Children and adolescent (pediatric) obesity is a growing global health challenge, with traditional weight-loss strategies often proving ineffective. Metabolic and bariatric surgery (MBS) is increasingly considered for pediatric patients with severe obesity. The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) published its latest recommendations on pediatric MBS in 2022. However, their adoption may vary across countries due to differences in healthcare systems, cultural norms, and resources. To assess global variability in indications, practices, and healthcare coverage for pediatric MBS among IFSO member countries, and to evaluate adherence to international guidelines. A descriptive survey was conducted among IFSO-affiliated national societies using a 17-item online questionnaire covering indications for pediatric MBS, recommended techniques, referral pathways, and financial coverage. Of 76 societies, 66 (86.8

Background and Aims: Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most prevalent chronic liver disease and frequently improves after bariatric surgery. Conventional postoperative follow-up is mainly based on weight-loss outcomes, such as Body Mass Index (BMI), excess weight loss (EWL), total weight loss (TWL), and routine biochemical parameters, which may not fully characterize hepatic fat response. Ultrasound-derived fat fraction (UDFF) provides a quantitative non-invasive assessment of hepatic steatosis, while DXA-derived visceral adipose tissue (VAT) reflects central adiposity and metabolic risk. This study aimed to evaluate whether combined UDFF and DXA-VAT assessment provides complementary information to conventional bariatric follow-up parameters after bariatric surgery. Methods: We conducted a prospective longitudinal cohort study on 41 patients with severe obesity who underwent bariatric surgery between July 2025 and May 2026. Anthropometric, body composition, metabolic, hepatic, and biochemical parameters were assessed at baseline (T0) and 6 months postoperatively (T1). UDFF, utilizing a DAX ultrasound transducer, was used for hepatic steatosis assessment, while DXA was performed for VAT, android fat mass, total body fat percentage, and lean mass quantification. Correlation analyses, multivariable linear regression, and an exploratory clinical discordance analysis were performed. Results: At 6 months after surgery, patients showed significant improvements in body weight, visceral adiposity, insulin resistance, biochemical parameters, and hepatic steatosis. VAT reduction showed the strongest association with UDFF reduction, whereas conventional weight-loss outcomes, anthropometric, and metabolic parameters did not fully identify patients with residual steatosis. These findings suggest that hepatic fat improvement after bariatric surgery is more closely related to changes in visceral adiposity than to weight loss alone. Conclusions: Combined UDFF and DXA-derived VAT assessment may provide a practical dual-compartment imaging framework for postoperative MASLD monitoring. This approach captures both hepatic fat response and visceral adiposity remodeling, offering information that complements conventional bariatric follow-up based on weight-loss outcomes.

Background: Despite the recognised benefits of laparoscopic colorectal surgery (LCS), its uptake in Romania has remained low, with less than 4% of cases performed using laparoscopy in 2018. To address this gap, LAPCO Romania (LAPCO-Ro), modelled on the UK National Training Programme, was established as a structured network for mentorship, competency-based evaluation and faculty development. The objective of this study is to evaluate the impact of this programme on the use of minimally invasive surgery in colorectal pathology and on complication rates. Methods: We describe the structure and early experience of LAPCO-Ro and evaluate its effect on nationwide LCS implementation, focusing on changes in adoption rates, comparison of complication rates between procedures supervised by LAPCO-Ro and those that were not, and projections of national outcomes in the absence of the programme. Results: From 2017 to 2024, the proportion of laparoscopic colorectal resections in Romania increased from 3.2% to 11.6%. Complication rates for laparoscopic cases remained consistently lower than open surgery (mean 2.8% vs 4.8%), with relative risk ranging from 0.31 to 0.87, indicating a 13 69% reduction in morbidity compared to open procedures. Excluding LAPCO-Ro trainee-related cases, the national trend in Romania would have followed its earlier linear trajectory (+177 cases/year), reaching only about 10% laparoscopic adoption by 2024 instead of the actual 13%. LAPCO-Ro thus accelerated national diffusion by 30 35%, resulting in approximately 500 additional minimally invasive colectomies in 2024 and over 1,000 since the start of the programme. Within LAPCO-Ro, mentored laparoscopic colorectal cases were associated with low postoperative morbidity (2.46%). Conclusions: The LAPCO-Ro experience demonstrates that a structured, competency-based national training network can accelerate the dissemination of minimally invasive colorectal surgery in a late-adopter health system.

