Laparoscopic Roux-Y-gastric bypass versus laparoscopic one-anastomosis gastric bypass for obesity: clinical & metabolic results of a prospective randomized controlled trial.

BACKGROUND: One anastomosis gastric bypass (OAGB) has been proposed as an effective alternative to the current standard procedure in Switzerland, Roux-en-Y gastric bypass (RYGB). Prospective data comparing both procedures are scarce. Therefore, we performed a non-inferiority randomized controlled trial assessing the effectiveness and safety of these 2 operative techniques. METHOD: Eighty patients were randomized 1:1. OAGB consisted of a very long gastric pouch with a 200 cm biliopancreatic limb, RYGB of a 150 cm ante-colic alimentary and a 60 cm biliopancreatic limb, respectively. Primary endpoint was the percent excess weight loss (%EWL) at 12 months after surgery. RESULTS: Mean %EWL at 12 months was 87.9% (SD24.4) in the RYGB group and 104.1% (SD24.6) in the OAGB group (p = 0.006). There was no mortality. The rate of marginal ulcers was higher in patients with OAGB compared to those with RYGB (p = 0.011), while the total number of late complications did not statistically differ between the two groups. Except for the remission of GERD, which was higher in the RYGB group compared to OAGB, there was no difference between the groups regarding the remission of comorbidities. OAGB showed improved glucose control compared to the RYGB after 1 year (p = 0.001). Furthermore, glucagon-like peptide-1 increase was significantly higher in OAGB at 6 weeks (p = 0.041) and 1 year after surgery (p = 0.029). Quality of life improved after both surgeries, without differences between the groups. CONCLUSIONS: %EWL 1 year after surgery was higher in OAGB than in RYGB. A better glycemic control with a higher increase in GLP-1 was observed after OAGB compared to RYGB. TRIAL REGISTRATION: This trial is registered on ClinicalTrials.gov under the identifier NCT02601092.

Efficacy of intraoperative cholangiography versus preoperative magnetic resonance cholangiography in patients with intermediate risk for common bile duct stones.

BACKGROUND: This is the first randomized trial to evaluate the efficacy of intraoperative cholangiography (IOC) and magnetic resonance cholangiopancreatography (MRCP) in patients with suspected CBDS. METHODS: This unblinded, multicenter RCT was conducted at five swiss hospitals. Eligibility criteria were suspected CBDS. Patients were randomized to IOC and laparoscopic cholecystectomy (LC), followed by endoscopic retrograde cholangiopancreatography (ERCP) if needed, or MRCP followed by ERCP if needed, and LC. Primary outcome was length of stay (LOS), secondary outcomes were cost, stone detection, and complication rates. RESULTS: 122 Patients were randomised to the IOC Group (63) or the MRCP group (59). Median LOS for the IOC and the MRCP groups were 4 days IQR [3, 6] and [4, 6], with an estimated increase of LOS of 1.2 days in the MRCP group (p = 0.0799) in the linear model. Median cost in the IOC and MRCP groups were 10 473 Swiss Francs (CHF) and 10 801 CHF, respectively (p = 0.694). CBDS were found in 24 and 12 patients in the IOC and the MRCP groups, respectively (p = 0.0387). The complication rate did not differ between both groups. CONCLUSION: There is equipoise between both pathways. IOC has a significantly higher diagnostic yield than MRCP. TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT02351492: Radiological Investigation of Bile Duct Obstruction (RIBO).

Spiradenocarcinoma: A Comprehensive Data Review.

