Frequency of cholelithiasis in need of surgical or endoscopic treatment a decade or more after Roux-en-Y gastric bypass.

BACKGROUND: Symptomatic cholelithiasis requiring treatment is a known side effect after Roux-en-Y gastric bypass (RYGB), but reported rates vary greatly. The objectives for this study were to evaluate the long-term frequency of surgical or endoscopic treatment for symptomatic cholelithiasis 10-15 years after RYGB and its relation to self-reported abdominal pain. METHODS: Observational data from 546 patients who underwent RYGB at public hospitals in Central Norway between March 2003 and December 2009 were analyzed. RESULTS: Median follow-up was 11.5 (range 9.1-16.8) years. Sixty-five (11.9%) patients had undergone cholecystectomy prior to RYGB. Out of the 481 patients with intact gallbladder, 77 (16.0%) patients underwent cholecystectomy and six (1.2%) patients had treatment for choledocholithiasis during the observation period. Median time from RYGB to cholecystectomy or treatment of choledocholithiasis was 51 (range 1-160) and 109 (range 10-151) months, respectively. Female sex was associated with an increased risk of subsequent cholecystectomy [OR (95% CI) 2.88 (1.31-7.15)], p < 0.05. There was a higher frequency of self-reported abdominal pain at follow-up [OR (95% CI) 1.92 (1.25-2.93)] among patients who underwent cholecystectomy before or after RYGB. CONCLUSION: With a median follow-up of more than 11 years after RYGB, one in six patients with an intact gallbladder at time of RYGB underwent cholecystectomy, and 1.1% of the patients needed surgical or endoscopic treatment for choledocholithiasis. Patients with a history of cholecystectomy reported a higher frequency of abdominal pain.

Construct validity of eoSim - a low-cost and portable laparoscopic simulator.

Purpose: To examine the construct validity of the low-cost, portable laparoscopic simulator eoSim using motion analysis.Material and methods: Novice and experienced surgeons (≤ 100 and >100 laparoscopic procedures performed, respectively) completed four tasks on the eoSim using the SurgTrac software: intracorporeal suture and tie, tube ligation, peg capping and precision cutting. The following metrics were recorded: Time to complete task, distance traveled, handedness (left- versus right hand use), time off-screen, distance between instrument tips, speed, acceleration and motion smoothness.Results: Compared to novices (n = 22), experienced surgeons (n = 14) completed tasks in less time (p ≤ .025), except when performing peg capping (p = .052). On all tasks, they also scored lower on the distance metric (p ≤ .001). Differences in handedness (left hand compared between groups, right hand compared between groups) were found to be significant for three tasks (p ≤ .025). In general, the experienced group made greater use of their left hand than the novice group.Conclusion: The eoSim can differentiate between experienced and novice surgeons on the tasks intracorporeal suture and tie, tube ligation and precision cutting, thus providing a convenient method for surgical departments to implement testing of their surgeons' basic laparoscopic skills.

Optimal timing of assessment tasks depending on experience level of surgical trainees.

Introduction: Box trainers with motion analysis are important add-ons to surgical training and skills assessment outside the operating room, given that they exhibit construct validity.Material and methods: Four different tasks were tested for construct validity on a new laparoscopic box trainer with integrated motion analysis. Tracking data from the simulator were analyzed for eighteen parameters per task using an in-house software comparing participants with three different experience levels.Results: In total, ten novices, 22 intermediates and 16 experts enrolled. No or limited significant differences were found for the peg picker and rope race. For the precision cutting task 12 parameters showed significant difference between novices and intermediates, 14 between novices and experts and one between intermediates and experts. For the suture task the corresponding results were one, 15 and six.Conclusions: The precision cutting and suture task both showed construct validity for many of the parameters. While the precision cutting task distinguished best between novices and the other two groups, the suture task distinguished best between experts and the other two groups. These results show the importance of the timing of an assessment task, and that an assessment task might have limited value if experience levels are not considered.

