Prediction of anastomotic insufficiency based on the mucosal microbiome prior to colorectal surgery: a proof-of-principle study.

Anastomotic leakage (AL) is a potentially life-threatening complication following colorectal cancer (CRC) resection. In this study, we aimed to unravel longitudinal changes in microbial structure before, during, and after surgery and to determine if microbial alterations may be predictive for risk assessment between sufficient anastomotic healing (AS) and AL prior surgery. We analysed the microbiota of 134 colon mucosal biopsies with 16S rRNA V1-V2 gene sequencing. Samples were collected from three location sites before, during, and after surgery, and patients received antibiotics after the initial collection and during surgery. The microbial structure showed dynamic surgery-related changes at different time points. Overall bacterial diversity and the abundance of some genera such as Faecalibacterium or Alistipes decreased over time, while the genera Enterococcus and Escherichia_Shigella increased. The distribution of taxa between AS and AL revealed significant differences in the abundance of genera such as Prevotella, Faecalibacterium and Phocaeicola. In addition to Phocaeicola, Ruminococcus2 and Blautia showed significant differences in abundance between preoperative sample types. ROC analysis of the predictive value of these genera for AL revealed an AUC of 0.802 (p = 0.0013). In summary, microbial composition was associated with postoperative outcomes, and the abundance of certain genera may be predictive of postoperative complications.

Barrett`s Esophagus in Bariatric Surgery: Regression or Progression?

INTRODUCTION: Morbid obesity is well known as a risk factor for gastroesophageal reflux disease (GERD) and its related disorders such as Barrett's esophagus (BE). This study aimed to evaluate the development of BE in patients who underwent bariatric surgery. MATERIALS AND METHODS: Using a single-center prospectively established database of obese patients who underwent bariatric surgery from 01/2012 to 12/2019, we retrospectively compared the preoperative endoscopic findings of BE to those after 1-2 years and 3-5 years following bariatric surgery. The change of BE was detected endoscopically according to Prague classification and histologically according to the British guidelines of detecting columnar epithelium on the distal esophagus. RESULTS: Among 914 obese patients who underwent bariatric surgery and received a preoperative esophagogastroduodenoscopy (EGD), we found 119 patients (13%) with BE. A follow-up EGD was performed in 74 of the BE patients (62.2%). A total of 37 (50%) patients underwent a follow-up EGD after 1-2 years and 45 (60.8%) patients underwent it after 3-5 years. Among many clinical parameters, the surgical procedure was the only significant factor for the change of BE after bariatric surgery (p < 0.05). A regression of BE was found in 19 patients (n = 54, 35%) after laparoscopic Roux-en-Y- gastric bypass (LRYGB). Furthermore, a progression of BE was detected in six patients (n = 20, 30%) after laparoscopic sleeve gastrectomy (LSG). CONCLUSION: RYGB should be considered in obese patients with BE. Detecting BE prior to bariatric surgery may have an impact on decision-making regarding the suitable surgical bariatric procedure.

[Anastomotic techniques in minimally invasive bariatric surgery]. / Anastomosentechniken in der minimal-invasiven bariatrischen Chirurgie.

BACKGROUND: Recommendations for the use of specific anastomotic techniques are not available in laparoscopic bariatric surgery. Recommendation criteria should consider the rate of insufficiency, bleeding, tendency to stricture or ulceration as well as the impact on weight loss or dumping. OBJECTIVE: This article gives a review of the available evidence on the anastomotic techniques of typical surgical procedures in laparoscopic bariatric surgery. MATERIAL AND METHODS: The current literature was reviewed and is discussed regarding anastomotic techniques for Roux-en­Y gastric bypass (RYGB), one-anastomosis gastric bypass (OAGB), single anastomosis sleeve ileal (SASI) bypass and biliopancreatic diversion with duodenal switch (BPD-DS). RESULTS: Few comparative studies exist, except for the RYGB. In RYGB gastrojejunostomy, a complete manual suture was shown to be equivalent to a mechanical anastomosis. In addition, the linear staple suture showed slight advantages over the circular stapler in terms of wound infections and bleeding. The anastomosis technique of the OAGB and SASI can be performed entirely with a linear stapler or with suture closure of the anterior wall defect. There seems to be an advantage of manual anastomosis in BPD-DS. CONCLUSION: Due to the lack of evidence, no recommendations can be made. Only in RYGB was there an advantage of the linear stapler technique with hand closure of the stapler defect compared to the linear stapler. In principle, prospective, randomized studies should be strived for.

Effectiveness and Tolerability of a Two-Week Hypocaloric Protein-Rich Diet Prior to Obesity Surgery with Two Different Diet Interventions: a Prospective Randomized Trial.

