Although our results are encouraging regarding the effectiveness of mini-gastric bypass on diabetes remission, further studies are needed to provide definitive conclusions in selecting the ideal procedure for diabetes remission.

If more invasive procedures as LSG or LMGB may entail higher operative and peroperative risks, conversely, in skilled hands their efficacy remains undisputed, especially in the long term, presenting a very low rate of major complications. In general, the efficacy of a bariatric surgery unit seems improved by the capability to offer both different primary procedures and re-do surgery.

The use of weight loss surgery is progressively increasing, and in recent years, restrictive bariatric surgery procedures have been more often used. Although thought to be associated with a lower incidence of post-operative side effects than malabsorpitive surgery, some cases of micronutrients deficiency have been reported because of an acquired thiamine deficiency; in this clinical setting, some cases of Wernicke encephalopathy (WE) have been described. Major determinants and predictors of this major neurological complication are currently unknown. The aim of this systematic review was to analyse literature data in order to address this issue. The main result of our systematic review was that persistent vomiting is the major determinant of WE in patients undergoing restrictive weight loss surgery. In addition, early thiamine supplementation can rapidly improve the clinical conditions, avoiding permanent deficiencies. On the other hand, given the wide variability of clinical and demographic characteristics, definite prognostic factors of WE occurrence and of clinical outcome cannot be identified. In conclusion, although our results are suggestive, further ad hoc prospective studies evaluating changes in micronutrients levels according to different types of surgery are needed.

Staple line leakage and bleeding are worrisome complications of laparoscopic sleeve gastrectomy (LSG). Solutions such as buttressing, oversewing or roofing the staple line with gelatin matrix have been proposed with controversial results. Because the use of fibrin sealant has shown a possible benefit in reducing the reoperation rate due to early complication in patients (pts) undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP), this solution has been tested in 100 consecutive pts undergoing LSG. A clinical trial has been performed on 100 consecutive pts. Exclusion criteria from the study were considered ASA IV pts, treated or untreated malignancies at any stage, steroids or FANS assumption, previous sovramesocolic surgery and conversion to open surgery. All pts were randomized to receive (group A, 50 pts) or to not receive (group B, 50 pts) 4 ml of human fibrin sealant (Tisseel™, Baxter(®) Deerfield, IL, USA) sprayed along the suture line. Primary endpoint was the incidence of postoperative complications: leaks, bleeding of the staple line or stenosis of the gastric remnant. Significance was assigned at a p level <0.05. By considering pts in group A vs. pts in group B our results shown no significant difference in fistulas or strictures occurrence (p = 0.2). Bleeding was significantly higher in patients not sprayed with sealant (group A vs. group B, 1/7, p = 0.03). This randomized trial has so far shown the use of fibrin sealant in LSG to significantly reduce postoperative bleeding. Although a trend in reducing leak occurrence emerges, it does not reach statistical significance.

Bariatric surgery is safe and effective to reach obesity related comorbidities resolution among elderly obese patients. Both LAGB and LSG determine a weight loss lesser than observed in a standard bariatric population. In this study LSG is significantly less cost effective than LAGB. Larger studies with longer follow up are however needed to evaluate the real impact of bariatric surgery on weight loss, resolution of comorbidities and improvement of quality of life in elderly obese patients.