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Background: Pilonidal sinus disease impacts a patient's quality of life. In the Netherlands, it is often treated with excision and secondary wound healing, which is associated with high recurrence rates and poor wound healing. The Bascom cleft lift, an alternative technique, has shown favorable healing times and recurrence rates., Objective: The present study compares successful wound healing, time to healing, complications, and recurrence rate between excision with secondary wound healing and Bascom cleft lift., Design: This is a multicenter retrospective study., Settings: Three institutions in the Rotterdam region of the Netherlands participated in the study., Patients: Patients who underwent excision with secondary wound healing or Bascom cleft lift between July 2015 and August 2021 were included., Main Outcome Measures: Primary end points included the rate of successful wound healing and the time to achieve healing. Secondary end points included postoperative complications and the recurrence rate within 12 months after surgery., Results: Of 272 patients, 128 underwent Bascom cleft lift and 144 patients underwent excision and secondary wound healing. Recurrent pilonidal sinus disease (47.7% vs 22.2%) and abscess history (53.1% vs 40.3%) were more common in the Bascom cleft lift group compared to excision with secondary wound healing. The median follow-up period at the outpatient clinic was 43 days. The wound healing rate was 84.4% after Bascom cleft lift versus 32.6% after excision and secondary wound healing ( p < 0.001), with a median time to wound healing of 55 and 101 days, respectively ( p < 0.001). Complications were 28.9% for Bascom cleft lift versus 13.2% for excision and secondary wound healing ( p = 0.003). The rate of recurrent disease was 6.3% after Bascom cleft lift and 11.8% after excision and secondary wound healing ( p = 0.113)., Limitations: This study used a retrospective design, which makes it prone to selection bias and residual confounding. In addition, the short follow-up period adds to these limitations because a longer follow-up period may better identify true recurrence rates. The absence of collected patient satisfaction data, which is currently a common scientific issue, is also a deficiency., Conclusions: This retrospective study shows that Bascom cleft lift is superior to excision and secondary wound healing, given the higher percentage of patients with successful wound healing within a shorter time. See Video Abstract ., Resultados Posoperatorios De La Elevacin De La Hendidura Tipo Bascom Versus La Escisin Con Cicatrizacin De La Herida Por Segunda Intensin Para La Enfermedad De Seno Pilonidal Un Anlisis Retrospectivo Multicntrico: ANTECEDENTES:La enfermedad de seno pilonidal afecta la calidad de vida del paciente. En los Países Bajos, a menudo se trata con escisión y cicatrización por segunda intensión, lo que se asocia con altas tasas de recurrencia y mala cicatrización de las heridas. La elevación de la hendidura de Bascom, una técnica alternativa, ha mostrado tiempos de curación y tasas de recurrencia favorables.OBJETIVO:El presente estudio tiene como objetivo comparar la cicatrización exitosa de la herida, el tiempo de cicatrización, las complicaciones y la tasa de recurrencia entre la escisión con cicatrización secundaria de la herida y la elevación de hendidura tipo Bascom.DISEÑO:Este es un estudio retrospectivo multicéntrico.AJUSTES:Tres instituciones en la región de Rotterdam de los Países Bajos participaron en el estudio.PACIENTES:Se incluyeron pacientes sometidos a escisión con cicatrización secundaria o elecación de la hendidura tipo Bascom entre julio de 2015 y agosto de 2021.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados primarios incluyeron la tasa de curación exitosa de la herida y el tiempo para lograr la curación. Los resultados secundarios incluyeron complicaciones posoperatorias y tasa de recurrencia dentro de los doce meses posteriores a la cirugía.RESULTADOS:De 272 pacientes, 128 se sometieron a elevación de hendidura tipo Bascom y 144 pacientes a escisión y cicatrización secundaria. La ESP recurrente (47.7% frente a 22.2%) y los abscesos (53.1% frente a 40.3%) fueron más comunes en el grupo de elevación tipo Bascom en comparación con la escisión con cicatrización secundaria de la herida. La mediana del período de seguimiento en la consulta externa fue de 43 días. La cicatrización de la herida fue del 84.4 % después del lifting de Bascom frente al 32.6 % después de la escisión y la cicatrización secundaria (p < 0.001), con una mediana de tiempo hasta la cicatrización de la herida de 55 días y 101 días, respectivamente (p < 0.001). Las complicaciones fueron del 28.9% para el lifting tipo Bascom frente al 13.2% para la escisión y cicatrización secundaria (p = 0.003). La enfermedad recurrente fue del 6.3% después del lifting de hendidura tipo Bascom y del 11.8% después de la escisión y cicatrización secundaria (p = 0.113).LIMITACIONES:Diseño retrospectivo que lo hace propenso a sesgos de selección y confusión residual. Adicionalmente, el corto período de seguimiento del estudio aumenta aún más estas limitaciones, ya que un seguimiento más prolongado puede identificar mejor las verdaderas tasas de recurrencia. Por último, una deficiencia es la ausencia de datos recopilados sobre la satisfacción del paciente, lo que hoy en día es un problema científico común.CONCLUSIONES:Este estudio retrospectivo muestra que la elevación de hendidura tipo Bascom es superior a la escisión y cicatrización secundaria dado el mayor porcentaje de pacientes con curación exitosa de la herida en un tiempo más corto. (Traducción-Dr. Jorge Silva Velazco )., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Colon and Rectal Surgeons.)

