Dumping syndrome is a common but underdiagnosed complication of gastric and oesophageal surgery. We initiated a Delphi consensus process with international multidisciplinary experts. We defined the ...scope, proposed statements and searched electronic databases to survey the literature. Eighteen experts participated in the literature summary and voting process evaluating 62 statements. We evaluated the quality of evidence using grading of recommendations assessment, development and evaluation (GRADE) criteria. Consensus (defined as >80% agreement) was reached for 33 of 62 statements, including the definition and symptom profile of dumping syndrome and its effect on quality of life. The panel agreed on the pathophysiological relevance of rapid passage of nutrients to the small bowel, on the role of decreased gastric volume capacity and release of glucagon-like peptide 1. Symptom recognition is crucial, and the modified oral glucose tolerance test, but not gastric emptying testing, is useful for diagnosis. An increase in haematocrit >3% or in pulse rate >10 bpm 30 min after the start of the glucose intake are diagnostic of early dumping syndrome, and a nadir hypoglycaemia level <50 mg/dl is diagnostic of late dumping syndrome. Dietary adjustment is the agreed first treatment step; acarbose is effective for late dumping syndrome symptoms and somatostatin analogues are preferred for patients who do not respond to diet adjustments and acarbose.
Summary
Background
Dumping syndrome, a common complication of esophageal, gastric or bariatric surgery, includes early and late dumping symptoms. Early dumping occurs within 1 h after eating, when ...rapid emptying of food into the small intestine triggers rapid fluid shifts into the intestinal lumen and release of gastrointestinal hormones, resulting in gastrointestinal and vasomotor symptoms. Late dumping occurs 1–3 h after carbohydrate ingestion, caused by an incretin‐driven hyperinsulinemic response resulting in hypoglycemia. Clinical recommendations are needed for the diagnosis and management of dumping syndrome.
Methods
A systematic literature review was performed through February 2016. Evidence‐based medicine was used to develop diagnostic and management strategies for dumping syndrome.
Results
Dumping syndrome should be suspected based on concurrent presentation of multiple suggestive symptoms after upper abdominal surgery. Suspected dumping syndrome can be confirmed using symptom‐based questionnaires, glycemia measurements and oral glucose tolerance tests. First‐line management of dumping syndrome involves dietary modification, as well as acarbose treatment for persistent hypoglycemia. If these approaches are unsuccessful, somatostatin analogues should be considered in patients with dumping syndrome and impaired quality of life. Surgical re‐intervention or continuous enteral feeding may be necessary for treatment‐refractory dumping syndrome, but outcomes are variable.
Conclusions
Implementation of these diagnostic and treatment recommendations may improve dumping syndrome management.
Background
Mini gastric bypass (MGB) is a promising and attractive alternative bariatric procedure. In 2011, we introduced MGB in our high-volume bariatric unit. Subsequently, we evaluated short- and ...midterm results of this procedure.
Methods
A prospective cohort of patients who underwent MGB between 2012 and 2013 was retrospectively evaluated.
Results
From 2012 to 2013, primary MGB was performed in 287 patients with a mean BMI of 42 kg/m
2
(range 32–76 kg/m
2
). The mean operation time was 50 min (range 25–120 min). The mortality rate was 0%. Serious complications, such as leakage, pulmonary embolism, or bleeding, occurred in 3.1% of patients; anastomotic leaks occurred in 1.4% of patients. Conversion to Roux-en-Y gastric bypass for biliary reflux or other indications occurred in six patients (2%). During our initial learning phase, biliary reflux rates were higher due to an overly short pouch. Surgical revision for malnutrition was performed in one patient. Percent excess weight loss and percent total body weight loss were 85 and 35%, respectively, after 1 year; 88 and 36.6%, respectively, after 2 years; and 83 and 34.3%, respectively, after 3 years. Follow-up rates after 1, 2, and 3 years were 96% (277/287), 72% (208/287), and 66% (190/287), respectively.
Conclusions
As a primary bariatric procedure, MGB is associated with good early and midterm results. MGB has the potential to become a significant alternative bariatric procedure. Correct technique is of extreme importance when performing MGB; therefore, the appointment of an experienced MGB surgeon as a guide when beginning to utilize this technique is advised.
