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Small Intestinal Bacterial Overgrowth in Patients with Roux-en-Y Gastric Bypass and One-Anastomosis Gastric Bypass

Obes Surg. 2022 Oct 5. doi: 10.1007/s11695-022-06299-z. Online ahead of print.

ABSTRACT

BACKGROUND: Small intestinal bacterial overgrowth (SIBO) is defined as an excessive growth and/or changed composition of bacteria in the small bowel. Obese patients are at increased risk of SIBO and related complications. The purpose of this study is to evaluate the incidence of SIBO after bariatric bypass procedures, connection between SIBO, symptoms, comorbidities, and liver pathology.

METHODS: Patients underwent a hydrogen breath test with glucose substrate (25 g/200 ml of water). The demographic, anthropometric data, comorbidities, and symptoms were analysed with a questionnaire. In 45 patients, the NAFLD Activity Score was evaluated in liver biopsies.

RESULTS: Glucose breath test was positive in 24/56 (43%) of patients and was associated with higher frequency of defecation (p = 0.022), lactose intolerance (p = 0.047), scleroderma (p = 0.042), irritable bowel syndrome (p = 0.018), and diabetes (p = 0.002). Mean NAFLD Activity Score in SIBO patients (n = 18) was 3.33 and 3.00 in non-SIBO patients (n = 27). In SIBO-positive cohort of patients, a statistically important trend in difference between NAS and difference to range value anti-Xa 4 h after subtherapeutic dose application was calculated.

CONCLUSIONS: The incidence of SIBO after bariatric surgery bypass procedures is alarmingly high (43%). The results of our study conclude that diagnosis cannot be set based on specific symptom and SIBO is related to reduced response to the application of LMWH. Mandatory SIBO screening and appropriate treatment would affect the clinical outcome of the underlying disease, improve it significantly, and prevent the development of its complications.

PMID:36197573 | DOI:10.1007/s11695-022-06299-z

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Preoperative endogenous testosterone density predicts disease progression from localized impalpable prostate cancer presenting with PSA levels elevated up to 10 ng/mL

Int Urol Nephrol. 2022 Oct 5. doi: 10.1007/s11255-022-03366-3. Online ahead of print.

ABSTRACT

OBJECTIVE: To investigate endogenous testosterone density (ETD) predicting disease progression from clinically localized impalpable prostate cancer (PCa) presenting with prostate-specific antigen (PSA) levels elevated up to 10 ng/mL and treated with radical prostatectomy.

MATERIALS AND METHODS: In a period ranging from November 2014 to December 2019, 805 consecutive PCa patients who were not under androgen blockade had endogenous testosterone (ET, ng/dL) measured before surgery. ETD was evaluated as the ratio of ET on prostate volume (PV). Unfavorable disease was defined as including ISUP ≥ 3 and/or seminal vesicle invasion in the surgical specimen. The risk of disease progression was evaluated by statistical methods.

RESULTS: Overall, the study selected 433 patients, of whom 353 (81.5%) had available follow-up. Unfavorable disease occurred in 46.7% of cases and was predicted by tumor quantitation features that were positively associated with ETD. Disease progression, which occurred for 46 (13%) cases, was independently predicted only by ETD (hazard ratio, HR = 1.037; 95% CI 1.004-1.072; p = 0.030) after adjusting for unfavorable disease. According to a multivariate model, ETD above the third quartile was confirmed to be an independent predictor for PCa progression (HR = 2.479; 95% CI 1.355-4.534; p = 0.003) after adjusting for unfavorable disease. The same ETD measurements, ET mean levels were significantly lower in progressing cancers.

CONCLUSIONS: In this particular subset of patients, increased ETD with low ET levels, indicating androgen independence, resulted in a more aggressive disease with poorer prognosis.

PMID:36197572 | DOI:10.1007/s11255-022-03366-3

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Endolymphatic space is age-dependent

J Neurol. 2022 Oct 5. doi: 10.1007/s00415-022-11400-8. Online ahead of print.

