Conventional vertical sleeve gastrectomy (cVSG), the most commonly performed bariatric surgery, is associated with low complications, durable weight loss, and significant improvement of many obesity-related comorbidities. However, numerous studies have reported that patients who underwent the cVSG have worsening or new onset (de novo) gastroesophageal reflux disease (GERD) which could be related to a negative effect of the operative procedure on the geometry of the gastroesophageal junction impacting on the function of the native gastroesophageal valve. It is imperative to innovate the cVSG procedure because chronic GERD is a debilitating condition associated with increased risk for Barrett's esophagus and esophageal cancer. INNOVATE-VSG aims to test whether a modified flap valve-preserving VSG (fvpVSG), compared to cVSG, will be associated with improvement of preexisting GERD.

The fvpVSG incorporates the following surgical modifications that strengthen the antireflux barrier: achieving 3 cm intrabdominal esophageal length; repair of the diaphragmatic crura; and preservation of 3 cm length of gastric fundus/cardia during the sleeve gastrectomy procedure which will be used to symmetrically wrap around the distal esophagus (120-160° wrap) to restore the naturally occurring gastroesophageal valve. A total of 44 obese patients (BMI 35-50 kg/m2) with pathologic GERD, confirmed by abnormal acid exposure time (AET), will be randomly assigned to cVSG or fvpVSG in this pilot randomized clinical trial at two academic sites. The primary outcome is the change in AET at 6-9 months after surgery. Secondary outcomes include changes in the lower esophageal sphincter pressure, compliance of the esophagogastric junction, weight loss, and quality of life.

Data generated from the INNOVATE-VSG trial will be used to design a larger multi-center randomized clinical trial to confirm the value of preserving a functioning gastroesophageal valve following sleeve gastrectomy.

Bariatric surgery is being offered to more medically complex patients, including patients on immunosuppressants, although outcomes after different bariatrics surgeries have not been studied in this population.

We compared perioperative safety of sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and duodenal switch (DS) in patients on immunosuppression.

National sample from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database.

The MBSAQIP database was queried from the years 2015 to 2021 for adult patients on chronic immunosuppression who underwent SG, RYGB, or DS. Revisional, open, endoscopic, or emergency surgeries were excluded, as were patients with an American Society of Anesthesiologists class of 5 and patients without full 30-day follow-up. Propensity-score matching was performed with a 3:3:1 ratio (SG:RYGB:DS) controlling for surgical approach, sex, age, functional status, American Society of Anesthesiologists, body mass index, and comorbidities.

There were 19,414 patients on immunosuppression who underwent SG (n = 14,358), RYGB (n = 4864), or DS (n = 192). After propensity-score matching , RYGB and DS had longer LOS (P < .01), greater global 30-day complication (P < .01), and 30-day reoperation rates (P = .048). Compared with SG and RYGB, DS had greater rates of patients requiring mechanical ventilation >48-hour postoperatively (P < .05). Compared with SG, DS had greater rates of renal insufficiency (P = .01), organ space infection (P = .01), unplanned intubation (P < .01), and unplanned intensive care unit admission (P < .01).

For patients on immunosuppression, SG carried the lowest complication and reoperation rates, whereas DS had overall complication rates in line with RYGB.

The primary goal of this study was to identify the risk factors contributing to moderate-to-severe postoperative pain in patients undergoing laparoscopic sleeve gastrectomy (LSG) and to create a predictive model for these risk factors. A retrospective analysis was performed on a cohort of 375 patients who underwent LSG at Jinan Central Hospital from January 2017 to June 2023. Data for this study was extracted using medical databases. Patients were classified into 2 groups based on their postoperative pain levels: those experiencing moderate-to-severe pain and those not experiencing moderate-to-severe pain. Univariate and multivariate logistic regression analyses were employed to determine which variables were significantly associated with moderate-to-severe pain. Receiver operating characteristic curves were utilized to assess the diagnostic efficacy of different indicators. Additionally, calibration curves and clinical decision curves were applied for model validation. Multifactorial logistic regression analysis identified age, body mass index (BMI), and the modified frailty index (mFI) as independent risk factors for moderate-to-severe postoperative pain in LSG patients. Based on the regression analysis, a predictive model was constructed. The receiver operating characteristic curve for this model demonstrated an area under the curve of 0.96 (95% CI: 0.94-0.97), indicating excellent discriminatory ability between patients likely and unlikely to experience moderate-to-severe pain post-surgery. A scoring system was developed from the predictive model, assigning points to each risk factor. BMI was the most significant predictor (100 points), followed by mFI (30 points) and age (15 points). Calibration analysis showed that the predicted values closely matched the actual values, with a mean error of 0.008, indicating high accuracy of the model. Clinical decision analysis demonstrated a positive net benefit when the threshold probability ranged from 0.001 to 0.999, suggesting broad applicability of the model in clinical decision-making. Age, BMI, and mFI are significant predictors of moderate-to-severe postoperative pain in patients undergoing LSG.

Laparoscopic sleeve gastrectomy (LSG) is one of the most frequently performed bariatric procedures worldwide due to its efficacy in achieving significant and sustained weight loss. While generally safe, rare but life-threatening complications can occur. This case report describes a 54-year-old female who presented with acute left-sided abdominal pain and hemodynamic instability six months after an otherwise uneventful LSG. She was found to have a delayed spontaneous splenic rupture secondary to a chronic gastric staple line leak. Following urgent surgical intervention with splenectomy, the patient's condition initially improved but persistent abdominal collections and ongoing pain prompted further investigation, ultimately revealing a small staple line defect. Endoluminal vacuum therapy (EVT) and prolonged intravenous antibiotics were required. This case emphasizes the importance of maintaining a high index of suspicion for delayed postoperative complications such as chronic staple line leaks and their potential to precipitate rare events like spontaneous splenic rupture. Early recognition, prompt surgical intervention, and appropriate multidisciplinary management are critical in preventing catastrophic outcomes.

The study objective was to identify variations in calibration tube use during sleeve gastrectomy and understand elements of ideal calibration tube performance.

A survey was distributed via email and social media to bariatric surgeons, who were asked to rate the performance of their current calibration tube and an ideal calibration tube for five technical milestones involving visualization, positioning, suction capability, and sleeve sizing. Data was analyzed using descriptive and bivariate analyses including chi-square, Mann-Whitney, and Kruskal-Wallis tests.

