1
|
Parmar CD, Felsenreich DM, Salminen P, Di Lorenzo N, Prager G. Guidelines for Management of Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) Occurring After Metabolic Bariatric Surgery (MBS). Obes Surg 2024; 34:1964-1968. [PMID: 38530553 DOI: 10.1007/s11695-024-07187-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 03/18/2024] [Accepted: 03/19/2024] [Indexed: 03/28/2024]
Affiliation(s)
- Chetan D Parmar
- Whittington Hospital, London, N19 5NF, UK.
- University College London, London, UK.
- Apollo Hospitals, Chennai, India.
| | | | | | - Nicola Di Lorenzo
- Department of Surgical Sciences, University of Tor Vergata, Policlinico Tor Vergata, Rome, Italy
| | - Gerhard Prager
- Department of Surgery, Vienna Medical University, Vienna, Austria
| |
Collapse
|
2
|
Selänne L, Haijanen J, Sippola S, Hurme S, Rautio T, Nordström P, Rantanen T, Pinta T, Ilves I, Mattila A, Rintala J, Marttila H, Meriläinen S, Laukkarinen J, Sävelä EL, Paajanen H, Grönroos J, Salminen P. Three-Year Outcomes of Oral Antibiotics vs Intravenous and Oral Antibiotics for Uncomplicated Acute Appendicitis: A Secondary Analysis of the APPAC II Randomized Clinical Trial. JAMA Surg 2024:2817651. [PMID: 38630471 PMCID: PMC11024776 DOI: 10.1001/jamasurg.2023.5947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 08/27/2023] [Indexed: 04/20/2024]
Abstract
Importance Current short-term evidence has shown that uncomplicated acute appendicitis can be treated successfully with oral antibiotics alone, but longer-term results are lacking. Objective To assess the treatment effectiveness of oral antibiotic monotherapy compared with combined intravenous (IV) and oral antibiotics in computed tomography-confirmed uncomplicated acute appendicitis at a longer-term follow-up. Design, Setting, and Participants This secondary analysis of a predefined year 3 follow-up of the Appendicitis Acuta II (APPAC II) noninferiority, multicenter randomized clinical trial compared oral moxifloxacin with combined IV ertapenem plus oral levofloxacin and metronidazole for the treatment of uncomplicated acute appendicitis. The trial was conducted at 9 university and central hospitals in Finland from April 2017 to November 2018, with the last follow-up in November 2022. Participants included patients aged 18 to 60 years, who were randomized to receive either oral antibiotics monotherapy (n = 301) or combined IV and oral antibiotics (n = 298). Interventions Antibiotics monotherapy consisted of oral moxifloxacin, 400 mg/d, for 7 days. Combined IV and oral antibiotics consisted of IV ertapenem sodium, 1 g/d, for 2 days plus oral levofloxacin, 500 mg/d, and metronidazole, 500 mg 3 times/d, for 5 days. Main Outcomes and Measures The primary end point was treatment success, defined as the resolution of acute appendicitis and discharge from hospital without the need for surgical intervention and no appendicitis recurrence at the year 3 follow-up evaluated using a noninferiority design. The secondary end points included late (after 1 year) appendicitis recurrence as well as treatment-related adverse events, quality of life, length of hospital stay, and length of sick leave, which were evaluated using a superiority design. Results After exclusions, 599 patients (mean [SD] age, 36 [12] years; 336 males [56.1%]) were randomized; after withdrawal and loss to follow-up, 582 patients (99.8%) were available for the year 3 follow-up. The treatment success at year 3 was 63.4% (1-sided 95% CI, 58.8% to ∞) in the oral antibiotic monotherapy group and 65.2% (1-sided 95% CI, 60.5% to ∞) in the combined IV and oral antibiotics group. The difference in treatment success rate between the groups at year 3 was -1.8 percentage points (1-sided 95% CI, -8.3 percentage points to ∞; P = .14 for noninferiority), with the CI limit exceeding the noninferiority margin. There were no significant differences between groups in treatment-related adverse events, quality of life, length of hospital stay, or length of sick leave. Conclusions and Relevance This secondary analysis of the APPAC II trial found a slightly higher appendectomy rate in patients who received oral antibiotic monotherapy; however, noninferiority of oral antibiotic monotherapy compared with combined IV and oral antibiotics could not be demonstrated. The results encourage future studies to assess oral antibiotic monotherapy as a viable treatment alternative for uncomplicated acute appendicitis. Trial Registration ClinicalTrials.gov Identifier: NCT03236961.
Collapse
Affiliation(s)
- Liisa Selänne
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Jussi Haijanen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Suvi Sippola
- Department of Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Saija Hurme
- Department of Biostatistics, University of Turku and Turku University Hospital, Turku, Finland
| | - Tero Rautio
- Department of Surgery, Oulu University Hospital, Oulu, Finland
- Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Pia Nordström
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
| | - Tuomo Rantanen
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland
- Department of Surgery, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Tarja Pinta
- Department of Surgery, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Imre Ilves
- Department of Surgery, Mikkeli Central Hospital, Mikkeli, Finland
| | - Anne Mattila
- Wellbeing Services County of Central Finland, Hospital Nova of Central Finland, Jyväskylä, Finland
| | - Jukka Rintala
- Department of Surgery, Oulu University Hospital, Oulu, Finland
- Department of Surgery, Rovaniemi Central Hospital, Rovaniemi, Finland
| | - Harri Marttila
- Department of Hospital Hygiene and Infection Control, Turku University Hospital, Turku, Finland
| | - Sanna Meriläinen
- Department of Surgery, Oulu University Hospital, Oulu, Finland
- Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
| | | | - Hannu Paajanen
- Department of Surgery, Mikkeli Central Hospital, Mikkeli, Finland
| | - Juha Grönroos
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
- Department of Surgery, Satakunta Central Hospital, Pori, Finland
| |
Collapse
|
3
|
Vahtera V, Pajarinen J, Kivimäki M, Ervasti J, Pentti J, Stenholm S, Vahtera J, Salminen P. Cohort study on incidence of new-onset type 2 diabetes in patients after bariatric surgery and matched controls. Br J Surg 2024; 111:znae105. [PMID: 38682425 PMCID: PMC11056794 DOI: 10.1093/bjs/znae105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 02/04/2024] [Accepted: 03/30/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Metabolic bariatric surgery the reduces risk of new-onset type 2 diabetes in individuals with obesity, but it is unclear whether the benefit varies by sex, age, or socioeconomic status. The aim was to assess the risk of new-onset type 2 diabetes after metabolic bariatric surgery in these subgroups. METHODS The Finnish Public Sector study, a follow-up study with matched controls nested in a large employee cohort, included patients without type 2 diabetes and with a diagnosis of obesity or self-reported BMI of at least 35 kg/m2. For each patient who had laparoscopic metabolic bariatric surgery (2008-2016), two propensity-score matched controls were selected. New-onset type 2 diabetes was ascertained from linked records from national health registries. RESULTS The study included a total of 917 patients and 1811 matched controls with obesity. New-onset type 2 diabetes was diagnosed in 15 of the patients who had metabolic bariatric surgery (4.1 per 1000 person-years) and 164 controls (20.2 per 1000 person-years). The corresponding rate ratio (RR) was 0.20 (95% c.i. 0.12 to 0.35) and the rate difference (RD) was -16.1 (-19.8 to -12.3) per 1000 person-years. The risk reduction was more marked in individuals of low socioeconomic status (RR 0.10 (0.04 to 0.26) and RD -20.6 (-25.6 to -15.5) per 1000 person-years) than in those with higher socioeconomic status (RR 0.35 (0.18 to 0.66) and RD -11.5 (-16.9 to -6.0) per 1000 person-years) (Pinteraction = 0.017). No differences were observed between sexes or age groups. CONCLUSION Metabolic bariatric surgery was associated with a reduced risk of new-onset type 2 diabetes in men and women and in all age groups. The greatest benefit was observed in individuals of low socioeconomic status.
Collapse
Affiliation(s)
- Viiko Vahtera
- Department of Surgery, Päijät-Häme Central Hospital, Lahti, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Jukka Pajarinen
- Department of Plastic and Reconstructive Surgery, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Mika Kivimäki
- Finnish Institute of Occupational Health, Finland
- UCL Brain Sciences, University College London, London, UK
- Clinicum, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | | | - Jaana Pentti
- Clinicum, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Public Health, University of Turku and Turku University Hospital, Turku, Finland
| | - Sari Stenholm
- Department of Public Health, University of Turku and Turku University Hospital, Turku, Finland
- Centre for Population Health Research, University of Turku and Turku University Hospital, Turku, Finland
| | - Jussi Vahtera
- Department of Public Health, University of Turku and Turku University Hospital, Turku, Finland
- Centre for Population Health Research, University of Turku and Turku University Hospital, Turku, Finland
| | - Paulina Salminen
- Department of Surgery, University of Turku, Turku, Finland
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| |
Collapse
|
4
|
Salminen P. Long-term trial outcomes of Roux-en-Y gastric bypass and one anastomosis gastric bypass: tipping the scale. Lancet Diabetes Endocrinol 2024; 12:221-222. [PMID: 38452781 DOI: 10.1016/s2213-8587(24)00066-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 02/22/2024] [Indexed: 03/09/2024]
Affiliation(s)
- Paulina Salminen
- Department of Digestive Surgery, Division of Digestive Surgery and Urology, Turku University Hospital, 20520 Turku, Finland; Department of Surgery, University of Turku, Turku, Finland.
| |
Collapse
|
5
|
Rebelos E, Mari A, Honka MJ, Pekkarinen L, Latva-Rasku A, Laurila S, Rajander J, Salminen P, Iida H, Ferrannini E, Nuutila P. Renal Cortical Glucose Uptake Is Decreased in Insulin Resistance and Correlates Inversely With Serum Free-fatty Acids. J Clin Endocrinol Metab 2024; 109:1033-1040. [PMID: 37955868 DOI: 10.1210/clinem/dgad663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/15/2023] [Accepted: 11/09/2023] [Indexed: 11/14/2023]
Abstract
CONTEXT Studies on human renal metabolism are scanty. Nowadays, functional imaging allows the characterization of renal metabolism in a noninvasive manner. We have recently demonstrated that fluorodeoxyglucose F18 (18F FDG) positron emission tomography can be used to analyze renal glucose uptake (GU) rates, and that the renal cortex is an insulin-sensitive tissue. OBJECTIVE To confirm that renal GU is decreased in people with obesity and to test whether circulating metabolites are related to renal GU. DESIGN, SETTING AND PARTICIPANTS Eighteen people with obesity and 18 nonobese controls were studied with [18F]FDG positron emission tomography during insulin clamp. Renal scans were obtained ∼60 minutes after [18F]FDG injection. Renal GU was measured using fractional uptake rate and after correcting for residual intratubular [18F]FDG. Circulating metabolites were measured using high-throughput proton nuclear magnetic resonance metabolomics. RESULTS Cortical GU was higher in healthy nonobese controls compared with people with obesity (4.7 [3.4-5.6] vs 3.1 [2.2-4.3], P = .004, respectively), and it associated positively with the degree of insulin sensitivity (M value) (r = 0.42, P = .01). Moreover, cortical GU was inversely associated with circulating β-OH-butyrate (r = -0.58, P = .009), acetoacetate (r = -0.48, P = .008), citrate (r = -0.44, P = .01), and free fatty acids (r = -0.68, P < .0001), even when accounting for the M value. On the contrary, medullary GU was not associated with any clinical parameters. CONCLUSION These data confirm differences in renal cortical GU between people with obesity and healthy nonobese controls. Moreover, the negative correlations between renal cortex GU and free fatty acids, ketone bodies, and citrate are suggestive of substrate competition in the renal cortex.
Collapse
Affiliation(s)
- Eleni Rebelos
- Turku PET Centre, University of Turku, 20520, Turku, Finland
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, 56126, Italy
- InFLAMES Research Flagship, University of Turku, 20014, Turku, Finland
| | - Andrea Mari
- CNR Institute of Neuroscience, Padova, 35121, Italy
| | - Miikka-Juhani Honka
- Turku PET Centre, University of Turku, 20520, Turku, Finland
- InFLAMES Research Flagship, University of Turku, 20014, Turku, Finland
- Division of Information Science, Nara Institute of Science and Technology, Takayamacho 8916-5, Ikoma, Nara 630-0192, Japan
| | - Laura Pekkarinen
- Turku PET Centre, University of Turku, 20520, Turku, Finland
- Department of Endocrinology, Turku University Hospital, 20521, Turku, Finland
| | - Aino Latva-Rasku
- Turku PET Centre, University of Turku, 20520, Turku, Finland
- Department of Endocrinology, Turku University Hospital, 20521, Turku, Finland
| | - Sanna Laurila
- Turku PET Centre, University of Turku, 20520, Turku, Finland
- Heart Center, Turku University Hospital, 20521, Turku, Finland
- Department of Medicine, University of Turku, 20520, Turku, Finland
| | - Johan Rajander
- Turku PET Centre, Accelerator Laboratory, Åbo Akademi University, 20521, Turku, Finland
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, 20521, Turku, Finland
| | - Hidehiro Iida
- Turku PET Centre, University of Turku, 20520, Turku, Finland
| | - Ele Ferrannini
- CNR Institute of Clinical Physiology, Pisa, 56124, Italy
| | - Pirjo Nuutila
- Turku PET Centre, University of Turku, 20520, Turku, Finland
- InFLAMES Research Flagship, University of Turku, 20014, Turku, Finland
- Department of Endocrinology, Turku University Hospital, 20521, Turku, Finland
| |
Collapse
|
6
|
Cohen RV, Salminen P, Schauer PR, Rubino F. Back to the future: malabsorption is the Achilles' heel of hypoabsorptive metabolic/bariatric procedures. Br J Surg 2024; 111:znae073. [PMID: 38551119 PMCID: PMC10979410 DOI: 10.1093/bjs/znae073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2024]
Affiliation(s)
- Ricardo V Cohen
- Centre for Obesity and Diabetes, Oswaldo Cruz German Hospital, Sao Paulo, Brazil
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Philip R Schauer
- Metamor Institute, Pennington Biomedical Research Center, Baton Rouge, LA, USA
| | - Francesco Rubino
- Bariatric and Metabolic Surgery, King’s College Hospital, London, UK
| |
Collapse
|
7
|
Ponce de Leon-Ballesteros G, Pouwels S, Romero-Velez G, Aminian A, Angrisani L, Bhandari M, Brown W, Copaescu C, De Luca M, Fobi M, Ghanem OM, Hasenberg T, Herrera MF, Herrera-Kok JH, Himpens J, Kow L, Kroh M, Kurian M, Musella M, Narwaria M, Noel P, Pantoja JP, Ponce J, Prager G, Ramos A, Ribeiro R, Ruiz-Ucar E, Salminen P, Shikora S, Small P, Stier C, Taha S, Taskin EH, Torres A, Vaz C, Vilallonga R, Verboonen S, Zerrweck C, Zundel N, Parmar C. Metabolic and Bariatric Surgery in Patients with Obesity Class V (BMI > 60 kg/m 2): a Modified Delphi Study. Obes Surg 2024; 34:790-813. [PMID: 38238640 DOI: 10.1007/s11695-023-06990-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 11/28/2023] [Accepted: 12/06/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND Metabolic and bariatric surgery (MBS) is the preferred method to achieve significant weight loss in patients with Obesity Class V (BMI > 60 kg/m2). However, there is no consensus regarding the best procedure(s) for this population. Additionally, these patients will likely have a higher risk of complications and mortality. The aim of this study was to achieve a consensus among a global panel of expert bariatric surgeons using a modified Delphi methodology. METHODS A total of 36 recognized opinion-makers and highly experienced metabolic and bariatric surgeons participated in the present Delphi consensus. 81 statements on preoperative management, selection of the procedure, perioperative management, weight loss parameters, follow-up, and metabolic outcomes were voted on in two rounds. A consensus was considered reached when an agreement of ≥ 70% of experts' votes was achieved. RESULTS A total of 54 out of 81 statements reached consensus. Remarkably, more than 90% of the experts agreed that patients should be notified of the greater risk of complications, the possibility of modifications to the surgical procedure, and the early start of chemical thromboprophylaxis. Regarding the choice of the procedure, SADI-S, RYGB, and OAGB were the top 3 preferred operations. However, no consensus was reached on the limb length in these operations. CONCLUSION This study represents the first attempt to reach consensus on the choice of procedures as well as perioperative management in patients with obesity class V. Although overall consensus was reached in different areas, more research is needed to better serve this high-risk population.
