[Roux-Y-Gastric Bypass for Morbid Obesity in Adolescents: Is it as Safe and Effective as in Obese Adults?] / Der Roux-Y-Magenbypass zur Therapie der Adipositas bei Jugendlichen: Analyse des Gewichtsverlaufs und des Einflusses auf Komorbiditäten im Vergleich zu adipösen Erwachsenen.

BACKGROUND: Obesity is one of the major challenges of the 21st century. There is also an increasing incidence of obesity in adolescents. Bariatric surgery has been proven safe and effective in obese adults. In adolescents, these operations are still subject to controversy. Current evidence is limited regarding its safety and outcome in this age group. METHODS: Within the German Bariatric Surgery Registry, data from obese patients that underwent bariatric procedures in Germany are prospectively registered. The current analysis includes all adolescent and adult subjects that underwent primary Roux-Y-gastric bypass (RYGB) surgery from 2005 to 2014. RESULTS: Overall, 370 adolescents (≤ 21 years) and 16,840 obese adults were enrolled. In 2014, RYGB was the second most common bariatric procedure in Germany. In the adolescent group, initial BMI was higher (49.2 vs. 47.9 kg/m2, p < 0.01); the proportion of associated comorbidities was lower (67.8 vs. 87.4%, p < 0.01). Operation time (104.9 vs. 113.0 min, p < 0.01) and hospital stay (5.2 vs. 5.9 days; p < 0.01) differed significantly between both groups. The leakage rate in adults was 1.6%; none of the adolescents experienced a postoperative anastomotic leak (p = 0.04). No mortalities were reported in adolescents; the mortality rate in adults was 0.2%. The mean percentage of excess weight loss (% EWL) did not differ between both groups at 12 (69.9 vs. 68.2%; p = 0.97) and 24 months (72.6 vs. 72.1% p = 1.0). The remission rate for hypertension was higher in the adolescent group. CONCLUSION: RYGB can be performed in obese adolescents with lower morbidity and mortality. Despite all limitations of a multicentre registry and the low follow-up rate, the results show that weight change and resolution of comorbidities in the short term were at least comparable to those achieved in adults. The evaluation of safety and efficiency in the long run should now be in the focus of future studies.

Correlation of CT-based bone mineralization with drilling-force measurements in anatomical specimens is suitable to investigate planning of trans-pedicular spine interventions.

This interdisciplinary study examined the relationship between bone density and drilling forces required during trans-pedicular access to the vertebra using fresh-frozen thoraco-lumbar vertebrae from two female body donors (A, B). Before and after biomechanical examination, samples underwent high-resolution CT-quantification of total bone density followed by software-based evaluation and processing. CT density measurements (n = 4818) were calculated as gray values (GV), which were highest in T12 for both subjects (GVmaxA = 3483.24, GVmaxB = 3160.33). Trans-pedicular drilling forces F (Newton N) were highest in L3 (FmaxB = 5.67 N) and L4 (FmaxA = 5.65 N). In 12 out of 13 specimens, GVs significantly (p < 0.001) correlated with force measurements. Among these, Spearman correlations r were poor in two lumbar vertebrae, fair in five specimens, and moderately strong in another five specimens, and highest for T11 (rA = 0.721) and L5 (rB = 0.690). Our results indicate that CT-based analysis of vertebral bone density acquired in anatomical specimens is a promising approach to predict the drilling force appearance as surrogate parameter of its biomechanical properties by e.g., linear regression analysis. The study may be of value as basis for biomechanical investigations to improve planning of the optimal trajectory and to define safety margins for drilling forces during robotic-assisted trans-pedicular interventions on the spine in the future.

Kinematic Stride Characteristics of Maximal Sprint Running of Elite Sprinters - Verification of the "Swing-Pull Technique".

