Magnetic single-anastomosis side-to-side duodeno-ileostomy for revision of sleeve gastrectomy in adults with severe obesity: 1-year outcomes.

INTRODUCTION: Uncomplicated surgical approaches that minimize anastomotic complications while improving revisional metabolic/bariatric surgical (MBS) outcomes are needed. METHODS: This prospective single-center study assessed the feasibility, safety, and efficacy of the novel linear magnetic anastomosis system (LMAS [3 cm]) in performing a side-to-side duodeno-ileostomy (MagDI) bipartition to revise clinically suboptimal primary sleeve gastrectomy (SG). Patients with severe obesity with/without type 2 diabetes (T2D) with suboptimal weight loss, regain, and/or T2D recurrence post SG underwent revisional MagDI. A distal and proximal magnet were delivered endoscopically to the ileum and duodenum and aligned via laparoscopic assistance. Gradual magnet fusion formed a DI bipartition. PRIMARY ENDPOINTS: technical feasibility, safety (Clavien-Dindo [CD] severe adverse event classification) at 1 year. Secondary endpoints: MBS weight and T2D reduction. RESULTS: July 29, 2022-March 28, 2023, 24 patients (95.8% female, mean age 44.9 ± 1.5 years, and body mass index [BMI] 39.4 ± 1.3 kg/m2) underwent MagDI. Feasibility was attained via correct magnet placement (mean operative time 63.5 ± 3.3 min), patent anastomoses created, and magnet passage per anus in 100.0% of patients. There were 4 CD-III mild or moderate severe AEs, 0.0% associated with the LMAS or MagDI: 0.0% anastomotic leakage, obstruction, bleeding, infection, reintervention, or death. Mean BMI reduction was 2.1 kg/m2 (p < 0.05); total weight loss 5.3%, excess weight loss 16.4%; and the patient with T2D improved. CONCLUSION: The single-anastomosis MagDI procedure using the novel 3-cm LMAS to revise clinically suboptimal SG was technically straightforward, incurred no major complications, mitigated weight regain, and renewed clinically meaningful weight loss. GOV IDENTIFIER: NCT05322122.

Association between operative position and postoperative nausea and vomiting in patients undergoing laparoscopic sleeve gastrectomy.

BACKGROUND: Bariatric surgery is one of the most effective ways to treat morbid obesity, and postoperative nausea and vomiting (PONV) is one of the common complications after bariatric surgery. At present, the mechanism of the high incidence of PONV after weight-loss surgery has not been clearly explained, and this study aims to investigate the effect of surgical position on PONV in patients undergoing bariatric surgery. AIM: To explore the effect of the operative position during bariatric surgery on PONV. METHODS: Data from obese patients, who underwent laparoscopic sleeve gastrectomy (LSG) in the authors' hospital between June 2020 and February 2022 were divided into 2 groups and retrospectively analyzed. Multivariable logistic regression analysis and the t-test were used to study the influence of operative position on PONV. RESULTS: There were 15 cases of PONV in the supine split-leg group (incidence rate, 50%) and 11 in the supine group (incidence rate, 36.7%) (P = 0.297). The mean operative duration in the supine split-leg group was 168.23 ± 46.24 minutes and 140.60 ± 32.256 minutes in the supine group (P < 0.05). Multivariate analysis revealed that operative position was not an independent risk factor for PONV (odds ratio = 1.192, 95% confidence interval: 0.376-3.778, P = 0.766). CONCLUSION: Operative position during LSG may affect PONV; however, the difference in the incidence of PONV was not statistically significant. Operative position should be carefully considered for obese patients before surgery.

Assessing clinical and metabolic responses related to hyperlipidemia, MASLD and type 2 diabetes: sleeve versus RYGB.

OBJECTIVE: Both Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) are effective at inducing weight loss, but more information is needed on their comparative effectiveness at improving clinical/biochemical outcomes related to the presence of hyperlipidemia, metabolic dysfunction-associated steatotic liver disease (MASLD), or type 2 diabetes (T2D) at baseline. Here we aimed to assess this in real-world practice. METHODS: This is a prospective cross-sectional and cohort study of 142 patients who underwent RYGB or LSG as per clinical practice. Clinical/biochemical data were collected at baseline, prior to surgery and 12 months post-bariatric surgery. Liver biopsy was performed during surgery to diagnose MASLD. The main outcome was 12-month changes in lipid parameters, mainly total cholesterol, between types of surgery. RESULTS: A TOTAL OF: 107 participants underwent RYGB and 35 underwent LSG. Both groups were similar at baseline except for a higher proportion of males and waist circumference in the LSG group. At 12 months postsurgery, RYGB versus LSG resulted in a significantly lower body mass index, triglycerides, total cholesterol, and low-density lipoprotein. However, alanine aminotransferase was significantly lower in those who underwent LSG. In subgroup analyses RYGB was superior at improving lipid-related parameters in those with hyperlipidemia, whereas LSG was superior at reducing alanine aminotransferase in those with MASLD. CONCLUSIONS: RYGB versus LSG leads to greater reductions in body mass index and lipid parameters, especially in those with hyperlipidemia, whereas LSG showed greater improvements in liver enzymes in those with MASLD.

