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IntroductionLaparoscopic sleeve gastrectomy (LSG) has rapidly become popular with excellent results. However, LSG may exacerbate or increase the risk of “de novo” gastroesophageal reflux disease (GERD). Adding a fundoplication has been proposed to increase the lower esophageal sphincter competency. The aim of this study was to examine the current evidence and outcomes of sleeve-fundoplication (Sleeve-F).Materials and MethodsSystematic review and meta-analysis. Web of Science, PubMed, and Embase data sets were consulted.ResultsSix studies (485 patients) met the inclusion criteria. The age of the patient population ranged from 17 to 72 years old and 82% were females. All patients underwent sleeve-fundoplication. Rossetti, Collis-Nissen, and Nissen were the most commonly performed fundoplications. The estimated pooled prevalence of postoperative leak, gastric perforation, and overall complications were 1.0% (95% CI = 0.0–2.0%), 2.9% (95% CI = 0.0–8.3%), and 9.8% (95% CI = 6.7–13.4%), respectively. The pooled reoperation rate was 4.1% (95% CI = 1.3–10%). There was no mortality. At 12-month follow-up, the estimated pooled BMI and %EWL were 29.9 kg/m2 (95% CI = 28.5–31.2) and 66.2% (95% CI = 59.3–71.1), respectively, while esophagitis, PPI consumption, and GERD rates were 8.0% (95% CI 3–21%), 7.8% (95% CI 5–13%), and 11% (95% CI 4–26%).ConclusionsThis systematic review and meta-analysis shows that current evidence for Sleeve-F is limited with high postoperative gastric perforation and overall complication rates. Weight loss and GERD resolution seem promising in the short term; however, further studies are warranted to explore long-term effects with instrumental investigations. Sleeve-F should be considered cautiously while future well-structured randomized trials are warranted.

BackgroundThe Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed procedures for surgical weight loss. It has been shown that overweight may be associated with an increased risk of gastric cancer. However, the risk of remnant gastric cancer after RYGB has not been defined yet and the development of neoplasm in the excluded stomach remains a matter of concern.MethodsPubMed, EMBASE, and Web of Science databases were consulted. Articles that described the diagnosis and management of remnant gastric cancer after RYGB were considered.ResultsSeventeen patients were included. The age of the patient population ranged from 38 to 71 years. The most commonly reported symptoms were abdominal pain, nausea/vomiting, and anemia. Abdominal computed tomography was used for diagnosis in the majority of patients. The neoplasm was located in the antrum/pre-pyloric region in 70% of cases and adenocarcinoma was the most common tumor histology (80%). An advanced tumor stage (III–IV) was diagnosed in almost 70% of patients and 40% were considered unresectable. Gastrectomy with lymphadenectomy was performed in 9 cases (53%). Post-operative morbidity was 12%. The follow-up ranged from 3 to 26 months and the overall disease-related mortality rate was 33.3%.ConclusionThe development of remnant gastric cancer after RYGB is rare. Surgeons should be aware of this potential event and the new onset of epigastric pain, nausea, and anemia should raise clinical suspicion. Further epidemiologic studies are warranted to deeply investigate the post-RYGB-related risk of remnant gastric cancer development in high-risk populations.

PurposeEsophageal dysmotility and disorders of the lower esophageal sphincter are well documented in morbidly obese patients. Esophageal achalasia has been reported in up to 1% of obese patients but the development of such esophageal motility disorder after laparoscopic sleeve gastrectomy (LSG) is extremely rare. The purpose of this video was to demonstrate the management of a type II esophageal achalasia diagnosed in a 46-year-old female patient 4-year after LSG.Materials and MethodsAn intraoperative video has been anonymized and edited to demonstrate the feasibility of laparoscopic Heller myotomy and anterior Dor fundoplication on the mentioned patient.ResultsThe operation started with the section of the perigastric adhesions. Proceeding in a clockwise direction, the esophagogastric junction, the anterior esophageal wall, and the His angle were freed. A residual slightly dilated fundus was found and isolated. After mobilization of the distal esophagus and identification of the anterior vagus nerve, a “hockey stick” myotomy was carried out for 6 cm on the esophagus and for 2 cm on the gastric side. An anterior Dor fundoplication was fashioned using the residual gastric fundus.ConclusionEsophageal achalasia in patients that previously underwent LSG is exceptional but should always be suspected in case of pathognomonic symptoms onset. In tertiary referral centers, laparoscopic Heller myotomy and, if technically feasible, an anterior Dor fundoplication seem safe and effective to relieve gastroesophageal outflow obstruction and prevent gastroesophageal reflux.

