Lidia Castagneto-Gissey

Aims: To compare sleeve gastrectomy (SG) with intensive lifestyle modification combined with obesity management medications (ILM/OMMs) in adults with severe obesity, focusing on BMI trajectory, time to achieving clinically meaningful weight loss, and metabolic outcomes in a real‐world clinical setting. Materials and Methods: This prospective matched cohort study included 190 patients (BMI ≥ 35 kg/m ² , obesity‐related comorbidities) assigned to SG or ILM/OMM in a 1:1 ratio, matched for age, sex, BMI, and diabetes duration. The primary outcomes were change in BMI at 12 months and time to achieving ≥ 25% total weight loss (TWL). Secondary outcomes included changes in weight and obesity‐related comorbidities (hypertension, dyslipidemia, type 2 diabetes) ( clinicalTrials.gov , NCT06820047). Results: At 12 months, model‐based BMI was lower after SG than after ILM/OMM (28.4 kg/m ² , 95% CI 27.2 to 29.6 vs. 31.6 kg/m ² , 95% CI 30.5 to 32.8; between‐group difference −3.2 kg/m ² , 95% CI −4.9 to −1.5; p < 0.001). Estimated %TWL was greater after SG than after ILM/OMM at 12 months (37.6%, 95% CI 36.5 to 38.7 vs. 18.0%, 95% CI 16.9 to 19.1; difference 19.6 percentage points, 95% CI 18.1 to 21.1; p < 0.001). Time to achieving ≥ 25% TWL was shorter after SG; the median time was 6 months in the SG group, whereas the median was not reached by 12 months in the ILM/OMM group (log‐rank p < 0.001; HR 13.85, 95% CI 7.81–24.58). Both groups showed metabolic improvement, although between‐group differences were limited. Conclusions: SG was associated with greater and more rapid weight loss than ILM/OMM over 1 year, with earlier achievement of ≥ 25% TWL. Both approaches produced clinically meaningful metabolic improvements, supporting individualized treatment selection.

Objective To assess safety and healthcare utilization (HU) after metabolic/bariatric surgery (MBS) and compare it to commonly performed general surgery procedures for benign indications. Research Design and Methods Data obtained from a nationwide database (NHS Digital) on 800 consecutive patients who underwent bariatric surgery (n = 100) and seven other types of surgery (n = 100 for each) for non-acute, non-cancer indications at a tertiary hospital in England. Non-MBS procedures included adrenalectomy, gastro-esophageal junction surgery (GEJ), in-patient cholecystectomy (IC), outpatient cholecystectomy (OC), colorectal surgery (CR), hernia surgery (HS) and neck endocrine surgery (NES). Results Despite a higher number of preoperative co-morbidities and ASA score, MBS had significantly lower odds of 30-day major complications (Clavien–Dindo grade≥IIIa) compared to CR (6%;p = 0.013) and GEJ (8%;p = 0.004). No differences in complication rates with all other groups. The total number of procedure-related readmissions over 5-year after MBS were similar to HS, NES or IC and lower than CR, AS, and GEJ. The average per-patient 5-year cost of procedure-related readmissions after MBS was £790 + 337, lower than for CR (£8,270 + 3218, p < 0.001), AS (£3242 + 772, p < 0.001) and GEJ (£1705 + 976, p = 0.013) and similar to other procedures. There was a higher number of outpatient visits after MBS in the first two years after surgery, consistent with national protocols and no differences in 5-year A&E attendance among groups. Conclusions MBS is associated with a relatively low risk of post-operative complications and 5-year healthcare use compared to other commonly used types of surgical treatments. These findings could help dispel misperceptions that undermine access to effective treatment of obesity.

