Impact of retrograde transillumination while securing the airway in obese patients undergoing bariatric surgery

Video laryngoscopy (VL) is a well-established technique used in anaesthetising obese patients who present with higher risks of airway-related difficulties and desaturations due to shorter safe apnoea periods. However, VL has certain limitations and may fail. We present the Infrared Red Intubation System (IRRIS), a new technique facilitating glottis identification in severely obese patients undergoing anaesthesia for bariatric surgery. This single-centre, prospective trial assessed the efficacy of the IRRIS for VL tracheal intubation in 20 severely obese adult patients undergoing elective bariatric surgery under general anaesthesia. We assessed the ability of the IRRIS to differentiate the transilluminated glottis from the oesophagus and laryngeal folds and evaluated the ease of intubation. The average weight in the investigated patient cohort was 145 ± 29 kg, the suprasternal tissue thickness was 12 ± 4 mm. The median IQR [range] larynx recognition time was 10 [2–50] s, which was similar to that of lean patients. The degree of obesity correlated with the duration to achieve optimal laryngoscopic view and complete the intubation procedure. We achieved successful VL insertion on the first attempt in 13 of 20 cases (65%), and on the second attempt in 7 cases (35%), emphasising the increased probability of successful intubation on the first attempt. Tracheal intubation with the IRRIS lasted 50 [IQR 20–100] s. The lowest SpO2 during intubation was 98 [IQR 83–100] %. Addition of IRRIS to VL insertion facilitated the intubation of difficult airways in severely obese patients. IRRIS improves the visualization of the intubation pathway by selectively highlighting the airway entrance and shortens the time to successfully conclude the intubation procedure

The device for diagnostic models biometry

Summary The device for measuring the anterior portion of the superior or interior mandible on a model, proposed by us, permits the effectuation of measures on diagnostic models. The apparatus can be regulated after individual properties of studied jaws. This fact increases the precision in this manipulation. The device is simple and comfortable in use.R e zu m at Dispozitivul pentru măsurarea porţiunii anterioare a maxilarului superior sau inferior pe un model, propus de către noi, permite efectuarea măsurărilor porţiunii frontale ale acestora pe modele diagnostice. Aparatul poate fi reglat conform particularităţilor individuale a maxilarului cercetat, ceea ce măreşte precizia în cadrul măsurării diverselor modele. Aparatul este simplu şi comod în utilizare

Eficienta economică şi tehnologică a utilizării giberelinei la soiurile pentru struguri de masă

iticulture for the agriculture of Moldova is an important and effective branch, but the table grapes sector is an efficient and more important for small, medium and family business. Increasing the quality of table grapes is a necessity for society and consumers. The purpose of the research from this article is to study the influence of Gobbi Gib 2LG on the quantity, quality and economic efficiency of grapes of Beauty Seedless and Prezentabil varieties. The research was conducted in the vineyards of the „Terra Vitis” LTd, from Southern wine region in Moldova. Research results have shown that the dose of 2.4 l/ha is most useful for conditions by the south part of Moldova, for Beauty seedless variety and the dose of 0,98 l/ha for Prezentabil varieti

Location and locoregional extension of gastric cancer – predisposant factors in postoperative acute pancreatitis evolution

