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BACKGROUND AND AIMS: Bile acids (BA) are vital regulators of metabolism. BAs are AQ6 secreted in the small intestine, reabsorbed, and transported back to the liver, where they can modulate metabolic functions. There is a paucity of data regarding the portal BA composition in humans. This study aimed to address this knowledge gap by investigating portal BA composition and the relation with peripheral and fecal BA dynamics in conjunction with the gut microbiome. APPROACH AND RESULTS: Thirty-three individuals from the BARIA cohort were included. Portal plasma, peripheral plasma, and feces were collected. BA and C4 levels were measured employing mass spectrometry. FGF19 was measured using ELISA. Gut microbiota composition was determined through metagenomics analysis on stool samples. Considerable diversity in the portal BA composition was observed. The majority (n = 26) of individuals had a 9-fold higher portal than peripheral BA concentration. In contrast, 8 individuals showed lower portal BA concentration compared with peripheral and had higher levels of unconjugated and secondary BA in this compartment, suggesting more distal origin. The altered portal BA profile was associated with altered gut microbiota composition. In particular, taxa within Bacteroides were reduced in abundance in the feces of these individuals. CONCLUSIONS: Characterization of the portal BA composition in relation to peripheral and fecal BA increased insight into the dynamics of BA metabolism in individuals with obesity. Peripheral BA composition was much more diverse due to microbial metabolism. About 24% of the portal samples was surprisingly low in total BA; the underlying mechanism requires further exploration.
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BACKGROUND: A learning curve (LC) is a graphic display of the number of consecutive procedures performed necessary to reach competence and is defined by complications and duration of surgery (DOS). There is little evidence on the LC of surgical residents in bariatric surgery. Aim of the study is to evaluate whether the laparoscopic Roux-en-Y gastric bypass (LRYGB) can be safely performed by surgical residents, to evaluate the LC of surgical residents for LRYGB and to assess whether surgical residents fit in the LC of the bariatric center which has been established by their proctors. METHODS: Records of all 3389 consecutive primary LRYGB patients, operated between December 2007 and January 2016 in a bariatric center-of-excellence in Amsterdam, were reviewed. Differences in DOS were assessed by means of a linear regression model. Differences in complications (classified as Clavien-Dindo ≥ 2) were evaluated with the χ 2 or the Fisher exact test. Cases were clustered in groups of 70 for comparison and reported for residents with ≥70 cases as primary surgeon. RESULTS: Four surgeons (S1-4) and three residents (R1-3) performed 2690 (88.2%) and 361 (11.8%) of 3051 LRYGBs, respectively. Median (IQR) DOS was 52.0 (42.0-65.0) min for S1-4 versus 53.0 (46.0-63.0) min for R1-3 (p = 0.52). The LC of R1-3 in their first 70 cases (n = 210) differs significantly from the individual (n = 70) LCs of surgeon 1, 2, and 3, with remarkably shorter DOS for the residents (adjusted p < 0.0001; p < 0.001 and p = 0.0002, respectively) and the same amount of surgical complications 5.1% (137/2690) for S1-4 versus 3.0% (11/361) for R1-3 (p = 0.089). CONCLUSION: Laparoscopic Roux-en-Y gastric bypass can be safely performed by surgical residents under supervision of experienced bariatric surgeons. Surgical residents benefit from the experience of their proctors and they fit faultlessly in the LC of the surgical team, as set out by their proctors in a large bariatric center-of-excellence.
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Derivação Gástrica/educação , Internato e Residência , Laparoscopia/educação , Curva de Aprendizado , Obesidade Mórbida/cirurgia , Adulto , Feminino , Derivação Gástrica/métodos , Humanos , Laparoscopia/métodos , Masculino , Pessoa de Meia-Idade , Países Baixos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
PURPOSE: Chronic pain and obesity often co-occur, negatively affecting one another and psychological wellbeing. Pain and psychological wellbeing improve after bariatric metabolic surgery (BMS), however, it is unknown whether psychological wellbeing improves differently after weight loss between patients with and without chronic pain. We investigated whether weight loss is associated with greater psychological wellbeing and functioning change after BMS, comparing patients with and without preoperative pain syndromes. METHODS: Depression, health-related quality of life, self-esteem, self-efficacy to exercise and controlling eating behaviours, physical activity, and food cravings were measured before and 24 months after BMS among 276 patients with obesity. The presence of preoperative chronic pain syndromes was examined as a moderator for the relationship between 24-month weight loss and changes in psychological outcomes. RESULTS: Chronic pain syndromes were present among 46% of patients. Weight loss was associated with greater improvement in health-related quality of life, self-efficacy to exercise and controlling eating behaviours, self-esteem and greater amelioration in food cravings. Pain syndromes only moderated negatively the relationship between the postoperative weight loss and change in self-efficacy to control eating behaviours (b = -0.49, CI [-0.88,-0.12]). CONCLUSION: Patients with and without chronic pain showed similar improvements in weight and psychological wellbeing and behaviours after BMS. The relationship between weight loss and the improvement of self-efficacy to control eating behaviours was weaker among patients with chronic pain syndrome. Further work, measuring pain severity over time, is needed to shed light on the mechanism underlying pain and postoperative change in psychological wellbeing and weight loss.
