Cost-Effectiveness of Bariatric Surgery in Patients Living with Obesity and Type 2 Diabetes.

Aims: The favourable effects of bariatric surgeries on body weight reduction and glucose control have been demonstrated in several studies. Additionally, the cost-effectiveness of bariatric surgeries has been confirmed in several analyses. The aim of the current analysis was to demonstrate the cost-effectiveness of bariatric surgeries in obese patients with type 2 diabetes in Hungary compared to conventional diabetes treatments based on economic modelling of published clinical trial results. Materials and Methods: Patients entered the simulation model at the age of 45 with body mass index (BMI) ≥ 30 kg/m2 and type 2 diabetes. The model was performed from the public payer's perspective, comparing sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) procedures to conventional care of diabetes. The results were provided separately for three BMI categories. Results: The base-case analysis demonstrated that both surgery types were dominant; i.e., they saved 17 064 to 24 384 Euro public payer expenditures and resulted in improved health outcomes (1.36 to 1.50 quality-adjusted life years gain (QALY)) in the three BMI categories. Bariatric surgeries extended the life expectancy and the disease-free survival times of all the investigated diabetes complications. All the scenario analyses confirmed the robustness of the base-case analysis, such that bariatric surgeries remained dominant compared to conventional diabetes treatments. Conclusion: The results of this cost-effectiveness analysis highlight the importance of bariatric surgeries as alternatives to conventional diabetes treatments in the obese population. Therefore, it is strongly recommended that a wider population has access to these surgeries in Hungary.

Therapy and prevention of obesity: nutrition, physical activity and medical treatment / Az elhízás kezelése és megelozése: táplálkozás, testmozgás, orvosi lehetoségek.

Összefoglaló. Az elhízás és következményes megbetegedései fontos népegészségügyi problémát jelentenek hazánkban is. Kezelése komoly szakmai kihívás, ugyanakkor prevenciója eredményesebb lehet. Az elhízott betegekkel leggyakrabban találkozó háziorvosok, más szakorvosok és egészségügyi szakemberek részérol nagy igény van egy viszonylag rövid, áttekintheto, naprakész gyakorlatias útmutatóra. A különbözo orvosszakmai társaságokban tevékenykedo, évtizedes szakmai tapasztalatokkal rendelkezo szerzok összefoglalják tudományosan megalapozott, bizonyítékokon alapuló ismereteiket. Az elhízás kezelését lépcsozetesen célszeru megkezdeni, elotte felmérve a beteg motivációját, általános állapotát, lehetoségeit. A szerzok leírják az energiaszükséglet meghatározásával, az étrenddel és a fizikai aktivitás megtervezésével kapcsolatos alapveto szempontokat. Felsorolják a hazánkban elérheto gyógyszereket és metabolikus sebészeti beavatkozásokat, az életmódi támogatás igényét. Az elhízás megelozésében az élet elso 1000 napjának táplálkozása, a késobbiekben a szüloi minta a meghatározó. Sok kihasználatlan lehetosége van a háziorvosok, a lakóközösségek, az állami szervek koordinált együttmuködésének, helyi kezdeményezéseknek. Az elhízás betegségként való meghatározása egyaránt igényel egészségpolitikai és kormányzati támogatást, az elhízottak ellátására szakosodott multidiszciplináris centrumok számának és kompetenciájának növelését. Orv Hetil. 2021; 162(9): 323-335. Summary. Obesity and related morbidities have a high public health impact in Hungary. The treatment is a challenge, but prevention seems more effective. General practitioners, other specialists and health care professionals who are treating obese persons require short, summarized, updated and practical guideline. Hungarian medical professionals of different scientific societies, having decennial practices, are summarizing their evidence-based knowledge. Obesity management requires step by step approach, evaluating previously the general health condition, motivation and options of the patients. The measurement of energy requirement, planning of diet and physical activities, available surgical methods and medications are described in detail with life style and mental support needed. The most important period in the prevention of obesity is the first 1000 days from conception. Other significant factors are the life style habits of the parents. Proper obesity prevention requires better coordination of primary health care, community and governmental activities. Obesity should be defined as morbidity, therefore stronger governmental support and more health-policy initiatives are needed, beside increasing number and developing of multidisciplinary centres. Orv Hetil. 2021; 162(9): 323-335.

