Purity of islet preparations and 5-year metabolic outcome of allogenic islet transplantation.

In allogenic islet transplantation (IT), high purity of islet preparations and low contamination by nonislet cells are generally favored. The aim of the present study was to analyze the relation between the purity of transplanted preparations and graft function during 5 years post-IT. Twenty-four patients with type 1 diabetes, followed for 5 years after IT, were enrolled. Metabolic parameters and daily insulin requirements were compared between patients who received islet preparations with a mean purity <50% (LOW purity) or ≥50% (HIGH purity). We also analyzed blood levels of carbohydrate antigen 19-9 (CA 19-9)-a biomarker of pancreatic ductal cells-and glucagon, before and after IT. At 5 years, mean hemoglobin A1c (HbA1c levels) (P = .01) and daily insulin requirements (P = .03) were lower in the LOW purity group. Insulin independence was more frequent in the LOW purity group (P < .05). CA19-9 and glucagon levels increased post-IT (P < .0001) and were inversely correlated with the degree of purity. Overall, our results suggest that nonislet cells have a beneficial effect on long-term islet graft function, possibly through ductal-to-endocrine cell differentiation. ClinicalTrial.gov NCT00446264 and NCT01123187.

Roux-en-Y gastric bypass increases systemic but not portal bile acid concentrations by decreasing hepatic bile acid uptake in minipigs.

Roux-en-Y gastric bypass (RYGB) surgery is widely used in the management of morbid obesity. RYGB improves metabolism independently of weight loss by still unknown mechanisms. Bile acids (BAs) are good candidates to explain this benefit, since they regulate metabolic homeostasis and their systemic concentrations increase upon RYGB. Here we analyzed the mechanisms underlying the increase in systemic BA concentrations after RYGB and the role of the liver therein. To this aim, we used the Göttingen-like minipig, a human-size mammalian model, which allows continuous sampling and simultaneous analysis of pre-hepatic portal and systemic venous blood. BA concentrations and pool composition were measured in portal blood, containing intestinal reabsorbed BAs and compared to systemic blood during a standardized meal test before and after RYGB. Systemic total BA concentrations increased after RYGB, due to an increase in conjugated BAs. Interestingly, the ratio of portal:systemic conjugated BAs decreased after RYGB, indicating a role for the liver in systemic BA concentrations changes. In line, hepatic expression of BA transporter genes decreased after RYGB. Our results show that the increase in systemic BAs after surgery is due to decreased selective hepatic recapture. Thus, alterations in hepatic function contribute to the increase in systemic BAs after RYGB.

Gastric bypass increases postprandial insulin and GLP-1 in nonobese minipigs.

BACKGROUND: Gastric bypass in obese patients induces a dramatic increase of postprandial insulin and glucagon-like peptide-1 (GLP-1) secretion, independently of weight loss. We explored postprandial insulin and GLP-1 secretion in nonobese minipigs before and after RYGB. METHODS: Lean adult Göttingen minipigs (n = 7) were submitted to an open gastric bypass surgery mimicking the clinical procedure in humans (30-cm(3) gastric pouch/150-cm alimentary limb/70-cm biliary limb). All animals were evaluated at baseline and then 10 and 30 days after surgery. At each time point, serum glucose, insulin, GLP-1 and D-xylose levels were measured 3 h after a standardized mixed meal. RESULTS: Weight remained stable during follow-up. Insulin and GLP-1 responses to the test meal were dramatically and similarly increased at 10 days and 1 month after RYGB. Maximal postprandial insulin and GLP-1 levels were 16.3 ± 1.7 mIU/l and 71.7 ± 16.5 pmol/l at baseline, 111.5 ± 38.9 mIU/l and 320.8 ± 84.0 pmol/l at 10 days and 96.6 ± 10.4 mIU/l and 297.3 ± 79.1 pmol/l at 1 month, respectively. D-Xylose absorption remained unchanged before and after surgery. CONCLUSIONS: RYGB induced a dramatic increase of postprandial insulin and GLP-1 secretion in nonobese minipigs. This preclinical model could help to understand the underlying metabolic effects of RYGB, focusing on the role of postsurgical anatomical rearrangement, especially duodenojejunal exclusion and ileal brake. This study supports the use of RYGB in diabetic nonobese patients in absence of obesity.

