Micronutrient Supplementation after Biliopancreatic Diversion with Duodenal Switch in the Long Term

Background Malabsorptive bariatric surgery requires lifelongmicronutrientsupplementation.Basedontherecommendations, we assessed the number of adjustments of micronutrientsupplementationandtheprevalenceofvitaminandmineral deficiencies at a minimum follow-up of 5 years after biliopancreatic diversion with duodenal switch (BPD-DS). Methods Between October 2010 and December 2013, a total of 51 patients at a minimum follow-up of 5 years after BPDDS were invited for a clinical check-up with a nutritional blood screening test for vitamins and minerals. Results Forty-three of fifty-one patients (84.3 %) completed the blood sampling with a median follow-up of 71.2 (range 60–102) monthsafter BPD-DS. At that time,all patientswere supplemented with at least one multivitamin. However, 35 patients (81.4 %) showed either a vitamin or a mineral deficiencyoracombinationofit.Nineteenpatients(44.1%)were anemic,and17patients(39.5%)hadanirondeficiency.High deficiency rates for fat-soluble vitamins were also present in 23.2 % for vitamin A, in 76.7 % for vitamin D, in 7.0 % for vitamin E, and in 11.6 % for vitamin K. Conclusions Theresultsofourstudyshowthattheprevalence ofvitaminandmineraldeficienciesafterBPD-DSis81.4%at a minimum follow-up of 5 years. The initial prescription of micronutrientsupplementationandfurtheradjustmentsduring thefirstfollow-upwereinsufficient toavoidlong-term micronutrient deficiencies. Life-long monitoring of micronutrients at a specialized bariatric center and possibly a better micronutrient supplementation, is crucial to avoid a deficient micronutrient status at every stage after malabsorptive bariatric surgery

Refractory Hematuria in an Oliguric Patient After Pancreas Transplantation with Exocrine Pancreas Bladder Drainage

A 52-yr-old man presented with hematuria and clot retention. He had undergone simultaneous pancreas-kidney transplantation with exocrine pancreas bladder drainage 16 yr ago. The patient suffered from progressive transplant kidney failure with gradually decreasing urine output and needed hemodialysis every other day. Gross hematuria persisted after removal of all blood clots. Cystoscopy showed multiple small, flat ulcers of the bladder mucosa. Some bled discretely and were coagulated cautiously. However, hematuria was refractory to multiple urological interventions, which eventually necessitated an enteric diversion of the exocrine pancreas. Hematuria ceased following an uneventful postoperative course.

A Portable Image Overlay Projection Device for Computer-Aided Open Liver Surgery

Image overlay projection is a form of augmented reality that allows surgeons to view underlying anatomical structures directly on the patient surface. It improves intuitiveness of computer-aided surgery by removing the need for sight diversion between the patient and a display screen and has been reported to assist in 3-D understanding of anatomical structures and the identification of target and critical structures. Challenges in the development of image overlay technologies for surgery remain in the projection setup. Calibration, patient registration, view direction, and projection obstruction remain unsolved limitations to image overlay techniques. In this paper, we propose a novel, portable, and handheld-navigated image overlay device based on miniature laser projection technology that allows images of 3-D patient-specific models to be projected directly onto the organ surface intraoperatively without the need for intrusive hardware around the surgical site. The device can be integrated into a navigation system, thereby exploiting existing patient registration and model generation solutions. The position of the device is tracked by the navigation system’s position sensor and used to project geometrically correct images from any position within the workspace of the navigation system. The projector was calibrated using modified camera calibration techniques and images for projection are rendered using a virtual camera defined by the projectors extrinsic parameters. Verification of the device’s projection accuracy concluded a mean projection error of 1.3 mm. Visibility testing of the projection performed on pig liver tissue found the device suitable for the display of anatomical structures on the organ surface. The feasibility of use within the surgical workflow was assessed during open liver surgery. We show that the device could be quickly and unobtrusively deployed within the sterile environment.

