatric-BMI <35 and >35, respectively (P<0.001). Bariatric patients were significantly younger (56.75±11 vs. 71±10 and 68.38±8.2 years; P<0.001). They tended to have lower rates of diabetes mellitus (30% vs. 43.9% and 73.3%; P=0.05) and significantly lower hypertension rates (50%, vs.86.5% and 93.3%, P<0.004). Bariatric procedures were performed 11.3 years (IQR 5.5-16.5) prior to EGC-surgery. Tumor characteristics were statistically comparable except a significantly higher number of positive LN in the bariatric group (6.9±13.6 vs. 2.7±4.9 and 1.9±4.8; P=0.006), and more bariatric patients received adjuvant treatment (P=0.035). Postoperative major complication rates (0% vs. 25.8%, and 33.3%; P=0.14) and length of hospital stay (14.1±15.3, vs. 23±28.5, and 21±18 days; P=0.59) were comparable. There was no significant difference in Disease- free survival (P=0.42) or overall survival (P=0.48) between patient-groups. CONCLUSIONS: Bariatric patients were diagnosed with EGC at a younger age, and tended to have worse nodal involvement. Although outcomes were comparable, clinical and endoscopic surveillance seem important as EGC can occur 10 years or earlier than in non-bariatric patients.

Implementation of updated enhanced recovery after bariatric surgery guidelines: adapted protocol in a single tertiary center.

The aim of this study is to evaluate the effects of an adapted protocol of enhanced recovery after bariatric surgery (ERABS) on outcomes. This is a single-center observational study comparing patients managed according to adapted ERABS protocol (March-May 2022) with a control group of old method (January 2021-February 2022). Totally, 253 bariatric patients were included in the study (n = 68) and control (n = 185) groups. Patients were mostly females (57.3% vs 70.2%; p = 0.053), of mean age 38.8 years and body mass index 41 ± 6.53 vs. 44.60 ± 7.37 kg/m2 (p = 0.007) in study and control groups, respectively. The majority (90.5%) underwent primary bariatric surgery. Adapted ERABS protocol compliance was 98.5%. The study group had shorter hospital stay (mean 2.86 ± 0.51 vs. 4.03 ± 0.28 days; p < 0.001), similar rates of total (3% vs. 2.7%, p = 0.92) and major complications (1.5% vs. 0, p = 0.10). Readmission rates were similar (1.5% vs 1.6%, p = 0.92). Applied only in the study group, early ambulation (p < 0.001), opioid restriction, and preventing postoperative nausea and vomiting (PONV), resulted in satisfactory scores (mean total visual analogue score 1.93 ± 0.80, morphine milligram equivalent 34.0 ± 14.5, and mean total PONV grade 0.17 ± 0.36). In conclusion, implementing adapted ERABS guidelines improved patients' postoperative care, raising awareness to pain management. Length of stay was shortened without safety compromise. Efforts to abandon old-school routines seem worthwhile, even if ERABS is partially implemented.

Long-term outcomes and patterns of recurrence in patients with thin melanoma and a negative sentinel lymph node biopsy: a single-center experience.

The majority of patients diagnosed with melanoma have thin melanomas (≤1 mm). Data on the rate and pattern of recurrence after a negative sentinel lymph node biopsy (SLNB) are sparse. We retrospectively searched our institutional database and retrieved the records of patients with thin melanomas who underwent an SLNB with negative results. We analyzed patterns of recurrence, time to recurrence, and mode of diagnosis. Thirteen of the 198 patients with thin melanomas and negative SLNB results had tumor recurrence (6.5%): two local in transit (15.4%), three regional (21.3%), and eight distant (61.5%). Distant recurrences tended to occur later than local or regional ones [median disease-free survival = 50 months (95% confidence interval: 36.1-63.9) vs. 34 and 15 months (95% confidence interval: 5.4-24.6), P = 0.005, respectively]. The percentage of patients with tumor thickness ≥0.8 mm was higher among those who sustained recurrence (84.6 vs. 64.9% for no recurrence, P = 0.04). The majority of patients with recurrence were not being followed up when diagnosed (69%), and they are presented because of clinical symptoms. Patients with recurrence had lower survival compared with those without recurrence (median: 118 months vs. ongoing survival, P < 0.001, respectively). Melanoma recurrence in patients with thin melanomas and negative SLNBs is rare, tends to be distant, and negatively affects prognosis. Recurrence tends to occur in patients with melanoma thickness ≥0.8 mm. Further studies are needed to identify patients with high recurrence risk and determine optimal follow-up protocols.

Sleeve gastrectomy after liver transplantation: results of a 5-year follow-up.