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Cirurgia Bariátrica , Dor Crônica , Obesidade Mórbida , Humanos , Qualidade de Vida/psicologia , Obesidade Mórbida/cirurgia , Cirurgia Bariátrica/psicologia , Obesidade/cirurgia , Redução de PesoRESUMO
BACKGROUND: We investigated whether genomic aberrations in primary colorectal cancer (CRC) can identify patients who are at increased risk of developing additional hepatic recurrence after colorectal liver metastases (CLM) resection. METHODS: Primary tumour DNA from 79 CLM resected patients was analysed for recurrent copy number changes (12x135k NimbleGen(™) aCGH). The cohort was divided into three groups: CLM patients with a recurrence-free survival after hepatic resection of at least 5 years (n = 21), patients who developed intra-hepatic recurrence (n = 32), and patients who developed extrahepatic recurrence (n = 26). By contrasting the primary tumour profiles of recurrence free and the extrahepatic recurrence CLM patients, a classifier, the extra-hepatic recurrence classifier (ERC1), predictive for subsequent extrahepatic-recurrence was developed. RESULTS: The ERC1 had an accuracy of 70 % (95 % confidence interval (CI): 55-82 %, misclassification error 30 %, base error rate: 45 %). This analysis identified a region on Chromosome 12p13 as differentially aberrated between these two groups. The classifier was further optimized by contrasting the extrahepatic recurrence group with the combined group of intrahepatic and no recurrence group, resulting in an extrahepatic prognostic classifier (ERC2) able to classify patients with CLMs suitable for hepatic resection with 74 % accuracy (95 % CI: 62-83 %, misclassification error 26 %, base error rate: 32 %). CONCLUSIONS: Patients with CLM who will develop extrahepatic recurrence may be identified with ERCs based on information in the primary tumour. Risk estimates for the occurrence of extrahepatic metastases may allow a reduction of hepatic resections of colorectal liver metastases for those who are unlikely to develop extrahepatic metastases.
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Aberrações Cromossômicas , Neoplasias Colorretais/genética , Genômica , Hepatectomia , Neoplasias Hepáticas/genética , Recidiva Local de Neoplasia/genética , Seleção de Pacientes , Adulto , Idoso , Cromossomos Humanos Par 12/genética , Neoplasias Colorretais/patologia , Neoplasias Colorretais/cirurgia , Hibridização Genômica Comparativa , DNA de Neoplasias/genética , Feminino , Seguimentos , Humanos , Neoplasias Hepáticas/secundário , Neoplasias Hepáticas/cirurgia , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/patologia , Recidiva Local de Neoplasia/cirurgia , Estadiamento de Neoplasias , Análise de Sequência com Séries de Oligonucleotídeos , PrognósticoRESUMO
BACKGROUND: Attachment avoidance and anxiety have been linked to overweight and poor health behaviours, yet the mechanisms that underpin the relationship between attachment and health behaviours are not fully understood. Self-esteem and self-efficacy have been found to differ between attachment styles, rendering these variables potential mediators of the relationship. This longitudinal study investigated the serial mediation between preoperative attachment and 2-year post-operative health behaviours through self-esteem and health self-efficacy. METHODS: Participants were 263 bariatric surgery patients (75.7% females, aged 47.7 ± 10.4 years, BMI 38.9 ± 3.6 kg/m2) assessed before the operation and again one and two years after the surgery. Patients completed the Experiences for Close Relationships Brief Scale, Rosenberg Self-esteem scale, Weight Efficacy Lifestyle Questionnaire, Bariatric Surgery Self-Management Questionnaire, Exercise Self-Efficacy Scale and the Exercise Behaviour Scale. RESULTS: Higher preoperative attachment anxiety and avoidance were associated with lower self-esteem one year after bariatric surgery and poorer health self-efficacy two years after the surgery. Self-esteem and health self-efficacy mediated the relationships between preoperative anxious and avoidant attachment and 2- year post-operative diet adherence and physical activity. CONCLUSIONS: Helping patients to feel more worthy and reinforcing their beliefs about their own competences could lead to higher engagement with healthy lifestyle and adherence to treatment protocols, ultimately helping patients to achieve their goals for bariatric surgery. CLINICAL TRIAL REGISTRATION: BARIA: Netherlands Trial Register: NL5837 (NTR5992) https://www.trialregister.nl/trial/5837 . Diabaria: ClinicalTrials.gov identifier (NCT number): NCT03330756.
