Efficacy of High-dose Liraglutide 3.0 mg in Patients with Poor Response to Bariatric Surgery: Real-world Experience and Updated Meta-analysis.

PURPOSE: Poor response to bariatric surgery, characterized by insufficient weight loss (IWL) or weight regain (WR), poses a significant challenge in obesity treatment. This study aims to assess the effectiveness of liraglutide in addressing this issue. MATERIALS AND METHODS: A retrospective, multicenter cohort study investigated the impact of liraglutide 3 mg on weight loss in adults with suboptimal responses or weight regain after bariatric surgery (BS). Additionally, a systematic review and meta-analysis were conducted for a comprehensive evaluation. RESULTS: A total of 119 patients (mean age 41.03 ± 11.2 years, 71.4% female) who experienced IWL or WR after BS received pharmacologic therapy with liraglutide 3 mg. Mean percent weight loss in the entire cohort was 5.6 ± 2.6% at 12 weeks and 9.3 ± 3.6% at 24 weeks with a significant reduction in waist circumference (p < 0.0001). No serious side effects were reported. A meta-analysis, utilizing the fixed effect model with the metafor package in R, included 6 and 5 papers for the change in body weight and BMI after liraglutide treatment, respectively. The analysis demonstrated a considerable reduction in body weight (7.9; CI - 10.4; - 5.4, p < 0.0001) and BMI (3.09; CI 3.89; - 2.28, p < 0.0001). CONCLUSION: Liraglutide 3 mg emerges as a viable option for significant weight loss in patients experiencing IWL or WR after BS. Its inclusion in a multimodal, sequential obesity treatment approach proves promising.

High-dose liraglutide improves metabolic syndrome in poor responders to bariatric surgery.

Background: Bariatric surgery (BS) represents the most effective therapy for obesity class III, or class II with at least one weight-related comorbidity. However, some patients have insufficient weight loss or clinically relevant weight regain after a successful primary procedure. This study aimed to assess the efficacy of liraglutide treatment on weight loss, body composition and improvement of metabolic syndrome (MS) in patients defined as poor responders after BS. Methods: The study involved 59 non-diabetic adults with obesity (M/F: 17/42, age: 38.6 ± 11.8 years, BMI 38.3 ± 5.5 kg/m2) who had been treated with BS and experienced a poor response, categorized as either IWL (insufficient weight loss) or WR (weight regain). All patients were prescribed pharmacological therapy with liraglutide and attended nutritional counseling. Anthropometric and clinical measurements, body composition and the presence of MS defined according to the ATP-III classification were evaluated before starting liraglutide and after 24 weeks of treatment. Results: After 24 weeks of treatment with liraglutide, the mean weight loss was 8.4% ± 3.6% with no difference between gender, bariatric procedure, or type of poor response (IWL or WR). A significant decrease in fat mass, free-fat mass and total body water was documented. After 24 weeks, patients presented significantly lowered fasting glucose, total cholesterol, triglycerides, AST and ALT. The prevalence of MS was reduced from 35% at baseline to 1.6% after 24 weeks. No patients discontinued the treatment during the study. Conclusion: In patients who experience poor response after BS, liraglutide is well tolerated and promotes significant weight loss, ameliorates cardiometabolic comorbidities, and reduces the prevalence of MS.

Trends and safety of bariatric revisional surgery in Italy: multicenter, prospective, observational study.