INTRODUCTION: Spiradenocarcinomas (SCs) are rare and potentially aggressive skin adnexal tumors. Optimal treatment has not yet been established. Experiences with this carcinoma are mostly presented in case reports and few case series. OBJECTIVE: To generate to a synopsis of published data on SC with regard to diagnostic procedures, treatment, and outcome. RESULTS: Median patient age was 60 years and sex distribution was balanced. Tumor manifestations were evenly distributed within the sweat gland carrying skin. The most commonly reported symptom was accelerated growth of a longstanding indolent lesion, typically present for more than 2 years. Metastatic spread to the lung, bone, lymph nodes, liver, kidney, and breast has been documented. For staging computed tomography (CT) and positron emission tomography-CT are recommended, especially for detection of hematogenic metastases and lymph node involvement. Clear resection margins and tumor free regional lymph nodes reduce recurrence and carcinoma related death. Although low-grade SCs were reported over 3 times more often, high-grade carcinomas show a greater likelihood for recurrence and lethal outcome. CONCLUSION: Suspicion of an SC should lead to performance of a magnetic resonance imaging for defining tumor extent, and a fludeoxyglucose positron emission tomography-CT for detection of metastases. Radical tumor excision and resection of tumor involved regional lymph nodes are essential for a curative approach. Histopathological evaluation should involve determination of tumor differentiation grade, because high-grade carcinomas seem to have a much more aggressive behavior. Excision of distant metastases has no therapeutic value. Follow-up needs to be carried out in short intervals with frequent imaging.

Primary non-closure of mesenteric defects in laparoscopic Roux-en-Y gastric bypass: reoperations and intraoperative findings in 146 patients.

BACKGROUND: Internal hernias (IH) after laparoscopic Roux-en-Y gastric bypass (LRYGB) have been reported with an incidence of 11 %. IH can lead to bowel incarceration and potentially bowel necrosis. The aim of this study was to analyze reoperations and intraoperative findings in a cohort of patients with unclosed mesenteric defects. METHODS: From a prospective database of patients with LRYGB, we selected as primary cohort patients with non-closure of mesenteric defects and abdominal reoperation for analysis. The data included pre-, intra- and post-operative findings, computed tomogram results and laboratory test results. This group underwent a very very long limb LRYGB, at that time the institutional standard technique. Additionally, a more recently operated cohort with primary closure of mesenteric defects was also analyzed. RESULTS: We identified 146 patients with primary non-closure and reoperation, mean age of 43.8 years. The main indication for reoperation was unclear abdominal pain in 119 patients with 27 patients undergoing a reoperation for other reasons (weight regain, prophylactic surgical inspection of mesenteric defects). Median time and mean excess weight loss from RYGB to reoperation were 41.1 months and 62.7 %, respectively. The incidence of IH was 14.4 %, with all patients with an IH being symptomatic. Conversion rate from laparoscopic to open surgery was 5.5 %, mortality 0.7 % and morbidity 3.4 %. Thirty-one patients underwent a second re-look laparoscopy. Eleven patients had recurrent open mesenteric defects. Three hundred and sixteen patients who underwent primary closure of the mesenteric defects had a reoperation rate of 13.6 % and an IH rate of 0.6 %. CONCLUSION: The incidence of IH in patients without closure of mesenteric defects and reoperation is high and substantially higher compared to patients with primary closure of mesenteric defects. Patients with or without closure of mesenteric defects following LRYGB with acute, chronic or recurrent pain should be referred to a bariatric surgeon for diagnostic laparoscopy.

A promising new device for the prevention of parastomal hernia.

Parastomal hernia (PSH) is the most frequent long-term stoma complication with serious negative effects on quality of life. Surgical revision is often required and has a substantial morbidity and recurrence rate. The development of PSH requires revisional surgery with a substantial perioperative morbidity and high failure rate in the long-term follow-up. Prophylactic parastomal mesh insertion during stoma creation has the potential to reduce the rate of PSH, but carries the risk of early and late mesh-related complications such as infection, fibrosis, mesh shrinkage, and/or bowel erosion. We developed a new stomaplasty ring (KORING), which is easy to implant, avoids potential mesh-related complications, and has a high potential of long-term prevention of PSH. Here we describe the technique and the first use.

