Search

Purpose: Minimally invasive right hemicolectomy (MIRH) is the cornerstone of treatment for patients with right-sided colon cancer. This operation has evolved during recent decades, with many innovations and improvements but this has also resulted in high variability of uptake with subsequent substantial variableness. The aim of this ongoing study is to identify current surgical variations, determine the most optimal and standardised MIRH and nationally train and implement that technique to improve short-term clinical and long-term oncological outcomes., Methods: The Right study is a national multicentre prospective interventional sequential cohort study. Firstly, current local practice was evaluated. Subsequently, a standardised surgical technique for right-sided colon cancer was determined using the Delphi consensus method, and this procedure was trained during hands-on courses. The standardised MIRH will be implemented with proctoring (implementation cohort), after which the performance will be monitored (consolidation cohort). Patients who will receive a minimally invasive (extended) right hemicolectomy for cT1-3N0-2M0 colon cancer will be included. The primary outcome is patient safety reflected in the 90-day overall complication rate according to the Clavien-Dindo classification. Secondary outcomes will include intraoperative complications, 90-day mortality rate, number of resected tumour-positive lymph nodes, completeness of mesocolic excision, surgical quality score, locoregional and distant recurrence and 5-year overall survival. A total number of 1095 patients (365 per cohort) will be included., Discussion: The Right study is designed to safely implement the best surgical practice concerning patients with right-sided colon cancer aiming to standardise and improve the surgical quality of MIRH at a national level., Trial Registration: ClinicalTrials.gov: NCT04889456, May 2021., (© 2023. The Author(s).)

Objective: The aim of this study was to systematically review the literature for each surgical step of the minimally invasive right hemicolectomy (MIRH) for non-locally advanced colon cancer, to define the most optimal procedure with the highest level of evidence., Background: High variability exists in the way MIRH is performed between surgeons and hospitals, which could affect patients' postoperative and oncological outcomes., Methods: A systematic search using PubMed was performed to first identify systematic reviews and meta-analyses, and if there were none then landmark papers and consensus statements were systematically searched for each key step of MIRH. Systematic reviews were assessed using the AMSTAR-2 tool, and selection was based on highest quality followed by year of publication., Results: Low (less than 12 mmHg) intra-abdominal pressure (IAP) gives higher mean quality of recovery compared to standard IAP. Complete mesocolic excision (CME) is associated with lowest recurrence and highest 5-year overall survival rates, without worsening short-term outcomes. Routine D3 versus D2 lymphadenectomy showed higher LN yield, but more vascular injuries, and no difference in overall and disease-free survival. Intracorporeal anastomosis is associated with better intra- and postoperative outcomes. The Pfannenstiel incision gives the lowest chance of incisional hernias compared to all other extraction sites., Conclusion: According to the best available evidence, the most optimal MIRH for colon cancer without clinically involved D3 nodes entails at least low IAP, CME with D2 lymphadenectomy, an intracorporeal anastomosis and specimen extraction through a Pfannenstiel incision., Competing Interests: Disclosure: The authors declare that they have nothing to disclose., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Postbariatric anastomotic or staple line leakage (ASLL) is a dreaded complication with an incidence up to 1.6% and a leak-associated mortality of 5.0% to 16.7%. Feared low sensitivity of abdominal computed tomography (CT) for detecting ASLL is causing surgeons to omit CT and directly perform a diagnostic laparoscopy in patients with suspected ASLL., Objectives: To evaluate the diagnostic value of CT in case of suspected ASLL after bariatric procedures and to identify reliable CT characteristics predicting the presence of ASLL., Setting: A large teaching hospital and bariatric center of excellence., Methods: All CT scans performed for suspected ASLL after bariatric surgery in the period November 2007 until August 2016 