Background: Undetected obstructive sleep apnea (OSA) is highly prevalent in patients undergoing bariatric surgery and increases perioperative risks. Screening for OSA using preoperative polygraphy (PG) with subsequent continuous positive airway pressure (CPAP) is costly and time-consuming. Postoperative continuous pulse oximetry (CPOX) is less invasive, and is hypothesized to be a safe and cost-effective alternative., Objectives: This nationwide multicenter prospective observational cohort study compared CPOX monitoring with OSA-screening using PG., Setting: High-volume bariatric centers., Methods: Patients were either postoperatively monitored using CPOX without preoperative OSA-screening, or underwent preoperative PG and CPAP treatment when OSA was diagnosed. Cohort placement was based on local hospital protocols. Cost-effectiveness was analyzed using quality adjusted life years (QALYs) and healthcare costs. Surgical outcomes were also analyzed. Propensity score matching was used in sensitivity analyses., Results: A total of 1390 patients were included. QALYs were similar between groups at baseline and 1-year postoperatively. Postoperative complications, intensive care unit (ICU)-admissions and admissions, particularly OSA-related, did not differ between groups. Mean costs per patient/year in the CPOX group was €3094 versus €3680 in the PG group; mean difference €-586 (95% CI €-933-€-242). Following propensity score matching, 1090 of 1390 included patients remained, and similar findings for cost-effectiveness, complications, and ICU admissions were observed., Conclusion: CPOX monitoring without preoperative OSA-screening was not associated with higher complication or readmission rates compared to PG. CPOX resulted in lower costs from a healthcare perspective and can therefore be considered a cost-effective alternative to routine OSA-screening in patients undergoing bariatric surgery., (Copyright © 2024 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Non-excisional techniques for pilonidal sinus disease (PSD) have gained popularity over the last years. The aim of this study was to review short and long-term outcomes for non-excisional techniques with special focus on the additive effect of treatment of the inner lining of the sinus cavity and the difference between primary and recurrent PSD. A systematic search was conducted in Embase, Medline, Web of Science Core Collection, Cochrane and Google Scholar databases for studies on non-excisional techniques for PSD including pit picking techniques with or without additional laser or phenol treatment, unroofing, endoscopic techniques and thrombin gelatin matrix application. Outcomes were recurrence rates, healing rates, complication rates, wound healing times and time taken to return to daily activities. In total, 31 studies comprising 8100 patients were included. Non-excisional techniques had overall healing rates ranging from 67 to 100%. Recurrence rates for pit picking, unroofing and gelatin matrix application varied from 0 to 16% depending on the follow-up time. Recurrence rates after additional laser, phenol and endoscopic techniques varied from 0 to 29%. Complication rates ranged from 0 to 16%, and the wound healing time was between three and forty-seven days. The return to daily activities varied from one to nine days. Non-excisional techniques are associated with fast recovery and low morbidity but recurrence rates are high. Techniques that attempt to additionally treat the inner lining of the sinus have worse recurrence rates than pit picking alone. Recurrence rates do not differ between primary and recurrent disease., (© 2023. The Author(s).)

