Indications and Coverage of Metabolic and Bariatric Surgery: A Worldwide IFSO Survey Comparing Different National Guidelines

INTRODUCTION

Knowing how metabolic and bariatric surgery (MBS) is indicated in different countries is essential information for the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO).

AIM

To analyze the indications for MBS recommended by each of the national societies that comprise the IFSO and how MBS is financed in their countries.

METHODS

All IFSO societies were asked to fill out a survey asking whether they have, and which are their national guidelines, and if MBS is covered by their public health service.

RESULTS

Sixty-three out of the 72 IFSO national societies answered the form (87.5%). Among them, 74.6% have some kind of guidelines regarding indications for MBS. Twenty-two percent are still based on the US National Institute of Health (NIH) 1991 recommendations, 43.5% possess guidelines midway the 1991s and ASMBS/IFSO 2022 ones, and 34% have already adopted the latest ASMBS/IFSO 2022 guidelines. MBS was financially covered in 65% of the countries.

CONCLUSIONS

Most of the IFSO member societies have MBS guidelines. While more than a third of them have already shifted to the most updated ASMBS/IFSO 2022 ones, another significant number of countries are still following the NIH 1991 guidelines or even do not have any at all. Besides, there is a significant number of countries in which surgical treatment is not yet financially covered. More effort is needed to standardize indications worldwide and to influence insurers and health policymakers to increase the coverage of MBS.

IFSO Worldwide Survey 2020-2021: Current Trends for Bariatric and Metabolic Procedures

PURPOSE

This IFSO survey aims to describe the current trends of metabolic and bariatric surgery (MBS) reporting on the number and types of surgical and endoluminal procedures performed in 2020 and 2021, in the world and within each IFSO chapter.

METHODS

All national societies belonging to IFSO were asked to complete the survey form. The number and types of procedures performed (surgical and endoluminal interventions) from 2020 to 2021 were documented. A special section focused on the impact of COVID-19, the existence of national protocols for MBS, the use of telemedicine, and any mortality related to MBS. A trend analysis of the data, both worldwide and within each IFSO chapter, was also performed for the period between 2018 and 2021.

RESULTS

Fifty-seven of the 74 (77%) IFSO national societies submitted the survey. Twenty-four of the 57 (42.1%) reported data from their national registries. The total number of surgical and endoluminal procedures performed in 2020 was 507,806 and in 2021 was 598,834. Sleeve gastrectomy (SG) remained the most performed bariatric procedure. Thirty national societies (52%) had regional protocols for MBS during COVID-19, 61.4% supported the use of telemedicine, and only 47.3% collected data on mortality after MBS in 2020. These percentages did not significantly change in 2021 (p > 0.05).

CONCLUSIONS

The number of MBS markedly decreased worldwide during 2020. Although there was a positive trend in 2021, it did not reach the values obtained before the COVID-19 pandemic. SG continued to be the most performed operation. Adjustable gastric banding (AGB) continues to decrease worldwide.

Metabolic and Bariatric Surgery in Patients with Obesity Class V (BMI > 60 kg/m2): a Modified Delphi Study

BACKGROUND

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.

METHODS

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% of experts' votes was achieved.

RESULTS

A total of 54 out of 81 statements reached consensus. Remarkably, more than 90% of the experts agreed that patients should be notified of the greater risk of complications, the possibility of modifications to the surgical procedure, and the early start of chemical thromboprophylaxis. Regarding the choice of the procedure, SADI-S, RYGB, and OAGB were the top 3 preferred operations. However, no consensus was reached on the limb length in these operations.

CONCLUSION

This study represents the first attempt to reach consensus on the choice of procedures as well as perioperative management in patients with obesity class V. Although overall consensus was reached in different areas, more research is needed to better serve this high-risk population.

Current recommendations for procedure selection in class I and II obesity developed by an expert modified Delphi consensus

Metabolic and bariatric surgery (MBS) is widely considered the most effective option for treating obesity, a chronic, relapsing, and progressive disease. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued new guidelines on the indications for MBS, which have superseded the previous 1991 National Institutes of Health guidelines. The aim of this study is to establish the first set of consensus guidelines for selecting procedures in Class I and II obesity, using an Expert Modified Delphi Method. In this study, 78 experienced bariatric surgeons from 32 countries participated in a two-round Modified Delphi consensus voting process. The threshold for consensus was set at an agreement or disagreement of ≥ 70.0% among the experts. The experts reached a consensus on 54 statements. The committee of experts reached a consensus that MBS is a cost-effective treatment option for Class II obesity and for patients with Class I obesity who have not achieved significant weight loss through non-surgical methods. MBS was also considered suitable for patients with Type 2 diabetes mellitus (T2DM) and a body mass index (BMI) of 30 kg/m2 or higher. The committee identified intra-gastric balloon (IGB) as a treatment option for patients with class I obesity and endoscopic sleeve gastroplasty (ESG) as an option for patients with class I and II obesity, as well as for patients with T2DM and a BMI of ≥ 30 kg/m2. Sleeve gastrectomy (1) and Roux-en-Y gastric bypass (RYGB) were also recognized as viable treatment options for these patient groups. The committee also agreed that one anastomosis gastric bypass (OAGB) is a suitable option for patients with Class II obesity and T2DM, regardless of the presence or severity of obesity-related medical problems. The recommendations for selecting procedures in Class I and II obesity, developed through an Expert Modified Delphi Consensus, suggest that the use of standard primary bariatric endoscopic (IGB, ESG) and surgical procedures (SG, RYGB, OAGB) are acceptable in these patient groups, as consensus was reached regarding these procedures. However, randomized controlled trials are still needed in Class I and II Obesity to identify the best treatment approach for these patients in the future.

Case report: Laparoscopic nissen-sleeve gastrectomy in a young adult with incidental finding of Morgagni-Larrey hernia

Laparoscopic sleeve Gastrectomy (LSG) is the most performed bariatric procedure worldwide but it is associated with an increased incidence of de-novo or recurrent GERD. Recently a new technique consisting in LSG with associated fundoplication has been described. Morgagni-Larrey hernia is very rare and there is a lack of evidences on its correct surgical treatment. There are only rare cases of a MLH incidental diagnosis in patients submitted to bariatric surgery. We present our experience of Morgagni-Larrey Hernia (MLH) incidentally found intraoperatively in a patient with Gastroesophageal Reflux Disease (GERD) with Hiatal Hernia (HH) undergoing a bariatric surgical procedure.

