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Background Micronutrient deficiencies represent a common condition after bariatric surgery (BS). The prevalence of these nutritional disorders before BS is still debated. The aim of our study was to retrospectively evaluate the prevalence of micronutrient deficiencies in candidates for BS. Methods A prospectively maintained database of our institution was searched to find all patients who underwent surgery between January and December 2021. The following data were collected: age, gender, body mass index (BMI), obesity-associated diseases, and preoperative serum levels of vitamin B12, folate, and vitamin D. Results A total of 174 patients were included in our study. Mean age and BMI were 39.2 ± 11.4 years and 44.3 ± 7.1 kg/m2, respectively. One hundred and thirty-nine patients (79.9%) had at least one preoperative micronutrient disorder, with vitamin D deficiency being the most common (116, 66.7%), followed by a deficit of folate (76, 43.7%) and vitamin B12 (10, 5.7%). Forty-seven (27%) individuals had insufficient levels of vitamin D. Comparison of deficiencies between sexes showed that vitamin B12 p = 0.03). DLP showed a mild significant effect on folate levels (p = 0.01), while the association of HNT and T2DM had a mild significant effect on vitamin B12 (p = 0.02). Conclusions Preoperative micronutrient deficiencies were frequently found in candidates for BS. Approximately 90% of patients had deficient or insufficient serum levels of vitamin D preoperatively. Almost half of the patients had a preoperative deficit of folate, and vitamin B12 deficiency was significantly more frequent in the female population. It is mandatory to screen all patients undergoing BS for vitamin deficiencies before surgery.

Background The laparoscopic approach is a very popular technique for many gastrointestinal operations and barbed sutures may improve the difficulties of intracorporeal anastomosis by eliminating the need for knot tying. The aim of this systematic review with a meta-analysis is to explore literature to establish the security profile of barbed suture compared with conventional laparoscopic sutures. Materials and methods A systematic search was performed in all electronic databases (PubMed, Web of Science, Scopus, EMBASE) and 12 studies were included in the analysis, involving 27,133 patients, whereof 3372 cases (patients undergone barbed suture usage) and 23,761 controls (patients undergone conventional suture usage). We found 3 studies discussing differences between barbed and conventional sutures in colorectal surgery and 8 studies presenting results in bariatric surgery, both in Roux-en-y gastric bypass and Mini Gastric/One Anastomosis Gastric Bypass. Results We found comparable rate of leaks, bleedings and stenosis. The meta-regression analysis demonstrated that, both in case of bariatric and colorectal surgery, the demographic characteristic of patients and the oncological features of neoplasms did not impact of these findings. As expected, operative time is significantly shorter when barbed suture is used. Conclusion Our analysis on current literature define an acceptable security profile for barbed suture with effective results particularly in terms of shorter operative time.

The aim of our study was to assess and compare postoperative nausea and pain after one anastomosis gastric bypass (OAGB) and sleeve gastrectomy (LSG). Patients undergoing OAGB and LSG at our institution between November 2018 and November 2021 have been prospectively asked to report postoperative nausea and pain on a numeric analogic scale. Medical records were retrospectively reviewed to collect scores of these symptoms at the 6th and 12th postoperative hour. One-way analysis of variance (ANOVA) was used to evaluate effect of type of surgery on postoperative nausea and pain scores. To adjust for baseline differences between cohorts, a propensity score algorithm was used to match LSG patients to MGB/OAGB patients in a 1:1 ratio with a 0.1 tolerance. A total number of 228 (119 SGs and 109 OAGBs) subjects were included in our study. Nausea after OAGB was significantly less severe than after LSG both at the 6th and 12th hour assessment; pain was less strong after OAGB at the 6th hour but not after 12 h. Fifty-three individuals had a rescue administration of metoclopramide after LSG and 34 after OAGB (44.5% vs 31.2%, p = 0.04); additional painkillers were required by 41 patients after LSG and 23 after OAGB (34.5% vs 21.1%, p = 0.04). Early postoperative nausea was significantly less severe after OAGB, while pain was comparable especially at the 12th hour.

Background Bariatric surgery in patients with BMI over 50 kg/m2 is a challenging task. The aim of this study was to address main issues regarding perioperative management of these patients by using a worldwide survey. Methods An online 48-item questionnaire-based survey on perioperative management of patients with a BMI superior to 50 kg/m2 was ideated by 15 bariatric surgeons from 9 different countries. The questionnaire was emailed to all members of the International Federation of Surgery for Obesity (IFSO). Responses were collected and analyzed by the authors. Results 789 bariatric surgeons from 73 countries participated in the survey. Most surgeons (89.9%) believed that metabolic/bariatric surgery (MBS) on patients with BMI over 50 kg/m2 should only be performed by expert bariatric surgeons. Half of the participants (55.3%) believed that weight loss must be encouraged before surgery and 42.6% of surgeons recommended an excess weight loss of at least 10%. However, only 3.6% of surgeons recommended the insertion of an Intragastric Balloon as bridge therapy before surgery. Sleeve Gastrectomy (SG) was considered the best choice for patients younger than 18 or older than 65 years old. SG and One Anastomosis Gastric Bypass were the most common procedures for individuals between 18 and 65 years. Half of the surgeons believed that a 2-stage approach should be offered to patients with BMI > 50 kg/m2, with SG being the first step. Postoperative thromboprophylaxis was recommended for 2 and 4 weeks by 37.8% and 37.7% of participants, respectively. Conclusion This survey demonstrated worldwide variations in bariatric surgery practice regarding patients with a BMI superior to 50 kg/m2. Careful analysis of these results is useful for identifying several areas for future research and consensus building.