BACKGROUND:Randomized, controlled trials (RCTs) comparing the effectiveness of metabolic bariatric surgery (MBS) in addition to one or more treatment interventions for obesity (i.e., lifestyle structured interventions-LSI, medical therapy-MT, obesity management medication-OMM or endobariatric procedures-EP) are lacking. This study aims to assess the effectiveness of multiple simultaneous (before or immediately after MBS) interventions for treating obesity. METHODS:We performed a meta-analysis including all RCTs enrolling patients undergoing different MBS procedures add-on to other anti-obesity strategies (LSI, MT, OMM or ES) versus MBS alone, with a duration of at least 6 months. The primary outcome was BMI at the end-point; secondary end-points included percentage total and excess weight loss (%TWL%, and EBWL%), total weight loss (TWL), fasting plasma glucose (FPG), HbA1c, surgical and non-surgical severe adverse events (SAE), mortality, remission of type 2 diabetes, hypertension, dyslipidemia and health-related quality of life (HR-QoL). RESULTS:A total of 25 RCTs were retrieved. The addition of either OMM (i.e., liraglutide) or EP (i.e., intragastric balloon-IB, endosleeve-ES) to MBS was associated with a significantly lower BMI at the end-point (p = 0.040). The addition of liraglutide only to MBS was associated with a greater %EWL%, but not %TWL and TBWL (p = 0.008). Three trials evaluated end-point HbA1c, showing a significant reduction in favour of liraglutide as an add-on therapy to MBS (p = 0.007). There was no mortality. CONCLUSIONS:MBS combined with non-surgical approaches appears more effective than MBS alone in reducing BMI. Further RCTs on combined therapies to MBS for severe obesity are needed to enhance the tailoring of treatment for severe obesity.

BackgroundWith over 1 billion individuals affected globally, obesity and obesity related diseases is now a leading cause of death. Metabolic and bariatric surgery (MBS) has emerged as a cornerstone intervention for severe obesity and its associated comorbidities. Despite its efficacy, postoperative care and follow-up after MBS remains highly variable worldwide.ObjectiveThe PARTNER study aimed to evaluate global clinical practices in the postoperative management following MBS by surveying multidisciplinary healthcare professionals.MethodsThis study was an international online survey conducted between October 2024 and January 2025. A multidisciplinary team developed the questionnaire based on existing literature and international guidelines. The survey assessed five domains: follow-up care, postoperative treatment, dietary management, patient support, and measurement of surgical outcomes. Responses were analysed descriptively.ResultsA total of 262 responses were received from 62 countries. Most respondents were bariatric surgeons (72.1%) working in public healthcare systems (73.3%). While 78.7% reported conducting three-month postoperative reviews, only 23.7% offered indefinite follow-up. Hybrid models of care (virtual and in-person) were common (56.9%). VTE prophylaxis and postoperative PPI use were recommended by 64.1% and 84.3% respectively. Nearly all respondents (98.1%) provided dietary advice, with protein and micronutrient supplementation widely endorsed. Only 56.1% routinely referred patients for psychological follow-up. Definitions of surgical success and failure varied widely, with inconsistent objective outcome measures.ConclusionThe PARTNER study reveals significant international variation in postoperative management practices following MBS. These findings underscore the need for more standardized, evidence-based guidelines to improve long-term outcomes and equity of care worldwide.