Evolution of Bariatric Surgery in Italy in the Last 11 Years: Data from the SICOB Yearly National Survey

BACKGROUND

Bariatric surgery (BS) is a relatively novel surgical field and is in continuous expansion and evolution.

PURPOSE

Aim of this study was to report changes in Italian surgical practice in the last decade.

METHODS

The Società Italiana di Chirurgia dell'Obesità (SICOB) conducted annual surveys to cense activity of SICOB centers between 2011 and 2021. Primary outcome was to detect differences in frequency of performance of adjustable gastric banding (AGB), sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), one anastomosis gastric bypass (OAGB), bilio-pancreatic diversion (BPD), and gastric plication (GP). Secondary outcome was to detect differences in performance of main non-malabsorptive procedures (AGB + SG) and overall bypass procedures (RYGB + OAGB). Geographical differences were also investigated.

RESULTS

Median response rate was 92%. AGB declined from 36% of procedures in 2011 to 5% in 2021 (p < 0.0001). SG increased from 30% in 2011 to 55% in 2021 (p < 0.0001). RYGB declined from 25 to 12% of procedures (p < 0.0001). OAGB rose from 0% of procedures in 2011 to 15% in 2021 (p < 0.0001). BPD underwent decrease from 6.2 to 0.2% in 2011 and 2021, respectively (p < 0.0001). Main non-malabsorptive procedures significantly decreased while overall bypass procedures remained stable. There were significant differences among regions in performance of SG, RYGB, and OAGB.

CONCLUSIONS

BS in Italy evolved significantly during the past 10 years. AGB underwent a decline, as did BPD and GP which are disappearing and RYGB which is giving way to OAGB. The latter is rising and is the second most-performed procedure after SG which has been confirmed as the preferred procedure by Italian bariatric surgeons.

2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) Indications for Metabolic and Bariatric Surgery

MAJOR UPDATES TO 1991 NATIONAL INSTITUTES OF HEALTH GUIDELINES FOR BARIATRIC SURGERY: Metabolic and bariatric surgery (MBS) is recommended for individuals with a body mass index (BMI) >35 kg/m2, regardless of presence, absence, or severity of co-morbidities.MBS should be considered for individuals with metabolic disease and BMI of 30-34.9 kg/m2.BMI thresholds should be adjusted in the Asian population such that a BMI >25 kg/m2 suggests clinical obesity, and individuals with BMI >27.5 kg/m2 should be offered MBS.Long-term results of MBS consistently demonstrate safety and efficacy.Appropriately selected children and adolescents should be considered for MBS.(Surg Obes Relat Dis 2022; https://doi.org/10.1016/j.soard.2022.08.013 ) © 2022 American Society for Metabolic and Bariatric Surgery. All rights reserved.

Gerd symptoms after laparoscopic Roux-en-Y gastric bypass: an emerging scenario

Laparoscopic Roux-en-Y gastric bypass (RYGB) is the second most performed bariatric procedure and it is considered the procedure of choice to treat patients with severe obesity and gastroesophageal reflux disease (GERD). However, some authors described the new onset or the recurrence of GERD symptoms after RYGB, and data at follow-up were scanty. In our center, we evaluated trend in weight, GERD symptoms and obesity-related comorbidities in 45 patients undergone RYGB at least 60 months before (mean follow-up 99.9 ± 22.9 months). At RYGB 51.1% patients referred preoperative GERD symptoms; among them, 47.8% showed an intraoperative hiatal hernia (HH). At medium-term follow-up mean BMI was significantly lower compared to baseline (p < 0.001). Among patients with preoperative GERD, 69.6% had GERD resolution and 30.4% reported postoperative GERD symptoms. Furthermore, 18.2% without preoperative GERD referred postoperative GERD new onset. We confirmed that RYGB as primary intervention provides satisfactory weight loss and a high percentage of GERD symptoms resolution. However, about 24.4% of patients complained of GERD symptoms at medium-term follow-up. The pathophysiology of GERD after RYGB, de novo or persistence, is not completely understood and several hypotheses could be drawn; however, further studies focusing the pathophysiology of these symptoms are needed.

Nonadherence to Micronutrient Supplementation After Bariatric Surgery: Results from an Italian Internet-Based Survey

BACKGROUND AND AIM

Bariatric surgery (BS) is a pillar for the treatment of morbid obesity and its related comorbidities. However, it might be associated with long-term deficiencies and absorption issues. Adherence to micronutrient supplementation is a crucial aspect in the management of these patients.

AIM

The aim of the present survey was to evaluate the adherence to micronutrient supplementation in a cohort of Italian patients submitted to BS (BS patients) and to identify predictors of adherence using a self-administered, anonymous, internet-based instrument.

METHODS

Patients who underwent BS over the last decade in a single center were invited to participate to a self-administered, anonymous, internet-based survey consisting of a 23 items structured questionnaire evaluating: a. demographic information b. Bariatric procedures performed; c. Indication to BS; d. Lapse of time since last BS, e. Frequency of follow up visits post-surgery, f. Perception of well-being post BS; g. Adherence to micronutrient supplementation; h. Changes in their quality of life and self-esteem.

RESULTS

We received an automatic notification of delivery from 1100 out of 1600 BS patients and 290 (81.4% female, mean age 39.5 ± 10.1 years) completed the questionnaire. The main reported bariatric procedures were: Sleeve Gastrectomy (59%), Roux-en-Y Gastric Bypass (31%) and Adjustable Gastric Banding (7.2%). Only 33.1% of the sample acknowledged to have taken all recommended medication regularly. BS patients who underwent malabsorptive procedures and had their last follow up visit more than 5 years earlier, had a higher risk of being nonadherent to micronutrient supplementation. Conversely, BS patients in their forties seemed more likely to adhere to treatment recommendations. Losing more weight was the only independent risk factors for nonadherence to micronutrient supplementation, independently from patient's perception of wellbeing.

CONCLUSION

After BS, several clinical and psychosocial factors might predict nonadherence to micronutrient supplementation.

