Quality of Life 10 Years after Sleeve Gastrectomy: A Multicenter Study

Objective: Sleeve gastrectomy (SG) has recently become the most commonly applied bariatric procedure worldwide. Substantial regaining of weight or severe reflux might compromise quality of life (QOL) after SG in the long-term follow-up. Long-term data on patients’ QOL is limited, even though the persistent improvement in QOL is one of the aims of bariatric surgery. The objective of this study was to present patients’ QOL 10 years after SG. Methods: Of 65 SG patients with a follow-up of ≥10 years after SG who were asked to fill out the Bariatric Quality of Life Index (BQL) and Short Form 36 (SF36) questionnaires, 48 (74%) completed them. This multicenter study was performed in a university hospital setting in Austria. Results: The BQL score revealed nonsignificant differences between the patients with > 50% or < 50% excess weight loss (EWL). It did show significant differences between patients with and without any symptoms of reflux. Patients with < 50% EWL scored significantly lower in 3/8 categories of SF36. Patients suffering from reflux had significantly lower scores in all categories. Conclusions: EWL and symptomatic reflux impair patients’ long-term QOL after SG

Bariatric Surgery–How Much Malabsorption Do We Need?—A Review of Various Limb Lengths in Different Gastric Bypass Procedures

The number of obese individuals worldwide continues to increase every year, thus, the number of bariatric/metabolic operations performed is on a constant rise as well. Beside exclusively restrictive procedures, most of the bariatric operations have a more or less malabsorptive component. Several different bypass procedures exist alongside each other today and each type of bypass is performed using a distinct technique. Furthermore, the length of the bypassed intestine may differ as well. One might add that the operations are performed differently in different parts of the world and have been changing and evolving over time. This review evaluates the most frequently performed bariatric bypass procedures (and their variations) worldwide: Roux-en-Y Gastric Bypass, One-Anastomosis Gastric Bypass, Single-Anastomosis Duodeno-Ileal Bypass + Sleeve Gastrectomy, Biliopancreatic Diversion + Duodenal Switch and operations due to weight regain. The evaluation of the procedures and different limb lengths focusses on weight loss, remission of comorbidities and the risk of malnutrition and deficiencies. This narrative review does not aim at synthesizing quantitative data. Rather, it provides a summary of carefully selected, high-quality studies to serve as examples and to draw tentative conclusions on the effects of the bypass procedures mentioned above. In conclusion, it is important to carefully choose the procedure and small bowel length excluded from the food passage suited best to each individual patient. A balance has to be achieved between sufficient weight loss and remission of comorbidities, as well as a low risk of deficiencies and malnutrition. In any case, at least 300 cm of small bowel should always remain in the food stream to prevent the development of deficiencies and malnutrition