Occurrence and Phenotypes of Pyrimethanil Resistance in Penicillium expansum from Apple in Washington State.

Penicillium expansum is the cause of blue mold in stored apple fruit. In 2010-11, 779 isolates of P. expansum were collected from decayed apple fruit from five packinghouses, tested for resistance to the postharvest fungicide pyrimethanil, and phenotyped based on the level of resistance. In 2010, 85 and 7% of the isolates were resistant to pyrimethanil in packinghouse A and B, respectively, where pyrimethanil had been used for four to five consecutive years. In 2011, pyrimethanil or fludioxonil was used in packinghouse A, and 96% of the isolates from the fruit treated with pyrimethanil were resistant but only 4% of the isolates from the fruit treated with fludioxonil were resistant to pyrimethanil, suggesting that fungicide rotation substantially reduced the frequency of pyrimethanil resistance. No pyrimethanil-resistant isolates were detected in 2010 in the three other packinghouses where the fungicide had been used recently on a small scale. However 1.8% of the isolates from one of the three packinghouses in 2011 were resistant to pyrimethanil. A significantly higher percentage of thiabendazole-resistant than thiabendazole-sensitive isolates were resistant to pyrimethanil. Of the pyrimethanil-resistant isolates, 37 to 52, 4 to 5, and 44 to 58% were phenotyped as having low, moderate, and high resistance to pyrimethanil, respectively. Fludioxonil effectively controlled pyrimethanil-resistant phenotypes on apple fruit but pyrimethanil failed to control phenotypes with moderate or high resistance to pyrimethanil and only partially controlled the low-resistance phenotype.

Islet survival and function following intramuscular autotransplantation in the minipig.

The liver may not be an optimal site for islet transplantation due to obstacles by an instant blood-mediated inflammatory response (IBMIR), and low revascularization of transplanted islets. Therefore, intramuscular islet transplantation (IMIT) offers an attractive alternative, based on its simplicity, enabling easier access for noninvasive graft imaging and cell explantation. In this study, we explored the outcome of autologous IMIT in the minipig (n = 30). Using the intramuscular injection technique, we demonstrated by direct histological evidence the rapid revascularization of islets autotransplanted into the gracilius muscle. Islet survival assessment was performed using immunohistochemistry staining for insulin and glucagon up to a period of 6 months. Furthermore, we showed the crucial role of minimizing mechanical trauma to the myofibers and limiting exocrine contamination. Intramuscular islet graft function after transplantation was confirmed by documenting the acute insulin response to intravenous glucose in 5/11 pancreatectomized animals. Graft function after IMIT remained however significantly lower than the function measured in 12 out of 18 minipigs who received a similar islet volume in the liver through intraportal infusion. Collectively, these results demonstrated in a clinically relevant preclinical model, suggest IMIT as a promising alternative to intraportal infusion for the transplantation of ß cells in certain medical situations.

First Report of Sphaeropsis Rot of Apple Caused by Sphaeropsis pyriputrescens in New York.