Psychomotor skills assessment by motion analysis in minimally invasive surgery on an animal organ.

BACKGROUND: A high level of psychomotor skills is required to perform minimally invasive surgery (MIS) safely. To be able to measure these skills is important in the assessment of surgeons, as it enables constructive feedback during training. The aim of this study was to test the validity of an objective and automatic assessment method using motion analysis during a laparoscopic procedure on an animal organ. MATERIAL AND METHODS: Experienced surgeons in laparoscopy (experts) and medical students (novices) performed a cholecystectomy on a porcine liver box model. The motions of the surgical tools were acquired and analyzed by 11 different motion-related metrics, i.e., a total of 19 metrics as eight of them were measured separately for each hand. We identified for which of the metrics the experts outperformed the novices. RESULTS: In total, two experts and 28 novices were included. The experts achieved significantly better results for 13 of the 19 instrument motion metrics. CONCLUSIONS: Expert performance is characterized by a low time to complete the cholecystectomy, high bimanual dexterity (instrument coordination), a limited amount of movement and low measurement of motion smoothness of the dissection instrument, and relatively high usage of the grasper to optimize tissue positioning for dissection.

Lack of transfer of skills after virtual reality simulator training with haptic feedback.

BACKGROUND AND OBJECTIVE: Virtual reality (VR) simulators enrich surgical training and offer training possibilities outside of the operating room (OR). In this study, we created a criterion-based training program on a VR simulator with haptic feedback and tested it by comparing the performances of a simulator group against a control group. MATERIAL AND METHODS: Medical students with no experience in laparoscopy were randomly assigned to a simulator group or a control group. In the simulator group, the candidates trained until they reached predefined criteria on the LapSim® VR simulator (Surgical Science AB, Göteborg, Sweden) with haptic feedback (XitactTM IHP, Mentice AB, Göteborg, Sweden). All candidates performed a cholecystectomy on a porcine organ model in a box trainer (the clinical setting). The performances were video rated by two surgeons blinded to subject training status. RESULTS: In total, 30 students performed the cholecystectomy and had their videos rated (N = 16 simulator group, N = 14 control group). The control group achieved better video rating scores than the simulator group (p < .05). CONCLUSIONS: The criterion-based training program did not transfer skills to the clinical setting. Poor mechanical performance of the simulated haptic feedback is believed to have resulted in a negative training effect.

Sleeve gastrectomy, but not duodenojejunostomy, preserves total beta-cell mass in Goto-Kakizaki rats evaluated by three-dimensional optical projection tomography.

BACKGROUND: In type 2 diabetes mellitus, there is a progressive loss of beta-cell mass. Bariatric surgery has in recent investigations showed promising results in terms of diabetes remission, but little is established regarding the effect of surgery on the survival or regeneration of pancreatic beta-cells. In this study, we aim to explore how bariatric surgery with its subsequent hormonal alterations affects the islets of Langerhans. METHODS: Twenty-four Goto-Kakizaki rats were operated with duodenojejunostomy (DJ), sleeve gastrectomy (SG) or sham operation. From the 38th week after surgery, body weight, fasting blood glucose, glycosylated hemoglobin, mixed meal tolerance with repeated measures of insulin, glucagon-like peptide 1, gastrin and total ghrelin were evaluated. Forty-six weeks after surgery, the animals were euthanized and the total beta-cell mass in all animals was examined by three-dimensional volume quantification by optical projection tomography based on the signal from insulin-specific antibody staining. RESULTS: Body weight did not differ between groups (P(g) = 0.37). SG showed lower fasting blood glucose compared to DJ and sham (P(g) = 0.037); HbA1c levels in SG were lower compared to DJ only (p < 0.05). GLP-1 levels were elevated for DJ compared to SG and sham (P(g) = 0.001), whereas gastrin levels were higher in SG compared to the two other groups (P(g) = 0.002). Beta-cell mass was significantly greater in animals operated with SG compared to both DJ and sham (p = 0.036). CONCLUSION: Sleeve gastrectomy is superior to duodenojejunostomy and sham operation when comparing the preservation of beta-cell mass 46 weeks after surgery in Goto-Kakizaki rats. This could be related to both the increased gastrin levels and the long-term improvement in glycemic parameters observed after this procedure.