Collapse
Affiliation(s)
- Guillermo Ponce de Leon-Ballesteros
- Department of Surgery, Hospital Angeles Morelia, Morelia, Postal: 331, Int. B-502, Av. Montaña Monarca, Montaña Monarca, 58350, Morelia, Michoacan, Mexico.
| | - Sjaak Pouwels
- Department of General, Abdominal Surgery and Coloproctology, Helios St. Elisabeth Hospital, Oberhausen, NRW, Germany
- Department of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
- Faculty of Health, Witten/Herdecke University, Witten, Germany
| | | | - Ali Aminian
- Department of General Surgery, Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Luigi Angrisani
- Department of Public Health, Federico II" University of Naples, Naples, Italy
| | | | - Wendy Brown
- Department of Surgery, Monash University, Melbourne, Australia
| | - Catalin Copaescu
- Department of Surgery, Ponderas Academic Hospital, Bucharest, Romania
| | | | | | - Omar M Ghanem
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Till Hasenberg
- Helios Obesity Center West, Helios University Hospital Wuppertal, Wuppertal, Germany
| | - Miguel F Herrera
- Clinic for Nutrition and Obesity, The American British Cowdray Medical Center Observatorio, Mexico City, Mexico
- Department of Surgery, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - Johnn H Herrera-Kok
- Department of General and Digestive Surgery, University Hospital of Leon, Leon, Spain
| | - Jacques Himpens
- Bariatric Surgery Unit, Delta CHIREC Hospital, Brussels, Belgium
| | - Lilian Kow
- Flinders Medical Centre, Adelaide, Australia
| | - Matthew Kroh
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | | | - Mario Musella
- Advanced Biomedical Sciences Department, "Federico II" University of Naples, Naples, Italy
| | | | - Patrick Noel
- Clinique Bouchard, ELSAN, Marseille, France
- Emirates Specialty Hospital, DHCC, Dubai, UAE
| | - Juan P Pantoja
- Department of Surgery, Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Jaime Ponce
- CHI Memorial Hospital Chattanooga, Chattanooga, TN, USA
| | - Gerhard Prager
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Rui Ribeiro
- Department of General Surgery, Hospital Lusiadas Amadora, Amadora, Portugal
| | - Elena Ruiz-Ucar
- Department of Bariatric and Endocrine Surgery, Fuenlabrada University Hospital, Madrid, Spain
| | - Paulina Salminen
- Department of Surgery, University of Turku, Turku, Finland
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Scott Shikora
- Department of Surgery, Division of Gastrointestinal and General Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Peter Small
- Directorate of General Surgery, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - Christine Stier
- Department of Interdisciplinary Endoscopy and Visceral Surgery, University Hospital Mannheim, Mannheim, Germany
| | - Safwan Taha
- Bariatric and Metabolic Surgery Center, Mediclinic Hospital Airport Road, Abu Dhabi, UAE
| | - Eren Halit Taskin
- Department of Surgery, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Antonio Torres
- General and Digestive Surgery Service, Department of Surgery, Hospital Clínico San Carlos, Complutense University Medical School, Universidad Complutense de Madrid (UCM); IdISSC, Madrid, Spain
| | - Carlos Vaz
- Obesity and Metabolic Surgery Unit, Hospital CUF Tejo, Lisbon, Portugal
| | - Ramon Vilallonga
- Department of Surgery, Enodcrine-Metabolic and Bariatric Surgery Unit, Vall Hebron Barcelona Hospital Campus, Universitat Autonoma de Barcelona, Barcelona, Spain
| | | | - Carlos Zerrweck
- The American British Cowdray Medical Center Santa Fe, Mexico City, Mexico
| | - Natan Zundel
- Department of Surgery, University of Buffalo, Buffalo, NY, USA
| | - Chetan Parmar
- Department of Surgery, The Whittington Hospital NHS Trust, London, UK
- Apollo Hospitals Educational and Research Foundation, Hyderabad, India
- University College London, London, UK
| |
Collapse
|
8
|
Butts CA, Byerly S, Nahmias J, Gelbard R, Ziesmann M, Bruns B, Davidson GH, Di Saverio S, Esposito TJ, Fischkoff K, Joseph B, Kaafarani H, Mentula P, Podda M, Sakran JV, Salminen P, Sammalkorpi H, Sawyer RG, Skeete D, Tesoriero R, Yeh DD. A core outcome set for appendicitis: A consensus approach utilizing modified Delphi methodology. J Trauma Acute Care Surg 2024; 96:487-492. [PMID: 37751156 DOI: 10.1097/ta.0000000000004144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
BACKGROUND Appendicitis is one of the most common pathologies encountered by general and acute care surgeons. The current literature is inconsistent, as it is fraught with outcome heterogeneity, especially in the area of nonoperative management. We sought to develop a core outcome set (COS) for future appendicitis studies to facilitate outcome standardization and future data pooling. METHODS A modified Delphi study was conducted after identification of content experts in the field of appendicitis using both the Eastern Association for the Surgery of Trauma (EAST) landmark appendicitis articles and consensus from the EAST ad hoc COS taskforce on appendicitis. The study incorporated three rounds. Round 1 utilized free text outcome suggestions, then in rounds 2 and 3 the suggests were scored using a Likert scale of 1 to 9 with 1 to 3 denoting a less important outcome, 4 to 6 denoting an important but noncritical outcome, and 7 to 9 denoting a critically important outcome. Core outcome status consensus was defined a priori as >70% of scores 7 to 9 and <15% of scores 1 to 3. RESULTS Seventeen panelists initially agreed to participate in the study with 16 completing the process (94%). Thirty-two unique potential outcomes were initially suggested in round 1 and 10 (31%) met consensus with one outcome meeting exclusion at the end of round 2. At completion of round 3, a total of 17 (53%) outcomes achieved COS consensus. CONCLUSION An international panel of 16 appendicitis experts achieved consensus on 17 core outcomes that should be incorporated into future appendicitis studies as a minimum set of standardized outcomes to help frame future cohort-based studies on appendicitis. LEVEL OF EVIDENCE Diagnostic Test or Criteria; Level V.
Collapse
Affiliation(s)
- Christopher A Butts
- From the Division of Trauma, Acute Care Surgery & Surgical Critical Care (C.A.B.), Department of Surgery, Reading Hospital-Tower Health, West Reading, Pennsylvania; Department of Surgery, University of Tennessee Health Science Center (S.B.), Memphis, Tennessee; UC Irvine Healthcare, Orange (J.N.), California; Department of Surgery, University of Alabama at Birmingham (R.G.), Birmingham, Alabama; University of Manitoba, Winnipeg (M.Z.), Manitoba, Canada; Department of Surgery, University of Texas Southwestern, Dallas (B.B.), Texas; Department of Surgery, University of Washington, Seattle (G.H.D.), Washington; AST5 ASR Marche, Hospital Madonna del Soccorso (S.D.S.), San Benedetto del Tronto, Italy; Department of Medicine, University of Illinois School of Medicine (T.J.E.), Peoria, Illinois; Department of Surgery, Columbia University Irving Medical Center (K.F.), New York, New York; Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery (B.J.), College of Medicine, University of Arizona, Tuscon, Arizona; Trauma, Emergency Surgery, and Surgical Critical Care (H.K.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Gastroenterological Surgery (P.M., H.S.), Helsinki University Hospital, Helsinki, Finland; Department of General and Emergency Surgery (M.P.), Cagliari University Hospital, Cagliari, Italy; Division of Acute Care Surgery, Department of Surgery (J.V.S.), Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Surgery (P.S.), University of Turku, Turku, Finland; Department of Surgery, Western Michigan University School of Medicine: Western Michigan University Homer Stryker MD School of Medicine (R.G.S.), Kalamazoo, Michigan; Roy J. and Lucille A. Carver College of Medicine (D.S.), University of Iowa, Iowa City, Iowa; Division of General Surgery, Trauma and Surgical Critical Care, Acute Care Surgery (R.T.), Zuckerberg San Francisco General Hospital, San Francisco, California; and Ernest E Moore Shock Trauma Center at Denver Health (D.D.Y.), University of Colorado, Denver, Colorado
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Peterli R, Hurme S, Bueter M, Grönroos S, Helmiö M, Salminen P. Standardized Assessment of Metabolic Bariatric Surgery Outcomes: Secondary Analysis of 2 Randomized Clinical Trials. JAMA Surg 2024; 159:306-314. [PMID: 38055284 PMCID: PMC10701667 DOI: 10.1001/jamasurg.2023.6254] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/03/2023] [Indexed: 12/07/2023]
Abstract
Importance A standardized definition and reporting of metabolic bariatric surgery (MBS) outcomes is not available for actual clinical practice and science. Objective To assess the feasibility of using a clinically relevant and feasible MBS outcome score (Swiss-Finnish Bariatric Metabolic Outcome Score [SF-BARI Score]). Design, Setting, and Participants This assessment of a bariatric surgery outcome score is based on the secondary analysis of merged 5-year individual patient data (N = 457) of 2 large randomized clinical trials (Swiss SM-BOSS [Swiss Multicenter Bypass or Sleeve Study], conducted from January 2007 to November 2011, and Finnish SLEEVEPASS [Laparoscopic Gastric Bypass Vs Sleeve Gastrectomy to Treat Morbid Obesity], conducted from March 2008 until June 2010) that compared laparoscopic sleeve gastrectomy with laparoscopic Roux-en-Y gastric bypass in the treatment of severe obesity. This secondary analysis was performed from January 2022 to January 2023. Main Outcomes and Measures The main outcome was the feasibility of the SF-BARI Score and the SF-BARI Score QOL (quality of life) as tools to assess MBS outcomes. The score includes percentage of total weight loss (%TWL), 4 obesity-related comorbidities (type 2 diabetes, hypertension, dyslipidemia, and obstructive sleep apnea), complications, and QOL, if available. Results Among the 457 included patients, 323 (70.7%) were female and 134 (29.3%) were male, and the mean (SD) age was 45.6 (10.7) years. Outcomes for the SF-BARI Score were available for 435 patients (95.2%) at 1 year and 398 patients (87.1%) at 5 years and for SF-BARI Score QOL in 289 (63.2%) patients at 1 year and 318 patients (69.6%) at 5 years. The SF-BARI Score was correlated with both the SF-BARI Score QOL (r = 0.96; 95% CI, 0.95-0.96; P < .001) and %TWL (r = 0.86; 95% CI, 0.84-0.89; P < .001) and with the Bariatric Analysis and Reporting Outcome System (r = 0.59; 95% CI, 0.51-0.65; P < .001). Score outcomes were categorized as excellent, very good, good, fair, and suboptimal response. There was a statistically significant difference in scores at 1 vs 5 years (4.0; 95% CI, 1.4-6.6; P = .003), and the gastric bypass group had a higher score compared with the sleeve gastrectomy group (7.4; 95% CI, 3.4-11.5; P < .001). Conclusions and Relevance These findings indicate that this metabolic bariatric surgery outcome score is a simple, relevant, and feasible composite tool to define and measure MBS outcomes, enabling standardized reporting. Trial Registration ClinicalTrials.gov Identifiers: NCT00356213 (SM-BOSS) and NCT00793143 (SLEEVEPASS).
Collapse
Affiliation(s)
- Ralph Peterli
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Claraunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St Clara Hospital and University Hospital Basel, Basel, Switzerland
| | - Saija Hurme
- Department of Biostatistics, University of Turku and Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Marco Bueter
- Department of Surgery and Transplantation, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Surgery, Männedorf Hospital, Männedorf, Switzerland
| | - Sofia Grönroos
- Department of Surgery, University of Turku, Turku, Finland
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Mika Helmiö
- Department of Surgery, University of Turku, Turku, Finland
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Paulina Salminen
- Department of Surgery, University of Turku, Turku, Finland
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| |
Collapse
|
10
|
Rebelos E, Latva-Rasku A, Koskensalo K, Pekkarinen L, Saukko E, Ihalainen J, Honka MJ, Tuisku J, Bucci M, Laurila S, Rajander J, Salminen P, Nummenmaa L, Jansen JFA, Ferrannini E, Nuutila P. Insulin-stimulated brain glucose uptake correlates with brain metabolites in severe obesity: A combined neuroimaging study. J Cereb Blood Flow Metab 2024; 44:407-418. [PMID: 37824728 PMCID: PMC10870965 DOI: 10.1177/0271678x231207114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 08/30/2023] [Accepted: 09/15/2023] [Indexed: 10/14/2023]
Abstract
The human brain undergoes metabolic adaptations in obesity, but the underlying mechanisms have remained largely unknown. We compared concentrations of often reported brain metabolites measured with magnetic resonance spectroscopy (1H-MRS, 3 T MRI) in the occipital lobe in subjects with obesity and lean controls under different metabolic conditions (fasting, insulin clamp, following weight loss). Brain glucose uptake (BGU) quantified with 18F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET)) was also performed in a subset of subjects during clamp. In dataset A, 48 participants were studied during fasting with brain 1H-MRS, while in dataset B 21 participants underwent paired brain 1H-MRS acquisitions under fasting and clamp conditions. In dataset C 16 subjects underwent brain 18F-FDG-PET and 1H-MRS during clamp. In the fasting state, total N-acetylaspartate was lower in subjects with obesity, while brain myo-inositol increased in response to hyperinsulinemia similarly in both lean participants and subjects with obesity. During clamp, BGU correlated positively with brain glutamine/glutamate, total choline, and total creatine levels. Following weight loss, brain creatine levels were increased, whereas increases in other metabolites remained not significant. To conclude, insulin signaling and glucose metabolism are significantly coupled with several of the changes in brain metabolites that occur in obesity.
Collapse
Affiliation(s)
- Eleni Rebelos
- Turku PET Centre, University of Turku, Turku, Finland
- Institute of Clinical Physiology, National Research Council (CNR), Pisa, Italy
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Aino Latva-Rasku
- Turku PET Centre, University of Turku, Turku, Finland
- Department of Endocrinology, Turku University Hospital, Turku, Finland
| | - Kalle Koskensalo
- Department of Medical Physics, Turku University Hospital, Turku, Finland
| | - Laura Pekkarinen
- Turku PET Centre, University of Turku, Turku, Finland
- Department of Endocrinology, Turku University Hospital, Turku, Finland
| | - Ekaterina Saukko
- Department of Radiology, Turku University Hospital, Turku, Finland
| | - Jukka Ihalainen
- Turku PET Centre, Accelerator Laboratory, Åbo Akademi University, Turku, Finland
| | | | - Jouni Tuisku
- Turku PET Centre, University of Turku, Turku, Finland
| | - Marco Bucci
- Turku PET Centre, University of Turku, Turku, Finland
- Theme Inflammation and Aging, Karolinska University Hospital, Stockholm, Sweden
- Division of Clinical Geriatrics, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Sanna Laurila
- Turku PET Centre, University of Turku, Turku, Finland
| | - Johan Rajander
- Turku PET Centre, Accelerator Laboratory, Åbo Akademi University, Turku, Finland
| | - Paulina Salminen
- Department of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Lauri Nummenmaa
- Turku PET Centre, University of Turku, Turku, Finland
- Department of Psychology University of Turku, Turku, Finland
| | - Jacobus FA Jansen
- Department of Radiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Ele Ferrannini
- Institute of Clinical Physiology, National Research Council (CNR), Pisa, Italy
| | - Pirjo Nuutila
- Turku PET Centre, University of Turku, Turku, Finland
- Department of Endocrinology, Turku University Hospital, Turku, Finland
| |
Collapse
|
11
|
Kermansaravi M, Chiappetta S, Parmar C, Shikora SA, Prager G, LaMasters T, Ponce J, Kow L, Nimeri A, Kothari SN, Aarts E, Abbas SI, Aly A, Aminian A, Bashir A, Behrens E, Billy H, Carbajo MA, Clapp B, Chevallier JM, Cohen RV, Dargent J, Dillemans B, Faria SL, Neto MG, Garneau PY, Gawdat K, Haddad A, ElFawal MH, Higa K, Himpens J, Husain F, Hutter MM, Kasama K, Kassir R, Khan A, Khoursheed M, Kroh M, Kurian MS, Lee WJ, Loi K, Mahawar K, McBride CL, Almomani H, Melissas J, Miller K, Misra M, Musella M, Northup CJ, O'Kane M, Papasavas PK, Palermo M, Peterson RM, Peterli R, Poggi L, Pratt JSA, Alqahtani A, Ramos AC, Rheinwalt K, Ribeiro R, Rogers AM, Safadi B, Salminen P, Santoro S, Sann N, Scott JD, Shabbir A, Sogg S, Stenberg E, Suter M, Torres A, Ugale S, Vilallonga R, Wang C, Weiner R, Zundel N, Angrisani L, De Luca M. Current recommendations for procedure selection in class I and II obesity developed by an expert modified Delphi consensus. Sci Rep 2024; 14:3445. [PMID: 38341469 PMCID: PMC10858961 DOI: 10.1038/s41598-024-54141-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/08/2024] [Indexed: 02/12/2024] Open
Abstract
Metabolic and bariatric surgery (MBS) is widely considered the most effective option for treating obesity, a chronic, relapsing, and progressive disease. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued new guidelines on the indications for MBS, which have superseded the previous 1991 National Institutes of Health guidelines. The aim of this study is to establish the first set of consensus guidelines for selecting procedures in Class I and II obesity, using an Expert Modified Delphi Method. In this study, 78 experienced bariatric surgeons from 32 countries participated in a two-round Modified Delphi consensus voting process. The threshold for consensus was set at an agreement or disagreement of ≥ 70.0% among the experts. The experts reached a consensus on 54 statements. The committee of experts reached a consensus that MBS is a cost-effective treatment option for Class II obesity and for patients with Class I obesity who have not achieved significant weight loss through non-surgical methods. MBS was also considered suitable for patients with Type 2 diabetes mellitus (T2DM) and a body mass index (BMI) of 30 kg/m2 or higher. The committee identified intra-gastric balloon (IGB) as a treatment option for patients with class I obesity and endoscopic sleeve gastroplasty (ESG) as an option for patients with class I and II obesity, as well as for patients with T2DM and a BMI of ≥ 30 kg/m2. Sleeve gastrectomy (1) and Roux-en-Y gastric bypass (RYGB) were also recognized as viable treatment options for these patient groups. The committee also agreed that one anastomosis gastric bypass (OAGB) is a suitable option for patients with Class II obesity and T2DM, regardless of the presence or severity of obesity-related medical problems. The recommendations for selecting procedures in Class I and II obesity, developed through an Expert Modified Delphi Consensus, suggest that the use of standard primary bariatric endoscopic (IGB, ESG) and surgical procedures (SG, RYGB, OAGB) are acceptable in these patient groups, as consensus was reached regarding these procedures. However, randomized controlled trials are still needed in Class I and II Obesity to identify the best treatment approach for these patients in the future.