Editorial: Management of Rare Oncological Cases The rapid evolution of oncology has brought new challenges and opportunities in the diagnosis and management of rare and complex tumors. Although infrequent in occurrence, these malignancies often carry poor prognoses due to diagnostic delays, limited treatment options, and lack of robust clinical trial data. The recent surge in detailed case reports, molecular analyses, and innovative treatment strategies contributes significantly to bridging these gaps. This editorial aims to synthesize recent findings from diverse rare tumor cases—spanning from gynecologic melanomas, to sarcomas, neuroendocrine neoplasms, and atypical metastases—and explore their implications for clinical practice and future research. Rare Soft Tissue & Mesenchymal Tumors The occurrence of malignant granular cell tumors (GCTs) outside their usual head and neck locations, such as the chest wall, exemplifies diagnostic challenges posed by atypical presentations (Flauto et al.). GCTs, typically benign and slow growing, occasionally demonstrate aggressive behavior with recurrence and metastasis, necessitating repeated surgical interventions and careful long-term monitoring. Similarly, the pediatric case of pancreatic Ewing sarcoma described by Liu et al. expands our understanding of rare extraskeletal manifestations in an uncommon anatomical site, demonstrating the value of molecular diagnostics and tailored chemotherapeutic regimens in improving outcomes in aggressive pediatric malignancies. Soft tissue sarcomas and stromal tumors constitute a heterogeneous group of mesenchymal neoplasms often posing diagnostic and therapeutic challenges. Bai et al. present uterine inflammatory myofibroblastic tumor (UIMT) involving the female reproductive tract with uncertain malignant potential. These lesions straddle the border between reactive and neoplastic processes and require excision for definitive diagnosis. The discovery of ALK gene rearrangements in UIMT has enabled targeted therapy with ALK inhibitors in select cases. Gastrointestinal schwannomas, although generally considered benign peripheral nerve sheath tumors, occasionally present in unusual locations such as the colon. Xiuzhang Yu et al present a compelling case of a colonic schwannoma causing intestinal obstruction, an atypical clinical manifestation that underscores the importance of including mesenchymal tumors in the differential diagnosis of obstructive colorectal lesions. The recurrence of benign tumors decades after surgery is another sobering reminder of the need for long-term surveillance. Hongyan Lei et al report a recurrent giant cystic lymphangioma of the peritoneum, which returned 20 years post-resection. The case raises important considerations regarding surveillance strategies and the latent potential for recurrence in ostensibly benign conditions. Rare Cutaneous & Skin-Associated Malignancies Cutaneous neoplasms with mixed histopathologic features, such as the endocrine mucin-producing sweat gland carcinoma with mucinous carcinoma components reported by Sun et al., illustrate the complexity of tumor classification and metastatic potential that can alter clinical course significantly. Zexin Zhang et al. explore the potential causal relationship between skin flora and cutaneous melanoma using Mendelian Randomization analyses, suggesting a novel area for further research in cancer etiology. Lambert-Swainston et al. describe a locally advanced basal cell carcinoma achieving pathologic complete response after combined neoadjuvant cemiplimab and vismodegib, paving the way for innovative immunotherapy-hedgehog inhibitor combinations. Chen et al conducted a population-based study on sebaceous carcinoma arising outside the head and neck, a subset that remains poorly characterized in the literature. Their findings reveal that while overall prognosis is favorable for non-head and neck sebaceous carcinoma, patients with distant metastases experience significantly poorer outcomes. Independent predictors of survival included age, tumor size, and stage, while undifferentiated tumors of the trunk demonstrated a higher propensity for distant spread. These insights underscore the potential value of stratified metastasis screening in high-risk subset. The review by Pedersen et al. provides a comprehensive overview of Merkel cell carcinoma (MCC) biology, focusing on tumor immunogenicity and the tumor microenvironment's role. MCC's strong association with Merkel cell polyomavirus (MCPyV) and UV-induced mutations positions it as a prime candidate for immunotherapy. The introduction of immune checkpoint inhibitors (ICI), particularly PD-1 and PD-L1 inhibitors, has transformed MCC management. Clinical trials demonstrate durable responses in metastatic MCC, yet not all patients benefit equally. Resistance mechanisms, including immune escape and tumor heterogeneity, limit efficacy. Pedersen and colleagues emphasize ongoing efforts to identify biomarkers predictive of response, such as tumor mutational burden and MCPyV status. Additionally, combining ICI with radiotherapy is an area of interest, leveraging radiation-induced immunogenic cell death to augment immune responses. Ongoing trials evaluating combination regimens may further improve patient outcomes. Gynecologic & Female Reproductive Tumors The prognostic factors identified in uterine adenosarcoma through the SARCUT study subanalysis by Mancari et al. further refine risk stratification and guide postoperative treatment decisions in this rare uterine tumor. Intravenous leiomyomatosis (IVL), a rare vascular smooth muscle tumor with potential for significant morbidity, is highlighted by Jin Li et al. through the use of advanced ultrasound imaging techniques facilitating early diagnosis and successful surgical management. In parallel, Yiran Wang et al.'s case of urachal adenocarcinoma misdiagnosed as primary cervical adenocarcinoma draws attention to the...