After eliminating incorrect screening question responses, 552 of 585 responses were analyzed. Demographics included 82% practicing in the USA, 64% in community practice, performing an average of 114 (SD = 94.5) sleeves annually. Calibration tubes used were most commonly reusable (54.2%) versus disposable (27.4%), endoscope (5.3%), or other (13.2%). Ninety-six percent of calibration tube sizes were 32 to 44 French. The reusable calibration tube had the lowest mean scores in all five technical areas, while the endoscope performed the best. When comparing surgeon current to ideal calibration tube performance, the endoscope performed closest to an ideal device, with significant p-values for technical milestones (i-iv). Despite the endoscope having the highest ratings for technical performance, surgeons rated higher satisfaction using disposable calibration tubes.

Significant variation exists among the size and type of calibration tubes used for sleeve gastrectomy. Calibration tubes incorporating the visualization of an endoscope with the workflow of a disposable device could bridge technical performance and satisfaction goals for surgeons.

It has been observed that 5-8% of primary bariatric procedures result in inadequate treatment response, necessitating the need for revisional surgery. In this systematic review and meta-analysis, we aim to compare the effectiveness of single anastomosis duodeno-ileal bypass (SADI) and one anastomosis gastric bypass (OAGB) in addressing weight recurrence following sleeve gastrectomy.

We systematically searched PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials databases. Studies were considered eligible if they compared SADI with OAGB as revisional surgeries following sleeve gastrectomy.

Our search strategy yielded four articles with a total of 309 patients. Regarding weight loss at 1 year of follow-up, SADI was favorable based on excess weight loss percentage (EWL%) and total weight loss percentage (TWL%). At 2 years of follow-up, EWL% did not show a statistically significant difference between the two operations although TWL% was higher in SADI group. Regarding postoperative bile reflux, the OAGB group had a significantly higher incidence of biliary reflux (OR 0.15; 95% CI 0.04 to 0.53; P = 0.003). Patients enrolled in SADI did not develop anastomotic ulcers according to the four studies included in the analysis. In contrast, seven patients in the OAGB group did develop anastomotic ulcers, but the difference was not statistically significant (OR 0.23; 95% CI 0.05 to 1.10; P = 0.07).

ADI is a feasible procedure with a favorable outcome compared to OAGB as a revisional surgery following sleeve gastrectomy regarding weight loss at 1 year with a lower incidence of postoperative biliary reflux.

Sleeve gastrectomy (SG) is the most commonly performed metabolic and bariatric surgery (MBS) procedure. Technical considerations related to the performance of SG are well established and reported in the literature but not in relation to robotic-assisted (RA) SG. We report the results of the first modified Delphi consensus-building exercise addressing technical considerations of RA da Vinci (dV) SG.

Develop best practices for the performance of robotic-assisted da Vinci sleeve gastrectomy.

Survey based consensus statement.

A consensus building committee (CBC) was created comprising 10 experts in the field of RA surgery and MBS based on strict selection criteria. The CBC developed 49 consensus statements which were then shared with 240 experts in RA surgery. Our stopping criterion was stability in responses (≤15%). The consensus cut point was 70%.

The overall response rate was 49%. In the first round of voting, there was consensus agreement on 25 statements (51%), consensus disagreement on 14 (28%), and no consensus on the remaining statements (21%). In the second round of voting, we reached agreement on 3 additional statements. Experts recommended the use of the number of pauses generated by the stapler to guide choice of staple height (91.2%) and to upsize the staple height when using buttressing (92%). There was also consensus (81.4%) that the use of the closed staple height of 1.00 mm (white) is acceptable and that stapling of the antrum using a 1.5-mm staple (blue load) is also acceptable (73%).

Collective expert opinion structured through a modified Delphi consensus statement presents a practical guide for surgeons interested in performing dV-SG.

We aimed to compare the omentopexy and clipping reinforcement methods performed along the staple line during laparoscopic sleeve gastrectomy (LSG) in terms of the effectiveness on postoperative bleeding.

In this prospective randomized controlled study, patients were divided into two groups: clips group (CG) and omentopexy group (OG). The groups were compared in terms of postoperative bleeding, duration of surgery, length of hospital stay, hospital readmissions in the postoperative first 30-days.

A total of 148 patients were included in the study. Postoperative bleeding was observed in 11 patients (14.9%) of CG and 2 patients (2.7%) of the OG, and the difference between the groups was found to be significant (p = 0.009). Similarly, the number of patients with bleeding that did not require intervention was 9 (12.2%) in CG and 2 (2.7%) in OG, and the difference between the groups was also significant (p = 0.028). The duration of surgery in the CG was 30 (27 to 36) minutes, whereas in the OG, it was 43 (39 to 45) minutes, with a significant difference noted (p < 0.001). Additionally, the rate of patients readmitted to the hospital within the first 30 days was 16 (21.6%) in the CG and 7 (9.5%) in the OG, with a significant difference observed (p = 0.041).

In terms of bleeding requiring intervention, there was no difference between omentopexy and clipping techniques. In addition, omentopexy showed more satisfactory results than clipping in terms of non-interventional bleeding, but its clinical significance is unclear.

Obesity is a growing health concern in China, closely linked to metabolic disorders such as type 2 diabetes. Laparoscopic Sleeve Gastrectomy (LSG) is effective in promoting weight loss and improving metabolic outcomes. Emerging evidence highlights the role of gut microbiota in metabolic regulation, yet the specific alterations in gut microbiota and their association with metabolic changes post-surgery in Chinese patients remain unclear. Understanding these shifts could provide key insights into optimizing treatment strategies for metabolic improvement following bariatric surgery.

Stool samples and clinical data were collected from 30 obese patients before and 6 months after surgery. The composition of the gut microbiota was analyzed through 16S rRNA sequencing, and Spearman correlation analysis was used to determine the association between gut microbiota and clinical indicators.

The analysis of 30 patients showed a significant decrease in Body Mass Index (BMI) (36.75 ± 4.09 kg/m2 vs 26.37 ± 3.47 kg/m2, p < 0.0001). Glucose metabolism, including Hemoglobin A1C levels, improved significantly (6.05 ± 0.96 vs 5.05 ± 0.25, p < 0.0001), and liver function as well as serum lipid levels were also notably improved. LSG increased the richness and composition of gut microbiota in obese patients post-surgery. These changes in gut microbiota were closely associated with improved clinical metabolic parameters.

LSG not only significantly reduces body weight while also alleviating metabolic syndrome and comorbidities by altering gut microbiota.

Laparoscopic sleeve gastrectomy (LSG) is a commonly performed type of bariatric surgery. Early complications of LSG include bleeding, leakage, pulmonary embolism, and surgical site infections. Most surgeons try to implement preventive methods, such as omentopexy. Staple line-imbrication, which has a difficult learning curve, often prevents complications. This study aimed to evaluate the effect of omentopexy on patients with imbricated LSG.

