To compare costs for 2 days versus 5 days of postoperative antibiotics within the antibiotics after an aPPendectomy In Complex appendicitis trial.Background:Recent studies suggest that restrictive ...antibiotic use leads to a significant reduction in hospital stays without compromising patient safety. Its potential effect on societal costs remains underexplored.
This was a pragmatic, open-label, multicenter clinical trial powered for noninferiority. Patients with complex appendicitis (age ≥ 8 years) were randomly allocated to 2 days or 5 days of intravenous antibiotics after appendectomy. Patient inclusion lasted from June 2017 to June 2021 in 15 Dutch hospitals. The final follow-up was on September 1, 2021. The primary trial endpoint was a composite endpoint of infectious complications and mortality within 90 days. In the present study, the main outcome measures were overall societal costs (comprising direct health care costs and costs related to productivity loss) and cost-effectiveness. Direct health care costs were recorded based on data in the electronic patient files, complemented by a telephone follow-up at 90 days. In addition, data on loss of productivity were acquired through the validated Productivity Cost Questionnaire at 4 weeks after surgery. Cost estimates were based on prices for the year 2019.
In total, 1005 patients were evaluated in the "intention-to-treat" analysis: 502 patients were allocated to the 2-day group and 503 to the 5-day group. The mean difference in overall societal costs was - €625 (95% CI: -€ 958 to -€ 278) to the advantage of the 2-day group. This difference was largely explained by reduced hospital stay. Productivity losses were similar between the study groups. Restricting postoperative antibiotics to 2 days was cost-effective, with estimated cost savings of €31,117 per additional infectious complication.
Two days of postoperative antibiotics for complex appendicitis results in a statistically significant and relevant cost reduction, as compared with 5 days. Findings apply to laparoscopic appendectomy in a well-resourced health care setting.
The aim of this study is to investigate whether muscle mass is associated with the prevalence and incidence of type 2 diabetes and whether this association differs within men and women of normal ...weight, overweight or obesity.
Adult participants were included from the Lifelines cohort study. Low muscle mass was defined as < -1SD of the gender-stratified creatinine excretion rate (CER). Multivariate logistic regression analysis was used to assess the association between muscle mass and the prevalence and incidence of type 2 diabetes.
Muscle mass was associated with the prevalence of type 2 diabetes both in men and in women (OR 1.51 95 %CI 1.32–1.72; P < 0.001 and OR 1.53 1.36 – 1.73; P < 0.001). Incident type 2 diabetes was associated with a decreased muscle mass for both men and women (male; OR 1.22 1.05 – 1.43; P = 0.01 and female; OR 1.36 1.17 – 1.59; P < 0.001), and remained significant after adjustments in normal weight women (OR 1.77 1.16–2.70; P = 0.008).
Both a low muscle mass and loss of muscle mass are associated with the prevalence and incidence of diabetes in the general population. This association is strongest in people with normal weight, and weakens in people within higher BMI subgroups.
Aim
To evaluate medical and surgical treatment of postbariatric hypoglycaemia (PBH) in daily practice.
Materials and Methods
Retrospective data were extracted from medical records from four ...hospitals. PBH was defined by neuroglycopenic symptoms together with a documented glucose <3.0 mmol/L in the postprandial setting after previous bariatric surgery. Data were scored semiquantitatively on efficacy and side effects by two reviewers independently. Duration of efficacy and of use were calculated.
Results
In total, 120 patients were included with a median follow‐up of 27 months with a mean baseline age of 41 years, total weight loss of 33% and glucose nadir 2.3 mmol/L. Pharmacotherapy consisted of acarbose, diazoxide, short‐ and long‐acting octreotide and glucagon‐like peptide‐1 receptor agonist analogues (liraglutide and semaglutide) with an overall efficacy in 45%‐75% of patients. Combination therapy with two drugs was used by 30 (25%) patients. The addition of a second drug was successful in over half of the patients. Long‐acting octreotide and the glucagon‐like peptide‐1 receptor agonist analogues scored best in terms of efficacy and side effects with a median duration of use of 35 months for octreotide. Finally, 23 (19%) patients were referred for surgical intervention. Efficacy of the surgical procedures, pouch banding, G‐tube placement in remnant stomach and Roux‐en‐Y gastric bypass reversal, pooled together, was 79% with a median duration of initial effect of 13 months.
