Metabolic Bariatric Surgery Across the IFSO Chapters: Key Insights on the Baseline Patient Demographics, Procedure Types, and Mortality from the Eighth IFSO Global Registry Report.

INTRODUCTION: The International Federation for Surgery for Obesity and Metabolic Disorders (IFSO) Global Registry aims to provide descriptive data about the caseload and penetrance of surgery for metabolic disease and obesity in member countries. The data presented in this report represent the key findings of the eighth report of the IFSO Global Registry. METHODS: All existing Metabolic and Bariatric Surgery (MBS) registries known to IFSO were invited to contribute to the eighth report. Aggregated data was provided by each MBS registry to the team at the Australia and New Zealand Bariatric Surgery Registry (ANZBSR) and was securely stored on a Redcap™ database housed at Monash University, Melbourne, Australia. Data was checked for completeness and analyzed by the IFSO Global Registry Committee. Prior to the finalization of the report, all graphs were circulated to contributors and to the global registry committee of IFSO to ensure data accuracy. RESULTS: Data was received from 24 national and 2 regional registries, providing information on 502,150 procedures. The most performed primary MBS procedure was sleeve gastrectomy, whereas the most performed revisional MBS procedure was Roux-en-Y gastric bypass. Asian countries reported people with lower BMI undergoing MBS along with higher rates of diabetes. Mortality was a rare event. CONCLUSION: Registries enable meaningful comparisons between countries on the demographics, characteristics, operation types and approaches, and trends in MBS procedures. Reported outcomes can be seen as flags of potential issues or relationships that could be studied in more detail in specific research studies.

Indications and Coverage of Metabolic and Bariatric Surgery: A Worldwide IFSO Survey Comparing Different National Guidelines.

INTRODUCTION: Knowing how metabolic and bariatric surgery (MBS) is indicated in different countries is essential information for the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO). AIM: To analyze the indications for MBS recommended by each of the national societies that comprise the IFSO and how MBS is financed in their countries. METHODS: All IFSO societies were asked to fill out a survey asking whether they have, and which are their national guidelines, and if MBS is covered by their public health service. RESULTS: Sixty-three out of the 72 IFSO national societies answered the form (87.5%). Among them, 74.6% have some kind of guidelines regarding indications for MBS. Twenty-two percent are still based on the US National Institute of Health (NIH) 1991 recommendations, 43.5% possess guidelines midway the 1991s and ASMBS/IFSO 2022 ones, and 34% have already adopted the latest ASMBS/IFSO 2022 guidelines. MBS was financially covered in 65% of the countries. CONCLUSIONS: Most of the IFSO member societies have MBS guidelines. While more than a third of them have already shifted to the most updated ASMBS/IFSO 2022 ones, another significant number of countries are still following the NIH 1991 guidelines or even do not have any at all. Besides, there is a significant number of countries in which surgical treatment is not yet financially covered. More effort is needed to standardize indications worldwide and to influence insurers and health policymakers to increase the coverage of MBS.

2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) Indications for Metabolic and Bariatric Surgery.

MAJOR UPDATES TO 1991 NATIONAL INSTITUTES OF HEALTH GUIDELINES FOR BARIATRIC SURGERY: Metabolic and bariatric surgery (MBS) is recommended for individuals with a body mass index (BMI) >35 kg/m2, regardless of presence, absence, or severity of co-morbidities.MBS should be considered for individuals with metabolic disease and BMI of 30-34.9 kg/m2.BMI thresholds should be adjusted in the Asian population such that a BMI >25 kg/m2 suggests clinical obesity, and individuals with BMI >27.5 kg/m2 should be offered MBS.Long-term results of MBS consistently demonstrate safety and efficacy.Appropriately selected children and adolescents should be considered for MBS.(Surg Obes Relat Dis 2022; https://doi.org/10.1016/j.soard.2022.08.013 ) © 2022 American Society for Metabolic and Bariatric Surgery. All rights reserved.

From surgery to endoscopy: the evolution of the bariatric discipline.

