Telemonitoring for perioperative care of outpatient bariatric surgery: Preference-based randomized clinical trial.

IMPORTANCE: Implementation of bariatric surgery on an outpatient basis is hampered by concerns about timely detection of postoperative complications. Telemonitoring could enhance detection and support transition to an outpatient recovery pathway. OBJECTIVE: This study aimed to evaluate non-inferiority and feasibility of an outpatient recovery pathway after bariatric surgery, supported by remote monitoring compared to standard care. DESIGN: Preference-based non-inferiority randomized trial. SETTING: Center for obesity and metabolic surgery, Catharina hospital Eindhoven, the Netherlands. PARTICIPANTS: Adult patients scheduled for primary gastric bypass or sleeve gastrectomy. INTERVENTIONS: Same-day discharge with one week ongoing Remote Monitoring (RM) of vital parameters or Standard Care (SC) with discharge on postoperative day one. MAIN OUTCOMES: Primary outcome was a thirty-day composite Textbook Outcome score encompassing mortality, mild and severe complications, readmission and prolonged length-of-stay. Non-inferiority of same-day discharge and remote monitoring was accepted below the selected margin of 7% upper limit of confidence interval. Secondary outcomes included admission duration, post-discharge opioid use and patients' satisfaction. RESULTS: Textbook Outcome was achieved in 94% (n = 102) in RM versus 98% (n = 100) in SC (RR 2.9; 95% CI, 0.60-14.23, p = 0.22). The non-inferiority margin was exceeded which is a statistically inconclusive result. Both Textbook Outcome measures were above Dutch average (5% RM and 9% SC). Same-day discharge reduced hospitalization days by 61% (p<0.001) and by 58% with re-admission days included (p<0.001). Post-discharge opioid use and satisfaction scores were equal (p = 0.82 and p = 0.86). CONCLUSION: In conclusion, outpatient bariatric surgery supported with telemonitoring is clinically comparable to standard overnight bariatrics in terms of textbook-outcome. Both approaches reached primary endpoint results above Dutch average. However, statistically the outpatient surgery protocol was neither inferior, nor non-inferior to the standard pathway. Additionally, offering same-day discharge reduces the total hospitalization days while maintaining patient satisfaction and safety.

Paravertebral catheter versus EPidural analgesia in Minimally invasive Esophageal resectioN: a randomized controlled multicenter trial (PEPMEN trial).

BACKGROUND: Thoracic epidural analgesia is the standard postoperative pain management strategy in esophageal cancer surgery. However, paravertebral block analgesia may achieve comparable pain control while inducing less side effects, which may be beneficial for postoperative recovery. This study primarily aims to compare the postoperative quality of recovery between paravertebral catheter versus thoracic epidural analgesia in patients undergoing minimally invasive esophagectomy. METHODS: This study represents a randomized controlled superiority trial. A total of 192 patients will be randomized in 4 Dutch high-volume centers for esophageal cancer surgery. Patients are eligible for inclusion if they are at least 18 years old, able to provide written informed consent and complete questionnaires in Dutch, scheduled to undergo minimally invasive esophagectomy with two-field lymphadenectomy and an intrathoracic anastomosis, and have no contra-indications to either epidural or paravertebral analgesia. The primary outcome is the quality of postoperative recovery, as measured by the Quality of Recovery-40 (QoR-40) questionnaire on the morning of postoperative day 3. Secondary outcomes include the QoR-40 questionnaire score Area Under the Curve on postoperative days 1-3, the integrated pain and systemic opioid score and patient satisfaction and pain experience according to the International Pain Outcomes (IPO) questionnaire, and cost-effectiveness. Furthermore, the groups will be compared regarding the need for additional rescue medication on postoperative days 0-3, technical failure of the pain treatment, duration of anesthesia, duration of surgery, total postoperative fluid administration day 0-3, postoperative vasopressor and inotrope use, length of urinary catheter use, length of hospital stay, postoperative complications, chronic pain at six months after surgery, and other adverse effects. DISCUSSION: In this study, it is hypothesized that paravertebral analgesia achieves comparable pain control while causing less side-effects such as hypotension when compared to epidural analgesia, leading to shorter postoperative length of stay on a monitored ward and superior quality of recovery. If this hypothesis is confirmed, the results of this study can be used to update the relevant guidelines on postoperative pain management for patients undergoing minimally invasive esophagectomy. TRIAL REGISTRATION: Netherlands Trial Registry, NL8037. Registered 19 September 2019.

Cardiac structure and function before and after bariatric surgery: a clinical overview.

Obesity, defined as a body mass index of ≥30 kg/m2 , is the most common chronic metabolic disease worldwide and its prevalence has been strongly increasing. Obesity has deleterious effects on cardiac function. The purpose of this review is to evaluate the effects of obesity and excessive weight loss due to bariatric surgery on cardiac function, structural changes and haemodynamic responses of both the left and right ventricle.

Comparison of ultrasound guidance with palpation and direct visualisation for peripheral vein cannulation in adult patients: a systematic review and meta-analysis.

