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Data regarding the use of 1-anastomosis gastric bypass (OAGB) as a conversion technique after laparoscopic adjustable gastric banding (LAGB) failure is scarce in the literature.The aim of this study was to assess our experience with OAGB as a rescue procedure after failed LAGB.This study involved patients treated at a private hospital in France.This single-center retrospective study included all consecutive patients receiving OAGB from January 2005 to January 2016. Of the 3,224 patients, 63.5% received primary OAGB (pOAGB) and 36.5% received OAGB as a conversion procedure after LAGB (cOAGB).During the period considered, 2,046 patients with obesity received pOAGB, whereas 1,000 patients underwent conversion of LAGB to OAGB in 1 step. The rate of patients lost to follow-up at 5 years was 31% in the pOAGB group and 32.5% in the cOAGB group (P = .4). Five years after the surgery, the mean body mass index was 30.8 ± 10.2 kg/mIn this study, OAGB was effective and safe as a rescue technique after LAGB failure. Conversion in one step did not appear to increase the risk of early complications, whereas a history of gastric banding seems to increase the risk of bile reflux in the long term.

Introduction: The realization of an antireflux valve according to the Nissen technique during the operation of one-anastomosis gastric bypass (OAGB) may theoretically decrease the incidence of postoperative reflux in patients with hiatal hernia (HH). Material and Methods: In this retrospective study, we included all patients operated on between January 2015 and January 2019 for an OAGB associated with the creation of an antireflux Nissen valve (360-degree wrap). The patients included had type II or type III HH that had been diagnosed preoperatively or discovered intraoperatively. Results: Twenty-two patients were operated on during the period considered. The mean preoperative BMI was 40 ± 14 kg/m2. Five patients (22.7%) had a history of bariatric surgery. Typical symptoms of gastroesophageal reflux disease (GERD) were preoperatively present in four patients (18%), and HH was revealed preoperatively only in four patients; for all the other patients, the diagnosis of HH was made intraoperatively. The rate of early and/or late postoperative complications was 0%. The mean duration of follow-up was 23 ± 15 months. No dysphagia was reported during follow-up. Three patients presented with symptomatic GERD postoperatively, including one de novo. Mean BMI at the end of follow-up was 24 ± 3 kg/m2, and the % of total weight loss was 108 ± 30%. Conclusions: OAGB with a Nissen antireflux valve seems to be a safe and effective surgical technique and it could be an extra arrow in the surgeon’s quiver in the presence of HH in a patient scheduled for OAGB.

Background The main side effect of long-term laparoscopic sleeve gastrectomy is the onset of severe gastroesophageal reflux disease (GERD). Objectives The aim of this study was to evaluate the effectiveness of gastric bypass conversion in controlling postsleeve GERD. Setting University Hospital and Private Hospital, France and Private Hospital, Italy. Methods This retrospective multicenter study included patients who underwent laparoscopic sleeve gastrectomy and suffered from postoperative GERD, who did not respond to medical treatment and were converted to laparoscopic Roux-en-Y gastric bypass. The study involved 2 French university hospitals, 4 French private centers, and an Italian public hospital. Results A total of 80 patients were reviewed. Treatment of a hiatal hernia was performed during laparoscopic sleeve gastrectomy in 3 patients, while 19 patients were operated for hiatal hernia during conversion to bypass (P = .0004). Six months after surgery, 23 of 80 patients maintained reflux symptomatology with a daily frequency, for which continued proton pump inhibitor treatment was required. The persistence of GERD was significantly more frequent among patients with previous gastric banding (n = 19) compared with patients with no history of gastric banding (n = 4, P = .02). In other words, the likelihood of having poor clinical success from conversion of the sleeve to bypass because of intractable GERD was 3 times higher if the patient had a history of gastric banding (relative risk = 2.89, odds ratio = 3.69). Conclusion The results of this study show that, despite the conversion, the symptomatology of GERD does not always disappear, especially in patients with previous gastric banding.