BACKGROUND: Severe obesity and metabolic syndrome are common long-term complications after liver transplantation (LT). Metabolic bariatric surgery (MBS) is the essential treatment for severe obesity with laparoscopic sleeve gastrectomy (SG) being the most commonly performed procedure. METHODS: This is a retrospective analysis of all LT patients who underwent MBS between January 2006 and December 2020 in a single tertiary center. RESULTS: During the study period, a total of 226 LTs were performed. Four patients (1.8%) underwent SG following LT. Time interval from LT to SG ranged 11-72 months. The median Body Mass Index (BMI) before LT and SG was 38.8(±6.5) and 41.8(±2.7) kg/m2, respectively. All patients suffered from type II diabetes mellitus (T2DM) with a median A1c level of 5.9% (±1) under medications. All patients were consuming immunosuppressants perioperatively. All surgeries were approached laparoscopically, the median operative time was 65.5 minutes (±47.6), there were no intra-operative complications, and no conversions to open surgery. There were no early (30-day) major complications. The median length of stay was 3.5 days (±3.6). The median range of follow-up was 61.6 months (±18.2), there were no late (>30 day) complications. The median BMI at 24, and 60 months was 29.61(±3.9) and 31.10(±2.6) kg/m2, respectively. The median percentage of total weight loss at 24, and 60 months was 29.18 (±5.2) and 28.87(±3.7), respectively. The median percentage of excess weight loss at 24 and 60 months was 60.5% (±13) and 58.57% (±11.7), respectively. Three patients had T2DM resolution. CONCLUSIONS: SG following LT is associated with low perioperative morbidity and satisfactory long-term results.

Long-Term Results of Laparoscopic Sleeve Gastrectomy: a Review of Studies Reporting 10+ Years Outcomes.

Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure worldwide. Systematic search of Pubmed, Cochrane, and Embase was performed in order to find all the articles reporting 10+ years of LSG results. Eleven studies including 1020 patients met the inclusion criteria. Overall weighted mean %TWL was 24.4% (17-36.9%), and remission rates from TD2M to HTN were 45.6% (0-94.7%) and 41.4% (0-78.4%), respectively. De novo GERD had an overall prevalence of 32.3% (21.4-58.4%), and five cases (0.5%) of Barrett's disease were reported. Revisional surgery was required for 19.2% (1-49.5%) of patients, Roux-en-Y gastric bypass being the most common secondary procedure.

Safety of concomitant cholecystectomy during one anastomosis gastric bypass compared with sleeve gastrectomy and Roux-en-Y gastric bypass.

Candidates of metabolic and bariatric surgery (MBS) are prone for gallstone formation. Concomitant cholecystectomy (CC) during MBS is controversial. This study is first to examine the safety of CC during one anastomosis gastric bypass (OAGB), compared with sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). Single-center retrospective comparative study of CC (2012-2021) during OAGB, to SG and RYGB. CC was performed in 115 patients during OAGB (n = 50), SG (n = 39), and RYGB (n = 26). All procedures were completed laparoscopically. Baseline characteristics were similar except age, body mass index, gastroesophageal reflux disease, obstructive sleep apnea, and previous MBS (p < 0.05). Intraoperative complications occurred in one OAGB patient (2% vs. 0%, 0%; p = 0.52), which was not cholecystectomy related. There were no differences in total (6% vs. 2.6%, 15.4%; p = 0.13) and major (2% vs. 0%, 3.8; p = 0.50) early-complication rates. Of them, cholecystectomy-related complications occurred in one OAGB, compared with none of SG and one RYGB (2% vs. 0%, 3.8%; p = 0.50). The former was major, and the latter was minor complication. None of the OAGB patients needed re-admission (0% vs. 0%, 11.5; p = 0.04). All CC outcome parameters were similar between asymptomatic and symptomatic gallstones. Previous bariatric procedures were found to be a significant risk for major complications and readmissions (OR = 16.87, p = 0.019). CC during OAGB for gallstones seems safe, as in SG and RYGB. No cholecystectomy-related intraoperative complications occurred, and postoperative complication rates were low and acceptable. Outcomes for asymptomatic gallstones were similar to symptomatic ones, and we cautiously support CC in the presence of gallstones.

Comparison of One Anastomosis Gastric Bypass and Sleeve Gastrectomy for Revision of Laparoscopic Adjustable Gastric Banding: 5-Year Outcomes.

