Antonio Vitiello

Bariatric Surgery and Endoluminal Procedures: IFSO Worldwide Survey 2014

Background and aimSeveral bariatric surgery worldwide surveys have been previously published to illustrate the evolution of bariatric surgery in the last decades. The aim of this survey is to report an updated overview of all bariatric procedures performed in 2014.For the first time, a special section on endoluminal techniques was added.MethodsThe 2014 International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) survey form evaluating the number and the type of surgical and endoluminal bariatric procedures was emailed to all IFSO societies. Trend analyses from 2011 to 2014 were also performed.ResultsThere were 56/60 (93.3%) responders. The total number of bariatric/metabolic procedures performed in 2014 consisted of 579,517 (97.6%) surgical operations and 14,725 (2.4%) endoluminal procedures. The most commonly performed procedure in the world was sleeve gastrectomy (SG) that reached 45.9%, followed by Roux-en-Y gastric bypass (RYGB) (39.6%), and adjustable gastric banding (AGB) (7.4%). The annual percentage changes from 2013 revealed the increase of SG and decrease of RYGB in all the IFSO regions (USA/Canada, Europe, and Asia/Pacific) with the exception of Latin/South America, where SG decreased and RYGB represented the most frequent procedure.ConclusionsThere was a further increase in the total number of bariatric/metabolic procedures in 2014 and SG is currently the most frequent surgical procedure in the world. This is the first survey that describes the endoluminal procedures, but the accuracy of provided data should be hopefully improved in the next future. We encourage the creation of further national registries and their continuous updates taking into account all new bariatric procedures including the endoscopic procedures that will obtain increasing importance in the near future.

Acinic cell carcinoma of the breast: Review of the literature

INTRODUCTION The breast and salivary gland tissue share embryologic and thus pathological similarities. Acinic cell carcinoma (ACC) is a typical tumor in salivary glands, but rarely arises in breast too. We reviewed 38 cases of mammary ACC reported in literature and our case, the first ACC born within a fibroadenoma. MATERIALS AND METHODS Data were collected by a research for the key words acinic cell carcinoma breast on Pubmed in March 2014, including a case treated in our department. All reviewed cases were compared for clinical approach and histological pattern. RESULTS To date 23 articles presenting cases of ACC of the breast are reported in literature. We included in our review 38 cases previously described and one new case. The histological pattern was predominantly solid with a microglandular structure. All the tumor cells were cytologically characterized by monotonous round cells with a finely granular, weakly eosinophilic, or clearly vacuolated cytoplasm. The most of the cells were intensely stained with anti-lysozime, anti-amylase, anti-α1-chimotripsin, anti-EMA and anti-S100 protein antisera. Immunohistochemistry was also performed to point out: estrogen receptor (ER), progesterone receptor (PR), androgen receptors (AR), human epidermal growth factor receptor 2 overexpression (HER2/neu), E-cadherin (E-cad), cytokeratin-7 (CK7), gross cystic disease fluid protein 15 (GCDFP15), smooth muscle actin (SMA). CONCLUSION ACC of the breast is a rare tumor, showing similarities with the salivary gland counterpart, above all in terms of good prognosis, and differences from the ordinary invasive breast carcinoma. Further investigations are needed to elucidate the true histogenesis and the correct treatment.

Application of lock-in thermography in nondestructive evaluation of adhesively-bonded aluminum joints

A major problem in industrial applications of structural adhesives is the quality assurance of manufactured joints. At present, for lack of a suitable nondestructive technique, production standards for adhesively-bonded aluminum joints are established on the basis of destructive tests and statistical inference. An experimental study was carried out to assess if lock-in thermography (LT) could be used as a tool for nondestructive evaluation of adhesively-bonded aluminum joints. Several samples were fabricated by varying the governing parameters such as nature of aluminum alloy, substrate thickness, surface treatment, adhesive type and bondline thickness. The effects of surface treatments on the loading capability of lap joints were evaluated through both destructive tensile tests and nondestructive evaluation with infrared LT. Tensile tests showed that the joint performance was not affected by the nature of the aluminum alloy but by the substrate thickness, the adhesive type and the bondline thickness. LT was capable of detecting imperfections such as scratches on substrates and foreign inclusions in the adhesive layer.

Erratum to: Bariatric Surgery and Endoluminal Procedures: IFSO Worldwide Survey 2014

In Table 4, which reports numbers of different procedures in each country, column headings for Gastric Plication (GP) and One Anastomosis Gastric Bypass (OAGB) have been interchanged. Despite this error, we want to reassure the reader that all the numbers have been double-checked and the results are correct. All the other tables and charts have not been influenced by this mistake. Numbers and statistics of OAGB worldwide and in the IFSO chapters have not been altered.

