Rapid improvement of hepatic steatosis and liver stiffness after metabolic/bariatric surgery: a prospective study.

Metabolic dysfunction-associated steatotic liver disease (MASLD) and related steatohepatitis (MASH) are common among obese patients and may improve after metabolic/bariatric surgery (MBS). 93 Patients undergoing MBS in 2021-2022 were prospectively enrolled. Liver stiffness measurement (LSM; via vibration-controlled transient elastography [VCTE], point [pSWE] and 2D [2DSWE] shear wave elastography) and non-invasive steatosis assessment (via controlled attenuation parameter [CAP]) were performed before (baseline [BL]) and three months (M3) after surgery. 93 patients (median age 40.9 years, 68.8% female, median BL-BMI: 46.0 kg/m2) were included. BL-liver biopsy showed MASLD in 82.8% and MASH in 34.4% of patients. At M3 the median relative total weight loss (%TWL) was 20.1% and the median BMI was 36.1 kg/m2. LSM assessed by VCTE and 2DSWE, as well as median CAP all decreased significantly from BL to M3 both in the overall cohort and among patients with MASH. There was a decrease from BL to M3 in median levels of ALT (34.0 U/L to 31 U/L; p = 0.025), gamma glutamyl transferase (BL: 30.0 to 21.0 U/L; p < 0.001) and MASLD fibrosis score (BL: - 0.97 to - 1.74; p < 0.001). Decreasing LSM and CAP, as well as liver injury markers suggest an improvement of MASLD/MASH as early as 3 months after MBS.

The deep abdominal ultrasound transducer (DAX) increases the success rate and diagnostic accuracy of shear wave elastography for liver fibrosis assessment in patients with obesity-A prospective biopsy-controlled study.

BACKGROUND: Obesity impacts the diagnostic accuracy of shear wave elastography (SWE). A deep abdominal ultrasound transducer (DAX) capable of point (pSWE) and two-dimensional (2D)-SWE has recently been introduced to address this issue. METHODS: We performed a prospective study in a cohort of mostly patients with obesity undergoing liver biopsy with a high prevalence of metabolic dysfunction-associate steatotic liver disease (MASLD). Liver stiffness measurement (LSM) was measured using vibration-controlled transient elastography (VCTE), as well as pSWE and 2D SWE on the standard (5C1) and the DAX transducers. RESULTS: We included 129 patients with paired LSM and liver biopsy: median age 44.0 years, 82 (63.6%) women, median BMI: 43.2 kg/m2. Histologic fibrosis stages: F0: N = 55 (42.6%), F1: N = 14 (10.9%), F2: N = 50 (38.8%), F3: N = 2 (1.6%), F4: N = 8 (6.2%). VCTE-LSM failed (N = 13) or were unreliable (IQR/median ≤30% in ≥7.1 kPa, N = 14) in 20.9% of patients. The Pearson correlation of reliable VCTE-LSM with both pSWE and 2D SWE was strong (all >0.78). The diagnostic accuracy for all LSM techniques was poor for significant fibrosis (≥F2, AUC: 0.54-0.63); however, it was good to excellent for advanced fibrosis (≥F3, AUC: 0.87-0.99) and cirrhosis (F4, AUC: 0.86-1.00). In intention-to-diagnose analysis, pSWE on DAX was significantly superior to VCTE-LSM. CONCLUSIONS: pSWE- and 2D-SWE enable the non-invasive identification of advanced fibrosis and cirrhosis in patients with obese MASLD. The use of the DAX transducer for acoustic radiation force imaging (ARFI)-LSM avoids technical failures in an obese population and subsequently offers advantages over VCTE-LSM for the evaluation of fibrosis in an obese MASLD population at risk for fibrosis.

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.

Surgical Technique for Sphinkeeper® Implantation.

