Elli, Enrique F.

Abstract Background Distal (ileal) metabolic bariatric surgeries (DMBS) have gained increasing adoption due to their enhanced metabolic effects. However, the absence of standardized definitions, classification, and clinical indications limits their consistent application. This consensus aimed to establish an international consensus on the definition, classification, indications, and postoperative management of DMBS. Methods A three-round modified Delphi study was conducted including international expert surgeons from 16 countries. A total of 98 statements were developed across three domains: procedural characteristics, patient selection, and postoperative follow-up. Consensus was defined as ≥75% agreement. Statements not reaching consensus were revised and resubmitted. Results Consensus was achieved on 81 statements. DMBS were defined as procedures involving gastro-ileal or duodeno-ileal bypass, emphasizing ileal stimulation as a key metabolic mechanism. Procedures with a common channel ≤350 cm, including single-anastomosis duodenal-ileal with SG (SADI-S), single anastomosis sleeve-ileal transit bipartition (SASI), sleeve gastrectomy with Roux-en-Y transit bipartition (SG+TB), and biliopancreatic diversion with duodenal switch (BPD-DS), as well as one-anastomosis gastric bypass (OAGB) with biliopancreatic limb > 50% of total small bowel length were classified as DMBS. Routine measurement of total small bowel length was strongly recommended. DMBS were considered appropriate as primary procedures in patients with BMI ≥40 kg/m² with comorbidities, a BMI ≥50–60 kg/m², irrespective of the presence of comorbidities, and as revisional options for suboptimal clinical response (SoCR), recurrent weight gain (RWG), or persistent metabolic disease. Comprehensive preoperative and multidisciplinary evaluation was deemed mandatory, and liver cirrhosis, heart failure, end-stage kidney disease, and inflammatory bowel disease were considered contraindications. Postoperative care requires lifelong multidisciplinary follow-up, with increased attention to nutritional deficiencies and supplementation. Conclusions This consensus provides a standardized framework for DMBS, supporting harmonization of practice and improved patient safety.

Purpose: With the increasing prevalence of sleeve gastrectomy, complications and insufficient weight loss have become more common, making conversion to Roux-en-Y gastric bypass (RYGB) a frequent revisional approach. Given the higher risk of revisional surgery, we aimed to compare primary versus conversion RYGB surgery and assess whether robotic assistance impacts outcomes. Method: This retrospective study included 378 patients after 2:1 propensity score matching based on demographic and clinical characteristics, comparing primary Roux-en-Y gastric bypass (P-RYGB) with sleeve gastrectomy–to–Roux-en-Y gastric bypass (SG-RYGB). The matched cohort included both robotic and laparoscopic cases performed at a single tertiary center between 2012 and 2024. A secondary 2:1 matched sub-analysis of robotic cases ( n = 297) evaluated whether robotic assistance reduced differences between primary and revisional surgery. Weight-loss outcomes were assessed at 6 and 12 months in the full cohort, with an additional sub-analysis limited to SG-RYGB performed for weight-loss indications. Results: In the full cohort ( n = 378), SG-RYGB was associated with longer operative time, greater blood loss ( P < .001), longer hospital stay ( P = .04), and higher late complication rates ( P = .04). In the robotic-only matched analysis ( n = 297), differences in operative time and blood loss were no longer significant, and early and late outcomes were comparable, although length of stay still remained longer for SG-RYGB ( P = .05). Among patients undergoing SG-RYGB for weight loss purposes only, total body weight loss percentage reached 16.5% ± 6.6% at 6 months and 20.4% ± 7.1% at 12 months but remained lower than that observed in the P-RYGB group ( P < .001). Conclusion: SG-RYGB conversion demonstrated favorable outcomes and meaningful weight loss. Robotic assistance was associated with improved operative time, reduced blood loss, and fewer late complications in the SG-RYGB group, further narrowing differences with P-RYGB, supporting its role in complex revisional bariatric surgery at high-volume centers.