In March 2012, decayed 'Empire' apple fruit (Malus × domestica Borkh.) were sampled from apples grown in Albion (Orleans County) in New York State and stored in bins for 6 months under controlled atmosphere at a commercial packinghouse. At the packinghouse following storage prior to be packed, the fruit were completely rotten, spongy to firm, and light brown without pycnidia. All fruit rots originated from either stem-end or calyx-end infections but no wound infections were observed. The incidence of fruit with these symptoms in the total decay was relatively low (0.1%). To isolate the causal agent, small fragments of fruit flesh from 12 decayed fruit were cut and placed on potato dextrose agar (PDA) acidified with 0.1% lactic acid. The plates were incubated at 20°C for 4 days and sub-cultured on PDA to obtain a pure culture. The colonies initially appeared with dense hyaline mycelium and later turned light yellow to yellow, and black pycnidia formed after about 2 weeks of incubation under a 24-h fluorescent light at 20°C. Conidia were light brown to brown, clavate to subglobose to irregular, and 15 × 8 µm on average. The fungus was identified as Sphaeropsis pyriputrescens Xiao & J.D. Rogers based on the morphology of the fungus (3). The identity of a representative isolate was further confirmed by analysis of nucleotide sequences of the internal transcribed spacer (ITS) regions amplified using the primers ITS1/ITS4. A BLAST search in GenBank showed that the sequence had 99% homology to an S. pyriputrescens sequence (Accession No. GQ374241). One representative isolate was tested for pathogenicity on apple fruit. Organic 'Red Delicious' apple fruit were surface-disinfected in 0.6% sodium hypochlorite solution for 5 min, rinsed twice with deionized water, and air-dried. Each fruit was wounded with a sterilized finish-nail head (3 mm in depth and 4 mm in diameter) and inoculated by placing a 4-mm-diameter plug from the leading edge of a 4-day-old PDA culture on the wound. Control fruit were treated with sterile PDA plugs. The inoculation site was covered with two layers of moist cheesecloth to avoid dehydration. There were four 10-fruit replicates for each treatment, and fruit were placed in plastic crispers and stored at 4°C for 4 weeks. The experiments were conducted twice. Sphaeropsis rot developed on all inoculated fruit, while no decays appeared on the control fruit. Koch's postulates were fulfilled by reisolating the fungus from the decayed fruit. Sphaeropsis rot is a recently reported postharvest fruit rot disease of apple and pear (1,3). The disease was first observed on 'd'Anjou' pears, and later more serious economic losses were observed in apples in Washington State (1). The disease has also since been reported in British Columbia, Canada (2). To the best of our knowledge, this is the first report of the occurrence of Sphaeropsis rot caused by S. pyriputrescens on apple in New York or in any region outside of the Pacific Northwest in North America. References: (1) Y. K. Kim and C. L. Xiao. Plant Dis. 92:940, 2008. (2) P. L. Sholberg et al. Plant Dis. 93:843, 2009. (3) C. L. Xiao et al. Plant Dis. 88:223, 2004.

Future of bariatric surgery beyond simple weight loss: Metabolic surgery.

Anatomical modifications implemented during bariatric surgery not only result in weight loss, but also lead to metabolic corrections that translate into better glycemia stability and improvement in cardiovascular and liver disorders. The logical extension of surgical indications beyond mere reduction of the body mass index (BMI) (i.e. patients with<35kg/m2) is a hot topic today in France and worldwide. Metabolic surgeries make use of multiple modalities (endoscopic, mini-invasive, invasive) that should be carried out by trained physicians and within the same type of multidisciplinary formation as that for bariatric surgery. The aim of this update is to describe the physiological mechanisms that result in the benefits of bariatric surgery, the various procedures currently available and the perspectives for this new field in visceral and digestive surgery.

Diabetes cell therapy: a decade later.

Type 1 diabetes is an intrinsically unstable condition because of the loss of both insulin secretion and glucose sensing. Guidelines to treat type 1 diabetes have become stricter since results from the Diabetes Control and Complications Trial (DCCT) demonstrated the close relationship between microangiopathy and HbA1c levels. Therapeutic strategies first require the treatment of underlying organic causes of the brittleness associated with the optimization of insulin therapy including continuous subcutaneous insulin infusion and glucose monitoring. Alternative approaches may still be needed for the most severely affected patients. During the last decade, islet transplantation has gone from an inconsistent 1-year rate of insulin independence of 10% to 80% and could reach 50% at 5 years, at the expense of non-negligible side effects. Among potential causes of islet transplantation success, sufficient islet mass and low levels of cellular autoimmunity are of critical importance. The main issues are currently the availability of an unlimited source of insulin-secreting cells, and the immunosuppressive drug side effects. Today, islet alone and islet after kidney transplantation are offered in a limited number of isolation centres, usually in clinical trials. Islet after kidney transplantation can be considered in type 1 diabetic patients with end-stage kidney disease that are ineligible for double kidney-pancreas transplantation. Islet transplantation alone is proposed to C-peptide negative adult diabetic patients with a body weight <80 kg or low daily insulin needs with creatinine clearance above 60 ml/min, albuminuria lower than 300mg/24H and without desire for pregnancy in women. Currently and until a more complete assessment of the 5- and probably 10-year overall benefit-risk ratio is available, islet transplantation remains a clinical research procedure.

Long-term metabolic outcome and quality of life after laparoscopic adjustable gastric banding in obese patients with type 2 diabetes mellitus or impaired fasting glucose.

