Pathophysiological consequences of pneumoperitoneum

Laparoscopic surgery has been performed for more than a century, although its nse was mainly restricted to diagnostic purposes 1. 2 Recent developments in instrumental design and methods of visualization have contributed to further implementation of laparoscopic techniques 3 In 1985, Muhe performed the first laparoscopic cholecystectomy 4 After further development of this technique by Moure! and Dubois 5· 6, laparoscopic techniques have gained wide acceptance in surgical practice. Except for laparoscopic gallbladder removal, minimally invasive techniques now have been established for other surgical procedures such as gastric ftmdoplication, appendectomy, splenectomy and (donor) nephrectomy 7-10 The popularity of these techniques may be explained by the growing evidence that the minimally invasive approach is associated with a reduction in operative morbidity, such as less postoperative pain, decreased systemic stress response, shorter hospitalization and improved cosmesis 11-15 The pneumoperitoneum is the crucial element in laparoscopic surgery. Each laparoscopic procedure requires a working space in the abdominal cavity to allow safe introduction of trocars and instruments and for exposure of the abdominal contents. Intraperitoneal insufflation of gas is the most common method to elevate the abdominal wall and suppress the viscera. Carbon dioxide (C02) is the preferred gas for establishing a pneumoperitoneum because it is non-flammable and inexpensive. However, C02 absorption through the peritoneal membrane leads to hypercapnia and acidosis and in order to reduce these effects, minute ventilation has to be adjusted. In addition, the increased intra-abdominal pressure due to intraperitoneal gas insufflation influences hemodynamic and respiratory ftmction

Over standplaats en plantensociologische positie van Trifolium ornithopodioides Oeder; speciaal aan de Waddenzeekust van Texel

Nieuwe vindplaatsen van de Rode Lijst-soort vogelpootklave

A Prospective Clinical Study Characterizing the Influence of Morbid Obesity on the Pharmacokinetics of Gentamicin: Towards Individualized Dosing in Obese Patients

Background and Objective Gentamicin is an aminoglycoside antibiotic predominantly used in bloodstream infections. Although the prevalence of obesity is increasing dramatically, there is no consensus on how to adjust the dose in obese individuals. In this prospective clinical study, we study the pharmacokinetics of gentamicin in morbidly obese and non-obese individuals to develop a dosing algorithm that results in adequate drug exposure across body weights. Methods Morbidly obese subjects undergoing bariatric surgery and non-obese healthy volunteers received one intravenous dose of gentamicin (obese: 5 mg/kg based on lean body weight, non-obese: 5 mg/kg based on total body weight [TBW]) with subsequent 24-h sampling. All individuals had a normal renal function. Statistical analysis, modelling and Monte Carlo simulations were performed using R version 3.4.4 and NONMEM® version 7.3. Results A two-compartment model best described the data. TBW was the best predictor for both clearance [CL = 0.089 × (TBW/70)0.73] and central volume of distribution [Vc = 11.9 × (TBW/70)1.25] (both p < 0.001). Simulations showed how gentamicin exposure changes across the weight range with currently used dosing algorithms and illustrated that using a nomogram based on a ‘dose weight’ [70 × (TBW/70)0.73] will lead to similar exposure across the entire population. Conclusions In this study in morbidly obese and non-obese individuals ranging from 53 to 221 kg we identifed body weight as an important determinant for both gentamicin CL and Vc. Using a body weight-based dosing algorithm, optimized exposure across the entire p

Evaluation of gastrectomy in patients with delayed gastric emptying after antireflux surgery or large hiatal hernia repair