The effect of duodenojejunostomy and sleeve gastrectomy on type 2 diabetes mellitus and gastrin secretion in Goto-Kakizaki rats.

BACKGROUND: Bariatric surgery is a highly effective treatment of type 2 diabetes in patients with morbid obesity. The weight-loss independent improvement of glycemic control observed after these procedures has led to the discussion whether bariatric surgery can be introduced as treatment for type 2 diabetes in patients with a body mass index < 35 kg/m(2). We have studied the effects of two bariatric procedures on type 2 diabetes and on gastrointestinal hormone secretion in a lean diabetic animal model. METHODS: Male Goto-Kakizaki rats, 17-18 weeks old, were randomized into three groups: duodenojejunostomy (DJ), sleeve gastrectomy (SG), or sham operation. During 36 postoperative weeks we evaluated body weight, fasting blood glucose, glucose tolerance, insulin, HbA1c, glucagon-like peptide 1, cholesterol parameters, triglycerides, total ghrelin, and gastrin. RESULTS: Oral glucose tolerance was significantly improved for both DJ and SG at four weeks after surgery (p < 0.05). At the 34th postoperative week, SG had significantly lower area under the curve during oral glucose tolerance test compared to sham (p = 0.007). SG had significantly lower HbA1c compared to sham at 12 weeks; (mean ± SEM) 4.3 ± 0.1 % versus 5.2 ± 0.3 % (p < 0.05) and compared to both DJ and sham 34 weeks after surgery [median (75 %;25 %)] 5.2 (6.0; 4.3) % versus 7.0 (7.5; 6.7) % and 7.3 (7.6; 6.7) % (p = 0.009). Serum gastrin levels were markedly elevated for SG compared to DJ and sham; 188.0 (318.0; 121.0) versus 77.5 (114.0; 58.0) and 68.0 (90.0; 59.5) pmol/L (p = 0.004) at six weeks and 192.0 (587.8; 110.8) versus 65.5 (77.0; 59.0) and 69.5 (113.0; 55.5) (p = 0.001) 36 weeks after surgery. CONCLUSION: Sleeve gastrectomy induces hypergastrinemia, lowers HbA1c, and improves glycemic control in Goto-Kakizaki rats. Sleeve gastrectomy is superior to duodenojejunostomy as treatment of type 2 diabetes mellitus in this animal model.

Obese, fat, or just overweight?

BACKGROUND: Discussing obesity with the patient without this being perceived as offensive may represent a challenge. Prevention of lifestyle diseases requires that this topic be addressed with those concerned. In this study, we investigate the patients' sensitivity to expressions, i.e. their notions of appropriateness or inappropriateness regarding various terms for obesity, and what patient characteristics are associated with such sensitivity to expressions. MATERIAL AND METHOD: The investigation is part of a five-year study of patients in Central Norway who were treated for morbid obesity. The terms used in the study had been suggested by the Overweight Patients' Association. Data on sensitivity to expressions were collected with the aid of a questionnaire one year after completion of the treatment. RESULTS: Altogether 157 out of 206 participants completed the questionnaire. Their average body mass index (BMI) (SD) amounted to 37.6 kg/m² (7.3 kg/m²). Their sensitivity to 14 different designations varied. «Weight¼, «overweight¼ and «weight problem¼ returned the best scores, whereas «obesitas¼, «obese¼ and «fat¼ were deemed least appropriate. The highest sensitivity to expressions was found among women, those who developed overweight early in life, those who had higher education and those who were dissatisfied with their weight. INTERPRETATION: The perceptions of various expressions for overweight and obesity varied considerably. Knowledge about this topic may be relevant for doctors and other health personnel in prevention and treatment of obesity.

