With rapid advances of metabolic and bariatric surgery（MBS）, decision-making process is becoming more and more complex regarding its application in patients with obesity and specific comorbidities. Efficacy and safety of MBS in high-risk cohorts, including those with cirrhosis, renal insufficiency and across an age spectrum from elders to adolescents, has remained controversial subjects. An expert consensus on optimal surgical approaches for these individuals has yet to be established, necessitating further investigations and validations. This paper focused upon the intricacies of conducting MBS in patients with unique metabolic and bariatric profiles.The authors critically assessed the risks and benefits associated with these procedures and offered a comprehensive overview of clinical considerations. There were four major issues of special weight considerations, age-related factors, challenging comorbidities and transitional procedures. The Objective was to contribute valuable insights to the existing body of knowledge and aid clinicians in making informed decisions when contemplating MBS for patients with special needs.

Greated the limbs of small bowel has been a key link during Roux-en-Y gastric bypass （RYGB）. However, there is still no consensus on a proper length of small bowel exclusion. In current era of precision medicine, through accurately measuring the length of small bowel, appropriate length of small bowel exclusion may be individualized for optimizing surgical efficacies and lowering the occurrence of postoperative complications. Summarizing the effects of different small bowel exclusion lengths during gastric bypass on surgical outcomes, this review was intended to provide new rationales for future clinical practices and research designs.

Objective To evaluate the efficacies and risk factors of metabolic and bariatric surgery for obesity hypoventilation syndrome （OHS）. Methods Between January 2018 and June 2022, retrospective review was conducted for 957 OHS patients undergoing metabolic and bariatric surgery.Clinical data of baseline profiles, arterial blood gas analysis, sleep study and anthropometric parameters were collected retrospectively for preoperative assessments and 2-year postoperative follow-ups. Perioperative changes of body mass index （BMI）, arterial blood gas, sleep study and anthropometric parameters were compared. The relationship between OHS resolution and variables was examined. Multivariate analysis was utilized for identifying the risk factors for OHS resolution. Results Among them, 105 were preoperatively diagnosed as OHS [BMI （40.1±7.2） kg/m², partial pressure of carbon dioxide in arterial blood（PaCO₂）（48.5±4.0） mmHg].At 2-year postoperative follow-up 89 cases （84.8%） fulfilled the criteria for OHS resolution. BMI dropped to（28.9±5.4） kg/m²（P<0.001,vs.BMI in preoperation period） and PaCO₂ declined to （44.4±4.8） mmHg （P<0.001, vs. PaCO₂ in preoperation period）. Percentage of total weight loss （%TWL） was lower in non-resolution group than that in OHS resolution group[（25.8±7.9）% vs. （27.7±8.9）%,P=0.017].Multivariate analysis revealed that preoperative arterial blood pH<7.35（OR=3.227,95% CI：1.002-10.392,P=0.049） and preoperative hypertension（OR=5.018,95%CI：1.476-17.064,P=0.010） were independent risk factors affecting OHS resolution after metabolic and bariatric surgery. Conclusion Metabolic and bariatric surgery is efficacious for OHS. And resolution of OHS depends upon achieving a certain level of ∆BMI and %TWL. Preoperative decompensation may be an independent risk factor for postoperative non-resolution of OHS.

