Bariatric surgery for metabolic unhealthy obesity (MUO) during the COVID era: short-term results of a high-volume center.

PURPOSE: During the coronavirus disease 19 (COVID-19) outbreak, most public hospitals worldwide have been forced to postpone a major part of bariatric surgery (BS) operations with unfavorable consequences for weight and obesity complications. The aim of this study was to evaluate the effectiveness and safety of laparoscopic BS on subjects with metabolically unhealthy obesity (MUO) during COVID-19 pandemic in a high-volume Italian center. METHODS: Between March 2020 and January 2021, all patients with MUO submitted to laparoscopic BS (sleeve gastrectomy [SG], one anastomosis gastric bypass [OAGB] and Roux-en-Y gastric bypass [RYGB]) were enrolled according to the ATP III Guidelines, with a minimum follow-up of 3 months. RESULTS: In the study period, 210 patients with MUO underwent laparoscopic BS (77 RYGB, 85 SG and 48 OAGB) in our obesity referral center. Postoperative major complications occurred in 4 patients (1.9%) with zero mortality. At 9-month follow-up, a total weight loss (TWL) of 28.2 ± 18.4, 26.1 ± 23.1 and 24.5 ± 11.3% (p = 0.042) was observed in RYGB, OAGB and SG groups, respectively. The rate of comorbidity resolution was very similar for all type of surgeries (p = 0.871). Only two cases of postoperative SARS-CoV-2 infection were registered (0.9%) and both cases resolved with medical therapy and observation. CONCLUSION: Among the patients studied, all surgical techniques were safe and effective for MUO during the COVID era. This group of patients is at high risk for general and SARS-CoV-2-related mortality and therefore should be prioritized for BS. LEVEL OF EVIDENCE: Level III, single-center retrospective cohort study.

The burden of depressive disorders in musculoskeletal diseases: is there an association between mood and inflammation?

IMPORTANCE: Evidence emerged concerning how inflammatory arthritis and mood disorders can often occur in the same patient and show a similar clinical pattern. An overview of the rheumatological and psychiatric aspects of these diseases can certainly be useful for the improvement of patients' clinical and therapeutic management. OBJECTIVE: The aim of this narrative review was to summarize existing literature about common pathogenetic and clinical aspects as a means of improving management and therapeutic approach in patients affected by rheumatoid arthritis, psoriatic arthritis and spondyloarthritis. Outcomes such as disease activity indexes and patient reported outcomes (PROs) were considered. FINDINGS: Common pathogenetic pathways emerged between inflammatory arthritis and mood disorders. Pro-inflammatory mechanisms, such as TNFα, IL-6, IL-17 and oxidative stress factors as well as neurotransmitter alterations at the level of CNS and blood-brain barrier (BBB) cells are involved. The activation of these common pathogenetic pathways is, also, affected by the same triggers, such as smoking, stress, lifestyle, and evidence has emerged concerning the possibility of the clinical efficacy of using the same therapeutic approaches. CONCLUSIONS: The main causes of the variability in clinical studies outcomes are the rheumatological diseases considered, the prevalence of depression in the general population and in patients with rheumatological diseases and the type of depressive symptom examined. Patients affected by inflammatory arthritis can present symptoms and signs in common with mood disorders, leading to possible clinical overlap. There are still few studies analyzing this concept: they are extremely heterogeneous, both in the characteristics of the population taken into consideration and in the methods used for the definition of depressive disorder, but the suggestions of the data obtained so far are promising and deserve to be pursued.

Laparoscopic sleeve gastrectomy for morbid obesity and Klinefelter syndrome: clinical report on two patients, with long-term follow-up.

