Konservative versus chirurgische Therapie beim idiopathischen und sekundären Megakolon oder Megarektum im Erwachsenenalter - eine retrospektive multizentrische Kontrollstudie.

BACKGROUND: Idiopathic and secondary megacolon (MC) and megarectum (MR) in adults is associated with persistent bowel dilatation and reduced intestinal motility. Little is known about the optimal treatment of this rare disease. Therefore, we retrospectively analysed long-term data from these patients in 5 community and university hospitals, focusing on conservative versus surgical treatment. METHODS: Patient records from 7/2004 to 9/2021 were screened for colorectal diseases with severe constipation and persistent megacolon ≥ 9.0 cm and/or megarectum ≥ 6.5 cm. Follow up-data was collected through telephone interviews and written surveys. ClinicalTrialsgov NCT04340856. RESULTS: Sixty-seven patients with idiopathic (n=10) and secondary (n=57) MC or MR were identified with only 20 of 67 patients (29.9%) correctly diagnosed. Mean/median age was 64/69 (range 18-93) years. Thirty-two patients were treated with laxative regimens, and 35 underwent surgery (colostomy: n=12, segmental resection, or hemicolectomy: n=10, (sub)total colectomy: n= 13) after conservative treatment attempts in 32/35 (91.4%). The mean/median follow-up was 4.2/2.7 (range 0.1-17.0) years. The readmission rate for MC-associated symptoms was significantly higher after conservative treatment than after surgical therapy at 12 (0.84 vs. 0.36 per patient, p=0.036), 24 (1.00 vs. 0.52, p=0.048) and 36 (1.13 vs. 0.58, p=0.047) months, as was the number of patients with persistent laxative dependence (28/32 (87.5%) vs. 19/33 (57.6%); p = 0.007). Therapy-associated adverse events (Clavien-Dindo classification) were documented more often in surgically treated patients (11/35, 31.4%) (p=0.025). CONCLUSION: Surgical treatment may be considered earlier if idiopathic or secondary MC or MR is correctly diagnosed, and conservative treatment has been attempted.

Reliability of neural food cue-reactivity in participants with obesity undergoing bariatric surgery: a 26-week longitudinal fMRI study.

Obesity is highly prevalent worldwide and results in a high disease burden. The efforts to monitor and predict treatment outcome in participants with obesity using functional magnetic resonance imaging (fMRI) depends on the reliability of the investigated task-fMRI brain activation. To date, no study has investigated whole-brain reliability of neural food cue-reactivity. To close this gap, we analyzed the longitudinal reliability of an established food cue-reactivity task. Longitudinal reliability of neural food-cue-induced brain activation and subjective food craving ratings over three fMRI sessions (T0: 2 weeks before surgery, T1: 8 weeks and T2: 24 weeks after surgery) were investigated in N = 11 participants with obesity. We computed an array of established reliability estimates, including the intraclass correlation (ICC), the Dice and Jaccard coefficients and similarity of brain activation maps. The data indicated good reliability (ICC > 0.6) of subjective food craving ratings over 26 weeks and excellent reliability (ICC > 0.75) of brain activation signals for the contrast of interest (food > neutral) in the caudate, putamen, thalamus, middle cingulum, inferior, middle and superior occipital gyri, and middle and superior temporal gyri and cunei. Using similarity estimates, it was possible to re-identify individuals based on their neural activation maps (73%) with a fading degree of accuracy, when comparing fMRI sessions further apart. The results show excellent reliability of task-fMRI neural brain activation in several brain regions. Current data suggest that fMRI-based measures might indeed be suitable to monitor and predict treatment outcome in participants with obesity undergoing bariatric surgery.

Interdisciplinary Successful Revascularization of Traumatic Occlusion of the Right Common Carotid Artery.