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Cirurgia Bariátrica , Autoeficácia , Feminino , Humanos , Masculino , Comportamentos Relacionados com a Saúde , Estudos Longitudinais , Autoimagem , Adulto , Pessoa de Meia-IdadeRESUMO
PURPOSE: Long-term follow-up after bariatric surgery (BS) reveals high numbers of patients with abdominal pain that often remains unexplained. The aim of this prospective study was to give an overview of diagnoses for abdominal pain, percentage of unexplained complaints, number and yield of follow-up visits, and time to establish a diagnosis. MATERIALS AND METHODS: Patients who visited the Spaarne Gasthuis Hospital, The Netherlands, between December 2020 and December 2021 for abdominal pain after BS, were eligible and followed throughout the entire episode of abdominal pain. Distinction was made between presumed and definitive diagnoses. RESULTS: The study comprised 441 patients with abdominal pain; 401 (90.9%) females, 380 (87.7%) had Roux-en-Y gastric bypass, mean (SD) % total weight loss was 31.4 (10.5), and median (IQR) time after BS was 37.0 (11.0-66.0) months. Most patients had 1-5 follow-up visits. Readmissions and reoperations were present in 212 (48.1%) and 164 (37.2%) patients. At the end of the episode, 88 (20.0%) patients had a presumed diagnosis, 183 (41.5%) a definitive diagnosis, and 170 (38.5%) unexplained complaints. Most common definitive diagnoses were cholelithiasis, ulcers, internal herniations, and presumed diagnoses irritable bowel syndrome (IBS), anterior cutaneous nerve entrapment syndrome, and constipation. Median (IQR) time to presumed diagnoses, definitive diagnoses, or unexplained complaints was 16.0 (3.8-44.5), 2.0 (0.0-31.5), and 13.5 (1.0-53.8) days (p < 0.001). Patients with IBS more often had unexplained complaints (OR 95%CI: 4.457 [1.455-13.654], p = 0.009). At the end, 71 patients (16.1%) still experienced abdominal pain. CONCLUSION: Over a third of abdominal complaints after BS remains unexplained. Most common diagnoses were cholelithiasis, ulcers, and internal herniations.
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Cirurgia Bariátrica , Colelitíase , Derivação Gástrica , Síndrome do Intestino Irritável , Obesidade Mórbida , Feminino , Humanos , Masculino , Obesidade Mórbida/cirurgia , Estudos Prospectivos , Úlcera , Derivação Gástrica/efeitos adversos , Cirurgia Bariátrica/efeitos adversos , Dor Abdominal/diagnóstico , Dor Abdominal/epidemiologia , Dor Abdominal/etiologia , Estudos RetrospectivosRESUMO
The association of adherence to follow-up (FU) after laparoscopic gastric bypass - and gastric sleeve with weight loss (WL) is unclear. The aim of this study was to evaluate this association. Fourteen full text articles were included in the systematic review. Eight studies were included in the meta-analysis concerning FU up to 3 years postoperatively and 3 for the FU between 3 and 10 years postoperatively. Results showed a significant association between adherence to FU 0.5 to 3 years postoperatively and percentage excess WL (%EWL) but did not demonstrate a significant association between FU > 3 years postoperatively and total WL (%TWL). In conclusion, adherence to FU may not be associated with WL and therefore stringent lifelong FU in its current form should be evaluated.
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Cirurgia Bariátrica , Derivação Gástrica , Laparoscopia , Obesidade Mórbida , Cirurgia Bariátrica/métodos , Seguimentos , Gastrectomia , Derivação Gástrica/métodos , Humanos , Laparoscopia/métodos , Obesidade Mórbida/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Redução de PesoRESUMO
PURPOSE: The importance of follow-up (FU) for midterm weight loss (WL) after bariatric surgery is controversial. Compliance to this FU remains challenging. Several risk factors for loss to FU (LtFU) have been mentioned. The aim was therefore to evaluate the association between WL and LtFU 3 to 5 years postoperatively and to identify risk factors for LtFU. MATERIALS AND METHODS: A single-center cross-sectional study in the Netherlands. Between June and October 2018, patients scheduled for a 3-, 4-, or 5-year FU appointment were included into two groups: compliant (to their scheduled appointment and overall maximally 1 missed appointment) and non-compliant (missed the scheduled appointment and at least 1 overall). Baseline, surgical, and FU characteristics were collected and a questionnaire concerning socio-economic factors. RESULTS: In total, 217 patients in the compliant group and 181 in the non-compliant group were included with a median body mass index at baseline of 42.0 and 42.9 respectively. Eighty-eight percent underwent a laparoscopic Roux-en-Y gastric bypass. The median percentage total weight loss for the compliant and non-compliant groups was 30.7% versus 28.9% at 3, 29.3% versus 30.2% at 4, and 29.6% versus 29.9% at 5 years respectively, all p>0.05. Age, persistent comorbidities and vitamin deficiencies, a yearly salary <20,000 euro, no health insurance coverage, and not understanding the importance of FU were risk factors for LtFU. CONCLUSION: Three to 5 years postoperatively, there is no association between LtFU and WL. The compliant group demonstrated more comorbidities and vitamin deficiencies. Younger age, not understanding the importance of FU, and financial challenges were risk factors for LtFU.
