Effects of sarcopenia and myosteatosis are alleviated in reduced port surgery for diverticulitis.

PURPOSE: Many studies report the predictive value of sarcopenia, myosteatosis, and visceral fat for clinical outcome after surgery. Radiological analysis of body composition is a valuable tool for identifying high-risk patients undergoing major abdominal surgery. Despite the high prevalence of diverticular disease, patients with benign conditions have hardly been studied in this context. This study aims to evaluate the impact of reduced port surgery on the outcome of patients with diverticulitis, adjusting for body composition. METHODS: We assessed body composition profiles using preoperative CT slices at the level of the third lumbar vertebra in consecutive patients undergoing single-port elective surgery for diverticulitis in a single center. The effects of sarcopenia, myosteatosis, and visceral fat on mortality and complications were analyzed and adjusted for age and gender. RESULTS: We enrolled 99 patients with diverticulitis undergoing elective single port surgery in this study. Of the patients, 71.2% had sarcopenia and 60.6% had myosteatosis. The overall complication rate was 17.2%, and the rate of anastomotic leakage was 4.0%. Thirty-day mortality was 2.0%. Loss of skeletal muscle mass, myosteatosis, and visceral fat were not associated with higher complication or mortality rates in our cohort. CONCLUSION: Body composition profiles had no impact on the clinical course in our cohort. Minimally invasive surgery may potentially compensate for the adverse effects of sarcopenia and myosteatosis in diverticulitis.

Surgeon and patient-specific factors influencing the decision for minimally invasive or open surgery in acute bowel obstruction: a retrospective single-center analysis.

PURPOSE: Despite continuous improvement in minimally invasive surgery (MIS) and growing evidence for its superiority in procedures in various organ systems, a routinely application in patients with acute bowel obstruction (ABO) cannot be seen to date. Besides very general explanations for this attitude, not much is known about the decision process in a particular patient. This retrospective study aims at investigating surgeon- and patient-specific factors for or against MIS in acute bowel obstruction. METHODS: A retrospective analysis of all patients undergoing either MIS or open surgery (OS) for ABO at a single center between 2009 and 2017 was performed. All available preoperative parameters were included in the analysis and subdivided into patient- (age, gender, BMI, previous abdominal procedures, inflammatory process, ASA score, bowel dilatation) and surgeon-specific (time of patient admission, senior surgeon performed the procedure or taught the case, availability of a surgical resident or junior doctor as assisting surgeon) factors. Statistical analysis was performed to reveal their influence on the surgeon's decision for or against MIS. RESULTS: Of 106 patients requiring surgical intervention, 57 were treated by OS (53.77%) and 49 by MIS (46.23%). Patients with a higher ASA score (ASA III) and a bowel width of ≥ 3.8 cm in preoperative radiologic imaging were more likely to undergo OS (p < 0.01). Also, a late admission time to the hospital (x̄ = 14.78 h) was associated with OS (p = 0.01). Concerning previous abdominal surgical interventions, patients with prior appendectomy rather were assigned to MIS (p < 0.01) whereas those with prior colectomy to OS (p < 0.01). CONCLUSIONS: The choice of procedure in patients with bowel obstruction is a highly individualized decision. Whereas scientifically proven parameters, such as high age and BMI, had no influence on the decision process, impaired general health condition (ASA score), high bowel width, previous surgical intervention, and a late admission time influenced the decision process towards open surgery. TRIAL REGISTRATION: Retrospectively registered with the German Clinical Trials Register: DRKS00021600.

Incidence and risk factors for umbilical incisional hernia after reduced port colorectal surgery (SIL + 1 additional port)-is an umbilical midline approach really a problem?