The study applied a retrospective data analysis design to patients who underwent LSG between 2020 and 2023. All patients' staple lines were imbricated, and patients were then divided into two groups: omentopexy group and control group. Patients' demographic features, such as age, gender, height, weight, body mass index(BMI), bleeding, leakage, and reoperations, were recorded and examined retrospectively.

A total of 1356 patients were included in the study (540 in omentopexy, 816 in control), of which the mean age was 37.9 ± 10.5 years, 82.3% were women, and mean BMI was 40.9 ± 5.8 kg/m2. The mean bleeding rate was 1.0% (1.3-0.7%), the mean leakage rate was 0.2% (0.2-0.2%, respectively), and the mean reoperation rate was 0.6% (0.7% and 0.5%, respectively). No statistically significant differences were observed.

Omentopexy is a technique that is widely used to prevent staple line complications. According to our study, omentopexy applied to an imbricated stapler line increased the operation time but did not affect bleeding or leakage ratios. This is the first study to evaluate the effect of omentopexy on imbricated staple lines. The findings of the study indicate that omentopexy has no additional benefit on early complications when using staple-line imbrication.

Metabolic bariatric surgery (MBS) is standardized and safe. Nevertheless, complications such as anastomotic leakage (AL) or staple-line leakage (SLL) can occur. In upper GI or colorectal surgery, endoluminal vacuum therapy (EVT) offers a therapeutic alternative to revisional surgery. Data on EVT in patients with leakage after MBS remain scarce. The aim of this study is to evaluate the efficacy of EVT and its potential as endoscopic alternative to revisional surgery.

All patients treated for AL or SLL with EVT after MBS between 01/2016 and 08/2023 at the Department for General Surgery, Medical University Vienna, were included in this retrospective, single-center study. Therapeutic value of EVT as management option for acute postoperative leakage after MBS in daily practice was evaluated. Statistical analyses were performed descriptively.

Twenty-one patients were treated with EVT within the observational period of 7 years. In 11 cases (52.4%), the index surgery was a primary bariatric intervention; in 10 cases (47.6%), a secondary surgery after initial MBS was performed. Favored approach was a combination of revisional surgery and EVT (n = 18; 85.7%), intermediate self-expanding metal stent (SEMS) in 16 (76.2%) cases. EVT was changed six times (0-33) every 3-4 days. Mean EVT time was 25.1 days (3-97). No severe associated complications were detected and EVT showed an efficacy of 95.2%.

This small case series supports the trend to establish EVT in daily clinical practice when revisional surgery after MBS is needed, thus preventing further reoperation and reducing associated morbidity and mortality in critically ill patients.

Post-sleeve gastrectomy fistulas are a rare but possibly severe life-threatening complication. Besides early reoperation and drainage, endoscopy is the main treatment option. According to the clinical setting, endoscopic treatment options comprise stent or clip placement. New endoscopic therapies have recently gained attention, including endoscopic vacuum therapy, VacStent therapy, endoscopic internal drainage with pigtail stents, endoscopic suturing and stem cell injection. In this narrative review, we shed light on recent literature, developments, indications and contraindications of these treatments. Intragastric gastric band migration is a rare complication after gastric band positioning. Reoperation can sometimes be difficult, especially when a gastric band has already migrated far into the stomach. Endoscopic retrieval can be a valid, non-invasive therapeutic solution. We reviewed the current literature on this matter.

Sleeve gastrectomy (SG) is widely recognized as the leading bariatric procedure worldwide. However, leakage, its major complication, remains a significant concern. This study focuses on the challenges of managing leakage, especially when conventional endoscopic treatments are ineffective. Although a novel one-step approach as reported by Pulimuttil James Zachariah from Wei-Jei Lee's team has demonstrated promise, further investigations and reports on its efficacy are currently insufficient. Between January 2021 and November 2023, we analyzed five patients treated at our center for SG leakage. Patient data include demographics, comorbidities, surgical details, and outcomes. The study details Laparo-Endoscopic Gastrostomy procedures performed post-SG leakage diagnosis, highlighting differences between acute and chronic instances. The study effectively implemented Zachariah's one-step approach, achieving favorable results in all five cases. Patient characteristics, presentation, postoperative progression, and additional treatments were documented. The outcome supports Zachariah's assertion that the one-step approach is a simple, safe, and cost-effective approach for SG leakage, avoiding digestive tract reconstruction. Despite potential limitations, including challenges in closing large defects and extended healing times, the procedure's effectiveness in decompression, drainage, and nutritional support significantly contributes to its elevated healing rate. The study emphasizes the importance of timely abdominal drain removal based on clinical conditions, challenging traditional practices for better clinical outcomes.

Splenic abscess is a rare complication often associated with sleeve gastrectomy (SG) due to factors including local infections, distant infections, tumors, ischemia, and trauma, which presents substantial challenges. We report four cases of gastrosplenic fistula and/or splenic abscess after SG. Patient data, including demographics, comorbidities, diagnostic procedures, treatments, and outcomes, were recorded. Surgical techniques for SG adhered to established protocols. Four patients had a male-to-female ratio of 2:2, with an average age of 39.8 years and an average preoperative BMI of 38.9 kg/m2. All patients were readmitted due to recurrent fever and chills caused by splenic abscesses detected on CT scans, with an average admission duration of 16.5 weeks. Treatments varied from fasting and antibiotics to percutaneous drainage and surgical interventions. The average treatment duration post-diagnosis of splenic abscess was 37.25 weeks. Managing gastrosplenic fistula and/or splenic abscess is complex, underscoring the significance of prompt diagnosis and proper treatment. This highlights the need for heightened awareness among healthcare professionals to promptly recognize and manage this rare complication after SG.

With a rising number of bariatric procedures, the absolute number of postoperative complications is increasing, too. Postoperative bleeding, particularly along the staple line, is a recognized challenge. Numerous strategies including reinforcement of the staple line (SLR) have been proposed to improve bleeding rates, but no single technique has shown superiority over the others. In our bariatric center, we have implemented intraoperative blood pressure regulation alone, without SLR, to reduce hemorrhagic complications postoperatively.

This retrospective observational analysis compares the incidence of postoperative bleeding in two groups of consecutive patients (total n = 438 patients), one with and one without intraoperative blood pressure elevation to 150 mmHg systolic without the additional use of staple line reinforcement. This intervention was integrated into our standard bariatric surgical procedure, no randomization or matching was conducted. Significant postoperative bleeding was defined as drop of hemoglobin of more than 2.5 mg/dl in 48 h and one of the following symptoms: lactate ≥ 2 mmol/L, bloody drainage, quantity of drainage more than 200 ml and/or radiological signs.

