Reduced Need for In-hospital Care After Sleeve Gastrectomy: a Single Center Observational Study.

SETTING: Private clinic, Stockholm, and nation-wide in-hospital care, Sweden. OBJECTIVES: The use of sleeve gastrectomy (SG) for treatment of morbid obesity has increased worldwide, but information about long-term outcome is still limited. Our objective was to evaluate the need for additional in-hospital care after SG for obesity (body mass index [BMI] > 30) in 862 patients, all operated at a single center. METHODS: Two national registries, the Inpatient Registry and the Death Registry, were used to collect long-term data on in-hospital care, grouped by the International Statistical Classification of Diseases and Related Health Problems (ICD-10) and mortality, respectively. RESULTS: In-hospital care for SG-operated females was decreased for four groups of obesity-related ICD-10 diagnoses: endocrine and metabolic diseases and circulatory, digestive, and genitourinary diseases, as well as injuries and poisoning (p < 0.001 for all). However, female SG patients still required in-hospital care above the national level for women of corresponding ages. CONCLUSIONS: Although a significant reduction in in-hospital care was observed, SG patients did not reach national levels.

International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is an emerging surgical approach, but 1 that has seen a surge in popularity because of its perceived technical simplicity, feasibility, and good outcomes. An international expert panel was convened in Coral Gables, Florida on March 25 and 26, 2011, with the purpose of providing best practice guidelines through consensus regarding the performance of LSG. The panel comprised 24 centers and represented 11 countries, spanning all major regions of the world and all 6 populated continents, with a collective experience of >12,000 cases. It was thought prudent to hold an expert consensus meeting of some of the surgeons across the globe who have performed the largest volume of cases to discuss and provide consensus on the indications, contraindications, and procedural aspects of LSG. The panel undertook this consensus effort to help the surgical community improve the efficacy, lower the complication rates, and move toward adoption of standardized techniques and measures. The meeting took place at on-site meeting facilities, Biltmore Hotel, Coral Gables, Florida. METHODS: Expert panelists were invited to participate according to their publications, knowledge and experience, and identification as surgeons who had performed >500 cases. The topics for consensus encompassed patient selection, contraindications, surgical technique, and the prevention and management of complications. The responses were calculated and defined as achieving consensus (≥70% agreement) or no consensus (<70% agreement). RESULTS: Full consensus was obtained for the essential aspects of the indications and contraindications, surgical technique, management, and prevention of complications. Consensus was achieved for 69 key questions. CONCLUSION: The present consensus report represents the best practice guidelines for the performance of LSG, with recommendations in the 3 aforementioned areas. This report and its findings support a first effort toward the standardization of techniques and adoption of working recommendations formulated according to expert experience.

Adding 11C-acetate to 18F-FDG at PET Examination Has an Incremental Value in the Diagnosis of Hepatocellular Carcinoma.

OBJECTIVE: The sensitivity of FDG at PET examination of Hepatocellular Carcinoma (HCC) is restricted. In a few studies, all done in Oriental patients, PET-examination with (11)C-acetate has shown a higher accuracy than with FDG. In the current study, the uptake of (11)C-acetate has been compared with the uptake of FDG in the primary HCC in a cohort of Occidental patients. MATERIAL AND METHODS: 44 patients underwent PET-examination with both tracers with a mean of 9 days between the examinations. 26 patients had a microscopical diagnosis and 18 were diagnosed with multimodal radiological methods. At least one relevant radiological examination was available for comparison. RESULTS: At visual evaluation, 13 of the HCC's were positive at PET-examination using FDG and 34 were positive using (11)C-acetate (p<0.001). Median tumor SUVmean of (11)C-acetate was 4.7 and of FDG was 1.9 (p<0.001). There was also a higher uptake of (11)C-acetate by the surrounding liver tissue than of FDG. Median liver SUVmean of [u]11[/u]C-acetate was 3.2 and of FDG it was 1.7 (p<0.001). This corresponded to a median tumour/liver tissue ratio for (11)C-acetate of 1.4 and for FDG of 1.0 (p<0.05). Previous reports of a negative correlation between the uptake of the tracers were weakly supported. In 4 large tumors some portions being hot using one of the tracers were cold using the other tracer and vice versa. CONCLUSION: Adding registration with (11)C-acetate to registration with FDG at PET-examination has an incremental value in the diagnosis of HCC. A higher tumor uptake of (11)C-acetate cannot be taken full advantage of because of a higher uptake also by the surrounding liver tissue. CONFLICT OF INTEREST: None declared.

Acceptance and commitment therapy for bariatric surgery patients, a pilot RCT.

SUMMARY: Bariatric surgery (BS) is rated as the best evidence based treatment for obesity with regard to weight loss and maintenance of weight loss evaluated to date. Although BS interventions are effective, 20-30% of BS patients start to regain weight within 24 months. Emotional eating is a behavior pattern which has been found to predict poor outcome. The aim of this study is to evaluate the effects of acceptance and commitment therapy (ACT) for patients who underwent BS, with regard to emotional eating, body dissatisfaction and quality of life. This study is a randomized controlled trial (n = 39) with two conditions (1) ACT including two face-to-face sessions and support via an Internet application and (2) treatment as usual (TAU) comprising the standard follow-up used by the BS team. Results show that participants in the ACT condition significantly improve on eating disordered behaviors, body dissatisfaction, quality of life and acceptance for weight related thoughts and feelings, as compared to those in the TAU group. This study shows that it is possible to improve effects of BS by specifically targeting emotional eating behavior.:

Initial results with sleeve gastrectomy for patients with class I obesity (BMI 30-35 kg/m2).

