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Background: Postoperative bleeding remains a relatively common complication following bariatric surgery and may lead to morbidity and even mortality., Objective: To develop a prediction model to identify patients at risk for postoperative bleeding., Setting: Rode Kruis Ziekenhuis, Beverwijk, the Netherlands. Based on Dutch nationwide obesity audit data., Methods: Patients undergoing primary bariatric surgery were selected from January 2015 to December 2020 from the Dutch Audit for Treatment of Obesity. The primary outcome was postoperative bleeding within 30 days. Assessed predictors included patient factors and operative data. A prediction model was developed using backward stepwise logistic regression. Internal validation was performed using bootstrapping techniques., Results: A total of 59,055 patients were included; 13,399 underwent a sleeve gastrectomy, and 45,656 underwent a gastric bypass procedure. Postoperative bleeding occurred in 1.5%. The following predictors were identified: male patients (odds ratio [OR] = 1.40; 95% confidence interval [CI]: 1.21-1.63), patients >45 years of age (OR = 1.50; 95% CI: 1.29-1.76), body mass index <40 kg/m 2 (OR = 1.22; 95% CI: 1.06-1.41), cardiovascular disease (OR = 1.36; 95% CI: 1.17-1.57), and sleeve gastrectomy (OR = 1.43; 95% CI: 1.24-1.67). Area under the curve for the model was .612. Following bootstrapping for internal validation, a correction of .9817 was applied., Conclusion: A clinical decision rule was designed to assess the risk of postoperative bleeding in patients undergoing bariatric surgery. If 3 or more risk factors are present, there is an increased risk for postoperative bleeding. The model can aid in clinical decision-making: implementing extra preventative measures in high-risk patients. External validation is needed to further develop the model., (Copyright © 2022 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Internal herniation (IH) is a well-known complication after laparoscopic gastric bypass (LGB). Diagnosing and managing IH can be challenging. This retrospective cohort study aimed to achieve a greater understanding of symptomatology, diagnostic tools, complications, risk of IH recurrence, and symptom relief in IH patients., Methods: We included patients who underwent LGB surgery at our institution between 2011 and 2015. Mesenteric defects were not preventively closed during LGB. We focused on LGB patients who underwent surgical intervention(s) for suspected IH during a 7-year study period. We studied patient characteristics, (predictive) symptoms and signs, abdominal imaging, operative findings, post-operative course, and risk of (recurrent) IH., Results: A total of 1588 patients were included. In total, 243 patients underwent IH-related diagnostic laparoscopy. Radiating pain to the back (OR 2.45, p = .03), post-prandial pain (OR 3.23, p = .00), and leukocytosis (OR 15.53, p = .01) were identified as predictors of IH. The estimated risk of IH-related diagnostic laparoscopy was 16% at 3 years post-LGB, and the risk of confirmed IH was 12%. The estimated risk of diagnostic laparoscopy for suspected recurrent IH was 10% at 5 years post-LGB. In patients who underwent secondary mesenteric defects closure, post-operative symptom relief was reported in 84%., Conclusion: This study demonstrates a considerable risk of developing IH after LGB without preventive closure of the mesenteric defects. We emphasize the value of diagnostic laparoscopy to achieve symptom relief in patients with suspicion of IH. Preoperative diagnosis of IH can be improved by being watchful of specific symptoms and signs which can predict the intra-operative presence of IH.