The gastric mucosa 25 years after proximal gastric vagotomy.

OBJECTIVE: Vagotomy causes inhibition of basal and post-prandial acid secretion in humans, but the knowledge about the trophic effect of the vagal nerves is limited. Vagotomy is known to induce hypergastrinemia and we aimed to study the long-term effects of proximal gastric vagotomy (PGV) on the oxyntic mucosa and the enterochromaffin-like (ECL) cell density in particular. MATERIAL AND METHODS: Eleven patients operated with PGV because of duodenal ulcer and age- and sex-matched controls were examined 26 to 29 years postoperatively by gastroscopy with biopsies from the antrum and oxyntic mucosa. Neuroendocrine cell volume densities were calculated after immunohistochemical labeling of gastrin, the general neuroendocrine cell marker chromogranin A (CgA) and the ECL cell marker vesicular monoamine transporter 2 (VMAT2). Gastritis was graded and Helicobacter pylori (H. pylori) status was determined by polymerase chain reaction of gastric biopsies. Fasting serum gastrin and CgA were measured. RESULTS: Serum gastrin was higher in the PGV group compared to controls (median 21.0 [interquartile range (IQR) = 22.0] pmol/L vs 13.0 [IQR = 4.0] pmol/L, p = 0.04). However, there was neither a significant difference in serum CgA or in CgA (neuroendocrine) nor VMAT2 (ECL cell) immunoreactive cell volume density in the oxyntic mucosa. There was significantly more inflammation and atrophy in H. pylori-positive patients, but PGV did not influence the grade of gastritis. CONCLUSION: Despite higher serum gastrin concentrations, patients operated with PGV did not have higher ECL cell mass or serum CgA. Vagotomy may prevent the development of ECL cell hyperplasia caused by a moderate hypergastrinemia.

Perceiving haptic feedback in virtual reality simulators.

BACKGROUND: To improve patient safety, training of psychomotor laparoscopic skills is often done on virtual reality (VR) simulators outside the operating room. Haptic sensations have been found to influence psychomotor performance in laparoscopy. The emulation of haptic feedback is thus an important aspect of VR simulation. Some VR simulators try to simulate these sensations with handles equipped with haptic feedback. We conducted a survey on how laparoscopic surgeons perceive handles with and without haptic feedback. METHODS: Surgeons with different levels of experience in laparoscopy were asked to test two handles: Xitact IHP with haptic feedback and Xitact ITP without haptic feedback (Mentice AB, Gothenburg, Sweden), connected to the LapSim (Surgical Science AB, Sweden) VR simulator. They performed two tasks on the simulator before answering 12 questions regarding the two handles. The surgeons were not informed about the differences in the handles. RESULTS: A total of 85 % of the 20 surgeons who participated in the survey claimed that it is important that handles with haptic feedback feel realistic. Ninety percent of the surgeons preferred the handles without haptic feedback. The friction in the handles with haptic feedback was perceived to be as in reality (5 %) or too high (95 %). Regarding the handles without haptic feedback, the friction was perceived as in reality (45 %), too low (50 %), or too high (5 %). A total of 85 % of the surgeons thought that the handle with haptic feedback attempts to simulate the resistance offered by tissue to deformation. Ten percent thought that the handle succeeds in doing so. CONCLUSIONS: The surveyed surgeons believe that haptic feedback is an important feature on VR simulators; however, they preferred the handles without haptic feedback because they perceived the handles with haptic feedback to add additional friction, making them unrealistic and not mechanically transparent.

A study of psychomotor skills in minimally invasive surgery: what differentiates expert and nonexpert performance.

