Revision bariatric surgery. What technical choices should be taken depending on the first intervention?

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Management of duodenal stump fistula after gastrectomy for gastric cancer: systematic review

AIM: To identify the most effective treatment of duodenal stump fistula (DSF) after gastrectomy for gastric cancer. METHODS: A systematic review of the literature was performed. PubMed, EMBASE, Cochrane Library, CILEA Archive, BMJ Clinical Evidence and UpToDate databases were analyzed. Three hundred eighty-eight manuscripts were retrieved and analyzed and thirteen studies published between 1988 and 2014 were finally selected according to the inclusion criteria, for a total of 145 cases of DSF, which represented our group of study. Only patients with DSF after gastrectomy for malignancy were selected. Data about patients' characteristics, type of treatment, short and long-term outcomes were extracted and analyzed. RESULTS: In the 13 studies different types of treatment were proposed: conservative approach, surgical approach, percutaneous approach and endoscopic approach (3 cases). The overall mortality rate was 11.7% for the entire cohort. The more frequent complications were sepsis, abscesses, peritonitis, bleeding, pneumonia and multi-organ failure. Conservative approach was performed in 6 studies for a total of 79 patients, in patients with stable general condition, often associated with percutaneous approach. A complete resolution of the leakage was achieved in 92.3% of these patients, with a healing time ranging from 17 to 71 d. Surgical approach included duodenostomy, duodeno-jejunostomy, pancreatoduodenectomy and the use of rectus muscle flap. In-hospital stay of patients who underwent relaparotomy ranged from 1 to 1035 d. The percutaneous approach included drainage of abscesses or duodenostomy (32 cases) and percutaneous biliary diversion (13 cases). The median healing time in this group was 43 d. CONCLUSION: Conservative approach is the treatment of choice, eventually associated with percutaneus drainage. Surgical approach should be reserved for severe cases or when conservative approaches fail

Ruolo dell’inattivazione del pathway molecolare di Hedgehog (Hh) nell’adenocarcinoma colorettale primitivo e metastatico

Il cancro colorettale (CC) è il quarto tumore più frequentemente diagnosticato e la seconda causa di morte negli Stati Uniti. Il ruolo del pathway di Hedgehog (Hh) nel carcinoma colorettale rimane controverso. In questo studio, abbiamo analizzato l'associazione tra l'espressione degli mRNA di GLI1 e GLI2, due geni bersaglio di HH e la sopravvivenza e recidiva di CC mediante microarray di espressione genica da una coorte di 382 pazienti con CC. I pazienti con una maggiore espressione di GLI1 avevano una sopravvivenza significativamente minore. Al fine di dimostrare un ruolo causale dell'attivazione del pathway HH nel pathogenesis di CC, abbiamo trattato le linee di cellule HCT 116, SW480 e SW620 CC con GDC-0449, un inibitore farmacologico di Smoothened (SMO). GGL-0449 ha marcatamente ridotto l'espressione dei geni bersaglio HH GLI1, PTCH1, HIP1, MUC5AC, indicando così che questo percorso è attivo nelle linee di cellule di CC. Inoltre, GDC-0449 ha parzialmente ridotto la proliferazione cellulare, che è stata associata a sovraregolazione di p21 e downregulation di CycD1. Ha modificato l'espressione di Snail1, il gene principale EMT, e dei marcatori epiteliali Cytokeratin-18 e E-caderina. Questi risultati sono stati confermati dal silenziamento genico di SMO. Inoltre, il trattamento con 5E1, un mAb specifico di Sonic Hedgehog, ha ridotto marcatamente l'espressione dei geni bersaglio di Hedgehog, così come ha inibito la proliferazione cellulare e la reversione verso un fenotipo epiteliale. Tali risultati dimostrano l'esistenza di un segnale autocrino mediato da Hedgehog che influenza la plasticità delle cellule e favorisce la proliferazione cellulare e la migrazione / invasione nelle linee cellulari di CC. Queste scoperte incoraggiano indagini future per caratterizzare meglio il ruolo di Hedgehog nella plasticità e invasione cellulare durante le diverse fasi della cancerogenesi colorettal

Neoadjuvant treatment in pancreatic cance. Evidence-based medicine? A systematic review and meta-analysis

