The effects of glucagon like peptide-1 (GLP-1) on cardiac remodeling: exploring the role of medication and physiological modulation after metabolic surgery.

Obesity and associated comorbidities reach epidemic proportions nowadays. Several treatment strategies exist, but bariatric surgery has the only longstanding effects. Since a few years, there is increasing interest in the effects of gastro-intestinal hormones, in particular Glucagon-Like Peptide-1 (GLP-1) on the remission of Type 2 Diabetes (T2DM) and its effects on cardiac cardiovascular morbidity, cardiac remodeling, and mortality. In the past years several high quality multicenter randomized controlled trials were developed to assess the effects of GLP-1 receptor agonist therapy on cardiovascular morbidity and mortality. Most of the trials were designed and powered as non-inferiority trials to demonstrate cardiovascular safety. Most of these trials show a reduction in cardiovascular morbidity in patients with T2DM. Some follow-up studies indicate potential beneficial effects of GLP-1 receptor agonists on cardiovascular function in patients with heart failure, however the results are contradictory, and we need long-term studies to make firm conclusions about the pleiotropic properties of incretin-based therapies. However, it seems that GLP-1 receptor agonists have different effects than the increased GLP-1 production after bariatric surgery on cardiovascular remodeling. One of the hypotheses is that the blood concentrations of GLP-1 receptor agonists are three times higher compared to GLP-1 increase after bariatric and metabolic surgery. The purpose of this narrative review is to summarize the effects of GLP-1 on cardiovascular morbidity, mortality and remodeling due to medication but also due to bariatric and metabolic surgery. The second objective is to explain the possible differences in effects of GLP-1 agonists and bariatric and metabolic surgery.

Evolution of the body image perception of people with obesity on the pathway from bariatric surgery to body contouring lift surgery.

INTRODUCTION: Being obese has a significant impact on the quality of life limiting physical condition, life and professional activity, causing lack of acceptance from the environment, and a disturbing self-esteem. The main aim of this study is to identify which factors contribute to changes of self-esteem and satisfaction of female patients' body image perception as well as their correlation during the various stages of bariatric therapy. METHODS: This prospective observational study included 438 bariatric female patients and a control group that consisted of 127 female subjects with reference body weight and BMI. Parametric data were collected in all the subgroups; anthropometric measurements and subjective assessment of body image were checked depending on the stage of bariatric treatment. RESULTS: The body image and self-esteem of bariatric patients is changing according to the stage of bariatric treatment. At the beginning of the bariatric pathway, patients are characterized by a negative body image and low self-esteem. Women undergoing contour lifting surgery got the highest score, even higher than women from the control group. The lowest scores are in the group entering the therapy and 24 h after surgery. A more favorable body image and a higher self-esteem were presented by patients with higher education and a better financial situation. CONCLUSION: For female bariatric patients, the body image and self-esteem scores are higher with the consecutive stages of treatment. A more favorable body image and higher self-esteem is demonstrated with patients having a higher education and a better financial situation.

Endothelial function in obesity and effects of bariatric and metabolic surgery.

INTRODUCTION: Due to the lifestyle changes and the on-going urbanization waves there is obesity pandemic. The visceral fatty tissue of patients with obesity, in comparison with subcutaneous fat, has more gene expression related to inflammation, oxidative stress, cytokine production, and angiogenesis. The abovementioned leads to a decrease in arteriolar function and also an impaired endothelial vasodilatation and eventually endothelial dysfunction. AREAS COVERED: This review aims to provide an overview of the pathophysiology of obesity and endothelial dysfunction and the effects after bariatric and metabolic surgery and the consequences of surgery for the endothelial function. In this review, we focussed and searched for literature in Pubmed and The Cochrane library (from the earliest date of each database until February 2020) regarding endothelial function, obesity, and effects of bariatric and metabolic surgery. EXPERT OPINION: Within cardiovascular research, the endothelium and its function have a prominent role and it is the responsibility of the researchers to unravel the pathophysiological mechanisms and potential new targets for treatment of cardiovascular diseases.