BACKGROUND: A high level of psychomotor skills is required to perform minimally invasive surgery (MIS) safely. To assure high quality of skills, it is important to be able to measure and assess these skills. For that, it is necessary to determine aspects that indicate the difference between performances at various levels of proficiency. Measurement and assessment of skills in MIS are best done in an automatic and objective way. The goal of this study was to investigate a set of nine motion-related metrics for their relevance to assess psychomotor skills in MIS during the performance of a labyrinth task. METHODS: Thirty-two surgeons and medical students were divided into three groups according to their level of experience in MIS; experts (>500 MIS procedures), intermediates (31-500 MIS), and novices (no experience in MIS). The participants performed the labyrinth task in the D-box Basic simulator (D-Box Medical, Lier, Norway). The task required bimanual maneuvering and threading a needle through a labyrinth of 10 holes. Nine motion-related metrics were used to assess the MIS skills of each participant. RESULTS: Experts (n = 7) and intermediates (n = 14) performed significantly better than the novices (n = 11) in terms of time and parameters measuring the amount of instrument movement. The experts had significantly better bimanual dexterity, which indicated that they made more simultaneous movements of the two instruments compared to the intermediates and novices. The experts also performed the task with a shorter instrument path length with the nondominant hand than the intermediates. CONCLUSIONS: The surgeon's performance in MIS can be distinguished from a novice by metrics such as time and path length. An experienced surgeon in MIS can be differentiated from a less experienced one by the higher ability to control the instrument in the nondominant hand and the higher degree of simultaneous (coordinated) movements of the two instruments.

Limitations of haptic feedback devices on construct validity of the LapSim® virtual reality simulator.

BACKGROUND: Surgeons performing laparoscopy need a high degree of psychomotor skills, which can be trained and assessed on virtual reality (VR) simulators. VR simulators simulate the surgical environment and assess psychomotor skills according to predefined parameters. This study aimed to validate a proficiency-based training setup that consisted of two tasks with predefined threshold values and handles with haptic feedback on the LapSim(®) VR simulator. The two tasks have been found to have construct validity in previous studies using handles without haptic feedback. METHODS: The participants were divided into three groups: novices (0-50 laparoscopic procedures), intermediates (51-300 laparoscopic procedures), and experts (more than 300 procedures). It was assumed that psychomotor skills increase with experience. All participants conducted the tasks lifting and grasping and fine dissection 20 times each. Validity of the training setup was investigated by comparing the number of times each participant passed a predefined threshold level for a set of 19 parameters. RESULTS: Construct validity was established for one parameter; "misses on right side" on the lifting and grasping task, whereas the other 18 parameters did not show construct validity. CONCLUSION: The setup employed in this study failed to establish construct validity for more than one parameter. This indicates that the simulation of haptic feedback influences the training performance on laparoscopic simulators and is an important part of validating a training setup. A haptic device should generate haptic sensations in a realistic manner, without introducing frictional forces that are not inherent to laparoscopy.

Vitamin and Mineral Deficiency 12 Years After Roux-en-Y Gastric Bypass a Cross-Sectional Multicenter Study.

PURPOSE: Micronutrient deficiencies are common after Roux-en-Y gastric bypass (RYGB). This study explores whether vitamin and mineral deficiency was associated with adherence to recommended supplementation 12 years after RYGB. MATERIALS AND METHODS: The cross-sectional Bariatric Surgery Observation Study (BAROBS) was conducted in 2018-2020 at three hospitals in Central Norway. We report data on 490 patients' self-reported adherence to recommended supplements and vitamin and mineral levels in the blood. The patients, who had RYGB between 2003 and 2009, were recommended an over-the-counter multivitamin-mineral supplement, calcium/vitamin D (1000 mg/20 µg) and vitamin B12 injections (reimbursed), since bariatric supplements were not available then. RESULTS: Mean (SD) age was 40.1 ± 9 years at RYGB, and time to follow-up 11.7 ± 1.6 years. Of 490 patients, 393 (80%) were women. Among 361 (74%) patients' adherent to multivitamin-mineral supplements; folate, vitamin B2, and vitamin B6 deficiency were present in 39 (11%), 103 (29%), and 63 (17%) patients, respectively. The same deficiencies occurred in 44 (34%), 67 (52%), and 67 (52%) patients' non-adherent to recommendations. Although 466 (95%) patients reported adherence to vitamin B12 supplements, sub-optimal levels were found in 73 (16%) patients. Though 336 (69%) patients adhered to calcium/vitamin D supplements (1000 mg/20 µg), sub-optimal vitamin D levels (< 75 nmol/l) were found in 174/336 (52%) adherent patients and 120/154 (78%) non-adherent patients. CONCLUSION: Twelve years after RYGB, adherence to supplements, though in sub-optimal doses of new recommendations, decreases the probability of vitamin and mineral deficiency, especially for thiamine, vitamin B2, vitamin B6, folate, vitamin B12, and vitamin D, but does not eliminate it.

