Background: Identifying impactful research is increasingly challenging. Citation count cannot distinguish innovative from incremental work. The disruption index (DI) quantifies this by measuring how research is cited. DI scores range from -1 to 1, where positive scores indicate paradigm-shifting, disruptive contributions, while negative scores indicate those that consolidate existing research. DI has been applied to surgical specialties to identify influential research and guide funding. Despite rapid growth in bariatric surgery literature, no study has evaluated disruption patterns in this field. Objectives: To characterize disruption patterns in bariatric surgery literature from 2010-2020. Setting: Academic research study. Methods: We queried MEDLINE and EMBASE for bariatric surgery articles (2010-2020). DI was calculated using the Semantic Scholar API. Articles were categorized as disruptive (DI>0), consolidating (DI<0), or neutral (DI=0); those with <5 citations were excluded. We analyzed temporal trends, DI-citation correlations, and characteristics of highly disruptive papers (p<0.05). Results: Among 20,428 articles, mean DI indicated slight consolidation (-0.00073 ±0.006). Consolidating articles increased over five-fold faster than disruptive articles (110% vs 19% growth). Citation count weakly correlated with DI (r=0.21, p<0.001). Disruptive papers had higher citations (64.0±258.3 vs 45.8±66.4, p <0.001) and fewer authors (5.3±3.8 vs 6.2±4.7 authors, p <0.001). Reviews and case reports demonstrated higher disruption than primary studies and clinical trials. Conclusions: This is the first DI analysis of bariatric surgery. The field demonstrates increasing consolidation while disruptive work remained stable. Weak DI-citation correlation confirms these metrics measure different impacts, which can guide funding toward transformative research. Our automated approach is scalable to other specialties.

Gastrojejunal (GJ) anastomotic strictures are a challenging complication following Roux-en-Y gastric bypass (RYGB) and may be refractory to conventional balloon dilation. Lumen-apposing metal stents (LAMS) provide anchored, wide-caliber support that may treat strictures, yet long-term outcomes remain variable, and stent migration is a concern. This study evaluates the clinical effectiveness and safety of LAMS with or without concurrent endoscopic stricturoplasty in patients with GJ strictures. We conducted a single-center retrospective cohort study of patients with GJ strictures who underwent LAMS placement between January 2020 and May 2025. Patients were stratified by whether concurrent endoscopic stricturoplasty was performed at the time of stent placement. Clinical success was defined as symptom resolution without need for reintervention. The primary outcome was long-term clinical success (> 90 days). Secondary outcomes included short-term clinical success (≤ 30 days), stent dwell time, procedure duration, stent migration, and adverse events. Twenty-five patients were included (mean age 46.8 ± 12.9 years; 76

BACKGROUND:Transversus abdominis plane (TAP) block is an effective strategy to improve recovery after bariatric surgery, but its large-scale clinical impact remains uncertain. OBJECTIVES:To evaluate the effect of concomitant TAP block on length of stay (LOS) and complication rates in bariatric surgery patients. SETTING:Multi-institutional analysis of 902 accredited bariatric surgery centers across the United States and Canada. METHODS:Retrospective analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant Use Data File (2020-2022) comparing patients undergoing primary Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) with or without concomitant TAP block. Primary outcomes were prolonged LOS (>2 standard deviations above mean) and 30-day serious complications. Multivariable logistic regression determined the independent predictive value of TAP block. RESULTS:Of 511,981 patients, 43,146 (8.4%) received concomitant TAP block. The distribution of procedures was similar between groups: SG (75.7% TAP versus 72.8% no TAP, P < .001) and RYGB (24.3% TAP versus 27.2% no TAP). TAP block patients had slightly more favorable clinical profiles, with lower rates of diabetes (21.8% versus 23.1%, P < .001) and hyperlipidemia (21.4% versus 22.4%, P < .001). Operative time was longer in the TAP block group (89.3 versus 83.8 min, P < .001). Prolonged LOS occurred in 5.6% of TAP block patients versus 5.9% in the no TAP block group. The TAP block group exhibited a statistically significant but clinically modest reduction in prolonged LOS (unadjusted odds ratio [OR] .89, 95% confidence interval [CI] .82-.97, P = .01) with no difference in serious complications (2.7% versus 2.7%, P = .993). Multivariable analysis confirmed TAP block was independently associated with reduced odds of prolonged LOS (adjusted OR .89, 95% CI .82-.97, P = .01). CONCLUSIONS:Concomitant TAP block during bariatric surgery was independently associated with a statistically significant but modest reduction in odds of prolonged LOS, with an absolute difference of .3%, and no increased risk of serious complications. While the absolute effect size is small, at a population level this may translate to meaningful reductions in health care utilization. These findings suggest TAP block may be a safe adjunct for optimizing recovery in bariatric surgery, though the modest magnitude of benefit should be weighed against costs and resource utilization when considering implementation.