ABSTRACT: Obesity, with its increasing morbidity and prevalence, is now a worldwide public health problem. Obesity and its related comorbidities impose a heavy burden on societal health and the economy. The practice of bariatric surgery has evolved from its early surgical procedures, many of which are no longer routine operations. With clinical practice, research, and experience, bariatric surgery has gradually become an important last resort for the control of weight and obesity-related metabolic diseases in moderately and severely obese patients. However, there is still room for further improvements in bariatric surgical procedures, especially with regard to long-term issues and complications. Endoscopic weight loss technology has developed rapidly in recent years. The advantages of this technology include minimal invasiveness, an obvious weight loss effect, and few complications, thus filling the gap between medications and lifestyle adjustments and surgical treatment of obesity. Endoscopic weight loss technology may even replace surgical bariatric procedures. This review summarized the current status of bariatric metabolic surgery and newly developed bariatric endoscopic procedures.

Domino hepatocyte transplantation using explanted human livers with metabolic defects attenuates D-GalN/LPS-induced acute liver failure.

BACKGROUND: Explanted livers from patients with inherited metabolic liver diseases possess the potential to be a cell source of good-quality hepatocytes for hepatocyte transplantation (HT). This study evaluated the therapeutic effects of domino HT using hepatocytes isolated from explanted human livers for acute liver failure (ALF). METHODS: Isolated hepatocytes were evaluated for viability and function and then transplanted into D-galactosamine/lipopolysaccharide-induced ALF mice via splenic injection. The survival rate was analyzed by the Kaplan-Meier method and log-rank test. Liver function was evaluated by serum biochemical parameters, and inflammatory cytokine levels were measured by ELISA. The pathological changes in the liver tissues were assessed by hematoxylin-eosin staining. Hepatocyte apoptosis was investigated by TUNEL, and hepatocyte apoptosis-related proteins were detected by western blot. The localization of human hepatocytes in the injured mouse livers was detected by immunohistochemical analyses. RESULTS: Hepatocytes were successfully isolated from explanted livers of 10 pediatric patients with various liver-based metabolic disorders, with an average viability of 85.3% ± 13.0% and average yield of 9.2 × 106 ± 3.4 × 106 cells/g. Isolated hepatocytes had an excellent ability to secret albumin, produce urea, uptake indocyanine green, storage glycogen, and express alpha 1 antitrypsin, albumin, cytokeratin 18, and CYP3A4. Domino HT significantly reduced mortality, decreased serum levels of alanine aminotransferase and aspartate aminotransferase, and improved the pathological damage. Moreover, transplanted hepatocytes inhibited interleukin-6 and tumor necrosis factor-α levels. Domino HT also ameliorates hepatocyte apoptosis, as evidenced by decreased TUNEL positive cells. Positive staining for human albumin suggested the localization of human hepatocytes in ALF mice livers. CONCLUSION: Explanted livers from patients with inheritable metabolic disorders can serve as a viable cell source for cell-based therapies. Domino HT using hepatocytes with certain metabolic defects has the potential to be a novel therapeutic strategy for ALF.

2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): Indications for Metabolic and Bariatric Surgery.

Major updates to 1991 National Institutes of Health guidelines for bariatric surgery.

Preliminary Exploration on the Efficacy of Augmented Reality-Guided Hepatectomy for Hepatolithiasis.

BACKGROUND: The augmented reality-assisted navigation system (AR-ANS) has been initially applied to the management of hepatolithiasis. The current study examines the safety and efficacy of the AR-ANS for hepatectomy in the treatment of hepatolithiasis. It is the first study to assess the preoperative and long-term outcomes of hepatectomy guided by the AR-ANS for hepatolithiasis. STUDY DESIGN: From January 2018 to December 2021, 77 patients with hepatolithiasis who underwent hepatectomy at Zhujiang Hospital of Southern Medical University were included. The subjects were divided into the AR group (n = 31) and the non-AR group (n = 46) according to whether the surgery was guided by the AR-ANS. Clinical baseline features, operation time, intraoperative blood loss, immediate postoperative residual stone rate, postoperative stone recurrence rate at 6 months, and postoperative complications were analyzed. RESULTS: There was no significant difference between preoperative baseline data from the 2 groups (p > 0.05). The AR group had a longer surgical time than the non-AR group (p < 0.001). The intraoperative blood loss in the AR group was lower than in the non-AR group (p < 0.001). Alanine transaminase, aminotransferase, immediate residual stone rate, and stone recurrence rate in the AR group were lower than in the non-AR group (p < 0.05). There was no significant difference in postoperative complications between the 2 groups. CONCLUSIONS: The application of the AR-ANS in hepatectomy for hepatolithiasis has not only achieved satisfactory therapeutic efficacy, but has also shown significant advantages in reducing intraoperative blood loss, immediate stone residual rate, and stone recurrence rate, which has clinical promotion value.