Evaluation of a portable image overlay projector for the visualisation of surgical navigation data: phantom studies

Presenting visual feedback for image-guided surgery on a monitor requires the surgeon to perform time-consuming comparisons and diversion of sight and attention away from the patient. Deficiencies in previously developed augmented reality systems for image-guided surgery have, however, prevented the general acceptance of any one technique as a viable alternative to monitor displays. This work presents an evaluation of the feasibility and versatility of a novel augmented reality approach for the visualisation of surgical planning and navigation data. The approach, which utilises a portable image overlay device, was evaluated during integration into existing surgical navigation systems and during application within simulated navigated surgery scenarios.

[Secondary malignancies in urinary diversions]

In contrast to ureterosigmoidostomy no reliable clinical data exist for tumor risk in different forms of urinary diversion using isolated intestinal segments.In 44 German urological departments, operation frequencies, indications, patient age, and operation dates of the different forms of urinary diversion, operated between 1970 and 2007, could be registered. The secondary tumors up to 2009 were registered as well and related to the numbers of the different forms of urinary diversions resulting in tumor prevalences.In 17,758 urinary diversions 32 secondary tumors occurred. The tumor risk in ureterosigmoidostomy (22-fold) and cystoplasty (13-fold) is significantly higher than in other continent forms of urinary diversion such as neobladders or pouches (p<0.0001). The difference between ureterosigmoidostomy and cystoplasty is not significant, nor is the difference between ileocecal pouches (0.14%) and ileal neobladders (0.05%) (p=0.46). The tumor risk in ileocecal (1.26%) and colonic neobladders (1.43%) is significantly higher (p=0.0001) than in ileal neobladders (0.5%). Of the 16 tumors that occurred following ureterosigmoidostomy, 16 (94%) developed directly at the ureterocolonic borderline in contrast to only 50% following urinary diversions via isolated intestinal segments.From postoperative year 5 regular endoscopic controls of ureterosigmoidostomies, cystoplasties, and orthotopic (ileo-)colonic neobladders are necessary. In ileocecal pouches, regular endoscopy is necessary at least in the presence of symptoms or should be performed routinely at greater intervals. Following neobladders or conduits, only urethroscopies for urethral recurrence are necessary.

Twenty years experience with an ileal orthotopic low pressure bladder substitute--lessons to be learned

PURPOSE: We present the long-term results of a large consecutive series of patients undergoing ileal orthotopic bladder substitution following radical cystectomy. MATERIALS AND METHODS: Between April 1985 and 2005 orthotopic bladder substitution with an ileal low pressure reservoir was performed in 482 patients (including 40 women) after radical and, if possible, nerve sparing cystectomy. In 447 cases the procedure was combined with an afferent ileal isoperistaltic tubular segment. The patients were followed prospectively. RESULTS: In the 482 patients 61 early (less than 30 days) diversion related complications requiring prolonged hospital stay or readmission were noted and 115 late complications required treatment. At 1 year continence was good in 92% of patients during the day and in 79% at night. At last followup 93% of patients could void spontaneously. Of 442 evaluable men 99 (22.4%) reported having erections without and 68 (15.4%) with medical assistance. Ureteroileal stenosis was observed in 12 of 447 (2.7%) patients. Urethral recurrence was detected in 25 of 482 (5%) patients. A total of 15 (5%) patients received vitamin B12 substitution. Renal parenchyma decreased only in patients with preoperative or postoperative ureteral obstruction. After 10 years patients with normal renal function had no long-term acidosis and in 20 patients the incidence of osteoporosis resembled that of the normal population. CONCLUSIONS: Ileal orthotopic bladder substitution combined with an afferent ileal tubular segment allows for good long-term functional results provided patients are restrictively selected, postoperative instructions are followed carefully, and typical complications such as outlet obstruction and hernias are treated early.

