Faculty Bibliography

BACKGROUND:Portomesenteric venous thrombosis (PMVT) is a rare complication of bariatric surgery that can lead to cavernous transformation of the portal vein. There are no established treatment algorithms regarding anticoagulation (AC) only vs. catheter-directed thrombolysis in this population. METHODS:Medical records at 4 urban bariatric surgery centers were queried for patients diagnosed with PMVT between 2012 and 2025. Patient characteristics, perioperative details, imaging at PMVT diagnosis, treatment course, and follow-up imaging were reviewed. Fisher's exact testing was conducted to identify correlations between extent of thrombosis, treatment course (anticoagulation vs. interventional radiology [IR] thrombolysis), and the outcome of cavernous transformation. RESULTS:71 patients were diagnosed with PMVT following bariatric surgery (68 LSG, 3 RYGB) at 4 centers between 2012 and 2025. Median time from surgery to PMVT diagnosis was 13 days. Three patients (4%) required reoperation for small bowel resection, of whom 2 underwent open thrombectomy and 1 underwent subsequent IR thrombolysis. Of the remaining patients, 6/68 (9%) underwent IR catheter-directed thrombolysis, and 62/68 (91%) received AC only. Of 53 patients with long-term data, 18 (34%) developed cavernous transformation. Among patients who had a main portal vein + intrahepatic portal vein + inflow (superior mesenteric vein or splenic vein) thrombosis, treatment with AC only was strongly associated with cavernous transformation (13/17, 76%) vs IR (1/5, 20%, p < 0.05). There were no deaths related to PMVT. CONCLUSIONS:In this largest known case series of postbariatric surgery PMVT treated with anticoagulation vs. IR, we found that the PMVT clot pattern with the highest risk of developing cavernous transformation was the extensive type involving the main portal vein, an intrahepatic portal vein, and an inflow vein, whether the main portal vein clot was occlusive or nonocclusive. Early IR intervention was associated with decreased cavernous transformation.

BACKGROUND/UNASSIGNED:Preclinical and early human evidence indicate that splenic neuromodulation modulates immune activity either independently or in conjunction with biologic or targeted synthetic (b/ts) disease modifying antirheumatic drugs (DMARDs). This study evaluated the safety, tolerability, and preliminary effectiveness of splenic nerve stimulation (SpNS) as monotherapy and in combination with b/tsDMARDs in adult patients with difficult-to-treat rheumatoid arthritis. METHODS/UNASSIGNED:ConsideRAte was an early-feasibility, multicentre, randomised sham-controlled trial of an implantable device (Galvani System) delivering SpNS conducted across six centres in the USA and Netherlands. Adults with difficult-to-treat rheumatoid arthritis, defined by inadequate response to at least two b/tsDMARDs, were implanted and randomised 1:1 to active (STIM ON) or sham (STIM OFF) stimulation following five sentinel patients. Participants received 12 weeks of stimulation in the monotherapy phase, defined as stimulation added to stable conventional synthetic DMARDS (csDMARDs) and/or low dose corticosteroids. Participants with Disease Activity Score using Erythrocyte Sedimentation Rate (DAS28-ESR) improvement of ≥1.2 continued stimulation for an additional 12 weeks; non-responders discontinued stimulation and received baricitinib for 12 weeks. Thereafter, participants who were not in remission could receive adjunct tsDMARDs (baricitinib) together with SpNS in an open-label phase for six months, after which the participants moved to long-term-follow-up. The primary objective was to assess safety and tolerability of the Galvani System, its implantation and subsequent stimulation; key secondary outcomes included assessment of disease activity Disease Activity Score using C-Reactive Protein (DAS28-CRP) and patient-reported outcomes. This study is registered with ClinicalTrials.gov (NCT05003310). FINDINGS/UNASSIGNED:Between January 2022 and November 2024, eleven participants (Five Open Label STIM ON, six randomised to STIM ON (n = 3) and STIM OFF (n = 3)) were successfully implanted with the Galvani System. No device-related serious adverse events, or unanticipated adverse device effects occurred. During the 12-week monotherapy phase, mean DAS28-CRP decreased by 1.02 ± 0.45 (mean ± Standard Error, [SE]) in the STIM ON group compared with -0.34 ± 0.14 in the STIM OFF group. Five of eight (62.5%) STIM ON participants achieved a clinically meaningful improvement (≥1.0-point reduction). Nine participants entered the adjunct phase, with mean (±SE) DAS28-CRP decreasing with -2.95 ± 0.56 points at week 12 and -2.28 ± 0.69 points at week 24; 55.6% (5/9) achieved low disease activity (LDA) and 33.3% (3/9) remission. Two participants remained on monotherapy. In exploratory analysis, biomarkers were assessed in the monotherapy phase at the end of 12 weeks and trends for systemic proinflammatory cytokine reductions and in TH17 (T-helper 17) cell populations were observed in responders as defined by DAS28-CRP changes. INTERPRETATION/UNASSIGNED:SpNS demonstrated a favourable safety profile and was well tolerated in this small cohort. Clinical improvements were observed for monotherapy, and enhanced outcomes were observed for adjunct treatment resulting in multiple participants reaching LDA or remission. By engaging neuro-immune pathways rather than targeting single cytokines, this approach represents a novel therapeutic option that warrants further evaluation as stand-alone therapy or to complement existing pharmacological treatments for difficult-to-treat rheumatoid arthritis patients. FUNDING/UNASSIGNED:Galvani Bioelectronics.