Collapse
Affiliation(s)
- Mohammad Kermansaravi
- Department of Surgery, Minimally Invasive Surgery Research Center, Division of Minimally Invasive and Bariatric Surgery, Hazrat-e Fatemeh Hospital, Iran University of Medical Sciences, Tehran, Iran.
| | - Sonja Chiappetta
- Department of General and Laparoscopic Surgery, Obesity and Metabolic Surgery Unit, Ospedale Evangelico Betania, Naples, Italy.
| | | | - Scott A Shikora
- Department of Surgery, Center for Metabolic and Bariatric Surgery, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | | | - Teresa LaMasters
- Unitypoint Clinic Weight Loss Specialists, West Des Moines, IA, USA
- Department of Surgery, University of Iowa, Iowa City, IA, USA
| | - Jaime Ponce
- Bariatric Surgery Program, CHI Memorial Hospital, Chattanooga, TN, USA
| | - Lilian Kow
- Adelaide Bariatric Centre, Flinders University of South Australia, Adelaide, Australia
| | - Abdelrahman Nimeri
- Department of Surgery, Center for Metabolic and Bariatric Surgery, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Shanu N Kothari
- Prisma Health, Department of Surgery, University of South Carolina School of Medicine, Greenville, SC, USA
| | - Edo Aarts
- WeightWorks Clinics and Allurion Clinics, Amersfoort, The Netherlands
| | | | - Ahmad Aly
- Austin and Repatriation Medical Centre, University of Melbourne, Heidelberg, VIC, Australia
| | - Ali Aminian
- Department of General Surgery, Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ahmad Bashir
- Minimally Invasive and Bariatric Surgery, Gastrointestinal Bariatric and Metabolic Center (GBMC)-Jordan Hospital, Amman, Jordan
| | | | - Helmuth Billy
- Ventura Advanced Surgical Associates, Ventura, CA, USA
| | - Miguel A Carbajo
- Centre of Excellence for the Study and Treatment of Obesity and Diabetes, Valladolid, Spain
| | - Benjamin Clapp
- Department of Surgery, Texas Tech HSC Paul Foster School of Medicine, El Paso, TX, USA
| | | | - Ricardo V Cohen
- Center for the Treatment of Obesity and Diabetes, Hospital Alemão Oswaldo Cruz, Sao Paolo, Brazil
| | | | - Bruno Dillemans
- Department of General Surgery, AZ Sint Jan Brugge-Oostende, Bruges, Belgium
| | - Silvia L Faria
- Gastrocirurgia de Brasilia, University of Brasilia, Brasilia, Brazil
| | | | - Pierre Y Garneau
- Division of Bariatric Surgery, CIUSSS-NIM, Montreal, Canada
- Department of Surgery, Université de Montréal, Montréal, Canada
| | - Khaled Gawdat
- Bariatric Surgery Unit, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ashraf Haddad
- Minimally Invasive and Bariatric Surgery, Gastrointestinal Bariatric and Metabolic Center (GBMC)-Jordan Hospital, Amman, Jordan
| | | | - Kelvin Higa
- Fresno Heart and Surgical Hospital, UCSF Fresno, Fresno, CA, USA
| | - Jaques Himpens
- Bariatric Surgery Unit, Delta Chirec Hospital, Brussels, Belgium
| | - Farah Husain
- University of Arizona College of Medicine, Phoenix, USA
| | - Matthew M Hutter
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Kazunori Kasama
- Weight Loss and Metabolic Surgery Center, Yotsuya Medical Cube, Tokyo, Japan
| | - Radwan Kassir
- Department of Digestive Surgery, CHU Félix Guyon, Saint Denis, La Réunion, France
| | - Amir Khan
- Walsall Healthcare NHS Trust, Walsall, UK
| | | | - Matthew Kroh
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Marina S Kurian
- Department of Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Wei-Jei Lee
- Medical Weight Loss Center, China Medical University Shinchu Hospital, Zhubei City, Taiwan
| | - Ken Loi
- Director of St George Surgery, Sydney, Australia
| | - Kamal Mahawar
- South Tyneside and Sunderland Foundation NHS Trust, Sunderland, UK
| | | | | | - John Melissas
- Bariatric Unit, Heraklion University Hospital, University of Crete, Crete, Greece
| | - Karl Miller
- Diakonissen Wehrle Private Hospital, Salzburg, Austria
| | | | - Mario Musella
- Advanced Biomedical Sciences Department, Federico II" University, Naples, Italy
| | | | - Mary O'Kane
- Department of Nutrition and Dietetics, Leeds Teaching Hospitals, NHS Trust, Leeds, UK
| | - Pavlos K Papasavas
- Division of Metabolic and Bariatric Surgery, Hartford Hospital, Hartford, CT, USA
| | - Mariano Palermo
- Department of Surgery, Centro CIEN-Diagnomed, University of Buenos Aires, Buenos Aires, Argentina
| | - Richard M Peterson
- Department of General and Minimally Invasive Surgery, UT Health San Antonio, San Antonio, TX, USA
| | - Ralph Peterli
- Department of Visceral Surgery, Clarunis, University Digestive Health Care Center, St. Clara Hospital and University Hospital Basel, Basel, Switzerland
| | - Luis Poggi
- Department of Surgery Clinica Anglo Americana, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Janey S A Pratt
- Department of Surgery, Stanford School of Medicine, VA Palo Alto Health Care System, 3801 Miranda Avenue, GS 112, Palo Alto, CA, 94304, USA
| | - Aayad Alqahtani
- New You Medical Center, King Saud University, Obesity Chair, Riyadh, Saudi Arabia
| | - Almino C Ramos
- Medical Director of Gastro-Obeso-Center, Institute for Metabolic Optimization, Sao Paulo, Brazil
| | - Karl Rheinwalt
- Department of Bariatric, Metabolic, and Plastic Surgery, St. Franziskus Hospital, Cologne, Germany
| | - Rui Ribeiro
- Centro Multidisciplinar Do Tratamento da Obesidade, Hospital Lusíadas Amadora e Lisbon, Amadora, Portugal
| | - Ann M Rogers
- Department of Surgery - Division of Minimally Invasive and Bariatric Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | | | - Paulina Salminen
- Division of Digestive Surgery and Urology, Department of Digestive Surgery, Turku University Hospital, Turku, Finland
| | - Sergio Santoro
- Hospital Israelita Albert Einstein, Av. Albert Einstein, 627, São Paulo, 05652-900, Brazil
| | - Nathaniel Sann
- Advanced Surgical Partners of Virginia, Richmond, VA, USA
| | - John D Scott
- Division of Bariatric and Minimal Access Surgery, Department of Surgery, University of South Carolina School of Medicine, Greenville, SC, USA
| | - Asim Shabbir
- National University of Singapore, Singapore, Singapore
| | - Stephanie Sogg
- Massachusetts General Hospital Weight Center, Boston, MA, USA
| | - Erik Stenberg
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Michel Suter
- Department of Surgery, Riviera-Chablais Hospital, Rennaz, Switzerland
| | - Antonio Torres
- Department of Surgery, Hospital Clínico San Carlos, Complutense University of Madrid, Calle del Prof Martín Lagos, S/N, 28040, Madrid, Spain
| | - Surendra Ugale
- Kirloskar and Virinchi Hospitals, Hyderabad, Telangana, India
| | - Ramon Vilallonga
- Endocrine, Bariatric, and Metabolic Surgery Department, Universitary Hospital Vall Hebron, Barcelona, Spain
| | - Cunchuan Wang
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Rudolf Weiner
- Bariatric Surgery Unit, Sana Clinic Offenbach, Offenbach, Germany
| | - Natan Zundel
- Department of Surgery, University of Buffalo, Buffalo, NY, USA
| | - Luigi Angrisani
- Department of Public Health, Federico II University of Naples, Naples, Italy
| | | |
Collapse
|
12
|
Salminen P, Kow L, Aminian A, Kaplan LM, Nimeri A, Prager G, Behrens E, White KP, Shikora S. IFSO Consensus on Definitions and Clinical Practice Guidelines for Obesity Management-an International Delphi Study. Obes Surg 2024; 34:30-42. [PMID: 37999891 PMCID: PMC10781804 DOI: 10.1007/s11695-023-06913-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/13/2023] [Accepted: 10/18/2023] [Indexed: 11/25/2023]
Abstract
INTRODUCTION This survey of international experts in obesity management was conducted to achieve consensus on standardized definitions and to identify areas of consensus and non-consensus in metabolic bariatric surgery (MBS) to assist in an algorithm of clinical practice guidelines for the management of obesity. METHODS A three-round Delphi survey with 136 statements was conducted by 43 experts in obesity management comprising 26 bariatric surgeons, 4 endoscopists, 8 endocrinologists, 2 nutritionists, 2 counsellors, an internist, and a pediatrician spanning six continents over a 2-day meeting in Hamburg, Germany. To reduce bias, voting was unanimous, and the statements were neither favorable nor unfavorable to the issue voted or evenly balanced between favorable and unfavorable. Consensus was defined as ≥ 70% inter-voter agreement. RESULTS Consensus was reached on all 15 essential definitional and reporting statements, including initial suboptimal clinical response, baseline weight, recurrent weight gain, conversion, and revision surgery. Consensus was reached on 95/121 statements on the type of surgical procedures favoring Roux-en-Y gastric bypass, sleeve gastrectomy, and endoscopic sleeve gastroplasty. Moderate consensus was reached for sleeve gastrectomy single-anastomosis duodenoileostomy and none on the role of intra-gastric balloons. Consensus was reached for MBS in patients > 65 and < 18 years old, with a BMI > 50 kg/m2, and with various obesity-related complications such as type 2 diabetes, liver, and kidney disease. CONCLUSIONS In this survey of 43 multi-disciplinary experts, consensus was reached on standardized definitions and reporting standards applicable to the whole medical community. An algorithm for treating patients with obesity was explored utilizing a thoughtful multimodal approach.
Collapse
Affiliation(s)
- Paulina Salminen
- Department of Surgery, University of Turku, Turku, Finland.
- Division of Digestive Surgery and Urology, Turku University Hospital, P.O. Box 52, 20521, Turku, Finland.
| | - Lilian Kow
- Department of Surgery, Flinders University, Adelaide, SA, Australia
| | - Ali Aminian
- Department of General Surgery, Cleveland Clinic, Bariatric and Metabolic Institute, Cleveland, OH, USA
| | - Lee M Kaplan
- Section On Obesity Medicine, Geisel School of Medicine at Darthmouth, Hanover, NH, USA
| | - Abdelrahman Nimeri
- Division of General & GI Surgery, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gerhard Prager
- Division of Visceral Surgery, Vienna Medical University, Vienna, Austria
| | | | - Kevin P White
- ScienceRight International Health Research, London, ON, Canada
| | - Scott Shikora
- Division of General & GI Surgery, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
13
|
Salminen R, Rautio T, Nordström P, Rantanen T, Mällinen J, Grönroos J, Salminen P. Five-year follow-up of appendiceal neoplasm risk in periappendicular abscess in the Peri-Appendicitis Acuta Randomized Clinical Trial. Scand J Surg 2023; 112:265-268. [PMID: 37655682 DOI: 10.1177/14574969231192128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Affiliation(s)
- Roosa Salminen
- Department of Surgery, University of Oulu, Oulu, Finland
| | - Tero Rautio
- Department of Surgery, University of Oulu, Oulu, Finland
- Division of Operative Care, Oulu University Hospital and Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Pia Nordström
- Divison of Surgery, Gastroenterology and Oncology, Tampere University Hospital, Tampere, Finland
| | - Tuomo Rantanen
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Jari Mällinen
- Department of Surgery, University of Oulu, Oulu, Finland
- Division of Operative Care, Oulu University Hospital and Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Juha Grönroos
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Paulina Salminen
- Paulina Salminen Division of Digestive Surgery and Urology Turku University Hospital P.O. Box 52 Turku 20520 Finland
- Department of Surgery University of Turku Turku Finland
| |
Collapse
|
14
|
Kivivuori A, Salminen P, Ukkonen M, Ilves I, Vihervaara H, Zalevskaja K, Pajari J, Paajanen H, Rantanen T. Laparoscopic cholecystectomy versus antibiotic therapy for acute cholecystitis in patients over 75 years: Randomized clinical trial and retrospective cohort study. Scand J Surg 2023; 112:219-226. [PMID: 37572012 DOI: 10.1177/14574969231178650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/14/2023]
Abstract
BACKGROUND AND OBJECTIVE The prevalence of acute cholecystitis among elderly patients is increasing. The aim of this study was to compare laparoscopic cholecystectomy (LC) to antibiotics in elderly patients with acute cholecystitis. METHODS A randomized multicenter clinical trial including patients over 75 years with acute calculous cholecystitis was conducted in four hospitals in Finland between January 2017 and December 2019. Patients were randomized to undergo LC or antibiotic therapy. Due to patient enrollment challenges, the trial was prematurely terminated in December 2019. To assess all eligible patients, we performed a retrospective cohort study including all patients over 75 years with acute cholecystitis during the study period. The primary outcome was morbidity. Predefined secondary outcomes included mortality, readmission rate, and length of hospital stay. RESULTS Among 42 randomized patients (LC n = 24, antibiotics n = 18, mean age 82 years, 43% women), the complication rate was 17% (n = 4/24) after cholecystectomy and 33% (n = 6/18, 5/6 patients underwent cholecystectomy due to antibiotic treatment failure) after antibiotics (p = 0.209). In the retrospective cohort (n = 630, mean age 83 years, 49% women), 37% (236/630) of the patients were treated with cholecystectomy and 63% (394/630) with antibiotics. Readmissions were less common after surgical treatment compared with antibiotics in both randomized and retrospective cohort patients (8% vs 44%, p < 0.001% and 11 vs 32%, p < 0.001, respectively). There was no 30-day mortality within the randomized trial. In the retrospective patient cohort, overall mortality was 6% (35/630). CONCLUSIONS LC may be superior to antibiotic therapy for acute cholecystitis in the selected group of elderly patients with acute cholecystitis.
Collapse
Affiliation(s)
- Antti Kivivuori
- Kuopio University Hospital Puijonlaaksontie 270210 Kuopio Finland
| | - Paulina Salminen
- Turku University Hospital, Turku, Finland
- University of Turku, Turku, Finland
| | | | - Imre Ilves
- Mikkeli Central Hospital, Mikkeli, Finland
| | - Hanna Vihervaara
- Turku University Hospital, Turku, Finland
- University of Turku, Turku, Finland
| | | | | | - Hannu Paajanen
- Mikkeli Central Hospital, Mikkeli, Finland
- University of Eastern Finland, Kuopio, Finland
| | - Tuomo Rantanen
- Kuopio University Hospital, Kuopio, Finland
- University of Eastern Finland, Kuopio, Finland
| |
Collapse
|
15
|
Fleming CA, Augustinus S, Lemmers DHL, López-López V, Nitschke C, Farges O, Salminen P, O'Connell PR, Campos RR, Caiazzo R. Career Needs Assessment for Early Career Academic Surgeons Using a Modified Accelerated Delphi Process. Ann Surg 2023; 278:655-661. [PMID: 37465982 DOI: 10.1097/sla.0000000000006014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
INTRODUCTION Over the past 2 decades, physicians' wellbeing has become a topic of interest. It is currently unclear what the current needs are of early career academic surgeons (ECAS). METHODS Consensus statements on academic needs were developed during a Delphi process, including all presenters from the previous European Surgical Association (ESA) meetings (2018-2022). The Delphi involved (1) a literature review, (2) Delphi form generation, and (3) an accelerated Delphi process. The Delphi form was generated by a steering group that discussed findings identified within the literature. The modified accelerated e-consensus approach included 3 rounds over a 4-week period. Consensus was defined as >80% agreement in any round. RESULTS Forty respondents completed all 3 rounds of the Delphi. Median age was 37 years (interquartile range 5), and 53% were female. Majority were consultant/attending (52.5%), followed by PhD (22.5%), fellowship (15%), and residency (10%). ECAS was defined as a surgeon in 'development' years of clinical and academic practice relative to their career goals (87.9% agreement). Access to split academic and clinical contracts is desirable (87.5%). Consensus on the factors contributing to ECAS underperformance included: burnout (94.6%), lack of funding (80%), lack of mentorship (80%), and excessive clinical commitments (80%). Desirable factors to support ECAS development included: access to e-learning (90.9%), face-to-face networking opportunities (95%), support for research team development (100%), and specific formal mentorship (93.9%). CONCLUSION The evolving role and responsibilities of ECAS require increasing strategic support, mentorship, and guidance on structured career planning. This will facilitate workforce sustainability in academic surgery in the future.