Blunt carotid artery injury (BCI) poses a rare yet severe threat following vascular trauma, often leading to significant morbidity and mortality. We present a case of a 33-year-old male who suffered complete thrombotic occlusion of the right common carotid artery (CCA) following a workplace accident. Clinical evaluation revealed profound neurological deficits, prompting multidisciplinary surgical intervention guided by the Denver criteria (Grade I - disruption inside the vessel that results in a narrowing of the lumen by less than 25%; Grade II - dissection or intramural hematoma causing greater than 25% stenosis; Grade III - comprises pseudoaneurysm formation; Grade IV - causes total vessel occlusion; Grade V - describes vessel transection with extravasation). Surgical exploration unveiled extensive arterial damage, necessitating thrombectomy, primary repair, and double-layered patch angioplasty using an autologous saphenous vein. Postoperative recovery was uneventful, with the restoration of pulsatile blood flow confirmed by Doppler ultrasound. Three-month follow-up demonstrated patent arterial reconstruction and improved cerebral perfusion, despite the persistent neurological deficits. Our case underscores the challenges in diagnosing and managing BCI, advocating for a tailored approach based on injury severity and neurological status. While conservative management remains standard, surgical intervention offers a viable option in select cases, particularly those with complete vessel occlusion and neurological compromise. Long-term surveillance is imperative to assess the durability of arterial reconstruction and monitor for recurrent thromboembolic events. Further research is warranted to refine management algorithms and elucidate optimal treatment strategies in this rare but critical vascular pathology.

In Situ Electron Paramagnetic Resonance Monitoring of Predegradation Radical Generation in a Lithium Electrolyte.

Herein we present an innovative in situ EPR spectroscopy approach complemented with computational modeling as a methodology for assessing a nonaqueous electrolyte behavior just before its massive degradation. As a proof of concept, we use the conventional lithium electrolyte (1 M LiPF6 in EC/DMC), which is utilized in current lithium-ion batteries. Through in situ EPR, long-lived EC•- associates in amounts of 10-250 ppm were detected in a broad potential window (>2.0 V) prior to the electrolyte oxidation or reduction. The pathways of radical formation are discussed in terms of the imperfection in the electron flow across the electrolyte-electrode interface and of the strong affinity of EC to electron trapping. The radical amount could be amplified markedly (above 1000 ppm) by addition of vinylene carbonate (VC) to the electrolyte, while the added CeO2 has a moderate effect. The proposed in situ EPR methodology could be transferred to other electrolyte solutions to become a universal approach.

Remote Follow-up with a Mobile Application Is Equal to Traditional Outpatient Follow-up After Bariatric Surgery: the BELLA Pilot Trial.

PURPOSE: Medical follow-up after bariatric surgery is recommended. However, the compliance was poor. This study aimed to evaluate the feasibility of a smartphone-based fully remote follow-up (FU) program for patients after bariatric surgery. METHODS: In the interventional group, patients were followed up using a smartphone application (app), through which questionnaires were sent regularly. Participants in the control group underwent standard FU at the outpatient clinic every three months. After 12 months, all the participants were evaluated at an outpatient clinic. RESULTS: Between August 2020 and March 2021, 44 and 43 patients in the interventional and control groups, respectively, were included in the analysis after three patients were lost to FU, and three withdrew their informed consent because they wished for more personal contact with medical caregivers. After 12 months, total weight loss (TWL), %TWL, and percentage of excess weight loss (%EWL) did not differ between groups. There were no significant differences in the complication rates, including surgical complications, malnutrition, and micronutrition deficiency. The parameters of bioelectrical impedance analysis and quality of life did not differ between the groups. Vitamins and minerals in serum were similar in both groups except for calcium, which was significantly higher in the interventional group (2.52 mmol/L vs. 2.35 mmol/L, p = 0.038). CONCLUSION: Fully remote FU with a smartphone application is at least as effective as traditional in-person FU in an outpatient clinic after bariatric surgery. Through remote FU, patients can save time and medical professionals may have more resources for patients with more severe problems.