Cardiac remodeling in obesity and after bariatric and metabolic surgery; is there a role for gastro-intestinal hormones?

Introduction: Obesity is associated with various diseases such as type 2 diabetes, hypertension, obstructive sleep apnea syndrome (OSAS), metabolic syndrome, and cardiovascular diseases. It affects several organ systems, including the pulmonary and cardiac systems. Furthermore, it induces pulmonary and cardiac changes that can result in right and/or left heart failure.Areas covered: In this review, authors provide an overview of obesity and cardiovascular remodeling, the individual actions of the gut hormones (like GLP-1 and PYY), the effects after bariatric/metabolic surgery and its influence on cardiac remodeling. In this review, we focussed and searched for literature in Pubmed and The Cochrane library (from the earliest date until April 2019), regarding cardiac function changes before and after bariatric surgery and literature regarding changes in gastrointestinal hormones.Expert opinion: Regarding the surgical treatment of obesity and metabolic diseases there is recognition of the importance of both weight loss (bariatric surgery) and improvement in metabolic milieu (metabolic surgery). A growing body of evidence further suggests that bariatric surgical procedures [like the Sleeve Gastrectomy (SG), Roux-en Y Gastric Bypass (RYGB), or One Anastomosis Gastric Bypass (OAGB)] have can improve outcomes of patients suffering from a number of cardiovascular diseases, including heart failure.

Obesity Surgery and Anesthesiology Risks: a Review of Key Concepts and Related Physiology.

The obesity epidemic is swelling to epic proportions. Obese patients often suffer from a combination of hypertension, dyslipidemia, and type 2 diabetes mellitus (T2DM), also known as the "metabolic syndrome." The metabolic syndrome is an independent predictor of cardiac dysfunction and cardiovascular disease and a risk factor for perioperative morbidity and mortality. In this paper, we discuss the perioperative risk factors and the need for advanced care of obese patients needing general anesthesia for (bariatric) surgical procedures based on physiological principles.

Applying Enhanced Recovery After Bariatric Surgery (ERABS) Protocol for Morbidly Obese Patients With End-Stage Renal Failure.

BACKGROUND: In 2015 our hospital implemented the ERABS protocol. From that moment also morbidly obese patients with end-stage renal disease (ESRD) were enrolled. The objective of this study was to evaluate the potential benefits and safety of the ERABS protocol for ESRD morbidly obese patients compared with patients who are morbidly obese patients undergoing bariatric surgery. METHODS: A retrospective review of a prospectively collected database was conducted for ESRD patients who underwent bariatric surgery according to the ERABS protocol. The primary endpoint was the length of hospital stay in days. Secondary endpoints were the number of re-admissions, re-operations, length of renal replacement therapy, and complications during admission and within 30 days after surgery. Propensity score matching was used to compare groups. RESULTS: From 2015 onward 1199 non-ESRD patients and 21 with ESRD were operated. Propensity score matching resulted in two groups of 19 patients. In terms of comorbidities, both groups presented typical components of metabolic syndrome. In the ESRD group, one patient had serious complications (rated as Clavien-Dindo IIIb and IVb) at the first postoperative day after OAGB. The overall complication rate was comparable and not significantly different compared with the non-ESRD group. CONCLUSION: Our study shows that ERAS in this population has overall minimal adverse events and lack of any ERAS-related complications.

A comprehensive study of serum odd- and branched-chain fatty acids in patients with excess weight.