Revisional versus primary Roux-en-Y gastric bypass: a case-matched analysis.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) has been a widely performed bariatric procedure. Unfortunately, revisional surgery is required in 20-30% of cases. Data comparing revisional and primary gastric bypass procedures are scarce. This study compared revisional malabsorptive laparoscopic very very long limb (VVLL) Roux-en-Y gastric bypass (RYGB) with primary VVLL RYGB and tested the hypothesis that one-stage revisional laparoscopic VVLL RYGB is an effective procedure after failed LAGB. METHODS: In this study, 48 revisional VVLL RYGBs were matched one-to-one with 48 primary VVLL RYGBs. The outcome measures were operating time, conversion to open surgery, excess weight loss (EWL), and early and late morbidity. RESULTS: Surgical and medical morbidities did not differ significantly. No conversions occurred. The revisional group showed an EWL of 41.8% after 12 months of follow-up evaluation and 45.1% after 24 months based on the pre-revisional weight. The total EWL based on the weight before the LAGB was calculated to be 54.3% after 12 months and 57.2% after 24 months. The EWL in the primary RYGB group was significantly higher for both types of calculation: 41.8%/54.3% versus 64.1 % (p < 0.001 and <0.01) after 12 months and 45.1%/57.2% versus 70.4% (p < 0.001 and <0.002) after 24 months. CONCLUSIONS: Revisional laproscopic VVLL RYGB can be performed as a one-stage procedure by experienced bariatric surgeons but shows less effective EWL than primary RYGB procedures.

Preoperative factors predicting clinical outcome following laparoscopic fundoplication.

BACKGROUND: Antireflux surgery is effective for the treatment of gastroesophageal reflux, but not all patients benefit equally from it. The challenge is to identify the patients who will ultimately benefit from antireflux surgery. The aim of this study was to identify preoperative factors that predict clinical outcome after antireflux surgery, with special interest in the influence of socioeconomic factors. METHODS: Preoperative clinical and socioeconomic data from 1,650 patients who were to undergo laparoscopic fundoplication were collected prospectively. Clinical outcome measures (persistent heartburn, dysphagia, satisfaction) were assessed at short-term (1 year) and longer-term (≥ 3 years) follow-up. RESULTS: At early follow-up, male gender (relative risk [RR] 1.091, p < 0.001) and the presence of a hiatus hernia (RR 1.065, p = 0.002) were independently associated with less heartburn. Male gender was also associated with higher overall satisfaction (RR 1.046, p = 0.034). An association was found between postoperative dysphagia and age (RR 0.988, p = 0.007) and the absence of a hiatus hernia (RR 0.767, p = 0.001). At longer-term follow-up, only male gender (RR 1.125, p < 0.001) was an independent prognostic factor for heartburn control. Male gender (RR 0.761, p = 0.001), the presence of a hiatus hernia (RR 0.823, p = 0.014), and cerebrovascular comorbidities (RR 1.306, p = 0.019) were independent prognosticators for dysphagia at longer-term follow-up. A hiatus hernia was the only factor associated with better overall satisfaction. Socioeconomic factors did not influence any clinical outcomes at short- and longer-term follow-up. CONCLUSION: Male gender and hiatus hernia are associated with a better clinical outcome following laparoscopic fundoplication, whereas socioeconomic status does not influence outcome.

Clinical, functional and radiological outcome after osteosynthesis of ankle fractures using a specific provocation test.

BACKGROUND: Ankle fractures are frequent, and despite numerous publications on their treatment and outcome, there is a lack of precise data on the functional results in young, healthy and physically active patients. We hypothesized that patients who underwent open reduction and internal fixation (ORIF) for simple ankle fractures would have similar function compared to a healthy control group, whereas patients with complex fractures will have significant functional deficits. Furthermore, we postulate that there is a discrepancy between the radiological and the functional outcomes. METHODS: A set of specific provocation tests was developed to evaluate the postoperative possibility of weight bearing, stop-and-go activities and range of motion. In combination with three questionnaires and a radiographic evaluation, the true functional outcome and the possibility of participating in sporting activities were investigated and compared with those of an age- and sex-matched control group. RESULTS: A significant impairment was found in unilateral and simple ankle fractures. This impairment increased in tests including stop-and-go activities in combination with load bearing and with the complexity of the fractures. Concerning the subjective outcome, there was a significant adverse effect for daily activities without any difference in preoperative or postoperative sporting activity between the groups. No difference was found in the radiological assessment. CONCLUSIONS: Both simple and complex ankle fractures treated with ORIF have a significant and long-lasting impact on functional outcome in young and active patients. The radiological result is not associated with a good functional outcome. TRIAL REGISTRATION: BASEC-Nr. 2018 - 01124.

Accuracy of PET-CT in predicting survival in patients with esophageal cancer.

