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van den Hil LCL, Mommers EHH, Bosmans JWAM, Morales-Conde S, Gómez-Gil V, LeBlanc K, Vanlander A, Reynvoet E, Berrevoet F, Gruber-Blum S, Altinli E, Deeken CR, Fortelny RH, Greve JW, Chiers K, Kaufmann R, Lange JF, Klinge U, Miserez M, Petter-Puchner AH, Schreinemacher MHF, Bouvy ND. META Score: An International Consensus Scoring System on Mesh-Tissue Adhesions. World J Surg 2021; 44:2935-2943. [PMID: 32621037 DOI: 10.1007/s00268-020-05568-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Currently, the lack of consensus on postoperative mesh-tissue adhesion scoring leads to incomparable scientific results. The aim of this study was to develop an adhesion score recognized by experts in the field of hernia surgery. METHODS Authors of three or more previously published articles on both mesh-tissue adhesion scores and postoperative adhesions were marked as experts. They were queried on seven items using a modified Delphi method. The items concerned the utility of adhesion scoring models, the appropriateness of macroscopic and microscopic variables, the range and use of composite scores or subscores, adhesion-related complications and follow-up length. This study comprised two questionnaire-based rounds and one consensus meeting. RESULTS The first round was completed by 23 experts (82%), the second round by 18 experts (64%). Of those 18 experts, ten were able to participate in the final consensus meeting and all approved the final proposal. From a total of 158 items, consensus was reached on 90 items. The amount of mesh surface covered with adhesions, tenacity and thickness of adhesions and organ involvement was concluded to be a minimal set of variables to be communicated separately in each future study on mesh adhesions. CONCLUSION The MEsh Tissue Adhesion scoring system is the first consensus-based scoring system with a wide backing of renowned experts and can be used to assess mesh-related adhesions. By including this minimal set of variables in future research interstudy comparability and objectivity can be increased and eventually linked to clinically relevant outcomes.
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Affiliation(s)
- L C L van den Hil
- Department of General Surgery, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, The Netherlands. .,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands.
| | - E H H Mommers
- Department of General Surgery, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - J W A M Bosmans
- Department of General Surgery, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - S Morales-Conde
- Unit of Innovation and Minimally Invasive Surgery, University Hospital Virgen Del Rocío, Seville, Spain
| | - V Gómez-Gil
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, Networking Research Centre on Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), University of Alcalá, Alcalá de Henares, Madrid, Spain
| | - K LeBlanc
- Our Lady of the Lake Physician Group, Minimally Invasive Surgery Institute, Baton Rouge, LA, USA
| | - A Vanlander
- Department of General and Hepatobiliary Surgery, Ghent University Hospital, Ghent, Belgium
| | - E Reynvoet
- Department of General and Hepatobiliary Surgery, Ghent University Hospital, Ghent, Belgium
| | - F Berrevoet
- Department of General and Hepatobiliary Surgery, Ghent University Hospital, Ghent, Belgium
| | - S Gruber-Blum
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - E Altinli
- Department of General Surgery, Bilim University, Istanbul, Turkey
| | | | - R H Fortelny
- Department of General Surgery, Wilhelminenspital Der Stadt Wien, Vienna, Austria
| | - J W Greve
- Department of General Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
| | - K Chiers
- Department of Veterinary Pathology, Faculty of Veterinary Medicine, University of Ghent, Ghent, Belgium
| | - R Kaufmann
- Department of Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - J F Lange
- Department of Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - U Klinge
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen University Hospital, Aachen, Germany
| | - M Miserez
- Department of Abdominal Surgery, University Hospitals, KU Leuven, Leuven, Belgium
| | - A H Petter-Puchner
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Austrian Cluster for Tissue Regeneration, Vienna, Austria.,Department of General Surgery, Wilhelminenspital Der Stadt Wien, Vienna, Austria
| | - M H F Schreinemacher
- Department of General Surgery, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - N D Bouvy
- Department of General Surgery, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
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De Munck TJI, Verhaegh PLM, Verbeek J, Verheij J, Greve JW, Jonkers DMAE, Masclee AAM, Koek GH. Crashing NASH in Patients Listed for Bariatric Surgery. Obes Surg 2019; 29:1012-1014. [DOI: 10.1007/s11695-018-03637-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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3
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Nies VJM, Struik D, Wolfs MGM, Rensen SS, Szalowska E, Unmehopa UA, Fluiter K, van der Meer TP, Hajmousa G, Buurman WA, Greve JW, Rezaee F, Shiri-Sverdlov R, Vonk RJ, Swaab DF, Wolffenbuttel BHR, Jonker JW, van Vliet-Ostaptchouk JV. TUB gene expression in hypothalamus and adipose tissue and its association with obesity in humans. Int J Obes (Lond) 2017; 42:376-383. [PMID: 28852204 DOI: 10.1038/ijo.2017.214] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 07/21/2017] [Accepted: 07/30/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND/OBJECTIVES Mutations in the Tubby gene (TUB) cause late-onset obesity and insulin resistance in mice and syndromic obesity in humans. Although TUB gene function has not yet been fully elucidated, studies in rodents indicate that TUB is involved in the hypothalamic pathways regulating food intake and adiposity. Aside from the function in central nervous system, TUB has also been implicated in energy metabolism in adipose tissue in rodents. We aimed to determine the expression and distribution patterns of TUB in man as well as its potential association with obesity. SUBJECTS/METHODS In situ hybridization was used to localize the hypothalamic regions and cells expressing TUB mRNA. Using RT-PCR, we determined the mRNA expression level of the two TUB gene alternative splicing isoforms, the short and the long transcript variants, in the hypothalami of 12 obese and 12 normal-weight subjects, and in biopsies from visceral (VAT) and subcutaneous (SAT) adipose tissues from 53 severely obese and 24 non-obese control subjects, and correlated TUB expression with parameters of obesity and metabolic health. RESULTS Expression of both TUB transcripts was detected in the hypothalamus, whereas only the short TUB isoform was found in both VAT and SAT. TUB mRNA was detected in several hypothalamic regions involved in body weight regulation, including the nucleus basalis of Meynert and the paraventricular, supraoptic and tuberomammillary nuclei. We found no difference in the hypothalamic TUB expression between obese and control groups, whereas the level of TUB mRNA was significantly lower in adipose tissue of obese subjects as compared to controls. Also, TUB expression was negatively correlated with indices of body weight and obesity in a fat-depot-specific manner. CONCLUSIONS Our results indicate high expression of TUB in the hypothalamus, especially in areas involved in body weight regulation, and the correlation between TUB expression in adipose tissue and obesity. These findings suggest a role for TUB in human obesity.
