Current applications of indocyanine green (ICG) in abdominal, gynecologic and urologic surgery: a meta-review and quality analysis with use of the AMSTAR 2 instrument.

BACKGROUND: Indocyanine green (ICG) is an injectable fluorochrome that has recently gained popularity as a means of assisting intraoperative visualization during laparoscopic and robotic surgery. Many systematic reviews and meta-analyses have been published. We conducted a meta-review to synthesize the findings of these studies. METHODS: PubMed and Embase were searched to identify systematic reviews and meta-analyses coping with the uses of ICG in abdominal operations, including Metabolic Bariatric Surgery, Cholecystectomy, Colorectal, Esophageal, Gastric, Hepato-Pancreato-Biliary, Obstetrics and Gynecology (OG), Pediatric Surgery, Surgical Oncology, Urology, (abdominal) Vascular Surgery, Adrenal and Splenic Surgery, and Interdisciplinary tasks, until September 2023. We submitted the retrieved meta-analyses to qualitative analysis based on the AMSTAR 2 instrument. RESULTS: We identified 116 studies, 41 systematic reviews (SRs) and 75 meta-analyses (MAs), spanning 2013-2023. The most thoroughly investigated (sub)specialties were Colorectal (6 SRs, 25 MAs), OG (9 SRs, 15 MAs), and HPB (4 SRs, 12 MAs). Interestingly, there was high heterogeneity regarding the administered ICG doses, routes, and timing. The use of ICG offered a clear benefit regarding anastomotic leak prevention, particularly after colorectal and esophageal surgery. There was no clear benefit regarding sentinel node detection after OG. According to the AMSTAR 2 tool, most meta-analyses ranked as "critically low" (34.7%) or "low" (58.7%) quality. There were only five meta-analyses (6.7%) that qualified as "moderate" quality, whereas there were no "high" quality reviews. CONCLUSIONS: Regardless of the abundance of pertinent literature and reviews, surgeons should be cautious when interpreting their results on ICG use in abdominal surgery. Future reviews should focus on ensuring methodological vigor; establishing clear protocols of ICG dose, route of administration, and timing; and improving reporting quality. Other sources of data (e.g., registries) and novel methods of data analysis (e.g., machine learning) might also contribute to an enhanced role of ICG as a decision-making tool in surgery.

Comment on Salazar et al. Weight Regain after Metabolic Surgery: Beyond the Surgical Failure. J. Clin. Med. 2024, 13, 1143.

I read the article by Salazar J. [...].

Hypocalcemia in the Immediate Postoperative Period Following Metabolic Bariatric Surgery - Hype or Harm?

PURPOSE: Hypocalcemia post-metabolic bariatric surgery (MBS) is a known long-term complication after hypoabsorptive procedures. However, data on immediate postoperative calcium are limited. Our aim was to evaluate the prevalence of hypocalcemia on the 1st postoperative day after MBS and correlate it with potential associated factors. MATERIALS AND METHODS: We analyzed data from all consecutive index MBS over 1 year. We collected data on demographics and on preoperative and postoperative values of serum calcium (TC), albumin, adjusted calcium (AC-Payne formula), magnesium, phosphorus, preoperative vitamin-D, and postoperative 24-h urine output, intravenous fluids (IVF), bolus intravenous furosemide, and creatine phosphokinase (CPK). Continuous data are expressed as means ± SD (range). Categorical data are presented as frequencies (%). Linear regression was implemented to designate potential correlations. RESULTS: The cohort included 86 patients (58.1% females). The mean preoperative TC was 9.4mg/dL ± 0.4 (8.5-10.5) and mean postoperative TC 7.8mg/dL ± 0.6 (6.3-9.3, 17.0% decrease). The mean preoperative AC was 10.1mg/dL ± 0.4 (9.2-11.2) and mean postoperative AC 8.5mg/dL ± 0.6 (7.0-10.0, 15.8% decrease). Seventy-three patients (84.8%) had abnormally low TC (< 8.5mg/dL), and 43 (50%) abnormally low AC. There was only weak correlation between postoperative TC and AC with magnesium (r = 0.258), phosphorus (r = 0.269), vitamin-D (-0.163), 24-h urine output (r = -0.168), IVF (r = -0.237), bolus furosemide (r = 0.155), and mean operative time (r = 0.010). CONCLUSIONS: In our cohort of patients, hypocalcemia was a real problem but we did not find any significant correlation with the examined factors. Further studies are warranted to validate our findings and investigate other potential correlations.