Successful Diagnoses and Remarkable Metabolic Disorders in Patients With Solitary Hypothalamic Mass: A Case Series Report.

Background: Solitary intracranial hypothalamic mass occurs rarely. The etiological diagnosis of solitary hypothalamus lesion is challenging and often unachievable. Although previous studies indicated that lesions affecting the hypothalamus often cause significant metabolic disorders, few reports about the metabolic disturbances of patients with solitary hypothalamic mass have been reported. Method: Twenty-five patients with solitary hypothalamus lesions who had been evaluated and treated in Huashan Hospital from January 2010 to December 2020 were retrospectively enrolled. The clinical manifestations, radiological features, endocrine and metabolic disorders, and pathology were analyzed. Results: The male to female ratio was 5/20. The median age of onset was 22 (19, 35) years old. The most common initial symptom was polydipsia/polyuria (19/25, 76.0%) and amenorrhea (9/20, 45.0%). A high prevalence of hypopituitarism of different axes was found, with almost all no less than 80%. Central hypogonadism (21/22, 95.5%) and central diabetes insipidus (19/21, 90.5%) were the top two pituitary dysfunctions. Conclusive diagnoses were achieved by intracranial surgical biopsy/resection or stereotactic biopsy in 16 cases and by examining extracranial lesions in 3 cases. The pathological results were various, and the most common diagnoses were Langerhans cell histiocytosis (7/19) and hypothalamitis (5/19). The mean timespan from onset to diagnosis in the 19 cases was 34 ± 26 months. Metabolic evaluations revealed remarkable metabolic disorders, including hyperlipidemia (13/16, 81.3%), hyperglycemia (10/16, 62.5%), hyperuricemia (12/20, 60%), overweight/obesity (13/20, 65.0%), and hepatic adipose infiltration (10/13, 76.6%). Conclusion: Either surgical or stereotactic biopsy will be a reliable and relatively safe procedure to help to confirm the pathological diagnosis of solitary hypothalamic mass. Metabolic disorders were severe in patients with solitary hypothalamic mass. The management of such cases should cover both the treatment of the primary disease, as well as the endocrine and metabolic disorders.

Domino transplantation for pediatric liver recipients: Obstacles, challenges, and successes.

BACKGROUND: Domino liver transplantation aims to address the need to increase the liver donor supply. In a domino liver transplant, the domino recipient receives the explanted liver from the recipient of a traditional liver transplant. The domino donor typically requires liver transplant to correct a metabolic disorder; the explanted liver thus has a single gene defect but otherwise normal structure and function. METHODS: In this review, we detail the history of domino liver transplantation, appropriate domino donor indications, the technical advances to the surgical approach, current outcomes, and future opportunities. RESULTS: Development of de novo disease in the domino recipient has relegated adult domino liver transplant to be considered a source of marginal donor livers. However, pediatric domino liver transplant has leveraged certain metabolic disorders, especially maple syrup urine disease, in which the liver enzyme deficiency can be compensated by the systemic presence of sufficient enzyme. Advances in the surgical aspects of assuring adequate length of vasculature have improved the safety of the procedure in both domino donors and recipients. CONCLUSIONS: Pediatric domino liver transplant utilizing domino donors with specific metabolic liver diseases should be considered a viable live donor option for children awaiting liver transplant.

Mining Gut Microbiota From Bariatric Surgery for MAFLD.

The progression of metabolic dysfunction associated fatty liver disease (MAFLD) leads to steatohepatitis, liver fibrosis and hepatocellular carcinoma. Thus far, there have been no FDA-approved medications for MAFLD. Bariatric surgery (BS) has been found to improve insulin resistance, steatohepatitis and liver fibrosis but is not recommended for treating MAFLD due to its invasiveness. Recent studies suggest the improved glucose metabolism after BS is a result of, at least partly, alterations to the gut microbiota and its associated metabolites, including short chain fatty acids and bile acids. It makes sense the improved steatohepatitis and fibrosis after BS are also induced by the gut microbiota that involves in host metabolic modulation, for example, through altering bile acids composition. Given that the gut-liver axis is a path that may harbor unexplored mechanisms behind MAFLD, we review current literatures about disentangling the metabolic benefits of MAFLD after BS, with a focus on gut microbiota. Some useful research tools including the rodent BS model, the multiomics approach, and the human microbiota associated (HMA) mice are presented and discussed. We believe, by taking advantage of these modern translational tools, researchers will uncover microbiota related pathways to serve as potential therapeutic targets for treating MAFLD.

