Clinical practice guidelines for perioperative care in bariatric surgery 2023: Adapted ERAS (enhanced recovery after surgery) guidelines with consensual voting of the working group of the Joint Bariatric and Metabolic Surgery Section of the Czech Surgery .

INTRODUCTION: Currently, bariatric surgery is the most effective treatment for the morbid obesity. It provides sustained weight loss as well as demonstrated positive effects on obesity-related comorbidities. The number of procedures performed worldwide has seen a sharp increase in the past twenty years. Therefore, an effort has been developed to establish a consensus in perioperative care based on best evidence. METHODS: The working group of the Joint Bariatric and Metabolic Surgery Section of the Czech Surgery Society and Czech Society of Obesitology prepared clinical practice guidelines for the ERAS (enhanced recovery after surgery) concept in perioperative care in bariatric surgery. The working group based its guidelines on ERAS guidelines published in 2021. The working group adopted the original text and then adapted the text and added its comments to specific items as appropriate. Electronic voting of all members of the working group was the final phase, by which the strength of consensus was expressed with respect to individual elements of the guidelines. RESULTS: The Czech working group reached a consensus with ERABS (enhanced recovery after bariatric surgery) guidelines for most elements. The quality of evidence is low for some interventions of the ERAS protocol for bariatric surgery. Therefore, extrapolation from other surgeries and fields is needed for evidence-based practice. CONCLUSION: The guidelines are intended for clinical practice in bariatric surgery with the ERAS protocol based on updated evidence and guidelines. It is based on recent and comprehensive ERAS guidelines adopted and adapted by the Czech working group of the Joint Bariatric and Metabolic Surgery Section of the Czech Surgery Society and Czech Society of Obesitology. Some supplementations and specifications are reflected in comments added to the Czech version.

Wernicke´s encephalopathy as rare complication after sleeve gastrectomy.

The authors report a case study of a 24-year-old female patient after sleeve gastrectomy with subsequent manifestation of Wernickes encephalopa-thy. After 5 weeks following the surgery, which were uneventful, the patient was repeatedly hospitalized in the surgical department for extreme vomiting; however, her health status rapidly improved with infusion therapy followed by careful re-alimentation. At the same time, her GIT was closely examined without any clear finding. Problems progressively deteriorated into neurological manifestations. The final diagnosis was established by MR imaging of the brain. In addition, the patients condition was complicated by sudden febrile status with elevated CRP values; therefore, with regard to the unclear CT finding in the abdominal cavity, a laparoscopic revision was made 8 weeks after the primary surgery. The patient survived thanks to the final correct diagnosis and administration of adequate therapy in the form of thiamine substitution. After 30 days following the last admission, the patient was discharged for home treatment in a satisfactory health condition. The aim of the case study is to describe the onset of atypical symptoms in a patient following bariatric surgery - particularly from the point of view of a surgeon - and difficult and prolonged diagnosis of this syndrome due to its relative rarity, also from the point of view of other colleagues with various specializations who participated in the establishment of the diagnostics.

[10 years of sleeve gastrectomy in the Czech Republic in terms of the surgical procedure]. / 10 let sleeve gastrectomy - tubulizace zaludku v Ceské republice z hlediska operacního výkonu.

INTRODUCTION: Sleeve gastrectomy (SG) as a single bariatric/metabolic procedure has been performed since 2003 in the world, and since 2006 in the Czech Republic. We report 10 years experience with SG in the Czech Republic from 2006 to 2015. METHOD: Prospectively collected data from 14 surgical departments was evaluated retrospectively using descriptive statistics for every year from 2006 to 2015 and subsequently evaluated and compared for the entire period. The number of the patients, mean age, mean weight and BMI at the time of surgery, the number of patients with T2DM after SG, mean follow-up, mean %BMIL (% Body Mass Index Loss), distance of the starting point of the resection line from the pylorus, the size of the calibration bougie, the rate of complications, and the number and type of conversion procedures were evaluated. RESULTS: 4134 sleeve gastrectomies were done in the Czech Republic from 2006 to 2015 with the mean follow-up of 32.9 months (range 2145 months) from the procedure. The mean weight at the time of surgery fluctuated between 114.2 kg and 128.9 kg; mean BMI fluctuated between 42.3 and 46.7. Mean %BMIL was 63.2% for the entire evaluated period. The distance of the starting point of the resection line from the pylorus changed from the mean 6.1 cm (range 67 cm) to mean 4.2 cm (range 36 cm) and the size of the calibration bougie changed from the mean 39.2 F (range 3642 F) to mean 37.1 F (range 3542 F). As regards early postoperative complications, bleeding from the resection line occurred in 1.4% and a leak from the staple line occurred in 1.1%. The gastroesophageal reflux disease and hiatal hernia occurred in 17.3% as the most frequent late complications. Conversion to another bariatric procedure was approached in 3.8% in the event of an unsatisfactory effect of the SG. CONCLUSION: Bariatric or metabolic surgery, respectively, is a safe and effective surgical method for the treatment of severe obesity and T2DM in morbidly obese patients. Currently, SG is the most widely used bariatric/metabolic procedure in the Czech Republic as well as in most other countries and the long-time results are similar in comparison with other authors.Key words: bariatric surgery - sleeve gastrectomy - resection line - complications.

[Late postoperative colonic stenosis caused by the biofragmentable anastomosis ring (BAR)]. / Pozdní pooperacní stenóza BAR anastomózy tracníku.

The authors focused their attention on the prevalence of late postoperative stenoses of anastomoses following resection of the colon. In 42 patients the anastomosis was implemented by means of a Valtrac ring--i.e. by compressive biofragmentable seamless technique. Within an interval of 6 months after surgery the majority of these patients were subjected to colonoscopic examination with direct visualization of the intestinal anastomosis. The authors did not record any late postoperative stenoses of the BAR anastomosis of the colon. Moreover on colonoscopic examination in the majority of patients the original intestinal anastomosis was only difficult to detect.

