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Background The prevalence of cholelithiasis in morbidly obese individuals is 19–45 %. Laparoscopic sleeve gastrectomy (LSG) has become one of the most performed procedures worldwide. The management of gallstones at the time of LSG is under debate. We herein report our experience with concomitant LSG and cholecystectomy. Methods Patients undergoing LSG, between 2006 and 2014 with symptomatic cholelithiasis (SC), underwent concomitant cholecystectomy (SGC), and were compared to those who had LSG alone. Gender, age, and BMI were noted. Preoperative ultrasonography was performed for all patients and gallstone presence was recorded. Operative time, intraoperative mishaps, perioperative complications, length of hospital stay (LOS), and the incidence of subsequent symptomatic gallbladder disease were collected as well. Results SC was present in 180 patients who underwent SGC. LSG was performed in 2,383, of whom 43 (2 %) had asymptomatic cholelithiasis (AC). SGC patients had a higher percentage of females and were older (79 % and 46 years vs. 62 % and 43 years, respectively). BMI, LOS, and complications were similar. Operative time was prolonged by 35 min in SGC. Two patients with SGC had bile leakage. Of patients with AC, 9.3 % required cholecystectomy during the first post-operative year after LSG due to evolution of symptoms, compared to only 2.7 % of those with normal preoperative gallbladders. Presenting symptoms and severity of the disease were worse in the first group. Conclusions For SC, LSC is safe and warranted. Prophylactic cholecystectomy when gallstones are absent is unnecessary. Management of AC at the time of LSG is still debatable.

One anastomosis gastric bypass (OAGB) is an emerging bariatric procedure, yet data on its effect on the gastrointestinal tract are lacking. This study sought to evaluate the incidence of small-intestinal bacterial overgrowth (SIBO) following OAGB; explore its effect on nutritional, gastrointestinal, and weight outcomes; and assess post-OABG occurrence of pancreatic exocrine insufficiency (PEI) and altered gut microbiota composition. A prospective pilot cohort study of patients who underwent primary-OAGB surgery is here reported. The pre-surgical and 6-months-post-surgery measurements included anthropometrics, glucose breath-tests, biochemical tests, gastrointestinal symptoms, quality-of-life, dietary intake, and fecal sample collection. Thirty-two patients (50% females, 44.5 ± 12.3 years) participated in this study, and 29 attended the 6-month follow-up visit. The mean excess weight loss at 6 months post-OAGB was 67.8 ± 21.2%. The glucose breath-test was negative in all pre-surgery and positive in 37.0% at 6 months (p = 0.004). Positive glucose breath-test was associated with lower reported dietary intake and folate levels and higher vitamin A deficiency rates (p ≤ 0.036). Fecal elastase-1 test (FE1) was negative for all pre-surgery and positive in 26.1% at 6 months (p = 0.500). Both alpha and beta diversity decreased at 6 months post-surgery compared to pre-surgery (p ≤ 0.026). Relatively high incidences of SIBO and PEI were observed at 6 months post-OAGB, which may explain some gastrointestinal symptoms and nutritional deficiencies.

Given the health benefits of carotenoids, it is crucial to evaluate their levels in patients undergoing malabsorptive procedures like one anastomosis gastric bypass (OAGB). This study aimed to assess serum carotenoid levels before and 6 months following OAGB. Prospectively collected data from patients who underwent primary OAGB were analyzed. Data included anthropometrics, dietary intake assessments, and biochemical tests. Serum samples were analyzed for lipid profile and serum carotenoids, including lutein, zeaxanthin, α-carotene, β-carotene, phytofluene, ζ-carotene, and lycopene. Data from 27 patients (median age 47.0 years and 55.6% female) were available before and 6 months post-OAGB. The median pre-surgical BMI was 39.5 kg/m2, and the median excess weight loss at 6 months post-surgery was 63.9%. Significant decreases in all carotenoid levels were observed over time (p < 0.001 for all). A median relative decline of 65.1% in absolute total carotenoid levels and 12.7% in total cholesterol levels were found. No associations were observed between changes in clinical outcomes and carotenoid levels during the study period. This study reveals significant decreases in carotenoid levels within the first 6 months following OAGB. Nutritional intervention studies are needed to explore how incorporating carotenoid-rich foods affects post-surgery carotenoid levels and clinical outcomes.