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Affiliation(s)
- V J M Nies
- Section of Molecular Metabolism and Nutrition, Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - D Struik
- Section of Molecular Metabolism and Nutrition, Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - M G M Wolfs
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - S S Rensen
- Department of General Surgery, Maastricht University Medical Center, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands
| | - E Szalowska
- Centre for Medical Biomics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - U A Unmehopa
- Department of Endocrinology & Metabolism, Academic Medical Center, Amsterdam, The Netherlands
| | - K Fluiter
- Department of Genome Analysis, Academic Medical Center, Amsterdam, The Netherlands
| | - T P van der Meer
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - G Hajmousa
- Cardiovascular Regenerative Medicine, Department Pathology and Medical Biology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - W A Buurman
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - J W Greve
- Department of Surgery, Zuyderland Medical Center Heerlen; Dutch Obesity Clinic South, Heerlen, The Netherlands
| | - F Rezaee
- Centre for Medical Biomics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - R Shiri-Sverdlov
- Departments of Molecular Genetics, School of Nutrition & Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | - R J Vonk
- Centre for Medical Biomics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - D F Swaab
- Netherlands Institute for Neuroscience, an Institute of the Royal Netherlands Academy of Arts and Sciences, Amsterdam, The Netherlands
| | - B H R Wolffenbuttel
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - J W Jonker
- Section of Molecular Metabolism and Nutrition, Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - J V van Vliet-Ostaptchouk
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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4
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Wolfs MGM, Gruben N, Rensen SS, Verdam FJ, Greve JW, Driessen A, Wijmenga C, Buurman WA, Franke L, Scheja L, Koonen DPY, Shiri-Sverdlov R, van Haeften TW, Hofker MH, Fu J. Determining the association between adipokine expression in multiple tissues and phenotypic features of non-alcoholic fatty liver disease in obesity. Nutr Diabetes 2015; 5:e146. [PMID: 25664838 PMCID: PMC4338415 DOI: 10.1038/nutd.2014.43] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 09/28/2014] [Accepted: 11/15/2014] [Indexed: 12/20/2022] Open
Abstract
Objectives: Non-alcoholic fatty liver disease (NAFLD) is an obesity-associated disease, and in obesity adipokines are believed to be involved in the development of NAFLD. However, it is still not clear whether adipokines in the liver and/or adipose tissues can be related to the development of specific characteristics of NAFLD, such as steatosis and inflammation. We aimed to address this question by simultaneously examining the adipokine expression in three tissue types in obese individuals. Methods: We enrolled 93 severely obese individuals with NAFLD, varying from simple steatosis to severe non-alcoholic steatohepatitis. Their expression of 48 adipokines in the liver, visceral and subcutaneous adipose tissue (SAT) was correlated to their phenotypic features of NAFLD. We further determined whether the correlations were tissue specific and/or independent of covariates, including age, sex, obesity, insulin resistance and type 2 diabetes (T2D). Results: The expression of adipokines showed a liver- and adipose tissue-specific pattern. We identified that the expression of leptin, angiopoietin 2 (ANGPT2) and chemerin in visceral adipose tissue (VAT) was associated with different NAFLD features, including steatosis, ballooning, portal and lobular inflammation. In addition, the expression of tumor necrosis factor (TNF), plasminogen activator inhibitor type 1 (PAI-1), insulin-like growth factor 1 (somatomedin C) (IGF1) and chemokine (C-X-C motif) ligand 10 (CXCL10) in the liver tissue and the expression of interleukin 1 receptor antagonist (IL1RN) in both the liver and SAT were associated with NAFLD features. The correlations between ANGPT2 and CXCL10, and NAFLD features were dependent on insulin resistance and T2D, but for the other genes the correlation with at least one NAFLD feature remained significant after correcting for the covariates. Conclusions: Our results suggest that in obese individuals, VAT-derived leptin and chemerin, and hepatic expression of TNF, IGF1, IL1RN and PAI-1 are involved in the development of NAFLD features. Further, functional studies are warranted to establish a causal relationship.
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Affiliation(s)
- M G M Wolfs
- Molecular Genetics Section, Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - N Gruben
- Molecular Genetics Section, Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - S S Rensen
- Department of General Surgery, Maastricht University Medical Center, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht, The Netherlands
| | - F J Verdam
- Department of General Surgery, Maastricht University Medical Center, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht, The Netherlands
| | - J W Greve
- Department of General Surgery, Maastricht University Medical Center, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht, The Netherlands
| | - A Driessen
- 1] Department of Pathology, Maastricht University Medical Centre, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht, The Netherlands [2] Department of Pathology, University Hospital Antwerp, Edegem, Belgium
| | - C Wijmenga
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - W A Buurman
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - L Franke
- 1] Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands [2] Institute of Cell and Molecular Science, Barts and The London School of Medicine and Dentistry, London, UK
| | - L Scheja
- Department of Biochemistry and Molecular Cell Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - D P Y Koonen
- Molecular Genetics Section, Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - R Shiri-Sverdlov
- Department of Molecular Genetics, Maastricht University, Maastricht, The Netherlands
| | - T W van Haeften
- 1] Molecular Genetics Section, Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands [2] Department of Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M H Hofker
- Molecular Genetics Section, Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - J Fu
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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5
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Abstract
BACKGROUND Laparoscopic adjustable gastric banding (LAGB) is a safe and frequently performed bariatric procedure. Unfortunately, re-operations are often necessary. Reports on the success of revisional procedures are scarce and show variable results, either supporting or declining the idea of revising LAGB. This study describes a large cohort of re-operations after failed LAGB to determine the success of revision. METHODS By use of a prospective cohort, all LAGB revisions performed between 1996 and 2008 were identified. From 301 primary LAGB procedures in our centre, 43 patients (14.3%) required a band revision. In addition, 51 patients were referred from other centres. Our analysis included in total 94 patients with a mean follow-up period of 38 months after revision. RESULTS Revision was mainly necessary due to anterior slippage (46%) and symmetrical pouch dilatation (36%), which could be resolved by replacing (70%) or refixating the band (27%). Weight loss significantly increased after revision (excess BMI loss (EBMIL), 37.2 ± 36.3% versus 47.5 ± 30.4%, P < 0.05). After revision, 23 patients (24%) needed a second re-operation. Patients converted to other procedures (16%) during the second re-operation showed larger weight loss than the revised group (EBMIL, 64.3 ± 28.1% versus 44.3 ± 28.7%, P < 0.05). CONCLUSIONS We report on a large cohort of LAGB revisions with 38 months of follow-up. Revision of failed LAGB by either refixation or replacement of the band is successful and further increases weight loss.
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Affiliation(s)
- G H E J Vijgen
- Department of General Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, the Netherlands.