ABSTRACT

Knowledge of the physiological endolymphatic space (ELS) is necessary to estimate endolymphatic hydrops (ELH) in patients with vestibulocochlear syndromes. Therefore, the current study investigated age-dependent changes in the ELS of participants with normal vestibulocochlear testing. Sixty-four ears of 32 participants with normal vestibulocochlear testing aged between 21 and 75 years (45.8 ± 17.2 years, 20 females, 30 right-handed, two left-handed) were examined by intravenous delayed gadolinium-enhanced magnetic resonance imaging of the inner ear (iMRI). Clinical diagnostics included neuro-otological assessment, video-oculography during caloric stimulation, and head-impulse test. iMRI data analysis provided semi-quantitative visual grading and automatic algorithmic quantitative segmentation of ELS volume (3D, mm3) using a deep learning-based segmentation of the inner ear’s total fluid space (TFS) and volumetric local thresholding, as described earlier. As a result, following a 4-point ordinal scale, a mild ELH (grade 1) was found in 21/64 (32.8%) ears uni- or bilaterally in either cochlear, vestibulum, or both. Age and ELS were found to be positively correlated for the inner ear (r(64) = 0.33, p < 0.01), and vestibulum (r(64) = 0.25, p < 0.05). For the cochlea, the values correlated positively without reaching significance (r(64) = 0.21). In conclusion, age-dependent increases of the ELS should be considered when evaluating potential ELH in single subjects and statistical group comparisons.

PMID:36197569 | DOI:10.1007/s00415-022-11400-8

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Endovascular thrombectomy with or without intravenous alteplase in acute stroke: a systematic review and meta-analysis of randomized clinical trials

J Neurol. 2022 Oct 5. doi: 10.1007/s00415-022-11413-3. Online ahead of print.

ABSTRACT

BACKGROUND AND PURPOSE: This study investigated clinical outcomes after direct endovascular thrombectomy (EVT) compared to bridging therapy (EVT with prior intravenous alteplase) in acute stroke within 4.5 h after onset.

METHODS: PubMed and Embase were searched for eligible randomized controlled trials. The primary outcome was the rates of neurological functional independence defined as modified Rankin scale score 0-2 at 90 days, whose non-inferiority margin was set at – 15%, – 10%, – 6.5%, – 5%, and – 1.3% for its risk difference (RD).

RESULTS: We included six studies enrolling 2334 participants. The crude cumulative rates of functional independence were 49.0% with direct EVT vs 50.9% with bridging therapy, without significant difference (Odd ratio [OR] = 0.93, 95% confidence interval [CI] 0.79-1.09) between two groups, where the pooled RD was – 2% (95% CI – 6 to 2%) whose lower 95% CI bound fell within non-inferiority margins of – 15%, – 10%, -6.5%, but not – 5% and – 1.3%. Between the two groups, no significant difference was found in excellent function rate (30.2% vs 30.6%, OR = 0.99, 95% CI 0.82-1.18) with RD of 0% (95% CI – 3 to 4%), mortality rate (16.0% vs 15.0%, OR = 1.08, 95% CI 0.86-1.35) with RD of 1% (95% CI – 2 to 4%), and symptomatic intracranial hemorrhage rate (4.3% vs 5.0%, OR = 0.86, 95% CI 0.58-1.27) with RD of 0% (95% CI – 2 to 1%).

CONCLUSIONS: No statistical difference was found in functional and safety outcomes between direct EVT and bridging therapy groups in acute stroke within 4.5 h after symptom onset. EVT alone was non-inferior to bridging therapy for several, but not the more stringent, non-inferiority margins.

PMID:36197568 | DOI:10.1007/s00415-022-11413-3

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Inflammation-based prognostic scores in geriatric patients with rectal cancer

Tech Coloproctol. 2022 Oct 5. doi: 10.1007/s10151-022-02710-0. Online ahead of print.

ABSTRACT

BACKGROUND: Morbidity/mortality and oncologic outcomes can be worsened in geriatric rectal cancer patients due to comorbidities and frailty. The aim of this study was to compare surgical and oncological results of geriatric rectal cancer patients using inflammation-based prognostic scores.

