Robotic-Assisted Nissen Fundoplication in Pediatric Patients: A Matched Cohort Study.

BACKGROUND: Nissen Fundoplication (NF) is a frequently performed procedure in children. Robotic-assisted Nissen Fundoplication (RNF), with the utilization of the Senhance® Surgical System (SSS®) (Asensus Surgical® Inc., Durham, NC, USA) featuring 3 mm instruments, aims to improve precision and safety in pediatric surgery. This matched cohort study assesses the safety and feasibility of RNF in children using the SSS®, comparing it with Laparoscopic Nissen Fundoplication (LNF). METHODS AND RESULTS: Twenty children underwent RNF with the SSS® between 2020 to 2023 and were 1:1 matched with twenty LNF cases retrospectively selected from 2014 to 2023. Both groups were similar regarding male/female ratio, age, and weight. Two of the twenty RNF cases (10%) experienced intraoperative complications, whereas three in the LNF group of whom two required reinterventions. The observed percentage of postoperative complications was 5% in the RNF group compared to 15% in the LNF group (p = 0.625). The operative times in the RNF group significantly dropped towards the second study period (p = 0.024). CONCLUSIONS: Utilizing SSS® for NF procedures in children is safe and feasible. Observational results may tentatively suggest that growing experiences and continued development will lead to better outcomes based on more accurate and safe surgery for children.

RBP4 increases lipolysis in human adipocytes and is associated with increased lipolysis and hepatic insulin resistance in obese women.

Retinol-binding protein-4 (RBP4) is elevated in serum and adipose tissue (AT) in obesity-induced insulin resistance and correlates inversely with insulin-stimulated glucose disposal. But its role in insulin-mediated suppression of lipolysis, free fatty acids (FFA), and endogenous glucose production (EGP) in humans is unknown. RBP4 mRNA or protein levels were higher in liver, subcutaneous adipose tissue (SAT), and visceral adipose tissue (VAT) in morbidly obese subjects undergoing Roux-en-Y gastric bypass surgery compared to lean controls undergoing elective laparoscopic cholecystectomy. RBP4 mRNA expression in SAT correlated with the expression of several macrophage and other inflammation markers. Serum RBP4 levels correlated inversely with glucose disposal and insulin-mediated suppression of lipolysis, FFA, and EGP. Mechanistically, RBP4 treatment of human adipocytes in vitro directly stimulated basal lipolysis. Treatment of adipocytes with conditioned media from RBP4-activated macrophages markedly increased basal lipolysis and impaired insulin-mediated lipolysis suppression. RBP4 treatment of macrophages increased TNFα production. These data suggest that elevated serum or adipose tissue RBP4 levels in morbidly obese subjects may cause hepatic and systemic insulin resistance by stimulating basal lipolysis and by activating macrophages in adipose tissue, resulting in release of pro-inflammatory cytokines that impair lipolysis suppression. While we have demonstrated this mechanism in human adipocytes in vitro, and correlations from our flux studies in humans strongly support this, further studies are needed to determine whether this mechanism explains RBP4-induced insulin resistance in humans.

ERAS: Improving outcome in the cachectic HPB patient.

The enhanced recovery after surgery (ERAS) program has reduced postoperative morbidity and duration of hospital stay but not mortality in patients undergoing hepatopancreatobiliary (HPB) surgery. Many HPB patients suffer from cancer cachexia, a syndrome of severe weight and muscle loss. This may affect outcomes of HPB surgery even within an ERAS program. A tailored ERAS approach may be essential in further improving outcome in this vulnerable patient category.

Visceral obesity, muscle mass and outcome in rectal cancer surgery after neo-adjuvant chemo-radiation.