BACKGROUND: Revisional bariatric surgery (RBS) represents a further solution for patients who experience inadequate weight loss (IWL) following primary bariatric surgery (BS) or significant weight regain (WR) following initial satisfactory response. RBS guidelines are lacking; however, an increased trend in further BS offerings has been reported recently. OBJECTIVE: Analyze trend, mortality, complication, readmission, and reoperation rates for any reason at 30 days after RBS in Italy. SETTING: Ten Italian high-volume BS centers (university hospitals and private centers). METHODS: Prospective, observational, multicenter study enrolling patients undergoing RBS between October 1, 2021, and March 31, 2022, registering reasons for RBS, technique, mortality, intraoperative and perioperative complications, readmissions, and reinterventions for any reason. Patients undergoing RBS during the same calendar interval in 2016-2020 were considered control patients. RESULTS: A total of 220 patients were enrolled and compared with 560 control-group patients. Mortality was .45% versus .35% (n.s), with an overall mortality of .25%, while open surgery or conversion to open surgery was registered in 1%. No difference was found for mortality, morbidity, complications, readmission (1.3%), and reoperation rates (2.2%). IWL/WR was the most frequent cause, followed by gastroesophageal reflux disease; Roux-en-Y gastric bypass was the most used revisional procedure (56%). Sleeve gastrectomy was the most revised procedure in the study group, while gastric banding was the most revised in the control group. RBS represents up to 9% of the total BS in the Italian participating centers. CONCLUSIONS: Laparoscopy represents the standard approach for RBS, which appears safe. Current Italian trends show a shift toward sleeve gastrectomy being the most revised procedure and Roux-en-Y gastric bypass being the most frequent revisional procedure.

Bariatric Surgery for Patients with Overweight/Obesity. A Comprehensive Grading Methodology and Network Metanalysis of Randomized Controlled Trials on Weight Loss Outcomes and Adverse Events.

This study aims to compare different types of metabolic bariatric surgery (MBS) with lifestyle intervention/medical therapy (LSI/MT) for the treatment of overweight/obesity. The present and network meta-analysis (NMA) includes randomized trials. MBS was associated with a reduction of BMI, body weight, and percent weight loss, when compared to LSI/MT, and also with a significant reduction of HbA1c and a higher remission of diabetes. Meta-regression analyses revealed that BMI, a higher proportion of women, and a longer duration of trial were associated with greater effects of MBS. The NMA showed that all surgical procedures included (except greater curvature plication) were associated with a reduction of BMI. MBS is an effective option for the treatment of obesity. The choice of BMI thresholds for eligibility for surgery of patients with different complications should be performed making an evaluation of risks and benefits in each BMI category.

Subhepatic perforated acute appendicitis in a patient with midgut malrotation: A case report and review of the literature.

INTRODUCTION AND IMPORTANCE: Subhepatic acute appendicitis (SHAA) is a very rare cause of acute abdomen, developing in association with two types of congenital anomalies like as midgut malrotation (MM) and maldescent of the caecum. Preoperative diagnosis of SHAA is a challenge because of its rarity and atypical presentation. Imaging may be helpful for determining the correct diagnosis. Surgery represents the standard treatment of SHAA. CASE PRESENTATION: A 25-year-old Caucasian male presented to the Emergency Department with a one-day history of right lower quadrant (RLQ) abdominal pain, nausea and vomiting. Physical examination revealed RLQ abdominal rebound tenderness with guarding. Laboratory tests reported high levels of C-reactive protein and neutrophilic leukocytosis. Abdominal contrast-enhanced computed tomography showed a SHAA with intraluminal appendicolith, fat infiltration and pelvic fluid collection in a patient with MM. The patient underwent laparoscopic appendectomy: a retrocaecal subhepatic phlegmonous and perforated appendicitis was sectioned and removed with drainage of pelvic abscess. The postoperative course of the patient was uneventful. CLINICAL DISCUSSION: SHAA is characterized by anatomical variation of appendix and atypical presentation. Preoperative clinical diagnosis of SHAA is very difficult and imaging may be helpful for determining the correct diagnosis, as well as confirming MM or maldescent of the caecum. Laparoscopic appendectomy represents the correct treatment of SHAA. CONCLUSION: SHAA is a rare surgical emergency that should be considered in the differential diagnosis of patients with RLQ abdominal pain. Preoperative diagnosis needs a high index of suspicion and is facilitated by imaging. Surgery represents the appropriate treatment of SHAA.

Misdiagnosed desmoid fibromatosis of the chest wall presenting in emergency like as recurrence of post-traumatic hematoma: A case report and review of the literature.