PURPOSE: Laparoscopic adjustable gastric banding (LAGB) is in continuous decline due to low effectiveness and high reoperation rates. This study aims to evaluate outcomes of converting LAGB to one anastomosis gastric bypass (OAGB) and sleeve gastrectomy (SG) for insufficient weight loss or weight regain. MATERIALS AND METHODS: Retrospective comparative study, based on prospective registry database of a tertiary center (2012-2019). RESULTS: In all, 276 LAGB patients were converted to OAGB (n = 125) and SG (n = 151). Body mass index (BMI) at revision was 41.3 ± 6.6 and 42.3 ± 9.6 kg/m2 (P = 0.34) in OAGB and SG patients, respectively. Time interval was longer in OAGB patients (p < 0.001). Major early complication rates were comparable (2.4% and 4%; p = 0.46). At 5-years, OAGB patients had lower BMI (31.9 vs. 34.5 kg/m2; p = 0.002), and a higher total weight loss (25.1% vs. 18.8%; p = 0.003), compared with SG patients. Resolution of type 2 diabetes was higher in OAGB patients (93.3% vs. 66.6%; p = 0.047), while resolution of hypertension was not significantly different (84.6% and 80.5%; p = 0.68). Revision due to delayed complications was required in five (4%) OAGB patients and nine (8.6%) SG patients (p = 0.14). CONCLUSION: OAGB for revision after LAGB due to insufficient weight loss or weight regain is safe, and has better effectiveness in weight reduction and resolution of type 2 diabetes than SG.

The Effect of Revisional One Anastomosis Gastric Bypass After Sleeve Gastrectomy on Gastroesophageal Reflux Disease, Compared with Revisional Roux-en-Y Gastric Bypass: Symptoms and Quality of Life Outcomes.

BACKGROUND: Gastroesophageal reflux disease (GERD) is common after sleeve gastrectomy (SG). We aimed to evaluate the effect of revisional one anastomosis gastric bypass (OAGB) on GERD, compared with revisional Roux-en-Y gastric bypass (RYGB) METHODS: A retrospective single-center study of a prospectively maintained patient registry (2018-2022). All patients with GERD undergoing OAGB and RYGB after SG were retrieved and included in the study. RESULTS: Seventy-eight SG patients had conversion to OAGB (n=31) and RYGB (n=47). Baseline characteristics were similar except age (43.8±11.5 vs. 50.3±13.4 years; p=0.03), body mass index (39.9±8.8 vs. 30.6±6 kg/m2; p<0.001), time interval (8±2.7 vs. 6.4±3.4 years; p=0.01), and sleep apnea (29% vs 8.5%; p=0.01), respectively. There was no significant difference between groups in number of patients consuming proton pump inhibitors (70.1% vs. 72.3%; p=0.66), GERD-health-related quality of life (HRQL) score (9.6±7.2 vs. 13.1±8; p=0.06), and pathological endoscopic findings (48.4% vs. 46.8%; p=0.89). Major complication rates were 0% vs. 8.5% (p=0.09). At 32.4 months follow-up, total weight loss was 22%±12.9 and 4.4%±14.6 (p<0.001), GERD resolution 77.4% and 91.9% (p=0.03), HRQL scoring improved to 1.7±4.5 and 1.7±2.7; p=0.94 for OAGB and RYGB, respectively. CONCLUSIONS: SG conversion to RYGB provides better chances for definitive treatment of GERD. OAGB results in good symptom resolution and improved quality of life and may be considered for post-SG GERD treatment. The most appropriate solution should be individualized to each patient.

One Anastomosis Gastric Bypass Compared with Sleeve Gastrectomy in Elderly Patients: Safety and Long-term Outcomes.

BACKGROUND: As life expectancy increases, more elderly patients are being considered for metabolic bariatric surgery. We aimed to assess the safety and long-term effectiveness of one anastomosis gastric bypass (OAGB) compared to sleeve gastrectomy (SG). METHODS: Single-center retrospective comparative study of OAGB and SG (2012-2019) in patients aged ≥ 65 years. RESULTS: In all, 124 patients underwent OAGB (n = 41) and SG (n = 83). Mean age was 67.6 ± 2.8 and 67.6 ± 2.6 years (p = 0.89), respectively. Baseline characteristics were comparable, except lower rates of hypertension (HTN) and non-alcoholic fatty liver disease in OAGB than SG patients (43.9% vs. 74.6%; p < 0.001, and 39.0% vs. 89.1%; p < 0.001, respectively). Body mass index (BMI) of OAGB and SG patients decreased from 41.8 ± 7.8 and 43.3 ± 5.9 kg/m2 (p = 0.25) to 28.6 ± 4.7 and 33.2 ± 5.3 (p < 0.001), at long-term follow-up, respectively. Excess weight loss (EWL) > 50% was achieved in 80.6% and 43.2% of OAGB and SG patients, with a mean EWL of 67.2% ± 22.3 and 45.8% ± 18.0 (p < 0.001) and a mean total weight loss (TWL) of 30.7% ± 10.4 and 21.9% ± 8.1 (p < 0.001), respectively. Resolution rates of obesity-associated medical problems were similar, except type 2 diabetes (T2D) and HTN, which were 86.6% and 73.3% in OAGB, compared with 29.7% and 36.3% in SG patients (p < 0.001 and p = 0.001), respectively. Major early complication rates were comparable (2.4% vs. 3.6%; p = 0.73, respectively). Revision for late complications was required in two OAGB patients. CONCLUSIONS: OAGB in the elderly is safe and results in better long-term weight reduction and resolution of T2D and HTN than SG.