Persistent staple-line leak is a challenging complication after laparoscopic sleeve gastrectomy (LSG). The over-the-scope clip (OTSC) (Ovesco®, Tübingen, Germany) and the Mega stent (Taewoong medical, Seoul, South Korea) recently gained encouraging results in the management of early leaks. This is a retrospective series (n = 8) focused on the management of persistent leaks after LSG with the simultaneous OTSC/Mega stent strategy. Seven patients underwent primary LSG. The median time from LSG to OTSC/Mega stent treatment was 48.5 days (range 28–63), and the median defect size was 9.5 mm (range 7–12). The median time to clear liquid diet, hospital length of stay, and overall treatment time were 4 days (range 2–5), 31 days (range 26–57), and 47 days (range 34–107), respectively. Overall success rate was 87.5%. Postoperative morbidity was 25%. The mean follow-up time was 18 months (range 3–24) with no fistula recurrence.

IntroductionThe development of achalasia after Roux-en-Y gastric bypass (RYGB) is rare. Heller myotomy (HM) is the gold standard treatment while peroral endoscopic myotomy (POEM) is an emerging technique with promising results. The aim of this narrative review was to summarize the current knowledge on the treatment of esophageal achalasia after RYGB.MethodsPubMed, EMBASE, and Web of Science databases were consulted. All articles that described the management of achalasia after RYGB were included in this narrative review.ResultsTwelve studies for a total of 28 patients were included. The age of the patient population ranged from 44 to 70 years old and 80% were females. Overall, 61.5% underwent laparoscopic RYGB while 38.5% underwent open RYBG. The elapsed time from the RYGB to myotomy ranged from 14 months to 14 years. Dysphagia (64%) and regurgitation (60.7%) were the most commonly reported symptoms; type I achalasia was diagnosed in 50% of patients. Surgical HM was performed in 17 patients (61%) while POEM was performed in 11 patients (39%). Postoperative morbidity was 3.6% with no differences comparing surgical HM and POEM (6% vs. 0%, p = 0.43). The follow-up time ranged from 1 to 43 months. The overall recurrence rate requiring reoperation was 7% with no differences comparing surgical HM and POEM (12% vs. 0%; p = 0.25).ConclusionBoth HM and POEM seem feasible, safe, and effective in the management of achalasia after RYGB. The role of POEM in the management algorithm of these patients should be further evaluated.

Background and aim Several studies have shown that bariatric surgery reduces long term mortality compared to medical weight loss therapy. In a previous study we have demonstrated that gastric banding (LAGB) is associated with reduced mortality in patients with and without diabetes, and with reduced incidence of obesity co-morbidities (cardiovascular disease, diabetes, and cancer) at a 17 year follow-up. The aim of this study was to verify at a longer time interval (23 years) mortality and incidence of co-morbidities in patients undergoing LAGB or medical weight loss therapy. Patients and methods As reported in the previous shorter-time study, medical records of obese patients [body mass index (BMI) > 35 kg/m 2 undergoing LAGB (n = 385; 52 with diabetes) or medical treatment (controls, n = 681; 127 with diabetes), during the period 1995–2001 (visit 1)] were collected. Patients were matched for age, sex, BMI, and blood pressure. Identification codes of patients were entered in the Italian National Health System Lumbardy database, that contains life status, causes of death, as well as exemptions, prescriptions, and hospital admissions (proxies of diseases) from visit 1 to June 2018. Survival was compared across LAGB patients and matched controls using Kaplan–Meier plots adjusted Cox regression analyses. Results Final observation period was 19.5 ± 1.87 years (13.4–23.5). Compared to controls, LAGB was associated with reduced mortality [HR = 0.52, 95% CI 0.33–0.80, p = 0.003], significant in patients with diabetes [HR = 0.46, 95% CI 0.22–0.94, p = 0.034], borderline significant in patients without diabetes [HR = 0.61, 95% CI = 0.35–1.05, p = 0.076]. LAGB was associated with lower incidence of diabetes (15 vs 75 cases, p = 0.001), of CV diseases (61 vs 226 cases, p = 0.009), of cancer (10 vs 35, p = 0.01), and of renal diseases (0 vs 35, p = 0.001), and of hospital admissions (92 vs 377, p = 0.001). Conclusion The preventive effect of LAGB on mortality is maintained up to 23 years, even with a decreased efficacy compared with the shorter-time study, while the preventive effect of LAGB on co-morbidities and on hospital admissions increases with time.