BACKGROUND: The long-term outcome of type 2 diabetes mellitus after laparoscopic adjustable gastric banding (LAGB) is unknown. METHODS: A longitudinal cohort study was undertaken of patients with grade 3 obesity and type 2 diabetes or impaired fasting glucose (IFG) undergoing LAGB. Metabolic outcomes and quality of life (QoL) were assessed before and 5 years after LAGB. RESULTS: At 5 years, data for 22 out of 23 patients with type 2 diabetes and 51 out of 53 with IFG were available. Mean(s.d.) excess weight loss was 41(25) and 41(27) per cent in patients with type 2 diabetes and IFG respectively, and was associated with a significant decrease in haemoglobin (Hb) A1c, fasting and postprandial blood glucose, insulin and triglyceride levels, and in liver steatosis. There were significant increases in insulin sensitivity, beta-cell function, disposition index, high-density lipoprotein-cholesterol and QoL (Nottingham Health Profile). Good metabolic control (HbA1c 7 per cent or less) was obtained in 13 diabetic patients, but complete diabetes remission was maintained in only four. Longer duration of diabetes, and poor preoperative glucose control and beta-cell function at baseline were associated with a less favourable outcome. CONCLUSION: LAGB improved metabolic outcomes and QoL in patients with grade 3 obesity with IFG or type 2 diabetes but rarely led to prolonged remission in long-standing diabetes.

Decision tree algorithm in locally advanced rectal cancer: an example of over-interpretation and misuse of a machine learning approach.

PURPOSE: To analyse the classification performances of a decision tree method applied to predictor variables in survival outcome in patients with locally advanced rectal cancer (LARC). The aim was to offer a critical analysis to better apply tree-based approach in clinical practice and improve its interpretation. MATERIALS AND METHODS: Data concerning patients with histological proven LARC between 2007 and 2014 were reviewed. All patients were treated with trimodality approach with a curative intent. The Kaplan-Meier method was used to estimate overall survival (OS). Decision tree methods were was used to select important variables in outcome prediction. RESULTS: A total of 100 patients were included. The 5-year and 7-year OS rates were 76.4% and 71.3%, respectively. Age, co-morbidities, tumor size, clinical tumor classification (cT) and clinical nodes classification (cN) were the important predictor variables to the tree's construction. Overall, 13 distinct groups of patients were defined. Patients aged < 65 years with cT3 disease and elderly patients with a tumor size < 5 cm seemed to have highest rates of survival. But the process over-fitted the data, leading to poor algorithm performance. CONCLUSION: We proposed a decision tree algorithm to identify known and new pre-treatment clinical predictors of survival in LARC. Our analysis confirmed that tree-based machine learning method, especially classification trees, can be easily interpreted even by a non-expert in the field, but controlling cross validation errors is mandatory to capture its statistical power. However, it is necessary to carefully analyze the classification error trend to chose the important predictor variables, especially in little data. Machine learning approach should be considered the new unexplored frontier in LARC. Based on big datasets, decision trees represent an opportunity to improve decision-making process in clinical practice.

A French National Study on Gastropleural and Gastrobronchial Fistulas After Bariatric Surgery: the Impact of Therapeutic Strategy on Healing.

PURPOSE: Gastropleural and gastrobronchial fistulas (GPF/GBFs) are serious but rare complications after bariatric surgery whose management is not consensual. The aim was to establish a cohort and evaluate different clinical presentations and therapeutic options. MATERIALS AND METHODS: A multicenter and retrospective study analyzing GPF/GBFs after bariatric surgery in France between 2007 and 2018, via a questionnaire sent to digestive and thoracic surgery departments. RESULTS: The study included 24 patients from 9 surgical departments after initial bariatric surgery (21 sleeve gastrectomies; 3 gastric bypass) for morbid obesity (mean BMI = 42 ± 8 kg/m2). The GPF/GBFs occurred, on average, 124 days after bariatric surgery, complicating an initial post-operative gastric fistula (POGF) in 66% of cases. Endoscopic digestive treatment was performed in 79% of cases (n = 19) associated in 25% of cases (n = 6) with thoracic endoscopy. Surgical treatment was performed in 83% of cases (n = 20): thoracic surgery (n = 5), digestive surgery (n = 8), and combined surgery (n = 7). No patient died. Overall morbidity was 42%. The overall success rate of the initial and secondary strategies was 58.5% and 90%, respectively. The average healing time was approximately 7 months. Patients who had undergone thoracic surgery (n = 12) had more initial management failures (n = 9/12) than patients who had not (n = 3/12), p = 0.001. CONCLUSION: Complex and life-threatening fistulas that are revealed late require a multidisciplinary strategy. Thoracic surgery should be reserved once the abdominal leak heals; otherwise, it is associated with a higher risk of failure.