INTRODUCTION AND IMPORTANCE: Desmoid Fibromatosis (DF) represents a rare neoplasm developing from fascial and musculoaponeurotic structures. Preoperative diagnosis of DF is a challenge because of its rarity and nonspecific presentation. Imaging may be helpful for determining the correct diagnosis. Currently there are different clinical treatments of DF including surgical treatment, drug treatment and radiotherapy. CASE PRESENTATION: A 43-year-old Caucasian male presented to the Emergency Department with a 6-month history of recurrence of post-traumatic chest wall hematoma. Physical examination revealed a partially solid, painless mass on the right anterior chest wall. Laboratory tests reported and neutrophilic leukocytosis. Thoracic contrast-enhanced computed tomography showed a smooth contour, heterogeneous and hypodense subcutaneous soft tissue mass anterior to the right pectoral muscles and to the right 4th-7th rib. The patient underwent surgery: a solid suprafascial neoplasm was completely excised. The postoperative course of the patient was uneventful. CLINICAL DISCUSSION: DF is a soft tissue neoplasm with a tendency for local invasion and recurrence. The course of DF cannot be predicted, being fatal if DF infiltrates vital structures. Diagnosis of DF is difficult and imaging may be helpful for determining the correct diagnosis. Currently the treatment for DF has shifted from surgery (post-operative recurrence rates of 20%-70%) to conservative therapy including watchful waiting. CONCLUSION: DF is a myofibroblastic proliferative soft tissue tumor and classified as an intermediate malignancy. Preoperative diagnosis of DF needs a high index of suspicion and is facilitated by imaging. Surgery, among different treatments, represents a potentially curative treatment of DF.

An unusual cause of abdominal pain: Case report of a Superior Mesenteric Artery syndrome.

INTRODUCTION AND IMPORTANCE: Superior Mesenteric Artery (SMA) syndrome is an occlusive vascular disease, mainly caused by a severe weight loss that leads to a reduction of the fatty cushion around the SMA. Postprandial abdominal pain, early satiety, vomits, weight loss and malnutrition are the main symptoms of SMA syndrome. Therapy consists of nutritional support, while mini-invasive surgery is indicated when conservative measures are unsuccessful. CASE PRESENTATION: A 39-years old caucasian woman reported the following symptoms: epigastric pain irradiated up to the right hypochondrium, late post-prandial vomiting and severe weight loss. During previous hospitalizations a gastroscopy, a colonoscopy, and radiographic study of food transit were performed, these exams showed a slow gastric emptying. We performed an abdomen CT scan discovering SMA syndrome typical features. A duodenojejunostomy was performed in videolaparoscopy; the procedure was completed easily without complications. CLINICAL DISCUSSION: Debilitating conditions with severe weight loss or anatomic abnormalities are the main causes of SMA syndrome. Symptoms are usually unclear and non-specific. The commonest SMA syndrome features are highlighted with contrast CT. This syndrome is often misunderstood and not considered in differential diagnosis of abdominal pain, determining a delay in diagnosis and further weight loss. An early diagnosis is useful to choose the best treatment of the case. For severe cases, surgery represents the best treatment, especially duodenojejunostomy that is usually linked to rapid symptoms' resumptions without post-operative consequences. CONCLUSION: SMA syndrome should be included in differential diagnosis of abdominal pain. Severe cases can be treated with mini-invasive surgery.

Radiological stent placement of post sleeve gastrectomy leak: efficacy, imaging features and post-procedure complications.