INTRODUCTION: Klinefelter syndrome (KS) can appear as a wide spectrum of clinical manifestations, with no guidelines for appropriate treatment. We present the first study of bariatric surgery (BS) with a 48-month follow-up, for the management of two patients affected by obesity and KS. CASES PRESENTATION: The first patient was a 32-year-old man with diagnosis of Klinefelter mosaicism (46 XY/47, XXY), Body Mass Index (BMI) of 50 kg/m2, metabolic syndrome and Binge Eating Disorder (BED). He underwent a Laparoscopic Sleeve Gastrectomy (LSG) with weight loss (BMI = 38 kg/m2) and improvements to his metabolic profile at 48 months. The second patient was a 44-year-old man with KS (47, XXY), BMI of 49 kg/m2, Obstructive Sleep Apnea Syndrome and BED. He underwent a banded LSG. After 48 months, he showed a satisfactory weight loss (BMI = 32 kg/m2) and amelioration of comorbidities. CONCLUSION: In patients with KS, LSG demonstrated long-term beneficial effects for weight loss and amelioration of comorbidities. An interdisciplinary approach is mandatory, since it leads to adherence to follow-up programs and mental health well-being.

Assessing psychopathology in bariatric surgery candidates: discriminant validity of the SCL-90-R and SCL-K-9 in a large sample of patients.

PURPOSE: Pre-surgical psychosocial evaluation of bariatric surgery (BS) patients should identify psychiatric issues that could worsen after surgery and those requiring additional ongoing intervention. In this view, the use of reliable, appropriate and concise evaluating instruments is of critical importance. The aim of the present study was to investigate the clinical utility of both the Symptom Checklist 90-Revised (SCL-90-R) and its brief unidimensional version, the so-called Symptom-Checklist-K-9 (SCL-K-9) in detecting the presence of psychiatric disorders among bariatric surgery (BS) candidates. METHODS: Seven-hundred-and-ninety-eight BS candidates (563 women and 235 men; mean age: 44.15 ± 11.45) were enrolled in the present study. All participants underwent a full psychiatric interview and were administered the SCL-90-R. RESULTS: Three-hundred-and-sixty-two patients (45.4%) met the criteria for a diagnosis of at least one psychiatric disorder and ninety-nine patients (12.4%) had psychiatric comorbidities. In the current sample, 219 patients (27.4%) met the criteria for binge eating disorders (BED), 158 (19.8%) met the criteria for major depressive disorder (MDD), and 67 (8.4%) met both criteria. A receiver operating characteristic (ROC) curves procedure showed that both the SCL-90-R and the SCL-K-9 satisfactorily categorize patients with any psychiatric disorder, both BED and MDD (area under the ROC curve ≥ 0.70, p < 0.001). CONCLUSION: Our results suggest that the SCL-90-R and the SCL-K-9 may represent first-level screening tests identifying at-risk patients, eligible for a more expensive or time-consuming clinical assessment. LEVEL OF EVIDENCE: Level V, cross-sectional, descriptive study.

The anxious aspects of insecure attachment styles are associated with depression either in pregnancy or in the postpartum period.

BACKGROUND: Perinatal depression (PND) is a major complication of pregnancy and many risk factors have been associated with its development both during pregnancy and postpartum. The transition to motherhood activates the attachment system. The aim of our study was to investigate the relationship between women's attachment style (AS) and PND in pregnancy, and 1 month after childbirth, in a large cohort of women. We hypothesized that different patterns of AS were associated with either antenatal or postnatal depression. We, further, explored the role of other possible risk factors such as life-stress events. METHODS: A final sample of 572 women was enrolled. At the third trimester of pregnancy, clinical data sheet and self-report questionnaires (ASQ, PSS, LTE-Q, and EPDS) were administered. One month after delivery, EPDS was administered by telephone interview. RESULTS: We found 10.1% of the women with depression during pregnancy and 11.1% in the postpartum period. The first logistic regression showed that ASQ-CONF subscale (OR = 0.876, p < 0.0001), ASQ-NFA subscale (OR = 1.097, p = 0.002), foreign nationality (OR = 2.29, p = 0.040), low education levels (OR = 0.185, p = 0.012), PSS total score (OR = 1.376, p = 0.010), and recent life adversities (OR = 3.250, p = 0.012) were related to EPDS ≥ 14 during pregnancy.The second logistic regression showed that ASQ-PRE subscale (OR = 1.077, p < 0.001) and foreign nationality (OR = 2.88, p = 0.010) were related to EPDS ≥ 12 in the postpartum period. CONCLUSIONS: Different dimensions of anxious insecure AS were, respectively, associated with either antenatal or postnatal depression. These findings support the literature investigating subtypes of perinatal depression. The PND may be heterogeneous in nature, and the comprehension of psychopathological trajectories may improve screening, prevention, and treatment of a disorder which has a long-lasting disabling impact on the mental health of mother and child. We provided a rationale for targeting an attachment-based intervention in this group of women.

