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Abstract Bacterial cell growth and division require the coordinated action of enzymes that synthesize and degrade cell wall polymers. Here, we identify enzymes that cleave the d-arabinan core of arabinogalactan, an unusual component of the cell wall of Mycobacterium tuberculosis and other mycobacteria. We screened 14 human gut-derived Bacteroidetes for arabinogalactan-degrading activities and identified four families of glycoside hydrolases with activity against the d-arabinan or d-galactan components of arabinogalactan. Using one of these isolates with exo-d-galactofuranosidase activity, we generated enriched d-arabinan and used it to identify a strain of Dysgonomonas gadei as a d-arabinan degrader. This enabled the discovery of endo- and exo-acting enzymes that cleave d-arabinan, including members of the DUF2961 family (GH172) and a family of glycoside hydrolases (DUF4185/GH183) that display endo-d-arabinofuranase activity and are conserved in mycobacteria and other microbes. Mycobacterial genomes encode two conserved endo-d-arabinanases with different preferences for the d-arabinan-containing cell wall components arabinogalactan and lipoarabinomannan, suggesting they are important for cell wall modification and/or degradation. The discovery of these enzymes will support future studies into the structure and function of the mycobacterial cell wall.

Background: Due to centralization and super-specialization in medicine, hospital mergers are increasingly common. Their effect on postoperative outcomes in highly specialized surgical departments is unclear. As quality metrics often worsen after major organizational changes, preservation of quality of care during an hospital merge is of the utmost importance. Objective: To evaluate the effect of a merger of two Dutch university hospitals on quality of surgical care, volume, and timeliness of care. Methods: The upper gastro-intestinal and hepato-biliary-pancreatic sections merged on the 27th of January 2020 and the 31th of May 2021 respectively. Outcomes of all adult surgical patients were compared six months before and six months after the merger. Short-term quality metrics, volume, and timeliness of care were assessed. Results: Overall, a cohort of 631 patients were included of whom 195 were upper gastro-intestinal (97 prior to the merger, 98 after the merger) and 436 (223 prior to the merger, 213 after) hepato-biliary-pancreatic patients. There were no differences in mortality, readmission, number and severity of complications, volume, and timeliness of care six months post-merger as compared to before merger. Conclusion: This study shows that a hospital merger of two university hospitals can be performed without jeopardizing patient safety and while benefitting from centralization of highly specialized care and enhancement of medical research. Key message: This study investigated the impact of a merger of two Dutch university hospitals on quality of care, timeliness of care, and volume. It showed no deterioration in the evaluated short-term quality metrics, volume or timeliness for upper GI and HPB surgery, suggesting that a hospital merger of two university hospitals can be performed safely, while benefitting from centralization of highly specialized care and enhancement of medical research.

The structure of the title compound, 2C18H19ClN4O·HCl or (CNO)2·HCl (C36H39Cl3N8O2), at 100 K has tetragonal (I4/m) symmetry. The dihedral angle between the benzene rings of the fused ring system of the CNO molecule is 40.08 (6)° and the equivalent angle between the seven-membered ring and its pendant N-oxide ring is 31.14 (7)°. The structure contains a very strong, symmetrical O—H...O hydrogen bond [O...O = 2.434 (2) Å] between two equivalent R3N+—O− moieties, which share a proton lying on a crystallographic twofold rotation axis. These units then form a (CNO)4·(HCl)2 ring by way of two equivalent N—H...Cl hydrogen bonds (Cl− site symmetry m). These rings are catenated into infinite chains propagating along the c-axis direction by way of shape complementarity and directional C—H...N and C—H...π interactions.