Postoperative gastric leak after bariatric surgery is a serious complication associated with prolonged treatment, repeated interventions, and substantial morbidity. Endoscopic internal drainage by using double pigtail stents is widely adopted. However, current stents, originally designed for biliary use and often based on simple cylindrical geometries, are not optimized for post-bariatric gastric leak anatomy, mechanical support, or fluid drainage. Here, we present BRIDGE (biodegradable architected internal drainage), a stent concept integrating triply periodic minimal surface (TPMS) architectures to control mechanical compliance, kink resistance, and drainage performance. Using computational modeling, mechanical testing, and benchtop flow studies, we evaluate TPMS designs and identify volume fraction as a key parameter balancing flexibility, structural integrity, and hydraulic performance. TPMS-integrated designs tolerated a 7.1-fold smaller bend radius than a commercial stent without kinking and achieved up to a 2-fold increase in drainage. We also developed a stereolithography-printable biodegradable resin and fabricated a prototype lattice-integrated stent.

Background Patients who undergo Roux-en-Y gastric bypass (RYGB) can develop anastomotic marginal ulcers, which can lead to other complications such as stricture, bleeding, or perforation. Objective To examine if patients undergoing conversion of sleeve gastrectomy to RYGB (SG-to-RYGB) were at higher risk of marginal ulceration than a cohort of primary RYGB patients. Setting Cleveland Clinic Health System in the United States Method This retrospective study included patients who underwent primary RYGB or SG-to-RYGB at an academic health system between 2015 and 2023. Follow-up ended in March 2025. The Kaplan-Meier method estimated time to incident marginal ulcer. Results The study included 1,910 patients who underwent primary RYGB and 202 patients who underwent SG-to-RYGB. During the follow-up time of 3.8±2.9 years, 275 primary RYGB patients and 40 SG-to-RYGB patients developed a marginal ulcer. The cumulative incidence of marginal ulcer at 5 years was 16% (95% CI, 14%-18%) in the primary RYGB group and 27% (95% CI, 18%-35%) in the SG-to-RYGB group. The cumulative incidence of marginal ulcers at 8 years was 20% (95% CI, 17%-22%) in the primary RYGB group and 35% (95% CI, 20%-47%) in the SG-to-RYGB group (P=0.01). In the SG-to-RYGB group, the cumulative incidence of marginal ulcer between patients who underwent RYGB primarily for GERD versus for inadequate weight loss following SG was not statistically significant. Conclusion Follow-up data up to 8 years indicate that approximately 20% of patients who undergo primary RYGB and 35% of those who undergo SG-to-RYGB may develop marginal ulceration. Given role of antrum in acid secretion, future clinical trials could potentially test if antrectomy at the time of conversion of SG-to-RYGB has the potential to decrease rate of marginal ulceration.

