Hyperuricemia and acute gout after laparoscopic sleeve gastrectomy.

The aim of this study was to evaluate the prevalence of hyperuricemia and acute gout after laparoscopic sleeve gastrectomy (LSG). Risk factors for developing gout were also examined. Eighty-five patients underwent LSG were enrolled in this prospective study. Serum uric acid levels, gout attacks and total water levels % derived by bioimpedance were examined pre-operatively and 1 month post-operatively. Hyperuricemia was identified in 30.6% pre-operatively and in 18.82% of patients post-operatively. From the patients' group with pre-operative hyperuricemia, 53.9% were normalized, 46.2% had increased uric acid post-operatively while gout was observed in 11.5%. From the patients group without pre-operative hyperuricemia, hyperuricemia and gout were observed in 6.8% and 5.1% post-operatively, respectively. The relative risk for developing hyperuricemia was 6.2 (95% confidence interval [CI] 2.2-17.8) and for developing gout was 2.3 (95% CI 2.2-17.8). Statistical significant differences for gout among the groups with and without gout were indicated concerning pre-operative use of medications (P < 0.001), age (P = 0.025), post-operative uric acid levels (P < 0.001) and post-operative total water levels % (P = 0.048). The prevalence of hyperuricemia was 18.8% and gout attack of 7.1% 1 month after LSG. From the cohort of patients with pre-operative hyperuricemia, a significant proportion normalized uric acid, while 11.5% developed gout. Patients without hyperuricemia pre-operatively developed hyperuricemia and gout in 6.8% and 5.1% post-operatively, respectively. The patients who had gout were younger and had 37% water levels post-operatively.

Validation of the suter questionnaire after laparoscopic sleeve gastrectomy in the Greek population.

BACKGROUND & AIMS: The purpose of this study was to validate the Greek version of Suter questionnaire in order to be used for the evaluation of patients after Laparoscopic Sleeve Gastrectomy (LSG). METHODS: A total of 170 patients were enrolled in the study. RESULTS: The correlation coefficients for criterion validity had range between 0.202 (Food Tolerance) and 0.252 (Suter Total Score) (p < 0.05).There was moderate correlation between the questionnaire's subscales and the Hematocrit which satisfied the criterion validity marginally. The internal consistency measured with Cronbach's alpha yielded a value of 0.866 for the factor tolerance and 0.78 for the factor symptoms, which indicate excellent internal consistency. Excellent test-retest reliability with ICC of 0.997 for food tolerance and 0.990 for symptoms were also observed. The Suter questionnaire demonstrated a high sensitivity to detect clinical changes. CONCLUSION: The Greek version of Suter questionnaire seemed to be valid and reliable to assess morbidly obese patients after LSG.

Hair Loss After Laparoscopic Sleeve Gastrectomy.

AIM: The aim of this study was to evaluate the prevalence of hair loss after laparoscopic sleeve gastrectomy (LSG). The effects of variables on the likelihood that patients developed hair loss were also examined. MATERIAL AND METHODS: Fifty patients who underwent LSG were enrolled in this prospective study. Demographics, hematocrit, iron, zinc, folic acid, vitamin B12, total proteins, and albumin were evaluated preoperatively and 6 months postoperatively. RESULTS: Hair loss was observed in 56% of patients and particularly in 46% in females and in 10% in males. Analysis of variance indicated statistical differences for hair loss among the groups with and without hair loss concerning preoperative zinc (p < 0.001), postoperative zinc (p < 0.001), preoperative B12 (p < 0.001), postoperative B12 (p < 0.001), postoperative folic acid (p = 0.039), and postoperative use of supplements (p < 0.001). Patients with hair loss had lower values of zinc preoperatively and postoperatively compared to patients without hair loss (0.61 vs 0.81 mcg/ml) (0.46 vs 0.73 mcg/ml) and also lower values of vitamin B12 preoperatively and postoperatively compared to patients without hair loss (243.04 vs 337.41 pg/ml) (261.54 vs 325.68 pg/ml). Interestingly, the zinc levels were normal preoperatively and lower to normal levels postoperatively and the levels of vitamin B12 were lower than normal values preoperatively in patients with hair loss. Patients with hair loss had mean lower levels of postoperative folic acid of 8 ng/ml. CONCLUSION: The prevalence of hair loss was 56% 6 months after LSG. Preoperative monitoring and counseling of these micronutrients may be a preventive and therapeutic measure.

