BACKGROUND:Obesity is considered a global epidemic and has shown a progressive increase in recent decades. Bariatric surgery, such as Roux-en-Y gastric bypass (RYGB), is the most effective sustainable weight loss option. However, weight regain is one of the challenges facing patients and is attributed to several factors, including dilatation of the gastrojejunal anastomosis (GJA). OBJECTIVES:The central objective of this study is to correlate the influence of time on GJA widening in patients undergoing RYGB over a 7-year period. METHODS:Prospective and longitudinal study conducted over 7 years in patients undergoing RYGB. Surgical and endoscopic procedures were performed in a medium hospital in the same city. Weight, body mass index (BMI) and GJA size were assessed at intervals of 2, 6, 12, 24, 30, 48, 60, and 72 months after the surgical procedure. RESULTS:The highest mean value in the distribution of anastomosis diameter was 20±2.27 mm at 72 months after surgery. The lowest mean value was 10.2±1.70 mm at 2 months after surgery. The analysis showed that there is a significant effect of time on anastomosis diameter, with statistically significant differences in the mean value between 2, 6, 12, 24, 60, and 72 months after surgery (F(1,724,5,172)=9.555, P<0.05). CONCLUSION:Multiple comparative analysis showed that there are statistically significant differences between the mean lengths of anastomosis across the times studied, with a greater influence of the time factor 24 months after surgery.

Bariatric surgery remains underutilized despite rising global obesity rates, with less than 2

BACKGROUND Pancreatic cancer has one of the highest mortality rates among malignant tumors, with increasing prevalence and ranking sixth as the leading cause of cancer death worldwide. Histological diagnosis is made preferably by using tissue samples obtained with endoscopic ultrasound, using fine-needle aspiration (FNA) or fine-needle biopsy (FNB) needles. Currently, there are no studies comparing the sensitivity between punctures performed with both needles, when evaluated and compared by general pathologists and experts in pancreaticobiliary cytology. AIM To compare the diagnostic yield for suspected solid pancreatic malignancies using 22-gauge FNA and FNB needles between general pathologists and experts in pancreaticobiliary cytology focus on positive detection rate. METHODS Thirty patients were selected and underwent endoscopic ultrasound-guided punctures using FNA and FNB needles, for a total of 4 punctures per patient. All samples were analyzed by a general pathologist and an expert pathologist. Sensitivity was the diagnostic parameter evaluated. RESULTS Overall, 100 slides [83.3%, 95% confidence interval (CI): 75.9%-89.2%] were considered positive by general pathologists, while 95 slides (79.2%, 95%CI: 71.3%-85.7%) were considered positive by expert pathologists. General pathologists from the Hospital das Clínicas of the Medical School of the University of São Paulo and Hospital das Clínicas of the Medical School of Ribeirão Preto centers (high-volume centers) concluded that 90% of the samples (95%CI: 78%-96.5%) were positive, whereas those from the Hospital Geral de Fortaleza center (low-volume center) considered 70% of the samples positive (95%CI: 54.8%-82.4%). When comparing sensitivity between different needles and centers, and controlling for the expertise of the pathologist, FNB showed significantly superior performance for general pathologists (FNB: 85%, 95%CI: 62.1%-96.8% vs FNA: 55%, 95%CI: 31.5%-76.9%; P = 0.042). CONCLUSION In low-volume centers, the use of FNB may help improve the diagnostic sensitivity of general pathologists.

Background: Within the spectrum of gastroesophageal reflux disease (GERD), pathologic reflux applies to the subset of patients with either erosive esophagitis or abnormal esophageal acid exposure on pH-metry, consequences of a dysfunctional antireflux barrier (ARB). Methods: The American Foregut Society (AFS) tasked a 13-member working group of expert foregut surgeons and esophagologists (The ARB Cooperative) to develop a white paper on ARB function, dysfunction, and mechanisms of action of antireflux surgery through discussion of relevant literature summarized herein. Results: The ARB Cooperative concluded that pathologic reflux is a consequence of the interplay between progressive anatomical distortion of the ARB and physiology. Factors contributing to ARB dysfunction include (1) separation of crural diaphragm from the lower esophageal sphincter with widening of the hiatus and diminished crural diaphragm sphincteric function; (2) loss of the intra-abdominal lower esophageal sphincter segment with complete disabling of the flap valve component of the ARB; (3) axial hiatal hernia leading to reflux during swallow-induced lower esophageal sphincter (LES) relaxation, LES hypotension, inspiration related reflux, a lowered threshold for eliciting transient LES relaxations, and increased compliance of the gastroesophageal junction leading to greater diameter of sphincter opening during transient LES relaxations. With regard to antireflux surgery, the objectives include: (1) reduction of hiatal hernia and restoration of the intra-abdominal esophageal segment; (2) repair of the dilated hiatus; (3) restoring flap valve function by modifying gastroesophageal anatomy; and (4) restricting gastroesophageal junction opening during periods of relaxation. Conclusions: This ARB Cooperative white paper supports the concept of there being 3 major inter-related mechanisms promoting ARB competence: the LES as an intrinsic sphincter, the crural diaphragm as an extrinsic sphincter, and the gastroesophageal valve, a mechanical 1-way valve. Pathological reflux occurs with progressive anatomical disruption of the ARB which in turn leads to physiological dysfunction, the severity of which parallels the extent of anatomical disruption. The corollary of this is that the primary mechanism of antireflux surgery is to restore the ARB by eliminating or compensating for its anatomical disruption. It is the hope of the cooperative that understanding the proposed framework will help clinicians and researchers in improving antireflux procedures.