METHODS: The prospectively maintained database of 991 rectal cancer patients treated at our center between 2007 and 2020 were analyzed. All conventional clinicopathologic features, and oncologic outcomes are compared between patients ≥ 65 years old (geriatric patients: Group I) and < 65 years old (non-geriatric patients: Group II). The modified Glasgow Prognostic Score (mGPS) and the C-reactive protein-albumin ratio (CAR), were determined. The prognostic value of mGPS and CAR as well as the well-known clinico-pathologic factors to predict surgical morbidity, mortality, local and/or distant recurrence, and overall survival was assessed.

RESULTS: There were 567 (57.2%) patients who were ≥ 65 years old (Group I; 349 males, median age 74 [range 65-9]) years) and 424 (42.8%) who were < 65 years old (Group II; 252 males, median age 58 [range 20-64] years). The high-grade [Clavien-Dindo III-IV] complications rates of Group I and Group II patients sere 20% (n = 113), and 9% (n = 37), respectively. High-grade complications were related to mGPS (p < 0.001) and CAR (p < 0.001) values. The high-grade complication rate was found to be higher in Group I than in Group II, and this was statistically significant (p < 0.001). High preoperative mGPS and CAR values were significantly associated with postoperative mortality (p < 0.001). In Cox multivariate analysis, mGPS (p = 0.003) and CAR (p = 0.001) were significantly in correlation with lowered overall survival. The mGPS and CAR were found to be independent prognostic factors for overall survival.

CONCLUSIONS: The mGPS and CAR can predict severe postoperative complications and early mortality. mGPS, and CAR have a powerful prognostic value and the potential clinical usefulness to predict decreased overall survival in both geriatric and non-geriatric rectal cancer patients.

PMID:36197565 | DOI:10.1007/s10151-022-02710-0

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Predictive factors for functional failure of ventral mesh rectopexy in the treatment of rectal prolapse and obstructed defecation

Tech Coloproctol. 2022 Oct 4. doi: 10.1007/s10151-022-02708-8. Online ahead of print.

ABSTRACT

BACKGROUND: Ventral mesh rectopexy (VMR) is widely accepted for the treatment of rectal prolapse or obstructed defecation. However, despite good anatomical results, the improvement of functional symptoms (constipation or incontinence) cannot always be obtained and in some cases these symptoms may even worsen. The aim of the present study was to identify possible predictors of functional failure after VMR.

METHODS: Data of all consecutive patients who had VMR for the treatment of rectal prolapse and/or obstructed defecation between January 2017 and December 2020 in three different pelvic floor surgical centres in Italy were analysed to identify possible predictors of functional failure, intended as persistence, worsening or new onset of constipation or faecal incontinence. Symptom severity was assessed pre- and postoperatively with the Wexner Constipation score and Obstructed Defecation Syndrome score. Quality of life was assessed, also before and after treatment, with the Patients Assessment of Constipation Quality of Life questionnaire, the Pelvic Floor Disability Index and the Pelvic Floor Impact Questionnaire. Faecal incontinence was evaluated with the Cleveland Clinic Incontinence Score. The functional outcomes before and after surgery were compared.

RESULTS: Sixty-one patients were included (M:F ratio 3:60, median age 64 years [range 33-88 years]). Forty-two patients (68.9%) had obstructed defecation syndrome, 12(19.7%) had faecal incontinence and 7 patients (11.5%) had both. A statistically significant reduction between pre- and postoperative Obstructed Defecation Syndrome and Wexner scores was reported (p < 0.0001 in both cases). However, the postoperative presence of constipation occurred in 22 patients (36.1%) (this included 3 cases of new-onset constipation). The presence of redundant colon and the pre-existent constipation were associated with an increased risk of persistence of constipation postoperatively or new-onset constipation (p = 0.004 and p < 0.0001, respectively). The use of postoperative pelvic floor rehabilitation (p = 0.034) may reduce the risk of postoperative constipation.

CONCLUSIONS: VMR is a safe and effective intervention for correcting the anatomical defect of rectal prolapse. The degree of prolapse, the presence of dolichocolon and pre-existing constipation are risk factors for the persistence or new onset of postoperative constipation. Postoperative rehabilitation treatment may reduce this risk.

PMID:36197564 | DOI:10.1007/s10151-022-02708-8

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Association between laser flare photometry and symptom duration in primary rhegmatogenous retinal detachment

Int Ophthalmol. 2022 Oct 5. doi: 10.1007/s10792-022-02532-x. Online ahead of print.