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Cirurgia Bariátrica , Derivação Gástrica , Laparoscopia , Obesidade Mórbida , Índice de Massa Corporal , Estudos Transversais , Seguimentos , Gastrectomia , Humanos , Países Baixos/epidemiologia , Obesidade Mórbida/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Redução de PesoRESUMO
BACKGROUND: Average long-term outcome after laparoscopic Roux-en-Y gastric bypass is 25% total weight loss. The risk of short-term complications (leakage and bleeding), acute internal herniation, and mortality are 4.0%, 2.5%, and .2%, respectively. There is a paucity of evidence on what patients expect in terms of weight loss and to what extent surgical risks are tolerated. OBJECTIVE: To examine the patient's weight loss expectations and acceptance of the morbidity and mortality risk after primary laparoscopic Roux-en-Y gastric bypass. SETTING: Teaching hospital, Amsterdam, the Netherlands. METHODS: Two-hundred patients participated in a standardized survey after completion of an extensive multidisciplinary screening, before surgery. Weight loss expectations, naive assessment, and acceptation of risks of morbidity and mortality were addressed with standard gamble methods. RESULTS: The 200 participants (156 female, 78%) had a mean age of 45.1 years and a mean body mass index of 42.3 kg/m2. Weight loss was overestimated by 151 patients (75.5%), and 79 participants (39.5%) were disappointed with the predicted weight loss. Median accepted risks on short-term complications, acute internal herniation, and mortality were 35.8% (interquartile range, 21.0%-58.0%), 25.1% (interquartile range, 15.9%-50.8%), and 4.5% (interquartile range, 1.0%-10.0%), respectively. CONCLUSION: Patients seeking bariatric surgery seem to have unrealistic weight loss objectives and are willing to accept substantial risks to achieve these goals.
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Cirurgia Bariátrica , Derivação Gástrica , Laparoscopia , Obesidade Mórbida , Cirurgia Bariátrica/efeitos adversos , Índice de Massa Corporal , Feminino , Derivação Gástrica/efeitos adversos , Humanos , Pessoa de Meia-Idade , Motivação , Países Baixos/epidemiologia , Obesidade Mórbida/cirurgia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
PURPOSE: Currently, bariatric surgery is the most effective intervention for treating morbid obesity and its complications. Smoking cessation is likely to improve smoking-related comorbidities and decrease postoperative complications. This study evaluated the smoking behaviour and thoughts about smoking cessation of patients more than 18 months after bariatric surgery. MATERIALS AND METHODS: A cross-sectional study was performed in patients who underwent bariatric surgery from July 2012 to December 2013. A questionnaire was used to evaluate smoking status, thoughts about the health benefits of cessation and characteristics of previous quit attempts in current and former smokers. Finally, actual bariatric surgery outcomes were evaluated in current, former and never smokers. RESULTS: Six hundred nine patients (response rate 52.0%) were included. Of them, 101 (16.6%) patients were current smokers, 239 (39.2%) former smokers and 269 (44.2%) patients were lifetime never smokers. Compared with former smokers, current smokers were less aware of the beneficial effects of smoking cessation on their general health; 66.4% of the former smokers thought smoking cessation would be much better for general health, compared with 20.6% of current smokers. Total weight loss was 2.8% higher in current smokers compared with former smokers. Actual long-term bariatric surgery outcomes were not significantly different between the groups. CONCLUSION: Despite advice to quit smoking and temporary quitting before surgery, a considerable group of bariatric surgery patients continues smoking after surgery. These patients were less aware of the beneficial effects of smoking cessation. This study emphasizes the need for better strategies to increase the number of successful cessations.
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Cirurgia Bariátrica , Obesidade Mórbida , Abandono do Hábito de Fumar , Estudos Transversais , Humanos , Obesidade Mórbida/cirurgia , FumarRESUMO
OBJECTIVE: To predict clinical outcome by classification of peritoneal metastases (PM) of colorectal or appendiceal origin. BACKGROUND: This study investigates whether standardized histological classification can predict outcome for PM of colorectal or appendiceal origin treated with cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS: Histology of PM (n = 269) was evaluated by analysis of mitotic activity, atypia, cellularity, and mucinous component. For overall survival (OS) and disease-free survival (DFS) Cox proportional-hazard models were constructed. Covariates included tumor, patient, and treatment characteristics. RESULTS: PM could be categorized into four groups: low-grade, well-differentiated mucinous tumor (DPAM); intermediated-grade mucinous carcinoma (PMCA-i); high-grade mucinous carcinoma (PMCA); and high-grade nonmucinous carcinoma (PCA). Multivariate analysis showed that histological classification, gender, number of segments affected, completeness of cytoreduction, and HIPEC as primary treatment were significant related to OS and DFS. The 5-year OS was 64% in the DPAM group, 36% in the PMCA group, and 24% in the PCA group. Of PM originating from an appendix tumor, 29% were of non-DPAM type. Of primary colorectal tumors, 37% resulted in mucinous PM, and another 26% of PM of colorectal origin had partly mucinous histology. CONCLUSION: Histology is a significant predictive factor of OS and DFS in PM treated with surgical cytoreduction and HIPEC. Low-grade PM (DPAM) should be regarded as a separate entity because of its clearly different clinical course. High-grade mucinous PM has significant better prognosis than nonmucinous PM and should thus be distinguished.