Purpose: Obstructive sleep apnea (OSA) is prevalent in the bariatric population. OSA should be recognized in patients undergoing bariatric surgery preoperatively to prevent peri- and post-operative complications. Lipid metabolism-related biomarkers are associated with OSA. Triglyceride metabolism is, among others, regulated by angiopoietin-like protein five (ANGPTL5). We aimed to evaluate the level of ANGPTL5 in patients with OSA of different severity levels before and after bariatric surgery., Methods: We performed a single-center prospective cohort study including a consecutive series of patients who underwent bariatric surgery. We collected the clinical data, polysomnography (PSG) or polygraphy (PG) parameters, and plasma derived via venipuncture before and 6 to 12 months after surgery. Lipid profile, glucose levels, and ANGPTL5 levels were assessed. ANGPTL5 levels were measured using an enzyme-linked immunosorbent assay (ELISA)., Results: The study included 88 patients for analysis. The patients were divided into two subgroups: no or mild OSA (apnea-hypopnea index (AHI) < 15 events/hour, n = 57) and moderate-to-severe OSA (AHI ≥ 15 events/hour, n = 31). The ANGPTL5 level was higher in the moderate-to-severe OSA group (20.5 [15.6, 26.5] ng/mL) compared to the no or mild OSA group (16.3 [12.5, 19.4] ng/mL) (p = 0.008). A significant positive correlation was observed between ANGPTL5 and AHI (ρ = 0.256, p = 0.017), apnea index (AI) (ρ = 0.318, p = 0.003), and triglyceride levels (ρ = 0.240, p = 0.025). ANGPTL5 levels were reduced significantly after bariatric surgery in both moderate-to-severe OSA (15.6 [10.3, 18.7] ng/mL) and no or mild OSA (13.4 [9.2, 15.8] ng/mL) groups, though to a lower level in the group without or mild OSA. Post-surgery, the significant positive correlation between ANGPTL5 and AHI (ρ = 0.210, p = 0.047), AI (ρ = 0.230, p = 0.034), and triglyceride (ρ = 0.397, p < 0.001) remained., Conclusion: The data showed increased levels of ANGPTL5 in patients with moderate-to-severe OSA. Both AHI and ANGPTL5 levels decreased significantly after bariatric surgery. We also report an association between ANGPTL5 levels and OSA severity., (© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Treatment of obstructive sleep apnoea (OSA) in adults is evolving, as new therapies have been explored and introduced in clinical practice, while other approaches have been refined or reconsidered. In this European Respiratory Society (ERS) guideline on non-continuous positive airway pressure (CPAP) therapies for OSA, we present recommendations determined by a systematic review of the literature. It is an update of the 2011 ERS statement on non-CPAP therapies, advanced into a clinical guideline. A multidisciplinary group of experts, including pulmonary, surgical, dentistry and ear-nose-throat specialists, methodologists and patient representatives considered the most relevant clinical questions (for both clinicians and patients) relating to the management of OSA. Eight key clinical questions were generated and a systematic review was conducted to identify published randomised clinical trials that answered these questions. We used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to assess the quality of the evidence and the strength of recommendations. The resulting guideline addresses gastric bypass surgery, custom-made dual-block mandibular advancement devices, hypoglossal nerve stimulation, myofunctional therapy, maxillo-mandibular osteotomy, carbonic anhydrase inhibitors and positional therapy. These recommendations can be used to benchmark quality of care for people with OSA across Europe and to improve outcomes., Competing Interests: Conflicts of Interest: W. Randerath reports personal fees received from Weinmann, Heinen & Löwenstein, Resmed, Inspire, Philips Respironics, and Bioprojet, outside the submitted work. Conflicts of interest: J. Verbraecken reports receiving payments to institution for lectures, presentations, speakers bureaus, manuscript writing or educational events from SomnoMed and Inspire Medical Systems, outside the submitted work. Participation on a Data Safety Monitoring Board or Advisory Board for ResMed Narval, payments to institution, outside the submitted work. Conflicts of interest: C.A.L. de Raaff has nothing to disclose. Conflicts of interest: J. Heder reports grants received from ResMed, outside the submitted work. Lecture fees from Bayer Pharma and Jazz Pharmaceuticals outside the submitted work. Patent filed and granted for Pharmacological therapy in OSA. Participation on a data safety monitoring board or advisory board for DSMB. Conflicts of interest: S. Herkenrath has nothing to disclose. Conflicts of interest: W. Hohenhorst has nothing to disclose. Conflicts of interest: T. Jakob has nothing to disclose. Conflicts of interest: O. Marrone has nothing to disclose. Conflicts of interest: M. Marklund has nothing to disclose. Conflicts of interest: W.T. McNicholas has nothing to disclose. Conflicts of interest: R.L. Morgan has nothing to disclose. Conflicts of interest: J-L. Pépin reports grants and research funds from (payments made to the institutions) Air Liquide Foundation, Agiradom, AstraZeneca, Fisher and Paykel, Mutualia, Philips, Resmed and Vitalaire, outside the submitted work. Consulting fees from: Agiradom, AstraZeneca, Boehringer Ingelheim, Jazz pharmaceutical, Night Balance, Philips, Resmed, and Sefam, outside the submitted work. Conflicts of interest: S. Schiza has nothing to disclose. Conflicts of interest: N. Skoetz reports support for the present manuscript from the European Respiratory Society. Personal payments received from Cochrane outside the submitted work. Conflicts of interest: D. Smyth has nothing to disclose. Conflicts of interest: J. Steier reports receiving grants from the British Lung Foundation, outside the submitted work. Payments of honoraria received from Jazz Pharmaceuticals and Sanofi. Named inventor on pending patent WO2016124739A1. President of the British Sleep Society. Conflicts of interest: T. Tonia acts as an ERS methodologist. Conflicts of interest: W. Trzepizur has nothing to disclose. Conflicts of interest: P-H. van Mechelen has nothing to disclose. Conflicts of interest: P. Wijkstra has nothing to disclose., (Copyright ©The authors 2021.)