Background: Early anastomotic bleeding is a relatively understated compli cation of colorectal surgery. Despite intraoperative preventing protocols aiming to limit postoperative anastomotic hemorrhage, in some cases it can be dramatic. Therefore, we have decided to find out if our protocol of prompt emergency endoscopic management ("Stop-the-Bleeding" Protocol) is feasible, effective and safe. Methods: Between January, 1st 2017 and July 1st 2024 we run a prospective single-center study including all the patients who underwent colorectal resection with stapled anastomosis and experienced significant per rectum bleeding within the first 30 postoperative days. Primary outcomes were feasibility and efficacy of the endoscopic approach, related complications and mortality. Results: We had 599 patients who underwent colorectal resections with mechanical anastomosis in our Center, of whom 48 patients (8%) experienced per rectum bleeding. Bleeding was encountered after all types of stapled anastomosis: recto-colic anastomoses (28 patients, 10.1%), side-to-side colo-colic anastomoses (5 patients, 3.7%), and side-to-side ileocolic anastomoses (15 patients, 8%). Hemostasis was obtained endoscopically in all the cases, mostly by only one session. No anastomotic dehiscence/ leakage or fatality related to the hemorrhagic complication, or the endoscopic procedure were encountered in these series. Conclusions: Emergency endoscopic hemostasis for postoperative bleeding after colorectal stapled anastomosis is feasible, effective, and safe.

Introduction: minimally invasive surgery is the surgery of the present and has become the "gold standard" for the most pathologies. The training of surgeons in minimally invasive techniques is mandatory required to be carried out during the residency program. In Romania, there is no national minimally invasive surgical training program, only universities and certain university hospitals are concerned with this aspect. The aim of this study was to assess the level of minimally invasive surgical training at the national level and to identify the concerns of residents and young specialists in surgical specialties. Material and Method: the Young-RAES team designed a confidential 25-question online questionnaire that explores the individual minimally invasive surgical training and needs of young medical surgeons. The online questionnaire was sent to young surgeons from Romania, RAES members and non-members, and was distributed on social networks. All young surgeons, regardless of specialty (age 40 years), were invited to participate in the period December 2023 " January 2024 on the survey. Results: a total of 197 respondents from 9 University Centers participated in the survey. The majority of respondents (55.3%) described their current position as a resident doctor, 94.4% working in a public hospital. Only 20.3% have the benefit of having a laparoscopic simulation center in the institution where they work, and 63.5% have followed some form of individual training in minimally invasive techniques. Most respondents performed their first surgical intervention after the 3rd year of residency, the most common procedure being laparoscopic cholecystectomy. Regardless of gender distribution, most respondents wanted more than 1 year of minimally invasive training during their residency program. Conclusions: this national survey emphasizes the need for a training program in minimally invasive surgery at the national level, with a common structure and program and with the possibility of periodic individual evaluation, the importance of promoting surgical training being mandatory for improving postoperative results.

Background: Micronutrient deficiencies (MNDs) are commonly reported after bariatric and metabolic surgery, including laparoscopic sleeve gastrectomy (LSG). Nevertheless, the micronutrient status changes over time and the influence of sex or initial body mass index (BMI) on these changes are less explored. This study aims to investigate the changes in micronutrient levels at 6 and 12 months after LSG and the potential influence of sex or baseline BMI (≥40 kg/m2) on these changes in patients submitted to LSG. Additionally, the frequency of MNDs before and at 12 months after the procedure was investigated. Materials and methods: Fifty patients with obesity underwent LSG and were assessed anthropometrically and nutritionally at baseline and at 6 and 12 months, respectively, after LSG. The changes in micronutrients levels over time were tested by a linear mixed model. Results: Vitamin B12 and vitamin D [25(OH)D] did not change significantly, while iron (p < 0.001), calcium (p = 0.01), and parathormone (p < 0.001) differed significantly from baseline to 12 months after LSG. Ferritin significantly decreased from baseline to 6 months and 12 months after LSG (LS-means, 95% CI: 202 [163, 240] vs. 160 [130, 191] vs. 150 [115, 185]). Sex or initial severe obesity (BMI ≥ 40 kg/m2) exhibited significant modifying effects for 25(OH)D and calcium, respectively. The 25(OH)D levels increased significantly in men, but not in women, while the calcium plasma concentration changed significantly only in patients with initial severe obesity. No significant changes over time were found for MNDs’ frequency (p > 0.05). The most consistent deficiency frequency was observed for 25(OH)D both before and after LSG. Conclusions: Overall, our findings revealed changes in micronutrient status across the follow-up period, except for vitamin B12. Variations in 25(OH)D levels were reported exclusively in men, suggesting that they depend on sex. The calcium plasma concentration showed significant changes exclusively in patients with BMI ≥ 40 kg/m2. MNDs’ frequency was not significantly altered during the study follow-up. Our results reinforce the need for developing national dietary guidelines tailored for Romanian patients following LSG.