Collapse
Affiliation(s)
- Christina A Fleming
- Department of Colorectal Surgery, University of Limerick Hospital Group, Limerick, Ireland
- PROGRESS Fellow, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Simone Augustinus
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Daan H L Lemmers
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Fondazione Poliambulanza, Brescia, Italy
| | - Victor López-López
- Department of Surgery and Liver and Pancreas Transplantation, Virgen de la Arrixaca Clinic and University Hospital, IMIB-Arrixaca, Murcia, Spain
| | - Christine Nitschke
- Department of General Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Olivier Farges
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France
| | - Paulina Salminen
- Departments of Acute and Digestive Surgery, Turku University Hospital, Turku, Finland
| | | | - Ricardo Robles Campos
- Department of Surgery and Liver and Pancreas Transplantation, Virgen de la Arrixaca Clinic and University Hospital, IMIB-Arrixaca, Murcia, Spain
| | - Robert Caiazzo
- Department of Endocrine Surgery, Lille University Hospital, Lille, France
| |
Collapse
|
16
|
Salminen P, Aminian A. Treatment of Severe Obesity-All-Hands-on-Deck Approach. JAMA Surg 2023; 158:1011-1012. [PMID: 37494032 DOI: 10.1001/jamasurg.2023.2931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Affiliation(s)
- Paulina Salminen
- Department of Digestive Surgery, Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Ali Aminian
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
17
|
Saux P, Bauvin P, Raverdy V, Teigny J, Verkindt H, Soumphonphakdy T, Debert M, Jacobs A, Jacobs D, Monpellier V, Lee PC, Lim CH, Andersson-Assarsson JC, Carlsson L, Svensson PA, Galtier F, Dezfoulian G, Moldovanu M, Andrieux S, Couster J, Lepage M, Lembo E, Verrastro O, Robert M, Salminen P, Mingrone G, Peterli R, Cohen RV, Zerrweck C, Nocca D, Le Roux CW, Caiazzo R, Preux P, Pattou F. Development and validation of an interpretable machine learning-based calculator for predicting 5-year weight trajectories after bariatric surgery: a multinational retrospective cohort SOPHIA study. Lancet Digit Health 2023; 5:e692-e702. [PMID: 37652841 DOI: 10.1016/s2589-7500(23)00135-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 05/04/2023] [Accepted: 07/11/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Weight loss trajectories after bariatric surgery vary widely between individuals, and predicting weight loss before the operation remains challenging. We aimed to develop a model using machine learning to provide individual preoperative prediction of 5-year weight loss trajectories after surgery. METHODS In this multinational retrospective observational study we enrolled adult participants (aged ≥18 years) from ten prospective cohorts (including ABOS [NCT01129297], BAREVAL [NCT02310178], the Swedish Obese Subjects study, and a large cohort from the Dutch Obesity Clinic [Nederlandse Obesitas Kliniek]) and two randomised trials (SleevePass [NCT00793143] and SM-BOSS [NCT00356213]) in Europe, the Americas, and Asia, with a 5 year follow-up after Roux-en-Y gastric bypass, sleeve gastrectomy, or gastric band. Patients with a previous history of bariatric surgery or large delays between scheduled and actual visits were excluded. The training cohort comprised patients from two centres in France (ABOS and BAREVAL). The primary outcome was BMI at 5 years. A model was developed using least absolute shrinkage and selection operator to select variables and the classification and regression trees algorithm to build interpretable regression trees. The performances of the model were assessed through the median absolute deviation (MAD) and root mean squared error (RMSE) of BMI. FINDINGS 10 231 patients from 12 centres in ten countries were included in the analysis, corresponding to 30 602 patient-years. Among participants in all 12 cohorts, 7701 (75·3%) were female, 2530 (24·7%) were male. Among 434 baseline attributes available in the training cohort, seven variables were selected: height, weight, intervention type, age, diabetes status, diabetes duration, and smoking status. At 5 years, across external testing cohorts the overall mean MAD BMI was 2·8 kg/m2 (95% CI 2·6-3·0) and mean RMSE BMI was 4·7 kg/m2 (4·4-5·0), and the mean difference between predicted and observed BMI was -0·3 kg/m2 (SD 4·7). This model is incorporated in an easy to use and interpretable web-based prediction tool to help inform clinical decision before surgery. INTERPRETATION We developed a machine learning-based model, which is internationally validated, for predicting individual 5-year weight loss trajectories after three common bariatric interventions. FUNDING SOPHIA Innovative Medicines Initiative 2 Joint Undertaking, supported by the EU's Horizon 2020 research and innovation programme, the European Federation of Pharmaceutical Industries and Associations, Type 1 Diabetes Exchange, and the Juvenile Diabetes Research Foundation and Obesity Action Coalition; Métropole Européenne de Lille; Agence Nationale de la Recherche; Institut national de recherche en sciences et technologies du numérique through the Artificial Intelligence chair Apprenf; Université de Lille Nord Europe's I-SITE EXPAND as part of the Bandits For Health project; Laboratoire d'excellence European Genomic Institute for Diabetes; Soutien aux Travaux Interdisciplinaires, Multi-établissements et Exploratoires programme by Conseil Régional Hauts-de-France (volet partenarial phase 2, project PERSO-SURG).
Collapse
Affiliation(s)
- Patrick Saux
- Université de Lille, Inria, CNRS, Centrale Lille, UMR 9189 - CRIStAL, France
| | - Pierre Bauvin
- Université de Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1190-EGID, Lille, France
| | - Violeta Raverdy
- Université de Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1190-EGID, Lille, France
| | - Julien Teigny
- Université de Lille, Inria, CNRS, Centrale Lille, UMR 9189 - CRIStAL, France
| | - Hélène Verkindt
- Université de Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1190-EGID, Lille, France
| | - Tomy Soumphonphakdy
- Université de Lille, Inria, CNRS, Centrale Lille, UMR 9189 - CRIStAL, France
| | - Maxence Debert
- Université de Lille, Inria, CNRS, Centrale Lille, UMR 9189 - CRIStAL, France
| | - Anne Jacobs
- Nederlandse Obesitas Kliniek, Huis Ter Heide, Netherlands
| | - Daan Jacobs
- Nederlandse Obesitas Kliniek, Huis Ter Heide, Netherlands
| | | | - Phong Ching Lee
- Department of Endocrinology, Division of Medicine, Singapore General Hospital, Singapore
| | - Chin Hong Lim
- Department of Upper Gastrointestinal and Bariatric Surgery, Division of Surgery, Singapore General Hospital, Singapore
| | - Johanna C Andersson-Assarsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Lena Carlsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Per-Arne Svensson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden; Institute of Health and Care Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Florence Galtier
- Endocrinology Department, CHU de Montpellier, University of Montpellier, Montpellier, France; Clinical Investigation Center 1411, INSERM, CHU de Montpellier, University of Montpellier, Montpellier, France
| | | | | | | | - Julien Couster
- Centre Hospitalier Boulogne-sur-Mer, Boulogne-sur-Mer, France
| | - Marie Lepage
- Centre Hospitalier Boulogne-sur-Mer, Boulogne-sur-Mer, France
| | - Erminia Lembo
- Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore Rome, Rome, Italy
| | - Ornella Verrastro
- Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore Rome, Rome, Italy
| | - Maud Robert
- Department of Digestive Surgery, Center of Bariatric Surgery, Hopital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland; Department of Surgery, University of Turku, Turku, Finland
| | - Geltrude Mingrone
- Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore Rome, Rome, Italy
| | - Ralph Peterli
- University of Basle, Basle, Switzerland; Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St Clara Hospital and University Hospital Basle, Basle, Switzerland
| | - Ricardo V Cohen
- The Center for Obesity and Diabetes, Oswaldo Cruz German Hospital, São Paulo, Brazil
| | - Carlos Zerrweck
- Clínica Integral de Cirugía para la Obesidad y Enfermedades Metabólicas, Hospital General Tláhuac, Mexico City, Mexico
| | - David Nocca
- Department of Digestive Surgery, CHU de Montpellier, University of Montpellier, Montpellier, France
| | | | - Robert Caiazzo
- Université de Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1190-EGID, Lille, France
| | - Philippe Preux
- Université de Lille, CNRS, Inria, Centrale Lille, UMR 9189 - CRIStAL, Lille, France.
| | - François Pattou
- Université de Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1190-EGID, Lille, France.
| |
Collapse
|
18
|
Salminen P, Stenberg E, Batterham R. Benefits of Mandated Registries for Generating Real-World Outcome Data. JAMA Surg 2023; 158:824. [PMID: 37223923 DOI: 10.1001/jamasurg.2023.1646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Paulina Salminen
- Department of Digestive Surgery, Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Erik Stenberg
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Rachel Batterham
- Division of Medicine, University College of London, London, United Kingdom
| |
Collapse
|
19
|
Talan DA, Salminen P. Management of Acute Uncomplicated Appendicitis. JAMA Surg 2023; 158:328-329. [PMID: 36515927 DOI: 10.1001/jamasurg.2022.6541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- David A Talan
- Ronald Reagan UCLA Medical Center, Department of Emergency Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles
| | - Paulina Salminen
- Department of Surgery, University of Turku, Turku, Finland.,Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| |
Collapse
|
20
|
Salminen P, Grönroos S, Helmiö M. Laparoscopic Sleeve Gastrectomy vs Roux-en-Y Gastric Bypass in Adult Patients With Obesity-Reply. JAMA Surg 2023; 158:219-220. [PMID: 36350611 DOI: 10.1001/jamasurg.2022.5330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | - Sofia Grönroos
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | - Mika Helmiö
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| |
Collapse
|
21
|
Winter DC, Haukoos J, Salminen P. Practical Guide to Clinical Trial Publication. JAMA Surg 2023; 158:208-209. [PMID: 36287533 DOI: 10.1001/jamasurg.2022.4910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This Guide to Statistics and Methods describes the process for publishing about a clinical trial by planning its clinical relevance, knowing the audience, and following reporting guidelines.
Collapse
Affiliation(s)
- Des C Winter
- Division of Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - Jason Haukoos
- Department of Emergency Medicine, Denver Health Medical Center, University of Colorado School of Medicine, Denver.,Department of Epidemiology, Colorado School of Public Health, Aurora.,Statistical Editor, JAMA Surgery
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| |
Collapse
|
22
|
Fleshman J, Haukoos J, Salminen P. Practical Guide to Surgical Clinical Trial Implementation, Oversight, and Regulatory Aspects. JAMA Surg 2023; 158:93-94. [PMID: 36287531 DOI: 10.1001/jamasurg.2022.4901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
This Guide to Statistics and Methods describes the steps necessary for a successful trial implementation that can safeguard credible results and conclusions while minimizing potential harm.
Collapse
Affiliation(s)
- James Fleshman
- Department of Surgery, Baylor University Medical Center, Dallas, Texas
| | - Jason Haukoos
- Department of Emergency Medicine, Denver Health Medical Center, University of Colorado School of Medicine, Denver.,Department of Epidemiology, Colorado School of Public Health, Aurora.,Statistical Editor, JAMA Surgery
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| |
Collapse
|
23
|
Fingerhut A, Wexner S, Behrns K, Arrezo A, Buhler L, Francis N, Keller DS, Knoefel W, Salminen P, Swanstrom L, Winter D. Why say “statistically significant” rather than just “significant”—a plea to rid the medical literature of linguistic ambiguity. Ann Laparosc Endosc Surg 2023. [DOI: 10.21037/ales-22-78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
|
24
|
Kim LT, Kaji AH, Salminen P. Practical Guide to Quality Control in Surgical Trials. JAMA Surg 2023; 158:91-92. [PMID: 36287542 DOI: 10.1001/jamasurg.2022.4898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
This Guide to Statistics and Methods outlines the elements of clinical trial quality control that are important to safeguarding data integrity and addressing the unique challenges of procedural trials.
Collapse
Affiliation(s)
- Lawrence T Kim
- Department of Surgery, Division of Surgical Oncology and Endocrine Surgery, University of North Carolina at Chapel Hill
| | - Amy H Kaji
- Department of Emergency Medicine, Harbor-UCLA Medical Center, David Geffen School of Medicine at University of California, Los Angeles, Torrance.,Statistical Editor, JAMA Surgery
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| |
Collapse
|
25
|
Puputti J, Suominen JS, Luoto T, Hiltunen P, Ripatti L, Nikoskelainen M, Nuutinen S, Sinikumpu JJ, Tahkola E, Porela-Tiihonen S, Hurme S, Salminen P, Pakarinen MP. A randomized, controlled multicenter feasibility pilot trial on imaging confirmed uncomplicated acute appendicitis: Appendectomy vs. symptomatic treatment in pediatric patients (the APPSYPP) trial study protocol. Contemp Clin Trials 2022; 123:106970. [PMID: 36280033 DOI: 10.1016/j.cct.2022.106970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 10/16/2022] [Accepted: 10/18/2022] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Imaging-confirmed uncomplicated acute appendicitis can be effectively and safely treated with antibiotics in most adults and children. Symptomatic treatment may have similar efficacy and safety. METHODS AND ANALYSIS The APPSYPP trial is a randomized national multicenter feasibility superiority pilot study comparing appendectomy with symptomatic treatment in children with imaging-confirmed uncomplicated acute appendicitis. INCLUSION CRITERIA 1) age ≥ 7 and < 16 years, 2) imaging-confirmed uncomplicated acute appendicitis and 3) CRP ≤ 65 mg/l. Patients are randomized to receive emergency laparoscopic appendectomy or symptomatic treatment. To ensure patient safety, symptomatically treated patients are hospitalized for at least 24 h receiving standard practice intravenous fluids and analgesics according to standard clinical practice. Primary outcome is 30-day treatment success defined by the absence of any treatment failure criteria. In appendectomy, treatment failure is defined as normal appendiceal histopathology or any postintervention complication requiring general anesthesia. In symptomatic treatment, treatment failure is defined as 1) inability for hospital discharge without appendectomy within 48 h after randomization with a finding of histopathologically inflamed appendix, 2) appendectomy during the initial hospital stay due to clinical progression of appendicitis with complicated acute appendicitis both histopathologically and surgically, 3) appendectomy with a histopathological finding of acute appendicitis after hospital discharge, or 4) any complication of appendicitis requiring general anesthesia. Detailed predefined secondary outcomes will be analyzed. ETHICS AND DISSEMINATION Study was approved by Ethics Committee of Helsinki University Hospital (ID:HUS/1993/2021), conducted in compliance with the declaration of Helsinki with results disseminated in peer-reviewed scientific journals. TRIAL REGISTRATION ClinicalTrials.gov (NCT05289713). STRENGTHS AND LIMITATIONS OF THIS STUDY
Collapse
Affiliation(s)
- Jenny Puputti
- Department of Pediatric Surgery, Helsinki University Central Hospital, Helsinki, Finland.
| | - Janne S Suominen
- Department of Pediatric Surgery, Helsinki University Central Hospital, Helsinki, Finland.