Conclusions
In daily practice, pharmacotherapy for PBH was successful in half to three quarters of patients. Combination therapy was often of value. One in five patients finally needed a surgical procedure, with overall good results.
Purpose
Bariatric procedures are technically complex and skill demanding. In order to standardize the procedures for research and training, a Delphi analysis was performed to reach consensus on the ...practice of the laparoscopic gastric bypass and sleeve gastrectomy in the Netherlands.
Methods
After a pre-round identifying all possible steps from literature and expert opinion within our study group, questionnaires were send to 68 registered Dutch bariatric surgeons, with 73 steps for bypass surgery and 51 steps for sleeve gastrectomy. Statistical analysis was performed to identify steps with and without consensus. This process was repeated to reach consensus of all necessary steps.
Results
Thirty-eight participants (56%) responded in the first round and 32 participants (47%) in the second round. After the first Delphi round, 19 steps for gastric bypass (26%) and 14 for sleeve gastrectomy (27%) gained full consensus. After the second round, an additional amount of 10 and 12 sub-steps was confirmed as key steps, respectively.
Thirteen steps in the gastric bypass and seven in the gastric sleeve were deemed advisable. Our expert panel showed a high level of consensus expressed in a Cronbach’s alpha of 0.82 for the gastric bypass and 0.87 for the sleeve gastrectomy.
Conclusions
The Delphi consensus defined 29 steps for gastric bypass and 26 for sleeve gastrectomy as being crucial for correct performance of these procedures to the standards of our expert panel. These results offer a clear framework for the technical execution of these procedures.
Purpose
Feedback on technical and procedural skills is essential during the training of residents and fellows. The aim of this study was to assess the performance of a newly created instrument for ...the assessment of operative skills using laparoscopic Roux-en-Y gastric bypass (LRYGB) video fragments.
Materials and Methods
A new procedure-based assessment (PBA) was created by combining LRYGB key steps with a 5-point independence scale. LRYGB performed by residents and surgeons with different levels of expertise were video recorded. Fragments of the pouch creation, gastro-jejunostomy and jejunojejunostomy, were review by 12 expert bariatric surgeons and the operative skills assessed with the PBA,
Objective Structured Assessment of Technical Skill
(OSATS), and the Bariatric OSATS (BOSATS). The PBA was compared to the OSATS and BOSATS. Mean scores for all items of the different assessments were summarized and compared using a
T
-test.
Results
The scores of the procedural steps were combined and compared for all levels. The mean scores for beginner, intermediate, and expert level were 2.71, 3.70, and 3.90 for the PBA; for the OSATS 1.84, 2.86, and 3.44; and for the BOSATS 2.78, 3.56, and 4.19. Each of these assessments differentiated between the three skill levels (all
p
< 0.05).
Conclusion
The PBA discriminates well between different levels of operative skills. Similar patterns were found for the OSATS and BOSATS, showing that the randomly selected video fragments are representative samples for assessing skill level. Future research will demonstrate whether these results can be extrapolated to clinical training, and which scores allow for procedure certification.
Graphical Abstract
Determining limb length in gastric bypass procedures is a crucial step to ensure significant weight loss without risking malnutrition. This study investigated the effect of ex vivo training on the ...skills needed to determine limb lengths.
This was a single-center ex vivo training experiment in a teaching hospital in the Netherlands. We designed a training exercise with marked ropes in a laparoscopic trainer box. All ten surgical residents participated and practiced the skill of estimating limb length. Before and after the two-week period their results on a 150-centimeter limb length task were evaluated.
Before training, 10 surgical residents estimated 150 centimeters of small bowel with an absolute deviation of 21% range 9-30. After the training experiment, the residents measured with 8% 2-20 deviation (
= .17). The 8 residents who trained sufficiently improved statistically significantly to an absolute deviation of 5% 2-17 (
= .012). Over 70% of the participants felt their skills had improved.