Purpose: Almost two-thirds of the population undergoing bariatric surgery (BS) suffers from obstructive sleep apnea (OSA). Continuous positive airway pressure (CPAP) is the standard treatment for moderate to severe OSA and is recommended in patients undergoing BS perioperatively. A severe and dreaded complication after BS is anastomotic leakage. There is theoretical concern that perioperative CPAP use may result in increased distension of the gastrointestinal tract and increase the risk of developing an anastomotic leakage. The aim of this study was to evaluate the effect of postoperative CPAP use on the risk of developing anastomotic leakages after BS., Methods: Retrospectively, all patients from a single bariatric center who underwent BS from November 2007 to August 2019 were included. Presence and severity of OSA were determined using poly(somno)graphy. To evaluate the effect of postoperative CPAP use on anastomotic leakage, a multivariable logistic regression analysis was performed., Results: A total of 4052 patients were included, with OSA being diagnosed in 62%. Overall, 970 patients (24%) used CPAP after BS. Anastomotic leakage occurred in 64 (1.6%) patients after BS. Leakage rate was 1.3% in non-CPAP group versus 2.5% in CPAP group (p = 0.01). CPAP use was associated with anastomotic leakage; however, after adjustment, CPAP use was not an independent predictor (OR = 1.40, 95% CI 0.60-3.28, p = 0.44)., Conclusion: There is no independent relation between postoperative CPAP use and anastomotic leakage after BS. Only revision surgery was an independent predictor of anastomotic leakage.

Introduction: Despite the high prevalence of obstructive sleep apnoea (OSA) in obese patients undergoing bariatric surgery, OSA is undiagnosed in the majority of patients and thus untreated. While untreated OSA is associated with an increased risk of preoperative and postoperative complications, no evidence-based guidelines on perioperative care for these patients are available. The aim of the POPCORN study ( P ost- O perative P ulse oximetry without OSA s C reening vs perioperative continuous positive airway pressure (CPAP) treatment following O SA sc R ee N ing by polygraphy (PG)) is to evaluate which perioperative strategy is the most cost-effective for obese patients undergoing bariatric surgery without a history of OSA., Methods and Analysis: In this multicentre observational cohort study, data from 1380 patients who will undergo bariatric surgery will be collected. Patients will receive either postoperative care with pulse oximetry monitoring and supplemental oxygen during the first postoperative night, or care that includes preoperative PG and CPAP treatment in case of moderate or severe OSA. Local protocols for perioperative care in each participating hospital will determine into which cohort a patient is placed. The primary outcome is cost-effectiveness, which will be calculated by comparing all healthcare costs with the quality-adjusted life-years (QALYs, calculated using EQ-5D questionnaires). Secondary outcomes are mortality, complications within 30 days after surgery, readmissions, reoperations, length of stay, weight loss, generic quality of life (QOL), OSA-specific QOL, OSA symptoms and CPAP adherence. Patients will receive questionnaires before surgery and 1, 3, 6 and 12 months after surgery to report QALYs and other patient-reported outcomes., Ethics and Dissemination: Approval from the Medical Research Ethics Committees United was granted in accordance with the Dutch law for Medical Research Involving Human Subjects Act (WMO) (reference number W17.050). Results will be submitted for publication in peer-reviewed journals and presented at (inter)national conferences., Trial Registration Number: NTR6991., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: To date, no consensus exists regarding optimal perioperative care of patients with obstructive sleep apnea (OSA) undergoing upper airway (UA) surgery. These patients are at risk related to anesthesia and postoperative analgesia, among other risks associated with difficult airway control, and may require intensified perioperative management., Objective: To provide a consensus-based guideline by reviewing available literature and collecting expert opinion during an international consensus meeting with experts from relevant speciliaties., Evidence Review: In a consensus meeting conducted on April 4, 2018, a total of 47 questions covering preoperative, intraoperative, and postoperative care were formulated by 12 international experts with extensive clinical experience in the field of UA surgery for OSA. Systematic literature searches were performed by an independent information specialist and 6 researchers