Defined postoperative bleeding occurred in 33 (7.5%) patients. We observed a decrease in bleeding rates from 10% to 5% (n = 22 vs. n = 11) after introducing intraoperative blood pressure increase (p = 0.034). The rate of revisional surgery for bleeding also decreased from 2.7% to 0.5% (n = 6 vs. n = 1). In multivariate analysis, the intervention with blood pressure elevation showed a significant decrease on bleeding rates (p = 0.038).

The use of increased intraoperative blood pressure alone, without staple line reinforcement, appears to be an effective and suitable method for reducing post-bariatric hemorrhagic complications.

Background Laparoscopic sleeve gastrectomy (LSG) has become a widely accepted bariatric procedure for treating morbid obesity and associated comorbidities due to its relatively straightforward technique and positive outcomes in terms of weight loss and metabolic improvement. Objective To investigate the frequency and types of early complications following LSG using four ports. Methods This prospective observational study was conducted at Al Hadi International Hospital, Swabi, Pakistan, from January 2022 to December 2022. A total of 369 patients aged 25-65 years with a BMI of 35-55 kg/m2 were included. Data on demographic characteristics, surgery duration, intraoperative blood loss, and hospital stay were collected. Early complications within 30 days post-surgery, including bleeding, infection, and leakage, were documented. Statistical analyses were performed using IBM SPSS Statistics for Windows, Version 26 (Released 2019; IBM Corp., Armonk, New York, United States). Results The mean age of patients was 43.6 years (SD = 11.8) and the mean BMI was 42.3 kg/m2 (SD = 6.5). The average surgery duration was 92 minutes (SD = 22) and the mean intraoperative blood loss was 100 mL (SD = 50). Early complications occurred in 18% of patients with bleeding, infection, and leakage each accounting for 5%, 4%, and 3%, respectively. Reoperation was required in 5% of patients due to these complications. Higher BMI (45.2 vs. 41.8 kg/m2, p = 0.04) and longer surgery duration (105 vs. 88 minutes, p = 0.03) were significantly associated with increased complication rates. Comorbidities were present in 60% of patients with complications compared to 34% without complications (p = 0.03). Conclusion The four-port technique in LSG is associated with an 18% early complication rate with significant risk factors being higher BMI and longer surgery duration. Careful patient selection, standardized surgical techniques, and robust postoperative care are essential to minimize complications and improve outcomes in LSG.

Despite the success of bariatric surgery in treating obesity, it can still lead to complications. The most serious and feared technical complications are bleeding and leakage from the gastric staple line. In this study, stapler line reinforcement was investigated to determine whether it affects postoperative leakage and bleeding rates and their management.

Overall, 510 patients who underwent sleeve gastrectomy were evaluated retrospectively. They were divided into 2 groups according to whether reinforcement of the staple line with running imbricating sutures was performed.

In the reinforcement group, there were two leaks (0.7%), which were diagnosed seven and eight days after surgery. In the non-reinforcement group, there were nine leaks (4%). There was no difference between the two groups in staple line bleeding.

This study shows that reinforcement with continuous imbricating sutures is associated with less stapler line leakage and a lower reoperation rate at the cost of increased operative time.

Background and Objectives: Functional gastric stenosis, a consequence of sleeve gastrectomy, is defined as a rotation of the gastric tube along its longitudinal axis. It is brought on by gastric twisting without the anatomical constriction of the gastric lumen. During endoscopic examination, the staple line is deviated with a clockwise rotation, and the stenosis requires additional endoscopic manipulations for its transposition. Upper gastrointestinal series show the gastric twist with an upstream dilatation of the gastric tube in some patients. Data on its management have remained scarce. The objective was to assess the efficacy and safety of endoscopic balloon dilatation in the management of functional post-sleeve gastrectomy stenosis. Patients and Methods: Twenty-two patients with functional post-primary-sleeve-gastrectomy stenosis who had an endoscopic balloon dilatation between 2017 and 2023 were included in this retrospective study. Patients with alternative treatment plans and those undergoing endoscopic dilatation for other forms of gastric stenosis were excluded. The clinical outcomes were used to evaluate the efficacy and safety of balloon dilatation in the management of functional gastric stenosis. Results: A total of 45 dilatations were performed with a 30 mm balloon in 22 patients (100%), a 35 mm balloon in 18 patients (81.82%), and a 40 mm balloon in 5 patients (22.73%). The patients' clinical responses after the first balloon dilatation were a complete clinical response (4 patients, 18.18%), a partial clinical response (12 patients, 54.55%), and a non-response (6 patients, 27.27%). Nineteen patients (86.36%) had achieved clinical success at six months. Three patients (13.64%) who remained symptomatic even after achieving the maximal balloon dilation of 40 mm were considered failure of endoscopic dilatation, and they were referred for surgical intervention. No significant adverse events were found during or following the balloon dilatation. Conclusions: Endoscopic balloon dilatation is an effective and safe minimally invasive procedure in the management of functional post-sleeve-gastrectomy stenosis.

The metabolic benefits of bariatric surgery that contribute to the alleviation of metabolic dysfunction-associated steatotic liver disease (MASLD) have been reported. However, the processes and mechanisms underlying the contribution of lipid metabolic reprogramming after bariatric surgery to attenuating MASLD remain elusive.

A case-control study was designed to evaluate the impact of three of the most common adipokines (Nrg4, leptin, and adiponectin) on hepatic steatosis in the early recovery phase following sleeve gastrectomy (SG). A series of rodent and cell line experiments were subsequently used to determine the role and mechanism of secreted adipokines following SG in the alleviation of MASLD.

In morbidly obese patients, an increase in circulating Nrg4 levels is associated with the alleviation of hepatic steatosis in the early recovery phase following SG before remarkable weight loss. The temporal parameters of the mice confirmed that an increase in circulating Nrg4 levels was initially stimulated by SG and contributed to the beneficial effect of SG on hepatic lipid deposition. Moreover, this occurred early following bariatric surgery. Mechanistically, gain- and loss-of-function studies in mice or cell lines revealed that circulating Nrg4 activates ErbB4, which could positively regulate fatty acid oxidation in hepatocytes to reduce intracellular lipid deposition.

This study demonstrated that the rapid effect of SG on hepatic lipid metabolic reprogramming mediated by circulating Nrg4 alleviates MASLD.