Neoadjuvant treatment in non-metastatic pancreatic cancer (PaC) has the theoretical advantages of downstaging the tumor, sterilizing any present systemic undetectable disease, selecting patients for surgery and administering therapy to each patient. The aim of this systematic review is to analyze the state of the art on neoadjuvant protocols for non-metastatic PaC. A literature search over the last 10 years was conducted, and papers had to be focused on resectable, borderline resectable (BLR) or locally advanced (LA) histo- or cytologically proven PaC; to be prospective studies or prospectively collected databases; to report percentage of protocol achievement and survival data at least in an intention-to-treat (ITT) analysis. Twelve studies were eligible for systematic review. Studies included a total of 624 patients: 248 resectable, 268 BLR, 71 LA and 37 non-specified. All studies were included for meta-analysis. ITT overall survival (OS) was 16.7 months (95% CI 15.16-18.26 months); for resected patients OS was 22.78 months (95% CI 20.42-25.16), and for eventually non-resected patients it was 9.89 months (95% CI 8.84-10.96). Neoadjuvant approaches for resectable, BLR and LA PaC are spreading. Outcomes tend to be better outside an RCT context, but strong evidences are lacking. Actually such treatments should be performed only in a randomized clinical trial setting

SMO Inhibition Modulates Cellular Plasticity and Invasiveness in Colorectal Cancer

Colon Cancer (CC) is the fourth most frequently diagnosed tumor and the second leading cause of death in the USA. Abnormalities of Hedgehog pathway have been demonstrated in several types of human cancers, however the role of Hedgehog (Hh) in CC remain controversial. In this study, we analyzed the association between increased mRNA expression of GLI1 and GLI2, two Hh target genes, and CC survival and recurrence by gene expression microarray from a cohort of 382 CC patients. We found that patients with increased expression of GLI1 showed a statistically significant reduction in survival. In order to demonstrate a causal role of Hh pathway activation in the pathogenesis of CC, we treated HCT 116, SW480 and SW620 CC cells lines with GDC-0449, a pharmacological inhibitor of Smoothened (SMO). Treatment with GDC-0449 markedly reduced expression of Hh target genes GLI1, PTCH1, HIP1, MUC5AC, thus indicating that this pathway is constitutively active in CC cell lines. Moreover, GDC-0449 partially reduced cell proliferation, which was associated with upregulation of p21 and downregulation of CycD1. Finally, treatment with the same drug reduced migration and three-dimensional invasion, which were associated with downregulation of Snail1, the EMT master gene, and with induction of the epithelial markers Cytokeratin-18 and E-cadherin. These results were confirmed by SMO genetic silencing. Notably, treatment with 5E1, a Sonic Hedgehog-specific mAb, markedly reduced the expression of Hedgehog target genes, as well as inhibited cell proliferation and mediated reversion toward an epithelial phenotype. This suggests the existence of a Hedgehog autocrine signaling loop affecting cell plasticity and fostering cell proliferation andmigration/invasion in CC cell lines. These discoveries encourage future investigations to better characterize the role of Hedgehog in cellular plasticity and invasion during the different steps of CC pathogenesis.Peer reviewe

Potential role of glucagon-like peptide-1 (GLP-1) receptor agonists in substance use disorder: a systematic review of randomized trials

Background: Increasing evidence suggests that GLP-1 receptor agonists (GLP-1RA) have a potential use in addiction treatment. Few studies have assessed the impact of GLP-1RA on substance use disorder (SUD), particularly in humans. The study aimed to do systematic review of clinical trials to assess GLP-1RA's effect on reducing SUD in patients. Methods: The scientific literature was reviewed using the MEDLINE, Scopus and Cochrane Library databases, following PRISMA guidelines. Studies including patients with a diagnosis of SU who were treated with GLP-1RA were selected. The primary outcome was GLP-1RA's therapeutic effect on SUD, and the secondary outcomes were therapeutic effects of GLP-1RA on weight, BMI and HbA1c. Results: 1218 studies were retrieved, resulting in 507 papers after title and abstract screening. Following full-text review, only 5 articles met inclusion criteria. We incorporated a total of 630 participants utilizing Exenatide (n=3) and Dulaglutide (n=2) as GLP-1RAs. Therapeutic effect of GLP-1RA on SUD was assessed in 5 studies, with 3 demonstrating a significant decrease in SUD (alcohol and nicotine). GLP-1RA's impact on body weight, BMI, and HbA1c, was reported in 3 studies. These revealed a notable reduction in these parameters among the GLP-1RA treated group. Conclusion: This review will give an overview of current new findings in human studies; we suggest that the effects of GLP-1RA in SUD is a possible new option of therapy in addiction medicine