Efficacy and safety of transgastric closure in natural orifice transluminal endoscopic surgery using the OTSC system and T-bar sutures: a survival study in a porcine model.

BACKGROUND: In natural orifice transluminal endoscopic surgery (NOTES), procedures are performed with an endoscope passed through a natural orifice. One of the most important factors that will determine the future of transgastric NOTES is obtaining a reliable closure of the access site. The aim of this study was to determine the efficacy and safety of transgastric closure using the over-the-scope clip (OTSC) system or T-bar sutures. METHODS: We performed a survival study that included 15 pigs. A standardized transgastric approach to the peritoneal cavity and a peritoneoscopy were performed. The gastrotomy was closed using the OTSC system or T-bar sutures. The gastrotomy closure was tested for leaks with the methylene blue test. All animals were observed for 2 weeks before they were sacrificed and necropsy was performed. Histopathological examination of tissue samples retrieved from the access sites was performed. RESULTS: There were no perioperative complications. The methylene blue test did not demonstrate any leakage of fluid. Necropsy after 2 weeks confirmed completeness of gastric closure in all animals with full-thickness healing and no spillage of gastric contents into the peritoneal cavity. No differences between the OTSC system and T-bar sutures were observed. CONCLUSION: We observed no differences between the efficacy and safety of the OTSC system and those of T-bar sutures used in closing gastric incisions in NOTES. Both methods are safe and effective.

Suboptimal Weight Loss 13 Years After Roux-en-Y Gastric Bypass: Is Hedonic Hunger, Eating Behaviour and Food Reward to Blame?

PURPOSE: Suboptimal weight loss (SWL) and weight regain (WR) following bariatric surgery are common. The exact reasons for this phenomenon remain to be fully elucidated. To compare hedonic hunger, food preferences, food reward and eating behaviour traits between participants with SWL and optimal weight loss (OWL) 13 years after Roux-en-Y gastric bypass (RYGB). MATERIALS AND METHOD: Cross-sectional case control study where participants experiencing SWL or OWL (< or ≥ 50% of excess weight, respectively) post-RYGB were compared to a non-surgical control group matched for pre-operative body mass index. Hedonic hunger (Power of Food Scale), implicit and explicit liking and wanting for high-fat and low-fat savoury and sweet food (Leeds Food Preference Questionnaire) and eating behaviour (Dutch Eating Behavior Questionnaire, Three-Factor Eating Questionnaire and the Food Cravings Questionnaires State and Trait-reduced) were assessed. RESULTS: In total, 75 participants were recruited from the bariatric surgery observation study (BAROBS). Disinhibition, hunger, emotional, external and restrained eating, frequency of cravings and hedonic hunger were lower in the OWL, compared with the SWL and/or control groups. Implicit wanting and explicit liking and wanting for high-fat savoury and high-fat sweet food were lower, and implicit wanting for low-fat savoury food higher, in the OWL, compared with the SWL and/or control groups. CONCLUSION: SWL 13 years after RYGB is associated with dysfunctional eating behaviours, increased preference and reward for high-fat food and increased hedonic hunger. Future longitudinal studies are needed to establish the cause-effect relationship between these variables.

