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Purpose: To (1) assess dietary intakes of pregnant women with previous bariatric surgery in comparison with Dietary Reference Intakes (DRIs); (2) compare their dietary intakes as well as their diet quality with a control group of pregnant women with no history of bariatric surgery., Methods: Twenty-eight (28) pregnant women with previous surgery (sleeve gastrectomy, n = 7 and biliopancreatic diversion with duodenal switch, n = 21) were matched for pre-pregnancy body mass index with 28 pregnant women with no history of bariatric surgery. In at least one trimester, participants completed a minimum of 2 Web-based 24-h dietary recalls from which energy, macro- and micronutrient intakes as well as the Canadian Healthy Eating Index (C-HEI) were derived., Results: No differences were observed for energy intake between groups. All women had protein intakes within the recommended range, but most women with previous surgery had carbohydrate (67%) and dietary fiber intakes (98%) below recommendations. In both groups, mean total fat, saturated fatty acids, free sugars and sodium intakes were above recommendations, as opposed to mean vitamin D, folic acid and iron dietary intakes below recommendations for most women. Compared with the control group, pregnant women with previous bariatric surgery had lower overall C-HEI scores., Conclusion: These results suggest that pregnant women with previous bariatric surgery would benefit from a nutritional follow-up throughout their pregnancy., Level of Evidence: III: Evidence obtained from well-designed cohort or case-control analytic studies., (© 2021. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Introduction: Sleeve gastrectomy (SG) is the commonest bariatric procedure worldwide. Yet there is significant variation in practice concerning its various aspects. This paper report results from the first modified Delphi consensus-building exercise on SG., Methods: We established a committee of 54 globally recognized opinion makers in this field. The committee agreed to vote on several statements concerning SG. An agreement or disagreement amongst ≥ 70.0% experts was construed as a consensus., Results: The committee achieved a consensus of agreement (n = 71) or disagreement (n = 7) for 78 out of 97 proposed statements after two rounds of voting. The committee agreed with 96.3% consensus that the characterization of SG as a purely restrictive procedure was inaccurate and there was 88.7% consensus that SG was not a suitable standalone, primary, surgical weight loss option for patients with Barrett's esophagus (BE) without dysplasia. There was an overwhelming consensus of 92.5% that the sleeve should be fashioned over an orogastric tube of 36-40 Fr and a 90.7% consensus that surgeons should stay at least 1 cm away from the angle of His. Remarkably, the committee agreed with 81.1% consensus that SG patients should undergo a screening endoscopy every 5 years after surgery to screen for BE., Conclusion: A multinational team of experts achieved consensus on several aspects of SG. The findings of this exercise should help improve the outcomes of SG, the commonest bariatric procedure worldwide, and guide future research on this topic., (© 2021. Crown.)

Background: In Canada, bariatric surgery continues to remain the most effective treatment for severe obesity and its comorbidities. As the number of bariatric surgeries continues to grow, the need for consensus guidelines for optimal perioperative care is imperative. In colorectal surgery, enhanced recovery after surgery (ERAS) protocols were created for this purpose. The objective of this review is to develop evidence-based ERAS guidelines for bariatric surgery., Methods: A literature search of the MEDLINE database was performed using ERAS-specific search terms. Recently published articles with a focus on randomized controlled trials, systematic reviews, and meta-analyses were included. Quality of evidence and recommendations were evaluated using the GRADE assessment system., Results: Canadian bariatric surgeons from six provinces and ten bariatric centers performed a review of the evidence surrounding ERAS in bariatric surgery and created consensus guidelines for 14 essential ERAS elements. Our main recommendations were (1) to encourage participation in a presurgical weight loss program; (2) to abstain from tobacco and excessive alcohol; (3) low-calorie liquid diet for at least 2 weeks prior to surgery; (4) to avoid preanesthetic anxiolytics and long-acting opioids; (5) unfractionated or low-molecular-weight heparin prior to surgery; (6) antibiotic prophylaxis with cefazolin ± metronidazole; (7) reduced opioids during surgery; (8) surgeon preference regarding intraoperative leak testing; (9) nasogastric intubation needed only for Veress access; (10) to avoid abdominal drains and urinary catheters; (11) to prevent ileus by discontinuing intravenous fluids early; (12) postoperative analgesia with acetaminophen, short-term NSAIDS, and minimal opioids; (13) to resume full fluid diet on first postoperative day; (14) early telephone follow-up with full clinic follow-up at 3-4 weeks., Conclusions: The purpose of addressing these ERAS elements is to develop guidelines that can be implemented and practiced clinically. ERAS is an excellent model that improves surgical efficiency and acts as a common perioperative pathway. In the interim, this multimodal bariatric perioperative guideline serves as a common consensus point for Canadian bariatric surgeons.

