The Trajectory of Revisional Bariatric Surgery: Open to Laparoscopic to Robotic.

Metabolic and bariatric surgery (MBS) is the most effective therapeutic intervention for patients with obesity, with sleeve gastrectomy (SG) being the most commonly performed primary MBS procedure. Long-term studies have demonstrated that 15-20% of patients require revisional bariatric surgery (RBS) due to weight-related issues or surgical complications. Despite the gold standard being laparoscopic revision, there are other available approaches such as open or robotic-assisted. An extensive literature review was performed for articles from their inception to February 2024. A descriptive review of MBS procedures (SG, Roux-en-Y gastric bypass (RYGB), single anastomosis duodeno-ileostomy (SADI) and biliopancreatic diversion-duodenal switch (BPD-DS)) was carried out to report and compare outcomes between primary and revisional bariatric surgery. A similar review was conducted to compare outcomes of revisional approaches (open, laparoscopic, robotic). RYGB remains the dominant RBS with a similar safety profile compared to revisional SADI and BPD-DS. In terms of the RBS surgical approach, all three options showed comparable short and long-term outcomes, with robotic RBS being associated with longer operative time and variable length of stay. Additional long-term studies are required to further validate our conclusions.

Gastrointestinal histoplasmosis with small intestinal perforation: 20-year experience.

Postmortem studies show gastrointestinal tract involvement in as many as 70% of patients affected by disseminated histoplasmosis. Although gastrointestinal involvement is common in disseminated disease, the presentation of small intestinal perforation is exceedingly rare with few reported cases in the literature. Herein we present our institutional case series. The aim of the study is to describe small intestinal perforation in gastrointestinal histoplasmosis with attention to management and outcomes. This is a retrospective single-institution review of patients ≥ 18 years of age treated for small intestinal perforation due to gastrointestinal histoplasmosis. A prospectively maintained institutional database was searched from 2002 to 2022. Data obtained included demographics, comorbidities, treatment course, and outcomes. Five patients with a mean age of 54 years (range 25-72) were identified. Pertinent underlying comorbid conditions included Crohn's disease, psoriatic arthritis, rheumatoid arthritis, and solid organ transplantation. All patients were on chronic immunosuppressive medication(s) with the most common being tumor necrosis factors alpha inhibitors and corticosteroids. Four had a clinical diagnosis of perforation based on physical examination and imaging. All patients underwent segmental resection(s) of the small intestine and received medical treatment with intravenous amphotericin B and eventual transition to an oral antifungal. No patients experienced complications related to surgery. The limitations of the study include nonrandomized retrospective review, single-institution experience, and small patient sample size. Although rare, histoplasmosis should be considered in the differential of patients on chronic immunosuppressive therapy who present with gastrointestinal symptoms concerning perforation, especially from endemic areas. Small intestinal perforation due to gastrointestinal histoplasmosis can be successfully treated with resection and antifungal therapy.

Preoperative duration of type 2 diabetes mellitus and remission after Roux-en-Y gastric bypass: A single center long-term cohort study.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) has demonstrated excellent glycemic control and type 2 diabetes mellitus (T2DM) remission for patients with obesity and T2DM. Duration of T2DM is a consistent negative predictor of remission after RYGB. However, the exact timing to offer surgical intervention during the course of the disease is not well elucidated. MATERIAL AND METHODS: We performed a retrospective cohort study between 2008-2020 to establish the exact association between duration of T2DM and remission after RYGB. We divided our cohort into quartiles of preoperative disease duration to quantify the change in remission rates for each year of delay between T2DM diagnosis and RYGB. We also compared the average time to remission and changes in glycemic control parameters. RESULTS: A total of 519 patients (67.2% female; age 53.4±10.7 y; BMI 46.6±8.4 kg/m2) with a follow-up period of 6.6±3.8 years were included. Remission was demonstrated in 51% of patients. Longer duration of T2DM was a significant negative predictor of remission with an estimated decrease in remission rates of 7% for each year of delay ([OR=0.931 (95% CI 0.892-0.971)]; P<0.001). Compared to patients with <3 years of T2DM, remission decreased by 37% for patients with 3-6 years, 64% for those with 7-12 years and 81% for patients with more than 12 years (P<0.001). Half of the patients reached T2DM remission after 0.5 and 1.1 years respectively for the first and second quartiles, while patients in the other quartiles never reached 50% remission. Lastly, we noted an overall improvement in all glycemic control parameters for all quartiles at last follow-up. CONCLUSION: Patients with a recent history of T2DM who undergo early RYGB experience significantly higher and earlier T2DM remission compared to patients with a prolonged history of preoperative T2DM, suggesting potential benefit of early surgical intervention to manage patients with obesity and T2DM.

A Case of Hepatitis B Virus Reactivation Triggered by Acute Epstein-Barr Virus Infection.

Reactivation ofHepatitis B virus (HBV) is not an uncommon condition. It is known to occur with immunosuppressive therapy. There are several viral infections that can trigger HBV reactivation, such as human immunodeficiency virus (HIV) infection. However, there is no reported case of HBV reactivation triggered by Epstein-Barr virus (EBV) infection in the literature. To our knowledge, we report the first case of reactivation of HBV secondary to acute Epstein-Barr virus (EBV) infection in the literature. A 47-year-old Caucasian male with a remote history of resolved acute Hepatitis B virus infection presented to our hospital with severe acute hepatitis, which manifested as epigastric pain, jaundice, dark urine, light-colored stools, hyperbilirubinemia, and transaminitis in the 1000s. Ultimately, the patient was diagnosed with reactivation of HBV triggered by acute EBV infection. After several days of supportive treatment, his hepatic function normalized. He was discharged with a scheduled follow-up at a hepatology clinic. In conclusion, EBV infection should be suspected as a trigger in cases with HBV reactivation, particularly when common etiologies are excluded.