The Long-Term Impact of Postoperative Educational Programs on Weight Loss After Roux-en-Y Gastric Bypass.

PURPOSE: Roux-en-Y gastric bypass (RYGB) is a well-documented treatment of severe obesity. Attending postoperative educational programs may improve the outcome. The aim of this study was to evaluate whether participation in educational programs lasting 2-3 years after RYGB influences long-term weight loss, weight regain, physical activity, and compliance to multivitamin supplements. MATERIALS AND METHODS: The Bariatric Surgery Observation Study (BAROBS) is a multicenter retrospective, cross-sectional study 10-15 years after primary RYGB. Four hundred and ninety-seven participants answered questions regarding participation in postoperative educational programs. Participants were divided into frequent attendees (FA) and infrequent attendees (IFA) at the educational programs. RESULTS: Ten to 15 years after surgery, a total weight loss (TWL) of 23.2 ± 11.6% were seen in the FA group vs 19.5 ± 12.6% in the IFA group, p < 0.001. Percent excess weight loss (%EWL) was 55.7 ± 28.9% vs 46.0 ± 31.1%, p < 0.001. Weight regain in percent of maximal weight loss for the FA was 32.1 ± 32.8% vs IFA 38.4 ± 40.0%, p = 0.052. No difference between the groups in compliance to multivitamin and physical activity. CONCLUSION: Participants with frequent participation in group-based educational programs had better weight loss outcomes 10-15 years after RYGB and tended to have less weight regain. There was no difference between the two groups in participants compliance to recommended multivitamin supplements and physical activity.

Characteristics of Patients Reporting Presumed Problematic Drinking Behavior After Gastric Bypass: Exploring Long-Term Data From the BAROBS Study.

Objective: To explore patients' long-term experiences with drinking alcohol after Roux-n-Y gastric bypass (RYGB) for conceptualizing what may indicate problematic drinking behavior after bariatric surgery. Study Design: Three-center, observational study. Patients: 546 adult patients undergoing RYGB in the period 2003-2009 in Norway. Main Outcome Measures: Self-reported data on drinking behavior and experiences related to alcohol collected 10-15 years after surgery. Results: Out of the 959 patients undergoing RYGB in the period, 29 were diseased and 546 participated in this follow-up study (58.7%). Focusing on suspicious changes in drinking behavior, 8.8% reported drinking more, 11.5% consumed alcohol at least twice a week, and 10.6% consumed at a minimum of 6 units of alcohol at a frequency of at least once monthly. The nature of hangovers had changed for about a third of the patients, with 21.6% reporting these to feel weaker or absent. Repeated alcoholic blackouts were reported by 11.9%. A subgroup of the patients were categorized as displaying presumed problematic drinking behavior(PPDB). Among the PPDB-men there was a significant association to having had a fall last year (6 (100.0%) PPDB-patients vs. 30 (29.7%) non-PPDB, p<.001). Among the PPDB-women, there was a significant association to having had alcohol problems prior to surgery (7 (70.0%) PPDB-patients vs. 67 (17.7%) non-PPDB, p<.001). Less significant associations to PPDB reported for explorative purposes were lack of patient education (men) (16 (26.2%) PPDB-patients vs. 8 (61.5%) non-PPDB, p=.014); more than 3 months persistent musculoskeletal pain (women) (45 (15.3%) PPDB-patients vs. 29 (24.6%) non-PPDB, p=.026); subjective problems with memory (women) (58 (20.7%) PPDB-patients vs. 10 (9.1%) non-PPDB, p=.006); and, receiving professional help for mental problems last 12 months (women) (29 (22.7%) PPDB-patients vs. 45 (14.7%) non-PPDB, p=.043). Conclusion: A subset of patients display drinking behaviors that may be consistent with postsurgical alcohol problems. Screening instruments like AUDIT may not be sufficiently specific to capture several risk behaviors occurring after bariatric surgery.

