Comparative analysis of linear- and circular-stapled gastrojejunostomies in Roux-en-Y gastric bypass: a focus on postoperative morbidity using the comprehensive complication index.

PURPOSE: The linear-stapled (LSA) and the circular-stapled anastomosis (CSA) are the two most commonly performed techniques for the gastrojejunostomy (GJ) during laparoscopic Roux-en-Y gastric bypass (RYGB). This study compared the outcome after both techniques with special focus on postoperative morbidity using the comprehensive complication index (CCI). METHODS: Five hundred eighty-eight patients operated between 01/2010 and 12/2019 were included in the final analysis and divided in two cohorts according to the surgical technique of the GJ (LSA (n = 290) or CSA (n = 298)). Before 09/2016, the CSA was exclusively performed for the GJ, while after 09/2016, the LSA was solely used. RESULTS: The mean CCI for patients with Clavien-Dindo complication grade ≥ 2 within the first 90 days after RYGB was 31 ± 9.1 in the CSA and 25.7 ± 6.8 in the LSA group (p < 0.001), both values still below the previously published benchmark cutoff (≤ 33.73). The C-reactive Protein (CRP)-levels on postoperative days (POD) 1 and 3 as well as the use of opioids on POD 1 were significantly higher in the CSA- than in the LSA-group (all p < 0.001). There were significantly more internal herniations in the CSA group during the first 24 postoperative months (p < 0.001). CONCLUSION: Patients after RYGB with CSA were found to have higher CCI values during the first 90 PODs compared to patients in which the LSA was applied. To achieve optimal outcomes in terms of patient morbidity, the LSA seems to be the superior technique for GJ in RYGB.

Results of robotic TAPP and conventional laparoscopic TAPP in an outpatient setting: a cohort study in Switzerland.

PURPOSE: Recently, robotic surgery has been increasingly performed in hernia surgery. Although feasibility and safety of robot-assisted inguinal hernia repair in an inpatient setting have been already shown, its role in outpatient hernia surgery has not yet been investigated. Thus, this study aimed to compare robot-assisted TAPP (r-TAPP) and conventional laparoscopic TAPP (l-TAPP) in an outpatient setting. METHODS: A prospective database of patients with inguinal hernia treated by l-TAPP or r-TAPP in an outpatient setting during a 1-year period was analyzed in a comparative cohort study. All patients underwent a check-up appointment with their surgeon within 3 days and 6 weeks postoperatively. Data on surgical time, perioperative complications, and postoperative pain were collected. Pain was recorded by using a Verbal Rating Scale (VRS). RESULTS: Overall, outpatient laparoendoscopic inguinal hernia repair was performed in 58 patients (29 l-TAPP; 29 r-TAPP). Mean age was 57 years (21-81), mean BMI 24.5 kg/m2 (19-33) with no differences between both groups. Most patients reported none or only a low postoperative pain level in both groups (89.6% in l-TAPP group; 100% in r-TAPP), while there was a trend for less pain after r-TAPP. In both groups, there was one case of postoperative hematoma, which was successfully treated by conservative means. No other complications occurred during follow-up in either group and there was no 30-day-readmission, no unplanned overstay or any 30-day mortality in the cohort. CONCLUSION: Robot-assisted inguinal hernia surgery can be safely performed in an outpatient setting with a tendency to less pain when compared to the conventional laparoscopic technique. Cost-effectiveness and cost-coverage of outpatient robot-assisted inguinal hernia surgery must be further investigated in times of limited health cost resources and diagnosis-related medical reimbursements.

Surgical outcome and complications of total laparoscopic hysterectomy for very large myomatous uteri in relation to uterine weight: a prospective study in a continuous series of 461 procedures.