Switching from paliperidone palmitate 3-monthly long-acting injection to oral aripiprazole in a pregnant woman with schizophrenia: a case report and short review.

Treatment with long-acting injection (LAI) antipsychotics, such as paliperidone palmitate, has improved the quality of life in terms of symptoms and prevention of relapses in patients with schizophrenia. Although there are plenty of evidences about the efficacy and safety of paliperidone palmitate 3-monthly injection (PP3M) in adults with schizophrenia, literature appears lacking about the use of LAIs during pregnancy. We hereby describe the clinical case of a pregnant woman affected by schizophrenia (DSM-5-TR), taking pharmacological treatment of PP3M. Considering the inadequate evidence regarding the use of PP3M in pregnancy in agreement with the patient, we switched PP3M to an oral therapy with aripiprazole. The switch to oral aripiprazole allowed the patient to improve her sense of autonomy and strengthen the therapeutic relationship. To our knowledge, this is the first case report monitoring an entire pregnancy of a women affected by schizophrenia in treatment with PP3M injection and oral aripiprazole. No obstetrical or fetal complications were reported. As the research in this field is very demanding, it would be precipitous to derive final conclusions from the current case report, but we hope to build a growing number of data that would allow us to make more appropriate and safe therapeutic choices in such a vulnerable phase as the peripartum.

The Mother-Baby Bond: Role of Past and Current Relationships.

During the perinatal period, up to 25% of women experience difficulties in relating to their child. The mother-child bond promotes the transition to motherhood, protects the woman from depression, and protects the child from the intergenerational transmission of the disease. This study prospectively investigated if the relationship with the co-parent, the attachment style, and the bond that women had with their parents influenced the mother-fetus and then mother-child bond. We also explored the role of depression and anxiety. One hundred nineteen pregnant women were enrolled. We administered clinical interviews and psychometric tools. A telephone interview was conducted at 1, 3, and 6 months of follow-up. Maternal insecure attachment style (r = -0.253, p = 0.006) and women's dyadic adjustment in the couple's relationships (r = 0.182, p = 0.049) were correlated with lower maternal-fetal attachment. Insecure attachment styles and depression correlate with bottle-feeding rather than breastfeeding. The bond women had with their mothers, not their fathers, was associated with breastfeeding. Depression (OR = 0.243, p = 0.008) and anxiety (OR = 0.185, p = 0.004; OR = 0.304, p < 0.0001) were related to mother-infant bonding. Close relationships, past and present, affect the bond with the fetus and the child differently. Psychotherapy can provide reassuring and restorative intersubjective experiences.

Safety and Efficacy of Laparoscopic Vertical Clip Gastroplasty: Early Results of an Italian Multicenter Study.

PURPOSE: Sleeve gastrectomy, the most commonly performed bariatric surgery procedure, carries limitations both short term including postoperative complications such as hemorrhage and gastric fistula and long term such as weight regain and gastroesophageal reflux. A new procedure has been proposed to overcome many of these limitations: laparoscopic vertical clip gastroplasty (LVCG) with BariClip. MATERIALS AND METHODS: Fifty patients were offered LVCG and enrolled for a feasibility study in two referral bariatric centers. Indication was given as for sleeve gastrectomy, after a multidisciplinary path evaluating age, gender, BMI, comorbidities, eating behaviors, and gastroesophageal reflux. The primary outcome was major postoperative complications. Secondary outcomes included weight loss, incidence of de-novo GERD, and comorbidity resolution. RESULTS: Patients had a mean age of 44 years and mean BMI of 37 kg/m2 ± 6.2. All procedures were performed successfully in laparoscopy, with no conversion or intraoperative adverse events. The overall major postoperative complication rate was 6%. Re-operation was required in three patients for slippage. No mortality occurred. Excess weight loss, excess BMI loss, and total weight loss at 6 months were 36%, 57%, and 22%, respectively. There was no instance of de-novo GERD. Resolution of hypertension occurred in 50% of cases, OSAS in 65% of cases, and DMII in 80% of cases. CONCLUSION: The safety of LVCG procedure has been reproduced in a multicentric, multi-surgeon study. Weight loss outcomes appear promising. A randomized trial is needed to fully assess the benefits of LVCG.