Italy was the first European country to have a major outbreak of COVID-19. Bariatric procedures were stopped and telemedicine had to be implemented. A large percentage of patients struggled to follow postoperative diet and to start physical activity due to social restrictions. We have compared short-term outcomes of patients who had bariatric procedures prior to lockdown with subjects that had undergone obesity surgery in the same period of the previous year at our institution. A total number of 63 patients were included in this study. Weight loss at 1, 3 and 6 postoperative months in the 2019 group was significantly higher at any point of follow-up when compared to 2020. Social limitations and nonattendance of clinical appointments may have compromised early results. Graphical Abstract: [Figure not available: see fulltext.].

Background Recent reports have demonstrated that de novo reflux and worsening of pre-existing symptoms occur after SG; concerns are still expressed about the risk of symptomatic biliary reflux gastritis and oesophagitis. The aim of our study was to investigate and compare the rate of postoperative acid and non-acid reflux following Mini-/One anastomosis gastric bypass (MGB/OAGB) and laparoscopic sleeve gastrectomy (LSG). Study design A prospective randomized open-label, controlled trial registered on clinicaltrial.gov (NCT number: NCT02987673) has been carried out to evaluate esophagogastric junction exposure to reflux in the first year after MGB/OAGB and LSG using high impedance manometry, endoscopy, and a validated questionnaire. Results A total of 58 individuals were eventually enrolled in this trial and represented the per-protocol population (n = 28 MGB/OAGB, n = 30 LSG). No difference was found between the two groups in terms of demographic characteristics, PAGI-SYM score, acid exposure time percent of the esophagus (AET%), esophagitis, and other HRiM and MII-pH data at baseline. Comparing MII-pH outcomes of the two groups, AET% resulted significantly higher after LSG at 12 months. Endoscopic findings showed a significant increase of esophagitis ≥ B in the LSG group after 1 year; postoperative esophagitis ≥ B resulted also significantly worsened after LSG when compared to MGB/OAGB. Conclusion Since AET% and rate of esophagitis are significantly higher after LSG when compared to MGB/OAGB, this procedure should be preferred in case of preoperative subclinical reflux or low grade (A) esophagitis.

One anastomosis gastric bypass (OAGB/MGB) has gained popularity in the past decade. International databases were searched for articles published by September 10, 2020, on OAGB/MGB as a revisional procedure after restrictive procedures. Twenty-six studies examining a total of 1771 patients were included. The mean initial BMI was 45.70 kg/m2, which decreased to 31.52, 31.40, and 30.54 kg/m2 at 1, 3, and 5-year follow-ups, respectively. Remission of type-2 diabetes mellitus (T2DM) following OAGB/MGB at 1-, 3-, and 5-year follow-up was 65.16 ± 24.43, 65.37 ± 36.07, and 78.10 ± 14.19%, respectively. Remission/improvement rate from gastroesophageal reflux disease (GERD). Also, 7.4% of the patients developed de novo GERD following OAGB/MGB. Leakage was the most common major complication. OAGB/MGB appears to be feasible and effective as a revisional procedure after failed restrictive bariatric procedures. Supplementary Information The online version contains supplementary material available at 10.1007/s11695-020-05079-x.

Background Laparoscopic Adjustable Gastric Banding (LAGB) has been widely performed in the past at our university bariatric center. Aim of this study was to retrospectively assess long term outcomes of LAGB at our university hospital, with special regard to non-response (EWL Methods Retrospective search of prospectively maintained database of our university bariatric center was carried out to find all consecutive patients that had undergone LAGB at our department with a minimum follow-up of 10 years. Collected data were sex, age, body mass index (BMI), obesity related diseases remission, complications and weight loss. Results After 10 years, patients with the band (n = 144) in place had a BMI of 35.2 ± 7.5 kg/m2, while %EWL and % TWL were 40.8 ± 52.4 and 18.9 ± 20.7. Seventy-four (41.6%) achieved a success (%EWL > 50), while 38 (21.3%) were non-responders (%EWL Conclusion LAGB is a safe and moderately effective bariatric procedure but it showed disappointing rates of removal, non-response and remission from comorbidities. However, LAGB could still be proposed for selected/motivated patients.