Obesity is associated with several chronic conditions including diabetes, cardiovascular disease, and metabolic dysfunction-associated steatotic liver disease and malignancy. Bariatric surgery, most commonly Roux-en-Y gastric bypass and sleeve gastrectomy, is an effective treatment modality for obesity and can improve associated comorbidities. Over the last 20 years, there has been an increase in the rate of bariatric surgeries associated with the growing obesity epidemic. Sleeve gastrectomy is the most widely performed bariatric surgery currently, and while it serves as a durable option for some patients, it is important to note that several complications, including sleeve leak, stenosis, chronic fistula, gastrointestinal hemorrhage, and gastroesophageal reflux disease, may occur. Endoscopic methods to manage post-sleeve gastrectomy complications are often considered due to the risks associated with a reoperation, and endoscopy plays a significant role in the diagnosis and management of post-sleeve gastrectomy complications. We perform a detailed review of the current endoscopic management of post-sleeve gastrectomy complications.

Gastric peroral endoscopic myotomy (G-POME) is an emerging minimally invasive endoscopic technique involving the establishment of a submucosal tunnel around the pyloric sphincter. In 2013, Khashab et al used G-POME for the first time in the treatment of gastroparesis with enhanced therapeutic efficacy, providing a new direction for the treatment of gastroparesis. With the recent and rapid development of G-POME therapy technology, progress has been made in the treatment of gastroparesis and other upper digestive tract diseases, such as congenital hypertrophic pyloric stenosis and gastric sleeve stricture, with G-POME. This article reviews the research progress and future prospects of G-POME for the treatment of upper digestive tract gastrointestinal diseases.

Conversional surgery is common after laparoscopic sleeve gastrectomy (LSG) because of suboptimal weight loss (SWL) or poor responders and gastroesophageal reflux disease (GERD). Roux-en-Y gastric bypass (RYGB) is the most common conversional procedure after LSG.

A retrospective cohort study analyzed patients who underwent primary RYGB (PRYGB) or conversional RYGB (CRYGB) at three specialized bariatric centers between 2008 and 2019 and tested for weight loss, resolution of GERD, food tolerance (FT), early and late complications, and the resolution of associated medical problems. This was analyzed by propensity score matching (PSM).

In total, 558 (PRYGB) and 155 (CRYGB) completed at least 2 years of follow-up. After PSM, both cohorts significantly decreased BMI from baseline (p < 0.001). The CRYGB group had an initially more significant mean BMI decrease of 6.095 kg/m2 at 6 months of follow-up (p < 0.001), while the PRYGB group had a more significant mean BMI decrease of 5.890 kg/m2 and 8.626 kg/m2 at 1 and 2 years, respectively (p < 0.001). Food tolerance (FT) improved significantly in the CRYGB group (p < 0.001), while CRYGB had better FT than PRYGB at 2 years (p < 0.001). A GERD resolution rate of 92.6% was recorded in the CRYGB (p < 0.001). Both cohorts had comparable rates of early complications (p = 0.584), late complications (p = 0.495), and reoperations (p = 0.398). Associated medical problems at 2 years significantly improved in both cohorts (p < 0.001).

CRYGB is a safe and efficient option in non- or poor responders after LSG, with significant weight loss and improvement in GERD. Moreover, PRYGB and CRYGB had comparable complications, reoperations, and associated medical problem resolution rates.

A large variation in outcome has been reported after sleeve gastrectomy (SG) across countries and institutions. We aimed to evaluate the effect of surgical technique on total weight loss (TWL) and gastro-esophageal reflux disease (GERD).

Observational cohort study based on data from the national registries for bariatric surgery in the Netherlands, Norway, and Sweden. A retrospective analysis of prospectively obtained data from surgeries during 2015-2017 was performed based on 2-year follow-up. GERD was defined as continuous use of acid-reducing medication. The relationship between TWL, de novo GERD and operation technical variables were analyzed with regression methods.

A total of 5927 patients were included. The average TWL was 25.6% in Sweden, 28.6% in the Netherlands, and 30.6% in Norway (p < 0.001 pairwise). Bougie size, distance from the resection line to the pylorus and the angle of His differed between hospitals. A minimized sleeve increased the expected total weight loss by 5-10 percentage points. Reducing the distance to the angle of His from 3 to just above 0 cm increased the risk of de novo GERD five-fold (from 3.5 to 17.8%).

Smaller bougie size, a shorter distance to pylorus and to the angle of His were all associated with greater weight loss, whereas a shorter distance to angle of His was associated with more de novo reflux.

We investigated how laparoscopic sleeve gastrectomy (LSG) affected serum levels of thyroid-stimulating hormone (TSH), free thyroxine (FT4), and free triiodothyronine (FT3) in obese patients with hypothyroidism. We additionally examined whether the dose of levothyroxine decreases as a result of weight loss in this study.

Fifty-one people with obesity who received levothyroxine treatment for hypothyroidism and underwent LSG between January 2017 and January 2023 were retrospectively examined. Weight, body mass index (BMI), TSH, FT4, FT3, weekly levothyroxine dose changes, and weight-adjusted levothyroxine doses before surgery and the sixth month after surgery were compared.

Among the 51 patients included in this study, 50.98% ceased the use of levothyroxine, and nearly half (41.18%) required an adjustment of their levothyroxine dose during the follow-up period (sixth month). Notably, the total weekly dose of levothyroxine (mcg) decreased in the sixth month following surgery (p<0.001). The weekly weight-adjusted dose (mcg/kg) decreased during the same time frame (p<0.001). The preoperative total weekly dose of levothyroxine, EWL% and absence of hyperlipidemia were found to be the independent predictors of the weight-adjusted weekly levothyroxine dose change (p<0.001, p=0.038, and p=0.044, respectively).

Thyroid function tests in people with obesity can show improvement after LSG. LSG may reduce the weight-adjusted dose of levothyroxine at six months postoperatively and therefore patients should be monitored for possible levothyroxine dose readjustments based on weight loss.

Gastroesophageal reflux disease (GERD) after sleeve gastrectomy (SG) may be related to surgical technique. The fact that there is a lack of technical standardization may explain large differences in GERD incidence. The aim of this study is to evaluate auto- and hetero-agreement for SG technical key points based on recorded videos.

Ten experienced (minimum of 5 years performing bariatric surgery, minimum of 30 SG per year) bariatric surgeons (9 (90%) males) were selected. Participants were invited to send an unedited video with a typical laparoscopic SG (first round of the Delphi process). Videos were cropped into small clips comprising 11 key points of the technique. All anonymized clips (including their own) were returned to all surgeons. Individuals were asked to agree or not with the technique demonstrated (second round). The percentage of agreement was presented to the entire group that was asked for a second vote (third round).