PURPOSE: Umbilical midline incisions for single incision- or reduced port laparoscopic surgery are still discussed controversially because of a higher rate of incisional hernia compared to conventional laparoscopic techniques. The aim of this study was to evaluate incidence and risk factors for incisional hernia after reduced port colorectal surgery. METHODS: A total 241 patients underwent elective reduced port colorectal surgery between 2014 and 2020. Follow-up was achieved through telephone interview or clinical examination. The study collective was examined using univariate and multivariate analysis. RESULTS: A total of 150 patients with complete follow-up were included into this study. Mean follow-up time was 36 (IQR 24-50) months. The study collective consists of 77 (51.3%) female and 73 (48.7%) male patients with an average BMI of 26 kg/m2 (IQR 23-28) and an average age of 61 (± 14). Indication for surgery was diverticulitis in 55 (36.6%) cases, colorectal cancer in 65 (43.3%) patients, and other benign reasons in 30 (20.0%) cases. An incisional hernia was observed 9 times (6.0%). Obesity (OR 5.8, 95% CI 1.5-23.1, p = 0.02) and pre-existent umbilical hernia (OR 161.0, 95% CI 23.1-1124.5, p < 0.01) were significant risk factors for incisional hernia in the univariate analysis. Furthermore, pre-existent hernia is shown to be a risk factor also in multivariate analysis. CONCLUSION: We could demonstrate that reduced port colorectal surgery using an umbilical single port access is feasible and safe with a low rate of incisional hernia. Obesity and pre-existing umbilical hernia are significant risk factors for incisional hernia.

Dual trocar laparoscopy improves reduced-port surgery of the distal pancreas.

BACKGROUND: The technical feasibility of transumbilical single-incision surgery (SIL) for pancreatic resections has been demonstrated. However, this technique is hampered by the limited degrees of freedom for instrument handling. Dual-incision laparoscopy (DIL) with an additional trocar may simplify dissection and allow drainage. MATERIAL AND METHODS: Between December 2009 and May 2017, 21 patients were treated with SIL (12/2009 to 01/2014) or DIL (02/2014 to 05/2017) pancreatic resection. All data were collected in a database and retrospectively analysed. RESULTS: Demographic parameters of the patients did not differ significantly in the DIL or the SIL group. No conversion to open surgery was required. No intraoperative complication occurred in either group. The surgical difficulty score was significantly higher in the SIL group (4.4 ± 1.56 vs 2.18 ± 1.95; p = .006). Postoperative serum amylase levels were higher (101.9 U/l ± 50.11 vs 48.91 U/l ± 35.20; p = .01) and return to normal levels (6.4 ± 9.66 days vs 2.09 ± 1.98 days; p = .045) was later in the SIL group. Three complications requiring radiological or surgical intervention were witnessed in the SIL group and one complication in the DIL group (p = .42). CONCLUSION: DIL surgery is a safe and feasible alternative to SIL surgery, facilitating key steps of distal pancreatic tail resection.

Skeletal muscle index is an independent predictor of early recurrence in non-obese colon cancer patients.

PURPOSE: Progressive loss (sarcopenia) and fatty infiltration of muscle mass (myosteatosis) are well-established risk factors for an adverse clinical outcome in obese patients. Data concerning non-obese sarcopenic patients in oncologic surgery are scarce and heterogeneous. The aim of this study was to determine the impact of sarcopenia and myosteatosis in non-obese patients with cancer of the right colon on clinical outcome. METHODS: This study comprised 85 patients with a BMI < 30 kg/m2, who underwent surgery for right colon cancer in a single center. Skeletal muscle area (SMA), visceral fat area (VFA), and myosteatosis were retrospectively assessed using preoperative abdominal CT images. Univariate und multivariate analysis was performed to evaluate the association between body composition, complications, and oncologic follow-up. RESULTS: Traditional risk factors such as visceral fat (p = 0.8653), BMI (p = 0.8033), myosteatosis (p = 0.7705), and sarcopenia (p = 0.3359) failed to show any impact on postoperative complications or early recurrence. In our cohort, the skeletal muscle index (SMI) was the only significant predictor for early cancer recurrence (p = 0.0467). CONCLUSION: SMI is a significant prognostic factor for early cancer recurrence in non-obese colon cancer patients. Our study shows that conventional thresholds for sarcopenia and BMI do not seem to be reliable across various cohorts. Target prehabilitation programs could be useful to improve outcome after colorectal surgery. TRIAL REGISTRATION: DRKS00014655, www.apps.who.int/trialsearch.

European association for endoscopic surgery (EAES) consensus statement on single-incision endoscopic surgery.