Over the course of diet-induced obesity (DIO), adipose tissue macrophage (ATM) populations transition from highly oxidative and protective to highly inflammatory and metabolically deleterious. Here, we demonstrate that the Interferon Regulatory Factor (IRF)-5 is a key molecular switch mediating repression of macrophage oxidative capacity early in DIO. ATMs from mice with a myeloid-specific deletion of IRF5 are characterised by increased mitochondrial activity and oxidative respiration compared to ATMs from wild-type mice. This hyper-oxidative phenotype is inducible and reversible in vitro by delivery of an inhibitory IRF5-decoy peptide and through IRF5 adenoviral over-expression, respectively. In a data-driven approach, using public IRF5-cistrome data and in-house RNA-sequencing, we identified a transcriptional mechanism by which cellular oxidative capacity is repressed in an IRF5-dependent manner. The hyper-oxidative phenotype of IRF5-deficient macrophages is mediated by the Growth Hormone Inducible Transmembrane Protein (GHITM), known for maintaining mitochondrial architecture for optimal oxidative respiration. Cas9-mediated simultaneous knock-down of GHITM and of IRF5 reverses the hyper-oxidative phenotype associated with IRF5-deficiency in vitro. IRF5-dependent regulation of GHITM expression and mitochondrial activity extends to human ATMs and monocytes from obese and diabetic patients.

The purpose of this study was to evaluate the efficacy and safety of the OAGB at least 10 years after surgery. We retrospectively reviewed our prospectively collected data on consecutive morbid patients with obesity receiving OAGB from January 2005 to December 2007. A total of 385 patients met the inclusion criteria. The mean follow-up was 149 months. Of all patients, 52% underwent OAGB as a primary procedure and 48% as a revisional procedure. At the 10-year follow-up, the mean body mass index (BMI) was 30.7 ± 11.8, the mean %TWL was 33.4 ± 10.6, and the mean %EWL was 64.1 ± 24.6. We did not find a significant statistical difference in terms of weight loss between primary OAGB and secondary OAGB. In total, 43% of patients achieved a %EWL greater than 75%, while 29% of the patients had an EWL% that was below 50%. All of the comorbidities related to obesity showed a high improvement or fully resolved. Early complications occurred in 9 patients (2.3%), while the overall rate of late complications was 17.1%. Nineteen patients (4.9%) developed an ulcer at the gastrojejunal anastomosis level, nine patients (2.3%) were re-hospitalized for major malnutrition, thirty-eight patients (9.8%) showed a postoperative biliary reflux, and five patients (2.7%) experienced severe anemia, which required several hospitalizations for iron I.V. supplementation. According to results of the present study, we believe that OAGB has shown to be a technique with a reasonable balance between long-term efficacy and undesirable sequelae.

Background Endoscopy plays a pivotal role in the management of adverse events (AE) following bariatric surgery. Leaks, fistulae, and post-operative collection after sleeve gastrectomy (SG) may occur in up to 10% of cases. Objectives To evaluate the efficacy and safety of endoscopic internal drainage (EID) for the management of leak, fistula, and collection following SG. Setting Retrospective, observational, single center study on patients referred from several bariatric surgery departments to an endoscopic referral center. Methods EID was used as first-line treatment for the management of leaks, fistulae, and collections. Leaks and fistulae were treated with double pigtail stent (DPS) deployment in order to guarantee internal drainage and second intention cavity obliteration. Collections were treated with endoscropic ultrasound (EUS)–guided deployment of DPS or lumen apposing metal stents. Results A total of 617 patients (83.3% female; mean age, 43.1 yr) were enrolled in the study for leak (n = 300, 48.6%), fistula (n = 285, 46.2%), and collection (n = 32, 5.2%). Median follow-up was 19.5 months. Overall clinical success was 84.7% whereas 15.3% of cases required revisional surgery after EID failure. Clinical success according to type of AE was 89.5%, 78.5%, and 90% for leak, fistula, and collection, respectively. A total of 10 of 547 (1.8%) presented a recurrence during follow-up. A total of 28 (4.5%) AE related to the endoscopic treatment occurred. At univariate logistic regression predictors of failure were: fistula (OR 2.012), combined endoscopic approach (OR 2.319), need for emergency surgery (OR 1.755), and previous endoscopic treatment (OR 4.818). Conclusion Early EID for the management of leak, fistula, and post-operative collection after SG seems a safe and effective first-line approach with good long-term results.

