Safety and Efficiency of an Articulating Needle Driver in Advanced Laparoscopic Abdominal Surgery.

Objective: Robotic platforms offer articulating needle drivers but are associated with high costs and lack tactile feedback. The recently developed mechanical Laparoscopic Articulating Needle Driver (LAND) (Flexdex®) for conventional laparoscopy offers enhanced dexterity without these limitations. The goal of this study was to assess safety and efficiency during the implementation of the LAND, and describe its learning curve, in an expert center for laparoscopic surgery. Methods: All LAND-assisted procedures after clinical implementation for a period of 16 months were included into this study. Primary outcome domains were safety (intra- and postoperative complications within 30 days) and efficiency (operative time, suturing, and knot tying time of staple defects of enteroenterostomy). CUmulative SUM (CUSUM) analysis was utilized to describe the enteroenterostomy suturing time learning curve across consecutive cases by plotting the deviation from the series mean. Results: Forty-five procedures (34 Roux-en-Y gastric bypass [of which 7 including diaphragmatic hernia repair], 2 diaphragmatic hernia repair with Nissen fundoplication, and 2 right-sided hemicolectomy) were included into this study. Median (range) operative time and enteroenterostomy suturing time were 68 (46-177) minutes and 161 (112-241) seconds, respectively, comparable with conventional needle driver standards. One procedure was converted to the conventional needle driver due to device malfunctioning and one patients' postoperative course was complicated by a Clavien-Dindo grade 3a complication (intraluminal bleeding requiring gastroscopy). CUSUM chart displays a progression toward the mean from case 22 onward, indicating a limited learning curve. Conclusion: The LAND can be implemented safely and efficiently at a center of excellence for laparoscopic surgery and is associated with a limited learning curve.

The Acute Abdomen in Pregnant Women After Roux-en-Y Gastric Bypass: Encouraging Results from a National Referral Centre.

BACKGROUND: Pregnant women with a history of bariatric surgery (BS) may develop acute abdominal pain related to this surgery, especially after Roux-en-Y gastric bypass. Studies showed alarming results regarding maternal and foetal morbidity and mortality. The aim of this study was to analyse these outcomes for pregnant women and their offspring. METHODS: Single-centre retrospective cohort study in a tertiary referral centre for bariatric complications during pregnancy. Pregnant women with a history of BS referred between September 2015 and November 2019 with acute abdominal pain suspected for a bariatric complication were included. Data were retrospectively collected from the patient files, and a questionnaire was sent regarding the postoperative course and childbirth. RESULTS: Fifty women were included. At presentation, mean maternal age was 31 (± 4) years, and median gestational age was 28+4 (25+4, 30+5) weeks. Thirteen women were treated conservatively. Thirty-seven women underwent surgery for, among others, internal herniation (n = 26) and intussusception (n = 6). Six women required small bowel resection. Two women underwent an emergency caesarean section shortly after the surgery due to foetal distress. Eight women delivered preterm of whom five infants required respiratory support. There was one intrauterine foetal death. Surgery > 48 h after the onset of the symptoms was not associated with an increase in small bowel resections or preterm birth. CONCLUSION: Acute abdominal pain in pregnant women may be related to a bariatric complication. Further awareness of bariatric complications within the obstetric care and transferal to specialized care to prevent diagnostic delay may improve maternal and neonatal outcome.

Primary and Secondary Nonresponse Following Bariatric Surgery: a Survey Study in Current Bariatric Practice in the Netherlands and Belgium.

PURPOSE: Primary nonresponse (1NR) - inability to achieve adequate weight loss after surgery - and secondary nonresponse (2NR) - excessive weight regain after initial adequate weight loss after surgery - can occur in up to 25-35% of patients after bariatric surgery. The aim of this study was to explore the variations in both definition as well as management of 1NR and 2NR amongst bariatric surgeons. MATERIALS AND METHODS: An online survey was distributed to all members of the national bariatric societies in the Netherlands and Belgium regarding questions about definition, work-up and treatment of 1NR and 2NR after bariatric surgery. RESULTS: A total of 45 responses from bariatric surgeons were obtained, representing 32 medical centers that perform bariatric procedures. When assessing 1NR, excess weight loss(EWL) was reported to be used by most respondents(30/45), total body weight loss(TBWL) by 18/45 and body mass index(BMI) by 25/45. A great variation in cut off values was observed. When assessing 2NR, percentage weight gain from the lowest (nadir) weight was preferred most by 22/45 respondents with cut off values varying from 5 to 20%. Most respondents deemed 18 months after initial surgery the most appropriate timeframe to determine 1NR or 2NR. CONCLUSIONS: The current practice regarding primary and secondary nonresponse after bariatric surgery has a wide variety in definitions, work-up and treatment options. Consensus on the definition of 1NR and 2NR is needed to optimize the treatment of bariatric patients.

Reliability and usefulness of upper gastro intestinal contrast studies to assess pouch size in patients with weight loss failure after Roux-en-Y gastric bypass.