BACKGROUND: Positron emission tomography (PET) is an integral part of tumor staging for patients with esophageal cancer. Recent studies suggest a role for PET scan in predicting survival in these patients, but this relationship is unclear in the setting of neoadjuvant therapy. We examined pretreatment maximum standard uptake value (SUV(max)) of the primary tumor in patients treated with and without neoadjuvant therapy. METHODS: All patients undergoing esophagectomy with a preoperative PET scan over a nine-year period (2001-2010) were identified from a prospectively maintained database. Positron emission tomography data were obtained from computers housing the original PET scans. Overall survival was correlated with SUV(max) of the primary tumor. RESULTS: A total of 191 patients were identified, and 103 patients met inclusion criteria. Eighty-two had an adenocarcinoma (80%), and 21 (20%) had a squamous cell carcinoma. Fifty-seven (55%) patients received neoadjuvant therapy. In the surgery alone group, a SUV(max) of > 5.0 in the primary tumor was associated with poor prognosis [Hazard Ratio (HR) 0.32; p = 0.007], but this factor did not retain its significance on multivariate analysis (HR 0.65; p = 0.43). Pretreatment SUV(max) in patients who underwent neoadjuvant therapy was not significant in predicting overall survival (p = 0.10). CONCLUSIONS: This study does not support the use of SUV(max) on pretreatment PET scans as a prognostic tool for patients with esophageal cancer, especially in those who have received neoadjuvant therapy. Lymph node status is a more accurate predictor of outcome, and efforts to improve pretreatment staging should focus on this factor.

[Functional syndromes after surgery of the upper gastrointestinal tract]. / Funktionelle Syndrome nach Oberbaucheingriffen.

Functional and metabolic syndromes after surgery of the upper gastrointestinal tract (including the pancreas) are frequent. Resections of organs mandate the reconstruction with a change of anatomy. Predominantly, the reconstruction using a Y-en-Roux jejunal loop is used. The surgical alteration of the anatomy may lead to a different physiology. Patients after esophagectomy or gastrectomy may suffer from dysphagia, dumping syndromes, reflux and anaemia. Pancreatic resections or drainage operations may cause an exocrine or endocrine insufficiency. Patients after surgery for gastroesophageal reflux or achalasia may have gas-related symptoms such as bloating and flatulence. The treatment options of these syndromes include physical measures, drugs, interventional procedures and even revisional surgery. Detailed preoperative information of the procedure and multidisciplinary postoperative treatment (general practitioner, surgeon, gastroenterologist etc.) of evolving functional syndromes is mandatory to achieve a high standard of care.

Risk of Reopening of the Mesenteric Defects After Routine Closure in Laparoscopic Roux-en-Y Gastric Bypass: a Single-Centre Experience.

PURPOSE: Small bowel obstruction (SBO) due to internal hernias (IH) is a well-recognised complication after laparoscopic Roux-en-Y gastric bypass (LRYGB). Routine closure of the mesenteric defects (MDs) is recommended to reduce the risk of IH and subsequent SBO. However, data about the rates of reopening of the MDs after LRYGB is scarce. The main aim of this study was to evaluate the risk of reopening of the MDs after routine closure during LRYGB. The secondary objective was to determine any risk factors associated with the reopening of the MDs. METHODS: Data of all patients who underwent reoperations after LRYGB with closure of both MDs between January 2010 and December 2018 were retrospectively reviewed. RESULTS: A total of 162 patients were included. The median time between LRYGB and reoperation was 17 months. At the time of reoperation, both MDs were closed in 83 patients (51.2%); thus, 79 patients (48.8%) presented at least one open MD. The group of patients with preoperative diagnosis of SBO or with recurrent abdominal pain showed significantly higher rates of open Petersen's space compared to the group of patients with other preoperative diagnoses. Preoperative body mass index (BMI) less than 40 kg/m2 at time of LRYGB was associated with a higher risk for an open MD. CONCLUSION: At least one MD reopened in almost half of the patients despite routine closure during LRYGB. Therefore, the status of MDs should be routinely examined during every reoperation after LRYGB and closure of open MDs should be performed.