With sufficient training, surgical residents' skills in measuring small bowel length improved when tested in an ex vivo model. Residents became more confident in their laparoscopic measurement skills. This ex vivo training model is a alternative and addition to on-site training.
Dumping syndrome (DS) and postbariatric hypoglycemia (PBH) are frequent complications of bariatric surgery. Bile acids (BA) have been implicated in their pathogenesis because both bariatric surgery ...and cholecystectomy (CCx) are known to modulate human BA metabolism.
Our investigation aimed to compare the prevalence of self-reported complaints of DS and PBH in postbariatric patients with and without CCx.
A large peripheral hospital in the Netherlands.
All patients who underwent bariatric surgery in 2008–2011 received standardized questionnaires on DS/PBH complaints. The relative risk (RR) of CCx was calculated as the risk of perceived DS and PBH in patients with and without CCx.
Of 590 participants, 146 (25%) had CCx before assessment of DS/PBH complaints. Participants were mostly female (82%) with median age of 46 years (interquartile range, 39–53). The RR for DS after CCx was higher in patients with body mass index <30 kg/m2 at the study (RR, 1.59; 95% CI, 1.04–2.42; P = .007) and in primary Roux-and-Y gastric bypass surgery patients (RR, 1.63; 95% CI, 1.10–2.42; P = .018). Detailed analysis of the latter group associated women, age younger than 50 years, without diabetes and (most prominently) with excess weight loss ≥70% (RR, 2.73; 95% CI, 1.57–4.77; P = .0004) with greater risk of DS. The RR for PBH was higher after CCx in sleeve gastrectomy patients (RR, 4.5; 95% CI, 1.00–20.3; P = .036).
High suspicion of DS and PBH after CCx is increased after bariatric surgery in certain subgroups, suggesting involvement of altered BA metabolism in their pathophysiology.
-Of the 590 bariatric patients studied, 146 (25%) underwent a cholecystectomy (CCx).-Complaints of dumping syndrome was present in several subgroups after CCx.-Complaints of postbariatric hypoglycemia were found in certain subgroups after CCx.-Altered bile acids metabolism might be involved in the dumping pathophysiology.
Objective Roux-en-Y gastric bypass (RYGB) is an effective way to induce sustainable weight loss and can be complicated by postprandial hyperinsulinaemic hypoglycaemia (PHH). To study the prevalence ...and the mechanisms behind the occurrence of hypoglycaemia after a mixed meal tolerance test (MMTT) in patients with primary RYGB. Design This is a cross-sectional study of patients 4 years after primary RYGB. Methods From a total population of 550 patients, a random sample of 44 patients completed the total test procedures. A standardized mixed meal was used as stimulus. Venous blood samples were collected at baseline, every 10 min during the first half hour and every 30 min until 210 min after the start. Symptoms were assessed by questionnaires. Hypoglycaemia is defined as a blood glucose level below 3.3 mmol/L. Results The prevalence of postprandial hypoglycaemia was 48% and was asymptomatic in all patients. Development of hypoglycaemia was more frequent in patients with lower weight at surgery (P = 0.045), with higher weight loss after surgery (P = 0.011), and with higher insulin sensitivity calculated by the homeostasis model assessment indexes (HOMA2-IR, P = 0.014) and enhanced beta cell function (insulinogenic index at 20 min, P = 0.001). Conclusion In a randomly selected population 4 years after primary RYGB surgery, 48% of patients developed a hypoglycaemic event during an MMTT without symptoms, suggesting the presence of hypoglycaemia unawareness in these patients. The findings in this study suggest that the pathophysiology of PHH is multifactorial.
Circulating amino acids have been associated with both appetite and the secretion of anorexigenic hormones in healthy and obese populations. This effect has not been investigated in subjects having ...undergone Roux-en-Y gastric bypass surgery (RYGB).
To investigate the association between postprandial plasma concentrations of amino acids and the anorexigenic hormones glucagon-like peptide-1 (GLP-1) and peptide tyrosine tyrosine (PYY), the orexigenic hormone ghrelin, and satiety and hunger in post-RYGB subjects.