according to the Oxford and GRADE systems, and 164 articles published on or before December 31, 2011, were included in the analysis. Two moderators chaired the meeting according to the Amsterdam Delphi Method, including iteration of literature conclusions, expert discussion, and voting rounds. Consensus was reached when there was 70% or more agreement among experts., Findings: Of 47 questions, 35 led to a recommendation or statement. The remaining 12 questions provided no additional information and were excluded in the judgment of experts. Consensus was reached for 32 recommendations. For 1 question there was less than 70% agreement among experts; therefore, consensus was not achieved. Highlights of these recommendations include (1) postoperative bleeding is a complication described for all types of UA surgery; (2) OSA is a relative risk factor for difficult mask ventilation and intubation, and plans for difficult airway management should be considered and implemented; (3) safe perioperative care should be provided, with aspects such as OSA severity, adherent use of positive airway pressure, type of surgery, and comorbidities taken into account; (4) although there is no direct evidence to date, in patients undergoing UA surgery, preoperative treatment with positive airway pressure may reduce the risk of postoperative airway complications; and (5) alternative pain management options perioperatively to reduce opioid use should be considered., Conclusions and Relevance: This consensus contains 35 recommendations and statements on the perioperative care of patients with OSA undergoing UA surgery and may be used as a guideline in daily practice.

Background: Postbariatric anastomotic or staple line leakage (ASLL) is a dreaded complication with an incidence up to 1.6% and a leak-associated mortality of 5.0% to 16.7%. Feared low sensitivity of abdominal computed tomography (CT) for detecting ASLL is causing surgeons to omit CT and directly perform a diagnostic laparoscopy in patients with suspected ASLL., Objectives: To evaluate the diagnostic value of CT in case of suspected ASLL after bariatric procedures and to identify reliable CT characteristics predicting the presence of ASLL., Setting: A large teaching hospital and bariatric center of excellence., Methods: All CT scans performed for suspected ASLL after bariatric surgery in the period November 2007 until August 2016 were independently reevaluated by abdominal radiologists. The diagnostic value of CT by means of sensitivity, specificity, and positive and negative predictive value was analyzed comparing results of reevaluation to a standard of reference. Multivariable regression was performed to identify reliable CT characteristics for the presence of ASLL., Results: A total of 66 CT scans were performed because of suspected leakage. Reevaluation of CT scans revealed a sensitivity of 89% to 100%, a specificity of 69% to 78%, a positive predictive value of 39% to 50%, and a negative predictive value of 97% to 100% of CT for detecting ASLL after bariatric surgery. Multivariable logistic regression of ASLL characteristics on CT revealed 'air near the anastomosis/staple line' as the only independent predictor for the presence of ASLL., Conclusion: With a sensitivity of 89% to 100% and negative predictive value of 97% to 100%, a negative CT can rule out ASLL in patients with a lower suspicion of ASLL., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: One third of bariatric surgery patients have an apnea-hypopnea index (AHI)>15/hr, representing moderate and severe forms of obstructive sleep apnea (OSA). Treating these forms of OSA is recommended to reduce the risk of perioperative complications. The AHI derived from poly(somno)graphy [P(S)G] is the gold standard for OSA diagnosis. However, performing P(S)G in all patients scheduled for bariatric surgery is time consuming and expensive. An accurate and simple screening tool able to rule out moderate to severe OSA would reduce the number of patients needing mandatory P(S)Gs., Objectives: To assess the validity of a simple sleep monitor (Checkme Health Monitor) as a screening tool for OSA in bariatric surgery patients., Setting: Obesity Center Amsterdam, OLVG-West, Amsterdam, the Netherlands METHODS: Patients scheduled for bariatric surgery were prospectively enrolled in this study. All patients underwent preoperative P(S)G and simultaneously used the Checkme to assess the oxygen desaturation index. The diagnostic performance of the Checkme for AHI ≥15/hr was assessed using receiver operating characteristic curve analysis., Results: A total of 50 patients were analyzed. Sensitivity and negative predictive value were 100% and 100%, respectively, specificity and positive