30-Day Morbidity and Mortality of Bariatric Surgery During the COVID-19 Pandemic: a Multinational Cohort Study of 7704 Patients from 42 Countries

BACKGROUND

There are data on the safety of cancer surgery and the efficacy of preventive strategies on the prevention of postoperative symptomatic COVID-19 in these patients. But there is little such data for any elective surgery. The main objectives of this study were to examine the safety of bariatric surgery (BS) during the coronavirus disease 2019 (COVID-19) pandemic and to determine the efficacy of perioperative COVID-19 protective strategies on postoperative symptomatic COVID-19 rates.

METHODS

We conducted an international cohort study to determine all-cause and COVID-19-specific 30-day morbidity and mortality of BS performed between 01/05/2020 and 31/10/2020.

RESULTS

Four hundred ninety-nine surgeons from 185 centres in 42 countries provided data on 7704 patients. Elective primary BS (n = 7084) was associated with a 30-day morbidity of 6.76% (n = 479) and a 30-day mortality of 0.14% (n = 10). Emergency BS, revisional BS, insulin-treated type 2 diabetes, and untreated obstructive sleep apnoea were associated with increased complications on multivariable analysis. Forty-three patients developed symptomatic COVID-19 postoperatively, with a higher risk in non-whites. Preoperative self-isolation, preoperative testing for SARS-CoV-2, and surgery in institutions not concurrently treating COVID-19 patients did not reduce the incidence of postoperative COVID-19. Postoperative symptomatic COVID-19 was more likely if the surgery was performed during a COVID-19 peak in that country.

CONCLUSIONS

BS can be performed safely during the COVID-19 pandemic with appropriate perioperative protocols. There was no relationship between preoperative testing for COVID-19 and self-isolation with symptomatic postoperative COVID-19. The risk of postoperative COVID-19 risk was greater in non-whites or if BS was performed during a local peak.

30-Day Morbidity and Mortality of Bariatric Surgery During the COVID-19 Pandemic: a Multinational Cohort Study of 7704 Patients from 42 Countries

BACKGROUND

There are data on the safety of cancer surgery and the efficacy of preventive strategies on the prevention of postoperative symptomatic COVID-19 in these patients. But there is little such data for any elective surgery. The main objectives of this study were to examine the safety of bariatric surgery (BS) during the coronavirus disease 2019 (COVID-19) pandemic and to determine the efficacy of perioperative COVID-19 protective strategies on postoperative symptomatic COVID-19 rates.

METHODS

We conducted an international cohort study to determine all-cause and COVID-19-specific 30-day morbidity and mortality of BS performed between 01/05/2020 and 31/10/2020.

RESULTS

Four hundred ninety-nine surgeons from 185 centres in 42 countries provided data on 7704 patients. Elective primary BS (n = 7084) was associated with a 30-day morbidity of 6.76% (n = 479) and a 30-day mortality of 0.14% (n = 10). Emergency BS, revisional BS, insulin-treated type 2 diabetes, and untreated obstructive sleep apnoea were associated with increased complications on multivariable analysis. Forty-three patients developed symptomatic COVID-19 postoperatively, with a higher risk in non-whites. Preoperative self-isolation, preoperative testing for SARS-CoV-2, and surgery in institutions not concurrently treating COVID-19 patients did not reduce the incidence of postoperative COVID-19. Postoperative symptomatic COVID-19 was more likely if the surgery was performed during a COVID-19 peak in that country.

CONCLUSIONS

BS can be performed safely during the COVID-19 pandemic with appropriate perioperative protocols. There was no relationship between preoperative testing for COVID-19 and self-isolation with symptomatic postoperative COVID-19. The risk of postoperative COVID-19 risk was greater in non-whites or if BS was performed during a local peak.

Bariatric Surgery Survey 2018: Similarities and Disparities Among the 5 IFSO Chapters

BACKGROUND

The 2018 IFSO Survey focused on similarities and disparities in the number and types of surgical and endoluminal interventions among the IFSO chapters occurred in the last decade.

METHODS

All IFSO Societies were asked to fill in the IFSO survey form on how many and which surgical and endoluminal interventions have been performed in the 2018. A special section was added, asking about the existence of national guidelines for bariatric and metabolic surgery, national recommendations for preoperative gastroscopy, type of reimbursement for bariatric/metabolic surgery, including for patients with BMI < 35 kg/m². The trend analyses from 2008 to 2018 were also performed.

RESULTS

Fifty-seven/65 (87.7%) IFSO Societies submitted completed forms. The American Society for Metabolic and Bariatric Surgery did not fill the IFSO survey form but provided an official report on the performed interventions. The total number of surgical and endoluminal procedures performed in 2018 in the world was 696,191. Sleeve gastrectomy (SG) remained the most commonly performed bariatric procedure (N = 386,096; 55.4%). Among the total reported bariatric/metabolic interventions, 604,223 (86.8%) were primary surgical and 29,167 (4.2%) primary endoluminal operations; 62,801 (9%) were revisional procedures.

CONCLUSIONS

There was only a slight increase (10.317 procedures) in the total number of the reported bariatric interventions compared to the last IFSO survey. SG continues to be the most commonly performed operation since 2014. The one anastomosis gastric bypass (OAGB), currently the third most performed procedure after SG and Roux-en-Y gastric bypass (RYGB), continues to rise in popularity worldwide.

Effect of COVID-19 pandemic on global Bariatric surgery PRActiceS - The COBRAS study

Introduction

There is a paucity of data in scientific literature on the impact of Coronavirus Disease 2019 (COVID-19) pandemic on bariatric surgery. The aim of this study was to evaluate the impact of COVID-19 pandemic on Bariatric Surgery globally.

Methods

We conducted a global online survey of bariatric surgeons between 16/04/20 – 15/05/20. The survey was endorsed by five national bariatric surgery societies and circulated amongst their memberships. Authors also shared the link through their personal networks, email groups, and social media.