Purpose: This systematic review and meta-analysis aims to evaluate the outcomes of laparoendoscopic extraperitoneal techniques for repairing rectus diastasis (RD) with concomitant ventral hernias, focusing on recurrence rates, surgical site occurrences, and the effectiveness of various surgical approaches and mesh placement sites. Methods: A comprehensive literature search was conducted using PubMed and the Cochrane Library, adhering to PRISMA guidelines. Prospective and retrospective cohort studies involving adults with RD and concomitant ventral hernias were included. Surgical techniques were classified based on working space (subcutaneous vs. retromuscular) and wall repair technique (stapled vs. fascial plication suture). The primary outcome was recurrence of RD or hernia, and secondary outcomes included seroma, surgical site infections (SSIs), and bleeding. Results: Twenty-two studies comprising 1,616 patients were analyzed. Mean age was 45.6 years, BMI 30.5 kg/m², with a mean follow-up of 10.5 months. All studies were non-randomized and rated as having a “Serious” risk of bias using the ROBINS-I tool. Recurrence occurred in 19 patients (0.99%), with no significant differences between subcutaneous and retromuscular approaches (0.93% vs. 1.16%, p = 0.802) or between stapled and fascial plication techniques (0% vs. 1.18%, p = 0.090). Seroma rates were significantly higher in the subcutaneous group compared to retromuscular approach (11.8% vs. 0.70%, p < 0.001). SSIs were more common in subcutaneous approaches (2.33% vs. 0.58%, 0.005). Bleeding was low across all groups (1.3%), with higher rates in the stapled compared to the fascial plication group (6.39% vs. 0.37%, p < 0.001). Conclusions: Laparoendoscopic extraperitoneal approaches for RD and ventral hernia repair demonstrate favorable outcomes, with low and comparable recurrence rates among subgroups. The subcutaneous approach is associated with a higher risk of seroma formation while the stapled technique may increase bleeding risk. Further studies with higher methodological quality are needed to guide optimal technique selection.

The global prevalence of obesity has reached alarming proportions, with its associated comorbidities imposing a significant workload on healthcare systems worldwide (1). Obesity contributes to a spectrum of metabolic, cardiovascular, and inflammatory conditions, including type 2 diabetes (T2D), metabolic dysfunction-associated steatohepatitis (MASH), and renal dysfunction, while also exacerbating issues such as periodontitis and irregular menstruation (2). Bariatric surgery has emerged as a transformative intervention for managing morbid obesity, offering not only sustained weight loss but also profound metabolic benefits (3)(4)(5). The studies featured in this special issue illuminate the multifaceted effects and mechanisms of bariatric surgery, particularly focusing on Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG), in addressing obesity and its complications. This Research Topic spans through the key findings from these research papers, highlighting the evolving understanding of bariatric surgery's therapeutic potential.Weight loss remains a cornerstone of bariatric surgery's benefits, with studies underscoring its pivotal role in mediating metabolic and hormonal improvements. For instance, Tian et al. demonstrated that total weight loss (TWL%) following bariatric surgery is closely correlated with reductions in thyroidstimulating hormone (TSH) levels, suggesting enhanced thyroid function in euthyroid patients with obesity. Interestingly, this relationship was independent of baseline factors such as age, sex, or comorbidities, emphasizing the universal metabolic benefits of significant weight loss.Similarly, Zhao et al. investigated the effects of SG on women with polycystic ovary syndrome (PCOS) and found that weight loss-rather than preoperative body mass index (BMI)-was a critical determinant of menstrual regularity. With 79.03% of participants achieving remission of irregular menstruation within a year, this study highlights the potential of bariatric surgery to address reproductive dysfunctions associated with obesity. These findings underscore the importance of targeting substantial weight loss to maximize health outcomes, regardless of baseline BMI.Gender-specific differences in predictors of weight loss after SG were highlighted in the study by Shu et al. Both men and women achieved comparable weight loss outcomes when baseline characteristics were matched. However, distinct predictors emerged: in men, baseline BMI and insulin dynamics were significant, while in women, age, thyroid function, and mental health measures played a more substantial role. These insights advocate for personalized preoperative evaluations to optimize weight-loss outcomes across genders.The role of gut microbiota in mediating the metabolic benefits of bariatric surgery has garnered significant attention. Liu et al. employed a multi-omics approach to investigate changes in gut microbiota and metabolism following SG. They reported increased microbial diversity and enrichment of beneficial bacteria such as Alistipes and Parabacteroides. These microbial changes were correlated with enhanced lipid metabolism, as evidenced by elevated levels of free fatty acids and bile acids. Similarly, the study by Li et al. on duodenojejunal bypass (DJB) in obese T2D mice demonstrated that proximal gut microbiota play a dominant role in improving glucose metabolism and reducing inflammation. Both studies underscore the essential role of intestinal remodeling in achieving metabolic improvements post-surgery. Bariatric surgery is not without complications, and gastroesophageal reflux disease (GERD) is a prominent concern, particularly after SG (6-7). Liu et al. provided a comprehensive review of strategies to manage GERD in these patients, emphasizing the efficacy of RYGB as the gold standard for refractory cases. Innovative approaches such as magnetic sphincter augmentation and antireflux mucosectomy were also explored, offering minimally invasive alternatives for GERD management.Periodontal health, often overlooked in obese populations, was addressed by Bi et al. Their study found significant improvements in periodontal parameters such as plaque index (PLI) and bleeding index (BI) following SG, particularly in patients with T2D. Reduced systemic inflammation, as evidenced by declines in hs-CRP and IL-6 levels, was likely a key contributor to these improvements. However, persistent disparities in pocket depth between diabetic and non-diabetic groups highlight the need for continued oral health monitoring in this population. The studies in this special issue collectively highlight the multifactorial mechanisms underlying bariatric surgery's success in addressing obesity and its complications. From gut microbiota remodeling and molecular pathway modulation to gender-specific influences and genetic predispositions, these findings emphasize the importance of a multidisciplinary approach in understanding and optimizing surgical outcomes.While the benefits of bariatric surgery are well-documented, challenges remain in ensuring equitable access, managing complications, and refining surgical techniques. Further research is needed to develop standardized guidelines for managing postoperative complications such as GERD and nutritional deficiencies; explore long-term outcomes in diverse populations, with particular attention to sex and genetic variability; leverage multi-omics approaches to identify novel biomarkers and therapeutic targets for obesity-related diseases; enhance interdisciplinary care, integrating endocrinology, gastroenterology, and behavioral health to address the holistic needs of patients.The insights presented in this special issue advance our understanding of the underlying mechanisms, paving the way for personalized and effective treatment strategies. By continuing to integrate clinical research with molecular and genetic insights, we can further harness the potential of bariatric surgery to...