[The idopathic granulomatous mastitis. A rare entity in our departments practice]. / Az idiopátiás granulomatózus mastitis. Egy ritka kórkép elofordulása osztályunkon.

Introduction: Two cases of idiopathic granolomatous mastitis were diagnosed by histological examination in our Surgical Department in 2017. The idiopathic granulomatous mastitis is a rare, benign inflammatory laesion of the breast which can mimic malignancy in it's clinical appearance. We would like to draw attention to this differential diagnostic problem based on the cases of our Surgery Department.

[Our experiences with the use of 3-dimensional meshes to prevent and to repair parastomal hernias]. / Parastomalis sérvek megelozése és megoldása: a háromdimenziós hálókkal szerzett eddigi tapasztalataink.

INTRODUCTION: Albeit there is decreasing tendency nowadays for stoma construction, if it still happens, parastomal herniation might occur in up to 50% of cases afterwards. One third of the cases requires surgical correction, not rarely as an emergency. The different methods of repair can be quite demanding and the complication rates are high. From 2003 we have started to use specially designed 3-dimensional meshes for the prevention and repair of parastomal hernias. METHODS: From 1st of January 2012 to 1st of June 2016 we have used these devices within the framework of a prospective, controlled, randomized study enrolling the patients in preventive and repair arms. Until now mesh was implanted for prevention at the time of the index operation in 38 cases, (control group: 46 cases), and for repair in 14 cases (control group: 18 cases). Recruitment of the patients will end in 2017. The operations were performed by laparoscopic approach in 22 cases and by open approach in 62 cases in the preventive arm, and 6/26 cases in the repair arm respectively. Mean follow up period is 19.2 months in the mesh group and 22.6 months in the non mesh group in the preventive arm, and 25.9/20.4 months in the repair arm respectively. RESULTS: No statistical analysis was used to interpret these interim results in this paper, we intend to analyze our results at the end of the study. At this stage apparently there is no difference between the group of patients in terms of complications in both arms. Parastomal herniation was found in 18 cases (39.1%) in the non mesh group and in 3 cases (7.8%) in the mesh group in the preventive arm. Recurrency was noted in 8 cases (44%) in the non mesh group, and in 1 case (7.1%) in the mesh group in the repair arm. CONCLUSIONS: Our results correlate with other studies where mesh insertion was used to prevent and/or repair parastomal hernias. We attribute these results mainly to the special, 3-dimensional design of the meshes used by us. This construction was developed based on understanding the patomechanism of parastomal hernia formation.

[Retrospective analysis of carcinomas of the rectum operated by TEM during one year at our institute]. / Transanalis endoszkópos mikrosebészeti technikával eltávolított rectumcarcinomák retrospektív vizsgálata osztályunk egyéves beteganyagában.

INTRODUCTION: The very first TEM (transanal endoscopyc microsurgery) in Hungary was performed in our department by professor Attila Nagy in 1992. Up to August 2016, 1385 operation in total was performed with an average number of 60 per year., 992 operations were carried out for benign reasons and 393 cases for malignancies. We analyze the malignant cases operated by TEM in 2013. SUBJECTS AND METHODS: In 2013 we performed 121 TEM on 118 patients (in 3 cases twice). 70 patients had benign, 48 patients had malignant pathology. The average follow-up was 32 (12-39) month.We analyzed the cases retrospectively, presenting the history of each patient in detail. The pathological stages were the following: 8 in situ carcinomas, 14 T1, 12 T2, 9 T3 and 5 Tx. 17 patients received preoperative RCT, (4 ypT0, 2 ypT1, 3 ypT2, 8 ypT3). RESULTS: In the pTis group one patient was lost to follow up. Local recurrence was noted in 2 cases (14.28%), from which one was malignant. No distant metastasis was observed; DFS: 85.71%, OS: 100%. From the pT1 group one patient was lost to follow up after 4 month. Local recurrence was found in 2/13 cases (15.38%), distant metastases in 1 out of 13 (7.69%); DFS: 84.61%, OS: 84.61%. In the pT2 group 3 local recurrences was observed (27.2%). Distant metastases occurred in one patient (9.09%); DFS: 81.81%, OS: 81.81%. In the pT3 group 2/8 local recurrence (25%), and 3/8 (37.5%) distant metastasis was found, DFS: 62.5%,OS: 75%. 4 patient out of the 5 pTx cases showed complete pathological response after neoadjuvant RCT and one patient's histology turned out to be carcinoid. Downstaging was observed in 10 patients who received neoadjuvant RCT. CONCLUSIONS: By a thorough discussion of each individual patient's history we would like to draw attention on the complexity of treatment of rectal malignancies with TEM and the need of personalized care. Firm conclusions cannot be drawn from our series because of the small number of the patients and the heterogeneity of the therapies. The establishment of a precise preoperative diagnostic algorithm and accurate histopathological staging is inevitable for the effective use of the TEM and TEM like techniques. The number of the patients eligible for TEM after neoadjuvant RCT does not depends only on bowel screening programme, but also on finding an accurate way to determine the responder-non-responder status for neoadjuvant treatment.