Objective To explore the clinical value of Apfel score in predicting postoperative nausea and vomiting（PONV） after laparoscopic sleeve gastrectomy（LSG）. Methods Between January 2022 and March 2023, the relevant clinical data were collected from 80 morbidly obese patients undergoing LSG. They were assessed by the Apfel scoring system, including such factors as gender, smoking history, history of motion sickness or PONV and postoperative opioid use. PONV occurrences within 72 h post-LSG were assessed by visual analogue scale（VAS）, verbal descriptor scale（VDS） and PONV frequency score. Spearman's correlation was utilized for examining the relationship between Apfel and VAS/VDS/PONV frequency scores. Receiver operating characteristic（ROC） curve was plotted for evaluating the predictive value of Apfel score for PONV occurrence/severity and the area under the curve（AUC） calculated. Results Mean Apfel score was （1.76±0.96）. Within 72 h post-LSG, mean VAS/VDS/PONV frequency scores were （4.19±2.96）, （1.09±0.77） and （2.68±1.81）.Spearman's correlation coefficients between Apfel and VAS/VDS/PONV frequency scores were 0.3639, 0.3563 and 0.2985, all denoting a positive correlation （P<0.05）. Apfel score had the highest predictive value for VDS in predicting the occurrence of PONV （AUC=0.741,P<0.05） while it offered the best predictive value for VAS in predicting the severity of PONV （AUC=0.706, P<0.05）. Conclusion Apfel score is correlated with PONV score after LSG. However, its predictive value for VAS/VDS/PONV frequency score varies when assessing the occurrence/severity of PONV. Clinically Apfel score should be utilized with a consideration of specific predictive goals.

Objective To explore the effect of sarcopenic obesity（SO） on efficacy of laparoscopic sleeve gastrectomy（LSG） for weight reduction and examine the influencing factors for successful postoperative weight reduction. Methods From May 2020 to September 2023, retrospective analysis was performed for the relevant clinical data of 104 obese patients undergoing LSG. They were assigned into two groups of SO（n=34） and non-sarcopenic obesity（NSO,n=70）. SO was diagnosed on the basis of preoperative third lumbar spine on computed tomography（CT） with a ratio of fat mass to defatted mass of not less than 0.8. The effects of SO on efficacy of LSG were analyzed comparatively and the risk factors for successful postoperative weight loss examined by unifactorial and multifactorial analyses. Results As compared with NSO patients, preoperative baseline data indicated that mean values of preoperative body mass index （BMI） and subcutaneous fat area were greater in SO patients and there was a greater percentage of patients with degree Ⅲ obesity. However, mean values of desiccated mass and skeletal muscle area were smaller. And the differences were statistically significant（P<0.001）. Postoperative follow-up data showed that mean values of postoperative BMI and excess BMI were greater in SO patients.However, mean values of percent excess weight loss and success rate of weight loss were lower and the differences were statistically significant（P<0.05）. Multivariate analyses revealed that BMI and diabetes mellitus were two independent risk factors for successful postoperative weight loss. Conclusion LSG is less effective for weight loss in SO patients. And DM and BMI are two independent risk factors for successful postoperative weight reduction.

Objective To explore the changes of body composition in an early stage after bariatric surgery to formulate the nutrition and treatment plan. Methods From March 2019 to April 2022, retrospective analysis was performed for 106 patients undergoing laparoscopic sleeve gastrectomy （LSG）. Bioelectrical resistance analysis （BIA） was utilized for detecting body composition, obesity, muscle, water and nutritional parameters pre-operation and during follow-ups. Results LSG was all successfully performed. There were 40 （37.7%） males and 66 （62.3%） females with an average age of （28.4±7.2） year. 85 patients （80.2%）, 72（67.9%）, 65（61.3%） and 60（56.6%） were followed up at Month 1/3/6/12. Body weight, total body water （TBW）, protein, minerals, body fat mass （BFM）, soft lean mass and fat-free mass declined post-operation. Body weight and BFM dropped from （108.6±20.5） and （49.8±12.8） to （72.4±14.7） and （20.1±5.7） kg at Month 12 post-operation. Body mass index （BMI）, percent body fat （PBF）, waist-hip ratio, visceral fat area （VFA）, obesity degree and BFM of limbs/trunk showed a progressive decline. At Month 12 post-operation, BMI decreased from （38.6±5.9） to （26.2±4.6） kg/m², PBF dropped from （45.4±5.2）% to （26.9±6.2）% and VFA declined from （173±46） to （78±32） cm². Skeletal muscle mass, arm circumference, arm muscle circumference, muscle mass of upper limbs and trunk decreased in different degrees at Month 6 post-operation. Muscle mass of lower limbs decreased and stabilized at Month 1 post-operation. Intracellular water and extracellular water （ECW） declined while ECW/TBW rose at Month 3 post-operation. InBody score increased at Month 3 and 6 post-operation than that of the previous follow-up time point and body cell mass showed a lowering trend at Month 3 post-operation. Conclusion Body composition changes after bariatric surgery. Thus it may provide scientific rationales for weight control, muscle gain/loss and nutrition balance.