BACKGROUND: Peripheral vein cannulation is a routine and straightforward invasive procedure, although i.v. access can be difficult to obtain. To increase the success rate of inserting an i.v. catheter, many devices have been proposed, including ultrasonography. The objective of this study was to compare ultrasound guidance with the traditional approach of palpation and direct visualisation for peripehral vein cannulation. The primary outcome was successful peripheral i.v. cannulation. METHODS: Database search was performed on PubMed, Clinical Key, CINAHL, Cochrane Library of Clinical Trials, and Trip Database (from January 2000 to December 2017). Random-effect meta-analysis was performed to determine the pooled odds ratio for success in peripheral i.v. cannulation. RESULTS: After database review and eligibility screening, eight studies were included in the final analysis, with a total of 1660 patients. The success rate in the ultrasound group was 81% (n=855), and was 70% (n=805) in the control group, resulting in a pooled odds ratio for success upon ultrasound-guided peripheral i.v. cannulation of 2.49 (95% confidence interval 1.37-4.52, P=0.003). Furthermore, the ultrasound-guided technique reduced the number of punctures and time needed to achieve i.v. access, and increased the level of patient satisfaction, although it did not result in a decreased number of complications. CONCLUSIONS: Ultrasound guidance increases the success rate of peripheral i.v. cannulation, especially in patients with known or predicted difficult i.v. access.

[Risk of heart failure diminished thanks to stomach reduction in obesity]. / Hartfalen afgenomen door maagverkleining bij obesitas.

BACKGROUND: Obesity is a chronic disease and a risk factor for heart failure. In end-stage heart failure, heart transplantation may be the only available treatment option, but obesity is a contraindication for this treatment because of its unfavourable prognosis. Bariatric surgery and its subsequent weight loss may affect the indication for transplantation in patients with heart failure and morbid obesity. CASE DESCRIPTION: A 46-year-old patient with morbid obesity and heart failure underwent gastric sleeve resection in preparation of a heart transplantation. Without it, he would not have been considered eligible for transplantation because of his obesity. The bariatric intervention was also intended to use weight loss as a way to reduce the symptoms of his heart failure and to make rehabilitation possible. One year after surgery, the condition of the patient had improved so much that heart transplantation was no longer necessary. CONCLUSION: Bariatric surgery is safe for morbidly obese patients with severe heart failure and may sometimes even avoid heart transplantation.

[A postpartum woman with toxic shock syndrome: group A streptococcal infection, a much feared postpartum complication.] / Een kraamvrouw met toxische-shocksyndroom.

BACKGROUND: The development of toxic shock syndrome (TSS) after an invasive group A streptococcal (GAS) infection in the postpartum period is a much feared complication. The mortality rate of TSS with necrotizing fasciitis is 30 to 50%. CASE DESCRIPTION: We present the case of a woman with atypical pelvic pain which was the first symptom of toxic shock syndrome as a consequence of a GAS infection. Clinical deterioration necessitated a hysterectomy. Also a fasciotomy was performed as consequence of lower extremity compartment syndrome. After this, multiple debridement operations were necessary, followed by split skin grafts. CONCLUSION: This case illustrates the extremely serious complications of GAS infection. In some cases aggressive surgical intervention is necessary, in addition to an optimal antibiotic treatment regime. Ideally, the treatment of a GAS-induced TSS should be managed by a multidisciplinary medical team.

Perioperative statin therapy in patients at high risk for cardiovascular morbidity undergoing surgery: a review.

Statins feature documented benefits for primary and secondary prevention of cardiovascular disease and are thought to improve perioperative outcomes in patients undergoing surgery. To assess the clinical outcomes of perioperative statin treatment in statin-naive patients undergoing surgery, a systematic review was performed. Studies were included if they met the following criteria: randomized controlled trials, patients aged ≥18 yr undergoing surgery, patients not already on long-term statin treatment, reported outcomes including at least one of the following: mortality, myocardial infarction, atrial fibrillation, stroke, and length of hospital stay. The following randomized clinical trials were excluded: retrospective studies, trials without surgical procedure, trials without an outcome of interest, studies with patients on statin therapy before operation, or papers not written in English. The literature search revealed 16 randomized controlled studies involving 2275 patients. Pooled results showed a significant reduction in (i) mortality [risk ratio (RR) 0.53, 95% confidence interval (CI) 0.30-0.94, P=0.03], (ii) myocardial infarction (RR 0.54, 95% CI 0.38-0.76, P<0.001), (iii) perioperative atrial fibrillation (RR 0.53, 95% CI 0.43-0.66, P<0.001), and (iv) length of hospital stay (days, mean difference -0.58, 95% CI -0.79 to -0.37, P<0.001) in patients treated with a statin. Subgroup analysis in patients undergoing non-cardiac surgery showed a decrease in the perioperative incidence of mortality and myocardial infarction. Consequently, anaesthetists should consider prescribing a standard-dose statin before operation to statin-naive patients undergoing cardiac surgery. However, there are insufficient data to support final recommendations on perioperative statin therapy for patients undergoing non-cardiac surgery.