Evaluation of the Introduction of a Colorectal Bundle in Left Sided Colorectal Resections (EvaCol): Study Protocol of a Multicentre, Observational Trial.

Purpose: Overall complication and leak rates in colorectal surgery showed only minor improvements over the last years and remain still high. While the introduction of the WHO Safer Surgery Checklist has shown a reduction of overall operative mortality and morbidity in general surgery, only minor attempts have been made to improve outcomes by standardizing perioperative processes in colorectal surgery. Nevertheless, a number of singular interventions have been found reducing postoperative complications in colorectal surgery. The aim of the present study is to combine nine of these measures to a catalogue called colorectal bundle (CB). This will help to standardize pre-, intra-, and post-operative processes and therefore eventually reduce complication rates after colorectal surgery. Methods: The study will be performed among nine contributing hospitals in the extended north-western part of Switzerland. In the 6-month lasting control period the patients will be treated according to the local standard of each contributing hospital. After a short implementation phase all patients will be treated according to the CB for another 6 months. Afterwards complication rates before and after the implementation of the CB will be compared. Discussion: The overall complication rate in colorectal surgery is still high. The fact that only little progress has been made in recent years underlines the relevance of the current project. It has been shown for other areas of surgery that standardization is an effective measure of reducing postoperative complication rates. We hypothesize that the combination of effective, individual components into the CB can reduce the complication rate. Trial registration: Registered in ClinicalTrials.gov on 11/03/2020; NCT04550156. Highlights: Purpose: Overall complications in colorectal surgery remain still highStandardizing can reduce overall operative mortality and morbidityOnly minor attempts have been made to standardize perioperative processes in colorectal surgerySingular interventions have been found reducing postoperative complicationsThe aim is to combine nine of these measures to a colorectal bundle (CB)The CB will help to reduce complication rates after colorectal surgery Methods: The observational study will be performed among nine hospitals in SwitzerlandSix month the patients will be treated according to the local standardsAfterwards patients will be treated according to the CB for another six monthsComplication rates before and after the implementation of the CB will be compared Discussion: Only little progress has been made to reduce complication rate in colorectal surgeryStandardization is an effective measure of reducing complication ratesThe combination of effective, individual components into the CB can reduce the complication rate.

Factors associated with postoperative pulmonary morbidity after esophagectomy for cancer.

BACKGROUND: Most studies analyzing risk factors for pulmonary morbidity date from the early 1990s. Changes in technology and treatment such as minimally invasive esophagectomy (MIE) and neoadjuvant treatment mandate analysis of more contemporary cohorts. METHODS: Predictive factors for overall and specific pulmonary morbidity in 858 patients undergoing esophagectomy between 1998 and 2008 in five Australian university hospitals were analyzed by logistic regression models. RESULTS: A total of 394 patients underwent open esophagectomy, and 464 patients underwent MIE. A total of 259 patients received neoadjuvant chemoradiotherapy, 139 preoperative chemotherapy alone, and 2 preoperative radiotherapy alone. In-hospital mortality was 3.5%. Smoking and the number of comorbidities were risk factors for overall pulmonary morbidity (odds ratio [OR] 1.47, P = 0.016; OR 1.35, P = 0.001) and pneumonia (OR 2.29, P = 0.002; 1.56, P = 0.005). The risk of respiratory failure was higher in patients with more comorbidities (OR 1.4, P = 0.035). Respiratory comorbidities (OR 3.81, P = 0.017) were strongly predictive of postoperative acute respiratory distress syndrome (ARDS). ARDS (4.51, P = 0.032) or respiratory failure (OR 8.7, P < 0.001), but not anastomotic leak (OR 2.22, P = 0.074), were independent risk factors for death. MIE (OR 0.11, P < 0.001) and thoracic epidural analgesia (OR 0.12, P = 0.003) decreased the risk of respiratory failure. Neoadjuvant treatment was not associated with an increased risk of pulmonary complications. CONCLUSIONS: Preoperative comorbidity and smoking were risk factors for respiratory complications, whereas neoadjuvant treatment was not. MIE and the use of thoracic epidural analgesia decreased the risk of respiratory failure. Respiratory failure and ARDS were the only independent factors associated with an increased risk of in-hospital death, whereas anastomotic leakage was not.

