One-Stage Vs. Two-Step One Anastomosis Duodenal Switch (OADS/SADI-S): A Safety and Efficacy Single-Center Propensity-Score Matched Analysis.

INTRODUCTION: One Anastomosis Duodenal Switch (OADS/SADI-S) is used both as a one stage and a second-step procedure, either planned or revisional after a failed sleeve gastrectomy. However, there is lack of adjusted comparative evidence validating its use. MATERIAL AND METHODS: Propensity-score matched comparison between patients submitted to one-stage vs. two-step OADS, adjusted by age, gender, and initial body mass index (BMI). RESULTS: One hundred ninety-five patients (130 one-stage and 65 two-step OADS) were included, with mean initial BMI 52.4 kg/m2. Overall complication rate was 6.6% in the short-term (3.3% Clavien-Dindo ≥ III), and 7.3% in the long-term, with no differences between groups. Follow-up at 1 and 3 years was 83.6% and 61.5%. After one-stage OADS, total weight loss was 36.6 ± 8.2% at 1 year and 30.4 ± 10.3% at 3 years, vs. 30.2 ± 9.4% and 25.6 ± 10.2% after two-steps OADS (p = 0.021). Resolution rates of diabetes mellitus, hypertension, dyslipidemia, and obstructive sleep apnea were 86.4%, 80.4%, 78.0%, and 73.3%, with no differences between groups. CONCLUSION: One-stage OADS is a safe and effective bariatric technique for patients with grade III and IV obesity. The two-step strategy does not reduce postoperative risks and may compromise weight loss results at mid-term.

A specific gut microbiota signature is associated with an enhanced GLP-1 and GLP-2 secretion and improved metabolic control in patients with type 2 diabetes after metabolic Roux-en-Y gastric bypass.

Objective: To determine changes in incretins, systemic inflammation, intestinal permeability and microbiome modifications 12 months after metabolic RYGB (mRYGB) in patients with type 2 diabetes (T2D) and their relationship with metabolic improvement. Materials and methods: Prospective single-center non-randomized controlled study, including patients with class II-III obesity and T2D undergoing mRYGB. At baseline and one year after surgery we performed body composition measurements, biochemical analysis, a meal tolerance test (MTT) and lipid test (LT) with determination of the area under the curve (AUC) for insulin, C-peptide, GLP-1, GLP-2, and fasting determinations of succinate, zonulin, IL-6 and study of gut microbiota. Results: Thirteen patients aged 52.6 ± 6.5 years, BMI 39.3 ± 1.4 kg/m2, HbA1c 7.62 ± 1.5% were evaluated. After mRYGB, zonulin decreased and an increase in AUC after MTT was observed for GLP-1 (pre 9371 ± 5973 vs post 15788 ± 8021 pM, P<0.05), GLP-2 (pre 732 ± 182 vs post 1190 ± 447 ng/ml, P<0.001) and C- peptide, as well as after LT. Species belonging to Streptococaceae, Akkermansiacea, Rickenellaceae, Sutterellaceae, Enterobacteriaceae, Oscillospiraceae, Veillonellaceae, Enterobacterales_uc, and Fusobacteriaceae families increased after intervention and correlated positively with AUC of GLP-1 and GLP-2, and negatively with glucose, HbA1c, triglycerides and adiposity markers. Clostridium perfringens and Roseburia sp. 40_7 behaved similarly. In contrast, some species belonging to Lachnospiraceae, Erysipelotricaceae, and Rumnicocaceae families decreased and showed opposite correlations. Higher initial C-peptide was the only predictor for T2D remission, which was achieved in 69% of patients. Conclusions: Patients with obesity and T2D submitted to mRYGB show an enhanced incretin response, a reduced gut permeability and a metabolic improvement, associated with a specific microbiota signature.

Patient-Reported Outcomes and Quality of Life After Single-Anastomosis Duodeno-ileal Bypass with Sleeve Gastrectomy (SADI-S): a Cross-Sectional Study with 283 Patients from a Single Institution.