predictive value were 69% and 64%, respectively, for the optimal cutoff value of Checkme-3% oxygen desaturation index ≥9/hr for P(S)G-AHI ≥15. The area under the curve value expressed by the receiver operating characteristic curve was .95., Conclusion: The Checkme is valid for exclusion of moderate and severe OSA in bariatric surgery patients. The Checkme enables bariatric clinics not to perform P(S)G in all patients scheduled for bariatric surgery., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: To examine the influence of obstructive sleep apnea (OSA) on the quality of life (QoL) in bariatric surgery., Methods: All patients who underwent a laparoscopic Roux-and-Y gastric bypass (LRYGB), preoperative poly(somno)graphy and completed an Impact of Weight on QoL-Lite questionnaire before and after surgery were included., Results: A total of 276 patients were included. OSA was diagnosed in 150 (53.3%) patients. All subscale scores improved 15 months post-surgery (p < 0.01). Total score improved from 51.2 (SD 19.1) to 89.7 (SD 13.9). Lower postoperative scores were seen in OSA patients on subscales Public Distress (90.4 SD 18.8 versus 95.7 SD 10.2; p = 0.003) and Work (92.9 SD 15 versus 96.1 SD 9.7; p = 0.031). All postoperative subscale scores were negatively correlated with OSA severity (p < 0.01)., Conclusions: After LRYGB, QoL improved in both OSA and non-OSA patients. OSA patients, especially patients with severe OSA, have lower postoperative scores on subscales Public Distress and Work after LRYGB., (Copyright © 2017 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

Background: The decision to undergo bariatric surgery is multifactorial and made both by patient and doctor. Information is of the utmost importance for this decision., Objective: To investigate the bariatric surgery patient's preferences regarding information provision in bariatric surgery., Setting: A teaching hospital, bariatric center of excellence in Amsterdam, the Netherlands., Methods: All patients who underwent a primary laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy between September 2013 and September 2014 were approached by mail to participate. A questionnaire was used to elicit patient preferences for the content and format of information. Sociodemographic characteristics, clinicopathologic factors, and psychologic factors were explored as predictors for specific preferences., Results: Of the 356 eligible patients, 112 (31.5%) participated. The mean age was 49.2 (±10.7) years, and 91 (81.3%) patients were female. Patients deemed the opportunity to ask questions (96.4%) the most important feature of the consult, followed by a realistic view on expectations-for example, results of the procedure (95.5%) and information concerning the consequences of surgery for daily life (89.1%). Information about the risk of complications on the order of 10% was desired by 93% of patients; 48% desired information about lower risks (.1%). Only 25 patients (22.3%) desired detailed information concerning their weight loss after surgery., Conclusion: Bariatric patients wished for information about the consequences of surgery on daily life, whereas the importance of information concerning complications decreased when their incidence lessened., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: Increasing numbers of bariatric surgical procedures and the high prevalence of obstructive sleep apnea (OSA) in this population have resulted in a growing interest in the perioperative management of OSA in bariatric surgery. This review provides a summary of the first consensus guideline on this topic as well as an update of the newest literature available., Recent Findings: All bariatric patients should be screened for OSA and obesity hypoventilation syndrome (OHS) to reduce the risk of perioperative complications. Intraoperative precautions are preoxygenation, induction and intubation in ramped position, continuous positive airway pressure (CPAP) and positive end-expiratory pressure during induction, maintenance of low tidal volumes during surgery, multimodal anesthesia and analgesia with avoidance of opioids and extubation when patients are free of neuromuscular blockage. CPAP therapy and continuous monitoring with a minimum of pulse oximetry is recommended in the early postoperative period., Summary: Multiple precautions exist to minimize the risk of cardiopulmonary complications and to enhance recovery after surgery. A combination of these procedures seems to provide optimal perioperative care of OSA patients undergoing bariatric surgery. Nearly 75% of recommendations are based on low quality of evidence, indicating the high value of experts' opinion and potential for future research.