Contains fulltext : 118394.pdf (Publisher’s version ) (Closed access)BACKGROUND: Revision antireflux surgery and large hiatal hernia repair require extensive dissection at the gastroesophageal junction. This may lead to troublesome symptoms due to delayed gastric emptying, eventually requiring gastrectomy. The aim of this study was to evaluate the outcome of gastrectomy for severely delayed gastric emptying after large hiatal hernia repair or redo antireflux surgery. METHODS: Eleven patients were treated between 1995 and 2010 and entered in the study. Preoperative and operative data were retrospectively collected. Standardized questionnaires were sent to all of the patients to evaluate symptomatic outcome. RESULTS: The primary intervention was Nissen fundoplication in nine patients, Toupet fundoplication in one, and cruroplasty in another. The repairs were for refractory gastroesophageal reflux disease in five patients and a symptomatic large hiatal hernia in six. Subsequent gastrectomy was partial in four patients, subtotal in six, and total in one. There was one minor postoperative complication. After a mean (+/-SD) duration of 102 +/- 59 months, nine patients were available for symptomatic follow-up. Eight patients experienced daily symptoms related to dumping. Daily symptoms indicative of delayed gastric emptying were present in seven patients at follow-up. Mean general quality of life was increased from 3.8 +/- 2.2 before gastrectomy to 5.4 +/- 1.8 at follow-up. Eight patients reported gastrectomy as worthwhile. CONCLUSION: Gastrectomy after previous antireflux surgery or large hiatal hernia repair is safe with the potential to improve quality of life. Although upper gastrointestinal symptoms tend to persist, gastrectomy can be considered a reasonable, last-resort surgical option for alleviating upper gastrointestinal symptoms after this kind of surgery

Obesity affects brain structure and function- rescue by bariatric surgery?

Contains fulltext : 219675.pdf (Publisher’s version ) (Open Access)Obesity has a major impact on metabolic health thereby negatively affecting brain function and structure, however mechanisms involved are not entirely understood. The increasing prevalence of obesity is accompanied by a growing number of bariatric surgeries (BS). Weight loss after BS appears to improve cognitive function in patients. Therefore, unraveling mechanisms how BS influences brain function may be helpful to develop novel treatments or treatments in combination with BS preventing/inhibiting neurodegenerative disorders like Alzheimer's disease. This review shows the relation between obesity and impaired circulation to and in the brain, brain atrophy, and decreased cognitive functioning. Weight loss seems to recover some of these brain abnormalities as greater white matter and gray matter integrity, functional brain changes and increased cognitive functioning is seen after BS. This relation of body weight and the brain is partly mediated by changes in adipokines, gut hormones and gut microbiota. However, the exact underlying mechanisms remain unknown and further research should be performed

Reflux and belching after 270 degree versus 360 degree laparoscopic posterior fundoplication.

Item does not contain fulltextOBJECTIVE: To investigate differences in effects of 270 degrees (270 degrees LPF) and 360 degrees laparoscopic posterior fundoplication (360 degrees LPF) on reflux characteristics and belching. BACKGROUND: Three hundred sixty degrees LPF greatly reduces the ability of the stomach to vent ingested air by gastric belching. This frequently leads to postoperative symptoms including inability to belch, gas bloating and increased flatulence. Two hundred seventy degrees LPF allegedly provides less effective reflux control compared with 360 degrees LPF, but theoretically may allow for gastric belches (GBs) with a limitation of gas-related symptoms. METHODS: Endoscopy, stationary esophageal manometry, and 24-hour impedance-pH monitoring off PPIs was performed before and 6 months after fundoplication for PPI-refractory gastroesophageal reflux disease (n = 14 270 degrees LPF vs. n = 28 360 degrees LPF). GBs were defined as gas components of pure gas and mixed reflux episodes reaching the proximal esophagus. Absolute reductions (Delta) were compared. RESULTS: Reflux symptoms and the 24-hour incidence of acid (Delta -77.6 vs. -76.7), weakly acidic (Delta -9.4 vs. -6.6), liquid (Delta -59.0 vs. -49.8) and mixed reflux episodes (Delta -28.0 vs. -33.5) were reduced to a similar extent after 270 degrees LPF and 360 degrees LPF, respectively. The reduction in proximal, mid-esophageal and distal reflux episodes were similar in both groups as well. Persistent symptoms were not related to acid or weakly acidic reflux. Two hundred seventy degrees LPF had no significant impact on the number of gas reflux episodes (Delta -3.6; P = 0.363), whereas 360 degrees LPF significantly reduced gas reflux episodes (Delta -17.0; P = 0.002). After 270 degrees LPF, GBs (Delta -29.3 vs. -50.6; P = 0.026) were significantly less reduced and the prevalence of gas bloating (7.1% vs. 21.4%; P = 0.242) and increased flatulence (7.1% vs. 42.9%; P = 0.018) was lower compared to 360 degrees LPF. Twenty-eight patients (67%) showed supragastric belches (SGBs) before and after surgery. The increase in SGBs without reflux (Delta +32.4 vs. +25.5) and the decrease in reflux-associated SGBs (Delta -12.1 vs. -14.0) were similar after 270 degrees LPF and 360 degrees LPF. CONCLUSIONS: Two hundred seventy degrees LPF and 360 degrees LPF alter the belching pattern by reducing GBs (air venting from stomach) and increasing SGBs (no air venting from stomach). However, gas reflux and GBs are reduced less after 270 degrees LPF than after 360 degrees LPF, resulting in more air venting from the stomach and less gas bloating and flatulence, whereas reflux is reduced to a similar extent in the short-term.1 januari 201