PURPOSE: To analyze whether a large uterine size was associated with increased rate of intraoperative and postoperative surgical complications in patients who underwent total laparoscopic hysterectomy (TLH) for myomatous uteri. METHODS: We examined prospectively data from 461 consecutive TLHs performed by a single surgeon between August 2004 and August 2014 at the Department of Obstetrics and Gynecology, Sirai Hospital, Carbonia, and at the Department of Gynecologic Oncology, Businco Hospital, Cagliari, Italy. Demographic and surgical data were stratified by uterine weight (range 90-5500 g) into four groups: <300 g; from 300 to 500 g; from 500 to 800 g; and >800 g. Outcomes examined included blood loss, operative time, intraoperative and postoperative complications, and duration of hospital stay. A linear regression analysis was performed to identify whether uterine weight was an independent predictor affecting these outcomes. In addition, BMI, previous surgery with adhesiolysis, and endometriosis were tested as a predictor of surgical complications and outcomes. RESULTS: No significant difference was found in intraoperative and postoperative complications, as well as hospital stay, by uterine weight. Increased uterine size was significantly associated with longer operative time and increased blood loss. Beside uterine weight, prior surgery was predictive of postoperative complications. In contrast, higher BMI was not associated with increased complication rate. Independent predictors of longer operative time included previous surgery, endometriosis, and BMI. CONCLUSIONS: Our results showed that in experienced hands, TLH is feasible and safe also in presence of very large uteri. TLH results in a few complications and short hospital stay regardless of uterine weight.

Assessing daily energy intake in adult women: validity of a food-recognition mobile application compared to doubly labelled water.

Accurate dietary assessment is crucial for nutrition and health research. Traditional methods, such as food records, food frequency questionnaires, and 24-hour dietary recalls (24HR), have limitations, such as the need for trained interviewers, time-consuming procedures, and inaccuracies in estimations. Novel technologies, such as image-based dietary assessment apps, have been developed to overcome these limitations. SNAQ is a novel image-based food-recognition app which, based on computer vision, assesses food type and volume, and provides nutritional information about dietary intake. This cross-sectional observational study aimed to investigate the validity of SNAQ as a dietary assessment tool for measuring energy and macronutrient intake in adult women with normal body weight (n = 30), compared to doubly labeled water (DLW), a reference method for total daily energy expenditure (TDEE). Energy intake was also estimated using a one-day 24HR for direct comparison. Bland-Altman plots, paired difference tests, and Pearson's correlation coefficient were used to assess agreement and relationships between the methods. SNAQ showed a slightly higher agreement (bias = -329.6 kcal/day) with DLW for total daily energy intake (TDEI) compared to 24HR (bias = -543.0 kcal/day). While both SNAQ and 24HR tended to underestimate TDEI, only 24HR significantly differed from DLW in this regard (p < 0.001). There was no significant relationship between estimated TDEI and TDEE using SNAQ (R2 = 27%, p = 0.50) or 24HR (R2 = 34%, p = 0.20) and there were no significant differences in energy and macronutrient intake estimates between SNAQ and 24HR (Δ = 213.4 kcal/day). In conclusion, these results indicate that SNAQ provides a closer representation of energy intake in adult women with normal body weight than 24HR when compared to DLW, but no relationship was found between the energy estimates of DLW and of the two dietary assessment tools. Further research is needed to determine the clinical relevance and support the implementation of SNAQ in research and clinical settings. Clinical trial registration: This study is registered on ClinicalTrials.gov with the unique identifier NCT04600596 (https://clinicaltrials.gov/ct2/show/NCT04600596).

Bottom-up vs. top-down connectivity imbalance in individuals with high-autistic traits: An electroencephalographic study.

Brain connectivity is often altered in autism spectrum disorder (ASD). However, there is little consensus on the nature of these alterations, with studies pointing to either increased or decreased connectivity strength across the broad autism spectrum. An important confound in the interpretation of these contradictory results is the lack of information about the directionality of the tested connections. Here, we aimed at disambiguating these confounds by measuring differences in directed connectivity using EEG resting-state recordings in individuals with low and high autistic traits. Brain connectivity was estimated using temporal Granger Causality applied to cortical signals reconstructed from EEG. Between-group differences were summarized using centrality indices taken from graph theory (in degree, out degree, authority, and hubness). Results demonstrate that individuals with higher autistic traits exhibited a significant increase in authority and in degree in frontal regions involved in high-level mechanisms (emotional regulation, decision-making, and social cognition), suggesting that anterior areas mostly receive information from more posterior areas. Moreover, the same individuals exhibited a significant increase in the hubness and out degree over occipital regions (especially the left and right pericalcarine regions, where the primary visual cortex is located), suggesting that these areas mostly send information to more anterior regions. Hubness and authority appeared to be more sensitive indices than the in degree and out degree. The observed brain connectivity differences suggest that, in individual with higher autistic traits, bottom-up signaling overcomes top-down channeled flow. This imbalance may contribute to some behavioral alterations observed in ASD.