Maximum sprinting speed constitutes an optimum relation between the stride length and the step rate in addition to an appropriate sprinting technique. The kinematics of the sprint step at maximum sprinting speed have already been examined in numerous studies, without reaching a consensus. The aim of this study was to analyze the relationship between maximum sprinting speed and the stride kinematics based on the "Swing-Pull Technique". German elite sprinters (N = 26, body height = 182 ± 6 cm, leg length 93.8 ± 4.1 cm) were tested while performing a 30-meter flying sprint at maximum sprinting speed. The relationship between sprinting speed and kinematic variables was determined via Pearson correlation. Sprinting speed (10.1 - 11.3 m/s) correlated with stride length (r = 0.53), ground contact time (r = -0.53) and variables from the technique model: the knee angle at the end of the knee lift swing (r = 0.40), the maximum knee angle prior to backswing (r = 0.40), the hip extension angle velocity (r = 0.63), and vertical foot velocity (r = 0.77) during pre-support, the ankle angle at the take-on (r = -0.43), knee flexion (r = -0.54), and knee extension (r = -0.47) during support. The results indicate that greater stride length, smaller contact time, and the mentioned kinematic step characteristics are relevant for the production of maximum sprinting speed in athletes at an intermediate to advanced performance level. The association of sprinting speed and these features should primarily be taken into account in conditioning and technical training.

Tumor visualization and fluorescence angiography with indocyanine green (ICG) in laparoscopic and robotic hepatobiliary surgery - valuation of early adopters from Germany.

OBJECTIVES: Indocyanine green (ICG) is a fluorescent dye which was initially used for liver functional assessment. Moreover, it is of value for intraoperative visualization of liver segments and bile ducts or primary and secondary liver tumors. Especially in minimally invasive liver surgery, this is essential to enhance the precision of anatomical guided surgery and oncological quality. As early adopters of ICG implementation into laparoscopic and robotic-assisted liver surgery in Germany, we summarize the current recommendations and share our experiences. METHODS: Actual strategies for ICG application in minimally invasive liver surgery were evaluated and summarized during a review of the literature. Experiences in patients who underwent laparoscopic or robotic-assisted liver surgery with intraoperative ICG staining between 2018 and 2020 from the Magdeburg registry for minimally invasive liver surgery (MD-MILS) were evaluated and the data were analyzed retrospectively. RESULTS: ICG can be used to identify anatomical liver segments by fluorescence angiography via direct or indirect tissue staining. Fluorescence cholangiography visualizes the intra- and extrahepatic bile ducts. Primary and secondary liver tumors can be identified with a sensitivity of 69-100%. For this 0.5 mg/kg body weight ICG must be applicated intravenously 2-14 days prior to surgery. Within the MD-MILS we identified 18 patients which received ICG for intraoperative tumor staining of hepatocellular carcinoma (HCC), cholangiocarcinoma, peritoneal HCC metastases, adenoma, or colorectal liver metastases. The sensitivity for tumor staining was 100%. In 27.8% additional liver tumors were identified by ICG fluorescence. In 39% a false positive signal could be detected. This occurred mainly in cirrhotic livers. CONCLUSIONS: ICG staining is a simple and useful tool to assess individual hepatic anatomy or to detect tumors during minimally invasive liver surgery. It may enhance surgical precision and improve oncological quality. False-positive detection rates of liver tumors can be reduced by respecting the tumor entity and liver functional impairments.

Attentional processing of pain faces and other emotional faces in chronic pain-an eye-tracking study.

Altered attentional processing of pain-associated stimuli-which might take the form of either avoidance or enhanced vigilance-is thought to be implicated in the development and maintenance of chronic pain. In contrast to reaction time tasks like the dot probe, eye tracking allows for tracking the time course of visual attention and thus differentiating early and late attentional processes. Our study aimed at investigating visual attention to emotional faces in patients with chronic musculoskeletal pain (N = 20) and matched pain-free controls (N = 20). Emotional faces (pain, angry, happy) were presented in pairs with a neutral face for 2000 ms each. Three parameters were determined: First fixation probabilities, fixation durations (overall and divided in four 500 ms intervals) and a fixation bias score as the relative fixation duration of emotional faces compared to neutral faces. There were no group differences in any of the parameters. First fixation probabilities were lower for pain faces than for angry faces. Overall, we found longer fixation duration on emotional compared to neutral faces ('emotionality bias'), which is in accord with previous research. However, significant longer fixation duration compared to the neutral face was detected only for happy and angry but not for pain faces. In addition, fixation durations as well as bias scores yielded evidence for vigilant-avoidant processing of pain faces in both groups. These results suggest that attentional bias towards pain-associated stimuli might not generally differentiate between healthy individuals and chronic pain patients. Exaggerated attentional bias in patients might occur only under specific circumstances, e.g., towards stimulus material specifically relating to the specific pain of the patients under study or under high emotional distress.