OBJECTIVE: While small amounts of odd-chain fatty acids (OCFAs) and branched-chain fatty acids (BCFAs) were known to be present in mammals, it was quite recently that they were shown to play an important role in human health. However, still little is known on OCFA and BCFA profiles in subjects who have obesity. The aim of this study was to verify whether obesity is associated with changes in serum OCFA and BCFA profiles. METHODS: Serum content of fatty acids was determined by gas chromatography-mass spectroscopy in 23 patients with excess weight and 21 nonobese controls. RESULTS: Six OCFAs and six BCFAs (three iso-BCFAs and three anteiso-BCFAs) were found in sera from the examined subjects. Patients with excess weight presented with significantly lower serum iso-BCFA levels than the controls. Total serum content of iso-BCFAs correlated inversely with serum insulin, triglycerides, and 18:1/18:0 desaturation index. Both OCFA and iso-BCFA levels correlated inversely with C-reactive protein concentration. CONCLUSIONS: Lower iso-BCFA content in patients with excess weight may be involved in elevation of serum concentration of triglycerides and inflammation. Decreased contents of iso-BCFAs in subjects with have obesity, and established anti-inflammatory, antidiabetic, and anticancer properties of these fatty acids, point to potential beneficial effects of an iso-BCFA-rich diet.

Increased Serum Level of Cyclopropaneoctanoic Acid 2-Hexyl in Patients with Hypertriglyceridemia-Related Disorders.

We recently reported the presence of various cyclopropane fatty acids-among them, cyclopropaneoctanoic acid 2-hexyl-in the adipose tissue of obese women. The aim of this study was to verify whether the presence of cyclopropaneoctanoic acid 2-hexyl in human serum was associated with obesity or chronic kidney disease (both being related to dyslipidemia), and to find potential associations between the serum level of this compound and specific markers of the these conditions. The serum concentration of cyclopropaneoctanoic acid 2-hexyl was determined by gas chromatography-mass spectrometry (GC-MS) in non-obese controls, obese patients, obese patients after a 3-month low-calorie diet, and individuals with chronic kidney disease. Obese patients and those with chronic kidney disease presented with higher serum levels of cyclopropaneoctanoic acid 2-hexyl than controls. Switching obese individuals to a low-calorie (low-lipid) diet resulted in a reduction in this fatty acid concentration to the level observed in controls. Cyclopropaneoctanoic acid 2-hexyl was also found in foods derived from animal fat. Serum concentrations of triacylglycerols in the analyzed groups followed a pattern similar to that for serum cyclopropaneoctanoic acid 2-hexyl, and these variables were positively correlated with each other among the studied groups. Patients with hypertriglyceridemia-related conditions presented with elevated serum levels of cyclopropaneoctanoic acid 2-hexyl. Our findings suggest that its high serum level is related to high serum triacylglycerol concentrations rather than to body mass or BMI.

Implementing enhanced recovery after bariatric surgery protocol: a retrospective study.

While the demand for bariatric surgery is increasing, hospital capacity remains limited. The ERABS (Enhanced Recovery After Bariatric Surgery) protocol has been implemented in a number of bariatric centers. We retrospectively compared the operating room logistics and postoperative complications between pre-ERABS and ERABS periods in an academic hospital. The primary endpoint was the length of stay in hospital. The secondary endpoints were turnover times-the time required for preparing the operating room for the next case, induction time (from induction of anesthesia until a patient is ready for surgery), surgical time (duration of surgery), procedure time (duration of stay in the operating room), and the incidence of re-admissions, re-operations and complications during admission and within 30 days after surgery. Of a total of 374 patients, 228 and 146 received surgery following the pre-ERABS and ERABS protocols, respectively. The length of hospital stay was significantly shortened from 3.7 (95 % confidence interval [CI] 3.1-4.7) days to 2.1 (95 % CI 1.6-2.6) days (P < 0.001). Procedure (surgical) times were shortened by 15 (7) min and 12 (5) min for gastric bypass and gastric sleeve surgery, respectively (P < 0.001 for both), by introducing the ERABS protocol. Induction times were reduced from 15.2 (95 % CI 14.3-16.1) min to 12.5 (95 % CI 11.7-13.3) min (P < 0.001).Turnover times were shortened significantly from 38 (95 % CI 44-32) min to 11 (95 % CI 8-14) min. The incidence of re-operations, re-admissions and complications did not change.

A prospective evaluation of the influence of three bariatric procedures on insulin resistance improvement. Should the extent of undiluted bile transit be considered a key postoperative factor altering glucose metabolism?