10 years of laparoscopic sleeve gastrectomy a multicenter study

Hintergrund Die laparoskopische Sleeve Gastrektomie hat sich zur meist-durchgeführten Operationsmethode für adipöse sowie superadipöse Patienten weltweit entwickelt. Es handelt sich dabei um eine restriktive Operation, bei der ein Großteil des Magens reseziert und aus dem Rest ein enger Sleeve geformt wird. Interessante Aspekte sind hierbei neu auftretender Reflux und seine Folgen (z.B. Barretts Ösophagus), Langzeitgewichtsverlust und Lebensqualität. Methoden Bei dieser Studie handelt es sich um eine Multi-Center-Querschnittsstudie (durchgeführt an der Medizinischen Universität Wien, am Krankenhaus Klosterneuburg Hospital und Krankenhaus Rudolfsstiftung Wien) der ersten 53 konsekutiven SG Patienten mit einem durchschnittlichen Follow-up von mindestens 10 Jahren. Daten wurden zum Gewichtsverlust, zu den Komplikationen und Reoperationen gesammelt. Nicht-konvertierte Patienten wurden außerdem gebeten, Fragebögen (BAROS, SF36, GIQOL, BQL) zu ihrer Lebensqualität auszufüllen. Sie wurden auch mittels Gastroskopie, Manometrie und 24h-pH-Metrie untersucht. Ergebnisse Die Ergebnisse zeigen eine Konversionsrate von über einem Drittel der 53 Patienten sowie symptomatischen Reflux und/oder Weight Regain bei über 50% nach 10 Jahren Follow-ups. Die Resultate der Fragebögen haben auch gezeigt, dass Reflux und Weight Regain die Lebensqualität der Patienten beträchtlich einschränkt. Conclusio Die Ergebnisse der Studie haben bewiesen, dass ein bedeutender Teil der Patienten unter den Auswirkungen oder Folgen der SG, wie Konversionen, Reflux und/oder Wiederzunahme des Gewichts, leiden diese wirken sich auch deutlich auf die Lebensqualität aus. Daher sollte die Auswahl der Patienten für diese Methode sehr sorgfältig vorgenommen werden.Background Laparoscopic Sleeve Gastrectomy (SG) has become the most frequently performed procedure in obese and morbidly obese patients worldwide. SG is a restrictive method that involves resecting a major part of the stomach, which creates a narrow Sleeve. Interesting aspects are new onset reflux and its consequences (e.g. Barretts esophagus), patients weight loss success in a long-term follow-up and their quality of life. Methods This study is a cross-sectional multi-center study (conducted at the Vienna Medical University, Klosterneuburg Hospital, and Vienna Rudolfsstiftung Hospital) of the first 53 consecutive SG patients with a minimum follow-up of 10 years. Data was gathered on weight loss success, complications, and reoperations. In addition, non-converted patients were requested to fill in questionnaires (BAROS, SF36, GIQOL, BQL) about their quality of life. Patients also had gastroscopies (including biopsies), manometries and 24h pH-metries. Results Results of this study include a conversion rate of over a third of the 53 participating patients and symptomatic reflux and/or weight regain in over 50% of the patients after at least 10 years of follow-up. The use of questionnaires in this study also proved that reflux and weight regain do affect patients quality of life considerably. Conclusion The results of this study show that at 10 years a number of patients is dealing with conversions and/or postoperative reflux and weight regain, which in turn affects their daily quality of life. Selecting patients very carefully should therefore be recommended when considering this procedure.submitted by Daniel Moritz FelsenreichAbweichender Titel laut Übersetzung der Verfasserin/des VerfassersMeduniversität Wiwen, DissertationOeBB(VLID)258108

Does the Mesorectal Fat Area Impact the Histopathology Metrics of the Specimen in Males Undergoing TME for Distal Rectal Cancer?

The aim of this study was to evaluate whether the mesorectal fat area (MFA) has an impact on the histopathology metrics of the specimen in male patients undergoing robotic total mesorectal excision (rTME) for cancer in the distal third of the rectum. Prospectively collected data of patients undergoing rTME for resectable rectal cancer by five surgeons during 3 years were extracted from the REgistry of Robotic SURgery for RECTal cancer (RESURRECT). MFA was measured at preoperative MRI. Distal rectal cancer was defined as within 6 cm from the anal verge. Specimen metrics included circumferential resection margin (CRM) measured by pathologists as involved if \u3c 1 mm, distal resection margin (DRM) and TME quality. Of 890 patients who underwent rTME for rectal cancer, a subgroup analysis compared 116/581 (33.4%) with MFA \u3e 20 cm to 231/581 (66.6%) with MFA ≤ 20 cm. The mean CRM in patients with MFA \u3e 20 cm was neither statistically nor clinically significantly different from patients with MFA ≤ 20 m (6.8 ± 5.6 mm vs. 6.0 ± 7.5 mm; p = 0.544). The quality of TME did not significantly differ: complete TME 84.3% vs. 80.3%; nearly complete TME 12.9% vs. 10.1%; incomplete TME 6.8% vs. 5.6%. The DRM was not significantly different: 1.9 ± 1.9 cm vs. 1.9 ± 2.5 cm; p = 0.847. In addition, the intraoperative complication rate was not significantly different: 4.3% (n = 5) vs. 2.2% (n = 5) (p = 0.314). This prospective multicenter study did not find any evidence to support that larger MFA would result in poorer histopathology metrics of the specimen when performing rTME in male patients with distal rectal cancer