Robotic surgery is now an essential part of general surgery practice and general surgery training. The educational risk is not robotic adoption itself but unmeasured substitution: the replacement of foundational laparoscopic experience in common operations before robotic proficiency can be defined, assessed, and entrusted. This Perspective argues for platform-balanced training in which robotics expands resident capability without consuming the basic laparoscopic case pool. The proposed framework: (1) separates operative logs by platform, role, and task; (2) protects junior laparoscopic experience in appendectomy, cholecystectomy, and hernia repair; (3) moves residents to console modules after documented basic laparoscopic competence; and (4) uses maintenance drills and dashboards to detect curricular displacement. For trainees, this is fairness. For programs, it is governance. For patients, it is safety.

BACKGROUND:Semaglutide and tirzepatide have transformed obesity treatment, but recent changes to bariatric surgery utilization are not well understood. METHODS:Epic's nationwide Cosmos database was queried for patients who underwent primary sleeve gastrectomy or gastric bypass between 2018 and 2025. Patient characteristics including preoperative semaglutide or tirzepatide dispense history were compared using chi-squared and Wilcoxon rank sum tests. Modified Poisson regression was used to identify factors independently associated with pre-surgery GLP-1RA use. Multilevel models were used to examine hospital- and state-level variation in pre-surgery GLP-1RA use. RESULTS:Bariatric surgery utilization increased after Q3 2018, peaked in Q4 2022, and subsequently decreased 39% through Q4 2025. Between Q4 2018 and Q4 2025, the proportion of Hispanic bariatric surgery patients increased (8.1% vs. 16.8%, p < 0.001), and the proportion of patients who received pre-surgery GLP-1RA increased (0.2% vs. 35.3%, p < 0.001). Factors associated with receiving pre-surgery GLP-1RA were year, private insurance, White race, type 2 diabetes (RR 2.94 [2.88-3.00]), older age, sleep apnea, and metabolic dysfunction-associated steatotic liver disease. Factors associated with receiving surgery upfront were Hispanic ethnicity, Black race, and public or no insurance. After adjusting for patient characteristics and year, there was a 15-fold difference in pre-surgery GLP-1RA use between the highest and lowest hospitals (RR 0.19-2.88). CONCLUSIONS:In the Epic Cosmos database, bariatric surgery utilization decreased from 2022 to 2025, and those who underwent bariatric surgery increasingly received GLP-1RA before surgery. Patients who received pre-surgery GLP-1RA were older, White, privately insured, with diabetes and other weight-related comorbidities, while patients who received surgery upfront were Hispanic, Black, and publicly insured. Pre-surgery GLP-1RA use was also driven by center-specific non-clinical factors.