Results

703 respondents from 77 countries completed the survey. Respondents reported a drop in elective bariatric activity from a median (IQR) of 130 (60–250) procedures in 2019 to a median of 0 (0–2) between16/03/2020 and 15/04/2020 during the pandemic. The corresponding figures for emergency activity were 5 (2–10) and 0 (0–1) respectively. 441 (63%) respondents did not perform any bariatric procedures during this time period. Surgeons reported outcomes of 61 elective bariatric surgical procedures during the pandemic with 13 (21%) needing ventilation and 2 (3.3%) deaths. Of the 13 emergency bariatric procedures reported, 5 (38%) needed ventilation and 4 (31%) died. 90 (13%) surgeons reported having had to perform a bariatric surgical or endoscopic procedure without adequate Personal Protective Equipment.

Conclusions

COVID-19 pandemic led to a remarkable decline in global elective and emergency bariatric surgery activity at its beginning. Both elective and emergency procedures performed at this stage of the pandemic had considerable morbidity and mortality.

Sarcopenia: What a Surgeon Should Know

Sarcopenia is an increasingly frequent syndrome characterized by generalized and progressive loss of muscle mass, reduction in muscle strength, and resultant functional impairment. This condition is associated with increased risk of falls and fractures, disability, and increased risk of death. When a sarcopenic patient undergoes major surgery, it has a higher risk of complications and postoperative mortality because of less resistance to surgical stress. It is not easy to recognize a sarcopenic patient preoperatively, but this is essential to evaluate the correct risk to benefit ratio. The role of sarcopenia in surgical patients has been studied for both oncological and non-oncological surgery. For correct surgical planning, data about sarcopenia are essential to design a correct tailored treatment.

Long-term results of laparoscopic Roux-en-Y gastric bypass for morbid obesity: 105 patients with minimum follow-up of 15 years

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the second most frequently performed bariatric procedure worldwide; however, long-term results are not frequently reported.

OBJECTIVES

To evaluate the outcomes of LRYGB on weight loss and co-morbidities in a single center 15 years after the operation.

SETTING

Tertiary-care referral hospital.

METHODS

From February 2000 to December 2003, 105 patients (86 women; mean age 39.9 ± 17.4; mean body mass index [BMI] 47.2 ± 6.4 kg/m²; 78 with BMI < 50 kg/m² and 27 with BMI ≥ 50 kg/m²) underwent LRYGB. Retrospective analyses of a prospectively maintained database were carried out to evaluate weight loss; resolution of co-morbidities, including type 2 diabetes mellitus (T2D), hypertension (HTN), and dyslipidemia; complications; and nutritional status.

RESULTS

The follow-up rate at 15 years was 87.6%. Mean excess weight loss was 58.6 ± 27%, with 74.1% of patients achieving a total weight loss ≥ 20%. According to the Biron et al. criteria, an inadequate outcome was found in 11/21 (52.4%) of patients with an initial BMI ≥ 50 kg/m² versus 21/64 (32.8%) of patients with a preoperative BMI < 50 kg/m² (P = .001). Both groups experienced gradual weight regain (WR); specifically, 34.1% of patients regained more than 15% of their lowest postoperative weight. The rates of reoperations due to early and late surgical complications were 3.8% and 9.5%, respectively. T2D was resolved in 50% of patients, HTN in 61.1%, and dyslipidemia in 58.3%. Iron deficiency anemia (53%) was the most common postoperative nutritional finding.

CONCLUSION

LRYGB provides satisfactory weight loss and resolution of co-morbidities up to 15 years. WR was a common finding. A significant proportion of patients with a preoperative BMI ≥ 50 kg/m² did not achieve a favorable weight loss outcome. Indications to perform LRYGB in this group of patients should be definitively reconsidered.

Bariatric Surgery Survey 2018: Similarities and Disparities Among the 5 IFSO Chapters

BACKGROUND

The 2018 IFSO Survey focused on similarities and disparities in the number and types of surgical and endoluminal interventions among the IFSO chapters occurred in the last decade.

METHODS

All IFSO Societies were asked to fill in the IFSO survey form on how many and which surgical and endoluminal interventions have been performed in the 2018. A special section was added, asking about the existence of national guidelines for bariatric and metabolic surgery, national recommendations for preoperative gastroscopy, type of reimbursement for bariatric/metabolic surgery, including for patients with BMI < 35 kg/m². The trend analyses from 2008 to 2018 were also performed.

RESULTS

Fifty-seven/65 (87.7%) IFSO Societies submitted completed forms. The American Society for Metabolic and Bariatric Surgery did not fill the IFSO survey form but provided an official report on the performed interventions. The total number of surgical and endoluminal procedures performed in 2018 in the world was 696,191. Sleeve gastrectomy (SG) remained the most commonly performed bariatric procedure (N = 386,096; 55.4%). Among the total reported bariatric/metabolic interventions, 604,223 (86.8%) were primary surgical and 29,167 (4.2%) primary endoluminal operations; 62,801 (9%) were revisional procedures.

CONCLUSIONS

There was only a slight increase (10.317 procedures) in the total number of the reported bariatric interventions compared to the last IFSO survey. SG continues to be the most commonly performed operation since 2014. The one anastomosis gastric bypass (OAGB), currently the third most performed procedure after SG and Roux-en-Y gastric bypass (RYGB), continues to rise in popularity worldwide.

The first modified Delphi consensus statement on sleeve gastrectomy

INTRODUCTION

Sleeve gastrectomy (SG) is the commonest bariatric procedure worldwide. Yet there is significant variation in practice concerning its various aspects. This paper report results from the first modified Delphi consensus-building exercise on SG.

METHODS

We established a committee of 54 globally recognized opinion makers in this field. The committee agreed to vote on several statements concerning SG. An agreement or disagreement amongst ≥ 70.0% experts was construed as a consensus.

RESULTS

The committee achieved a consensus of agreement (n = 71) or disagreement (n = 7) for 78 out of 97 proposed statements after two rounds of voting. The committee agreed with 96.3% consensus that the characterization of SG as a purely restrictive procedure was inaccurate and there was 88.7% consensus that SG was not a suitable standalone, primary, surgical weight loss option for patients with Barrett's esophagus (BE) without dysplasia. There was an overwhelming consensus of 92.5% that the sleeve should be fashioned over an orogastric tube of 36-40 Fr and a 90.7% consensus that surgeons should stay at least 1 cm away from the angle of His. Remarkably, the committee agreed with 81.1% consensus that SG patients should undergo a screening endoscopy every 5 years after surgery to screen for BE.

