Development and Validation of the Scoring System of Appendicitis Severity 2.0.

Importance: When considering nonoperative treatment in a patient with acute appendicitis, it is crucial to accurately rule out complicated appendicitis. The Atema score, also referred to as the Scoring System of Appendicitis Severity (SAS), has been designed to differentiate between uncomplicated and complicated appendicitis but has not been prospectively externally validated. Objective: To externally validate the SAS and, in case of failure, to develop an improved SAS (2.0) for estimating the probability of complicated appendicitis. Design, Setting, and Participants: This prospective study included adult patients who underwent operations for suspected acute appendicitis at 11 hospitals in the Netherlands between January 2020 and August 2021. Main Outcomes and Measures: Appendicitis severity was predicted according to the SAS in 795 patients and its sensitivity and negative predictive value (NPV) for complicated appendicitis were calculated. Since the predefined targets of 95% for both were not met, the SAS 2.0 was developed using the same cohort. This clinical prediction model was developed with multivariable regression using clinical, biochemical, and imaging findings. The SAS 2.0 was externally validated in a temporal validation cohort consisting of 565 patients. Results: In total, 1360 patients were included, 463 of whom (34.5%) had complicated appendicitis. Validation of the SAS resulted in a sensitivity of 83.6% (95% CI, 78.8-87.6) and an NPV of 85.0% (95% CI, 80.6-88.8), meaning that the predefined targets were not achieved. Therefore, the SAS 2.0 was developed, internally validated (C statistic, 0.87; 95% CI, 0.84-0.89), and subsequently externally validated (C statistic, 0.86; 95% CI, 0.82-0.89). The SAS 2.0 was designed to calculate a patient's individual probability of having complicated appendicitis along with a 95% CI. Conclusions and Relevance: In this study, external validation of the SAS fell short in accurately distinguishing complicated from uncomplicated appendicitis. The newly developed and externally validated SAS 2.0 was able to assess an individual patient's probability of having complicated appendicitis with high accuracy in patients with acute appendicitis. Use of this patient-specific risk assessment tool can be helpful when considering and discussing nonoperative treatment of acute appendicitis with patients.

The burden of abdominal pain after bariatric surgery in terms of diagnostic testing: the OPERATE study.

BACKGROUND: Abdominal pain after bariatric surgery (BS) is frequently observed. Despite numerous diagnostic tests, the cause of abdominal pain is not always found. OBJECTIVES: 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. SETTING: A bariatric center in the Netherlands. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Efficacy and safety of revisional treatments for weight regain or insufficient weight loss after Roux-en-Y gastric bypass: A systematic review and meta-analysis.

Weight regain or inadequate weight loss following Roux-en-Y gastric bypass poses a significant clinical challenge. Our objective was to evaluate various revisional techniques for addressing weight regain and insufficient weight loss after Roux-en-Y gastric bypass through a systematic review and meta-analysis. We performed a literature search (in PubMed and Embase) on revisional interventions in collaboration with a medical information specialist. Measured outcomes included body mass index at intervention, total weight loss during follow-up, and complications. Random effects models were used to determine pooled effect size and corresponding 95% confidence intervals. Thirty-nine studies were included: four studies reported on argon plasma coagulation, four studies on transoral outlet reduction, nine studies on transoral outlet reduction + argon plasma coagulation, four studies on pouch/gastrojejunal anastomosis revision, five on laparoscopic gastric banding, two studies on laparoscopic gastric banding + pouch resizing, 10 on distalization-RYGB, and one on duodenal switch. All techniques resulted in short-term clinically relevant weight loss. Endoscopic procedures had a short follow-up and resulted in modest and temporary weight loss. Surgical revision techniques were successful for weight loss in longer term follow-up, at the expense of high complication rates.

Treatment Options for Weight Regain or Insufficient Weight Loss After Sleeve Gastrectomy: a Systematic Review and Meta-analysis.

