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Purpose: An increasing Pnumber of individuals with obesity over the age of 60 years require bariatric surgery to treat obesity and its related medical problems. Sleeve gastrectomy and Roux-en-Y gastric bypass have already proven their efficacy in this population, but literature lacks reports of long-term results. The aim of this study is to compare long-term results of sleeve gastrectomy and Roux-en-Y gastric bypass in individuals older than 60 years old., Materials and Methods: This is a single-center, retrospective, comparative study of 204 patients undergoing either sleeve gastrectomy (123, 60.3%) or Roux-en-Y gastric bypass (81, 39.7%) for morbid obesity with a mean follow-up of 44.5 ± 19.1 months and 54.6 ± 17.9 months, respectively., Results: Total weight loss was significantly increased for patients who underwent Roux-en-Y gastric bypass compared to sleeve gastrectomy from 12 to 48 months after surgery, while no significant difference was found after 60 (30.39% vs. 27.63%) and 72 (27.36% vs. 23.61%) months. Roux-en-Y gastric bypass was associated to a significant increased rate of early postoperative complications (22.2% vs. 4%; p < 0.0001), but no difference was found concerning late postoperative morbidity (6.2% vs. 1.6%). Both procedures were effective in obesity related medical problems., Conclusion: Roux-en-Y gastric bypass confers an increased weight loss than sleeve gastrectomy in patients over the age of 60 in the mid-term, but it is associated with more early postoperative complications. Sleeve gastrectomy can be considered a valid alternative as long-term weight loss results are superposable to those ensured by Roux-en-Y gastric bypass., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Over the last two decades, a progressive increase in failure rate of bariatric surgery (BS) has occurred in conjunction with an exponential increase in BS worldwide. Bariatric surgeons are confronted with challenging situations in patients with a complex bariatric history. In this study, we aim to evaluate the feasibility and outcomes of revisional BS in patients with at least two or more previous bariatric procedures., Methods: Data were retrospectively retrieved from a prospectively held database of bariatric procedures performed at our tertiary referral bariatric center and included procedures done from February 2013 up to April 2019 by a single center., Results: Thirty patients underwent a third bariatric procedure. The median age was 40 (18-57) and 54 (27-69) years at the time of the first and the last procedures, respectively. Laparoscopic adjustable gastric banding was the first procedure in 26 patients. The complication rate was 33%; no patient required additional surgery because of postoperative complications. A total weight loss of 29.6% and an excess loss of 53.4% were obtained at a mean follow-up of 61 months after the last redo bariatric procedure., Conclusion: This study indicates that redo BS either conversional or revisional is feasible and effective in patients with a complex bariatric history including two or more previous procedures. Careful patients' selection is mandatory and extensive information should be given on the increased risk of postoperative complications., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Obstructive sleep apnea syndrome (OSAS) and obesity are frequently associated with hypertension (HTN), dyslipidemia (DLP), and insulin resistance (IR). In patients with obesity and OSAS scheduled for bariatric surgery (BS), guidelines recommend at least 4 weeks of preoperative continuous positive airway pressure (CPAP). Low-calorie ketogenic diets (LCKDs) promote pre-BS weight loss (WL) and improve HTN, DLP, and IR. However, it is unclear whether pre-BS LCKD with CPAP improves OSAS more than CPAP alone. We assessed the clinical advantage of pre-BS CPAP and LCKD in patients with obesity and OSAS. Seventy patients with obesity and OSAS were randomly assigned to CPAP or CPAP+LCKD groups for 4 weeks. The effect of each intervention on the apnea-hypopnea index (AHI) was the primary endpoint. WL, C-reactive protein (CRP) levels, HTN, DLP, and IR were secondary endpoints. AHI scores improved significantly in both groups (CPAP, p=0.0231; CPAP+LCKD, p=0.0272). However, combining CPAP and LCKD registered no advantage on the AHI score (p=0.863). Furthermore, body weight, CRP levels, and systolic/diastolic blood pressure were significantly reduced in the CPAP+LCKD group after 4 weeks (p=0.0052, p=0.0161, p=0.0008, and p=0.0007 vs baseline, respectively), and CPAP+LCKD had a greater impact on CRP levels than CPAP alone (p=0.0329). The CPAP+LCKD group also registered a significant reduction in serum cholesterol, LDL, and triglyceride levels (p=0.0183, p=0.0198, and p<0.001, respectively). Combined with CPAP, LCKD-induced WL seems to not have a significant incremental effect on AHI, HTN, DLP, and IR but lower CRP levels demonstrated a positive impact on chronic inflammatory status., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The Elipse™ intragastric balloon (EIGB) is a new swallowable balloon for weight loss (WL). Preserving metabolically active fat-free mass (FFM) and resting metabolic rate (RMR) during WL are crucial to maximize fat mass (FM) loss. After EIGB placement, a standard low-calorie diet (LCD) is generally prescribed. A low-calorie ketogenic diet (LCKD) has proven to be safe and effective in reducing FM while preserving FFM and RMR., Objective: To prospectively compare the effects on WL, FM, FFM, and RMR in two groups of patients who were randomized to two different diets: LCKD and a standard LCD after EIGB placement., Methods: WL, FM, FFM, and RMR were measured before EIGB and at 4 months in 48 patients who received either a LCKD (n = 24) or a standard LCD (n = 24). Compliance in following the prescribed diet was determined with food frequency questionnaires in all patients. The impact of LCKD and LCD on renal function was also evaluated., Results: The LCKD group showed a significantly lower decrease in FFM and RMR when compared with the LCD group (3.55 vs 14.3%, p < 0.001; 9.79 vs 11.4%, p < 0.001, respectively). FM decreased more significantly with LCKD compared to LCD (41.6 vs 33.1%, p = 0.0606). Compliance in following the prescribed diets, without negative impact on renal function, was found., Conclusion: Based on our findings, despite the small sample size, we were able to support the hypothesis that LCKD is associated with an increased FM loss while reducing the FFM loss and the RMR, without interfering with renal function after EIGB.