Cost-effectiveness and safety of continuous pulse oximetry for management of undiagnosed obstructive sleep apnea in bariatric surgery: a nationwide cohort study.

BACKGROUND: Undetected obstructive sleep apnea (OSA) is highly prevalent in patients undergoing bariatric surgery and increases perioperative risks. Screening for OSA using preoperative polygraphy (PG) with subsequent continuous positive airway pressure (CPAP) is costly and time-consuming. Postoperative continuous pulse oximetry (CPOX) is less invasive, and is hypothesized to be a safe and cost-effective alternative. OBJECTIVES: This nationwide multicenter prospective observational cohort study compared CPOX monitoring with OSA-screening using PG. SETTING: High-volume bariatric centers. METHODS: Patients were either postoperatively monitored using CPOX without preoperative OSA-screening, or underwent preoperative PG and CPAP treatment when OSA was diagnosed. Cohort placement was based on local hospital protocols. Cost-effectiveness was analyzed using quality adjusted life years (QALYs) and healthcare costs. Surgical outcomes were also analyzed. Propensity score matching was used in sensitivity analyses. RESULTS: A total of 1390 patients were included. QALYs were similar between groups at baseline and 1-year postoperatively. Postoperative complications, intensive care unit (ICU)-admissions and admissions, particularly OSA-related, did not differ between groups. Mean costs per patient/year in the CPOX group was €3094 versus €3680 in the PG group; mean difference €-586 (95% CI €-933-€-242). Following propensity score matching, 1090 of 1390 included patients remained, and similar findings for cost-effectiveness, complications, and ICU admissions were observed. CONCLUSION: CPOX monitoring without preoperative OSA-screening was not associated with higher complication or readmission rates compared to PG. CPOX resulted in lower costs from a healthcare perspective and can therefore be considered a cost-effective alternative to routine OSA-screening in patients undergoing bariatric surgery.

Development of predictive model for predicting postoperative BMI and optimize bariatric surgery: a single center pilot study.

BACKGROUND: The pilot study addresses the challenge of predicting postoperative outcomes, particularly body mass index (BMI) trajectories, following bariatric surgery. The complexity of this task makes preoperative personalized obesity treatment challenging. OBJECTIVES: To develop and validate sophisticated machine learning (ML) algorithms capable of accurately forecasting BMI reductions up to 5 years following bariatric surgery aiming to enhance planning and postoperative care. The secondary goal involves the creation of an accessible web-based calculator for healthcare professionals. This is the first article that compares these methods in BMI prediction. SETTING: The study was carried out from January 2012 to December 2021 at GZOAdipositas Surgery Center, Switzerland. Preoperatively, data for 1004 patients were available. Six months postoperatively, data for 1098 patients were available. For the time points 12 months, 18 months, 2 years, 3 years, 4 years, and 5 years the following number of follow-ups were available: 971, 898, 829, 693, 589, and 453. METHODS: We conducted a comprehensive retrospective review of adult patients who underwent bariatric surgery (Roux-en-Y gastric bypass or sleeve gastrectomy), focusing on individuals with preoperative and postoperative data. Patients with certain preoperative conditions and those lacking complete data sets were excluded. Additional exclusion criteria were patients with incomplete data or follow-up, pregnancy during the follow-up period, or preoperative BMI ≤30 kg/m2. RESULTS: This study analyzed 1104 patients, with 883 used for model training and 221 for final evaluation, the study achieved reliable predictive capabilities, as measured by root mean square error (RMSE). The RMSE values for three tasks were 2.17 (predicting next BMI value), 1.71 (predicting BMI at any future time point), and 3.49 (predicting the 5-year postoperative BMI curve). These results were showcased through a web application, enhancing clinical accessibility and decision-making. CONCLUSION: This study highlights the potential of ML to significantly improve bariatric surgical outcomes and overall healthcare efficiency through precise BMI predictions and personalized intervention strategies.