Background: laparoscopy has emerged as a pivotal tool for the management of acute abdominal pathologies. It provides diagnostic and therapeutic advantages, enabling surgeons to evaluate and address diverse acute abdominal conditions using minimally invasive techniques. The aim of this consensus was to obtain evidence-based guidance for surgeons regarding the utilization of laparoscopy in emergency medical settings, and has been divided into trauma and non-trauma emergencies. This is the part dedicated for trauma. Material and Methods: the task forces of the RAES Research Committee and a panel of experts were established. The development of consensus statements started with an extensive literature review of available medical databases (PubMed, Cochrane, and EMBASE). A set of questions addressing major issues related to the use of laparoscopy in trauma and non-trauma emergencies was defined. The validation of the questions set was performed by the expert group through the first Delphi round. Consensus statements and recommendations were also obtained. The quality of evidence and recommendation strength were rated using the GRADE system. The recommendations were formulated in a directive manner and then assessed by an expert panel using the Delphi technique for agreement. Results: the two main types of emergencies were trauma and non-trauma. There were seven recommendations for the trauma section. For each statement, agreement from the expert panel was obtained. The statements included training for surgeons involved in trauma care, indications and contraindications for laparoscopy in trauma cases, and conversions and complications of laparoscopy for trauma. Conclusions: the RAES consensus offers a set of guidelines for surgeons managing acute abdominal conditions using laparoscopic techniques.

IntroductionRenal dysfunction is a recognized complication of obesity with an incompletely characterized pathophysiology. Improvement of glomerular filtration rate (GFR) after metabolic and bariatric surgery (MBS) has been reported across all classes of renal function. Inter-gender differences with regard to correlates of renal function have been described, but the influence of body composition is an understudied area. We aimed to explore determinants of renal function in obesity and to assess its variations after MBS, with a focus on body composition parameters in males and females, respectively.Materials, methodsWe conducted a retrospective study on 196 patients who underwent laparoscopic sleeve gastrectomy, evaluated preoperatively and 6 months after the intervention. Recorded data included clinical and biochemical assessment, as well as body composition estimation via dual-energy X-ray absorptiometry. Serum creatinine-based formulas were used for the estimation of GFR.ResultsWe included a total of 196 patients (80 males and 116 females), with a mean age of 41.43 ± 10.79. Median baseline body mass index was 42.6 (6.61) kg/m2 and 6 months excess weight loss (EWL) reached 71.43 ± 17.18%, in females, estimated GFR correlated negatively with visceral adipose tissue (VAT) mass (rho=-.368) and this correlation was stronger in females with type 2 diabetes mellitus. Moreover, women in the third VAT mass tertile were 5 times more likely to have reduced GFR compared to the first tertile. Renal function improved after MBS across all classes of filtration. In males, this improvement correlated with EWL (rho=.358) and lean mass variation (rho=-.412), while in females it correlated with VAT mass variation (rho=-.266).ConclusionsOur results are consistent with previous findings on the positive impact of MBS on renal function and suggest a more prominent impact of visceral adiposity on GFR in females.