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Adenocarcinoma Mucinoso/secundário , Neoplasias do Apêndice/patologia , Neoplasias Colorretais/patologia , Neoplasias Peritoneais/secundário , Adenocarcinoma Mucinoso/terapia , Idoso , Neoplasias do Apêndice/terapia , Neoplasias Colorretais/terapia , Terapia Combinada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Neoplasias Peritoneais/terapia , Prognóstico , Taxa de SobrevidaRESUMO
BACKGROUND: Accurate staging of colorectal cancer (CRC) with clinicopathological parameters is important for predicting prognosis and guiding treatment but provides no information about organ site of metastases. Patterns of genomic aberrations in primary colorectal tumors may reveal a chromosomal signature for organ specific metastases. METHODS: Array Comparative Genomic Hybridization (aCGH) was employed to asses DNA copy number changes in primary colorectal tumors of three distinctive patient groups. This included formalin-fixed, paraffin-embedded tissue of patients who developed liver metastases (LM; n = 36), metastases (PM; n = 37) and a group that remained metastases-free (M0; n = 25).A novel statistical method for identifying recurrent copy number changes, KC-SMART, was used to find specific locations of genomic aberrations specific for various groups. We created a classifier for organ specific metastases based on the aCGH data using Prediction Analysis for Microarrays (PAM). RESULTS: Specifically in the tumors of primary CRC patients who subsequently developed liver metastasis, KC-SMART analysis identified genomic aberrations on chromosome 20q. LM-PAM, a shrunken centroids classifier for liver metastases occurrence, was able to distinguish the LM group from the other groups (M0&PM) with 80% accuracy (78% sensitivity and 86% specificity). The classification is predominantly based on chromosome 20q aberrations. CONCLUSION: Liver specific CRC metastases may be predicted with a high accuracy based on specific genomic aberrations in the primary CRC tumor. The ability to predict the site of metastases is important for improvement of personalized patient management.
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Aberrações Cromossômicas , Cromossomos Humanos Par 20 , Neoplasias Colorretais/genética , Neoplasias Colorretais/patologia , Dosagem de Genes , Neoplasias Hepáticas/genética , Neoplasias Hepáticas/secundário , Adulto , Idoso , Distribuição de Qui-Quadrado , Neoplasias Colorretais/mortalidade , Neoplasias Colorretais/terapia , Hibridização Genômica Comparativa , Bases de Dados Genéticas , Feminino , Fixadores , Formaldeído , Perfilação da Expressão Gênica/métodos , Predisposição Genética para Doença , Humanos , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/terapia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Países Baixos , Análise de Sequência com Séries de Oligonucleotídeos , Inclusão em Parafina , Fenótipo , Valor Preditivo dos Testes , Análise de Sobrevida , Fatores de Tempo , Fixação de Tecidos/métodos , Resultado do TratamentoRESUMO
BACKGROUND: Recently, excellent results are reported on laparoscopic lavage in patients with purulent perforated diverticulitis as an alternative for sigmoidectomy and ostomy.The objective of this study is to determine whether LaparOscopic LAvage and drainage is a safe and effective treatment for patients with purulent peritonitis (LOLA-arm) and to determine the optimal resectional strategy in patients with a purulent or faecal peritonitis (DIVA-arm: perforated DIVerticulitis: sigmoidresection with or without Anastomosis). METHODS/DESIGN: In this multicentre randomised trial all patients with perforated diverticulitis are included. Upon laparoscopy, patients with purulent peritonitis are treated with laparoscopic lavage and drainage, Hartmann's procedure or sigmoidectomy with primary anastomosis in a ratio of 2:1:1 (LOLA-arm). Patients with faecal peritonitis will be randomised 1:1 between Hartmann's procedure and resection with primary anastomosis (DIVA-arm). The primary combined endpoint of the LOLA-arm is major morbidity and mortality. A sample size of 132:66:66 patients will be able to detect a difference in the primary endpoint from 25% in resectional groups compared to 10% in the laparoscopic lavage group (two sided alpha = 5%, power = 90%). Endpoint of the DIVA-arm is stoma free survival one year after initial surgery. In this arm 212 patients are needed to significantly demonstrate a difference of 30% (log rank test two sided alpha = 5% and power = 90%) in favour of the patients with resection with primary anastomosis. Secondary endpoints for both arms are the number of days alive and outside the hospital, health related quality of life, health care utilisation and associated costs. DISCUSSION: The Ladies trial is a nationwide multicentre randomised trial on perforated diverticulitis that will provide evidence on the merits of laparoscopic lavage and drainage for purulent generalised peritonitis and on the optimal resectional strategy for both purulent and faecal generalised peritonitis. TRIAL REGISTRATION: Nederlands Trial Register NTR2037.