BACKGROUND: Laparoscopic surgery changed the management of numerous surgical conditions. It was associated with many advantages over open surgery, such as decreased postoperative pain, faster recovery, shorter hospital stay and excellent cosmesis. Since two decades single-incision endoscopic surgery (SIES) was introduced to the surgical community. SIES could possibly result in even better postoperative outcomes than multi-port laparoscopic surgery, especially concerning cosmetic outcomes and pain. However, the single-incision surgical procedure is associated with quite some challenges. METHODS: An expert panel of surgeons has been selected and invited to participate in the preparation of the material for a consensus meeting on the topic SIES, which was held during the EAES congress in Frankfurt, June 16, 2017. The material presented during the consensus meeting was based on evidence identified through a systematic search of literature according to a pre-specified protocol. Three main topics with respect to SIES have been identified by the panel: (1) General, (2) Organ specific, (3) New development. Within each of these topics, subcategories have been defined. Evidence was graded according to the Oxford 2011 Levels of Evidence. Recommendations were made according to the GRADE criteria. RESULTS: In general, there is a lack of high level evidence and a lack of long-term follow-up in the field of single-incision endoscopic surgery. In selected patients, the single-incision approach seems to be safe and effective in terms of perioperative morbidity. Satisfaction with cosmesis has been established to be the main advantage of the single-incision approach. Less pain after single-incision approach compared to conventional laparoscopy seems to be considered an advantage, although it has not been consistently demonstrated across studies. CONCLUSIONS: Considering the increased direct costs (devices, instruments and operating time) of the SIES procedure and the prolonged learning curve, wider acceptance of the procedure should be supported only after demonstration of clear benefits.

Intra-abdominal Trocar-Free Vacuum Liver Retractor for Upper-Gastrointestinal Surgery.

BACKGROUND: In laparoscopic upper-gastrointestinal (GI) surgery, an adequate retraction of the liver is crucial. Especially in single-port surgery and obese patients, problems may occur during liver retraction. The current study seeks to evaluate the efficacy and safety of the LiVac trocar-free liver retractor in laparoscopic upper-GI surgery. METHODS: The present study is a nonrandomized dual-center clinical series describing our preliminary results using the LiVac system for liver retraction. The primary end points of the present study included the effectiveness and safety of the LiVac device as well as complications and documentation of problems with the device during surgery. RESULTS: The device was used in 11 patients for simple and complex laparoscopic procedures. The mean age of the study population was 59.6 years (SD = 20.6; range = 30-84). There were 6 female and 5 male patients with a mean body mass index (BMI) of 31.9 kg/m2 (SD = 8.1; range = 26.0-45.3). The efficacy of the device was excellent in all cases, reducing the number of trocars needed. There were no device-related complications. CONCLUSION: The LiVac liver retractor is easy to use and provides a good exposure of the operative field in upper-GI laparoscopic surgery, even in obese patients with a high BMI.

Wound complications in 1145 consecutive transumbilical single-incision laparoscopic procedures.

OBJECTIVE: To evaluate the wound complication rate in patients undergoing transumbilical single-incision laparoscopic (SIL) surgery. BACKGROUND: SIL surgery claims to be less invasive than conventional laparoscopy. Small SIL series have raised concerns toward a higher wound complication rate related to the transumbilical incision. METHODS: In a 44-month period, 1145 consecutive SIL procedures were included. The outcomes were assessed according to the intention-to-treat analysis principle. All procedures were followed for a minimum of 6 months postoperatively, and wound complications were recorded as bleeding, infection (superficial/deep), or hernia. Patients were classified as having a wound complication or not. For all comparisons, significance level was set at P<0.05. RESULTS: Pure transumbilical SIL surgery was completed in 92.84%, and additional trocars were used in 7.16%. After a median follow-up of 22.1 (range, 7.67-41.11) months, 29 wound complications (2.53%) had occurred [bleeding 0%/infection 1.05% (superficial 0.9%/deep 0.17%)/early-onset hernia 0.09%/late-onset hernia 1.40%, respectively]. Factors associated with complications were higher patient body mass index (28.16±4.73 vs 26.40±4.68 kg/m; P=0.029), longer skin incisions (3.77±1.62 vs 2.96±1.06 cm; P=0.012), and multiport SIL versus single-port SIL (8.47% vs 2.38%; P=0.019) in complicated versus uncomplicated procedures. Furthermore, a learning curve effect was noted after 500 procedures (P=0.015). CONCLUSIONS: With transumbilical SIL surgery, the incidence of wound complications is acceptable low and is further reduced once the learning curve has been passed.

Laparoscopic liver packing to protect surrounding organs during thermal ablation.