Evolution of Bariatric Surgery in Italy in the Last 11 Years: Data from the SICOB Yearly National Survey.

BACKGROUND: Bariatric surgery (BS) is a relatively novel surgical field and is in continuous expansion and evolution. PURPOSE: Aim of this study was to report changes in Italian surgical practice in the last decade. METHODS: The Società Italiana di Chirurgia dell'Obesità (SICOB) conducted annual surveys to cense activity of SICOB centers between 2011 and 2021. Primary outcome was to detect differences in frequency of performance of adjustable gastric banding (AGB), sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), one anastomosis gastric bypass (OAGB), bilio-pancreatic diversion (BPD), and gastric plication (GP). Secondary outcome was to detect differences in performance of main non-malabsorptive procedures (AGB + SG) and overall bypass procedures (RYGB + OAGB). Geographical differences were also investigated. RESULTS: Median response rate was 92%. AGB declined from 36% of procedures in 2011 to 5% in 2021 (p < 0.0001). SG increased from 30% in 2011 to 55% in 2021 (p < 0.0001). RYGB declined from 25 to 12% of procedures (p < 0.0001). OAGB rose from 0% of procedures in 2011 to 15% in 2021 (p < 0.0001). BPD underwent decrease from 6.2 to 0.2% in 2011 and 2021, respectively (p < 0.0001). Main non-malabsorptive procedures significantly decreased while overall bypass procedures remained stable. There were significant differences among regions in performance of SG, RYGB, and OAGB. CONCLUSIONS: BS in Italy evolved significantly during the past 10 years. AGB underwent a decline, as did BPD and GP which are disappearing and RYGB which is giving way to OAGB. The latter is rising and is the second most-performed procedure after SG which has been confirmed as the preferred procedure by Italian bariatric surgeons.

Psychological Characteristics of Women with Perinatal Depression Who Require Psychiatric Support during Pregnancy or Postpartum: A Cross-Sectional Study.

Antenatal depression may be distinct from postpartum depression in terms of prevalence, severity of symptoms, comorbidities, prognosis, and risk factors. Although risk factors for perinatal depression have been identified, it is unclear whether there are differences in the onset of perinatal depression (PND). This study explored the characteristics of women requiring mental health support during pregnancy or postpartum. A sample of 170 women (58% in pregnancy; 42% postpartum) who contacted the SOS-MAMMA outpatient clinic was recruited. Clinical data sheets and self-report questionnaires (EPDS, LTE-Q, BIG FIVE; ECR; BSQ; STICSA) were administered, hypothesizing possible risk factors, such as personality traits, stressful life events, body dissatisfaction, attachment style, and anxiety. Hierarchical regression models were carried out in the pregnancy (F10;36 = 8.075, p < 0.001, adjR2 = 0.877) and postpartum groups (F10;38 = 3.082, p < 0.05, adjR2 = 0.809). Recent stressful life events and conscientiousness were associated with depression in both the pregnant (29.3%, 25.5% of variance) and postpartum groups (23.8%, 20.7% of variance). In pregnant women, "openness" (11.6%), body dissatisfaction (10.2%), and anxiety (7.1%) symptoms were predictive of depression. In the postpartum group, "neuroticism" (13.8%) and insecure romantic attachment dimensions (13.4%; 9.2%) were the strongest predictors. Perinatal psychological interventions should consider the differences between mothers with depression during pregnancy and postpartum.