Introduction Diabetic foot ulcers (DFUs) are a major complication of diabetes and often associated with peripheral arterial occlusive disease. Current available evidence shows hyperbaric oxygen therapy (HBOT) can reduce the risk of major amputation, but clinicians remain sceptical about the (cost-)effectiveness and feasibility of HBOT for ischaemic DFUs in clinical practice. Therefore, vascular surgeons and HBOT physicians worldwide feel a strong need for a sufficiently powered clinical trial to determine whether and how many HBOT sessions may be a (cost-)effective adjunctive treatment to ischaemic DFUs.Methods An international, multicentre, multi-arm multi-stage design is chosen to conduct an efficient randomised clinical trial. Patients will be randomised to receive standard care (wound treatment and surgical interventions following international guidelines) with either 0, 20, 30 or at least 40 sessions of HBOT. These sessions will comprise 90–120 min of HBOT at a pressure of 2.2–2.5 atmospheres absolute according to international standards. Based on a planned interim analysis, the best performing study arm(s) will continue. Primary end point is major amputation (ie, above ankle) rate after 12 months. Secondary end points are amputation-free survival, wound healing, health-related quality of life and cost-effectiveness.Ethics and dissemination All patients enrolled in this trial will receive maximum vascular, endovascular or conservative treatment and local wound care according to best practice and (inter)national guidelines. HBOT therapy is added to the standard treatment and is regarded as a low-risk to moderate-risk therapy. The study is approved by the medical ethics committee of the Amsterdam University Medical Centers, location University of Amsterdam.Trial registration number 2020-000449-15, NL9152, NCT05804097.

A multi-suckling (MS) system for sows and piglets has been developed aiming to improve animal welfare. In this system, large variation in BW gain exists between piglets up to weaning at 9 weeks of age. We aimed to study the causes of variation in BW gain and DM intake of solid feed (DFI) (piglet + sow feed) of piglets during lactation in the MS system. A total of 15 sows and 60 focal piglets across three batches were studied. Individual intake of piglet and sow feed was measured by the dual marker method, and multiple variables were recorded. Multiple linear regression analysis with forward selection was conducted on BW gain and DFI after correcting for piglet sex and batch, using multiple explanatory variables including genetic background, birthweight (BiW), DM feed intake, behaviours and number of skin lesions. These factors jointly explained less than 45 % and 21 % of the variation in BW gain and DFI, respectively. In weeks 2–4, variation in BW gain was mainly explained by BiW (12.0 %) and play and nosing behaviours (7.6 %). In weeks 4–6 and 6–8, it was largely explained by DM intake of piglet feed with 15.1 % and 25.9 %, respectively. Individual variation in DFI in weeks 2–4 was explained by the presence at front and middle teats during suckling bouts (2.9 %), in weeks 4–6 by BiW (9.6 %), and in weeks 6–8 by the number of skin lesions (5.1 %). The unexplained variation in BW gain and DFI warrants further investigation.

Identifying patients that will respond to a particular therapy remains a key challenge in precision oncology. Here, in gastric cancer, the authors show that circulating tumour DNA can predict recurrence, provided that the signal from white blood cells is filtered out.