Objective To explore the effects of different types of metabolic and bariatric surgery on body weight （BW）, body mass index（BMI）, ovarian morphology, follicle number, menstrual cycle, androgens and anti-mullerian hormone （AMH） in obese patients with polycystic ovary syndrome （PCOS）. Methods From February 2021 to June 2023,70 obese patients with PCOS and 60 obese patients without PCOS admitted were assigned into two groups. For obese patients with PCOS, sleeve gastrectomy （SG, n=35） and Roux-en-Y gastric bypass （RYGB,n=35） were performed. And for obese patients without PCOS, SG（n=30） and RYGB（n=30） were performed. The changes of BW, BMI, ovarian morphology, follicle number, menstrual cycle and androgen/AMH level of two groups were recorded. Results BW and BMI at post-operation were significantly lower than those at pre-operation. Ovarian volume and follicle number declined markedly, menstrual cycle became obviously shortened and AMH/androgen level dropped significantly as compared with those at pre-operation. SG/RYGB demonstrated marked weight loss in both PCOS and non-PCOS obese patients and no significant difference existed in weight loss effect.And RYGB was superior to SG in long-term weight loss, long-term regulation of follicle volume/quantity, long-term improvement of androgen level, short-term adjustment of menstrual cycle and lowering the level of AMH. Conclusion SG/RYGB may significantly relieve PCOS in obese patients.

Objective To explore the potential categories and influencing factors of grazing behavior among patients undergoing metabolic and bariatric surgery （MBS）. Methods From January to June 2024, MBS outpatients were selected by convenience sampling. Baseline Demographic Information Questionnaire, Chinese version of Repetitive Eating Questionnaire[Rep（eat）-Q], 21-item Three-Factor Eating Questionnaire（TFEQ-R21） and Chinese Version of Depression Anxiety and Stress Scale-21（DASS-21） were administered. One-way ANOVA and Logistic regression analyses were performed for identifying the factors associated with potential categories of grazing behavior. Results Among a total of 236 questionnaires, 230 valid ones were returned with an effective recovery rate of 97.5%. Grazing behavior occured in 178 patients （77.4%）. Grazing behaviors among MBS patients were divided into 3 latent classes of "low risk of grazing behavior-regular"（48.3%）,"medium risk of grazing behavior-compulsive"（37.4%） and "high risk of grazing behavior-repetitive"（14.3%）. As compared with "medium risk of grazing behavior-compulsive", patients with postoperative time <12 month, postoperative time 12-<24 month and lower scores of uncontrolled eating were more likely to be classified as "low risk of grazing behavior-regular"（OR=0.256,P=0.003;OR=0.311,P=0.020; OR=1.195,P<0.001）;As compared with "high risk of grazing behavior-repetitive", patients with no-depression, restricted eating and uncontrolled eating were more likely to be classified as "low risk of grazing behavior-regular"（OR=0.184,P<0.001;OR=0.670,P<0.001;OR=1.261,P=0.001）. Conclusion The incidence of grazing behavior in MBS patients is at a high level with distinct characteristics of classification. Healthcare professionals may design personalized intervention strategies according to the influencing factors of different latent classes of grazing behavior.