Reduction of Pain After Laparoscopic Bariatric Surgery by Personalized Checkpoint Acupuncture-Data of a STRICTA Conform Pilot Study.

BACKGROUND: It remains challenging in clinical practice to perform optimal pain management following bariatric surgeries. Acupuncture (AC) is an effective method of postoperative pain management, but its clinical efficacy depends on the rationale used to select AC points. METHODS: We developed a method to identify individual patterns of pain and a corresponding set of acupoints (corrAC) based on the relative pressure sensitivity of six abdominal visceral pressure points, i.e., the gastrointestinal (GI) checkpoints (G1-G6). Patients with moderate to severe pain were included and received a single AC treatment following surgery. The visual analog scale (VAS) score, pain threshold, and skin temperature were assessed before AC and at 5 min, 1 h, and 24 h following AC. AC was performed with 1-mm-deep permanent needles. RESULTS: From April 2021 to March 2022, 72 patients were included in the analysis. Fifty-nine patients received corrAC, whereas 13 received a noncorresponding AC (nonAC) as an internal control. Patients receiving corrAC showed a significant reduction (74%) in pain at 5 min after treatment (p < 0.0001) and a significant increase (37%) in the pain threshold (p < 0.0001). In this group, a significant increase in skin temperature above G1, G3, G4, and G5 was observed. Patients receiving nonAC showed neither significant pain reduction nor significant changes in pain threshold. The skin above G3 and G4 did not reveal temperature changes. CONCLUSION: Checkpoint AC may be an effective tool in postoperative pain therapy after bariatric surgery. Vegetative functional involvement might be associated with pain relief.

Sarcopenia after Roux-en-Y Gastric Bypass: Detection by Skeletal Muscle Mass Index vs. Bioelectrical Impedance Analysis.

Background: In sarcopenic patients the skeletal muscle reduction is the primary symptom of age- or disease-related malnutrition, which is linked to postoperative morbidity and mortality. The skeletal muscle mass index (SMI) from magnet resonance imaging (MRI) is increasingly used as a prognostic factor in oncologic and surgical patients, but under-represented in the field of obesity surgery. The bioelectrical impedance analysis (BIA), on the other hand is a commonly used method for the estimation of the body composition of bariatric patients, but still believed to be inaccurate, because of patient-related and environmental factors. The aim of this study was to compare the postoperative SMI values as a direct, imaging measured indicator for muscle mass with the BIA results in patients undergoing Roux-en-Y gastric bypass (RYGB). Methods: We performed a prospective single-center trial. Patients undergoing RYGB between January 2010 and December 2011 at our institution were eligible for this study. MRI and BIA measurements were obtained 1 day before surgery and at 6, 12 and 24 weeks after surgery. Results: A total of 17 patients (four male, 13 female, average age of 41.9 years) were included. SMI values decreased significantly during the postoperative course (p < 0.001). Comparing preoperative and postoperative measurements at 24 weeks after surgery, increasing correlations of SMI values with body weight (r = 0.240 vs. r = 0.628), phase angle (r = 0.225 vs. r = 0.720) and body cell mass (BCM, r = 0.388 vs. r = 0.764) were observed. Conclusions: SMI decreases significantly after RYGB and is correlated to distinct parameters of body composition. These findings show the applicability of the SMI as direct imaging parameter for the measurement of the muscle mass in patients after RYGB, but also underline the important role of the BIA, as a precise tool for the estimation of patients' body composition at low costs. BIA allows a good overview of patients' status post bariatric surgery, including an estimation of sarcopenia.

Smartphone application-based follow-up care of patients after bariatric surgery: A mixed-method study of usability.