Weight failure after sleeve gastrectomy (SG) is frequently observed. Consensus on the most effective treatment is lacking. The aim of this meta-analysis was to assess revisional strategies for weight regain (WR) or insufficient weight loss (IWL) following SG. The included studies reported on endoscopic gastroplasty (ESG), re-sleeve gastrectomy (re-SG), Roux-en-Y gastric bypass (RYGB), one-anastomosis gastric bypass (OAGB), single-anastomosis duodeno-ileal bypass (SADI), and duodenal switch (DS). All techniques resulted in clinically relevant weight loss. Although our data suggest that revisional OAGB was the most effective procedure, the lack of direct comparisons precludes strong conclusions. All procedures were feasible but differed regarding complication rates. Choice of procedure is depending on patient's characteristics and surgeons' expertise.

Increased risk for ascending aortic dilatation in patients with complex compared to simple aortic coarctation.

AIMS: Aortic coarctation (CoA) occurs as a "simple" isolated disorder, and in a more "complex" form, combined with associated congenital cardiac abnormalities. Long term outcome of all CoA patients may be complicated by dilatation of the thoracic aorta. The aim of this study was to quantify progressive aortic dilatation, and identify determinants for progressive aortic dilatation. METHODS AND RESULTS: Cardiovascular Magnetic Resonance Imaging (CMR) and echocardiographic data of 93 CoA patients were analyzed retrospectively on the progression, and determinants, of progressive thoracic aortic dilatation. Outcome of simple- versus complex CoA patients were compared. 93 CoA patients (mean age 39 ± 12 years, male 59%) were followed with CMR (follow-up 5.3 ± 1.8 years). Twenty-eight patients were classified as simple- and 68 as complex CoA. The mean progression rate of thoracic aortic dilatation was highest in the ascending aorta with 2.2 ± 2.0mm/5 years (range 0-7.2mm/5 years). History of VSD (ß=1.77, P=0.004) and an increased left ventricular mass index (ß=0.02, P=0.04) were associated with progressive ascending aortic dilatation. Complex CoA patients show an increased progression rate compared to simple CoA patients with 2.4mm/5 years versus 1.5mm/5 years respectively. (P=0.03). CONCLUSION: Adult post-coarctectomy patients show an increased mean progression rate of ascending aortic dilatation with 2.2mm/5 years. The progression rate of ascending aortic dilatation is increased in complex CoA patients, as compared to simple CoA patients. These findings point towards a more comprehensive genetic subset of patients with an increased risk for progressive ascending aortic dilatation.

Free Intra-Abdominal Air without Peritoneal Perforation after TEM: A Report of Two Cases.

Transanal endoscopic microsurgery (TEM) is a minimally invasive treatment modality for a variety of rectal lesions. Due to its minimally invasive nature, TEM has emerged as a safe method. Among most threatening complications are hemorrhage and peritoneal perforation. We report on two patients who demonstrated intra-abdominal free air on an erect chest X-ray after TEM procedure without other findings of a pneumoperitoneum. We hypothesize that due to the combination of elevated pressures in the retroperitoneal cavity and decreased integrity of the retroperitoneal barrier, insufflated CO(2) gas can diffuse into the intraperitoneal cavity. Conservative treatment should be considered in patients with free intra-abdominal air postoperatively. However, there should be no suspicion of peritoneal entry during the procedure and the patient should be in generally good condition without severe abdominal symptoms.

Hypoxia induces a hedgehog response mediated by HIF-1alpha.

Recently, it has become clear that the developmental hedgehog pathway is activated in ischaemic adult tissue where it aids in salvaging damaged tissue. The exact driving force for the initial hedgehog response is unclear and as most physiological and cellular processes are disturbed in ischaemic tissue, hedgehog-activating signals are hard to dissect. Here, we demonstrate that hypoxia per se is able to induce a rapid systemic hedgehog response in adult mice, as evident from expression of the pathway ligand, Sonic hedgehog, as well as the pathway activity marker Patched1 in various organs. Using in vitro models of hypoxia, we showed that the hedgehog response was transient and preceded by the accumulation of HIF-1alpha, which we hypothesized to communicate between hypoxia and hedgehog expression. Indeed, pharmacological inhibition, knockdown or genetic ablation of HIF-1alpha abolished hedgehog pathway activation. In conclusion, we have established that hypoxia is translated into a hedgehog response through HIF-1alpha and this mechanism is likely to be responsible for the hedgehog response observed in various ischaemia models.