INTRODUCTION: Single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is a safe and effective technique with good short- and mid-term weight control and associated medical problems remission for patients with a body mass index (BMI) > 45 kg/m2. The aim of this study was to analyze patient-reported symptoms, specifically symptomatic gastroesophageal reflux disease symptoms (GERD), depositional habit, and quality of life (QOL) following SADI-S, using telemedicine and validated tests. METHODS: A prospective unicentric cross-sectional study was conducted including all patients submitted to SADI-S in the University Hospital of Bellvitge from May 2014 to September 2019. A baseline control group was composed of 67 patients who were planning to undergo SADI-S in the following 4 months. Patients were divided into four groups: pre-SADIS, < 2 years, 2-3 years, and > 3 years after surgery. The information gathered via a telematic questionnaire was analyzed and compared with its presence in patients' clinical history derived from the last presential visit. RESULTS: The response rate to telematic tests was 86.9%. The mean BMI exhibited significant differences depending on the moment of evaluation: 50.8 kg/m2, 30.0 kg/m2, 31.1 kg/m2, and 32.7 kg/m2 at pre-SADIS, < 2, 2-3, and > 3 years follow-up, respectively (p < 0.001). The proportion of GERD symptoms increased over time (17.9%, 18.8%, 26.9%, and 30.2%, p = 0.320). After SADIS, the percentage of patients with loose stools was progressively higher (17.4% vs 25.4% vs 30.2%, p = 0.04). Patients with < 2-year follow-up presented an improvement in both physical component (PCS) and mental component (MCS) summaries compared to the baseline group (PCS = 51.3, and MCS = 49.4). The mean BMI of patients with PCS ≥ 50 was 31.9 kg/m2, compared with 41.7 kg/m2 in the PCS < 50 group (p < 0.001). In the MCS ≥ 50 group, there were more patients with a BMI < 35 kg/m2 than the MCS < 50 group (66.7% vs 48.7%, p = 0.004). Telematic follow-up offered a more systemic and detailed information: in the last presential visit only, 13.9% of patients had complete data regarding weight evolution, remission of associated medical problems, GERD symptoms, and depositional habit in comparison with the 82.9% of patients with telematic follow-up (p < 0.001). CONCLUSION: Weight control is the main factor related to long-term QOL after SADI-S. The incidence of GERD symptoms and diarrhea was up to 30% in patients with > 3-year follow-up. Monitoring postoperative patient-related symptoms with validated objective tests seems a feasible and useful resource for the long-term follow-up of patients submitted to SADI-S.

Duodenal Switch vs. Single-Anastomosis Duodenal Switch (SADI-S) for the Treatment of Grade IV Obesity: 5-Year Outcomes of a Multicenter Prospective Cohort Comparative Study.

PURPOSE: The aims were to compare the 5-year outcomes of duodenal switch (DS) and single-anastomosis duodenal switch (SADI-S) in terms of weight loss; remission of comorbidities; nutritional status short- and long-term complications; postoperative mortality; and need for revisional surgery. MATERIALS AND METHODS: Multicenter prospective observational study of all consecutive patients undergoing DS or SADI-S in three high-volume hospitals. RESULTS: A total of 87 patients were included in the study, 43 submitted to DS and 44 to SADI-S, with similar basal characteristics, nutritional parameters, and BMI (52.9 kg/m2 DS vs. 52.5 kg/m2 SADI-S). Operative time was 152 min (± 32.6) in DS vs. 116 min (± 21.9) in SADI-S (p = 0.043). Short-term complications were similar for DS and SADI-S, both overall (11.8% vs. 11.6%), and ranged as Clavien-Dindo > II (4.5% vs. 4.7%), with no mortality. At 5 years, DS and SADI-S results were as follows: BMI 30.6 vs. 33.3 kg/m2 (p = 0.023); %EWL 80.5% vs. 68.6% (p = 0.006); and %TWL 42.1 vs. 36.0 (p = 0.006). Comorbidity remission rates for DS and SADI-S were as follows: for diabetes, 92.8% vs. 85.7% (n.s.); for hypertension, 95.2% vs. 85.1% (n.s.); for sleep apnea, 75% vs. 73.3% (n.s.); and for dyslipidemia, 76.4% vs. 73.3% (n.s.). DS showed lower levels of vitamin B12, iron, vitamin E, and zinc than SADI-S (p = < 0.005). In the long term, there were 4 surgical reinterventions (due to 1 internal hernia in the DS group and 1 internal hernia and 2 biliary refluxes in the SADI-S group) with no cases of persistent diarrhea or malnutrition. CONCLUSION: Both DS and SADI-S allowed good weight control and resolution of comorbidities. DS achieved a greater weight loss compared to SADI-S, at the expense of longer operative time and lower vitamin and mineral levels.