Background Ghrelin is secreted mainly in the stomach and plays a role in food intake regulation. Morbidly obese (MO) individuals report a decline in appetite after sleeve gastrectomy (SG), presumably due, in part, to ghrelin cell removal. Ghrelin cell distribution and expression were determined in three areas of resected stomach specimens from MO patients subjected to SG. Methods Resected stomach specimens from 20 MO patients undergoing SG were analyzed. Real-time polymerase chain reaction of ghrelin mRNA and immunohistostaining for ghrelin cells in three stomach regions (fundus, body, and pre-antral areas) were performed. Body mass index (BMI) and total plasma ghrelin levels were obtained before and 3 months postoperatively. Results Ghrelin mRNA was detected throughout the stomach, its expression decreasing from the fundus towards the antrum. The relative quantification for ghrelin mRNA expression was 0.043, 0.026, and 0.015 at the fundus, body, and pre-antral region, respectively ( P  = 0.05, fundus vs. pre-antral region). Average ghrelin cell counts declined from 60 ± 40 to 45 ± 20 and 39 ± 13 cells/high power fields in the fundus, body, and pre-antral region, respectively. Three months after surgery, total plasma ghrelin levels decreased from 1,676 ± 470 to 1,179 ± 188 pg/ml ( P  < 0.00001) and BMI dropped from 46 ± 6 to 38 ± 5 kg/m 2 ( P  < 0.00001). Conclusions Distribution and expression of ghrelin-secreting cells throughout the stomach were defined, emphasizing the importance of meticulous resection of the fundus during SG for maximal ghrelin cell removal.

This study aimed to describe nutritional and lifestyle parameters following one-anastomosis gastric bypass (OAGB). A multicenter study among OAGB patients across Israel (n = 277) and Portugal (n = 111) was performed. Patients were approached according to the time elapsed since surgery. An online survey with information regarding demographics, anthropometrics, and nutritional and lifestyle aspects was administered in both countries simultaneously. Respondents from Israel (pre-surgery age of 41.6 ± 11.0 years, 75.8% females) and Portugal (pre-surgery age of 45.6 ± 12.3 years, 79.3% females) reported changes in their appetite (≤94.0% and ≤94.6%), changes in their taste (≤51.0 and ≤51.4%), and intolerance to specific foods (i.e., red meat, pasta, bread, and rice). Bariatric surgery-related eating recommendations were generally followed well, but a trend toward lower adherence was evident in groups with longer time elapsed since surgery in both countries. Most respondents from Israel and Portugal reported participation in follow-up meetings with a surgeon (≤94.0% and 100%) and a dietitian (≤92.6% and ≤100%), while far fewer reported participation in any follow-up meeting with a psychologist/social worker (≤37.9% and ≤56.1%). Patients following OAGB might experience changes in appetite, taste, and intolerance to specific foods. Adherence to bariatric surgery-related eating recommendations is not always satisfying, especially in the longer term post-surgery.

Introduction The European Association of Endoscopic Surgeons (EAES) conducted this study aiming to identify the top research questions which are relevant to surgeons in Minimal Access Surgery (MAS). This is in order to promote and link research questions to the current clinical practice in MAS in Europe. Methods Using a systematic methodology, (modified Delphi), the EAES members and leadership teams were surveyed to obtain consensus on the top research priorities in MAS. The responses were categorized and redistributed to the membership to rate the level of importance of each research question. The data were reported as the weighted average score with a scale from 1 (lowest agreement) to 5 (highest agreement). Results In total, 324 of 2580 (12.5%) of the EAES members and the leaders responded to the survey and contributed to the final consensus. The ranked responses over the 80th percentile identified 39 research priorities with rating ranged from 4.22 to 3.67. The top five highest ranking research priorities in the EAES were centered on improving training in MAS, laparoscopic surgery for benign upper gastrointestinal conditions, integration of novel technology in OR, translational and basic science research in bariatric surgery and investigating the role of MAS in rectal cancer. Conclusion An EAES research agenda was developed using a systematic methodology and can be used to focus MAS research. This study was commissioned by the European Association for Endoscopic Surgery (EAES).