Laparoscopic Sleeve Gastrectomy (LSG) is a common bariatric procedure with low complication rates. Several hemostatic agents have been used to reduce staple line bleeding, but its impact is unclear. The primary endpoint of this study was to compare the early (30-day) complications comparing oxidized regenerated cellulose (ORC) and fibrin sealant (FS) application on the staple line. The secondary endpoints were to compare the need for postoperative blood transfusion, postoperative blood work values of Hemoglobin (Hb), white blood cell (WBC), C-reactive protein (CRP), drain output volume and hospital length of stay (LOS).A retrospective analysis of all patients who underwent LSG between January and October 2021 was performed. Subjects were divided into two groups according to the use of ORC versus FS on the staple line. Early postoperative complications, Hb level, WBC count, and drain output volume were compared between groups.A total number of 77 patients were included: 27 in the ORC-group and 50 in the FS-group. No major complication was recorded in both groups. There was no significant difference in the need for blood transfusion, Hb value, and drain output volume on postoperative day (POD) 1 and 2. There was a significantly higher WBC count in the ORC-group on POD 1 and 2. There was no difference in hospital LOS between the groups.The use of FS and ORC was associated with a comparable low rate of bleeding. ORC causes an increased WBC count postoperatively, but this showed no clinical relevance.

Background The development of fast internet connection has stimulated different types of video-assisted teaching programs. However, a remote mentoring with the proctor not on site has never been reported in bariatric surgery. We described our experiences with remote telementoring for laparoscopic sleeve gastrectomy. Methods A qualified general surgeon at the beginning of his bariatric practice performed a series of 8 laparoscopic sleeve gastrectomies (LSG) while tutored by an experienced bariatric surgeon connected from a different city through a specific videoconferencing platform. Data on demographics at baseline, operative time, hospital stay, intraoperative early, and late complications were collected. Results Mean age and BMI of patients were 36.9 ± 9.6 years old and 41.8 ± 1.7 kg/m2. All procedures were carried out without conversion to open or complications. Mean operative time was 112.4 ± 21.9 min while the hospital stay was 3.5 ± 0.5 days. Operative time significantly decreased after the fourth operation. Conclusions Remote coaching appears to be possible and safe for LSG.

Purpose: Bariatric surgery (BS) is considered the most efficient treatment for severe obesity. International guidelines recommend multidisciplinary approach to BS (general practitioners, endocrinologists, surgeons, psychologists, or psychiatrists), and access to BS should be the final part of a protocol of treatment of obesity. However, there are indications that general practitioners (GPs) are not fully aware of the possible benefits of BS, that specialty physicians are reluctant to refer their patients to surgeons, and that patients with obesity choose self-management of their own obesity, including internet-based choices. There are no data on the pathways chosen by physicians and patients to undergo BS in the real world in Italy. Methods: An exploratory exam was performed for 6 months in three pilot regions (Lombardy, Lazio, Campania) in twenty-three tertiary centers for the treatment of morbid obesity, to describe the real pathways to BS in Italy. Results: Charts of 2686 patients (788 men and 1895 women, 75.5% in the age range 30–59 years) were evaluated by physicians and surgeons of the participating centers. A chronic condition of obesity was evident for the majority of patients, as indicated by duration of obesity, by presence of several associated medical problems, and by frequency of previous dietary attempts to weight loss. The vast majority (75.8%) patients were self-presenting or referred by bariatric surgeons, 24.2% patients referred by GPs and other specialists. Self-presenting patients were younger, more educated, more professional, and more mobile than patients referred by other physicians. Patients above the age of 40 years or with a duration of obesity greater than 10 years had a higher prevalence of all associated medical problems. Conclusions: The majority of patients referred to a tertiary center for the treatment of morbid obesity have a valid indication for BS. Most patients self-refer to the centers, with a minority referred by a GP or by specialists. Self-presenting patients are younger, more educated, more professional, and more mobile than patients referred by other physicians. Older patients and with a longer duration of obesity are probably representative of the conservative approach to BS, often regarded as the last resort in an endless story. Graphical abstract: [Figure not available: see fulltext.]

Introduction: Inguinal hernia repair is one of the most commonly performed surgical procedures in general surgery. Despite surgical advances, recurrence and chronic pain are still major issues after this intervention. Aim of our study was to retrospectively assess and compare outcomes of robotic versus laparoscopic repair of recurrent inguinal hernia. Methods: All patients who underwent recurrent inguinal hernia repair between 2014 and 2021 in five different institutions were included in our study. Baseline data on age, gender, body mass index, comorbidities, smoking habit, and anticoagulant therapy were retrospectively collected from prospectively maintained databases. Operative time, length of stay, and early and late complications were compared between the robotic and the laparoscopic approach. Results: Forty-eight patients underwent recurrent inguinal hernia repair between January 2014 and December 2021. Twenty-three patients underwent a robotic procedure, whereas 25 were submitted to the laparoscopic intervention. Overall mean follow-up was 26.2 months. There was no significant difference in the baseline characteristics of the two groups. Acceptable and comparable rates of peri- and postoperative outcomes were recorded. However, postoperative visual analog scale score and incidence of chronic pain were lower after the robotic rather than after the laparoscopic approach. (2.9 versus 3.8 P = .002; 20% versus 0%; P = .02, respectively). Conclusions: Minimally invasive repair of recurrent inguinal hernia is safe and feasible; robotic surgery is associated with low rate of postoperative and chronic pain without a significant increase in operative time.