Agreement was poor/fair for all points except hiatal repair that had a very good agreement in the second round. For the third round, there was a slight increase in agreement for distance esophagogastric junction/proximal stapling and gastric mobilization for stapling and a slight decrease in agreement for gastric tube final shape. Only 1 (10%) surgeon recognized that he evaluated his own video. Five (50%) surgeons disagreed with themselves on 1 or more points.

SG lacks intrasurgeon and intersurgeon agreement in technical key points that may justify significant differences in GERD incidence after the procedure.

Postoperative staple line leakage (SLL) after sleeve gastrectomy (SG) is a rare but serious complication. Many surgeons routinely test anastomosis with an intraoperative leak test (IOLT) as part of the SG procedure. This meta-analysis aims to determine whether an IOLT plays a role in reducing the rate of postoperative staple line related complications in patients who underwent SG.

The authors searched the PubMed, Web of science, the Cochrane Library, and Clinical Trials.gov databases for clinical studies assessing the application of IOLT in SG. The primary endpoint was the development of postoperative SLL. Secondary endpoints included the postoperative bleeding, 30 days mortality rates, and 30 days readmission rates.

Six studies totaling 469 588 patients met the inclusion criteria. Our review found that the SLL rate was 0.38% (1221/ 324 264) in the IOLT group and 0.31% (453/ 145 324) in the no intraoperative leak test (NIOLT) group. Postoperative SLL decreased in the NIOLT group compared with the IOLT group (OR=1.27; 95% CI: 1.14-1.42, P =0.000). Postoperative bleeding was fewer in the IOLT group than that in the NIOLT group (OR 0.79; 95% CI: 0.72-0.87, P =0.000). There was no significant difference between the IOLT group and the NIOLT group regarding 30 days mortality rates and 30 days readmission rates ( P >0.05).

IOLT was correlated with an increase in SLL when included as a part of the SG procedure. However, IOLT was associated with a lower rate of postoperative bleeding. Thus, IOLT should be considered in SG in the situation of suspected postoperative bleeding.

Background: Postoperative pain is one of the major problems after laparoscopic sleeve gastrectomy besides complications. Management of pain control is still unclear in the obese population. Modified BRILMA (blocking the cutaneous branches of intercostal nerves in the middle axillary line) is a new analgesia technique which is performed by ultrasonography guided through the way between eighth and ninth rib level. This study is to evaluate the efficiency of modified BRILMA in bariatric patients while comparing with trocar site infiltration. Materials and Methods: This is a prospective designed retrospective data analysis study. Patients undergoing laparoscopic sleeve gastrectomy between June 2019 and January 2020 were divided into two groups. One group underwent BRILMA block; the other group used traditional trocar site injection. Postoperative pain was followed by using visual analogue scale (VAS) (at 1, 3, 6, 12, 24, 36, 48 hours postoperatively). Results: Thirty patients were included in the study. Twenty-four (80%) of the patients were women, and 6 (20%) of the patients were men. Mean body mass index of patients were 39.83 ± 4.02 kg/m2. Mean operational time was calculated 86.16 ± 19.94 minutes. When the patients' VAS was compared, 12th hour VAS value was statistically less in the BRILMA group. There were no significant differences in other hours' VAS between two groups. When compared with the use of opioid amount, there were no statistically significant difference between the two groups (P = .66), but BRILMA group had less amount. Conclusion: Modified BRILMA is an alternative technique to the use of trocar site bupivacain injection in bariatric surgery. It is new technique that is tried in bariatric population, which is also cost-effective and has less opioid consumption.

To preserve the aesthetic benefits achieved with Bikini line sleeve gastrectomy (BLSG), we have devised a novel approach for simultaneous hiatal hernia repair (HHR), known as bikini-line hiatal hernia repair (BLHHR). This manuscript presents our initial experience with BLHHR and assesses its feasibility and outcomes.

A prospective preliminary study was conducted on patients who underwent BLHHR between September 2020 and October 2022. Patient demographics, preoperative assessments, operative details, postoperative outcomes, and aesthetic evaluations were recorded. Feasibility and safety were assessed.

Among 891 BLSG patients, 89 (9.9%) underwent BLHHR. The mean distances between the xiphoid process and the umbilicus, symphysis pubis, and anterior superior iliac spine (ASIS) were 28.8 ± 2.2, 33.9 ± 3.1, and 31.2 ± 1.8 cm, respectively. Optimal visualization and accessibility of the gastroesophageal junction (GEJ) were achieved without compromising HHR repair or sleeve gastrectomy. The mean operative time was 76.5 ± 11 min, longer than the 58 ± 10 min required for BLSG alone. Patient scar satisfaction ranged from 87.5 to 97.9%, and the mean pain score was 2.9 ± 0.8. No major complications were reported. At 6 months, %EWL (percentage of excess weight loss) was 53.3 ± 13.7%, GERD (gastroesophageal reflux disease) remission was achieved in 62.8% of patients and comorbidities were improved.

BLHHR was potentially feasible and safe. Outcomes related to patient scar satisfaction, weight loss, improvement of associated comorbidities, and GERD symptoms were not compromised. The aesthetic benefits achieved by BLSG were maintained.

Laparoscopic sleeve gastrectomy (LSG) has become an increasingly popular bariatric procedure. LSG still conveys some risks, including early staple line complications such as bleeding and leaks. It has been proposed that staple line complications can be reduced by staple line reinforcement (SLR). This study aimed to compare the short-term efficacy and safety of the SLR during LSG by oversewing versus no SLR in an Egyptian cohort over a period of 11 years.

This is a retrospective study that analyzed data from patients undergoing LSG by the same surgeon over a period of 11 years. The patients' early postoperative complications were compared according to performing SLR.

The SLR group showed significantly longer surgery time (p = 0.021) and a lower rate of postoperative bleeding (p = 0.027). All leakage cases occurred in the non-SLR group (0.7% vs. 0.0%) without statistical significance (p = 0.212). The two mortality cases occurred in the non-SLR group. The LOS was comparable in the two groups (p = 0.289).

This study confirms the short-term benefits of SLR by oversewing during LSG in terms of a lower incidence of 30-day morbidity, particularly bleeding, and lower rates of reoperation, with a clinically questionable longer operation time.

Laparoscopic sleeve gastrectomy (LSG) is the most performed bariatric procedure worldwide. The most challenging postoperative complication is gastric leak. The objectives of this study are to examine the efficacy and morbidity of different therapeutic strategies addressing leakage, and the long-term outcomes of a cohort of LSG leaks.

A retrospective review of patients treated for LSG leaks between September 2014 and January 2023 at our high-volume bariatric surgery center was performed.