In spite of its evident success, several late complications can occur after gastric bypass surgery. One of these is post‐gastric bypass hypoglycaemia. No evidence‐based guidelines exist in the ...literature on how to confirm the presence of this syndrome. This study aims to describe and compare the tests aimed at making a diagnosis of post‐gastric bypass hypoglycaemia and to provide a diagnostic approach based upon the available evidence. A search was conducted in PubMed, Cochrane and Embase. A few questionnaires have been developed to measure the severity of symptoms in post‐gastric bypass hypoglycaemia but none has been validated. The gold standard for provocation of a hypoglycaemic event is the oral glucose tolerance test or the liquid mixed meal tolerance test. Both show a high prevalence of hypoglycaemia in post‐gastric bypass patients with and without hypoglycaemic complaints as well as in healthy volunteers. No uniformly established cut‐off values for glucose concentrations are defined in the literature for the diagnosis of post‐gastric bypass hypoglycaemia. For establishing an accurate diagnosis of post‐gastric bypass hypoglycaemia, a validated questionnaire, in connection with the diagnostic performance of provocation tests, is the most important thing missing. Given these shortcomings, we provide recommendations based upon the current literature.
Background
Several different procedures have been proposed as a revisional procedure for treatment of failed laparoscopic adjustable gastric banding (LAGB). Laparoscopic Roux-en-Y gastric bypass ...(LRYGB) has been advocated as the procedure of choice for revision. In this study, we compare the single- and two-step approaches for the revision of failed LAGB to LRYGB.
Method
All patients who underwent bariatric surgery were included in a prospective database. For the purpose of this study, patients who underwent revisional surgery from LAGB to LRYGB were selected. Records for individual patients were completed by data review. Complication rates and weight development were recorded until 2 years postoperatively. Data were compared between both procedures and with complications rates reported in literature.
Results
Revisional gastric bypass surgery was performed in 257 patients. This was done as a planned single-step procedure in 220 (86 %) patients without indications for acute band removal and in 32 patients as a planned 2 step procedure. Five patients were planned as a single-step procedure but were intraoperatively converted to a 2-step procedure based on poor pouch tissue quality. No postoperative mortality occurred in both groups. No differences in early major morbidity and stricture formation were seen between the two groups. Gastric ulceration was more frequently observed after 2-steps procedure (8.5 vs. 1.7 %,
p
< 0.05). In comparison with data reported in literature, the single-step procedure had similar to lower complication rates. Percentage excess weight loss two years after revisional gastric bypass procedure was, respectively, 53 versus 67 % (
p
= 0.147) for single- and two-step procedure.
Conclusion
In patients without indications for acute band removal, the planned conversion of gastric banding to Roux-Y gastric bypass can be safely done in a single-step procedure without increase in morbidity and no difference in postoperative weight loss.
Background
One of the most important ways to reduce biliary duct injury in laparoscopic cholecystectomy is to achieve the critical view of safety (CVS) before transection of the cystic artery and ...duct. Documenting CVS is possible with photo prints, video imaging, or both. These documentations can be used as a proof of the right procedure in case of biliary duct injury, but only if the documentation is good enough to be judged independently by others.
Methods
In 102 consecutive laparoscopic cholecystectomies, CVS was recorded by photo prints and video images. Imaging was done just before transection of the cystic artery and duct. The photo prints and video images were analyzed independently by two surgeons. These surgeons had to judge whether the documentation method was of sufficient quality to determine whether CVS was achieved.
Results
Photo prints were made for 81% and video images for 59% of the 102 patients treated with a laparoscopic cholecystectomy. The mean age of the patients was 54 years (range, 22–83 years), and 71% were women. The diagnosis for 62 of the patients was symptomatic cholecystolithiasis, and 18 patients had acute cholecystitis. The remaining patients had earlier experienced acute cholecystitis, biliary pancreatitis, or endoscopic retrograde cholangiopancreatography (ERCP). Respectively, 30% and 21% of the CVS photo prints were judged to be of insufficient quality to determine whether CVS had been established, mostly because of difficulties adequately showing the lateral side (κ = 0.67). In all but two video images, achievement of CVS was documented sufficiently to be judged 97% (κ = 1.00).
Conclusion
Photo prints are inferior to video images for judging achievement of CVS. Therefore, a practical and logistical solution must be devised in hospitals for storage and insight in all video documentation, for example, by implementation of a link with the electronic patient database.
Background
Antibiotics are advised in most guidelines on acute diverticulitis, despite a lack of evidence to support their routine use. This trial compared the effectiveness of a strategy with or ...without antibiotics for a first episode of uncomplicated acute diverticulitis.
Methods
Patients with CT‐proven, primary, left‐sided, uncomplicated, acute diverticulitis were included at 22 clinical sites in the Netherlands, and assigned randomly to an observational or antibiotic treatment strategy. The primary endpoint was time to recovery during 6 months of follow‐up. Main secondary endpoints were readmission rate, complicated, ongoing and recurrent diverticulitis, sigmoid resection and mortality. Intention‐to‐treat and per‐protocol analyses were done.