[Proctocolectomy with J pouch. Ileo-anal anastomosis performed with PPH stapler. Our experiences after 88 cases]. / J-pouchcsal rekonstruált proctocolectomia során PPH-géppel készített ileoanalis anastomosis. Tapasztalataink 88 eset kapcsán.

AIM: Ulcerative colitis (CU) or Familiar Polyposis (FAP) can be the indication for proctocolectomy reconstructed with J pouch. The complete removal of the colon mucosa is essential regarding the late complications and at the same time the atraumatic surgical technique is very important concerning on the long term functional results. Both aspects seems to be answered by the stapled ileo-anal anastomosis using a "procedure for prolaps and haemorrhoids (PPH)" stapler applied by us since 2000. PATIENTS AND METHODS: 117 proctocolectomies reconstructed with J pouch and ileo-anal anastomosis were performed in our department between March 1990 and September 2016 indicated by CU or by FAP. In the first time period the ileo-anal anastomosis was sutured by hand (29 cases) and since 2000 the PPH stapler was applied as a routine (88 patients). Deviating ileostomy was performed in most cases of us. The data of the 117 patients were collected from the database of our hospital, 45 of them were interviewed personally and another 31 patients were contacted by phone, so 76 patients (65%) were eligible for follow-up. Frequency of stool, use of loperamid, level of incontinence (Wexner score) and perianal dermatitis were detected. The mean follow-up time was 18.6 years in the hand-sewn anastomosis group and 7.6 years in the PPH group. RESULTS: In the hand-sewn anastomosis group in 4/29 cases (13.8%) the removal of the pouch with definite ileostomy were necessary (2 pouchitis, 1 pouch necrosis, 1 recidiv rectum cancer); the mean stool frequency was 4.3 per day; the Wexner incontinence score was 8.5 and 2/15 patients (13.3%) live with ileostomy caused by incontinence. In the PPH stapled ileo-anal anastomosis group in 4/88 cases (4.5%) were the pouch removed (caused by pouchitis), the mean stool frequency was 4.0 per day; the Wexner score was 7.6 and 4/61 patients (6.6%) live with ileostomy caused by incontinence. CONCLUSIONS: Based on our experience the ileo-anal anastomosis performed by PPH stapler is technically feasible, seems to be effective concerning on the complete removal of the rectal mucosa and we observed better functional results compared with the hand-sewn anastomosis. Our data should be confirmed because of the low patients' volume.

[Our metabolic surgical activity, 2010-2016]. / Metabolikus sebészeti tevékenységünk, 2010­2016.

INTRODUCTION: The prevalence of morbid obesity and its co-morbidities - first of all diabetes type 2 - increased dramatically in the last decades. As the conservative ways of treatment (diet, training, etc.) in most cases does not lead to effective and long term weight loss, there is an increasing need for the metabolic surgical interventions. METHOD: During the last 6 and half years 514 laparoscopic RouxY gastric bypass (LRYGB) and 54 laparoscopic gastric sleeve resection (LGSR) were performed in our department. The data of random selected 40 patients after primary LRYGB and 15 patients after sleeve resection were collected. The applied criteria of the indication for surgery, the routine examinations and treatments before and after the intervention, the results and the type and the rate of the complications will be presented. RESULTS: According to our experience both procedures are long term effective for weight loss and for the resolution of co-morbidities, and can be performed with low risk of complications. After LRYGB more effective weight loss (extra weight loss 88% vs. 68%) and higher rate of resolution of diabetes type 2, hypertension and gastro-esophageal reflux were found compared to sleeve resection. CONCLUSION: Based on our results we prefer LRYGB. Gastric sleeve resection is indicated by us, when there is no way - or only with high risk - to perform gastric bypass, taking into consideration of course the individual requirements of the patients.

