Short-term gut microbiota's shift after laparoscopic Roux-en-Y vs one anastomosis gastric bypass: results of a multicenter randomized control trial.

BACKGROUND: Roux-en-Y (RYGB) and one anastomosis gastric bypass (OAGB) represent two of the most used bariatric/metabolic surgery (BMS) procedures. Gut microbiota (GM) shift after bypass surgeries, currently understated, may be a possible key driver for the short- and long-term outcomes. METHODS: Prospective, multicenter study enrolling patients with severe obesity, randomized between OAGB or RYGB. Fecal and blood samples were collected, pre- (T0) and 24 months postoperatively (T1). GM was determined by V3-V4 16S rRNA regions sequencing and home-made bioinformatic pipeline based on Qiime2 plugin and R packages. OBJECTS: To compare OAGB vs RYGB microbiota profile at T1 and its impact on metabolic and nutritional status. RESULTS: 54 patients completed the study, 27 for each procedure. An overall significant variation was detected in anthropometric and serum nutritional parameters at T1, with a significant, similar decrease in overall microbial alpha and beta diversity observed in both groups. An increase in relative abundances of Actinobacteria and Proteobacteria and a reduction of Bacteroidetes, no significant changes in Firmicutes and Verrucomicrobia, with an increase of the Firmicutes/Bacteroidetes ratio were observed. CONCLUSIONS: BMS promotes a dramatic change in GM composition. This is the first multicenter, RCT evaluating the impact of OAGB vs Roux-en-Y bypass on GM profile. The bypass technique per se did not impact differently on GM or other examined metabolic parameters. The emergence of slightly different GM profile postoperatively may be related to clinical conditions or may influence medium or long-term outcomes and as such GM profile may represent a biomarker for bariatric surgery's outcomes.

Leaks after laparoscopic sleeve gastrectomy: 2024 update on risk factors.

PURPOSE: Leaks after sleeve gastrectomy remain a deadly complication significantly affecting outcomes and medical costs. The aim of the present review is to provide an updated decalogue on leak prevention. METHODS: Risk factors of leakage after LSG were examined based on an extensive review of literature (in period time 2016-2024) and summary of evidence was provided using Oxford levels of evidence scale. RESULTS: Pathogenesis of leakage after LSG still remain related to ischemic and mechanical factors and, therefore, no new evidence has been reported. Conversely, some technical aspect of the procedure has changed: bougie size, antrum resection, staple line reinforcement, and intraoperative leak testing. CONCLUSIONS: Bougie size 36 F is effective and safe achieving similar leakage rate compared to larger bougie sizes (EL:2) 2024 UPDATE; There is no significant difference in the leak rate between restrictive (< 6 cm) and conservative (6 cm) antrum resection (EL: 1) 2024 UPDATE; Surgical experience and case volume affect the leak rate more consistently than every kind of SLR (EL: 2) 2024 UPDATE; Intraoperative leak test after LSG represents a decision based on surgeon preference in absence of standardization (endoscopy, bubble test, methylene blue, indocyanine green.) and strong detection/prevention rate (EL: 3) 2024 UPDATE.

Childhood traumatic experiences in people with obesity with and without eating disorders who are seeking bariatric surgery: the role of attachment relationships and family functioning.

PURPOSE: The present study examines the impact of traumatic childhood experiences in people with obesity seeking bariatric surgery. It considers the presence of eating disorders (ED) in the population with obesity and tests the role of attachment and family relationships as mediators of the relationship between traumatic events and ED. METHOD: 110 participants with severe obesity and 98 participants of a healthy weight (control group) filled out The Childhood Trauma Questionnaire (CTQ-SF), the Attachment Style Questionnaire (ASQ) and the Family Adaptability and Cohesion Evaluation Scale (FACES IV). RESULTS: Comparing the two groups on psychological variables, higher scores in the CTQ Emotional neglect and ASQ insecure attachment scales emerged in the control group than the group with obesity. Considering the presence/absence of an ED only in the group with obesity, and comparing these subgroups, higher scores in traumatic experiences emerged in the individuals with obesity and with ED than the individuals with obesity without ED. Moreover, participants with ED scored higher in ASQ insecure attachment and had lower levels of flexibility in family functioning than the group without ED. Finally, Logistic Regression models showed that insecure anxious attachment and dysfunctional familial relationships affected the relationship between traumatic childhood experiences and the presence of ED in the group with obesity. CONCLUSION: These findings suggest the importance focusing on psychosocial factors linked to obesity, specifically on attachment styles and familial relationships as emotion regulation strategies, since the impact of traumatic childhood events on psychopathology could be ameliorated by an individual's ability to rely on a significant attachment figure. LEVEL OF EVIDENCE: Level II, evidence obtained from well-designed controlled trials without randomization.

