Effect of Lactobacillus kefiri, in Conjunction with PENS T6 and a Hypocaloric Diet, on Weight Loss, Hypertension and Laboratory Glycemic and Lipid Profile.

The pathogenesis of obesity has been linked to alterations in gut microorganisms. The aim of this study was to investigate the effect of Lactobacillus kefiri, together with PENS T6 and a hypocaloric diet, on weight loss, hypertension and laboratory glycemic and lipid profile. A prospective non-randomized study was conducted involving adult patients with a body mass index (BMI) > 30 kg/m2. Patients were divided into two groups: those undergoing PENS-T6 and hypocaloric diet (PENS-Diet Group) and those undergoing the same PENS-T6 scheme and hypocaloric diet, but additionally receiving probiotics including Lactobacillus kefiri (PENS-Diet + L. kefiri Group). Weight loss was assessed at the end of the treatment, and analytical glycemic and lipid profile, and microbiological analysis of feces were performed before and after treatment. The addition of Lactobacillus kefiri to PENS T6 and a low-calorie diet, increases weight loss and further improves the glycemic and lipid profile. L. kefiri also causes a further improvement in obesity-associated dysbiosis, mainly by increasing the muconutritive (Akkermansia muciniphila) and regulatory (Bifidobacterium spp.) microbiome, and the Phylum Bacteroidetes (Prevotella spp.) and decreasing the Firmicutes/Bacteroidetes ratio.

A Pilot Study: The Reduction in Fecal Acetate in Obese Patients after Probiotic Administration and Percutaneous Electrical Neurostimulation.

Previous data suggested that anti-obesity interventions, such as percutaneous electric neurostimulation and probiotics, could reduce body weight and cardiovascular (CV) risk factors by attenuation of microbiota alterations. However, potential mechanisms of action have not been unveiled, and the production of short-chain fatty acids (SCFAs) might be involved in these responses. This pilot study included two groups of class-I obese patients (N = 10, each) who underwent anti-obesity therapy by percutaneous electric neurostimulations (PENS) and a hypocaloric diet (Diet), with/without the administration of the multi-strain probiotic (Lactobacillus plantarum LP115, Lactobacillus acidophilus LA14, and Bifidobacterium breve B3), for ten weeks. Fecal samples were used for SCFA quantification (by HPLC-MS) in relation to microbiota and anthropometric and clinical variables. In these patients, we previously described a further reduction in obesity and CV risk factors (hyperglycemia, dyslipemia) after PENS-Diet+Prob compared to PENS-Diet alone. Herein, we observed that the administration of probiotics decreased fecal acetate concentrations, and this effect may be linked to the enrichment of Prevotella, Bifidobacterium spp., and Akkermansia muciniphila. Additionally, fecal acetate, propionate, and butyrate are associated with each other, suggesting an additional benefit in colonic absorption. In conclusion, probiotics could help anti-obesity interventions by promoting weight loss and reducing CV risk factors. Likely, modification of microbiota and related SCFA, such as acetate, could improve environmental conditions and permeability in the gut.

Perianal Application of Glyceryl Trinitrate Ointment Versus Tocopherol Acetate Ointment in the Treatment of Chronic Anal Fissure: A Randomized Clinical Trial.