Catedra de oncologie, hematologie și radioterapie, USMF „Nicolae Testemițanu”, Laboratorul de chirurgie gastrică și toracică, Secția Gastrologie, Institutul Oncologic, Chișinău, Republica Moldova, Conferința stiințifică „Nicolae Anestiadi – nume etern al chirurgiei basarabene” consacrată centenarului de la nașterea profesorului Nicolae Anestiadi 26 august 2016Introducere. Pancreatitele acute postoperatorii (PAPO) se întâlnesc frecvent, factorii declanșatori fiind diferiți.Scop. Analiza corelaţiei dintre sediul și extinderea locoregională a cancerului gastric și declanşarea PAPO. Material şi metode. Grupul de studiu este constituit din 192 pacienți operați radical pentru cancer gastric în secția Gastrologie a Institutului Oncologic în perioada 2010-2014: barbaţi - 131 (68,23%) și femei – 61 (31,77 %), raportul fiind 2:1, cu vârsta cuprinsă între 21 și 80 ani și incidența maximă între 51 – 60 ani (40,11%). Rezultate. PAPO a evoluat: în 38,09% (24 din 63) din cazuri – cu afecția peretelui posterior gastric; în 26,32% (5 din 19) din cazuri cu aderarea tumorii gastrice la pancreas și în 20,83% (10 din 48) – cu aderarea tumorii la alte organe. Incidența maximă a PAPO a constituit 50% în cazurile cu invazie în pancreas și 44,54% - în cele cu invazie în alte organe adiacente. Concluzii. Afectarea peretelui posterior gastric și aderarea cancerului gastric la organele adiacente, pot fi considerați factori care ar favoriza PAPO. Invazia cu infiltrarea cancerului gastric în organele adiacente, îndeosebi pancreasul, este factorul declanșator pentru PAPO.Introduction. Postoperative acute pancreatitis (POAP) is common, but triggers are different. Purpose. Analysis of correlation between location and loco-regional extension of gastric cancer and POAP evolution. Materials and methods. Our study includes 192 patients, radically operated for gastric cancer in Gastropulmonology Department of Institute of Oncology during 2010-2014: men - 131 (68.23%), women - 61 (31.77 %), the ratio being 2:1 aged between 21 and 80, with high incidence between 51 and 60 years (40.11%). Results. POAP developed as follows: in 38.09% (24 of 63) of cases with affection of posterior gastric wall; in 26.32% (5 of 19) – with invasion into the pancreas and in 20,83% (10 of 48) – with invasion of adjacent organs. Incidence of POAP was 50% in cases with invasion into the pancreas and 44.54% - in cases of invading adjacent organs. Conclusions. Affection of posterior gastric wall and tumor invasion into adjacent organs can be considered as factors that would favor POAP. Invasion with tumor infiltration into adjacent organs, especially into the pancreas, is the triggering factor for POAP

Clinical practice guidelines of the European Association for Endoscopic Surgery (EAES) on bariatric surgery: update 2020 endorsed by IFSO-EC, EASO and ESPCOP

Background: Surgery for obesity and metabolic diseases has been evolved in the light of new scientific evidence, long-term outcomes and accumulated experience. EAES has sponsored an update of previous guidelines on bariatric surgery. Methods: A multidisciplinary group of bariatric surgeons, obesity physicians, nutritional experts, psychologists, anesthetists and a patient representative comprised the guideline development panel. Development and reporting conformed to GRADE guidelines and AGREE II standards. Results: Systematic review of databases, record selection, data extraction and synthesis, evidence appraisal and evidence-to-decision frameworks were developed for 42 key questions in the domains Indication; Preoperative work-up; Perioperative management; Non-bypass, bypass and one-anastomosis procedures; Revisional surgery; Postoperative care; and Investigational procedures. A total of 36 recommendations and position statements were formed through a modified Delphi procedure. Conclusion: This document summarizes the latest evidence on bariatric surgery through state-of-the art guideline development, aiming to facilitate evidence-based clinical decisions

EAES rapid guideline: systematic review, network meta-analysis, CINeMA and GRADE assessment, and European consensus on bariatric surgery-extension 2022

Background The European Association for Endoscopic Surgery Bariatric Guidelines Group identified a gap in bariatric surgery recommendations with a structured, contextualized consideration of multiple bariatric interventions.Objective To provide evidence-informed, transparent and trustworthy recommendations on the use of sleeve gastrectomy, Roux-en-Y gastric bypass, adjustable gastric banding, gastric plication, biliopancreatic diversion with duodenal switch, one anastomosis gastric bypass, and single anastomosis duodeno-ileal bypass with sleeve gastrectomy in patients with severe obesity and metabolic diseases. Only laparoscopic procedures in adults were considered.Methods A European interdisciplinary panel including general surgeons, obesity physicians, anesthetists, a psychologist and a patient representative informed outcome importance and minimal important differences. We conducted a systematic review and frequentist fixed and random-effects network meta-analysis of randomized-controlled trials (RCTs) using the graph theory approach for each outcome. We calculated the odds ratio or the (standardized) mean differences with 95% confidence intervals for binary and continuous outcomes, respectively. We assessed the certainty of evidence using the CINeMA and GRADE methodologies. We considered the risk/benefit outcomes within a GRADE evidence to decision framework to arrive at recommendations, which were validated through an anonymous Delphi process of the panel.Results We identified 43 records reporting on 24 RCTs. Most network information surrounded sleeve gastrectomy and Rouxen-Y gastric bypass. Under consideration of the certainty of the evidence and evidence to decision parameters, we suggest sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass over adjustable gastric banding, biliopancreatic diversion with duodenal switch and gastric plication for the management of severe obesity and associated metabolic diseases. One anastomosis gastric bypass and single anastomosis duodeno-ileal bypass with sleeve gastrectomy are suggested as alternatives, although evidence on benefits and harms, and specific selection criteria is limited compared to sleeve gastrectomy and Roux-en-Y gastric bypass. The guideline, with recommendations, evidence summaries and decision aids in user friendly formats can also be accessed in MAGICapp: https://app.magicapp.org/#/guideline/Lpv2kEConclusions This rapid guideline provides evidence-informed, pertinent recommendations on the use of bariatric and metabolic surgery for the management of severe obesity and metabolic diseases. The guideline replaces relevant recommendations published in the EAES Bariatric Guidelines 2020