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Kox M, Lubbers T, De Haan JJ, Greve JW, Pompe JC, Ramakers BP, Pickkers P, Buurman WA. Lipid-enriched and protein-enriched enteral nutrition limits inflammation in a human endotoxemia model. Crit Care 2011. [PMCID: PMC3068312 DOI: 10.1186/cc9803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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De Haan J, Derikx J, Relja B, Lubbers T, Luyer MD, Buurman WA, Greve JW, Marzi I. Evidence for early presence of intestinal epithelial cell damage in multitrauma patients. Crit Care 2008. [PMCID: PMC4088507 DOI: 10.1186/cc6357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Ayodeji ID, Schijven M, Jakimowicz J, Greve JW. Face validation of the Simbionix LAP Mentor virtual reality training module and its applicability in the surgical curriculum. Surg Endosc 2007; 21:1641-9. [PMID: 17356944 DOI: 10.1007/s00464-007-9219-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2006] [Revised: 09/09/2006] [Accepted: 09/15/2006] [Indexed: 01/19/2023]
Abstract
BACKGROUND The goal of our study was to determine expert and referent face validity of the LAP Mentor, the first procedural virtual reality (VR) laparoscopy trainer. METHODS In The Netherlands 49 surgeons and surgical trainees were given a hands-on introduction to the Simbionix LAP Mentor training module. Subsequently, a standardized five-point Likert-scale questionnaire was administered. Respondents who had performed over 50 laparoscopic procedures were classified as "experts." The others constituted the "referent" group, representing nonexperts such as surgical trainees. RESULTS Of the experts, 90.5% (n = 21) judge themselves to be average or above-average laparoscopic surgeons, while 88.5% of referents (n = 28) feel themselves to be less-than-average laparoscopic surgeons (p = 0.000). There is agreement between both groups on all items concerning the simulator's performance and application. Respondents feel strongly about the necessity for training on basic skills before operating on patients and unanimously agree on the importance of procedural training. A large number (87.8%) of respondents expect the LAP Mentor to enhance a trainee's laparoscopic capability, 83.7% expect a shorter laparoscopic learning curve, and 67.3% even predict reduced complication rates in laparoscopic cholecystectomies among novice surgeons. The preferred stage for implementing the VR training module is during the surgeon's residency, and 59.2% of respondents feel the surgical curriculum is incomplete without VR training. CONCLUSION Both potential surgical trainees and trainers stress the need for VR training in the surgical curriculum. Both groups believe the LAP Mentor to be a realistic VR module, with a powerful potential for training and monitoring basic laparoscopic skills as well as full laparoscopic procedures. Simulator training is perceived to be both informative and entertaining, and enthusiasm among future trainers and trainees is to be expected. Further validation of the system is required to determine whether the performance results agree with these favorable expectations.
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Affiliation(s)
- I D Ayodeji
- Department of General Surgery, University Hospital, Maastricht, The Netherlands.
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9
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Pham NV, Cox-Reijven PLM, Greve JW, Soeters PB. Application of subjective global assessment as a screening tool for malnutrition in surgical patients in Vietnam. Clin Nutr 2006; 25:102-8. [PMID: 16239052 DOI: 10.1016/j.clnu.2005.09.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2005] [Accepted: 09/05/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND AIMS In most hospitals in Vietnam, clinical assessment of nutritional status has yet to become part of the routine clinical history taking and physical examination. It is the aim of this study to apply subjective global assessment (SGA) of nutritional status in surgical patients in the Mekong Delta, Vietnam, to determine the incidence of malnutrition according to SGA and to know whether there was an association between SGA class and infectious complications. METHODS A prospective, cross-sectional study design was used. SGA of nutritional status was applied. Patients were rated as well nourished (A), moderately malnourished (B) or severely malnourished (C). Infectious complications (wound infection, intra-abdominal abscesses, anastomotic leakage) were recorded. RESULTS Of the 438 patients assessed, 194 (44.3%) were classified as A, 126 patients (28.8%) were classified as B and 118 patients (26.9%) were classified as C. Of the 274 patients who underwent major abdominal surgery assessed, 61 patients (22.3%) were classified as A, 97 patients (35.4%) were classified as B and 116 patients (42.3%) were classified as C. Weight loss and percent weight loss, muscle wasting, loss of subcutaneous fat, functional capacity and significant gastrointestinal symptoms correlate significantly with the severity of SGA class (P<0.001). The rate of postoperative infectious complications was higher in patients classified as SGA class C (33.6%) than as class A (6%) and B (11%). CONCLUSIONS A high rate of malnutrition was found, applying SGA of nutritional state in surgical patients in Vietnam. Malnutrition was associated with an increase in infectious complications. Special attention should be paid to weight loss, muscle wasting, loss of subcutaneous fat, functional capacity and gastrointestinal symptoms.
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Affiliation(s)
- N V Pham
- Department of Surgery, Can Tho University of Medicine and Pharmacy, Vietnam
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van Dielen FMH, Buurman WA, Hadfoune M, Nijhuis J, Greve JW. Macrophage inhibitory factor, plasminogen activator inhibitor-1, other acute phase proteins, and inflammatory mediators normalize as a result of weight loss in morbidly obese subjects treated with gastric restrictive surgery. J Clin Endocrinol Metab 2004; 89:4062-8. [PMID: 15292349 DOI: 10.1210/jc.2003-032125] [Citation(s) in RCA: 117] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Obesity is demonstrated to be associated with an enhanced inflammatory state, which is suggested to be a cause for the development of obesity-related morbidity. It was hypothesized that a decrease in body weight in morbid obese subjects would lead to a reduction of the inflammatory state in these subjects. Weight loss was achieved by gastric restrictive surgery in 27 morbidly obese patients. Preoperative as well as 3-, 6-, 12-, and 24-month postoperative plasma concentrations of inflammatory mediators macrophage inhibitory factor, plasminogen activator inhibitor-1, lipopolysaccharide binding protein, alpha-1 acid glycoprotein, C-reactive protein, soluble TNFalpha receptors 55 and 75, and leptin were measured. Macrophage inhibitory factor levels remained low normal for 6 months, during weight loss, after which they significantly increased to normal levels at 24 months postoperatively. The other inflammatory mediators remained elevated up to minimally 3 months postoperatively; thereafter they decreased significantly. Both TNFalpha receptors remained elevated up to at least 12 months postoperatively to decrease significantly at 2 yr postoperatively. This study demonstrates that during weight loss, after gastric restrictive surgery, inflammatory mediators remain elevated for at least 3 months postoperatively, suggesting initially an ongoing inflammatory state. However, 2 yr after surgery, the inflammatory mediators reach near normal values.These findings may be an explanation for the reduced comorbidity seen in morbidly obese patients after gastric restrictive surgery.
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Affiliation(s)
- F M H van Dielen
- Department of General Surgery, Nutrition Research Institute Maastricht and University Hospital Maastricht, 6202 AZ Maastricht, The Netherlands.