Impact of Laparoscopic Sleeve Gastrectomy on Gastrointestinal Motility.

OBJECTIVE: Laparoscopic sleeve gastrectomy (LSG) was considered mainly as a restrictive procedure due to anatomic alterations in the upper gastrointestinal tract. Additionally, due to neurohormonal alterations, LSG modifies the gastrointestinal motility, which controls appetite and feeling of satiety. AIM: The aim of the study was to review the impact of laparoscopic sleeve gastrectomy on gastrointestinal motility. MATERIAL AND METHODS: A search of the medical literature was undertaken in Pubmed, Web of Science, and Cochrane library. Esophageal, gastric, bowel motility were assessed separately. RESULTS: Nine studies assessed esophageal motility. The data remain debatable attributing to the heterogeneity of follow-up timing, surgical technique, bougie size, and distance from pylorus. The stomach motility was assessed in eighteen studies. Functionally, the sleeve was divided into a passive sleeve and an accelerated antrum. All scintigraphic studies revealed accelerated gastric emptying after LSG except of one. Patients demonstrated a rapid gastroduodenal transit time. The resection of the gastric pacemaker had as a consequence aberrant distal ectopic pacemaking or bioelectrical quiescence after LSG. The bowel motility was the least studied. Small bowel transit time was reduced; opposite to that the initiation of cecal filling and the ileocecal valve transit was delayed. CONCLUSION: Laparoscopic sleeve gastrectomy has impacts on gastrointestinal motility. The data remain debatable for esophageal motility. Stomach and small bowel motility were accelerated, while the initiation of cecal filling and the ileocecal valve transit was delayed. Further pathophysiological studies are needed to evaluate the correlation of motility data with clinical symptoms.

Current knowledge and perception of bariatric surgery among Greek doctors living in Thessaly.

INTRODUCTION: The purpose of this study was to assess doctors' knowledge, current conceptions, and clinical practice regarding obesity and bariatric surgery. METHODS: A self-administered survey was administered to 500 doctors with varying medical specialties in public and private practice. RESULTS: The response rate was 60%. Most participants (77.3%) were in private practice. Although almost half of the participants could define morbid obesity and obesity-related comorbidities, only 8.7% felt educated about bariatric surgery. Participants had little knowledge of various types of bariatric procedures. A minority of doctors (24.7%) knew of the existence of a bariatric center in their area. Only 21.3% of doctors had referred a patient to a bariatric center. Reasons for non-referral included lack of interest in bariatric surgery (37.3%), patient refusal (35.3%), increased operative fees (17.3%), lack of confidence in bariatric surgery (6.3%), and lack of access to a nearby bariatric center (3.7%). The majority of doctors were interested in learning more about bariatric surgery and related guidelines, but they remained reluctant to conduct patients' postoperative follow-ups. CONCLUSION: The penetration of bariatric surgery in the medical community remains limited, despite its proven effectiveness in facilitating sustained weight loss and resolving several obesity-related comorbidities. A great effort should be made to inform health-care providers about the evolution of bariatric procedures, the potential benefits they offer, and the existence of certified bariatric centers. This will allow doctors to provide optimum health care to patients who could benefit from bariatric surgery.

The use of over-the-scope clip in the treatment of persistent staple line leak after re-sleeve gastrectomy: Review of the literature.

Staple line leak after sleeve gastrectomy (SG) is a severe complication associated with increased mortality rates and the potential need for reoperation. We report the successful management of a re-SG staple line leak with the use of an endoscopic over-the-scope clip.

Comparison of glucose homeostasis parameters between patients with high and low risk of diabetes at 6 weeks and 6 months after sleeve gastrectomy.

