Additional preparation program for bariatric surgery: Two-year results of a large cohort study.

Background: Multidisciplinary screening of bariatric surgery candidates is recommended, and some centers provide an additional preparation program (APP) to optimize patients preoperatively. Objective: To compare patients with APP to standard care 2 years after primary bariatric surgery regarding postoperative weight loss and resolution of obesity-related comorbidities. Methods: A retrospective cohort study was conducted for patients undergoing primary Roux-en-Y gastric bypass and sleeve gastrectomy between September 2017 and March 2019. The first 12 months patients received an APP, after September 2018, the APP was no longer part of the weight loss trajectory. A multivariable linear regression model was built. Results: Of the 384 patients receiving an APP advice, 50 were lost to follow up. In total, 192 (57%) received the APP and 142 (43%) received standard care. Percentage total weight loss after 2 years was significantly different, 28.8% for the APP group versus 32% for the standard group (p = 0.001). Postoperative weight loss after 2 years was increased in patients who had a gastric bypass, a higher baseline body mass index, and female gender in multivariable analysis. An APP was predictive for decreased postoperative weight. Diabetes mellitus was in remission significantly more often in the preparation group (84.1% of the cases) compared with the standard group (61.9%, p = 0.028). Conclusion: A weight loss trajectory is at least as effective without additional preparation in terms of 2 years postoperative %TWL for primary gastric bypass and sleeve procedures. For comorbidities, diabetes mellitus was in remission more often in the APP group.

A randomized clinical trial evaluating eHealth in bariatric surgery.

BACKGROUND: Supporting patients before, and long after, their bariatric treatment contributes a lot to successful outcome. eHealth interventions have a hypothetical benefit in addition to standard care. This could lead to increased weight loss, reduction of obesity-related diseases, patient adherence, and quality of life. This randomized controlled trial aims to evaluate the value of an eHealth platform and self-monitoring devices as additions to standard bariatric care. MATERIALS AND METHODS: Two-hundred-and-five patients who underwent primary bariatric surgery were randomized (2:1:1) to receive standard care (control group), additional access to an educational patient eHealth platform (online group), or additional access to eHealth platform as well as self-monitoring devices (device group). The platform consisted of an interactive educational environment with informational videos, dietary advice, news, and more. The self-monitoring devices used were a weight scale, blood pressure monitor, pulse oximeter, and activity bracelet. The primary endpoint was weight loss and secondary outcomes included reduction of obesity-related diseases, quality of life, and eHealth use. RESULTS: Postoperative weight loss, reduction of obesity-related diseases, frequency of consultations, and quality of life were similar between groups. Participation to the eHealth platform was high (online group 90%, device group 98%). Most frequently accessed contents were informational messages, videos, and the treatment preparation modules. The percentage of active users of the self-monitoring devices dropped from 62% in the first postoperative month to 19% after 2 years. Thirteen patients in the device group withdrew due to unwillingness to use self-monitoring devices. CONCLUSION: Participation to the eHealth intervention in addition to the standard post-bariatric guidance program was high, however, had no significant impact on clinical outcomes such as weight loss, reduction of obesity-related diseases, and quality of life. Trial registration ClinicalTrials.gov (identifier number NL56992.100.16) https://clinicaltrials.gov/ct2/show/NCT03394638.

Impact of Preoperative Weight Loss on Postoperative Weight Loss Revealed from a Large Nationwide Quality Registry.

PURPOSE: Weight loss before bariatric surgery is not mandatory, but questions remain as to whether preoperative weight loss has an impact on weight loss after surgery. Most studies have small sample sizes. The objective was to evaluate the relationship between preoperative and successful postoperative weight loss defined as ≥25% total weight loss (TWL) at 1 and 2 years after primary bariatric surgery with regard to the obesity-related comorbidities. MATERIALS AND METHODS: Data were extracted from a large nationwide quality registry of patients who underwent a sleeve gastrectomy (SG) or gastric bypass (GBP) between January 2015 and January 2018. Patients with completed screening and preoperative and postoperative data were included. A multivariate logistic regression analysis was performed for each technique and follow-up years separately. RESULTS: In total, 8751 were included in the analysis. Patients with preoperative weight loss were more likely to achieve ≥25% postoperative TWL in both procedures. Patients with higher preoperative weight loss of 5-10% had an increased likelihood for achieving 25% TWL compared to 0-5%, OR 1.79 (CI (1.42-2.25), p < 0.001) vs 1.25 (CI (1.08-1.46), p < 0.004) for the GBP group for year 2 postoperative. This was the same for the SG group at year 2, OR 1.30 (CI (1.03-1.64), p < 0.029) vs 1.14 (CI (0.94-1.38), p < 0.198). CONCLUSION: Patients with preoperative weight loss were more likely to achieve ≥25% postoperative TWL at 1 and 2 years after surgery in both procedures; moreover, the extent of preoperative weight loss contributes to the significance and odds of this success.