Accurate estimation of individual feed intake (FI) of pigs could help better understand the variation in performance between individual animals. We studied dual marker methods to estimate individual FI in pigs. This method is based on the measurement of the ratio between two indigestible markers in faeces. Twelve 6.5-week-old individually housed male pigs were assigned to one of three oral dosing treatments supplying 180 mg of ytterbium chloride (YbCl3)/day and 111 mg of dotriacontane (C32)/day as reference markers, either once (R1), three times (R3) or five times (R5) daily. Pigs were offered a diet containing 0.46 g/kg of chromium chloride (CrCl3) and 0.15 g/kg of hexatriacontane (C36) as in-feed markers. The experiment lasted for 10 days: days −5 to 0: adaptation; days 1–3: dosing of reference marker; days 2–4: total faecal collection. Spot faecal samples were taken on day 3 at 1200 h, 1700 h and on day 4 at 0700 h. Pigs were fed restrictedly three times daily, at 133.6 g/kg BW0.60. Individual measured FI was recorded daily and was compared to predicted FI using the ratio of the dual marker pairs (Yb:Cr and C32:C36), both in total faecal collection and spot samples. Due to unequal variance, R1 pigs were omitted from the statistical treatment comparison. When using total faecal collection samples, the absolute prediction error (APE) (predicted FI minus measured FI) in R3 and R5 pigs was numerically lower than in R1 pigs, regardless of the marker pair used. The APE measured by C32:C36 was numerically lower than measured by Yb:Cr at all frequencies, and significantly (P = 0.039) in R3 pigs (C32:C36: 0.15 ± 0.02 kg/day; Yb:Cr: 0.29 ± 0.04 kg/day). This was related to a larger difference in faecal recovery between Yb and Cr compared with C32 and C36. Daily total faecal collection revealed that for R3 pigs, starting faecal collections 2 days after the onset of provision of the reference marker improved the APE when compared with starting after 1 day. When using C32:C36 to predict feed intake, pooled, but not single spot samples gave similar APEs compared with total faecal collections. Therefore, we recommend dosing the reference marker three times per day for 2 days on days 1 and 2, combined with pooled spot faecal sampling collected on days 3 and 4. In this way, absolute prediction errors of 10%-15% of simultaneously measured intakes of multiple nutrient resources in a complex housing system are feasible using the dual marker technique.

Multi-suckling systems aim to improve animal welfare, but in these systems, a large variation is seen in piglet growth rate. Birthweight (BiW) plays an important role in explaining the variation in body weight (BW) gain of piglets. This study aims to investigate the relationships between BiW and piglet traits up to day 44 postpartum (p.p.). A total of 55 sows were used. The growth rate and mortality were assessed for all piglets. Feed and milk intake, behaviours, and skin lesions were assessed in four focal piglets per litter. Focal piglets were divided into four groups based on their BiW class (high BiW (HBiW) vs. low BiW (LBiW)) and growth rate class (fast vs. slow). Results showed that increased mortality was observed in piglets with a BiW below 1.1 kg. Birthweight was positively related with the number of sucklings (β = 2.8 no./kg of BiW per 7.5 h), corresponding to milk intake (β = 102 g/kg of BiW per day), and to a lesser extent, to the intake of sow feed (β = 44 g/kg of BiW per day) in week 6. Birthweight was positively related with the number of skin lesions (β = 4.3 no./kg of BiW) in week 4. We found no indications that fast-growing LBiW piglets differed from fast-growing HBiW piglets, however, fast-growing piglets of both HBiW and LBiW tended to eat more feed (485 ± 18 vs. 420 ± 17 g/day, p = 0.068), were present less often at teats of alien sows (1.1 ± 0.2 vs. 1.8 ± 0.3, p = 0.010), and had more skin lesions (9.0 ± 0.6 vs. 7.4 ± 0.4, p = 0.047), compared to slow growing piglets. Our study, thus, provides little insight into the traits that affect catchup growth in a multi-suckling environment but increases insight into the differences between fast-growing and slow-growing piglets, regardless of their birthweight class.