Introduction: Achalasia after bariatric surgery is a rare pathological entity. Nonetheless, several cases have been described in literature. Per oral endoscopic myotomy has recently emerged as the preferred approach for the management of esophageal motility disorders. Material and Methods: We report a video case of POEM performed in a female patient with prior multiple bariatric surgical procedures. In her past medical history, she underwent to laparoscopic lap band, sleeve gastrectomy, and Roux-Y-gastric bypass. Results: POEM was carried out without complication. Myotomy was performed only for 1 cm below the cardias due to the presence of the gastro-jejunal anastomosis. Post-operative course was uneventful and oral diet was restarted after one day. At 2 months follow-up, the patient is asymptomatic with no weight regain. Conclusion: We report the first case of POEM after three different bariatric surgical procedure. Fibrosis due to prior interventions did not hampered POEM procedure, and the shorter myotomy due to the presence of small gastric pouch did not reduced its efficacy.

The deep inferior epigastric perforator (DIEP) flap is a workhorse of breast reconstruction. Risks of herniation derive from violation of the rectus abdominis muscle anterior rectus sheath and might be reduced by minimally invasive laparoscopic dissection ("MILD") of the deep inferior epigastric vessels. The authors performed a feasibility study on five anatomical subjects and performed a secondary right breast reconstruction on a 67-year-old woman. A 30-degree laparoscope was used with laparoscopy ports inset to preserve the flap. Blunt preperitoneal dissection followed by carbon dioxide insufflation allowed the deep inferior epigastric pedicle to be dissected and clip-sectioned. The anterior rectus sheath was opened around the perforating vessels, and the flap was anastomosed on the internal mammary vessels. The length of incision in the anterior rectus sheath was compared between laparoscopic and conventional approaches. The mean incision length in the anterior rectus sheath was 3 cm versus 12 cm in the classic approach. Average duration of laparoscopic flap harvest was 50 minutes, including a mean of 30 minutes for deep inferior epigastric dissection. Adhesions led to a 1-cm peritoneal laceration in our first anatomical subject. There were no preoperative or postoperative complications in the clinical case. The clinical procedure duration was 8 hours 15 minutes, with the anterior rectus sheath incision reduced from the conventional 12 cm to 5 cm. Flap ischemia lasted 50 minutes. The patient was discharged on postoperative day 5. This anatomical study and first successful laparoscope-assisted DIEP flap harvest prove that reduced trauma to the anterior rectus sheath is feasible and promising.

Emerging evidence indicates that a dynamic interplay between the immune system and adipocytes contributes to the disturbed homeostasis in adipose tissue of obese subjects. Recently, we observed IL-6-secretion by CD4+ T cells from the stromal vascular fraction (SVF) of the infrapatellar fat pad (IFP) of knee osteoarthritis patients directly ex vivo. Here we show that human IL-6+ CD4+ T cells from SVF display a more activated phenotype than the IL-6- T cells, as evidenced by the expression of the activation marker CD69. Analysis of cytokines secretion, as well as expression of chemokine receptors and transcription factors associated with different Th subsets (Treg, Th1, Th2, Th17 and Tfh) revealed that IL-6-secreting CD4+ T cells cannot be assigned to a conventional Th subset. TCRβ gene analysis revealed that IL-6+ and IL-6- CD4+ T cells appear clonally unrelated to each other, suggesting a different specificity of these cells. In line with these observations, adipocytes are capable of enhancing IL-6 production by CD4+ T cells. Thus, IL-6+ CD4+ T cells are TCRαβ T cells expressing an activated phenotype potentially resulting from an interplay with adipocytes that could be involved in the inflammatory processes in the OA joint. This article is protected by copyright. All rights reserved