Bariatric surgery volumes are declining despite rising obesity prevalence. Practice patterns have shifted toward more complex conversion procedures and away from sleeve gastrectomy. Quality improvements at accredited centers have maintained low complication rates despite increasing patient complexity, but falling volumes threaten training capacity and access. OBJECTIVE: To characterize trends in bariatric surgery volumes, patient complexity, procedure selection, and outcomes from 2020 to 2024. Bariatric surgery remains the most effective obesity treatment, yet fewer than 1% of eligible patients undergo surgery. The COVID-19 pandemic and glucagon-like peptide-1 receptor agonists have disrupted surgical volumes. Understanding current practice patterns is critical for resource planning, fellowship training, and maintaining surgical access as obesity prevalence rises. METHODS: Retrospective analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database (2020 to 2024). Demographics, comorbidities, procedure types, and 30-day outcomes were analyzed. Trends were evaluated using chi-square and linear regression. RESULTS: Among 1,006,270 procedures, volumes declined 23% from the 2022 peak (230,707 to 177,789 in 2024). Primary procedures decreased from 90.2% to 83.9% of total cases, while conversions increased from 8.9% to 11.0%. Sleeve gastrectomy declined from 73.4% to 70.6% of primary procedures; Roux-en-Y gastric bypass increased from 26.6% to 29.4% (all p<0.0001). Patient complexity increased: ASA class III or higher rose from 79.8% to 82.5%. Despite this, serious complications declined from 3.39% to 3.10% and mortality remained stable (0.08% to 0.06%). Readmissions increased from 3.2% to 3.6%. CONCLUSIONS: Bariatric surgery volumes declined substantially to pandemic levels while patient complexity increased. Conversion procedures now constitute over 11% of all cases. Improving outcomes despite rising complexity reflect quality improvements at accredited centers. Volume decline threatens training capacity and surgical access for the growing obesity epidemic.

Background Obesity accelerates the progression of chronic kidney disease (CKD) and often limits access to kidney transplantation. Although metabolic and bariatric surgery has been associated with improvements in kidney function and cardiometabolic outcomes, evidence regarding long-term kidney failure, dialysis, transplantation, cardiovascular, and survival outcomes among patients with established CKD remains heterogeneous. Objectives To evaluate the association between MBS and long-term renal, cardiovascular, and transplant outcomes, and all-cause mortality, in patients with obesity and CKD using a large, propensity score-matched real-world cohort. Settings Analysis of TriNetX Global Collaborative Network, a de-identified real-world database from over 140 health care organizations. Methods Adults (≥18 years) with severe obesity and CKD who underwent sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) between 2010 and 2020. Patients were propensity score-matched 1:1 to those without MBS based on demographics, comorbidities, baseline kidney function, and medication use. Outcomes were assessed over five years. Primary endpoints included incidence of end-stage renal disease (ESRD), dialysis initiation, kidney transplantation, cardiovascular events, and all-cause mortality. A subgroup analysis comparing SG and RYGB was performed using propensity score matching. Results A total of 4,481 MBS patients were matched to 4,481 non-MBS patients, with well-balanced baseline characteristics. Compared to the non-MBS group, MBS was associated with significantly lower risks of ESRD (5.9% vs. 11.9%; OR 0.47, 95% CI 0.40–0.55), dialysis dependence (4.1% vs. 9.0%; OR 0.43, 95% CI 0.36–0.52), and composite cardiovascular events (15.5% vs. 27.7%; OR 0.48, 95% CI 0.42–0.54). Interestingly, kidney transplant rates were more than twice as high in the MBS group (4.6% vs. 2.2%; OR 2.13, 95% CI 1.67–2.72), and all-cause mortality was markedly lower (5.0% vs. 16.3%; OR 0.27, 95% CI 0.23–0.32). In subgroup analyses, outcomes were comparable between SG and RYGB, although SG was associated with higher kidney transplantation rates. Conclusions In this large TriNetX cohort of patients with obesity and CKD, MBS was associated with lower observed rates of ESRD, dialysis dependence, cardiovascular events, and all-cause mortality and with a higher rate of kidney transplantation. Similar renal, cardiovascular, and survival outcomes were observed after SG and RYGB. Because of residual differences in baseline kidney function, unmeasured treatment-selection factors, and limitations in the geographic and institutional characterization of the TriNetX network, these findings should be interpreted as associations within the study cohort rather than causal effects or population-level estimates. Further prospective and population-based studies are needed to confirm these associations.