Abstract Background Postoperative pulmonary complications after major abdominal surgery are associated with adverse outcome. The diagnostic accuracy of chest X-rays (CXR) to detect pulmonary disorders is limited. Alternatively, lung ultrasound (LUS) is an established evidence-based point-of-care diagnostic modality which outperforms CXR in critical care. However, its feasibility and diagnostic ability for postoperative pulmonary complications following abdominal surgery are unknown. In this prospective observational feasibility study, we included consecutive patients undergoing major abdominal surgery with an intermediate or high risk developing postoperative pulmonary complications according to the Assess Respiratory risk In Surgical patients in CATalonia (ARISCAT) score. LUS was routinely performed on postoperative days 0–3 by a researcher blinded for CXR or other clinical findings. Then, reports were drawn up for LUS concerning feasibility and detection rates of postoperative pulmonary complications. CXRs were performed on demand according to daily clinical practice. Subsequently, we compared LUS and CXR findings. Results A total of 98 consecutive patients with an ARISCAT score of 41 (34–49) were included in the study. LUS was feasible in all patients. In 94 (95%) patients, LUS detected one or more postoperative pulmonary complications during the first four postoperative days. On day 0, LUS detected 31 out of 43 patients (72.1%) with one or more postoperative pulmonary complications, compared to 13 out of 36 patients (36.1%) with 1 or more postoperative pulmonary complications detected with CXR RR 2.0 (95 CI [1.24–3.20]) (p = 0.004). The number of discordant observations between both modalities was high for atelectasis 23 (43%) and pleural effusion 29 (54%), but not for pneumothorax, respiratory infection and pulmonary edema 8 (15%), 3 (5%), and 5 (9%), respectively. Conclusions This study shows that LUS is highly feasible and frequently detects postoperative pulmonary complications after major abdominal surgery. Discordant observations in atelectasis and pleural effusions for LUS and CXR can be explained by a superior diagnostic ability of LUS in detecting these conditions. The effects of LUS as primary imaging modality on patient outcome should be evaluated in future studies.

Abstract Background An important parameter for survival in patients with esophageal carcinoma is lymph node status. The distribution of lymph node metastases depends on tumor characteristics such as tumor location, histology, invasion depth, and on neoadjuvant treatment. The exact distribution is unknown. Neoadjuvant treatment and surgical strategy depends on the distribution pattern of nodal metastases but consensus on the extent of lymphadenectomy has not been reached. The aim of this study is to determine the distribution of lymph node metastases in patients with resectable esophageal or gastro-esophageal junction carcinoma in whom a transthoracic esophagectomy with a 2- or 3-field lymphadenectomy is performed. This can be the foundation for a uniform worldwide staging system and establishment of the optimal surgical strategy for esophageal cancer patients. Methods The TIGER study is an international observational cohort study with 50 participating centers. Patients with a resectable esophageal or gastro-esophageal junction carcinoma in whom a transthoracic esophagectomy with a 2- or 3-field lymphadenectomy is performed in participating centers will be included. All lymph node stations will be excised and separately individually analyzed by pathological examination. The aim is to include 5000 patients. The primary endpoint is the distribution of lymph node metastases in esophageal and esophago-gastric junction carcinoma specimens following transthoracic esophagectomy with at least 2-field lymphadenectomy in relation to tumor histology, tumor location, invasion depth, number of lymph nodes and lymph node metastases, pre-operative diagnostics, neo-adjuvant therapy and (disease free) survival. Discussion The TIGER study will provide a roadmap of the location of lymph node metastases in relation to tumor histology, tumor location, invasion depth, number of lymph nodes and lymph node metastases, pre-operative diagnostics, neo-adjuvant therapy and survival. Patient-tailored treatment can be developed based on these results, such as the optimal radiation field and extent of lymphadenectomy based on the primary tumor characteristics. Trial registration NCT03222895, date of registration: July 19th, 2017.

Abstract Background Infected necrosis complicates 10% of all acute pancreatitis episodes and is associated with 15–20% mortality. The current standard treatment for infected necrotizing pancreatitis is the step-up approach (catheter drainage, followed, if necessary, by minimally invasive necrosectomy). Catheter drainage is preferably postponed until the stage of walled-off necrosis, which usually takes 4 weeks. This delay stems from the time when open necrosectomy was the standard. It is unclear whether such delay is needed for catheter drainage or whether earlier intervention could actually be beneficial in the current step-up approach. The POINTER trial investigates if immediate catheter drainage in patients with infected necrotizing pancreatitis is superior to the current practice of postponed intervention. Methods POINTER is a randomized controlled multicenter superiority trial. All patients with necrotizing pancreatitis are screened for eligibility. In total, 104 adult patients with (suspected) infected necrotizing pancreatitis will be randomized to immediate (within 24 h) catheter drainage or current standard care involving postponed catheter drainage. Necrosectomy, if necessary, is preferably postponed until the stage of walled-off necrosis, in both treatment arms. The primary outcome is the Comprehensive Complication Index (CCI), which covers all complications between randomization and 6-month follow up. Secondary outcomes include mortality, complications, number of (repeat) interventions, hospital and intensive care unit (ICU) lengths of stay, quality-adjusted life years (QALYs) and direct and indirect costs. Standard follow-up is at 3 and 6 months after randomization. Discussion The POINTER trial investigates if immediate catheter drainage in infected necrotizing pancreatitis reduces the composite endpoint of complications, as compared with the current standard treatment strategy involving delay of intervention until the stage of walled-off necrosis. Trial registration ISRCTN, 33682933. Registered on 6 August 2015. Retrospectively registered.