Emerging evidence indicates that a dynamic interplay between the immune system and adipocytes contributes to the disturbed homeostasis in adipose tissue of obese subjects. Recently, we observed IL‐6‐secretion by CD4+ T cells from the stromal vascular fraction (SVF) of the infrapatellar fat pad (IFP) of knee osteoarthritis patients directly ex vivo. Here we show that human IL‐6+CD4+ T cells from SVF display a more activated phenotype than the IL‐6− T cells, as evidenced by the expression of the activation marker CD69. Analysis of cytokines secretion, as well as expression of chemokine receptors and transcription factors associated with different Th subsets (Treg, Th1, Th2, Th17 and Tfh) revealed that IL‐6‐secreting CD4+ T cells cannot be assigned to a conventional Th subset. TCRβ gene analysis revealed that IL‐6+ and IL‐6−CD4+ T cells appear clonally unrelated to each other, suggesting a different specificity of these cells. In line with these observations, adipocytes are capable of enhancing IL‐6 production by CD4+ T cells. Thus, IL‐6+CD4+ T cells are TCRαβ T cells expressing an activated phenotype potentially resulting from an interplay with adipocytes that could be involved in the inflammatory processes in the OA joint.

Malnutrition after mini-gastric bypass (MGB) is a rare and dreaded complication with few data available regarding its surgical management. We aim to report the feasibility, safety, and results of laparoscopic reversal of MGB to normal anatomy (RMGB) in case of severe and refractory malnutrition syndrome after intensive nutritional support (SRMS). A 10-year retrospective chart review was performed on patients who underwent RMGB (video included) for SRMS following MGB. Twenty-six of 2934 patients underwent a RMGB at a mean delay of 20.9 ± 13.4 months post-MGB. At presentation, mean body mass index (BMI), excess weight loss (%EWL), and albumin serum level were 22 ± 4.4 kg/m2, 103.6 ± 22.5%, and 25.5 ± 3.6 gr/L, respectively. Seventeen (63.5%) patients had at least one severe malnutrition related complication including severe edema in 13 (50%), venous ulcers in 2 (7.7%), infectious complications in 7 (27%), deep venous thrombosis in 5 (19.2%), and motor deficit in 5 (19.2%) patients. At surgical exploration, 8 of 12 (66.5%) patients had a biliary limb longer than 200 cm and 9 (34.6%) had bile reflux symptoms. Overall morbidity was 30.8% but lower when resecting the entire previous gastrojejunostomy with creation of a new jejunojejunostomy (8.3 vs 50%, p = 0.03). After a mean follow-up of 8 ± 9.7 months, all patients experienced a complete clinical and biological regression of the SRMS after the RMGB despite a mean 13.9 kg weight regain in 16 (61.5%) patients. Post-MGB SRMS and its related comorbidities are rare but dreaded conditions. Although burdened by a significant postoperative morbidity and weight regain, RMGB remains an effective option to consider, when intensive nutritional support fails.

International audience; Humans with obesity differ in their susceptibility to developing insulin resistance and type 2 diabetes (T2D). This variation may relate to the extent of adipose tissue (AT) inflammation that develops as their obesity progresses. The state of macrophage activation has a central role in determining the degree of AT inflammation and thus its dysfunction, and these states are driven by epigenomic alterations linked to gene expression. The underlying mechanisms that regulate these alterations, however, are poorly defined. Here we demonstrate that a co-repressor complex containing G protein pathway suppressor 2 (GPS2) crucially controls the macrophage epigenome during activation by metabolic stress. The study of AT from humans with and without obesity revealed correlations between reduced GPS2 expression in macrophages, elevated systemic and AT inflammation, and diabetic status. The causality of this relationship was confirmed by using macrophage-specific Gps2-knockout (KO) mice, in which inappropriate co-repressor complex function caused enhancer activation, pro-inflammatory gene expression and hypersensitivity toward metabolic-stress signals. By contrast, transplantation of GPS2-overexpressing bone marrow into two mouse models of obesity (ob/ob and diet-induced obesity) reduced inflammation and improved insulin sensitivity. Thus, our data reveal a potentially reversible disease mechanism that links co-repressor-dependent epigenomic alterations in macrophages to AT inflammation and the development of T2D.