Single- Versus Double-Anastomosis Duodenal Switch: Outcomes Stratified by Preoperative BMI.

PURPOSE: Describe and analyze the safety and weight loss performance of biliopancreatic diversion and duodenal switch (BPD-DS) and single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S), verifying any possible superiority according to preoperative BMI. METHODS: Retrospective review of patients who underwent primary SADI-S or BPD-DS in three bariatric centers. Study groups were further stratified according to preoperative BMI (subgroup 1: BMI < 50; subgroup 2: 50 ≤ BMI < 55; subgroup 3: BMI ≥ 55). RESULTS: Four hundred and sixty patients underwent BPD-DS (n = 220) or SADI-S (n = 240). The mean LOS was 3.48 ± 3.7 and 3.13 ± 2.3 days for BPD-DS and SADI-S respectively (p = 0.235). The mean operative time was shorter in the SADI-S group (167.25 ± 33.6 vs 140.85 ± 56.7 min) (p < 0.00). The mean %EWL was 44.2, 62.4, and 69.4 for the BPD-DS group and 48.4, 64.5, and 67.1 for the SADI-S group at 6, 12, and 24 months respectively. The mean %TBWL was 25, 35.9, and 40.3 for the BPD-DS group, and 26.2, 35, and 36.9 for the SADI-S group at 6, 12, and 24 months respectively. Overall complication rates were comparable between BPD-DS and SADI-S groups (14% vs 18%) (p = 0.219). SADI-S showed greater emergency department visits (17% vs 7%) (p = 0.005); similar readmission rates (6% vs 7%) (p = 0.80); similar reoperation rates (3% vs 7%) (p = 0.102); and similar mortality rate (0.9% vs 0.4%), after BPD-DS and SADI-S respectively. CONCLUSION: BPD-DS achieved greater %TBWL at 2 years, but no superiority was perceived among study subgroups. SADI-S and BPD-DS showed similar overall complication rates.

Intestinal Bipartition After Failed Sleeve Gastrectomy: a Safe and Simple Alternative Technique in a Challenging Case with Vascular Anomalies.

Sleeve gastrectomy (SG) is the most performed bariatric surgery worldwide but approximately 50% of patients will present insufficient weight loss or weight regain after surgery. In 2004, Santoro et al. described an alternative revisional technique other than DS and RYGBP called intestinal bipartition (IB). It involves a pre-pyloric gastro-ileal and an ileo-ileal anastomosis without exclusion of intestinal segments. Duodenal dissection is not necessary, making it an easier and more reproducible technical alternative to DS. its preliminary reports show good weight control with resolution of obesity related comorbidities. We present our technical suggestions to perform a safe IB in a patient with a failed SG in whom revisional DS or RYGBP were not feasible due to a vascular anomaly.

Combined endoscopic-laparoscopic surgery (CELS) can avoid segmental colectomy in endoscopically unremovable colonic polyps: a cohort study over 10 years.