Learning curve for laparoscopic repair of very large hiatal hernia.

BACKGROUND: Laparoscopic repair of a large hiatal hernia is technically challenging. A significant learning curve likely exists that has not been studied to date. METHODS: Since 1992, the authors have prospectively collected data for all patients undergoing laparoscopic repair of a very large hiatal hernia (50% or more of the stomach within the chest). Follow-up evaluation was performed after 3 months, then yearly. Visual analog scores were used to assess heartburn and dysphagia. Patients were grouped according to institutional and individual surgeons' experience to determine the impact of any learning curve. The outcome for procedures performed by consultant surgeons was compared with that for trainees. RESULTS: From 1992 to 2008, 415 patients with a 1-year minimum follow-up period were studied. Institutional and individual experience had a significant influence on operation time, conversion to open surgery, and length of hospital stay. However, except for heartburn scores during a 3-month follow-up evaluation of institutional experience (p=0.03), clinical outcomes were not influenced by either an institutional or individual learning curve. Furthermore, in general terms, whether the procedure was performed by a consultant or a supervised trainee had little effect on outcome. CONCLUSIONS: Institutional and individual learning curves had no significant influence on clinical outcomes, although improved experience was reflected in improved operation time, conversion rate, and hospital stay. These outcomes improved over the first 50 institutional cases, and the outcomes for individual surgeons improved for up to 40 cases.

In-hospital delay increases the risk of perforation in adults with appendicitis.

BACKGROUND: The influence of in-hospital delay (time between admission and operation) on outcome after appendectomy is controversial. METHODS: A total of 1,827 adult patients underwent open or laparoscopic appendectomy for suspected appendicitis in eleven Swiss hospitals between 2003 and 2006. Of these, 1,675 patients with confirmed appendicitis were included in the study. Groups were defined according in-hospital delay (≤12 vs. >12 h). RESULTS: Delay>12 h was associated with a significantly higher frequency of perforated appendicitis (29.7 vs. 22.7%; P=0.010) whereas a delay of 6 or 9 h was not. Size of institution, time of admission, and surgical technique (laparoscopic vs. open) were independent factors influencing in-hospital delay. Admission during regular hours was associated with higher age, higher frequency of co-morbidity, and higher perforation rate compared to admission after hours. The logistic regression identified four independent factors associated with an increased perforation rate: age (≤65 years vs. >65 years, odds ratio (OR) 4.5, P<0.001); co-morbidity (Charlson index>0 vs. Charlson index=0, OR 2.3, P<0.001); time of admission (after hours vs. regular hours, OR 0.8, P=0.040), in-hospital delay (>12 vs. ≤12 h, OR 1.5, P=0.005). Perforation was associated with an increased reintervention rate (13.4 vs. 1.6%; P<0.001) and longer length of hospital stay (9.5 vs. 4.4 days; P<0.001). CONCLUSIONS: In-hospital delay negatively influences outcome after appendectomy. In-hospital delay of more than 12 h, age over 65 years, time of admission during regular hours, and the presence of co-morbidity are all independent risk factors for perforation. Perforation was associated with a higher reintervention rate and increased length of hospital stay.

Incidence and Prognostic Factors for the Development of Symptomatic and Asymptomatic Marginal Ulcers After Roux-en-Y Gastric Bypass Procedures.

INTRODUCTION: Marginal ulcer (MU) is a serious complication after Roux-en-Y gastric bypass (RYGB) procedures. This study reports the incidence, risk factors, and treatment outcomes of symptomatic and incidentally, at routine endoscopy diagnosed, MU. METHODS: All patients undergoing RYGB procedures between 2013 and 2018 at a single center were included. Upper endoscopy was performed in case of symptoms and/or routinely 2 and 5 years postoperatively. RESULTS: In total, 568 patients (83.3% female) underwent RYGB procedure with a median age of 40 years and median initial body mass index of 41 kg/m2. The median time to follow-up was 2.99 years. Routine 2- and 5-year upper endoscopy was performed in 256 (55.3%) and 65 (38.0%) eligible patients, respectively. In 86 (15.1%) patients, MU was diagnosed at a median time of 14.2 months (4.58-26.2) postoperatively and 24.4% of patients with MU were asymptomatic. In total, 76.7% of MUs were located on the side of the Roux limb. 88.4% of MUs were treated conservatively; re-operation was necessary in 10 (11.6%) patients. Smoking and type 2 diabetes mellitus were the only independent risk factors for MU development in multivariate analysis with a hazard ratio of 2.65 and 1.18 (HbA1c per unit >6.0), respectively. CONCLUSION: MU is a common complication after gastric bypass surgery with 25% of patients being asymptomatic. Follow-up routine endoscopy is recommended for early MU detection and subsequent accurate therapy, especially in patients with the independent risk factors smoking and type 2 diabetes mellitus.