Metabolic and bariatric surgery (MBS) is the preferred method to achieve significant weight loss in patients with Obesity Class V (BMI > 60 kg/m2). However, there is no consensus regarding the best procedure(s) for this population. Additionally, these patients will likely have a higher risk of complications and mortality. The aim of this study was to achieve a consensus among a global panel of expert bariatric surgeons using a modified Delphi methodology. A total of 36 recognized opinion-makers and highly experienced metabolic and bariatric surgeons participated in the present Delphi consensus. 81 statements on preoperative management, selection of the procedure, perioperative management, weight loss parameters, follow-up, and metabolic outcomes were voted on in two rounds. A consensus was considered reached when an agreement of ≥ 70

Background: The prevalence of obesity is already a worldwide health concern. The development of straightforward guidelines regarding the whole available armamentarium (i.e., medical, endoscopic, and surgical interventions in conjunction with a guidance program) is paramount to offering the best multimodal approach to patients with obesity. Methods: The International Federation for Surgery of Obesity and Metabolic Disorders-European Chapter (IFSO-EC) identified a panel of experts to develop the present guidelines. The panel formulated a series of clinical questions (based on the patient, intervention, comparison, and outcome conceptual framework), which have been voted on and approved. A GRADE methodology will be applied to assess the quality of evidence and formulate recommendations employed to minimize selection and information biases. This approach aims to enhance the reliability and validity of recommendations, promoting greater adherence to the best available evidence. Results: These guidelines are intended for adult patients with a body mass index (BMI) ≥ 30 kg/m2 who are candidates for metabolic bariatric surgery (MBS). The expert panel responsible for developing these guidelines comprised 25 panelists (92% were bariatric surgeons) and 3 evidence reviewers, with an average age of 50.1 ± 10.2 years. The panel focused on 3 key questions regarding the combined use of structured lifestyle interventions, approved obesity management medications, and endoscopic weight loss procedures with MBS. Conclusions: The complexity of obesity as a chronic disease requires a comprehensive knowledge of all the available and feasible therapeutic options. The IFSO-EC society felt the urgent need to develop methodologically valid guidelines to give a full picture and awareness of the possible surgical and non-surgical therapeutic strategies employed with a multimodal approach.

Laparoscopic Sleeve Gastrectomy (LSG) is the most attractive bariatric procedure, but the postoperative intrathoracic gastric migration (ITM) and “de novo” GERD are major concerns. The main objective of our study was to evaluate the efficiency of the concomitant HHR with or without partial reconstruction of phreno-esophageal ligament (R-PEL) to prevent ITM after LSG. The secondary objectives focused on procedure’s metabolic and GERD-related outcomes. Consecutive patients who underwent primary LSG and concomitant HHR were included in a single-center prospective study. According to the HHR surgical technique, two groups were analyzed and compared: Group A included patients receiving crura approximation only and Group B patients with R-PEL. The patients’ evolution of co-morbidities, GERD symptoms, radiologic, and endoscopic details were prospectively analyzed. Two hundred seventy-three patients undergoing concurrent HHR and LSG were included in the study (Group A and B, 146 and 127 patients) The mean age and BMI were 42.6 ± 11.3 and 43.4 ± 6.8 kg/m2. The 12-month postoperative ITM was radiologically found in more than half of the patients in Group A, while in group B, the GEJ’s position appeared normal in 91.3