BACKGROUND: Medical treatment, including glyceryl trinitrate ointment, represents the first step for the management of chronic anal fissure. However, glyceryl trinitrate ointment is associated with headache and, consequently, a high withdrawal rate of the treatment. OBJECTIVE: The aim of the present study was to evaluate the effect of the topical application of tocopherol acetate ointment on pain relief and chronic anal fissure epithelialization, comparing it with the effect of a standard treatment with glyceryl trinitrate ointment. DESIGN: This is a 2-parallel-group, single-center, randomized controlled, intent-to-treat clinical trial. SETTINGS: This study was conducted at the Garcilaso Clinic affiliated with Universidad Alfonso X (Madrid, Spain). PATIENTS: Patients with chronic anal fissure were selected. INTERVENTIONS: Patients were randomly assigned into 2 groups: patients receiving tocopherol acetate ointment and patients receiving glyceryl trinitrate ointment. MAIN OUTCOME MEASURES: The primary end point was quantification of anal pain 8 weeks after beginning the treatment as measured by a Visual Analogue Scale ranging from 0 to 100 mm. The secondary end points were the healing rate (during the treatment period of 8 weeks) and the recurrence rate. RESULTS: One hundred sixty consecutive patients were treated, 80 in each group. By 8 weeks after treatment, mean anal pain score declined by 56.2 mm in the glyceryl trinitrate ointment group compared with a mean anal pain score decline of 67.1 mm in the tocopherol acetate ointment group (mean difference, 10.9 mm (95% CI, 4.3-18.6); p = 0.018). Sixteen weeks after finishing the therapy, the recurrence rate was 13.2% in the glyceryl trinitrate ointment group vs 2.9 in the tocopherol acetate ointment group (p = 0.031). LIMITATIONS: Limitations of the study include the absence of manometric measurements of the internal anal sphincter before and after the treatments and the use of glyceryl trinitrate ointment as an active comparator, whereas calcium channel blockers are actually the standard treatment. CONCLUSIONS: Anal pain was significantly lower in the tocopherol acetate ointment group than in the glyceryl trinitrate ointment group at 8 weeks after treatment. Tocopherol acetate ointment achieved a greater healing rate and a lower recurrence rate 16 weeks after finishing the treatment. See Video Abstract at http://links.lww.com/DCR/B751. REGISTRATION: URL: https://www.clinicaltrials.gov; Identifier: NCT03787030.APLICACIÓN PERIANAL DE POMADA DE TRINITRATO DE GLICERILO FRENTE A LA POMADA DE ACETATO DE TOCOFEROL EN EL TRATAMIENTO DE LA FISURA ANAL CRÓNICA: UN ENSAYO CLÍNICO ALEATORIZADOANTECEDENTES:El tratamiento médico, incluida la pomada de trinitrato de glicerilo, representa el primer paso para el tratamiento de la fisura anal crónica. Sin embargo, la pomada de trinitrato de glicerilo se asocia con cefalea y, en consecuencia, una alta tasa de cancelación del tratamiento.OBJETIVO:El objetivo del presente estudio fue evaluar el efecto de la aplicación tópica de pomada de acetato de tocoferol en el alivio del dolor y la epitelización de la fisura anal crónica, comparándolo con el efecto de un tratamiento estándar con pomada de trinitrato de glicerilo.DISEÑO:Ensayo clínico con intención de tratar controlado, aleatorizado, de un solo centro, con dos grupos paralelos.ESCENARIO:Clínica Garcilaso adscrita a la Universidad Alfonso X (Madrid, España).PACIENTES:Pacientes con fisura anal crónica.INTERVENCIONES:Los pacientes fueron aleatorizados en 2 grupos: pacientes que recibieron pomada de acetato de tocoferol y pacientes que recibieron pomada de trinitrato de glicerilo.PRINCIPALES MEDIDAS DE RESULTADO:El criterio de valoración principal fue la cuantificación del dolor anal 8 semanas después de comenzar el tratamiento, medido por la escala analógica visual que varía de 0 a 100 mm. Los criterios de valoración secundarios fueron la tasa de curación (durante el período de tratamiento de 8 semanas) y la tasa de recurrencia.RESULTADOS:Se trataron ciento sesenta pacientes consecutivos, 80 en cada grupo. A las ocho semanas después del tratamiento, la puntuación media de dolor anal se redujo en 56.2 mm en el grupo de pomada de trinitrato de glicerilo en comparación con una disminución de la puntuación de dolor anal medio de 67.1 mm en el grupo de pomada de acetato de tocoferol (diferencia media: 10.9 mm (intervalo de confianza del 95%; 4.3 a 18.6; p = 0.018) Dieciséis semanas después de finalizar la terapia, la tasa de recurrencia fue del 13.2% en el grupo de pomada de trinitrato de glicerilo frente a 2.9 en el grupo de pomada de acetato de tocoferol (p = 0.031).LIMITACIONES:Ausencia de medidas manométricas del esfínter anal interno antes y después de los tratamientos. Ungüento de trinitrato de glicerilo como comparador activo, mientras que los bloqueadores de los canales de calcio son en realidad el tratamiento estándar de oro.CONCLUSIONES:El dolor anal fue significativamente menor en el grupo de ungüento de acetato de tocoferol que en el grupo de ungüento de trinitrato de glicerilo a las 8 semanas después del tratamiento. La pomada de acetato de tocoferol logró una mayor tasa de curación y una menor tasa de recurrencia 16 semanas después de finalizar el tratamiento. Consulte Video Resumen en http://links.lww.com/DCR/B751. (Traducción-Dr. Jorge Silva Velazco).

Mammary Volume-to-Body Mass Index Ratio: Preoperative Predictor of Cardiovascular Risk Factor and Indicator of Long-term Postoperative Remission of Comorbidities in Premenopausal Women Undergoing Sleeve Gastrectomy.