BACKGROUND: Preoperative chemoradiation has become a routine modality in the treatment of rectal carcinoma that may impair a patients general condition. In these patients, it is important to identify factors that influence postoperative recovery. Visceral obesity(VO) as a metabolic risk factor was studied in rectal cancer patients receiving preoperative chemoradiation. AIM: The impact of VO on post-operative outcome in rectal carcinoma surgery after preoperative chemoradiation was studied. In addition, the effect of chemoradiation on body composition was studied. METHOD: The visceral fat area(VFA), total fat area(TFA) and skeletal muscle area(SMA) were measured on cross-sectional CT-slides in 74 patients who underwent rectal cancer surgery after chemoradiation. CT-scans taken before and after chemoradiation were analysed. Associations between VFA, per- and postoperative complications were studied. A VFA of 100 cm(2) and 130 cm(2) was used to differentiate between non-VO and VO. RESULTS: Using a VO cut-off point of a VFA of 100 cm(2), the VO patients had more per-operative blood loss(471 mL vs 271 mL p = 0.020), a higher complication rate(10% vs 49% p = 0.001), more ileus(2% vs 28% p = 0.027) and a longer length of stay(9.7days vs 13days p = 0.027). When a VFA of 130 cm(2) was used, VO patients showed more complications(17% vs 55%, p = 0.001) and ileus(10% vs 32% p = 0.017). During chemoradiation the SMA increased(Mean difference: 2.2 cm(2) p = 0.024), while the VFA showed no change. CONCLUSION: It appears that VO is associated with co-morbidity and poor outcome in rectal cancer patients. Using different cutoff values for VO different associations with outcome were found. SMA increased during chemoradiation, a phenomenon that remains to be explained.

Risk of anastomotic leakage with nonsteroidal anti-inflammatory drugs within an enhanced recovery program.

INTRODUCTION: Anastomotic leakage is a serious complication after colorectal resection. Recent studies suggest that nonsteroidal anti-inflammatory drugs may increase the risk of anastomotic leakage. We investigated this association in our enhanced recovery population. MATERIAL AND METHODS: Patients undergoing an elective colon or rectal resection with primary anastomosis because of malignancy and treated within our enhanced recovery program were included. Univariable and multivariable logistic regression analyses were used to study risk factors for anastomotic leakage. RESULTS: Between 2006 and 2013, 856 patients were included. The anastomotic leakage rate was significantly higher in the group that received nonsteroidal anti-inflammatory drugs compared to patients who did not: 9.2 vs. 5.3%, p = 0.038. This higher rate was only seen in patients receiving diclofenac: for colonic resections, 11.8 vs. 6.0%, p = 0.016; for rectal resections, 13.1 vs. 0%, p = 0.017. Only male sex (odds ratio 2.20, p = 0.005) was also independently associated with anastomotic leakage. CONCLUSION: The results of this study are in line with other comparable studies in the literature, showing an increased risk for anastomotic leakage with diclofenac. The use of diclofenac in colorectal surgery can no longer be recommended. Alternatives for postoperative analgesia need to be explored within an enhanced recovery program.

Eight years of experience with Enhanced Recovery After Surgery in patients with colon cancer: Impact of measures to improve adherence.

BACKGROUND: Perioperative treatment of patients with colorectal cancer according to the Enhanced Recovery After Surgery (ERAS) protocol has proven to reduce complications and duration of stay. However, strict adherence remains a challenge and the benefits may decrease with lower adherence. In this study, we report on 8 years of adherence to the ERAS protocol and its effect on postoperative outcome in patients with colon cancer. METHODS: In 2006, the ERAS protocol was introduced for treatment of colon cancer patients in the Medical Center Alkmaar, a large teaching hospital. Patients scheduled for elective colon cancer resection were included in this study. Adherence to ERAS items was monitored and along with clinical data prospectively gathered in a database. In 2011, several measures to improve adherence were implemented. RESULTS: In total, 816 patients were included. Mean adherence rate was 73% in 2006 and 2007, 66% in 2008 and 2009, 63% in 2010 and 2011, and 82% in 2012 and 2013. There was a shorter duration of stay in the years with high adherence (5.7 days) compared with the years with low adherence (7.3 days; P < .001). The ERAS items that were the strongest predictors for a shorter duration of stay were no nasogastric tube, early mobilization, early oral nutrition, early removal of epidural, early removal of catheter, and nonopioid oral analgesia. CONCLUSION: It is possible to improve adherence to the ERAS protocol and related outcomes with specific measures. Adherence to the ERAS protocol was related inversely to duration of stay. Only postoperative items of the ERAS protocol were predictive for a shorter duration of stay. Keeping adherence optimal remains an ongoing challenge that requires repeated training and dedicated personnel.