Endocrine surgery during and after the COVID-19 epidemic: Expert guidelines from AFCE.

The COVID-19 pandemic commands a major reorganisation of the entire French healthcare system. In France, general rules have been issued nationally and implemented by each healthcare centre, both public and private, throughout France. Guidelines drafted by an expert group led by the French-speaking Association of Endocrine Surgery (AFCE) propose specific surgical management principles for thyroid, parathyroid, endocrine pancreas and adrenal surgery during and after the COVID-19 epidemic.

[Endocrine surgery during and after the COVID-19 epidemic: Guidelines from AFCE]. / Chirurgie endocrinienne au cours et au décours de l'épidémie de COVID-19 : recommandations de l'AFCE.

The COVID-19 pandemic commands a major reorganization of the entire French healthcare system. In France, general rules have been issued nationally and implemented by each healthcare center, both public and private, throughout France. Guidelines drafted by an expert group led by the French-speaking Association of Endocrine Surgery (AFCE) propose specific surgical management principles for thyroid, parathyroid, endocrine pancreas and adrenal surgery during and after the COVID-19 epidemic.

Acute insulin response to arginine in deceased donors predicts the outcome of human islet isolation.

Despite a stringent donor selection, human islet isolation remains frustratingly unpredictable. In this study, we measured acute insulin response to arginine (AIRarg), an in vivo surrogate measure of islet mass, in 29 human deceased donors before organ donation, and correlated values with the outcome of islet isolation. Thirteen isolations (45%) met the threshold for clinical islet transplantation. Among all measured donor characteristics, the only discriminating variable between successful or unsuccessful isolations was donor AIRarg (p < 0.01). Using a threshold of 55 microIU/mL (ROC curve AUC: 72%), isolation was successful in 12/19 donors with high AIRarg and in 1/10 donors with low AIRarg (p < 0.001). The negative and positive predictive values were 90 and 63%, respectively. If used to select donors in the entire cohort, AIRarg would have increased our success rate by 40% and avoided 56% of unsuccessful isolations while missing only 8% of successful preparations. Our results suggest that donor AIRarg is markedly superior to body mass index (BMI) and other criteria currently used to predict isolation outcome. If routinely performed in deceased donors, this simple test could significantly reduce the failure rate of human islet isolation.

Evaluation of alternative sites for islet transplantation in the minipig: interest and limits of the gastric submucosa.

Since the introduction of glucocorticoid-free immunosuppressive regimens, islet transplantation offers a less invasive alternative to pancreas transplantation. However, complications associated with intraportal islet injection and the progressive functional decline of intrahepatic islets encourage the exploration of alternative sites. Herein we evaluated, in the minipig, the use of the gastric submucosa (GS; group 1, n = 5) for islet transplantation compared with the kidney capsule (KC; group 2, n = 5). Subsequently we attempted to improve the vascularization of the submucosal graft (group 3, n = 5) by the addition of an extracellular matrix rich in growth factors (Matrigel). One month after grafting, we evaluated transplanted islet function in vivo and in vitro. Our study showed better function of islets engrafted in the GS than in the KC (P < .05). Despite the growth factors, Matrigel did not offer a more suitable environment to further improve engraftment (group 3, P < .05). Thus, even if the liver remains the gold standard, the GS represents a potential islet engraftment site, confirming the data obtained in vitro and in the rodent. Offering easy access by endoscopy, this site could constitute an interesting alternative for experimental studies in large mammals and, eventually, for clinical application.

First Report of Sclerotinia sclerotiorum on Buckwheat (Fagopyrum esculentum) in Italy.