Background: Pathologic reflux is a common debilitating digestive condition and anti-reflux surgery is an effective treatment option. Depending on the specifics of the procedure, anti-reflux surgery leads to distinct changes in the endoscopic appearance of the esophagogastric junction (EGJ). This American Foregut Society (AFS) white paper develops nomenclature for describing the endoscopic characteristics of the EGJ after commonly performed laparoscopic antireflux operations.Methods: The AFS Anti-Reflux Barrier Collaborative analyzed the anatomic manipulation and corresponding endoscopic appearance of the EGJ after commonly performed anti-reflux surgery including: (1) 360 degrees anterior/posterior (AP) fundoplication (Nissen); (2) posterior partial fundoplication (Toupet); (3) anterior partial fundoplication (Watson, Dor); (4) magnetic sphincter augmentation; and (5) concomitant hiatal hernia repair with transoral fundoplication (cTIF).Results: Characteristics common to the anti-reflux surgery procedures include restoration of intra-abdominal esophageal length and crural diaphragm repair such that the hiatal aperture is no longer visible in the retroflexed endoscopic view. With regard to the geometry of anti-reflux procedures, the Collaborative established that when evaluated endoscopically in retroflection, the surgically constructed valve should be described in reference to the angle of His and the extent of anatomic change described in terms of (1) the depth of the anterior and posterior grooves, (2) the apposition of the valve collar to the endoscope, (3) the length of the valve, and (4) the position of the squamocolumnar junction relative to the lip of the valve.Conclusions: Current anti-reflux operations share much in common but employ varying degrees of valvular reconstruction leading to distinct endoscopic characteristics. Developing a consistent nomenclature for describing the appearance of the post-surgical valve is essential to develop a better understanding of how variables such as the tightness of the hiatal repair, tightness of the valve collar, and length of the valve can impact the outcome of anti-reflux surgery and predict reflux recurrence.

Duodeno-ileal anastomoses are technically challenging and associated with high complication rates, limiting their adoption in bariatric surgery despite their efficacy in weight loss. Magnetic compression anastomoses (MCAs) have emerged as a promising technique, promoting tissue fusion and reducing risks of bleeding and leakage. However, delayed patency limits their application. The OTOLoc™ system, combined with Flexagon self-forming magnets (SFMs), addresses this limitation by enabling immediate patency during healing. This study reports the first-in-human experience of immediately patent magnetic duodeno-ileal anastomosis (IMPA-DI) using these novel devices during single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S). This single-center, observational study evaluated the feasibility and short-term safety of IMPA-DI. Seven adult patients with moderate to severe obesity were included. The SFM assembly, coupled with the OTOLoc™ system, was laparoscopically deployed to create an immediately patent duodeno-ileal anastomosis. Primary endpoints were technical success and freedom from anastomosis-related adverse events (AEs) within 30 days. Secondary outcomes included procedural metrics and overall safety. All seven procedures were successfully completed, with a median overall duration of 58 min and magnet placement duration of 12 min. Three intraoperative AEs (serosal and liver injuries, staple line bleeding) were unrelated to IMPA and resolved without complications. All patients resumed liquid diets within 2 days, and no anastomosis-related AEs were observed within 30 days. All devices were naturally expelled without complications. This first-in-human study demonstrates the feasibility, safety, and efficiency of the IMPA-DI approach using Flexagon SFMs and the OTOLoc™ system. The immediate patency and straightforward deployment highlight the potential for broader application in challenging anastomotic sites. While limited by the small sample size and single-center design, the results underscore the promise of magnetic compression anastomoses. Further studies are warranted to validate these findings and explore long-term outcomes.