Background: Obstructive sleep apnea (OSA) affects two third of morbidly obese individuals undergoing bariatric surgery. Perioperative usage of continuous positive airway pressure (CPAP) is advised for moderately and severe OSA to avoid respiratory failure and cardiac events. CPAP increases the air pressure in the upper airway, but also may elevate the air pressure in the esophagus and stomach. Concern exists that this predisposes to mechanical stress resulting in suture or staple line disruption (further referred to as suture line disruption)., Objectives: To evaluate whether perioperative CPAP usage is associated with an increased risk of suture line disruption after bariatric surgery., Setting: Obesity Center Amsterdam, OLVG-west, Amsterdam, the Netherlands., Methods: All patients who underwent bariatric surgery including a suture line were eligible for inclusion. Only patients with information regarding OSA severity as defined by the apnea-hypopnea-index and postoperative CPAP usage were included., Results: From November 2007 to August 2016, postoperative CPAP status was documented in 2135 patients: 497 (23.3%) used CPAP postoperatively, whereas 1638 (76.7%) used no CPAP. Mean body mass index was 44.1 kg/m 2 (standard deviation 6.6). Suture line disruption occurred in 25 patients (1.2%). The leakage rate was not associated with CPAP usage (8 [1.6%] in CPAP group versus 17 [1%] in non-CPAP group, P = .300). CPAP was no risk factor for suture line disruption in multivariable analysis as well., Conclusion: Postoperative CPAP does not appear to increase the risk of suture line disruption in bariatric surgery. CPAP is recommended in all patients with moderate or severe OSA who undergo bariatric surgery., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Around 20% of bariatric surgery patients develop a short- or long-term complication., Objective: Aim of this study was to develop a risk model predicting complications: the Bariatric Surgery Index for Complications (BASIC)., Setting: The Obesity Center Amsterdam, located in a large teaching hospital, in Amsterdam, The Netherlands., Methods: A prospective consecutive database including patients operated between November 2007 and February 2015 was used. For the BASIC, analysis according to the TRIPOD statement was performed to identify risk factors for complications. Class I included patients with zero to one risk factor, class II patients with two risk factors, and class III patients with three or more risk factors., Results: Of 1709 analyzed patients, mean age was 45 years (±SD 10.7), 1393 (81.5%) were female; mean body mass index was 44.5 kg/m 2 (6.8). Overall, 271 (15.9%) patients developed a complication of which 197 (72.5%) occurred within 30 days. Predictors in multivariable analysis were use of anticoagulants (odd's ratio (OR) 1.5); chronic obstructive pulmonary disease (OR 2.3); dyslipidemia (OR 1.4); gender (OR 1.4); psychiatric history (OR 1.3); and revisional surgery (OR 1.5). In class I, 13.5% (181 out of 1338) experienced complications, in class II 58 (21.6%) of the 269 patients and in class III 32 (31.4%) of the 102 patients, respectively. There was a significant difference (p < 0.001) in both overall and 30 day complications., Conclusion: The BASIC uses six preoperative variables to classify patients in a low-, intermediate-, or high-risk group for postoperative complications after bariatric surgery.

Background: There is an overall complication rate of 6.3%-10% after bariatric surgery. After ruling out anatomic/physical causes, there is a substantial group of patients who develop unexplained postsurgical abdominal pain., Objectives: To inventory the prevalence of unexplained abdominal pain after laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy and to determine predictive factors for unexplained abdominal pain., Setting: Obesity Center Amsterdam, Amsterdam, the Netherlands., Methods: A retrospective study in a prospective database was performed. Baseline characteristics and postoperative course were evaluated., Results: A total of 1788 patients underwent laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy between November 2007 and April 2015. The average follow-up consisted of 33.5 months, without loss to follow-up. Abdominal pain was presented in 387 patients (21.6%). The study population consisted of 337 women (87.1%) and 50 men (12.9%); the mean age was 43.3 years (standard deviation 10.1) and the median preoperative body mass index was 43.7 kg/m². An explanation for abdominal pain was found in 246 of 387 patients (63.6%), whereas no explanation was found in 133 patients (34.4%). Revisional surgery was a significant predictor for unexplained pain (odds ratio 1.7; confidence interval 1.0-2.8; P = 0.037)., Conclusion: A total of 133 patients (7.4%) experienced unexplained abdominal pain after laparoscopic bariatric surgery. Revisional surgery was found to be a significant predictive factor for this outcome. Present study results suggest that postoperative unexplained abdominal pain is a significant morbidity and should be part of the informed consent. More research is needed regarding further diagnosis and management and treatment., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The aim of this study was to evaluate the value of preoperative liver function tests (LFTs) in patients with uncomplicated gallstone disease and scheduled for laparoscopic cholecystectomy., Methods: All 1112 patients who underwent a laparoscopic cholecystectomy for symptomatic gallstone disease during a 6-year cohort were retrospectively reviewed. Only patients who presented with uncomplicated disease were selected. Preoperative LFTs, pre-, and postoperative endoscopic retrograde cholangio pancreaticographies (ERCPs) and postoperative complications were collected., Results: A total of 697 patients were included. There were 629 (90.2%) patients with (group I) and 68 (9.8%) patients without (group II) preoperative LFTs. The incidence of ERCPs, ERCPs positive for bile duct stones, and postoperative complications were not significantly different between groups. Second, Group I patients were divided into four groups: 360 patients with normal LFTs (I-A1), 269 patients with at least one LFT > normal value (I-A2), 531 patients with all LFTs <2× normal (I-B1), and 98 patients with at least one LFT >2× normal (I-B2). More ERCPs were performed in group I-A2 (10%) than in group I-A1 (2.2%) and more in group I-B2 (18.4%) than I-B1 (3.2%), as a consequence of significantly more ERCPs performed preoperatively. No differences were detected between groups regarding ERCPs positive for bile duct stones or postoperative complications., Conclusions: Preoperative LFTs do not influence the occurrence of postoperative complications nor the total rate of ERCPs in patients undergoing cholecystectomy for uncomplicated gallstone disease. Preoperative determination of LFTs seems to cause a slight shift from post- to preoperative ERCPs without further clinical consequences.