Effects of anti-reflux surgery on weakly acidic reflux and belching

Item does not contain fulltextBACKGROUND: Laparoscopic Nissen fundoplication (LNF) is the most frequently performed operation for gastro-oesophageal reflux disease (GORD). However, 12% of the patients have persistent reflux symptoms and 19% develop gas-related symptoms after LNF. Weakly acidic reflux and inability to belch have been alleged to cause these symptoms, respectively. The effect of LNF on weakly acidic reflux and (supra) gastric belching was evaluated. METHODS: In 31 patients upper gastrointestinal endoscopy, stationary oesophageal manometry and 24-h impedance-pH monitoring off acid secretion inhibiting drugs was performed before and 6 months after primary LNF for GORD that was refractory to proton pump inhibitors. Patients filled out validated questionnaires on GERD-HRQoL before and 3, 6 and 12 months after surgery. RESULTS: LNF reduced reflux symptoms (18.6-->1.6; p = 0.015). The procedure drastically reduced the incidence (number per 24 h) of acid (76.0-->1.6; p 5.7; p = 0.001) as well as liquid (53.4-->5.4; p1.9; p 25.7; p = 0.022). Proximal, mid-oesophageal and distal reflux were reduced to a similar extent. Persistent GORD symptoms were neither preceded by acid nor by weakly acidic reflux. The number of air swallows did not change, but the number of gastric belches (GBs) was greatly reduced (68.5-->23.9; p 46.0; p = 0.036). Reflux-associated SGBs were abolished after surgery (14.0-->0.4; p < 0.001). CONCLUSIONS: LNF similarly controls acid and weakly acidic reflux, but gas reflux is reduced to lesser extent. Persistent reflux symptoms are neither caused by acid nor by weakly acidic reflux. LNF alters the belching pattern by reducing GBs (air venting from stomach) and increasing SGBs (no air venting from stomach). This explains the increase in belching experienced by some patients after LNF, despite the reduction in gastric belching. It can be hypothesised that the reduction in GBs after LNF incites patients to increase SGBs in a futile attempt to vent air from the stomach

The magnitude and progress of lean body mass, fat-free mass, and skeletal muscle mass loss following bariatric surgery: A systematic review and meta-analysis.

Postbariatric loss of muscle tissue could negatively affect long-term health due to its role in various bodily processes, such as metabolism and functional capacity. This meta-analysis aimed to unravel time-dependent changes in the magnitude and progress of lean body mass (LBM), fat-free mass (FFM), and skeletal muscle mass (SMM) loss following bariatric surgery. A systematic literature search was conducted in Pubmed, Embase, and Web of Science. Fifty-nine studies assessed LBM (n = 37), FFM (n = 20), or SMM (n = 3) preoperatively and ≥1 time points postsurgery. Random-effects meta-analyses were performed to determine pooled loss per outcome parameter and follow-up time point. At 12-month postsurgery, pooled LBM loss was -8.13 kg [95%CI -9.01; -7.26]. FFM loss and SMM loss were -8.23 kg [95%CI -10.74; -5.73] and -3.18 kg [95%CI -5.64; -0.71], respectively. About 55% of 12-month LBM loss occurred within 3-month postsurgery, followed by a more gradual decrease up to 12 months. Similar patterns were seen for FFM and SMM. In conclusion, >8 kg of LBM and FFM loss was observed within 1-year postsurgery. LBM, FFM, and SMM were predominantly lost within 3-month postsurgery, highlighting that interventions to mitigate such losses should be implemented perioperatively