PURPOSE: A correct preoperative selection of candidates to undergo a sleeve gastrectomy (SG) is advisable. However, there is a dearth of available literature addressing outcome predictors after SG, besides surgical factors. To assess the accuracy of the mammary volume-to-body mass index (MV-BMI) ratio as an indicator of cardiovascular disease (CVD) risk in morbidly obese patients and as a preoperative predictor of long-term outcomes after SG. MATERIALS AND METHODS: A prospective observational study of 100 consecutive females under 40 years old and planned to undergo a SG was performed. Mammary volume was calculated based on a geometry of the breast model. Correlation of the preoperative MV-BMI ratio with preoperative Framingham risk score (FRS) and triglyceride/HDL-cholesterol ratio was investigated. The correlation of preoperative MV-BMI with 5-year postoperative remission of comorbidities was also assessed. RESULTS: Preoperative MV-BMI showed an inverse correlation with preoperative FRS and triglyceride/high-density lipoprotein-cholesterol ratio. It also showed a direct correlation with long-term T2D, hypertension, and dyslipidemia remission after SG. A cutoff point of MV-BMI 60 has been established as the most accurate predictive value. CONCLUSION: MV-BMI can be used as a predictive factor of long-term outcome after SG in premenopausal women.

Addition of Probiotics to Anti-Obesity Therapy by Percutaneous Electrical Stimulation of Dermatome T6. A Pilot Study.

Obesity is becoming a pandemic and percutaneous electrical stimulation (PENS) of dermatome T6 has been demonstrated to reduce stomach motility and appetite, allowing greater weight loss than isolated hypocaloric diets. However, modulation of intestinal microbiota could improve this effect and control cardiovascular risk factors. Our objective was to test whether addition of probiotics could improve weight loss and cardiovascular risk factors in obese subjects after PENS and a hypocaloric diet. A pilot prospective study was performed in patients (n = 20) with a body mass index (BMI) > 30 kg/m2. Half of them underwent ten weeks of PENS in conjunction with a hypocaloric diet (PENS-Diet), and the other half was treated with a PENS-Diet plus multistrain probiotics (L. plantarum LP115, B. brevis B3, and L. acidophilus LA14) administration. Fecal samples were obtained before and after interventions. The weight loss and changes in blood pressure, glycemic and lipid profile, and in gut microbiota were investigated. Weight loss was significantly higher (16.2 vs. 11.1 kg, p = 0.022), whereas glycated hemoglobin and triglycerides were lower (-0.46 vs. -0.05%, p = 0.032, and -47.0 vs. -8.5 mg/dL, p = 0.002, respectively) in patients receiving PENS-Diet + probiotics compared with those with a PENS-Diet. Moreover, an enrichment of anti-obesogenic bacteria, including Bifidobacterium spp, Akkermansia spp, Prevotella spp, and the attenuation of the Firmicutes/Bacteroidetes ratio were noted in fecal samples after probiotics administration. In obese patients, the addition of probiotics to a PENS intervention under a hypocaloric diet could further improve weight loss and glycemic and lipid profile in parallel to the amelioration of gut dysbiosis.

Incisional Surgical Site Infection after Abdominal Fascial Closure with Triclosan-Coated Barbed Suture vs Triclosan-Coated Polydioxanone Loop Suture vs Polydioxanone Loop Suture in Emergent Abdominal Surgery: A Randomized Clinical Trial.

BACKGROUND: Triclosan-coated sutures have been shown to reduce surgical-site infection (SSI) in emergent operation for fecal peritonitis. Barbed sutures provoke a homogeneous distribution of tension throughout the suture, implying better blood supply to the wound edges and healing. The aim of this study was to evaluate the effect, on SSI and evisceration, of using triclosan-coated and barbed sutures for fascial closure in patients undergoing emergent surgery. STUDY DESIGN: A prospective, randomized clinical trial was performed. Patients were randomized into 3 groups: those undergoing aponeurotic closure with triclosan-coated barbed suture (Stratafix Symmetric [Johnson & Johnson]), patients undergoing closure with triclosan-coated polydioxanone loop suture (PDS plus [Johnson & Johnson]), and patients undergoing closure with polydioxanone loop suture (PDS [Johnson & Johnson]). Primary investigated outcomes were SSI and evisceration rates during a follow-up period of 30 days. The primary analysis plan was based on a per-protocol approach. RESULTS: Incisional SSI was 6.4% (3 of 47) in the Stratafix Symmetric group, 8.9% (4 of 45) in the PDS plus group, and 23.4% (11 of 47) in PDS group (p = 0.03). The evisceration rate was 0% in Stratafix Symmetric, 8.9% (4 of 45) in PDS plus, and 12.8% (6 of 47) in PDS (p = 0.05). Median hospital stay was 4 days (range 2 to 14 days) in Stratafix Symmetric, 5 days (range 2 to 21 days) in PDS plus, and 8 days (range 2 to 60 days) in PDS (p = 0.012). The use of triclosan-coated sutures (Stratafix Symmetric and PDS plus) was associated with a lower risk of incisional SSI (p = 0.009), and the use of barbed suture was associated with a lower risk of evisceration (p = 0.019). Comparing Stratafix Symmetric with PDS plus, there were no significant differences in SSIs, but the evisceration rate was significantly higher in the PDS plus group (p = 0.036). CONCLUSIONS: The use of triclosan-coated sutures (Stratafix Symmetric and PDS plus) in emergent surgery reduces the incidence of incisional SSIs. The use of barbed sutures reduces the incidence of evisceration.