Reduced Lipopolysaccharide-Binding Protein (LBP) Levels Are Associated with Non-Alcoholic Fatty Liver Disease (NAFLD) and Adipose Inflammation in Human Obesity.

Lipopolysaccharide (LPS) and its binding protein LBP have emerged as potential contributors to the progression from overweight/obesity to overt metabolic diseases and NAFLD. While LPS is known to activate hepatocyte inflammation, thus contributing toward NAFLD development, the role of LBP is more intricate, and recent data have shown that experimental reduction in hepatic LBP promotes NAFLD progression. In this cross-sectional investigation, we evaluated circulating LBP in relation to obesity, NAFLD, visceral adipose tissue (VAT) inflammation, and type 2 diabetes (T2D). We recruited 186 individuals (M/F: 81/105; age: 47 ± 10.4 years; BMI: 35.5 ± 8.6 kg/m2); a subgroup (n = 81) underwent bariatric surgery with intra-operative VAT and liver biopsies. LBP levels were higher in obese individuals than non-obese individuals but were inversely correlated with the parameters of glucose metabolism. Reduced LBP predicted T2D independent of age, sex, and BMI (p < 0.001). LBP levels decreased across more severe stages of hepatosteatosis and lobular inflammation, and were inversely associated with VAT inflammation signatures. In conclusion, LBP levels are increased in obese individuals and are associated with a more favorable metabolic profile and lower NAFLD/NASH prevalence. A possible explanation for these findings is that hepatic LBP production may be triggered by chronic caloric excess and facilitate LPS degradation in the liver, thus protecting these individuals from the metabolic consequences of obesity.

ERas and COLorectal endoscopic surgery: an Italian society for endoscopic surgery and new technologies (SICE) national report.

BACKGROUND: Several reports demonstrated a strong association between the level of adherence to the protocol and improved clinical outcomes after surgery. However, it is difficult to obtain full adherence to the protocol into clinical practice and has still not been identified the threshold beyond which improved functional results can be reached. METHODS: The ERCOLE (ERas and COLorectal Endoscopic surgery) study was as a cohort, prospective, multi-centre national study evaluating the association between adherence to ERAS items and clinical outcomes after minimally invasive colorectal surgery. The primary endpoint was to associate the percentage of ERAS adherence to functional recovery after minimally invasive colorectal cancer surgery. The secondary endpoints of the study was to validate safety of the ERAS programme evaluating complications' occurrence according to Clavien-Dindo classification and to evaluate the compliance of the Italian surgeons to each ERAS item. RESULTS: 1138 patients were included. Adherence to the ERAS protocol was full only in 101 patients (8.9%), > 75% of the ERAS items in 736 (64.7%) and > 50% in 1127 (99%). Adherence to > 75% was associated with a better functional recovery with 90.2 ± 98.8 vs 95.9 ± 33.4 h (p = 0.003). At difference, full adherence to the ERAS components 91.7 ± 22.1 vs 92.2 ± 31.6 h (p = 0.8) was not associated with better recovery. CONCLUSIONS: Our results were encouraging to affirm that adherence to the ERAS program up to 75% could be considered satisfactory to get the goal. Our study could be considered a call to simplify the ERAS protocol facilitating its penetrance into clinical practice.

AGREE-S: AGREE II extension for surgical interventions: appraisal instrument.