Background: Small steps wound closure of midline laparotomy has been reported to decrease the incidence of incisional hernia development in two randomized controlled trials. The aim of the present study was to evaluate the effect of implementing the small steps wound closure technique in clinical practice with regards to the development of incisional ventral hernia (IVH) and surgical site infections (SSI) in clinical practice., Methods: Implementation of the small steps wound closure technique using the small tissue bites technique as the standard closure technique for abdominal midline incisions in our clinical practice was done in March 2015. For this study, all patients from June 2013 until June 2016 with a midline laparotomy, either long or small in case of specimen extraction in laparoscopic surgery, in either elective or emergency setting were included. Conventional large bite wound closure was compared to small steps wound closure with regards to the development of SSI, IVH as well as burst abdomen., Results: A total of 327 patients were included. The small steps suture technique was used in 136 (42%) of the patients, whereas the conventional large bites suture technique was used in 191 patients (58%). A total of 54 patients in the large bites group developed SSI (28%) compared to 23 (17%) patients in the small steps group (p = 0.02). A total number of 10 patients (7%) developed IVH in the small steps group compared to 27 patients (14%) in the large bites group (p = 0.08)., Conclusion: Implementation of small bites wound closure of abdominal midline incisions in clinical practice was correlated with a reduction in surgical site infections.

Introduction: Vagus nerve stimulation (VNS) exerts beneficial anti-inflammatory effects in various animal models of inflammation, including collagen-induced arthritis, and is implicated in representing a novel therapy for rheumatoid arthritis. However, evidence of anti-inflammatory effects of VNS in humans is very scarce. Transvenous VNS (tVNS) is a newly developed and less invasive method to stimulate the vagus nerve. In the present study, we determined whether tVNS is a feasible and safe procedure and investigated its putative anti-inflammatory effects during experimental human endotoxemia., Methods: We performed a randomized double-blind sham-controlled study in healthy male volunteers. A stimulation catheter was inserted in the left internal jugular vein at spinal level C5-C7, adjacent to the vagus nerve. In the tVNS group (n = 10), stimulation was continuously performed for 30 minutes (0-10 V, 1 ms, 20 Hz), starting 10 minutes before intravenous administration of 2 ng kg(-1) Escherichia coli lipopolysaccharide (LPS). Sham-instrumented subjects (n = 10) received no electrical stimulation., Results: No serious adverse events occurred throughout the study. In the tVNS group, stimulation of the vagus nerve was achieved as indicated by laryngeal vibration. Endotoxemia resulted in fever, flu-like symptoms, and hemodynamic changes that were unaffected by tVNS. Furthermore, plasma levels of inflammatory cytokines increased sharply during endotoxemia, but responses were similar between groups. Finally, cytokine production by leukocytes stimulated with LPS ex vivo, as well as neutrophil phagocytosis capacity, were not influenced by tVNS., Conclusions: tVNS is feasible and safe, but does not modulate the innate immune response in humans in vivo during experimental human endotoxemia., Trial Registration: Clinicaltrials.gov NCT01944228. Registered 12 September 2013.

A detailed analysis of the results of the international annual International Committee for Dermatopathology-Union Européene des Médecins Specialistes dermatopathology examination was undertaken to identify clues for further improvement. The analysis covered 5 consecutive years (2006-2010) and involved a total of 860 questions (591 common questions and 269 uncommon questions) and 181 participants. It focused on the overall performance of the participants, the performance per part of the examination (theoretical or practical), the performance per format of question (multiple choice or open), the performance per dermatopathological topic, and the performance per professional background (dermatologist or pathologist). The overall performance of the participants was high (on average 75% correct answers in 2006 and 85% correct answers in the subsequent years). In the theoretical part of the examination, the topics of vascular diseases and lichenoid dermatoses scored better than the average of all topics, and the topics of cutaneous lymphoproliferative diseases and melanocytic disorders scored worse. In the first practical part (interpretation of images), dermatologists outperformed pathologists, especially on providing a diagnosis (open question format) of clinical images. In the second practical part (microscopical examination), the topics of vascular diseases, granulomatous diseases, including necrobiotic and degenerative and metabolic diseases scored better than the average of all topics, and the topic of infectious diseases scored worse. The results of this detailed analysis provide an excellent feedback to the examination committee that will be used to consider the adjustment of parts and/or topics of the examination that showed a deviant performance by the participants. In addition, it is recommended to give more attention to the postgraduate education of certain dermatopathological topics, including cutaneous lymphoproliferative diseases, melanocytic disorders, and infectious diseases.