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11
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Greve JW. Alternative techniques for the treatment of colon carcinoma metastases in the liver: current status in The Netherlands. Scand J Gastroenterol Suppl 2002:77-81. [PMID: 11768565 DOI: 10.1080/003655201753265488] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
BACKGROUND Review of current treatment modalities for liver metastases resulting from colorectal cancer. METHODS Literature review. RESULTS An increasing number of techniques are available for the treatment of colorectal liver metastases. When it is not possible to use the current gold standard, radical surgical resection, many patients can be treated with alternative techniques. Chemotherapy in its present form must be considered as purely palliative, perhaps with the exclusion of isolated liver perfusion: however, this therapy should still be considered as experimental. Most other possible treatments focus on local destruction of the metastases. This can be achieved using either immuno-guided techniques (tumor antibodies which carry a local active agent), direct local application of a toxic agent (injection) or thermo therapy, which has been applied in patients on a large scale. Thermo therapy involves either localized heating, by means or laser photocoagulation or radiofrequency or microwave ablation, or localized freezing using cryo probes. CONCLUSIONS Local destruction of liver metastases, especially by means of thermo therapy, is feasible and safe. Currently, cryotherapy is most frequently used in patients. New treatment modalities, such as radiofrequency ablation, arc very promising but their true clinical value should be determined in a randomized clinical trial.
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Affiliation(s)
- J W Greve
- Dept. of Surgery, University Hospital Maastricht, The Netherlands.
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12
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van Dielen FM, van't Veer C, Schols AM, Soeters PB, Buurman WA, Greve JW. Increased leptin concentrations correlate with increased concentrations of inflammatory markers in morbidly obese individuals. Int J Obes (Lond) 2001; 25:1759-66. [PMID: 11781755 DOI: 10.1038/sj.ijo.0801825] [Citation(s) in RCA: 147] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2000] [Revised: 04/17/2001] [Accepted: 05/30/2001] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To study whether an increase of plasma leptin concentrations, as observed in the case of increased body weight, is associated with an inflammatory state. SUBJECTS Sixty-three healthy subjects with body mass index (BMI) ranging from 20 to 61 kg/m2. MEASUREMENTS Plasma concentrations of leptin, the inflammatory parameter soluble TNF-alpha receptors (TNFR55 and TNFR75), the acute phase proteins lipopolysaccharide binding protein (LBP), serum amyloid A (SAA), alpha-acid glycoprotein (AGP), C-reactive protein (CRP), plasminogen activator inhibitor-1 (PAI-1) and the anti-inflammatory soluble Interleukin-1 decoy receptor (sIL-1RII) were measured. RESULTS As expected, BMI correlated significantly with leptin (r=0.823, P<0.001), but also with all acute phase proteins, both soluble TNF receptors and PAI concentrations. After correction for BMI and sex, no significant correlation between leptin and the acute phase proteins was seen. Interestingly, however, leptin strongly correlated with both TNF receptors (r=0.523, P<0.001 for TNFR55 and r=0.438, P<0.001 for TNFR75). CONCLUSIONS This study shows the development of a pro-inflammatory state with increasing body weight. The BMI independent relationship between leptin and both soluble TNF-receptors is consistent with a regulatory role for leptin in the inflammatory state in morbidly obese subjects.
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Affiliation(s)
- F M van Dielen
- Department of General Surgery, University Hospital, Maastricht, The Netherlands
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13
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Abstract
Acute pancreatitis is a disease with varying severity. Patients with the mild form do not require nutritional support because oral intake is resumed rapidly. Studies on nutritional support in acute pancreatitis have included patients with both mild and severe disease. In this heterogeneous group, total parenteral nutrition did not improve outcome compared with no nutrition at all. This is caused in part by an increase in septic complications during total parenteral nutrition. Likewise, no benefit from enteral nutrition was observed compared with no nutrition, probably because the group was heterogeneous or because nutritional goals were not achieved. Patients with severe acute pancreatitis become profoundly catabolic. This group undoubtedly requires nutritional support to treat undernutrition. The limited available data indicate that enteral nutrition, if well tolerated, is superior to parenteral nutrition for patients with severe acute pancreatitis. Based on current knowledge, a combination of early total parenteral nutrition and enteral nutrition is advisable as soon as enteral nutrition is tolerated. Monitoring of gut function is crucial in this situation.
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Affiliation(s)
- C H Dejong
- Department of Surgery, Academic Hospital Maastricht, NL-6202 Maastricht, The Netherlands.
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14
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Greve JW. Surgical treatment of morbid obesity: role of the gastroenterologist. Scand J Gastroenterol Suppl 2001:60-4. [PMID: 11232494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
AIM Obesity is an increasing medical problem with associated disorders such as type 2 diabetes mellitus, cardiovascular disorders and many others. The chance to develop co-morbidity is related to the body mass index (BMI) (weight in kg divided by height in metres2) and increases exponentially when the BMI is above 40 (morbid obesity). Permanently effective treatment of morbid obesity is necessary to prevent the development of co-morbidities and to improve the life expectancy of these patients. To date, surgical intervention is the only treatment that can provide the required long-lasting reduction of the excess weight. DISCUSSION Two types of surgical intervention are currently used, restrictive (including vertical banded gastroplasty (VBG) and adjustable gastric banding) and malabsorptive procedures (gastric bypass, biliopancreatic diversion (BPD)). These interventions effectively reduce weight, with on average a permanent reduction of the excess weight by 60% after gastric restrictive procedures. However, long-term follow-up has shown that up to 30-40% of patients require additional surgical interventions to maintain the acquired weight loss. Long-term failures are dependent on the primary intervention. After VBG the most common problems are occlusion of the outlet by a foreign body, vertical staple line disruption, band stenosis and band erosion. For the adjustable silicone gastric band outlet problems similar to the VBG, band erosion and particularly pouch dilation or slippage have been reported. Failure of the gastric bypass are mainly due to stenosis of the gastro-jejunostomy and stoma ulcers, whereas BPD mainly has metabolic long-term complications. CONCLUSION The gastroenterologist has an important role in the diagnosis (stoma stenosis, band erosion, staple line disruption, foreign body) and treatment (dilatation, removal of foreign body) of the complications associated with surgical procedures for morbid obesity. In light of the increasing number of procedures performed, a basic knowledge of the currently used techniques and the associated complications is important.
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Affiliation(s)
- J W Greve
- Dept. of Surgery, University Hospital Maastricht, P. O. Box 5800, 6202 AZ Maastricht, The Netherlands.