Background: Weight loss failure or weight regain occurs in up to 25% of patients with a Roux-en-Y gastric bypass (RYGB). Post-operative anatomical changes, like pouch or stoma dilatation, might contribute. Aim of this study is to assess reliability and usefulness of upper gastro intestinal (UGI) contrast studies to detect pouch dilatation.Methods: Retrospective case-control study of patients with weight loss failure between 2010 and 2015 (failure group, n = 101) and a control group (n = 101) with adequate weight loss. Pouch dilatation was systematically reassessed. Clinical parameters were extracted from the electronic patient records.Results: Systematic reassessment showed 23/101 (23%) pouch dilatation in the failure group, compared to 11/101 (11%) in the control group (p = .024). Revision surgery was performed in 43/101 patients in the failure group. After this surgery, only 8% of patients with pouch dilatation achieved adequate weight loss, whereas 39% of patients without pouch dilatation achieved adequate weight loss (p = .07). There was no difference in return to adequate weight loss between patients treated surgically and conservatively (30% vs 28%).Conclusion: Systematic reassessment of UGI contrast studies showed 23% pouch dilatation in patients with weight loss failure after RYGB. However, low interobserver agreement and discrepancy in success rate of revision surgery greatly questions the reliability and usefulness of this diagnostic modality.

Pregnant patient with acute abdominal pain and previous bariatric surgery.

Pregnant women who previously had bariatric surgery may develop acute abdominal pain during pregnancy. Two patients, 38-year-old twin primigravida (gestational age of 24+6 weeks) and a 26-year-old woman (gestational age of 24+0 weeks), both of whom had laparoscopic gastric bypass surgery previously, developed abdominal pain. The patients both had diffuse abdominal pain in combination with normal blood tests and imaging. Patient B had undergone laparoscopy at another centre after 5 weeks of gestation for internal herniation. After referral to our multidisciplinary bariatric-obstetric-neonatal (MD-BON) team, diagnostic laparoscopy was advised as internal herniation was deemed possible. In both patients, internal herniation was indeed found in Petersen's space and jejunal mesenteric defect, which was closed using laparoscopic surgery. Both women delivered healthy offspring afterwards. The presence of an MD-BON team allows for an increased awareness of potential long-term complications associated with earlier bariatric surgery in pregnancy.

Diet-Induced Alteration of Microbiota and Development of Obesity, Nonalcoholic Fatty Liver Disease, and Diabetes: Study Protocol of a Prospective Study.

BACKGROUND: Development of obesity and obesity-related diseases, such as type 2 diabetes mellitus and nonalcoholic fatty liver disease (NAFLD), is associated with altered gut microbiota composition. The aim of this study is to investigate associations among dietary compounds, intestinal cell function, and gut microbiota composition. We hypothesize that dietary lipid intake is associated with Paneth cell and goblet cell properties that affect gut microbiota composition. OBJECTIVE: The primary objective of this study is to determine whether a difference in dietary intake is associated with a difference in intestinal mucin-2 expression and gut microbiota composition. METHODS: This is a single-center prospective study, including 1 obese group undergoing laparoscopic Roux-en-y gastric bypass and 2 lean control groups undergoing either laparoscopic cholecystectomy or upper gastrointestinal endoscopy (n=228). During laparoscopy, biopsies will be taken of visceral fat (omentum majus), liver, muscle tissue of the abdominal wall, and subcutaneous fat. In the obese group, a small segment of the jejunum will be collected for analysis, which will be compared with an endoscopically derived jejunal biopsy from the upper gastrointestinal endoscopy control group. Stool samples for microbiota profiling will be collected at baseline and 1 year after surgery. Primary outcomes are fecal microbiota composition and mucus characteristics. Secondary outcomes include Paneth cell phenotype, body weight, diet composition, glucose tolerance, resolution of comorbidities, and weight loss 1 year after surgery. RESULTS: This trial is currently open for recruitment. The anticipated completion date is December 2019. CONCLUSIONS: The Diet-Induced Alteration of Microbiota and Development of Obesity, NAFLD, and Diabetes study will improve insight into the pathophysiology of obesity and its associated metabolic disorders. Better understanding of weight loss failure and weight regain following bariatric surgery might also behold new therapeutic opportunities for obesity and obesity-related comorbidities. TRIAL REGISTRATION: Netherlands Trial Register NTR5660; https://www.trialregister.nl/trial/5540 (Archived by WebCite at http://www.webcitation.org/78l7jOZre). INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/11553.

Lack of Standard Definitions of Primary and Secondary (Non)responders After Primary Gastric Bypass and Gastric Sleeve: a Systematic Review.

Lack of standard definitions of primary and secondary (non)responders after RYGB and SG makes it impossible to compare the literature. The aim was to analyze the different definitions used. MEDLINE® was searched for literature published between 01-07-2014 and 01-07-2017 concerning (1) patients who received a primary RYGB or SG and (2) the outcomes of primary and secondary (non)responders. One hundred twelve out of 650 papers were eligible. Forty out of 47 papers described a definition of weight loss success. Sixty-seven out of 112 papers mentioned weight loss failure of which 42 described a definition, in total 23 different definitions. Weight regain was mentioned in 77 papers; only 21 papers provided a definition. The recent literature regarding definitions of these outcomes is highly inconsistent. To compare the literature international consensus is required.

