Brunaldi, Vitor Ottoboni

ABSTRACT 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.

Abstract 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]; I2=29%). Overall immediate bleeding: Statistical significance was found to favor Endocut, (P=0.05; RD=–0.15 [range, –0.29 to –0.00]; I2=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]; I2=88%), immediate bleeding with endoscopic intervention (P=0.06; RD=–0.07 [range, –0.14 to 0.00]; I2=76%), delayed bleeding (P=0.40; RD=0.01 [range, –0.02 to 0.05]; I2=72%), zipper cut (P=0.58; RD=–0.03 [range, –0.16 to 0.09]; I2=97%), perforation (P=1.00; RD=0.00 [range, –0.01 to 0.01]; I2=0%) and cholangitis (P=0.77; RD=0.00 [range, –0.01 to 0.02]; I2=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.

Abstract Background and study aims Transoral outlet reduction (TORe) has long been employed in treating weight regain after Roux-en-Y gastric bypass. However, its impact on gut hormones and their relationship with weight loss remains unknown. Patients and methods This was a substudy of a previous randomized clinical trial. Adults with significant weight regain and dilated gastrojejunostomy underwent TORe with argon plasma coagulation (APC) alone or APC plus endoscopic suturing (APC-suture). Serum levels of ghrelin, GLP-1, and PYY were assessed at fasting, 30, 60, 90, and 120 minutes after a standardized liquid meal. Results were compared according to allocation group, clinical success, and history of cholecystectomy. Results Thirty-six patients (19 APC vs. 17 APC-suture) were enrolled. There were no significant baseline differences between groups. In all analyses, the typical postprandial decrease in ghrelin levels was delayed by 30 minutes, but no other changes were noted. GLP-1 levels significantly decreased at 12 months in both allocation groups. Similar findings were noted after dividing groups according to the history of cholecystectomy and clinical success. The APC cohort presented an increase in PYY levels at 90 minutes, while the APC-suture group did not. Naïve patients had significantly lower PYY levels at baseline (P = 0.01) compared with cholecystectomized individuals. This latter group experienced a significant increase in area under the curve (AUC) for PYY levels, while naïve patients did not, leading to a higher AUC at 12 months (P = 0.0001). Conclusions TORe interferes with the dynamics of gut hormones. APC triggers a more pronounced enteroendocrine response than APC-suture, especially in cholecystectomized patients.

Background The primary obesity surgery endoluminal 2.0 (POSE 2.0) procedure involves full-thickness gastric body plications to narrow the stomach using durable suture anchor pairs. We evaluated POSE 2.0 as a treatment strategy for nonalcoholic fatty liver disease (NAFLD) in patients with obesity. Methods Adults with obesity and NAFLD were prospectively allocated based on their preference to undergo POSE 2.0 with lifestyle modification or lifestyle modification alone (control). Primary end points were improvement in controlled attenuation parameter (CAP) and resolution of hepatic steatosis at 12 months. Secondary end points included %total body weight loss (%TBWL), change in serum measures of hepatic steatosis and insulin resistance, and procedure safety. Results 42 adult patients were included (20 in the POSE 2.0 arm and 22 in the control arm). At 12 months, POSE 2.0 significantly improved CAP, whereas lifestyle modification alone did not (P < 0.001 for POSE 2.0; P = 0.24 for control). Similarly, both resolution of steatosis and %TBWL were significantly higher with POSE 2.0 than with control at 12 months. Compared with controls, POSE 2.0 significantly improved liver enzymes, hepatic steatosis index, and aspartate aminotransferase to platelet ratio at 12 months. There were no serious adverse events. Conclusion POSE 2.0 was effective for NAFLD in patients with obesity, with good durability and safety profile.

Abstract Background and study aims Significant weight regain affects up to one-third of patients after Roux-en-Y gastric bypass (RYGB) and demands treatment. Transoral outlet reduction (TORe) with argon plasma coagulation (APC) alone or APC plus full-thickness suturing TORe (APC-FTS) is effective in the short term. However, no study has investigated the course of gastrojejunostomy (GJ) or quality of life (QOL) data after the first post-procedure year. Patients and methods Patients eligible for a 36-month follow-up visit after TORe underwent upper gastrointestinal endoscopy with measurement of the GJ and answered QOL questionnaires (RAND-36). The primary aim was to evaluate the long-term outcomes of TORe, including weight loss, QOL, and GJ anastomosis (GJA) size. Comparisons between APC and APC-FTS TORe were a secondary aim. Results Among 39 eligible patients, 29 returned for the 3-year follow-up visit. There were no significant differences in demographics between APC and APC-FTS TORe groups. At 3 years, patients from both groups regained all the weight lost at 12 months, and the GJ diameter was similar to the pre-procedure assessment. As to QOL, most improvements seen at 12 months were lost at 3 years, returning to pre-procedure levels. Only the energy/fatigue domain improvement was kept between the 1- and 3-year visits. Conclusions Obesity is a chronic relapsing disease. Most effects of TORe are lost at 3 years, and redilation of the GJA occurs. Therefore, TORe should be considered iterative rather than a one-off procedure.