[Importance of splenectomy in the operative treatment of gastric cancer]. / Bedeutung der Splenektomie im Rahmen der operativen Behandlung des Magenkarzinoms.

BACKGROUND: The value of simultaneous splenectomy as part of an oncologically adequate resection for gastric cancer has been controversially discussed over the last decades. METHODS: As part of a prospective multicenter observational study data were obtained from patients admitted to hospital with histologically diagnosed primary gastric cancer or adenocarcinoma of the esophagogastric junction (AEG). The profiles of care of patients who had undergone surgical treatment in 141 surgical departments from 1 January 2007 to 31 December 2009 were collated. Overall, 2897 patients were enrolled in the study (tumor resection, n = 2545). RESULTS: The overall splenectomy rate was 11.1% (n = 283) and the highest proportion was found in AEG tumor lesions (19.4%). In the whole group of patients as well as depending on the tumor site, there was a higher preoperative comorbidity in splenectomized patients. While the rate of general postoperative complications after splenectomy was significantly increased in all patients and also depending on various tumor sites, there were no differences in the rate of specific postoperative complications. A significantly higher hospital mortality comparing the splenectomy group of patients with those in whom the spleen could be preserved, was only observed in AEG-associated tumor lesions (15.2% vs. 5.0%). All splenectomized patients showed a shorter long-term survival (p < 0.001) compared to resections with a preserved spleen (18 months vs. 36 months). CONCLUSION: In the surgical treatment of gastric cancer, splenectomy can be considered a negative predictor for a worse perioperative outcome and a worse long-term survival.

Quality of medical care in colorectal cancer in Germany.

BACKGROUND: To investigate recent developments in therapeutic approaches, we examine the quality of and discuss current trends in the routine treatment of colorectal cancer in Germany. MATERIAL AND METHODS: We conducted a prospective, multicentre, country-wide observational study in Germany at a representative number of hospitals providing care at all levels. RESULTS: The perioperative morbidity and mortality rates were found not to have changed for a given risk profile of patient and tumour characteristics. The resection rates and long-term oncological results achieved in clinical routine are comparable with those reported in the current literature for colorectal cancer. The quality of care of rectal carcinoma patients has improved significantly, as measured by perioperative oncosurgical criteria (abdominoperineal resection rate, total mesorectal excision rate and quality, and proportion of neoadjuvant procedures). CONCLUSION: At present, it remains to be seen whether these factors will lead to a further improvement in long-term results (e.g. rates of local recurrence), and this will require further critical analysis.

Trends in Early Morbidity and Mortality after Sleeve Gastrectomy in Patients over 60 Years : Retrospective Review and Data Analysis of the German Bariatric Surgery Registry.

BACKGROUND: The population are getting older and obesity is growing. Laparoscopic sleeve gastrectomy (LSG) is increasingly used worldwide but is still used with skepticism in the elderly. The purpose of our analysis is to judge the security of LSG in patients older than 60 years compared to patients younger than 60 years. METHODS: This retrospective review included data of all patients in Germany who underwent LSG between January 2005 and December 2016.The data were published online in the German Bariatric Surgery Registry. A total of 21,571 operations were gathered and divided into two groups: group I, patients < 60 years old; and group II, patients ≥ 60 years old. RESULTS: The total number of patients and the mean body mass index of group I and group II was 19,786, 51.7 ± 9.5 kg/m2 and 1771, 49.2 ± 8.1 kg/m2, respectively. Regarding comorbidities, group II suffered statistically significantly more comorbidities than group I (p < 0.001). The general postoperative complications were 4.9% in group I and 7.8% in group II (p < 0.001). There was no significant difference in special postoperative complications (p = 0.048) and a slightly higher intraoperative complication rate in group II (2.2% vs. 1.6%, p = 0.048). Thirty-day mortality rate for group I versus II was 0.22% and 0.23% (p = 0.977), respectively. CONCLUSIONS: LSG is a low-risk operation and safe surgical method with acceptable, not elevated perioperative morbidity and mortality rates in patients ≥ 60 years of age.

Perioperative Course, Weight Loss and Resolution of Comorbidities After Primary Sleeve Gastrectomy for Morbid Obesity: Are There Differences Between Adolescents and Adults?