CONCLUSION

A multinational team of experts achieved consensus on several aspects of SG. The findings of this exercise should help improve the outcomes of SG, the commonest bariatric procedure worldwide, and guide future research on this topic.

Sleeve gastrectomy with concomitant hiatal hernia repair in obese patients: long-term results on gastroesophageal reflux disease

BACKGROUND

Hiatal hernia repair (HHR) during Sleeve Gastrectomy (SG) is recommended when the defect is intraoperatively found; however, the long term effect on gastro-esophageal reflux disease (GERD) remains controversial.

OBJECTIVES

This study aimed to report long-term follow-up data, at least after 7 years, of SG with concomitant HHR and the outcome on GERD symptoms.

SETTING

Tertiary-care referral hospital.

METHODS

This study retrospectively analyzed 91 obese patients submitted to SG + HHR with a minimum of 7-years follow-up. The preoperative evaluation included GERD symptoms assessment by a standardized questionnaire, proton pump inhibitor usage evaluation, an upper gastrointestinal endoscopy, and a barium-swallow esophagogram to detect the presence of HH. At long-term follow-up visit, GERD assessment was performed to evaluate remission, persistence, or new onset of typical GERD symptoms; proton pump inhibitor usage was also investigated. Patients underwent barium-swallow esophagogram and/or upper gastrointestinal endoscopy.

RESULTS

At long-term evaluation, 2 of 91 patients (2.2%) were lost and 1 patient underwent Roux-en-Y gastric bypass. Of patients with preoperative GERD, 60% had GERD resolution; however, 27 of 88 (30.6%) patients reported postoperative GERD symptoms. Among these patients 15 (55.5%) showed the HH recurrence detected by barium-swallow esophagogram. All patients with HH recurrence had esophagitis and 1 case had a Barrett's esophagus. In the remaining 12 patients (44.4%) with postoperative GERD without HH recurrence, the barium-swallow esophagogram showed signs of reflux in reverse Trendelenburg.

CONCLUSIONS

At long-term follow-up HH recurrence was consistently related to the presence of GERD symptoms and to a high rate of esophagitis and Barrett's esophagus. In all patients with GERD symptoms after SG + HHR, a HH recurrence should be suspected and an upper gastrointestinal endoscopy strongly recommended to rule out esophagitis, and especially Barrett's esophagus.

The First Modified Delphi Consensus Statement for Resuming Bariatric and Metabolic Surgery in the COVID-19 Times

The purpose of this study was to achieve consensus amongst a global panel of expert bariatric surgeons on various aspects of resuming Bariatric and Metabolic Surgery (BMS) during the Coronavirus Disease-2019 (COVID-19) pandemic. A modified Delphi consensus-building protocol was used to build consensus amongst 44 globally recognised bariatric surgeons. The experts were asked to either agree or disagree with 111 statements they collectively proposed over two separate rounds. An agreement amongst ≥ 70.0% of experts was construed as consensus as per the predetermined methodology. We present here 38 of our key recommendations. This first global consensus statement on the resumption of BMS can provide a framework for multidisciplinary BMS teams planning to resume local services as well as guide future research in this area.

Sleeve gastrectomy with concomitant hiatal hernia repair in obese patients: long-term results on gastroesophageal reflux disease

BACKGROUND

Hiatal hernia repair (HHR) during Sleeve Gastrectomy (SG) is recommended when the defect is intraoperatively found; however, the long term effect on gastro-esophageal reflux disease (GERD) remains controversial.

OBJECTIVES

This study aimed to report long-term follow-up data, at least after 7 years, of SG with concomitant HHR and the outcome on GERD symptoms.

SETTING

Tertiary-care referral hospital.

METHODS

This study retrospectively analyzed 91 obese patients submitted to SG + HHR with a minimum of 7-years follow-up. The preoperative evaluation included GERD symptoms assessment by a standardized questionnaire, proton pump inhibitor usage evaluation, an upper gastrointestinal endoscopy, and a barium-swallow esophagogram to detect the presence of HH. At long-term follow-up visit, GERD assessment was performed to evaluate remission, persistence, or new onset of typical GERD symptoms; proton pump inhibitor usage was also investigated. Patients underwent barium-swallow esophagogram and/or upper gastrointestinal endoscopy.

RESULTS

At long-term evaluation, 2 of 91 patients (2.2%) were lost and 1 patient underwent Roux-en-Y gastric bypass. Of patients with preoperative GERD, 60% had GERD resolution; however, 27 of 88 (30.6%) patients reported postoperative GERD symptoms. Among these patients 15 (55.5%) showed the HH recurrence detected by barium-swallow esophagogram. All patients with HH recurrence had esophagitis and 1 case had a Barrett's esophagus. In the remaining 12 patients (44.4%) with postoperative GERD without HH recurrence, the barium-swallow esophagogram showed signs of reflux in reverse Trendelenburg.

CONCLUSIONS

At long-term follow-up HH recurrence was consistently related to the presence of GERD symptoms and to a high rate of esophagitis and Barrett's esophagus. In all patients with GERD symptoms after SG + HHR, a HH recurrence should be suspected and an upper gastrointestinal endoscopy strongly recommended to rule out esophagitis, and especially Barrett's esophagus.

Bariatric surgery and the COVID-19 pandemic: SICOB recommendations on how to perform surgery during the outbreak and when to resume the activities in phase 2 of lockdown

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its related disease, coronavirus disease 2019 (COVID-19), has been rapidly spreading all over the world and is responsible for the current pandemic. The current pandemic has found the Italian national health system unprepared to provide an appropriate and prompt response, heavily affecting surgical activities. Based on the limited data available in the literature and personal experiences, the Società Italiana di Chirurgia dell’OBesità e Malattie Metaboliche (SICOB) provides recommendations regarding the triage of bariatric surgical procedures during the COVID-19 pandemic defining a dedicated path for surgery in morbidly obese patients with known or suspected COVID-19 who may require emergency operations. Finally, the current paper delineates a strategy to resume outpatient visits and elective bariatric surgery once the acute phase of the pandemic is over. Models developed during the COVID-19 crisis should be integrated into hospital practices for future use in similar scenarios. Surgeons are presented with a golden opportunity to embrace systemic change and to drive their professional future.