Background: To assess dietary habits in a cohort of patients at minimum follow-up of 4 years after sleeve gastrectomy (SG) by comparing their dietary records to the Italian Mediterranean diet (IMD) recommendations., Methods: We prospectively evaluated in 74 patients who had the SG in 2014 dietary habits by a 7-day food dietary records, weight and micronutrient status, evolution of comorbidities, use of micronutrient supplements, and frequency of physical activity., Results: The IMD recommendations in terms of daily/weekly portions of fruits, vegetables, and complex carbohydrates were followed by 40.5%, 35.1%, and 40.5% of the participants, respectively. Concerning milk/dairy, olive oil, poultry, fish/shellfish, eggs, legumes, processed/red meat, and cold cuts, 54.1%, 85.1%, 44.5%, 75.7%, 67.6%, 35.1%, 87.8%, and 55.4% of the participants, respectively, followed the IMD recommendations. Weight regain appeared in 37.8% of participants, while physical activity was reported by the 54.0% of them. Deficiencies of vitamin B12, vitamin D, folate, iron, and anemia were found present in 6.8%, 8.1%, 24.3%, 33.8%, and 59.5% of the participants, respectively, and 18.9% of them were found to take micronutrient supplements. Improvement/remission of type 2 diabetes, hypertension, or obstructive sleep apnea was 73.3%, 64.7%, and 100% respectively., Conclusions: In this prospective cohort with a minimum follow-up of 4 years after SG, we found an inadequate intake of fruit, vegetables, poultry, and complex carbohydrates according to the IMD recommendations; the frequency of physical activity and the use of micronutrients supplements were also inadequate. This may contribute to weight regain and micronutrient deficiencies in the long term.

Background: Gastroesophageal reflux disease (GERD) is present in half of the obese candidates for bariatric surgery. Variability of symptoms and new onset of GERD are often debated. Prior studies have demonstrated that sleeve gastrectomy (SG) is associated with significant weight loss., Objectives: We prospectively evaluated the effect of a standardized SG technique on GERD symptoms in 104 patients., Methods: All patients were surveyed on the presence of heartburn and/or regurgitation with a specific questionnaire (GERD-HRQL). Esophagogastroduodenoscopy (EGDS) was performed in the preoperative phase and after 12 months., Results: All patients completed a 12-month follow-up. In the preoperative phase, 27.9% presented GERD symptoms (29 cases), while endoscopic findings were observed in 19.2% (20 cases). Preoperative GERD was ameliorated/solved in 65.5% of cases. The mean value of the GERD-HRQL score was significantly lower in postoperative evaluation (33.8 vs 19.4; p < 0.05). At 12-month EGDS, esophagitis was present in 13.5%, and GERD-HRQL symptoms were recorded in 10.6%. Considering patients treated until December 2015 (group 1, 44 patients) and those treated after December 2015 (group 2, 60 patients), all new clinical and endoscopic GERD diagnoses were observed in group 1; the majority of unsolved GERD cases was present in Ggoup 1 (8 vs 2; p < 0.05)., Conclusion: Significant amelioration on preoperative GERD was confirmed after SG. New characteristics of reflux are emerging in SG patients, often asymptomatic. Standardization is necessary to define the real effect of SG on GERD.