Patients with a history of Metabolic and Bariatric Surgery (MBS) face an increased risk of acute pancreatitis (AP) due to factors like rapid weight loss and altered gastrointestinal anatomy. However, data on the severity and outcomes of AP in these patients are limited. This study evaluates whether a history of MBS, particularly Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion with duodenal switch (BPD/DS), affects the severity and clinical outcomes of AP. This retrospective matched cohort study included patients admitted with AP to Mayo Clinic between 2013 and 2022. Patients with a history of RYGB or BPD/DS were matched to two control groups without prior bariatric surgery: (1) BMI-matched controls (± 1 kg/m2), and (2) higher-BMI controls (≥ 5 kg/m2 higher). The primary outcome was AP severity, and secondary outcomes included local complications, hospital length of stay, recurrence, and 30-day readmission. Compared to the higher-BMI control group, the MBS group had lower rates of severe AP (0

ABSTRACT Background: Among the 2.0 billion overweight individuals in the world, Brazil ranks fifth in the number of obese people, therefore requiring treatment options for obesity. Aim: The aim of this study was to compare the percentage of total body weight loss (%TWL), change in body mass index (BMI), percentage of excess weight loss (%EWL), incidence of reflux esophagitis, and occurrence of Barrett's esophagus in obese patients undergoing gastric bypass (Roux-en-Y gastric bypass [RYGB]) and sleeve gastrectomy (SG), both techniques by videolaparoscopy. Methods: The study included 100 consecutive patients who underwent RYGB and SG techniques, totaling 200 patients, and were followed up for 60 months, from June 2013 to July 2018. Results: The frequency of gastroesophageal reflux disease (GERD) was lower in RYGB patients (p<0.05). At 60 months, the %EWL was 77.4±13.3 kg (RYGB) versus 80.5±17.5 kg (SG) (p<0.05). The BMI data were statistically significantly different between groups after 5 years (28.5±3.9 kg/m2 in RYGB and 31.9±5.3 kg/m2 in SG groups, p<0.05). During the follow-up, the RYGB showed higher %EWL compared to the SG (at 60 months, 80.1% vs. 59.1%, respectively, p<0.05). The %TWL was 30% for the RYGB and 19.7% for the SG (p<0.05). The RYGB had a lower frequency of reflux esophagitis and Barrett's esophagus. Conclusions: The RYGB technique showed greater absolute weight loss, %TWL, BMI reduction, and %EWL in higher obesity classes compared to the SG technique. Additionally, RYGB had a lower frequency of reflux esophagitis and Barrett's esophagus.

Background and study aims Recently, over-the-scope clips (OTSCs) have been extensively studied for hemostasis of nonvariceal upper gastrointestinal bleeding (NVUGIB). Our goal was to compare the efficacy of OTSCs with standard endoscopic interventions (SEIs) as first-line treatments. Patients and methods A comprehensive search of electronic databases was performed to identify randomized clinical trials (RCTs) comparing OTSCs with SEIs as first-line therapy for NVUGIB. This search was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Results Of 819 reviewed studies, five RCTs comprising 555 patients (277 OTSCs vs. 278 SEIs) were included. The OTSC group had a lower 30-day rebleeding rate (risk ratio [RR] 0.43; 95% confidence interval [CI] 0.24-0.77; I-2 = 0%; P = 0.004) and a higher clinical success rate (RR 1.19; 95% CI 1.11-1.28; I-2 = 0%; P < 0.00001). There was no significant difference in technical success (RR 1.06; 95% CI 0.98-1.14; I-2 = 73%; P = 0.13), 30-day all-cause mortality (RR 0.50; 95% CI 0.22-1.14; I-2 = 0%; P = 0.10), need for further intervention (RR 1.22; 95% CI 0.43-3.47; I-2 = 0%; P = 0.71), or length of hospital stay (mean difference 0.31; 95% CI: -1.08- 1.70; I-2 = 0%; P = 0.66). Risk of bias, which was assessed using the Cochrane Risk of Bias 2.0 tool, indicated some concerns about bias. Conclusions OTSCs are more efficient than SEIs as first-line treatment in terms of rebleeding within 30 days and clinical success rates.