BACKGROUND: The Appraisal of Guidelines Research and Evaluation (AGREE) II instrument was developed to evaluate the quality of clinical practice guidelines. Evidence suggests that development, reporting, and appraisal of guidelines on surgical interventions may be better informed by modification of the instrument. OBJECTIVE: We aimed to develop an AGREE II extension specifically designed for appraisal of guidelines of surgical interventions. METHODS: In a three-part project funded by the United European Gastroenterology and the European Association for Endoscopic Surgery, (i) we identified factors that were associated with higher quality of surgical guidelines, (ii) we statistically calibrated the AGREE II instrument in the context of surgical guidelines using correlation, reliability, and factor analysis, and (iii) we undertook a Delphi consensus process of stakeholders to inform the development of an AGREE II extension instrument for surgical interventions. RESULTS: Several features were prioritized by stakeholders as of particular importance for guidelines of surgical interventions, including development of a guideline protocol, consideration of practice variability and surgical expertise in different settings, and specification of infrastructures required to implement the recommendations. The AGREE-S-AGREE II extension instrument for surgical interventions has 25 items, compared to the 23 items of the original AGREE II instrument, organized into the following 6 domains: Scope and purpose, Stakeholders, Evidence synthesis, Development of recommendations, Editorial independence, and Implementation and update. As the original instrument, it concludes with an overall appraisal of the quality of the guideline and a judgement on whether the guideline is recommended for use. Several items were amended and rearranged among domains, and an item was deleted. The Rigor of Development domain of the original AGREE II was divided into Evidence Synthesis and Development of Recommendations. Items of the AGREE II domain Clarity of Presentation were incorporated in the new domain Development of Recommendations. Three new items were introduced, addressing the development of a guideline protocol, support by a guideline methodologist, and consideration of surgical experience/expertise. CONCLUSION: The AGREE-S appraisal instrument has been developed to be used for assessment of the methodological and reporting quality of guidelines on surgical interventions.

EAES rapid guideline: systematic review, network meta-analysis, CINeMA and GRADE assessment, and European consensus on bariatric surgery-extension 2022.

BACKGROUND: The European Association for Endoscopic Surgery Bariatric Guidelines Group identified a gap in bariatric surgery recommendations with a structured, contextualized consideration of multiple bariatric interventions. OBJECTIVE: To provide evidence-informed, transparent and trustworthy recommendations on the use of sleeve gastrectomy, Roux-en-Y gastric bypass, adjustable gastric banding, gastric plication, biliopancreatic diversion with duodenal switch, one anastomosis gastric bypass, and single anastomosis duodeno-ileal bypass with sleeve gastrectomy in patients with severe obesity and metabolic diseases. Only laparoscopic procedures in adults were considered. METHODS: A European interdisciplinary panel including general surgeons, obesity physicians, anesthetists, a psychologist and a patient representative informed outcome importance and minimal important differences. We conducted a systematic review and frequentist fixed and random-effects network meta-analysis of randomized-controlled trials (RCTs) using the graph theory approach for each outcome. We calculated the odds ratio or the (standardized) mean differences with 95% confidence intervals for binary and continuous outcomes, respectively. We assessed the certainty of evidence using the CINeMA and GRADE methodologies. We considered the risk/benefit outcomes within a GRADE evidence to decision framework to arrive at recommendations, which were validated through an anonymous Delphi process of the panel. RESULTS: We identified 43 records reporting on 24 RCTs. Most network information surrounded sleeve gastrectomy and Roux-en-Y gastric bypass. Under consideration of the certainty of the evidence and evidence to decision parameters, we suggest sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass over adjustable gastric banding, biliopancreatic diversion with duodenal switch and gastric plication for the management of severe obesity and associated metabolic diseases. One anastomosis gastric bypass and single anastomosis duodeno-ileal bypass with sleeve gastrectomy are suggested as alternatives, although evidence on benefits and harms, and specific selection criteria is limited compared to sleeve gastrectomy and Roux-en-Y gastric bypass. The guideline, with recommendations, evidence summaries and decision aids in user friendly formats can also be accessed in MAGICapp:  https://app.magicapp.org/#/guideline/Lpv2kE CONCLUSIONS: This rapid guideline provides evidence-informed, pertinent recommendations on the use of bariatric and metabolic surgery for the management of severe obesity and metabolic diseases. The guideline replaces relevant recommendations published in the EAES Bariatric Guidelines 2020.

Multicenter retrospective cohort Italian study on elective laparoscopic cholecystectomy performed by the surgical residents.