Desmoid Tumor after Sleeve Gastrectomy: Case Report and Literature Review.

Desmoid tumor is a rare mesenchymal neoplasm of unknown etiology. Despite rare, the diagnosis of desmoid tumors after bariatric surgery is increased over the last few years. We report a case of a 26-year-old male with complains of abdominal pain and postprandial fullness, diagnosed with a locally advanced large intra-abdominal mass (40 × 21 × 11.7 cm) centered in the mesentery, developed 3 years after sleeve gastrectomy. Percutaneous biopsy was suggestive of a mesenquimatous tumor and the patient underwent surgery. R0 surgical resection was achieved, despite intimal contact and common vascularization with a jejunal loop. Histopathology examination of the surgical specimen revealed fusiform to stellate cells with mild atypia, thin-walled vessels, and diffuse beta-catenin expression (negative for DOG-1, CD117, CD34, S100, desmin, and alpha-actin). The diagnosis of a desmoid tumor was made. The patient remained asymptomatic, and no recurrence occurred over a 4-year follow-up. With the increasing number of bariatric surgeries, owing to the alarming growing incidence of obesity and related conditions, it is expected that desmoid tumors reports will gradually increase over the next few years. Thus, both gastroenterologists and surgeons should be aware of the potential for desmoid tumor development shortly after surgery, to offer a prompt diagnosis and treatment.

O tumor desmóide é uma neoplasia mesenquimatosa rara de etiologia desconhecida. Apesar de raros, temos assistido a um aumento do número de diagnósticos, ao longo dos últimos anos, de tumores desmóides que se desenvolvem após cirurgia bariátrica. Descrevemos o caso de um homem de 26 anos com queixas de dor abdominal e enfartamento pós-prandial, diagnosticado com uma massa intra-abdominal centrada no mesentério (40 × 21 × 11.7 cm), localmente avançada, 3 anos após ter realizado gastrectomia vertical. Foi efetuada biópsia percutânea, cujo resultado foi sugestivo de tumor mesenquimatoso e o paciente foi referenciado para cirurgia. O doente foi submetido a cirurgia e o tumor foi passível de ressecção cirúrgica R0, apesar de contacto íntimo e vascularização comum com uma ansa jejunal. O exame anatomopatológico revelou células fusiformes a estreladas com atipia ligeira e vasos de parede fina, bem como expressão difusa de beta-catenina (na ausência de expressão de DOG-1, CD117, CD34, S100, desmina e alfa-actina), sendo compatível com o diagnóstico de um tumor desmóide. O doente permanece assintomático e sem evidência de recidiva ao longo de 4 anos de vigilância. Com o aumento do número de cirurgias bariátricas devido ao aumento alarmante da incidência de obesidade e condições relacionadas, espera-se que os diagnósticos de tumores desmóides aumentem nos próximos anos. Assim, tanto gastroenterologistas quanto cirurgiões devem estar alerta para o desenvolvimento desta entidade, de forma a oferecer um diagnóstico e tratamento adequado e atempado.

Bariatric Metabolic Surgery Might be More of a Benefit than a Risk During a Pandemic Outbreak.

Introduction: This report aimed to analyze the outcomes of patients with obesity who were on a bariatric program during the SARS-Cov-2 pandemic outbreak and compare those who received surgery with the ones who were not operated on. Methods: This was a retrospective study between 2020 and 2021. Patients were divided into two groups: those who underwent surgery (O) and those who were not operated (NO). The evolution of the risk factors identified for severe COVID infection and death was studied (ASMBS criteria). For this study, a follow-up period of 12 months was initiated. Results: In the O group, 83 patients were included and 99 were in the NO group. In the O group, patients with body mass index (BMI) > 35 Kg/m2 before surgery resolved the condition in 73.5% (61) cases, and this was done in the first 30 days by 38 (45.7%). Type 2 diabetes mellitus remission was documented in 18 patients (85.7%) of the O group, and the mean time elapsed for remission was 102.2 days (P < .01). Hypertension remitted in 66.7% (20) of the patients in group O in 82.4 days (P < .01). The subgroup of patients with obesity and one high-risk associated condition (30.2%, 25) resolved both in 44% (11) cases and one in 48% (12) cases. In the group of patients with obesity and two high-risk associated conditions (15.6%, 13), 47% (6) patients resolved the three conditions, 38% (5) resolved two conditions, and 15% (2) resolved one condition. Among the NO group, no comorbidity resolutions were recorded (P < .01). Admission because of COVID infection was necessary for 7.1% of NO and 1.2% of O (P = .04). Conclusion: Bariatric metabolic surgery would not increase the risk of COVID infection or of suffering serious complications resulting from it. Patients undergoing bariatric metabolic surgery rapidly resolved high-risk comorbidities and had less need for hospitalization because of SARS-CoV-2 infection.