Background Laparoscopic sleeve gastrectomy (LSG) is gaining wide acceptance as a single surgical treatment for obesity. The reported morbidity and mortality rates are low. We herein report the results of LSG performed in a high-volume center by an experienced team. Methods Retrospective analysis of a prospectively maintained database of all bariatric surgery (BS) was performed between May 2006 and December 2014. Data inspected included operative time, length of hospital stay (LOS), comorbidity resolution, re-operation, percent excess weight loss (%EWL), and 30-day morbidity and mortality. Results In the study period, 3003 patients underwent BS (1901 (63 %) female). Mean age and body mass index (BMI) were 43 years (range 14–73) and 42.8 kg/m 2 (range 35–73), respectively. %EWL at 1 year was 72 % ( n  = 937; 57 % follow-up rate). There was 1 perioperative mortality due to bleeding (0.03 %). Comorbidity improvement and resolution were 98 % for obstructive sleep apnea, 79 % for diabetes mellitus, 87 % for dyslipidemia, and 85 % for hypertension. Mean operative time and LOS were 50 min (range 32–94) and 2.2 days (range 1–38), respectively. Of the patients, 132 had complications (4.4 %), 25 leaks (0.83 %), 63 bleeding (2.1 %), 1 intra-abdominal abscesses (0.03 %), 3 sleeve strictures (0.1 %), 2 mesenteric vein thromboses (0.06 %), 10 trocar site hernias (0.3 %), and 78 symptomatic cholelithiasis (2.6 %). Re-operation was needed in 13 patients (0.43 %). Conclusion In a high-volume center with an experienced team, LSG can be performed with low morbidity and mortality.

Background Laparoscopic Roux-Y gastric bypass (LRYGBP) is the gold-standard procedure for the treatment of morbid obesity. It has been reported to be somewhat more efficient and durable than laparoscopic sleeve gastrectomy (LSG). However, it is considered more invasive and, therefore, more hazardous. There is a lack of unity in complication reporting following bariatric surgery. Thus, there is a possible misconception regarding the relative safety of the two major bariatric procedures performed worldwide. This may have contributed to a shift in practice with LSG gaining momentum “at the expense” of LRYGBP. The aim of this study was to evaluate the relative safety of primary LSG and LRYGBP according to the Clavien–Dindo complication grading system. Methods A total of 2651 and 554 patients underwent primary LSG and LRYGBP, respectively at three high-volume centers. Thirty-day perioperative complications were recorded and graded. Length of hospital stays (LOS) and readmission rates were collected as well. Results Complications occurred in 110 (3.7 %) and 24 (4.3 %) patients following LSG and LRYGBP, respectively ( p  = 0.9). No significant difference was found between the groups regarding overall and complication-grade-specific rates. Individual complication types were unevenly distributed, but not significantly so. Patients with complications were older than those without (47 and 43 years, respectively; p  = 0.01). Gender was not a risk factor for complication. Median LOS and readmission rates were not significantly different. Conclusions LSG and LRYGBP are equally safe, at least in the perioperative period. Acknowledging and conveying this finding to surgeons and patients alike is important and might cause a pendulum shift in the distribution of bariatric procedures performed.

Background Laparoscopic sleeve gastrectomy (LSG) remains under scrutiny as a stand-alone bariatric procedure. The most feared complication after LSG is staple line leak. Methods Eight bariatric centers in Israel participated in this study. A retrospective analysis was performed by querying all the LSG cases performed between June 2006 and June 2010. The data collected included patient demographics, anthropometrics, and operative and perioperative parameters. Results Among the 2,834 patients who underwent LSG, 44 (1.5 %) with gastric leaks were identified. Of these 44 patients, 30 (68 %) were women. The patients had a mean age of 41.5 years and a body mass index (BMI) of 45.4 kg/m 2 . Intraoperative leak tests and routine postoperative swallow studies were performed with 33 patients, and all but one patient (3 %) failed to detect the leaks. Leaks were diagnosed at a median of 7 days postoperatively: early (0–2 days) in nine cases (20 %), intermediately (3–14 days) in 32 cases (73 %), and late (>14 days) in three cases (7 %). For 38 patients (86 %), there was clinical suspicion, later confirmed by imaging or operative findings. Computed tomography, swallow studies, and methylene blue tests were performed for 37, 21, and 15 patients, respectively, and the results were positive, respectively, for 31 (84 %), 11 (50 %), and 9 (60 %) of these patients. Reoperation was performed for 27 of the patients (61 %). Other treatment methods included percutaneous drainage ( n  = 28, 63.6 %), endoscopic placement of stents ( n  = 11, 25 %), clips ( n  = 1, 2.3 %), and fibrin glue ( n  = 1, 2.3 %). In 33 of the patients (75 %), the leak site was found in the upper sleeve near the gastroesophageal junction. The median time to leak closure was 40 days (range, 2–270 days), and the overall leak-related mortality rate was 0.14 % (4/2,834). Conclusion Gastric leak is the most common cause of major morbidity and mortality after LSG. Routine tests to rule out leaks seem to be superfluous. Rather, selective utilization is recommended. Management options vary, depending mainly on patient disposition. An accepted algorithm for the diagnosis and treatment of gastric leak has yet to be proposed.