Background: Only a small percentage of candidates for bariatric surgery ever undergo a procedure for weight loss. Devices duplicating key effects of bariatric surgeries with removable, fully trans-oral implants could extend their benefits to patients unwilling to undergo anatomy-altering abdominal surgeries., Methods: Thirty-two obese subjects (mean BMI: 42.3) were enrolled in a prospective, multicenter, single-arm, feasibility trial of the first fully trans-oral endoscopic gastrointestinal bypass device. The device is a cuff attached to the distal esophagus by transmural anchors and connected to a 120-cm sleeve diverting undigested nutrients to the jejunum. Bodyweight, vital signs, adverse events, medications, HbA1c, fasting glucose, and lipids were collected at baseline and follow-up visits. Device status was endoscopically assessed every 6 months., Results: The fully trans-oral procedure was successful in all subjects without intraoperative adverse events or postoperative infections. Twenty-eight of 32 subjects (88%) remained implanted with continuing follow-up beyond their 12-month visit. At 12 months, the 32 subjects had lost an average of 44.8% of excess body weight, 17.6% of total body weight, 20.8 kg, and 7.5 BMI points. Weight loss depended on capture of ingesta by the esophageal cuff, with 18 of 32 subjects without visible gaps around their cuffs at the 6 month endoscopy having significantly greater EWL (53.6 vs. 33.4% in the remaining subjects, p < 0.002). Mean HbA1c and fasting glucose declined by 1.1% points and 29 mg/dL in type 2 diabetic subjects, 80% of whom had remission of their diabetes at 12 months., Conclusion: This study demonstrates the feasibility, safety, and efficacy of a fully trans-oral gastrointestinal bypass implant. This purely endoscopic device may provide a valuable addition to the armamentarium of treatment available for the management of morbid obesity.

Food addiction (FA) has recently emerged as a new field in the study of obesity. Previous studies have contributed to identifying psychological correlates of FA. However, few researchers have examined the cognitive profile related to this condition; up until now, attentional biases related to food cues and a poorer performance monitoring have been observed. The present study aimed to examine the psychological profile and executive functioning related to FA in individuals with severe obesity and awaiting bariatric surgery. Participants (N = 86) were split into two groups, according to their level of FA symptoms (low FA vs high FA). Groups were compared on questionnaires measuring binge eating, depression and anxiety symptoms, and impulsivity as well as on measures reflecting executive functioning (D-KEFS and BRIEF-A). The relationship between FA groups and patterns of errors during the D-KEFS' Color-Word Interference Test was further analyzed. Individuals within the high FA group reported significantly more binge eating, depressive and anxiety symptoms, and more metacognitive difficulties. They also tended to show a poorer inhibition/cognitive flexibility score and a typical pattern of errors, characterized by an increased number of errors as the tasks' difficulty rose as opposed to a decreased number of errors, which characterizes an atypical pattern of errors. The present results show that the inability to learn from errors or past experiences is related to the severity of FA and overall impairments.Level of evidence Level V, descriptive study.