[Minimal invasive esophageal resection with anastomosis on the neck [McKeown]. Our experiences after 20 cases]. / Minimálisan invazív oesophagusreszekció nyaki anastomosissal (McKeown-mutét). Tapasztalataink 20 eset kapcsán.

OBJECTIVE: Esophageal resection is a traumatic intervention usually performed on patients with poor condition, resulting high mortality and morbidity. To improve the high incidence of complications, minimal invasive interventions were introduced. The results of the thoracoscopically and laparoscopically performed esophageal resection (McKeown) was investigated after 20 cases and the technical details of the surgical intervention are presented. PATIENTS AND METHOD: 20 thoracoscopic esophageal resection with laparoscopic gastric tube formation (sec. Akiyama) preparing the esophago-gastric anastomosis on the neck were performed in our department in the last four years. 1 patient with stricture and the other 19 patients with esophageal cancer were operated on, among them11 had T4 stage. 17 patient received neoadjuvant chemo-radiotherapy because of advanced disease. Regular follow up examinations were performed in the oncological outpatient department. RESULTS: 8 patients are alive after a mean follow up period of 25 months, 2 of them are treated oncologically because of recurrent disease. 19 patients were extubated within 12 hours after the intervention and the time spent in the intensive care unit were reduced to 1 or 2 days. The mean duration of the intervention was 320 minutes. Thoracoscopic dissection was performed in 8 patients without ventilation of the right lung using double lumen tracheal tube, among them 3 patients developed pneumonia in the postoperative period. The remaining 12 patients were operated with ventilated right lung, among them one patient developed pneumonia. One patient was converted because of injury of the thoracic aorta, after urgent thoracotomy we managed to suture the aortic wall. 1 patient died in 30 days after the operation, caused by leakage of the anastomosis, resulting mediastinitis and esophago-tracheal fistula. In two patients re-thoracoscopy and ligation of the thoracic duct was performed because of chylothorax refractory for conservative treatment. CONCLUSIONS: According to our observation the minimal invasive esophageal resection resulted in comparable oncological results with relevant reduction of mortality and morbidity compared to the open procedure. After procedures performed with ventilated lung further reduction of pulmonary complication was found. In case of tumors infiltrating the tracheal or the aortic wall, thoracotomy should be considered to explore the thoracic cavity and to carry out the dissection, if it is possible. Our results should be reinforced because of low number of patients.

Quality of life, weight loss and improvement of co-morbidities after primary and revisional laparoscopic roux Y gastric bypass procedure-comparative match pair study.

BACKGROUND: The prevalence of morbid obesity and its co-morbidities is dramatically increasing, as is the extent of weight loss surgery. A large number of patients after various bariatric procedures need revisional intervention for various reasons. We investigated the efficacy and the safety of revisional laparoscopic Roux Y gastric bypass (LRYGB) among our patients, who were revised as a consequence of inadequate weight loss or weight regain after previous bariatric interventions. METHODS: A comparative, double-centre, match pair study was performed comparing the data of 44 patients after revisional surgery with 44 patients after primary gastric bypasses, focusing on weight loss, life quality and improvement of co-morbidities. Matching criteria were age, gender, preoperative BMI and follow-up period. Previous procedures consisted of 23 gastric bandings, 13 sleeve resections, 4 LRYGB and 4 vertical banded gastroplasties. RESULTS: Extra weight loss (EWL) was significantly reduced after revisional gastric bypasses compared to primary intervention (EWL 66 vs. 91 %, p<0.05). Life quality scores were also decreased in the revisional group compared to the control group without statistical significance (SF 36 score 635 vs. 698.5, p=0.22; Moorehead-Aldert II score 1.4 vs. 2.0, p=0.10). The resolution rate of co-morbidities (T2DM, hypertension, gastro-oesophageal reflux (GER), osteoarthrosis, sleep apnoea) was also higher after primary gastric bypasses. CONCLUSIONS: Revisional LRYGB is an effective and safe method for patients with inadequate weight loss after previous bariatric surgery concerning weight reduction, life quality and improvement of co-morbidities. Our results indicate lower efficacy of revisional compared to primary LRYGB reaching statistical significance in regard to weight loss.