Early fixation versus conservative therapy of multiple, simple rib fractures (FixCon): protocol for a multicenter randomized controlled trial.

Background: Multiple rib fractures are common injuries in both the young and elderly. Rib fractures account for 10% of all trauma admissions and are seen in up to 39% of patients after thoracic trauma. With morbidity and mortality rates increasing with the number of rib fractures as well as poor quality of life at long-term follow-up, multiple rib fractures pose a serious health hazard. Operative fixation of flail chest is beneficial over nonoperative treatment regarding, among others, pneumonia and both intensive care unit (ICU) and hospital length of stay. With no high-quality evidence on the effects of multiple simple rib fracture treatment, the optimal treatment modality remains unknown. This study sets out to investigate outcome of operative fixation versus nonoperative treatment of multiple simple rib fractures. Methods: The proposed study is a multicenter randomized controlled trial. Patients will be eligible if they have three or more multiple simple rib fractures of which at least one is dislocated over one shaft width or with unbearable pain (visual analog scale (VAS) or numeric rating scale (NRS) > 6). Patients in the intervention group will be treated with open reduction and internal fixation. Pre- and postoperative care equals treatment in the control group. The control group will receive nonoperative treatment, consisting of pain management, bronchodilator inhalers, oxygen support or mechanical ventilation if needed, and pulmonary physical therapy. The primary outcome measure will be occurrence of pneumonia within 30 days after trauma. Secondary outcome measures are the need and duration of mechanical ventilation, thoracic pain and analgesics use, (recovery of) pulmonary function, hospital and ICU length of stay, thoracic injury-related and surgery-related complications and mortality, secondary interventions, quality of life, and cost-effectiveness comprising health care consumption and productivity loss. Follow-up visits will be standardized and daily during hospital admission, at 14 days and 1, 3, 6, and 12 months. Discussion: With favorable results in flail chest patients, operative treatment may also be beneficial in patients with multiple simple rib fractures. The FixCon trial will be the first study to compare clinical, functional, and economic outcome between operative fixation and nonoperative treatment for multiple simple rib fractures. Trial registration: www.trialregister.nl, NTR7248. Registered May 31, 2018.

Should the Extended Lateral Approach Remain Part of Standard Treatment in Displaced Intra-articular Calcaneal Fractures?

The aim of this study was to evaluate the results of open reduction and internal fixation through the extended lateral approach (ELA) in displaced intra-articular calcaneal fractures and to determine whether this approach should remain part of standard therapy. This retrospective cohort study included 60 patients with 64 displaced intra-articular calcaneal fractures who underwent surgical treatment through the ELA. Outcome measures were the visual analog scale foot and ankle (VAS FA), the American Orthopedic Foot and Ankle Society (AOFAS) score, surgical site infections (SSIs), and reoperations. We determined the AOFAS score for 40 patients with 42 fractures, and 42 patients with 44 fractures completed the VAS FA questionnaire. The mean VAS FA score was 61.0 ± 23.4 and the median AOFAS score was 83 (range 33 to 100), with 55% good to excellent scores. We found 10.9% superficial SSIs successfully treated with antibiotics. In 4.7% of patients a deep SSI was diagnosed, wherefore premature implant removal was necessary. Patients with an SSI did not have significantly lower VAS FA or AOFAS scores than did patients without an SSI (p = .318 and p = .766, respectively). Implant removal in absence of SSIs was necessary in 17 patients because of pain, and 3 patients needed secondary arthrodesis because of persistent pain. We concluded that the ELA proved to be a safe procedure, and moreover the most common complications did not influence the long-term outcomes of patients. However, recent literature demonstrates that less invasive techniques seem to exceed the ELA with respect to wound complications.