Laparoscopic Banded One Anastomosis Gastric Bypass: A Single-Center Series.

INTRODUCTION: Laparoscopic one anastomosis gastric bypass (LOAGB) is a relatively new procedure for the treatment of morbid obesity and related comorbidities. On average, this procedure results in good postoperative weight loss with a low complication rate. Recent publications suggest that dumping syndrome and weight regain might be reduced by placing a silicone ring over the gastric pouch during the procedure, so called laparoscopic banded one anastomosis gastric bypass (LBOAGB). METHODS: 86 patients undergoing LBOAGB between 2018 and 2020 were enrolled in this retrospective study. Hospital records were used to assess weight loss, comorbidity resolution, and any complications either in the short or medium term. RESULTS: 54 Female and 32 male patients were included with a mean age of 43 years (25-64), preoperative body mass index of 42 kg/m2 (35-49), and preoperative weight of 114 kg (86-162). Thirty-four patients presented with type 2 diabetes (39.5%), 42 patients (49%) diagnosed with hypertension, 24 presented with OSAS (28%), and 21 (24%) hypercholesterolaemia patients were included. In total, 36 patients were diagnosed with multiple comorbidities. The operative data showed an average operative time of 48 minutes with 3.4% of patients suffering from early (minor) complications and 2.3% with a late (minor) complication. One patient required reoperation due to intra-abdominal bleeding. The median length of hospital stay was 2.5 days. Median follow-up was 18 months (5-36). In that period, no patient required ring removal or conversion to Roux-en-Y gastric bypass surgery. Food intolerance/vomiting was present in 1 patient (1.1%), bile reflux was present in 1 patient (1.1%), and no stomal ulcers were observed. Mean % excess weight loss at 12 and 24 months was 72% and 80%, respectively. Fifty-two out of 86 patients (60%) had a complete resolution of comorbidities. A CONUT score >2 (mild malnutrition) was found in 40% of patients, while a CONUT score 0-1 was found in 60% of patients. CONCLUSION: LBOAGB shows promising results in terms of safety and efficacy in the short term. Further prospective studies will be required to evaluate the consistency of the results in the long term.

Benign Anorectal Disorders and Pelvic Floor Disease After Bariatric Surgery.

The correlations between morbid obesity, bariatric surgery and gastrointestinal disorders are well known and reported. Symptoms like abdominal pain, constipation, bloating, heartburn and gastroesophageal reflux disease are known to be significantly more prevalent in overweight patients and body mass index is associated positively with abdominal pain and diarrhea. In spite of these conditions, less is known about the lower gastrointestinal tract. Of these, anorectal disorders and pelvic floor disease are both believed to be more frequent in obese patients compared to the general population. Weight loss related to bariatric surgery seems to improve quality of life and weight-related symptoms, although some of these conditions may get worse. All these conditions are rarely studied in patients undergoing bariatric surgery for morbid obesity. This concise review aimed to focus on these conditions in patients undergoing bariatric surgery for morbid obesity in order to improve patient selection and post-operative management.

Internal herniation of small bowel through the minimizer ring after banded one anastomosis gastric bypass: Case report with diagnosis and management of a rare complication.

INTRODUCTION: One Anastomosis Gastric Bypass has been increasingly performed in the setting of bariatric surgery. The addition of gastric pouch banding (BOAGB) may reduce weight regain in the long term. BOAGB may rarely be complicated by MiniMizer ring-related affections. This article reports for the first time a case of bowel obstruction due to internal hernia (IH) through the ring itself, occurring 15 months after BOAGB. CASE REPORT: A 55 years-old woman presented with unspecific symptoms of sub-acute bowel obstruction 15 months after BOAGB. Work-up revealed IH through the MiniMizer ring and its erosion into the liver. Successful management included laparoscopic ring removal and adhesion-lysis. Postoperative course was uneventful. DISCUSSION AND CONCLUSION: IH through MiniMizer ring is a rare complication of BOAGB and awareness of this possibility may help diagnosis and prevention. Diagnosis requires high index of suspicion and per-oral contrast CT. Successful management entails laparoscopic device removal. Prevention includes non re-absorbable suture fixation and adequate gastric pouch encirclement.