Anhedonia and functional dyspepsia in obese patients: Relationship with binge eating behaviour

BACKGROUND

Obese patients (Ob) with a binge eating disorders (BED) behavior pattern have a higher prevalence of postprandial distress syndrome (PDS) compared to Ob without a BED behavior pattern, while an increase of PDS has been described in Ob after sleeve gastrectomy (SG). Hedonic response to a meal is dissociable from satiation in healthy subjects. Anhedonia is the lowered ability to experience pleasure. There are no studies investigating the presence of anhedonia in Ob with and without SG and its relationship to PDS symptoms.

AIM

To assess the relationship among anhedonia, BED and upper gastrointestinal symptoms in two group of morbidly Ob with and without SG.

METHODS

Eighty-one Ob without SG, 45 Ob with SG and 55 healthy controls (HC) were studied. All subjects fulfilled the binge eating scale (BES) to investigate BED, the validated 14 items Snaith-Hamilton pleasure scale (SHAPS) to assess Anhedonia as well as the Beck Depression Inventory-II (BDI II) and State Trait Anxiety Inventory (STAI) questionnaires to screen for depression and anxiety. All patients underwent a standardized questionnaire investigating the intensity-frequency scores (0-6) of upper gastrointestinal symptoms and were diagnosed for the presence of functional dyspepsia (FD) and its subtypes according to ROME IV criteria.

RESULTS

Ob without SG who were positive for BED had a 4.7 higher risk of FD compared to Ob without SG who were negative for BED (OR: 4.7; 95.0%CI 1.23-18.24; P = 0.02). STAI-Y2 scores were significantly higher in Ob without SG positive for BED (42.2 ± 1.5 vs Ob negative for BED: 39.6 ± 1 .0, P = 0.04), while SHAPS scores and BDI II did not differ in the two groups (1.16 ± 1.30 vs 0.89 ± 1.02, P = 0.49). A lower prevalence of BED (BES > 17: 11.4% vs 40.7%, P = 0.001) and BDI-II (6.8 ± 1.2 vs 13.8 ± 1.9, P = 0.005) was reported in Ob with SG than Ob without SG, on the contrary total mean scores of STAI-Y1 and STAI-Y2 were significantly higher in Ob with SG than Ob without SG. Thirty-five percent of Ob with SG fulfilled the diagnosis of FD. SHAPS mean scores and the prevalence of anhedonia did not differ among the two groups (18.2 vs 8.1%, P = 0.2). Fifty-four percent of Ob with SG achieved surgical success excess weight loss > 50%. Excess weight loss was negatively related to SHAPS total mean scores [adjusted B: -7. 099 (95%CI: -13.91 to -0.29), P = 0.04].

CONCLUSION

Ob without SG showed a higher prevalence of PDS, mood disorders and anxiety when positive for BE behavior compared to those negative for BE behavior, whereas no differences were found in SHAPS score. Ob with SG showed a higher prevalence of PDS compared to Ob without SG. Concerning psychological aspect, BED and depression are less frequent in the Ob with SG, while both state and trait anxiety are significantly higher. Moreover, the more an Ob with SG is anhedonic, less surgical success was achieved.

Hiatal hernia diagnosis prospectively assessed in obese patients before bariatric surgery: accuracy of high-resolution manometry taking intraoperative diagnosis as reference standard

BACKGROUND

Hiatal hernia (HH) is common in obese patients undergoing bariatric surgery. Preoperative traditional techniques such as upper gastrointestinal endoscopy (UGIE) or barium swallow/esophagram do not always correlate with intraoperative findings. High-resolution manometry (HRM) has shown a higher sensitivity and specificity than traditional techniques in non-obese patients in the HH diagnosis, whereas there is a lack of data in the morbidly obese population. We aimed to prospectively assess the diagnostic accuracy of HRM in HH detection, in comparison with barium swallow and UGIE, assuming intraoperative diagnosis as a standard of reference.

METHODS

Forty-one consecutive morbidly obese patients prospectively recruited from a tertiary-care referral hospital devoted to bariatric and metabolic surgery underwent a preoperative evaluation including standardized GERD questionnaires, barium swallow, UGIE, and HRM. The surgical procedures were performed by a single surgeon who was blinded to the results of other investigations.

RESULTS

HH was intraoperatively diagnosed in 11/41 patients (26.8%). In 10/11 patients, the preoperative HRM showed an esophagogastric junction suggestive of HH. When compared to intraoperative evaluation, the sensitivity of the HRM was 90.9% and the specificity 63.3%, with a positive predictive value of 47.6% and a negative predictive value of 95.0%. HRM showed a higher sensitivity and specificity compared to barium swallow and UGIE.

CONCLUSIONS

HRM has a high accuracy of HH detection in morbidly obese patients assuming an intraoperative diagnosis as reference standard. It could therefore be a very useful tool in the preoperative work-up of obese patients undergoing bariatric surgery.

The first consensus statement on revisional bariatric surgery using a modified Delphi approach

BACKGROUND

Revisional bariatric surgery (RBS) constitutes a possible solution for patients who experience an inadequate response following bariatric surgery or significant weight regain following an initial satisfactory response. This paper reports results from the first modified Delphi consensus-building exercise on RBS.

METHODS

We created a committee of 22 recognised opinion-makers with a special interest in RBS. The committee invited 70 RBS experts from 27 countries to vote on 39 statements concerning RBS. An agreement amongst ≥ 70.0% experts was regarded as a consensus.

RESULTS

Seventy experts from twenty-seven countries took part. There was a consensus that the decision for RBS should be individualised (100.0%) and multi-disciplinary (92.8%). Experts recommended a preoperative nutritional (95.7%) and psychological evaluation (85.7%), endoscopy (97.1%), and a contrast series (94.3%). Experts agreed that Roux-Y gastric bypass (RYGB) (94.3%), One anastomosis gastric bypass (OAGB) (82.8%), and single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) (71.4%) were acceptable RBS options after gastric banding (84.3%). OAGB (84.3%), bilio-pancreatic diversion/duodenal switch (BPD/DS) (81.4%), and SADI-S (88.5%) were agreed as consensus RBS options after sleeve gastrectomy. lengthening of bilio-pancreatic limb was the only consensus RBS option after RYGB (94.3%) and OAGB (72.8%).