The COVID-19 pandemic caused a lockdown in many countries, which induced negative dietary habits and sedentary behavior. Studies suggest that weight loss of patients undergoing bariatric surgery was equally affected. The aim was to evaluate the impact of COVID-19 on weight loss, obesity-related comorbidities, and nutritional status at 1-year follow-up after gastric bypass (GB).Retrospective observational case-control study of patients undergoing primary GB in a tertiary referral Belgian center. COVID-19 period group was composed by those whose 1-year postoperative period was affected by the COVID-19 pandemic and lockdown: from October 1, 2019, to March 31, 2020. The control group was composed of patients operated from October 1, 2018, to March 31, 2019. Electronic clinical records were reviewed searching: baseline characteristics, weight and comorbidities evolution, and biochemical values.A total of 47 patients in the COVID-19 period group and 66 in the non-COVID-19 period group were analyzed. There were no significant differences in baseline characteristics. A reduced weight loss was observed at 1-year follow-up, in terms of percentage of excess weight loss (%EWL) (82.4% [SD: 21.6] vs. 82.4% [SD: 21.6]; p: 0.043) and body mass index (BMI) (27.8 kg/mThe COVID-19 pandemic and lockdown had an impact on weight loss at 1-year follow-up after gastric bypass.

Background Age ≥ 65 years is regarded as a relative contraindication for bariatric surgery. Advanced age is also a recognised risk factor for adverse outcomes with Coronavirus Disease-2019 (COVID-19) which continues to wreak havoc on global populations. This study aimed to assess the safety of bariatric surgery (BS) in this particular age group during the COVID-19 pandemic in comparison with the younger cohort. Methods We conducted a prospective international study of patients who underwent BS between 1/05/2020 and 31/10/2020. Patients were divided into two groups — patients ≥ 65-years-old (Group I) and patients < 65-years-old (Group II). The two groups were compared for 30-day morbidity and mortality. Results There were 149 patients in Group 1 and 6923 patients in Group II. The mean age, preoperative weight, and BMI were 67.6 ± 2.5 years, 119.5 ± 24.5 kg, and 43 ± 7 in Group I and 39.8 ± 11.3 years, 117.7±20.4 kg, and 43.7 ± 7 in Group II, respectively. Approximately, 95% of patients in Group 1 had at least one co-morbidity compared to 68% of patients in Group 2 (p = < 0.001). The 30-day morbidity was significantly higher in Group I (11.4%) compared to Group II (6.6%) (p = 0.022). However, the 30-day mortality and COVID-19 infection rates were not significantly different between the two groups. Conclusions Bariatric surgery during the COVID-19 pandemic is associated with a higher complication rate in those ≥ 65 years of age compared to those < 65 years old. However, the mortality and postoperative COVID-19 infection rates are not significantly different between the two groups. Graphical abstract

Very little has been published on the learning curve (LC) of the One Anastomosis /Mini Gastric Bypass (OAGB/MGB). Aim of this study was to compare perioperative outcomes of OABG/MGBs performed during the LC of an experienced laparoscopic surgeon to global benchmark cut-offs. First 200 patients undergoing OAGB/MGB at our university hospital from 2010 to 2016 were retrospectively included in this study. LC of the surgeon was divided in two groups of 100 consecutive patients each and perioperative outcomes were compared to abovementioned global benchmarks for LSG and RYGB. A cumulative sum (CUSUM) analysis was performed for operative time and hospital stay. Uneventful postoperative recovery was recorded in 95% of patients. All benchmark values for RYGB were met in group 2. Comparison with cut-offs for LSG showed longer hospital stay and operative time in both groups but postoperative rate of complications resulted lower even for Group 1. CUSUM graph of the operative time runs randomly above the predetermined limit till the 40th cases but reaches the plateau after the 115th operation. CUSUM curve of the hospital stay reaches the plateau after the 57th case. OAGB/MGB confirms to be a feasible procedure, which can be safely and effectively performed during the learning curve. However, at least 100 hundred cases are required to reduce operative time and hospital stay.

The risk of gastric and/or esophageal cancers after bariatric surgery has been previously discussed in literature. A systematic review was performed to identify articles published between June 2012 and December 2018 reporting new cases of esophageal or gastric cancer not included in previous systematic reviews. Ten gastric malignancies, 28 esophageal cancers, and 2 gastro-intestinal stromal tumors (GIST) were identified. Primary bariatric surgery was a restrictive procedure in 26 cases, a purely malabsorptive procedure in 1 subject, and a gastric bypass in 13 patients. Although the vast majority of bariatric procedures seem to present a negligible relationship with any esophagogastric (EG) malignancy, published data remain incomplete. It was however considered of interest to update the number of EG neoplasms arisen following bariatric surgery.