Using Pre-operative Insulin Dose to Predict Diabetes Remission After Roux-En-Y Gastric Bypass and Sleeve Gastrectomy.

BACKGROUND: Obesity is intricately associated with type-2 diabetes (T2D) and other cardiovascular conditions, increasing morbidity, mortality, and health care costs. Metabolic and bariatric surgeries (MBS) have shown promising results in significant weight loss and T2D remission, but existing predictive scores for post-MBS diabetes remission do not consider insulin dosage, potentially overlooking a critical factor. METHODS: A retrospective analysis of patients with T2D who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). The study focused on insulin dosage impact, divided into quartiles, on remission rates post-MBS. The effectiveness of RYGB vs SG was compared within insulin dose quartiles with up to 5 years of follow up. RESULTS: A total of 508 patients (64% female, 94.9% White, mean age 53.5 ± 10.5 years, BMI (46.0 ± 8.3 kg/m2) were included in the analysis. This study demonstrates a profound association between insulin dosage quartiles and T2D remission after MBS. Patients with lower insulin requirements showed superior remission rates; those in the lowest quartile had remission rates of 73%, 70%, and 62% at 1, 3, and 5 years, respectively, compared to 34%, 37%, and 36% in the highest quartile (P < 0.001 across all intervals). RYGB surgery showed a significantly better remission in the second and third insulin quartiles, suggesting its effectiveness over SG for patients with mid-range insulin requirements. CONCLUSION: This study underscores the importance of considering insulin dosage when predicting T2D remission post-MBS. The findings advocate for a more nuanced selection of MBS procedures based on individual insulin profiles, potentially enhancing diabetes remission outcomes.

Perioperative Outcomes Using Single-Fire Stapler.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is the most common bariatric surgery performed worldwide. The Titan stapler aims to standardize the sleeve gastrectomy by eliminating inconsistencies and simplifying the procedure. METHODS: A retrospective chart review was performed on all patients > 18 years of age undergoing LSG using the Titan. Pre-operative demographics, perioperative findings, and post-operative complications were all abstracted from the MBSAQIP database. RESULTS: A total of 807 LSG have been performed using the latest iteration of the Titan stapler since November 2022. Data from these patients was compared to 3829 patients who underwent LSG using a sequential staple firing technique from September 2016-September 2021. The median age of Titan patients was 42 years (IQR 33-52) compared to 44 years (IQR 35-54) for sequential firing. The median pre-operative BMI was 47.1 (IQR 43.5-52.1) for Titan versus 47.6 (IQR 43.1-53.3) for sequential staple firing. After propensity matching, operative duration was significantly less for the Titan. Titan patients had decreased hospital length of stay, experienced fewer 30-day readmissions, and had less post-operative nausea/vomiting. Post-op bleed rates were similar between the two cohorts. Weight loss at 6 months favored the sequential fire arm, but our preliminary data shows this difference diminishes at 1 year. CONCLUSIONS: Here we report our data on patients undergoing LSG using the latest Titan stapler. We show the device is safe, effective, and has resulted in an improvement in length of stay, readmissions, and post-operative nausea/vomiting. We also noted reduced operative time with this technique.

Association Between Indole-3-Pyruvic Acid and Change in Fat-Free Mass Relative to Weight Loss in Patients Undergoing Sleeve Gastrectomy.

Sleeve gastrectomy typically leads to weight loss, including a reduction in fat-free mass (FFM). Studies have shown significant FFM loss within 1 year after the procedure but with individual variations. This study aimed to assess whether preoperative amino acid metabolite levels can predict FFM changes following sleeve gastrectomy. This study involved 42 patients. Body weight, fat mass (FM), and FFM were measured preoperatively and 3, 6, and 12 months postoperatively. All participants experienced weight loss, FM reduction, and FFM decrease for up to 3 months after surgery. However, the following distinct groups emerged from 3 to 6 months postoperatively: one showed FFM gain relative to weight loss, whereas the other exhibited continued FFM reduction relative to weight loss. This trend persisted for up to 12 months postoperatively and became more pronounced. The group with FFM gain had lower preoperative BMI and higher levels of indole-3-pyruvic acid (IPyA). Logistic regression and ROC curve analyses confirmed IPyA's ability to predict FFM gain between 3 and 6 months after sleeve gastrectomy, with a useful cutoff value of 20.205. Preoperative IPyA levels were associated with FFM gain relative to weight loss in the 3 to 6 months following sleeve gastrectomy. These findings suggest that IPyA may be a potential predictor for FFM changes during this period.