BACKGROUND: Combined-Endoscopic-Laparoscopic-Surgery (CELS) was developed for benign colonic polyps, endoscopically unresectable, to avoid segmental colectomy. This observational study aims to compare surgical outcomes of endoscopically unresectable colonic polyps treated laparoscopically before and since the institutional introduction of CELS. Primary endpoint was postoperative morbidity and mortality; secondary endpoints were time of hospitalization and histopathological findings. METHODS: Charts of all patients with preoperative diagnosis of benign colonic tumors, treated laparoscopically at our institution from 1/2010 to 2/2020 were reviewed. Patients with polyps (1) affecting ileocecal valve, (2) occupying > 50% of the circumference, (3) ≥ 3 endoscopically unresectable polyps, (4) inflammatory bowel disease, (5) polyps within diverticular area post diverticulitis, (6) rectal polyps (7) foreseen impossibility of laparoscopy (8) preoperatively biopsy proven invasive adenocarcinoma were excluded. Group I consists of all patients potentially treatable by CELS but operated by laparoscopic colonic resection as CELS was not yet institutionally established. Group II includes all patients treated with CELS (since 11/2017). RESULTS: One hundred-fifteen consecutive patients were reviewed. Applying exclusion criteria, twenty-three patients form group I and twenty-three group II (female 30.4%, median age 68 years). Groups distributed homogenously for age, BMI (body mass index) and polyps´ localization with most polyps (60.4%) localized in right colon; group II patients had significantly higher American Society of Anesthesiologists (ASA) score. Median operating time, hospital stay and morbidity were significantly less in group II. Postoperative morbidity occurred overall in 14 patients (30.4%), mostly Clavien-Dindo class I-II (26.1%) and significantly less in group II (p = 0.017), Clavien-Dindo III-IV distributed equally (one patient each group) without postoperative mortality. Definitive histopathology showed invasive adenocarcinoma in 8.3% without differences between groups. Two patients with invasive adenocarcinoma after CELS were advised for oncological resection. CONCLUSION: CELS is safe and efficient to treat complex, benign colonic polyps by a complete minimal invasive laparoscopic approach. CELS showed better surgical outcomes with less morbidity, no mortality and appropriate pathological results avoiding unnecessary laparoscopic surgery with intestinal anastomosis.

Revisional Laparoscopic SADI-S vs. Duodenal Switch Following Failed Primary Sleeve Gastrectomy: a Single-Center Comparison of 101 Consecutive Cases.

BACKGROUND: Single-anastomosis duodeno-ileal bypass (SADI-S) is being proposed for obese patients with insufficient weight loss or weight regain after sleeve gastrectomy (SG), but limited information is available. The purpose of this study is to assess the safety and efficacy of SADI-S as a revisional surgery after SG, compared with standard duodenal switch (DS). METHODS: Unicentric cohort study including all patients submitted to SADI-S and DS after failed SG in a high-volume institution, between 2008 and 2020. RESULTS: Forty-six patients submitted to SADI-S and 55 to DS were included, 37.2 and 41.5 months after SG (p = 0.447), with initial BMI of 56.2 vs. 56.6 (p = 0.777) and 39.2 vs. 39.7 before revisional surgery (p = 0.675). All surgeries were laparoscopic. Clavien-Dindo > II complication rate was 6.5% for SADI-S and 10.9% for DS (p = 0.095), with no 90-day mortality. Follow-up at 2 years was available for 38 SADI-S' and 38 DS' patients, with total weight loss of 35.3% vs. 41.7% (p = 0.009), and excess weight loss 64.1% vs. 75.3% (p = 0.014). Comorbidities resolution for SADI-S and DS was: 44.4% vs. 76.9% for diabetes (p = 0.029) and 36.4% vs. 87.5% for hypertension (p = 0.006); with no differences for resolution of dyslipidemia (72.7% vs. 88.9%, p = 0.369) and obstructive sleep apnea (93.3% vs. 91.7%, p = 0.869). DS' patients required more extra nutritional supplementation. Three SADI-S patients needed conversion to DS, two for biliary reflux and one for weight regain. CONCLUSION: After a failed SG, revisional DS permits better weight control and diabetes and hypertension resolution than SADI-S, at the expense of higher supplementation needs.

Risk factors for ileocolic anastomosis dehiscence; a cohort study.