Background Obesity has previously been related to reduced female fertility, with prolonged waiting time to pregnancy among women with a body mass index (BMI) >35 kg/m2 but there are few studies investigating the relationship between high BMI, bariatric surgery, and male fertility. Objectives The primary objective of this article was to investigate the effect of bariatric surgery on in vitro fertilization (IVF) outcomes in a cohort of men with morbid obesity who underwent sleeve gastrectomy (SG). Setting University hospital, bariatric surgery unit. Methods Pre- and postsurgery data on patient age, body mass index (BMI), and variables related to male fertility (semen volume, concentration, progressively motile sperm count, and sperm morphology) were collected; assisted reproductive technology outcomes before and after bariatric surgery were measured by the number of metaphase II oocytes; the number of top-quality oocytes and embryos; the number of fertilized oocytes; the number of transferred embryo; the implantation rate; the pregnancy rate; the live birth rate and the miscarriage rate. Results Thirty-five men with obesity and idiopathic infertility were included in this study. We found a significant increase, after bariatric surgery, in semen volume, total sperm concentration, progressively motile sperm count, and sperm morphology. Considering IVF outcomes, mean number of top-quality oocytes, mean number of fertilized oocytes, mean number of embryos obtained, and top-quality embryos were significantly increased after bariatric procedure. Conclusion Bariatric surgery is confirmed to be safe and effective in increasing the outcomes of assisted reproductive technology treatment also in case of infertile men with obesity, both in terms of pregnancy and live birth rate.

Background Although different procedures have been proposed as revisional surgery for patients who had previously undergone a failed primary restrictive procedure, the ideal revisional procedure is still a matter of debate. Methods A systematic search was performed in all electronic databases to find studies comparing one anastomosis-mini gastric bypass (OAGB-MGB) or Roux-en-Y gastric bypass (RYGB) as revisional bariatric surgery for weight regain or intolerance/complications of a primary restrictive procedure. The data regarding sample size, patients’ gender, age, primary surgery type, number of perioperative complications, operative time, pre- and post-revisional body mass index (BMI), and excess weight loss % (EWL%) at 1-year follow-up were extracted. Five studies were included in the analysis. Results The primary bariatric procedures were represented by vertical banded gastroplasty (VBG), laparoscopic adjustable gastric band (LAGB) and laparoscopic sleeve gastrectomy (LSG). About perioperative complications, both RYGB and OAGB-MGB showed a similar rate of leaks but OAGB-MGB had a lower rate of bleedings; considering the progression from pre- to post-revisional BMI, OAGB-MGB reveals a better outcome as well as a shorter operative time. Conclusions Our meta-analysis has shown OAGB-MGB, used as revisional intervention after failed restrictive surgery, achieves outcomes comparable to RYGB in terms of perioperative complications providing a simpler and more effective technique.

Background The laparoscopic sleeve gastrectomy (LSG) is the most common bariatric procedure performed worldwide while the laparoscopic adjustable gastric banding (LAGB) has been almost abandoned. Aim of this study was to retrospectively assess 10-year outcomes of LSG through a matched comparison with LAGB. Materials and Methods Retrospective search of prospectively maintained database of our university was carried out to find all patients that underwent LSG before December 2010. Each subject with LSG was matched one-to-one with a patient that had undergone LAGB in the same period with correspondent preoperative age, BMI, and sex. Results A total of 76 patients underwent LSG before 2010 and were all included in this study; a matched group of 76 out of 178 LAGB patients with 10-year follow-up was retrieved from our database. Comparison between the two groups showed better outcomes after LSG at 1 and 5 years but weight loss was comparable with the LAGB group at 10 years (%TWL 22.2 ± 13 vs 21.2 ± 16.1; p = 0.89). No significant difference was found in conversion/removal rate (15.8% vs 18.4%; p = 0.67). Conclusion LSG is an effective stand-alone bariatric procedure with better outcomes than LAGB in medium term, but results are comparable at 10 years. Subjects undergoing LSG should be informed that conversion to RYGB or OAGB may be necessary to achieve further weight loss or to treat reflux. Graphical abstract

Seroma formation following mastectomy is one of the most experienced complications, with a very variable incidence ranging from 3 to 90%. In recent years, many publications have been realized to define an effective technique to prevent its formation and several approaches have been proposed. Given the potential of flap fixation in reducing seroma formation, we performed a meta-analysis of the literature to investigate the role of this approach as definitive gold standard in mastectomy surgery. Inclusion criteria regarded all studies reporting on breast cancer patients undergoing mastectomy with or without axillary lymph node dissection; studies that compared mastectomy with flap fixation to mastectomy without flap fixation were selected. Papers were eligible for inclusion if outcome was described in terms of seroma formation. As secondary outcome, also surgical site infection (SSI) was evaluated. The included studies were 12, involving 1887 female patients: 221/986 (22.41%) patients experienced seroma formation after flap fixation and 393/901 (43.61%) patients had this complication not receiving flap fixation, with a significant statistical difference between the two groups (OR = 0.267, p = 0.001, 95% CI 0.153, 0.464). About, SSI 59/686 (8.6%) in flap fixation group and 67/686 (9.7%) in patients without flap fixation, with no statistical differences between groups (OR = 0.59, p = 0.056, 95% CI 0.344, 1.013).The heterogeneity between included studies does not allow us to reach definitive conclusions but only to suggest the strong evaluation of this approach after mastectomy in seroma preventing and SSI reduction.