Obesity has reached pandemic proportion not only in the West but also in other countries around the world; it is now one of the leading causes of death worldwide. A Western diet is rich in saturated fats and provides more calories than necessary, contributing to the rise of the obesity rate. It also promotes the development of liver steatosis, insulin resistance, hyperglycemia, and hyperlipidemia. In this issue of the JCI , Goetzman and colleagues describe the effects of consuming dicarboxylic acids (DAs) as an alternative source of dietary fat. The 12-carbon dicarboxylic acid (DC12) was administered to mice at 20% of their daily caloric intake for nine weeks in place of triglycerides. Notably, the change in diet increased the metabolic rate, reduced body fat, reduced liver fat, and improved glucose tolerance. These findings highlight DAs as useful energy nutrients for combatting obesity and treating various metabolic disorders.

Editorial: Women in surgical oncology vol II: 2022

(1) Background: There is still disagreement over how sleeve gastrectomy (SG) affects gastroesophageal reflux disease (GERD). The debate regarding the best option for patients undergoing bariatric surgery who are also affected by GERD and/or hiatal hernia continues to divide the community of bariatric surgeons. While concomitant hiatal hernia repair (SG + HHR) has been proposed as a means of reducing the risk of GERD following SG with varying degrees of success, the addition of a fundoplication (SG + FP) has been suggested in recent years as a way to improve the lower esophageal sphincter’s competency. The aim of this study is to systematically review and meta-analyze the efficacy of SG + HHR versus SG + FP on GERD remission in patients with obesity. (2) Methods: A systematic review of the literature was conducted, and studies analyzing the effects of SG + HHR versus SG + FP on postoperative GERD were included. The methodological quality of included trials was evaluated. The primary outcome was postoperative GERD rate, erosive esophagitis, and 12-month weight loss. Secondary outcomes included postoperative complications and mortality. The PRISMA guidelines were used to carry out the present systematic review (PROSPERO Registration Number: CRD42023405600). (3) Results: Fifteen articles with a total of 1164 patients were included in the meta-analysis; 554 patients underwent SG + HHR while 610 underwent SG + FP. In the SG + HHR group, 58.5 ± 28.9% of subjects presented clinical GERD symptoms compared to 20.4 ± 17.5% postoperatively (p < 0.001). In the SG + FP group, 64.8 ± 39.4% were affected by GERD preoperatively compared to only 5 ± 8.1% postoperatively (p < 0.001). SG + FP patients had a significantly greater GERD remission compared to SG + HHR (p < 0.001). Weight loss was similar between groups (p = 0.125). The rate of leaks was 0.18% and 0.33% in the SG + HHR and SG + FP, respectively (p = 0.657), while perforations were significantly higher after SG + FP compared to the SG + HHR group (3.1% versus 0%, p = 0.002). The mortality rate was significantly greater in the SG + FP group (0.5% versus 0%, p = 0.002). (4) Conclusions: This study revealed that both SG with concomitant HHR and sleeve–fundoplication are effective in terms of reflux resolution and weight outcomes, with superiority of SG + FP in terms of GERD control, despite a greater overall complication rate. Both strategies can therefore be suggested as a suitable alternative variant to a conventional SG in subjects with obesity and concomitant hiatal hernia and/or GERD. Studies with extended follow-up and direct comparisons of these surgical approaches to conventional SG are warranted.