Research & Academic Contributions

Background Obesity negatively impacts male sexual function and fertility through hormonal imbalances, endothelial dysfunction, and psychosocial factors. Metabolic and bariatric surgery (MBS) constitutes an effective intervention; however, procedure-stratified changes in male reproductive parameters after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) remain incompletely synthesized. Methodology A systematic search of PubMed, Embase, Cochrane Library, Scopus, and Web of Science was conducted in November 2024. Sexual function, testosterone levels, and semen quality were included. Risk of bias was assessed using MINORS criteria. Random-effects meta-analyses were performed separately for each surgical modality, with heterogeneity quantified via I2 statistics. Results Twenty-one studies comprising 848 patients were included. Meta-analysis of pre–post data demonstrated that both RYGB and SG were independently associated with improvements in sex hormone–binding globulin and testosterone levels. In studies examining SG, significant improvements were observed in erectile function (SMD: 1.38, 95% CI: 0.66–2.10, p = 0.0002) and sperm concentration (SMD: 0.91, 95% CI: 0.56–1.26, p < 0.00001). Studies evaluating RYGB did not demonstrate statistically significant changes in erectile function (SMD: 0.62, 95% CI: −0.06 to 1.30, p = 0.07) or sperm concentration (SMD: −0.01, 95% CI: −0.45 to 0.42, p = 0.95). Conclusion The meta-analytical findings suggest beneficial effects of both RYGB and SG on male hormonal parameters. Studies of SG demonstrated significant improvements in erectile function and sperm concentration. However, direct comparative analyses between the two procedures were not performed, precluding definitive conclusions regarding their relative efficacy. Future research necessitates head-to-head comparisons with standardized reproductive endpoints and extended follow-up periods.

Background Sleeve gastrectomy (SG) is the most frequently performed metabolic and bariatric surgery (MBS) worldwide, but long-term suboptimal weight loss (SOWL) or recurrent weight gain (RWG) affects up to one third of patients and often necessitates revisional procedures. One-anastomosis gastric bypass (OAGB) is an effective revision, yet pouch dilation and late RWG remain concerns. Ring augmentation (RA) has been proposed to enhance restriction and sustain weight loss, but evidence in the revisional OAGB setting is limited. Methods This retrospective comparative cohort study analyzed 94 adults who underwent revisional OAGB after SG at a high-volume tertiary MBS center. Patients were grouped into two categories: Ring Augmented OAGB (RaOAGB) (n = 45) and Non-Ring Augmented OAGB (NRa-OAGB) (n = 49). The primary outcomes were percentage excess weight loss (%EWL), percentage total weight loss (%TWL), and change in body mass index (BMI) at 3, 6, and 12 months. Secondary outcomes included improvement of obesity-related conditions, metabolic parameters (lipid profile, HbA1c), nutritional markers, operative time, hospital stay, and early/late complications. Results Both groups achieved significant weight reduction at 12 months (p < 0.001 within groups). RaOAGB yielded greater BMI reduction (27.6 vs. 32.2 kg/m²), %EWL (81.7% vs. 61.3%), and %TWL (31.5% vs. 24.2%) compared with NRa-OAGB (all p < 0.001). Lipid profiles improved in both groups; LDL decreased, and total cholesterol equalized by 12 months. Glycemic control changes were modest and similar between cohorts. Operative time, length of stay, and early postoperative complications were comparable. Ring-related adverse events were infrequent (food intolerance 6.7% vs. 4.1%; no erosions were observed; one patient (2.2%) required ring removal at 10 months due to persistent vomiting and food intolerance). Conclusions RaOAGB is a safe and effective revisional option for RWG and SOWL after SG, achieving significantly greater 1-year weight loss than standard OAGB, with uncommon ring-related adverse events, including one ring removal. These findings support the role of mechanical reinforcement to enhance the durability of revisional bypass but warrant confirmation through long-term, multicenter randomized trials.

Obesity is associated with breast cancer risk, and metabolic bariatric surgery (MBS) may reduce obesity-related cancer incidence. Prior reviews suggest lower breast cancer incidence after MBS, but uncertainty remains across design, menopausal status, procedure type, and confounding control. We conducted a PROSPERO-registered systematic review (CRD420261384078), meta-analysis, and network meta-analysis according to PRISMA. PubMed, Embase/MEDLINE, and Scopus were searched for comparative studies of breast cancer incidence after MBS versus control. Risk of bias was assessed using ROBINS-I and certainty using GRADE. Seventeen studies including 343,531 surgical patients and 1,587,413 controls were included. MBS was associated with lower breast cancer incidence in the primary hazard-ratio analysis (HR 0.75, 95% CI 0.70–0.81; I2 = 0%) and women-only cohorts (HR 0.74, 95% CI 0.67–0.81). Propensity-score-matched analyses showed a larger but heterogeneous association (RR 0.56, 95% CI 0.31–0.99; I2 = 91%). Premenopausal estimates favoured MBS (HR 0.74, 95% CI 0.60–0.91), whereas postmenopausal estimates were not significant (HR 0.73, 95% CI 0.50–1.07). Network estimates favoured sleeve gastrectomy and Roux-en-Y gastric bypass versus control, but no procedure was superior. Certainty ranged very low-to-moderate overall. MBS may be associated with lower breast cancer incidence, but evidence remains observational; future work must clarify causality, patient selection, and procedure effects.

Robotic adoption in metabolic and bariatric surgery has increased, but its procedure-specific short-term outcomes remain uncertain. This study compared robotic and laparoscopic Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion with duodenal switch (BPD-DS) over a decade. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database was queried for primary RYGB and BPD-DS performed from 2015 to 2024. Missing data were addressed using multiple imputation followed by stabilized inverse probability of treatment weighting. Propensity-score and outcome models were fitted separately within four predefined procedure-period strata: RYGB 2015–2019, RYGB 2020–2024, BPD-DS 2015–2019, and BPD-DS 2020–2024. Thirty-day outcomes were estimated within each stratum, with Benjamini-Hochberg false-discovery-rate adjustment applied across the modeled comparisons. The analysis included 411,155 patients: 87,028 R-RYGB, 307,420 L-RYGB, 5,283 R-BPD-DS, and 11,424 L-BPD-DS. Robotic utilization increased from 8.6% to 44.0% for RYGB and from 28.2% to 50.3% for BPD-DS. For RYGB, the robotic approach was associated with higher readmission in both periods (OR 1.23 and 1.19), lower odds of serious complications (OR 0.84 and 0.87), and longer operative duration (mean differences 39.83 and 26.17 min). For BPD-DS, robotic surgery was associated with higher readmission in both periods (OR 1.38 and 1.25), higher intervention in 2015–2019 (OR 1.65), and longer operative duration (mean differences 87.49 and 40.85 min). BPD-DS estimates were less precise, and some associations attenuated in the complete-case sensitivity analysis. Robotic utilization increased substantially but was associated with longer operative duration and higher readmission for both procedures, without a clear overall 30-day safety advantage. BPD-DS findings were less precise and should be considered exploratory.

Gastric bypass procedures are highly effective for severe obesity management, but a small subset of patients develop devastating complications refractory to medical management. This study evaluates the outcomes of complete reversal to normal anatomy following failed gastric bypass. Methods We conducted a retrospective case series of 13 patients (0.9% of 1,450 bypass patients) who underwent complete laparoscopic reversal to normal anatomy between 2020 and 2024. Indications included severe malnutrition after one-anastomosis gastric bypass (OAGB) (n = 5), intractable marginal ulcers after Roux-en-Y gastric bypass (RYGB) (n = 4), and severe dumping syndrome after RYGB (n = 4). We assessed operative outcomes, symptom resolution, nutritional markers, and weight changes at 1-year follow-up. Results The cohort was predominantly female (76.9%) with a mean age of 42.1 ± 2.2 years. Mean time to reversal was 1.9 ± 0.6 years. Mean operative time was 76.0 ± 6.2 min with zero intraoperative complications. All patients (100%) achieved complete resolution of their primary complication. In the malnutrition cohort, serum albumin improved from 2.16 ± 0.11 g/dL to 3.84 ± 0.10 g/dL (p < 0.001), and hemoglobin improved from 9.12 ± 0.31 g/dL to 12.64 ± 0.35 g/dL (p < 0.001). However, mean BMI increased significantly from 23.9 ± 1.8 kg/m² to 31.8 ± 1.2 kg/m² (p < 0.001), with 84.6% of patients returning to a BMI > 30 kg/m² at one year. Conclusion Complete reversal to normal anatomy is a safe and highly effective treatment for severe, refractory complications of gastric bypass, providing symptom resolution. However, it is universally associated with significant weight regain, necessitating careful patient selection, preoperative counseling, and aggressive postoperative weight management.

Background The global burden of obesity continues to rise, and metabolic and bariatric surgery is the most effective intervention for durable weight loss and improvement of obesity-related diseases. The International Federation for the Surgery and Other Therapies for Obesity (IFSO) Global Registry was established in 2013 to provide standardised, multinational surveillance of MBS. No longitudinal synthesis of the successive IFSO Global Registry reports has been undertaken. Methods We performed a retrospective secondary analysis of all nine IFSO Global Registry reports published from 2014 to 2024; all source reports were accessed on October 18, 2025. Following RECORD principles, we prespecified core domains, harmonised definitions across editions, and documented transformations in a reproducible extraction log. Report-level patterns were described for registry participation, procedure volumes and mix, operative approach, patient demographics, perioperative outcomes, and methodological evolution. A FAIR-informed appraisal of report-level transparency was conducted using a pragmatic, registry-oriented rubric. Because the registry underwent a structural transition from individual-level or mixed reporting to aggregated national reporting between the sixth and seventh editions, analyses were structured into two non-equivalent reporting eras: Reports 1–6 and Reports 7–9. Cross-era comparisons were therefore interpreted as descriptive contrasts shaped by reporting architecture, rather than as continuous epidemiological trends. Findings Reported metabolic and bariatric surgery activity ranged from 100,092 operations across 18 countries in the First Report to 598,736 operations across 36 countries in the Ninth Report, with the highest submitted volume in the Fifth Report. These values reflect changing contributor networks and reporting frameworks and should not be interpreted as directly comparable estimates of global procedural incidence. Within submitted primary-procedure data, Sleeve gastrectomy increased from 22.0% in the First Report to 60.4% in the Ninth Report, while Roux-en-Y gastric bypass decreased from 66.0% in the First Report to 29.7% in the Ninth Report; adjustable gastric banding became uncommon, and one-anastomosis gastric bypass accounted for 4–7% where reported. Median age and body mass index were broadly stable, and Female patients represented 71.3–79.5% of patients in reports with comparable sex reporting. Revisional procedures showed higher rates of unplanned reoperation, intensive care unit admission, readmission, and mortality than primary procedures. Report-level Findable, Accessible, Interoperable, and Reusable transparency scores improved modestly, mainly through gains in findability and accessibility, while interoperability and reusability remained limited. Interpretation Across successive public reports, sleeve gastrectomy became the most frequently reported primary procedure within submitted registry data, with substantial regional heterogeneity and important limitations in cross-edition comparability. Further harmonisation of definitions, improved follow-up completeness, and privacy-preserving access to more granular data would enhance the registry’s value for benchmarking, policy, and patient-level research.