INTRODUCTION: Insulin resistance (IR), the essential step in development of type 2 diabetes mellitus (T2DM), resolves quickly after bariatric surgery, but the effectiveness depends on the type of the procedure. Although the long-term influence on IR improvement is well documented, the mechanisms of the ultra-fast response after restrictive and bypass procedures require explanation. AIM: To determine IR evolution from the initial preparative period to 6 months after the operation, exposing the rapid postoperative response while comparing the 3 bariatric methods, with the belief that the metabolic effect may be correlated with anatomical combinations. MATERIAL AND METHODS: From January to December, 2013, a cohort of severely obese, insulin resistant individuals recruited to the prospective study underwent laparoscopic sleeve gastrectomy (SG-30), Roux-en-Y gastric bypass (RYGB-30) and one-anastomosis gastric bypass (OAGB-30). Main laboratory parameters of glucose metabolism were evaluated in fasting patients preoperatively, 4 days and 1, 3 and 6 months after surgery. RESULTS: Within the whole observation period the most significant improvement in homeostasis model assessment for IR (HOMA-IR) was observed in the first 4 days after each operation. The decrease of HOMA-IR was higher (p < 0.0001) in gastric bypass groups than in patients after SG (-41%). The difference between bypass groups favors OAGB over RYGB (63 vs. -56%, p = 0.0489). CONCLUSIONS: Among all bariatric management factors, operation type is the most important in IR improvement. The significant difference in response after SG vs. RYGB and OAGB supports the concept of metabolic competence of duodeno-jejunal exclusion. Altered bile flow after duodeno-jejunal exclusion may be responsible for enhanced glucose metabolism improvement.

Fasting and postprandial acyl and desacyl ghrelin levels in obese and non-obese subjects.

INTRODUCTION: The potentially differential roles of both forms of ghrelin in obesity are undefined, and little is known about desacyl ghrelin's (DAG) regulation by meals. We aimed to assess changes in acyl ghrelin (AG) and DAG in response to mixed-meal consumption in obese and non-obese subjects. MATERIAL AND METHODS: Venous blood for plasma glucose, AG and DAG assays were collected in both groups after an overnight fast and two hours after the consumption of a standard 300 kcal-mixed meal (Nutridrink, Nutricia). RESULTS: Mean fasting values of both AG and DAG were significantly lower in the obese individuals. On the other hand, among non-obese controls, the mean postprandial DAG levels did not change and AG levels decreased, whereas in obese individuals the mean DAG levels after a mixed-meal diminished and AG levels were unchanged. CONCLUSIONS: It is necessary to distinguish between the desacylated and acylated forms of ghrelin, as we have shown differential postprandial AG and DAG responses in obese and non-obese individuals. Whether targeting changed proportions between AG and DAG could be a successful strategy in obesity treatment remains a question for future studies.

The relationship between specific Fatty acids of serum lipids and serum high sensitivity C- reactive protein levels in morbidly obese women.

BACKGROUND/AIMS: The fatty acid profile in plasma lipids contributes to the increase of plasma high sensitivity C-reactive protein (hsCRP), a marker of inflammation and predictor of cardiovascular risk. The aim of this study was to examine the relationship between specific fatty acids (FA) of serum lipids and serum hsCRP in morbidly obese woman. METHODS: The study included 16 morbidly obese (mean BMI= 43 ± 2.2 kg/m(2)) non-diabetic woman awaiting bariatric surgery. FA extracted from serum lipids were methylated and analyzed on GC-MS. Commercially available ELISA kits were used to determine the serum inflammatory markers. RESULTS: We demonstrated that total saturated FA (SFA) and total monounsaturated FA (MUFA) of serum lipids were positively correlated with serum hsCRP, whereas both n-3 and n-6 total polyunsaturated FA (PUFA) were negatively correlated with serum hsCRP. Serum interleukin-6 correlated positively with some SFA and MUFA, whereas negatively with some of PUFA. Positive correlation between serum hsCRP and specific SFA and MUFA or negative correlation with PUFA decreased with the increased FA chain length. The number and localization of double bonds also had impact on these correlations. CONCLUSION: Our findings suggest that individual serum lipid FA levels, depending on the length of FA chain, number and the localization of double bonds are distinctly associated with hsCRP in morbidly obese subjects.