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Diverticulite/complicações , Perfuração Intestinal/cirurgia , Lavagem Peritoneal/métodos , Peritonite/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anastomose Cirúrgica , Colectomia , Colostomia , Feminino , Humanos , Perfuração Intestinal/etiologia , Laparoscopia , Pessoa de Meia-Idade , Peritonite/etiologia , Resultado do TratamentoRESUMO
BACKGROUND: After laparoscopic Roux-en-Y gastric bypass many patients present with complaints for which an upper endoscopy is performed. However, often no abnormalities are found. OBJECTIVES: To investigate the incidence of relevant findings at upper endoscopy and identify patient characteristics associated with a relevant finding. SETTING: A high-volume bariatric center. METHODS: A retrospective cohort study was performed. All patients presenting with complaints after laparoscopic Roux-en-Y gastric bypass who consequently underwent a diagnostic upper endoscopy were identified from a prospective endoscopic database. Primary outcomes were the number and type of relevant findings at upper endoscopy and its association with patient characteristics. Relevant findings were defined as abnormalities requiring treatment. RESULTS: Ninety-eight (39.2%) of 250 patients had a relevant finding at upper endoscopy, mostly marginal ulcer and stomal stenosis. Male sex (odds ratio [OR] 3.47 [1.12-10.76]), alcohol consumption (OR 7.27 [1.58-33.36]), dysphagia or suspicion of bleeding as referral reason (OR 3.62 [1.54-8.52] and 39.93 [4.96-321.47], respectively, compared with abdominal pain), an abnormal upper gastrointestinal series (OR 6.81 [2.06-22.48]), and no abdominal ultrasound (OR 7.41 [1.48-37.08] compared with a normal ultrasound) were significantly associated with a relevant finding at upper endoscopy. CONCLUSIONS: In this study sex, alcohol consumption, referral reason, and prior imaging studies were associated with a relevant finding at upper endoscopy after laparoscopic Roux-en-Y gastric bypass.
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Derivação Gástrica , Laparoscopia , Obesidade Mórbida , Derivação Gástrica/efeitos adversos , Gastroscopia , Humanos , Masculino , Obesidade Mórbida/cirurgia , Estudos Prospectivos , Estudos RetrospectivosRESUMO
BACKGROUND: Smoking has been associated with postoperative complications and mortality in bariatric surgery. The evidence for smoking is based on self-report and medical charts, which can lead to misclassification and miscalculation of the associations. Determination of cotinine can objectively define nicotine exposure. We determined the accuracy of self-reported smoking compared to cotinine measurement in three phases of the bariatric surgery trajectory. METHODS: Patients in the phase of screening (screening), on the day of surgery (surgery), and more than 18 months after surgery (follow-up) were consecutively selected. Self-reported smoking was registered and serum cotinine was measured. We evaluated the accuracy of self-reported smoking compared to cotinine, and the level of agreement between self-report and cotinine for each phase. RESULTS: In total, 715 patients were included. In the screening, surgery, and follow-up group, 25.6%, 18.0%, and 15.5%, respectively, was smoking based on cotinine. The sensitivity of self-reported smoking was 72.5%, 31.0%, and 93.5% in the screening, surgery, and follow-up group, respectively (p < 0.001). The specificity of self-report was > 95% in all groups (p < 0.02). The level of agreement between self-report and cotinine was 0.778, 0.414, and 0.855 for the screening, surgery, and follow-up group, respectively. CONCLUSIONS: Underreporting of smoking occurs before bariatric surgery, mainly on the day of surgery. Future studies on effects of smoking and smoking cessation in bariatric surgery should include methods taking into account the issue of underreporting.