EAES rapid guideline: systematic review, network meta-analysis, CINeMA and GRADE assessment, and European consensus on bariatric surgery–extension 2022

none38Background: The European Association for Endoscopic Surgery Bariatric Guidelines Group identified a gap in bariatric surgery recommendations with a structured, contextualized consideration of multiple bariatric interventions. Objective: To provide evidence-informed, transparent and trustworthy recommendations on the use of sleeve gastrectomy, Roux-en-Y gastric bypass, adjustable gastric banding, gastric plication, biliopancreatic diversion with duodenal switch, one anastomosis gastric bypass, and single anastomosis duodeno-ileal bypass with sleeve gastrectomy in patients with severe obesity and metabolic diseases. Only laparoscopic procedures in adults were considered. Methods: A European interdisciplinary panel including general surgeons, obesity physicians, anesthetists, a psychologist and a patient representative informed outcome importance and minimal important differences. We conducted a systematic review and frequentist fixed and random-effects network meta-analysis of randomized-controlled trials (RCTs) using the graph theory approach for each outcome. We calculated the odds ratio or the (standardized) mean differences with 95% confidence intervals for binary and continuous outcomes, respectively. We assessed the certainty of evidence using the CINeMA and GRADE methodologies. We considered the risk/benefit outcomes within a GRADE evidence to decision framework to arrive at recommendations, which were validated through an anonymous Delphi process of the panel. Results: We identified 43 records reporting on 24 RCTs. Most network information surrounded sleeve gastrectomy and Roux-en-Y gastric bypass. Under consideration of the certainty of the evidence and evidence to decision parameters, we suggest sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass over adjustable gastric banding, biliopancreatic diversion with duodenal switch and gastric plication for the management of severe obesity and associated metabolic diseases. One anastomosis gastric bypass and single anastomosis duodeno-ileal bypass with sleeve gastrectomy are suggested as alternatives, although evidence on benefits and harms, and specific selection criteria is limited compared to sleeve gastrectomy and Roux-en-Y gastric bypass. The guideline, with recommendations, evidence summaries and decision aids in user friendly formats can also be accessed in MAGICapp: https://app.magicapp.org/#/guideline/Lpv2kE Conclusions: This rapid guideline provides evidence-informed, pertinent recommendations on the use of bariatric and metabolic surgery for the management of severe obesity and metabolic diseases. The guideline replaces relevant recommendations published in the EAES Bariatric Guidelines 2020.noneCarrano F.M.; Iossa A.; Di Lorenzo N.; Silecchia G.; Kontouli K.-M.; Mavridis D.; Alarcon I.; Felsenreich D.M.; Sanchez-Cordero S.; Di Vincenzo A.; Balague-Ponz M.C.; Batterham R.L.; Bouvy N.; Copaescu C.; Dicker D.; Fried M.; Godoroja D.; Goitein D.; Halford J.C.G.; Kalogridaki M.; De Luca M.; Morales-Conde S.; Prager G.; Pucci A.; Vilallonga R.; Zani I.; Vandvik P.O.; Antoniou S.A.; Agresta F.; Azran C.; Busetto L.; Buza M.; Prats B.G.; Herlesova J.; Piatto G.; Pruijssers S.; Rayman S.; Romano E.Carrano, F. M.; Iossa, A.; Di Lorenzo, N.; Silecchia, G.; Kontouli, K. -M.; Mavridis, D.; Alarcon, I.; Felsenreich, D. M.; Sanchez-Cordero, S.; Di Vincenzo, A.; Balague-Ponz, M. C.; Batterham, R. L.; Bouvy, N.; Copaescu, C.; Dicker, D.; Fried, M.; Godoroja, D.; Goitein, D.; Halford, J. C. G.; Kalogridaki, M.; De Luca, M.; Morales-Conde, S.; Prager, G.; Pucci, A.; Vilallonga, R.; Zani, I.; Vandvik, P. O.; Antoniou, S. A.; Agresta, F.; Azran, C.; Busetto, L.; Buza, M.; Prats, B. G.; Herlesova, J.; Piatto, G.; Pruijssers, S.; Rayman, S.; Romano, E