Background: The frequency of metabolic and bariatric surgery (MBS) is increasing worldwide, with over 500,000 cases performed every year. Obstructive sleep apnea (OSA) is present in 35%-94% of MBS patients. Nevertheless, consensus regarding the perioperative management of OSA in MBS patients is not established., Objectives: To provide consensus based guidelines utilizing current literature and, when in the absence of supporting clinical data, expert opinion by organizing a consensus meeting of experts from relevant specialties., Setting: The meeting was held in Amsterdam, the Netherlands., Methods: A panel of 15 international experts identified 75 questions covering preoperative screening, treatment, postoperative monitoring, anesthetic care and follow-up. Six researchers reviewed the literature systematically. During this meeting, the "Amsterdam Delphi Method" was utilized including controlled acquisition of feedback, aggregation of responses and iteration., Results: Recommendations or statements were provided for 58 questions. In the judgment of the experts, 17 questions provided no additional useful information and it was agreed to exclude them. With the exception of 3 recommendations (64%, 66%, and 66% respectively), consensus (>70%) was reached for 55 statements and recommendations. Several highlights: polysomnography is the gold standard for diagnosing OSA; continuous positive airway pressure is recommended for all patients with moderate and severe OSA; OSA patients should be continuously monitored with pulse oximetry in the early postoperative period; perioperative usage of sedatives and opioids should be minimized., Conclusion: This first international expert meeting provided 58 statements and recommendations for a clinical consensus guideline regarding the perioperative management of OSA patients undergoing MBS., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Fibroepithelial tumours are the most common type of solid breast tumours. They include the common fibroadenomas and the rare phyllodes tumours. Fibroadenomas usually present in younger patients and are smaller than phyllodes tumours. They are benign and do not require any treatment or follow-up. Further examination (usually ultrasound-guided thick-needle biopsy) is recommended if in doubt about the diagnosis. Phyllodes tumours can be divided into benign, borderline and malignant tumours and are primarily treated with surgery, breast-conserving surgery if possible. In this article, we present three cases and an overview of characteristics, diagnosis, and treatment of fibroepithelial breast tumours.

Background: Around 10 % of the bariatric surgery patients experience postoperative complications (<30 days). It could be hypothesized that complications influence postoperative weight loss, which is one of the most important endpoints of bariatric surgery. Therefore, this study inventoried the effect of complications on postoperative weight loss., Methods: A consecutive database including patients who were operated from November 2007 onwards was retrospectively reviewed. All short-term complications were classified according to the Clavien-Dindo classification. Weight loss was assessed at 6 and 12 months postoperatively., Results: A total of 1130 patients underwent either primary (n = 907, 80.3 %) or revisional (n = 233, 19.7 %) surgery till October 2013. Short-term complications occurred in 115 (10.2 %) patients, of whom 48 (41.7 %) had a severe (Clavien-Dindo ≥ 3) complication. One year post surgery, 184 patients (16.3 %) were lost to follow-up. Patients with a short-term complication had a higher percentage of excess weight loss (%EWL) at 6 months (58.6 (SD 16.6) versus 52.9 (SD 17.6), p = 0.003) and 1 year (71.9 (SD 22.3) versus 65.9 (SD 21.3), p = 0.017) of follow-up. Although a trend was seen toward higher BMI loss and total weight loss (TWL) after 6 months, no effect was seen 1 year postoperatively. In multivariable linear regression analysis, complications were not a significant predictor for 1-year %EWL., Conclusions: Although short-term complications alter 1-year %EWL, no effect was seen on BMI loss and TWL. In addition, complications were not a predictor in a multivariable linear regression model for 1-year %EWL. It can be concluded that short-term complications do not impair weight loss after Roux-en-Y gastric bypass.