Iron Deficiency and Anemia 10 Years After Roux-en-Y Gastric Bypass for Severe Obesity.

Iron deficiency with or without anemia is a well-known long-term complication after Roux-en-Y, gastric bypass (RYGB) as the procedure alters the gastrointestinal absorption of iron. Iron is essential for hemoglobin synthesis and a number of cellular processes in muscles, neurons, and other organs. Ferritin is the best marker of iron status, and in a patient without inflammation, iron deficiency occurs when ferritin levels are below 15 µg/L, while iron insufficiency occurs when ferritin levels are below 50 µg/L. Lifelong regular blood tests are recommended after RYGB, but the clinical relevance of iron deficiency and iron insufficiency might be misjudged as long as the hemoglobin levels are normal. The aim of this study was to explore the frequency of iron deficiency and iron deficiency anemia one decade or more after RYGB, the use of per oral iron supplements, and the frequency of intravenous iron treatment. Nine hundred and thirty patients who underwent RYGB for severe obesity at three public hospitals in Norway in the period 2003-2009 were invited to a follow-up visit 10-15 years later. Results from blood tests and survey data on the use of oral iron supplements and intravenous iron treatment were analyzed. Ferritin and hemoglobin levels more than 10 years after RYGB were available on 530 patients [423 (79.8%) women]. Median (IQR) ferritin was 33 (16-63) µg/L, and mean (SD) hemoglobin was 13.4 (1.3) g/dl. Iron deficiency (ferritin ≤ 15 µg/L) was seen in 125 (23.6%) patients; in addition, iron insufficiency (ferritin 16-50 µg/L) occurred in 233 (44%) patients. Mean (SD) hemoglobin levels were 12.5 (1.4) g/dl in patients with iron deficiency, 13.5 (1.2) g/dl in patients with iron insufficiency, 13.8 (1.3) g/dl in the 111 (21%) patients with ferritin 51-100 µg/L, and 13.8 (1.2) g/dl in the 55 (10%) patients with ferritin >100 µg/L. Two hundred and seventy-five (56%) patients reported taking oral iron supplements, and 138 (27.5%) had received intravenous iron treatment after the RYGB procedure. Iron deficiency or iron insufficiency occurred in two-thirds of the patients 10 years after RYGB, although more than half of them reported taking oral iron supplements.

Laparoscopic ultrasound: a survey of its current and future use, requirements, and integration with navigation technology.

BACKGROUND: Laparoscopic ultrasound (LUS) increases surgical safety by allowing the surgeon to see beyond the organ surface, by visualizing vascular structures and by improving surgical precision of tumor resection. A questionnaire-based survey was used to investigate the current use and future expectations of LUS technology. METHODS: A questionnaire consisting of 26 questions was distributed manually at four different conferences (60% at the European Association for Endoscopic Surgery (EAES) conference, Stockholm 2008). The answers were summarized with descriptive statistics and nonparametric tests at a significance level of 0.05. RESULTS: The questionnaire was answered by 177 surgeons from 40 different countries (85% from Europe). Of these surgeons, 43% use ultrasound during laparoscopic procedures. Generally, more LUS users are found at university hospitals than at general community hospitals. Surgeons use LUS primarily in procedures related to the liver (67% of the surgeons who use LUS), but LUS also is used in other procedures related to the pancreas, biliary tract, and colon. In a 5-year perspective, 82% of surgeons believe in an increased use of LUS, and 79% of surgeons also think that the use of LUS combined with navigation technology will increase and that the most important requirements for such a system are good image quality, easy interpretation, and a high degree of precision. CONCLUSIONS: Although the surgeons believe LUS has advantages, only 43% of the respondents reported using it. The surveyed surgeons were largely positive toward an increased use of LUS in a 5-year perspective and believe that LUS combined with navigation technology will contribute to improving the surgical precision of tumor resection.