BACKGROUND: The changes in glucose homeostasis after sleeve gastrectomy (SG) for patients with high (HRD) and low risk (LRD) of developing diabetes have not been investigated. OBJECTIVE: To compare the glucose homeostasis parameters between patients with HRD and LRD after SG. SETTING: University hospital in Greece. METHODS: Thirteen patients were categorized as HRD (9 females, mean body mass index 46.3±1.6 kg/m2) and 10 as LRD (8 females, mean body mass index 45.4±1.7 kg/m2) based on a preoperative 2-hour oral glucose tolerance test (OGTT). OGTT was repeated 6 weeks and 6 months postoperatively. OGTT-derived indices of insulin secretion, insulin sensitivity, and ß-cell function (oral disposition index [ODI]) were calculated. RESULTS: Preoperatively, in the HRD group, fasting and postload glucose levels were higher and the ODIs were lower compared with those in the LRD group. Six weeks postoperatively, glucose levels and ODIs were not different between the 2 groups. However, 6 months postoperatively, the HRD group had demonstrated higher postload glucose levels and lower ODI (0-30) and ODI (0-120) compared with the LRD group. Six weeks postoperatively, insulin levels, early insulin secretion, and insulin resistance indices were decreased compared with preoperative levels only in the HRD group. Six months postoperatively, ODIs and insulin sensitivity indices improved in both groups compared with baseline. CONCLUSION: Six months after SG, glucose levels and ODIs improved for both HRD and LRD patients; however, postprandial glucose levels and ODI (0-30) and ODI (0-120) in HRD patients did not return to LRD levels. Moreover, during the first 6 postoperative weeks, the changes in glucose homeostasis parameters compared with preoperative levels were different for HRD and LRD patients.

Differences in Anthropometric and Metabolic Parameters Between Subjects with Hypoglycaemia and Subjects with Euglycaemia After an Oral Glucose Tolerance Test Six Months After Laparoscopic Sleeve Gastrectomy.

BACKGROUND: Hypoglycaemia after an oral glucose tolerance test (OGTT) can occur in up to 33 % of subjects after laparoscopic sleeve gastrectomy (LSG). The underlying pathophysiology is not well understood. We aimed to compare the anthropometric and metabolic characteristics of subjects with post-OGTT hypoglycaemia (HYPO) to subjects with post-OGTT euglycaemia (EU) 6 months after LSG. METHODS: Eighteen morbidly obese patients with normal glucose tolerance (NGT) were evaluated with an OGTT before and 6 months after LSG. Serum glucose and insulin were measured before and every 30 min after glucose ingestion up to 120'. The patients were categorized as HYPO or EU based on lowest glucose levels 90' to 120' post-OGTT 6 months after LSG (hypoglycaemia defined as glucose levels <60 mg/dl). OGTT derived indices of insulin secretion; insulin sensitivity and beta cell function were also evaluated. RESULTS: Eight patients (44.4 %) were categorized as HYPO. Preoperatively, subjects with HYPO had lower BMI (p = 0.02) compared to that with EU. Postoperatively, subjects with HYPO had lower BMI (p = 0.01), lower weight (p = 0.01), and higher percentage of total weight loss (%TWL) (p = 0.03) compared to that with EU. The beta cell function index was higher in the HYPO group postoperatively compared to EU (p = 0.02)-especially during the latter portion of the OGTT. No difference was detected in insulin secretion and insulin sensitivity indices between the two groups preoperatively or postoperatively. CONCLUSIONS: Subjects with NGT who developed HYPO 6 months after LSG are leaner, with higher TWL% and higher beta cell function at the latter portion of the OGTT compared to those with EU.

Desire for Body Contouring Surgery After Laparoscopic Sleeve Gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is an effective approach for the treatment of morbid obesity. Surgically induced massive weight loss provokes skin deformities that can be addressed with plastic surgery. However, there is a paucity of data regarding the esthetic outcome of patients after LSG. The aim of the study was to assess the postoperative appearance and the request for body contouring surgery after LSG. METHODS: All the patients who underwent LSG between August 2006 and September 2014 with a minimum follow-up of 1 year were interviewed using the Post-Bariatric Surgery Appearance Questionnaire. Postoperative satisfaction with their appearance, and the desire and frequency for body contouring surgery were assessed. RESULTS: A total of 175 patients were interviewed. Overall, 75% of the patients rated that they felt attractive with their appearance. More specifically, 84% of men and 72% of women were satisfied with their appearance. Females were most dissatisfied with waist/abdomen, chest/breasts, and upper arms, in descending order. Males were dissatisfied with chest/breasts, upper arms, and waist/abdomen, respectively. The most desired procedures were abdominoplasty, chest/breast lift, and upper arm lift in females and abdominoplasty, thigh lift and upper arm lift in males. Only 3.6% of patients underwent body contouring surgery postoperatively. CONCLUSION: LSG patients rated their overall appearance from slightly to moderately attractive. There was a strong desire for abdominoplasty; breast lift and upper arm lift in females, although only a small proportion of patients proceeded to plastic surgery. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266.