Predictors for the occurrence of major complications after primary Roux-en-Y gastric bypass surgery.

BACKGROUND: The risk of developing postoperative complications after primary Roux-en-Y gastric bypass (RYGB) is relatively low. Nevertheless, postoperative complications can have serious consequences in terms of severe morbidity and health care costs. Identification of potential predictors is useful for further reduction of the postoperative complication rate. METHODS: This retrospective study included all patients undergoing primary RYGB between January 2010 and December 2013, using data from a prospectively collected database. Patients' characteristics, operative details and perioperative outcome were analyzed. RESULTS: A total of 773 patients (14.5% male) were included for analysis, with a mean age of 42.1±10.4 years and a mean Body Mass Index of 42.8±4.3 kg/m2. A total of 66 (8.5%) direct postoperative complications occurred. Clavien-Dindo grade 3a and higher occurred in 55 patients. Univariate analysis identified age (P=0.013), gender (P=0.017), BMI over 50 kg/m2 (P=0.096), hypertension (P=0.099), chronic obstructive pulmonary disease (P=0.002) and previous upper gastrointestinal surgery (P=0.095) as potential predictors. Multivariate logistic regression analysis showed that male gender (OR 2.412; 95%CI [1.212-4.797]) and chronic obstructive pulmonary disease (COPD) (OR 3.716; 95%CI [1.543-8.949]) were found to be independent predictors for the occurrence of major complications after primary RYGB. CONCLUSIONS: This study showed a number of potential predictors, of which male gender and COPD after multivariate regression analysis were found to be independent predictive factors for the occurrence of major complications after primary RYGB.

Long-term results after revisions of failed primary vertical banded gastroplasty.

AIM: To compare the results after revision of primary vertical banded gastroplasty (Re-VBG) and conversion to sleeve gastrectomy (cSG) or gastric bypass (cRYGB). METHODS: In this retrospective single-center study, all patients with a failed VBG who underwent revisional surgery were included. Medical charts were reviewed and additional postal questionnaires were sent to update follow-up. Weight loss, postoperative complications and long-term outcome were assessed. RESULTS: A total 152 patients were included in this study, of which 21 underwent Re-VBG, 16 underwent cSG and 115 patients underwent cRYGB. Sixteen patients necessitated a second revisional procedure. No patients were lost-to-follow-up. Two patients deceased during the follow-up period, 23 patients did not return the questionnaire. Main reasons for revision were dysphagia/vomiting, weight regain and insufficient weight loss. Excess weight loss (%EWL) after Re-VBG, cSG and cRYGB was, respectively, 45%, 57% and 72%. Eighteen patients (11.8%) reported postoperative complications and 27% reported long-term complaints. CONCLUSION: In terms of additional weight loss, postoperative complaints and reintervention rate, Roux-en-Y gastric bypass seems feasible as a revision for a failed VBG.

Relax, it's just laparoscopy! A prospective randomized trial on heart rate variability of the surgeon in robot-assisted versus conventional laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic surgery might be beneficial for the patient, but it imposes increased physical and mental strain on the surgeon. Robot-assisted laparoscopic surgery addresses some of the laparoscopic drawbacks and may potentially reduce mental strain. This could reduce the risk of surgeon's fatigue, mishaps and strain-induced illnesses, which may eventually improve the safety of laparoscopic surgical procedures. METHODS: To test this hypothesis, a randomized study was performed, comparing both heart rate and heart rate variability (HRV) of the surgeon as a measure of total and mental strain, respectively, during conventional and robot-assisted laparoscopic cholecystectomy. RESULTS: Both heart rate and HRV (the low-frequency band/high-frequency band ratio) were significantly decreased when using robotic assistance. CONCLUSIONS: These data suggest the use of the daVinci® Surgical System leads to less physical and mental strain of the surgeon during surgery. However, assessing mental strain by means of HRV is cumbersome since there is no clear cutoff point or scale for maximum tolerated strain levels and its related effects on surgeon's health.