Background Roux-en-Y gastric bypass (RYGB) is a widely performed metabolic and bariatric surgery (MBS) procedure with proven efficacy. However, significant variability exists in its technical execution. This study aimed to evaluate global practice patterns among surgeons affiliated with the International Federation for the Surgery and Other Therapies for Obesity (IFSO), identifying key variations and factors influencing intraoperative decision-making. Methods A cross-sectional survey was distributed between January and November 2025 to active IFSO members performing RYGB. The survey explored techniques related to the gastric pouch configuration, intestinal limb lengths, gastrojejunostomy, ring augmentation, and adjunct use. Responses from 245 surgeons across 47 countries were analyzed using descriptive statistics, subgroup comparisons, and multivariable logistic regression. Results Technical variability was widespread. Only 53.5% routinely measured gastric pouch length; 67.3% described their pouches as “short” or “small,” with variable anatomical endpoints. Bougie sizes ranged from 28 to 46 Fr, with 36 Fr being most common (41.2%). Only 21.6% of respondents reported routinely measuring total bowel length. Ring-augmentation was used by 20.4%, with significant regional and experiential variation. Linear stapling was preferred for gastrojejunostomy (81.2%), but stoma size and suture materials varied. Routine closure of both Petersen’s space and the jejunojejunal mesenteric defect was common (69%) yet non-uniform. High-volume surgeons had shorter hospital stays and longer follow-up, but technical patterns were similar. Conclusion Global RYGB practice exhibits heterogeneity in several key operative steps. Improved reporting of intraoperative technical variables may help clarify which differences are most relevant to perioperative, long-term, and registry-based outcomes, and may support future consensus-building in areas where standardization is clinically justified.

Gastric remnant or duodenal perforation after Roux-en-Y gastric bypass (RYGB) or one-anastomosis gastric bypass (OAGB) is rare and may be missed radiologically. We systematically reviewed PubMed, Scopus, and Web of Science and included 26 reports (34 patients), alongside a video-illustrated late OAGB case. Mean age was 49 years, 73.5% were female, and BMI at presentation was 33.58 kg/m²; 32 events followed RYGB and 2 OAGB, occurring a mean of 118.7 months postoperatively. CT was performed in 79.4% and more often showed free fluid than pneumoperitoneum. Laparoscopy (70.6%) with primary repair with or without omental flap or limited remnant resection achieved source control; no completion gastrectomies or 30-day deaths were reported. Early diagnostic laparoscopy should be considered in septic bypass patients with unexplained free fluid; however, the available evidence is limited to case reports and small case series, so definitive conclusions regarding incidence, comparative risk, or causative mechanisms cannot be drawn.

Background Sleeve gastrectomy (SG) is effective but prone to late recurrent weight gain (RWG). Ring-augmented SG (Ra-SG) may preserve restriction and enhance long-term durability. Methods In this single-center, prospective, single-blind randomized trial, adults with a BMI > 50 kg/m² were randomized to SG or Ra-SG and followed for 36 months. The primary endpoint was percent total weight loss (%TWL) at 36 months. Secondary outcomes included RWG, gastric pouch volumetry, relapse of associated medical problems, complications, endoscopic findings, laboratory parameters, and patient-reported outcomes (SF-36, Suter). Results Ra-SG produced significantly greater weight loss at 36 months (48.8 ± 8.3 vs. 45.5 ± 9.0%TWL; mean difference 3.25% points, 95% CI 0.86 to 5.63; p 0.008). Exploratory analyses showed lower rates of clinically significant RWG (≥ 30% regain: 5.9% vs. 16.3%; absolute risk difference − 10.4%, 95% CI − 19.6 to − 1.2; p = 0.033) and smaller pouch volumes (160.1 ± 8.9 vs. 194.2 ± 10.3 mL; p < 0.001). Perioperative complications were infrequent and comparable. At three years, the prevalence of endoscopic GERD was similar (17.3% vs. 19.6%). Food tolerance scores were consistently better after SG (all p < 0.05). HRQoL improved significantly in both groups, with no differences observed at 36 months. Two Ra-SG patients (1.8%) underwent ring removal. Conclusions Ra-SG enhanced weight-loss durability and lowered RWG compared to SG, with similar safety and GERD outcomes but decreased food tolerance at mid-term. Ra-SG may be considered in patients at higher risk of RWG, though multicenter studies with longer follow-up are needed to confirm these findings.

Background Large language models (LLMs) are increasingly applied in medicine; however, their accuracy in guideline-driven, high-stakes specialties, such as metabolic and bariatric surgery (MBS), remains uncertain. This study evaluates the performance of ChatGPT-4o, Gemini 2.0 Flash, and DeepSeek-V3 in generating guideline-concordant responses to MBS clinical questions. Methods Thirty standardized, guideline-based MBS questions were presented to each model. Responses were randomized in order, anonymized (blinded as Model A/B/C), and evaluated by 93 MBS experts using a validated 0–3 scale (0 = inaccurate; 3 = fully guideline-concordant). A repeated-measures ANOVA with Bonferroni correction tested model differences; reliability was assessed with Cronbach’s α and intraclass correlation coefficients (ICC). Results DeepSeek-V3 achieved the highest mean score (2.44 ± 0.40), followed by ChatGPT-4o (1.79 ± 0.46) and Gemini 2.0 Flash (1.63 ± 0.47) (p < 0.001). Fully guideline-concordant ratings (score = 3) were most frequent for DeepSeek (80%) vs. ChatGPT (0%) and Gemini (3.3%). Internal consistency was excellent (α > 0.90), and inter-rater reliability was strong (ICC > 0.88). When mapped against the QUEST evaluation framework, the study addressed Quality and Understanding but did not fully capture Expression, Safety, or Trust dimensions. Conclusions DeepSeek-V3 outperformed ChatGPT-4o and Gemini 2.0 Flash in generating guideline-concordant responses in MBS. These results highlight the need for ongoing, domain-focused validation before clinical use.

We present a case of a 36-year-old female with a BMI of 41.1 kg/m² who underwent a one-anastomosis Gastric Bypass (OAGB) with remnant stomach resection following an aborted sleeve gastrectomy (SG) due to an incidental gastric lesion. Case Presentation Two weeks post-aborted SG, the patient underwent evaluation, including contrast-enhanced CT and multiple esophagogastroduodenoscopies (EGD), which failed to confirm a definitive diagnosis. Following a multidisciplinary team decision, she underwent OAGB with remnant stomach resection of the segment harboring the lesion. Intraoperatively, a raised nodular mass was identified, and the stomach containing the lesion was resected. Histopathology confirmed benign heterotopic pancreatic tissue. Conclusion Resectional bariatric procedures provide a viable option for patients with incidental gastric lesions detected intraoperatively, enabling both weight loss and definitive diagnosis.

Introduction Obstructive Sleep Apnea (OSA) represents a significant global health challenge, closely linked to obesity and a heightened risk for cardiovascular and metabolic disorders. Continuous Positive Airway Pressure (CPAP) remains the cornerstone of OSA management; however, its effectiveness is often hindered by patient adherence and tolerance. Metabolic and bariatric surgery (MBS) has emerged as a viable alternative by reducing excess weight and improving upper airway anatomy. Among the various MBS techniques, Sleeve Gastrectomy (SG) has gained prominence due to its favorable outcomes and limited complications. This study aims to assess the impact of SG on OSA, utilizing Magnetic Resonance Imaging (MRI) and polysomnography to analyze structural changes and clinical outcomes. Methods In this prospective study, 40 participants aged 18–65 years with a BMI exceeding 30 kg/m² and a confirmed diagnosis of OSA (apnea-hypopnea index [AHI] ≥ 5) were enrolled. Pre- and post-operative evaluations included an MRI of the upper airway, polysomnography, and the Epworth Sleepiness Scale (ESS) to quantify daytime somnolence. Statistical analysis was conducted using Generalized Estimating Equations (GEE) and correlation tests in R software, focusing on changes in weight, BMI, AHI, Oxygen Desaturation Index (ODI), and airway dimensions. Results Post-SG, participants exhibited significant weight reduction, averaging − 43.8 kg (p < 0.001), and a decrease in BMI of -15.7 kg/m² (p < 0.001). Both AHI and ODI demonstrated significant declines (p < 0.001), with daytime sleepiness normalizing in all subjects. MRI analysis indicated notable increases in upper airway dimensions coupled with a reduction in tongue volume. Additionally, CPAP reliance decreased from 90% to 22.5%. Remarkably, diabetes and hypertension were resolved in all subjects. Conclusion This study suggests that SG may yield 12-month improvements in OSA severity, upper airway structure, and CPAP dependency in patients with obesity. The findings highlight SG as a potentially valuable adjunct treatment, although larger, long-term studies are warranted to confirm these results and inform clinical decision-making.