Long-Term Outcome of Proximal Versus Very-Very Long Limb Roux-en-Y Gastric Bypass: the Roux-Limb to Common Channel Ratio Determines the Long-Term Weight Loss.

BACKGROUND: The influence of the Roux limb (RL) length on weight loss in Roux-en-Y (RYGB)-type gastric bypass procedures is still unclear. This study analyzes the true impact of RL length by comparing the long-term outcomes of proximal RYGB (PRYGB) and very-very long limb RYGB (VVLL-RYGB). METHODS: RL length in PRYGB was 150 cm. In VVLL-RYGB, common channel length was 100 cm. In both groups, biliopancreatic limbs measured 50-60 cm, resulting in equal total alimentary limb lengths. To adjust for pre-operative differences between groups, and to predict the long-term outcome, a mixed model analysis was performed. RESULTS: Two hundred thirty-two patients with VVLL-RYGB (73.7% female, mean age 41.1 ± 10 years, initial BMI 45.8 ± 6.3 kg/m2) and 223 with PRYGB (83.9% female, mean age 38.5 ± 11 years, initial BMI 42.9 ± 4.9 kg/m2) were included. Mean follow-up was 9.4 ± 4 years in VVLL-RYGB and 5.3 ± 1.9 years in PRYGB. After 5 years, mean BMI reduction was 15.7 ± 5.9 kg/m2 in VVLL-RYGB and 11.9 ± 4.1 kg/m2 in PRYGB (p < 0.001), and mean %EWL was 78.3 ± 23.1% and 70.2 ± 23.7% (p = 0.002) with a follow-up rate of 78% and 75.9%, respectively. The mixed model analysis showed a significantly higher weight rebound after PRYGB. Frequency of revisional surgery (i.e., limb length alteration, pouch banding) was similar between VVLL-RYGB and PRYGB (25 vs. 29 revisions, p = 0.463). CONCLUSION: The VVLL-RYGB has a significantly higher long-term BMI reduction and a significantly lower weight rebound. The length of the Roux limb significantly influences long-term outcome.

Short or Long Biliopancreatic Limb Bypass as a Secondary Procedure After Failed Laparoscopic Sleeve Gastrectomy.

PURPOSE: Laparoscopic sleeve gastrectomy (SG) may be associated with long-term problems such as insufficient weight loss or weight regain, persistence or relapse of comorbidities, and gastroesophageal reflux disease (GERD). This study analyzes the outcome of patients that underwent conversion of SG to a gastric bypass procedure. MATERIALS AND METHODS: All patients that underwent conversion from SG to the following four different gastric bypass procedures were analyzed: short biliopancreatic limb (BPL) bypass types such as proximal Roux-en-Y gastric bypass (PRYGB) or type 2 distal Roux-en-Y gastric bypass (type 2 DRYGB) and long BPL types such as long BPL RYGB or one anastomosis gastric bypass (OAGB). RESULTS: Between 2012 and 2016, 52 patients received the following revisional procedures after primary SG: proximal RYGB (n = 12, 23.1%), type 2 DRYGB (n = 8, 15.4%), long BPL RYGB (n = 20, 38.5%), and OAGB (n = 12, 23.1%). The long BPL type procedures (long BPL RYGB, OAGB) resulted in a significant long-term additional %EWL (33.8%; 33.2%) at 3 years. In the PRYGB, the effect lasted only for 2 years. In all patients with GERD and dysphagia as the dominant post-SG symptoms, the conversion to a bypass procedure resulted in the complete resolution of these. CONCLUSION: In case of weight regain or insufficient weight loss after SG, revisional surgery with a long BPL should be considered. The OAGB provides effective additional weight loss, with low morbidity and malnutrition rates, respectively. Conversion to the malabsorptive long BPL RYGB with a total alimentary limb length below 400 cm should be avoided. Patients that suffer primarily from post-SG GERD or dysphagia should undergo conversion to PRYGB.