Postoperative gastric leaks (GL), a serious complication of bariatric surgery, are often managed by endoscopic internal drainage using biliary double-pigtail stents (DPS). However, conventional extruded thermoplastic (e.g., polyethylene, polyurethane, and polytetrafluoroethylene) stents often provide inadequate drainage, suboptimal anatomical conformity, and are prone to migration, collectively hindering patient recovery and contributing to an adverse event rate of 13.8%. To address these limitations, we developed PETALS (Personalized Endoscopic Transmural Abscess Leak Solution), an analytical framework for the optimization of stent designs dedicated to transmural fluid drainage. We identified stent length and diameter as critical geometric parameters influencing fluid dynamics. Using PETALS, we designed a family of stents with longitudinal fins fabricated by stereolithography (SLA) using Formlabs Flexible 80A resin. The Lily design, a six-segment PETALS construct, achieved a 32% reduction in hydraulic resistance and a 30% increase in flow rate compared with a commercial DPS in a benchtop GL model, while also exhibiting superior flexibility. PETALS thus enables the fabrication of patient-specific, additively manufactured stents with increased flow rate, potentially reducing complications and shortening hospitalization.

Bariatric surgery patients with body mass index (BMI) ≥ 60 kg/m2 present unique technical and perioperative challenges. While robotic-assisted bariatric surgery is thought to offer potential technical advantages, direct comparisons between robotic and laparoscopic approaches (R-BS and L-BS) in this population remains limited. An analysis of the 2020–2023 MBSAQIP database was conducted and all patients with BMI ≥ 60 kg/m2 who underwent primary laparoscopic or robotic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) were included. Baseline demographics, operative characteristics, and 30-day postoperative outcomes were compared. Multivariable logistic regression identified independent predictors of serious complications. Of 32,295 patients, 22,211 (68.8

Current minimally invasive surgery techniques face persistent challenges: limited depth perception, assistant-dependent retraction, and added invasiveness from multiple ports. We present the first clinical experience combining three novel technologies: Magnetic-Assisted Robotic Surgery (MARS), 3D visualization, and augmented reality (AR). This IRB-approved retrospective review included 10 patients who underwent reduced-port laparoscopic surgery using the MARS system with Meta Quest 3 AR headset and EinsteinVision 3D camera in October 2024. Procedures included cholecystectomy (n = 4), oophorectomies (n = 2), Roux-en-Y gastric bypass (n = 2), combined cholecystectomy with sleeve gastrectomy (n = 1), and hiatal hernia repair (n = 1). Median operative time was 108 min (range: 44–218 min). Each procedure required at least one fewer port than traditional approaches. No complications occurred, and there were no readmissions or protocol deviations within 30 days. Surgeons reported greatly improved visualization compared with standard laparoscopy, and no device malfunctions were encountered. Integrating MARS, 3D visualization, and AR proved feasible and safe across multiple surgical specialties. This platform enhanced visualization and reduced invasiveness while maintaining efficiency and safety.

Obesity limits access to kidney transplantation (KT) and worsens outcomes in patients with end-stage renal disease (ESRD). Sleeve gastrectomy (SG) is increasingly used to facilitate transplant eligibility; however, the safety of simultaneous SG and KT (SG + KT) remains poorly defined at a multi-institutional level. This study evaluates 30-day perioperative outcomes of SG + KT using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. A retrospective analysis of the MBSAQIP database (2020–2023) was performed. Adult patients undergoing SG were identified with simultaneous KT and captured using CPT codes. Demographics, comorbidities, operative characteristics, and 30-day outcomes were compared between SG-only and SG + KT cohorts. Multivariable logistic regression was used to identify independent predictors of serious complications and 30-day mortality. Among 582,860 patients undergoing SG, 22 (0.004

The prevalence of revision and conversion metabolic bariatric surgery (MBS) has increased alongside the growing number of primary Roux-en-Y gastric bypass (RYGB) procedures performed worldwide. Common indications for revision or conversion after RYGB include weight recurrence (WR), suboptimal clinical response (SoCR), and late postoperative complications such as internal hernia, marginal ulcers, malnutrition, dumping syndrome, and post-bariatric hypoglycemia. However, high-quality comparative evidence remains limited, and no international consensus exists regarding optimal management strategies. This study aimed to evaluate current international practices and expert opinions on revision and conversion surgery after RYGB through a global expert survey. This international online binary survey comprised 61 questions and was conducted via SurveyMonkey™ between November 14 and December 10, 2025. A total of 188 specialists participated (75.2% of invitees), with 184 completing the questionnaire (98% completion rate). Item-specific response rates ranged from 177 to 187. The survey demonstrated broad international agreement that WR and SoCR are multifactorial conditions requiring individualized, multidisciplinary management. Endoscopic approaches were generally favored as first-line options in selected patients with anatomical dilation, whereas hypoabsorptive procedures (distal RYGB, SADI-S, BPD-DS) were considered more effective for long-term weight loss and metabolic outcomes. High agreement (> 90%) was observed for multidisciplinary follow-up, individualized procedure selection, lifelong nutritional surveillance, and management of several late complications. Important areas of controversy remain. These findings provide preliminary insights that may support future standardized definitions, clinical pathways, and evidence-based guidelines.