Visceral obesity determined by CT scan and outcomes after colorectal surgery; a systematic review and meta-analysis.

BACKGROUND: Visceral obesity may affect outcome after colorectal surgery. The visceral fat area as determined by CT scanning is considered the standard in the detection of visceral obesity. METHOD: A systematic review was performed of trials investigating the effect of visceral obesity on outcomes of patients with colorectal cancer with no radiotherapy or chemotherapy and measured by CT scanning. The main endpoints were primary hospital stay, morbidity, operative time and blood loss. Quality assessment and data extraction were performed independently by two observers. RESULTS: Seven studies were eligible for analysis, including 1230 patients. Primary hospital stay (weighted mean difference 1.16 days, 95% CI 0.0.05 to 2.28 days, p = 0.04), morbidity rates (RR 0.15, 95% CI 0.10 to 0.21, p < 0.00001) and operative time (weighted mean difference 20.47 min, 95% CI 12.76 to 28.17 min, p < 0.00001) were significantly higher for visceral obese patients. No difference was found in blood loss. CONCLUSION: Visceral obesity leads to a longer hospital stay, higher morbidity and longer operative time after elective colon surgery. These findings show that the preoperative CT scan for detecting disseminated disease can be used to assess visceral obesity and helps in risk profiling patients undergoing elective colon surgery.

Visceral obesity, body mass index and risk of complications after colon cancer resection: A retrospective cohort study.

BACKGROUND: The aim of our study was to assess the influence of visceral obesity (VO), as measured by preoperative abdominal CT scan, in relation to body mass index (BMI) on the incidence of postoperative complications and duration of hospital stay after colon cancer surgery. METHODS: Patients who underwent elective resection for colon cancer between January 1, 2006, and December 31, 2013, and had a preoperative CT scan were entered in the study. Visceral fat area (VFA) was determined by using the preoperative CT scan at the L3-L4 level. The effect of VO, defined as a VFA of >100 cm², on postoperative complications and duration of hospital stay was analyzed. RESULTS: Of 564 included patients, 65% had VO. VO was associated with more anastomotic leakage (P = .04), pneumonia (P = .02), wound infection (P = .03), reoperations (P = .04), and longer duration of hospital stay (P = .05). Of patients with a BMI < 25 kg/m², 44% had VO. In this group, VO was associated significantly with postoperative complications, cardiac (P < .01) and pulmonary (P = .01) comorbidity, hypertension (P < .01), and diabetes (P < .01). In the overweight (BMI 25-30 kg/m²) and obese (BMI > 30 kg/m²) groups, the rate of VO was much higher (81% and 90%, respectively), but was not associated significantly with complications or comorbidity, except for cardiac comorbidity (P < .02) in the BMI = 25-30 kg/m² group. After multivariable analysis, VO was shown to be an independent predictor of anastomotic leakage and wound infection. CONCLUSION: The association of VO with worse outcome after colon cancer surgery is most pronounced in patients with a BMI < 25 kg/m².

The new Body Mass Index as a predictor of postoperative complications in elective colorectal cancer surgery.

BACKGROUND & AIMS: A new Body Mass Index (BMI) formula has been developed for a better approximation of under and overweight. The aim of this study was to investigate the predictive value of this newly proposed BMI formula for postoperative complications in elective colorectal cancer surgery compared with the conventional BMI formula. METHODS: A digital database of patients undergoing elective colorectal cancer surgery was prospectively maintained in three centers and retrospectively analyzed. Data consisted of patient characteristics, surgical procedure, length of hospital stay (LOS), postoperative complications, mortality, reoperation and readmission. The BMI was calculated using both the conventional and new BMI formula. Patients were divided into four groups (BMI <20, 20-25, 25-30, ≥30 kg/m(2)). RESULTS: A total of 1614 patients were included. There was no significant difference in mean BMI between males and females using the conventional BMI formula (26.0 versus 26.2, p = 0.347), whereas a trend was observed using the new BMI formula (26.3 versus 25.6, p = 0.071). The proportion of overweight (BMI ≥25) male patients was significantly higher compared with the proportion of overweight female patients using the conventional formula (58.9% versus 51.0%, p = 0.021), whereas a non-significant difference was observed using the new formula (51.7% versus 53.4%, p = 0.515). Neither the conventional nor the new BMI were associated with postoperative complications and LOS. Higher age, higher ASA classification, male gender, and conventional surgery were independent predictors of the occurrence of postoperative complications. A longer LOS was also independently predicted by higher age, higher ASA classification and conventional surgery. CONCLUSIONS: This study showed no superiority of the new BMI formula in predicting postoperative complications after colorectal cancer surgery. Confirmation of the results in a larger cohort is desirable.