A Narrative Review on the Clinical Utility of Electrical Impedance Spectroscopy for Diagnosing High-Grade Cervical Intraepithelial Neoplasia.

Colposcopy constitutes a pivotal step in the diagnosis and management of cervical intraepithelial neoplasia; nevertheless, the method has several inherent and external limitations. Electrical impedance spectroscopic (EIS) has been among the adjuncts that have been developed to increase the diagnostic accuracy of colposcopy. EIS is based on the principle that the trajectory of electrical current alters depending on the consistency of the tissues. In the present study, we investigate the diagnostic accuracy and clinical utility of EIS by means of searching the available evidence. Our search yielded 17 articles during the period 2005-2023. Subsequently, we focused on the performance metrics of the included studies. The general concept is that EIS, in combination with colposcopy, is a method with increased sensitivity and specificity in detecting high-grade cervical intraepithelial neoplasia as compared to colposcopy alone. However, we documented a heterogeneous distribution of these and other metrics, including the positive predictive value, the negative predictive value, and the area under the receiver operating characteristic curve (AUC). Additionally, we located potential confounders that might hamper the measurements of EIS and, as such, warrant further investigation in future research. We conclude that future studies should be directed towards randomized multicentric trials, whereas the advent of artificial intelligence might improve the diagnostic accuracy of the method by helping incorporate a large amount of data.

The Effectiveness of Metabolic Bariatric Surgery in Preventing Gynecologic Cancer - from Pathophysiology to Clinical Outcomes.

Obesity and cancer represent two pandemics of current civilization, the progression of which has followed parallel trajectories. To time, thirteen types of malignancies have been recognized as obesity-related cancers, including breast (in postmenopausal women), endometrial, and ovarian cancer. Pathophysiologic mechanisms that connect the two entities include insulin resistance, adipokine imbalance, increased peripheral aromatization and estrogen levels, tissue hypoxia, and disrupted immunity in the cellular milieu. Beyond the connection of obesity to carcinogenesis at a molecular and cellular level, clinicians should always be cognizant of the fact that obesity might have secondary impacts on the diagnosis and treatment of gynecologic cancer, including limited access to effective screening programs, resistance to chemotherapy and targeted therapies, persisting lymphedema, etc. Metabolic bariatric surgery represents an attractive intervention not only for decreasing the risk of carcinogenesis in high-risk women living with obesity but most importantly as a measure to improve disease-specific and overall survival in patients with diagnosed obesity-related gynecologic malignancies. The present narrative review summarizes current evidence on the underlying pathophysiologic mechanisms, the clinical data, and the potential applications of metabolic bariatric surgery in all types of gynecologic cancer, including breast, endometrial, ovarian, cervical, vulvar, and vaginal.

Status of Body Contouring Following Metabolic Bariatric Surgery in a Tertiary Hospital of Greece-Still a Long Way to Go.