PURPOSE: To evaluate the feasibility of liver packing for the prevention of injury to adjacent organs during thermal ablation of liver tumors. MATERIAL AND METHODS: Between January 2005 and March 2010, 47 (52 sessions) patients with non-resectable liver tumors were treated and their tumors (55 primary carcinomas and 65 metastases, 1-12) were isolated from adjacent organs by laparoscopic liver mobilization and packing. Stereotactic radiofrequency ablation (SRFA) comprised body fixation, contrast-enhanced CT, 3-D planning, navigation, needle placement, control CT of needle positions (with image fusion), thermal ablation and control CT (with image fusion). Liver packing was removed laparoscopically thereafter. Complications, primary success and local recurrence rates were analyzed. RESULTS: A total of 120 liver lesions with a median size of 2.4 cm (range 1-15 cm) were treated. Laparoscopic packing could be performed in all patients. The primary success rate of ablation was 91.6% (110/120) and the local recurrence rate was 4.5% (5/110). There was one perioperative death (1.9%). All remaining complications could be managed by radiological interventions. Despite broad surface contact thermal injury of surrounding organs could be prevented in all patients. CONCLUSION: Liver packing presents a viable and safe option for RFA of tumors with broad surface contact to surrounding organs with excellent local tumor control.

The Single-port Laparoscopic Omental Free Flap: Reconstruction of Dorsal Hand Defects with Negligible Donor-site Scar.

The reconstruction of complex dorsal hand injuries can be challenging. For coverage of dorsal hand defects, thin flap tissue is preferred. In addition, it is ideal to raise flaps with minimal donor-site morbidity and a discrete scar. In a 65-year-old obese man, we successfully reconstructed a soft-tissue defect measuring 7 × 5 cm at the dorsal hand with an omental free flap harvested through single-port laparoscopy. Our patient regained hand function and is satisfied with the aesthetic results. We propose the single-port laparoscopic omental free flap to be a suitable option for free flap dorsal hand reconstruction, especially in obese patients with small defects. The technique provides a thin free tissue with a concomitant negligible donor-site scar.

Percutaneous stereotactic radiofrequency ablation of colorectal liver metastases.

OBJECTIVES: To evaluate the outcome of patients with colorectal liver metastasis (CRLM) treated with stereotactic radiofrequency ablation (SRFA). METHODS: Following IRB approval, a retrospective evaluation of 98 SRFA treatment sessions of 189 CRLMs in 63 consecutive patients was performed. Local recurrence rate (LR), overall survival (OS) and disease-free survival (DFS) were analysed. RESULTS: LR was identified in 16% of the tumours (31/189), with no significant differences (P = 0.635) when comparing tumour sizes <3 cm (17.7%), 3-5 cm (11.1%) and >5 cm (17.4%). The median OS from SRFA treatment was 33.2 months after a mean follow-up of 25 months (range 2-66); the corresponding 1-, 3- and 5- year survival rates were 87%, 44% and 27%. The median OS was significantly different when comparing unresectable and resectable patients (27 vs. 58 months, P = 0.002) with OS rates of 92%, 66% and 48% at 1, 3 and 5 years in resectable patients. Tumour size did not affect OS and DFS. CONCLUSION: Due to the favourable outcome, SRFA challenges resection as first-line local treatment of patients with CRLM. As long as randomised studies are pending, we recommend entering an individual decision-making process with every patient. KEY POINTS: Large colorectal liver metastases can be effectively treated by stereotactic radiofrequency ablation (SRFA). Using SRFA the overall survival is not affected by tumour size. SRFA achieves similar overall and disease-free survival rates as surgical resection. SRFA challenges surgical resection as the first-line treatment for colorectal liver metastases.

Flexible single port access in transoral endoscopic thyroidectomy vestibular approach.

Background: Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is regarded the only no-scar technique which combines minimized surgical trauma with all advantages of endoscopy such as enhanced view, fluorescent parathyroid imaging (FPI) and optimum cosmesis. Addressing TOETVA specific local risk profiles like mental nerve injury, the potential of skin lesions or difficult specimen retrieval we modified the three trocar based TOETVA towards a soft single port platform. Methods: Single port-TOETVA (SP-TOETVA) was established and retrospectively analysed in five patients using a soft handmade single port housing multiple trocar valves. Standard laparoscopic instruments, one articulating instrument and a vessel-sealing device were utilized. CO2 insufflation was maintained at 6-8 mmHg. Results: In all patients SP-TOETVA was completed successfully. Hemigland and total thyroid volumes ranged from 5-40 and 55 mL, respectively. Neither additional trocars nor conversion to open was required. Operation time yielded 102-214 min. Neuromonitoring and FPI were applied. The soft wound protection foil served for convenient specimen harvest. No intra- or postoperative complication occurred. In particular, no functional impairment on mental nerve was seen. Conclusions: SP-TOETVA with the soft and flexible handmade single port system is feasible and ensures wound protection. It allows for easy instrument application and benefits of minimally invasive surgery without the specific risk of lateral vestibular incisions.

