The SAGES masters program presents the 10 seminal articles for laparoscopic sleeve gastrectomy.

BACKGROUND: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program includes eight distinct clinical pathways. The Bariatric Surgery Pathway focuses on three anchoring procedures, including the laparoscopic sleeve gastrectomy (LSG) which is the most commonly performed bariatric procedure in the United States. In this article, we present and discuss the top 10 seminal articles regarding the LSG. METHODS: The literature was systematically searched to identify the most cited papers on LSG. The SAGES Metabolic and Bariatric Surgery committee reviewed the most cited article list, and using expert consensus elected the seminal articles deemed most pertinent to LSG. These articles were reviewed in detail by committee members and are presented here. RESULTS: The top 10 most cited sentinel papers on LSG focus on operative safety, outcomes, surgical technique, and physiologic changes after the procedure. A summary of each paper is presented, including expert appraisal and commentary. CONCLUSIONS: The seminal articles presented support the widespread acceptance and use of the LSG by bolstering the understanding of its mechanism of action and by demonstrating its safety and excellent patient outcomes. All bariatric surgeons should be familiar with these 10 landmark articles.

Management of abdominal wall hernias in patients with severe obesity.

Obesity is a risk factor for abdominal wall hernia development and hernia recurrence. The management of these two pathologies is complex and often entwined. Bariatric and ventral hernia surgery require careful consideration of physiologic and technical components for optimal outcomes. In this review, a multidisciplinary group of Society of American Gastrointestinal and Endoscopic Surgeons' bariatric and hernia surgeons present the various weight loss modalities available for the pre-operative optimization of patients with severe obesity and concurrent hernias. The group also details the technical aspects of managing abdominal wall defects during weight loss procedures and suggests the optimal timing of definitive hernia repair after bariatric surgery. Since level one evidence is not available on some of the topics covered by this review, expert opinion was implemented in some instances. Additional high-quality research in this area will allow for better recommendations and therefore treatment strategies for these complex patients.

Subunit architecture of the Golgi Dsc E3 ligase required for sterol regulatory element-binding protein (SREBP) cleavage in fission yeast.

The membrane-bound sterol regulatory element-binding protein (SREBP) transcription factors regulate lipogenesis in mammalian cells and are activated through sequential cleavage by the Golgi-localized Site-1 and Site-2 proteases. The mechanism of fission yeast SREBP cleavage is less well defined and, in contrast, requires the Golgi-localized Dsc E3 ligase complex. The Dsc E3 ligase consists of five integral membrane subunits, Dsc1 through Dsc5, and resembles membrane E3 ligases that function in endoplasmic reticulum-associated degradation. Using immunoprecipitation assays and blue native electrophoresis, we determined the subunit architecture for the complex of Dsc1 through Dsc5, showing that the Dsc proteins form subcomplexes and display defined connectivity. Dsc2 is a rhomboid pseudoprotease family member homologous to mammalian UBAC2 and a central component of the Dsc E3 ligase. We identified conservation in the architecture of the Dsc E3 ligase and the multisubunit E3 ligase gp78 in mammals. Specifically, Dsc1-Dsc2-Dsc5 forms a complex resembling gp78-UBAC2-UBXD8. Further characterization of Dsc2 revealed that its C-terminal UBA domain can bind to ubiquitin chains but that the Dsc2 UBA domain is not essential for yeast SREBP cleavage. Based on the ability of rhomboid superfamily members to bind transmembrane proteins, we speculate that Dsc2 functions in SREBP recognition and binding. Homologs of Dsc1 through Dsc4 are required for SREBP cleavage and virulence in the human opportunistic pathogen Aspergillus fumigatus. Thus, these studies advance our organizational understanding of multisubunit E3 ligases involved in endoplasmic reticulum-associated degradation and fungal pathogenesis.

Yeast sterol regulatory element-binding protein (SREBP) cleavage requires Cdc48 and Dsc5, a ubiquitin regulatory X domain-containing subunit of the Golgi Dsc E3 ligase.

Schizosaccharomyces pombe Sre1 is a membrane-bound transcription factor that controls adaptation to hypoxia. Like its mammalian homolog, sterol regulatory element-binding protein (SREBP), Sre1 activation requires release from the membrane. However, in fission yeast, this release occurs through a strikingly different mechanism that requires the Golgi Dsc E3 ubiquitin ligase complex and the proteasome. The mechanistic details of Sre1 cleavage, including the link between the Dsc E3 ligase complex and proteasome, are not well understood. Here, we present results of a genetic selection designed to identify additional components required for Sre1 cleavage. From the selection, we identified two new components of the fission yeast SREBP pathway: Dsc5 and Cdc48. The AAA (ATPase associated with diverse cellular activities) ATPase Cdc48 and Dsc5, a ubiquitin regulatory X domain-containing protein, interact with known Dsc complex components and are required for SREBP cleavage. These findings provide a mechanistic link between the Dsc E3 ligase complex and the proteasome in SREBP cleavage and add to a growing list of similarities between the Dsc E3 ligase and membrane E3 ligases involved in endoplasmic reticulum-associated degradation.

A Nationwide Safety Analysis of Discharge on the First Postoperative Day After Bariatric Surgery in Selected Patients.

BACKGROUND: Enhanced recovery after surgery has led to early recovery and shorter hospital stay after laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). This study aims to assess feasibility and outcomes of postoperative day (POD) 1 discharge after LRYGB and LSG from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) 2015 dataset. METHODS: Patients who underwent elective LRYGB and LSG and were discharged on POD 1 and 2 were extracted from the MBSAQIP dataset. A 1:1 propensity score matching was performed between cases with POD 1 vs POD 2 discharge, and the 30-day outcomes of the cohorts were compared. RESULTS: A total of 80,464 patients met the study criteria: 8862 LRYGB and 31,370 LSG cases, which were discharged on POD 1, and matched 1:1 with those discharged on POD 2. Within the LRYGB cohort, patients discharged on POD 2 had higher all-cause morbidity (7.5% vs 6.1%; p < 0.001) and 30-day re-intervention (2.0% vs 1.5%; p = 0.004) in comparison with patients discharged on POD 1. There were no statistical differences with respect to serious morbidity (0.5% vs 0.4%; p = 0.15), 30-day readmission (4.9% vs 4.5%; p = 0.2), and 30-day reoperation (1.3% vs 1.2%; p = 0.7). Within the LSG cohort, patients discharged on POD 2 had higher all-cause morbidity (4.2% vs 3.4%; p < 0.001), serious morbidity (0.4% vs 0.3%; p < 0.001), 30-day re-intervention (1.0% vs 0.6%; p < 0.001), and 30-day readmission (2.9% vs 2.5%; p = 0.002) in comparison with patients discharged on POD 1. CONCLUSIONS: Early discharge on POD 1 may be safe in a selective group of bariatric patients without significant comorbidities.