To evaluate whether the learning curve for sleeve gastrectomy could be completed after 50 cases. First 100 patients undergoing LSG under a newly trained laparoscopic surgeon were included in this study and divided into two groups of 50 consecutive patients each. Perioperative outcomes were compared to recently introduced global benchmarks. Short-term weight loss was calculated as Total Weight Loss Percent (%TWL) and complications were classified in accordance with the Clavien–Dindo classification. CUSUM analysis was performed for operative time and hospital stay. Mean preoperative age and BMI were 41.8 ± 10.3 years and 42.9 ± 5.4 kg/m2, respectively. Demographics and rate of patients with previous surgery were comparable preoperatively in the two groups. Mean operative time was 92.1 ± 19.3 min and hospital stay was 3.4 ± 0.6 days as per our standard protocol of discharge. Uneventful postoperative course was recorded in 93% of patients and only one case of staple line leak was registered in the first 50 cases (group 1). No statistical difference in BMI and %TWL was found between the two groups at any time of follow-up. Comparison between two groups showed a significant reduction in hospital stay and operative time after the first 50 LSGs (p . At least 50 cases are needed to meet global benchmark cut-offs and few more cases may be required to reach the plateau of the learning curve.

Purpose: Periumbilical hernias are a common finding in morbidly obese patients undergoing bariatric surgery; however, the timing of repair is still debated. The aim of this paper is to compare the outcomes of simultaneous versus delayed mesh repair of umbilical hernia in patients undergoing laparoscopic sleeve gastrectomy (LSG). Methods: We retrospectively compared 2 groups of morbidly obese patients with small/medium periumbilical hernia (up to 4 cm) in a casematched study: the first group underwent LSG with simultaneous periumbilical hernia repair; in the second, hernioplasty was performed after weight loss induced by LSG. Patients were matched at a 1:1 ratio according to age, comorbidities, defect size (

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its related disease, coronavirus disease 2019 (COVID-19), has been rapidly spreading all over the world and is responsible for the current pandemic. The current pandemic has found the Italian national health system unprepared to provide an appropriate and prompt response, heavily affecting surgical activities. Based on the limited data available in the literature and personal experiences, the Società Italiana di Chirurgia dell’OBesità e Malattie Metaboliche (SICOB) provides recommendations regarding the triage of bariatric surgical procedures during the COVID-19 pandemic defining a dedicated path for surgery in morbidly obese patients with known or suspected COVID-19 who may require emergency operations. Finally, the current paper delineates a strategy to resume outpatient visits and elective bariatric surgery once the acute phase of the pandemic is over. Models developed during the COVID-19 crisis should be integrated into hospital practices for future use in similar scenarios. Surgeons are presented with a golden opportunity to embrace systemic change and to drive their professional future.

Background: Bilio-intestinal bypass (BIBP) is an uncommon bariatric procedure. In 1999, a prospective trial was started at our institution to evaluate the effectiveness of BIBP. Trial was interrupted in 2006 due to high rate of complications. The aim of the present paper was to retrospectively review 10-year outcomes of BIBP. Methods: Retrospective review of bariatric database was performed to find patients that had undergone BIBP from 1999 to 2006. Data collected were as follows: age, gender, body weight, body mass index (BMI), percentage of excess weight loss (%EWL), remission from weight-related diseases, complications, and deaths at 1,3, 5, 7, and 10 years. Quality of life was evaluated using “BAROS” questionnaire. Results: From May 1999 to September 2006, 86 patients underwent BIBP. The mean age was 34.9 ± 22.4 years, and the initial weight and BMI were 141.2 ± 40.4 kg and 49.8 ± 15.5 kg/m 2 , respectively. After 10 years, the mean %EWL and BMI were 72.6 ± 18.7 and 31.2 ± 5.6 kg/m 2 . Almost all patients had diarrhea after surgery. Bloating syndrome occurred in 24% of patients, 48% had nephrolithiasis, and 20.9% had cholelithiasis. Remission from diabetes and hypertension was obtained in 75% and 80% of patients. Mortality was 3.2% and reoperation rate was 14.5%. Conclusions: Malabsorption plays a determinant role to obtain a long-lasting treatment for obese patients. However, BIBP is not recommendable due to high rate of complications and metabolic disorders.

Introduction: Bariatric surgery is considered the most effective treatment for obesity. A recent worldwide survey demonstrated that Laparoscopic Sleeve Gastrectomy (LSG) is the most commonly performed bariatric procedure, while Laparoscopic Adjustable Gastric Banding (LAGB) has been almost abandoned. Objectives: The aim of this retrospective study was to compare 5-year results of LSG and LAGB at our Institution. Materials and Methods: Prospective maintained database of our Institution was reviewed to find all patients who had undergone LSG between January 2009 and December 2011. Inclusion criteria were BMI of 40–50 kg/m2 and age of 18–60 years old. Patients with Class I and II obesity, superobese subjects, and patients with previous history of bariatric surgery were excluded. Data on sex, age, pre-operative BMI, obesity-related diseases (diabetes, hypertension, dyslipidemia), and early and late complications were collected. Each subject who underwent LSG was matched one-to-one with a patient that had undergone LAGB. Outcomes were analyzed at 1, 3, and 5 years of follow-up. Results: A total number of 122 patients were included in this study, 61 in each group. Better %EWL was observed in the LSG group at 1, 3, and 5 years. Both procedures induced improvements of obesity-related diseases without significant difference. In the LAGB group, ten patients underwent uneventful band removal. In the LSG group, two patients had serious postoperative complications. Conclusion: LSG achieves better %EWL than LAGB within 5 years, but comorbidities improvement is not significantly different. Severity of complication is higher after LSG. LAGB is still a good option for selected patients.