Laparoscopic sleeve gastrectomy (SG) is the most commonly performed bariatric procedure. The primary and insidious early post-SG complication is the gastric leak (GL). In literature, there are many studies describing the endoscopic stent placement as treatment of GL and few studies about stent placement performed by interventional radiology under fluoroscopic guide. Our aims were to describe the radiological stent placement technique, to compare endoscopic and radiological stent placement, to illustrate normal diagnostic features and summarise the incidence of complications after stent placement, removal, and their imaging features. This was a single centre retrospective study of 595 patients who underwent SG between 2011 and 2019. Inclusion criteria: patients who developed GL after SG and treated with gastro-oesophageal stent placement by endoscopy or interventional radiology; availability of medical history and imaging studies; follow-up time after stent removal (1 year). The rates of technical success, clinical success and complications after stent placement and removal were collected and compared between the two methods of stent positioning. A total of 17/595 (2.8%) patients developed a radiologically diagnosed GL after SG. The type II-III GLs (15/17) were treated with endoscopic or radiological stent placement. 9/15 (60%/Group A) patients underwent gastro-oesophageal stenting by interventional radiology and 6/15 (40%/Group B) were treated with endoscopic stent placement. The technical and clinical success rate was 100% for both groups. Stent migration occurred in 22% and 27% for Group A and B respectively. Post-extraction stenosis was the main late complication, occurring in 22% in Group A and 0% in Group B. Gastro-esophageal stent placement performed by interventional radiologists is a valid "mini-invasive" treatment for GL. This procedure is not inferior to endoscopic positioning regarding efficacy, periprocedural and postprocedural complication rate. It's necessary to be familiar with radiological findings after stent placement and removal. Computed tomography (CT) scan is the main radiological technique to identify stent placement complications. Upper gastrointestinal (UGI) series are the first radiological procedures used to detect late complications after stent removal.

Jejunal volvulus within an inguinal hernia sac like as an extremely rare cause of acute mechanical gastrointestinal obstruction in adults: First literature report.

INTRODUCTION AND IMPORTANCE: Small bowel volvulus (SBV) represents a rare and life-threatening cause of gastrointestinal obstruction among adults. SBV can be classified as primary and secondary subtypes. Preoperative diagnosis of SBV is a challenge because of the absence of pathognomonic clinical, radiographic and laboratory findings. Surgery represents the correct treatment of SBV. CASE PRESENTATION: A 69-year-old Caucasian male presented to the Emergency Department with a two-day history of abdominal pain, inability to pass gas or stool, nausea, vomiting. Physical examination revealed abdominal distension, generalized abdominal pain without guarding or rebound tenderness, a partially reducible and painless right inguinal hernia. Laboratory tests reported neutrophilic leukocytosis. Abdominal computed tomography revealed massive gastroduodenal dilatation with pneumoperitoneum and small bowel loops in the right inguinal sac. The patient underwent exploratory laparotomy: a jejunal volvulus (JV) located within the right inguinal hernia sac, causing gastrointestinal obstruction, was devolvulated and a right prosthetic inguinal hernia repair was also performed. The patient was discharged on the 10th postoperative day. CLINICAL DISCUSSION: Secondary SBV is due to any congenital or acquired lesions and rarely occurs among adults in Western countries. This is the first literature report of a JV located within an inguinal hernia sac causing gastrointestinal obstruction. CONCLUSION: Secondary JV represents an extremely rare abdominal emergency necessitating early diagnosis to prevent the development of intestinal ischemia, bowel necrosis and peritonitis. Diagnosis of JV needs a high index of suspicion and may be facilitated by imaging, often it is made intraoperatively. Surgery represents the appropriate treatment of JV.

Left-sided acute appendicitis in a patient with situs viscerum inversus totalis: A case report.

