he most effective long-term treatments for severe obesity complicated by type 2 diabetes are bariatric procedures. Few clinicians and patients have conversations about these procedures, mainly because of persistent concerns that the short-and long-term risks of surgery outweigh the benefits. 1 Indeed, bariatric procedures have a checkered history. The jejunoileal bypass, vertical banded gastroplasty, and laparoscopic adjustable gastric banding (AGB) procedures have been largely abandoned due to intolerable adverse effects, high rates of reoperation, or poor long-term efficacy. In contrast, the long-term evidence base for the Roux-en-Y gastric bypass (RYGB) procedure has substantially improved. A relatively new procedure, the sleeve gastrectomy, is now the most commonly performed bariatric proce-dure worldwide (Box 1). The goal of this review is to update clinicians on the latest evidence for the most common bariatric procedures, with a focus on the long-term outcomes for major obesity-related comorbidities, weight loss, and safety outcomes to guide shared decision-making conversations. MethodsThis narrative review was based on articles found by searching PubMed from its inception until January 2020 for the terms bariatric surgery, gastric bypass, and sleeve gastrectomy. Our search was limited to English-language articles. Priority was given to evidence IMPORTANCE Severe obesity and its related diseases, such as type 2 diabetes, hypertension, dyslipidemia, and sleep apnea, are very common in the United States, but currently very few patients with these conditions choose to undergo bariatric surgery. Summaries of the expanding evidence for both the benefits and risks of bariatric surgery are needed to better guide shared decision-making conversations.OBSERVATIONS There are approximately 252 000 bariatric procedures (per 2018 numbers) performed each year in the US, of which an estimated 15% are revisions. The 1991 National Institutes of Health guidelines recommended consideration of bariatric surgery in patients with a body mass index (calculated as weight in kilograms divided by height in meters squared) of 40 or higher or 35 or higher with serious obesity-related comorbidities. These guidelines are still widely used; however, there is increasing evidence that bariatric procedures should also be considered for patients with type 2 diabetes and a body mass index of 30 to 35 if hyperglycemia is inadequately controlled despite optimal medical treatment for type 2 diabetes. Substantial evidence indicates that surgery results in greater improvements in weight loss and type 2 diabetes outcomes, compared with nonsurgical interventions, regardless of the type of procedures used. The 2 most common procedures used currently, the sleeve gastrectomy and gastric bypass, have similar effects on weight loss and diabetes outcomes and similar safety through at least 5-year follow-up. However, emerging evidence suggests that the sleeve procedure is associated with fewer reoperations, and the bypass procedure may lead to more durable...

Histologic resection margin involvement in disease process in patients with IBD, preoperative albumin levels lower than 3.5 g/dL, intraoperative blood loss of 200 mL or more, operative time of 200 minutes or more, and/or intraoperative transfusion requirement increased AL risk. Enteral nutritional optimization prior to elective surgery is essential. Proximal diversion should be considered for patients with all 3 intraoperative risk factors because they are at high risk for AL.

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This article is the largest hospital-based series evaluating the laparoscopic versus open approach for pregnant patients with presumed acute appendicitis. While methodological limitations preclude a definitive recommendation, laparoscopy appears to be a safe, feasible, and efficacious approach for pregnant patients with presumed acute appendicitis. We conclude that it is likely not the surgical approach but the underlying diagnosis combined with maternal factors that determine the risk for pregnancy complications. A benefit of laparoscopy is the diagnostic ability to identify other intra-abdominal pathology which may mimic appendicitis and harbor pregnancy risks.