BACKGROUND: Anastomotic leak (AL) after ileocolic anastomosis influences morbidity, mortality, length of hospitalization and costs. This study analyzes risk and protective factors for AL on ileocolic anastomoses. METHODS: We retrospectively analyzed our single institution patients' series undergoing elective ileocolic anastomosis for AL between 1/2008-12/2017. AL grade A/B (antibiotic treatment and/or radiological drainage) were summarized as mild, grade C (surgical re-intervention) corresponds to severe AL. RESULTS: We included 470 patients (mean age 70.8 years, 43.2% females). Overall AL rate was 9.4% (44 patients) with 6.0% severe and 3.4% mild AL. There was no difference in AL between hand sewn and stapled anastomoses. Multivariate analysis revealed preoperative serum albumin (p = 0.004), smoking habits (p = 0.005) and perioperative blood transfusion (p = 0.038) as risk factors for AL. Suture oversewing as anastomotic reinforcement resulted as independent protective factor (p < 0.001). CONCLUSION: Poor nutritional status, smoking habits and perioperative blood transfusion are negative factors influencing on AL. Suture oversewing as anastomotic reinforcement associates with significantly less AL.

Gastric Histopathologic Findings in South Italian Morbidly Obese Patients Undergoing Laparoscopic Sleeve Gastrectomy: Is Histopathologic Examination of All Resected Gastric Specimens Necessary?

BACKGROUND: The value of the routine histopathologic examination of resected gastric remnants following laparoscopic sleeve gastrectomy (LSG) remains to be controversial. This study aimed to determine whether the routine histopathologic examination of gastric specimens is necessary for all patients undergoing LSG if upper gastrointestinal endoscopy (UGIE) plus multiple biopsies are performed routinely during the preoperative work-up. MATERIALS AND METHODS: Clinicopathologic data of 474 patients who underwent LSG were analysed. Types of histopathologic findings in LSG specimens and the prevalence of these and Helicobacter pylori (HP) infection were estimated. Comparisons were conducted to assess the association of risk factors with the most frequent abnormal and premalignant histopathologic findings. RESULTS: Chronic gastritis was the most common gastric pathology (63.5%) and premalignant lesions were present in 7.8% of the specimens. The prevalence of HP infection was 36.9%. A statistically significant association was observed between HP infection and chronic gastritis (P = .000), and premalignant lesions (P = .000). Similarly, a statistically significant association was noted between age and premalignant gastric lesions (P = .000). CONCLUSION: Histopathologic examination of LSG specimens may not be routinely needed and can be performed on selected patients. While we recommend routine preoperative UGIE in all LSG-treated patients, we suggest that histopathologic assessment of the LSG specimens should be mandatory when UGIE biopsies demonstrate HP infection and/or premalignant lesions, in all patients older than 42 years, and in cases of intraoperative detection of incidental tumours or suspicious lesions.

One Anastomosis Gastric Bypass-Mini Gastric Bypass with Tailored Biliopancreatic Limb Length Formula Relative to Small Bowel Length: Preliminary Results.

BACKGROUND: One Anastomosis Gastric Bypass-Mini Gastric Bypass (OAGB-MGB) is rapidly gaining popularity and is currently being performed by an increasing number of bariatric surgeons worldwide. However, excessive postoperative weight loss and malnutrition still remain a major concern regarding this procedure. The aim of this observational retrospective study was to investigate whether a tailored biliopancreatic limb (BPL) length relative to small bowel length (SBL) is superior to a fixed BPL length of 200 cm in terms of weight loss results and nutritional deficiencies in morbidly obese patients 1 year following OAGB-MGB. MATERIALS AND METHODS: Sixty-four patients who underwent OAGB-MGB were divided into two consecutive groups depending on the BPL length used: fixed 200-cm BPL and tailored BPL groups. Anthropometric measurements (%EWL, TWL, %TWL) and nutritional parameters (vitamin A, vitamin D3, vitamin B12, serum iron, serum albumin, total protein) were compared between the two groups at 1-year follow-up. RESULTS: No statistically significant differences were observed between the patients in two groups in terms of %EWL, TWL, %TWL. The number of patients with deficiencies of vitamin A (p = 0.030), vitamin D3 (p = 0.020), and albumin (p = 0.030) was significantly higher in fixed 200-cm BPL group as compared with tailored BPL group, 1 year following OAGB-MGB. No statistically significant differences were seen between the patients in two groups in terms of vitamin B12, iron, and total protein deficiencies. CONCLUSION: Tailoring BPL length by bypassing about 40% of the SBL seems to be safe and effective. According to preliminary results of this study, a tailored BPL length relative to SBL is even likely to be superior to the fixed 200-cm BPL as it is associated with less nutritional deficiencies while providing similar weight loss results. Further randomized studies with larger sample sizes and longer follow-up periods are necessary to confirm the primary results of this study.