Obesity is a disease rather than a state, and metabolic bariatric surgery (MBS) is its most effective treatment. Body contouring surgery (BCS) is an integral part of the continuum of care following MBS, provided that the body mass index (BMI) has stabilized for an adequate period. This study is an attempt to capture the current status of BCS following MBS in Greece, based on data from one of the country's highest-volume hospitals. We recruited patients from the Bariatric and Plastic-Reconstructive Surgery registries who had undergone both MBS and BCS and invited them to answer a structured questionnaire with components on demographics, safety and effectiveness of previous operations, quality of life (QoL), body image, social activity, sexual activity, and doctor-patient communication. Twenty-four patients participated in the survey (response rate 88.1%). The mean BMI pre-MBS was 43.8 kg/m2 and that pre-BCS was 28.6 kg/m2. Based on the Bariatric sub-cohort, only 2.5% of post-bariatric patients underwent BCS. The mean interval between MBS and BCS was 2.9 years. The distribution of patients by MBS was as follows: sleeve gastrectomy 8 (33.3%), gastric band 7 (29.2%), gastric bypass 5 (20.8%), and gastric plication 2 (8.3%). The distribution of patients by BCS was as follows: abdominoplasty 23 (94.7%), breast contouring 8 (33.3%), thigh contouring 3 (12.5%), and arm contouring 5 (20.8%). Most positive components (70.6%) regarding QoL were appraised by >80% of the participants, indicating overall satisfaction after BCS. Conversely, only 12.5% of negative components were endorsed by >20% of patients. In conclusion, BCS has a low prevalence after MBS, although it is related to an improved quality of life and body image.

Metabolomics in Bariatric and Metabolic Surgery Research and the Potential of Deep Learning in Bridging the Gap.

During the past several years, there has been a shift in terminology from bariatric surgery alone to bariatric and metabolic surgery (BMS). More than a change in name, this signifies a paradigm shift that incorporates the metabolic effects of operations performed for weight loss and the amelioration of related medical problems. Metabolomics is a relatively novel concept in the field of bariatrics, with some consistent changes in metabolite concentrations before and after weight loss. However, the abundance of metabolites is not easy to handle. This is where artificial intelligence, and more specifically deep learning, would aid in revealing hidden relationships and would help the clinician in the decision-making process of patient selection in an individualized way.

Artificial Intelligence and Machine Learning in the Diagnosis and Management of Gastroenteropancreatic Neuroendocrine Neoplasms-A Scoping Review.

Neuroendocrine neoplasms (NENs) and tumors (NETs) are rare neoplasms that may affect any part of the gastrointestinal system. In this scoping review, we attempt to map existing evidence on the role of artificial intelligence, machine learning and deep learning in the diagnosis and management of NENs of the gastrointestinal system. After implementation of inclusion and exclusion criteria, we retrieved 44 studies with 53 outcome analyses. We then classified the papers according to the type of studied NET (26 Pan-NETs, 59.1%; 3 metastatic liver NETs (6.8%), 2 small intestinal NETs, 4.5%; colorectal, rectal, non-specified gastroenteropancreatic and non-specified gastrointestinal NETs had from 1 study each, 2.3%). The most frequently used AI algorithms were Supporting Vector Classification/Machine (14 analyses, 29.8%), Convolutional Neural Network and Random Forest (10 analyses each, 21.3%), Random Forest (9 analyses, 19.1%), Logistic Regression (8 analyses, 17.0%), and Decision Tree (6 analyses, 12.8%). There was high heterogeneity on the description of the prediction model, structure of datasets, and performance metrics, whereas the majority of studies did not report any external validation set. Future studies should aim at incorporating a uniform structure in accordance with existing guidelines for purposes of reproducibility and research quality, which are prerequisites for integration into clinical practice.

A Scoping Review of Artificial Intelligence and Machine Learning in Bariatric and Metabolic Surgery: Current Status and Future Perspectives.

Artificial intelligence (AI) is a revolution in data analysis with emerging roles in various specialties and with various applications. The objective of this scoping review was to retrieve current literature on the fields of AI that have been applied to metabolic bariatric surgery (MBS) and to investigate potential applications of AI as a decision-making tool of the bariatric surgeon. Initial search yielded 3260 studies published from January 2000 until March 2021. After screening, 49 unique articles were included in the final analysis. Studies were grouped into categories, and the frequency of appearing algorithms, dataset types, and metrics were documented. The heterogeneity of current studies showed that meticulous validation, strict reporting systems, and reliable benchmarking are mandatory for ensuring the clinical validity of future research.