Purpose: The aetiology underlying addiction has often been investigated to shed more light on the factors contributing to the development and maintenance of various disorders. In the field of addictive eating behaviours, data on the aetiological factors related to food addiction (FA) in the bariatric context remain scarce. The present study aimed to explore mechanisms and variables underlying FA among individuals suffering from severe obesity and awaiting bariatric surgery., Methods: Participants (N = 146) were recruited at the Quebec Heart and Lung Institute during their pre-operative visit and were invited to complete questionnaires. Participants with and without FA were compared on reward sensitivity, impulsivity, emotion dysregulation, and personality traits., Results: Findings showed that bariatric candidates with FA (16%) presented more emotion dysregulation, more harm avoidance, and less self-directedness. Further exploration showed that the association between harm avoidance and the number of FA criteria endorsed was mediated by emotion dysregulation, while the association between self-directedness and the number of FA criteria endorsed was mediated by reward sensitivity., Conclusions: These results indicate that an inability to regulate affect by strategies other than eating highly palatable food, in a context where negative affect and long-term goals can hardly be sustained, underlies a diagnostic of FA among bariatric candidates. From a clinical standpoint, the presence of a double vulnerability leading to FA symptomatology could help design better-targeted interventions to maximise weight loss maintenance in the bariatric context., Level of Evidence: Level V, descriptive study.

Background: Gastroesophageal reflux disease (GERD) is considered the main etiologic process in the metaplastic development of Barrett's esophagus (BE). The most serious complication of BE is the possible dysplastic evolution to esophageal carcinoma. Many treatments have been described to prevent the progression of BE. The outcomes of these interventions are controversial. The aim of this study was to assess whether laparoscopic fundoplication for GERD had an impact on the development of BE., Methods: Prospective data were collected from patients who were treated with a laparoscopic fundoplication for BE. Data was collected and analyzed for a variety of clinical and pathologic outcomes., Results: Laparoscopic fundoplications were completed between 1993 and 2001, with a total sample size of 92 (mean age 53 +/- 11.8 years). Each patient was diagnosed with GERD associated with BE confirmed by both endoscopy and biopsy. A laparoscopic fundoplication was performed in all patients (360 degree fundoplication in 81 patients and partial fundoplication in 11 patients). There was no postoperative mortality or major complications from the procedure. The mean postoperative stay was 3 +/- 1 days. Seventy patients (76% of the overall sample size) were followed up for a mean 4.2 +/- 2.6 years. Of the patients available for follow-up, 33% (n = 23) had a complete regression of their BE; 21% (n = 15) had a decrease in the degree of metaplasia/dysplasia; 39% (n = 27) had no significant change; and 7% (n = 5) experienced a progression of the BE. Five patients required further procedures for three reasons: (1) GERD recurrence (n = 2), (2) progression of BE (n = 2), and (3) intrathoracic migration (n = 1). No patients developed high-grade dysplasia or esophageal carcinoma., Conclusions: The results of this study suggest that laparoscopic fundoplication offers a safe and effective long-term treatment for BE. The procedure also demonstrated regression of BE in more than 50% of the sample size.

Background: Laparoscopic Nissen fundoplication (LNF) efficiently controls the symptoms of gastroesophageal reflux disease (GERD); however, other nonspecific gastrointestinal (GI) symptoms have been reported following LNF. The aim of this study was to evaluate the long-term effects of LNF on nonspecific GI complaints., Methods: The basis for this study is the prospective follow-up of 515 patients (mean age 46 +/- 13 years) who underwent a LNF between 1992 and 1998. A questionnaire was designed to evaluate GERD symptoms (i.e., heartburn, epigastric pain, regurgitation, dysphagia, and fullness, score 0-60) and nonspecific GI symptoms (i.e., vomiting, diarrhea, constipation, and lack of appetite, score 0-48). Patients were assessed before surgery, at 6 months, 2 years, and 5 years after surgery., Results: Laparoscopic Nissen fundoplication was associated with a significant decrease in both GERD and nonspecific GI symptoms score at 6 months and up to 5 years, in the whole group (p < 0.001). 360 patients (69.7%) had preoperative nonspecific GI symptoms and experienced a significant reduction in these symptoms following the surgery and lasting up to 5 years. The other 155 patients (30.3%) had no preoperative GI symptoms (GI symptoms score of 0). In this group, there was a small but statistically significant increase in GI symptoms score (p < 0.001). It was, however, clinically significant (defined as a score >12) in only 9.9% of the patients., Conclusions: Laparoscopic Nissen fundoplication provides an efficient treatment of GERD up to 5 years, and in a majority of patients, it is not associated with any significant increase in nonspecific GI complaints. New nonspecific bowel symptoms can develop after LNF in some patients but are unlikely to be clinically significant.