BACKGROUND:Endoscopic sleeve gastroplasty (ESG) is increasingly utilized for treating obesity, but some patients may subsequently present for conversion to a surgical procedure. Foreign material or distorted anatomy may make conversion more challenging. The preoperative evaluation, intraoperative findings, and postoperative outcomes of converting ESG to bariatric surgery are not well described. METHODS:Bariatric surgery patients at a single center with history of ESG were identified by review of electronic medical records from 2016 to 2026. Background characteristics, preoperative imaging, endoscopic findings, intraoperative details, and outcomes were obtained by chart review. Intraoperative videos were obtained when possible. RESULTS:. Most patients (19/20, 95%) underwent preoperative esophagram, which showed a tubularized stomach in half of cases (10/19, 53%) but no radiopaque materials precluding conversion to surgery. Preoperative endoscopy (n = 5) and intraoperative endoscopy (n = 3), when performed, revealed no apparent gastroplasty. Intraoperative findings included mild adhesions around the stomach, with sutures sometimes visible, but an otherwise native stomach not requiring any changes to the staple line. Mean total weight loss was 29.1% at 1 year postoperatively. No stapler misfires occurred, and none of the postoperative complications were related to the gastric staple line. There were no gastric staple line leaks or bleeds. CONCLUSION/CONCLUSIONS:In our experience, sleeve gastrectomy and gastric bypass were both technically feasible and relatively straightforward to perform in patients with a history of ESG.

OBJECTIVE:Directly compare the real-world effectiveness of semaglutide and tirzepatide to bariatric operations: sleeve gastrectomy and gastric bypass. METHODS:This study included adults with BMI ≥ 35 who received injectable semaglutide or tirzepatide (GLP-1RAs) or sleeve gastrectomy or gastric bypass (bariatric surgery) at two urban health systems from 2018 to 2024. Total weight loss (TWL) was compared up to 3 years post treatment with inverse probability weighting and mixed linear models. Intention-to-treat (any GLP-1RA) and per-protocol (1 year of continuous GLP-1RA orders) analyses were performed. RESULTS:Of 44,025 patients studied, bariatric surgery was associated with greater weight loss at 1, 2, and 3 years post treatment: semaglutide (n = 25,804) TWL (95% CI): 5.4% (5.3%-5.6%), 6.5% (6.4%-6.7%), and 7.4% (7.3%-7.6%); tirzepatide (n = 7308): 9.1% (8.9%-9.4%) and 10.8% (10.2%-11.3%); sleeve gastrectomy (n = 8728): 24.4% (24.3%-24.6%), 22.4% (22.3%-22.5%), and 22.0% (21.8%-22.1%); gastric bypass (n = 2185): 29.8% (29.7%-29.9%), 28.1% (28.0%-28.2%), and 28.4% (28.3%-28.5%). With 1 year of continuous GLP-1RA, findings were: semaglutide TWL: 7.2% (7.0%-7.4%), 8.0% (7.8%-8.2%), and 8.8% (8.6%-9.0%); tirzepatide TWL: 11.7% (11.4%-11.9%) and 11.9% (11.5%-12.3%). CONCLUSIONS:In this retrospective two-center study, bariatric surgery was associated with greater weight loss than GLP-1RAs among patients eligible for both options.

BACKGROUND:Severe obesity and its association with advanced knee osteoarthritis are established risk factors for surgical complications and associated costs of total knee arthroplasty (TKA). This clinical trial examines the functional knee outcomes of severely obese patients who have severe knee osteoarthritis undergoing bariatric surgery versus immediate TKA and examines the impact of surgical weight loss on the pursuit of TKA. METHODS:The SWIFT Trial (Surgical Weight-loss to improve Functional status Trajectories) following total knee arthroplasty was a multicenter, prospective trial examining outcomes of weight loss surgery and TKA in patients who have severe obesity (body mass index ≥ 40 or greater than 35 who have comorbidities) and symptomatic Kellgren-Lawrence grades 3 or 4 radiographic knee osteoarthritis. Study patients were recruited prospectively from November 2015, to October 2024 and divided into two groups: the bariatric arm (patients undergoing bariatric surgery) and the TKA arm (patients undergoing TKA). Each study arm underwent a comprehensive battery of knee functional assessments at baseline, six, 12, and 24 months, as well as re-evaluations in the bariatric surgery arm to assess the need for delaying or proceeding with TKA at 12 and 24 months. There were 232 study subjects who completed surgery and knee evaluation (n = 159: immediate TKA versus n = 73: bariatric surgery). The study groups had comparable degrees of knee disability at study initiation. RESULTS:Longitudinal functional analysis demonstrated major improvement extending to two years in patient-reported outcomes and performance-based functional assessments in both study arms, with a slight superiority in the TKA arm. Total weight loss % was higher in bariatric surgery patients (28.7%, P < 0.0001). Bariatric surgery resulted in 45 and 36% delays in TKA at 12 and 24 months, respectively, due to improved knee status. CONCLUSION/CONCLUSIONS:Knee function and mobility improved significantly in both study arms, with superiority in the Knee Injury and Osteoarthritis Outcome and Western Ontario and McMaster Universities Osteoarthritis Index scores in the TKA group. Improved knee function with surgical weight loss can be associated with up to a two-year delay in the need for TKA.