[Orthotopic ileal neobladder. Postoperative management and results]

Urinary diversion after cystectomy have evolved from simple diversion and protection of the upper tracts to functional and anatomic restoration as close as possible to the natural preoperative state. Over the past 15 years, orthotopic reconstruction has evolved from "experimental surgery" to the "preferred method of urinary diversion" in both sexes. Urologist that perform this technique should have an appropriate experience with pelvic surgery and be able to perform a nerve sparing radical cystectomy. Nevertheless, the postoperative management of these patients is more important than the surgical construction if good longterm results are to be achieved. For this reason, a great knowledge about the neobladder's physiology, postoperative complications and their treatment are needed. We review the most important aspects in the postoperative management of patients with ileal neobladder. We also resume the long term outcomes concerning to continence, sexual function, renal impairment, oncologic safety and quality of life.

Is a sustaining rod necessary for diverting loop ileostomy?

Objective: Whether or not a protective stoma reduces the rate of anastomotic leakage after distal colorectal anastomosis is still discussed controversially. It does however facilitate clinical management once leakage has occurred. Loop ileostomies seem to be associated with a lower morbidity and a better quality of life compared to loop colostomies. Generally, diverting loop ileostomies are secured at skin level by means of a supporting device in order to prevent retraction of the ileostomy into the abdomen. However, due to the supporting rod, difficulties may occur in applying a stoma bag correctly and leakage of faeces onto the skin may occur even with correct eversion of the afferent limb. Our aim was to compare morbidity and time to self-sufficient stoma-care in patients having a loop ileostomy with rod to those without rod. Methods: A total of 60 patients necessitating loop ileostomy were analyzed. Patients received surgery in of the two involved institutions according to inhouse standard procedures. 30 patients had an ileostomy with rod (VCHK Inselspital) and a further 30 without rod (KSW Winterthur). Morbidity and time to self-sufficiency regarding stoma care was analyzed during the first 90 postoperative days. Morbidity was determined according to a scoring system ranging from 0 to 4 points for any given set of possible complications (bleeding, necrosis, skin irritation, abscess, stenosis, retraction, fistula, prolapse, parastomal hernia, incomplete diversion), where 0 = no complication and 4 = severe complication. Continuous variables were expressed as median (95% Confidence Interval). For comparisons between the groups the Mann-Whitney U test was used, between categorical variables the X2 test was applied. Results: There were no significant differences in length of hospital stay or time to self-sufficient stoma-care between the groups. Although not significant, patients with a rod ileostomy had a tendency towards more stoma-related complications as well as stoma-related reoperations. The number of patients reaching total self-sufficiency regarding stoma care was higher after rodless ileostomy. Conclusion: According to our data, rodless ileostomies seemto fare just as well as those with a supporting rod, with equal morbidity rates and more patients reaching self-sufficient stoma care. Therefore routine application of a rod for diverting loop ileostomy seems unnecessary

Complications following radical cystectomy for bladder cancer in the elderly

CONTEXT: The incidence of bladder cancer increases with advancing age. Considering the increasing life expectancy and the increasing proportion of elderly people in the general population, radical cystectomy will be considered for a growing number of elderly patients who suffer from muscle-invasive or recurrent bladder cancer. OBJECTIVE: This article reviews contemporary complication and mortality rates after radical cystectomy in elderly patients and the relationship between age and short-term outcome after this procedure. EVIDENCE ACQUISITION: A literature review was performed using the PubMed database with combinations of the following keywords cystectomy, elderly, complications, and comorbidity. English-language articles published in the year 2000 or later were reviewed. Papers were included in this review if the authors investigated any relationship between age and complication rates with radical cystectomy for bladder cancer or if they reported complication rates stratified by age groups. EVIDENCE SYNTHESIS: Perioperative morbidity and mortality are increased and continence rates after orthotopic urinary diversion are impaired in elderly patients undergoing radical cystectomy. Complications are frequent in this population, particularly when an extended postoperative period (90 d instead of 30 d) is considered. CONCLUSIONS: Although age alone does not preclude radical cystectomy for muscle-invasive or recurrent bladder cancer or for certain types of urinary diversion, careful surveillance is required, even after the first 30 d after surgery. Excellent perioperative management may contribute to the prevention of morbidity and mortality of radical cystectomy, supplementary to the skills of the surgeon, and is probably a reason for the better perioperative results obtained in high-volume centers.

