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BackgroundSurgery for obesity and metabolic diseases has been evolved in the light of new scientific evidence, long-term outcomes and accumulated experience. EAES has sponsored an update of previous guidelines on bariatric surgery.MethodsA multidisciplinary group of bariatric surgeons, obesity physicians, nutritional experts, psychologists, anesthetists and a patient representative comprised the guideline development panel. Development and reporting conformed to GRADE guidelines and AGREE II standards.ResultsSystematic review of databases, record selection, data extraction and synthesis, evidence appraisal and evidence-to-decision frameworks were developed for 42 key questions in the domains Indication; Preoperative work-up; Perioperative management; Non-bypass, bypass and one-anastomosis procedures; Revisional surgery; Postoperative care; and Investigational procedures. A total of 36 recommendations and position statements were formed through a modified Delphi procedure.ConclusionThis document summarizes the latest evidence on bariatric surgery through state-of-the art guideline development, aiming to facilitate evidence-based clinical decisions.

PurposeReport the analysis from a single center series of consecutive primary sleeve gastrectomy (SG) on the factors affecting weight loss at long term.Materials and MethodsPatients submitted to primary SG with a follow-up of 7 years were screened. Weight loss was evaluated with %excess weight loss (%EWL) and %excess BMI loss (%BMIL). Weight regain (WR) was defined as in increase of 25% of the obtained %EWL and insufficient weight loss (IWL) as loss < 50% EWL. Eating behaviors were evaluated with 7 days record (7dR). All the variables potentially affecting the weight loss were cross-matched for correlation. The study population was divided in three groups: group A (WR), group B (IWL), and group C (sustained weight loss) for comparative analysis.ResultsA total of 86 patients (21 M/65 F) with a preoperative BMI of 47.08 ± 6.15 kg/m2 were evaluated. Cumulative 7 years weight loss was as follows: 61.66 ± 22.69% EWL and 32 ± 9% EBMIL. A total of 4.6% had an IWL while 27.9% a WR. The analysis showed a significant difference among the daily calories and fats consuming, number of meals, physical activity, grazing/sweet eating habits, and adherence to follow-up (p < 0.05) between groups A and C. Cox hazard demonstrated a significant risk (p < 0.05) to WR in case of adherence to follow-up shorter than 48 months, high daily calories, and fats intake (hazard ratio (HR) range 5–9). Eight patients (9.3%) had a surgical revision.ConclusionOur data demonstrated that long-term results (7 years) of SG are strongly related to eating habits and patient’s behaviors.

Background Hiatal hernia (HH) repair during laparoscopic sleeve gastrectomy (LSG) has been advocated to reduce the incidence of postoperative gastroesophageal reflux disease (GERD) and/or intrathoracic migration (ITM). The necessity of intraoperative repair in asymptomatic patients is still controversial. Previous, mid-term results of a prospective, comparative study evaluating posterior cruroplasty concomitant with LSG (group A 48 patients with simple vs. group B 48 reinforced with bioabsorbable mesh) confirmed the safety and effectiveness of simultaneous procedures. Present aim was to report the 60 months follow-up update, evaluating GERD and esophageal lesions’ incidence and HH’s recurrence. Results Follow-up was completed in 87.5% of the patients. Recurrent GERD was registered in 6/38 (15.7%, group A) and in 9/46 (19.5%, group B) ( p  = 1.0000). Grade A esophagitis and GERD was shown in 2 patients (5.2%), respectively 2 (4.3%) of each group ( p  = 1.0000), and recurrent HH was confirmed subsequently by contrast study and CT scan. Neither Barrett’s lesions nor de novo GERD was found in any patient. Failure of the cruroplasty with ITM was recorded in 7 patients from group A (18.4%) and 2 patients from group B (4.3%) p  < 0.05; hence, a repeat posterior, reinforced cruroplasty was performed in all cases. A total of 12 patients (14.2%, 8 respective 4) were converted within 5 years for persistent/recurrent GERD, with only 1 case of de novo (group B). Conclusions Accurate patient selection and proper sleeve technique, combined with posterior cruroplasty (simple or reinforced) ensure effectiveness, with a rate of failure (HH recurrence) at 5 years of 10.7%.