Complicated gallstones after laparoscopic sleeve gastrectomy.

BACKGROUND: The natural history of gallstone formation after laparoscopic sleeve gastrectomy (LSG), the incidence of symptomatic gallstones, and timing of cholecystectomy are not well established. METHODS: A retrospective review of prospectively collected database of 150 patients that underwent LSG was reviewed. RESULTS: Preoperatively, gallbladder disease was identified in 32 of the patients (23.2%). Postoperatively, eight of 138 patients (5.8%) became symptomatic. Namely, three of 23 patients (13%) who had evident cholelithiasis preoperatively developed complicated cholelithiasis. From the cohort of patients without preoperative cholelithiasis, five of 106 patients (4.7%) experienced complicated gallstones after LSG. Total cumulative incidence of complicated gallstones was 4.7% (95% CI: 1.3-8.1%). The gallbladder disease-free survival rate was 92.2% at 2 years. No patient underwent cholecystectomy earlier than 9 months or later than 23 months indicating the post-LSG effect. CONCLUSION: A significant proportion of bariatric patients compared to the general population became symptomatic and soon developed complications after LSG, thus early cholecystectomy is warranted. Routine concomitant cholecystectomy could be considered because the proportion of patients who developed complications especially those with potentially significant morbidities is high and the time to develop complications is short and because of the real technical difficulties during subsequent cholecystectomy.

Influence of eating profile on the outcome of laparoscopic sleeve gastrectomy.

BACKGROUND: The aim of this study was to assess the eating profile of patients after laparoscopic sleeve gastrectomy (LSG) and its impact on weight loss. METHODS: One hundred ten patients who underwent LSG were interviewed using Suter questionnaire and revised Questionnaire on Eating and Weight Patterns in follow-up visits. Eating patterns were assessed preoperatively and postoperatively. Patients were divided into six groups according to the timing point of assessment. Group 1 (n = 10) included patients < 3 months, group 2 (n = 11) 3-6 months, group 3 (n = 11) 6-12 months, group 4 (n = 39) 1-2 years, group 5 (n = 23) 2-3 years, and group 6 (n = 16) > 3 years. The excess weight loss (EWL) was correlated with the results. RESULTS: The total score of the Suter questionnaire was 15.0 ± 5.87, 20.3 ± 7.07, 26.2 ± 1.54, 23.8 ± 4.25, 24.65 ± 2.8, and 23.43 ± 4.14 for the groups 1-6, respectively (p < 0.0001). No significant differences were denoted when long-term follow-up groups 3 to 6 were compared. No association was found between the preoperative eating pattern and EWL. Postoperatively, 91 patients modified their eating pattern. Postoperative eating pattern was significantly correlated with EWL (p = 0.015). Patients with normal and snacking eating pattern achieve the best EWL (63.57 ± 21.32 and 60.73 ± 20.62, respectively). Binge eating disorder and emotional patterns had the worst EWL (42.84 ± 29.42 and 34.55 ± 19.34, respectively). CONCLUSIONS: Better food tolerance is detected after the first postoperative year after LSG. The postoperative eating patterns seem to affect excessive weight loss.

Complicated cholelithiasis: an unusual combination of acute pancreatitis and bouveret syndrome.

Bouveret syndrome is a rare form of gallstone ileus. The purpose of the present study was to present the unusual case of a female patient with complicated cholelithiasis manifested as a combination of acute pancreatitis and concomitant Bouveret syndrome. A 61-year-old female patient was admitted to the emergency department complaining of mid-epigastric and right upper quadrant abdominal pain radiating band-like in the thoracic region of the back as well as repeated episodes of vomiting over the last 24 h. The initial correct diagnosis of pancreatitis was subsequently combined with the diagnosis of Bouveret syndrome as a computed tomography scan revealed the presence of a gallstone within the duodenum causing luminal obstruction. After failure of endoscopic gallstone removal, a surgical approach was undertaken where gallstone removal was followed by cholecystectomy and restoration of the anatomy by eliminating the fistula. The concomitant pancreatitis complicated the postoperative period and prolonged the length of hospital stay. However, the patient was discharge on the 45th postoperative day. Attempts for endoscopic removal of the impacted stone should be the initial therapeutic step. Surgery should be reserved for cases refractory to endoscopic intervention and when definite treatment is the actual challenge.