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Greve JW. Should laparoscopic surgeons re-invent bariatric surgical procedures? Obes Surg 2001; 11:101-4. [PMID: 11361161 DOI: 10.1381/096089201321454231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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16
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Vreugdenhil AC, Snoek AM, van 't Veer C, Greve JW, Buurman WA. LPS-binding protein circulates in association with apoB-containing lipoproteins and enhances endotoxin-LDL/VLDL interaction. J Clin Invest 2001; 107:225-34. [PMID: 11160139 PMCID: PMC199173 DOI: 10.1172/jci10832] [Citation(s) in RCA: 108] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
LPS-binding protein (LBP) and serum lipoproteins cooperate in reducing the toxic properties of LPS. In the present study, we demonstrate that LBP circulates in association with LDL and VLDL in healthy persons. ApoB was found to account at least in part for the interaction of LBP with LDL and VLDL. Although LBP interacted with purified apoA-I in vitro, no association of LBP with apoA-I or HDL was found in serum. Consistent with the observed association of LBP with LDL and VLDL, these lipoproteins also were demonstrated to be the predominant LPS-binding lipoproteins. Most interestingly, the association of LBP with LDL and VLDL strongly enhanced the capacity of these lipoproteins to bind LPS. Because this function of LBP is of utmost importance during infection, the association of LBP and LPS with lipoproteins was also studied in serum from septic patients. In septic serum containing high LBP levels and a markedly altered lipoprotein spectrum, most of the LBP is associated with LDL and VLDL, although some LBP appeared to circulate free from lipoproteins. Also in this serum, LPS was found to bind predominantly to LDL and VLDL. The observed binding of LBP and LPS to LDL and VLDL, as well as the LBP-dependent incorporation of LPS into these lipoproteins, emphasizes a crucial role for circulating LBP-LDL/VLDL complexes in the scavenging of LPS.
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Affiliation(s)
- A C Vreugdenhil
- Department of General Surgery, Maastricht University, PO Box 616, 600 MD Maastricht, The Netherlands
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17
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Vreugdenhil AC, Snoek AM, Greve JW, Buurman WA. Lipopolysaccharide-binding protein is vectorially secreted and transported by cultured intestinal epithelial cells and is present in the intestinal mucus of mice. J Immunol 2000; 165:4561-6. [PMID: 11035097 DOI: 10.4049/jimmunol.165.8.4561] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Lipopolysaccharide-binding protein (LBP) is an important modulator of the host's response to endotoxin. In a previous study, we found evidence for the synthesis of LBP by intestinal epithelial cells. In this study, we explored the polarity of LBP secretion by these cells. Polarized monolayers of Caco-2 cells were used as intestinal mucosa model. Cells were stimulated apically or basally with cytokines, and LBP secretion was analyzed. Furthermore, the presence of LBP in intestinal mucus of healthy and endotoxemic mice was studied using a mucus-sampling technique. The constitutive unipolar LBP secretion from the apical cell surface was markedly enhanced when cells were exposed to cytokines at their apical surface. However, bioactive LBP was secreted from both cell surfaces after basolateral stimulation of cells. Cytokines also influenced the secretion of the acute phase proteins serum amyloid A, apoA-I, and apoB from both surfaces of Caco-2 cells. Furthermore, transport of exogenous LBP from the basolateral to the apical cell surface was demonstrated. In line with these in vitro data, the presence of LBP in intestinal mucus was strongly enhanced in mice after a challenge with endotoxin. The results indicate that LBP is present at the mucosal surface of the intestine, a phenomenon for which secretion and transport of LBP by intestinal epithelial cells may be responsible.
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Affiliation(s)
- A C Vreugdenhil
- Department of General Surgery, Maastricht University, Maastricht, The Netherlands
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18
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Poeze M, Froon AH, Ramsay G, Buurman WA, Greve JW. Decreased organ failure in patients with severe SIRS and septic shock treated with the platelet-activating factor antagonist TCV-309: a prospective, multicenter, double-blind, randomized phase II trial. TCV-309 Septic Shock Study Group. Shock 2000; 14:421-8. [PMID: 11049104 DOI: 10.1097/00024382-200014040-00001] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Sepsis and organ failure remain the main cause of death on the ICU. Sepsis is characterized by a severe inflammatory response, in which platelet-activating factor (PAF) is considered to play an important role. This study investigated whether treatment with the PAF-antagonist TCV-309 reduces morbidity and mortality in patients with septic shock. The study was conducted as a double-blind, randomized, placebo controlled multicenter study. The included patients had to fulfill the SIRS criteria with a clinical suspicion of infection, an admission APACHE II score greater than 15, and shock, defined as a mean arterial pressure <70 mmHg and/or a decrease > or =40 mmHg despite adequate fluid resuscitation. Patients received 1.0 mg/kg TCV-309 or placebo, twice daily, intravenously during 14 days. The prospectively set goals were MOF score, recovery from shock, mortality, and assessment of the safety of the medication. A total of 98 patients were included of which 97 were analyzed on an intention-to-treat basis. The overall survival at day 56 of TCV-309 treated patients was similar compared to placebo treated patients (51.0% vs. 41.7%, P = 0.47). In contrast, the mean percentage of failed organs per patient present after 14 days in the TCV-309 treated patients was significantly lower compared to the placebo treated patients (11.9% vs. 25.1%, P = 0.04), leading to a reduced need for vasopressors, dialysis, and ventilatory support. Furthermore, the mean APACHE-II score during treatment with TCV-309 was significantly lower and the number of patients recovered from shock after day 14 was significantly higher in the TCV-309 treated patient group (2/32 vs. 9/29, P = 0.01). The number of adverse events was not significantly different between the TCV-309 and placebo treated patients. TCV-309 did not change overall mortality of septic shock, however a substantial reduction in organ dysfunction and morbidity, frequently associated with septic shock was achieved, without significant adverse events.
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Affiliation(s)
- M Poeze
- Department of Surgery, University Hospital Maastricht, The Netherlands
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19
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Abstract
OBJECTIVE To determine whether a) pre-operative measurement of gastric intramucosal pHi is predictive for mortality and morbidity in high-risk surgical patients and b) peri-operative improvement of global oxygen delivery (DO2) with fluids and dopexamine leads to increased gastric pHi and c) either improved global perfusion or improved splanchnic perfusion is related to the prevention of multiple organ failure (MOF). DESIGN Retrospective analysis of a double-blind, placebo-controlled, randomised study. SETTING General intensive care units from 14 hospitals. PATIENTS Two hundred eighty-six high-risk surgical patients. INTERVENTIONS Swan-Ganz and tonometer catheter placement; patients were stabilised pre-operatively using fluids, blood and/or oxygen to preset goals before receiving placebo or two doses of dopexamine (0.5 or 2.0 microg.kg.min) peri-operatively. MEASUREMENTS AND RESULTS Haemodynamic assessment (including DO2 and oxygen consumption (VO2)) was performed together with measurement of gastric mucosal pHi pre-operatively and directly, 2, 6, 12, 24 and 36 h post-operatively. Retrospectively, patients were divided pre-operatively into two sub-groups based on the optimal cut-off value for mortality of the first pHi measurement after induction of anaesthesia as calculated by a receiver operator characteristic (ROC) curve analysis --low pHi group (< 7.35) and normal pHi (> or =7.35). Mortality in the low pHi, was higher than in the normal pHi, group (16.8 vs 2.3%; p = 0.0001). In the normal pHi group dopexamine, which was given prior to the first pHi measurement, had no effect on pHi, while DO2 increased significantly. In this group MOF score and number of patients with MOF remained similar for the treatment sub-groups. In the low pHi group gastric pHi increased significantly during dopexamine infusion (p = 0.008), despite the lack of an increase in DO2 and VO2. In this group the MOF score and the number of patients developing MOF decreased significantly with the use of dopexamine (p = 0.04). In both groups bicarbonate levels remained similar for the treatment subgroups. CONCLUSIONS In high-risk surgical patients pre-operative measurement of pHi was predictive for mortality. The peri-operative response of pHi to dopexamine seemed to be dependent on pre-operative gastric pHi.