Background: This study aimed to evaluate the long-term impact of laparoscopic Nissen fundoplication on esophageal motility in patients with preoperative esophageal dysmotility., Methods: This study prospectively followed 580 patients who underwent laparoscopic Nissen fundoplication between 1992 and 1999. Esophageal manometry, 24-h pH monitoring, and symptom score assessment were performed before surgery, then 6 months, 2 years, and 5 years after surgery. Preoperatively, 533 of the patients (93.5%) had normal esophageal contractile pressure (group 1), whereas 38 of the patients (6.5%) had reduced contractile pressure (<30 mmHg) (group 2)., Results: Esophageal contractile pressures increased significantly in the patients with low preoperative values, whereas it remained unchanged in the patients with normal preoperative contractile pressures. Both groups reported a significant reduction in the dysphagia symptom score after surgery., Conclusion: Nissen fundoplication produces a significant long-lasting increase in esophageal contractile pressures in patients with preoperative esophageal dysmotility (i.e., contractile pressure lower than 30 mmHg). Preoperative esophageal dysmotility is therefore not a contraindication to laparoscopic Nissen fundoplication.

Background: Symptoms of gastroesophageal reflux disease (GERD) are experienced by up to 85% of pregnant women. Some young women on maintenance proton pump inhibitor (PPI) treatment are choosing surgery to stop their medical treatment and avoid severe symptoms during pregnancy. There are no reports describing the effect of pregnancy on the long-term efficacy of laparoscopic Nissen fundoplication. The aim of this study was to evaluate the effect of pregnancy on the efficacy of laparoscopic Nissen fundoplication., Methods: This study surveyed 146 women of childbearing age with proven GERD who had undergone laparoscopic Nissen fundoplication from 1992 through 2002. The patients who became pregnant (group 1) were compared with those who did not (group 2)., Results: The study focused on 25 patients who became pregnant after surgery. Of these patients, 40% (n = 10) had chosen surgery as a way to discontinue PPI treatment before pregnancy. The mean time from laparoscopic Nissen fundoplication to pregnancy was 25.9 +/- 4.6 months. A total of 19 patients (76%) had no reflux symptoms, whereas 5 (20%) required antacids during pregnancy. One patient (4%) experienced an acute intrathoracic stomach migration during her pregnancy and required emergency open surgery, which resulted in the loss of her fetus. After pregnancy, six patients (24%) had recurrence of GERD symptoms, and three (12%) required a redo fundoplication. The higher rate of GERD recurrence (24% vs 16.7%) and redo surgery (12% vs 4%) in group 1 did not reach statistical significance, but showed a definite trend., Conclusion: For most patients, laparoscopic Nissen fundoplication is effective in controlling GERD symptoms during and after pregnancy.

Background: Only recently has the spleen been perceived as an organ with a major immune function. This raised an interest in spleen salvage after spleen trauma and pancreatic tail resection, for the treatment of hematologic disorders and inducement tolerance for allogenic transplants. The purpose of this study was to evaluate the feasibility of a new technique for spleen transplantation: laparoscopic spleen autotransplantation in a large animal model., Methods: Ten 35-kg pigs were used for this study. A laparoscopic hand-assisted splenectomy was first performed. The spleen was extracted through the handport to be flushed with a 4 degrees C saline solution and prepared extracorporeally. The graft was then reintroduced into the same animal's abdominal cavity, and a splenic-to-common iliac artery and vein bypass was performed laparoscopically using a 7-0 polytetrafluoroethylene running suture. The animal was killed 1 week postoperatively for histologic examination., Results: All 10 animals tolerated the procedure well. No conversion to open surgery was required. The mean operative time was 253 +/- 45 min. The mean time needed to create the artery and vein anastomoses was 116 +/- 165 min, and the mean blood loss was 190 +/- 120 ml. There was no intra- or postoperative death. Intraoperative complications included two stenosed vascular anastomoses, which were taken down and revised. Seven of the 10 spleens were histologically viable 1 week after surgery. The nonviable transplantations were attributable to a thrombosis of the common iliac artery (n = 1) or the transplant artery (n = 2)., Conclusions: Hand-assisted laparoscopic spleen autotransplantation is feasible in an animal model. This procedure could constitute an option when spleen resection is necessary for pancreatic tail resection, or when spleen preservation is important to the maintenance or restoration of an immune function.