Metabolic Effect of the Hepatic Branch of the Vagal Nerve in One-Anastomosis Gastric Bypass (OAGB).

BACKGROUND: Bariatric surgery is often performed not only to lose weight, but also to improve obesity-related comorbidities. A certain metabolic effect of the bariatric techniques has been demonstrated, as the improvement or even remission of comorbidities is patent, before having lost a relevant amount of weight. The autonomic innervation of diverse viscera by the vagus nerve has been hypothesized to participate in it. We aimed to evaluate the ponderal and metabolic impact of the preservation of the hepatic branch of the vagus in type 2 diabetic (T2D) patients undergoing one-anastomosis gastric bypass (OAGB). PATIENTS AND METHODS: We conducted a prospective study on patients with a preoperative diagnosis of morbid obesity and T2D, who underwent an OAGB. Preservation of the hepatic branch of the vagus was carried out in the first 14 patients (Group 1), whereas in another 14 patients it was sectioned. Ponderal and metabolic outcomes were assessed 1 and 2 years after surgery. RESULTS: The length of the biliary limb was 210 cm in both groups. Postoperative BMI or excess BMI loss was not significantly different between groups. The patients included in Group 1 showed a statistically greater improvement in glycemic and lipid variables. CONCLUSION: The preservation of the hepatic branch of the vagus in an OAGB leads to more favorable postoperative glycemic and lipid profiles.

Impact of Biliopancreatic Limb Length (70 cm vs 120 cm), with Constant 150 cm Alimentary Limb, on Long-Term Weight Loss, Remission of Comorbidities and Supplementation Needs After Roux-En-Y Gastric Bypass: a Prospective Randomized Clinical Trial.

BACKGROUND: The best alimentary and biliopancreatic limb (BPL) lengths in the Roux-en-Y gastric bypass (RYGB) still remain unclear. The aim of this study was to compare the effect of a BPL of 70 vs 120 cm, with a constant AL of 150 cm on long-term weight loss, remission of comorbidities, and supplementation needs after RYGB. PATIENTS AND METHODS: A prospective randomized study of morbidly obese patients undergoing RYGB was performed. Patients were randomized into two groups: those patients undergoing RYGB with a BPL of 70 cm (BPL 70 cm) and those ones undergoing RYGB with a BPL of 120 cm (BPL 120 cm). BMI, excess BMI loss (EBMIL), remission of comorbidities and specific vitamin and mineral supplementation needs at 1, 2, and 5 years were analyzed. RESULTS: Two hundred fifty-three patients were included in each group. There were no significant differences in BMI, EBMIL and the remission of diabetes mellitus, hypertension, and dyslipidemia between groups at 1, 2, and 5 years after surgery. Patients from group BPL 120 cm required greater specific supplementation of vitamin B12, folic acid, and vitamin A during all the follow-up. CONCLUSION: A RYGB with 120 cm BPL does not achieve greater weight loss or remission of comorbidities than a RYGB with 70 cm BPL but is associated with greater deficiencies of vitamin B12, vitamin A, and folic acid. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT03607305. https://clinicaltrials.gov/.

Incidence of postoperative nausea and vomiting after laparoscopic sleeve gastrectomy with staple line reinforcement with oversewing and staple line inversion vs buttressing material: A randomized clinical trial.

BACKGROUND: Postoperative nausea and vomiting are relevant complications after restrictive bariatric procedures, such as sleeve gastrectomy, mainly secondary to a drastic reduction in the gastric volume. However, other causes can be involved. The aim of this study was to determine the incidence of postoperative nausea and vomiting (PONV) after laparoscopic sleeve gastrectomy (LSG), with staple line reinforcement with oversewing vs buttressing material. PATIENTS AND METHODS: A prospective randomized clinical trial of all the patients undergoing LSG was performed. Patients were divided into 2 groups: patients undergoing staple line inversion (Group 1) and patients undergoing staple line reinforcement with buttressing material (Group 2). Nausea and vomiting were assessed by the Postoperative Nausea and Vomiting Intensity Scale. RESULTS: A total of 100 females were included in the study, 50 in each group. Mean operative time was 66.1 ±â€¯11.6 min in Group 1 and 55.4 ±â€¯9.4 in Group 2 (p < 0.001). There were no significant differences in staple line leaks and bleeds between groups. The PONV intensity score at 6 h was 316.4 in Group 1 and 77.1 in Group 2 (p < 0.001). 24 h after surgery, the PONV intensity score was 86 in Group 1 and 7.9 in Group 2 (p = 0.022). CONCLUSION: The reinforcement with a running suture in LSG creates more PONV and increases the duration of the symptoms during the first hours after surgery, and prevents from early oral intake in a greater number of cases, when compared with the use of buttressing material as reinforcement method.