were independently reevaluated by abdominal radiologists. The diagnostic value of CT by means of sensitivity, specificity, and positive and negative predictive value was analyzed comparing results of reevaluation to a standard of reference. Multivariable regression was performed to identify reliable CT characteristics for the presence of ASLL., Results: A total of 66 CT scans were performed because of suspected leakage. Reevaluation of CT scans revealed a sensitivity of 89% to 100%, a specificity of 69% to 78%, a positive predictive value of 39% to 50%, and a negative predictive value of 97% to 100% of CT for detecting ASLL after bariatric surgery. Multivariable logistic regression of ASLL characteristics on CT revealed 'air near the anastomosis/staple line' as the only independent predictor for the presence of ASLL., Conclusion: With a sensitivity of 89% to 100% and negative predictive value of 97% to 100%, a negative CT can rule out ASLL in patients with a lower suspicion of ASLL., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: To examine the influence of obstructive sleep apnea (OSA) on the quality of life (QoL) in bariatric surgery., Methods: All patients who underwent a laparoscopic Roux-and-Y gastric bypass (LRYGB), preoperative poly(somno)graphy and completed an Impact of Weight on QoL-Lite questionnaire before and after surgery were included., Results: A total of 276 patients were included. OSA was diagnosed in 150 (53.3%) patients. All subscale scores improved 15 months post-surgery (p < 0.01). Total score improved from 51.2 (SD 19.1) to 89.7 (SD 13.9). Lower postoperative scores were seen in OSA patients on subscales Public Distress (90.4 SD 18.8 versus 95.7 SD 10.2; p = 0.003) and Work (92.9 SD 15 versus 96.1 SD 9.7; p = 0.031). All postoperative subscale scores were negatively correlated with OSA severity (p < 0.01)., Conclusions: After LRYGB, QoL improved in both OSA and non-OSA patients. OSA patients, especially patients with severe OSA, have lower postoperative scores on subscales Public Distress and Work after LRYGB., (Copyright © 2017 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

Background: Patient satisfaction of scar quality and their influence on health-related quality of life (HRQoL) have never been investigated in morbidly obese patients., Objectives: Our objectives were (1) to assess scar quality 1 year post laparoscopic bariatric surgery by means of the Patient and Observer Scar Assessment Scale (POSAS), and (2) to examine the influence of patients' perception of scar quality on patients' HRQoL., Setting: A large Bariatric Center of Excellence in the Netherlands., Methods: This was a descriptive pilot study of patients who underwent primary laparoscopic bariatric surgery. One year after surgery, patients and 2 observers completed the POSAS. HRQoL was assessed by using the RAND-36. Agreement of POSAS scores between patients and observers was calculated with intraclass correlation coefficient. Correlations between POSAS scores and HRQoL scores were calculated with Spearman's rho., Results: A total of 50 patients were included. Patients scored their scar quality worse than observers (21 versus 15-16), particularly on visual parameters (4-5 versus 2-3). Patients and observers showed poor agreement on all POSAS items (intraclass correlation coefficient = .16-.32). No significant correlations were detected between POSAS and HRQoL scores., Conclusion: While patient scar quality satisfaction was relatively low after bariatric surgery, these outcomes were not correlated with HRQoL. Bariatric surgeons should be aware that patients could have a different view on scar quality compared with them. This realization is important to manage patient expectations regarding scar quality after bariatric surgery. Effective communication may improve patient satisfaction as an outcome., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The decision to undergo bariatric surgery is multifactorial and made both by patient and doctor. Information is of the utmost importance for this decision., Objective: To investigate the bariatric surgery patient's preferences regarding information provision in bariatric surgery., Setting: A teaching hospital, bariatric center of excellence in Amsterdam, the Netherlands., Methods: All patients who underwent a primary laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy between September 2013 and September 2014 were approached by mail to participate. A questionnaire was used to elicit patient