Results
A total of 528 patients were included. Median time to recovery was 14 (i.q.r. 6–35) days for the observational and 12 (7–30) days for the antibiotic treatment strategy, with a hazard ratio for recovery of 0·91 (lower limit of 1‐sided 95 per cent c.i. 0·78; P = 0·151). No significant differences between the observation and antibiotic treatment groups were found for secondary endpoints: complicated diverticulitis (3·8 versus 2·6 per cent respectively; P = 0·377), ongoing diverticulitis (7·3 versus 4·1 per cent; P = 0·183), recurrent diverticulitis (3·4 versus 3·0 per cent; P = 0·494), sigmoid resection (3·8 versus 2·3 per cent; P = 0·323), readmission (17·6 versus 12·0 per cent; P = 0·148), adverse events (48·5 versus 54·5 per cent; P = 0·221) and mortality (1·1 versus 0·4 per cent; P = 0·432). Hospital stay was significantly shorter in the observation group (2 versus 3 days; P = 0·006). Per‐protocol analyses were concordant with the intention‐to‐treat analyses.
Conclusion
Observational treatment without antibiotics did not prolong recovery and can be considered appropriate in patients with uncomplicated diverticulitis. Registration number: NCT01111253 (http://www.clinicaltrials.gov).
Antibiotics not needed
Purpose
Annually approximately 18,044 patients are admitted to Dutch hospitals with hip fractures. This is an increasing demand for medical care due to the increasing amount of elderly people. ...Although previous studies showed that routine check of X-rays following hip fracture surgery is unnecessary, it remains routine in most clinics in the Netherlands. In addition to the radiation exposure to the patient, it is painful and leads to unnecessary costs. This study aims to establish if routine check X-rays 1 day after internal fixation for hip fracture with adequate image intensifier guidance influence postoperative management.
Patients and methods
A retrospective study was performed for all patients undergoing internal fixation of hip fractures with image intensifier guidance in the period from January 2006 until December 2007 in our hospital.
Results
In that period 294 patients underwent internal fixation of hip fractures, 254 underwent a check X-ray and were included in this study. In only two patients the check X-ray did change patient management.
Conclusion
A check X-ray following internal fixation of hip fractures after adequate peroperative image intensifier guidance is not useful. Dismissing this unuseful medical investigation, leads to less radiation exposure, less pain and less costs.
To weigh the harms and benefits of short-term pre-operative radiotherapy in the treatment of resectable rectal cancer.
The benefits (reduction of local recurrence) and harm (increase of short-term ...complications) of short-term pre-operative radiotherapy are balanced using a model which classifies patients in one of five outcome combinations; 1—benefit without additional harm, 2—benefit with additional harm, 3—no benefit, no additional harm, 4—no benefit but additional harm, 5—mortality due to combined treatment.
The results of four randomised clinical trials (RCT) which study the addition of short-term pre-operative radiotherapy in rectal cancer were classified according to this model.
Five to thirteen percent of the patients have benefit without additional harm of pre-operative radiotherapy, while 0–2% have benefit with additional harm; 74–87% has neither benefit nor additional harm and 6–11% have no benefit but additional harm. A small percentage of patients (1–6%) dies post-operatively as a result of the addition of radiotherapy.
This model provides a transparent appreciation of the harmful and beneficial effects of any treatment modality investigated by means of a randomised clinical trial. As for short-term pre-operative radiotherapy in resectable rectal cancer is shown, a small percentage of patients benefits from such treatment. Most patients have neither benefit nor additional harm, while a small percentage suffers from additional harm while not receiving any benefit.
Staging laparoscopy is a common diagnostic tool in gastric cancer, but its performance varies widely. The aim of this study was to gain Dutch nationwide consensus regarding the indications for and ...execution of staging laparoscopy in patients with gastric cancer.
All surgeons in the Netherlands specialized in gastric cancer surgery (n = 52) were asked to participate in a Delphi consensus study. The study involved an initial questionnaire with a 3-point Likert scale, an online consensus meeting, and a second questionnaire using a 2-point Likert scale (agree/disagree). Consensus was defined as 70% or more agreement among participants.
In total, 45 experts completed both questionnaires (87% response rate). Consensus was reached on the indication to perform staging laparoscopy in cT3-4 or cN + or diffuse-type gastric cancer, including Siewert type III oesophagogastric junctional cancer. The experts agreed that if preoperative scans suggest infiltration of surrounding organs (cT4), the tumour's resectability should explicitly be investigated. Consensus was also reached for a systematic peritoneal cavity inspection according to Sugarbaker's Peritoneal Cancer Index (PCI) score. All regions should be inspected routinely, although the omental bursa may be inspected on indication. Aspiration of ascites or peritoneal washing should be performed for cytology. The experts agreed that restaging laparoscopy should be performed before resection in case of progressive disease on preoperative imaging. Without progression, global inspection was considered sufficient.
The results of this Dutch nationwide Delphi consensus study exposed the variability of performing staging laparoscopy in patients with gastric cancer and provided the concept for a standardized protocol.
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