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Two important hitches encountered by the most expert TaTME surgeons worldwide are related to some limitations of standard CO2 insufflators in obtaining and maintaining an excellent transanal endoscopic operative field: the excessive diathermy-induced smoke in an already confined surgical field and the billowing, ‘breathing’ or ‘unstable pneumorectum’ due to fluctuations in insufflation pressure. [...]the procedure takes longer and the correct identification of tissue planes is hindered. [...]both surgical smoke and pumping of the rectal tissue are highly reduced.

BackgroundOne 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 MethodsSixty-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.ResultsNo 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.ConclusionTailoring 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.

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/m 2 . 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. Graphical Abstract

BackgroundSingle-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).MethodsUnicentric cohort study including all patients submitted to SADI-S and DS after failed SG in a high-volume institution, between 2008 and 2020.ResultsForty-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.ConclusionAfter a failed SG, revisional DS permits better weight control and diabetes and hypertension resolution than SADI-S, at the expense of higher supplementation needs.

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. 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. 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). 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. •Stapled or hand sewn ileocolic anastomoses do not differ in anastomotic leaks (AL).•Low serum albumin, smoking and perioperative blood transfusion increase independently the risk for AL.•Oversewing of the entire anastomosis associates with significantly reduced AL risk.

IntroductionSingle-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.MethodsA 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.ResultsThe 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).ConclusionWeight 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.

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/m 2 DS vs. 52.5 kg/m 2 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/m 2 ( 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 B 12 , 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. Graphical abstract

BackgroundCombined-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.MethodsCharts 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).ResultsOne 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.ConclusionCELS 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.

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.