Obesity is a global health challenge, and minimally invasive surgery (MIS) has become a cornerstone of its management [1]. While MIS offers patients faster recovery and reduced postoperative pain, it imposes significant physical and cognitive demands on surgeons [2, 3]. Prolonged non-neutral postures, constrained visual–manual coordination, and heightened mental workload contribute to work-related musculoskeletal disorders (WRMSDs) and burnout [4, 5]. WRMSDs encompass a wide range of conditions, including cervical disc degeneration, thoracic outlet syndrome, carpal tunnel syndrome, and chronic back and neck pain [6]. For example, prevalence estimates are striking in MBS: up to 66% of surgeons report persistent pain or physical discomfort attributed to their operative work, and approximately 27% experience symptoms severe enough to consider altering or limiting their surgical practice [7]. Moreover, cognitive stressors, including prolonged concentration, complex decision-making, and high-stakes outcomes, contribute to mental fatigue and elevate the risk of occupational burnout [8]. Addressing these ergonomic risks is essential for sustaining surgical performance and career longevity, yet no standardized framework exists for metabolic and bariatric surgeries (MBS). Here, we propose the Unified Ergonomic Checklist for Minimally Invasive Surgeries in Obesity (UEC-MISO) as a preliminary, multidimensional tool to guide assessment and improvement of surgeon ergonomics (Fig. 1). Fig. 1 Fig. 1 Full size image Unified Ergonomic Checklist for Minimally Invasive Surgeries in Obesity (UEC-MISO) Current Ergonomic Tools in Surgery Several tools have been developed to assess ergonomic risk in surgical practice, each addressing a specific dimension of strain. However, these instruments are typically applied in isolation, offering fragmented insight into the multifactorial demands of MIS in patients with obesity. The Rapid Upper Limb Assessment (RULA), introduced by McAtamney and Corlett, is used to evaluate static postures and biomechanical stress on the neck, trunk, and upper limbs [9, 10]. It is quick and equipment-free, making it ideal for identifying postural risks in laparoscopic and robotic procedures [11, 12]. However, RULA is limited by its single time-point evaluation, inability to assess dynamic movements, and lack of consideration for technical skill or procedural complexity [13]. The NASA Task Load Index (NASA-TLX) complements RULA by quantifying perceived workload across six domains: mental, physical, temporal, performance, effort, and frustration [14]. Widely used in surgical ergonomics, NASA-TLX has demonstrated that both mental and physical demands often exceed critical thresholds in minimally invasive surgery, contributing to performance degradation and burnout [15, 16]. Yet, NASA-TLX is not specific to surgery and does not capture postural or procedural ergonomics. The PSPOSO checklist, developed for laparoscopic MBS, assesses trocar number, placement, and working angles with surgical outcomes [17]. While offering procedural specificity and reflecting surgical ergonomic impact on outcomes, PSPOSO does not evaluate surgeon posture or cognitive load and is limited by the lack of global generalizability [17]. To capture real-time musculoskeletal discomfort, the body part discomfort (BPD) scale has been employed in surgical ergonomics research [18, 19]. This 10-point scale provides subjective ratings of pain intensity across anatomical regions. In operative studies, such as those comparing laparoscopic and robotic Roux-en-Y gastric bypass, BPD scores have revealed significantly greater neck and back discomfort in laparoscopic cases (median 2.5 vs. 1.0, P = 0.028), confirming its sensitivity to procedural ergonomic differences [18]. Each of these tools offers important but partial insight. RULA quantifies postural load, NASA-TLX captures cognitive strain, PSPOSO introduces procedural specificity, and BPD provides symptom-level feedback. However, their siloed application generates fragmented data, making it difficult to implement coordinated ergonomic improvements. This highlights the need for a unified, multidimensional framework that integrates these elements to comprehensively assess the ergonomic landscape of MIS in patients with obesity. This gap highlights the urgent need for an integrated ergonomic assessment framework that encompasses the physical, cognitive, and procedural dimensions of surgical practice. The Unified Ergonomic Checklist for Minimally Invasive Surgeries in Obesity (UEC-MISO) was developed to fill this void. Toward a Unified Checklist: Rationale and Framework Ergonomics, as defined by the International Ergonomics Association, is the science of optimizing interactions among humans, tools, and environments to enhance safety, efficiency, and performance [20]. Despite growing awareness of ergonomic hazards in surgical practice, these principles remain underutilized, especially in the context of MBS, where prolonged static postures, constrained visual fields, and elevated mental workload converge [21]. Reported rates of WRMSDs among surgeons range from 66% to nearly 100%, depending on specialty and technique [22, 23]. Conventional laparoscopy, in particular, is associated with a high ergonomic burden due to non-neutral postures, long operative times, and repetitive motion. Cognitive load, as measured by tools such as the NASA-TLX, also shows a dose-dependent relationship with burnout and diminished intraoperative performance [24]. Despite the availability of several ergonomic assessment tools, their fragmented application has created a gap in standardized, holistic evaluation. RULA offers a rapid means of evaluating postural risk, yet it does not account for cognitive or procedural factors [10, 25]. Conversely, NASA-TLX quantifies mental workload but fails to address surgical setup and biomechanical load [14]. PSPOSO introduces procedural specificity by standardizing port configuration but lacks integration with posture and mental fatigue measures [17]. To bridge these limitations, we propose the Unified Ergonomic Checklist for Minimally Invasive Surgeries in Obesity (UEC-MISO), a multidimensional framework designed to provide a comprehensive, repeatable, and institutionally scalable assessment of surgeon ergonomics. The UEC-MISO synthesizes components from RULA, NASA-TLX, PSPOSO, and the BPD scale, organized into four ergonomic domains (Table 1). Table 1 Unified Ergonomic Checklist for Minimally Invasive Surgeries in Obesity (UEC-MISO) and scoring rubric Full size table The preoperative setup domain encompasses key elements from PSPOSO, including patient positioning (between-leg vs. side), the number and placement of trocars, and instrument working angles. The intraoperative posture domain draws on a modified RULA framework, evaluating alignment of the upper limbs, neck, trunk, and lower extremities throughout the case. The workload assessment domain utilizes the NASA-TLX, administered immediately after the procedure’s critical phase. Each domain is scored on a 0–100 scale; a value ≥ 60 in any domain is considered high and contributes + 1 point to the total ergonomic risk score. This threshold reflects prior studies identifying 60 as a cutoff above which cognitive or physical workload impairs performance or increases strain [15, 16]. The postoperative feedback domain integrates the short-form BPD scale to capture subjective musculoskeletal symptoms. Additional points are assigned for operative durations > 180 min and any reported port-site issues, including pain, hernia, or bleeding. Each component contributes to a cumulative ergonomic risk score (maximum 15 points), which is color-coded by severity to support intuitive interpretation and institutional benchmarking (Table 2). The structure is designed for use in both clinical and research settings, offering a practical framework for identifying modifiable ergonomic hazards and promoting surgeon safety. Table 2 Color-coded ergonomic risk categories Full size table Pilot testing of UEC-MISO in high-volume centers will be essential to validate inter-rater reliability, usability, and predictive value. Integration into operative reports, peer training, and enhanced recovery protocols may facilitate uptake. We call on professional societies such as IFSO and SAGES to support structured validation and adoption of this framework to improve surgeon safety and procedural sustainability. Limitations While the Unified Ergonomic Checklist for Minimally Invasive Surgeries in Obesity (UEC-MISO) offers a structured, multidimensional framework, several limitations must be acknowledged before its broader adoption. The checklist, although grounded in validated components, has yet to undergo formal external validation across diverse surgical teams and institutions. Its reliance on observer scoring introduces potential for inter-rater variability, particularly in posture assessment and trocar placement evaluation. Additionally, some domains, such as postoperative discomfort, depend on self-reported data, which is vulnerable to recall bias and subjectivity. The current version of the checklist is tailored to MIS and MBS procedures. Adaptation may be required for broader use in other surgical contexts, given potential variability in team dynamics, instrumentation, and institutional workflow. Finally, even modest additions to intraoperative or postoperative documentation can encounter resistance in high-throughput environments. Conclusion The UEC-MISO framework represents a pivotal step forward in MBS not by modifying procedures, but by protecting the performing surgeons. By unifying posture, workload, trocar configuration, and discomfort into a single ergonomic risk score, it fills a critical gap left by existing tools. It enables institutions to audit ergonomic safety, supports research into surgeon health and performance, and lays the groundwork for integration into registries, training programs, and ERAS protocols. In a specialty increasingly focused on precision and sustainability, UEC-MISO restores attention to the operator, not just the operation. We advocate for the formal validation and structured implementation of UEC-MISO through pilot testing, multicenter studies, and institutional integration. A standardized, evidence-informed ergonomic framework, endorsed by professional societies and embedded in surgical education, has the potential to enhance surgeon well-being, improve operative safety, and sustain procedural excellence in the evolving field of MIS.

A 56-year-old female presented with recurrent weight gain (RWG) and vomiting, 10 years after open VBG. Imaging and endoscopy revealed an anatomically distorted pouch, two staple line dehiscences, and a gastro-gastric fistula (GGF). Multiple revisional options were evaluated. Due to the presence of mesh and anatomical limitations, a decision was made to perform a one-anastomosis gastric bypass (OAGB) below the mesh, guided by a calibration tube passed through the area of disruption. Laparoscopic OAGB was performed with a 150-cm biliary limb and a 3-cm gastrojejunostomy. Intraoperative leak testing was negative. The patient had an uneventful recovery and was discharged on postoperative day 3. At 18-month follow-up, she achieved a weight of 74 kg (body mass index (BMI) 25.4 kg/m2), with complete symptom resolution and normal laboratory parameters.

Introduction Postoperative bradycardia, particularly in the early postoperative phase, is a potential complication following bariatric surgeries such as sleeve gastrectomy (SG). While various types of bradycardias have been documented as complications, early-onset sinus bradycardia has received limited attention. This case series specifically investigates the incidence and progression of early postoperative sinus bradycardia in patients undergoing laparoscopic SG, excluding those with hiatal hernias or cardiovascular comorbidities. Methods We conducted a retrospective series of patients aged 18 to 50 years with morbid obesity (BMI ≥ 35 kg/m2) who underwent laparoscopic SG from January 2016 to March 2023. All patients were monitored for postoperative bradycardia, defined as heart rates below 60 beats per minute (bpm), and were evaluated with electrocardiograms (ECG) and echocardiograms (ECHO). Data were analyzed using descriptive statistics and R software version 4.3.1. Results The study included eight patients with a mean age of 34.88 ± 9.05 years and a mean BMI of 44.25 ± 3.62. Postoperative heart rates showed an initial increase to 79.6 ± 4.8 bpm, followed by a gradual decline, reaching 50 ± 3.17 bpm by discharge. Heart rates dropped significantly after 12 h, stabilizing by 24 h. The mean time to return to normal heart rate was 14 ± 4.36 days. All patients had routine preoperative ECG and ECHO, and no significant cardiac abnormalities were noted postoperatively. Conclusion This case series underscores the occurrence of early postoperative sinus bradycardia in SG patients, a phenomenon that is underexplored in the literature. Future studies should investigate the pathophysiology of this condition and evaluate its clinical implications for postoperative care.

We read with interest the recent multimedia article by Abdallah and Alawadi titled “Fixation of the Esophagus to Diaphragmatic Hiatus as a Routine Step in Hiatal Hernia Repair During Bariatric Surgery: How to Do It?” [1]. While the technical description is clear and the intraoperative steps are thoughtfully illustrated, we believe that several aspects of the article warrant closer scrutiny, particularly regarding the positioning of the technique as a routine step and the absence of supporting clinical data.

We read with interest the recent meta-analysis by Monteiro Delgado et al., titled “Long-Term Outcomes in Sleeve Gastrectomy versus Roux-en-Y Gastric Bypass: A Systematic Review and Meta-Analysis of Randomized Trials.” [1]. While we appreciate the authors’ efforts to synthesize long-term data on two cornerstone metabolic and bariatric surgery (MBS) procedures, we identified protocol-level deviations that conflict with the stated eligibility criteria of randomized trials comparing SG and RYGB with ≥ 5-year follow-up. Specifically, two included trials used interventions that were not equivalent to SG or standard RYGB, introducing clinical heterogeneity that compromises the validity of the pooled SG-versus-RYGB estimates.

The ethical landscape of metabolic surgery is evolving in response to new understanding of obesity as a disease, growing evidence of surgical effectiveness, and recognition of the harms associated with therapeutic inaction. While the principle of “first, do no harm” remains important, it must be balanced with the imperative to act when intervention can prevent greater harm. The framework proposed here, emphasizing “primum succurrere” alongside traditional ethical principles, offers a path forward that honors both the potential benefits and risks of metabolic surgery. However, this framework must be implemented thoughtfully, with robust safeguards, careful patient selection, and ongoing attention to the complexity of individual clinical decisions. Ultimately, ethical practice in metabolic surgery requires not just courage to act, but wisdom to know when action is appropriate, how to implement it safely, and how to respect patient autonomy throughout the process. As our understanding of obesity and its treatment continues to evolve, so too must our ethical frameworks, always to serve our patients’ best interests while maintaining the highest standards of medical practice.