The charts of 37 patients (29 women and 8 men) were reviewed, with a mean age of 43 years and a median follow-up of 24 months. The mean preoperative body mass index was 45.1 kg/m2. Overall, 30/37 (81%) patients were successfully treated with endoscopic management, and 7/37 (19%) ultimately underwent salvage surgery. If the leak was diagnosed earlier than 6 weeks, endoscopic treatment had a 97% success rate. The median number of endoscopic procedures was 2 per patient, and included internal pigtails, stents, septoplasty, endoluminal vacuum therapy and over-the-scope clips. Complications included stent-related ulcers (10), esophageal stenosis requiring endoscopic dilatations (4), stent migrations (2) and kinking requiring repositioning (1), and internal pigtail migration (3). Revisional surgery consisted of proximal gastrectomy and Roux-en-Y esophago-jejunal anastomosis, Roux-en-Y fistulo-jejunostomy or classic Roux-en-Y gastric bypass proximal to the gastric stricture. In 62% of the cases, the axis/caliber of the LSG was abnormal. Beyond 4 attempts, endoscopy was unsuccessful. The success rate of endoscopic management dropped to 25% when treatment was initiated more than 45 days after the index surgery.

Purely endoscopic management was successful in 81% of cases; with 97% success rate if diagnosis earlier than 6 weeks. After four failed endoscopic procedures, a surgical approach should be considered. Delayed diagnosis appears to be a significant risk factor for failure of endoscopic treatment.

The continuous evolution of endoscopic tools over the years has paved the way for minimally invasive alternatives to surgical procedures for multiple gastrointestinal conditions. While few endoscopic techniques have supplanted their surgical counterparts like percutaneous gastrostomy tubes, many have emerged as noninferior, less morbid alternatives for such diverse conditions as achalasia (peroral endoscopic myotomy), obesity (endoscopic sleeve gastroplasty), drainage of pancreatic walled off necrosis (EUS-guided cystogastrostomy), and gastric outlet obstruction (EUS-guided gastrojejunostomy). These techniques were based on surgical concepts and would not have been feasible without collaboration between surgeons and endoscopists. Such collaboration is exemplified by the antireflux fundoplication, which features combined hiatal hernia repair with transoral and incisionless fundoplication. The burgeoning armamentarium of endoscopic alternatives to traditional surgical procedures requires a multidisciplinary discussion and individually tailored treatment plans that consider patient preferences as well as the relative risks and benefits of surgical and endoscopic approaches. As technological advances give rise to ever more innovative endoscopic techniques, studies to evaluate clinical outcomes and define their role in treatment algorithms will be required.

Upper gastrointestinal postsurgical leaks are life-threatening conditions with high mortality rates and are one of the most feared complications of surgery. Leaks are challenging to manage and often require radiological, endoscopic, or surgical intervention. Steady advancements in interventional endoscopy in recent decades have allowed the development of new endoscopic devices and techniques that provide a more effective and minimally invasive therapeutic option compared to surgery. Since there is no consensus regarding the most appropriate therapeutic approach for managing postsurgical leaks, this review aimed to summarize the best available current data. Our discussion specifically focuses on leak diagnosis, treatment aims, comparative endoscopic technique outcomes, and combined multimodality approach efficacy.

Postoperative nausea and vomiting (PONV) is a frequent unappealing laparoscopic sleeve gastrectomy (LSG) sequel. The study's purpose was to determine the prevalence, risk factors of PONV, and management of PONV after LSG.

This multicenter retrospective study included patients with morbid obesity who had LSG between January 2022 and April 2023. The age range for LSG was 16 to 65 years, and the eligibility requirements included morbid obesity according to international guidelines.

PONV was experienced by 74.6% of patients who underwent LSG at 6 h postoperative. Multivariate analysis revealed that female gender, smokers, preoperative GERD, gastropexy, and severity of pain were found to be independent risk variables of the development of PONV, while antral preservation, opioid-free analgesia, and intraoperative combined analgesia were found to be independent protective variables against the development of PONV. Combined intravenous ondansetron and metoclopramide improved 92.6% of patients who developed PONV. Dexamethasone and antihistamines drugs are given for 42 cases with persistent PONV after using intravenous ondansetron and metoclopramide. Pain management postoperatively by opioid-free analgesia managed PONV. Helicobacter pylori status has no role in the development of PONV after LSG.

Female gender, smoking, presence of preoperative GERD, gastropexy, and severity of pain were found to be independent risk variables of the development of PONV, while antral preservation, opioid-free analgesia, and intraoperative combined analgesia were observed to be independent protective factors against the occurrence of PONV. Combined intravenous ondansetron and metoclopramide improved PONV. Dexamethasone and antihistamines drugs are given for persistent PONV.

Hiatal hernia (HH), whenever encountered during sleeve gastrectomy (SG), needs to be addressed because of its strong association with gastroesophageal reflux disease (GERD). However, the mid-term to long-term effects of hiatal hernia repair (HHR) on GERD remain unclear.

This was a cross-sectional observational analysis of patients who underwent SG + HHR and had completed at least 1 year of follow-up. The preoperative data were retrieved from a prospectively maintained database. Of the 590 patients who underwent SG, 63 patients (10.7%) with concomitant HHR were assessed for the use of proton pump inhibitors (PPIs) and symptoms of GERD using the GERD-Q questionnaire.

Of the 63 patients, 11 were lost to follow-up, and one underwent Roux-en-Y gastric bypass for HH recurrence and severe reflux. The remaining 51 patients were assessed at a mean follow-up of 3.7±2.0 years. Of these, 51% (26/51) patients had preoperative reflux symptoms. On follow-up, 69.2% (18/26) had complete resolution with significant improvement in their GERD-Q scores (9.8±3.1 to 6.5±2.1; P =0.001), while 76.2% (16/21) of patients were off the PPIs. The incidence of de novo GERD was found in 20% (5/25) of the patients.

In patients of morbid obesity with HH, concomitant HHR with SG leads to improvement of the reflux symptoms in more than two-thirds of the patients, besides alleviating the use of PPIs.

It is critical to ensure appropriate and consistent sleeve size and orientation during laparoscopic sleeve gastrectomy (LSG). Various devices are used to achieve this, including weighted rubber bougies, esophagogastroduodenoscopy (EGD), and suction calibration systems (SCS). Prior reports suggest that SCSs may decrease operative time and stapler load firings but are limited by single-surgeon experience and retrospective design. We performed the first randomized controlled trial comparing SCS against EGD in patients undergoing LSG to investigate whether the SCS decreases the number of stapler load firings.