| | - Topi Luoto
- Department of Pediatric Surgery, Tampere University Hospital, Tampere, Finland
| | - Pauliina Hiltunen
- Department of Pediatrics, Tampere University Hospital, Tampere, Finland
| | - Liisi Ripatti
- Department of Pediatric Surgery, TYKS Turku University Hospital, Turku, Finland
| | | | - Susanna Nuutinen
- Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
| | | | - Esko Tahkola
- Department of Pediatric Surgery, Kuopio University Hospital, Kuopio, Finland
| | | | - Saija Hurme
- Department of Biostatistics, University of Turku, Turku, Finland
| | - Paulina Salminen
- Department of Surgery, Turku University Hospital, University of Turku, Turku, Finland
| | - Mikko P Pakarinen
- Department of Pediatric Surgery, Helsinki University Central Hospital, Helsinki, Finland and Karolinska University, Stockholm, Sweden
| |
Collapse
|
26
|
Saarinen I, Grönroos S, Hurme S, Peterli R, Helmiö M, Bueter M, Strandberg M, Wölnerhanssen BK, Salminen P. Validation of the Individual Metabolic Surgery Score for Bariatric Procedure Selection in the Merged Data of Two Randomized Clinical Trials (SLEEVEPASS and SM-BOSS). Surg Obes Relat Dis 2022; 19:522-529. [PMID: 36503734 DOI: 10.1016/j.soard.2022.10.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 10/06/2022] [Accepted: 10/27/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND LSG and LRYGB are globally the most common bariatric procedures. IMS score categorizes T2D severity (mild, moderate, and severe) based on 4 independent preoperative predictors of long-term remission as follows: T2D duration, number of diabetes medications, insulin use, and glycemic control. IMS score has not been validated in a randomized patient cohort. OBJECTIVES To assess the feasibility of individualized metabolic surgery (IMS) score in facilitating procedure selection between laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) for patients with severe obesity and type 2 diabetes (T2D). SETTING Merged individual patient-level 5-year data of 2 large randomized clinical trials (SLEEVEPASS and SM-BOSS [Swiss Multicenter Bypass or Sleeve Study]). METHODS IMS score was calculated for study patients and its performance was analyzed. RESULTS One hundred thirty-nine out of 155 patients with T2D had available preoperative data to calculate IMS score as follows: mild stage (n = 41/139), moderate stage (n = 77/139), severe stage (n = 21/139). At 5 years, 135 (87.1%, 67 LSG/68 LRYGB) were available for follow-up and 121 patients had both pre- and postoperative data. Diabetes remission rates according to preoperative IMS score were as follows: mild stage 87.5% (n = 14/16) after LSG and 85.7% (n = 18/21) after LRYGB (P = .999), moderate stage 42.9% (n = 15/35) and 45.2% (n = 14/31) (P = .999), and severe stage 18.2% (n = 2/11) and 0% (n = 0/7) (P = .497), respectively. The T2D remission rate varied significantly between the stages as follows: mild versus moderate odds ratio (OR) 8.3 (95% CI, 2.8-24.0; P < .001), mild versus severe OR 52.2 (95% CI 9.0-302.3; P < .001), and moderate versus severe OR 6.3 (95% CI, 1.3-29.8; P = .020). CONCLUSIONS In our study, remission rates of T2D were not statistically different after LSG and LRYGB among all patients and among patients with mild, moderate, and severe diabetes stratified by the IMS score. However, the study may be underpowered to detect differences due to small number of patients in each subgroup. IMS score seemed to be useful in predicting long-term T2D remission after bariatric surgery.
Collapse
|
27
|
Vanhatalo S, Munukka E, Kallonen T, Sippola S, Grönroos J, Haijanen J, Hakanen AJ, Salminen P. Appendiceal microbiome in uncomplicated and complicated acute appendicitis: A prospective cohort study. PLoS One 2022; 17:e0276007. [PMID: 36240181 PMCID: PMC9565418 DOI: 10.1371/journal.pone.0276007] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 09/12/2022] [Indexed: 11/05/2022] Open
Abstract
Background Uncomplicated and complicated acute appendicitis seem to be two different forms of this common abdominal emergency. The contribution of appendiceal microbiota to appendicitis pathogenesis has been suggested, but differences between uncomplicated and complicated appendicitis are largely unknown. We compared the appendiceal microbiota in uncomplicated and complicated acute appendicitis. Methods This prospective single-center clinical cohort study was conducted as part of larger multicenter MAPPAC trial enrolling adult patients with computed tomography or clinically confirmed uncomplicated or complicated acute appendicitis. The microbial composition of the appendiceal lumen was determined using 16S rRNA gene amplicon sequencing. Results Between April 11, 2017, and March 29, 2019, 118 samples (41 uncomplicated and 77 complicated appendicitis) were available. After adjusting for age, sex, and BMI, alpha diversity in complicated appendicitis was higher (Shannon p = 0.011, Chao1 p = 0.006) compared to uncomplicated appendicitis. Microbial compositions were different between uncomplicated and complicated appendicitis (Bray-Curtis distance, P = 0.002). Species poor appendiceal microbiota composition with specific predominant bacteria was present in some patients regardless of appendicitis severity. Conclusion Uncomplicated and complicated acute appendicitis have different appendiceal microbiome profiles further supporting the disconnection between these two different forms of acute appendicitis. Study registration ClinicalTrials.gov NCT03257423.
Collapse
Affiliation(s)
- Sanja Vanhatalo
- Research Center for Infections and Immunity, Institute of Biomedicine, University of Turku, Turku, Finland
- Laboratory Division, Department of Clinical Microbiology, Turku University Hospital, Turku, Finland
| | - Eveliina Munukka
- Faculty of Medicine, Microbiome Biobank, University of Turku and Turku University Hospital, Turku, Finland
- Biocodex Nordics, Espoo, Finland
| | - Teemu Kallonen
- Research Center for Infections and Immunity, Institute of Biomedicine, University of Turku, Turku, Finland
- Laboratory Division, Department of Clinical Microbiology, Turku University Hospital, Turku, Finland
- Faculty of Medicine, Microbiome Biobank, University of Turku and Turku University Hospital, Turku, Finland
| | - Suvi Sippola
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Juha Grönroos
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Jussi Haijanen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Antti J. Hakanen
- Research Center for Infections and Immunity, Institute of Biomedicine, University of Turku, Turku, Finland
- Laboratory Division, Department of Clinical Microbiology, Turku University Hospital, Turku, Finland
- Faculty of Medicine, Microbiome Biobank, University of Turku and Turku University Hospital, Turku, Finland
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
- * E-mail:
| |
Collapse
|
28
|
Fingerhut A, Wexner S, Behrns K, Arrezo A, Buhler L, Francis N, Keller DS, Knoefel W, Salminen P, Swanstrom L, Winter D. Why say "statistically significant" rather than just "significant"? a plea to rid the medical literature of linguistic ambiguity. Surgery 2022; 172:1039-1040. [PMID: 36150773 DOI: 10.1016/j.surg.2022.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Abe Fingerhut
- GuangCi Laureate Professor Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine and Shanghai Minimally Invasive Surgery Center, Shanghai, P. R. China and Section for Surgical Research, Department of Surgery, Medical University of Graz, Austria
| | - Steve Wexner
- Director Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL USA
| | - Kevin Behrns
- Professor of Surgery, Chief Medical Officer, University of Florida Central Florida USA
| | - Alberto Arrezo
- Department of Surgical Sciences, University of Turin, Italy
| | - Leo Buhler
- Professor of Surgery University of Fribourg, Fribourg, Switzerland
| | - Nader Francis
- Honorary Professor at the Division of Surgery and Interventional Science - UCL, London, Great Britain
| | - Deborah S Keller
- Marks Colorectal Surgical Associates, Lankenau Medical Center, Wynnewood, PA, USA
| | - Wolfram Knoefel
- Professor of Surgery University Hospital Dusseldorf, Germany
| | - Paulina Salminen
- Chief of Surgery Department of Surgery, University of Turku, Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Lee Swanstrom
- Professor of Surgery, Oregon Health and Science University, Portland Oregon, USA; Chief Innovations Officer and Scientific Director IHU-Strasbourg; France
| | - Des Winter
- Professor of Surgery St Vincent's Private Hospital Dublin, Ireland
| |
Collapse
|
29
|
Sula S, Han T, Marttila H, Haijanen J, Löyttyniemi E, Sippola S, Grönroos J, Hakanen AJ, Salminen P. Blood culture positivity in patients with acute appendicitis: A propensity score-matched prospective cohort study. Scand J Surg 2022; 111:31-38. [PMID: 36000748 DOI: 10.1177/14574969221110754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND OBJECTIVE The prevalence of bacteremia in acute appendicitis is unknown. We aimed to assess prevalence and predictive factors of bacteremia in adult patients with appendicitis. METHODS In this prospective propensity score-matched cohort study, patients were recruited as part of one single-center prospective observational study assessing appendicitis microbiology in concurrence with two randomized controlled trials on non-operative treatment of uncomplicated acute appendicitis. All patients evaluated for enrollment in these three trials between April 2017 and December 2018 with both a confirmed diagnosis of appendicitis and available blood culture on admission were included in this study. Potential predictive factors of bacteremia (age, sex, body mass index (BMI), body temperature, C-reactive protein (CRP), leukocyte count, comorbidities, symptom duration, and appendicitis severity) were assessed. Prevalence of bacteremia was determined by all available blood cultures followed by propensity score matching using sex, age, BMI, CRP, leukocyte count, and body temperature of the patients without available blood culture. RESULTS Out of the 815 patients with appendicitis, 271 patients had available blood culture and the prevalence of bacteremia was 12% (n = 33). Based on propensity score estimation, the prevalence of bacteremia in the whole prospective appendicitis cohort was 11.1%. Bacteremia was significantly more frequent in complicated acute appendicitis (15%; 29/189) compared with uncomplicated acute appendicitis (5%; 4/82) (p = 0.015). Male sex (p = 0.024) and higher body temperature (p = 0.0044) were associated with bacteremia. CONCLUSIONS Estimated prevalence of bacteremia in patients with acute appendicitis was 11.1%. Complicated appendicitis, male sex, and higher body temperature were associated with bacteremia in acute appendicitis.
Collapse
Affiliation(s)
- Sami Sula
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, FinlandDepartment of Surgery, University of Turku, Turku, FinlandSatasairaala Central Hospital, Pori, Finland
| | - Tatu Han
- Department of Surgery, University of Turku, Turku, FinlandFaculty of Medicine, University of Turku, Turku, Finland
| | - Harri Marttila
- Department of Hospital Hygiene and Infection Control, Turku University Hospital, Turku, Finland
| | - Jussi Haijanen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, FinlandDepartment of Surgery, University of Turku, Turku, Finland
| | | | - Suvi Sippola
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, FinlandDepartment of Surgery, University of Turku, Turku, Finland
| | - Juha Grönroos
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, FinlandDepartment of Surgery, University of Turku, Turku, Finland
| | - Antti J Hakanen
- Laboratory Division, Department of Clinical Microbiology, Turku University Hospital, Turku, FinlandResearch Center for Infections and Immunity, Institute of Biomedicine, University of Turku, Turku, Finland
| | - Paulina Salminen
- Professor of Surgery Division of Digestive Surgery and Urology Turku University Hospital P.O. Box 52 20520 Turku Finland
| |
Collapse
|
30
|
Salminen P, Grönroos S, Helmiö M, Hurme S, Juuti A, Juusela R, Peromaa-Haavisto P, Leivonen M, Nuutila P, Ovaska J. Effect of Laparoscopic Sleeve Gastrectomy vs Roux-en-Y Gastric Bypass on Weight Loss, Comorbidities, and Reflux at 10 Years in Adult Patients With Obesity: The SLEEVEPASS Randomized Clinical Trial. JAMA Surg 2022; 157:656-666. [PMID: 35731535 PMCID: PMC9218929 DOI: 10.1001/jamasurg.2022.2229] [Citation(s) in RCA: 80] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance Long-term results from randomized clinical trials comparing laparoscopic sleeve gastrectomy (LSG) with laparoscopic Roux-en-Y-gastric bypass (LRYGB) are limited. Objective To compare long-term outcomes of weight loss and remission of obesity-related comorbidities and the prevalence of gastroesophageal reflux symptoms (GERD), endoscopic esophagitis, and Barrett esophagus (BE) after LSG and LRYGB at 10 years. Design, Setting, and Participants This 10-year observational follow-up evaluated patients in the Sleeve vs Bypass (SLEEVEPASS) multicenter equivalence randomized clinical trial comparing LSG and LRYGB in the treatment of severe obesity in which 240 patients aged 18 to 60 years with median body mass index of 44.6 were randomized to LSG (n = 121) or LRYGB (n = 119). The initial trial was conducted from April 2008 to June 2010 in Finland, with last follow-up on January 27, 2021. Interventions LSG or LRYGB. Main Outcomes and Measures The primary end point was 5-year percentage excess weight loss (%EWL). This current analysis focused on 10-year outcomes with special reference to reflux and BE. Results At 10 years, of 240 randomized patients (121 randomized to LSG and 119 to LRYGB; 167 women [69.6%]; mean [SD] age, 48.4 [9.4] years; mean [SD] baseline BMI, 45.9 [6.0]), 2 never underwent surgery and there were 10 unrelated deaths; 193 of the remaining 228 patients (85%) completed follow-up on weight loss and comorbidities, and 176 of 228 (77%) underwent gastroscopy. Median (range) %EWL was 43.5% (2.1%-109.2%) after LSG and 50.7% (1.7%-111.7%) after LRYGB. Mean estimate %EWL was not equivalent between the procedures; %EWL was 8.4 (95% CI, 3.1-13.6) higher in LRYGB. After LSG and LRYGB, there was no statistically significant difference in type 2 diabetes remission (26% and 33%, respectively; P = .63), dyslipidemia (19% and 35%, respectively; P = .23), or obstructive sleep apnea (16% and 31%, respectively; P = .30). Hypertension remission was superior after LRYGB (8% vs 24%; P = .04). Esophagitis was more prevalent after LSG (31% vs 7%; P < .001) with no statistically significant difference in BE (4% vs 4%; P = .29). The overall reoperation rate was 15.7% for LSG and 18.5% for LRYGB (P = .57). Conclusions and Relevance At 10 years, %EWL was greater after LRYGB and the procedures were not equivalent for weight loss, but both LSG and LRYGB resulted in good and sustainable weight loss. Esophagitis was more prevalent after LSG, but the cumulative incidence of BE was markedly lower than in previous trials and similar after both procedures. Trial Registration ClinicalTrials.gov Identifier: NCT00793143.
Collapse
Affiliation(s)
- Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland,Department of Surgery, University of Turku, Turku, Finland
| | - Sofia Grönroos
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland,Department of Surgery, University of Turku, Turku, Finland
| | - Mika Helmiö
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland,Department of Surgery, University of Turku, Turku, Finland
| | - Saija Hurme
- Department of Biostatistics, University of Turku, Turku, Finland
| | - Anne Juuti
- Department of Abdominal Surgery, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Risto Juusela
- Department of Surgery, Vaasa Central Hospital, Vaasa, Finland
| | - Pipsa Peromaa-Haavisto
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - Marja Leivonen
- Department of Surgery, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Pirjo Nuutila
- Department of Endocrinology, Turku University Hospital, Turku, Finland,Turku PET Centre, University of Turku, Turku, Finland
| | - Jari Ovaska
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland,Department of Surgery, University of Turku, Turku, Finland
| |
Collapse
|
31
|
Moritz E, Dadson P, Saukko E, Honka MJ, Koskensalo K, Seppälä K, Pekkarinen L, Moriconi D, Helmiö M, Salminen P, Nuutila P, Rebelos E. Renal Sinus Fat Is Expanded in Patients with Obesity and/or Hypertension and Reduced by Bariatric Surgery Associated with Hypertension Remission. Metabolites 2022; 12:metabo12070617. [PMID: 35888741 PMCID: PMC9320187 DOI: 10.3390/metabo12070617] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/25/2022] [Accepted: 06/29/2022] [Indexed: 02/04/2023] Open
Abstract
Renal sinus fat is a fat depot at the renal hilum. Because of its location around the renal artery, vein, and lymphatic vessels, an expanded renal sinus fat mass may have hemodynamic and renal implications. We studied whether renal sinus fat area (RSF) associates with hypertension and whether following bariatric surgery a decrease in RSF associates with improvement of hypertension. A total of 74 severely obese and 46 lean controls were studied with whole-body magnetic resonance imaging (MRI). A total of 42 obese subjects were re-studied six months after bariatric surgery. RSF was assessed by two independent researchers using sliceOmatic. Glomerular filtration rate (eGFR) was estimated according to the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration). Patients with obesity accumulated more RSF compared to lean controls (2.3 [1.7–3.1] vs. 1.8 [1.4–2.5] cm2, p = 0.03). Patients with hypertension (N = 36) had a larger RSF depot compared to normotensive subjects (2.6 [2.0–3.3] vs. 2.0 [1.4–2.5] cm2, p = 0.0007) also after accounting for body mass index (BMI). In the pooled data, RSF was negatively associated with eGFR (r = −0.20, p = 0.03), whereas there was no association with systolic or diastolic blood pressure. Following bariatric surgery, RSF was reduced (1.6 [1.3–2.3] vs. 2.3 [1.7–3.1] cm2, p = 0.03) along with other markers of adiposity. A total of 9/27 of patients achieved remission from hypertension. The remission was associated with a larger decrease in RSF, compared to patients who remained hypertensive (−0.68 [−0.74 to −0.44] vs. −0.28 [−0.59 to 0] cm2, p = 0.009). The accumulation of RSF seems to be involved in the pathogenesis of hypertension in obesity. Following bariatric surgery, loss of RSF was associated with remission from hypertension.