[Abdominal pain in a pregnant patient who had gastric reduction surgery: risks associated with a history of bariatric surgery]. / Buikpijn bij een zwangere die een maagverkleining heeft gehad.

Pregnant women who previously had bariatric surgery may develop acute abdominal pain during pregnancy that may be related to previous operations. Two patients, a 38-year-old twin-primigravida who had a gestation period of 24+6 weeks and a 26-year-old woman who had a gestation period of 24 weeks, both of whom had laparoscopic gastric bypass (RYGB) surgery 2 and 3 years previously, developed abdominal pain. The patients were not ill, but had diffuse abdominal pain in combination with normal blood tests and imaging. Patient B had undergone laparoscopy at another centre after 5 weeks of gestation for internal herniation. After referral to our multidisciplinary Bariatric-Obstetric-Neonatal (MD-BON) team, diagnostic laparoscopy was advised as internal herniation was deemed possible. In both patients, internal herniation was indeed found in Petersen's space and jejunal mesenteric defect, which was closed using laparoscopic surgery. Both women delivered healthy offspring afterwards. The presence of a MD-BON team allows for an increased awareness of potential long-term complications associated with earlier bariatric surgery in pregnancy.

Laparoscopic Adjustable Gastric Banding After Failed Roux-En-Y Gastric Bypass.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) is associated with approximately 25 % weight loss failure, resulting in insufficient weight loss or weight regain. Strategies of revisional surgery focus on alteration of limb length, pouch or stoma size. Altering pouch size and outlet by adding laparoscopic adjustable gastric band (LAGB) might initiate further weight loss. The goal of this study is to review the safety and efficacy of LAGB after failed RYGB in a retrospective cohort of patients in our institute. METHODS: Patients with secondary LAGB (n = 44) were studied between May 2012 and January 2015. Demographics, effects on weight loss and complications were analysed. RESULTS: Mean age and body mass index (BMI) at time of LAGB was 45.8 ± 8.2 years and 37.2 ± 5.4 kg/m2, respectively. Mean interval between RYGB and LAGB was 2.6 ± 1.3 years. Mean follow-up was 14 ± 7.9 months, with 25 % loss to follow-up at 12 months. Due to LAGB, patients lost an additional 17.6 % ± 28.3 % excess weight. Patients with weight regain after initial weight loss success showed more excess weight loss (EWL) compared to patients whom never reached 50% EWL after RYGB. Overall complication and reoperation rates were 30 and 21 %, respectively, with 16 % band removal. One fatality due to septic shock following band erosion was observed. CONCLUSION: In this largest published cohort, secondary banding of failed RYGB provides only limited additional weight loss. Furthermore, this technique is associated with high morbidity and reoperation rates. A significant difference in effect was found between patients with weight loss failure and weight regain. Larger prospective series are necessary to evaluate if the modest benefits are worth the risks of secondary LAGB.

Loss of Skeletal Muscle Mass During Neoadjuvant Chemoradiotherapy Predicts Postoperative Mortality in Esophageal Cancer Surgery.

BACKGROUND: Esophageal surgery is associated with complications and mortality. It is highly important to develop tools predicting unfavorable postoperative outcome. Esophageal cancer and neoadjuvant chemoradiotherapy (CRT) induce skeletal muscle wasting, which leads to diminished physiologic reserves. The purpose of this study was to investigate whether the degree of muscle mass lost during neoadjuvant CRT predicts postoperative mortality. METHODS: A total of 123 consecutive patients undergoing surgery for esophageal malignancy in the period 2008-2012 were included, of whom 114 received neoadjuvant CRT. Skeletal muscle mass was measured on routinely performed CT scans by assessing L3 muscle index (according to the Prado method) before and after neoadjuvant CRT, and the amount of muscle mass lost during neoadjuvant CRT (muscle loss index) was calculated. It was investigated whether this amount was associated with postoperative 30-day or in-hospital mortality and morbidity. RESULTS: In the complete cohort, no significant association between loss of muscle mass and mortality was found. However, skeletal muscle mass was significantly lower in patients with stage III-IV tumors compared with stage I-II tumors, prior to neoadjuvant CRT. In the stage III-IV subgroup, the amount of muscle mass lost during neoadjuvant CRT was predictive of postoperative mortality: -13.5 % (standard deviation 6.2 %) in patients who died postoperatively compared with -5.0 % (standard deviation 8.3 %) in surviving patients, p = 0.02. CONCLUSIONS: Measurement of muscle mass loss during neoadjuvant chemoradiotherapy may provide a readily available and inexpensive assessment to identify patients at risk for developing unfavorable postoperative outcome after resection of esophageal malignancies, especially in patients with stage III-IV tumors.