STOP-Bang and the effect on patient outcome and length of hospital stay when patients are not using continuous positive airway pressure.

BACKGROUND: In patients undergoing surgical interventions under general anesthesia, obstructive sleep apnea syndrome (OSA) can cause serious perioperative cardiovascular or respiratory complications leading to fatal consequences, even sudden death. In this study we test the hypothesis that morbidly obese patients diagnosed by a polysomnography test and using continuous positive airway pressure (CPAP) therapy have fewer and less severe perioperative complications and a shorter hospital stay than patients who have a medical history that meets at least three STOP-Bang criteria and are not using CPAP therapy. METHODS: Postoperative hospital stay and pulmonary complications were analyzed in three groups of morbidly obese patients undergoing bariatric surgery (Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy) between January 2009 and November 2013 (n = 693). Group A comprised 99 patients who were preoperatively diagnosed with OSA based on polysomnography results. These patients used CPAP therapy before and after surgery. Group B consisted of 182 patients who met at least three STOP-Bang criteria but who were not diagnosed with OSA based on polysomnography results. These patients did not use CPAP. Group C, the reference group, comprised 412 patients who scored one to two items on the STOP-Bang. RESULTS: During the perioperative period, Group B patients had a significantly (p < 0.001) higher cumulative rate of pulmonary complications, worse oxygen saturation, respiratory rates, and increased length of stay in hospital. There was also two cases of sudden death in this group. CONCLUSION: Based on these results, we conclude that patients meeting at least three STOP-BANG criteria have higher postoperative complications and an increased length of hospital stay than patients using CPAP.

Does the length of the biliary limb influence medium-term laboratory remission of type 2 diabetes mellitus after Roux-en-Y gastric bypass in morbidly obese patients?

INTRODUCTION: The Roux-en-Y gastric bypass (RYGB) is an effective treatment of morbid obesity leading to type 2 diabetes mellitus (T2DM) resolution. However, evidence demonstrates that standard limb lengths can have a limited impact on long-term weight loss and durable T2DM remission. AIM: The authors evaluated the impact of biliary limb (BL) length on the T2DM laboratory markers in 2-year follow-up. MATERIAL AND METHODS: The data of 93 obese patients with T2DM who underwent RYGB between 2008 and 2010 were collected from prospectively designed database. The length of BL was standard in one group of 51 patients (S-BL: 50-75 cm) and longer in another group of 42 patients (L-BL: 100-150 cm). The laboratory parameters defining T2DM remission - fasting plasma glucose (FPG) and glycosylated hemoglobin (HbA1c) - were measured 3, 6, 12 and 24 months after surgery. RESULTS: The average level of FPG and HbA1c remained non-diabetic 24 months after the RYGB in both groups. A statistical difference was not observed in direct FPG, HbA1c, ΔFPG and ΔHbA1c comparisons at any follow-up point. However, a significantly higher proportion of patients in L-BL than in S-BL reached the laboratory remission criteria without anti-diabetic medicaments. Additional analysis revealed a strong correlation between the measured T2DM parameters and length of the common limb (CL) in both groups. CONCLUSIONS: A longer BL can intensify the anti-diabetic effect of RYGB. The length of CL rather than BL influences the medium-term T2DM remission. Long-term observation is needed to fully assess whether introduced technical aspects of RYGB provide a durable effect of T2DM resolution.

Dynamics of type 2 diabetes mellitus laboratory remission after Roux-en-Y gastric bypass in patients with body mass index lower than 35 kg/m(2) and higher than 35 kg/m(2) in a 3-year observation period.