Pulmonary morbidity following esophagectomy is decreased after introduction of a multimodal anesthetic regimen.

Respiratory morbidity is the most frequent complication after esophagectomy, which can occur in 50% of the patients treated for esophageal cancer. We tested the hypothesis whether an anesthetic regimen, emphasizing intraoperative fluid restriction and early extubation could, positively influence postoperative morbidity, without affecting the gastric tube reconstruction. We introduced an anesthetic regimen, based on early extubation and a controlled intraoperative fluid management (net fluid balance < 4 L) in combination with the use of norepinephrine to maintain mean arterial blood pressure > 65 mmHg. Postoperative morbidity and mortality were compared with a similar group of patients operated one year before. From June 2005 till September 2006, 83 patients were treated according to the new regimen (NR) and compared to a similar number of patients from the same period in 2003-2005 (standard regimen: SR). Applying the NR resulted in significantly less fluid administration (balance of 3.5 +/- 0.2 L NR vs. 5.1 +/- 0.2 L SR, p < 0.05) resulting in fewer patients developing pneumonia (26% in the NR group vs. 42% in the SR group, p < 0.05). Similar per operative blood loss and urine output and occurrence of leakage or ischemia of the gastric tube anastomosis occurred in both groups. Respiratory morbidity is significantly reduced with the introduction of a new anesthetic regimen directed at intraoperative fluid restriction and early extubation, without increasing anastomotic leakage of the gastric tube reconstruction.

The effect of oral administration of L-arginine on anal resting pressure and anodermal blood flow in healthy volunteers.

BACKGROUND: Topical application of L-arginine, the precursor of nitric oxide, reduces anal resting pressure without significant side effects and may therefore be of benefit in the treatment of anal fissure. This in vivo study investigated the effect of orally administered L-arginine on anal resting pressure and anodermal blood flow in healthy volunteers. METHODS: Eight healthy volunteers took 3 sachets of Arginaid (Novartis Consumer Health, Breda, The Netherlands) containing 15 g L-arginine on a daily basis, for 7 days. At the start of the experiment (day 0) and on days 3 and 7, plasma levels of L-arginine, anal resting pressures and anodermal blood flow were determined. RESULTS: Arginine plasma levels increased from 107.0+/-8.6 micromol/l (day 0) to 283.7+/-44.0 micromol/l on day 3 (p< 0.01) and remained elevated at day 7 (157.3+/-19.6 micromol/l, p<0.05). Anodermal blood flow and anal resting pressures were similar on days 0, 3 and 7. CONCLUSIONS: Oral administration of 15 g arginine in healthy volunteers on a daily basis increased arginine plasma levels but had no influence on anodermal blood flow and anal resting pressure.

[A woman with an advanced malignant clear cell hidradenoma]. / Een vrouw met een voortgeschreden maligne 'clear cell'-hidradenoma.

A 67-year-old patient was admitted for diabetes mellitus. Incidentally a large ulcerating tumour was found on the right upper leg. The patient had been suffering from the lesion for six years but had never dared to show it to her physician. Notwithstanding negative outcome of thin needle aspiration oncological dissection was carried out. Histopathological examination proved the tumour to be a malignant clear cell hidradenoma, which is a rare eccrine tumour. This tumour is known to be aggressive and easily spreads to locoregional lymph nodes. Even though it is a rare disease, the aggressive behaviour and the poor prognosis warrant alertness to this neoplasm.

New assessment techniques for evaluation of posttraumatic spinal cord function in the rat.

To evaluate new pharmacologic agents with potentially beneficial effects on posttraumatic spinal cord function, we used a modified weight drop (WD) technique to induce spinal cord injuries. These contusive spinal cord injuries in the rat closely mimic the human clinicopathologic situation. Especially for drug screening purposes, the moderate and mild injuries are of interest, as both the beneficial and potentially harmful effects of experimental treatment can be detected. In this study, we describe two new functional tests that were particularly designed to detect small differences in spinal cord function after moderate and mild injuries. First, for examination of locomotion, a computer analysis of the thoracolumbar height (TLH) was designed. Second, for investigation of the conduction properties of the injured rat spinal cord, we measured rubrospinal motor evoked potentials (MEP). The efficacy of the new assessment techniques to monitor spinal cord function was compared to Tarlov scores and to morphometric analysis of preserved white matter at the injury site. The results of this study indicated that for behavioral analysis, TLH measurements as compared with Tarlov rating appeared to be more sensitive for exact and objective discrimination between small differences in motor function. Amplitudes of the rubrospinal MEP, but not latencies or the number of peaks, proved to be most sensitive to determine subtle differences in posttraumatic spinal cord function. A significant linear correlation was found between TLH and amplitude of the rubrospinal MEP. We conclude that for objective assessment of the spinal cord after moderate and mild contusive injury, TLH and rubrospinal MEP amplitudes are very valuable measures to demonstrate small functional differences.