ABSTRACT

PURPOSE: The purpose of this study was to investigate preoperative blood-ocular barrier disruption via laser flare photometry (LFP) in patients diagnosed with rhegmatogenous retinal detachment (RRD), and to analyse possible associations with symptom duration and anatomical parameters.

METHODS: We retrospectively analysed consecutive patients presenting with RRD at a single centre between January 2016 and March 2020. LFP was performed in both eyes after pupillary dilatation prior to RRD surgery. Symptom duration, extent of retinal detachment, and lens status were assessed. For statistical analysis, we carried out the unequal variances t test and Welch’s analysis of variance (ANOVA).

RESULTS: We included 373 eyes of 373 patients (mean age 63.96 years ± 10.29; female:male ratio 1:1.8). LFP values quantified in photon count per millisecond (pc/ms) increased with longer symptom duration when comparing patients with a symptom duration of 0-3 days (n = 158; 9.25 ± 6.21 pc/ms) and ≥ 4 days (n = 215; 11.97 ± 11.58 pc/ms; p = 0.004). LFP values also rose with the number of retinal quadrants affected by RRD (1 quadrant, 6.82 ± 4.08 pc/ms; 2 quadrants, 10.08 ± 7.28 pc/ms; 3 quadrants, 12.79 ± 7.9 pc/ms; 4 quadrants, 31.57 ± 21.27 pc/ms; p < 0.001), macula off status (macula on, 8.89 ± 6.75 pc/ms; macula off, 12.65 ± 11.66 pc/ms; p < 0.001), and pseudophakic lens status (pseudophakia, 12.86 ± 9.52 pc/ms; phakia: 9.31 ± 9.67 pc/ms; p < 0.001).

CONCLUSION: In RRD patients, blood-ocular barrier disruption quantified by LFP is associated with the duration of symptoms and the disease’s anatomical extent. These results warrant further investigation of the potential clinical use of LFP in RRD.

PMID:36197523 | DOI:10.1007/s10792-022-02532-x

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Propensity score matching analysis comparing outcomes between primary and revision Roux-en-Y gastric bypass after adjustable gastric banding: a retrospective record-based cohort study

Surg Endosc. 2022 Oct 5. doi: 10.1007/s00464-022-09675-z. Online ahead of print.

ABSTRACT

BACKGROUND: One-stage revision Roux-en-Y gastric bypass (RRYGB) after Laparoscopic adjustable gastric banding (LAGB) is widely adopted, but its safety is still debated.

OBJECTIVE: This study aimed to compare outcomes between primary Roux-en-Y gastric bypass (PRYGB and RRYGB after LAGB.

METHOD: A retrospective record-based cohort study of patients who underwent PRYGB and RRYGB for failed LAGB and completed at least 2 years of follow-up from 2008 to 2019. Propensity score matching (PSM) analysis was conducted to obtain a balanced sample of patients with RRYGB and PRYGB interventions by adjusting for baseline covariates including age and sex.

RESULTS: Patients with PRYGB (n = 558) and RRYGB (n = 156) were included. PSM identified 98 patients for RRYGB and 98 patients for PRYGB. Both cohorts exhibited significant reductions in BMI compared to baseline values (p < 0.001), but reductions were significantly higher in PRYGB compared to those in RRGYB at 6 months (- 10.55 ± 8.54 vs. – 8.38 ± 5.07; p = 0.032), 1-year (- 21.50 ± 8.19 vs. 16.14 ± 6.93; p < 0.001), and 2 years (- 24.02 ± 7.85 vs. – 18.93 ± 6.80; p < 0.001), respectively. A significant improvement in food tolerance from the 1st to the 2nd year was seen after RYGB (p < 0.001). The rates of early and late complications were similar in both cohorts (p = 0.537, p = 1.00). Overall re-intervention rates were 5.1 and 3.1% for RRYGB and PRYGB p = 0.721). Both cohorts exhibited significant improvement in comorbidities after 2 years (p < 0.001).