Background: Recent evidence has indicated an increased risk of Barrett's esophagus (BE) in the long term after sleeve gastrectomy (SG)., Aim: The aim of the study is to investigate the spectrum of gastroesophageal reflux disease (GERD) symptoms as well as the prevalence of BE, at minimum 5 years after SG in patients who underwent SG in different bariatric centers of two countries: France and Italy., Patients and Methods: Five high volume outpatient centers dedicated to bariatric surgery that routinely perform upper GI endoscopy before any bariatric procedures were invited to participate in the study. From January 2017 to June 2018, each center during scheduled postoperative evaluation after surgery asked a minimum 10 consecutive patients, which had performed SG at least 5 years before and with no evidence of BE preoperatively, to undergo another upper GI endoscopy., Results: Ninety (66 F) consecutive patients were enrolled. The mean follow-up was 78 ± 15 months, and the mean total body weight loss was 25 ± 12%. The prevalence of BE was 18.8% with no significant difference among centers. Weight loss failure was significantly associated with BE (p < 0.01). The prevalence of GERD symptoms, erosive esophagitis, and the usage of PPIs increased from 22%, 10%, and 22% before the SG to 76%, 41%, and 52% at the time of follow-up, respectively (p < 0.05)., Conclusions: This multicenter study show a high rate of BE at least 5 years after SG. Weight loss failure was significantly associated with BE. We suggest to provide systematic endoscopy in these patients to rule out this condition.

Background: The impact of bariatric surgery (BS) on the sexual functioning of patients is poorly studied. Our aim was to analyze the sexual function, depressive symptoms, and self-esteem of morbidly obese women (MOW) undergoing BS., Patients and Methods: Quality of sexual life was prospectively evaluated in 43 consecutive MOW (18-50 years) who underwent BS. Female sexual function index (FSFI), Beck depression inventory (BDI), and Rosenberg self-esteem scale (RSES) questionnaires were administered to evaluate sexual satisfaction, depressive symptoms, and self-esteem, respectively. A control group of 36 healthy, non-obese, female patients (HW) was recruited for comparison. Results of questionnaires were compared between three periods (before BS and at 3- and 6-month follow-up) and between MOW and HW., Results: Before BS, the FSFI score was significantly lower in MOW compared to HW (17 ± 12 vs 27 ± 8, p = 0.0001) while at 3- and 6-month post-BS, a significant amelioration (p = 0.01) occurred. In particular, after BS, all components of the FSFI score (sexual desire, excitement, lubrification, orgasm, satisfaction, and pain) were ameliorated. The pre-BS BDI score was higher in MOW than in HW (8 ± 6 vs 5 ± 5, p = 0.004) while at postoperative months 3 and 6, a significant amelioration was found (p = 0.025 and 0.005, respectively). Before BS, no significant differences occurred in the RSES score between MOW and HW (30 ± 7 vs 32 ± 6, p = 0.014), whereas the MOW RSES scores at 6-month post-BS were improved when compared with the HW RSES scores., Conclusions: BS results in a significant improvement in the quality of sexual life, depressive symptoms, and self-esteem in MOW.

Background: Before bariatric surgery (BS), moderate weight loss, left hepatic lobe volume reduction, and micronutrient deficiency (MD) identification and correction are desirable., Objectives: The objective of this study was to assess the safety and the effectiveness of a 4-week preoperative ketogenic micronutrient-enriched diet (KMED) in reducing body weight (BW), left hepatic lobe volume, and correcting MD in patients scheduled for BS., Materials and Methods: In this prospective pilot study, a cohort of morbidly obese patients (n = 27, 17 females, 10 males) with a mean body mass index (BMI) of 45.2 kg/m 2 scheduled for BS underwent a 4-week preoperative KMED. Their BW, BMI, fat mass (FM), fat-free mass (FFM), resting metabolic rate (RMR), left hepatic lobe volume, micronutrient status, and biochemical and metabolic patterns were measured before and after the 4-week KMED. Patient compliance was assessed by validated questionnaires (3-day estimated food records and 72-h recall). Qualitative methods (5-point Likert questionnaire) were used to measure diet acceptability and side effects., Results: All patients completed the study. We observed highly significant decreases in BW (- 10.3%, p < 0.001, in males; - 8.2%, p < 0.001, in females), left hepatic lobe volume (- 19.8%, p < 0.001), and an amelioration of patient micronutrient status. All patients showed a high frequency of acceptability and compliance in following the diet. No adverse side effect was reported., Conclusion: This study demonstrates that a 4-week preoperative KMED is safe and effective in reducing BW, left hepatic lobe volume, and correcting MD in obese patients scheduled for BS.