Fecal incontinence is a distressing condition characterized by the involuntary loss of solid and liquid stool and gas, It affects a significant proportion of the general population, with a reported prevalence ranging from 1% to 20%. Despite its considerable impact on quality of life, therapeutic options for fecal incontinence remain limited. Current treatment modalities for fecal incontinence include conservative approaches such as dietary modifications, pelvic floor exercises, and pharmacotherapy. Surgical interventions, including sphincteroplasty or sacral nerve stimulation, may be considered in more severe cases. Recently, THD Labs (THD S.p.A. Correggio (RE), Italy) introduced the Gatekeeper® as a novel device that supports the implantation of up to four solid prostheses into the intersphincteric groove. Early data were promising, with success rates above 50% and only a few perioperative complications. Subsequently, Gatekeeper® was modified by increasing the length and number (up to 10) of prostheses, and renamed Sphinkeeper® (THD). With this device, nine to 10 small incisions measuring 2 mm are made at a distance of 2-3 cm from the anus. The intersphincteric space is accessed using the delivery system, and positioning is verified through endoanal ultrasound. This procedure is repeated for all 10 prostheses placed around the entire circumference. The Sphinkeeper® offers the potential to improve the management of fecal incontinence, and offers patients a less-invasive alternative to traditional surgical approaches.

[Overweight and obesity in adults: general principles of treatment and conservative management]. / Übergewicht und Adipositas bei Erwachsenen: allgemeine Behandlungsgrundsätze und konservatives Management.

The prevalence of overweight and obesity is steadily increasing in Austria as well as internationally. Obesity in particular is associated with multiple health risks, comorbidities, functional disability, and social stigma. Obesity is an independent, complex, chronic disease and should be treated as such by a multidisciplinary team of appropriately qualified personnel. In addition to recent international guidelines, this consensus paper outlines the overall principles of the management of overweight and obesity and provides guidance for the diagnosis and conservative treatment, focusing on lifestyle modifications and pharmacotherapy. Using the "5A" framework of behavioral health intervention, guidelines for a structured, pragmatic, and patient-centered medical care of adults with overweight or obesity are presented.

[Indications and preoperative planning for bariatric surgery]. / Indikation und präoperative Planung zur bariatrischen Operation.

These clinical practice guidelines represent the consensus opinion of a group of Austrian specialist physicians associated with the treatment of obesity. The recommendations incorporate the current literature and guidelines and aim to balance both procedural feasibility and patient acceptance and adherence. Special emphasis was placed on simplification of the preoperative clarification and maximum patient safety. Therefore, this article makes no claim to be complete in all fields.

[Prevention and management of postinterventional weight regain]. / Prävention und Management von postinterventioneller Gewichtszunahme.

Decreasing levels of patient motivation or compliance are far from being the only causes of postinterventional weight regain after lifestyle, psychological, pharmacological and surgical interventions. Weight regain originates from a complex and individually varying set of central and peripheral mechanisms, with the overall purpose of increasing food intake by both stimulating hunger and reducing satiety (mediated by gastrointestinal hormones) and decreasing the body's energy demands (via metabolic adaption). These mechanisms counteract any attempts to reduce or maintain body weight in today's increasingly prevalent adipogenic environments. The knowledge about the biological mechanisms of body weight regulation should be taken into consideration when planning treatment programs for long-term weight reduction, including follow-up treatment for the prevention and individualized treatment of postinterventional weight regain. Therapeutic measures as well as the frequency of medical follow-ups should be based on the extent of weight regain.

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]; P < .0001) than CC. Hematoma rates (OR [95%CI] = 1.07 [.52, 2.20]; P = .85), SSI rates (OR [95%CI] = .93 [.61, 1.41]; P = .73), and flap necrosis rates (OR [95%CI] = .61 [.30, 1.23]; P = .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.

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 residents (GSRs) to simulated patient cart docking, and to evaluate the residents' 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 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.

The male patient with obesity undergoing metabolic and bariatric surgery: changes in testosterone levels correlate with weight loss after one-anastomosis gastric bypass and Roux-en-Y gastric bypass.