Collapse
Affiliation(s)
- Emilia Moritz
- Turku PET Centre, University of Turku, 20520 Turku, Finland; (E.M.); (P.D.); (M.-J.H.); (K.S.); (L.P.); (P.N.)
| | - Prince Dadson
- Turku PET Centre, University of Turku, 20520 Turku, Finland; (E.M.); (P.D.); (M.-J.H.); (K.S.); (L.P.); (P.N.)
| | - Ekaterina Saukko
- Department of Radiology, Turku University Hospital, 20521 Turku, Finland;
| | - Miikka-Juhani Honka
- Turku PET Centre, University of Turku, 20520 Turku, Finland; (E.M.); (P.D.); (M.-J.H.); (K.S.); (L.P.); (P.N.)
| | - Kalle Koskensalo
- Department of Medical Physics, Turku University Hospital, 20521 Turku, Finland;
| | - Kerttu Seppälä
- Turku PET Centre, University of Turku, 20520 Turku, Finland; (E.M.); (P.D.); (M.-J.H.); (K.S.); (L.P.); (P.N.)
- Department of Medical Physics, Turku University Hospital, 20521 Turku, Finland;
| | - Laura Pekkarinen
- Turku PET Centre, University of Turku, 20520 Turku, Finland; (E.M.); (P.D.); (M.-J.H.); (K.S.); (L.P.); (P.N.)
- Department of Endocrinology, Turku University Hospital, 20521 Turku, Finland
| | - Diego Moriconi
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa, 56124 Pisa, Italy;
| | - Mika Helmiö
- Division of Digestive Surgery and Urology, Turku University Hospital, 20521 Turku, Finland; (M.H.); (P.S.)
- Department of Surgery, University of Turku, 20520 Turku, Finland
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, 20521 Turku, Finland; (M.H.); (P.S.)
- Department of Surgery, University of Turku, 20520 Turku, Finland
| | - Pirjo Nuutila
- Turku PET Centre, University of Turku, 20520 Turku, Finland; (E.M.); (P.D.); (M.-J.H.); (K.S.); (L.P.); (P.N.)
- Department of Endocrinology, Turku University Hospital, 20521 Turku, Finland
| | - Eleni Rebelos
- Turku PET Centre, University of Turku, 20520 Turku, Finland; (E.M.); (P.D.); (M.-J.H.); (K.S.); (L.P.); (P.N.)
- National Research Council, 56124 Pisa, Italy
- Correspondence: ; Tel.: +39-3488454140
| |
Collapse
|
32
|
Salminen P. RCT Evidence Supports Incorporating Nonoperative Management Option for Uncomplicated Acute Appendicitis-How to Implement This in Clinical Practice? JAMA Surg 2022; 157:607-608. [PMID: 35612876 DOI: 10.1001/jamasurg.2022.1555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Paulina Salminen
- Department of Digestive Surgery, Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| |
Collapse
|
33
|
Rebelos E, Rissanen E, Bucci M, Jääskeläinen O, Honka MJ, Nummenmaa L, Moriconi D, Laurila S, Salminen P, Herukka SK, Singhal T, Nuutila P. Circulating neurofilament is linked with morbid obesity, renal function, and brain density. Sci Rep 2022; 12:7841. [PMID: 35551210 PMCID: PMC9098484 DOI: 10.1038/s41598-022-11557-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/25/2022] [Indexed: 12/14/2022] Open
Abstract
Neurofilament light chain (NfL) is a novel biomarker reflecting neuroaxonal damage and associates with brain atrophy, and glial fibrillary acidic protein (GFAP) is a marker of astrocytic activation, associated with several neurodegenerative diseases. Since obesity is associated with increased risk for several neurodegenerative disorders, we hypothesized that circulating NfL and GFAP levels could reflect neuronal damage in obese patients. 28 morbidly obese and 18 lean subjects were studied with voxel based morphometry (VBM) MRI to assess gray and white matter densities. Serum NfL and GFAP levels were determined with single-molecule array. Obese subjects were re-studied 6 months after bariatric surgery. Morbidly obese subjects had lower absolute concentrations of circulating NfL and GFAP compared to lean individuals. Following bariatric surgery-induced weight loss, both these levels increased. Both at baseline and after weight loss, circulating NfL and GFAP values correlated inversely with eGFR. Cross-sectionally, circulating NfL levels correlated inversely with gray matter (GM) density, and this association remained significant also when accounting for age and total eGFR. GFAP values did not correlate with GM density. Our data suggest that when determining circulating NfL and GFAP levels, eGFR should also be measured since renal function can affect these measurements. Despite the potential confounding effect of renal function on NfL measurement, NfL correlated inversely with gray matter density in this group of subjects with no identified neurological disorders, suggesting that circulating NfL level may be a feasible biomarker of cerebral function even in apparently neurologically healthy subjects.
Collapse
Affiliation(s)
- Eleni Rebelos
- Turku PET Centre, University of Turku, Turku, Finland. .,CNR, Pisa, Italy.
| | - Eero Rissanen
- Turku PET Centre, University of Turku, Turku, Finland.,PET Imaging Program in Neurologic Diseases, Singhal Lab, Ann Romney Center for Neurologic Diseases, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Marco Bucci
- Turku PET Centre, University of Turku, Turku, Finland.,Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Karolinska Institutet, Stockholm, Sweden.,Turku PET Centre, Åbo Akademi University, Turku, Finland
| | - Olli Jääskeläinen
- Institute of Clinical Medicine-Neurology, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | | | - Lauri Nummenmaa
- Turku PET Centre, University of Turku, Turku, Finland.,Department of Psychology, University of Turku, Turku, Finland
| | - Diego Moriconi
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Sanna Laurila
- Turku PET Centre, University of Turku, Turku, Finland
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | - Sanna-Kaisa Herukka
- Institute of Clinical Medicine-Neurology, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland.,Neurocenter, Kuopio University Hospital, Kuopio, Finland
| | - Tarun Singhal
- PET Imaging Program in Neurologic Diseases, Singhal Lab, Ann Romney Center for Neurologic Diseases, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Department of Neurology, Brigham Multiple Sclerosis Center, Ann Romney Center for Neurologic Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pirjo Nuutila
- Turku PET Centre, University of Turku, Turku, Finland.,Department of Endocrinology, Turku University Hospital, Turku, Finland
| |
Collapse
|
34
|
Stenberg E, dos Reis Falcão LF, O’Kane M, Liem R, Pournaras DJ, Salminen P, Urman RD, Wadhwa A, Gustafsson UO, Thorell A. Correction to: Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations: A 2021 Update. World J Surg 2022; 46:752. [DOI: 10.1007/s00268-022-06459-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
35
|
Stenberg E, Dos Reis Falcão LF, O'Kane M, Liem R, Pournaras DJ, Salminen P, Urman RD, Wadhwa A, Gustafsson UO, Thorell A. Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations: A 2021 Update. World J Surg 2022; 46:729-751. [PMID: 34984504 PMCID: PMC8885505 DOI: 10.1007/s00268-021-06394-9] [Citation(s) in RCA: 120] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2021] [Indexed: 02/08/2023]
Abstract
Background This is the second updated Enhanced Recovery After Surgery (ERAS®) Society guideline, presenting a consensus for optimal perioperative care in bariatric surgery and providing recommendations for each ERAS item within the ERAS® protocol. Methods A principal literature search was performed utilizing the Pubmed, EMBASE, Cochrane databases and ClinicalTrials.gov through December 2020, with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohort studies. Selected studies were examined, reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. After critical appraisal of these studies, the group of authors reached consensus regarding recommendations. Results The quality of evidence for many ERAS interventions remains relatively low in a bariatric setting and evidence-based practices may need to be extrapolated from other surgeries. Conclusion A comprehensive, updated evidence-based consensus was reached and is presented in this review by the ERAS® Society.
Collapse
Affiliation(s)
- Erik Stenberg
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
| | | | - Mary O'Kane
- Dietetic Department, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UK
| | - Ronald Liem
- Department of Surgery, Groene Hart Hospital, Gouda, Netherlands.,Dutch Obesity Clinic, The Hague, Netherlands
| | - Dimitri J Pournaras
- Department of Upper GI and Bariatric/Metabolic Surgery, North Bristol NHS Trust, Southmead Hospital, Southmead Road, Bristol, UK
| | - Paulina Salminen
- Department of Surgery, University of Turku, Turku, Finland.,Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anupama Wadhwa
- Department of Anesthesiology, Outcomes Research Institute, Cleveland Clinic, University of Texas Southwestern, Dallas, USA
| | - Ulf O Gustafsson
- Division of Surgery, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Anders Thorell
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Ersta Hospital, Stockholm, Sweden
| |
Collapse
|
36
|
Park JH, Salminen P, Tannaphai P, Lee KH. Low-Dose Abdominal CT for Evaluating Suspected Appendicitis in Adolescents and Young Adults: Review of Evidence. Korean J Radiol 2022; 23:517-528. [PMID: 35289145 PMCID: PMC9081692 DOI: 10.3348/kjr.2021.0596] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/18/2021] [Accepted: 11/21/2021] [Indexed: 11/15/2022] Open
Abstract
Due to its excellent diagnostic performance, CT is the mainstay of diagnostic test in adults with suspected acute appendicitis in many countries. Although debatable, extensive epidemiological studies have suggested that CT radiation is carcinogenic, at least in children and adolescents. Setting aside the debate over the carcinogenic risk of CT radiation, the value of judicious use of CT radiation cannot be overstated for the diagnosis of appendicitis, considering that appendicitis is a very common disease, and that the vast majority of patients with suspected acute appendicitis are adolescents and young adults with average life expectancies. Given the accumulated evidence justifying the use of low-dose CT (LDCT) of only 2 mSv, there is no reasonable basis to insist on using radiation dose of multi-purpose abdominal CT for the diagnosis of appendicitis, particularly in adolescents and young adults. Published data strongly suggest that LDCT is comparable to conventional dose CT in terms of clinical outcomes and diagnostic performance. In this narrative review, we will discuss such evidence for reducing CT radiation in adolescents and young adults with suspected appendicitis.
Collapse
Affiliation(s)
- Ji Hoon Park
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Paulina Salminen
- Department of Surgery, University of Turku, Turku, Finland, Thailand
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland, Thailand
| | - Penampai Tannaphai
- Department of Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kyoung Ho Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Interdisciplinary Program in Bioengineering, Seoul National University, Seoul, Korea
| |
Collapse
|
37
|
Salminen P, Sippola S, Haijanen J, Nordström P, Rantanen T, Rautio T, Sallinen V, Löyttyniemi E, Hurme S, Tammilehto V, Laukkarinen J, Savolainen H, Meriläinen S, Leppäniemi A, Grönroos J. OUP accepted manuscript. Br J Surg 2022; 109:503-509. [PMID: 35576384 PMCID: PMC10364767 DOI: 10.1093/bjs/znac086] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/28/2022] [Accepted: 03/04/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Non-operative management of uncomplicated acute appendicitis is an option, but omission of antibiotics from the regimen has not been tested. METHODS A double-blind, placebo-controlled, superiority RCT in adults with CT-confirmed uncomplicated acute appendicitis was designed to compare placebo with antibiotics (intravenous ertapenem followed by oral levofloxacin and metronidazole). The primary endpoint was treatment success (resolution resulting in discharge without appendicectomy within 10 days); secondary outcomes included pain scores, complications, hospital stay, and return to work. RESULTS From May 2017 to September 2020, 72 patients with a mean(s.d.) age of 37.5 (11.1) years were recruited at five hospitals. Six were excluded after randomization (5 early consent withdrawals, 1 randomization protocol violation), 35 were assigned to receive antibiotics, and 31 to receive placebo. Enrolment challenges (including hospital pharmacy resources in an acute-care surgery setting) meant that only the lowest sample size of three predefined scenarios was achieved. The 10-day treatment success rate was 87 (95 per cent c.i. 75 to 99) per cent for placebo and 97 (92 to 100) per cent for antibiotics. This clinical difference of 10 (90 per cent c.i. -0.9 to 21) per cent was not statistically different for the primary outcome (1-sided P = 0.142), and secondary outcomes were similar. CONCLUSION The lack of antibiotic superiority statistically suggests that a non-inferiority trial against placebo is warranted in adults with CT-confirmed mild appendicitis. Registration number: EudraCT 2015-003634-26 (https://eudract.ema.europa.eu/eudract-web/index.faces), NCT03234296 (http://www.clinicaltrials.gov).
Collapse
Affiliation(s)
- Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Suvi Sippola
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
- Department of Surgery, Jyväskylä Central Hospital, Jyväskylä, Finland
| | - Jussi Haijanen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Pia Nordström
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
| | - Tuomo Rantanen
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland
- Department of Surgery, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Tero Rautio
- Department of Surgery, Oulu University Hospital, Oulu, Finland
- Medical Research Centre Oulu, University of Oulu, Oulu, Finland
| | - Ville Sallinen
- Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | - Saija Hurme
- Department of Biostatistics, University of Turku, Turku, Finland
| | - Ville Tammilehto
- Department of Radiology, Turku University Hospital, Turku, Finland
| | - Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
| | - Heini Savolainen
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland
- Department of Surgery, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Sanna Meriläinen
- Department of Surgery, Oulu University Hospital, Oulu, Finland
- Medical Research Centre Oulu, University of Oulu, Oulu, Finland
| | - Ari Leppäniemi
- Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Juha Grönroos
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| |
Collapse
|
38
|
Affiliation(s)
- Paulina Salminen
- Division of Digestive Surgery and Urology, Department of Digestive Surgery, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | - Gerhard Prager
- Division of Surgery, Department of Digestive Surgery, Medical University of Vienna, Vienna, Austria
| | - Phil R Schauer
- Pennington Biomedical Research Center, Baton Rouge, Louisiana
| |
Collapse
|
39
|
Haijanen J, Sippola S, Tammilehto V, Grönroos J, Mäntyoja S, Löyttyniemi E, Niiniviita H, Salminen P. Diagnostic accuracy using low-dose versus standard radiation dose CT in suspected acute appendicitis: prospective cohort study. Br J Surg 2021; 108:1483-1490. [PMID: 34761262 PMCID: PMC10364876 DOI: 10.1093/bjs/znab383] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 10/05/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Contrast-enhanced CT is the reference standard used in diagnostic imaging for acute appendicitis in adults. The radiation dose has been of concern. This study aimed to assess whether a lower radiation dose would affect the diagnostic accuracy of CT. METHODS This was a prospective single-centre cohort study of patients (aged over 16 years) with suspected appendicitis evaluated for enrolment in concurrent APPAC II-III trials. The diagnostic accuracy of contrast-enhanced low- and standard-dose CT was compared with study protocols guiding imaging based on BMI; this enabled direct CT imaging comparison only in patients with a BMI below 30 kg/m2. The on-call CT diagnosis was compared with the final clinical diagnosis. RESULTS Among all 856 patients investigated, the accuracy of low-dose (454 patients) and standard-dose (402 patients) CT in identifying patients with and without appendicitis was 98·0 and 98·5 per cent respectively. In patients with a BMI under 30 kg/m2, respective values were 98·2 per cent (434 patients) and 98·6 per cent (210 patients) (P = 1·000). The corresponding accuracy for differentiating between uncomplicated and complicated acute appendicitis was 90·3 and 87·6 per cent in all patients, and 89·8 and 88·4 per cent respectively among those with a BMI below 30 kg/m2 (P = 0·663). The median radiation dose in the whole low- and standard-dose CT groups was 3 and 7 mSv respectively. In the group with BMI below 30 kg/m2, corresponding median doses were 3 and 5 mSv (P < 0·001). CONCLUSION Low- and standard-dose CT were accurate both in identifying appendicitis and in differentiating between uncomplicated and complicated acute appendicitis. Low-dose CT was associated with a significant radiation dose reduction, suggesting that it should be standard clinical practice at least in patients with a BMI below 30 kg/m2.