INTRODUCTION: Bariatric surgery as treatment of type 2 diabetes mellitus (T2DM) in morbidly obese patients is becoming common. Although a large number of studies demonstrating high efficacy of bariatric methods in diabetics with body mass index (BMI) < 35 kg/m(2) have been published, this promising solution is still not accepted enough even in the era of a diabetes offensive. AIM: To analyze the dynamics of T2DM remission in patients with BMI < 35 kg/m(2) and > 35 kg/m(2) after Roux-en-Y gastric bypass (RYGB). MATERIAL AND METHODS: Data of 30 patients with BMI < 35 kg/m(2) and 82 with BMI > 35 kg/m(2) who underwent RYGB between 2007 and 2010 were collected from a prospectively designed database. The laboratory resolution of T2DM was determined by fasting plasma glucose (FPG ≤ 100 mg/dl) and glycosylated hemoglobin (HbA1c ≤ 6%). RESULTS: The T2DM regression was observed in 80% of the patients with BMI < 35 kg/m(2) and 83% in a group with BMI > 35 kg/m(2) 1 year after RYGB and about 80% 2 and 3 years after the operation in both groups. Normalization of average HbA1c and FPG was observed in the BMI > 35 kg/m(2) group after 3 months, while in the BMI < 35 kg/m(2) group it was reached 6 months postoperatively. Changes in main markers of T2DM were parallel with the BMI decrease 3-12 months after RYGB, but early resolution in some patients was observed independently of weight loss. CONCLUSIONS: The mid-term observation of patients after RYGB revealed the laboratory remission of T2DM. Ultimate evaluation of T2DM markers 3 years after surgery demonstrates high effectiveness of RYGB in managing T2DM in both groups.

Completion thyroidectomy of well-differentiated thyroid cancer - a prospective, randomised study.

INTRODUCTION: Postoperatively diagnosed papillary or follicular thyroid cancer in subtotally thyroidectomised patients requires a completion thyroidectomy. Re-operation with a gamma probe can be particularly useful in these patients. The aim of this study was to evaluate the benefits of using an intraoperative hand-held gamma detector during completion thyroidectomy in patients with well-differentiated thyroid cancer (WTC). MATERIAL AND METHODS: 75 patients with WTC qualified for total re-thyroidectomy. In 43 patients, Group I (Nav), a hand-held gamma probe (Navigator GPS) was used intraoperatively. 32 patients were re-operated without the gamma probe (Group II). In Group I, thyroid remnants were removed based on counted gamma signals. To estimate the radicality of reoperation in both groups, thyroglobulin (Tg) levels were determined and total body scanning (TBS) - I(131) uptake - was performed. RESULTS: Total thyroidectomy with central lymphadenectomy was performed in 75 cases. The average level of Tg and iodine uptake after radicalisation was lower in Group I (Nav) than in Group II (3.32 ± 2.09 v. 4.58 ± 2.5 ng/mL, respectively, for Tg [p = 0.021] and 6.29 ± 3.38 v. 7.31 ± 2.29 ng/mL, respectively, for iodine uptake [p = 0.187]). Additionally, the frequency of postoperative complications was comparable, the difference in both groups was not significant, despite the use of the gamma probe (p = 0.109). CONCLUSIONS: The intraoperative use of a hand-held gamma detector can help to improve the radicality of a completion thyroidectomy procedure after an incomplete primary thyroid resection, but the results of this procedure in the hands of an experienced surgeon are comparable whether or not the gamma detector is used.

New comprehensive surgical curriculum of pre-graduate surgical education.