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Affiliation(s)
- M Poeze
- Department of Surgery, University Hospital Maastricht, The Netherlands.
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20
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Abstract
BACKGROUND Report on a case of incorrect diagnosis after laparoscopy and peritoneal fluid sampling. METHODS Case description and literature review. RESULTS Diagnostic laparoscopy is a frequently used tool. In a patient with chronic abdominal pain, a diagnostic laparoscopy was performed, and a peritoneal fluid sample was taken. Cytology of the aspirated peritoneal fluid revealed an adenocarcinoma. At laparotomy, ectopic pancreas was found as the source of the false-positive cytology. CONCLUSION In the diagnosis of adenocarcinomas from peritoneal fluid aspirates without an obvious clinical location (tumor), ectopic pancreatic tissue should be considered in the differential diagnosis.
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Affiliation(s)
- C E Sloots
- Department of Surgery, University Hospital Maastricht, Maastricht, The Netherlands
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21
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Poeze M, Greve JW, Ramsay G. Goal-oriented haemodynamic therapy: a plea for a closer look at using peri-operative oxygen transport optimisation. Intensive Care Med 2000; 26:635-7. [PMID: 10923742 DOI: 10.1007/s001340051216] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- M Poeze
- Department of Surgery, Academic Hospital Maastricht, The Netherlands
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22
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23
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van Gemert WG, Adang EM, Kop M, Vos G, Greve JW, Soeters PB. A prospective cost-effectiveness analysis of vertical banded gastroplasty for the treatment of morbid obesity. Obes Surg 1999; 9:484-91. [PMID: 10605908 DOI: 10.1381/096089299765552792] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Surgical treatment of morbid obesity is gaining in popularity, because conservative treatment is ineffective. However, a cost-effectiveness analysis has never been performed and is the main goal of the present study. METHODS 21 consecutive morbidly obese patients were tested before and after vertical banded gastroplasty (VBG). Quality of life was assessed with the Nottingham Health Profile and a visual analogue scale. A prevalence-based cost-of-illness analysis of morbid obesity was performed and the cost-effectiveness of VBG assessed. RESULTS VBG resulted in a significant weight loss and an improved quality of life. The improved quality of life combined with 3.6 life-years gained after VBG resulted in 12 quality adjusted life-years (QALY) gained in a lifelong scenario. Lifelong costs of illness of morbidly obese persons ranged from $8,304 to $9,367. Total direct costs of VBG were $5,865. The percentage of patients performing paid labor increased from 19% before VBG to 48% after VBG, resulting in an average productivity gain of $2,765 per year. In summary, the cost-effectiveness analysis revealed that surgical treatment of morbid obesity by means of VBG saves $4,004 to $3,928 per QALY (overall dominance). CONCLUSION Because treatment of morbid obesity with VBG results in QALYs gained and less costs, there is no doubt that this procedure should be introduced or continued from a societal point of view.
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Affiliation(s)
- W G van Gemert
- Department of Surgery, University Hospital Maastricht, The Netherlands.
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24
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Vreugdenhil AC, Dentener MA, Snoek AM, Greve JW, Buurman WA. Lipopolysaccharide binding protein and serum amyloid A secretion by human intestinal epithelial cells during the acute phase response. J Immunol 1999; 163:2792-8. [PMID: 10453023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
The acute phase proteins LPS binding protein (LBP) and serum amyloid A (SAA) are produced by the liver and are present in the circulation. Both proteins have been shown to participate in the immune response to endotoxins. The intestinal mucosa forms a large surface that is continuously exposed to these microbial products. By secretion of antimicrobial and immunomodulating agents, the intestinal epithelium contributes to the defense against bacteria and their products. The aim of this study was to explore the influence of the inflammatory mediators TNF-alpha, IL-6, and IL-1beta on the release of LBP and SAA by intestinal epithelial cells (IEC). In addition, the induction of LBP and SAA release by cell lines of intestinal epithelial cells and hepatic cells was compared. The data obtained show that in addition to liver cells, IEC also expressed LBP mRNA and released bioactive LBP and SAA upon stimulation. Regulation of LBP and SAA release by IEC and hepatocytes was typical for class 1 acute phase proteins, although differences in regulation between the cell types were observed. Endotoxin did not induce LBP and SAA release. Glucocorticoids were demonstrated to strongly enhance the cytokine-induced release of LBP and SAA by IEC, corresponding to hepatocytes. The data from this study, which imply that human IEC can produce LBP and SAA, suggest a role for these proteins in the local defense mechanism of the gut to endotoxin. Furthermore, the results demonstrate that tissues other than the liver are involved in the acute phase response.
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Affiliation(s)
- A C Vreugdenhil
- Department of General Surgery, Maastricht University, The Netherlands.
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25
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Poeze M, Ramsay G, Greve JW, Singer M. Prediction of postoperative cardiac surgical morbidity and organ failure within 4 hours of intensive care unit admission using esophageal Doppler ultrasonography. Crit Care Med 1999; 27:1288-94. [PMID: 10446822 DOI: 10.1097/00003246-199907000-00013] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare esophageal Doppler ultrasonography with standard hemodynamic variables used in postoperative care for the prediction of postoperative complications after cardiac surgery. DESIGN Prospective, observational pilot study. SETTING University hospital, multidisciplinary intensive care unit PATIENTS Postoperative cardiac surgical patients. INTERVENTIONS Standard postoperative management as guided by routinely measured hemodynamic variables. MEASUREMENTS An esophageal Doppler ultrasound probe was inserted for measurement of stroke volume (SV), cardiac output (CO), and other flow-related variables. Both these and routine hemodynamic variables (mean arterial pressure, central venous pressure, heart rate, arterial base deficit, urine output, core-toe temperature difference) were recorded at half-hourly intervals for the first 4 postoperative hrs. The incidence of systemic inflammatory response syndrome at 24 hrs, Acute Physiology and Chronic Health Evaluation II, and multiple organ failure scores, postoperative complications, and length of ICU and hospital stays were recorded. MAIN RESULTS Twenty consecutively admitted patients were studied: eight after emergency bypass grafting and 12 after elective bypass grafts and/or valve replacement. Of the nine patients who developed postoperative complications, two died. At admission, significant differences were seen between patients with a complicated and those with an uncomplicated surgical procedure for SV, heart rate, and standard base excess, but not for cardiac output. By using receiver operator characteristic curves, SV was the best marker for predicting postoperative complications during the initial postoperative period. CONCLUSIONS A low SV and a high heart rate, both at ICU admission and during the subsequent 4 hrs, were the best prognostic factors for development of complications after cardiac surgery. Cardiac output values were not useful. This pilot study suggests that the minimally invasive technique of esophageal Doppler ultrasonography may be a useful tool to assist early prognostication.