Background Laparoscopic sleeve gastrectomy (LSG) results in reduced calorie intake and weight loss. Whether patients consume the same types of food before and after surgery or whether they reduce the volume and calorie density of the foods they consume remains unknown. Objectives The aim of this prospective study was to evaluate the changes in daily caloric and macronutrient intake after LSG and the relation between changes of taste and food tolerance over 2 years. Methods Thirty morbidly obese patients with median body mass index (BMI) of 43.9 kg/m 2 (39.5–57.3) were prospectively enrolled prior to LSG. Weight, BMI, %EWL, weight loss percentage (%WL), and daily intake were evaluated preoperatively at 1, 3, 6, 12, and 24 months after surgery along with a questionnaire evaluating food choices, quality of eating, tolerance of certain types of food, frequency of vomiting, and changes in taste. Results The median %EWL and %WL at 12 and 24 months was 65 % (33.9–93.6 %), 27.3 % (14.2–45.5 %) and 71.5 % (39.6–101.1 %), 31 % (19.1–50.3 %) respectively. Six months after surgery, the daily caloric intake reduced by 68 % and the reduction was maintained until 24 months. The median score of the eating questionnaire was 18 (10–27) at 6 months, 22 (16–26) at 12 months, and 23 (10–27) at 24 months, suggesting that the quality of nutrition improved over time. At 6, 12, and 24 months, 75 % of the patients reported changes in taste with reduced interest in sweets, high fat food, and alcoholic drinks. However, at 24 months, 20 % of patients reported a heightened interest in sweets compared to 12 months previously. Conclusions LSG reduced calorie intake both through volume of food and the calorie density of the food consumed. The mechanisms for the changes in food preferences may involve both unconditioned and conditioned effects. The influence of dietary counseling on learning which foods are consumed still requires further exploration.

PurposeOnly anecdotally reported, intrathoracic migration (ITM) represents an unacknowledged complication after sleeve gastrectomy (LSG) contributing to gastroesophageal reflux disease (GERD) development, both recurrent and de novo. The primary endpoint of this study was to evaluate the incidence of postoperative ITM ≥ 2 cm; the secondary endpoint was to determine the relationships between ITM, GERD, endoscopic findings, and percentage of patients requiring surgical revision.Materials and MethodsA retrospective, multicenter study on prospective databases was conducted, analyzing LSGs performed between 2013 and 2018. Inclusion criteria consisted of primary operation; BMI ranging 35–60 kg/m2; age 18–65 years; minimum follow-up 24 months; and postoperative UGIE, excluding concomitant hiatal hernia repair. Esophageal manometry and 24-h pH-metry were indicated, based on postoperative questionnaires and UGIE; patients with GERD due to ITM, and non-responders to medical therapy, were converted to R-en-Y gastric bypass (RYGB).ResultsAn ITM ≥ 2cm was postoperatively diagnosed in 94 patients (7% of 1337 LSGs), after mean 24.16 ± 13.6 months. Postoperative esophagitis was found in 29 patients vs. 15 initially (p=0.001), while GERD was demonstrated in 75 (vs. 20 preoperatively, p< 0.001). Fifteen patients (16%) underwent revision to RYGB with posterior cruroplasty. Seventeen patients with severe GERD presented improvement of endoscopic findings and clinical symptoms as a result of conservative therapy.ConclusionsITM after LSG is not a negligible complication and represents an important pathogenic factor in the development or worsening of GERD. Postoperative UGIE plays a fundamental role in the diagnosis of esophageal mucosal lesions.