Nutritional Status after Roux-En-Y (Rygb) and One Anastomosis Gastric Bypass (Oagb) at 6-Month Follow-Up: A Comparative Study.

INTRODUCTION: Roux-en-Y gastric bypass (RYGB) and one anastomosis gastric bypass (OAGB) are two effective bariatric surgical procedures with positive outcomes in terms of weight loss, comorbidities remission, and adverse events profiles. OAGB seems to carry a higher risk of malnutrition, but existing data are controversial. The aim of this study is to objectively evaluate and compare malnutrition in patients undergoing RYGB and OAGB. METHODS: Retrospective monocentric study of obese patients undergoing RYGB or OAGB between the 15 September 2020 and the 31 May 2021. Nutritional status was assessed using the Controlling Nutritional Status (CONUT) score and compared between groups. The primary outcome was the mean CONUT score at 6 months. The secondary outcomes included the incidence of malnutrition, comorbidities, including hypertension, insulin resistance and type II diabetes mellitus, and weight loss. RESULTS: 78 patients were included: 30 underwent RYGB and 48 underwent OAGB. At 6-Month Follow-Up there was no difference between groups in the mean CONUT score nor in incidence of malnutrition. In both groups, the nutritional status significantly worsened 6 months after surgery (preoperative and postoperative score of 0.48 ± 0.9 and 1.38 ± 1.5; p = 0.0066 for RYGB and of 0.86 ± 1.5 and 1.45 ± 1.3; p = 0.0422 for OAGB). Type II Diabetes mellitus (DMII) and hypertension remission were significant in the OAGB group with a 100% relative remission in the DMII-OAGB group (p = 0.0265), and a 67% relative remission in the hypertension-OAGB group (p = 0.0031). CONCLUSIONS: No difference in nutritional status has been detected between patients undergoing RYGB or OAGB at the 6-Month Follow-Up. Both procedures may have significant mal-absorptive effects leading to decline in nutritional status. OAGB may be more efficacious in inducing DMII and hypertension remission. Larger prospective studies dedicated specifically to nutritional status after gastric bypass are needed to confirm the impact of different bypass procedures on nutritional status.

Off-label Uses of Selective Serotonin Reuptake Inhibitors (SSRIs).

Psychiatric drugs have primacy for off-label prescribing. Among those, selective serotonin reuptake inhibitors (SSRIs) are highly versatile and, therefore, widely prescribed. Moreover, they are commonly considered as having a better safety profile compared to other antidepressants. Thus, when it comes to off-label prescribing, SSRIs rank among the top positions. In this review, we present the state of the art of off-label applications of selective serotonin reuptake inhibitors, ranging from migraine prophylaxis to SARS-CoV-2 antiviral properties. Research on SSRIs provided significant evidence in the treatment of premature ejaculation, both with the on-label dapoxetine 30 mg and the off-label paroxetine 20 mg. However, other than a serotoninergic syndrome, serious conditions like increased bleeding rates, hyponatremia, hepatoxicity, and post-SSRIs sexual dysfunctions, are consistently more prominent when using such compounds. These insidious side effects might be frequently underestimated during common clinical practice, especially by nonpsychiatrists. Thus, some points must be addressed when using SSRIs. Among these, a psychiatric evaluation before every administration that falls outside the regulatory agencies-approved guidelines has to be considered mandatory. For these reasons, we aim with the present article to identify the risks of inappropriate uses and to advocate the need to actively boost research encouraging future clinical trials on this topic.

Metabolic surgery for type II diabetes: an update.