PURPOSE: This retrospective multicenter cohort study aimed to evaluate the clinical outcomes (mortality rate, operative time, complications) of elective laparoscopic cholecystectomy (LC) when performed by a surgical resident in comparison to experienced consultant in the backdrop of Italian academic centers. METHODS: Retrospective review of all patients undergoing elective LC between January 2016 and January 2022 at six teaching hospitals across Italy was performed. Cases were identified using the Current Procedural Terminology (CPT) code 5123 (LC without cholangiogram). All cases of emergency surgery, ASA score > 3, or when cholecystectomy was performed with another surgical procedure, were excluded. All suitable cases were divided into 2 groups based on primary surgeon: consultant or senior resident. Main outcome was complication rates (intraoperative and peri/postoperative); secondary outcomes included operative time, the length of stay, and the rate of conversion to open. RESULTS: A total of 2331 cases (1425 females) were included, of which, consultants performed 1683 LCs (72%), while the residents performed 648 (28%) surgeries. The groups were statistically comparable regarding demographics, history of previous abdominal surgery, operative time, or intraoperative complications. The rate of conversion to open cholecystectomy was 1.42% for consultant and none for resident (p = 0.02). A statistically significant difference was observed between groups regarding the average length of stay (2.2 ± 3 vs 1.6 ± 1.3 days p = 0.03). Similarly, postoperative complications (1.7% vs 0.5%) resulted in statistically significant (p = 0.02) favoring resident group. CONCLUSIONS: Our study demonstrates that in selected patients, senior residents can safely perform LC when supervised by senior staff surgeons.

Platelet-rich plasma PRP vs. absorbable mesh as cruroplasty reinforcement: a study on an animal model.

BACKGROUND: Reinforcement of posterior cruroplasty has been proposed to minimize the failure of hiatal hernia repair (HHR). The applications of autologous platelet-rich plasma (PRP) and absorbable mesh are barely reported in this area. AIMS: To analyze local macroscopic and microscopic changes induced by mesh vs. PRP as reinforcement of HHR, using a reliable laparoscopic experimental porcine model. MATERIAL AND METHODS: This prospective, comparative pilot study was conducted on 14 female pigs, aged four to six months. An iatrogenic hiatal defect was laparoscopically simulated and repaired, reinforced with Bio-A® mesh (group A) or PRP (group B). Specimen retrieval was performed after seven months for histopathological (HP) examination. RESULTS: No local or general complications were registered, with complete resorption of reinforcements, that determined inflammatory infiltrates with local collagen production and tissue neo-vascularization. Group A had an increased mean chronic inflammation score (p = .3061), showing significant sclerotic collagenizing process. PRP enhanced angiogenesis, collagenizing, myofibroblast recruitment and tissue ingrowth. CONCLUSIONS: No residual materials or evidence of anatomical distortion were found. Animal model was safe and reliable. This is the first report of complete absorption of Bio-A® positioned on crural area. HP results suggest the clinical application of PRP in HHR as a promising co-adjuvant to local remodeling and healing.Abbreviations: ASA: American Society of Anesthesiologists; AB: Alcian Blue; PAS: Periodic Acid-Schiff; CP: platelet concentrate; fPC: filtered plasma concentrate; GERD: gastro-esophageal reflux disease; HSA: hiatal surface area; HHR: hiatal hernia repair; HP: histopathological; HH: hiatal hernia; HE: hematoxylin and eosin; HR: hiatus repair alone; HRM: hiatus repair and acellular dermal matrix; NM: Nicolae Manolesccu; LNF: laparoscopic Nissen fundoplication; PC: posterior cruroplasty; PPP: platelet-poor plasma; RP: platelet-rich plasma.

A Narrative Review on Bariatric ERAS.

Introduction: Bariatric/metabolic surgery (BMS) is the most effective treatment of morbid obesity, while Enhanced Recovery After Surgery (ERAS) after BMS represents a multimodal perioperative protocol designed to achieve early recovery for patients with peculiar characteristics. The aim of the current narrative review is to summarize and discuss the current role, the application, and the future developments of ERAS protocols in the field of BMS. Methods: A literature search for studies published up to June 30, 2022, with no restrictions on language or publication period, was performed on Medline and Embase, using the keywords "ERAS" OR "enhanced recovery after surgery" AND "bariatric surgery" OR "metabolic surgery". Postoperative length of hospital stay LOS, overall and major morbidity and mortality, readmission rates, postoperative nausea or vomit PONV, opioids and antiemetics use, hospital costs, ERAS in specific health care settings, barriers to ERAS and further developments were analyzed. Results/Conclusions: The results were presented with a narrative review, using tabulation to summarize the results of meta-analyses and RCTs: 6 articles reporting guidelines, 5 metaanalyses, 9 randomized controlled trials, and 48 observational studies. ERAS protocols are feasible and safe in the setting of BMS, and associated to reduced LOS, PONV and postoperative pain, reduced opioid and antiemetic use and reduced costs. Postoperative mortality and readmission rates are similar between patients receiving standard care and those with ERAS protocols. Furthermore, increase of ERAS application may be useful in health care systems dealing with epidemic infectious diseases and implemented by technological advancements.