Introduction: Ectopic thyroid tissue (ETT) is a rare cause of mediastinal masses, representing less than 1% of all mediastinal tumors (1). ETT could be detected anywhere along the path of the first embryonic descent of the thyroid gland from the primordial foregut floor to its usual pre-tracheal position. ETT mediastinal localization accounts for fewer than 1% of all ectopic thyroid cases (2,3). Various surgical methods for approaching mediastinal masses have been documented in the literature, including median sternotomy, posterolateral thoracotomy, and, video-assisted thoracoscopic surgery (VATS) (4). More recently, robotic-assisted thoracoscopic surgery (RATS) has been proposed for these masses. The aim of this article is to present the use of robotic-assisted thoracoscopic surgery (RATS) for a rare case of a mediastinal ETT. Case presentation: We present the case of a 40-year-old male with no significant medical history who discovered a mediastinal mass on a thoracic CT scan following COVID-19 infection. Symptoms were dysphagia and anterior thoracic pain with cervical extension. Scintigraphy confirmed the presence of ectopic thyroid tissue in the mediastinum as well as a normal cervical thyroid gland. ETT was histologically confirmed by endoscopic ultrasound guided biopsy. Robotic assisted surgery was the chosen approach to surgically treat this mass and the technical details are presented. The mass was extracted through the cervical incision. Total surgical time was 230 minutes, and the blood loss was 60 ml. The patient was discharged after 48 hours with follow up showing a full recovery with no residual pain or respiratory symptoms. Conclusion: Ectopic thyroid tissue (ETT) is a rare cause of mediastinal masses, and the diagnosis is always a challenge. Robotic assisted thoracoscopic surgery was proved to be safe and efficient in this rare case of ETT developed in the superior mediastinum.

Porto-mesenteric vein thrombosis (PVMT) is a rare but life-threatening complication after laparoscopic sleeve gastrectomy (LSG). Laparoscopic sleeve gastrectomy (LSG) is considered the most common procedure for efficiently realizing weight loss and treating obesity-related co-morbidities. This study aimed to shed light on this relatively rare complication by presenting a series of patients who developed PMVT after LSG in light of the need to change the specific protocol of thromboprophylaxis in bariatric patients. We proposed to answer two questions: whether we should perform a thrombophilia workup as a standard practice and whether we should extend chemoprophylaxis to more than 3 weeks among all bariatric patients. This study also aimed to investigate the possible risk factors and eventually present our updated protocol for PMVT management and prophylaxis.

Introduction: Pancreaticoduodenectomy, commonly known as the Whipple procedure, is a complex surgical technique employed for the treatment of various pancreatic and periampullary pathologies. Minimally invasive PD was created in an attempt to enhance the outcomes of the traditional, open technique. However, the reconstruction phase has been recognized as a substantial barrier to widespread adoption of the laparoscopic technique. Several research appraisals and case studies recommend the robotic technique as a facilitator during the reconstruction steps. We propose a hybrid approach to combine the versatility of laparoscopy and the visual and motor advantages of the DaVinci Xi in order to maximize the precision of the reconstruction. Our suggestion is based on the experience that our institution has had with the standardization of different surgical procedures and protocols. Methods This article is focused on the outcomes of robotic assisted PD in our institution. Eleven patients underwent robotic assisted laparoscopic PD between 1st January, 2020 and 7th March, 2023 (N=11). There were two approaches involved: hybrid PD type A (N=6) and hybrid PD type B (N=5). Results Of the eleven patients who underwent hybrid PD, most of them were men (81.8%) and mean age was 61.9 years-old (range 45 to 75 years). The mean operative duration was 618 minutes (range 480 to 780 minutes). Mean blood loss was 159 mL (range 50 to 350 mL). Ten operations were performed for malignancy and one for neuroendocrine duodenal tumour; the mean number of lymph nodes retrieved was 16.2 (range 11 to 24 nodes) and all the specimens were reported by pathology as R0. Mean hospital stay was 18 days (range 8 to 40 days). Reoperations were necessary in five patients (N=5), all from the type A group, and mortality occurred in one (N=1) patient. There were no conversions to open surgery during the index procedures as well as no clinically relevant postoperative pancreatic fistulae. Thirty-day mortality was nil, with 1 mortality at 90-days due to massive pulmonary embolism. Conclusions The hybrid approach facilitates the advantages of both laparoscopic and robotic approaches. While laparoscopy is safer in manipulating the bowel and allows the Roux en Y reconstruction and gastro-pancreatic anastomosis, the robotic assistance enables the surgeon to perform delicate anastomosis with a high accuracy. The learning curve's most important element is standardization and careful patient selection along with a stepwise approach.