Objectives The objective of this web-based study is to analyze the attributes of bariatric surgery cases ensuing health implications. Additionally, the study seeks to delve into the factors influencing post-bariatric psychological evaluations and the impact of various bariatric surgeries on weight loss and psycho-social assessment scores for patients who had undergone bariatric surgeries within a specific bariatric surgery center in Egypt between January 2017 and January 2024. Methods An analytical cross-sectional study recruited 411 adults who had undergone different bariatric procedures by the same surgical team. We collected the data using a validated self-administered questionnaire that included the Body Image Scale (BIS), the Rosenberg Self-Esteem Scale (RSES), the quality-of-life score (QOLS), and the modified General Patient Satisfaction Score after Bariatric Surgeries (GSABS). Results The most commonly performed bariatric surgery was sleeve gastrectomy (SG), accounting for 82.7% of the procedures. The majority of the patients (78%) were female, with a mean age of 35.8. Among the participants, 32.4% reported experiencing complications, and 21.2% of those individuals were still experiencing complications at the time of assessment. The BIS had a mean score of 16.54 ± 6.27, indicating an average body image perception. The RSES yielded a mean score of 20.11 ± 4.63, indicating average self-esteem, while the GSABS had a mean score of 8.08 ± 2.39, indicating an overall average level of patient satisfaction. No statistically significant differences were found between the various types of bariatric surgeries in terms of total body weight loss percentage, excess body weight loss percentage, or the timing of the intervention. However, increased time intervals from surgeries noted a significant reduction in the BIS. Conclusion The majority of patients who underwent SG and Roux-en-Y gastric bypass (RYGB) surgeries exhibited high GSABS scores. SG patients also had high BIS scores. However, all other interventions showed normal GSABS and BIS scores. All types of surgeries resulted in normal RSES and QOLS. Furthermore, the BIS score increases with the intervention's recentness, but it significantly decreases after the second-year post-surgery. Conversely, the older the timing of the intervention, the higher the RSES score after surgery.

In a Letter to Robert Hooke in 1675, Isaac Newton articulated, “If I have seen further, it is by standing on the shoulders of Giants,” a phrase that aptly reflects the essence of scientific advancement [1] (Fig. 1). Advances in surgical techniques and clinical knowledge in metabolic and bariatric surgery (MBS) are largely attributed to the invaluable contributions of senior surgeons, whose expertise has shaped the field through innovative procedures like the Roux-en-Y gastric bypass and sleeve gastrectomy [2]. Their influence extends beyond technical skills; they have established essential principles in decision-making, care ethics, and surgical mastery. An AI-generated symbolic representation of mentorship and legacy, illustrating the concept of progress achieved by building upon the foundational wisdom of predecessors, inspired by the metaphor of “standing on the shoulders of giants’ by Isaac Newton. The image was created using OpenAI’s DALL·E platform As the field embraces rapid technological advancements, there is a pressing need to preserve the unique expertise of these pioneering surgeons. Historically, recognition of such figures often occurs posthumously, through memorials or biographies [3,4,5,6,7]. While important, these acknowledgments fail to influence the current generation of practitioners. Proactively honoring and documenting their insights ensures that their expertise benefits contemporary and future surgeons. Surgical mastery is deeply rooted in experience, encompassing nuanced skills that cannot be fully captured in textbooks or publications; rather, it is an accumulation of years of hands-on practice, observation, trial and error, and relentless refinement [8]. The way seasoned surgeons handle instruments, navigate complex anatomy, and make critical decisions represents a tacit knowledge that defines surgery as both an art and a science and is often difficult to formalize. Preserving this invaluable expertise requires intentional efforts to document and transmit their skills. Initiatives such as mentorship grants, lifetime achievement awards, and oral history projects can formalize their contributions and create enduring legacies. The benchmarks in MBS are products of decades of innovation and collaboration [9]. These standards of excellence, established by earlier generations, continue to guide modern surgical practice. Today’s surgeons build on this foundation through mentorship, practice, and observation, internalizing the principles of precision, safety, and patient-centered care. This linkage between historical expertise and current benchmarks ensures that the field continues to evolve while remaining grounded in the principles of precision, safety, and patient-centered care. Technology offers unprecedented opportunities to preserve and enhance this legacy. Surgical videos can provide detailed records of techniques, but advancements in 3D modeling and artificial intelligence (AI) can elevate these resources further [10, 11]. AI can annotate surgical footage, highlight critical maneuvers, and analyze decision-making processes, transforming traditional videos into interactive training tools [12]. These resources could form the basis of an IFSO-endorsed library, ensuring global access to the collective wisdom of senior MBS surgeons. Consequently, leveraging the IFSO virtual academy[13] with these AI-enhanced tools can promote the synthesis of operative data into more engaging and interactive learning formats. Integrating robotics and artificial intelligence into surgical practice allows for the preservation of senior surgeons’ expertise. By encoding their techniques into AI and robotic systems, we create a valuable repository that influences the future of surgery while maintaining high precision standards [14]. This approach may ensure that the skills of experienced surgeons endure, enhancing the effectiveness of robotic-assisted surgeries and serving as a practical tool for improving patient outcomes for years to come. While the promise of technology is undeniable, it is crucial to preserve the human elements that define surgery as both an art and a science [15]. Robotics and AI may amplify precision, but the empathy and intuition of a surgeon remain irreplaceable [16]. Patients do not merely seek technical solutions; they seek caregivers who understand their struggles and celebrate their victories. Senior surgeons are often the custodians of this human connection. Their stories of perseverance and compassion remind us that the ultimate goal of MBS is not merely technical excellence but holistic patient care. Preserving these values in an era dominated by data and devices requires a conscious effort to humanize technology and maintain the essence of patient-centered care. Thus it is imperative that traditional education should align with the rising technologies. Therefore preserving technical expertise is only part of the equation. Formalized mentorship programs pairing senior surgeons with early-career professionals can share senior mentors’ decision-making heuristics and technical expertise [17, 18]. Moreover, intergenerational collaborative research teams can explore new and arising topics allowing seasoned clinicians to guide the ethical and technical application of technology while younger researchers navigate its development [19]. Furthermore, encouraging narratives to struggle and triumph from senior surgeons can shape the resilience and values of younger generations. Likewise, open forums where senior surgeons share their philosophy of patient care ethics and decision-making can be transformative in shaping the next generations of leaders. Moreover, it is equally important to celebrate and acknowledge the contributions of senior surgeons while they are still active in the field. Naming conferences, awards, instruments, or even hospitals after these pioneers can serve as a lasting tribute to their impact. Additionally, lifetime achievement lectures or mentorship programs can create formal opportunities for these surgeons to share their experiences and philosophies with the next generation [17, 19]. Their journeys, struggles, and triumphs are not only inspirational but also critical in shaping the values and resilience of young surgeons entering the field. Recognizing senior surgeons’ contributions and ensuring the preservation of their knowledge is not merely an act of respect; it is a responsibility. As a global community, we must actively work to bridge the gap between generations by integrating their expertise into the frameworks of modern education and technology by maintaining annual IFSO summits to ensure the legacy of senior surgeons, formulating global mentorship initiatives endorsed by the IFSO and its chapters, and formulation of a digital legacy library via an AI-enhanced archive to highlight the surgeon’s expertise.

We read with great interest the article titled “Guillain-Barré Syndrome Following Laparoscopic Sleeve Gastrectomy: A Tale of Two Cases” by Hamdeh et al. [1], which highlights a rare but serious complication of bariatric surgery. While the authors provide detailed case descriptions and discuss potential mechanisms linking Guillain-Barré Syndrome (GBS) to laparoscopic sleeve gastrectomy (LSG), we observed some critical gaps in the diagnostic and nutritional assessments that warrant further attention.

Learning taxonomies present valuable opportunities for advancing medical education and simulation, significantly enhancing learning outcomes [1]. Among these, Bloom’s taxonomy, originally introduced in 1956 and revised in 2001, is an essential framework for crafting and assessing educational objectives, focusing on three integral domains: cognitive, affective, and psychomotor [2, 3]. Recent discussions by Tuma and Nassar et al. illustrate Bloom’s taxonomy as a promising framework for clinical surgical education, presented in a simplified way with clinical examples [4]. However, there is a notable gap in its implementation within bariatric surgery training. Embracing this taxonomy in bariatric surgical education could effectively support curriculum development and improve the assessment of learning outcomes, thereby elevating training programs. Particularly, the psychomotor domain plays a vital role in the training of bariatric surgeons, as it is indispensable for cultivating technical skills and manual dexterity [5]. While the cognitive and affective domains aid in knowledge acquisition and emotional investment, psychomotor skills are essential for hands-on practice [4, 6]. This domain facilitates a structured progression from basic imitation to expert-level performance, underscoring the importance of physical engagement in mastering surgical techniques [7]. By prioritizing the psychomotor domain, we can lay a solid foundation for future surgeons in the field of bariatrics [4, 6, 7]. In the context of bariatric surgery training, skill development adheres to Bloom’s psychomotor taxonomy [8] (Fig. 1). The initial stage, imitation, involves the observation of surgeries to grasp the intricacies of operating room dynamics and the rationale behind clinical decision-making. This is followed by manipulation, where trainees engage in closely monitored practice sessions to cultivate confidence and develop necessary muscle memory [9].

Since the early 1980s, efforts to standardize ergonomic practices in laparoscopic surgeries have aimed to improve procedural efficiency and reduce complications, but clinical validation remains limited. In metabolic and bariatric surgeries (MBS), innovations in trocar site placements, driven by the popularity of laparoscopic sleeve gastrectomy (LSG), have advanced surgical techniques. However, practices often vary based on individual surgeon preferences rather than standardized evidence-based criteria. This study introduces the Port Site Placement and Outcomes for Surgical Obesity and Metabolic Surgeries (PSPOSO) checklist, aiming to standardize port placements and improve reporting consistency. A systematic review and meta-analysis of LSG studies were conducted following PRISMA guidelines. Data were extracted from 34 studies involving 7173 cases. Key variables included port configurations, manipulation angles, and outcomes such as operative time and excess weight loss percentage (EWL%). Innovative methods were used to estimate manipulation and azimuth angles from available intraoperative images. Statistical analyses and meta-regression were performed to identify associations between port configurations and surgical outcomes. Findings revealed substantial variability in port placements, with no significant effect of manipulation angles or port numbers on operative time or EWL% at 6, 12, and 24 months (p-values > 0.05). High residual heterogeneity suggests that factors beyond manipulation angles and port counts contribute to outcome variability. The PSPOSO checklist provides a framework for standardizing port placement and ergonomic parameters in MBS, enhancing reproducibility and safety. Future studies should validate the checklist across diverse clinical settings to refine surgical approaches and improve patient outcomes. PROSPERO: CRD42024598674.