INTRODUCTION: Endoscopic sleeve gastroplasty (ESG) has gained popularity over the past decade and has been adopted in both academic and private institutions globally. We present outcomes of the largest cohort of patients from the United States undergoing ESG and evaluate these according to obesity class. METHODS: We performed a retrospective analysis of adult patients who underwent ESG. Medical information was abstracted from the electronic record with weight records up to 2 years after ESG. Percent total body weight loss (%TBWL) at 6, 12, 18, and 24 months was calculated based on baseline weight at the procedure. SPSS (version 29.0) was used for all statistical analyses. RESULTS: A total of 1,506 patients from 7 sites were included (501 Class I obesity, 546 Class II, and 459 Class III). Baseline demographics differed according to obesity class due to differences in age, body mass index (BMI), height, sex distribution, and race. As early as 6 months post-ESG, mean BMI for each class dropped to the next lower class and remained there through 2 years. %TWBL achieved in the Class III group was significantly greater when compared with other classes at all time points. At 12 months, 83.2% and 60.9% of patients had ≥10% and ≥15% TBWL for all classes. There were no differences in adverse events between classes. DISCUSSION: Real-world data from a large cohort of patients of all BMI classes across the United States shows significant and sustained weight loss with ESG. ESG is safe to perform in a higher obesity class with acceptable midterm efficacy.

Background and study aims Endoscopic sleeve gastroplasty (ESG) is performed in clinical practice by gastroenterologists and bariatric surgeons. Given the increasing regulatory approval and global adoption, we aimed to evaluate real-world outcomes in multidisciplinary practices involving bariatric surgeons and gastroenterologists across the United States. Patients and methods We included adult patients with obesity who underwent ESG from January 2013 to August 2022 in seven academic and private centers in the United States. Patient and procedure characteristics, serious adverse events (SAEs), and weight loss outcomes up to 24 months were analyzed. SPSS (version 29.0) was used for all statistical analyses. Results A total of 1506 patients from seven sites included 235 (15.6%) treated by surgeons and 1271 (84.4%) treated by gastroenterologists. There were no baseline differences between groups. Gastroenterologists used argon plasma coagulation for marking significantly more often than surgeons (P<0.001). Surgeons placed sutures in the fundus in all instances whereas gastroenterologist placed them in the fundus in less than 1% of the cases (P<0.001>). Procedure times were significantly different between groups, with surgeons requiring approximately 20 minutes more during the procedure than gastroenterologists (P<0.001). Percent total body weight loss (%TBWL) and percent responders achieving >10 and >15% TBWL were similar between the two groups at 12, 18, and 24 months. Rates of SAEs were low and similar at 1.7% for surgeons and 2.7% for gastroenterologists (P>0.05). Conclusions Data from a large US cohort show significant and sustained weight loss with ESG and an excellent safety profile in both bariatric surgery and gastroenterology practices, supporting the scalability of the procedure across practices in a multidisciplinary setting.

Background and study aims Biliary sphincterotomy is a crucial step in endoscopic retrograde cholangiopancreatography (ERCP), a procedure known to carry a 5% to 10% risk of complications. The relationship between Pure cut, Endocut, post-ERCP pancreatitis (PEP) and bleeding is unclear. This systematic review and meta-analysis compared these two current types and their relationships with adverse events. Patients and methods This systematic review involved searching articles in multiple databases until August 2023 comparing pure cut versus Endocut in biliary sphincterotomy. The meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Results A total of 987 patients from four randomized controlled trials were included. Overall pancreatitis: A higher risk of pancreatitis was found in the Endocut group than in the Pure cut group ( P =0.001, RD=0.04 [range, 0.01 to 0.06]; I 2 =29%). Overall immediate bleeding: Statistical significance was found to favor Endocut, ( P =0.05; RD=-0.15 [range, -0.29 to -0.00]; I 2 =93%). No statistical significance between current modes was found in immediate bleeding without endoscopic intervention ( P =0.10; RD=-0.13 [range, -0.29 to 0.02]; I 2 =88%), immediate bleeding with endoscopic intervention ( P =0.06; RD=-0.07 [range, -0.14 to 0.00]; I 2 =76%), delayed bleeding (P=0.40; RD=0.01 [range, -0.02 to 0.05]; I 2 =72%), zipper cut ( P =0.58; RD=-0.03 [range, -0.16 to 0.09]; I 2 =97%), perforation ( P =1.00; RD=0.00 [range, -0.01 to 0.01]; I 2 =0%) and cholangitis ( P =0.77; RD=0.00 [range, -0.01 to 0.02]; I 2 =29%). Conclusions The available data in the literature show that Endocut carries an increased risk for PEP and does not prevent delayed or clinically significant bleeding, although it prevents intraprocedural bleeding. Based on such findings, Pure cut should be the preferred electric current mode for biliary sphincterotomy.

