Malnutrition and vitamin deficiencies after surgery for esophageal and gastric cancer: A metanalysis.

BACKGROUND & AIMS: Patients receiving oncological esophagectomy or gastrectomy are known to be at high risk for vitamin and micronutrient deficiency before, during and after surgery. However, there are no clear guidelines for these cancer patients regarding postoperative vitamin supplementation. METHODS: We conducted a metanalysis consisting of 10 studies regarding vitamin and micronutrient deficiencies after oncological gastric or esophageal resection. 5 databases were searched. RESULTS: Data was sufficient regarding Vitamins B12 and 25-OH D3 as well as calcium. We were able to show deficiencies in 25-OH Vitamin D3 levels (p < 0.001) and lower levels of Vitamin B12 and calcium (bit p < 0.001) when compared to the healthy population. CONCLUSIONS: Patients from these groups are at risk for vitamin deficiencies. A guideline on postoperative supplementation is needed.

Removable Transduodenal Bypass: Development of a New Endoscopic Concept.

Introduction: Obesity and obesity-related disease such as diabetes mellitus type 2 are a permanently rising concern worldwide. Current effective therapeutic options mostly include medication and surgery, but there is a lack of effective treatment options between medication and surgery. Previously, devices such as EndoBarrier® have been placed on the market. However, high complication rates, especially liver abscesses, were seen in patients after implantation of the device. Nevertheless, duodenal lining seems to be an effective therapy for type 2 diabetes in obese patients and can lead to weight loss. Methods: A new removable transduodenal bypass was developed and tested on a porcine model. In this course, the device evolved in its mechanism and handling. The device is designed to avoid typical complications seen in previous duodenal liners. Results: After further development of the device, implantation and use were feasible and safe in the porcine model. Autopsies showed that the device stayed in place and remained intact. Discussion: The new removable transduodenal bypass aims to be a removable therapeutic option for diabetes mellitus type 2 and obesity, replacing previous duodenal lining devices. Use and handling of the device, however, are yet to be tested in the human model in the future.

Depression in brain tumor patients-early detection and screening.

BACKGROUND: Depres sion is reported in up to 90% of cancer patients but to this date, a standardized screening tool for depression specifically modified for patients diagnosed with brain tumors is lacking. Thus, this study aims to develop an adapted screening tool and identify a suitable time slot for screening. METHODS: Sixty-one patients with brain lesions were interviewed prior to neurosurgical resection. For screening purposes, established depression scores were used. A study-specific questionnaire (SSQ) was developed based on patient interviews prior to the trial. Two subgroups were analyzed: patients with benign and patients with malignant tumors (including brain metastases). As a subgroup within malignant lesions, patients with glioblastoma (GBM) were also analyzed separately. RESULTS: Of patients, 87.5% with GBM presented with results > 16 points on the Center for Epidemiologic Studies Depression Scale (CES-D) after surgery. A decline in patients with benign brain tumors (p = 0.0058) and an increase in patients with malignant tumors (p = 0.0491) could be shown over time for CES-D scores. In this study, we established a new prototype screening tool for depression. In patients diagnosed with GBM, the number of patients needed to screen for identification of symptoms of depression was 1.59. Best time for screening was 35 days after surgery. CONCLUSIONS: Considering the high prevalence and low number needed to screen of depression in patients diagnosed with GBM, we strongly encourage their routine screening during follow-up appointments (35 days after surgery). We encourage a plan to further establish the questionnaire developed in this pilot study.

[Therapeutic Options for Regaining Weight after Bariatric Surgery]. / Therapieoptionen bei Weight-Regain nach Bariatrischer Operation.