Bariatric operations have been documented in clinical trials to promote remission or dramatic improvement of Type II Diabetes Mellitus and related comorbidities. Herein we review randomized trials and meta-analyses published during the last 20 years on the results of bariatric/metabolic surgery in obese patients with type 2 diabetes with the aim of highlighting the scientific evidence available. Several studies and RCTs in the last 20 years have showed outstanding results of bariatric/metabolic surgery on Type II diabetes and comorbidities in patients with either BMI > 35 kg/m2 or BMI < 35 kg/m2. They have established that bariatric procedures are superior to non-surgical interventions for inducing weight loss and amelioration of type 2 diabetes, even in patients with a BMI between 30 and 35 kg/m2. The physiopatologic changes that improve glucose homeostasis after bariatric surgery remain unclear but glycemic control is improved after sleeve gastrectomy, duodenal-jejunal bypass, Roux-en-Y gastric bypass, gastric banding, One Anastomosis Gastric Bypass, and biliopancreatic diversion. Nevertheless, it is suggested that the various gastrointestinal procedures may have different effects and mechanisms of action. Metabolic surgery will help integrate knowledge and multidisciplinary expertise to provide a combination of conservative and surgical treatments for Type II diabetes. These treatments must be considered as complementary options and not alternative strategies, with the same goal of controlling diabetes and achieving cure.

Safety and Outcomes of Laparoscopic Sleeve Gastrectomy in a General Surgery Residency Program.

BACKGROUND: With the escalation of surgical treatment of morbid obesity, there is a growing interest in the training of bariatric surgeons. Laparoscopic sleeve gastrectomy (LSG) gained popularity both as a first-stage approach and as a stand-alone procedure. OBJECTIVES: The aim of this study was to assess detectable differences in LSG with intra-operative resident involvement. METHODS: We reviewed obese patients, who had undergone LSG between January 1, 2017 and January 31, 2020. Collected data reported demographic factors, operative time, postoperative complications, and outcomes. RESULTS: Among 313 patients who met the inclusion criteria, 94 were men and 219 were women. The procedures were performed either by an expert bariatric surgeon (group 1), or a general surgery resident (group 2), respectively in 228 and 85 cases. Mean operative time of the first group was 65.3 ± 18.8 minutes, while it was 74.3 ± 17.2 among trainees (p < 0.001). Perioperative complications were diagnosed in 13 patients (10 in group 1 and 3 in group 2). Mean excess body weight loss after 12 months was 87.7 ± 28.2% in the first group and 81.1 ± 31.6% in the residents group. Between the two groups, we found no differences in the incidence of perioperative complications and in surgical outcomes. Trainee involvement was associated with increased operative time, with no correlation with a worse postoperative course. CONCLUSIONS: Residents can safely perform LSG in referral centers under the supervision of an expert bariatric surgeon. Trainee involvement is not related to increased leak rate, nor to suboptimal short-term outcome.

Laparoscopic Banded Sleeve Gastrectomy: Single-Center Experience with a Four-Year Follow-Up.

Introduction: Laparoscopic sleeve gastrectomy (LSG) is now the most common bariatric procedure to treat morbidly obese patients. The main concern of LSG lies in the long-term weight regain, which is reported to happen in up to 75.6% of patients after 6 years. In this study, we report our overall experience with Laparoscopic Banded Sleeve Gastrectomy (LBSG) using the MiniMizer® over a 6-year period. Materials and Methods: We performed a retrospective review of data from a prospectively collected database. All patients submitted to primary LBSG were examined. Patients were submitted to LBSG between February 2014 and January 2020. Collected data included demographic factors, preoperative body mass index (BMI), operative time, surgical complications, and clinical outcomes. Results: Two hundred nine patients were submitted to primary LBSG in the study period. They were 136 females (65%) and 73 males (35%) with a median age of 43.0 years (range, 18-65 years). Median preoperative BMI was 48.4 kg/m2 (range, 36.2-65.5 kg/m2). Median operative time was 72.0 minutes (range, 40-142 minutes). Median time for ring placement was 8.0 minutes. Median postoperative hospital stay was 2.8 days. Seven major complications occurred in the postoperative period (3.3%): five gastric leaks (2.3%) and two major bleedings (0.9%). There was no postoperative mortality in the 209 patients. Long-term major complications occurred in 2 patients (0.9%). Median follow-up was 49.2 months (range, 2-72 months). Median postoperative BMI was 29.6 kg/m2 (range, 22-42 kg/m2). Median %excess weight loss (%EWL) at 1 year after surgery was 52.0%. Median %EWL at last follow-up visit was 64.0%. Conclusion: LBSG is as safe as standard LSG with excellent results in terms of postoperative morbidity and weight loss outcomes. Whether this procedure may result superior to standard LSG in the long-term period needs to be evaluated in randomized trials. Clinical Study Registration Number: NCT04354532.