[Functional MRI investigation of brain activity triggered by taste stimulation]. / Ízstimulációval kiváltott agyi tevékenység funkcionális MR-vizsgálata elhízásban.

INTRODUCTION: Many factors contribute to the pathogenesis of morbid obesity, and the central nervous system - as one of those - also has an important role. Numerous studies focus on the central regulation of eating and metabolism, since associated problems like obesity, anorexia, diabetes or metabolic syndrome put an increasing burden on the health system of modern societies. Neither the pathophysiologic changes, nor the normal regulation of these systems are known adequately. Functional MR (fMRI) imaging, which has certainly gained popularity recently, aims to better understand these mechanisms. In this series we studied the brain fMRI activity changes of normal and obese persons, triggered by gustatory stimulation. METHODS: 10 obese and 10 normal weight healthy volunteers took part in the study, with comparable age and sex distribution. Gustatory stimulation was performed by 0.1 M sucrose (pleasant), 0.5 mM quinine HCl (unpleasant) and complex vanilla flavored (Nutridrink) solutions, which were administered through 0.5 mm PVC tubes, in 5-5 ml portions. For rinsing distilled water with neutral flavor was used. Imaging was performed in a 3T MRI, applying standard EPI sequences. Post processing of data was accomplished by FSL software package. RESULTS: Brain activation for gustatory stimuli was characteristically different between the two groups. There were high intensity activations in more cortical and subcortical regions of the obese volunteers compared to the normal ones. CONCLUSIONS: Our current fMRI investigations revealed different activations of numerous brain regions of normal and obese individuals, triggered by pleasant and unpleasant gustatory stimulation. Based on these results this method can help to recognize the role of the central nervous system in obesity, and may contribute to develop new therapies for weight loss.

Examination of the efficacy and safety of intraoperative gastroscopic testing of the gastrojejunal anastomosis in laparoscopic Roux Y gastric bypass surgery.

The laparoscopic Roux Y gastric bypass (LRYGB) is one of the most often performed bariatric surgical intervention. Intraoperative gastroscopy (IOG) seems to be reliable to decrease the leakage rate of gastrojejunal anastomosis (GJA) and of gastric pouch (GP). Our aim was to test the efficacy and the safety of this method. Two hundred fifty-two LRYGB operations were performed in our institution between 1 January 2008 and 1 January 2010. IOG is routinely made to test the integrity of GJA and of GP. Patients' dates were retrospectively analysed. The intragastric pressure developed during gastroscopy in humans was measured and compared with pressure values led to destruction (positive air test) of the GJA and/or GP in animal models (hybrid pigs). Stomach and bowel wall samples from the test animals without pressure strain, with pressure strain developed at gastroscopy in humans and with pressure strains led to destruction of GJA and/or GP were histologically examined. IOG resulted in six of our cases (2.3%) positive air test. There was no anastomosis insufficiency in postoperative period. Mean pressure during IOG was 32 mmHg, mean time of examination was 3.8 min and mean maximal pressure was 43 mmHg in humans. The mean pressure leading to positive air test in pigs was 150 mmHg. We could not detect any microscopical difference between stomach and jejunum samples without pressure strain and after pressure strain developed in humans during the gastroscopy. We conclude that intraoperative gastroscopy is an effective and safe method to test the integrity of GJA and GP in LRYGB surgery.

[Our experiences with laparoscopic Roux-en-Y gastric bypass (LRYGB) and description of the surgical technique]. / Laparoscopos Roux Y Gastric Bypass (LRYGB) mutéttel szerzett tapasztalataink és az alkalmazott mutéti módszer leírása.