Structure of CO2 adsorbed on the KCl(100) surface.

The structure and dynamics of the adsorbate CO(2)/KCl(100) from a diluted phase to a saturated monolayer have been investigated with He atom scattering (HAS), low-energy electron diffraction (LEED), and polarization dependent infrared spectroscopy (PIRS). Two adsorbate phases with different CO(2) coverage have been found. The low-coverage phase is disordered at temperatures near 80 K and becomes at least partially ordered at lower temperatures, characterized by a (2√2×√2)R45° diffraction pattern. The saturated 2D phase has a high long-range order and exhibits (6√2×√2)R45° symmetry. Its isosteric heat of adsorption is 26 ± 4 kJ mol(-1). According to PIRS, the molecules are oriented nearly parallel to the surface, the average tilt angle in the saturated monolayer phase is 10° with respect to the surface plane. For both phases, structure models are proposed by means of potential calculations. For the saturated monolayer phase, a striped herringbone structure with 12 inequivalent molecules is deduced. The simulation of infrared spectra based on the proposed structures and the vibrational exciton approach gives reasonable agreement between experimental and simulated infrared spectra.

Anti-inflammatory effects of excessive weight loss: potent suppression of adipose interleukin 6 and tumour necrosis factor alpha expression.

OBJECTIVE: Severe obesity is a chronic inflammatory disease where various cytokines/adipocytokines play a key role. Pro-inflammatory cytokines such as interleukin 6 (IL-6) and tumour necrosis factor-alpha (TNFalpha) are produced by human adipose tissue dependent on the degree of obesity. Mouse studies suggest a key role of adipose tissue-derived IL-6 in hepatic insulin resistance via modification of liver suppressor of cytokine signalling 3 (SOCS-3) expression. DESIGN AND METHODS: We examined the effect of excessive weight loss on systemic levels, subcutaneous and visceral adipose tissue and liver expression of IL-6 and TNFalpha in 20 severely obese patients undergoing laparoscopic adjustable gastric banding (LAGB). Furthermore, we studied liver expression of SOCS3, an important regulator of insulin resistance, and fat tissue expression of the anti-inflammatory adipocytokine adiponectin and its receptors. Serum and tissue samples were collected before and 6 months after LAGB surgery. RESULTS: IL-6/TNFalpha mRNA expression before weight loss were similar in subcutaneous and visceral adipose tissue and much higher compared to hepatic expression. Subcutaneous adipose tissue mRNA expression of both pro-inflammatory cytokines, but especially of IL-6 decreased dramatically after extensive weight loss whereas expression of adiponectin and its receptors increased. Weight loss also led to a significant reduction in liver IL-6 expression, whereas liver TNFalpha mRNA expression did not change. IL-6 and C-reactive protein serum levels decreased after weight loss whereas TNFalpha serum levels were below the detection limit before and after surgery. These effects were paralleled by reduced hepatic SOCS3 expression and improved insulin resistance 6 months after LAGB surgery. CONCLUSION: Expression of IL-6 and TNFalpha mRNA is more pronounced in adipose compared to liver tissue in patients with severe obesity. Our results highlight excessive weight loss as a successful anti-inflammatory strategy.

Analogies between medusa and single port surgery in gastroenterology and hepatology: A review.

Single port surgery (SPS) was introduced as an attractive, minimally invasive surgical technique that ensures esthetic results for many types of visceral surgery. Initially, surgeons immediately set about performing SPS without preliminary knowledge or training, which resulted in higher complication rates. Today, current studies conclusively show that SPS is scientifically rehabilitated and indicated for simple and complex laparoscopic procedures. We here describe the astonishing analogies between Greek mythology and modern surgery.

The Shift from Multiport to Single Port Increases the Amount of Bleeding in Laparoscopic Major Hepatectomy.