INTRODUCTION: Surgical education has become one of the most important directions in modern surgery evolution. To meet growing need for appropriate training in laparoscopic and, even more importantly, classic surgical skills, a curriculum involving contemporary tuition methods is needed. Advanced, structuralised training, which includes advanced technologies like virtual reality training, video coaching and motivative aspects of competition, seems to be important for an adequate education programme. MATERIAL AND METHODS: In academic years 2009/2010 and 2010/2011 the Department of General, Endocrine and Transplant Surgery of the Medical University of Gdansk together with the Pomeranian Foundation for Progress in Surgery organized 4480 h of training in that area of classic (2744) and laparoscopic (1736) skills. Both groups were involved in the programme of training in which the two most important aspects were reliable evaluation of the results and effective motivation to work. Skill evaluation at different stages of the programme were based on completion time and quality measurements. Apart from that, at the end of the course, the participants completed a questionnaire on their subjective perspective on this innovative curriculum, the quality and stability of the skills they obtained. RESULTS: In both arms of the programme (laparoscopic and classic) a statistically significant improvement was obtained as early as after the second and third sessions in half of the exercises. The acquired skills were stable over time, as proved by the plateau of completion time achieved in 11 out of 12 exercises. The results of the post-training questionnaire revealed that the participants were very satisfied with the structuralised form of training and appreciated the motivational role of competition. CONCLUSIONS: Contemporary surgical training should be organized as a systematic, well-evaluated and goal-oriented programme similar to the one proposed by our team. The use of contemporary training aids should be utilized in training of every surgical skill, not only laparoscopy. This form of training, associated with the component of competition, enables good and stable results to be achieved, as well as high satisfaction of trainees.

Single incision laparoscopic surgery - is it time for laboratory skills training?

INTRODUCTION: With the introduction of new surgical equipment, there is always the need for new, more advanced training. The authors try to answer whether the use of the newest generation tools has an impact on achieving better results in single incision laparoscopic surgery (SILS) technique during the exercises in the surgical skills laboratory. MATERIAL AND METHODS: There were 51 participants in the study: 44 'novices' and 7 'experts'. All subjects performed the 'advanced grasping' exercise according to the FLS programme manual using four types of laparoscopic approach including two SILS ports and SILS-dedicated instruments. The outcome measures involved task completion time and the number of errors. RESULTS: Tasks using straight laparoscopic instruments set together with classic three-port access as well as SILS access ports were finished significantly faster when compared with SILS-dedicated instruments (p < 0.05). There were no significant differences in performance times between the two setups with straight instruments (p < 0.05) and both setups with SILS-dedicated instruments, irrespective of the use of curved or dynamic articulated tools. Students with no previous laparoscopic experience had significantly worse task completion times in all tasks in comparison to students with laparoscopic laboratory training and the 'experts' group. CONCLUSIONS: The use of the straight instruments in the SILS technique remain similar to its performance in full triangulation. SILS-dedicated instruments paradoxically increase the task completion time irrespective of possessed skills. The study showed the necessity of a SILS-dedicated tools training programme.

Bariatric surgery in morbidly obese patients with chronic renal failure, prepared for kidney transplantation--case reports.

Recent years, obesity is a growing health problem also in patients with chronic renal failure and end it's end stage. This situation has a negative impact both on the extension of the waiting period for transplantation, and the survival rate of the transplanted organ and the recipient. Weight loss through lifestyle modification before transplantation is ambiguous. Its well known fact of rapid body mass gain after transplantation, and finally the results of transplantation are not better than those of patients who have not reduced body weight. The paper presents preliminary experience associated with bariatric operations of three chronic dialysed patients with morbid obesity BMI> 35 kg/m², all patients had been treated by Roux-en-Y gastric by-pass (RYGB). All operated patients were classified as potential recipients were listed by Poltransplant. One of them three months after RYGB surgery underwent without complications a renal transplantation. Preliminary experiences based on operating these three case confirmed the complete safety of this type of approach in patients with end-stage chronic kidney disease (CKD).

Roux-en-Y gastric bypass in dialysed morbidly obese patients as a preparation for a kidney transplantation: case series.

Morbid obesity in group of patients with chronic kidney failure has an important impact on access to kidney transplantation. Bariatric procedures can be used as an preparation for potential recipients, which can help to improve their metabolic status and reduce weight. We present the first experience of our centre based on a series of 3 morbidly obese patients with chronic kidney disease underwent Roux-en-Y gastric bypass before being reported to the national registry of recipients.