Background: Hiatal hernia (HH) is common in obese patients undergoing bariatric surgery. Preoperative traditional techniques such as upper gastrointestinal endoscopy (UGIE) or barium swallow/esophagram do not always correlate with intraoperative findings. High-resolution manometry (HRM) has shown a higher sensitivity and specificity than traditional techniques in non-obese patients in the HH diagnosis, whereas there is a lack of data in the morbidly obese population. We aimed to prospectively assess the diagnostic accuracy of HRM in HH detection, in comparison with barium swallow and UGIE, assuming intraoperative diagnosis as a standard of reference. Methods: Forty-one consecutive morbidly obese patients prospectively recruited from a tertiary-care referral hospital devoted to bariatric and metabolic surgery underwent a preoperative evaluation including standardized GERD questionnaires, barium swallow, UGIE, and HRM. The surgical procedures were performed by a single surgeon who was blinded to the results of other investigations. Results: HH was intraoperatively diagnosed in 11/41 patients (26.8%). In 10/11 patients, the preoperative HRM showed an esophagogastric junction suggestive of HH. When compared to intraoperative evaluation, the sensitivity of the HRM was 90.9% and the specificity 63.3%, with a positive predictive value of 47.6% and a negative predictive value of 95.0%. HRM showed a higher sensitivity and specificity compared to barium swallow and UGIE. Conclusions: HRM has a high accuracy of HH detection in morbidly obese patients assuming an intraoperative diagnosis as reference standard. It could therefore be a very useful tool in the preoperative work-up of obese patients undergoing bariatric surgery.

Bleeding after bariatric surgery may occur during the operation or immediately after as a consequence of vascular or parenchymal injury related to laparoscopy or of failure after hemostasis at the suture line or anastomosis. Although the occurrence of bleeding is rare, it represents a true emergency and needs immediate diagnostic and therapeutic measures. Bleeding into the gastrointestinal tract causing hematemesis and/or melena is better assessed by endoscopy, whereas intraperitoneal bleeding is diagnosed by computed tomography. The first goal of treatment is to make the patient stable, whereas removal of the cause of bleeding is performed by endoscopic or radiological procedures after the diagnostic phase. When the patient remains unstable, treatment must be promptly established. Remedial surgery is the last resource of treatment. Delayed bleeding is related to peptic ulcer development and usually resolves with pharmacological and endoscopic treatment.

BACKGROUND Abdominoplasty after massive weight loss is not a cosmetic procedure. The aim of this study was to compare three different techniques for postbariatric abdominoplasty. METHODS All postbariatric patients that have undergone abdominoplasty from January 2013 to December 2016 were included in the study. Patients were divided into 3 groups: subjects who underwent standard procedure were allocated ingroup A; those cases performed using a synthetic glue were assigned to group B; cases performed with an energy device were inserted in group C. Operative time, length of stay and complications were recorded. RESULTS Seventy-one abdominoplasties were performed in the selected period. Mean operative time was shorter (P

Background Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure, while laparoscopic adjustable gastric banding (LAGB) has been for a decade one of the most popular interventions for weight loss. After LSG and LAGB, some patients may require a second surgery due to weight regain or late complications. One anastomosis gastric bypass (OAGB) is a promising bariatric procedure, which provides effective long-term weight loss and has a favorable effect on type 2 diabetes. Objectives To retrospectively analyze data from 10 Italian centers on conversion from LAGB and LSG to OAGB. Setting High-volume centers for bariatric surgery. Methods Prospectively collected data from 10 high-volume centers were retrospectively reviewed. Body mass index (BMI), percentage of excess BMI loss, reasons for redo, remission from co-morbidities (hypertension, diabetes, gastroesophageal reflux, and dyslipidemia), and major complications were recorded. Results Three hundred patients were included in the study; 196 patients underwent conversion from LAGB to OAGB and 104 were converted from LSG. BMI was 45.1 ± 7 kg/m2 at the time of first intervention, 41.8 ± 6.3 kg/m2 at redo time, and 30.5 ± 5.5 kg/m2 at last follow-up appointment. Mean percentage of excess BMI loss was 13.2 ± 28.2 at conversion and 73.4 ± 27.5 after OAGB. Remission rates from hypertension, diabetes, gastroesophageal reflux, and dyslipidemia were 40%, 62.5%, 58.7% and 52%, respectively. Mean follow-up was 20.8 (range, 6–156) months and overall complications rate was 8.6%. Conclusion Our data show that OAGB is a safe and effective revisional procedure after failed restrictive bariatric surgery.