Laparoscopic-Guided Transversus Abdominis Plane (TAP) Block as Part of Multimodal Analgesia in Laparoscopic Roux-en-Y Gastric Bypass Within an Enhanced Recovery After Surgery (ERAS) Program: a Prospective Randomized Clinical Trial.

BACKGROUND: Despite the ultrasound guidance of transversus abdominis plane (TAP) blocks has allowed greater precision of needle placement in the desired tissue plane, visualization of the abdominal wall muscles can be hindered by morbid obesity and could lead to failed regional anesthesia. The aim of this study was to assess the feasibility and effect of laparoscopic-guided TAP block in patients undergoing Roux-en-Y gastric bypass and to compare it with port-site infiltration. PATIENTS AND METHODS: A prospective randomized clinical trial was performed. Patients were randomized into two groups: patients undergoing laparoscopic-guided TAP (TAP-lap) and patients undergoing port-site infiltration (PSI). Pain quantification as measured by visual analogic scale (VAS) and morphine needs during the first 24 h were evaluated. RESULTS: One hundred and forty patients were included, 70 in each group. The mean operation time was 83.3 + 15.6 min in TAP-lap and 80.5 + 14.4 min in PSI (NS). The mean postoperative pain, as measured by VAS, 24 h after surgery was 16.8 + 11.2 mm in PSI and 10 + 8.1 mm in TAP-lap (p = 0.001). Morphine rescues were necessary in 13.2% in PSI and 2.9% in TAP-lap (p = 0.026). The mean hospital stay was 2.1 + 1.2 days in TAP-lap and 2.9 + 1.3 days in PSI (p = 0.019). Hospital discharge during the first 48 h after surgery was possible in 52.9% of the patients in PSI and 71% in TAP-lap (OR 4.75; 95% CI 2.1-10.8; p = 0.029). CONCLUSION: Laparoscopic-guided TAP block can reduce postoperative pain, opioid needs, and hospital stay, when compared with port-site infiltration with the same anesthetic drug, without increasing operation time. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03203070.

Food Tolerance and Quality of Alimentation Following Laparoscopic Sleeve Gastrectomy Calibrated with a 50-Fr Bougie: Long-Term Results.

BACKGROUND: Adjustable gastric banding and vertical banded gastroplasty are associated with the worst postoperative food tolerance of all bariatric techniques. However, food tolerance tends to improve over time. The aim of this study was to assess food tolerance and diet quality in patients undergoing a sleeve gastrectomy, 1 and 5 years after surgery. PATIENTS AND METHODS: A prospective observational study of all the morbidly obese patients undergoing laparoscopic sleeve gastrectomy was performed. Food tolerance was assessed using the Quality of Alimentation questionnaire validated in bariatric patients. RESULTS: Ninety-three patients were analyzed. One year after surgery, mean excess weight loss (EWL) was 81.1% ± 8.3%, and 5 years after surgery, mean EWL was 79.9% ± 6.4%. Preoperatively, 39.8% of patients perceived their eating patterns as good or excellent, 1 year after surgery, 79.6% and 5 years postoperatively, 86%. One year after surgery, the patients reported some difficulty in tolerance of rice, pasta, and red meat. Five years after surgery, these difficulties disappeared and very few patients just refer some tolerance difficulties with red meat. One year after surgery, 10% of the patients reported that they suffered postprandial vomiting often and 22% rarely. Five years postoperatively, only 8% of subjects describe rarely vomiting. CONCLUSION: After sleeve gastrectomy, the patients recognize an improvement in the quality of alimentation. During the first postoperative year, they present tolerance problems with rice, pasta, and red meat, and that disappeared 5 years after surgery.

Effect of the application of a bundle of three measures (intraperitoneal lavage with antibiotic solution, fascial closure with Triclosan-coated sutures and Mupirocin ointment application on the skin staples) on the surgical site infection after elective laparoscopic colorectal cancer surgery.