Objective: Due to potential short-term and long-term complications, adequate lifelong follow-up is crucial for patients after bariatric surgery. However, compliance with postoperative follow-up is poor despite clear national and international guidelines. This feasibility trial aimed to evaluate the usability of a smartphone application-based follow-up program in patients after bariatric surgery. Methods: Patients were included after having undergone a primary bariatric surgery. Instead of attending meetings in our outpatient clinic, they were followed up using a smartphone application. After 6 months, the System Usability Scale (SUS) was used to measure participant perception. Additional interviews were performed to gain more insight into the usability of the app. Results: Between August 2020 and February 2021, 52 patients met the inclusion criteria and agreed to participate in the study, of whom 5 (9.6%) dropped out of the study. At the time of analysis, 31 patients have been followed up for 6 months, among whom 26 patients completed the SUS questionnaire. The mean overall score of SUS is 82.1 ± 19.8. In the qualitative analysis, participants were generally positive about the follow-up care and found it easy to use, despite some minor technical problems. Conclusion: Our smartphone app-based follow-up program was proven to be effective in the aftercare succeeding bariatric surgery. Our data indicates that the satisfaction, efficiency, learnability, and ease of use of the smartphone application were coherent in the acceptance and use of mobile technology by patients.

Morbidity and Mortality conference as part of PDCA cycle to decrease anastomotic failure in colorectal surgery.

BACKGROUND AND AIMS: Morbidity and Mortality meetings are an accepted tool for quality management in many hospitals. However, it is not proven whether these meetings increase quality. It was the aim of this study to investigate whether Morbidity and Mortality meetings as part of a PDCA cycle (Plan, Do, Check, Act) can improve the rate of anastomotic failure in colorectal surgery. MATERIALS AND METHODS: From January 1, 2004, to December 31, 2009, data for all anastomotic failures in patients operated on for colorectal diseases in the Department of Surgery (Klinikum Friedrichshafen, Germany) were prospectively collected. The events were discussed in Morbidity and Mortality meetings. On the basis of these discussions, a strategy to prevent anastomotic leaks and a new target were defined (i.e. 'Plan'). This strategy was implemented in the following period (i.e. 'Do') and results were prospectively analysed. A new strategy was established when the results differed from the target, and a new standard was defined when the target was achieved (i.e. 'Check, Act'). RESULTS: The year 2004 was set as the base year. In 2005 and 2006, new strategies were established. Comparing this period with the period of strategy conversion (2007-2009), we found a significant decrease in the anastomotic failure rate in colorectal surgery patients (5.7% vs 2.8%; p = 0.05), whereas the risk factors for anastomotic failure were unchanged or unfavourable. CONCLUSIONS: If Morbidity and Mortality meetings are integrated in a PDCA cycle, they can decrease anastomotic failure rates and improve quality of care in colorectal surgery. Therefore, the management tool 'PDCA cycle' should be considered also for medical issues.

Dental Erosion in Obese Patients before and after Bariatric Surgery: A Cross-Sectional Study.

Obese patients are at risk of dental erosion due to micronutrient deficiency, consumption of soft drinks, gastric reflux disease and vomiting. The present study evaluates the presence of dental erosion in obese patients before and after bariatric surgery using the BEWE (basic erosive wear examination) scoring system. A total of 62 patients with severe obesity were included in the analysis, 31 in the control group (without bariatric surgery) and 31 in the surgery group (after bariatric surgery). BEWE scores did not vary between groups. Vitamin D deficiency was detected in 19 patients in the control group and three in the surgery group (p < 0.001). The serum calcium and vitamin D values were significantly higher in the surgery group (p = 0.003, p < 0.001 consecutively). All patients after bariatric surgery showed compliance with supplements, including vitamin D and calcium daily. Patients after bariatric surgery were less likely to drink soft drinks regularly (p = 0.026). Obese patients, before or after bariatric surgery, are at risk for erosive dental wear. However, with sufficient education prior to surgery and consistent intake of vitamin and mineral supplements, significant erosive dental wear after bariatric surgery could be avoided. Regular dental examination should be included in the check-up and follow-up program.

Serum Glucagon, Bile Acids, and FGF-19: Metabolic Behavior Patterns After Roux-en-Y Gastric Bypass and Vertical Sleeve Gastrectomy.