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Cirurgia Bariátrica , Cotinina/sangue , Obesidade Mórbida , Autorrelato , Fumar/epidemiologia , Adulto , Cirurgia Bariátrica/estatística & dados numéricos , Estudos de Coortes , Cotinina/análise , Feminino , Seguimentos , Humanos , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Obesidade Mórbida/sangue , Obesidade Mórbida/epidemiologia , Obesidade Mórbida/cirurgia , Período Pré-Operatório , Reprodutibilidade dos Testes , Autorrevelação , Autorrelato/normas , Autorrelato/estatística & dados numéricos , Sensibilidade e Especificidade , Fumar/sangue , Abandono do Hábito de Fumar/estatística & dados numéricos , Inquéritos e Questionários , Fumar Tabaco/sangue , Fumar Tabaco/epidemiologiaRESUMO
OBJECTIVES: Long-chain fatty acids (LCFAs) released from adipocytes inhibit lipolysis through an unclear mechanism. We hypothesized that the LCFA receptor, FFAR4 (GPR120), which is highly expressed in adipocytes, may be involved in this feedback regulation. METHODS AND RESULTS: Liquid chromatography mass spectrometry (LC-MS) analysis of conditioned media from isoproterenol-stimulated primary cultures of murine and human adipocytes demonstrated that most of the released non-esterified free fatty acids (NEFAs) are known agonists for FFAR4. In agreement with this, conditioned medium from isoproterenol-treated adipocytes stimulated signaling strongly in FFAR4 transfected COS-7 cells as opposed to non-transfected control cells. In transfected 3T3-L1 cells, FFAR4 agonism stimulated Gi- and Go-mini G protein binding more strongly than Gq, effects which were blocked by the selective FFAR4 antagonist AH7614. In primary cultures of murine white adipocytes, the synthetic, selective FFAR4 agonist CpdA inhibited isoproterenol-induced intracellular cAMP accumulation in a manner similar to the antilipolytic control agent nicotinic acid acting through another receptor, HCAR2. In vivo, oral gavage with the synthetic, specific FFAR4 agonist CpdB decreased the level of circulating NEFAs in fasting lean mice to a similar degree as nicotinic acid. In agreement with the identified anti-lipolytic effect of FFAR4, plasma NEFAs and glycerol were increased in FFAR4-deficient mice as compared to littermate controls despite having elevated insulin levels, and cAMP accumulation in primary adipocyte cultures was augmented by treatment with the FFAR4 antagonist conceivably by blocking the stimulatory tone of endogenous NEFAs on FFAR4. CONCLUSIONS: In white adipocytes, FFAR4 functions as an NEFA-activated, autocrine, negative feedback regulator of lipolysis by decreasing cAMP though Gi-mediated signaling.
Assuntos
Ácidos Graxos não Esterificados/metabolismo , Receptores Acoplados a Proteínas G/metabolismo , Células 3T3-L1 , Adipócitos/metabolismo , Adipócitos Brancos/metabolismo , Tecido Adiposo/metabolismo , Tecido Adiposo Branco/metabolismo , Animais , Comunicação Autócrina/fisiologia , Cromatografia Líquida/métodos , Meios de Cultivo Condicionados/farmacologia , Ácidos Graxos/metabolismo , Retroalimentação Fisiológica/fisiologia , Feminino , Humanos , Lipólise/fisiologia , Masculino , Espectrometria de Massas/métodos , Camundongos , Camundongos Endogâmicos C57BL , Receptores Acoplados a Proteínas G/fisiologiaRESUMO
In the last decades, laparoscopic surgery has become the gold standard in patients with colorectal cancer. To overcome the drawback of reduced tactile feedback, real-time tissue classification could be of great benefit. In this ex vivo study, hyperspectral imaging (HSI) was used to distinguish tumor tissue from healthy surrounding tissue. A sample of fat, healthy colorectal wall, and tumor tissue was collected per patient and imaged using two hyperspectral cameras, covering the wavelength range from 400 to 1700 nm. The data were randomly divided into a training (75%) and test (25%) set. After feature reduction, a quadratic classifier and support vector machine were used to distinguish the three tissue types. Tissue samples of 32 patients were imaged using both hyperspectral cameras. The accuracy to distinguish the three tissue types using both hyperspectral cameras was 0.88 (STD = 0.13) on the test dataset. When the accuracy was determined per patient, a mean accuracy of 0.93 (STD = 0.12) was obtained on the test dataset. This study shows the potential of using HSI in colorectal cancer surgery for fast tissue classification, which could improve clinical outcome. Future research should be focused on imaging entire colon/rectum specimen and the translation of the technique to an intraoperative setting.
Assuntos
Colo/diagnóstico por imagem , Neoplasias Colorretais/diagnóstico por imagem , Neoplasias Colorretais/cirurgia , Cirurgia Colorretal , Laparoscopia , Idoso , Algoritmos , Reações Falso-Positivas , Feminino , Humanos , Processamento de Imagem Assistida por Computador , Luz , Masculino , Pessoa de Meia-Idade , Fótons , Curva ROC , Reprodutibilidade dos Testes , Espectrofotometria Infravermelho , Máquina de Vetores de Suporte , Resultado do TratamentoRESUMO
BACKGROUND: Percentile charts would be ideal for assessing sufficient weight loss in bariatric surgery. They allow comparing individual results to the outcome of many others, at any postoperative time. Unfortunately, percentile charts can be problematic when comparing unequally heavy peers, a circumstance not uncommon among bariatric patients. We investigate the relevance of this disadvantage and combine new insights to improve the practical use of percentile charts in bariatric surgery. METHODS: Laparoscopic Roux-en-Y gastric bypass outcome expressed with body mass index (BMI), excess weight loss (%EWL), total weight loss (%TWL), and alterable weight loss (%AWL), a new metric rendering outcome independent of baseline BMI, is used to build percentile curves p97/p90/p75/p50/p25/p10/p03 with the lambda-mu-sigma method. We used the %AWL p25 curve as baseline BMI-independent reference for sufficient weight loss and compared it to p25 curves based on common metrics and to traditional criteria ≥50 % EWL, <25 % EWL, and BMI < 35 kg/m2. RESULTS: We operated 2880 patients, with baseline BMI of 43.4 kg/m2, follow-up 71 %, and mean of 23.3 (0-87.6) months. Independent %AWL outcome is presented in one percentile chart. Percentile curves p25/p50/p75 show 40/48/57 % AWL at nadir 15/16/19 months, 35/45/54 % AWL at 3 years, and 30/38/47 % AWL at 7 years. Traditional criteria and p25 curves based on %EWL and BMI match with most sufficient results (high sensitivities), but overlook many insufficient results (low specificities). CONCLUSIONS: We present the first baseline BMI-independent bariatric weight loss percentile chart. It allows comparing heavier patients to lighter peers and vice versa, at any postoperative time, up to 7 years. With these advantages, we compared it to traditional bariatric criteria like ≥50 % EWL and found that they are weak in recognizing insufficient weight loss. The visual aspect of consecutive results plotted on a chart among the percentile curves of peers conveys a strong, intuitive message on the personal progress of postoperative weight loss.