INTRODUCTION AND IMPORTANCE: Left-sided acute appendicitis (LSAA) is a very rare cause of acute abdomen, developing in association with two types of congenital anomalies like as situs viscerum inversus (SVI) and midgut malrotation (MM). Preoperative diagnosis of LSAA is a challenge because of its rarity and atypical presentation. Imaging may be helpful for determining the correct diagnosis. Surgery represents the standard treatment of LSAA. CASE PRESENTATION: A 67-year-old Caucasian male with presented to the Emergency Department with a two-day history of left lower quadrant (LLQ) abdominal pain, nausea, vomiting, diarrhea and fever. Physical examination revealed LLQ abdominal rebound tenderness with guarding. Laboratory tests reported high levels of C-reactive protein and neutrophilic leukocytosis. Abdominal contrast-enhanced computed tomography showed a LSAA with intraluminal appendicoliths, fat infiltration and pericecal fluid collection in a patient with SVI. The patient underwent laparoscopic appendectomy: a gangrenous and perforated appendicitis was sectioned and removed with drainage of pericecal abscess. The postoperative course of the patient was uneventful. CLINICAL DISCUSSION: LSAA is characterized by anatomical variation of appendix and atypical presentation. Preoperative clinical diagnosis of LSAA is very difficult and imaging may be helpful for determining the correct diagnosis, as well as confirming SVIT or MM. Laparoscopic appendectomy represents the correct treatment of LSAA. CONCLUSION: LSAA is a rare surgical emergency that should be considered in the differential diagnosis of patients with LLQ abdominal pain. Preoperative diagnosis of LSAA needs a high index of suspicion and is facilitated by imaging. Surgery represents the appropriate treatment of LSAA.

Revisional Surgery After One Anastomosis/Minigastric Bypass: an Italian Multi-institutional Survey.

BACKGROUND: Efficacy and safety of OAGB/MGB (one anastomosis/mini gastric bypass) have been well documented both as primary and as revisional procedures. However, even after OAGB/MGB, revisional surgery is unavoidable in patients with surgical complications or insufficient weight loss. METHODS: A questionnaire asking for the total number and demographics of primary and revisional OAGB/MGBs performed between January 2006 and July 2020 was e-mailed to all S.I.C. OB centres of excellence (annual caseload > 100; 5-year follow-up > 50%). Each bariatric centre was asked to provide gender, age, preoperative body mass index (BMI) and obesity-related comorbidities, previous history of abdominal or bariatric surgery, indication for surgical revision of OAGB/MGB, type of revisional procedure, pre- and post-revisional BMI, peri- and post-operative complications, last follow-up (FU). RESULTS: Twenty-three bariatric centres (54.8%) responded to our survey reporting a total number of 8676 primary OAGB/MGBS and a follow-up of 62.42 ± 52.22 months. A total of 181 (2.08%) patients underwent revisional surgery: 82 (0.94%) were suffering from intractable DGER (duodeno-gastric-esophageal reflux), 42 (0.48%) were reoperated for weight regain, 16 (0.18%) had excessive weight loss and malnutrition, 12 (0.13%) had a marginal ulcer perforation, 10 (0.11%) had a gastro-gastric fistula, 20 (0.23%) had other causes of revision. Roux-en-Y gastric bypass (RYGB) was the most performed revisional procedure (109; 54%), followed by bilio-pancreatic limb elongation (19; 9.4%) and normal anatomy restoration (19; 9.4%). CONCLUSIONS: Our findings demonstrate that there is acceptable revisional rate after OAGB/MGB and conversion to RYGB represents the most frequent choice.

N-3 polyunsaturated fatty acids reduces post-operative atrial fibrillation incidence in patients undergoing "on-pump" coronary artery bypass graft surgery.

BACKGROUND: The aim of this study was to evaluate the efficacy of preoperative and postoperative therapy with n-3 polyunsaturated fatty acids in reducing the incidence of atrial fibrillation after coronary artery bypass graft surgery. METHODS: 201 patients undergoing coronary artery bypass graft surgery were randomized to 1) a control group (105 patients), or 2) n-3 polyunsaturated fatty acids 2 g/day group (96 patients) for at least 5 days before surgery and until hospital discharge. Groups were further subdivided in four subgroups according to the operative technique: "off-pump" or "on-pump". The primary end point was to evaluate the reduced incidence of postoperative in-hospital atrial fibrillation in the (N-3 PUFA) group. Secondary end points were the impact of the surgical technique on the incidence of postoperative arrhythmia and the impact of n-3 polyunsaturated fatty acids therapy on post-operative hospital length of stay. RESULTS: The overall incidence of post-operative atrial fibrillation was 17.4% (35/201). The arrhythmia occurred in 11.4% (11/96) of the patients in therapy with n-3 polyunsaturated fatty acids and in 22.8% (24/105) in the control groups. In particular, the statistical analysis of subgroups showed a significant reduction of postoperative atrial fibrillation only in the group including patients treated with n-3 polyunsaturated fatty acids undergoing "on-pump" coronary artery bypass graft surgery. The length of hospital stay did not differ among all groups. CONCLUSIONS: N-3 polyunsaturated fatty acids administration significantly reduces the incidence of post-operative atrial fibrillation in patients undergoing "on-pump" coronary artery bypass graft surgery. N-3 polyunsaturated fatty acids therapy is not associated with a shorter hospital stay.