Marginal ulcer is a common complication after Roux-en-Y gastric bypass and its improper management may cause serious consequences, including perforation, hemorrhage and stenosis.This report described one female case of anastomotic marginal ulcer after Roux-en-Y gastric bypass. She initially underwent laparoscopic Roux-en-Y gastric bypass in April 2011 for metabolic syndrome.In September 2017, there was an onset of recurrent abdominal pain with altered stool consistency. After thorough examinations, marginal ulcer was diagnosed due probably to an enlargement of gastric pouch. Consequently,in October 2019,laparoscopic sleeve gastrectomy was performed along with partial small bowel resection. Despite regular postoperative dosing of antacids, recurrent abdominal pain, nausea and vomiting persisted. Follow-up gastroscopy revealed non-healing of anastomotic marginal ulcer. In June 2022, after completing thorough preoperative preparation, laparoscopic partial gastric-gastrointestinal anastomosis, nutritional branch jejunostomy and gastric bypass revision were performed. Postoperative symptoms improved markedly. Follow-up gastroscopy at Month 8 showed no sign of ulceration. This case illustrated the challenge of managing marginal ulcers since two revision operations over nearly 5 years were required for curing. Focusing upon the relevant literature on marginal ulcers after Roux-en-Y gastric bypass, this review summarized risk factors, treatments and prevention strategies to provide references for bariatric and metabolic surgeons.

Objective To explore the clinical efficacy of transanal anastomotic drainage for colorectal anastomotic leakage and examine its impact on anal function and quality-of-life. Methods From January 1, 2007 to December 31, 2023, the relevant clinical data were retrospectively reviewed for 1 016 patients undergoing colorectal anastomosis. Postoperative anastomotic leakage occurred in 218 patients and colostomy was repeated in 15 patients due to severe abdominal infection and diffuse peritonitis. And 115 patients of anastomotic leakage improved after conservative measures and 10 cases could not be followed up due to missing data. Finally the relevant clinical data were retrospectively reviewed for 78 patients of anastomotic leakage. They were assigned into two groups of transanal drainage （study, n=18） and simple transabdominal drainage （control, n=60）. They were examined by assessment scales of low anterior resection syndrome （LARS） and Wexner fecal incontinence and European Organization for Research and Treatment of Cancer （EORTC）. And EORTC Quality-of-Life Scale （EORTC QLQ-C30） was employed for assessing postoperative quality-of-life and anal function. Results After colorectal operation, 78 patients of anastomotic leakage were cured and discharged from hospital. No obvious diffuse peritonitis or abdominal infection occurred. Both groups were followed up for 3 months post-discharge. There was no recurrence of tumor, anastomotic stenosis or scar hyperplasia. Anal function： As compared with control group, the scores of LARS [（20.28±9.95） vs. （25.55±11.71） points] and Wexner [（10.56±2.36） vs. （13.00±2.52） points] were lower in study group pre-catheterization and the differences were statistically significant （all P<0.05）. However, there was no significant inter-group difference post-catheterization （all P>0.05）. EORTC QLQ-C30 quality-of-life： Prior to catheterization, study group demonstrated worse performance in the domains of role function, social function and respiratory symptoms than those in control group. And the differences were statistically significant （all P<0.05）. However, no significant inter-group difference existed in EORTC QLQ-C30 score post-catheterization （all P>0.05）. Conclusion Catheter irrigation and drainage through anal anastomotic leakage may be an important treatment for patients of anastomotic leakage after colorectal surgery. As anal function is restored after surgery, quality-of-life improves, rate of anastomotic stenosis drops and the chance of a second stomy is minimized. This safe treatment is worthy of wider clinical applications

Objective To explore the clinical application value of right hepatic parenchymal transection-first approach during laparoscopic resection of benign occupation lesions in superior segment of right hepatic posterior. Methods From January 2022 to January 2024, the relevant clinical data were retrospectively reviewed for 21 laparoscopic resections for benign occupation lesions in superior segment of right hepatic posterior by right hepatic parenchymal transection-first approach. Operative duration, intraoperative volume of blood loss, postoperative hemorrhage, bile leakage and postoperative hospital stay were recorded. Results There was no instance of intraoperative blood transfusion, conversion into laparotomy or severe complications. The pathological diagnoses were hepatic hemangioma （n=11）, focal nodular hyperplasia （n=6） and hepatic adenoma （n=4）. Average operative duration of laparoscopic group was （310±10） min, average volume of blood loss （300±87） mL and postoperative hospitalization stay （7±3） day. Conclusion Right hepatic parenchymal transection-first approach for laparoscopic resection of benign occupation lesions in superior segment of right hepatic posterior is both safe and efficacious. It may shorten operative duration, boost operative safety and lower operative difficulty. A wider popularization is worthwhile.