Introduction: The American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation of Surgery for Obesity (IFSO) have both stated that bariatric surgery (BS) should not be denied in Class I patients. However, lifestyle intervention (LI), such as diet plus gym programs, is still considered the preferred approach for subjects with a BMI ranging from 30 to 35 kg/m2. The aim of this study was to retrospectively compare results of LI and BS in patients in Class I obesity. Methods: Retrospective analysis of prospective maintained databases of two centers for the “Interdisciplinary Treatment of Obesity” was performed. All patients in Class I obesity and follow-up >7 years were included in the study. Subjects were divided into two groups: BS group that included patients who had undergone surgery and LI group that included patients who underwent lifestyle intervention (LI). Percentage of excess body mass index loss (ëMIL) and comorbidities remission were recorded. Results: Seventy-six patients were included in the study. Fifty-six subjects were submitted to surgery (BS group); 20 subjects were treated with nonsurgical approach (LI group). In BS group, 34 underwent laparoscopic adjustable gastric band, 13 laparoscopic sleeve gastrectomy (LSG), and 9 laparoscopic Roux-en-Y gastric bypass. EWL% resulted significantly higher in BS group at 1, 3, 5, 7 and 10 years (p < 0.01). Conclusion: Bariatric surgery is more effective than LI for patients in Class I obesity. Due to its versatility, low-risk profile and high-effectiveness LSG could be the standard intervention for these patients.

In the normal population, peptic disease is mainly caused by Helicobacter pylori infection and nonsteroidal anti-inflammatory drugs (NSAIDs); after bariatric surgery peptic ulcers (PUs) are generally due to ischemia, foreign bodies or hyperacidity caused by the anatomical rearrangement. Despite this difference, treatment of post-bariatric PUs does not differ from common peptic disease with medical therapy as the treatment of choice. Endoscopy is necessary for diagnosis and can be used for the treatment of bleedings. Surgery is nowadays indicated only in the emergency setting, or for recurrent or intractable ulcers.

Background The gold standard approach for surgical treatment of benign and malignant adrenal lesion is considered the laparoscopic one, due to a lot of advantages compared to open approach. The rapid propagation of this surgical technique is due to the diffusion of haemostatic devices in laparoscopic adrenal surgery. The principal aim of this study is to analyze the outcome of LA using each energy modality, evaluating the eventual superiority of an instrument over the others. Methods A retrospective study, involving 75 consecutive patients submitted to LA by transperitoneal lateral approach from January 2013 to June 2017, was performed. Age less than 70 years old, adrenal adenomas less than 8 cm in diameter, incidentalomas 0.05). Significant statistical difference are detectable in operation time and intraoperative blood losses. Thunderbeat, compared respectively with Ligasure and Harmonic Scalpel, is the fastest device (p

Background. New laparoscopic devices, such as electrothermal bipolar-activated devices (LigaSure™ (LS)) or ultrasonic systems (Harmonic® scalpel (HS)), have been applied recently to bariatric surgery allowing to reduce blood loss and surgical risks. The aim of this study was to retrospectively compare intraoperative performance of HS and LS, postoperative results, and clinical outcomes in a large cohort of patients undergoing LSG. Methods. Data from 422 morbidly obese patients undergoing LSG in our Bariatric Unit at the Advanced Biomedical Sciences Department of the “Federico II” University of Naples (Italy) between January 2009 and December 2017 were retrospectively analyzed. Subjects were divided into two groups (HS and LS), and operative time, intraoperative complications, and postoperative (within 30 days from surgery) complications were compared. Bleeding from the omentum or from the staple line, use of hemostatic clips, and absorbable hemostat were recorded as intraoperative complications; hemorrhages, abscess formation, gastric leaks, fever, and mortality were considered as postoperative complications. Results. Statistical analysis showed no difference in terms of baseline demographics between the two cohorts. Operative time (48 ± 9 vs 49 ± 6 min, p=0.646) and the rates of intraoperative and postoperative complications did not significantly differ between groups. Conclusion. Harmonic® and LigaSure™ are both useful tools in bariatric surgery, and these two advanced power devices are user-friendly and can facilitate surgeon work; from this point of view, the choice of the energy device should be based on the preference of the surgeon and on the hospital costs policy and availability.

Background and aim The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), being a Federation of 62 national societies, is the ideal network to monitor the number and type of procedures at a global level. The IFSO survey, enriched with a special section on revisional procedures, aims to report the number and types of bariatric procedures performed worldwide in 2016 and analyzes the surgical trends from 2008 to 2016. Methods The 2016 IFSO Survey form was emailed to all IFSO societies. Each Society was requested to indicate the number and type of bariatric procedures performed in the country. Trend analyses from 2008 to 2016 were also performed. Results The total number of bariatric/metabolic procedures performed in 2016 was 685,874; 634,897 (92.6%) of which were primary and 50,977 were revisional (7.4%). Among the primary interventions, 609,897 (96%) were surgical and 25,359 (4%) were endoluminal. The most performed primary surgical bariatric/metabolic procedure was sleeve gastrectomy (SG) (N = 340,550; 53.6%), followed by Roux-en-Y gastric bypass (N = 191,326; 30.1%), and one-anastomosis gastric bypass (N = 30,563; 4.8%). Conclusions In 2016, there was an increase in the total number both of surgical and endoluminal bariatric/metabolic procedures. Revisional procedures represent about 7% of the total bariatric interventions. SG remains the most performed surgical procedure in the world.