preferences for the content and format of information. Sociodemographic characteristics, clinicopathologic factors, and psychologic factors were explored as predictors for specific preferences., Results: Of the 356 eligible patients, 112 (31.5%) participated. The mean age was 49.2 (±10.7) years, and 91 (81.3%) patients were female. Patients deemed the opportunity to ask questions (96.4%) the most important feature of the consult, followed by a realistic view on expectations-for example, results of the procedure (95.5%) and information concerning the consequences of surgery for daily life (89.1%). Information about the risk of complications on the order of 10% was desired by 93% of patients; 48% desired information about lower risks (.1%). Only 25 patients (22.3%) desired detailed information concerning their weight loss after surgery., Conclusion: Bariatric patients wished for information about the consequences of surgery on daily life, whereas the importance of information concerning complications decreased when their incidence lessened., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Obstructive sleep apnea (OSA) affects two third of morbidly obese individuals undergoing bariatric surgery. Perioperative usage of continuous positive airway pressure (CPAP) is advised for moderately and severe OSA to avoid respiratory failure and cardiac events. CPAP increases the air pressure in the upper airway, but also may elevate the air pressure in the esophagus and stomach. Concern exists that this predisposes to mechanical stress resulting in suture or staple line disruption (further referred to as suture line disruption)., Objectives: To evaluate whether perioperative CPAP usage is associated with an increased risk of suture line disruption after bariatric surgery., Setting: Obesity Center Amsterdam, OLVG-west, Amsterdam, the Netherlands., Methods: All patients who underwent bariatric surgery including a suture line were eligible for inclusion. Only patients with information regarding OSA severity as defined by the apnea-hypopnea-index and postoperative CPAP usage were included., Results: From November 2007 to August 2016, postoperative CPAP status was documented in 2135 patients: 497 (23.3%) used CPAP postoperatively, whereas 1638 (76.7%) used no CPAP. Mean body mass index was 44.1 kg/m 2 (standard deviation 6.6). Suture line disruption occurred in 25 patients (1.2%). The leakage rate was not associated with CPAP usage (8 [1.6%] in CPAP group versus 17 [1%] in non-CPAP group, P = .300). CPAP was no risk factor for suture line disruption in multivariable analysis as well., Conclusion: Postoperative CPAP does not appear to increase the risk of suture line disruption in bariatric surgery. CPAP is recommended in all patients with moderate or severe OSA who undergo bariatric surgery., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Around 20% of bariatric surgery patients develop a short- or long-term complication., Objective: Aim of this study was to develop a risk model predicting complications: the Bariatric Surgery Index for Complications (BASIC)., Setting: The Obesity Center Amsterdam, located in a large teaching hospital, in Amsterdam, The Netherlands., Methods: A prospective consecutive database including patients operated between November 2007 and February 2015 was used. For the BASIC, analysis according to the TRIPOD statement was performed to identify risk factors for complications. Class I included patients with zero to one risk factor, class II patients with two risk factors, and class III patients with three or more risk factors., Results: Of 1709 analyzed patients, mean age was 45 years (±SD 10.7), 1393 (81.5%) were female; mean body mass index was 44.5 kg/m 2 (6.8). Overall, 271 (15.9%) patients developed a complication of which 197 (72.5%) occurred within 30 days. Predictors in multivariable analysis were use of anticoagulants (odd's ratio (OR) 1.5); chronic obstructive pulmonary disease (OR 2.3); dyslipidemia (OR 1.4); gender (OR 1.4); psychiatric history (OR 1.3); and revisional surgery (OR 1.5). In class I, 13.5% (181 out of 1338) experienced complications, in class II 58 (21.6%) of the 269 patients and in class III 32 (31.4%) of the 102 patients, respectively. There was a significant difference (p < 0.001) in both overall and 30 day complications., Conclusion: The BASIC uses six preoperative variables to classify patients in a low-, intermediate-, or high-risk group for postoperative complications after bariatric surgery.