We have read with great interest the recent meta-analysis by Ahmed et al. comparing single anastomosis duodeno-ileal bypass (SADI) and one anastomosis gastric bypass (OAGB) as revisional surgeries following sleeve gastrectomy (SG) [1]. The study provides valuable insights into the relative effectiveness of these two procedures in addressing weight recurrence, highlighting SADI’s superiority in weight loss at 12 months and its lower incidence of bile reflux compared to OAGB [1]. However, we believe that there is an important aspect that warrants further attention in this otherwise comprehensive review, the nutritional implications of both procedures, which have not been thoroughly evaluated in the meta-analysis due to limitations in the available data

Roux-en-Y gastric bypass (RYGB) has long been a foundational procedure in metabolic and bariatric surgery (MBS) [1]. Over the decades, the technique has undergone extensive refinements aimed at optimizing surgical outcomes and minimizing complications [2,3,4]. However, a surprising lack of consensus persists regarding numerous technical variables, particularly the design and dimensions of the gastric pouch. The variability in RYGB outcomes across different practitioners and surgical settings is well-documented, with notable statistical heterogeneity evident in most meta-analyses [5,6,7,8]. A significant portion of this heterogeneity can be attributed to procedural differences between the different interventions being assessed and variations within the techniques utilized within RYGB, including the lengths of the biliary pancreatic limb (BPL) and the alimentary limb (AL), both of which have proven to significantly influence weight loss and metabolic results [2,3,4]. In contrast, the gastric pouch—a fundamental component of RYGB—has not received equivalent scrutiny [9], despite evidence indicating that pouch dimensions can critically affect weight loss efficacy [4, 9,10,11,12] and the incidence of complications such as marginal ulcers and gastroesophageal reflux [10, 11, 13]. Studies have consistently noted that reducing the size of the gastric pouch can mitigate complications like marginal ulcers, while increasing its size may enhance weight loss outcomes [4, 14]. Despite this recognition, there is no consensus on the optimal gastric pouch length, and the evidence supporting these associations is weakened by methodological inconsistencies. Most studies rely on qualitative descriptions or rough estimates of pouch size, often using the number of stapler cartridges as a proxy for length [4, 14]. In some cases, anatomical landmarks, such as gastric veins, have been proposed as guides, but these methods are infrequently utilized and lack standardization [15]. Consequently, the variability in pouch length continues to be a source of uncertainty in clinical practice. This methodological heterogeneity presents a significant obstacle to advancing our understanding of gastric pouch length and its role in RYGB. By categorizing pouches into vague groups such as “small” and “long,” most studies fail to provide precise measurements or a reproducible framework for comparison [16]. This lack of rigor not only undermines the reliability of findings but also hinders the development of evidence-based guidelines that could standardize surgical practice. To address this gap, the bariatric surgery community must develop and adopt standardized measurement protocols for gastric pouch length with standardizing BPL and AL lengths to decrease analytical bias. Longitudinal studies utilizing such standardized methods would then be able to establish clear relationships between pouch length, weight loss outcomes, and the risk of complications [13]. These efforts would provide the evidence needed to refine surgical techniques, optimize patient outcomes, and move toward a consensus on this critical aspect of RYGB. The variability in gastric pouch length represents a crucial, yet often overlooked, dimension of RYGB. Addressing this issue requires a concerted effort to develop robust methodological tools and generate high-quality evidence. By prioritizing this area of research, the bariatric surgery community can enhance the consistency and effectiveness of RYGB, ultimately improving the lives of patients undergoing this transformative procedure.

We acknowledge the authors’ recent publication, “Incidental GIST in Patients Undergoing Bariatric Surgery: A Systematic Review of Incidence and Management”[1], and commend their efforts to bring attention to this critical topic. However, despite the intended significance of their work, the methodology, conclusions, and recommendations presented are fraught with significant shortcomings that undermine the credibility and utility of their findings. The study falls short in several areas, and its contribution to the existing literature is questionable.

We would like to express our sincere appreciation for the study by Ertekin et al., titled A Comparative Analysis of Liver Retraction with Long Surgical Gauze in Three-Port Sleeve Gastrectomy and the Four-Port Nathanson Retractor Technique [1]. This study introduces an innovative technique for liver retraction using long surgical gauze during laparoscopic sleeve gastrectomy, aiming to enhance cosmetic outcomes and reduce retractor-associated liver complications [2]. Ertekin et al. novel approach, meticulous research methodology, and clear data presentation significantly contribute to the existing body of knowledge in bariatric surgery.

Since the introduction of Single anastomosis Sleeve ileal Bipartition (SASI) many studies have focused on the nutritional malnutrition effect of SASI. Although there is still no consensus on whether SASI causes malnutrition, many studies have disagreed with such claims. In this study, we focused on re-evaluating the malnutritional effects of SASI using the same methodology in the short-term outcome. Methods 147 cases of SASI were recruited retrospectively from 2018 to 2023 with a 2-year follow-up period. All cases had undergone periodical follow-ups for Cholesterol, LDL, HDL, TG, Serum iron, Ferritin, Calcium, Vitamin D3, and Vitamin B12. Results Postoperative Lipid profile significantly reduced (P ≤ 0.001). However, there was no significant reduction in serum iron (P = 0.387), Ferritin (P = 0.061), and serum calcium (P = 0.091). with postoperative supplementation, there was a significant reduction in, Vitamin D3 (P ≤ 0.001), and Vitamin B12 (P ≤ 0.001). Conclusion Although there is a rising concern for malnutrition with SASI, unification of the SASI technique, and the usage of the correct postoperative supplementation with regular follow-ups does avoid malnutrition.

The international consensus regarding the necessity of routine preoperative abdominal ultrasonography in metabolic and bariatric surgery (MBS) remains elusive. Some guidelines advise imaging only for patients with biliary symptoms or abnormal liver tests, citing limited impact on surgical planning [1]. For instance, the updated 2019 ASMBS/AACE/TOS guidelines recommend ultrasonography in symptomatic patients, noting a weak evidence base for routine screening [2]. This conservative approach is rooted in concerns about its utilization being time-consuming and having limited effectiveness due to excessive soft tissue in patients with severe obesity [1,2,3]. Conversely, some practitioners support universal preoperative US screening to detect occult gallstones, especially considering the high risk of gallstone diseases in patients undergoing MBS [1]. Notably, obesity itself is a well-recognized risk factor for gallstone formation [4]. Studies show that about 20.7% of patients develop de novo gallstones after MBS, with 8.2% becoming symptomatic [5]. Rapid weight loss significantly increases the risk of cholelithiasis [5, 6], particularly after gastric bypass, complicating endoscopic access to the biliary tree [7, 8]. Interestingly, post-MBS patients who have had cholecystectomy demonstrate high rates of weight loss [9]. Impact on Concomitant Cholecystectomy Rates The variability in practices related to the utilization of US and cholecystectomy during MBS is significant. Some centers require US for all MBS candidates, while others reserve it for symptomatic patients [1]. There is also a tendency among certain practitioners to perform prophylactic Concomitant Cholecystectomy (CC) on normal gallbladders [10], justified by the aim of preventing postoperative biliary complications despite a lack of supporting evidence [11,12,13]. This inconsistency and lack of standard guidelines result in varying CC rates and practices among surgical centers. Centers that routinely use US screenings identify many patients with asymptomatic cholelithiasis, with some studies reporting detection rates of up to 15.9% [1]. This proactive approach results in approximately one in six patients benefiting from the detection of gallstones, allowing for prophylactic cholecystectomy [1], a higher incidence of CC alongside MBS [1]. Conversely, selective imaging programs exhibit lower CC rates, as they only operate on symptomatic patients, with some reporting rates as low as 2.4% for symptomatic gallbladders [3, 14]. Previous guidelines have not predominantly advocated for prophylactic cholecystectomy in asymptomatic gallstone cases [15], which explains the hesitance of many surgeons to perform cholecystectomy unless biliary symptoms are present, a position supported by previous recommendations [2, 16]. A multicentric study indicated that routine US is not pivotal in preoperative planning, as most US findings did not affect the surgical approach to the MBS intervention [3]. In such practices, asymptomatic gallstones are often managed conservatively, with either observation or medical prophylaxis. This divergence in clinical philosophy is underscored by a study conducted in the UAE. In contravention of established guidelines, the surgeons performed CC in over 120 instances of incidental gallstone findings, successfully demonstrating that such procedures can be performed safely without an increase in complication rates when conducted by experienced surgeons [17]. Their rationale for this preventive measure stems from long-term follow-up data indicating that a significant proportion of MBS patients ultimately develop biliary symptoms, though this remains an area of debate [18]. A center’s policy regarding preoperative US directly correlates with the rate of CC. Routine US screening that uncovers silent gallstones can elevate CC rates [1], whereas centers adhering to selective scanning have CC in only a few percent of cases. Postoperative Gallstone Incidence and Outcomes The decision to forgo routine cholecystectomy during MBS significantly increases the risk of gallstone-related complications postoperatively. Literature indicates that 3 to 22% of patients without prophylaxis develop symptomatic gallstones, needing interval cholecystectomy within 2 years [19]. A Bayesian meta-analysis by Amorim-Cruz et al. suggests that approximately 8% of post-MBS patients experience symptomatic gallstone disease [5]. A key distinction in this analysis is between de novo gallstones and preexisting stones, the latter significantly increasing the risk of biliary complications. In a cohort of 505 patients retaining their gallbladders, only 1.9% developed symptomatic biliary disease within 1 year, with symptomatic cases predominantly linked to visible stones preoperatively on US imaging (62.5% symptomatic versus 10.7% asymptomatic) [14]. The presence of preoperative gallstones is an independent risk factor for post-MBS cholecystitis, with an odds ratio of around 10.7 [14]. In contrast, about 20% of patients without prior stones develop de novo stones within 2 years, though most remain asymptomatic [5]. Studies suggest that sleeve gastrectomy leads to fewer gallstones than gastric bypass, possibly due to differing weight loss effects and bile duct anatomy [19]. To reduce gallstone risk, many centers prescribe ursodeoxycholic acid for high-risk patients instead of routine cholecystectomy, adhering to previous guidelines, although adherence to this practice varies [2]. The debate on gallstone management post-MBS centers on two approaches: performing prophylactic cholecystectomy to eliminate biliary complications versus retaining the gallbladder and managing complications as they arise (Fig. 1). Each strategy has trade-offs; routine cholecystectomy increases operative complexity [18] but mitigates the risk of later cholecystectomy in certain patients [17]. Clinicians should interpret reported incidences of post-MBS cholecystitis within the context of each center’s US screening practices and prophylaxis protocols. Thus, a “low” complication rate may reflect an aggressive screen-and-remove strategy, whereas a “high” rate could indicate a conservative watchful waiting approach.