Molecular properties of epimutation hotspots.

Mistakes in the maintenance of CG methylation are a source of heritable epimutations in plants. Multigenerational surveys indicate that the rate of these stochastic events varies substantially across the genome, with some regions harbouring localized 'epimutation hotspots'. Using Arabidopsis as a model, we show that epimutation hotspots are indexed by a specific set of chromatin states that map to subregions of gene body methylation genes. Although these regions comprise only ~12% of all CGs in the genome, they account for ~63% of all epimutation events per unit time. Molecular profiling revealed that these regions contain unique sequence features, harbour steady-state intermediate methylation levels and act as putative targets of antagonistic DNA methylation pathways. We further demonstrate that experimentally induced shifts in steady-state methylation in these hotspot regions are sufficient to significantly alter local epimutation intensities. Our work lays the foundation for dissecting the molecular mechanisms and evolutionary consequences of epimutation hotspots in plants.

Online survey on factors influencing patients' motivation to undergo bariatric surgery.

Given the worldwide increasing prevalence of severe obesity and considering the amount of scientific evidence demonstrating the beneficial effects of bariatric surgery (BS), it is surprising that only a fraction of patients with obesity undergo BS. We therefore conducted an anonymized online survey among individuals with a history of BS to understand factors influencing the deciding process leading to BS. Respondents were recruited on a voluntary basis from obesity-related social media groups between April and June 2020. The self-designed, non-validated questionnaire consisted of 20 questions and was open to any participants with a history of BS. Of 851 participants who started the survey, 665 completed the questionnaire (completion rate of 78.1%). Five years after BS, still 70% of the survey-participants were very satisfied or satisfied with the surgical result. However, the majority (73.3%) would have undergone BS earlier. The main motivation to choose BS was related to health status or quality of life. Important characteristics for a bariatric surgeon to obtain patients' trust are "taking time and listen" (74.7%), empathy (64%) and sympathy (56%). Post-operative satisfaction with the surgical outcome was high and long-lasting in this large cohort of BS patients. However, most participants would retrospectively have undergone BS earlier. The main reason to choose BS as treatment for their obesity were impaired physical health or reduced quality of life. Nearby location to patients' residence and availability of surgeons with empathy were decisive motives for bariatric centre selection.

Burst-pause criterion derivation for drinkometer measurements of ingestive behavior.

The drinkometer is a promising device for the study of ingestive behavior of liquid meals in humans. It can be used to investigate behavior in different target populations. However, ingestive behavior has a great variability across study participants. Therefore, a new analytical approach is required for the extraction and analysis of drinkometer-derived data that could account for this variability. We developed an optimized protocol to predict an optimal burst-pause criterion (PC) for the extraction of PC-dependent microstructural parameters of ingestive behavior. These describe the microstructure of bursts, while PC-independent parameters describe the microstructure of sucks. Therefore, a PC is required to analyze separately two physiologically different parts of behavior. To accomplish this burst-pause criterion derivation (BPCD), a Gaussian Mixture Model (GMM) was built for estimation of two probability density functions (PDFs). These model the distribution of inter-suck intervals (ISIs) and inter-burst intervals (IBIs), respectively. The PC is defined at the intersection point of the two density functions. A Kaplan-Meier (KM) survival analysis was performed for post-hoc verification of the fit of the predicted optimal PC to the ISI distribution. In this protocol paper, we present a walkthrough of the data analysis of drinkometer-derived data for the measurement of microstructure of ingestive behavior based on previous results published by our group [1].•Standardization of the burst-pause criterion derivation for drinkometer measurements of ingestive behavior.•All codes are publicly available in a repository.•The method can be easily adapted to studies with larger sample size or more than one study stimulus.

Association between microstructure of ingestive behavior and body weight loss in patients one year after Roux-en-Y gastric bypass.