Phenotypic divergence but not genetic distance predicts assortative mating among species of a cichlid fish radiation

The hypothesis of ecological divergence giving rise to premating isolation in the face of gene flow is controversial. However, this may be an important mechanism to explain the rapid multiplication of species during adaptive radiation following the colonization of a new environment when geographical barriers to gene flow are largely absent but underutilized niche space is abundant. Using cichlid fish, we tested the prediction of ecological speciation that the strength of premating isolation among species is predicted by phenotypic rather than genetic distance. We conducted mate choice experiments between three closely related, sympatric species of a recent radiation in Lake Mweru (Zambia/DRC) that differ in habitat use and phenotype, and a distantly related population from Lake Bangweulu that resembles one of the species in Lake Mweru. We found significant assortative mating among all closely related, sympatric species that differed phenotypically, but none between the distantly related allopatric populations of more similar phenotype. Phenotypic distance between species was a good predictor of the strength of premating isolation, suggesting that assortative mating can evolve rapidly in association with ecological divergence during adaptive radiation. Our data also reveals that distantly related allopatric populations that have not diverged phenotypically, may hybridize when coming into secondary contact, e.g. upon river capture because of diversion of drainage systems.

Restrictive deferred hydration combined with preemptive norepinephrine infusion during radical cystectomy reduces postoperative complications and hospitalization time: a randomized clinical trial.

BACKGROUND Anesthetics and neuraxial anesthesia commonly result in vasodilation/hypotension. Norepinephrine counteracts this effect and thus allows for decreased intraoperative hydration. The authors investigated whether this approach could result in reduced postoperative complication rate. METHODS In this single-center, double-blind, randomized, superiority trial, 166 patients undergoing radical cystectomy and urinary diversion were equally allocated to receive 1 ml·kg·h of balanced Ringer's solution until the end of cystectomy and then 3 ml·kg·h until the end of surgery combined with preemptive norepinephrine infusion at an initial rate of 2 µg·kg·h (low-volume group; n = 83) or 6 ml·kg·h of balanced Ringer's solution throughout surgery (control group; n = 83). Primary outcome was the in-hospital complication rate. Secondary outcomes were hospitalization time, and 90-day mortality. RESULTS In-hospital complications occurred in 43 of 83 patients (52%) in the low-volume group and in 61 of 83 (73%) in the control group (relative risk, 0.70; 95% CI, 0.55-0.88; P = 0.006). The rates of gastrointestinal and cardiac complications were lower in the low-volume group than in the control group (5 [6%] vs. 31 [37%]; relative risk, 0.16; 95% CI, 0.07-0.39; P < 0.0001 and 17 [20%] vs. 39 [48%], relative risk, 0.43; 95% CI, 0.26-0.60; P = 0.0003, respectively). The median hospitalization time was 15 days [range, 11, 27d] in the low-volume group and 17 days [11, 95d] in the control group (P = 0.02). The 90-day mortality was 0% in the low-volume group and 4.8% in the control group (P = 0.12). CONCLUSION A restrictive-deferred hydration combined with preemptive norepinephrine infusion during radical cystectomy and urinary diversion significantly reduced the postoperative complication rate and hospitalization time.