BACKGROUND: To investigate the role of sleeve gastrectomy for patients with class I obesity (body mass index 30-35 kg/m(2)) at a private hospital with self-paying patients. Randomized trials have shown a benefit for bariatric surgery compared with conservative treatment in patients with class I obesity. Sleeve gastrectomy is a relatively new method that has not been previously evaluated in this group of patients. METHODS: We performed a prospective, consecutive, nonrandomized trial of 79 patients. This is the initial report of the first 23 patients with > or =6 months of follow-up. RESULTS: The patients lost, on average, 100% of their excess body mass index in the first 6 months for an average body mass index of 25 kg/m(2). Most co-morbidities had resolved or improved. Their quality of life was regarded as excellent or very good by most patients. Some complications occurred in the early phase of our series, but after adjusting our operative technique and the routines for venous thromboembolic prophylaxis, the complications were reduced. CONCLUSION: Sleeve gastrectomy results in a promising early weight loss and quality of life improvement in patients with class I obesity. However, additional studies of larger numbers of patients with longer follow-up are necessary before any firm conclusions can be drawn.

Laparoscopic left lobe liver resection in a porcine model: a study of the efficacy and safety of different surgical techniques.

INTRODUCTION: Laparoscopic liver surgery is evolving and the best technique for dividing the liver parenchyma is currently under debate. The aim of this study was to study different techniques during a full laparoscopic lobe resection, and determine the efficacy and risks of bleeding and gas embolism. METHODS: Sixteen pigs were randomized to two groups: group US underwent an operation with Ultracision shears (AutoSonix) and ultrasonic dissector (CUSA) and group VS with a vessel sealing system (Ligasure) and ultrasonic dissector. A left lobe resection was performed. Transesophageal endoscopic echocardiography (TEE) was used to detect gas emboli in the right side of the heart and pulmonary artery. The operations and TEE were recorded for later assessment. RESULTS: Compared with group VS, group US exhibited significantly more intraoperative bleeding (p = 0.02), a trend towards a longer operation time (p = 0.08), and a trend towards more embolization for grade I emboli. In total, 10 of 15 animals had emboli during the operation. CONCLUSIONS: This study showed that a laparoscopic left lobe resection can be performed with a combination of AutoSonix and CUSA as well as with Ligasure and CUSA instrumentation. In our hands, less bleeding was incurred with Ligasure than with AutoSonix.

Does chemotherapy prior to liver resection increase the potential for cure in patients with metastatic colorectal cancer? A report from the European Colorectal Metastases Treatment Group.

Liver resection offers the only chance of cure for patients with advanced colorectal cancer (CRC). Typically, the 5-year survival rates following liver resection range from 25% to 40%. Unfortunately, approximately 85% of patients with stage IV CRC have liver disease which is considered unresectable at presentation. However, the rapid expansion in the use of improved combination therapy regimens has increased the percentage of patients eligible for potentially curative surgery. Despite this, the selection criteria for patients potentially suitable for resection are not well documented and patient management by multidisciplinary teams, although essential, is still evolving. The goal of the European Colorectal Metastases Treatment Group is to establish pan-European guidelines for the treatment of patients with CRC liver metastases that can be adopted more widely by established treatment centres and to develop more accurate staging systems and evaluation criteria.

Proficiency-based virtual reality training significantly reduces the error rate for residents during their first 10 laparoscopic cholecystectomies.

BACKGROUND: Virtual reality (VR) training has been shown previously to improve intraoperative performance during part of a laparoscopic cholecystectomy. The aim of this study was to assess the effect of proficiency-based VR training on the outcome of the first 10 entire cholecystectomies performed by novices. METHODS: Thirteen laparoscopically inexperienced residents were randomized to either (1) VR training until a predefined expert level of performance was reached, or (2) the control group. Videotapes of each resident's first 10 procedures were reviewed independently in a blinded fashion and scored for predefined errors. RESULTS: The VR-trained group consistently made significantly fewer errors (P = .0037). On the other hand, residents in the control group made, on average, 3 times as many errors and used 58% longer surgical time. CONCLUSIONS: The results of this study show that training on the VR simulator to a level of proficiency significantly improves intraoperative performance during a resident's first 10 laparoscopic cholecystectomies.

Is the learning curve for laparoscopic fundoplication determined by the teacher or the pupil?

BACKGROUND: For all surgical procedures, a surgeons' learning curve can be anticipated during which complication rates are increased. The aims of this study were to evaluate individual learning curves for a group of surgeons performing laparoscopic fundoplication and to evaluate if the Procedicus MIST-simulator (Mentice Inc., Göteborg, Sweden) accurately predicts surgical performance. METHODS: Twelve Nordic centers participated, each contributing with a "master" and a "pupil" surgeon. The pupils were tested in the simulator and thereafter performed their first 20 supervised operations. All procedures were videotaped and evaluated by 3 independent reviewers. RESULTS: A significant decrease in operative time (P <0.001) and a trend (P = 0.12) toward improved score were seen during the series. The master significantly affected the pupil's score (P =0.0137). The simulator-test showed no correlation with the operative score. CONCLUSIONS: Individual learning curves varied, and the teacher was shown to be the most important factor influencing the pupil's performance score. The correlation between assessed performance and patient outcome will be further investigated.