Background: Emergent colostomies are associated with increased morbidity related to second closure operations. The purpose of this canine pilot study was to create a minimally invasive procedure that would reduce the time interval and morbidity involved with colostomy reversals after left colon end colostomies., Methods: Six mongrel dogs underwent modified laparoscopic Hartmann's procedures in which the stapled end of the rectal stump was approximated to the left colon proximal to the stoma. After 1 week, they underwent an endoluminal colostomy reversal with a computer-mediated, circular stapling device and varying anvil insertion methods. Variables recorded included anvil insertion technique and feasibility, OR time, complications, and number of days to first meal and bowel movement. A contrast enema performed 1 week post colostomy reversal ruled out anastomosis leaks and stenosis. The dogs were euthanized and subjected to necropsy., Results: Of four anvil insertion techniques tested, the most feasible employed a large-bore needle to perforate through the stapled end of the Hartmann pouch into the lumen of the left colon. Simultaneous endoluminal views of the rectal stump with a sigmoidoscope and the left colon lumen with an endoscope permitted a controlled and safe needle puncture. Through the needle, a guide wire was inserted to withdraw the anvil via the colostomy into place. A transanally inserted stapler was then married to the anvil under fluoroscopic guidance, thus completing the anastomosis. The colostomy was then taken down and transected at the level of the colocolostomy. Average operating time was 126 min (range 90-180), diet was tolerated within 1.5 days, and average number of days to first bowel movement was 2.5. The absence of stenosis, leaks, and inadvertent visceral injuries confirmed feasibility., Conclusions: In this canine model, a dual endoscopic-assisted colostomy reversal with a computer-mediated, circular stapling device is feasible. Using this technique, colostomy reversals can possibly be performed 1 week post-colostomy without entering the peritoneal cavity, thus reducing the number of invasive operations and subsequent morbidity required to manage emergent colon perforations.

Background: Small bowel transplantation represents a valid therapeutic option for patients with intestinal failure, obviating the need for long-term total parenteral nutrition. Recently, reports have shown the feasibility of performing living related intestinal transplantation using segmental small bowel grafts. The limitations of this technique include inadequate harvested small bowel lengths, as compared with the lengths obtained in cadaveric small bowel harvests, and large incisions for the donor. In this pilot study, we evaluated the feasibility of laparoscopically harvesting long segments of proximal jejunum for small bowel transplantation using a porcine model. The results can be used to evaluate the potential for applying this technique in human cases., Methods: For this study 10 yorkshire pigs were used. Under general anesthesia, each pig underwent laparoscopic segmental resection of 200 cm of proximal jejunum on a vascular pedicle. The harvested graft then was autoreimplanted using an open technique by anastomosing the vascular pedicle to the superior mesenteric vessels. Success was determined 2 hours after anastomosis by visually identifying a pink graft with viable-appearing mucosa, an artery with a strong thrill, and palpable venous flow. The animals were then sacrificed., Results: The mean operation time required to laparoscopically harvest the small bowel graft was 80 min (range, 35-120 min), and the mean length of harvested graft was 220 cm (range, 200-260 cm). The mean length of the graft's vascular pedicle was 4.5 cm (range, 4-5 cm). All 10 grafts were successfully harvested laparoscopically and then reimplanted using an open technique. All the grafts maintained good vascular flow, and showed no evidence of mucosal necrosis at necropsy. Obviously, further studies would be required to examine the long-term results of reimplanting a laparoscopically harvested small bowel graft, but proposals for such studies is beyond the scope of this report., Conclusion: Minimally invasive techniques can be used to harvest proximal small bowel grafts for living related small bowel transplantation.