CONCLUSION

Experts achieved consensus on a number of aspects of RBS. Though expert opinion can only be regarded as low-quality evidence, the findings of this exercise should help improve the outcomes of RBS while we develop robust evidence to inform future practice.

Hiatal hernia diagnosis prospectively assessed in obese patients before bariatric surgery: accuracy of high-resolution manometry taking intraoperative diagnosis as reference standard

BACKGROUND

Hiatal hernia (HH) is common in obese patients undergoing bariatric surgery. Preoperative traditional techniques such as upper gastrointestinal endoscopy (UGIE) or barium swallow/esophagram do not always correlate with intraoperative findings. High-resolution manometry (HRM) has shown a higher sensitivity and specificity than traditional techniques in non-obese patients in the HH diagnosis, whereas there is a lack of data in the morbidly obese population. We aimed to prospectively assess the diagnostic accuracy of HRM in HH detection, in comparison with barium swallow and UGIE, assuming intraoperative diagnosis as a standard of reference.

METHODS

Forty-one consecutive morbidly obese patients prospectively recruited from a tertiary-care referral hospital devoted to bariatric and metabolic surgery underwent a preoperative evaluation including standardized GERD questionnaires, barium swallow, UGIE, and HRM. The surgical procedures were performed by a single surgeon who was blinded to the results of other investigations.

RESULTS

HH was intraoperatively diagnosed in 11/41 patients (26.8%). In 10/11 patients, the preoperative HRM showed an esophagogastric junction suggestive of HH. When compared to intraoperative evaluation, the sensitivity of the HRM was 90.9% and the specificity 63.3%, with a positive predictive value of 47.6% and a negative predictive value of 95.0%. HRM showed a higher sensitivity and specificity compared to barium swallow and UGIE.

CONCLUSIONS

HRM has a high accuracy of HH detection in morbidly obese patients assuming an intraoperative diagnosis as reference standard. It could therefore be a very useful tool in the preoperative work-up of obese patients undergoing bariatric surgery.

Acute colonic pseudo-obstruction in elderly Report of a case

A case of acute colonic obstruction in an elderly patient is presented, with a brief discussion about peculiar aspects to pseudo-obstruction and particularly chronic idiopathic intestinal pseudo-obstruction (CIIP), in which it was classified by pathologists. Clinical and therapeutic implications of this classification are also discussed. In authors'opinion, interesting aspects of the reported case are represented by the acute presentation, without previous symptoms at medical history and above all by the evidence of a recto-sigmoid junction intraoperatively palpable mass, mimicking ring-like neoplastic disease. The preoperative and intraoperative features led surgeons to perform a total colectomy with ileo-rectal anastomosis and high ligation of mesenteric inferior artery, with complete regional lymphectomy according to oncologic standard, but at histological examination the mass revealed to be due to considerable muscular tissue thickening, therefore to a benign condition. These features probably suggest the need of a better clinical and pathological classification of this difficult and still controversial matter, in order to achieve better outcomes and to avoid misdiagnosis and overtreatment. KEY WORDS: Intestinal obstruction, Pseudo-obstruction, Total colectomy.

Systematic Endoscopy 5 Years After Sleeve Gastrectomy Results in a High Rate of Barrett's Esophagus: Results of a Multicenter Study

BACKGROUND

Recent evidence has indicated an increased risk of Barrett's esophagus (BE) in the long term after sleeve gastrectomy (SG).

AIM

The aim of the study is to investigate the spectrum of gastroesophageal reflux disease (GERD) symptoms as well as the prevalence of BE, at minimum 5 years after SG in patients who underwent SG in different bariatric centers of two countries: France and Italy.

PATIENTS AND METHODS

Five high volume outpatient centers dedicated to bariatric surgery that routinely perform upper GI endoscopy before any bariatric procedures were invited to participate in the study. From January 2017 to June 2018, each center during scheduled postoperative evaluation after surgery asked a minimum 10 consecutive patients, which had performed SG at least 5 years before and with no evidence of BE preoperatively, to undergo another upper GI endoscopy.

RESULTS

Ninety (66 F) consecutive patients were enrolled. The mean follow-up was 78 ± 15 months, and the mean total body weight loss was 25 ± 12%. The prevalence of BE was 18.8% with no significant difference among centers. Weight loss failure was significantly associated with BE (p < 0.01). The prevalence of GERD symptoms, erosive esophagitis, and the usage of PPIs increased from 22%, 10%, and 22% before the SG to 76%, 41%, and 52% at the time of follow-up, respectively (p < 0.05).

CONCLUSIONS

This multicenter study show a high rate of BE at least 5 years after SG. Weight loss failure was significantly associated with BE. We suggest to provide systematic endoscopy in these patients to rule out this condition.

Bariatric Surgery Versus Lifestyle Intervention in Class I Obesity: 7-10-Year Results of a Retrospective Study

INTRODUCTION

The American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation of Surgery for Obesity (IFSO) have both stated that bariatric surgery (BS) should not be denied in Class I patients. However, lifestyle intervention (LI), such as diet plus gym programs, is still considered the preferred approach for subjects with a BMI ranging from 30 to 35 kg/m². The aim of this study was to retrospectively compare results of LI and BS in patients in Class I obesity.

METHODS

Retrospective analysis of prospective maintained databases of two centers for the "Interdisciplinary Treatment of Obesity" was performed. All patients in Class I obesity and follow-up >7 years were included in the study. Subjects were divided into two groups: BS group that included patients who had undergone surgery and LI group that included patients who underwent lifestyle intervention (LI). Percentage of excess body mass index loss (%EBMIL) and comorbidities remission were recorded.

RESULTS

Seventy-six patients were included in the study. Fifty-six subjects were submitted to surgery (BS group); 20 subjects were treated with nonsurgical approach (LI group). In BS group, 34 underwent laparoscopic adjustable gastric band, 13 laparoscopic sleeve gastrectomy (LSG), and 9 laparoscopic Roux-en-Y gastric bypass. EWL% resulted significantly higher in BS group at 1, 3, 5, 7 and 10 years (p < 0.01).

CONCLUSION

Bariatric surgery is more effective than LI for patients in Class I obesity. Due to its versatility, low-risk profile and high-effectiveness LSG could be the standard intervention for these patients.