Background: There is an overall complication rate of 6.3%-10% after bariatric surgery. After ruling out anatomic/physical causes, there is a substantial group of patients who develop unexplained postsurgical abdominal pain., Objectives: To inventory the prevalence of unexplained abdominal pain after laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy and to determine predictive factors for unexplained abdominal pain., Setting: Obesity Center Amsterdam, Amsterdam, the Netherlands., Methods: A retrospective study in a prospective database was performed. Baseline characteristics and postoperative course were evaluated., Results: A total of 1788 patients underwent laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy between November 2007 and April 2015. The average follow-up consisted of 33.5 months, without loss to follow-up. Abdominal pain was presented in 387 patients (21.6%). The study population consisted of 337 women (87.1%) and 50 men (12.9%); the mean age was 43.3 years (standard deviation 10.1) and the median preoperative body mass index was 43.7 kg/m². An explanation for abdominal pain was found in 246 of 387 patients (63.6%), whereas no explanation was found in 133 patients (34.4%). Revisional surgery was a significant predictor for unexplained pain (odds ratio 1.7; confidence interval 1.0-2.8; P = 0.037)., Conclusion: A total of 133 patients (7.4%) experienced unexplained abdominal pain after laparoscopic bariatric surgery. Revisional surgery was found to be a significant predictive factor for this outcome. Present study results suggest that postoperative unexplained abdominal pain is a significant morbidity and should be part of the informed consent. More research is needed regarding further diagnosis and management and treatment., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The frequency of metabolic and bariatric surgery (MBS) is increasing worldwide, with over 500,000 cases performed every year. Obstructive sleep apnea (OSA) is present in 35%-94% of MBS patients. Nevertheless, consensus regarding the perioperative management of OSA in MBS patients is not established., Objectives: To provide consensus based guidelines utilizing current literature and, when in the absence of supporting clinical data, expert opinion by organizing a consensus meeting of experts from relevant specialties., Setting: The meeting was held in Amsterdam, the Netherlands., Methods: A panel of 15 international experts identified 75 questions covering preoperative screening, treatment, postoperative monitoring, anesthetic care and follow-up. Six researchers reviewed the literature systematically. During this meeting, the "Amsterdam Delphi Method" was utilized including controlled acquisition of feedback, aggregation of responses and iteration., Results: Recommendations or statements were provided for 58 questions. In the judgment of the experts, 17 questions provided no additional useful information and it was agreed to exclude them. With the exception of 3 recommendations (64%, 66%, and 66% respectively), consensus (>70%) was reached for 55 statements and recommendations. Several highlights: polysomnography is the gold standard for diagnosing OSA; continuous positive airway pressure is recommended for all patients with moderate and severe OSA; OSA patients should be continuously monitored with pulse oximetry in the early postoperative period; perioperative usage of sedatives and opioids should be minimized., Conclusion: This first international expert meeting provided 58 statements and recommendations for a clinical consensus guideline regarding the perioperative management of OSA patients undergoing MBS., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Obstructive sleep apnea (OSA), present in 60-70 % of bariatric surgery patients, is a potentially life-threatening condition when not detected and managed appropriately. The best available method to identify the severity of OSA is polysomnography. However, routine polysomnography measurements have not been accepted as standard modality in bariatric surgery. We report our experience with routine polysomnography in a cohort of patients undergoing bariatric surgery to determine the true prevalence of OSA with respect to the different severity levels as determined by the apnea-hypopnea index (AHI)., Methods: AHI data were retrospectively collected from all patients who underwent bariatric surgery from 2012 onward, when the performance of preoperative polysomnography became mandatory. Mild, moderate and severe OSA were defined as an AHI ≥5, ≥15 and ≥30/h, respectively. Prevalence and number needed to screen (NNS) were calculated for all OSA severity levels., Results: A total of 1358 patients were included. OSA was detected in 813 (59.9 %; NNS: 2) patients. Moreover, 405 (29.8 %; NNS: 4) patients were diagnosed with an AHI ≥15/h and 213 (15.7 %; NNS: 7) with severe OSA (AHI ≥30/h). Extreme AHI thresholds of ≥60 and ≥90/h were detected in 79 (5.8 %; NNS: 18) and 17 (1.3 %; NNS: 77) patients, respectively., Conclusion: One-third of the bariatric surgery patients have an AHI ≥15/h and would benefit from continuous positive airway pressure therapy. In order to increase perioperative safety and avoid the preventable risk of perioperative complications, we recommend mandatory P(S)G prior to bariatric surgery.