En-Bloc Excision of Sacral Squamous Cell Carcinoma With Immediate Reconstruction

Sacral squamous cell carcinoma is an uncommon condition that may arise in scars following burns or in chronic wounds, such as an untreated pilonidal cyst. The aim of the present technical note is to describe a surgical technique aimed at minimizing local recurrence rates by en-bloc resection as well as providing immediate plastic reconstruction: 1. right-sided extended vertical rectus abdominis myo-cutaneous (VRAM) flap; 2. abdomino-perineal excision of the rectum with end colostomy; 3. en-bloc excision of the mass inclusive of gluteus maximus muscles and distal sacrectomy; 4. sacrectomy defect covered with VRAM flap; 5. bilateral gluteal defects covered with single-layer dermal substitute of bovine collagen and elastin hydrolysate followed by immediate split-thickness skin grafting from bilateral thigh donor sites, and negative pressure wound therapy dressings. This approach resulted in a favorable outcome at 2-year follow-up in a male patient presenting with a large locally advanced sacral squamous cell carcinoma involving the external anal sphincter muscle

Robotic TAMIS: A Technical Note Comparing Si® versus Xi®

Transanal minimally invasive surgery (TAMIS) can be performed robotically assisted (R-TAMIS) for easier rectal defect suture closure particularly on the anterior rectal wall. The surgical technique described in this technical note emphasizes three safety points: 1) decreased likelihood for rectal injury when the ports are inserted into the GelPOINT® Path Transanal Access Platform (Applied Medical, Rancho Santa Margarita, California) on the back table rather than being inserted into the rectum; 2) decreased external collision between ports when using ports of different length; and 3) increased stabilization of pneumorectum when insufflating with an AirSeal™ port (Intelligent Flow System, ConMed, Utica, New York). Although R-TAMIS can be safely performed with the da Vinci® Si® or Xi® (Intuitive Surgical Inc., Sunnyvale, California) patient cart, the following differences are noteworthy: a) the Si® vertically-mounted arms design forces the patient in an uncomfortable position with asymmetrical hip flexion as opposed to the Xi® boom-mounted horizontal arm design; b) the 28cm circumference of each Si® patient cart arms operating between the patient\u27s legs offer decreased maneuvering freedom as opposed to the 19cm circumference of the Xi® counterparts; and c) the abduction pattern of movement of the Si® arms potentially increases the risk of external collision with the patient\u27s legs as opposed to the Xi® jack-knife pattern of movement

Meta-Analysis of Postoperative Mortality and Morbidity After Total Abdominal Colectomy Versus Loop Ileostomy With Colonic Lavage for Fulminant Clostridium Difficile Colitis

BACKGROUND: Emergency surgery is often required for fulminant Clostridium difficile colitis. Total abdominal colectomy has been the treatment of choice despite high morbidity and mortality. OBJECTIVE: The aim of this meta-analysis was to evaluate postoperative mortality and morbidity after total abdominal colectomy and loop ileostomy with colonic lavage in patients with fulminant C difficile colitis. DATA SOURCES: Studies comparing total abdominal colectomy to loop ileostomy for fulminant C difficile colitis were identified by a systematic search of PubMed, Cochrane Library, MEDLINE, and CINAHL. STUDY SELECTION: Relevant records were detected and screened using a cascade system (title, abstract, and/or full text article). INTERVENTION(S): Total abdominal colectomy (rectal-sparing resection of the entire colon with end ileostomy) was compared to loop ileostomy (exteriorization of an ileal loop not far from the ileocecal junction for colonic lavage). MAIN OUTCOMES MEASURES: This meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guidelines. Primary outcome was postoperative mortality, defined as death occurring within 30 days after the intervention. Secondary end points were the rates of ostomy reversal, deep venous thrombosis/embolism, surgical site infection, urinary tract infection, respiratory complications, reoperations, and adverse events. Mantel-Haenszel method with random-effects model was used for meta-analysis. RESULTS: Five observational studies (3 cohort and 2 database analysis studies) totaling 3683 patients were included. Postoperative mortality rate was 31.3% after total abdominal colectomy and 26.2% after loop ileostomy (OR = 1.36 (95% CI, 0.83-2.24); p = 0.22; number needed to treat/harm = 20; I = 55%). Ostomy reversal rate was both statistically and clinically significantly higher after loop ileostomy as compared with total abdominal colectomy (80% vs 25%; OR = 0.08 (95% CI, 0.02-0.30); p = 0.002; number needed to treat/harm = 2) with low heterogeneity (I = 0%). LIMITATIONS: A limitation is the observational nature of the included studies introducing an overall high risk of selection bias. CONCLUSIONS: This meta-analysis suggests that loop ileostomy with colonic lavage for fulminant C difficile colitis may be associated with similar survival and decreased surgical site infection rates as compared with total abdominal colectomy. Although loop ileostomy with colonic lavage was associated with higher ostomy reversal rates, this finding was based on the data from only 2 studies