Dumping symptoms and incidence of hypoglycaemia after provocation test at 6 and 12 months after laparoscopic sleeve gastrectomy.

BACKGROUND: A previous study has demonstrated that symptoms suggestive of dumping syndrome appear after a provocation test early after laparoscopic sleeve gastrectomy (LSG) in 45 % of patients, and these are mainly related to early dumping. The aim of this study is to evaluate the evolution of dumping symptoms during the first postoperative year. METHODS: Twenty-five non-diabetic morbidly obese patients (6 male, 19 female) were evaluated with an oral glucose tolerance test (OGTT) preoperatively, at 6 weeks and at 6 months postoperatively. In addition, 12 of them repeated the OGTT at 12 months after LSG. Sigstad score was used to separate dumpers from non-dumpers and Arts' questionnaire to differentiate between early and late dumping. Insulin and glucose levels were also measured. RESULTS: Sigstad score remained significantly elevated at 6 and 12 months postoperatively compared to preoperative values. Symptoms suggestive of dumping syndrome were recorded in 40 % of patients at 6 months and in 33 % at 12 months postoperatively. Arts' questionnaire demonstrated that early dumping score remained higher compared to baseline at 6 and 12 months postoperatively. Late dumping scores increased gradually during the time and that difference was statistically significant at 12 months after LSG. Hypoglycaemia occurred at 33 % of patients both at 6 and 12 months postoperatively. CONCLUSIONS: Symptoms suggestive of dumping syndrome after provocation still exist at 6 and 12 months in a significant proportion of patients after LSG and include both early and late dumping. These findings are consistent with the high incidence of hypoglycaemia after OGTT at 6 and 12 months after LSG.

A new endovascular radiofrequency device for dilatation of vascular stenosis in a rabbit model.

PURPOSE: To investigate the use of a new endovascular radiofrequency (RF) device, the Habib™ VesCoag™ Catheter, to induce vascular remodeling and dilatation of arterial stenosis in a rabbit model. MATERIALS AND METHODS: RF was used to induce arterial stenosis in 10 rabbits and this was confirmed by angiography and color Doppler ultrasound. Two groups of five animals were then subjected to (1) balloon dilatation of the stenosis (intervention group), (2) no intervention (control group). Two rabbits from each group were sacrificed following the procedures to investigate vessel histopathology. At six weeks, the remaining six rabbits underwent follow-up angiogram and color Doppler ultrasound to assess vessel patency. They were then sacrificed and the vessels prepared for histopathological analysis. Three-dimensional images with confocal microscopy of the arterial lumen were also acquired. RESULTS: In the intervention group, stenosis was reversed and patency confirmed by angiography and color Doppler ultrasound six weeks later in all surviving rabbits. Histopathology revealed degenerative changes of elastic fibers, focal losses of elastica lamella, disorganization of myocytes and extensive hyalinization of the tunica adventitia. Focal elastin changes of the arterial elastic lamella were also shown by three-dimensional confocal microscopy images. CONCLUSION: We have developed a novel endovascular RF catheter that can be safely and effectively used to induce vascular remodeling and dilatation of arterial stenosis in an experimental rabbit model.

Laparoendoscopic rendezvous versus preoperative ERCP and laparoscopic cholecystectomy for the management of cholecysto-choledocholithiasis: interim analysis of a controlled randomized trial.