BACKGROUND: Male obesity secondary hypogonadism (MOSH) is a common disease among men with obesity and can be associated with metabolic syndrome and a variety of metabolic problems ultimately leading to androgen deficiency. Metabolic and bariatric surgery is a well-established treatment option associated with significant weight loss and reduction in metabolic co-morbidities. OBJECTIVES: To evaluate the impact of surgery on plasma levels of sexual hormones and their effect on weight loss comparing 2 surgical methods (one-anastomosis gastric bypass [OAGB] and Roux-en-Y gastric bypass [RYGB]) in male patients with obesity. SETTING: University hospital, Austria. METHODS: Patients undergoing OAGB and RYGB between 2012 and 2017 were analyzed retrospectively. Follow-up in this study was up to 24 months. Systemic levels of sexual hormones (luteinizing hormone [LH]), follicle stimulating hormone [FSH], total testosterone [TT], sexual hormone binding globin [SHBG], 17 beta-estradiol [17bE], androstenedione [AS]) were retrieved at each visit. A linear mixed model was used to assess the correlation between changes in testosterone levels and percent excess weight loss (%EWL). RESULTS: In 30.8% of all patients, MOSH was present preoperatively. A significant increase of TT was observed postoperatively that led to a complete resolution of hypogonadism within the period observed. Bioavailable testosterone (bTT) and FSH levels significantly increased each month of follow-up after surgery (all P < .01). Levels of 17bE did not change significantly after surgery. The overall change of TT, comparing preoperative and 1-year postoperative TT levels (ΔTT), significantly correlated with %EWL. Changes in TT levels were not affected by the choice of surgical method. CONCLUSIONS: Serum plasma testosterone levels rise significantly after metabolic and bariatric surgery in male patients. The change of testosterone levels seems to play a role in continued weight loss after surgery. This is true irrespective of the surgical method used.

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 < 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 > 20 cm2 to 231/581 (66.6%) with MFA ≤ 20 cm2. The mean CRM in patients with MFA > 20 cm2 was neither statistically nor clinically significantly different from patients with MFA ≤ 20 m2 (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.

Fifteen Years after Sleeve Gastrectomy: Gastroscopies, Manometries, and 24-h pH-Metries in a Long-Term Follow-Up: A Multicenter Study.

INTRODUCTION: Sleeve gastrectomy (SG) is the most common bariatric operation with over 340,000 procedures per year. There are only few studies presenting follow-up results >10 years in the literature today. The aim of this study was the objective evaluation of long-term outcomes of at least 15 years after SG in non-converted patients. METHODS: This study (multicenter cross-sectional; university-hospital based) includes all non-converted patients with primary SG before December 2005 at participating bariatric centers. The following methods were used: gastroscopy, esophageal manometry, 24-h pH-metry, and Gastrointestinal Quality of Life Index (GIQLI). RESULTS: After removing converted patients, patients with bariatric procedures before SG, and deceased patients from the cohort, 20 of 53 participants have met the inclusion criteria. Of this group, 55% are suffering from symptomatic gastroesophageal reflux disease (GERD); 45% are without GERD. Esophagitis, hiatal hernias, Barrett's esophagus, and enlarged sleeves were found in 44%, 50%, 13%, and 69% of patients during gastroscopy. Mean lower esophageal sphincter pressure was normal at 20.2 ± 14.1 mm Hg during manometry. Reflux activity in 24 h, number of refluxes, and DeMeester score were increased at 12.9 ± 9.7%, 98.0 ± 80.8, and 55.3 ± 36.3 during 24-h pH-metry. Patients with GERD scored significantly lower in the GIQLI than patients without GERD: 107.6 ± 18.4 versus 127.6 ± 14.4 (p = 0.04). DISCUSSION/CONCLUSION: Fifteen years after primary SG, objective testing has shown that GERD, esophagitis, and Barrett's esophagus are major issues for these patients. Surveillance endoscopies at 5-year intervals in all SG patients and 3-year intervals in patients with Barrett's esophagus are recommended.

Neuroendocrine neoplasms of the gallbladder: early detection and surgery is key to improved outcome.