Laparoscopy is a valuable approach to primary ileocecal resection for ileocolonic Crohn's disease (CD). This study aimed to evaluate the feasibility of using laparoscopy for reoperation in the case of ileocolonic CD recurrence and to determine the risk factors and consequences of conversion for these patients.From 1998 to 2008, 57 patients underwent 62 reoperations for CD recurrence. Of these 62 reoperations, 29 were laparoscopic procedures (laparoscopy group [LG]). Preoperative and intraoperative characteristics and postoperative outcome were compared with those for 33 open procedures (open group [OG]).The preoperative characteristics were similar in the two groups. The number of intraoperative intestinal injuries was higher in the LG group (n = 5) than in the OG group (n = 0) (p = 0.01). The use of a temporary stoma (7/29 vs. 6/33; nonsignificant difference [NS]) and the mean operating time (215 + or - 70 vs. 226 + or - 107 min, NS) were similar in the two groups. The postoperative mortality was nil in both groups. The overall morbidity rate was 38% (11/29) in LG and 30% (10/33) in OG (NS). Severe complications (DINDOor = 3) occurred for three of the 29 patients in LG (10%) compared with five of 33 patients in OG (15%) (NS). The median hospital stay was 9 days in both groups. The conversion rate was 31% (9/29). Univariate analysis showed that the risk factors for conversion were fistulizing disease (p = 0.02) and intraoperative intestinal injury (p0.001). The morbidity rate was not increased by the need for a conversion (7/20 for the nonconverted vs. 4/9 for the converted patients, NS).Laparoscopy for ileocolonic CD recurrence is challenging and complex. The morbidity rate was similar to that for the open approach, and the risk of small bowel injury associated with laparoscopy could possibly induce postoperative septic complications. However, the authors believe that laparoscopy can be recommended for selected patients with CD recurrence, especially patients with nonfistulizing disease.

Few data exist about the characteristics and management of enteric leaks after mini-gastric bypass (MGB).We aimed to describe the incidence, presentation, and surgical management of enteric leaks in patients who underwent laparoscopic MGB for morbid obesity.Private practice.An 8-year, 9-month retrospective chart review was performed on patients who had enteric leak requiring reoperation after MGB at a single institution.Thirty-five of 2321 patients were included. Ninety-seven percent had symptoms. Arterial hypertension and heavy smoking were predicting factors of leaks occurrence post-MGB (P.01). Enteric leak was diagnosed by systematic upper gastrointestinal series in 4 pts (11.4%) and by computed tomography with oral water soluble contrast in 4 of 31 pts (13%). In the other 27 patients, diagnosis of the leak was made intraoperatively. Eleven patients (32%) had leak arising from the gastric stapler line (type 1), 4 (11%) from the gastrojejunal anastomosis (type 2), and 20 (57%) from undetermined origin. The most common presentation was intra-abdominal abscess in type 1 and leaks of undetermined origin and generalized peritonitis in type 2. One third of the patients who underwent reoperation developed well-drained chronic fistula into the irrigation-drainage system, with complete healing in all patients without any further procedure. The mean hospital stay was 19 days with no mortality reported.Enteric leak leading to intra-abdominal sepsis post-MGB is rare (1.5%) An operative aggressive management based on clinical symptoms is the treatment of choice allowing no postoperative leak-related mortality and complete healing.