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.

Immunological effects of heated intraperitoneal chemotherapy can be augmented by thymosin α1.

BACKGROUND: Peritoneal metastases of colorectal carcinoma origin (PM-CRC) are treated by cytoreductive surgery and heated intraperitoneal chemotherapy (HIPEC). However, the majority of patients recur, calling for novel treatments. We explored the immunogenic changes induced by HIPEC and the possibility to use thymosin α1 (Tα1) as an immune-stimulatory agent. METHODS: We used an experimental murine model of PM-CRC combined with mitomycin (MMC)-based HIPEC. We determined immune cell infiltration into tumor metastases after HIPEC administration by means of immunohistochemistry, and determined immunogenic cell death signals in tumor cells by real-time polymerase chain reaction. RESULTS: Mice with PM-CRC treated by HIPEC had increased overall survival (OS) compared to sham-treated mice (median OS 22.8 vs 18.9 days, respectively; P < 0.001). HIPEC induced increased infiltration of CD4+, CD8+, CD68 + and CD20 + cells into omental and visceral metastases at a magnitude of 40-100 %. We searched for potential immune signals induced by HIPEC by determining its effects on known immunogenic cell death proteins (heat-shock protein [HSP]-70, HSP-90 and calreticulin). HIPEC significantly increased HSP-90 mRNA expression (2.37 ± 1.5 vs 1-fold change, P < 0.05). The OS of Tα1 treated mice significantly improved compared to HIPEC-treated mice (16.3 ± 0.8 vs 14.1 ± 0.6 days, respectively, P = 0.02) and vs sham (11.8 ± 0.8 days, P = 0.007). CONCLUSIONS: HIPEC induced immunogenic changes that led to increased immune cell infiltration. These changes were further augmented by Tα1 treatment. Future studies aimed at optimizing Tα1 treatment should focus upon the immune response it evokes.

One Anastomosis Gastric Bypass for Revision of Restrictive Procedures: Mid-Term Outcomes and Analysis of Possible Outcome Predictors.

PURPOSE: Revisional one anastomosis gastric bypass (OAGB) for insufficient weight reduction following primary restrictive procedures is still investigated. We report mid-term outcomes and possible outcome predictors. MATERIALS AND METHODS: Single-center retrospective comparative study of revisional OAGB outcomes (2015-2018) following laparoscopic adjustable gastric banding (LAGB) and sleeve gastrectomy (SG); silastic ring vertical gastroplasty (SRVG) is separately discussed. RESULTS: In all, 203 patients underwent revisional OAGB following LAGB (n = 125), SG (n = 64), and SRVG (n = 14). Comparing LAGB and SG, body mass index (BMI) at revision were 41.3 ± 6.6 and 42 ± 11.2 kg/m2 (p = 0.64), reduced to 31.3 ± 8.3 and 31.9 ± 8.3 (p = 0.64) at mid-term follow-up, respectively. Excess weight loss (EWL) > 50% was achieved in ~ 50%, with EWL of 79.4 ± 20.4% (corresponding total weight loss 38.5 ± 10.4%). SRVG patients had comparable outcomes. Resolution rates of type 2 diabetes (T2D) and hypertension (HTN) were 93.3% and 84.6% in LAGB compared with 100% and 100% in SG patients (p = 0.47 and p = 0.46), respectively. In univariable analysis, EWL > 50% was associated with male gender (p < 0.001), higher weight (p < 0.001), and BMI (p = 0.007) at primary surgery, and higher BMI at revisional OAGB (p < 0.001). In multivariable analysis, independent predictors for EWL > 50% were male gender (OR = 2.8, 95% CI 1.27-6.18; p = 0.01) and higher BMI at revisional OAGB (OR = 1.11, 95% CI 1.03-1.19; p = 0.006). CONCLUSION: Revisional OAGB for insufficient restrictive procedures results in excellent weight reduction in nearly 50% of patients, with resolution of T2D and HTN at mid-term follow-up. Male gender and higher BMI at revision were associated with EWL > 50% following revisional OAGB. Identification of more predictors could aid judicious patient selection.