Demographics and functional outcome of toe fractures.

Toe fractures are common; however, there are few data on demographics and functional outcome. We studied outcomes in 339 consecutive patients with toe fractures treated between January 2006 and September 2008. Two hundred and sixty-four patients, aged 16 to 75, were mailed an outcome questionnaire, and overall subjective satisfaction with the outcome of treatment was measured using a visual analog scale (VAS). Most frequently affected were the first (38%) and fifth (30%) toes, and most (75.6%) of the fractures were caused by stubbing or crush injury. More than 95% of the fractures were displaced less than 2 mm, and all of the fractures were treated conservatively. The questionnaire was returned by 141 (53%) patients with a median follow-up of 27 months. Respondents were female in 57.4% of cases and had a median age of 45 years. The median AOFAS score was 100 (P(25), P(75) = 93,100) points; the median VAS was 10 (P(25), P(75) = 8, 10) points. Univariate regression analysis revealed no statistically significant associations between outcome and the particular toe or phalanx involved, number of fractured toes, fracture type and location, articular involvement, gender, age, body mass index, smoking habits, and the presence of diabetes mellitus. Satisfaction VAS was dependent on age (P = .047) and gender (P = .049) in the multivariate analysis. The AOFAS midfoot score was not influenced by any of the covariates. This is the first epidemiological investigation using 2 outcome-scoring systems to determine function and satisfaction following treatment of toe fractures.

[A man with a big tumour on his back]. / Een man met een grote tumor op de rug.

A 47-year-old man was seen with a big tumour on his back. The tumour had started growing a year earlier, but the man never consulted a doctor. Histopathology showed melanoma, and there were no signs of metastastatic disease. The tumour was surgically removed.

Atherosclerotic plaque surface morphology in the carotid bifurcation assessed with multidetector computed tomography angiography.

BACKGROUND AND PURPOSE: Complicated (irregular or ulcerated) carotid plaques have proven to be independent predictors of stroke. We analyzed the frequency and location of plaque irregularities in a large cohort of patients with ischemic cerebrovascular disease and the relation with severity of stenosis, cardiovascular risk factors, and symptomatology. METHODS: Multidetector CT angiography images from 406 patients were evaluated. Plaque surface morphology was classified as smooth, irregular, or ulcerated. The location of the ulceration was defined as proximal or distal to the point of maximum stenosis. RESULTS: Atherosclerotic plaques with an open lumen were present in 448 carotid arteries; these plaques were classified as: smooth, 276 (62%); irregular, 99 (22%); and ulcerated, 73 (16%). Sixty-two (69%) of the ulcerations were located proximal to the point of maximum luminal stenosis. Complicated plaques were significantly (P<0.001) more common in carotid arteries with stenosis >30% than in those with stenosis <30%. There is an association between complicated plaques and hypercholesterolemia (OR, 3.0) and a trend toward an association with smoking (OR, 1.9). Complicated plaques are more often present in the symptomatic carotid artery than in the contralateral asymptomatic carotid artery; however, this is fully attributed to a significantly higher degree of stenosis in the symptomatic arteries. CONCLUSIONS: Multidetector CT angiography allows the classification of atherosclerotic carotid plaque surface. Complicated plaques are frequent in atherosclerotic carotid disease, especially with higher stenosis degree. Ulcerations are mostly located in the proximal part of the atherosclerotic plaque. Hypercholesterolemia and smoking are related with the presence of complicated plaques.