Crohn's disease (CD) is notably characterized by the expansion of visceral fat with small adipocytes expressing a high proportion of anti-inflammatory genes. Conversely, visceral fat depots in ulcerative colitis (UC) patients have never been characterized. Our study aims were a) to compare adipocyte morphology and gene expression profile and bacterial translocation in omental (OM) and mesenteric (MES) adipose tissue of patients with UC and CD, and b) to investigate the effect of bacterial infection on adipocyte proliferation in vitro. Specimens of OM and MES were collected from 11 UC and 11 CD patients, processed and examined by light microscopy. Gene expression profiles were evaluated in adipocytes isolated from visceral adipose tissue using microarray and RTqPCR validations. Bacteria within adipose tissue were immuno-detected by confocal scanning laser microscopy. Adipocytes were incubated with Enterococcus faecalis and cells counted after 24 h. Morphology and molecular profile of OM and MES revealed that UC adipose tissue is less inflamed than CD adipose tissue. Genes linked to inflammation, bacterial response, chemotaxis and angiogenesis were down-regulated in adipocytes from UC compared to CD, whereas genes related to metallothioneins, apoptosis pathways and growth factor binding were up-regulated. A dense perinuclear positivity for Enterococcus faecalis was detected in visceral adipocytes from CD, whereas positivity was weak in UC. In vitro bacterial infection was associated with a five-fold increase in the proliferation rate of OM preadipocytes. Compared to UC, visceral adipose tissue from CD is more inflamed and more colonized by intestinal bacteria, which increase adipocyte proliferation. The influence of bacteria stored within adipocytes on the clinical course of IBD warrants further investigations.

Background Obesity is a major risk factor for several chronic diseases. The BioEnterics ® Intragastric Balloon (BIB ® ) is used worldwide as a short-term (6 months) treatment in morbid obese patients. However, removal of BIB ® past 6 months is a common occurrence in clinical practice often as a result of patient factors. The aim of the present Italian multicentre cohort study was to evaluate the safety and efficacy of the BIB ® left in situ for more than 6 months. Materials and methods A total of eight Italian centres participated in the study. Participating centres received a standardised questionnaire designed to capture safety and efficacy data. Weight loss data, as well as date, and reason for removal of the BIB ® after 6 months were recorded. Adverse events, including mortality and complications, operators’ subjective technical notes and findings, and difficulties during removal procedure were also collected. Results Six hundred and eleven patients were included. In the majority of cases, patient extended BIB ® treatment due to satisfactory weight loss (44 %). At 6 months, all patients achieved a BMI statistically lower than the initial BMI ( p  < 0.001). There was a non-significant trend towards greater BMIL % in patients who underwent removal up to 15 months versus the results achieved up to 6 months. No major complications were recorded. Conclusion Extending the duration of BIB ® use up to 14 months safely maintains weight loss and satiety with greater results than that up to 6 months, without complications.

We describe the case of a 58‐year‐old man presenting with myocardial infarction complicated by cardiogenic shock, treated with Impella CP which was escalated to an axillary 5.0 due to lack of cardiac recovery. Weaning from Impella 5.0 failed, and the patient was evaluated for heart transplantation (HTx) or left ventricular assist device (LVAD). HTx was excluded because of a rectal adenocarcinoma. The patient underwent colorectal surgery while on Impella. Perioperative course was uneventful. After 61 days of Impella, when the LVAD implantation was scheduled, the patient died due to K. pneumoniae infection.