Background: Robotic-assisted laparoscopic adrenalectomy (RALA) became a useful tool for the treatment of adrenal lesions. This study aims to identify areas where RALA may offer better outcomes than laparoscopic techniques. Methods: We conducted a retrospective study between August 2014 and November 2024. We involved 321 patients who underwent adrenalectomy during this time. Among these patients, 170 had laparoscopic adrenalectomy (LA), and 151 underwent RALA. We grouped these patients according to the surgical approach, collected, and analyzed preoperative data, and compared their perioperative and postoperative outcomes. Results: In this study, we compared two groups, showing the robotic approach was associated with a significantly shorter operative time compared with the laparoscopic group, 100.5 (±51.7) minutes versus 117.9 (±67.4) minutes, P = .02. There were no significant differences in estimated blood loss ( P = .97) or conversion to open ( P = .6) between the two groups. But robotic patients did exhibit a shorter duration of hospital stay, a median of 1 versus 2 days in the case of the laparoscopic approach, P value <0.01, and statistically lower 30-day complication rates in the robotic approach, 7.3% versus 14.7%, P = .035. Other short- and long-term complications were comparable between the two groups. Subanalysis of large tumor mass (>5 cm) showed comparable outcomes, with robotic cases showing statistically lower early complication rates ( P = .05). Conclusion: The study shows that RALA offers some advantages compared to the traditional LA, particularly with shorter operative time, lesser hospital stay, and fewer early complications. More randomized trials will help to confirm the findings and reach a more definitive conclusion.

Abstract Disclosure: A.M. Gonzalez Gil: None. E.F. Elli: None. R.J. Singh: None. S. Peres: None. A.Y. Chang: None. Background: Treatment of hypercortisolism in primary bilateral macronodular adrenal hyperplasia (PBMAH) with mild autonomous cortisol secretion (MACS) can be challenging. Medical treatment is useful for therapeutic purposes and as a bridge for adrenalectomy. We present the case of a patient who benefited from mifepristone but developed hyperestrogenism. Clinical Case: A 64-year-old man with prediabetes, hypertension, and cardiovascular disease had incidentally discovered bilateral nodular adrenal enlargement on CT scan following coronary artery bypass surgery. A few months later, he reported increasing fatigue, brain fog, weight gain, and worsening blood pressure. Physical exam showed no features of hypercortisolism. Work-up revealed baseline AM cortisol 17.3 mcg/dL [reference range (RR) 4.8-20], ACTH 10 pg/mL (RR 7.2-63) and DHEA-S 55 mcg/dL (RR 12-227); two abnormal AM cortisols after 1 mg overnight dexamethasone (5.4 and 6.9 mcg/dL; cut-off &lt;1.8), and a normal 24-hour urine free cortisol (23 mcg/24h, RR 3.5-45). 24-hour urine metanephrines and aldosterone/renin ratio were normal. A 2-hour 75 g oral glucose tolerance test was diagnostic for type 2 diabetes mellitus (2-hour glucose 214 mg/dL). Baseline total testosterone (TT) was 366 ng/dL (RR 264-916) with normal follicle stimulating hormone (FSH) and luteinizing hormone (LH)concentrations. After a diagnosis of MACS, adrenal vein sampling showed bilateral excess cortisol secretion (lateralization ratio 1.09). Medical management versus right adrenalectomy based on nodule burden were offered, and he started mifepristone. With initial symptom improvement, his dose was increased from 300 mg to 300 mg alternating with 600 mg daily. When he developed increased blood pressure and hypokalemia, eplerenone was added. After 6 months of mifepristone and 5 months eplerenone 50 mg daily, he developed tender gynecomastia with elevated estradiol (106 pg/mL, RR ≤39), low TT (112 ng/dL) and undetectable FSH and LH. As expected with mifepristone, 17-hydroxyprogesterone was high (933 ng/dL, RR 51-190), but androstenedione and DHEA-S were normal. Reduction in mifepristone and eplerenone decreased estradiol levels (56 pg/mL) but gonadotrophins remained undetectable and TT decreased to 72 ng/dL. Despite discontinuation of eplerenone for 1 month, estradiol again increased (91 pg/mL), TT remained low (77 ng/dL), and mastalgia persisted. A decision to stop mifepristone and proceed with right adrenalectomy was made. Conclusion: This is a previously unreported incident of symptomatic estradiol-induced secondary hypogonadism on mifepristone therapy. Hyperestrogenism with gynecomastia and secondary hypogonadism with mifepristone suggests that some individuals may convert cortisol precursors to estradiol. Presentation: Saturday, July 12, 2025