Public Awareness and Knowledge of Sleeve Gastrectomy in the Southwest Region of Saudi Arabia.

Background Obesity is a major global health concern, causing significant health dilemmas. Large groups of Saudi individuals are considered obese, with significant implications for medical practice. Bariatric surgery, including sleeve gastrectomy, is a crucial intervention for severe obesity, although it is associated with potential complications. This study aims to investigate the public knowledge about the indications and consequences of sleeve gastrectomy in the Southwest region of Saudi Arabia and assess their general awareness of sleeve gastrectomy. Methodology This descriptive, cross-sectional, online-based study included 347 individuals from the Southwest region of Saudi Arabia. Data were collected via an online questionnaire and analyzed using SPSS version 27 (IBM Corp., Armonk, NY, USA). Results This study included 347 participants, with a majority being females (88.5%, n = 307) and Saudis (98.6%, n = 342). The most common age group was 21-25 years (34%, n = 118), followed by those over 40 years of age (26.5%, n = 92). Most participants resided in Al-Qunfudhah (66.3%, n = 230) and held a bachelor's degree (75.8%, n = 263). Nearly half were students (48.7%, n = 169), and 56.2% (n = 195) earned less than 5,000 per month. The prevalent weight range was 40-60 kg (46.1%, n = 160), and most participants' height was 150-160 cm (58.5%, n = 203). Overall, 61% (x̄ = 211.6) of the respondents had good knowledge about sleeve gastrectomy, with 70.3% (x̄ = 244) understanding its general aspects, 56.1% (x̄ = 194.5) knowing the indications, and 60.1% (x̄ = 208.7) aware of the complications. Conclusions The majority of residents of the Southwest region of Saudi Arabia have moderate levels of knowledge regarding sleeve gastrectomy. However, the study demonstrated substantial gaps in knowledge and awareness regarding sleeve gastrectomy, mainly about its indications and potential.

Association of changes in appendicular skeletal muscle mass with weight loss and visceral fat reduction after laparoscopic sleeve gastrectomy.

PURPOSE: Laparoscopic sleeve gastrectomy (LSG) drastically affects body composition. However, studies focusing on the association between the changes in the pre-and postoperative muscle mass and postoperative results are limited. We evaluated the association between changes in the muscle mass and weight loss and fat reduction. METHODS: This retrospective study included 29 consecutive patients who underwent both LSG and a bioelectrical impedance analysis (BIA) consecutively. We investigated changes in the body composition on the BIA and visceral fat area (VFA) on computed tomography and correlational changes in muscle mass with weight loss and fat reduction. RESULTS: The total weight loss (%TWL) 12 months after surgery was 30.9%. The VFAs pre- and postoperatively were 224 and 71.0 cm2, respectively. The fat mass (FM), percentage of FM, appendicular skeletal muscle mass (ASM), and skeletal muscle mass index (SMI) decreased from pre- to postoperatively (54.8 vs. 32.2 kg; 49.0 vs. 41.2%, 26.7 vs. 23.9 kg, 9.24 vs. 8.27, respectively), whereas the percentage of ASM (%ASM) increased (22.1 vs. 28.0%). The rate of change in %ASM positively correlated with weight loss and fat reduction (%TWL, rs = 0.65; %VFA loss, rs = 0.62). CONCLUSION: The rate of change in %ASM was positively correlated with weight loss and fat reduction.

Association between geospatial disparities in food security with weight loss and nutritional outcomes of metabolic surgery.