BACKGROUND: Metabolic/bariatric surgery is a highly effective treatment for obesity and metabolic diseases. Serum glucagon, bile acids, and FGF-19 are key effectors of various metabolic processes and may play central roles in bariatric surgical outcomes. It is unclear whether these factors behave similarly after Roux-en-Y gastric bypass (RYGB) vs vertical sleeve gastrectomy (VSG). METHODS: Serum glucagon, bile acids (cholic acid [CA], chenodeoxycholic acid [CDCA], deoxycholic acid [DCA]), and FGF-19 were analyzed in samples of fasting blood collected before bariatric surgery, on postoperative days 2 and 10, and at 3- and 6-month follow-up. RESULTS: From September 2016 to July 2017, patients with obesity underwent RYGB or VSG; 42 patients (RYGB n = 21; VSG n = 21) were included in the analysis. In the RYGB group, glucagon, CA, and CDCA increased continuously after surgery (p = 0.0003, p = 0.0009, p = 0.0001, respectively); after an initial decrease (p = 0.04), DCA increased significantly (p = 0.0386). Serum FGF-19 was unchanged. In the VSG group, glucagon increased on day 2 (p = 0.0080), but decreased over the 6-month study course (p = 0.0025). Primary BAs (CA and CDCA) decreased immediately after surgery (p = 0.0016, p = 0.0091) and then rose (p = 0.0350, p = 0.0350); DCA followed the curve of the primary BAs until it fell off at 6 months (p = 0.0005). VSG group serum FGF-19 trended upward. CONCLUSION: RYGB and VSG involve different surgical techniques and final anatomical configurations. Between postoperative day 2 and 6-month follow-up, RYGB and VSG resulted in divergent patterns of change in serum glucagon, bile acids, and FGF-19.

Trocar Site HERnias After Bariatric Laparoscopic Surgery (HERBALS): a Prospective Cohort Study.

BACKGROUND: The exact prevalence of trocar site hernias after bariatric procedures is not yet known. Recent metaanalysis data indicated concerning rates of up to 25%. We conducted a prospective cohort study to estimate the prevalence and analyze the role of fascia closure in the development of trocar hernias. METHOD: A total of 365 patients who were operated for obesity in our department between 2009 and 2018 were included. All patients were invited for a follow-up ultrasonography scan in order to detect abdominal wall defects. The role of intraoperative fascia closure in the development of trocar site hernias was evaluated, and a logistic regression analysis was performed to detect potential risk factors. RESULTS: The overall prevalence of trocar hernias detected by ultrasonography was 34%. The prevalence of abdominal wall defects in patients who received a fascia closure was 37% compared with 34% in patients who did not receive a fascia closure (p = 0.37). The only factor that was associated with a higher risk for trocar site hernias was high excessive weight loss (p = 0.05). CONCLUSION: Trocar site hernias are an underestimated complication of minimally invasive, multiportal bariatric surgery, and the prevalence of asymptomatic hernias is probably higher than initially expected. In this study, fascia closure did not protect against trocar hernias. However, opposing evidence from similar trials suggests closing the fascia. This clinical problem should therefore be further assessed in a prospective randomized setting.

Skeletal Muscle Mass Index Predicts Postoperative Complications in Intestinal Surgery for Crohn's Disease.