PURPOSE: Preoperative very low-calorie diets (VLCDs) have been shown to reduce liver volume and improve bariatric surgery safety. Here, we compare two VLCD that differ in macronutrient composition. MATERIAL/METHODS: Ninety patients awaiting obesity surgery were included in a prospective, open-label, randomized mono-centre trial comparing the effects of 2-week preoperative VLCDs: BCM Diät™ (diet 1) versus Optifast™ (diet 2). RESULTS: Data from 33 patients in diet 1 and 36 in diet 2 could be analysed. There was no significant difference between the two diet intervention arms on outcome parameters. Overall, both VLCD strategies led to a mean weight reduction of 5.24 [4.72-5.76] kg (p < 0.001), mean excess weight loss was 8.2 [7.4-9.1] % (p < 0.001). BMI reduction was 1.81 [1.63-1.99] kg/m2 (p < 0.001). Over all patients, the liver volume was reduced by 397 [329-466] ml (p < 0.001), which corresponds to 14.6 [12.4; 16.8] %. Liver fat content was significantly reduced by 18.35 [8.98-27.71] %. Reduction of body weight correlates with liver volume loss. In addition, hip/waist circumferences, body fat and fat-free mass decreased significantly. We found an increase of ALAT/ASAT and a significant decrease of triglycerides, LDL-cholesterol and HbA1c. Parameters of inflammatory were significantly reduced upon VLCD. CONCLUSION: Independently of the macronutrient composition, VLCD leads to a significant decrease of body weight, reduction of liver volume and improved parameters of inflammation, glucose and lipid metabolism. Preoperative diets are widely used in conditioning; however, VLCD should be considered as option for patients with obesity undergoing other abdominal surgeries.

Hyperspectral Imaging (HSI)-A New Tool to Estimate the Perfusion of Upper Abdominal Organs during Pancreatoduodenectomy.

Hyperspectral imaging (HSI) in abdominal surgery is a new non-invasive tool for the assessment of the perfusion and oxygenation of various tissues and organs. Its benefit in pancreatic surgery is still unknown. The aim of this study was to evaluate the key impact of using HSI during pancreatoduodenectomy (PD). In total, 20 consecutive patients were included. HSI was recorded during surgery as part of a pilot study approved by the local Ethics Committee. Data were collected prospectively with the TIVITA® Tissue System. Intraoperative HS images were recorded before and after gastroduodenal artery (GDA) clamping. We detected four patients with celiac artery stenosis (CAS) caused by a median arcuate ligament (MAL). In two of these patients, a reduction in liver oxygenation (StO2) was discovered 15 and 30 min after GDA clamping. The MAL was divided in these patients. HSI showed an improvement of liver StO2 after MAL division (from 61% to 73%) in one of these two patients. There was no obvious decrease in liver StO2 in the other two patients with CAS. HSI, as a non-invasive procedure, could be helpful in evaluating liver and gastric perfusion during PD, which might assist surgeons in choosing the best surgical approach and in improving patients' outcomes.

[Cost-Effectiveness and Cost-Utility Analyses of Antireflux Medicine]. / Kosten-Effektivitäts- und Kosten-Nutzwert-Analysen der Antirefluxmedizin.

INTRODUCTION: Laparoscopic antireflux surgery and medical therapy with proton pump inhibitors are gold standards of gastroesophageal reflux treatment. On account of limited resources and increasing healthcare needs and costs, in this analysis, not only optimal medical results, but also superiority in health economics of these 2 methods are evaluated. METHODS: We performed an electronic literature survey in MEDLINE, PubMed, Cochrane Library, ISRCTN (International Standard Randomization Controlled Trial Number) as well as in the NHS Economic Evaluation Database, including studies published until 1/2017. Only studies considering the effect size of QALY (Quality-Adjusted Life Years) (with respect to different quality of life-scores) as primary outcome comparing laparoscopic fundoplication and medical therapy were included. Criteria of comparison were ICER (Incremental Cost-Effectiveness Ratio) and ICUR (Incremental Cost-Utility Ratio). Superiority of the respective treatment option for each publication was worked out. RESULTS: In total, 18 comparative studies were identified in the current literature with respect to above-mentioned search terms, qualifying for the defined inclusion criteria. Six studies were finally selected for analyses. Out of 6 publications, 3 showed superiority of laparoscopic fundoplication over long-term medical management based on current cost-effectiveness data. Limitations were related to different time intervals, levels of evidence of studies and underlying resources/costs of analyses, healthcare systems and applied quality of life instruments. CONCLUSION: Future prospective, randomized trials should examine this comparison in greater detail. Additionally, there is a large potential for further research in the health economics assessment of early diagnosis and prevention measures of reflux disease and Barrett's esophagus/carcinoma.