PURPOSE: Neuroendocrine neoplasms (NENs) of the gallbladder are very rare. As a result, the classification of pathologic specimens from gallbladder NENs, currently classified as gallbladder neuroendocrine tumors (GB-NETs) and carcinomas (GB-NECs), is inconsistent and makes nomenclature, classification, and management difficult. Our study aims to evaluate the epidemiological trend, tumor biology, and outcomes of GB-NET and GB-NEC over the last 5 decades. METHODS: This is a retrospective analysis of the SEER database from 1973 to 2016. The epidemiological trend was analyzed using the age-adjusted Joinpoint regression analysis. Survival was assessed with Kaplan-Meier analysis and Cox regression was used to assess predictors of poor survival. RESULTS: A total of 482 patients with GB-NEN were identified. Mean age at diagnosis was 65.2 ± 14.3 years. Females outnumbered males (65.6% vs. 34.4%). The Joinpoint nationwide trend analysis showed a 7% increase per year from 1973 to 2016. The mean survival time after diagnosis of GB-NEN was 37.11 ± 55.3 months. The most common pattern of nodal distribution was N0 (50.2%) followed by N1 (30.9%) and N2 (19.2%). Advanced tumor spread (into the liver, regional, and distant metastasis) was seen in 60.3% of patients. Patients who underwent surgery had a significant survival advantage (111.0 ± 8.3 vs. 8.3 ± 1.2 months, p < 0.01). Cox regression analysis showed advanced age (p < 0.01), tumor stage (P < 0.01), tumor extension (p < 0.01), and histopathologic grade (p < 0.01) were associated with higher mortality. CONCLUSION: Gallbladder NENs are a rare histopathological variant of gallbladder cancer that is showing a rising incidence in the USA. In addition to tumor staging, surgical resection significantly impacts patient survival, when patients are able to undergo surgery irrespective of tumor staging. Advanced age, tumor extension, and histopathological grade of the tumor were associated with higher mortality.

Gallbladder cancer: Historical treatment and new management options.

Gallbladder cancer is a rare, aggressive malignancy that has a poor overall prognosis. Effective treatment consists of early detection and surgical treatment. With the wide spread treatment of gallbladder disease with minimally invasive techniques, the rate of incidental gallbladder cancer has seen an equitable rise along with stage migration towards earlier disease. Although the treatment remains mostly surgical, newer modalities such as regional therapy as well as directed therapy based on molecular medicine has led to improved outcomes in patients with advanced disease. We aim to summarize the management of gallbladder cancer along with the newer developments in this formidable disease process.

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's 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's legs as opposed to the Xi® "jack-knife" pattern of movement.

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.

Robotic pancreaticoduodenectomy provides better histopathological outcomes as compared to its open counterpart: a meta-analysis.

The aim of this meta-analysis was to evaluate whether robotic pancreaticoduodenectomy (PD) may provide better clinical and pathologic outcomes compared to its open counterpart. The Pubmed, EMBASE, and Cochrane Library were systematically searched. Overall postoperative morbidity and resection margin involvement rate were the primary endpoints. Secondary endpoints included operating time, estimated blood loss (EBL), incisional surgical site infection (SSI) rate, length of hospital stay (LOS), and number of lymph nodes harvested. Twenty-four studies totaling 12,579 patients (2,175 robotic PD and 10,404 open PD were included. Overall postoperative mortality did not significantly differ [OR (95%CI) = 0.86 (0.74, 1.01); p = 0.06]. Resection margin involvement rate was significantly lower in robotic PD [15.6% vs. 19.9%; OR (95%CI) = 0.64 (0.41, 1.00); p = 0.05; NNT = 23]. Operating time was significantly longer in robotic PD [MD (95%CI) = 75.17 (48.05, 102.28); p < 0.00001]. EBL was significantly decreased in robotic PD [MD (95%CI) = - 191.35 (- 238.12, - 144.59); p < 0.00001]. Number of lymph nodes harvested was significantly higher in robotic PD [MD (95%CI) = 2.88 (1.12, 4.65); p = 0.001]. This meta-analysis found that robotic PD provides better histopathological outcomes as compared to open PD at the cost of longer operating time. Furthermore, robotic PD did not have any detrimental impact on clinical outcomes, with lower wound infection rates.