Background: Patients with severe obesity and obstructive sleep apnea (OSA) might decide to undergo bariatric surgery to improve this disease or, more specifically, to become independent of continuous positive airway pressure (CPAP) therapy, which is generally indicated in case of moderate and severe OSA. Knowledge of this topic is important for patient education on expectations of surgical outcome., Objectives: To evaluate the prevalence and phenotypes of patients with persistent moderate to severe OSA after bariatric surgery., Setting: Obesity Center Amsterdam, Amsterdam, the Netherlands., Methods: Patients who underwent a laparoscopic Roux-en-Y gastric bypass, had a preoperative apnea-hypopnea index (AHI)≥15/hr, and of whom a follow-up AHI/hr was available were included., Results: Out of 437 patients, 205 underwent pre- and postoperative polysomnography; 232 (53.1%) were lost to follow-up. Median AHI was 32.3/hr (range, 15-138) and mean body mass index was 46 (standard deviation 7.2) kg/m 2 . A postoperative AHI<15/hr was achieved in 152 patients (74.1%), whereas 53 (25.9%) still had moderate or severe disease 8.6 (standard deviation 4.8) months postoperatively. Predictive factors for persistent moderate to severe disease were age≥50 years, preoperative AHI≥30/hr, excess weight loss (EWL)<60%, and hypertension (area under the curve: .772)., Conclusion: After bariatric surgery, around three quarters of the moderate to severe OSA patients had no or mild OSA, whereas one quarter (25.9%) still had moderate to severe OSA. Age≥50 years, preoperative AHI≥30/hr, EWL<60%, and hypertension were predictive factors for this persistent postoperative AHI≥15/hr., (Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The Obesity Surgery Mortality Risk Score (OS-MRS) is a validated instrument for mortality risk prediction in patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures classifying patients into low risk (class A), intermediate risk (class B), and high risk (class C)., Objectives: The primary aim of this study was to evaluate the accuracy of the OS-MRS in predicting postoperative complications after LRYGB. Secondarily, the postoperative complication rate between primary and revisional LRYGB was systematically analyzed., Setting: The Obesity Center Amsterdam, located in a large teaching hospital, in Amsterdam, The Netherlands., Methods: The OS-MRS was applied to a consecutive database of patients who underwent LRYGB from November 2007 onwards. Postoperative complications were scored according to the Clavien-Dindo classification. Revisional LRYGB was separately analyzed., Results: LRYGB was performed in 1667 patients either as a primary (81.5%) or revisional (18.5%) procedure. The majority (n = 1371, 82.2%) were female, mean age 44.6 (standard deviation 14.4) years and mean body mass index 44.2 (6.5) kg/m 2 . Nine hundred and four (54.2%) were OS-MRS class A, 642 class B (38.5%), and 121 (7.3%) class C. Complications occurred in 143 (10.5%) and 44 (14.2%) patients after primary and revisional surgery, respectively. In both primary and revisional LRYGB, there was no association between complications and the OS-MRS classification. Subanalysis comparing primary with revisional LRYGB found a significant association between revisional surgery and the development of severe complications (Clavien-Dindo≥3) (P = .003) and mortality (P = .017)., Conclusion: The OS-MRS was not an accurate predictor for postoperative complications in patients who underwent primary or revisional LRYGB. As in other studies, revisional surgery is an independent risk factor for the development of severe complications., (Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Around 10 % of the bariatric surgery patients experience postoperative complications (<30 days). It could be hypothesized that complications influence postoperative weight loss, which is one of the most important endpoints of bariatric surgery. Therefore, this study inventoried the effect of complications on postoperative weight loss., Methods: A consecutive database including patients who were operated from November 2007 onwards was retrospectively reviewed. All short-term complications were classified according to the Clavien-Dindo classification. Weight loss was assessed at 6 and 12 months postoperatively., Results: A total of 1130 patients underwent either primary (n = 907, 80.3 %) or revisional (n = 233, 19.7 %) surgery till October 2013. Short-term complications occurred in 115 (10.2 %) patients, of whom 48 (41.7 %) had a severe (Clavien-Dindo ≥ 3) complication. One year post surgery, 184 patients (16.3 %) were lost to follow-up. Patients with a short-term complication had a higher percentage of excess weight loss (%EWL) at 6 months (58.6 (SD 16.6) versus 52.9 (SD 17.6), p = 0.003) and 1 year (71.9 (SD 22.3) versus 65.9 (SD 21.3), p = 0.017) of follow-up. Although a trend was seen toward higher BMI loss and total weight loss (TWL) after 6 months, no effect was seen 1 year postoperatively. In multivariable linear regression analysis, complications were not a significant predictor for 1-year %EWL., Conclusions: Although short-term complications alter 1-year %EWL, no effect was seen on BMI loss and TWL. In addition, complications were not a predictor in a multivariable linear regression model for 1-year %EWL. It can be concluded that short-term complications do not impair weight loss after Roux-en-Y gastric bypass.