BACKGROUND: Food insecurity has been linked to higher rates of obesity. It has also been shown to diminish the effectiveness of weight loss strategies, including intensive lifestyle interventions. One essential component of food insecurity is having a geospatial disadvantage in access to healthy, affordable food, such as living within a food desert. This study aims to determine if food insecurity also impacts weight loss and nutritional outcomes in patients who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). METHODS: Clinical outcomes of patients who underwent RYGB or SG at Cleveland Clinic or affiliate regional hospitals in the United States from 2010 to 2018 were collected. Modified Retail Food Environmental Index (mRFEI) data was collected from the Center for Disease Control and merged with patient census tract data, allowing the patient cohort to be divided into those living in areas identified as food secure (mRFEI > 10%), food swamps (mRFEI = 1-10%), or food deserts (mRFEI = 0). Postoperative weight change was evaluated with quadratic growth mixture models and stratified by surgery type. RESULTS: A total of 5097 patients were included in this study cohort, including 3424 patients who underwent RYGB and 1673 who underwent SG. The median duration of follow-up was 2.3 years (IQR 0.89-3.6 years). Food security status was not associated with postoperative weight change (RYGB p = 0.73, SG p = 0.60), weight loss nadir (RYGB p = 0.60, SG p = 0.79), or weight regain (RYGB p = 0.93, SG p = 0.85). Deficiencies in nutritional markers at 1-2 years after surgery were also not significantly different between food security groups. CONCLUSION: Despite the established relationship between food insecurity and obesity, food insecurity does not negatively impact weight loss or nutritional outcomes following RYGB or SG, demonstrating metabolic surgery as a powerful and equitable tool for treating obesity. LEVEL OF EVIDENCE: IV.

Open-bore MRI Scanner Assessment of Epicardial Adipose Tissue after Bariatric Surgery: A Pilot Study.

BACKGROUND: The recognition of epicardial adipose tissue (EAT) as a cardiac risk factor has increased the interest in strategies that target cardiac adipose tissue. AIM: The effect of bariatric and metabolic surgery (BMS)-induced weight loss on EAT volume was evaluated in this study. METHODS: Fifteen bariatric patients, with (MS) or without (wMS) Metabolic Syndrome, underwent magnetic resonance imaging (MRI) using an open-bore scanner to assess EAT volume, visceral adipose tissue (VAT) thickness, and other cardiac morpho-functional parameters at baseline and 12 months after BMS. Nine patients underwent laparoscopic sleeve gastrectomy (LSG), and 6 patients underwent Roux-en-Y Gastric Bypass (RYGBP). RESULTS: EAT volume significantly decreased in all the patients 12 months post-BMS from 91.6 cm3 to 67.1 cm3; p = 0.0002 in diastole and from 89.4 cm3 to 68.2 cm3; p = 0.0002 in systole. No significant difference was found between the LSG and RYGBP group. Moreover, EAT volume was significantly reduced among wMS compared with MS. In particular, EAT volume in diastole was significantly reduced from 80.9 cm3 to 54.4 cm3; p = 0.0156 in wMS and from 98.3 cm3 to 79.5 cm3; p = 0.031 in MS. The reduction was also confirmed in systole from 81.2 cm3 to 54.1 cm3; p = 0.0156 in wMS and from 105.7 cm3 to 75.1 cm3; p = 0.031 in MS. Finally, a positive correlation was found between EAT loss, BMI (r = 0.52; p = 0.0443) and VAT (r = 0.66; p = 0.008) reduction after BMS. CONCLUSION: These findings suggest that EAT reduction may be a fundamental element for improving the cardio-metabolic prognosis of bariatric patients. Moreover, this is the first study performed with an open-bore MRI scanner to measure EAT volume.

Robotic bariatric surgery reduces morbidity for revisional gastric bypass when compared to laparoscopic: outcome of 8-year MBSAQIP analysis of over 40,000 cases.

INTRODUCTION: Robotic-assisted metabolic and bariatric surgery (MBS) is gaining popularity. Revisional MBS is associated with higher perioperative morbidity compared to primary MBS. The optimal surgical approach to minimize complications in these complex cases is unclear. The goal of this study was to assess robot utilization in revisional MBS and compare laparoscopic and robotic revisional MBS outcomes in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. METHODS: A retrospective review of the MBSAQIP database was performed identifying revisional sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) cases from 2015 to 2022. Primary MBS, open/emergent cases, cases converted to another approach, and combined cases other than esophagogastroduodenoscopy were excluded. 30-Day outcomes for laparoscopic and robotic cases were compared using multivariate logistic regression adjusting for patient demographics, comorbidities, and operative variables. RESULTS: 41,404 Cases (14,474 SG; 26,930 RYGB) were identified. From 2015 to 2022, the percentage of revisional SG and RYGB cases performed robotically increased from 6.1% and 7.3% to 24.2% and 32.0% respectively. Laparoscopic SG had similar rates of overall morbidity, leak, bleeding, readmission, reoperation, and length of stay compared to robotic. Laparoscopic RYGB had significantly higher rates of overall morbidity (6.2% vs. 4.8%, p < 0.001, AOR 0.80 [0.70-0.93]), blood transfusion (1.5% vs. 1.0%, p < 0.05, AOR 0.74 [0.55-0.99]), superficial incisional SSI (1.2% vs. 0.4%, p < 0.001, AOR 0.30 [0.19-0.47]), and longer length of stay (1.87 vs. 1.76 days, p < 0.001) compared to robotic. Laparoscopic operative times were significantly shorter than robotic (SG: 86.4 ± 45.8 vs. 113.5 ± 51.7 min; RYGB: 130.7 ± 64.7 vs. 165.5 ± 66.8 min, p < 0.001). CONCLUSION: Robot utilization in revisional bariatric surgery is increasing. Robotic surgery has lower postoperative morbidity and shorter length of stay in revisional RYGB when compared to laparoscopic. Robotic platforms may have the capacity to improve the delivery of care for patients undergoing revisional bariatric surgery.