Roux-en-Y gastric bypass (RYGB) is one of the most effective procedures in the treatment of obesity. However, the predictive value of the microstructure of ingestion has not been widely investigated in this context. Here, we applied a recently developed drinkometer device to analyze the microstructure of ingestive behavior during a liquid meal in women and investigate whether it correlated with measures of weight loss after RYGB. Macro- and microstructural parameters of ingestive behavior of female patients (n = 24) one year after RYGB were measured in two different test sessions within a period of two weeks using the drinkometer. A Pearson correlation analysis was performed to compare the macro- and microstructural parameters of ingestive behavior with the percentage of total weight loss (%TWL), percentage excess BMI loss (%EBMIL), and body mass index (BMI) one year after RYGB, as well as age. A Bonferroni adjusted p < 0.003 was considered significant for the correlation analysis. For all other statistical tests, a p < 0.05 was considered significant. One year after surgery, a significant body weight loss was achieved in our study population (111.2 ± 15.6 kg vs 73.4 ± 11.7 kg; ***p < 0.001), with a mean%TWL of 33.8% (range: 20.4-48.6%). At the first test session,%TWL correlated with suck duration (r = 0.41, 0.05 > p > 0.003);%EBMIL correlated with both suck duration (r = 0.64, *p < 0.003) and inter-suck intervals (ISIs, r = -0.47, *p < 0.003), and, finally, BMI correlated with suck duration (r = 0.62, *p < 0.003) and ISIs (r = 0.48, *p < 0.003). However, at the second test session, no correlation was found between the body weight loss and the recorded ingestive parameters. Furthermore, no statistically significant difference was found in microstructural parameters of ingestive behavior between the two test sessions even though meal size decreased by 20% on the second visit (342.6.6 ± 167 kcal vs. 271.8 ± 142.8 kcal). A greater body weight loss of patients one year after surgery seems to be associated with longer suck duration and shorter ISIs, but only when the stimulus is tested for the first time by the study participants. This study contributes to the current knowledge about the ingestive behavior of bariatric patients one year after RYGB in terms of its association with the achieved weight loss. The use of the drinkometer device for the measurement of microstructure of ingestive behavior should be further expanded to different research questions and patient subgroups other than good responders. Its possible applications in clinical and behavioral research need to be included in the agenda of bariatric research.

Type, size, and position of metastatic lesions explain the deformation of the vertebrae under complex loading conditions.

BACKGROUND: Bone metastases may lead to spine instability and increase the risk of fracture. Scoring systems are available to assess critical metastases, but they lack specificity, and provide uncertain indications over a wide range, where most cases fall. The aim of this work was to use a novel biomechanical approach to evaluate the effect of lesion type, size, and location on the deformation of the metastatic vertebra. METHOD: Vertebrae with metastases were identified from 16 human spines from a donation programme. The size and position of the metastases, and the Spine Instability Neoplastic Score (SINS) were evaluated from clinical Quantitative Computed Tomography images. Thirty-five spine segments consisting of metastatic vertebrae and adjacent healthy controls were biomechanically tested in four different loading conditions. The strain distribution over the entire vertebral bodies was measured with Digital Image Correlation. Correlations between the features of the metastasis (type, size, position and SINS) and the deformation of the metastatic vertebrae were statistically explored. RESULTS: The metastatic type (lytic, blastic, mixed) characterizes the vertebral behaviour (Kruskal-Wallis, p = 0.04). In fact, the lytic metastases showed more critical deformation compared to the control vertebrae (average: 2-fold increase, with peaks of 14-fold increase). By contrast, the vertebrae with mixed or blastic metastases did not show a clear trend, with deformations similar or lower than the controls. Once the position of the lytic lesion with respect to the loading direction was taken into account, the size of the lesion was significantly correlated with the perturbation to the strain distribution (r2 = 0.72, p < 0.001). Conversely, the SINS poorly correlated with the mechanical evidence, and only in case of lytic lesions (r2 = 0.25, p < 0.0001). CONCLUSION: These results highlight the relevance of the size and location of the lytic lesion, which are marginally considered in the current clinical scoring systems, in driving the spinal biomechanical instability. The strong correlation with the biomechanical evidence indicates that these parameters are representative of the mechanical competence of the vertebra. The improved explanatory power compared to the SINS suggests including them in future guidelines for the clinical practice.