Background: Important endpoints of bariatric surgery are weight loss and improvement of comorbidities, of which obstructive sleep apnea (OSA) is the highest accompanying comorbidity (70%). This study aimed to evaluate the influence of OSA on weight loss after bariatric surgery and to provide predictive factors for insufficient weight loss (defined as ≤50% excess weight loss (EWL)) at 1 year follow-up., Methods: All consecutive patients, who underwent primary laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy between 2006 and 2014 were retrospectively reviewed. Patients with data on preoperative apnea-hypopnea index (AHI) and pre- and postoperative body mass index (BMI) were included. After surgery, the percentage excess weight loss (%EWL) and BMI changes were compared between preoperatively diagnosed OSA-, subdivided in mild, moderate, and severe OSA, and non-OSA patients. Multivariable logistic regression analysis evaluated predictive factors for ≤50% EWL., Results: A total of 816 patients, 522 (64%) with and 294 (36%) without OSA, were included. After 1 year, OSA patients achieved less %EWL than non-OSA patients (65.5 SD 20.7 versus 70.3 SD 21.0; p < 0.01). The lowest %EWL was seen in severe OSA patients (61.7 SD 20.2). However, when adjusted for waist circumference, BMI, and age, no effect of OSA was seen on %EWL or changes in BMI. Although AHI, gender, age, BMI, type of surgery, and type II diabetes were predictive factors for ≤50% EWL (area under the curve 0.778), the AHI as variable was of little importance., Conclusions: The presence of OSA does not individually impair weight loss after bariatric surgery.

Background and Study Aim: Obstructive sleep apnea (OSA) occurs in 70-80% of bariatric surgery patients. Patients with severe OSA (apnea/hypopnea index (AHI) >30/h) are postoperatively admitted to an intensive care unit (ICU) for continuous monitoring, to prevent complications. The aim of this study was to assess the necessity of routine postoperative monitoring at an ICU of severe OSA patients after bariatric surgery, attempting to prevent and detect cardiorespiratory complications., Methods: Patients undergoing bariatric surgery from November 2010 to July 2013 were entered into a database. Minimal follow-up was 1 month. Poly(somno)graphy (P(S)G) was routinely performed. Patients with severe OSA were admitted to the ICU for the first postoperative night. Oxygen saturation was continuously measured. The database was reviewed regarding patient characteristics, CPAP use, re-intubations, desaturations (saturation <90% and severe <85%), and complications., Results: Severe OSA was present in 151 of the 794 patients, and all 151 were admitted to the ICU. Thirty who underwent revisional surgery were excluded. Forty-seven percent was male, median age was 51 years (27.0-68.0), and median body mass index (BMI) was 46.6 (kg/m(2)) (34.0-77.6). No deaths, re-intubations, or cardiopulmonary complications occurred. Eighty-two (67.8%) patients used continuous positive airway pressure (CPAP). Twenty-one (17.4%) patients experienced desaturations with a median of 2.0 (1-8). Six patients (5.0%) had one episode of severe desaturation., Conclusion: Patients with severe OSA and adequate CPAP use are at low risk of cardiopulmonary complications after (laparoscopic) bariatric surgery. Routine admission to an ICU might be superfluous. However, continuous digital oximetry remains essential.