Transhiatal Migration After Laparoscopic Sleeve Gastrectomy: Myth or Reality? A Multicenter, Retrospective Study on the Incidence and Clinical Impact.

PURPOSE: Only anecdotally reported, intrathoracic migration (ITM) represents an unacknowledged complication after sleeve gastrectomy (LSG) contributing to gastroesophageal reflux disease (GERD) development, both recurrent and de novo. The primary endpoint of this study was to evaluate the incidence of postoperative ITM ≥ 2 cm; the secondary endpoint was to determine the relationships between ITM, GERD, endoscopic findings, and percentage of patients requiring surgical revision. MATERIALS AND METHODS: A retrospective, multicenter study on prospective databases was conducted, analyzing LSGs performed between 2013 and 2018. Inclusion criteria consisted of primary operation; BMI ranging 35-60 kg/m2; age 18-65 years; minimum follow-up 24 months; and postoperative UGIE, excluding concomitant hiatal hernia repair. Esophageal manometry and 24-h pH-metry were indicated, based on postoperative questionnaires and UGIE; patients with GERD due to ITM, and non-responders to medical therapy, were converted to R-en-Y gastric bypass (RYGB). RESULTS: An ITM ≥ 2cm was postoperatively diagnosed in 94 patients (7% of 1337 LSGs), after mean 24.16 ± 13.6 months. Postoperative esophagitis was found in 29 patients vs. 15 initially (p=0.001), while GERD was demonstrated in 75 (vs. 20 preoperatively, p< 0.001). Fifteen patients (16%) underwent revision to RYGB with posterior cruroplasty. Seventeen patients with severe GERD presented improvement of endoscopic findings and clinical symptoms as a result of conservative therapy. CONCLUSIONS: ITM after LSG is not a negligible complication and represents an important pathogenic factor in the development or worsening of GERD. Postoperative UGIE plays a fundamental role in the diagnosis of esophageal mucosal lesions.

Measuring Knowledge, Attitudes, and Barriers to Medication Adherence in Potential Bariatric Surgery Patients.

BACKGROUND: Bariatric surgery is an effective treatment for the obesity epidemic, but the poor attendance and adherence rates of post-surgery recommendations threaten treatment effectiveness and health outcomes. Preoperatively, we investigated the unique contributions of clinical (e.g., medical and psychiatric comorbidities), sociodemographic (e.g., sex, age, and educational level), and psychopathological variables (e.g., binge eating severity, the general level of psychopathological distress, and alexithymia traits) on differing dimensions of adherence in a group of patients seeking bariatric surgery. METHODS: The final sample consisted of 501 patients (346 women). All participants underwent a full psychiatric interview. Self-report questionnaires were used to assess psychopathology, binge eating severity, alexithymia, and three aspects of adherence: knowledge, attitude, and barriers to medical recommendations. RESULTS: Attitude to adherence was associated with alexithymia (ß = -2.228; p < 0.001) and binge eating disorder (ß = 0.103; p = 0.047). The knowledge subscale was related to medical comorbidity (ß = 0.113; p = 0.012) and alexithymia (ß = -2.256; p < 0.001); with age (ß = 0.161; p = 0.002) and psychiatric comorbidity (ß =0.107; p = 0.021) manifesting in the barrier subscale. CONCLUSION: We demonstrated that alexithymia and psychiatric and eating disorders impaired adherence reducing attitude and knowledge of treatment and increasing the barriers. Both patient and doctor can benefit from measuring adherence prior to surgery, with a qualitative approach shedding light on the status of adherence prior to the postsurgical phase when the damage regarding adherence is, already, done. Graphical Abstract.