A case of quadricuspid aortic valve characterized by echocardiography and magnetic resonance imaging.

We report a rare subtype of quadricuspid aortic valve (QAV) associated with moderate aortic regurgitation in a 17-year old woman symptomatic for palpitations. The patient was admitted to our department for cardiac evaluation due to a previous diagnosis of bicuspid aortic valve; she underwent a new two-dimensional echocardiography revealing a rare type of quadricuspid aortic valve with a moderate regurgitation. For further investigating potentially associated abnormalities, patient was referred to Cardiac MRI; MRI showed no other abnormalities and confirmed echocardiographic findings. Quadricuspid aortic valve is a rare form of congenital valvular anomaly often occasionally diagnosed. In most cases this malformation causes a valve dysfunction, commonly aortic regurgitation, and can be associated with other cardiac abnormalities such as ventricular or atrial septal defect, anomalies of coronary arteries, patent ductus arteriosus, subaortic fibromuscolar stenosis and mitral valve malformation.

Complicated Littre's umbilical hernia with normal Meckel's diverticulum: A case report and review of the literature.

INTRODUCTION AND IMPORTANCE: A Littre's hernia (LH) is defined by the presence of Meckel's diverticulum (MD) in any kind of hernia sac. Preoperative diagnosis of LH is a challenge because of its rarity and the absence of specific radiological findings and clinical presentation. Surgery is the appropriate treatment of complicated LH that is an extremely rare condition with approximately 50 cases reported in the literature over the past 300 years. CASE PRESENTATION: A 46-year-old Caucasian female was admitted to the Emergency Department with a two-day history of abdominal pain. Physical examination revealed an irreducible and painfull mass in umbilical region. Abdominal computed tomography scan showed the protrusion of greater omentum and small bowel loop through the umbilical ring. Laboratory tests were unremarkable. After diagnosis of strangulated umbilical hernia, the patient underwent exploratory laparotomy: the irreducible umbilical hernial sac was opened with presence of incarcerated and strangulated omentum and uncomplicated MD. Resection of incarcerated and ischemic greater omentum alone was performed. The postoperative course of patient was uneventful. CLINICAL DISCUSSION: Meckel's diverticulum (MD) is a vestigial remnant of the omphalomesenteric duct, representing the most common congenital malformation of the gastrointestinal tract. Preoperative diagnosis of LH is very difficult and surgery represents the correct treatment of complicated LH. CONCLUSION: LH represents an extremely rare complication of MD difficult to diagnose and suspect because of the lack of specific radiological findings and clinical presentation. Surgery represents the appropriate treatment of abdominal wall hernias and complicated MD.

Granular cell tumor of the cecum: Case report of mini invasive surgical resection and review of the literature.