Objective To explore the clinicopathological features, treatments and outcomes of follicular dendritic cell sarcoma （FDCS） in abdomen. Methods One rare case of pancreatic FDCS was reported in the Second Affiliated Hospital of Shaanxi University of Chinese Medicineand the relevant case reports in both domestic and foreign literatures were reviewed. Results A 66-year-old female patient with pancreatic FDCS was hospitalized for physical examination detecting a space-occupying lesion at tail of pancreatic body. Computed tomography （CT） indicated that tumor with a size of around 9 cm had distinct boundaries with a compression of splenic vein. Tumor marker CA125 was elevated. During pancreatic-caudal splenectomy, tumors presented spindles with distinct nucleolus and obvious mitosis. With the findings of CD21, CD35, fascin （+）, EBER in situ hybridization （-） and Ki-67 around 20%, pathological diagnosis was pancreatic FDCS. No other adjuvant treatment was offered. No recurrence or metastasis occurred during a follow-up period of 6 months. And 49 cases of abdominal FDCS were retrieved from a literature review. For a total of 50 cases, the average age was 50（19-77） year and most of them had a non-specific medical history. Liver and retroperitoneal cavity are dominant and spleen, large intestine, pancreas, small intestine, ileocecal part and appendix are also common sites. No significant inter-gender difference existed. Generally patients may have no obvious symptoms or varying severity of abdominal symptoms. Some dermal and pulmonary symptoms are extra-abdominal. Preoperative laboratory tests revealed no obvious abnormalities and tumor marker CA125 was elevated in 10% of patients. Ultrasonography and CT are two major auxiliary examinations. Colonic polyps is often detected under endoscope. And 22% of patients had metastases at an initial visit. Almost all macroscopic slides showed single solid tumors with distinct boundaries and maximal diameter of tumor was （1-30） cm. A definite diagnosis is often dependent upon a combination of several specific markers such as CD21, CD35, Fascin, CD23 and fascin plus histology. Most EBER in situ hybridizations was positive. And 96% of them were operated. Most of them survived tumor-free post-operation and few had recurrence and metastasis. Adjuvant chemotherapy or radiotherapy was rare. And efficacy should be further confirmed. Conclusion As a kind of rare moderate malignant tumor, abdominal FDCS carries a high risk of local recurrence and metastasis after excision and lacks a specificity of clinical pathogenesis. Its pathogenesis may be correlated with Epstein-Barr virus infection and immune system diseases. Whether or not postoperative chemoradiotherapy improves its prognosis remains uncertain. However, if high risk factors are present, long-term follow-ups, regular reviews and aggressive interventions are recommended.

Pancreaticoduodenectomy has been a golden standard for treating benign and malignant lesions of duodenum, distal bile duct and pancreatic head. Postoperative pancreatic fistula may significantly affect the survival and prognosis of patients. Pancreaticojejunostomy is one of the risk factors of postoperative pancreatic fistula. Researchers have modified anastomotic modes and auxiliary materials for minimizing the occurrence of postoperative pancreatic fistula. It may guide clinical decision-making for individualization to provide theoretical rationales for further lowering the incidence of postoperative pancreatic fistula.

An Objective measurement of surgical outcome quality has long been a daunting challenge for researchers. Technical skill of a surgeon is a crucial influencing factor of clinical outcomes. Assessing surgical skills is not only vital for education, training and professional growth of surgeons but also has profound implications for enhancing surgical quality, ensuring patient safety and advancing medicine. Gradually the assessment of surgical skills has evolved from an initial experiential evaluation model by panels of surgical experts to a data-based Objective assessment tool model, including global rating scales, procedure-specific assessment tools and error-based evaluation instruments. In recent years, with a growing integration of medical and engineering fields, some automated assessment tools equipped with automatic recognition capabilities have started to emerge. This article summarized the development, current status, advantages and limitations of different types of laparoscopic skill assessment tools in conjunctions with a literature review.