A Dutch surgical department.
Participants after primary RYGB were studied during a Mixed Meal Tolerance Test (MMTT). Satiety and hunger were assessed every 30 minutes on visual analogue scales. Blood samples were collected at baseline, every 10 minutes during the first half hour and every 30 minutes until 210 minutes after the start. The samples were assessed for 24 amino acids and 3 gastrointestinal hormones. Incremental areas under the curve (iAUCs) were calculated. Exploratory analyses were performed in which subjects were divided into high and low responders depending on the median iAUC.
42 subjects, aged 48 ± 11 (mean ± SD) years, 31 to 76 months post-RYGB and with total weight loss of 30 ± 9% completed the MMTT. Subjects with high satiety scores had more than a 25% higher net iAUC of PYY and GLP-1 and at least a 10% higher net iAUC of 10 amino acids compared to subjects with low scores (P < 0.05). The net iAUC of five of these amino acids (i.e. arginine, asparagine, histidine, serine and threonine) was more than 10% higher in subjects with high responses on GLP-1 and/or PYY (P < 0.05).
Certain postprandial amino acids were associated with satiety and anorexigenic hormones and could therefore play a role in appetite regulation after RYGB; either by a direct effect on satiety, indirectly through gastrointestinal hormones, or both.
Suboptimal surgical performance is hypothesized to be associated with less favorable patient outcomes in minimally invasive esophagectomy (MIE). Establishing this association may lead to programs ...that promote better surgical performance of MIE and improve patient outcomes.
To investigate associations between surgical performance and postoperative outcomes after MIE.
In this nationwide cohort study of 15 Dutch hospitals that perform more than 20 MIEs per year, 7 masked expert MIE surgeons assessed surgical performance using videos and a previously developed and validated competency assessment tool (CAT). Each hospital submitted 2 representative videos of MIEs performed between November 4, 2021, and September 13, 2022. Patients registered in the Dutch Upper Gastrointestinal Cancer Audit between January 1, 2020, and December 31, 2021, were included to examine patient outcomes.
Hospitals were divided into quartiles based on their MIE-CAT performance score. Outcomes were compared between highest (top 25%) and lowest (bottom 25%) performing quartiles. Transthoracic MIE with gastric tube reconstruction.
The primary outcome was severe postoperative complications (Clavien-Dindo ≥3) within 30 days after surgery. Multilevel logistic regression, with clustering of patients within hospitals, was used to analyze associations between performance and outcomes.
In total, 30 videos and 970 patients (mean SD age, 66.6 9.1 years; 719 men 74.1%) were included. The mean (SD) MIE-CAT score was 113.6 (5.5) in the highest performance quartile vs 94.1 (5.9) in the lowest. Severe postoperative complications occurred in 18.7% (41 of 219) of patients in the highest performance quartile vs 39.2% (40 of 102) in the lowest (risk ratio RR, 0.50; 95% CI, 0.24-0.99). The highest vs the lowest performance quartile showed lower rates of conversions (1.8% vs 8.9%; RR, 0.21; 95% CI, 0.21-0.21), intraoperative complications (2.7% vs 7.8%; RR, 0.21; 95% CI, 0.04-0.94), and overall postoperative complications (46.1% vs 65.7%; RR, 0.54; 95% CI, 0.24-0.96). The R0 resection rate (96.8% vs 94.2%; RR, 1.03; 95% CI, 0.97-1.05) and lymph node yield (mean SD, 38.9 14.7 vs 26.2 9.0; RR, 3.20; 95% CI, 0.27-3.21) increased with oncologic-specific performance (eg, hiatus dissection, lymph node dissection). In addition, a high anastomotic phase score was associated with a lower anastomotic leakage rate (4.6% vs 17.7%; RR, 0.14; 95% CI, 0.06-0.31).
These findings suggest that better surgical performance is associated with fewer perioperative complications for patients with esophageal cancer on a national level. If surgical performance of MIE can be improved with MIE-CAT implementation, substantially better patient outcomes may be achievable.
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