Assuntos
Benchmarking , Derivação Gástrica/estatística & dados numéricos , Obesidade Mórbida/cirurgia , Redução de Peso , Adolescente , Adulto , Idoso , Feminino , Derivação Gástrica/métodos , Derivação Gástrica/normas , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Adulto JovemRESUMO
INTRODUCTION: Internal herniation (IH) probably is the most elusive complication of laparoscopic Roux- en-Y gastric bypass (LRYGB) surgery. This study provides a definition for IH, a diagnosing algorithm, and information on several factors influencing IH formation. METHOD: Baseline characteristics, laboratory findings, imaging studies, operative findings, and follow up data of 1583 patients that underwent LRYGB at our bariatric facility between 2007 and 2013 were recorded. Follow up varied between 3 and 76 months, and 85 % of the data was available for analysis at 12 months. Our surgical technique was standardized. Intermesenteric spaces were not closed until July 2012, where after they were closed. To facilitate comparison, IH cases were matched with controls. RESULTS: Forty patients (2.5 %) had an IH during re-laparoscopy. The modal clinical presentation is acute onset epigastric discomfort, often crampy/colicky in nature. Additional examinations included laboratory testing, abdominal X-ray, abdominal ultrasound, and abdominal CT scanning. Patients who developed an IH lost a significantly higher percentage of their total body weight than their matched controls at every time point. IH incidence was higher in the non-closure group than the closure group. CONCLUSION: The large variation in reported IH incidence is due to the large variation in IH definition. To gain more uniformity in reporting IH prevalence, we propose the use of the AMSTERDAM classification. Post-LRYGB patients with acute onset crampy/colicky epigastric pain should undergo abdominal ultrasound to rule out gallbladder pathology and offered re-laparoscopy with a low threshold. IH incidence is highest among patients with rapid weight loss and non-closure of intermesenteric defects.
Assuntos
Técnicas de Apoio para a Decisão , Derivação Gástrica/efeitos adversos , Hérnia Abdominal/diagnóstico , Obesidade Mórbida/cirurgia , Dor Abdominal/etiologia , Adulto , Estudos de Casos e Controles , Feminino , Derivação Gástrica/métodos , Hérnia Abdominal/classificação , Hérnia Abdominal/diagnóstico por imagem , Hérnia Abdominal/etiologia , Humanos , Incidência , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Masculino , Países Baixos , Complicações Pós-Operatórias/classificação , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Índice de Gravidade de Doença , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: Risk prediction models are useful tools for informing patients undergoing bariatric surgery about their risk for complications and correcting outcome reports. The aim of this study is to externally validate risk models assessing complications after laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery. METHODS: All 740 patients who underwent a primary LRYGB between December 2007 and July 2012 were included in the validation cohort. PubMed was systematically searched for risk prediction models. Eight risk models were selected for validation. We classified our complications according to the Clavien-Dindo classification. Predefined criteria of a good model were a non-significant Hosmer and Lemeshow test, Nagelkerke R (2) ≥ 0.10, and c-statistic ≥0.7. RESULTS: There were 85 (7.8 %) grade 1, 54 (7.3 %) grade 2, 5 (0.7 %) grade 3a, 14 (1.9 %) grade 3b, and 14 (1.9 %) grade 4a complications in our validation cohort. Only one model predicted adverse events satisfactorily. This model consisted of one patient-related factor (age) and four surgeon- or center related factors (conversion to open surgery, intraoperative events, the need for additional procedures during LRYGB and the learning curve of the center). CONCLUSIONS: The overall majority of the included risk models are unsuitable for risk prediction. Only one model with an emphasis on surgeon- and center-related factors instead of patient-related factors predicted adverse outcome correctly in our external validation cohort. These findings support the establishment of specialty centers and warn benchmark data institutions not to correct bariatric outcome data by any other patient-related factor than age.