Management of Staple Line Leaks Following Laparoscopic Sleeve Gastrectomy for Morbid Obesity.

PURPOSES: Management of staple-line leaks following laparoscopic sleeve gastrectomy (LSG) is challenging and controversial. Guidelines for leak treatment are not standardized and often involve multidisciplinary management by surgical, medical and radiological methods. Herein we present our experience and proposed strategy for handling leaks after LSG. PATIENTS AND METHODS: Retrospective data regarding LSG performed from April 2012 to October 2017 at the Surgical Oncology Division, Department of Human Pathology in Adulthood and Childhood ''G. Barresi'', University Hospital "G. Martino", University of Messina, Italy, were reviewed. The management approaches and the surgical, endoscopic, and percutaneous procedures used were examined. Outcomes measured included the prevalence of gastric leaks, radiological features, related morbidities and mortalities, hospital stay and management. RESULTS: LSG was performed in 310 patients. Eight patients were managed for gastric leak within the 5-year period: 5 (1.6% overall prevalence) from our division, 3 referred from another hospital. All cases were successfully treated conservatively with combined CT/US-guided drainage using a locking pigtail catheter and endoscopic gastric stent positioning. Endoscopic therapy included the use of fully covered self-expanding esophageal metal stents (Hanarostent® 24 cm; M.I. Tech, Seoul, Korea) in addition to pigtail drains (Drainage Catheter Locking Pigtail 8F/21cm; Tru-Set® Ure-Sil, Skokie, IL, USA). Complete closure of the leak was achieved in all patients. The mean time from presentation to healing was 74 days ± 37.76 (SD). None of the patients underwent remedial surgery. CONCLUSION: This study presents our management strategy for leak resolution in LSG patients. Based on our results, we strongly recommend the conservative and combined management of gastric leaks following LSG by endoscopic stenting and percutaneous drainage.

Burden of hospitalizations due to Rotavirus infection in Emilia Romagna, Italy.

The aim of this study was to collect data on hospitalizations due to gastrointestinal diseases, in particular Rotavirus gastroenteritis (RVGE), in the Region of Emilia Romagna, Italy. The national hospital discharge database was used to evaluate the epidemiology of RV infections in the 2000-2003 period, analyzing only the principal diagnosis. The available age groups were 0-14 years, 15-64 years and, >64 years. Hospitalization related costs were estimated through Diagnosis Related Group (DRG) rates even though a specific DRG for RVGE does not exist. In the 0-14yr. old subjects, RV were responsible for an average of 310 GE-related hospitalizations per year and globally represented 17% of admissions for enteritis and 84% of hospitalized viral GE. Fifty-six percent of the enteritis was of undefined origin. Considering the three possible DRG codes to which the disease can be referred (184, 298, 422) and the classification of hospitals in two categories, the cost of each admission for RVGE ranged between 1,293.83 Euro and 2,263.79 Euro. RV seems to play an important role as a cause of severe viral gastroenteritis, although RV infections are certainly underestimated for several reasons, one of them being the low sensitivity of hospital discharge forms. Today we have safe and effective vaccines that can be used in order to protect from moderate/severe forms of RV-related diarrhea. The extensive use of these vaccines could reduce hospitalizations and related costs in industrialized countries.