BACKGROUND: Morbid obesity in both adolescents and adults has risen in an alarming rate. Bariatric surgery is playing an increasing role in pediatric surgery. However, current evidence is limited regarding its safety and outcome. METHODS: Since 2005, data from obese patients that undergo bariatric procedures in Germany are prospectively registered. For the current analysis, all adolescent and adult subjects that had undergone laparoscopic sleeve gastrectomy (LSG) from 2005 to 2014 were considered. RESULTS: LSG represents the most common bariatric procedure in Germany with a proportion of 48.1% in adolescent and 48.7% in adult obese in 2014. LSG was performed in 362 adolescent and 15,428 adult subjects. Pre-operative BMI was comparable between the two populations. However, adult obese had more frequently coexisting comorbidities (p < 0.01). Complication rates and mortality (0 vs. 0.2%) did not differ significantly. Adolescents achieved a BMI reduction of 16.8 and 18.0 kg/m2 at 12 and 24 months compared with 15.4 and 16.6 kg/m2 in the adult group. There was a significantly higher BMI reduction in late adolescents (19-21 years) compared with patients ≤18 years at 24 months (19.8 vs. 13.6 kg/m2). Resolution rate of hypertension was significantly higher in adolescents. CONCLUSION: LSG is a safe therapeutic option that can be performed in adolescents without mortality. Late adolescents experienced the highest weight loss; resolution rate of comorbidities was lower in adults. All future efforts should now be focused on the evaluation of the long-term outcomes of LSG in the pediatric population.

German Bowel Cancer Center: An Attempt to Improve Treatment Quality.

Background. Colorectal cancer remains the second most common cause of death from malignancies, but treatment results show high diversity. Certified bowel cancer centres (BCC) are the basis of a German project for improvement of treatment. The aim of this study was to analyze if certification would enhance short-term outcome in rectal cancer surgery. Material and Methods. This quality assurance study included 8197 patients with rectal cancer treated between 1 January 2008 and 31 December 2010. We compared cohorts treated in certified and noncertified hospitals regarding preoperative variables and perioperative outcomes. Outcomes were verified by matched-pair analysis. Results. Patients of noncertified hospitals had higher ASA-scores, higher prevalence of risk factors, more distant metastases, lower tumour localization, lower frequency of pelvic MRI, and higher frequencies of missing values and undetermined TNM classifications (significant differences only). Outcome analysis revealed more general complications in certified hospitals (20.3% versus 17.4%, p = 0.03). Both cohorts did not differ significantly in percentage of R0-resections, intraoperative complications, anastomotic leakage, in-hospital death, and abdominal wall dehiscence. Conclusions. The concept of BCC is a step towards improving the structural and procedural quality. This is a good basis for improving outcome quality but cannot replace it. For a primary surgical disease like rectal cancer a specific, surgery-targeted program is still needed.

Are There Gender-Specific Aspects in Obesity and Metabolic Surgery? Data Analysis from the German Bariatric Surgery Registry.

BACKGROUND: Since January 2005, the status of bariatric surgery in Germany has been examined in conjunction with a quality assurance study of the German Bariatric Surgery Registry (GBSR). All data are registered prospectively in cooperation with the Institute for Quality Assurance in Surgical Medicine at the Otto-von-Guericke University Magdeburg, Germany. METHODS: Data are registered in an online database. Data collection on obesity and metabolic surgery is voluntary, and was started in 2005. In addition, follow-up data are collected once a year. RESULTS: Since 2005, 8,293 sleeve gastrectomies, 10,330 Roux-en-Y gastric bypass procedures, and 3,741 gastric banding procedures have been performed in Germany, according to the data of the GBSR. Mean age and mean body mass index of female patients with gastric banding, sleeve gastrectomy, or Roux-en-Y gastric bypass were significantly lower than those of male patients. The incidence of relevant comorbidities was significantly higher in male than in female patients. CONCLUSION: Metabolic and obesity surgery is becoming more and more popular in Germany. Data from the GBSR study show significant differences in preoperative comorbidities and postoperative complication and mortality rates between male and female patients. There is a need for further evaluation of gender-specific aspects to optimize patient selection and reduce specific postoperative complications.