OBJECTIVE:We compared health care spending and utilization associated with semaglutide relative to bariatric surgery in patients with obesity and type 2 diabetes (T2D). METHODS:Using MarketScan insurance claims of patients with BMI ≥ 35 and T2D from 2016 to 2021, we examined associations between choice of semaglutide, sleeve gastrectomy, or gastric bypass; 3-year health care spending (out-of-pocket [OOP] and total); and clinical outcomes (ED visits, hospital admissions, and major adverse cardiovascular events [MACE]). Analyses were adjusted using generalized linear models, inverse probability weighting, and instrumental variables. RESULTS:Among 6748 patients (2797 semaglutide, 2300 sleeve gastrectomy, 1651 gastric bypass), bariatric surgery patients had higher BMI and more comorbidities. In IPTW-adjusted analysis, semaglutide was associated with the highest 3-year OOP costs ($7752 vs. $5980 [sleeve gastrectomy] vs. $6591 [gastric bypass], p < 0.001), but total spending was not statistically different across the groups. Relative to semaglutide, the gastric bypass group showed higher observed ED visits (hazard ratio relative to semaglutide [95% CI]: 1.36 [1.28-1.45]) and inpatient admissions (1.25 [1.13-1.37]) and fewer MACE (0.71 [0.59-0.88]). Sleeve gastrectomy was associated with fewer long-term admissions (0.79 [0.72-0.86]) and MACE (0.79 [0.66-0.93]). CONCLUSIONS:For patients with T2D and obesity, compared with semaglutide, bariatric surgery is associated with lower OOP spending and similar total spending at 3 years, as well as lower long-term MACE rates.

With the advent of new effective treatments for obesity, the field is rapidly changing creating an urgent need for evidence to guide best patient management. To help prioritise and plan for future trials, a meeting of experts was convened with the aim of reviewing the current literature to identify and prioritise current knowledge gaps; identify relevant research questions, and discuss appropriate trial methodologies that could be utilised to address the identified gaps in a timely and pragmatic manner. Participants included research-active academic surgeons and physicians, and industry representatives from various pharmaceutical and device companies. This report summarizes the key outcomes from this meeting.

BACKGROUND:Glucagon-like peptide-1(GLP-1) receptor agonists have transformed obesity treatment by inducing clinically significant weight loss. However, long-term use can lead to a plateau that may trigger discontinuation and weight regain. OBJECTIVE:Use mathematical modeling to test the hypothesis that the weight-loss plateau observed during long-term GLP-1 receptor agonist use reflects predictable changes in energy dynamics. DESIGN/METHODS:Secondary mathematical modeling applying Hall's human metabolism model to estimate changes in energy intake and expenditure over 176 weeks of treatment and 17 weeks following discontinuation. PARTICIPANTS/METHODS:Modeling was anchored to a single representative phenotype using average baseline demographics and weight dispersions from a clinical trial. MAIN OUTCOME MEASURES/METHODS:Percent change in body weight, body mass index, energy intake, energy expenditure. STATISTICAL ANALYSIS/METHODS:Monte Carlo methods captured variability. Modeled trajectories of energy intake expenditure illustrated energy balance dynamics. RESULTS:). A plateau persisted for ∼78 weeks despite continued treatment. Energy intake decreased 32.1% during the first 4 weeks, then rose to match energy expenditure by week 98 (2500 kcal, vs. 2508 kcal, respectively). After discontinuation (week 176), energy intake exceeded baseline, contributing to a 5.3% weight loss reversal. Energy expenditure declined 9.2% from baseline by week 98 and stabilized. CONCLUSION/CONCLUSIONS:Although GLP-1 receptor agonists achieve unprecedented weight loss, many individuals plateau but remain with overweight/obesity. This plateau reflects narrowing of the energy intake and expenditure gap during long-term treatment. To attenuate this, systematic integration of nutrition and behavioral therapy could be tested as adjuncts, particularly approaches that support nutrient adequacy and prevent excess energy intake. Whether such strategies can sustain or extend GLP-1 receptor agonist-induced weight loss warrants future study.