Effects of vitamin D deficiency on the improvement of metabolic disorders in obese mice after vertical sleeve gastrectomy.

Vertical sleeve gastrectomy (VSG) is one of the most commonly performed clinical bariatric surgeries for the remission of obesity and diabetes. Its effects include weight loss, improved insulin resistance, and the improvement of hepatic steatosis. Epidemiologic studies demonstrated that vitamin D deficiency (VDD) is associated with many diseases, including obesity. To explore the role of vitamin D in metabolic disorders for patients with obesity after VSG. We established a murine model of diet-induced obesity + VDD, and we performed VSGs to investigate VDD's effects on the improvement of metabolic disorders present in post-VSG obese mice. We observed that in HFD mice, the concentration of VitD3 is four fold of HFD + VDD one. In the post-VSG obese mice, VDD attenuated the improvements of hepatic steatosis, insulin resistance, intestinal inflammation and permeability, the maintenance of weight loss, the reduction of fat loss, and the restoration of intestinal flora that were weakened. Our results suggest that in post-VSG obese mice, maintaining a normal level of vitamin D plays an important role in maintaining the improvement of metabolic disorders.

Successful living donor liver transplantation plus domino-auxiliary partial orthotopic liver transplantation for pediatric patients with metabolic disorders.

PURPOSE: To investigate the efficacy of living donor liver transplantation (LDLT) plus domino-auxiliary partial orthotopic liver transplantation (D-APOLT) in pediatric patients with metabolic disorders. METHODS: From May 2017 to October 2018, two patients with ornithine aminotransferase deficiency (OTCD) and one patient with type I Crigler-Najjar syndrome (CNS1) received LDLT, their livers were prepared as donors for D-APOLT. Two patients with CNS1 received domino liver grafts from OTCD patients; one OTCD patient received a domino liver graft from a CNS1 patient. RESULTS: The mean follow-up was 26.6 months. The liver function and ammonia remained in the normal range at the end of the follow-up in all recipients. One D-APOLT patient experienced portal vein thrombosis 2 days after transplantation and required reoperation, this patient presented an imbalance of portal blood perfusion between the native and the domino liver at 8 months after liver transplant. The imbalance was improved by interventional radiology treatment. Two LDLT patients experienced early mild acute rejection. CONCLUSIONS: The non-cirrhotic livers from pediatric patients with metabolic liver disease can be used as domino donor grafts for selected pediatric patients with different metabolic liver disease. D-APOLT achieves ideal recipient outcomes and provides a strategy to expand donor source for children.

Liver transplant for inherited metabolic disease among siblings.

Liver transplantation is a successful option for inherited metabolic disease yet little is published on the outcome among siblings. We report outcomes of siblings who have undergone liver transplantation for metabolic disease in a single program. Seventy-one siblings (35 males) from 33 individual families underwent liver transplantation since 1982. Outcomes were compared over three consecutive eras. Twenty-eight families had two siblings, four had three siblings, and one had four siblings. In half of families where dates of listing were known, siblings were listed simultaneously. Mean (SD) age at listing for the oldest and second sibling was 13.2 (7.1) and 9.8 (5.7) years, respectively (p < .01). In 18/33 families, the oldest sibling underwent transplantation first. Mean (SD) age at transplant fell from the oldest to second sibling from 12.9 (7.2) to 9.5 (6.3) years, respectively (p < .001). Ten-year patient survival was 83.5% which improved over the eras: era 1 (1982-1994) 65.0%, era 2 (1995-2007) 87.5%, and era 3 (2008-2019) 93.8%: p < .03. Sex, age at transplant, order of transplant, and presence of structural liver disease did not significantly impact survival. When siblings undergo liver transplant for inherited metabolic disease, later siblings are listed and transplanted at a significantly younger age.

[Effects of sleeve gastrectomy base on "membrane anatomy" concept on postoperative nausea and vomiting in patients with obesity or metabolic diseases].