This was a randomized, non-blinded study from a single MBSAQIP-accredited academic center. Appropriate LSG candidates ≥ 18 years of age were randomized to EGD or SCS calibration. Exclusion criteria included prior gastric or bariatric surgery, detection of hiatal hernia before surgery, and intraoperative hiatal hernia repair. A randomized block design was employed controlling for body mass index, gender, and race. Seven surgeons employed a standardized LSG operative technique. The primary endpoint was the number of stapler load firings. Secondary endpoints were operative duration, reflux symptoms, and change in total body weight (TBW). Endpoints were analyzed via t-test.

A total of 125 LSG patients (84% female) underwent study enrollment, with an average age of 44 ± 12 years and average BMI of 49 ± 8 kg/m2. Overall, 117 patients were randomized to receive EGD (n = 59) or SCS (n = 58) calibration. No significant differences in baseline characteristics were identified. The mean number of stapler load firings for EGD and SCS groups were 5.43 ± 0.89 and 5.31 ± 0.81, respectively (p = 0.463). The mean operative times for EGD and SCS groups were 94.4 ± 36.5 and 93.1 ± 27.9 min, respectively (p = 0.83). There were no significant differences in post-operative reflux, TBW loss, or complications.

Use of EGD and SCS resulted in a similar number of LSG stapler load firings and operative duration. Additional research is needed to compare LSG calibration devices in different patients and settings to optimize surgical technique.

Background: Staple-line reinforcement has been used to decrease complications such as staple-line bleeding (SLB) and staple-line leaks (SLLs) in patients undergoing laparoscopic sleeve gastrectomy (SG). There is little data comparing bioabsorbable mesh reinforcement (BMR) with oversewing the staple line (OSL). The aim of our study was to compare BMR with OSL in SG. Materials and Methods: This is a single-institution retrospective analysis comparing risks and benefits of BMR (group a) with those of OSL (group b) for SG staple-line reinforcement between 2015 and 2020. Results: In total, 857 patients were identified. There were 452 (52.74%) in group a and 405 (47.26%) in group b. SLB requiring transfusion occurred in 6 (1.32%) patients in group a and 6 (1.48%) patients in group b, NS (P = .848). Zero SLL was identified in either group. One-year mean direct cost of SG in group a was $7881 compared with $6677 in group b. Conclusion: This retrospective study showed that there was low risk of bleeding or leak with either technique of staple-line reinforcement and there was no significant difference in SLB or leak rate with bioabsorbable mesh versus oversewing. The use of bioabsorbable mesh was more expensive than oversewing.

Sleeve gastrectomy (SG) has gained ever-increasing popularity among laparoscopic surgeons involved in bariatric surgery. This single-institution, retrospective cohort study aims to evaluate the prevalence of postoperative staple line leakage (PSLL) after LSG and identify risk factors for its development. We included patient data that underwent LSG at our institution for a span of 17 years-starting in January 2005 and ending in December 2022. We set the investigation of correlations of patient-related factors (age, weight, BMI, smoking status, presence of diabetes mellitus) with the occurrence of postoperative leaks. A total of 402 patients were included in our study. Of them, 26 (6.46%) developed PSLL. In total, 19 (73%) patients underwent percutaneous drainage and 14 patients (53.8%) were treated with intraluminal endoscopic stenting. Finally, five patients (19.2%) were treated with endoscopic clipping of the defect. Operative management was required in only one patient. There were no statistically significant differences in patient age, mean weight at the time of operation, and mean BMI. Abnormal drain amylase levels were associated with earlier detection of PSLL. More consideration needs to be given to producing a consensus regarding the management of PSLL, prioritizing nonoperative management with the combination of percutaneous drainage and endoscopic stenting as the safest and most efficient approach.

Cardiac sarcoidosis (CS) is a potentially serious form of infiltrative cardiomyopathy. Despite scarce evidence, immunosuppressive treatment is generally recommended, but local routines may vary significantly. We sought to survey the clinical practices in the treatment of CS, with the aim that the results may suggest future research priorities. We conducted a web-based survey focused on treatment-naive patients with CS. We subclassified CS according to the presence/absence of overt cardiac presentation (clinically manifest/silent) and to the presence/absence of active inflammation (metabolically active/inactive by fluorodeoxyglucose positron emission tomography). The survey was developed jointly by the authors and administered to expert clinicians (n = 79) involved in CS treatment. An agreement threshold was set at 70%. A total of 62 of 79 respondents (78.5%) from 12 countries completed the survey. The agreement threshold was reached for: (1) always treating clinically manifest, metabolically active CS, 57 of 62 (91.9%), (2) never treating clinically silent, metabolically inactive CS, 44 of 62 (71.0%), (3) not requiring histopathologic confirmation of sarcoidosis before treatment initiation, (49 of 62, 79.0%), (4) using fluorodeoxyglucose positron emission tomography for assessing treatment indication (44 of 62, 71.0%) and treatment response (44 of 62, 71.0%), and (5) using prednisone as a first-line agent (100%), although respondents were divided on monotherapy (69.4%) or combination with methotrexate 25.8%. The approach to particular scenarios, tapering, and duration of treatment showed the greatest variation in response. In conclusion, in this survey of clinical practice, important aspects of CS treatment reached the agreement threshold, whereas others showed a great degree of clinical equipoise.

Endoscopic vacuum therapy (EVT) possesses a unique mechanism of action providing a less invasive alternative for the management of transmural gastrointestinal defects (TGID). This study evaluates the efficacy and safety of a novel homemade EVT (H-EVT) for the treatment of TGID.

Retrospective multicenter study including patients who underwent H-EVT for TGID between January 2019 and January 2022. Main outcomes included technical and clinical success as well as safety outcomes. Subgroup analyses were included by defect location and classification. Logistic regression analyses were performed to determine predictors for successful closure.

A total of 144 patients were included. Technical success was achieved in all patients, with clinical success achieved in 88.89% after a mean of 3.49 H-EVT exchanges over an average of 23.51 days. After excluding 10 cases wherein it was not possible to achieve negative pressure, successful closure occurred in 95.52% of patients. Time to clinical success was less for defects caused by endoscopic (hazard ratio [HR] 0.63; 95% confidence interval [CI] 0.33-1.20) compared to surgical procedures and for patients with simultaneous intracavitary and intraluminal H-EVT placement (HR 0.70; 95% CI 0.55-0.91). Location and classification of defect did not impact clinical success rate. Simultaneous placement of both an intraluminal and intracavitary H-EVT (odds ratio 3.08; 95% CI 1.19-7.95) was a significant predictor of clinical success. Three device-related adverse events (2.08%) occurred.

The use of the H-EVT is feasible, safe, and effective for the management of TGID.