BACKGROUND:Weight recurrence and suboptimal response after metabolic and bariatric surgery (MBS) lack standardized definitions and management approaches, creating barriers to evidence-based treatment decisions and coordinated care across multiple specialties. OBJECTIVES:To establish international expert consensus on terminology, diagnostic approaches, and management strategies for suboptimal response and weight recurrence after MBS. SETTING:International Delphi study across multiple countries and health care systems. METHODS:A two-round modified Delphi study was conducted with 66 international experts across five specialties (MBS, obesity medicine, gastroenterology, endocrinology, dietetics and nutrition, and psychology). A 164-item questionnaire was developed, spanning seven dimensions: conservative management, diagnostic methods, endoscopic interventions, quantitative thresholds, risk factors, surgical interventions, and terminology. Consensus was defined a priori as ≥70% agreement. Inter-rater reliability was assessed using Gwet's AC1 coefficient. RESULTS:Response rates were 54.5% (Round 1) and 57.6% (Round 2). Consensus achievement improved significantly between rounds (26.2% to 40.9% of items). Experts reached unanimous agreement on core management principles including individualized patient care (100%) and the appropriateness of specialists prescribing antiobesity medications (100%). Strong consensus emerged on standardized terminology with "suboptimal" as the preferred term (89.5%) and %TWL as the optimal measurement approach (94.6). For quantitative thresholds, consensus was achieved on surgical nonresponse defined as <10% TWL at 12 months (73.0%), recurrent weight gain as >25% of lost weight from nadir (70.3%), and a 10% change in %EWL from nadir as normal physiologic response (83.8%). Conservative management items achieved the highest consensus rates (80.9%) while quantitative threshold items require additional research (28.1%). Inter-rater reliability improved across all domains, with conservative management achieving substantial agreement (AC1 = .70). CONCLUSION:Expert consensus was achieved on fundamental principles of postbariatric care, including preferred terminology, measurement metrics, and provider roles. These recommendations address important gaps in clinical practice standardization.

Obesity commonly coexists with systemic lupus erythematosus (SLE), exacerbating metabolic, cardiovascular, and renal complications. Metabolic and bariatric surgery (MBS) achieves durable weight loss and improves metabolic health, but its long-term safety and potential disease-modifying effects in SLE remain unclear. A multicenter, retrospective cohort study was conducted using the TriNetX global federated research network, comprising data from over 140 healthcare organizations between 2009 and 2024. Adults with SLE who underwent sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) were compared with propensity score-matched cohorts of non-SLE patients undergoing MBS and patients with SLE who do not undergo MBS. Primary outcomes included long-term nutritional and metabolic safety. Secondary outcomes evaluated changes in immunosuppressive medication use, inflammatory markers, renal function, and mortality over a five-year follow-up. Among 123,219 MBS patients, 713 (0.6