In each of two fields of buckwheat (Fagopyrum esculentum L.) grown in Benevento Province (southern Italy), 60 to 70% of the plants developed severe root and crown rot. Symptoms included irregular, water-soaked spots on stems that were eventually covered with cottony mycelia as the lesions enlarged. Black sclerotia usually developed within the mycelium. The fungus was isolated on potato dextrose agar and 2% water agar. On the basis of colony morphology, including the production of black sclerotia (1), the fungus was identified as Sclerotinia sclerotiorum (Lib.) De Bary. The identity of the fungus was confirmed by near exact identity of internal transcribed spacer sequences (99%) with two isolates of S. sclerotiorum in GenBank (Accession Nos. Z73800 and Z73799). Pathogenicity of the fungus on buckwheat was evaluated by transplanting 20 20-day-old healthy plants in a mixture of soil and fungal inoculum (0.5% of wet millet seeds colonized by four isolates of S. sclerotiorum). Lesions on crowns and roots developed after 12 days and sclerotia appeared approximately 20 days later. No symptoms developed on noninoculated plants. Reisolation from inoculated plants yielded colonies of S. sclerotiorum. To our knowledge, this is the first report of S. sclerotiorum on buckwheat in Italy. The high incidence and severity of the disease may be limiting factors in the development of buckwheat as an alternative crop of tobacco in southern Italy. Reference: (1) J. E. M. Mordue and P. Holliday. Sclerotinia sclerotiorum. No. 513 in: Descriptions of Pathogenic Fungi and Bacteria. CMI, Kew, Surrey, UK, 1976.

Elderly and poor prognosis patients with high grade glioma: hypofractionated radiotherapy.

AIM: To evaluate efficacy of short-course radiotherapy in elderly and/or poor performance status patients with high grade glioma. MATERIALS AND METHODS: Twenty-one patients with high grade astrocytoma were selected in our Institute to receive hypofractionated radiotherapy. We considered two radiotherapy treatment arms: in arm I there were 22 patients treated with 60 Gy in 30 fractions at 5 fractions per week; in arm 2 there were 21 patients who received hypofractionated radiotherapy course of 30 Gy in 10 fractions at 5 fractions per week. RESULTS: In arm1 the median survival time was 8.2 months and the 1 year overall survival was 36%; in arm 2 the estimated median survival was 6.2 months and the 1 year overall survival was 23%. Treatment was without acute toxicity. CONCLUSIONS: In our experience, hypofractionated radiotherapy seems to be a reasonable treatment option for poor prognosis patients with high grade astrocytoma. It is well tolerated and can reduce the overall treatment time without negative effects on survival compared with conventional fractionation.

[Type I neurofibromatosis, pheochromocytoma and somatostatinoma of the ampulla. Literature review]. / Association neurofibromatose de type I, phéochromocytome et somatostatinome de l'ampoule de Vater. Revue de la littérature.

Gastrointestinal involvement in Von Recklinghausen's neurofibromatosis (autosomal dominant disease) is observed in 25% of patients and is frequently represented by duodenal carcinoids. We report a case of somatostatinoma of the ampulla in a 42-year-old female with neurofibromatosis and pheochromocytoma and show a literature review about the association of neurofibromatosis and somatostatinoma. This pathological association appears non hasardous and surgical ampullectomy offers a good alternative to pancreaticoduodenectomy in localised tumors treatment.

Risk of Dumping Syndrome after Sleeve Gastrectomy and Roux-en-Y Gastric Bypass: Early Results of a Multicentre Prospective Study.

Background. Bariatric surgery is an important field of surgery. An important complication of bariatric surgery is dumping syndrome (DS). Aims. To evaluate the incidence of DS in patients undergoing bariatric surgery. Methods. 541 patients included from 5 nutrition and bariatric centers in France underwent either LSG or LRYGB. They were evaluated at 1 month (M1) and 6 months (M6) postoperatively by an interview and completion of a dumping syndrome questionnaire. Results. 268 patients underwent LSG (Group A) and 273 underwent LRYGB. From the LRYGB patients 229 had mechanical gastrojejunoanal anastomosis with 30 mm linear stapler (Group B) and 44 had manual (hand sewn) 15 mm gastrojejunal anastomosis (Group C). Overall incidence of DS was 8.5% at M1 and M6. In LSG group (Group A), only 4 patients (1.49%) reported episodes of DS at M1 and 3 (1.12%) at M6. In Group B, 41 patients (17.90%) reported episodes of DS at M1 and 43 (18.78%) at M6. Group C experienced one case (2.27%) of DS at M1 and none (0%) at M6. Conclusions. Patients undergoing LRYGB, especially with larger gastrojejunal anastomosis, are more prone to developing DS following surgery than patients undergoing LSG or LRYGB with calibrated manual anastomosis.