Actual situation of thromboembolic prophylaxis in obesity surgery: data of quality assurance in bariatric surgery in Germany.

Background. Evidence-based data on optimal approach for prophylaxis of deep venous thrombosis (VTE) and pulmonary embolism (PE) in bariatric operations is discussed. Using antithrombotic prophylaxis weight adjusted the risk of VTE and its complications have to be balanced with the increased bleeding risk. Methods. Since 2005 the current situation for bariatric surgery has been examined by quality assurance study in Germany. As a prospective multicenter observational study, data on the type, regimen, and time course of VTE prophylaxis were documented. The incidences of clinically diagnosed VTE or PE were derived during the in-hospital course and follow up. Results. Overall, 11,835 bariatric procedures were performed between January 2005 and December 2010. Most performed procedures were 2730 gastric banding (GB); 4901 Roux-en-Y-gastric bypass (RYGBP) procedures, and 3026 sleeve gastrectomies (SG). Study collective includes 72.5% (mean BMI 48.1 kg/m(2)) female and 27.5% (mean BMI 50.5 kg/m(2)) male patients. Incidence of VTE was 0.06% and of PE 0.08%. Conclusion. VTE prophylaxis regimen depends on BMI and the type of procedure. Despite the low incidence of VTE and PE there is a lack of evidence. Therefore, prospective randomized studies are necessary to determine the optimal VTE prophylaxis for bariatric surgical patients.

Small-diameter bands lead to high complication rates in patients after laparoscopic adjustable gastric banding.

BACKGROUND: While weight loss is the primary goal of bariatric procedures, the impact of quality of life (QoL), comorbidity, and surgery-related complications continue to grow. We report on our results of patients up to 12 years of follow-up undergoing laparoscopic adjustable gastric banding (LAGB). METHODS: Preoperative data of 153 patients treated with LAGB were collected retrospectively. Questionnaires were sent to patients to analyze weight loss, complications, and comorbidities. QoL was assessed using the Bariatric Qualit-of-Life (BQL) questionnaire. RESULTS: Of the patients, 83.7% completed the questionnaire. Median follow-up was 8.7 years. Patients were divided into the following groups: Group A (band still in place), group B (band removed), and group C (revision surgery). A significant increase of excess BMI loss (EBL) was found in group A (p<0.0001): EBL was 36.1%, 42.8%, 41.8%, and 37.1% after 1, 3, 5, and 8 years, respectively. Group B showed a significant weight regain after band removal (p=0.007). One hundred ten reoperations were necessary in 67 patients (52.3%): slippage or pouch dilatation in 25.8%, band migration in 3.9%, band intolerance in 6.2%, and 62 revisions due to port complications. According to BQL, a higher EBL correlated with a significantly better assessment of QoL (p<0.0001). CONCLUSIONS: LAGB resulted in improvement of comorbidities and QoL in banded patients even though not all of them achieved the expected EBL. However, the high complication rate could influence patients' outcome.

Status of bariatric surgery in Germany--results of the nationwide survey on bariatric surgery 2005-2007.

BACKGROUND: Most studies on bariatric surgery outcomes are performed as clinical trials or reflect the clinical experience in single centers. The status of bariatric surgery in Germany has been examined with the cooperation of clinics and hospitals at the Institute of Quality Assurance in Surgery at the Ottovon-Guericke University of Magdeburg (Germany) since January 1, 2005. METHODS: In this prospective multicenter observational study, the data obtained for all primary bariatric procedures, including all repeated operations, performed on consecutive patients with morbid obesity at participating hospitals from 2005 to 2007 were prospectively collected using an internet online data registry. Perioperative characteristics such as the spectrum of diagnostic measurements, type of surgical procedures, and short- and long-term outcomes were investigated. RESULTS: During the study period 3,123 surgical procedures were performed. In 2005 and 2006, gastric banding (GB) was the operation performed most frequently, followed by the Roux-en-Y gastric bypass (RYGBP). In 2007, a RYGBP was carried out in 42.1% of all bariatric procedures. Among all patients, 74.4% were female. The mean BMI ranged from 48.5 kg/m2 in 2005 to 48.0 kg/m2 in 2007. Follow-up data after 12 months were available for 63.8% of the patients operated in 2005 and 2006. The mortality was 0.1% (30 days) and 0.16% (overall). CONCLUSION: As indicated by the worldwide trend, there is an ongoing change from GB to sleeve gastrectomy (SG) and malabsorptive procedures. The BMI of German bariatric surgical patients is substantially higher than that of patients from most other countries. There were no differences in overall outcomes during follow-up as compared to published studies.