Background: To evaluate the influence of obstructive sleep apnea (OSA) on postoperative cardiopulmonary complications in bariatric surgery patients., Methods: PubMed, Embase, and the Cochrane central register databases were searched. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was used for reviewing., Results: Thirteen studies were included (n = 98,935). OSA was documented in 36,368 (37%) patients. The cardiopulmonary complication rate varied between .0% and 25.8%; no clear association with OSA was found (rate .0% to 18%), possibly because of optimized situations such as continuous positive airway pressure. OSA appeared to be no independent risk factor for intensive care unit (ICU) admission, death, or longer length of stay in most studies., Conclusions: Overall, presented data showed no clear association of OSA with cardiopulmonary morbidity, ICU admissions, mortality, and length of stay after bariatric surgery. Although this questions the justification of admitting OSA patients to the ICU, future studies are required investigating the effect of monitoring strategies and optimizing treatments including continuous positive airway pressure use., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Laparoscopic bariatric surgery is increasingly being performed worldwide. It is estimated that trocar port hernias occur more often in obese patients due to their obesity and because the ports are not closed routinely. The aim of the present study was to analyze the incidence, risk factors, and management of patients with trocar port hernias after laparoscopic bariatric surgery., Methods: All patients who were operated between 2006 and 2013 were included. During the study period, the trocar ports were not closed routinely. All patients who had any symptomatic abdominal wall hernia during follow-up were included., Results: Overall, 1524 laparoscopic bariatric procedures were performed. There were 1249 female (82 %) and 275 male (18 %) patients. The mean age was 44 years, and median body mass index was 43 kg/m(2). Patients underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) (n = 859), laparoscopic adjustable gastric banding (LAGB) (n = 364), laparoscopic sleeve gastrectomy (LSG) (n = 68), revisional surgery (n = 226), and other procedures (n = 7). Three hundred and one patients (20 %) had one or more postoperative complications and the overall mortality was 0.3 % (four patients). There were 14 patients (0.9 %) with an abdominal wall hernia, of which eight (0.5 %) had a trocar port hernia, three (0.2 %) an incisional hernia from other previous surgery, and three (0.2 %) an umbilical hernia. Gender, age, BMI, smoking, type II diabetes, procedure type, complications, and weight loss were not associated with the occurrence of abdominal wall hernias., Conclusions: Trocar port hernias after bariatric surgery occur seldom if the trocar port is not routinely closed.