INTRODUCTION AND IMPORTANCE: Granular Cell Tumor (GCT) is a rare lesion with unclear histogenesis, predominantly described as a skin lesion. Visceral localization of GCT is even more rare with few cases reported in the literature. Nowadays GCT guidelines are not available. CASE PRESENTATION: A 45-year-old Caucasian woman was visited in our surgical department for significant weight loss (about 30 kg) during the previous 6 months. Colonoscopy showed a caecal polypoid lesion that was resected with a diatermic loop and classified as GCT. Microscopically, the neoplasm partially involved the mucosa and diffusely the submucosa, extending to the endoscopic resection margins. Because of the high risk of perforation during endoscopic radicalisation attempt, the patient underwent ileocecal resection. The postoperative course was uneventful. CLINICAL DISCUSSION: GCT is a rare soft tissue neoplasm probably deriving from Schwann cells. The main treatment for GCT is an endoscopic mucosal/submucosal resection. Nevertheless, a radicalization of the lesion through a surgical attempt should be preferred when the endoscopic procedure is linked to a high risk of perforation. It is important to distinguish GCT from other polypoid lesions of the colon, due to its malignant potential (about 2%) and its relapsing capacity when margins are involved. CONCLUSION: GTC is a rare neoplasm and as its diagnosis is made only histologically, it should be included in differential diagnosis of colonic polypoid lesions. Surgery can be considered the best choice when an endoscopic attempt of GCT lesions is linked to a high risk of colon perforation.

Idiopathic giant pancreatic pseudocyst presenting in emergency with abdominal compartment syndrome and intestinal occlusion: Case report and review of the literature.

INTRODUCTION AND IMPORTANCE: This is the first case of idiopathic giant pancreatic pseudocyst (IGPP) causing intestinal occlusion, intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) reported in the literature. Diagnosis of IGPP in emergency is a challenge because of its rarity and the absence of a history of pancreatitis or pancreatic trauma and specific clinical presentation. Abdominal contrast-enhanced computed tomography (CECT) represents the gold standard in diagnosing of pancreatic cyst (PP). Different types of treatment of PP are reported in the literature. CASE PRESENTATION: A 52-year-old Caucasian female was admitted to the Emergency Department with a three-day history of abdominal pain, inability to pass gas or stool, nausea and vomiting, oliguria and a seven-day history of abdominal swelling and swollen legs. Physical examination revealed abdominal distention, abdominal pain, swelling in the legs. CECT showed a voluminous cystic pancreatic mass suspected of neoplasm. Laboratory tests reported high serum levels of BUN, creatinine and C-reactive protein and neutrophilic leukocytosis. After preoperative diagnosis of ACS, the patient was taken to the operating room for pancreatic resection. The postoperative course was uneventful. Diagnosis of IGPP was made by histopathological examination. CLINICAL DISCUSSION: IGPP is difficult to diagnose in emergency. Although different types of drainage of IGPP are described in the literature, pancreatic resection represents the treatment of choice when a cystic pancreatic neoplasm cannot be excluded. CONCLUSION: IGPP is a rare disease that may cause intestinal occlusion, IAH and ACS. Pancreatic resection if necessary is safe and therapeutic with acceptable morbidity and mortality.

Imaging features in management of laparoscopic mini/one anastomosis gastric bypass post-surgical complications.

Obesity is a widespread pathology among the population related to an increase in mortality and morbidity of patients. Bariatric surgery provides several forms of treatment for obese patients. Laparoscopic mini/one anastomosis gastric bypass (MGB/OAGB) is a recent low risk bariatric surgical procedure common in a large number of countries in the treatment of severe obesity. MGB/OAGB, compared to other bariatric surgery techniques, offers the significant technical improvement of requiring only one anastomosis in place of two. In this scenario, diagnostic imaging takes a significant role in the postoperative period, to evaluate the outcomes of surgical treatment and to detect possible complications both in early and late postoperative period. The prevalent radiological procedure to investigate suspicions of clinical post-operative complications is Computed tomography (CT) with oral and intravenous contrast administration. This pictorial essay aims to illustrate and identify normal radiological aspects of MGB/OAGB and post-surgery complication imaging features. We think that this article will serve to familiarize all the specialists with the diagnostic imaging of MGB/OAGB.

Laparoscopic mini/one anastomosis gastric bypass: anatomic features, imaging, efficacy and postoperative complications.