BACKGROUND: Surgical site infection (SSI) prevention bundles include the simultaneous use of different measures, which individually have demonstrated an effect on prevention of SSI. The implementation of bundles can yield superior results to the implementation of individual measures. The aim of this study was to address the effect of the application of a bundle including intraperitoneal lavage with antibiotic solution, fascial closure with Triclosan-coated sutures and Mupirocin ointment application on the skin staples, on the surgical site infection after elective laparoscopic colorectal cancer surgery. METHODS: A prospective, randomized study was performed, including patients with diagnosis of colorectal neoplasms and plans to undergo an elective laparoscopic surgery. The patients were randomized into two groups: those patients following standard bundles (Group 1) and those ones following the experimental bundle with three additional measures, added to the standard bundle. Incisional and organ space SSI were investigated. The study was assessor-blinded. RESULTS: A total of 198 patients were included in the study, 99 in each group. The incisional SSI rate was 16% in Group 1 and 2% in Group 2 [p = 0.007; RR = 5.6; CI 95% (1.4-17.8)]. The organ-space SSI rate was 4% in Group 1 and 0% in Group 2 [p = 0.039; RR = 1.7; CI 95% (1.1-11.6)]. Median hospital stay was 5.5 days in Group 1 and 4 days in Group 2 (p = 0.028). CONCLUSIONS: The addition of intraperitoneal lavage with antibiotic solution, fascial closure with Triclosan-coated sutures and Mupirocin ointment application on the skin staples, to a standard bundle of SSI prevention, reduces the incisional and organ-space SSI and consequently the hospital stay, after elective laparoscopic colorectal cancer surgery (ClinicalTrials.gov Identifier: NCT03081962).

Effect of the Abdominal Fascial Closure with Triclosan-Coated Sutures in Fecal Peritonitis, on Surgical Site Infection, and Evisceration: A Retrospective Multi-Center Study.

BACKGROUND: Surgical site infection (SSI) is a frequent complication in dirty surgery, reaching rates of up to 40%. The incidence of SSI might be influenced by the suture used for closure of the abdominal fascia. Sutures coated with antibacterial substances may reduce the bacterial load in the incision. PATIENTS AND METHODS: A retrospective study of patients with intra-operative diagnosis of fecal peritonitis undergoing a laparotomy in three Spanish hospitals was performed. Fascial closure consisted in running loop suture of Polyglactin (Vicryl loop®, Johnson & Johnson, New Brunswick, NY; group 1), running loop suture of triclosan-coated polyglactin (Vicryl plus loop®; group 2), running loop suture of polydioxanone (PDS loop® Johnson & Johnson; group 3), and running loop suture of triclosan-coated polydioxanone (PDS plus loop®; group 4). Incisional SSI and evisceration rates were assessed. RESULTS: One hundred four patients were included. There were no differences in age, gender, comorbidities, etiology of peritonitis, and mortality among groups. Surgical site infection rate was 34.6% in group 1; 8% in group 2; 33% in group 3; and 10% in group 4 (p = 0.029). The use of triclosan-coated sutures is associated with lower risk of SSI (risk ratio [RR]: 9; p = 0.003). Evisceration rate was 0% in groups 1 and 2; 15.2% in group 3; and 10% in group 4 (p = 0.05). All patients suffering from evisceration presented previous SSI. The use of monofilament sutures is associated with higher risk of evisceration (RR: 6.35; p = 0.033). CONCLUSION: Triclosan-coated sutures reduce SSI rate in fecal peritonitis, without differences between braided and monofilament type. The use of monofilament sutures is related to higher risk of evisceration, independent of a triclosan coating.

Changes in Frequency Intake of Foods in Patients Undergoing Sleeve Gastrectomy and Following a Strict Dietary Control.

PURPOSE: Dietary intake and food preferences change after bariatric surgery, secondary to gastrointestinal symptoms and dietitian counseling. The aim of this study was to evaluate the changes in the frequency intake of different foods in patients undergoing sleeve gastrectomy and following a strict dietary control. PATIENTS AND METHODS: A prospective observational study of all the morbidly obese patients undergoing laparoscopic sleeve gastrectomy as bariatric procedure between 2007 and 2012 was performed. Dietary assessment was performed using the Alimentary Frequency Questionnaire 1991-2002, developed and validated by the Department of Epidemiology of Miguel Hernandez University (Elche, Alicante Spain). RESULTS: Ninety-three patients were included for analysis, 73 females and 20 males, with a mean preoperative BMI of 46.4 ± 7.9 kg/m2. One year after surgery, excess weight loss was 81.1 ± 8.3% and 5 years after surgery, 79.9 ± 6.4%. Total weight loss at 1 year was 38.8 ± 5.3% and at 5 years, 35.4 ± 4.9%. Postoperatively, a reduction in the intake of dairy products, red meat, deli meat products, shellfish, fried potatoes, sweets, rice, pasta, beer, and processed foods was observed. Vegetables, fruits, and legumes intake increased after surgery. In the first postoperative year, there was a slight intolerance to red meat, fruits, vegetables and legumes, dairy products, pasta, and rice that mostly disappeared 5 years after surgery. CONCLUSION: One year after sleeve gastrectomy, calibrated with a 50-French bougie, there are not important problems in the intake of foods a priori difficult to digest. These problems mostly disappeared 5 years after surgery. The decrease intake of other unhealthy foods is mostly based on the dietary counseling.