Intraoperative Continuous Norepinephrine Infusion Combined with Restrictive Deferred Hydration Significantly Reduces the Need for Blood Transfusion in Patients Undergoing Open Radical Cystectomy: Results of a Prospective Randomised Trial

BACKGROUND Open radical cystectomy (ORC) is associated with substantial blood loss and a high incidence of perioperative blood transfusions. Strategies to reduce blood loss and blood transfusion are warranted. OBJECTIVE To determine whether continuous norepinephrine administration combined with intraoperative restrictive hydration with Ringer's maleate solution can reduce blood loss and the need for blood transfusion. DESIGN, SETTING, AND PARTICIPANTS This was a double-blind, randomised, parallel-group, single-centre trial including 166 consecutive patients undergoing ORC with urinary diversion (UD). Exclusion criteria were severe hepatic or renal dysfunction, congestive heart failure, and contraindications to epidural analgesia. INTERVENTION Patients were randomly allocated to continuous norepinephrine administration starting with 2 μg/kg per hour combined with 1 ml/kg per hour until the bladder was removed, then to 3 ml/kg per hour of Ringer's maleate solution (norepinephrine/low-volume group) or 6 ml/kg per hour of Ringer's maleate solution throughout surgery (control group). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Intraoperative blood loss and the percentage of patients requiring blood transfusions perioperatively were assessed. Data were analysed using nonparametric statistical models. RESULTS AND LIMITATIONS Total median blood loss was 800 ml (range: 300-1700) in the norepinephrine/low-volume group versus 1200 ml (range: 400-2800) in the control group (p<0.0001). In the norepinephrine/low-volume group, 27 of 83 patients (33%) required an average of 1.8 U (±0.8) of packed red blood cells (PRBCs). In the control group, 50 of 83 patients (60%) required an average of 2.9 U (±2.1) of PRBCs during hospitalisation (relative risk: 0.54; 95% confidence interval [CI], 0.38-0.77; p=0.0006). The absolute reduction in transfusion rate throughout hospitalisation was 28% (95% CI, 12-45). In this study, surgery was performed by three high-volume surgeons using a standardised technique, so whether these significant results are reproducible in other centres needs to be shown. CONCLUSIONS Continuous norepinephrine administration combined with restrictive hydration significantly reduces intraoperative blood loss, the rate of blood transfusions, and the number of PRBC units required per patient undergoing ORC with UD.

Opioid maintenance therapy in Switzerland: an overview of the Swiss IMPROVE study

BACKGROUND/AIMS: Switzerland’s drug policy model has always been unique and progressive, but there is a Need to reassess this system in a rapidly changing world. The IMPROVE study was conducted to gain understanding of the attitudes and beliefs towards opioid maintenance therapy (OMT) in Switzerland with regards to quality and Access to treatment. To obtain a “real-world” view on OMT, the study approached its goals from two different angles: from the perspectives of the OMT patients and of the physicians who treat patients with maintenance therapy. The IMPROVE study collected a large body of data on OMT in Switzerland. This paper presents a small subset of the dataset, focusing on the research design and methodology, the profile of the participants and the responses to several key questions addressed by the questionnaires. METHODS: IMPROVE was an observational, questionnaire-based cross-sectional study on OMT conducted in Switzerland. Respondents consisted of OMT patients and treating physicians from various regions of the country. Data were collected using questionnaires in German and French. Physicians were interviewed by phone with a computer-based questionnaire. Patients self-completed a paper-based questionnaire at the physicians’ Offices or OMT treatment centres. RESULTS: A total of 200 physicians and 207 patients participated in the study. Liquid methadone and methadone tablets or capsules were the medications most commonly prescribed by physicians (60% and 20% of patient load, respectively) whereas buprenorphine use was less frequent. Patients (88%) and physicians (83%) were generally satisfied with the OMT currently offered. The current political framework and lack of training or information were cited as determining factors that deter physicians from engaging in OMT. About 31% of OMT physicians interviewed were ≥60 years old, indicating an ageing population. Diversion and misuse were considered a significant problem in Switzerland by 45% of the physicians. CONCLUSION: The subset of IMPROVE data presented gives a present-day, real-life overview of the OMT landscape in Switzerland. It represents a valuable resource for policy makers, key opinion leaders and drug addiction researchers and will be a useful basis for improving the current Swiss OMT model.