Obesity produces a significant deterioration in general and sexual health. The aim of this cross-sectional study was to investigate the impact of obesity on sexuality, illustrating the psychological constructs that may play a significant role in determining sexual functioning and satisfaction. During the psychological assessment for bariatric surgery eligibility, 171 obese men filled out a socio-demographic questionnaire, the International Index of Erectile Function (IIEF), the 20 Item-Toronto Alexithymia Scale, the Symptom Checklist-90-Revised, the Body Uneasiness Test, and the Obesity-related Disability test. A series of hierarchical multiple regression analyses highlighted how obese men sexual desire ( F (11,159)  = 10.128, p  < 0.001), erectile function ( F (10,160)  = 63.578, p  < 0.001), orgasmic function ( F (10,160)  = 33.967, p  < 0.001), intercourse satisfaction ( F (7,163)  = 159.752, p  < 0.001), and general satisfaction ( F (10,160)  = 18.707, p  < 0.001) were significantly associated with other IIEF sexual domains, difficulties in identifying feelings, psychopathological symptoms (such as depression and paranoid ideation), body image, and quality of life. Findings are useful for deepening understanding of obese male sexual response, and more generally, for analyzing the complex and multivariate relation between obesity and sexuality, supporting the need of a multidisciplinary approach to obesity care that includes professionals with specific training in sexology.

ObjectiveObesity is one of the major health challenges throughout the world. The association between obesity and diabetes is well established because 90% of patients with type 2 diabetes mellitus (T2DM) show excess body weight. The aim of the study was to evaluate the effect of laparoscopic sleeve gastrectomy (LSG) on morbid obesity and type 2 diabetes (T2DM) in the long-term follow-up.MethodsOne hundred ninety-five obese patients, 78 with T2DM, were evaluated before and after LSG up to 10 years, to identify complete diabetes remission (FPG < 100 mg/dl, A1c < 6.0%), partial remission (FPG 100–125 mg/dl, A1c < 6.5%), or relapse.ResultsBefore surgery, body weight and BMI were 123 ± 21 kg and 44.6 ± 6.8 kg/m2 respectively; at a mean follow-up of 7 years (range 4–10), body weight was 104.9 ± 18 kg and BMI 37 ± 6 kg/m2. Minimum weight was reached after 2 years. T2DM remission was observed in 66, 57, and 52% at short (< 2 years), medium (2–5 years), and long-term (> 5 years) follow-up respectively. Furthermore, 45.2% maintained complete remission for at least 5 years and about 36% showed a persistent but improved diabetes. None of the patients cured from diabetes had a duration disease greater than 8 years and a glycemic control requiring insulin. The prevalence of hypertension and dyslipidemia significantly decreased from 49 to 35% and from 51 to 40% respectively.ConclusionsLSG significantly improves body weight, diabetes, hypertension, and dyslipidemia in long-term follow-up.

We evaluated laparoscopic sleeve gastrectomy (LSG) on major co-morbidities (hypertension, type 2 diabetes / impaired glucose tolerance, obstructive sleep apnea syndrome (OSAS) and on American Society of Anesthesiologists (ASA) operative risk score in high-risk super-obese patients undergoing two-stage laparoscopic biliopancreatic diversion with duodenal switch (LBPD-DS). 41 super-obese high-risk patients (mean BMI 57.3+/-6.5 kg/m(2), age 44.6+/-9.7 years) were entered into a prospective study (BMI > or = 60, or BMI > or = 50 with at least two severe co-morbidities, no Prader-Willi syndrome, no conversion, minimum follow-up 12 months). 9 patients had BMI > or = 60. 17 patients (41.4%) had OSAS on C-PAP therapy. In 10 patients, at least one intragastric balloon had been positioned and 4 had undergone laparoscopic adjustable gastric banding, all with unsatisfactory results. At surgery, 41.5% were classified ASA 4 and 58.5% as ASA 3 (mean ASA score 3.4+/-0.5). Patients underwent evaluation every 3 months postoperatively and were restaged at 12 months and/or before the second step. 60% of major co-morbidities were cured and 24% improved. Average BMI after 6 and 12 months was 44.5+/-8.1 and 40.8+/-8.5 respectively (mean follow-up 22.2+/-7.1 months). After 12 months, 57.8% of the patients were co-morbidity-free and 31.5% had only one major co-morbid condition. At restaging, 20% of patients were still classified as ASA score 4 (OSAS on C-PAP therapy). 3 patients showed BMI <30 and were co-morbidity-free 12 months after LSG. LSG represents a safe and effective procedure to achieve marked weight loss as well as significant reduction of major obesity-related co-morbidities. The procedure reduced the operative risk (ASA score) in super-obese patients undergoing two-stage LBPD-DS.