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This study aimed to investigate the impact of decreased crude protein (CP) levels (by 2% units) or acidifying diets (by adding 10 g benzoic acid/kg diet in combination with replacing a part of CaCO3 by about 10 g Ca-formate/kg diet) on urine, feces and manure composition and ammonia emissions from growing and finishing pig houses. Yorkshire x F1(Landrace x Yorkshire) pigs (n = 576) with an initial body weight of 24.9 ± 3.4 kg were randomly allocated to four treatments of (i) a control diet with normal protein content and no acidifying components added; (ii) a diet with 2% units CP reduction; (iii) a diet with an acidifying effect on the manure; (iv) or a diet consisting of a combination of diet (ii) and (iii). Pigs were housed in four mechanically ventilated and temperature-controlled rooms. Results showed that decreasing the dietary CP levels by 2% units reduced the ammonia emission from the floor by 46% (p = 0.06) and from the pig house by 31% (p = 0.08). Decreased CP diets reduced the total N in feces and in manure and NH4-N in the manure, as well as the ammonia concentration at 1 cm and 10 cm above the manure surface (p < 0.05). However, acidifying diets failed to reduce ammonia emissions from the floor and the pig house (p > 0.05). Reducing dietary crude protein is, therefore, a solution to reducing ammonia emissions from pig houses.

Abstract Background Although radical surgery remains the cornerstone of cure in resectable gastric cancer, survival remains poor. Current evidence-based (neo)adjuvant strategies have shown to improve outcome, including perioperative chemotherapy, postoperative chemoradiotherapy and postoperative chemotherapy. However, these regimens suffer from poor patient compliance, particularly in the postoperative phase of treatment. The CRITICS-II trial aims to optimize preoperative treatment by comparing three treatment regimens: (1) chemotherapy, (2) chemotherapy followed by chemoradiotherapy and (3) chemoradiotherapy. Methods In this multicentre phase II non-comparative study, patients with clinical stage IB-IIIC (TNM 8th edition) resectable gastric adenocarcinoma are randomised between: (1) 4 cycles of docetaxel+oxaliplatin+capecitabine (DOC), (2) 2 cycles of DOC followed by chemoradiotherapy (45Gy in combination with weekly paclitaxel and carboplatin) or (3) chemoradiotherapy. Primary endpoint is event-free survival, 1 year after randomisation (events are local and/or regional recurrence or progression, distant recurrence, or death from any cause). Secondary endpoints include: toxicity, surgical outcomes, percentage radical (R0) resections, pathological tumour response, disease recurrence, overall survival, and health related quality of life. Exploratory endpoints include translational studies on predictive and prognostic biomarkers. Discussion The aim of this study is to select the most promising among three preoperative treatment arms in patients with resectable gastric adenocarcinoma. This treatment regimen will subsequently be compared with the standard therapy in a phase III trial. Trial registration clinicaltrials.gov NCT02931890; registered 13 October 2016. Date of first enrolment: 21 December 2017.