Obesity: A Multimodal Disease Requiring Ongoing Innovation Obesity is a complex disease affecting nearly every organ system and is associated with various diseases like hypertension, type 2 diabetes, and cardiovascular risk [1]. Metabolic and bariatric surgery (MBS) has become the most effective long-term treatment for severe obesity, significantly improving both weight loss and related health conditions [1]. This editorial questions whether surgical innovations in MBS are aimed at benefiting patients or merely appealing to surgeons. From Open Surgery to the Laparoscopic Revolution The late twentieth century saw a shift from open surgery to laparoscopy in MBS, notably reducing operative morbidity. Studies showed lower perioperative risks with laparoscopic procedures, including fewer complications and shorter hospital stays, with no compromise in weight loss outcomes [2]. By the early 2000 s, laparoscopy became the gold standard in MBS, highlighting that appropriate technological innovations can reduce risk while maintaining efficacy [3, 4]. As shown in Fig. 1, the ongoing evolution in surgical techniques prompts a pivotal question: Are these innovations primarily serving the patient’s well-being, or are they sometimes driven more by the surgeon’s fascination with technology (Fig. 1)? Fig. 1 Fig. 1 Full size image Illustrative depiction highlighting the central ethical dilemma in adopting new surgical technologies in metabolic and bariatric surgery (MBS). While options such as open, laparoscopic, and robotic surgery advance in complexity and precision, the core question remains: Are we innovating for patient-centered outcomes or driven by surgical curiosity? The Rise of Robotic and Endoscopic Techniques Following the laparoscopic era, surgeons turned to new technologies, notably robotic assistance and advanced endoluminal endoscopic methods, to further enhance MBS. Robotic surgical systems (such as the da Vinci platform) were introduced in the early 2000 s and have since been adopted across many surgical specialties. These systems offer the surgeon high-definition three-dimensional visualization, articulated instrument control with wrist-like motion, tremor filtration, and ergonomic comfort while seated at a console [5]. These advantages have translated into clear benefits in certain fields of surgery. In urologic and pelvic surgeries, for instance, the robotic platform greatly facilitated minimally invasive prostatectomy and low rectal resections, where the deep pelvic anatomy is challenging to navigate laparoscopically [6]. Similarly, in hepatobiliary and pancreatic surgery, robotics can aid complex suturing and reconstruction during biliary anastomoses and pancreaticojejunostomy, which are technically demanding with straight laparoscopic instruments [7]. After about two decades of use, robotic surgery has proven its value in enabling precise surgery in confined or difficult-to-access areas, while potentially reducing surgeon fatigue and improving dexterity [8]. It is not surprising that robotic systems have been increasingly applied to MBS, in hopes of further refining an already minimally invasive field. In parallel, entirely incisionless endoscopic techniques have emerged in MBS, aiming to offer effective treatment with even less invasiveness. Endoscopic MBS therapies include procedures like intragastric balloon placement, aspiration therapy, and endoscopic sleeve gastroplasty (ESG) performed via flexible endoscope. Among these, ESG has gained particular prominence [9]. ESG involves transoral placement of full-thickness sutures in the stomach to create a sleeve-like restrictive tube. These endoluminal approaches were developed to appeal to patients who desire weight loss intervention but wish to avoid surgery, or who may not meet the criteria for surgery. They also hold appeal for surgeons and gastroenterologists as cutting-edge techniques expanding the toolset for obesity treatment. In concept, endoscopic procedures should carry lower immediate risks and faster recovery than any surgical option, aligning with the broader surgical trend toward less invasive interventions [9]. Over the last decade, early trials and series have shown that ESG and other endoscopic methods can indeed achieve meaningful weight loss with a good safety profile [9]. The question is how these novel methods compare to the well-established laparoscopic surgeries in terms of outcomes. Are Patient Outcomes Keeping Pace with Innovation? When introducing new technologies into MBS, it is critical to ask whether it measurably improves patient outcomes over existing gold-standard techniques. In the case of robotic MBS, the evidence to date indicates that it has not significantly outperformed traditional laparoscopy in most key metrics [10]. MBS procedures generally involve the upper gastrointestinal tract, which is relatively accessible laparoscopically, with fewer ergonomic hurdles than in other fields of surgery [4]. Unlike a deep pelvic dissection, standard MBS anatomy does not inherently demand the robotic platform’s advanced instrumentation. Indeed, numerous comparative studies and meta-analyses have found that for primary MBS procedures like gastric bypass or sleeve gastrectomy, robotic assistance yields similar clinical outcomes to straight laparoscopy [10]. A recent systematic review and meta-analysis of Roux-en-Y gastric bypass (RYGB) procedures concluded there were no significant differences in major complication rates, anastomotic leak, stricture, infection, or mortality between robotic and laparoscopic approaches [11]. Additionally, a recent large-scale MBSAQIP analysis by Seton et al. specifically examining robotic versus laparoscopic conversion of SG to RYGB found no significant differences in 30-day morbidity, mortality, reoperations, or readmissions, while robotic procedures were associated with significantly longer operative times [12]. These findings further reinforce that even in complex revisional MBS, where robotics was hypothesized to offer its greatest advantages, tangible improvements in patient outcomes remain unproven. Notably, longer operative times with robotic surgery have been consistently reported across studies, primarily owing to additional setup and docking requirements [5, 10, 11], and at least one meta-analysis observed a slightly higher 30-day reoperation rate after robotic RYGB compared to the laparoscopic technique (4.4% vs 3.4%) [11]. Overall, robotic MBS surgery has not shown superior weight loss or complication reductions that would justify its use purely on patient outcome grounds [11]. As one cost-analysis study frankly summarized, “overall hospital costs were higher in patients operated on with the robotic system than with laparoscopy, yet a clinical advantage has not been demonstrated so far [13].” This is a crucial point—the robotic platform substantially increases operative expense (due to the robot purchase/maintenance and disposable instruments) and resource utilization [13], and if it does not significantly improve safety, recovery, or long-term results in MBS, its routine use warrants scrutiny. Proponents of robotic MBS argue that it may confer advantages in specific scenarios (e.g., complex revisional surgeries or in surgeons with less laparoscopic experience), and indeed, robotics can facilitate fine suturing and difficult redo dissections [5]. However, for straightforward primary MBS, the current body of evidence indicates that robots make little outcome difference for the patient, despite adding considerable cost and operative time. This raises an uncomfortable question: Are some MBS programs adopting robotics more for the fascination and technical appeal it holds for surgeons than for any tangible benefit to patients? Turning to pure endoscopic MBS procedures, a similar skepticism is warranted. The allure of incisionless weight-loss intervention is strong, and early results with ESG and other endoluminal therapies have been encouraging in terms of safety. However, the effectiveness remains the Achilles’ heel of endoscopic MBS approaches when compared to surgical MBS. Laparoscopic sleeve gastrectomy (LSG) and gastric bypass lead to far greater and more durable weight loss outcomes than any current endoscopic procedure. For instance, ESG typically induces lower short- and mid-term weight loss when compared to LSG [14]. Surgical sleeve patients often lose 25–30% of total body weight (≈60–70% excess weight loss) in the first year or two after surgery and maintain superior long-term weight reduction in most comparative reports [14]. Current evidence states that despite the current advancements in endoscopic techniques and the safety of ESG in “impenetrable” abdomen, showing fewer adverse events [15], ESG remains inferior to laparoscopic sleeve gastrectomy in the magnitude of weight reduction [14]. Patients undergoing endoscopic therapies are more liable to recurrent weight gain, undermining their long-term effectiveness. Moreover, endoscopic treatments are still evolving and lack the decades-long outcomes data that exist for MBS. As of now, there is a consensus that endoscopic MBS procedures do not yet match the efficacy of established laparoscopic operations in treating obesity. They serve as alternatives or adjuncts—appropriate for select patients who cannot undergo surgery, rather than replacements for surgery [15]. This reality must be acknowledged when considering why such technologies are adopted. The excitement of offering a “scar-free” weight-loss procedure is understandable, but if the patient’s weight-related illnesses are far more likely to resolve with a surgical sleeve or bypass, we must question whether fascination with new technology could cloud clinical judgment. Uprising Technologies: Game-Changers or Gimmicks? The integration of emerging technologies in MBS necessitates a critical evaluation to separate substantial innovations from transient trends. For instance, intraoperative indocyanine green (ICG) fluorescence imaging has enhanced surgeons’ ability to assess tissue perfusion in real time [16], identifying compromised blood flow and facilitating immediate corrective measures, which may reduce postoperative complications like anastomotic leaks [17]. This technology illustrates how sound physiological principles can bolster patient safety and outcomes. Conversely, some high-tech developments, such as magnetic compression anastomosis, though promising, require further validation. Initial trials showed technical feasibility with no reported anastomotic leaks [18]. However, the small cohort size and preliminary nature of the data underline the need for larger, longitudinal studies to confirm efficacy, efficiency, and cost-effectiveness compared to traditional suture techniques [18]. Moreover, the surgical innovation landscape is susceptible to commercial hype. For example, the DEX Surgical System [19], marketed as “robotized” instruments, functions primarily as advanced laparoscopic tools without demonstrated superior outcomes over conventional laparoscopic methods. Similarly, robotic camera holders, such as the FreeHand® system, while enhancing ergonomics, have not shown improvements in surgical results compared to human operators, raising concerns about their utility beyond novelty [20]. Moreover, the single-fire stapler promises lower complication rates in SG with fewer complications [21]. However, concerns have been raised about potential methodological biases in these studies, including selection bias and unstandardized surgical variables, suggesting that further randomized trials are needed to substantiate their purported advantages [22]. Lastly, the economic implications of these technologies must be considered. Many innovative MBS solutions, including ESG, entail significant costs due to specialized devices, potentially impacting their practicality and overall value in clinical settings. In parallel, recent perspectives have emphasized that while embracing innovation is essential, it is equally crucial to preserve the experiential wisdom and patient-centered ethos of seasoned MBS surgeons, cautioning that not all technological advancements inherently improve clinical care [23]. Balancing Surgical Fascination with Patient Benefit Innovations in MBS are vital and should be pursued, but always with the primary goal of improving patient outcomes. The shift from open to laparoscopic MBS surgery exemplified technology adoption that unequivocally benefited patients by reducing risk. In contrast, the subsequent moves toward robotic and endoscopic techniques have so far shown more modest or equivocal gains for patients. Robotic surgery, with all its technological marvels, has not improved MBS outcomes relative to laparoscopy, although it has certainly made surgery more “fascinating” from a surgeon’s perspective. Endoscopic MBS procedures are less invasive and appealing in concept, yet currently deliver substantially less weight loss than surgical options. These facts are not an indictment of the technologies themselves; both robotics and endoscopy will continue to advance and may yet find their ideal niches in MBS, but they do demand reflection on our motivations. As MBS surgeons, we must ensure that the adoption of new techniques is driven by sound evidence of patient benefit, not the allure of novelty. It is human nature to be enamored with new gadgets and procedures, especially in surgery, where innovation is constant; however, we owe our patients a critical, objective appraisal of whether a new tool will genuinely improve their health outcomes. In an age of rapidly evolving surgical technology, the guiding principle remains: primum non nocere—first, do no harm (and by extension, do not trade proven success for unproven excitement). In conclusion, the question “Are we adopting new technologies in MBS to serve the patients or because they fascinate the Surgeon?” serves as a timely reminder to examine our own biases. The answer must be grounded in data and patient-centric reasoning. New technology and techniques should continue to be evaluated in rigorous studies and adopted only when they demonstrably enhance patient care or expand treatment to those in need. Fascination alone is never a sufficient indication. MBS will surely continue to evolve, integrating robotics, endoluminal methods, and innovations yet to be conceived, but as this evolution unfolds, keeping the patient’s best interests at the center of decision-making is paramount. By maintaining a healthy skepticism and demanding evidence of benefit, we can ensure that the next generation of MBS surgical advances truly serves our patients, not just our curiosity [13].

Background Esophagogastroduodenoscopy (EGD) is crucial in bariatric surgery for detecting gastro-esophageal conditions and incidental pathologies, impacting surgical decisions and outcomes. The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) recommends routine EGD before and after bariatric procedures to identify incidental pathologies. However, global adherence to these guidelines varies, especially in resource-constrained settings where economic limitations often dictate practice patterns. This study adapts a survey by Quake et al. (2022) to the Egyptian context, offering a comprehensive analysis of EGD utilization alongside broader trends in metabolic and bariatric surgery (MBS) practices in Egypt. Methods A survey adapted from Quake et al. (2022) was tailored to assess trends in metabolic and bariatric surgery (MBS) practices in Egypt. Conducted between April and August 2024 with a response rate of 53.3%, the survey targeted Egyptian bariatric surgeons. It evaluated EGD utilization, surgical expertise, institutional volumes, types of procedures, revisional surgeries, and adherence to the 2020 IFSO position statement. Data was collected through Google Forms and analyzed for trends, challenges, and gaps in practice, focusing on economic constraints and guideline implementation. Results Among the 80 respondents, 88.8% were consultants, with 73.8% performing over 100 surgeries annually. The volume of bariatric procedures increased from 2021 to 2023, with significant growth in sleeve gastrectomy (SG) and single-anastomosis sleeve ileal (SASI) bypasses/bipartition. Revisional surgeries were most commonly Roux-en-Y gastric bypass (RYGB). Despite this growth, EGD utilization remained limited. Pre-operatively, only 12.5% of surgeons performed EGD routinely for all patients, while 67.5% used it selectively based on patient or procedural factors. Post-operative EGD at one year was routinely offered by just 3.8% of surgeons, with 55% not routinely using it at all. Institutional and economic factors influenced these practices; surgeons in high-volume or private settings were more likely to adopt selective EGD use. Awareness of the 2020 IFSO guidelines showed a minimal impact on EGD practices, suggesting that financial considerations often outweigh clinical recommendations. Conclusions This study highlights critical trends in bariatric surgery practices in Egypt, including increasing procedural volumes and the limited utilization of EGD. Economic constraints remain the predominant barrier to routine EGD use, despite its potential to improve surgical outcomes by identifying incidental pathologies. Enhancing patient care requires establishing a national registry, upgrading training programs, and implementing observerships to align with international standards are pivotal in advancing bariatric care in Egypt and guaranteeing high-caliber, evidence-based patient care.