Impact of retrograde transillumination while securing the airway in obese patients undergoing bariatric surgery

Video laryngoscopy (VL) is a well-established technique used in anaesthetising obese patients who present with higher risks of airway-related difficulties and desaturations due to shorter safe apnoea periods. However, VL has certain limitations and may fail. We present the Infrared Red Intubation System (IRRIS), a new technique facilitating glottis identification in severely obese patients undergoing anaesthesia for bariatric surgery. This single-centre, prospective trial assessed the efficacy of the IRRIS for VL tracheal intubation in 20 severely obese adult patients undergoing elective bariatric surgery under general anaesthesia. We assessed the ability of the IRRIS to differentiate the transilluminated glottis from the oesophagus and laryngeal folds and evaluated the ease of intubation. The average weight in the investigated patient cohort was 145 ± 29 kg, the suprasternal tissue thickness was 12 ± 4 mm. The median IQR [range] larynx recognition time was 10 [2–50] s, which was similar to that of lean patients. The degree of obesity correlated with the duration to achieve optimal laryngoscopic view and complete the intubation procedure. We achieved successful VL insertion on the first attempt in 13 of 20 cases (65%), and on the second attempt in 7 cases (35%), emphasising the increased probability of successful intubation on the first attempt. Tracheal intubation with the IRRIS lasted 50 [IQR 20–100] s. The lowest SpO2 during intubation was 98 [IQR 83–100] %. Addition of IRRIS to VL insertion facilitated the intubation of difficult airways in severely obese patients. IRRIS improves the visualization of the intubation pathway by selectively highlighting the airway entrance and shortens the time to successfully conclude the intubation procedure

Protective intraoperative ventilation with higher versus lower levels of positive end-expiratory pressure in obese patients (PROBESE): Study protocol for a randomized controlled trial

Background: Postoperative pulmonary complications (PPCs) increase the morbidity and mortality of surgery in obese patients. High levels of positive end-expiratory pressure (PEEP) with lung recruitment maneuvers may improve intraoperative respiratory function, but they can also compromise hemodynamics, and the effects on PPCs are uncertain. We hypothesized that intraoperative mechanical ventilation using high PEEP with periodic recruitment maneuvers, as compared with low PEEP without recruitment maneuvers, prevents PPCs in obese patients. Methods/design: The PRotective Ventilation with Higher versus Lower PEEP during General Anesthesia for Surgery in OBESE Patients (PROBESE) study is a multicenter, two-arm, international randomized controlled trial. In total, 2013 obese patients with body mass index ≥35 kg/m2 scheduled for at least 2 h of surgery under general anesthesia and at intermediate to high risk for PPCs will be included. Patients are ventilated intraoperatively with a low tidal volume of 7 ml/kg (predicted body weight) and randomly assigned to PEEP of 12 cmH2O with lung recruitment maneuvers (high PEEP) or PEEP of 4 cmH2O without recruitment maneuvers (low PEEP). The occurrence of PPCs will be recorded as collapsed composite of single adverse pulmonary events and represents the primary endpoint. Discussion: To our knowledge, the PROBESE trial is the first multicenter, international randomized controlled trial to compare the effects of two different levels of intraoperative PEEP during protective low tidal volume ventilation on PPCs in obese patients. The results of the PROBESE trial will support anesthesiologists in their decision to choose a certain PEEP level during general anesthesia for surgery in obese patients in an attempt to prevent PPCs. Trial registration: ClinicalTrials.gov identifier: NCT02148692. Registered on 23 May 2014; last updated 7 June 2016