Laparoscopic mini/one anastomosis gastric bypass (MGB/OAGB) is an increasingly used bariatric surgical procedure. This surgical technique is effective in terms of both weight loss and the resolution of comorbidities, but it is not without complications. To report our experience in MGB/OAGB, assessing comorbidities and complications, and to illustrate post-surgical anatomy and radiological appearance of complications, a single-centre retrospective study of 953 patients undergoing MGB/OAGB between January 2005 and September 2018 was done. The inclusion criteria: body mass index (BMI) of 40 kg/m2 or higher or BMI between 35 and 40 kg/m2 with significant comorbidities not responsive to medical therapies. In the postoperative period, all patients were evaluated with clinical and laboratory tests and radiological examinations (upper gastrointestinal series, computed tomography and magnetic resonance imaging). Median weight was 126.69 kg and mean BMI was 49.4 kg/m2. Regarding comorbidities, 37.2%, 52.8%, 46.7% and 43.2% of patients presented with preoperatively diagnosed type 2 diabetes mellitus (T2DM), hypertensive disease, dyslipidaemia and obstructive sleep apnoea syndrome (OSAS), respectively. Median excess weight loss at 6, 12, 24 and 60 months after surgery was 33.45%, 53.81%, 68.75% and 68.80%, respectively. The remission of comorbidities was 91.4% for T2DM, 93.7% for hypertensive disease, 90.3% for dyslipidemia and 93.4% for OSAS. Early and late complication rates identified with radiological examinations were 1.5% and 1.6%, respectively. MGB/OAGB was effective for weight loss and comorbidities remission. Complications occurred at lower rate than with other surgical procedures were identified with imaging; CT was the main radiological technique.

Bariatric surgery and the COVID-19 pandemic: SICOB recommendations on how to perform surgery during the outbreak and when to resume the activities in phase 2 of lockdown.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its related disease, coronavirus disease 2019 (COVID-19), has been rapidly spreading all over the world and is responsible for the current pandemic. The current pandemic has found the Italian national health system unprepared to provide an appropriate and prompt response, heavily affecting surgical activities. Based on the limited data available in the literature and personal experiences, the Società Italiana di Chirurgia dell'OBesità e Malattie Metaboliche (SICOB) provides recommendations regarding the triage of bariatric surgical procedures during the COVID-19 pandemic defining a dedicated path for surgery in morbidly obese patients with known or suspected COVID-19 who may require emergency operations. Finally, the current paper delineates a strategy to resume outpatient visits and elective bariatric surgery once the acute phase of the pandemic is over. Models developed during the COVID-19 crisis should be integrated into hospital practices for future use in similar scenarios. Surgeons are presented with a golden opportunity to embrace systemic change and to drive their professional future.

Laparoscopic biliopancreatic diversion: our preliminary experience with 201 consecutive cases.

Surgery as a treatment modality for morbid obesity has shown impressive progress over the past decades because of a better understanding of the metabolic characteristics of obesity and the rationale for its surgical treatment. Biliopancreatic diversion was first performed in humans in 1976. Since then it has been an excellent operation for morbid obesity to achieve long-term weight reduction. We present our laparoscopic biliopancreatic diversion protocol, with or without distal gastrectomy (Resa's operation). From 1995 to October 2008 we operated on 201 patients; open biliopancreatic diversion was performed in 48 patients, while the remaining patients underwent laparoscopic biliopancreatic diversion (84 laparoscopic Scopinaro's operations, 69 laparoscopic Resa's operations). The mean operating time was 140 minutes for the open procedures, 180 minutes for Scopinaro's laparoscopic operation and 135 minutes for Resa's laparoscopic operation. The mean postoperative stay was 5.5 days. Our mortality rate consisted of two patients (0.99%) who had pulmonary embolisms. Other major complications were three cases of leakage from the jejuno-ileal anastomosis, 18 cases of incisional hernia, 6 cases of metabolic diseases; 1 case of acute hepatitis and 1 case of bronchopneumonia. Biliopancreatic diversion can be performed satisfactorily by laparoscopy. A factor that may reduce the technical difficulties and make the technique totally reversible is the gastric sparing. Thus an upper digestive endoscopy can determine preoperatively whether the patient will need a gastrectomy, depending on its results.