As obesity care moves towards precision-based stratification, future frameworks must integrate biological, functional, and real-world capacities for non-surgical treatments. This is especially important for patients eligible based on BMI but lacking functional impairment, or those who are overweight with early metabolic disturbances. The surgical community has increasingly unraveled the biological mechanisms behind treatment resistance, such as neuroendocrine disruption and altered energy homeostasis [13]. However, we have yet to match these insights with equally sophisticated tools that assess the feasibility and appropriateness of conservative care in individual patients. Torensma et al. emphasize the need for early escalation in such physiological resistance, reinforcing the imperative for risk-adapted decision-making [13]. Nevertheless, lifestyle capability remains underexamined as a driver of clinical outcomes, and staging models often fail to account for contextual barriers that shape real-world adherence. Despite wide variability in success, lifestyle modification is often prescribed as the first-line approach, particularly in preclinical cases [14]. Factors such as musculoskeletal limitations, inflexible work demands, caregiving responsibilities, psychiatric conditions, and socioeconomic adversity can make sustained behavioral change unfeasible, even in patients without overt comorbidities [15,16,17]. However, most frameworks do not incorporate these contextual constraints, leaving clinicians without objective guidance on when to escalate therapy based on feasibility. To address this, we propose the development of validated lifestyle capability metrics, tools designed to quantify not intent or motivation, but structural, psychosocial, and physical ability for behavioral adherence. We explicitly note that these metrics represent a conceptual proposal and will require rigorous methodological development and validation before they can be applied in routine clinical decision-making. Such metrics could help reclassify patients unlikely to succeed with conservative approaches, prompting timely intervention before complications arise. Conversely, they may identify patients for whom non-invasive strategies remain viable, supporting more proportionate and individualized care. Biologically anchored scores like the Visceral Adiposity Index (VAI) can assess metabolic dysfunction in cases where BMI and clinical presentation don’t align [8]. VAI is an example of a risk indicator, not a comprehensive staging system. As a validated measure of visceral fat and cardiometabolic risk, VAI can help identify individuals at high risk of disease progression, particularly in the preclinical phase [8, 18, 19]. However, it is critical to recognize VAI’s limited scope. While it captures important aspects of metabolic risk, it does not encompass the full spectrum of obesity-related dysfunction emphasized by the Lancet Commission [5]. Patients with substantial disease burden manifesting outside the metabolic axis, such as severe osteoarthritis, sleep-disordered breathing, or disabling psychological distress, may be misclassified if risk stratification is based solely on metabolic indices. In this light, VAI should be seen as a complementary, not a standalone, marker, useful for quantifying one dimension of risk but insufficient as a global staging tool. For this reason, VAI should be viewed as a complementary marker that quantifies only one dimension of risk. Perhaps the most valuable contribution of these tools lies in their potential to bridge the gap between disease definition and clinical action. The Commission offers a diagnostic lens rooted in systemic dysfunction. Tools such as VAI and future lifestyle capability metrics provide operational mechanisms for translating that diagnostic lens into timely, proportional care. Recognizing this distinction not only advances precision in clinical pathways but also reinforces a key ethical imperative: that treatment intensity should be proportionate to both the disease burden and the realistic likelihood of success. Ultimately, reconciling treatment eligibility with diagnostic clarity requires more than conceptual alignment. It calls for practical tools that quantify biological dysfunction and treatment feasibility in real-world contexts. As obesity care advances toward greater precision and personalization, the next critical step is not merely redefining the disease, but empowering clinicians to translate that definition into proportionate, ethical, and effective care.

Sleeve gastrectomy (SG) is the most frequently performed metabolic and bariatric surgery (MBS) worldwide, accounting for approximately 45–50% of all cases according to the 8th IFSO Global Registry, with similar figures reported in contemporary international and regional analyses [1,2,3]. This procedural dominance reflects SG’s relative technical simplicity, favorable safety profile, and durable weight loss outcomes [4]. Despite its perceived simplicity, SG remains technically variable. Key intraoperative differences, particularly in calibration tube (bougie) size and the point of antral transection, affect the final volume and may influence outcomes [5, 6]. The absence of standardized criteria for these steps has fostered inconsistencies in both practice and nomenclature [5, 6]. “Mini,” “Midi,” and “Super” Sleeve: Non-Standard Terms in the IFSO Atlas The IFSO’s Atlas of Bariatric and Metabolic Surgery (https://www.ifso.com/atlas-of-bariatric-and-metabolic-surgery/) [7] includes terms like “mini sleeve,” “midi sleeve,” and “super sleeve” to denote variations in sleeve gastrectomy techniques (Fig. 1). However, these labels are not formally defined surgical procedures in peer-reviewed literature or guidelines; they merely describe degrees of SG based on the bougie (calibration tube) size and resection extent. They represent different calibrations of the same operation, with no endorsement from major surgical societies. The usage of these terms is largely promotional and rarely appears in scientific discourse. A 2010 MBS forum pointed out that “super sleeve” is often a marketing term suggesting a smaller bougie for a smaller stomach pouch, rather than a new technique [8]. Fig. 1 Fig. 1 Full size image © Dr. Levent Efe, courtesy of IFSO Illustrative depiction of the non-standard labels “mini,” “midi,” and “super” sleeve gastrectomy as used in the IFSO Atlas of Metabolic and Bariatric Surgery. These terms are not formally defined in peer-reviewed literature or professional guidelines and lack standardization regarding bougie size, antral resection, or gastric volume. The cartoon highlights the resulting ambiguity and raises the question: Where are the guidelines? A unified technical framework for sleeve gastrectomy construction remains needed. Credit for the images used to conduct this figure was taken from the Atlas Insurance policies, such as Aetna’s clinical policy, view these variations with skepticism, categorizing “mini sleeve gastrectomy” as investigational [9]. This reflects the consensus that there is only one SG procedure, with no significant evidence supporting the claimed benefits of “mini” or “super” distinctions. Professional guidelines and textbooks focus on standard SG while recognizing variations in technique without differentiating between these terms. Technique Variations: Calibration Tube Size and Antral Resection True variations in SG are primarily influenced by two intraoperative variables: bougie size and antral resection length. Smaller bougies yield narrower sleeves, while larger ones produce more capacious gastric tubes. Resection closer to the pylorus results in more aggressive antral resection, with practice variability ranging from 32 to 50 Fr bougies and resection starting 2 to 6 cm from the pylorus [3, 6]. A 2019 international consensus identified a “standard” sleeve using a 32–40 Fr bougie, resected 1–2 cm from the gastroesophageal junction and 2–6 cm from the pylorus, typically yielding 75–150 cc sleeve volumes [3]. Multiple studies, including a meta-analysis of 2848 patients, show no significant advantage in outcomes for ultra-small bougies (≤ 32 Fr) compared to moderate sizes (33–36 Fr), with the former potentially increasing complication risks [10, 11]. Further analysis presented at a SAGES conference found no meaningful differences in weight loss or complication rates between ≤ 32 Fr and > 32 Fr bougies [12]. Interestingly, Yuval et al. found that larger bougies (≥ 40 Fr) were associated with lower leak rates (0.92% vs. 2.67%, p < 0.05) without adversely affecting weight loss [13]. Tight sleeves may incur complications without clear advantages. A study comparing 32 Fr vs. 40 Fr bougies in 60 patients revealed no significant differences in 1-year weight loss, but the 32 Fr group experienced more complications [5]. Smaller-caliber sleeves have also been associated with higher leak rates and reflux due to increased intraluminal pressure and reduced gastric compliance [13]. The conversion from French gauge to millimeters indicates that 1 French equals one-third of a millimeter. The difference in external diameter between 32 Fr (10.7 mm) and 50 Fr (16.7 mm) is just 6 mm, making the “mini-to-super” labels misleading. Furthermore, the functional lumen of the sleeve is affected by the height of closed staples, gastric wall thickness, bougie trajectory along the lesser curvature, reinforcement sutures, and postoperative edema, resulting in potential size variations of several millimeters even with the same bougie. The IFSO Atlas images showcase a range of sleeve designs categorized as “mini,” “midi,” and “super.” However, these classifications do not accurately capture the technical variations of SG that are discussed in academic literature. They lack a scientific foundation and do not reflect a consensus among experts. Such terminology risks misleading the surgical community regarding evidence-based variations in SG and may create avenues for disingenuous marketing practices. The “Mini Sleeve” Myth The term “mini sleeve” is increasingly used in marketing to promote a less invasive variant of SG, often misleadingly suggesting that it requires minimal postoperative supplementation and preserves normal gastric function, allegedly resecting 30–40% with non-evidenced indications for patients with a BMI of more than 28 kg/m2 [14]. Certain medical tourism platforms and private clinic advertisements, in some countries, advocate discontinuing supplementation within 6 to 9 months post-surgery, conflicting with established clinical guidelines [15, 16]. Current guidelines mandate that all MBS patients, including those undergoing SG, must engage in lifelong micronutrient monitoring and supplementation due to reduced gastric capacity and altered gastrointestinal physiology [15, 16]. Common deficiencies in iron, vitamin B₁₂, and fat-soluble vitamins make daily multivitamin regimens essential [17]. The alleged “mini sleeves” may also contribute to inadequate weight loss due to insufficient gastric restriction. Excessive residual gastric volume, resulting from conservative resection or postoperative dilation, is a known factor in primary failure after SG. Although re-sleeve gastrectomy can restore some restriction, its efficacy is generally inferior to that of a well-calibrated initial procedure due to neurohormonal adaptation and scar tissue formation [18, 19]. Adhering to clinical standards is crucial for optimizing outcomes in these patients [18, 19]. Professional Consensus and Guidelines on SG Guidelines do not recognize “mini,” “midi,” or “super” sleeves as distinct procedures; all major MBS societies view SG as one operation with acceptable variations in technique. The 2012 consensus from the International Sleeve Gastrectomy Expert Panel and IFSO Global Registry consistently refers to SG without subclassifying it by size [20, 21]. The 2012 expert panel found that 100% of surgeons use bougies for calibration, indicating standardization in practice, albeit with variability in bougie size preferences [21]. The panel emphasized best practices, such as consistent bougie use and avoiding large fundus retention, without endorsing terms like “mini” or “super” sleeve [21]. At the 2019 World Consensus Meeting, the definition of “Standard Sleeve Gastrectomy” was codified, reinforcing a unified approach and terminology without separate classifications [3]. Some surgeons have informally referred to “mini sleeve” in contexts like natural orifice surgery or reduced-port techniques, but these are merely variations of the same procedure [22]. Although some societal and marketing references to “mini sleeve gastrectomy” in the context of endoscopic sleeve gastroplasty exist, this terminology is also misleading due to the significant variability in ESG outcomes compared to SG [23, 24]. Recommendations and Call to Action The introduction of terms like “mini/midi/super sleeves” in the IFSO Atlas has raised concerns. Such labels may legitimize non-standard practices and confuse trainees and patients regarding distinct types of SGs. SG should be defined by a balance of restriction and safety, relying on surgical skill and adherence to evidence-based guidelines on sleeve size [5, 6, 11, 13]. To ensure a unified understanding of SG, the following actions are recommended: 1. The IFSO should eliminate the “mini/midi/super sleeve” images and labels from its Atlas. The current presentation gives undue legitimacy to terms that lack scientific backing. As noted, no high-level evidence delineates these as separate procedures, and their inclusion could perpetuate misconceptions. 2. The IFSO and other leading bodies should formally endorse a standard description of SG. This could mirror the consensus description of utilizing bougie in the 32–40 Fr range, approximately 100 mL sleeve volume, and preservation of 2–6 cm of antrum, unless clinically justified otherwise [3]. 3. An updated consensus conference or expert panel should be convened to address the current sleeve technique variations, reviewing existing data on how the technique affects outcomes, and issue guidance or even an official position statement. The consensus process itself will build buy-in from key opinion leaders, making it more likely that surgeons worldwide will adhere to the recommendations, just as prior consensus statements helped standardize metabolic surgery procedures. 4. An IFSO worldwide survey of its member surgeons is needed to detail how surgeons currently perform SG. While the 2020–2021 IFSO Worldwide Survey documented the number of sleeves performed [2], a future survey could delve into technique dictating the utilized bougie size, the current practice of reinforcing the staple line, and how much antrum is retained. Gathering such data would quantify the extent of practice variation. It would also identify whether certain regions or training backgrounds correlate with certain techniques. The results could highlight if any subset of surgeons are routinely doing “extra-tight” or “extra-loose” sleeves and whether their outcomes differ. This information is invaluable for guiding evidence-based standardization.