NONDESTRUCTIVE CONTROL OF POLYETHYLENE BLANKET INSULATION BY MEANS OF LOCK-IN THERMOGRAPHY

It is well known that cross-linking of polyethylene molecules into three-dimensional networks improves material properties; in particular, it enhances impact strength, thermal performance and chemical resistance. A product of good characteristics can be obtained if the manufacturing process is adequate and all involved machines are working properly. In this context, infrared thermography as a remote imaging technique may be a valuable tool to monitor the polyethylene cross-linking processes. Experimental tests were carried out on specimens without treatment and on specimens treated with either chemical processes or electron beam irradiation. Our results prove that lock-in thermography can detect local non-uniformity of material characteristics due to either the extrusion or cross-linking processes, and material differences linked to the different compound.

Characterization of NiTinol under torsional loads through a numerical implementation of the Boyd?Lagoudas constitutive model and comparison of the results with experimental data

Shape memory alloys (SMA) are a particular family of materials, discovered during the 1930s and only now used in technological applications, with the property of returning to an imposed shape after a deformation and heating process. The study of the mechanical behaviour of SMA, through a proper constitutive model, and the possible ensuing applications form the core of an interesting research field, developed in the last few years and still now subject to studies driven by the aim of understanding and characterizing the peculiar properties of these materials. The aim of this work is to study the behaviour of SMA under torsional loads. To obtain a forecast of the mechanical response of the SMA, we utilized a numerical algorithm based on the Boyd?Lagoudas model and then we compared the results with those from some experimental tests. The experiments were conducted by subjecting helicoidal springs with a constant cross section to a traction load. It is well known, in fact, that in such springs the main stress under traction loads is almost completely a pure torsional stress field. The interest in these studies is due to the absence of data on such tests in the literature for SMA, and because there are an increasing number of industrial applications where SMA are subjected to torsional load, in particular in medicine, and especially in orthodontic drills which usually work under torsional loads.

Elipse Balloon: the Pitfalls of Excessive Simplicity

To the Editor, We read with great interest the manuscript by Genco et al. [1] describing their initial experience with 38 patients who successfully completed the therapy with Elipse intragastric balloon (IGB) (Allurion Technologies, Wellesley, MA, USA). After the scheduled 16 weeks of therapy, 37 balloons were spontaneously evacuated, and one balloon was endoscopically removed, without any complication. The authors concluded that Elipse balloon is a safe device that can be swallowed and excreted without serious adverse events, avoiding an upper gastrointestinal (UGI) endoscopy. Despite these interesting and encouraging results, we report different experience with this device. A 55-yearold man with a BMI of 33.3 kg/m (weight 102 kg) and hepatic steatosis underwent insertion of Elipse balloon under our care in October 2016. After 6 weeks, the patient was readmitted to the hospital complaining with severe abdominal pain, nausea, vomiting, and no bowel movement since 24 h. Weight loss was about 10 kg (body weight = 92 kg; BMI = 30.06 kg/m). Abdominal ultrasound was unremarkable, but x-ray examination showed gastric dilation, air-fluid levels in the small bowel, and a radiopaque imagine that raised the suspicion of Elipse balloon valve in the left side of the abdomen (Fig. 1a, b). A nasogastric tube was positioned, and intravenous fluids and antibiotic therapy were administered. Computed tomography (CT) confirmed small bowel obstruction due to the presence of a partially desufflated balloon in the jejunal tract. The day after, another CT demonstrated the progression of the balloon, closer to the anterior abdominal wall allowing a guided aspiration of 85 cm from the device. A small amount of liquid was left in the lumen of device in order to allow further radiological studies (Fig. 2a, b). Due to persistence of symptoms and deterioration of clinical conditions, a laparoscopic exploration was performed but the Elipse device was not found during the small bowel inspection from Treitz ligament to ileocecal valve. A Foley catheter was positioned in the rectum and contrast medium was administered revealing the presence of balloon in the descending colon. So the desufflated balloon was removed by colonoscopy. There were no perioperative complications and the patient was discharged on the second postoperative day. Unfortunately few months later, the patient regained weight. Recently, a similar episode of small bowel obstruction due to Elipse balloon migration has been reported in a woman with previous multiple cesarean sections. A surgical intervention was required. The authors hypothesized that the incomplete balloon filling or the premature catheter disconnection during balloon placement could have promoted the balloon migration [2]. Previously, Machytk et al. reported the mechanism underlying balloon desufflation. According to their explanation, the * Paola Iovino piovino@unisa.it

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

Background and AimThe International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), being a Federation of 62 national societies, is the ideal network to monitor the number and type of procedures at a global level. The IFSO survey, enriched with a special section on revisional procedures, aims to report the number and types of bariatric procedures performed worldwide in 2016 and analyzes the surgical trends from 2008 to 2016.MethodsThe 2016 IFSO Survey form was emailed to all IFSO societies. Each Society was requested to indicate the number and type of bariatric procedures performed in the country. Trend analyses from 2008 to 2016 were also performed.ResultsThe total number of bariatric/metabolic procedures performed in 2016 was 685,874; 634,897 (92.6%) of which were primary and 50,977 were revisional (7.4%). Among the primary interventions, 609,897 (96%) were surgical and 25,359 (4%) were endoluminal. The most performed primary surgical bariatric/metabolic procedure was sleeve gastrectomy (SG) (N = 340,550; 53.6%), followed by Roux-en-Y gastric bypass (N = 191,326; 30.1%), and one-anastomosis gastric bypass (N = 30,563; 4.8%).ConclusionsIn 2016, there was an increase in the total number both of surgical and endoluminal bariatric/metabolic procedures. Revisional procedures represent about 7% of the total bariatric interventions. SG remains the most performed surgical procedure in the world.