The sleeve gastrectomy (SG) has become the most common bariatric procedure worldwide. However, insufficient weight loss or weight recidivism is frequent, which may require effective and safe revisional procedures. To determine the technical feasibility and safety of a minimally invasive, duodeno-ileal side-to-side anastomosis using a Sutureless Neodymium Anastomosis Procedure (SNAP) for patients with weight recidivism or inadequate weight loss following SG. This is a prospective, single-arm, open-label pilot study that enrolled patients with obesity to assist in weight reduction following an SG performed > 12 months prior. For the SNAP, self-assembling magnets were deployed into the ileum (laparoscopically) and duodenum (per-oral endoscopy). Magnets were coupled under laparoscopic and fluoroscopic guidance to create a compression anastomosis. The primary endpoints were technical feasibility, weight loss, and rate of serious adverse events (SAEs). Successful duodeno-ileal diversions were created with SNAP in 27 participants (mean age: 50.6 ± 9.1, mean BMI: 38.1 ± 4.6 kg/m2) with no device-related serious adverse events. Upper endoscopy at 3 months confirmed patent, healthy anastomoses in all patients. At 9 months, patients (n = 24) experienced 11.9 ± 6.2

OBJECTIVES:Endoscopic resection is the preferred approach to treat early Barrett's neoplasia, reducing the need for surgical interventions. However, the best choice between endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) remains unclear. The study aimed to compare the efficacy and safety of EMR vs. ESD for early Barrett's neoplasia. METHODS:An electronic search was conducted in MEDLINE, Central Cochrane, EMBASE, and LILACS until November 2023. Studies comparing ESD vs. EMR in the treatment of patients with early Barrett's neoplasia were included. This study was performed according to the Preferred Report Items for Systematic Reviews and Meta-Analyses guidelines. The ROBIN-I tool was used to analyze the risk of bias and GRADE to measure the quality of the evidence. RESULTS:A total of 9352 patients from 15 observational studies were included. Patients undergoing ESD had significantly higher rates of en-bloc (odds ratio [OR] 25.96, 95% confidence interval [CI] 13.82, 48.74; I2 = 52%; P < 0.00001) and R0 (OR 5.10, 95% CI 3.29, 7.91; I2 = 73%; P < 0.00001) with a higher risk of adverse events, including bleeding, stricture formation, and perforation. In a subgroup analysis of patients who did not receive radiofrequency ablation, ESD had a lower recurrence rate than EMR (OR 0.22, 95% CI 0.05, 0.94; I2 = 88%; P = 0.04). CONCLUSION:Endoscopic submucosal dissection is more effective than EMR in treating early Barrett's neoplasia at the expense of higher adverse events rates.

[This corrects the article DOI: 10.1016/j.obpill.2024.100112.].

BACKGROUND AND AIMS:Individual randomized controlled trials (RCTs) and pairwise meta-analyses do not compare all commercially available endoscopic bariatric therapies (EBTs) head-to-head. Therefore, the choice among them is currently made by inference or indirect data. We therefore assessed the comparative efficacy and safety of EBTs through a network meta-analysis. METHODS:We searched MEDLINE, EMBASE, and Cochrane CENTRAL from inception for intragastric balloons (IGBs) and from 2013 for endoscopic sleeve gastroplasty (ESG) until May 2023. Only RCTs comparing any of the currently commercially available EBTs with controls were considered eligible. Outcomes included percentage of total weight loss (%TWL), serious adverse events (SAEs), and intolerability. RESULTS:We identified 821 citations, of which 10 and 8 were eligible for the qualitative and quantitative analysis, respectively. Considering %TWL at the time of IGB removal, all EBTs were associated with statistically higher %TWL than controls. There were no significant differences among EBTs. However, considering the %TWL at the follow-up closest to 12 months, both ESG and the Spatz3 gastric balloon (Spatz Medical, Fort Lauderdale, Fla, USA) were more effective than the Orbera gastric balloon (Apollo Endosurgery, Austin, Tex, USA), with no statistical difference between ESG and Spatz3. For both outcomes, P score and ranking score suggested that ESG was probably associated with a greater weight loss (.889272 and .899469, respectively), followed by Spatz3 (.822894 and .842773, respectively), and Orbera (.536968 and .507165, respectively). CONCLUSIONS:All currently available EBTs approved by the U.S. Food and Drug Administration are more effective than both diet plus lifestyle intervention and sham procedures with an acceptable safety profile. ESG seems the most effective and may be prioritized for patients fit for both ESG and IGBs. Direct controlled trials between EBTs are warranted to confirm these findings.