UNLABELLED: The incidence of severe obesity and its co-morbidities are growing all over the world. Good long term results can be achieved in only in 5% of the patients by conservative treatment, so bariatric surgical procedures to decrease body weight are more often applied recently. The most often performed bariatric surgical intervention is the laparoscopic Roux-en-Y gastric bypass, which effectively decreases body weight in addition to having a favourable effect on the relatively frequent co-morbidities associated with severe obesity (such as diabetes type II, hypertension, gastro-esophageal reflux and locomotor diseases). METHOD: The authors report the results of 47 patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) and details of the applied surgical procedure are also described. The indication was a Body Mass Index (BMI) higher than 40 kg/m2 and with type II diabetes and severe gastro-esophageal reflux with BMI higher than 35. During the intervention a gastric pouch of 50 ml, an alimentary loop of 1.5 m and a bilio-pancreatic loop of 1 m in length were prepared. Data were collected from our hospital database and questionnaires filled in by the patients after a mean follow-up period of 15.7 months. RESULTS: The mean loss of weight was 51.9 kg, patients gave up 88% of their extra weight. 10 patients suffered from type II diabetes, after the intervention 9 of them became normoglycaemic without diet and medical treatment. The rate of the hypertension, GER and locomotor diseases were significantly improved. There was no mortality and anastomotic insufficiency. 94% of the patients were satisfied with the post-operative results. DISCUSSION: The LRYGB is an effective bariatric surgical procedure that affects favourably type II diabetes, hypertension, GER and locomotor diseases. As regards the biochemical background of the beneficial effects of this surgical intervention on the diabetes further examinations are necessary.

Quality of life parameters, weight change and improvement of co-morbidities after laparoscopic Roux Y gastric bypass and laparoscopic gastric sleeve resection--comparative study.

The laparoscopic Roux Y gastric bypass (LRYGB) and the laparoscopic gastric sleeve resection are frequently used methods for the treatment of morbid obesity. Quality of life, weight loss and improvement of the co-morbidities were examined. Match pair analysis of the prospectively collected database of the 47 gastric bypass and 47 gastric sleeve resection patients operated on in our hospital was performed. The quality of life parameters were measured with two standard questionnaires (SF 36 and Moorehead-Ardelt II). The mean preoperative and postoperative BMI was in gastric bypass group 46.1 and 28.1 kg/m(2) (mean follow-up: 15.7 months) and in gastric sleeve group 50.3 and 33.5 kg/m(2) (mean follow-up: 38.3 months). The SF 36 questionnaire yielded a mean total score of 671 for the bypass and 611 for the sleeve resection patients (p = 0.06). The Moorehead-Ardelt II test signed a total score of 2.09 for gastric bypass versus 1.70 for gastric sleeve patients (p = 0.13). Ninety percent of the diabetes was resolved in the bypass and 55% in the sleeve resection group. Seventy-three percent of the hypertension patients needed no more antihypertensive treatment after gastric bypass and 30% after sleeve resection. Ninety-two percent of the gastro-oesophageal reflux were resolved in the bypass group and 25% in the sleeve (with 33% progression) group. Ninety-four percent of the patients were satisfied with the result after gastric bypass and 90% after sleeve resection. The patients have scored a high level of satisfaction in both study groups. The gastric bypass is associated with a trend toward a better quality of life without reaching statistical significance, pronounced loss of weight and more remarkable positive effects on the co-morbidities comparing with the gastric sleeve resection.

[Surgical case of bronchopleural fistula caused by necrotizing pneumonia in a two year old child]. / Broncho-pleuralis fistulát okozó necrotizáló pneumonia operált esete 2 éves gyermeken.

The treatment possibilities of broncho-pleural fistula (BPF) caused by necrotizing pneumonia (NP) are discussed based on the experiences of a case and on the basis of the literature. In case of pleural fluid caused by NP the importance of thoracic drainage and--in selected cases--video assisted thoracoscopy (VATS) are emphasized. If BPF develops and the oxygen saturation in the blood can not be kept on acceptable level because of the large volume of the lost air through the fistula bronchoscopic occlusion of the bronchus leading to the BPF is recommended. In conservative therapy resistant cases thoracotomy can be indicated.