[Endoscopic stricturotomy--possible treatment of stenoses of colorectal anastomoses based on a stapling technique]. / Endoskopická strikturotomie--moznost resení stenózy kolorektální anastomózy zalozené staplerovou technikou.

The authors present the possibility of using colonoscopic stricturotomy by means of a papillotomy commonly used for sphinctertomy of the Papilla Vateri in order to influence a stenosis of a colorectal anastomosis implemented by the stapler technique. The operation proper and postoperative course were without any complications.

[Chemical contamination of the cervical mucus in cows in relation to pregnancy and age factors]. / Kontaminace cervikálního hlenu krav chemickými prvky ve vztahu ke koncepci a veku.

Applying the method of absorption atom spectrometry (AAS), the contamination of cervical mucus by chemical elements (Cd, Pb, Hg, Cr, Cu, Zn) was demonstrated in the oestrus period of cows in different ecological agricultural regions of the North Moravian region. The results of observation revealed only a statistically significant difference (P less than 0.05) in Cd contents in the test groups; test group mean = 0.015 micrograms.g-1 Cd, control group mean = 0.006 micrograms.g-1. Cr findings in cervical mucus are of priority importance, the same applies to Cu findings. Zinc was found to be an element influencing negatively the conception of cows. The Zn values in cervical mucus of nonpregnant cows were demonstrated to be significantly higher (P less than 0.01) (conception--group = 0.841 micrograms.g-1, conception + group = 0.219 micrograms.g-1 Zn. So called sum of chemical elements: Cd + Pb + Hg + Cr + Cu + Zn was proposed and evaluated as a picture of the total contamination of cervical mucus. This characteristic was also influenced by the Zn findings in the group of pregnant and nonpregnant cows. Zn: Cd antagonism in cervical secretions of barren and pregnant cows was statistically highly significant (P less than 0.01). Chemical elements in cervical mucus were determined for the first time in a digested sample of cervical secretion. The correlation coefficients used for the cows (n = 99) from a contaminated region showed that the content of chemical elements in cervical secretion was not influenced by the age of cows. The content of chemical elements in cervical secretion was not increasing with the age.

[Toxic elements in the sex organs of the cow and their relationship to fertility]. / Toxische Elemente im Geschlechtsapparat der Kühe und ihr Zusammenhang mit der Fruchtbarkeit.

The content of heavy metals (Cd, Hg, Pb, Cr, Cu and Zn) has been determined by atomic absorption spectrophotometry in parts of genital organs of cows with and without reproductive disorders, in blood, in placenta, in colostrum, and in the calf blood. The samples were collected in an industrially polluted area and in a relatively non-polluted area. It has been proven in the group of 99 cows that the biological quality of the oestrous cervical mucus is also influenced by toxic elements. The best conception rate after the artificial insemination (80.0%) has been found in cows with the cervical mucus without spermiotoxic properties. The genital organs of 49 cows culled because of reproductive disorders were examined. No significant differences in the content of heavy metals have been found in the separate parts of genital organs. There were also no differences between the cows with and without reproductive disorders. Toxic elements in blood have been found in cows after parturition and in newborn calves both in the polluted and the non-polluted areas. However, significant differences (p less than 0.01) were determined only in the content of Cd and Zn. The average content of all determined toxic elements in the samples of placenta in pluriparous and primiparous cows from the polluted and non-polluted areas was approximately at the same level. The content of Zn was 4.3 times higher than the hygienic standard in the colostrum of cows from the polluted area. The content of Zn exceeded the hygienic standard also in the non-polluted area, and the content of Cd and Hg was close to the hygienic standard there.

[Levels of toxic elements--Cd, Pb, Hg, Cr, Cu, Zn--in the blood and placenta of cows during parturition and in newborn calves]. / Obsah toxických prvku--Cd, Pb, Hg, Cr, Cu, Zn--v krvi a placente krav v dobe porodu a u narozenych telat.

It was demonstrated that mother's blood and the blood of new-born calves were contaminated by toxic elements in exposed and non-exposed area. The average Cd and Zn levels differed at high statistical significance (P less than 0.01) in the mothers blood from non-exposed regions in comparison with the average Cd and Zn levels from exposed region. The average residues of toxic elements in breeding cows placenta from the exposed and non-exposed regions were not statistically different. The average Zn content in new-born calves from non-exposed regions differ highly statistically significantly in comparison with the average Zn content in the blood of new-born calves from heifers of the exposed region. The transplacental ratio (TPx) of a toxic element in cow placenta during parturition was expressed from the average ratio of toxic element content in mother's blood: toxic element content in placenta: the toxic element content in blood of newborn calf, while the content of toxic element in mother's blood during parturition was expressed by a value equal to one. TPx in parturition period was expressed by mathematical formula TPx = 1 : Xp : Xk, where Xp = toxic element content in placenta, Xk = content of the toxic element in blood of new-born calf. TPPb, Hg, Cr, Cu, Zn values were not statistically different between the groups of breeding cows from exposed and non-exposed regions. TPCd in the group comprising 14 first-calves from the exposed region (TPCd = 1:0.89:2.59 in comparison with TPCd of six cows from non-exposed region, where TPCd = 1:0.29: 0.70;, differed statistically highly significantly (P less than .01). High statistical differences (P, less than 01) TPCd between these groups were explicitly affected highly statistically significantly (P less than .01) by different average Cd content in the blood of fourteen first-calves, compared with the average Cd content in blood of six cows from non-exposed region, in which the Cd value in blood during parturition was higher by 10(-1).