Background: Marginal ulceration at the gastrojejunostomy is a serious complication after laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) and occurs in 1%-16% of patients. Proton pump inhibitors (PPIs) might lower the occurrence of these ulcers., Objectives: The aim of the present study was to evaluate the effect of 6 months prophylactic usage of PPIs on the development of marginal ulceration and compare this with a historic patient control group., Setting: A single institution cohort at a bariatric center of excellence, The Sint Lucas Andreas Zienkenhuis, Amsterdam, Methods: A consecutive database of patients who underwent LRYGB from November 2007 to September 2012 in a single institution was retrospectively reviewed. From August 2011, patients received a standard dose of pantozol 40 mg once daily directly postoperatively for 6 months. No standard PPI prophylaxis was administered before August 2011, and the patients not using PPIs in this historic cohort served as the control group., Results: A total of 610 patients underwent LRYGB, of which 128 patients (21.0%) underwent revisional surgery. Postoperative PPIs were administered in the intervention group of 337 patients, compared with the historic control group consisting of 273 patients. Six patients (1.2%) who received postoperative PPIs versus 20 patients (7.3 %) in the historic control group developed marginal ulceration (P = .001). Patients using proton pump inhibitors developed fewer gastrointestinal complaints postoperatively (P< .001)., Conclusions: Routine usage of PPIs reduced the occurrence of marginal ulceration after LRYGB., (Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: One of the long-term complications of laparoscopic Roux-and-Y gastric bypass (LRYGB) is the development of marginal ulcers (MU). The aim of the present study is to assess the incidence, risk factors, symptomatology and management of patients with symptomatic MU after LRYGB surgery., Methods: A consecutive series of patients who underwent a LRYGB from 2006 until 2011 were evaluated in this study. Signs of abdominal pain, pyrosis, nausea or other symptoms of ulcer disease were analysed. Acute symptoms of (perforated) MU such as severe abdominal pain, vomiting, melena and haematemesis were also collected. Patient baseline characteristics, medication and intoxications were recorded. Statistical analysis was performed to identify risk factors associated with MU., Results: A total of 350 patients underwent a LRYGB. Minimal follow-up was 24 months. Twenty-three patients (6.6%) developed a symptomatic MU of which four (1.1%) presented with perforation. Smoking, the use of corticosteroids and non-steroidal anti-inflammatory drugs (NSAIDs) was significantly associated with the development of MU. Five out of 23 patients (22%) underwent surgery. All other patients could be treated conservatively., Conclusions: Marginal ulcers occurred in 6.6% of the patients after a LRYGB. Smoking, the use of corticosteroids and the use of NSAIDs were associated with an increased risk of MU. Most patients were managed conservatively.

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the gold standard in bariatric surgery. A long-term complication can be marginal ulceration (MU) at the gastrojejunostomy. The mechanism of development is unclear and symptoms vary. Management and prevention is a continuous subject of debate. The aim was to assess the incidence, mechanism, symptoms, and management of MU after LRYGB by means of a systematic review. Forty-one studies with a total of 16,987 patients were included, 787 (4.6%) developed MU. The incidence of MU varied between 0.6 and 25%. The position and size of the pouch, smoking, and nonsteroidal inflammatory drugs usage are associated with the formation of MU. In most cases, MU is adequately treated with proton pump inhibitors, sometimes reoperation is required. Laparoscopic approach is safe and effective.

The adjustable gastric band (L)AGB gained popularity as a weight loss procedure. However, long-term results are disappointing; many patients need revision to laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (LSG). The purpose of this study was to assess morbidity, mortality, and results of these two revisional procedures. Fifteen LRYGB studies with a total of 588 patients and eight LSG studies with 286 patients were included. The reason for revision was insufficient weight loss or weight regain in 62.2 and 63.9% in LRYGB and LSG patients. Short-term complications occurred in 8.5 and 15.7% and long-term complications in 8.9 and 2.5%. Reoperation was performed in 6.5 and 3.5%. Revision to LRYGB or LSG after (L)AGB is feasible and relatively safe. Complication rate is higher than in primary procedures.

Introduction: Delayed massive bleeding from an ischemic ulcer is a complication after Roux-en-Y gastric bypass (RYGB). Ischemic ulcers that present with massive bleeding are rare and challenging for the gastroenterologist as well as the bariatric surgeon., Case Description: This report reviews the case of a 63-year-old man who underwent an uncomplicated laparoscopic RYGB for morbid obesity and experienced two episodes of massive hemorrhage after the procedure, almost 1 year apart., Conclusion: To our knowledge, there are only a few such specific cases reported. Here, we describe the treatment and outcome for such a case and present a review of the literature.

While perianal fistulae and abscesses in infants usually occur as an isolated phenomenon, in older children Crohn's disease might be the underlying etiologic factor. We present four children of different ages with recurrent perianal fistulae and abscesses. Only after the diagnosis Crohn's disease was established and adequate treatment was initiated, the perianal lesions disappeared without further surgical treatment. Perianal fistulae and abscesses in older children should raise the suspicion of Crohn's disease, in which case therapy is indicated to induce and maintain remission of the underlying disease instead of surgical intervention.