Small bowel obstruction in pregnancy.

BACKGROUND: Intestinal obstruction in pregnancy is rare. Symptoms are often unspecific and a high level of suspicion is essential for early diagnosis. Fetal and maternal mortality rates are higher during pregnancy due to delay in diagnosis. CASE: A 31-year-old primigravida with a history of abdominal surgery was admitted because of worsening abdominal pain, abdominal distension and elevated pancreatic enzymes. Ultrasound showed dilated small bowel loops. Explorative laparotomy revealed a small bowel obstruction with partial bowel necrosis caused by a single adhesion. A jejuno-jejunostomy was performed. Five days later, she developed peritonitis. A secondary laparotomy and caesarean section were done. CONCLUSION: In spite of timely diagnosis and prompt surgical intervention, our case was still complicated by peritonitis and early delivery. This underlines the necessity of immediate clinical suspicion. Small bowel obstruction should be considered in differential diagnosis of pregnant patients with a history of abdominal surgery.

Value of a protective stoma in low anterior resections for rectal cancer.

INTRODUCTION: Anastomotic leakage is a major problem in colorectal surgery and in particular in operations for low rectal cancer. The present study investigates the question whether a protective stoma can reduce the (clinical and radiologic) anastomotic leakage rate and/or the rate of leakage requiring surgery. METHODS: The investigation took the form of a prospective multicenter study involving 75 German hospitals and was performed between January 1, 1999, and December 31, 1999. A comparison was made of the postoperative results of procedures performed with and those performed without a protective stoma in patients undergoing low anterior rectal resection. In addition, logistic regression using the target criteria, overall anastomotic leakage and anastomotic leakage requiring surgery, was applied. RESULTS: Among the 3,695 operations performed for carcinoma of the rectum or colon, 482 were low anterior resections. In 334 patients (69.3 percent) no protective stoma was constructed, whereas 148 (30.7 percent) received such protection. Age, American Society of Anesthesiologists physical status, and body mass index were identical in both groups. In the group receiving a protective stoma, however, neoadjuvant radiochemotherapy was more common, the tumors were lower-and thus the total mesorectal excision rate higher, the intraoperative complication rate was higher, and the duration of the operation was longer. The differences were all significant. The major criterion (overall anastomotic leakage rate) was identical in the two groups, but the rate of leakage requiring surgery was significantly lower in patients receiving a protective stoma (p = 0.028). The logistic regression revealed that use of a protective stoma is a predictor of protection against anastomotic leakage requiring surgery. The distance of the tumor from the anal verge and the duration of the operation are further predictors. CONCLUSION: The particular benefit of a covering stoma is reduction in the rate of leaks requiring surgery and thus in the severe consequences of an anastomotic leakage.

Early postoperative results of surgery for rectal carcinoma as a function of the distance of the tumor from the anal verge: results of a multicenter prospective evaluation.

BACKGROUND: The problems associated with rectal surgery are frequently discussed with no reference being made to the distance of the tumor from the anal verge. This study examined the effect of the location of the tumor on early postoperative results. PATIENTS AND METHODS: This was a multicenter study involving 75 German hospitals and 3756 patients, of whom 1463 had rectal carcinoma. On the basis of the location of the tumor (distance from the anal verge), four groups were distinguished: <4, 4-7.9, 8-11.9, and 12-16 cm. RESULTS: Resection and abdominoperineal resection rates and the incidence of postoperative complications depended on the location of the tumor. Significantly higher resection rates and fewer specific complications, and a significant reduction in overall postoperative morbidity were found with tumor locations more than 8 cm from the anal verge. The highest anastomotic leak rate was observed with anastomoses less than 7 cm from the anal verge. The logistic regression showed that the distance of the tumor from the anal verge is an independent variable for the development of an anastomotic leak. CONCLUSIONS: Early results are greatly affected by the location of the rectal carcinoma. This applies to both abdominoperineal resection rates and specific postoperative complications, such as anastomotic leak rate and operation morbidity in general.