Percutaneous Electrical Neurostimulation of Dermatome T6 for Short-term Weight Loss in Overweight and Obese Patients: Effect on Ghrelin Levels, Glucose, Lipid, and Hormonal Profile.

BACKGROUND: Percutaneous electrical neurostimulation of dermatome T6 (PENS T6), associated with a low-caloric diet, has previously demonstrated to achieve a reduction in the appetite perception, inducing a better compliance of the prescribed diet and finally leading to a greater weight loss. Ghrelin has been hypothesized to be implicated in the effect of PENS T6. The aim of this study was to evaluate the effect of PENS T6 with hypocaloric diet on appetite, weight loss and dietary compliance, and its association with plasma ghrelin levels, in comparison with PENS T6 associated with normocaloric diet, transcutaneous electrical neurostimulation of T11-T12 (placebo) with hypocaloric diet, and only hypocaloric diet. PATIENTS AND METHODS: A prospective, randomized study was performed. Patients with body mass index >25 kg/m were included. The subjects were randomized into 4 groups: patients undergoing PENS T6 in conjunction with a 1200 kcal/d diet (group 1). Patients undergoing PENS T6 and following a normocaloric diet (group 2), patients undergoing transcutaneous electrical neurostimulation of dermatomes in right iliac fossa (T11-T12) and following a 1200 kcal/d diet(group 3) and those patients following only a 1200 kcal/d diet (group 4). RESULTS: A total of 200 patients were included, 50 in each group. A significantly greater weight loss was obtained in patients following PENS T6 combined with diet, when compared with the other groups. Patients undergoing PENS T6, associated or not to hypocaloric diet, experienced appetite reduction and lower ghrelin levels, when compared with the other groups. CONCLUSIONS: The greater weight loss experienced in the patients undergoing PENS T6 is associated with appetite reduction and greater diet compliance. Appetite reduction is associated with ghrelin decrease.

Percutaneous Posterior Tibial Nerve Stimulation vs Perianal Application of Glyceryl Trinitrate Ointment in the Treatment of Chronic Anal Fissure: A Randomized Clinical Trial.

BACKGROUND: Current therapeutic guidelines for the treatment of chronic anal fissure establish a medical approach as the first step. Glyceryl trinitrate ointment is the most popular of the available topical treatments in Spain but it is associated with the appearance of headache. OBJECTIVE: The purpose of this study was to compare the compliance rate among patients receiving glyceryl trinitrate treatment for chronic anal fissure with that among patients receiving percutaneous posterior tibial nerve stimulation. DESIGN: This was a prospective randomized study. SETTINGS: The study was conducted at Garcilaso Clinic (Madrid, Spain). PATIENTS: Subjects with persistent anal fissure despite hygiene and dietary measures applied over at least a 6-week period were included. INTERVENTIONS: Study interventions were perianal application of glyceryl trinitrate ointment (twice daily for 8 weeks) and percutaneous posterior tibial nerve stimulation (30-minute session 2 days per week for 8 weeks). MAIN OUTCOME MEASURES: Compliance with the treatment and healing rate of chronic anal fissure in patients receiving glyceryl trinitrate ointment or undergoing percutaneous posterior tibial nerve stimulation were evaluated. RESULTS: Forty patients were included in each group. In the glyceryl trinitrate ointment group, 15% of the patients discontinued treatment because of disabling headaches. There were no adverse effects or treatment withdrawals in the percutaneous posterior tibial nerve stimulation group (p = 0.033). After 8 weeks of treatment, the healing rate in the percutaneous posterior tibial nerve stimulation group was 87.5% vs 65.0% in the glyceryl trinitrate ointment group (p = 0.018). LIMITATIONS: Because the patients were not blinded to the treatment, we cannot rule out a placebo effect derived from the needle insertion in the percutaneous posterior tibial nerve stimulation group. CONCLUSIONS: Percutaneous posterior tibial nerve stimulation is a safe and effective alternative that is in some ways superior to glyceryl trinitrate ointment for the treatment of chronic anal fissure.

Thromboembolic Prophylaxis for Morbidly Obese Patients Undergoing Bariatric Surgery.

Obesity itself is associated with an increased risk of thromboembolic events. Moreover, most bariatric procedures actually are performed by laparoscopic approach, implying an increased intraabdominal pressure during the surgical procedure that may favor the development of thrombus. Therefore, bariatric surgery is considered a high-risk procedure for thromboembolic events. Actual recommendations are to include low molecular weight heparins (LMWH) and compression stockings in the primary prophylaxis of thromboembolic events. Following these measures, a routine screening of thromboembolic complications with imaging tests is not recommended.