Bariatric surgery and new-onset substance use disorders: a systematic review and meta-analysis

: Increasing evidence suggests that bariatric surgery (BS) patients are at risk for substance abuse disorders (SUD). The purpose of this systematic review and meta-analysis was to determine the relationship between BS and the development of new-onset substance abuse disorder (SUDNO) in bariatric patients. On October 31, 2023, we reviewed the scientific literature following PRISMA guidelines. A total of 3242 studies were analyzed, 7 met the inclusion criteria. The pooled incidence of SUDNO was 4.28%. Patients' characteristics associated with SUDNO included preoperative mental disorders, high pre-BS BMI, and public health insurance. Surgical factors associated with new SUDNOs included severe complications in the peri- or postoperative period. The occurrence of SUDNOs is a non-negligeable complication after BS. Predisposing factors may be identified and preventive actions undertaken

A narrative review on bariatric ERAS

Bariatric/metabolic surgery (BMS) is the most effective treatment of morbid obesity, while Enhanced Recovery After Surgery (ERAS) after BMS represents a multimodal perioperative protocol designed to achieve early recovery for patients with peculiar characteristics. The aim of the current narrative review is to summarize and discuss the current role, the application, and the future developments of ERAS protocols in the field of BMS

Surprising complication of intussusception after colonoscopy. a case report and a review of the literature

This study discusses a case with a history of ileal-caecal intussusception post colonoscopy requiring urgent surgical intervention and a systematic review explores the literature on post-colonoscopy intussusception. A systematic review was conducted according to PRISMA guidelines. Studies reporting entero-enteric, ileo-colic, or colo-colic intussusception after colonoscopy, published in English before June 2023, were included. Data was extracted on patient demographics, indications for colonoscopy, procedural details, clinical symptoms, and management. Overall, 19 cases were identified from 17 studies. The median age was 48 years and 53 % were male. History of abdominal surgery was reported in 42% of cases. Symptoms typically appeared within a week of the procedure. The majority of cases required surgical intervention (63%), while others were managed conservatively (34%). The case report is an 85-year-old man with a history of diabetes, cardiopathy and abdominal surgery presented to the Emergency Department with 2 days of abdominal pain and vomiting after colonoscopy. A Computer Tomography abdomen revealed findings concerning for a small-bowel volvulus. Subsequent laparotomy revealed ileo-caecal intussusception, requiring surgical resection. Histology examination revealed a small-bowel intramucosal adenocarcinoma. The patient recovered and was discharged on postoperative day 7. The etiology of post-colonoscopy intussusception is multifactorial, with potential contributing factors including adhesions, altered bowel motility, and gas insufflation. Patients with a history of abdominal surgery should be considered at increased risk and prompt identification is crucial to reduce morbidity and mortality

Roux en Y gastric bypass and iterative intussusception at the jejuno-jejunal anastomosis: conversion into one anastomosis gastric bypass (with video). A case report

Introduction: The aim of this article is to describe a rare complication of Roux en Y gastric bypass (RYGB): recurrent intestinal intussusception of the biliary limb, and an original treatment: the removal of the jejunojejunal anastomosis with conversion into "short limb" one anastomosis gastric bypass (OAGB). Presentation of case: A 25-year-old patient underwent RYGB fashioned with a 50 cm-length biliary loop and a 150 cm-length alimentary loop. She was hospitalized other 3 times in the following months for episodes of acute abdominal pain and excessive weight loss, with CT scans showing intussusception at the jejuno-jejunal anastomosis. Conversion from RYGB to OAGB with "short biliary limb" was performed. The patient at 60-month followup has no bile reflux and regained weight. Discussion: Small bowel intussusception is a rare complication that can occur following Roux-en-Y gastric bypass (RYGB) surgery, leading to symptoms like acute or chronic abdominal pain. Treatment options reported in medical literature include resection and re-fashioning of the jejuno-jejunal anastomosis, simple reduction (with a risk of recurrence), and imbrication/plication of the jejuno-jejunal anastomosis. Given the rarity of this complication, there are no standardized recommendations, and the best treatment should be determined on a case-by-case basis, taking into consideration the patient's unique circumstances and the medical team's expertise. Conclusion: Intestinal intussusception at the jejuno-jejunal anastomosis responsible for chronic abdominal pain is a rare complication after RYGB. One of the possible treatments is conversion into OAGB