Objective: To explore the effects of the application of membrane anatomy concept in sleeve gastrectomy on postoperative nausea and vomiting (PONV) in patients with obesity or metabolic diseases. Methods: A retrospective cohort study was conducted. Clinical data of 88 patients with obesity or metabolic diseases who underwent laparoscopic sleeve gastrectomy in The First Affiliated Hospital of Jinan University from September 2018 to June 2019 were retrospectively analyzed. Forty patients underwent sleeve gastrectomy with membrane anatomy concept as membrane anatomy group, and the other 48 patients underwent traditional sleeve gastrectomy as traditional operation group. There were no significant differences in baseline data between the two groups (all P>0.05). The PONV score of and the times of antiemetic drugs used during 0-6 h and 6-24 h after operation were compared between the two groups. Higher PONV represents more serious nause and vomiting, the score ≥5 is defined as clinical significant PONV. Results: All patients of the two groups successfully completed the operation, and there was no conversion to open, reoperation, and operation-related death. The intraoperative blood loss in the membrane anatomy group was significantly less than that in the traditional surgery group [median: 5.0 (5.0, 5.8) ml vs. 10.0 (5.0, 10.0) ml, Z=-3.265, P=0.001]. There were no significant differences between the two groups in terms of operative time, postoperative hospital stay, gastroesophageal reflux, pain score and postoperative complications (all P>0.05). There was no postoperative bleeding or gastric leakage in either groups. There were no significant differences in PONV score, incidence of clinically significant PONV and use of antiemetics 0-6 h after operation between two groups (all P>0.05). From 6 to 24 hours after operation, compared with traditional surgery group, the membrane anatomy group had lower PONV score (4.6±0.9 vs. 5.1±0.7, t=-2.192, P=0.007), lower incidence of clinically significant PONV [55.0% (22/40) vs. 83.3% (40/48), χ(2)=8.414, P=0.004] and less use of antiemetics [3 times: 10.0% (4/40) vs. 27.1% (13/48), Z=-2.880, P=0.004]. Postoperative follow-up ranged from 1 to 6 months (median 3), 32 cases in membranous anatomy group and 38 cases in the traditional operation group were followed up. One case in the traditional operation group received symptomatic treatment in the local hospital due to functional intestinal obstruction 1 month after surgery and was discharged after recovery. The remaining patients had no postoperative complications and were not readmitted to hospital. Conclusion: Sleeve gastrectomy based on membrane anatomy in the treatment of patients with obesity or metabolic syndrome can make surgical procedure more precise and meticulous, reduce the intraoperative bleeding and the incidence of PONV.

Percutaneous endoscopic gastrostomy in small infants unable to swallow safely.

BACKGROUND: Data about percutaneous endoscopic gastrostomy (PEG) insertions in small infants are limited, and most studies include older children. We aimed to evaluate the safety of PEG placement in infants weighing ≤5 kg together with their follow-up results. METHODS: A retrospective evaluation was made of records between January 2005 and December 2019. RESULTS: A total of 43 infants were ≤5 kg at the time of PEG insertion. The mean age was 5 ± 3 (19 days-16 months) months and the mean weight was 4.3 ± 0.6 (2.7-5.0) kg. The primary diagnoses were neurological disorders in 25, metabolic disorders in nine, cleft palates in four, muscular disorders in four, and a cardiac disorder in one. All procedures were completed successfully. A self-resolving pneumoperitoneum developed in one (2.3%). The tube was extruded in six (14%) patients postoperatively which required suture-approximation of the skin and subcuticular tissues. The tube was removed in four (9%) patients with achievement of oral feeds on the long-term. Eighteen (42%) died of primary diseases. The tubes were in situ for a median of 12.4 (17 days-73 months) months in these patients. A total of 20 (46.5%) patients are currently being followed up and their tubes are in situ for a median of 50.3 (4.7 month-9.8 years) months. CONCLUSIONS: Percutaneous endoscopic gastrostomy placement is safe in small infants with associated morbidities. Complications related to the procedure are within acceptable limits. The accidental extrusion of the tube was a special consideration in this patient group. The overall mortality was high because of underlying primary diseases.

Inicios de la cirugía bariátrica y metabólica en España / Beginnings of bariatric and metabolic surgery in Spain

La cirugía bariátrica (CB) de bari = peso y iatrein = cura) trata la obesidad y comienza en España en 1973. Su mayor desarrollo ocurre tras la fundación de SECO (Sociedad Española de Cirugía de la obesidad) en 1997. La finalidad de este trabajo es reflejar los cambios que han ocurrido en éstos 42 años

Bariatric surgery (BS) from the Greek bari = weight and iatrein = cure) treats obesity and began in Spain in 1973. Its greatest development occurs after the founding of SECO (Spanish Society of Obesity Surgery) in 1997. The purpose of this work is to reflect the changes that have occurred in these 22 years