Achalasia is a rare, progressive oesophageal motility disorder defined by impaired lower oesophageal sphincter relaxation and absent peristalsis, leading to dysphagia, regurgitation, chest pain, weight loss, and increased long-term risks of aspiration and malignancy. Management has evolved from open surgical myotomy to minimally invasive laparoscopic and robotic techniques and, more recently, peroral endoscopic myotomy (POEM). This review summarizes contemporary diagnostic strategies, including high-resolution manometry, timed barium oesophagram, endoscopy, and emerging applications of impedance planimetry, and critically appraises current endoscopic and surgical therapies. The review compares outcomes of pneumatic dilation, botulinum toxin injection, minimally invasive Heller myotomy with fundoplication, POEM, POEM with fundoplication, and newer approaches for advanced disease such as peroral oesophageal plication and oesophagectomy, integrating data from randomized trials and long-term cohort studies. Key issues, including post-treatment gastro-oesophageal reflux, cancer surveillance, and management of recurrent or refractory symptoms, are addressed. Treatment selection is emphasized as individualized, incorporating manometric subtype, oesophageal morphology, patient co-morbidity, institutional expertise, procedural durability, complication profiles, and evolving guideline recommendations across international expert consensus groups. Contemporary multimodal therapy enables durable symptom control and meaningful quality-of-life improvement for most patients, while ongoing innovation and longer-term follow-up will continue to refine treatment algorithms and standards of care.

BACKGROUND:Median arcuate ligament syndrome is a rare condition characterized by celiac artery compression, leading to abdominal symptoms. Its variability in symptom severity and treatment responses presents challenges for clinicians, making accurate diagnosis and effective management critical for patient outcomes. The goal was to assess clinical features, diagnostic approaches, and outcomes following minimally invasive median arcuate ligament release for median arcuate ligament syndrome. METHODS:A retrospective analysis was conducted on patients treated for median arcuate ligament syndrome within our health care system between March 2015 and May 2021. Data including demographics, presenting symptoms, treatment modalities, surgical outcomes, and follow-up results were collected and analyzed. RESULTS:A total of 162 patients (130 female) with median arcuate ligament syndrome underwent minimally invasive median arcuate ligament release. Median age was 38.5, with a mean body mass index of 25.1. Common presenting symptoms included abdominal pain, postprandial pain, nausea/vomiting, and weight loss. Median duration of symptoms was 24 months. Preoperative celiac ganglion block was performed in 126 patients (77.7%). Median operative time was 77 minutes (range 32-287), and conversion rate to open surgery of 4.3%, primarily due to bleeding. Median hospital stay was 2 days. At 13-month median follow-up, 88.7% of patients reported partial or complete resolution of symptoms following surgery. However, symptom recurrence occurred in 73 patients (45%), frequently within 3 months postoperatively. Only 34 cases (28.8%) showed evidence of recurrence on postoperative imaging. CONCLUSIONS:Minimally invasive surgery for median arcuate ligament syndrome offers favorable outcomes in terms of symptom relief, with most patients experiencing initial improvement. However, symptom recurrence remains a challenge, often without evident radiographic evidence.

BACKGROUND:The use of artificial intelligence (AI) has rapidly increased in metabolic and bariatric surgery (MBS) in recent years, necessitating a comprehensive review characterizing the landscape of AI across the perioperative pathway of MBS care. OBJECTIVES:In this scoping review, we report on the applications of AI in the preoperative, intraoperative, and postoperative phases of care in MBS. SETTING:Scoping review including articles published internationally. METHODS:We systematically searched MEDLINE, Embase, Web of Science, and the Cochrane Database from inception until November 2024 for studies evaluating AI in any area of MBS. Studies were screened and extracted in duplicate, and a narrative synthesis of included studies was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews checklist. RESULTS:We identified 58 studies for inclusion, with the majority of studies evaluating the applications of AI in the postoperative (35/58, 60.3%) phase, followed by the intraoperative (7/58, 12.1%) and preoperative (4/58, 6.9%) phases. A further 11/58 (18.9%) of studies evaluated large language models (LLMs) in MBS. Neural networks were the most frequently described algorithm (used in 26/47, 55.3% of studies), with LLM studies most frequently evaluating ChatGPT (10/11, 90.9%). Studies demonstrated significant promise in the ability of AI to accurately predict postoperative outcomes and support preoperative and intraoperative decision-making, and LLM studies showed the promise of AI in improving patient education and clinical decision support. However, the vast majority of studies were limited by minimal external validation and lack of direct prospective clinical evaluation. CONCLUSIONS:While AI shows significant promise in MBS, the existing literature is limited by minimal clinical evaluation and lack of external validation. Future prospective large-scale studies of AI across the perioperative pathway in MBS are required to demonstrate the utility of these algorithms in improving MBS care and patient outcomes.