Collapse
Affiliation(s)
- Jussi Haijanen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | - Suvi Sippola
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland.,Department of Surgery, Jyväskylä Central Hospital, Jyväskylä, Finland
| | - Ville Tammilehto
- Department of Radiology, Medical Imaging Centre of Southwest Finland, Turku University Hospital, Turku, Finland
| | - Juha Grönroos
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | - Siiri Mäntyoja
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | | | - Hannele Niiniviita
- Department of Radiology, Medical Imaging Centre of Southwest Finland, Turku University Hospital, Turku, Finland.,Department of Medical Physics, Turku University Hospital, Turku, Finland
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| |
Collapse
|
40
|
Salminen P, Peterli R. Roux-en-Y gastric bypass limb lengths-how to optimize the balance between weight loss and risk of malnutrition? BJS Open 2021; 5:6460947. [PMID: 34904649 PMCID: PMC8670297 DOI: 10.1093/bjsopen/zrab120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/22/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Paulina Salminen
- Department of Digestive Surgery, Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | - Ralph Peterli
- Department of Clinical Research, University of Basel, Basel, Switzerland.,Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St Clara Hospital and University Hospital Basel, Basel, Switzerland
| |
Collapse
|
41
|
Gero D, Vannijvel M, Okkema S, Deleus E, Lloyd A, Lo Menzo E, Tadros G, Raguz I, San Martin A, Kraljević M, Mantziari S, Frey S, Gensthaler L, Sammalkorpi H, Garcia-Galocha JL, Zapata A, Tatarian T, Wiggins T, Bardisi E, Goreux JP, Seki Y, Vonlanthen R, Widmer J, Thalheimer A, Kasama K, Himpens J, Hollyman M, Welbourn R, Aggarwal R, Beekley A, Sepulveda M, Torres A, Juuti A, Salminen P, Prager G, Iannelli A, Suter M, Peterli R, Boza C, Rosenthal R, Higa K, Lannoo M, Hazebroek EJ, Dillemans B, Clavien PA, Puhan M, Raptis DA, Bueter M. Defining Global Benchmarks in Elective Secondary Bariatric Surgery Comprising Conversional, Revisional, and Reversal Procedures. Ann Surg 2021; 274:821-828. [PMID: 34334637 DOI: 10.1097/sla.0000000000005117] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To define "best possible" outcomes for secondary bariatric surgery (BS). BACKGROUND Management of poor response and of long-term complications after BS is complex and under-investigated. Indications and types of reoperations vary widely and postoperative complication rates are higher compared to primary BS. METHODS Out of 44,884 BS performed in 18 high-volume centers from 4 continents between 06/2013-05/2019, 5,349 (12%) secondary BS cases were identified. Twenty-one outcome benchmarks were established in low-risk patients, defined as the 75th percentile of the median outcome values of centers. Benchmark cases had no previous laparotomy, diabetes, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, thromboembolic events, BMI> 50 kg/m2 or age> 65 years. RESULTS The benchmark cohort included 3143 cases, mainly females (85%), aged 43.8 ± 10 years, 8.4 ± 5.3 years after primary BS, with a BMI 35.2 ± 7 kg/m2. Main indications were insufficient weight loss (43%) and gastro-esophageal reflux disease/dysphagia (25%). 90-days postoperatively, 14.6% of benchmark patients presented ≥1 complication, mortality was 0.06% (n = 2). Significantly higher morbidity was observed in non-benchmark cases (OR 1.37) and after conversional/reversal or revisional procedures with gastrointestinal suture/stapling (OR 1.84). Benchmark cutoffs for conversional BS were ≤4.5% re-intervention, ≤8.3% re-operation 90-days postoperatively. At 2-years (IQR 1-3) 15.6% of benchmark patients required a reoperation. CONCLUSION Secondary BS is safe, although postoperative morbidity exceeds the established benchmarks for primary BS. The excess morbidity is due to an increased risk of gastrointestinal leakage and higher need for intensive care. The considerable rate of tertiary BS warrants expertise and future research to optimize the management of non-success after BS.
Collapse
Affiliation(s)
- Daniel Gero
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Marie Vannijvel
- Department of General Surgery, AZ Sint Jan Brugge-Oostende, Bruges, Belgium
| | - Sietske Okkema
- Department of Surgery, Rijnstate Hospital/Vitalys Clinics, Arnhem, The Netherlands
| | - Ellen Deleus
- Department of General Surgery, University Hospital Leuven, Leuven, Belgium
| | - Aaron Lloyd
- Minimally Invasive and Bariatric Surgery, Fresno Heart and Surgical Hospital, Fresno, California
| | - Emanuele Lo Menzo
- The Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, Florida
| | - George Tadros
- The Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, Florida
| | - Ivana Raguz
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Andres San Martin
- Bariatric and Metabolic Center, Department of Surgery, Clinica Las Condes, Las Condes, Santiago, Chile
| | - Marko Kraljević
- Department of Visceral Surgery, Clarunis: St.Clara Hosptital, Basel, Switzerland
| | - Styliani Mantziari
- Department of Visceral Surgery, University Hospital Lausanne, Lausanne, Switzerland
| | - Sebastien Frey
- Digestive Surgery and Liver Transplantation Unit, University Hospital Nice, University Côte d'Azur, Nice, France
| | - Lisa Gensthaler
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Henna Sammalkorpi
- Department ofGastroenterological Surgery, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - José Luis Garcia-Galocha
- Department of Surgery, Hospital Clínico San Carlos, Complutense University of Madrid, Madrid, Spain
| | - Amalia Zapata
- Bariatric and Metabolic Surgery Center, Dipreca Hospital, Las Condes, Santiago, Chile
| | - Talar Tatarian
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Tom Wiggins
- Department of Upper Gastrointestinal and Bariatric Surgery, Musgrove Park Hospital, Taunton, UK
| | - Ekhlas Bardisi
- Department of Surgery, St Blasius Hospital, Dendermonde, Belgium
| | | | - Yosuke Seki
- Weight Loss and Metabolic Surgery Center, Yotsuya Medical Cube, Tokyo, Japan
| | - René Vonlanthen
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Jeannette Widmer
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Andreas Thalheimer
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Kazunori Kasama
- Weight Loss and Metabolic Surgery Center, Yotsuya Medical Cube, Tokyo, Japan
| | - Jacques Himpens
- Department of Surgery, St Blasius Hospital, Dendermonde, Belgium
- Department of Surgery, Delta CHIREC Hospital, Brussels, Belgium
- The European School of Laparoscopic Surgery, St Pierre University Hospital, Brussels, Belgium
| | - Marianne Hollyman
- Department of Upper Gastrointestinal and Bariatric Surgery, Musgrove Park Hospital, Taunton, UK
| | - Richard Welbourn
- Department of Upper Gastrointestinal and Bariatric Surgery, Musgrove Park Hospital, Taunton, UK
| | - Rajesh Aggarwal
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Alec Beekley
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Matias Sepulveda
- Bariatric and Metabolic Surgery Center, Dipreca Hospital, Las Condes, Santiago, Chile
| | - Antonio Torres
- Department of Surgery, Hospital Clínico San Carlos, Complutense University of Madrid, Madrid, Spain
| | - Anne Juuti
- Department ofGastroenterological Surgery, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | | | - Gerhard Prager
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Antonio Iannelli
- Digestive Surgery and Liver Transplantation Unit, University Hospital Nice, University Côte d'Azur, Nice, France
| | - Michel Suter
- Department of Visceral Surgery, University Hospital Lausanne, Lausanne, Switzerland
- Department of Surgery, Riviera-Chablais Hospital, Rennaz, Switzerland
| | - Ralph Peterli
- Department of Visceral Surgery, Clarunis: St.Clara Hosptital, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Camilo Boza
- Bariatric and Metabolic Center, Department of Surgery, Clinica Las Condes, Las Condes, Santiago, Chile
| | - Raul Rosenthal
- The Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, Florida
| | - Kelvin Higa
- Minimally Invasive and Bariatric Surgery, Fresno Heart and Surgical Hospital, Fresno, California
| | - Matthias Lannoo
- Department of General Surgery, University Hospital Leuven, Leuven, Belgium
| | - Eric J Hazebroek
- Department of Surgery, Rijnstate Hospital/Vitalys Clinics, Arnhem, The Netherlands
| | - Bruno Dillemans
- Department of General Surgery, AZ Sint Jan Brugge-Oostende, Bruges, Belgium
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Milo Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Dimitri A Raptis
- Department of Hepatobiliary and Pancreas Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Marco Bueter
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
42
|
Haijanen J, Sippola S, Löyttyniemi E, Hurme S, Grönroos J, Rautio T, Salminen P. Factors Associated With Primary Nonresponsiveness to Antibiotics in Adults With Uncomplicated Acute Appendicitis: A Prespecified Secondary Analysis of a Randomized Clinical Trial. JAMA Surg 2021; 156:1179-1181. [PMID: 34613361 DOI: 10.1001/jamasurg.2021.5003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Jussi Haijanen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Suvi Sippola
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | | | - Saija Hurme
- Department of Biostatistics, University of Turku, Turku, Finland
| | - Juha Grönroos
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Tero Rautio
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| |
Collapse
|
43
|
Gero D, Vannijvel M, Okkema S, Deleus E, Lloyd A, Lo Menzo E, Tadros G, Raguz I, San Martin A, Kraljević M, Mantziari S, Frey S, Gensthaler L, Sammalkorpi H, Garcia-Galocha JL, Zapata A, Tatarian T, Wiggins T, Bardisi E, Goreux JP, Vonlanthen R, Widmer J, Thalheimer A, Himpens J, Hollymann M, Welbourn R, Aggarwal R, Beekley A, Sepulveda M, Torres A, Juuti A, Salminen P, Prager G, Iannelli A, Suter M, Peterli R, Boza C, Rosenthal R, Higa K, Lannoo M, Hazebroek EJ, Dillemans B, Clavien PA, Puhan M, Raptis DA, Bueter M. Defining global benchmarks in elective secondary bariatric surgery comprising conversional, revisional and reversal procedures. Br J Surg 2021. [DOI: 10.1093/bjs/znab202.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Objective
Management of poor response and of long-term complications after bariatric surgery (BS) is complex and under-investigated. Indications and types of reoperations vary widely and postoperative complication rates are higher compared to primary BS. Benchmarking uses best performance in a given field as reference point for improvement. Our aim was to define ‘‘best possible’’ outcomes for elective secondary BS.
Methods
The establishment of benchmarks in secondary BS followed a standardized methodology, based on recommendations of a Delphi consensus panel of experts. This multicenter study analyzed patients undergoing elective secondary BS in 18 high-volume centers on 4 continents from 06/2013 to 05/2019. Twenty-one outcome benchmarks were established in low-risk patients, defined as the 75th percentile of the median outcome values of the centers. Benchmark cases had no: previous laparotomy, diabetes, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, history of thromboembolic events, BMI>50kg/m2 or age>65 years. Descriptive statistics, multivariate logistic regression and data visualization were performed using the R software.
Results
Out of 44’884 elective bariatric procedures performed in the participating centers, 5’328 secondary BS cases were identified. The benchmark cohort included 3143 cases, mainly females (85%), aged 43.8±10 years, 8.4±5.3 years after primary BS, with a body mass index 35.2±7kg/m2. Main indications were insufficient weight loss (43%) and gastro-esophageal reflux disease/dysphagia (25%). 90-days postoperatively, 14.57% of benchmark patients presented ≥1 complication, mortality was 0.06% (n = 2). Significantly higher morbidity was observed in non-benchmark cases (OR 1.36) and after conversional or revisional procedures with gastrointestinal suture/stapling (OR 1.7). Benchmark cutoffs at 90-days postoperatively were ≤5.8% re-intervention and ≤8.8% re-operation rate. At 2-years (IQR 1-3) 15.6% of benchmark patients required a reoperation.
Conclusion
Secondary BS is safe, although postoperative morbidity exceeds the established benchmarks for primary BS. The excess morbidity is due to an increased risk of gastrointestinal leakage and higher need for intensive care. The considerable rate of tertiary BS warrants expertise and future research to optimize the management of non-success after BS.
Collapse
Affiliation(s)
- D Gero
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - M Vannijvel
- Department of General Surgery, AZ Sint Jan Brugge-Oostende, Bruges, Belgium
| | - S Okkema
- Department of Surgery, Rijnstate Hospital/Vitalys Clinics, Arnhem, Netherlands
| | - E Deleus
- Department of Surgery, University Hospital Leuven, Leuven, Belgium
| | - A Lloyd
- Department of Minimally Invasive and Bariatric Surgery, Fresno Heart and Surgical Hospital, Fresno, USA
| | - E Lo Menzo
- The Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, USA
| | - G Tadros
- The Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, USA
| | - I Raguz
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - A San Martin
- Department of Surgery, Clinica Las Condes, Santiago de Chile, Chile
| | - M Kraljević
- Department of Visceral Surgery, Clarunis - University Abdominal Center, Basel, Switzerland
| | - S Mantziari
- Department of Visceral Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - S Frey
- Digestive Surgery and Liver Transplantation Unit, University Hospital Nice, University Côte d’Azur, Nice, France
| | - L Gensthaler
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - H Sammalkorpi
- Department of Surgery, University Hospital of Helsinki, Helsinki, Finland
| | - J L Garcia-Galocha
- Department of Surgery, Hospital Clínico San Carlos, Complutense University of Madrid, Madrid, Spain
| | - A Zapata
- Bariatric and Metabolic Surgery Center, Dipreca Hospital, Santiago de Chile, Chile
| | - T Tatarian
- Bariatric and Metabolic Surgery Department, Thomas Jefferson University Hospitals, Philadelphia, USA
| | - T Wiggins
- Bariatric and Metabolic Surgery Center, Musgrove Park Hospital, Taunton, United Kingdom
| | - E Bardisi
- Department of Surgery, St Blasius Hospital, Dendermonde, Belgium
| | - J -P Goreux
- Department of Surgery, Delta CHIREC Hospital, Brussels, Belgium
| | - R Vonlanthen
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - J Widmer
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - A Thalheimer
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - J Himpens
- Department of Surgery, St Blasius Hospital, Dendermonde, Belgium
| | - M Hollymann
- Department of Upper Gastrointestinal and Bariatric Surgery, Musgrove Park Hospital, Taunton, United Kingdom
| | - R Welbourn
- Department of Upper Gastrointestinal and Bariatric Surgery, Musgrove Park Hospital, Taunton, United Kingdom
| | - R Aggarwal
- Bariatric and Metabolic Surgery Department, Thomas Jefferson University Hospitals, Philadelphia, USA
| | - A Beekley
- Bariatric and Metabolic Surgery Center, Thomas Jefferson University Hospitals, Philadelphia, USA
| | - M Sepulveda
- Bariatric and Metabolic Surgery Center, Dipreca Hospital, Santiago de Chile, Chile
| | - A Torres
- Department of Surgery, Hospital Clínico San Carlos, Complutense University of Madrid, Madrid, Spain
| | - A Juuti
- Department of Surgery, University Hospital of Helsinki, Helsinki, Finland
| | - P Salminen
- Department of Surgery, University of Turku, Turku, Finland
| | - G Prager
- Department of Surgery, Medical University Vienna, Vienna, Austria
| | - A Iannelli
- Digestive Surgery and Liver Transplantation Unit, University Hospital Nice, University Côte d’Azur, Nice, France
| | - M Suter
- Department of Surgery, Riviera-Chablais Hospital, Rennaz, Switzerland
| | - R Peterli
- Department of Visceral Surgery, Clarunis - University Abdominal Center, Basel, Switzerland
| | - C Boza
- Department of Surgery, Clinica Las Condes, Santiago de Chile, Chile
| | - R Rosenthal
- Bariatric and Metabolic Surgery Department, Cleveland Clinic Florida, Weston, USA
| | - K Higa
- Bariatric and Metabolic Surgery Center, Fresno Heart and Surgical Hospital, Fresno, USA
| | - M Lannoo
- Department of Surgery, University Hospital Leuven, Leuven, Belgium
| | - E J Hazebroek
- Department of Surgery, Rijnstate Hospital/Vitalys Clinics, Arnhem, Netherlands
| | - B Dillemans
- Department of Surgery, AZ Sint Jan Brugge-Oostende, Bruges, Belgium
| | - P -A Clavien
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - M Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - D A Raptis
- Department of Hepatobiliary and Pancreas Surgery and Liver Transplantation, Royal Free Hospital, London, United Kingkom
| | - M Bueter
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
44
|
Karlsson HK, Tuominen L, Helin S, Salminen P, Nuutila P, Nummenmaa L. Preoperative brain μ-opioid receptor availability predicts weight development following bariatric surgery in women. JCI Insight 2021; 6:147820. [PMID: 33848266 PMCID: PMC8262287 DOI: 10.1172/jci.insight.147820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 04/07/2021] [Indexed: 01/15/2023] Open
Abstract
Bariatric surgery is the most effective method for weight loss in morbid obesity. There is significant individual variability in the weight loss outcomes, yet factors leading to postoperative weight loss or weight regain remain elusive. Alterations in the μ-opioid receptor (MOR) and dopamine D2 receptor (D2R) systems are associated with obesity and appetite control, and the magnitude of initial brain receptor system perturbation may predict long-term surgical weight loss outcomes. We tested this hypothesis by studying 19 morbidly obese women (mean BMI 40) scheduled to undergo bariatric surgery. We measured their preoperative MOR and D2R availabilities using positron emission tomography with [11C]carfentanil and [11C]raclopride, respectively, and then assessed their weight development association with regional MOR and D2R availabilities at 24-month follow-up. MOR availability in the amygdala consistently predicted weight development throughout the follow-up period, but no associations were found for D2R. This is the first study to our knowledge to demonstrate that neuroreceptor markers prior to bariatric surgery are associated with postoperative weight development. Postoperative weight regain may derive from dysfunction in the opioid system, and weight loss outcomes after bariatric surgery may be partially predicted based on preoperative brain receptor availability, opening up new potential for treatment possibilities.