Microstructural changes in human ingestive behavior after Roux-en-Y gastric bypass during liquid meals.

BACKGROUNDRoux-en-Y gastric bypass (RYGB) decreases energy intake and is, therefore, an effective treatment of obesity. The behavioral bases of the decreased calorie intake remain to be elucidated. We applied the methodology of microstructural analysis of meal intake to establish the behavioral features of ingestion in an effort to discern the various controls of feeding as a function of RYGB.METHODSThe ingestive microstructure of a standardized liquid meal in a cohort of 11 RYGB patients, in 10 patients with obesity, and in 10 healthy-weight adults was prospectively assessed from baseline to 1 year with a custom-designed drinkometer. Statistics were performed on log-transformed ratios of change from baseline so that each participant served as their own control, and proportional increases and decreases were numerically symmetrical. Data-driven (3 seconds) and additional burst pause criteria (1 and 5 seconds) were used.RESULTSAt baseline, the mean meal size (909.2 versus 557.6 kCal), burst size (28.8 versus 17.6 mL), and meal duration (433 versus 381 seconds) differed between RYGB patients and healthy-weight controls, whereas suck volume (5.2 versus 4.6 mL) and number of bursts (19.7 versus 20.1) were comparable. At 1 year, the ingestive differences between the RYGB and healthy-weight groups disappeared due to significantly decreased burst size (P = 0.008) and meal duration (P = 0.034) after RYGB. The first-minute intake also decreased after RYGB (P = 0.022).CONCLUSIONRYGB induced dynamic changes in ingestive behavior over the first postoperative year. While the eating pattern of controls remained stable, RYGB patients reduced their meal size by decreasing burst size and meal duration, suggesting that increased postingestive sensibility may mediate postbariatric ingestive behavior.TRIAL REGISTRATIONNCT03747445; https://clinicaltrials.gov/ct2/show/NCT03747445.FUNDINGThis work was supported by the University of Zurich, the Swiss National Fund (32003B_182309), and the Olga Mayenfisch Foundation. Bálint File was supported by the Hungarian Brain Research Program Grant (grant no. 2017-1.2.1-NKP-2017-00002).

Abdominal leiomyosarcomatosis after surgery with external morcellation for occult smooth muscle tumors of uncertain malignant potential: A case report.

INTRODUCTION: Although rare, cases of abdominal sarcomatosis (AS) after laparotomy/laparoscopic interventions for uterine smooth muscle tumors of uncertain malignant potential (STUMP) have been reported. PRESENTATION OF CASE: We describe a rare case of diffuse abdominal sarcomatosis in a patient that some year earlier had undergone myomectomy for a suspected uterine myoma, which was histologically proven to be a STUMP. Once the patient was admitted at our Department, she underwent a diagnostic laparoscopy that confirmed a condition of peritoneal sarcomatosis disseminated through the entire abdomen, and then a laparotomic total hysterectomy, bilateral salpingo-oophorectomy, and total omentectomy, achieving a complete cytoreduction. Histological examination showed high-grade uterine leyomiosarcoma (LMS). Since there is no evidence of any clinical benefit of adjuvant treatment, given the risk of disease recurrence, we decided, with the patient's agreement, to conduct close follow-up with a Positron Emission Tomography (PET)/Computed Tomography (CT) scan every 3months and diagnostic laparoscopy every 6months, even in the absence of PET/CT positivity. After 2years PET/CT showed a relapse of LMS in the perigastric region and, therefore the patient underwent a diagnostic/operative laparoscopy with complete removal of the neoplastic recurrence. To date, the patient is disease-free. DISCUSSION AND CONCLUSION: STUMPs should be submitted to a frequent surveillance for their risk of recurrence, dissemination and transformation into LMS, even many years after the first diagnosis. A follow-up including surgical re-exploration with laparoscopy and PET/CT imaging may allow early detection and timely treatment of the relapse with good long-term outcome, as demonstrated by our case.