Bariatric Surgery—from the Non-surgical Approach to the Post-Surgery Individual Care: Role of Endoscopy in Bariatric Therapy

Obesity is the underlying constant for the development of the most common modern diseases such as insulin resistance, high blood pressure, lipid metabolism disorders, non-alcoholic steatohepatitis (fatty liver), joint problems and various malignancies. The role of endoscopic diagnostic and therapy in obese patients is highlighted in this chapter. In this chapter all devices and methods used in flexible endoscopy for diagnostic and treatment in obese patients are introduced. Role of endoscopy is presented in three parts: in preoperative setting, in post-operative complication management and instead of surgery as endoscopic bariatric therapy. If possible presentation of the effectiveness is compiled with study data. Finally, the interaction between endoscopy and surgery in the treatment of obesity is complex, essential and promising. Endoscopy is indispensable in preoperative preparation, as a primary therapeutic approach, and also in the detection and treatment of acute complications and long-term complications of obesity surgery

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10 years; 78.2% included were male with a median age of 37 years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020

findings in normal and psoriatic skin and changes of psoriatic skin structure during a modified Goeckerman therapy regimen

Einleitung: Psoriasis ist eine rezidivierende chronisch-entzündliche Erkrankung der Haut, die mit einer deutlichen Beeinträchtigung der Lebensqualität betroffener Patienten einhergeht. Den typisch veränderten Kapillarschlingen der papillären Dermis in psoriatischer Haut wird eine wichtige Rolle bei der Entstehung und Unterhaltung psoriatischer Hautläsionen zugeschrieben. Diese Veränderungen der Hautgefäße werden durch die gesteigerte Sekretion proangiogenetischer Faktoren aus den aktivierten Basalzellen, welche die vergrößerten dermalen Papillen in psoriatischer Haut umgeben, hervorgerufen. Es existieren keine Biomarker für ein standardisiertes Monitoring der Psoriasis. Klinische Scores, die breite Anwendung im klinischen Alltag und in klinischen Studien finden, sind sehr uneinheitlich und zeigen große Schwächen bezüglich ihrer Validität. Material und Methoden: Mithilfe der konfokalen Laserscan-Mikroskopie (CLSM) wurden die Strukturen der Kapillarschlingen und der dermalen Papillen bei 5 gesunden Probanden mit denen bei 13 Psoriasispatienten verglichen. Außerdem wurden psoriatische Hautläsionen von 11 Patienten vor und nach einem modifizierten Goeckerman- Therapieschema mithilfe der CLSM untersucht. Der klinische Hautzustand wurde mit Hilfe von Psoriasis Area and Severity Index (PASI) dokumentiert, in regelmäßigen Abständen wurde nach Therapieende der von den Patienten ermittelte self-administered PASI erhoben. Ergebnisse: Die Hautkapillaren und die dermalen Papillen waren signifikant erweitert in der psoriatischen Haut (Kapillardurchmesser 24.3±2.3 µm, Papillendurchmesser 146.46±28.52 µm) im Vergleich zur gesunden Haut (Kapillardurchmesser 9.5±1.8 µm, Papillendurchmesser 69.4±17.1 µm). Im Laufe eines modifizierten Goeckerman- Therapieschemas konnte eine prozentuale PASI Reduktion von 30 bis 90,4 %, eine 17 - 53.7-prozentige Reduktion der Kapillardurchmesser und eine 13.1 - 44.2-prozentige Reduktion der Papillendurchmesser gemessen werden. Kapillardurchmesser und Papillendurchmesser am Ende der Therapie waren signifikant höher als die Kapillardurchmesser und Papillendurchmesser in gesunder Haut. Kapillar- und Papillendurchmesser korrelierten miteinander vor (r= 0.63, p=0.014) und nach Therapie (r= 0.64, p=0.002). PASI-Werte waren weitgehend unabhängig vom Kapillar- und Papillendurchmesser. Die klinische Besserung (Reduktion PASI in %) korrelierte am besten mit der prozentualen Reduktion des Papillendurchmessers (r= 0.63, p=0.03) und weniger mit der prozentualen Reduktion des Kapillardurchmessers (r= 0.29, p=0.25). Die Vorhersage der Rezidivwahrscheinlichkeit binnen eines Jahres nach Therapieende anhand der Kapillardurchmesser und Papillendurchmesser nach Therapieende war der Vorhersage der Rezidivwahrscheinlichkeit anhand des PASI am Therapieende überlegen. Schlussfolgerung: CLSM ist eine viel versprechende nicht-invasive Methode für die Evaluation der strukturellen Veränderungen in psoriatischer Haut in vivo und für das Monitoring des Therapieerfolges auf zellulärer Ebene. Subklinische Veränderungen der psoriatischen Haut nach klinischer Abheilung stellen ein legitimes Therapieziel dar.Introduction: Psoriasis is a chronic recurring inflammatory skin disease with a major impact on the quality of life of the afflicted patients. Several findings indicate that the altered capillary loops in the papillary dermis of psoriatic skin play an essential role in the pathogenesis and on the course of the disease. Microvascular changes in psoriasis are caused by an elevated production of pro-angiogenetic factors in the basal cells surrounding the enlarged dermal papilla. Biomarkers do not exist for a standardized assessment of psoriasis. Clinical scores, which are commonly used in the praxis and in clincal studies, lack uniformity and their validity is questionable. Materials and Methods: Confocal laser scanning microscopy (CLSM) was used to study the structures of the capillary loops and dermal papillae in 5 healthy volunteers and 13 psoriasis patients. Additionally, lesional skin of 11 psoriasis patients was investigated using CLSM prior to and after a modified Goeckerman therapy regimen. Clinical response was assessed using the Psoriasis Area and Severity Index (PASI) and self-administered PASI was conducted in regular intervals after the end of the treatment. Results: The capillary loops and the dermal papilla were significantly enlarged in the psoriatic skin lesions (diameters: 24.3±2.3 µm and 146.4±28.5 µm, respectively) in comparison to healthy skin (diameters: 9.5±1.8 and 69.4±17.1 µm, respectively). Following a modified Goeckerman therapy regimen, a 30% - 90.4% reduction of PASI, a 17 - 53.7% reduction of the feret capillary diameter and a 13.1 - 44.2% reduction of the feret papillary diameter (p<0.0001) were measured. Capillary loops and dermal papilla were still significantly enlarged after treatment when compared to those in normal skin. Capillary and papillary diameter correlated with each other before treatment (r= 0.63, p=0.014 ) and after treatment (r= 0.64, p=0.002). PASI values were to a large extent independent of the capillary and papillary diameter values. Clinical improvement (% reduction of PASI values) correlated more with the normalization of the papillary structure (r= 0.63, p=0.03) and correlated less with the normalization of the skin capillaries (r= 0.29, p=0.25). The predictability of a psoriasis recurrence within one year after treatment was more reliable when based upon the capillary and papillary diameters after treatment compared with the PASI values after treatment. Conclusion: CLSM represents a promising non-invasive technique for evaluating structural changes in psoriatic skin in vivo and for monitoring therapeutic response on a cellular level. Subclinical changes in psoriatic skin after therapy represent a legitimate goal for treatment