Cortisol/Cortisone Ratio in Youth with Obesity One Year Following Sleeve Gastrectomy.

Background: Glucocorticoid metabolites are associated with body composition measures and are altered with weight status. Metabolic and bariatric surgery (MBS) results in significant changes in weight and body composition. However, MBS effects on glucocorticoid metabolites are unknown. Objective: To evaluate (i) changes in the cortisol/cortisone ratio in youth with obesity 12 months after sleeve gastrectomy (SG) compared with nonsurgical controls with obesity (NS), and (ii) associations of these changes with body composition changes. Methods: A total of 38 participants 13-25 years old with obesity (29 female) were followed for 12 months. Half underwent SG, and the other half were followed with routine care (nonsurgical, NS). Fasting blood was assessed for cortisol and cortisone using liquid chromatography-mass spectroscopy as part of metabolomic analysis, and the cortisol/cortisone ratio was calculated. A single-slice MRI of the abdomen was performed to assess subcutaneous and visceral adipose tissue (SAT, VAT). Hepatic steatosis was assessed by computed tomography (CT). Results: SG did not differ from NS for baseline clinical characteristics, other than the mean age (SG 18.0 ± 0.46 vs. NS 16.6 ± 0.50 years, P = 0.041), BMI (BMI, 47.23 ± 1.5 vs. 41.32 ± 1.1 kg/m2, P = 0.003) weight and VAT, which were higher in SG. Significant reductions were noted over 12 months in BMI, BMI z-score, VAT, and SAT within the SG versus NS groups (P ≤ 0.001). Over 12 months, groups did not differ for changes in cortisol/cortisone ratio after controlling for age at baseline (P = 0.293). The ratio trended to decrease within the SG group [-1.40 (-5.08, 0.06), P = 0.080], particularly among those that had completed puberty (P = 0.048). No associations were found between changes in the cortisol/cortisone ratio and changes in body composition. Conclusions: The cortisol/cortisone ratio trended to decrease 12 months following SG. However, no associations were found between changes in the cortisol/cortisone ratio and changes in body composition. Studies with larger numbers of participants are necessary to confirm these findings.

Magnetic sphincter augmentation vs subtotal gastrectomy with Roux-en-Y reconstruction for the treatment of postsleeve gastrectomy gastroesophageal reflux disease.

BACKGROUND: Obesity affects more than one-third of Americans and can be treated with bariatric surgery, most commonly sleeve gastrectomy (SG). SG has been shown to increase the incidence of gastroesophageal reflux disease (GERD) in some patients, which can be refractory to medical management. Surgical options for post-SG GERD include magnetic sphincter augmentation (MSA) and subtotal gastrectomy with Roux-en-Y reconstruction (SGRY). A comparative analysis of MSA and SGRY for post-SG GERD was performed to evaluate postoperative outcomes. METHODS: A retrospectively maintained prospectively gathered database from 2018 to 2023 was used to identify patients who underwent MSA or SGRY for the indication of GERD after SG. Differences among patient characteristics; GERD assessments, including the health-related quality of life (HRQL) questionnaire and the reflux symptom index (RSI); and procedure outcomes were collected and analyzed according to surgery type. RESULTS: A total of 92 patients (85 females and 7 males) met the inclusion criteria. The study included 17 patients in the MSA group, 71 patients in the SGRY group, and 4 patients who underwent both procedures. The average preoperative body mass index (BMI) of all patients was 33.3. Compared with patients who underwent MSA, those who underwent SGRY presented with higher BMI (29.4 vs 34.2, respectively; P = .013), preoperative GERD-HRQL (35 vs 52, respectively; P = .046), and RSI (14 vs 28, respectively; P = .017). Postoperatively, patients who underwent SGRY demonstrated a higher decrease in mean postoperative DeMeester score than those who underwent MSA (44.2 vs 13.9, respectively; P = .040), with 22 patients (50%) in the SGRY group vs 10 patients (20%) in the MSA group achieving normalization. CONCLUSION: Although MSA remains a viable surgical alternative, our study indicated that SGRY can produce better symptom control and decrease acid exposure compared with MSA in patients with post-SG GERD.