Background: Bariatric surgery (BS) has grown exponentially in France, and long-term anemia due to micronutrient deficiencies has become common., Objectives: The objective of this study was to assess the long-term risk of anemia after BS and to investigate the factors associated with the occurrence of this complication., Materials and Methods: Data from the French National Health Service database on patients who had undergone gastric bypass (GB), sleeve gastrectomy (SG), or adjustable gastric banding (AGB), between 2008 and 2016 were extracted. Only patients with a primary intervention were considered., Results: Data from 306,298 patients (143.733 SG, 79.188 GB, and 36.413 AGB) were analyzed. Overall, 12.930 of them (5.0%) had a diagnosis of anemia due to micronutrient deficiencies as main diagnosis or related diagnosis at time of a hospital stay between 2008 and 2016. In multivariate analysis, GB surgery, female gender, age younger than 52 years, and 25-OH vitamin D deficiency were positively associated with the occurrence of anemia whereas hospital procedural volume was negatively associated. The risk to be diagnosed with anemia after BS was 13.0% after a GB, 5.6% after a SG and 4.0% after an AGB (Log-rank p < 0.0001). The hazard ratio for anemia after GB compared to SG was 2.0 (95% CI 1.9-2.1), adjusted for age and gender., Conclusion: In France, between 2008 and 2016, 5% of patients had anemia after BS. The risk to develop anemia was 2-fold higher after a GB than after a SG. Young women should be particularly aware of this long-term risk.

Background: Obese patients with preoperative gout often suffer of gouty attacks after bariatric surgery (BS), probably due to the lack of an adequate postoperative diet., Objectives: The objectives of the study are to assess whether sleeve gastrectomy (SG) is effective in reducing the frequency of gouty attacks and also whether a postoperative low-purine diet (LPD) may further reduce these attacks as compared to a normal-purine diet (NPD) in a series of patients suffering of gout before SG., Methods: In this retrospective study, we measured and compared total body weight (TBW), body mass index (BMI), uric acid levels (UAL), anti-gout medication (allopurinol) requirements, and frequency in gouty attacks in 40 patients that underwent SG and who received either a LPD (n = 24) or NPD (n = 16). Compliance in following the prescribed diet was assessed in both groups study., Results: Before surgery, LPD and NPD patients had hyperuricemia and were receiving allopurinol. One year after SG, LPD and NPD groups showed a significant decrease in serum UAL (p < 0.001 and p = 0.00175, respectively). However, serum UAL decreased more significantly with the LPD compared to the NPD (p < 0.001). Furthermore, while NPD group showed a significant decrease in allopurinol requirements (p = 0.00130) and on the frequency in gouty attacks (p < 0.001), LPD group were off allopurinol therapy and had no gouty attacks 12 months after SG. Both groups showed high compliance in following the prescribed diets., Conclusion: LPD is more effective in reducing the frequency of gouty attacks after SG compared with NPD in patients suffering of gout before surgery.

Background: We recently showed that an 8-week preoperative protein-enriched diet (PED) is associated with significant reductions in body weight and fat mass (FM) without significant loss of fat-free mass (FFM) in morbidly obese patients scheduled for laparoscopic sleeve gastrectomy (LSG)., Objectives: The objective of this study is to evaluate the impact of PED vs a normal protein diet (NPD) on total weight loss (TWL), FM, FFM, and resting metabolic rate (RMR) in patients after LSG., Methods: Before LSG and at 3, 6, and 12 months after, we prospectively measured and compared total body weight (TBW), FM, FFM, and RMR in 60 male patients who received either a NPD (n = 30) with protein intake 1.0 g/kg of ideal body weight, or a PED (n = 30) with protein intake 2.0 g/kg of ideal body weight. Compliance in following the prescribed diet was determined with food frequency questionnaires in all patients. The impact of NPD and PED on renal function was also evaluated., Results: Despite non-significant variation in total body weight (TBW), FM decreased more significantly (p < 0.01) with the PED compared to the NPD. In addition, the PED group showed a significantly (p < 0.01) lower decrease in FFM and RMR when compared with the NPD group. Both groups showed high compliance in following the prescribed diets, without negative impact on renal function., Conclusion: PED is more effective than NPD in determining FM loss and is associated with a lower decrease in FFM and RMR, without interfering with renal function in male patients after LSG.