BACKGROUND: The aim of this study was to evaluate the role of the skeletal muscle mass index (SMI) for major postoperative morbidity in patients with Crohn's disease (CD) and intestinal surgery at a tertiary referral center. METHODS: A retrospective analysis of the prospectively maintained database for surgical patients with CD at our institution was performed. The cases of all patients operated on between December 2009 and December 2017 with sectional imaging prior to surgery were eligible for this study. RESULTS: A total of 230 patients were included. Major postoperative complications were observed in 32 patients (13.9%). Common intestinal procedures were ileocecal resections (51.7%), segmental small-bowel resections (10%), and colectomy or proctocolectomy (8.3%). In multivariable analysis, SMI (P = .002; odds ratio = 0.914) was the only independent risk factor for major postoperative complications. Both computed tomography (CT) and magnetic resonance imaging (MRI) studies were suitable to determine SMI. The cutoff values for SMI were 31.8 cm2 /m2 for females and 41.5 cm2 /m2 for males. CONCLUSION: We present the largest published cohort investigating SMI with regard to major postoperative morbidity in surgery for CD. In multivariable analysis, SMI was the only significant risk factor for Clavien-Dindo complications grade ≥III. Lumbar SMI was reliably determined by CT and MRI alike. Because preoperative abdominal imaging with either modality is common for patients with CD, SMI could be a reliable and largely available tool to stratify the risk of postoperative complications.

Correction to: Trocar Site Hernias in Bariatric Surgery-an Underestimated Issue: a Qualitative Systematic Review and Meta-Analysis.

The review was not registered for systematic reviews and meta-analyses, and should be disregarded.

Trocar Site Hernias in Bariatric Surgery-an Underestimated Issue: a Qualitative Systematic Review and Meta-Analysis.

The reported incidence of trocar site hernias in bariatric surgery ranges between 0.5 and 3%. The best available evidence derives from retrospective studies analysing prospective databases, thus including only patients who presented with symptoms or received surgical treatment due to trocar site hernias after a laparoscopic bariatric procedure. A systematic literature research was conducted up until September 2017. Search strategies included proper combinations of the MeSH terms 'laparoscopy' and 'bariatric surgery', 'trocar/port' and 'hernia'. Searches were not limited by publication type or language. The review was registered in PROSPERO (ID 85102) and performed according to the PRISMA guidelines. Sixty-eight publications were included. Pooled hernia incidence was 3.22 (range 0-39.3%). Thirteen trials reported systematic closure of the fascia; 12 trials reported no closure. Data availability did not allow for pooling to calculate relative risk. Higher BMI and specific hernia examination using imaging modalities were associated with a significantly higher incidence of trocar site hernias. Studies dedicated to detection of TsH reported a pooled incidence of 24.5%. Trocar site hernias are an underestimated complication of minimally invasive multiportal bariatric surgery. While high-quality trials are not available allowing for a precise calculation of the incidence, existing data are indicative of very high incidence rates. Risk factors for developing a trocar site hernia in bariatric surgery have not yet been systematically analysed. Prospective studies in this field are necessary.

The Phase Angle of the Bioelectrical Impedance Analysis as Predictor of Post-Bariatric Weight Loss Outcome.

BACKGROUND: Bariatric surgery is proven to be the most effective therapy for obesity. However, the targeted weight reduction is not always achieved. Reliable predictors for postoperative success are rare. Also, most available predictors, such as gender and socioeconomic status, cannot be influenced. The aim of the study was to assess the reliability of the phase angle (PhA) as a predictor of weight reduction and body composition after bariatric surgery. METHODS: One hundred seventy-three patients (127 with Roux-en-Y gastric bypass and 46 with sleeve gastrectomy), treated between January 2004 and December 2012, were included into this prospective trial. Bioelectrical impedance analysis (BIA) was performed before and five times within the first year after the operation. Correlation between excess weight loss (EWL) was calculated using Pearson's correlation coefficient and a receiver operating characteristic (ROC) curve. RESULTS: The average weight loss was significant with a total weight loss of 30.1 %, while the PhA did not show any significant decrease during the first 12 months after surgery. The correlation between the preoperative PhA and the postoperative EWL was significant after 6 weeks and after 6, 9, and 12 months. The ROC curve has an area of 0.7. The best point of the curve is a PhA of 3.9° with a sensitivity of 81 % and a specificity of 54 %. CONCLUSIONS: PhA may be a useful predictor of EWL after bariatric surgery, and a PhA of 3.9° was calculated as the most suitable cut-off for a successful operation.