Abstract Background Initial staging of gastric cancer consists of computed tomography (CT) and gastroscopy. In locally advanced (cT3–4) gastric cancer, fluorodeoxyglucose positron emission tomography with CT (FDG-PET/CT or PET) and staging laparoscopy (SL) may have a role in staging, but evidence is scarce. The aim of this study is to evaluate the impact and cost-effectiveness of PET and SL in addition to initial staging in patients with locally advanced gastric cancer. Methods This prospective observational cohort study will include all patients with a surgically resectable, advanced gastric adenocarcinoma (cT3–4b, N0–3, M0), that are scheduled for treatment with curative intent after initial staging with gastroscopy and CT. The modalities to be investigated in this study is the addition of PET and SL. The primary outcome of this study is the proportion of patients in whom the PET or SL lead to a change in treatment strategy. Secondary outcome parameters are: diagnostic performance, morbidity and mortality, quality of life, and cost-effectiveness of these additional diagnostic modalities. The study recently started in August 2017 with a duration of 36 months. At least 239 patients need to be included in this study to demonstrate that the diagnostic modalities are break-even. Based on the annual number of gastrectomies in the participating centers, it is estimated that approximately 543 patients are included in this study. Discussion In this study, it is hypothesized that performing PET and SL for locally advanced gastric adenocarcinomas results in a change of treatment strategy in 27% of patients and an annual cost-reduction in the Netherlands of €916.438 in this patient group by reducing futile treatment. The results of this study may be applicable to all countries with comparable treatment algorithms and health care systems. Trial registration NCT03208621. This trial was registered prospectively on June 30, 2017.

The low feed intake and stress associated with abrupt weaning in conventional pig farming often result in poor post-weaning performance, which is related to impaired intestinal function. We investigated effects of housing conditions before weaning on performance around weaning of relatively light and heavy piglets. Before weaning, piglets were housed either with five sows and their litters in a multi-suckling (MS) system or in pens with individually housed sows in farrowing crates (FC). After weaning at 4 weeks of age (day 0), 16 groups of four piglets (two light and two heavy litter-mates) were housed under equal conditions in enriched pens. Mannitol (day −5 and day 5) and galactose (day 5) were orally administered as markers for gastrointestinal carbohydrate absorption, and after 20 min a blood sample was taken (sugar absorption test). In addition, BW, feed intake and faecal consistency as an indicator for diarrhoea, were assessed frequently during 2 weeks post-weaning. Pre-weaning housing, weight class and their interaction did not affect post-weaning faecal consistency scores. Weight gain over 2 weeks did not differ between pre-weaning housing treatments, but MS piglets gained more (0.67±0.12 kg) than FC piglets (0.39±0.16 kg) between days 2 and 5 post-weaning, P=0.02), particularly in the ‘heavy’ weight class (interaction, P=0.04), whereas feed intake was similar for both treatments. This indicates a better utilisation of the ingested feed of the MS piglets compared with the FC piglets in the early post-weaning period. Pre-weaning mannitol concentrations were unaffected by pre-weaning housing, weight class and their interaction. On day 5 post-weaning, however, MS piglets had a lower plasma concentration of mannitol (320 v. 592 nmol/ml, SEM=132, P=0.04) and galactose (91 v. 157 nmol/ml, SEM=20, P=0.04) than FC piglets, regardless of weight class. In conclusion, MS and FC piglets differed in aspects of post-weaning gastrointestinal carbohydrate absorption and in weight gain between days 2 and 5 after weaning, but pre-weaning housing did not affect feed intake, weight gain and measures of faecal consistency over the first 2 weeks after weaning.