Collapse
Affiliation(s)
- Henry K Karlsson
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Lauri Tuominen
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland.,Institute of Mental Health Research, University of Ottawa, Ottawa, Ontario, Canada
| | - Semi Helin
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | - Pirjo Nuutila
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland.,Department of Endocrinology, Turku University Hospital, Turku, Finland
| | - Lauri Nummenmaa
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland.,Department of Psychology, University of Turku, Turku, Finland
| |
Collapse
|
45
|
Puolakkainen P, Salminen P. An Evidence-Based Beneficial Shortcut for Distal Pancreatic Resection. JAMA Surg 2021; 156:429. [PMID: 33656545 DOI: 10.1001/jamasurg.2021.0116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Pauli Puolakkainen
- Helsinki University Hospital, Department of Abdominal Surgery, University of Helsinki, Helsinki, Finland
| | - Paulina Salminen
- Department of Surgery, Turku University, Turku, Finland.,Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| |
Collapse
|
46
|
Wölnerhanssen BK, Peterli R, Hurme S, Bueter M, Helmiö M, Juuti A, Meyer-Gerspach AC, Slawik M, Peromaa-Haavisto P, Nuutila P, Salminen P. Laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy: 5-year outcomes of merged data from two randomized clinical trials (SLEEVEPASS and SM-BOSS). Br J Surg 2021; 108:49-57. [PMID: 33640917 DOI: 10.1093/bjs/znaa011] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 08/03/2020] [Accepted: 09/01/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (LRYGB) are both effective surgical procedures to achieve weight reduction in patients with obesity. The trial objective was to merge individual-patient data from two RCTs to compare outcomes after LSG and LRYGB. METHODS Five-year outcomes of the Finnish SLEEVEPASS and Swiss SM-BOSS RCTs comparing LSG with LRYGB were analysed. Both original trials were designed to evaluate weight loss. Additional patient-level data on type 2 diabetes (T2DM), obstructive sleep apnoea, and complications were retrieved. The primary outcome was percentage excess BMI loss (%EBMIL). Secondary predefined outcomes in both trials included total weight loss, remission of co-morbidities, improvement in quality of life (QoL), and overall morbidity. RESULTS At baseline, 228 LSG and 229 LRYGB procedures were performed. Five-year follow-up was available for 199 of 228 patients (87.3 per cent) after LSG and 199 of 229 (87.1 per cent) after LRYGB. Model-based mean estimate of %EBMIL was 7.0 (95 per cent c.i. 3.5 to 10.5) percentage points better after LRYGB than after LSG (62.7 versus 55.5 per cent respectively; P < 0.001). There was no difference in remission of T2DM, obstructive sleep apnoea or QoL improvement; remission for hypertension was better after LRYGB compared with LSG (60.3 versus 44.9 per cent; P = 0.049). The complication rate was higher after LRYGB than LSG (37.2 versus 22.5 per cent; P = 0.001), but there was no difference in mean Comprehensive Complication Index value (30.6 versus 31.0 points; P = 0.859). CONCLUSION Although LRYGB induced greater weight loss and better amelioration of hypertension than LSG, there was no difference in remission of T2DM, obstructive sleep apnoea, or QoL at 5 years. There were more complications after LRYGB, but the individual burden for patients with complications was similar after both operations.
Collapse
Affiliation(s)
- B K Wölnerhanssen
- St Clara Research Ltd, St Clara Hospital, Basle, Switzerland.,University of Basle, Basle, Switzerland
| | - R Peterli
- University of Basle, Basle, Switzerland.,Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St Clara Hospital and University Hospital Basle, Basle, Switzerland
| | - S Hurme
- Department of Biostatistics, University of Turku, Turku, Finland
| | - M Bueter
- Department of Visceral and Transplantation Surgery, University Hospital, Zürich, Switzerland
| | - M Helmiö
- Department of Digestive Surgery, Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | - A Juuti
- Department of Abdominal Surgery, Abdominal Centre, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - A C Meyer-Gerspach
- St Clara Research Ltd, St Clara Hospital, Basle, Switzerland.,University of Basle, Basle, Switzerland
| | - M Slawik
- Department of Internal Medicine and Endocrinology, St. Clara Hospital, Basle, Switzerland
| | - P Peromaa-Haavisto
- Department of Surgery, Vaasa Central Hospital, Vaasa, Finland.,Department of Surgery, Hatanpää City Hospital, Tampere, Finland
| | - P Nuutila
- Department of Endocrinology, Turku University Hospital, Turku, Finland.,Turku PET Centre, University of Turku, Turku, Finland
| | - P Salminen
- Department of Digestive Surgery, Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland.,Department of Surgery, Satasairaala Central Hospital, Pori, Finland
| |
Collapse
|
47
|
Abstract
Background: Diagnostic work-up of acute appendicitis remains challenging. While some guidelines advise to use a risk stratification based on clinical parameters, others use standard imaging in all patients. As non-operative management of uncomplicated appendicitis has been identified as feasible and safe, differentiation between uncomplicated and complicated appendicitis is of paramount importance. We reviewed the literature to describe the optimal strategy for diagnosis of acute appendicitis. Methods: A narrative review about the diagnosis of acute appendicitis in adult patients was conducted. Both diagnostic strategies and goals were analyzed. Results: For diagnosing acute appendicitis, both ruling in and ruling out the disease are important. Clinical and laboratory findings individually do not suffice, but when combined in a diagnostic score, a better risk prediction can be made for having acute appendicitis. However, for accurate diagnosis imaging seems obligatory in patients suspected for acute appendicitis. Scoring systems combining clinical and imaging features may differentiate between uncomplicated and complicated appendicitis and may enable ruling out complicated appendicitis. Within conservatively treated patients with uncomplicated appendicitis, predictive factors for non-responsiveness to antibiotics and recurrence of appendicitis need to be defined in order to optimize treatment outcomes. Conclusion: Standard imaging increases the diagnostic power for both ruling in and ruling out acute appendicitis. Incorporating imaging features in clinical scoring models may provide better differentiation between uncomplicated and complicated appendicitis. Optimizing patient selection for antibiotic treatment of appendicitis may minimize recurrence rates, resulting in better treatment outcomes.
Collapse
Affiliation(s)
- W J Bom
- Department of Surgery, Amsterdam UMC, location AMC, Amsterdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, Amsterdam, The Netherlands
| | - J C G Scheijmans
- Department of Surgery, Amsterdam UMC, location AMC, Amsterdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, Amsterdam, The Netherlands
| | - P Salminen
- Department of Surgery, University of Turku, Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - M A Boermeester
- Department of Surgery, Amsterdam UMC, location AMC, Amsterdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
48
|
Haijanen J, Sula S, Salminen P. Optimizing the Gold Standard-Low-Dose Computed Tomography Modalities as a Part of Clinical Practice in Acute Appendicitis Imaging. JAMA Surg 2021; 156:351-352. [PMID: 33471044 DOI: 10.1001/jamasurg.2020.6358] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Jussi Haijanen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | - Sami Sula
- Department of Surgery, University of Turku, Turku, Finland.,Department of Surgery, Satasairaala Central Hospital, Pori, Finland
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| |
Collapse
|
49
|
Grönroos S, Helmiö M, Juuti A, Tiusanen R, Hurme S, Löyttyniemi E, Ovaska J, Leivonen M, Peromaa-Haavisto P, Mäklin S, Sintonen H, Sammalkorpi H, Nuutila P, Salminen P. Effect of Laparoscopic Sleeve Gastrectomy vs Roux-en-Y Gastric Bypass on Weight Loss and Quality of Life at 7 Years in Patients With Morbid Obesity: The SLEEVEPASS Randomized Clinical Trial. JAMA Surg 2021; 156:137-146. [PMID: 33295955 DOI: 10.1001/jamasurg.2020.5666] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Importance Laparoscopic sleeve gastrectomy (LSG) is currently the predominant bariatric procedure, although long-term weight loss and quality-of-life (QoL) outcomes compared with laparoscopic Roux-en-Y gastric bypass (LRYGB) are lacking. Objective To determine weight loss equivalence of LSG and LRYGB at 7 years in patients with morbid obesity, with special reference to long-term QoL. Design, Setting, and Participants The SLEEVE vs byPASS (SLEEVEPASS) multicenter, multisurgeon, open-label, randomized clinical equivalence trial was conducted between March 10, 2008, and June 2, 2010, in Finland. The trial enrolled 240 patients with morbid obesity aged 18 to 60 years who were randomized to undergo either LSG or LRYGB with a 7-year follow-up (last follow-up, September 26, 2017). Analysis was conducted on an intention-to-treat basis. Statistical analysis was performed from June 4, 2018, to November 8, 2019. Interventions Laparoscopic sleeve gastrectomy (n = 121) or LRYGB (n = 119). Main Outcomes and Measures The primary end point was percentage excess weight loss (%EWL) at 5 years. Secondary predefined follow-up time points were 7, 10, 15, and 20 years, with included 7-year secondary end points of QoL and morbidity. Disease-specific QoL (DSQoL; Moorehead-Ardelt Quality of Life questionnaire [range of scores, -3 to 3 points, where a higher score indicates better QoL]) and general health-related QoL (HRQoL; 15D questionnaire [0-1 scale for all 15 dimensions, with 1 indicating full health and 0 indicating death]) were measured preoperatively and at 1, 3, 5, and 7 years postoperatively concurrently with weight loss. Results Of 240 patients (167 women [69.6%]; mean [SD] age, 48.4 [9.4] years; mean [SD] baseline body mass index, 45.9 [6.0]), 182 (75.8%) completed the 7-year follow-up. The mean %EWL was 47% (95% CI, 43%-50%) after LSG and 55% (95% CI, 52%-59%) after LRYGB (difference, 8.7 percentage units [95% CI, 3.5-13.9 percentage units]). The mean (SD) DSQoL total score at 7 years was 0.50 (1.14) after LSG and 0.49 (1.06) after LRYGB (P = .63), and the median HRQoL total score was 0.88 (interquartile range [IQR], 0.78-0.95) after LSG and 0.87 (IQR, 0.78-0.95) after LRYGB (P = .37). Greater weight loss was associated with better DSQoL (r = 0.26; P < .001). At 7 years, mean (SD) DSQoL scores improved significantly compared with baseline (LSG, 0.50 [1.14] vs 0.10 [0.94]; and LRYGB, 0.49 [1.06] vs 0.12 [1.12]; P < .001), unlike median HRQoL scores (LSG, 0.88 [IQR, 0.78-0.95] vs 0.87 [IQR, 0.78-0.90]; and LRYGB, 0.87 [IQR, 0.78-0.92] vs 0.85 [IQR, 0.77-0.91]; P = .07). The overall morbidity rate was 24.0% (29 of 121) for LSG and 28.6% (34 of 119) for LRYGB (P = .42). Conclusions and Relevance This study found that LSG and LRYGB were not equivalent in %EWL at 7 years. Laparoscopic Roux-en-Y gastric bypass resulted in greater weight loss than LSG, but the difference was not clinically relevant based on the prespecified equivalence margins. There was no difference in long-term QoL between the procedures. Bariatric surgery was associated with significant long-term DSQoL improvement, and greater weight loss was associated with better DSQoL. Trial Registration ClinicalTrials.gov Identifier: NCT00793143.
Collapse
Affiliation(s)
- Sofia Grönroos
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | - Mika Helmiö
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | - Anne Juuti
- Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Roosa Tiusanen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | - Saija Hurme
- Department of Biostatistics, University of Turku, Turku, Finland
| | | | - Jari Ovaska
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
| | - Marja Leivonen
- Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital, Helsinki, Finland.,Department of Surgery, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Pipsa Peromaa-Haavisto
- Department of Surgery, Vaasa Central Hospital, Vaasa, Finland.,Department of Surgery, Hatanpää City Hospital, Tampere, Finland
| | - Suvi Mäklin
- Centre for Health and Social Economics, National Institute for Health and Welfare, Helsinki, Finland
| | - Harri Sintonen
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Henna Sammalkorpi
- Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Pirjo Nuutila
- Department of Endocrinology, Turku University Hospital, Turku, Finland.,Turku PET Centre, University of Turku, Turku, Finland
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland.,Department of Surgery, Pori, Satakunta Central Hospital, Pori, Finland
| |
Collapse
|
50
|
Sippola S, Haijanen J, Grönroos J, Rautio T, Nordström P, Rantanen T, Pinta T, Ilves I, Mattila A, Rintala J, Löyttyniemi E, Hurme S, Tammilehto V, Marttila H, Meriläinen S, Laukkarinen J, Sävelä EL, Savolainen H, Sippola T, Aarnio M, Paajanen H, Salminen P. Effect of Oral Moxifloxacin vs Intravenous Ertapenem Plus Oral Levofloxacin for Treatment of Uncomplicated Acute Appendicitis: The APPAC II Randomized Clinical Trial. JAMA 2021; 325:353-362. [PMID: 33427870 PMCID: PMC7802006 DOI: 10.1001/jama.2020.23525] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
IMPORTANCE Antibiotics are an effective and safe alternative to appendectomy for managing uncomplicated acute appendicitis, but the optimal antibiotic regimen is not known. OBJECTIVE To compare oral antibiotics with combined intravenous followed by oral antibiotics in the management of computed tomography-confirmed uncomplicated acute appendicitis. DESIGN, SETTING, AND PARTICIPANTS The Appendicitis Acuta (APPAC) II multicenter, open-label, noninferiority randomized clinical trial was conducted from April 2017 until November 2018 in 9 Finnish hospitals. A total of 599 patients aged 18 to 60 years with computed tomography-confirmed uncomplicated acute appendicitis were enrolled in the trial. The last date of follow-up was November 29, 2019. INTERVENTIONS Patients randomized to receive oral monotherapy (n = 295) received oral moxifloxacin (400 mg/d) for 7 days. Patients randomized to receive intravenous antibiotics followed by oral antibiotics (n = 288) received intravenous ertapenem (1 g/d) for 2 days followed by oral levofloxacin (500 mg/d) and metronidazole (500 mg 3 times/d) for 5 days. MAIN OUTCOMES AND MEASURES The primary end point was treatment success (≥65%) for both groups, defined as discharge from hospital without surgery and no recurrent appendicitis during 1-year follow-up, and to determine whether oral antibiotics alone were noninferior to intravenous and oral antibiotics, with a margin of 6% for difference. RESULTS Among 599 patients who were randomized (mean [SD] age, 36 [12] years; 263 [44%] women), 581 (99.7%) were available for the 1-year follow-up. The treatment success rate at 1 year was 70.2% (1-sided 95% CI, 65.8% to ∞) for patients treated with oral antibiotics and 73.8% (1-sided 95% CI, 69.5% to ∞) for patients treated with intravenous followed by oral antibiotics. The difference was -3.6% ([1-sided 95% CI, -9.7% to ∞]; P = .26 for noninferiority), with the confidence limit exceeding the noninferiority margin. CONCLUSION AND RELEVANCE Among adults with uncomplicated acute appendicitis, treatment with 7 days of oral moxifloxacin compared with 2 days of intravenous ertapenem followed by 5 days of levofloxacin and metronidazole resulted in treatment success rates greater than 65% in both groups, but failed to demonstrate noninferiority for treatment success of oral antibiotics compared with intravenous followed by oral antibiotics. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03236961; EudraCT Identifier: 2015-003633-10.
Collapse
Affiliation(s)
- Suvi Sippola
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Jussi Haijanen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
- Department of Surgery, Satakunta Central Hospital, Pori, Finland
| | - Juha Grönroos
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Tero Rautio
- Department of Surgery, Oulu University Hospital, Oulu, Finland
- Medical Research Center Oulu, University of Oulu, Finland
| | - Pia Nordström
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
| | - Tuomo Rantanen
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland
- Department of Surgery, Institute of Clinical Medicine, University of Eastern Finland
| | - Tarja Pinta
- Department of Surgery, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Imre Ilves
- Department of Surgery, Mikkeli Central Hospital, Mikkeli, Finland
| | - Anne Mattila
- Department of Surgery, Jyväskylä Central Hospital, Jyväskylä, Finland
| | - Jukka Rintala
- Department of Surgery, Oulu University Hospital, Oulu, Finland
- Department of Surgery, Rovaniemi Central Hospital, Rovaniemi, Finland
| | | | - Saija Hurme
- Department of Biostatistics, University of Turku, Turku, Finland
| | - Ville Tammilehto
- Department of Radiology, Turku University Hospital, Turku, Finland
| | - Harri Marttila
- Department of Hospital Hygiene & Infection Control, Turku University Hospital, Turku, Finland
| | - Sanna Meriläinen
- Department of Surgery, Oulu University Hospital, Oulu, Finland
- Medical Research Center Oulu, University of Oulu, Finland
| | - Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
| | | | - Heini Savolainen
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Tomi Sippola
- Department of Surgery, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Markku Aarnio
- Department of Surgery, Jyväskylä Central Hospital, Jyväskylä, Finland
| | - Hannu Paajanen
- Department of Surgery, Mikkeli Central Hospital, Mikkeli, Finland
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| |
Collapse
|