Effect of Pectoral Electrostimulation on Reduction of Mammary Ptosis After Bariatric Surgery.

BACKGROUND: Over 90% of women report to be very dissatisfied with the aspect of their breast after bariatric surgery. Breast reconstructive surgeries are often not funded by the National Health Service or private health insurances in many countries and the patient must pay a high economic amount to undergo it. PATIENTS AND METHODS: A prospective randomized clinical trial of patients undergoing bariatric surgery was performed. Patients were randomly assigned into 3 groups: patients undergoing percutaneous electrostimulation of the pectoral muscle combined with specific training (group 1), patients doing the specific training alone (group 2), and patients without any specific treatment (group 3). The assigned treatment began 15 days after surgery and was maintained during 12 weeks. RESULTS: Twenty-five women were included in each group. In the posttreatment anthropometric measures significant differences between groups could be observed in Regnault classification (P=0.014), ptosis (P=0.017), and projection (P=0.025). Multiple comparisons revealed that there were no significant differences in all these variables between group 2 and group 3, whereas a significant difference could be observed between groups 1 and 2 and 1 and 3. Median satisfaction score with the prescribed treatment was significantly better in group 1 than in the other groups. CONCLUSIONS: Percutaneous electrostimulation of the pectoral muscle combined with specific training achieves a reduction in the breast ptosis and an increased projection, resulting in greater satisfaction of the patients, when compared with only specific training or without any specific activity.

Long-term Effect of Percutaneous Electrical Neurostimulation of Dermatome T6 for Appetite Reduction and Weight Loss in Obese Patients.

INTRODUCTION: A continuous feeling of hunger is the major cause of dietary treatment failure and the patients abandon the diet. A previous study of our group demonstrated that percutaneous electrical neurostimulation (PENS) of T6 dermatome induces an appetite reduction and significantly greater weight loss compared with only diet as a preoperative measure in morbidly obese patients who are candidates for bariatric surgery. The aim of this study was to evaluate the long-term effect of this therapy. PATIENTS AND METHODS: A prospective study was performed, including obese patients with a body mass index between 30 and 40 kg/m undergoing PENS of dermatome T6. Weight loss, dietary compliance, and appetite were assessed before the treatment, after 12 weeks of treatment, and 3 and 9 months after completing the therapy. RESULTS: A total of 150 patients were included in the study. A mean weight loss of 11.8±2.6 kg was obtained after 12 weeks of treatment. Three months after completing the therapy, mean weight loss was 14.6±2.7 kg and 9 months after completing the treatment mean weight loss was 14.5±2.8 kg. Median appetite perception quantified by Visual Analogue Scale was 6 before the treatment, 1 after completing the treatment, 1 at 3 months after completing the treatment, and 4 at 9 months after completing the treatment. Dietary compliance after 12 weeks of treatment was 90%, 84% at 3 months after completing the treatment, and 62% at 9 months after completing the treatment. CONCLUSION: PENS of dermatome T6 achieves a significant appetite reduction, which is maintained 3 months after completing the therapy. Later, the patients' appetite is restored, but they do not regain the weight lost.

Maintenance of Multivitamin Supplements After Sleeve Gastrectomy.

INTRODUCTION: After all bariatric procedures, multivitamin supplements are uniformly prescribed to minimize eventual deficiencies. These supplements are usually maintained long time, even during the whole life after malabsorptive techniques, while these are maintained at least during 1 year after restrictive procedures. Given that sleeve gastrectomy does not alter intestinal absorption, the supplements are possibly unnecessary, once the patient can take an adequate diet. PATIENTS AND METHODS: A prospective randomized study of patients undergoing a laparoscopic sleeve gastrectomy was performed. Patients were randomized into two groups: those patients receiving the multivitamin supplement (Multicentrum, Pfizer, 1 tablet/day) during 3 months (group 1) and those receiving the supplement during 12 months (group 2). Laboratory data were recorded: vitamins (D, B12 and folic acid) and oligoelements (calcium, iron, phosphorus, magnesium and zinc) at 3, 6 and 12 months after surgery. RESULTS: Eighty patients were included, 40 in each group. At 3 months, 7.5 % of the patients presented iron deficiency and 2.5 % ferritin one, similarly in both groups, that was corrected with specific extra iron supplements. At 6 months, one patient (2.5 %) in group 1 presented iron deficiency and one in group 2 vitamin D deficiency (NS). At 12 months, only one patient in group 2 presented vitamin D deficiency, treated with specific supplements. CONCLUSION: The maintenance of multivitamin supplements more than 3 months postoperatively seems to be of no benefit. It is preferable monitoring laboratory values and adding specific supplements when necessary. CLINICALTRIALS. GOV IDENTIFIER: NCT02620137.