BACKGROUND: Although the ideal management of cholecysto-choledocholi-thiasis is controversial, the 2-stage approach [endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy, and common bile duct (CBD) clearance followed by laparoscopic cholecystectomy] remains the standard way of management worldwide. One-stage approach using the so-called laparoendoscopic rendezvous (LERV) technique offers some advantages, mainly by reducing the hospital stay and the risk of post-ERCP pancreatitis. OBJECTIVE: To compare the LERV 1-stage approach with the standard 2-stage approach consisting of preoperative ERCP followed by laparoscopic cholecystectomy for the treatment of cholecysto-choledocholithiasis. SETTING: Controlled randomized trial, University/Teaching Hospital. METHODS: : Patients with cholecysto-choledocholithiasis were randomized either to LERV or to the 2-stage approach. Both elective and emergency cases were included in the study. Primary endpoint was to detect difference in overall hospital stay, whereas secondary endpoints were (i) to detect differences in morbidity (especially post-ERCP pancreatitis) and (ii) success of CBD clearance. This is an interim analysis of the first 100 randomized patients. RESULTS: Hospital stay was significantly shorter in the LERV group; median 4 (2-19) days versus 5.5 (3-22) days, P = 0.0004. There was no difference in morbidity and success of CBD clearance between the 2 groups. Post-ERCP amylase value was found significantly lower in the LERV group: median 65 (16-1159) versus 91 (30-1846), P = 0.02. CONCLUSIONS: Interim analysis of the results suggests the superiority of the LERV technique in terms of hospital stay and post-ERCP hyperamylasemia.

Symptoms suggestive of dumping syndrome after provocation in patients after laparoscopic sleeve gastrectomy.

BACKGROUND: Dumping syndrome is a well-known complication after upper gastrointestinal (GI) surgery. There are scarce data in the literature about the incidence of dumping after bariatric operations but, certainly no relation between this syndrome and laparoscopic sleeve gastrectomy (LSG) has been attempted. METHODS: We conducted a prospective clinical study in order to evaluate the potential presence, incidence and severity of Dumping syndrome after LSG. Thirty one non-diabetic morbidly obese patients (eight male, 23 female) eligible for LSG were evaluated. Median age was 38 (22-58 years) and mean body mass index (BMI) was 45.55 (± 5.37). The diagnosis of dumping syndrome was based on clinical provocation of signs and symptoms using an oral glucose challenge before and 6 weeks after the operation. The Sigstad's dumping score was estimated in order to separate dumpers from non-dumpers, and the Arts questionnaire was completed to distinguish between early and late dumping. Moreover, blood glucose levels during the oral glucose challenge were measured. RESULTS: No patient had symptoms of dumping after provocation preoperatively, whereas after LSG 9 patients (29%) experienced definite dumping and other 5 patients (16%) symptoms suggestive of dumping syndrome. Arts' questionnaire demonstrated that dumping occurrence after LSG was associated with early symptoms. Late hypoglycaemia occurred in one patient. CONCLUSION: A significant proportion of patients after LSG experienced dumping syndrome upon provocation. It seems that LSG should no longer be considered as a pure restrictive procedure, and it might be an option for heavy sweeters by changing their food tolerance patterns.

Influence of the learning curve on safety and efficiency of laparoscopic sleeve gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is a relatively new bariatric procedure, and data regarding the learning curve are scarce. The aim of this study is to assess how the procedure can be safely implanted in a newly established bariatric unit and to define the learning curve. METHODS: Proctorship and mentorship in bariatric surgery were attended by two surgeons who were previously experienced in advanced laparoscopic surgery. The first consecutive 102 patients who underwent LSG in our newly established bariatric center were included. Patients were divided into three groups of 34 (groups 1, 2, and 3) according to case sequence. Data on demographics, operative time, conversion rate, hospital stay, morbidity, mortality, and excess weight loss (EWL) over time were compared between the groups. RESULTS: The operative time was significantly lower in groups 2 (p = 0.016) and 3 (p = 0.003) compared to group 1. The learning curve was flat up to the 68th case. A significant decrease in hospital stay was noted for group 3 compared to groups 1 (p < 0.001) and 2 (p = 0.002). The conversion rate, mortality and morbidity rates, and EWL did not differ significantly between the groups. Mortality was 0.98% and procedure-related morbidity was 7.8%. CONCLUSIONS: LSG can be safely and efficiently performed in a newly established bariatric center following a mentorship procedure. Proficiency seems to require 68 cases. The operative time and hospital stay may significantly decrease with experience early in the learning curve, as opposed to mortality and morbidity rates, conversion rate, and EWL.