Revisional Adjustable Gastric Band in Roux-en-Y Gastric Bypass-Is It Worth It?

PURPOSE: A subset of patients undergoing Roux-en-Y gastric bypass (RYGB) presents with either insufficient weight loss or weight regain. Data on the revisional restrictive options including laparoscopic adjustable gastric band (LAGB) is scarce. This study analyzes the mid-term efficacy and safety of LAGB as a revisional procedure after RYGB. METHODS: Data of all patients with revisional LAGB after primary RYGB between January 2011 and May 2019 were retrospectively reviewed. Outcomes included assessment of weight changes, resolution of comorbidities, and early and late complications during the study period. RESULTS: Twenty patients were included. The median Body Mass Index (BMI) before revisional LAGB was 34.8 (interquartile range [IQR] 31.9-38.1) kg/m2. After a median follow-up of 33.5 (IQR 19.5-76.5) months, the median BMI was 28.7 (IQR 26.1-32.2) kg/m2. The median additional Excess Weight Loss (EWL) was 37.6% (IQR 23-44.4), leading to a median total EWL of 79.5% (IQR 54.4-94.6). BMI and EWL post-LAGB improved significantly compared to BMI and EWL pre-LAGB (p<0.001 and p<0.001, respectively). Obstructive sleep apnea syndrome resolved 6 months after LAGB in one patient. Three band deflations occurred during the follow-up. Six patients underwent band removal after a median time of 19 (IQR 15.8-26) months. Overall, thirteen patients underwent a reoperation. There was no loss of follow-up until 5 years. After that, two patients were lost to follow-up. CONCLUSION: LAGB may be a salvage option after failed RYGB. However, the high rate of revisions after secondary LAGB needs to be taken into consideration.

High frequency of tumor-infiltrating FOXP3(+) regulatory T cells predicts improved survival in mismatch repair-proficient colorectal cancer patients.

Regulatory T cells (T(reg)) inhibit the generation of host-versus-tumor immunity via suppression of tumor-specific effector T-cell responses and development of immune tolerance to neoplastic cells. The transcription factor forkhead box P3 (FOXP3) is an intracellular key molecule for T(reg) development and function and is considered to represent the most specific T(reg) cell marker. The aim of this study was to analyze the frequency and prognostic impact of tumor-infiltrating FOXP3(+) T(reg) in colorectal cancer (CRC) stratified by mismatch-repair (MMR) status. Using the tissue microarray technique, 1,420 tumor samples were immunohistochemically stained for FOXP3 and stratified into 1,197 MMR-proficient and 223 MMR-deficient CRCs. Additionally, the 1,197 MMR-proficient CRCs were randomized into 2 subgroups (Test Groups 1 and 2; n = 613 and 584, respectively). In both MMR-proficient CRC subgroups high frequency tumor-infiltrating FOXP3(+) T(reg) was associated with early T stage (p = 0.001 and <0.001), tumor location (p = 0.01 and 0.045) and increased 5-year survival rate (p = 0.004 and <0.001), whereas in MMR-deficient CRCs an association between FOXP3(+) T(reg) and absence of lymph node involvement (p = 0.023), absence of vascular invasion (p = 0.023) and improved 5-year survival rate (p = 0.029) could be detected. In a multivariable analysis including age, gender, T stage, N stage, tumor grade, vascular invasion, and tumor border configuration, a high FOXP3(+) T(reg) frequency was an independent prognostic factor in both MMR-proficient CRC subsets (p = 0.019 and p = 0.007), but not in the MMR-deficient CRCs (p = 0.13). Therefore, high frequency of tumor-infiltrating FOXP3(+) T(reg) is associated with early T stage and independently predicts improved disease-specific survival in MMR-proficient CRC patients.