Dear Editor, We would like to acknowledge Dr. Paik et al. for their efforts in the study titled “Intrathoracic Sleeve Migration Following Sleeve Gastrectomy: Incidence and Outcomes.” However, while the study makes a commendable attempt to evaluate the occurrence of intrathoracic migration (ITM) following laparoscopic sleeve gastrectomy (LSG), several significant limitations must be addressed, as they undermine the validity of its conclusions [1]. The study’s sample of 206 patients offers strong statistical power, making its findings more reliable and applicable to broader populations. Comprehensive statistical analyses were conducted, comparing baseline characteristics and perioperative outcomes, which allowed for the adjustment of confounding factors. These factors contributed to well-supported conclusions. Nevertheless, the retrospective nature of the study raises questions about the reliability of the data, especially considering that many patients did not complete the preoperative surveys. This is particularly important when assessing the presence of gastroesophageal reflux disease (GERD) preoperatively, which appears to lack accurate documentation. Without a solid baseline, the conclusions regarding postoperative symptoms and complaints may be influenced by confounding factors, including the administration of proton pump inhibitors (PPIs) and prokinetic agents like domperidone or metoclopramide, which could mask symptom severity. Sleeve migration (SM) is defined in the study as the upward migration of the gastric sleeve above the hiatus by 2 or more cm. However, this definition lacks clarity and consistency, as there is no universally accepted standard for diagnosing SM. The term “sleeve migration” is not well defined across the literature, leading to variability in how the condition is diagnosed [2]. The use of non-contrast CT for diagnosing SM above the hiatus in the study also has notable limitations that require careful consideration. Although non-contrast CT is a non-invasive and readily available imaging technique, its effectiveness in diagnosing SM lacks well-established sensitivity and specificity, as pointed out by Aloulou et al. [3]. Without clear standards for its diagnostic reliability, depending solely on CT may lead to missed diagnoses or false positives, particularly since SM can manifest with subtle and non-specific symptoms [3, 4]. The diagnostic approach to SM shows significant variability, influenced by factors like case severity and surgeon judgment. This can lead to inconsistencies in diagnosing SM. There is a notable concern regarding patients with severe ITM reporting only mild symptoms and vice versa. This issue requires further investigation to understand its true clinical relevance. The study’s reliance on subjective symptoms without additional objective assessments like pH monitoring or oesophageal manometry diminishes its overall validity and raises doubts about the accuracy of symptom-based diagnoses [5]. This subjectivity has the potential to weaken the reliability of the results. The study briefly mentions the use of gastropexy in some patients, but it does not delve into enough detail about how this procedure affected the overall results. This is a major gap in the analysis. Additionally, the study does not account for the differences in how surgeons perform the procedure, which is another important limitation. Each surgeon has their technique, skill level, and experience, and these factors can greatly affect the outcomes, including the rate of complications like ITM [6]. By not addressing these variations, the study weakens its findings and makes it difficult to assess how much of the observed outcomes were due to differences in surgical practices. Additionally, another study with a 7-year follow-up on gastropexy showed no significant improvement in outcomes like reduced GERD symptoms or the need for additional treatments. This raises further concerns about the effectiveness of gastropexy as an adjunct to sleeve gastrectomy [7]. Furthermore, it is important to note that ITM may manifest or be diagnosed years after the surgery, typically between 3 and 5 years postoperatively [8]. The study’s follow-up period of 19 to 21 months is too short to adequately assess ITM’s long-term consequences. GERD and esophagitis, for example, are chronic conditions that often worsen over time. Therefore, the study’s short-term findings may significantly underestimate the severity of these complications. Without a longer follow-up period, the long-term implications of ITM on patient health, quality of life, and the potential need for further interventions, such as conversion to Roux-en-Y gastric bypass, remain speculative and inadequately addressed in the study [9]. In conclusion, while the study acknowledges some limitations, such as inconsistent diagnostic criteria and a short follow-up period, these factors still impact the validity of its findings. Further research with longer follow-up and more objective measures is essential to understand intrathoracic sleeve migration and the role of procedures like gastropexy better.

As bariatric surgeries (BS) increase, more incidental findings are liable to be discovered. Incidental gastric gastrointestinal stromal tumors (GISTs) during BS can be found in around 0.7% of the cases. In this article, we have performed a systematic review of the literature and added our data to those of the review to review a conceptual treatment strategy to both improve patient outcomes and decrease the risk of overall cancer. With the rise of new bariatric techniques, we have proposed a new classification to BS to enhance our description of the treatment strategy.

We would like to acknowledge Dr. Restrepo et al. for their thorough investigation into the correlation between endoscopic and surgical findings of hiatal hernias (HH) in patients undergoing laparoscopic sleeve gastrectomy (LSG) [1]. The study has several strengths, notably involving two surgical groups with over 10 and 15 years of bariatric surgery experience, ensuring procedures were performed by skilled professionals. Its clear methodology, including defined inclusion and exclusion criteria, enhances reliability. The focus on concordance between endoscopic and surgical findings, a relatively underexplored area, was assessed using descriptive statistics and Cohen’s kappa (0.667), offering valuable insights with an 83.3% agreement rate despite the small sample size. This raises important considerations about the role of preoperative Esophagogastroduodenoscopy (EGD) in planning hiatal hernia correction, as previous research emphasizes its utility in diagnosing smaller hernias and detecting various pathologies that could alter the surgical approach [2, 3]. In concerns to the routine use of preoperative EGD, The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) recommends that EGD should be considered for all patients planning bariatric surgery, particularly for those with upper gastrointestinal symptoms, due to the high frequency of abnormalities that may alter the management of the procedure [4]. The IFSO task force further emphasizes that EGD should also be considered for asymptomatic patients, as there is a 25.3% chance of finding abnormalities that could either influence the surgical approach or contraindicate surgery. This recommendation is supported by findings from a systematic review involving 22,495 patients [5], where the mean percentage of patients with at least one abnormal finding ranged from 4.6 to 89.7%. Specifically, 19.6% of patients had HH as a common abnormality detected during preoperative EGD [4]. This reinforces the significance of preoperative EGD, particularly in identifying conditions like HH, which could affect surgical management [2, 3]. The mentioned review [5] also found that patients requiring hiatal hernia repair had a median surgical time 20 min longer than those without hernias, though previous studies reported an even greater difference, such as 38 min. Investigating whether this variation stems from surgical technique, surgeon experience, or patient-specific factors could improve operative efficiency. Additionally, while endoscopic evaluations were performed by a highly experienced GI endoscopist, the study did not examine how operator skill or technique might influence the discrepancy between preoperative and intraoperative findings. Furthermore, as Dalkılıç et al. stated in their reply [6], Restrepo et al. did not specify how the hiatal hernia was defined endoscopically, which may have created a disparity between the endoscopic and surgical findings. The management of GERD and hiatal hernias in obese patients remains a challenge, prompting the exploration of new surgical techniques. Andrews et al. [7] question whether a more proactive intraoperative search for hiatal hernias should be pursued in patients with significant GERD symptoms, even without endoscopic findings. Carroll et al. emphasize that while fundoplication works well in non-obese populations, its higher failure rate in obese patients makes Roux-en-Y gastric bypass (RYGB) a more effective option for treating GERD in selected patients with hiatal hernias [8]. LSG, while popular, should be avoided in obese patients with a hiatal hernia or a history of GERD [9]. Additionally, a new technique, the Nissened sleeve (N-Sleeve), combines LSG with a Nissen’s fundoplication, offering a novel option for managing hiatal hernias and GERD in bariatric patients. This technically challenging procedure involves creating a 3-cm Nissen valve, which may offer similar outcomes in terms of weight loss and a lower rate of gastroesophageal reflux disease compared to standard LSG [10]. While the study acknowledges its limitation in sample size, there are additional factors that could affect the validity of the results. For instance, the retrospective nature of data collection introduces the potential for selection bias. Furthermore, since the study was conducted exclusively in Colombia, its findings may have limited applicability to other regions with different healthcare systems and obesity profiles. While acknowledging the moderate agreement (Cohen’s kappa of 0.667) between endoscopic and surgical findings, it misses an opportunity to discuss whether this level of concordance is clinically sufficient or if higher accuracy should be pursued. Additionally, while the utility of preoperative endoscopy for detecting other pathologies is recognized, the conclusion could benefit from offering specific suggestions for alternative or complementary diagnostic tools to enhance the detection of hiatal hernias. The emphasis on future studies is valid, but the limitations of the small sample size and single-country setting should be more explicitly acknowledged. In light of the above, explaining the value of endoscopy in detecting hiatal hernias is mandatory, as it is highly recommended preoperatively and for detecting other pathologies.

The incidental discovery of Meckel’s diverticulum (MD) during bariatric surgeries has not been thoroughly studied due to the low prevalence of MD (approximately 2%) [1]. However, recent reports in the literature have highlighted the occurrence of MD during or after bariatric procedures (BS), raising questions about the necessity of resecting MD during BS. This article aims to draw attention to this concern within the IFSO and the obesity surgery community, urging further research and debate to establish evidence-based consensus.

A case presentation of intraoperative detection of an iatrogenic chyle duct injury during laparoscopic sleeve gastrectomy. The chyle duct injury was identified and managed by ligature, preventing postoperative chylous ascites.