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Affiliation(s)
- M Poeze
- Department of Surgery, University Hospital Maastricht, The Netherlands
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van Heurn-Nijsten EW, Snoep G, Kootstra G, Greve JW, Forget P, van Heurn LW. Preoperative imaging of a choledochal cyst in children: non-breath-holding magnetic resonance cholangiopancreatography. Pediatr Surg Int 1999; 15:546-8. [PMID: 10631730 DOI: 10.1007/s003830050667] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Magnetic resonance cholangiopancreaticography (MRCP) was used to visualize the biliary tract in two children, aged 7 weeks and 10 years, with a choledochal cyst. MRCP was successful in both cases and the findings were confirmed by intraoperative cholangiography.
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Froon AH, Bonten MJ, Gaillard CA, Greve JW, Dentener MA, de Leeuw PW, Drent M, Stobberingh EE, Buurman WA. Prediction of clinical severity and outcome of ventilator-associated pneumonia. Comparison of simplified acute physiology score with systemic inflammatory mediators. Am J Respir Crit Care Med 1998; 158:1026-31. [PMID: 9769255 DOI: 10.1164/ajrccm.158.4.9801013] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Systemic kinetics of three inflammatory mediators (bactericidal/permeability-increasing protein [BPI], soluble intercellular adhesion molecule [sICAM], and soluble E-selectin [sE-selectin]) were studied during the development of ventilator-associated pneumonia (VAP) (n = 42), diagnosed on quantitative cultures of bronchoscopic samples. From a pool of collected samples, nested samples were used to measure mediators on Days -4, -2, 0, and +2, relative to diagnosis. Correlations between systemic levels of mediators and clinical severity of infection (VAP with or without severe sepsis or septic shock) and patient outcome (mortality at Day 10 after diagnosis) were studied. Predictive values of inflammatory mediators were compared with daily Simplified Acute Physiology Score II (SAPS II) values and the logarithmic number of bacteria in bronchoscopic samples. During the development of VAP, increasing SAPS II scores and rising systemic mediator levels were only found in patients in whom VAP was accompanied with severe sepsis or septic shock. Values of SAPS II and plasma levels of BPI and sE-selectin, but not sICAM, increased from the day of diagnosis on in patients who died within 10 d of diagnosis. Systemic levels of inflammatory mediators did not better predict clinical severity or patient outcome than daily SAPS II scores. The logarithmic number of bacteria in bronchoscopic samples poorly correlated with circulating levels of inflammatory mediators, severity of infection, and patient outcome. Our findings show that a clinical scoring system (SAPS II score) is at least as good as a predictor for the clinical severity of infection and patient outcome, and provide new information on the kinetics of inflammatory mediators during the development of VAP.
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Affiliation(s)
- A H Froon
- Departments of Surgery, Internal Medicine, Pulmonology, and Medical Microbiology, University Hospital Maastricht, Maastricht, The Netherlands
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Abstract
BACKGROUND Patients with a ruptured abdominal aortic aneurysm (AAA) are at risk of developing colonic ischaemia after surgery. It is difficult to diagnose this ischaemia at an early stage. D-lactate is produced by intestinal bacteria after ischaemia. L-lactate is released in increased amounts during hypoxia by anaerobic metabolism. This study investigated both variables as a marker for intestinal ischaemia in patients with a ruptured AAA. METHODS Twenty-four patients with ruptured AAA were divided retrospectively into two groups with and without ischaemic complications, as verified by colonoscopy. Blood had been taken on admission to the intensive care unit (ICU). Median time to colonoscopy was 9 days after surgery. As controls, four patients with pneumonia, six healthy subjects, five patients with an elective AAA repair, and six patients with sepsis and acute tubular necrosis were included. RESULTS D-lactate level on admission was significantly increased in patients with colonic ischaemia after ruptured AAA compared with the level in patients without ischaemia (P< 0.05), patients with sepsis (P< 0.001), those with pneumonia and healthy subjects (P< 0.01). L-lactate concentration was similar in the group with intestinal complications and in patients without colonic ischaemia; however, L-lactate levels were higher in patients with pneumonia and sepsis than in healthy subjects (P < 0.05). CONCLUSION On admission to the ICU, D-lactate, but not L-lactate, levels may predict later colonic ischaemia following repair of a ruptured AAA.
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Affiliation(s)
- M Poeze
- Department of Surgery, University Hospital Maastricht, The Netherlands
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29
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Poeze M, Greve JW, Ramsay G. [No additional benefit derived from determination of serum lactase levels for the evaluation of a patient with an acute abdomen]. Ned Tijdschr Geneeskd 1998; 142:1346-7. [PMID: 9752044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Abstract
Three cases of pouch diverticula following vertical banded gastroplasty for morbid obesity are presented. Symptoms, diagnosis, treatment and etiology are discussed.
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Affiliation(s)
- W P Zuidema
- Department of General Surgery, University Hospital Maastricht, The Netherlands
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Abstract
Two cases are presented in which the MRI findings following superparamagnetic iron oxide (SPIO) enhancement of hepatic adenoma and focal nodular hyperplasia (FNH) are described. Benign liver lesions show uptake of iron oxide particles, which allows differentiation from malignant liver lesions and tumors of other cell origin. There have been several publications in the literature, but the SPIO-enhanced MR findings of hemorrhage in a hepatic adenoma have not been previously described. To illustrate the role of SPIO-enhanced MRI in the differential diagnosis of adenoma from FNH, the SPIO-enhanced MR features of FNH are presented.
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Affiliation(s)
- R G Beets-Tan
- Department of Radiology, University Hospital Maastricht, The Netherlands
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Abstract
OBJECTIVE To investigate the long-term effects of surgically induced weight loss on the psychological functioning of morbidly obese patients. DESIGN Comparison between preoperative and postoperative psychometric test results in a cross-sectional study. PATIENTS AND METHODS Three psychometric tests were administered to 62 morbidly obese patients before and after surgery. RESULTS The mean follow-up was 85.9+/-48.1 months. Surgical treatment resulted in a mean weight loss of 45.0+/-21.3 kg (P < 0.0001). The psychometric test results before surgery demonstrated somatisation, depression, denial of emotional stress, social incompetence and an indifferent attitude towards certain aspects of interpersonal behaviour. All psychopathology, except for somatisation, disappeared after surgical treatment. Improvement of psychological functioning was determined by weight loss and not influenced by the surgical procedure. The level of self-esteem before surgery predicted 15.4% of the outcome variance (P < 0.05). CONCLUSION The psychopathology before surgery is almost totally reversed after sustained, surgically induced weight loss. This suggests that the preoperative psychological disturbances are the result, rather than the cause, of morbid obesity.