BACKGROUND: Bleeding is a negative outcome predictor in liver surgery. Reduction in the abdominal wall trauma in major hepatectomy is challenging but might offer possible benefits for the patient. This study was conducted to assess hemostasis techniques in single-port major hepatectomies (SP-MajH) as compared to multiport major hepatectomies (MP-MajH). METHODS: The non-randomized study comprised 34 SP-MajH in selected patients; 14 MP-MajH served as the control group. Intraoperative blood loss and number of blood units transfused served as the primary endpoints. Secondary endpoints were complications and oncologic five-year outcome. RESULTS: All resections were completed without converting to open surgery. Time for hepatectomy did not differ between SP-MajH and MP-MajH. Blood loss and number of patients with blood loss > 25 mL were significantly larger in MP-MajH (p = 0.001). In contrast, bleeding control was more difficult in SP-MajH, resulting in more transfusions (p = 0.008). One intestinal laceration (SP-MajH) accounted for the only intraoperative complication; 90-day mortality was zero. Postoperative complications were noted in total in 20.6% and 21.4% of patients for SP-MajH and MP-MajH, respectively. No incisional hernia occurred. During a median oncologic follow-up at 61 and 56 months (SP-MajH and MP-MajH), no local tumor recurrence was observed. CONCLUSIONS: SP-MajH requires sophisticated techniques to ensure operative safety. Substantial blood loss requiring transfusion is more likely to occur in SP-MajH than in MP-MajH.

Impact of the COVID-19 pandemic lockdown on the utilization of acute surgical care in the State of Salzburg, Austria: retrospective, multicenter analysis.

BACKGROUND: Some medical disciplines have reported a strong decrease of emergencies during the coronavirus disease 2019 (COVID-19) pandemic; however, the effect of the lockdown on general surgery emergencies remains unclear. METHODS: This study is a retrospective, multicenter analysis of general surgery emergency operations performed during the period from 1 March to 15th 2020 lockdown and in the same time period of 2019 in three medical centers providing emergency surgical care to the area Salzburg-North, Austria. RESULTS: In total 165 emergency surgeries were performed in the study period of 2020 compared to 287 in 2019. This is a significant decrease of 122 (42.5%) emergency surgeries during the COVID-19 lockdown (p = 0.005). The length of hospital stay was reduced to 3 days in 2020 compared to 4 in 2019. Appendectomy remained the most performed emergency surgery for both periods; however the number of surgeries was reduced to less than a half, with 72 cases in 2019 and 33 cases in 2020 (p = 0.118). Emergency colon surgery observed the strongest decrease of 75% from 17 cases in 2019 to 4 in 2020. In addition, the emergency abdominal wall hernia, cholecystectomies for acute cholecystitis, small surgeries and proctological emergencies recorded drops of 70%, 39%, 33% and 47% respectively. The strongest reduction in frequencies of emergency surgeries was reported from the designated COVID center in the examined region. CONCLUSIONS: Emergency general surgery is an essential service that continues to run under all circumstances. Our data show that COVID-19-related restrictions have resulted in a significant decrease in the utilization of acute surgical care.

Effect of bariatric surgery on both functional and structural measures of premature atherosclerosis.

AIMS: To bridge the beneficial metabolic effects of pronounced weight loss on one side and the data on morbidity and mortality on the other side, we investigated the impact of profound weight loss on structural and functional markers of early atherosclerosis. METHODS AND RESULTS: Thirty-seven obese adults were examined before and 18 months after bariatric surgery. Carotid intima-media thickness (CIMT), brachial flow-mediated dilation (FMD), nitroglycerine-mediated dilation, and abdominal fat distribution were assessed by high-resolution ultrasound. Surgery resulted in a body mass index decrease of 9.1 +/- 4.9 kg/m(2) with concomitant improvements in glucose and lipid metabolism. Carotid intima-media thickness diminished from 0.56 +/- 0.09 to 0.53 +/- 0.08 mm (n = 37; P = 0.004). Flow-mediated dilation improved from 5.81 +/- 3.25 to 9.01 +/- 2.93% (n = 25; P < 0.001). Both CIMT and FMD were associated with intra-abdominal fat diameter. CONCLUSION: The present results demonstrate that bariatric surgery-induced diminution of visceral fat improves both functional and structural markers of early atherosclerosis, providing a link between the weight loss-associated improvements of traditional and non-traditional risk factors and the reduced long-term morbidity and mortality after bariatric surgery.