IFSO Worldwide Survey 2016: Primary, Endoluminal, and Revisional Procedures

BACKGROUND AND AIM

The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), being a Federation of 62 national societies, is the ideal network to monitor the number and type of procedures at a global level. The IFSO survey, enriched with a special section on revisional procedures, aims to report the number and types of bariatric procedures performed worldwide in 2016 and analyzes the surgical trends from 2008 to 2016.

METHODS

The 2016 IFSO Survey form was emailed to all IFSO societies. Each Society was requested to indicate the number and type of bariatric procedures performed in the country. Trend analyses from 2008 to 2016 were also performed.

RESULTS

The total number of bariatric/metabolic procedures performed in 2016 was 685,874; 634,897 (92.6%) of which were primary and 50,977 were revisional (7.4%). Among the primary interventions, 609,897 (96%) were surgical and 25,359 (4%) were endoluminal. The most performed primary surgical bariatric/metabolic procedure was sleeve gastrectomy (SG) (N = 340,550; 53.6%), followed by Roux-en-Y gastric bypass (N = 191,326; 30.1%), and one-anastomosis gastric bypass (N = 30,563; 4.8%).

CONCLUSIONS

In 2016, there was an increase in the total number both of surgical and endoluminal bariatric/metabolic procedures. Revisional procedures represent about 7% of the total bariatric interventions. SG remains the most performed surgical procedure in the world.

Effects of Sleeve Gastrectomy and Gastric Bypass on Postprandial Lipid Profile in Obese Type 2 Diabetic Patients: a 2-Year Follow-up

BACKGROUND

Bariatric surgery (BS) is known to favorably impact fasting lipid profile. Fasting and postprandial lipids were evaluated before and 2 years after BS in obese type 2 diabetic (T2DM) patients.

METHODS

A prospective study was conducted in 19 obese T2DM patients: ten undergoing sleeve gastrectomy (SG) and nine undergoing Roux-en-Y gastric bypass (RYGB). Before and 2 years after BS, clinical parameters and the response of lipid and incretin hormones to a mixed meal (MM) were assessed.

RESULTS

The two groups had similar characteristics at baseline. After BS, weight loss was similar in the two groups (p ≤ 0.01). Fasting glucose, insulin, and triglycerides decreased while HDL cholesterol increased in a similar way (p < 0.05); in contrast, fasting LDL cholesterol decreased only after RYGB (p < 0.05). Post-meal glucose concentrations decreased while early insulin response significantly improved after both procedures (p < 0.001 for both). Postprandial triglycerides decreased after both procedures (p < 0.05) while postprandial LDL cholesterol decreased only after RYGB (p < 0.05). Meal-GLP-1 increased postoperatively in both groups although to a greater extent after RYGB (p < 0.001 vs. SG). GIP decreased after both procedures, especially after RYGB (p = 0.003). At multivariate analysis, GLP-1 peak was the best predictor of LDL reduction (β = -0.552, p = 0.039) while the improvement of HOMA-IR (β = 0.574, p = 0.014) and weight loss (β = 0.418, p = 0.036) predicted triglycerides reduction.

CONCLUSIONS

Both surgical procedures markedly reduce fasting and postprandial triglycerides and increase HDL cholesterol levels. LDL cholesterol decreases only after RYGB through a mechanism likely mediated by the restoration of GLP-1.

Bariatric surgery and long-term nutritional issues

Bariatric surgery is recognized as a highly effective therapy for obesity since it accomplishes sustained weight loss, reduction of obesity-related comorbidities and mortality, and improvement of quality of life. Overall, bariatric surgery is associated with a 42% reduction of the cardiovascular risk and 30% reduction of all-cause mortality. This review focuses on some nutritional consequences that can occur in bariatric patients that could potentially hinder the clinical benefits of this therapeutic option. All bariatric procedures, to variable degrees, alter the anatomy and physiology of the gastrointestinal tract; this alteration makes these patients more susceptible to developing nutritional complications, namely, deficiencies of macro- and micro-nutrients, which could lead to disabling diseases such as anemia, osteoporosis, protein malnutrition. Of note is the evidence that most obese patients present a number of nutritional deficits already prior to surgery, the most important being vitamin D and iron deficiencies. This finding prompts the need for a complete nutritional assessment and, eventually, an adequate correction of pre-existing deficits before surgery. Another critical issue that follows bariatric surgery is post-operative weight regain, which is commonly associated with the relapse of obesity-related co-morbidities. Nu-tritional complications associated with bariatric surgery can be prevented by life-long nutritional monitoring with the administration of multi-vitamins and mineral supplements according to the patient’s needs.

Bariatric Surgery and Endoluminal Procedures: IFSO Worldwide Survey 2014

BACKGROUND AND AIM

Several bariatric surgery worldwide surveys have been previously published to illustrate the evolution of bariatric surgery in the last decades. The aim of this survey is to report an updated overview of all bariatric procedures performed in 2014.For the first time, a special section on endoluminal techniques was added.

METHODS

The 2014 International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) survey form evaluating the number and the type of surgical and endoluminal bariatric procedures was emailed to all IFSO societies. Trend analyses from 2011 to 2014 were also performed.

RESULTS

There were 56/60 (93.3%) responders. The total number of bariatric/metabolic procedures performed in 2014 consisted of 579,517 (97.6%) surgical operations and 14,725 (2.4%) endoluminal procedures. The most commonly performed procedure in the world was sleeve gastrectomy (SG) that reached 45.9%, followed by Roux-en-Y gastric bypass (RYGB) (39.6%), and adjustable gastric banding (AGB) (7.4%). The annual percentage changes from 2013 revealed the increase of SG and decrease of RYGB in all the IFSO regions (USA/Canada, Europe, and Asia/Pacific) with the exception of Latin/South America, where SG decreased and RYGB represented the most frequent procedure.

CONCLUSIONS

There was a further increase in the total number of bariatric/metabolic procedures in 2014 and SG is currently the most frequent surgical procedure in the world. This is the first survey that describes the endoluminal procedures, but the accuracy of provided data should be hopefully improved in the next future. We encourage the creation of further national registries and their continuous updates taking into account all new bariatric procedures including the endoscopic procedures that will obtain increasing importance in the near future.