Transition from a circular to a linear stapling protocol in laparoscopic Roux-en-Y gastric bypass surgery and its impact on quality of life: a 5-year outcome study.

PURPOSE: Surgical technique in bariatric surgery has been refined over the past decades. This study analysed the effect of changing the stapling protocol on the quality of life (QoL) at a midterm follow-up. METHODS: The retrospective cohort study included patients undergoing Roux-en-Y gastric bypass between June 2012 and March 2016. Patients were stratified into the circular stapling protocol (CSP, n = 117) or the linear stapling protocol (LSP, n = 118). QoL was quantified by the Moorehead score at 12, 24 and 60 months. Multivariate testing was used to identify confounders. RESULTS: The age was 42.8 ± 11.5 years and the body mass index (BMI) was 43.8 ± 6.2 kg/m2, with no baseline intergroup differences. Overall baseline Moorehead score was 0.42 ± 1.1 and improved in both groups after 12 months (1.97 ± 0.74, p < 0.001), 24 months (1.86 ± 0.79, p < 0.001) and 60 months (1.71 ± 0.9, p < 0.001). LSP was associated with improved Moorehead score after 60 months (odds ratio [OR] 1.251, 95% confidence interval [CI] 1.06-1.48, p = 0.010). Overall, a drop of mean BMI occurred and this effect lasted throughout the observation period (- 12.48 kg/m2, p < 0.001). More profound BMI reduction was further positively associated with Moorehead scores after 24 and after 60 months (OR 0.97, p = 0.028; OR 0.96, p = 0.007). Complications, rehospitalisations and reoperations were more frequent in the CSP group (50% vs 23.7%, p < 0.001; 39.7% vs 22.9%, p = 0.009; 37.1% vs 18.6%, p = 0.003). CONCLUSION: The CSP and LSP achieve a long-lasting increase in QoL, although the LSP is associated with fewer complications, persistent weight loss and improved Moorehead score. Therefore, the LSP might be considered the favourable protocol in Roux-en-Y gastric bypass.

Shift of Neutrophils From Blood to Bone Marrow Upon Extensive Experimental Trauma Surgery.

Introduction: Extensive trauma surgery evokes an immediate cellular immune response including altered circulatory neutrophil numbers. The concurrent bone marrow (BM) response however is currently unclear. We hypothesize that these BM changes include (1) a relative reduction of the bone marrow neutrophil fraction and (2) increasing heterogeneity of the bone marrow neutrophil pool due to (3) the appearance of aged/returning neutrophils from circulation into the BM-compartment. Materials and Methods: Eight pigs were included in a standardized extensive trauma surgery model. Blood and bone marrow samples were collected at baseline and after 3 hours of ongoing trauma surgery. Leukocyte and subtype counts and cell surface receptor expression levels were studied by flow cytometry. Results: All animals survived the interventions. A significant drop in circulating neutrophil counts from 9.3 to 3.2x106 cells/ml (P=0.001) occurred after intervention, whereas circulatory neutrophil cell surface expression of CD11b increased. The concurrent bone marrow response included an increase of the BM neutrophil fraction from 63 ± 3 to 71 ± 3 percent (P<0.05). Simultaneously, the BM neutrophil pool became increasingly mature with a relative increase of a CXCR4high-neutrophil subtype that was virtually absent at baseline. Conclusion: The current study shows a shift in composition of the BM neutrophil pool during extensive trauma surgery that was associated with a relatively circulatory neutropenia. More specifically, under these conditions BM neutrophils were more mature than under homeostatic conditions and a CXCR4high-neutrophil subset became overrepresented possibly reflecting remigration of aged neutrophils to the BM. These findings may contribute to the development of novel interventions aimed to modify the trauma-induced immune response in the BM.

Lessons learned from the mechanisms of posttraumatic inflammation extrapolated to the inflammatory response in COVID-19: a review.

Up to 20% of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) patients develop severe inflammatory complications with diffuse pulmonary inflammation, reflecting acute respiratory distress syndrome (ARDS). A similar clinical profile occurs in severe trauma cases. This review compares pathophysiological and therapeutic principles of severely injured trauma patients and severe coronavirus disease 2019 (COVID-19). The development of sequential organ failure in trauma parallels deterioration seen in severe COVID-19. Based on established pathophysiological models in the field of trauma, two complementary pathways of disease progression into severe COVID-19 have been identified. Furthermore, the transition from local contained disease into systemic and remote inflammation has been addressed. More specifically, the traumatology concept of sequential insults ('hits') resulting in immune dysregulation, is applied to COVID-19 disease progression modelling. Finally, similarities in post-insult humoral and cellular immune responses to severe trauma and severe COVID-19 are described. To minimize additional 'hits' to COVID-19 patients, we suggest postponing all elective surgery in endemic areas. Based on traumatology experience, we propose that immunoprotective protocols including lung protective ventilation, optimal thrombosis prophylaxis, secondary infection prevention and calculated antibiotic therapy are likely also beneficial in the treatment of SARS-CoV-2 infections. Finally, rising SARS-CoV-2 infection and mortality rates mandate exploration of out-of-the box treatment concepts, including experimental therapies designed for trauma care.

Invasive surgery reduces infarct size and preserves cardiac function in a porcine model of myocardial infarction.

Reperfusion injury following myocardial infarction (MI) increases infarct size (IS) and deteriorates cardiac function. Cardioprotective strategies in large animal MI models often failed in clinical trials, suggesting translational failure. Experimentally, MI is induced artificially and the effect of the experimental procedures may influence outcome and thus clinical applicability. The aim of this study was to investigate if invasive surgery, as in the common open chest MI model affects IS and cardiac function. Twenty female landrace pigs were subjected to MI by transluminal balloon occlusion. In 10 of 20 pigs, balloon occlusion was preceded by invasive surgery (medial sternotomy). After 72 hrs, pigs were subjected to echocardiography and Evans blue/triphenyl tetrazoliumchloride double staining to determine IS and area at risk. Quantification of IS showed a significant IS reduction in the open chest group compared to the closed chest group (IS versus area at risk: 50.9 ± 5.4% versus 69.9 ± 3.4%, P = 0.007). End systolic LV volume and LV ejection fraction measured by echocardiography at follow-up differed significantly between both groups (51 ± 5 ml versus 65 ± 3 ml, P = 0.033; 47.5 ± 2.6% versus 38.8 ± 1.2%, P = 0.005). The inflammatory response in the damaged myocardium did not differ between groups. This study indicates that invasive surgery reduces IS and preserves cardiac function in a porcine MI model. Future studies need to elucidate the effect of infarct induction technique on the efficacy of pharmacological therapies in large animal cardioprotection studies.