Robotic-Assisted Surgery Training (RAST) Program: Module 1 of a Three-Module Program. Assessment of Patient Cart Docking Skills and Educational Environment

There is currently no standardized robotic surgery training program in General Surgery Residency. RAST involves three modules: ergonomics, psychomotor, and procedural. This study aimed to report the results of module 1, which assessed the responsiveness of 27 PGY (postgraduate year) 1-5 general surgery Resident/Fellows (GSRs) to simulated patient cart docking, and to evaluate the Resident/Fellows\u27 perception of the educational environment from 2021 to 2022. GSRs prepared with pre-training educational video and multiple-choice questions test (MCQs). Faculty provided one-on-one Resident/Fellow hands-on training and testing. Nine proficiency criteria (deploy cart; boom control; driving cart; docking camera port; targeting anatomy; flex joints; clearance joints; port nozzles; emergency undocking) were assessed with five-point Likert scale. A validated 50-item Dundee Ready Educational Environment Measure (DREEM) inventory was used by GSRs to assess the educational environment. Mean MCQ scores: (90.6 ± 16.1 PGY1), (80.2 ± 18.1PGY2), (91.7 ± 16.5 PGY3) and (PGY4, 86.8 ± 18.1 PGY5) (ANOVA test; p = 0.885). Hands-on docking time decreased at testing when compared to base line: median 17.5 (range 15-20) min vs. 9.5 (range 8-11). Mean hands-on testing score was 4.75 ± 0.29 PGY1; 5.0 ± 0 PGY2 and PGY3, 4.78 ± 0.13 PGY4, and 4.93 ± 0.1 PGY5 (ANOVA test; p = 0.095). No correlation was found between pre-course MCQ score and hands-on training score (Pearson correlation coefficient = - 0.359; p = 0.066). There was no difference in the hands-on scores stratified by PGY. The overall DREEM score was 167.1 ± 16.9 with CAC = 0.908 (excellent internal consistency). Patient cart training impacted the responsiveness of GSRs with 54% docking time reduction and no differences in hands-on testing scores among PGYs with a highly positive perception

Quilting Suture Technique After Mastectomy: A Meta-Analysis

BACKGROUND: There is no level 1a evidence testing quilting suture (QS) technique after mastectomy on wound outcomes. The aim of this systematic review and meta-analysis evaluates QS and association with surgical site occurrences as compared to conventional closure (CC) for mastectomy. METHODS: MEDLINE, PubMed, and Cochrane Library were systematically searched to include adult women with breast cancer undergoing mastectomy. The primary endpoint was postoperative seroma rate. Secondary endpoints included rates of hematoma, surgical site infection (SSI), and flap necrosis. The Mantel-Haenszel method with random-effects model was used for meta-analysis. Number needed to treat was calculated to assess clinical relevance of statistical findings. RESULTS: Thirteen studies totaling 1748 patients (870 QS and 878 CC) were included. Seroma rates were statistically significantly lower in patients with QS (OR [95%CI] = .32 [.18, .57]; \u3c .0001) than CC. Hematoma rates (OR [95%CI] = 1.07 [.52, 2.20]; = .85), SSI rates (OR [95%CI] = .93 [.61, 1.41]; = .73), and flap necrosis rates (OR [95%CI] = .61 [.30, 1.23]; = .17) did not significantly vary between QS and CC. CONCLUSION: This meta-analysis found that QS was associated with significantly decreased seroma rates when compared to CC in patients undergoing mastectomy for cancer. However, improvement in seroma rates did not translate into a difference in hematoma, SSI, or flap necrosis rates