CONCLUSIONS: One-stage RRYGB for failed LAGB is safe and effective with comparable rates of complications, re-interventions, and resolution of associated comorbid conditions compared to PRYGB.

PMID:36197519 | DOI:10.1007/s00464-022-09675-z

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Surgical management of high-grade paediatric spondylolisthesis: meta-analysis and systematic review

Eur Spine J. 2022 Oct 5. doi: 10.1007/s00586-022-07408-3. Online ahead of print.

ABSTRACT

PURPOSE: There is currently no consensus on the management of high-grade spondylolisthesis (HGS) in paediatric populations. The objective of this analysis is to compare the outcomes of reduction followed by fusion (RFF) or in situ fusion (ISF) in paediatric patients.

METHODS: Using major databases, a systematic literature search was performed. Primary studies comparing ISF with RFF in paediatric and adolescent patients were identified. Study data including patient-reported outcomes, complications, and spinopelvic parameters were collected and analysed.

RESULTS: Seven studies were included, comprising 97 ISF and 131 RFF. Average patient age was 14.4 ± 2.1 years and follow up was 8.2 ± 5.1 years. Patients undergoing RFF compared to patients undergoing ISF alone were less likely to develop pseudarthrosis (RR 0.51, 95% CI, [0.26, 0.99], p = 0.05). On average, RFF led to 11.97º more reduction in slip angle and 34.8% more reduction in sagittal translation (p < 0.00001) compared to ISF. There was no significant difference between patient satisfaction and pain at follow up. Neurologic complications and reoperation rates were not significantly different.

CONCLUSIONS: Both RFF and ISF are effective techniques for managing HGS. Performing a reduction followed by fusion reduces the likelihood of pseudarthrosis in paediatric patients. The difference between risk of neurologic complications, need for reoperation, patient satisfaction, and pain outcomes did not reach statistical significance. Correlation with patient-reported outcomes still needs to be further explored. LEVEL 3 EVIDENCE: Meta-analysis of Level 3 studies.

PMID:36197510 | DOI:10.1007/s00586-022-07408-3

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Adherence to guideline recommendations in the management of upper tract urothelial carcinoma: an analysis of the CROES-UTUC registry

World J Urol. 2022 Oct 5. doi: 10.1007/s00345-022-04168-z. Online ahead of print.

ABSTRACT

BACKGROUND: The European Association of Urology provides Clinical Practice Guideline on upper tract urothelial carcinoma (UTUC). Due to the rarity of UTUC, guidelines are necessary to help guide decision-making based on the highest quality of care evidence available.

OBJECTIVES: To evaluate guideline adherence in the management of UTUC by assessing recommendations on diagnostics needed for risk classification and subsequent treatment selection; to assess predictors for the latter.

PARTICIPANTS: Data from the Clinical Research Office of the Endo Urology Society UTUC-registry were included for analysis.

STATISTICAL ANALYSIS: Overall compliance were evaluated by cross-tables, differences in risk groups characteristics and treatment selection were assessed by Chi-square tests, predictors for treatment selection by logistic regression analysis.

RESULTS: Data from 2380 patients were included. Imaging by CT-scan had highest adherence (85%) but was low for other diagnostics (17.7-49.7%). Multivariable regression analysis showed higher odds of receiving radical nephroureterectomy in patients with large tumours (OR 5.45, 95% CI 3.77-7.87, p < 0.001), signs of invasion (OR 3.07,CI 2.11-4.46, p < 0.001), high tumour grade (OR 2.05, CI 1.38-3.05, p < 0.001) and multifocality (OR 1.76,CI 1.05-2.97, p =0.032).

CONCLUSIONS: CT-imaging is the most used and most impactful decision tool for risk-stratification and treatment selection in UTUC. Due to the low compliance in most of the diagnostic recommendations, proper risk stratification is not possible in a significant group of patients raising the question whether current stratification is deemed applicable in daily practice. Established prognostic factors on survival guides decision-making regarding radical versus kidney-sparing surgery. Tumour size was the most influencing factor on treatment decision.

CLINICAL TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov (ClinicalTrials.gov NCT02281188; https://clinicaltrials.gov/ct2/show/NCT02281188 ).

PMID:36197507 | DOI:10.1007/s00345-022-04168-z