Reply to Letter to the Editor in Response to “Elipse Balloon: the Pitfalls of Excessive Simplicity”

We thank the authors for their interesting comment on our letter BElipse Balloon: the Pitfalls of Excessive Simplicity^ [1]. The authors declare over 5100 Elipse balloons placed worldwide from the end of 2015 until May 2018 and among them, there were 14 cases (0.27%) of small bowel obstruction (SBO). Data sources are not clearly specified although in the bottom of Figure 1 is written BAllurion estimates throughMay 17, 2018^ then we hypothesized a manufacturer’s estimation. We recently collected data from the IFSOworldwide survey 2016, andwe analyzed the number and the type of surgical and endoluminal procedures from 52 IFSO National Societies. We reported 25,359 endoluminal procedures (EP) in the world representing about 4% of the total bariatric interventions. The most part of EP were intragastric balloons (IGB), especially Orbera BIB, representing about 97% of all IGB. Among EP, we collected 633 Elipse reported by 4 IFSO National Societies (Chile, France, Kuwait, and Saudi Arabia). However, since some IFSO nations do not specify the type of endoluminal procedures performed, we cannot rule out the possibility that the number of Elipse placed in 2016 is underestimated. To the best of our knowledge, some authors reported a small series of patients without any significant complication [2–5]. However, a recent multicenter, prospective study [6] enrolling a larger population of 135 patients described 1 SBO (0.74%) that required a laparoscopic enterotomy. The discrepancy among the 5100 Elipse balloons placed stated by the authors and what is reported from literature and from IFSO society raise a doubt: is it possible an underestimation in the number of SBO referred to the Allurion engineering team? Our strong belief is that the scientific community has to share bad and good results, because this could improve our knowledge. Therefore, we take this opportunity to stimulate not only the IFSONational Societies but as well as all bariatric teams to improve their local data collection system to provide more accurate outcomes of all performed procedures.

Reply to Letter to the Editor “Left Gastric Artery Embolization for Weight Loss—a Dead-End Procedure”

To the Editor, We read with great interest the comment of Dr. Fink et al. on the manuscript from Bai et al. entitled BBariatric embolization of the left gastric arteries for the treatment of obesity: 9-month data in 5 patients^ [1]. The authors expressed their criticism about the efficacy of this novel procedure for the treatment of obesity. We totally agree with the authors since, to date, there are not enough data to support this technique. In fact, the outcome of this radiological procedure has been reported only in few studies [2–4] with small samples and a short follow-up. It has been hypothesized that the main mechanism underlying the weight loss in this procedure is the decreased level of ghrelin [2]. However, as already underlined by Fink et al., the level of ghrelin in the five patients of the study [1] gradually increased from 6 months after the procedure, and there were not any significant difference between the level of ghrelin at baseline and after 6 and 9 months. The authors tried to explain these data considering some mechanisms such as the degree of left gastric artery embolization and the establishment of the collateral circulations to the fundus following the embolization. However, we could take into account other explanations. The mechanism of food intake and appetite is complex, and many hormones (ghrelin, leptin, obestatin, and insulin) act through neural pathways. Ghrelin is an orexigenic hormone that stimulates food intake and increases appetite [3]. Even if it is mainly produced by stomach fundus cells, there are also ghrelin-secreting cells in the proximal intestine, pancreas, pituitary gland, and colon [4], so we could also hypothesize an increased secretion by these Bminor^ sites. Fink and colleagues also criticized the safety of the left gastric artery embolization, defined as Ba dead-end procedure^ and warned that it could preclude a second surgical bariatric procedure. We agree with Fink et al. about the need of careful management, especially on the long term, of obese patients that often require more than one intervention, but we disagree with the concept that left gastric artery blood supply is fundamental to perform bariatric surgery. In experienced hands, in case of the 3rd or 4th revisional operations, a Bnear total gastrectomies^ cutting 2–3 cm from the esophagogastric junction can be performed without any problem for the Roux-en-Y limb anastomosis. In conclusion, the proofof-concept of left gastric artery embolization to reduce hormonal secretion to treat obesity was not confirmed in this limited experience. Further meticulous studies are mandatory before this technique might be suggested routinely in clinical practice. Gastric volume reduction remains the most effective mechanism currently available to control obesity.