Vascular surgery has evolved from durable yet invasive open reconstructions to less traumatic endovascular techniques. While endovascular repair reduces perioperative morbidity, it introduces durability challenges and the need for lifelong surveillance. Laparoscopic surgery bridged some gaps but was hindered by steep learning curves and technical limitations. Robotic-assisted surgery represents a “third revolution”, combining the durability of open repair with the recovery and ergonomic benefits of minimally invasive approaches through enhanced 3D visualization, wristed instrumentation, and tremor filtration. This review synthesizes current evidence on robotic applications in vascular surgery, including aortic, visceral, venous, and endovascular interventions. Feasibility of robotic vascular surgery has been demonstrated in over 1500 patients across aortic, visceral, venous, and decompression procedures. Reported outcomes include pooled conversion rates of ~5%, 30-day mortality of 1–3%, and long-term patency rates exceeding 90% in aortoiliac occlusive disease. Similarly favorable outcomes have been observed in AAA repair, visceral artery aneurysm repair, IVC reconstructions, renal vein transpositions, and minimally invasive decompression procedures such as median arcuate ligament and thoracic outlet syndromes. Endovascular robotics enhances catheter navigation precision and reduces operator radiation exposure by 85–95%, with multiple series demonstrating consistent benefit compared to manual techniques. Despite these advantages, adoption is limited by high costs, lack of dedicated vascular instruments, absent haptic feedback on most platforms, and the need for standardized training. Most available evidence is observational and from high-volume centers, highlighting the need for multicenter randomized trials. Future directions include AI-enabled planning and augmented-reality navigation, which are the most feasible near-term technologies since they rely largely on software integration with existing systems. Other advances such as microsurgical robotics, soft-robotic platforms, and telesurgery remain longer-term developments requiring new hardware and regulatory pathways. Overcoming barriers through collaborative innovation, structured training, and robust evidence generation is essential for robotics to become a new standard in vascular care.

Background Vascular injury is a feared complication of minimally invasive median arcuate ligament (MAL) release. The identified elements of variant anatomy that predispose to injury. Methods Between August 2018 and March 2025, 64 patients underwent laparoscopic (51) or robotic (13) median arcuate ligament release operation. Surgical anatomy was prospectively recorded with respect to variants of vascular and visceral anatomy. Results Only 17 cases (27%) had no observed anatomical variant. Visceral arterial variants occurred in 15 cases (23%), and included: Accessory left hepatic artery in 8 (requiring division in 6); common hepatic artery (CHA) variants were observed in 2 cases and included replaced CHA and early origin CHA; 5 left gastric artery (LGA) variants included early origin (N = 3) or duplicated LGA (N = 2). One or both IPA originated from the celiac artery in 32 cases (50%), of which anterior origin off the celiac was seen in 20 cases (31%). Both IPA originated separately from the anterior celiac in 2 cases, and from a common trunk in 9 cases (14%). One IPA arising from the anterior celiac was observed in 8 cases (13%). The coronary vein (CV) inserted into the portal vein superior to the CHA in 6 cases (9%), and coursed parallel to the CHA in 16 cases (25%). A high riding pancreas necessitating retraction was seen in 9 cases (14%). Conclusion Most patients undergoing median arcuate ligament release have elements of complexity that increase the difficulty of operation or increase operative risk.

Background: Revisional bariatric surgery for recurrent weight gain is becoming more common, though it carries higher risks and may be less effective than primary bariatric surgery. This study compares clinical outcomes between primary and revisional duodenal switch (DS) in patients with a body mass index (BMI) > 55 kg/m2. Methods: A retrospective cohort study was conducted on 20 patients who underwent either primary or revisional duodenal switch (DS) surgeries, including biliopancreatic diversion with duodenal switch (BPDDS) and Single-Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-s), between January 2015 and December 2023. Revisional DS was defined as the conversion from Sleeve Gastrectomy (SG) to either BPDDS (C-BPDDS) or SADI-S (C-SADI-S). Perioperative and postoperative variables were analyzed. A statistical analysis was performed using chi-square and McNemar tests for categorical variables and Student’s t-test for continuous variables. A p-value of <0.05 was considered significant. Results: Eleven primary DS patients (six BPDDS, five SADI-s) and nine revisional DS patients (five C-BPDDS, four C-SADI-s) were included. The revisional group had a slightly higher preoperative BMI (57.56 ± 5.92 kg/m2 vs. 55.93 kg/m2 ± 6.91 kg/m2). Although operative times were shorter in the revisional group (153.20 ± 53.26 vs. 193.27 ± 46.79 min), the length of stay was longer (2.70 ± 1.25 vs. 2.18 ± 1.16 days). Primary DS patients experienced three minor late complications (dehydration, nephrolithiasis), whereas the revisional group had one major complication (internal hernia requiring reoperation). At the 12-month follow-up, both groups demonstrated similar outcomes in terms of percentage of total weight loss (%TWL) (primary DS: 25.25% ± 12.38 vs. revisional DS: 30.31% ± 10.79) and percentage of excess weight loss (%EWL) (primary DS: 48.41% ± 22.93 vs. revisional DS: 53.24% ± 14.48). Conclusions: Revisional DS was associated with shorter operation times and similar weight loss to primary DS. Additionally, it was accomplished safely and led to adequate and sustained weight loss in patients with a BMI greater than 55 kg/m2.