PURPOSE: The purpose of this article is to create an overview of diagnostic and therapeutic options for weight regain (WR) and insufficient weight loss (IWL) after bariatric surgery (BS). With increasing popularity of BS, WR is becoming more relevant. METHODS: We combined recent literature on WR and IWL with personal experience to suggest possible proceedings if WR or IWL is diagnosed. RESULTS: If an anatomical-pathological cause can be detected, surgical therapy is the most effective. If WR or IWL is idiopathic, a multimodal therapeutic concept is necessary for sufficient therapeutic success. Depending on the initial BS, a combination of lifestyle intervention, medication and surgical therapy seems most effective. CONCLUSIONS: Extensive diagnostic testing is necessary prior to any surgical intervention. In idiopathic WR after Roux-en-Y Gastric Bypass (RYGB), we suggest lengthening the biliopancreatic limb and shortening the common channel. After Sleeve-Gastrectomy (SG), we currently see RYGB as most effective in patients with gastroesophageal reflux disease (GERD) and SADI-S as a feasible option if no GERD is present.

Circular vs. linear stapling after minimally invasive and robotic-assisted esophagectomy: a pooled analysis.

PURPOSE: Current data states that most likely there are differences in postoperative complications regarding linear and circular stapling in open esophagectomy. This, however, has not yet been summarized and overviewed for minimally invasive esophagectomy, which is being performed increasingly. METHODS: A pooled analysis was conducted, including 4 publications comparing linear and circular stapling techniques in minimally invasive esophagectomy (MIE) and robotic-assisted minimally invasive esophagectomy (RAMIE). Primary endpoints were anastomotic leakage, pulmonary complications, and mean hospital stay. RESULTS: Summarizing the 4 chosen publications, no difference in anastomotic insufficiency could be displayed (p = 0.34). Similar results were produced for postoperative pulmonary complications. Comparing circular stapling (CS) to linear stapling (LS) did not show a trend towards a favorable technique (p = 0.82). Some studies did not take learning curves into account. Postoperative anastomotic stricture was not specified to an extent that made a summary of the publications possible. CONCLUSIONS: In conclusion, data is not sufficient to provide a differentiated recommendation towards mechanical stapling techniques for individual patients undergoing MIE and RAMIE. Therefore, further RCTs are necessary for the identification of potential differences between LS and CS. At this point in research, we therefore suggest evading towards choosing a single anastomotic technique for each center. Momentarily, enduring the learning curve of the surgeon has the greatest evidence in reducing postoperative complication rates.

Sarcopenia after Roux-en-Y Gastric Bypass: Detection by Skeletal Muscle Mass Index vs. Bioelectrical Impedance Analysis.

Background: In sarcopenic patients the skeletal muscle reduction is the primary symptom of age- or disease-related malnutrition, which is linked to postoperative morbidity and mortality. The skeletal muscle mass index (SMI) from magnet resonance imaging (MRI) is increasingly used as a prognostic factor in oncologic and surgical patients, but under-represented in the field of obesity surgery. The bioelectrical impedance analysis (BIA), on the other hand is a commonly used method for the estimation of the body composition of bariatric patients, but still believed to be inaccurate, because of patient-related and environmental factors. The aim of this study was to compare the postoperative SMI values as a direct, imaging measured indicator for muscle mass with the BIA results in patients undergoing Roux-en-Y gastric bypass (RYGB). Methods: We performed a prospective single-center trial. Patients undergoing RYGB between January 2010 and December 2011 at our institution were eligible for this study. MRI and BIA measurements were obtained 1 day before surgery and at 6, 12 and 24 weeks after surgery. Results: A total of 17 patients (four male, 13 female, average age of 41.9 years) were included. SMI values decreased significantly during the postoperative course (p < 0.001). Comparing preoperative and postoperative measurements at 24 weeks after surgery, increasing correlations of SMI values with body weight (r = 0.240 vs. r = 0.628), phase angle (r = 0.225 vs. r = 0.720) and body cell mass (BCM, r = 0.388 vs. r = 0.764) were observed. Conclusions: SMI decreases significantly after RYGB and is correlated to distinct parameters of body composition. These findings show the applicability of the SMI as direct imaging parameter for the measurement of the muscle mass in patients after RYGB, but also underline the important role of the BIA, as a precise tool for the estimation of patients' body composition at low costs. BIA allows a good overview of patients' status post bariatric surgery, including an estimation of sarcopenia.