Rare events model of the MBSAQIP database: risk of early bowel obstruction following metabolic surgery.

BACKGROUND: Early small bowel obstruction (eSBO) (within 30-days) is a rare but important complication that is associated with high rates of morbidity, including readmission, reintervention, and reoperation. OBJECTIVES: To identify patient-specific and operation-specific characteristics that predispose patients to eSBO and to identify at-risk individuals preoperatively. SETTING: 2015-2021 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). METHODS: Utilizing the 2015-2021 MBSAQIP PUF, 1,016,484 records were analyzed. Pediatric, revisional, open-conversion, and cases with incomplete data in sex, body mass index, operative-time, 30-day-follow-up variables were excluded. Case details were compared using Fisher's exact & Wilcoxon -Mann -Whitney tests to identify at-risk patients. The likelihood of eSBO was modeled with rare event logistic regression. RESULTS: Incidence of eSBO was .40%. Of the 4103 occurrences of eSBO, RYGB (Roux-en-Y gastric bypass), SG (sleeve gastrectomy), and DS (duodenal switch) accounted for 79.4%, 19.3%, and 1.3%, respectively. Many patient-specific characteristics were significantly associated with eSBO. History of prior foregut surgery, a non-metabolic surgery trained operator, and longer operative times were all associated with increased eSBO (P < .0001). While simultaneously controlling for these factors, eSBO remained higher in DS (OR 9.55, P < .0001) and RYGB (OR 5.18, P < .0001) compared to SG. Increased length of operation (OR 1.03, P < .0001) and non -MS-trained operators (OR 1.33, P < .0001) remained highly significant. Male-sex (OR .70, P < .0001) and diabetes (OR .78, P < .0001) were both protective. CONCLUSIONS: In the largest analysis to date, eSBO remains a rare event. RYGB accounts for the largest proportion of eSBO, however, DS has a higher risk adjusted rate of eSBO.

Full esophageal mobilization during hiatal hernia repair with concomitant sleeve gastrectomy improves postoperative reflux symptoms for patients with preexisting reflux.

BACKGROUND: Hiatal hernia repair (HHR) performed concurrently with vertical sleeve gastrectomy (VSG) has been shown to improve postoperative gastroesophageal reflux disease (GERD). However, data on the optimal extent of esophageal mobilization during repair are lacking. Mobilization techniques for HHR during VSG include partial (PM) or full (FM) mobilization of the esophagus. We hypothesize that patients who undergo full mobilization will be less likely to develop postoperative reflux. METHODS: A single-institution retrospective review of all patients who underwent a VSG with a HHR between 2014 and 2021 was conducted. The primary outcome was postoperative reflux symptoms defined by diagnosis in the medical record, utilization of anti-reflux medications, and GERD health-related quality of life (GERD-HRQL) scores obtained via patient surveys. RESULTS: There were 190 patients included with 80 patients (42.1%) undergoing PM and 110 (57.9%) undergoing FM. Rates of preoperative reflux were similar between the two groups (47.5% vs. 51.8%; p = 0.55). During the GERD-HRQL survey, there were 114 patients (60.0%) contacted with a participation rate of 91.2% (104 patients). Patients with preoperative reflux who underwent PM were found to have a higher rate of reported postoperative reflux (90.0% vs. 62.5%; p = 0.03) and higher GERD-HRQL scores (16.40 ± 9.95 vs. 10.84 ± 9.01; p = 0.04). Patients without preoperative reflux did not have a significant difference in reported reflux (55.0% vs. 51.7%; p = 0.82) or GERD-HRQL scores (12.35 ± 14.14 vs. 9.93 ± 9.46; p = 0.25). CONCLUSION: Our study found that postoperative GERD was higher in patients with preexisting reflux who underwent partial esophageal mobilization during concurrent hiatal hernia repair with vertical sleeve gastrectomy. In patients without preoperative GERD, our data suggest that postoperative reflux symptoms are not dependent on the extent of esophageal mobilization during hiatal hernia repair with vertical sleeve gastrectomy.