Chemogenetics uses engineered proteins that are controlled by small molecule actuators, allowing in vivo functional studies of proteins with temporal and dose control, and include Designer Receptors Exclusively Activated by Designer Drugs (DREADDs). One major class of DREADDs are mutated muscarinic receptors that are unresponsive to acetylcholine, and are activated by administration of clozapine N-oxide (CNO). However, CNO is available in only small amounts and large scale studies involving animals and multiple cohorts are prohibitively expensive for many investigators. The precursor, clozapine, is also expensive when purchased from specialist suppliers. Here we report: • A simple extraction method of clozapine from commercial tablets; • A simple preparation of CNO from clozapine, and for the first time its single-crystal X-ray structure; and • That the CNO prepared by this method specifically activates the DREADD receptor hM3Dq in vivo.This method provides large quantities of CNO suitable for large-scale DREADD applications that is identical to commercial material. Method name: Preparation and application of clozapine N-oxide (CNO), Keywords: G-protein-coupled receptor (GPCR), Chemical-genetics, Chemical synthesis

Objective: To examine the influence of the LOGICA RCT (randomized controlled trial) upon the practice and outcomes of laparoscopic gastrectomy within the Netherlands. Background: Following RCTs the dissemination of complex interventions has been poorly studied. The LOGICA RCT included 10 Dutch centers and compared laparoscopic to open gastrectomy. Methods: Data were obtained from the Dutch Upper Gastrointestinal Cancer Audit (DUCA) on all gastrectomies performed in the Netherlands (2012-2021), and the LOGICA RCT from 2015 to 2018. Multilevel multivariable logistic regression analyses were performed to assess the effect of laparoscopic versus open gastrectomy upon clinical outcomes before, during, and after the LOGICA RCT. Results: Two hundred eleven patients from the LOGICA RCT (105 open vs 106 laparoscopic) and 4131 patients from the DUCA data set (1884 open vs 2247 laparoscopic) were included. In 2012, laparoscopic gastrectomy was performed in 6% of patients, increasing to 82% in 2021. No significant effect of laparoscopic gastrectomy on postoperative clinical outcomes was observed within the LOGICA RCT. Nationally within DUCA, a shift toward a beneficial effect of laparoscopic gastrectomy upon complications was observed, reaching a significant reduction in overall [adjusted odds ratio (aOR):0.62; 95% CI: 0.46-0.82], severe (aOR: 0.64; 95% CI: 0.46-0.90) and cardiac complications (aOR: 0.51; 95% CI: 0.30-0.89) after the LOGICA trial. Conclusions: The wider benefits of the LOGICA trial included the safe dissemination of laparoscopic gastrectomy across the Netherlands. The robust surgical quality assurance program in the design of the LOGICA RCT was crucial to facilitate the national dissemination of the technique following the trial and reducing potential patient harm during surgeons learning curve. [ABSTRACT FROM AUTHOR]

Abdominal pain after bariatric surgery (BS) is frequently observed. Despite numerous diagnostic tests, the cause of abdominal pain is not always found. To quantify type and number of diagnostic tests performed in patients with abdominal pain after BS and evaluate the burden and their yield in the diagnostic process. A bariatric center in the Netherlands. In this prospective study, we included patients who presented with abdominal pain after BS between December 1, 2020, and December 1, 2021. All diagnostic tests and reoperations performed during one episode of abdominal pain were scored using a standardized protocol. A total of 441 patients were included; 401 (90.9%) were female, median time after BS was 37.0 months (IQR, 11.0–66.0) and mean percentage total weight loss was 31.41 (SD, 10.53). In total, 715 diagnostic tests were performed, of which 355 were abdominal CT scans, 155 were ultrasounds, and 106 were gastroscopies. These tests yielded a possible explanation for the pain in 40.2% of CT scans, 45.3% of ultrasounds, and 34.7% of gastroscopies. The diagnoses of internal herniation, ileus, and nephrolithiasis generally required only 1 diagnostic test, whereas patients with anterior cutaneous nerve entrapment syndrome, irritable bowel syndrome, and constipation required several tests before diagnosis. Even after several negative tests, a diagnosis was still found in the subsequent test: 86.7% of patients with 5 or more tests had a definitive diagnoses. Reoperations were performed in 37.2% of patients. The diagnostic burden in patients with abdominal pain following BS is high. The most frequently performed diagnostic test is an abdominal CT scan, yielding the highest number of diagnoses in these patients. [ABSTRACT FROM AUTHOR]