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Affiliation(s)
- W G van Gemert
- Department of Surgery, University Hospital Maastricht, The Netherlands
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33
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van Gemert WG, Soeters PP, Greve JW. VBG: Marlex vs Dacron banding. Obes Surg 1998; 8:232-3. [PMID: 9730401 DOI: 10.1381/096089298765554881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
OBJECTIVE To investigate whether long-term weight loss after vertical banded gastroplasty (VBG) results in a sustained reduction of sleeping metabolic rate (SMR) as a persistent risk factor for weight regain. DESIGN Longitudinal clinical intervention study of morbidly obese patients undergoing VBG. PATIENTS Group I: Six patients in which body composition and SMR were measured before and at 3, 6 and 12 months after VBG. Group II (long-term effect): nine patients in which body mass (BM) was measured before VBG, and body composition and SMR were measured 98+/-30 months after VBG. MEASUREMENTS Body composition was assessed by deuterium dilution and hydrostatic weighing. SMR was measured (SMRm) in a respiration chamber and predicted (SMRp) based on body composition. RESULTS In group I, fat mass and fat free mass decreased significantly after VBG (P < 0.05). SMRm decreased from 11.1+/-1.8 (s.d.) MJ/d before VBG to 8.1+/-0.9 MJ/d (P < 0.05) at 12 months after VBG. In group II at a mean of 98 months after VBG, the SMRm (6.9+/-0.7 MJ/d) was lower than the preoperative value of group I (P < 0.05). SMRm was lower than SMRp at all intervals after VBG (P < 0.05). The ratio measured vs predicted SMR was in group I: 1.02+/-0.05 before VBG, 0.91+/-0.08 at 12 months after VBG (P<0.05), and in group 11: 0.94+/-0.08 at a mean of 98 months after VBG (P < 0.05). CONCLUSION The reduction of SMR adjusted for body composition after VBG is sustained as long as weight loss is maintained. The sustained and disproportional reduction of SMR may reflect the persistent susceptibility of the postobese to weight regain.
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Affiliation(s)
- W G van Gemert
- Department of Surgery, University Hospital Maastricht, The Netherlands
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van Gemert WG, van Wersch MM, Greve JW, Soeters PB. Revisional surgery after failed vertical banded gastroplasty: restoration of vertical banded gastroplasty or conversion to gastric bypass. Obes Surg 1998; 8:21-8. [PMID: 9562482 DOI: 10.1381/096089298765555006] [Citation(s) in RCA: 125] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND An increasing number of patients with a failed primary bariatric procedure present themselves for secondary treatment. Only a few studies have investigated critically the success of revisional surgery. In the present study, the effectiveness of revisional surgery for failed vertical banded gastroplasty (VBG) is analyzed: restoration of the VBG (reVBG) is compared to conversion to a Roux-en-Y gastric bypass (RYGB). PATIENTS AND METHODS From 1980 to 1996, 136 consecutive morbidly obese patients underwent primary RYGB (n = 20) or VBG (n = 16). Weight loss, indications and complications after revisional surgery were registered. The rate of revisional surgery after primary and secondary bariatric procedures was estimated by means of a Kaplan-Meier analysis. RESULTS Kaplan-Meier analysis revealed that 56% of the patients will eventually require revisional surgery after initial VBG over a 12-year period compared to 12% after initial RYGB (P<0.01). After reVBG 68% will need revisional surgery over a 5-year period, while no further revisional surgery was required after conversion to a RYGB (P<0.05). Body mass index dropped significantly after reVBG or conversion to RYGB for insufficient weight loss (P<0.05), however, more revisional surgery was necessary after reVBG to achieve this result. The complication rate was comparable between reVBG and conversion to RYGB (33%). CONCLUSION Conversion of a failed VBG to a RYGB is more effective than a reVBG, because conversion to RYGB provides satisfactory weight loss without requiring further revisional surgery.
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Affiliation(s)
- W G van Gemert
- Department of Surgery, University Hospital Maastricht, The Netherlands
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van Gemert WG, Adang EM, Greve JW, Soeters PB. Quality of life assessment of morbidly obese patients: effect of weight-reducing surgery. Am J Clin Nutr 1998; 67:197-201. [PMID: 9459366 DOI: 10.1093/ajcn/67.2.197] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The effect of surgically induced weight loss on the quality of life of morbidly obese patients was investigated in a controlled cross-sectional study. A postoperative group of 62 patients was compared with a control group of 20 preoperative patients. The Nottingham Health Profile part I (NHP-I) and part II (NHP-II) and a visual analogue scale were used for quality of life assessment. Significant differences were found on the NHP-II (P < 0.0001), the visual analogue scale (P < 0.001), and on the domains of mobility (P < 0.0001), energy (P < 0.001), and emotional reaction (P < 0.001) on the NHP-I in favor of the postoperative group. Better quality of life outcome was related to larger weight loss and shorter length of postoperative follow-up. No correlation was found between quality of life outcome and the type of surgical procedure or surgical complications. The unemployment rate was 53% for the overall postoperative group and 64% for the female postoperative group compared with 80% (P < 0.05) and 84% (NS) in the overall and female control groups, respectively. Overweight as the reason for unemployment was more frequent in the control group. The results of this study show that quality of life is better after surgically induced weight loss and is not related to the type of surgical procedure nor to surgical complications. Postoperative quality of life tends to decrease with time.
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Affiliation(s)
- W G van Gemert
- Department of Surgery, University Hospital Maastricht, The Netherlands.
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Bonten MJ, Froon AH, Gaillard CA, Greve JW, de Leeuw PW, Drent M, Stobberingh EE, Buurman WA. The systemic inflammatory response in the development of ventilator-associated pneumonia. Am J Respir Crit Care Med 1997; 156:1105-13. [PMID: 9351609 DOI: 10.1164/ajrccm.156.4.9610002] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Ventilator-associated pneumonia (VAP) is the most frequent occurring infection among mechanically ventilated patients. The clinical presentation of VAP ranges from relatively benign to a severe illness with septic shock. The influence of VAP on patient outcome has not been elucidated and its effects on the inflammatory response of the host are unknown. In a case-control study, the systemic inflammatory response was investigated in patients developing VAP as compared with control patients matched on duration of mechanical ventilation and underlying diseases. Patients developing VAP (n = 42) were matched to a single control (without VAP), who was matched on seven variables. VAP was diagnosed with bronchoscopic techniques. The inflammatory response, reflected by circulating levels of interleukin-6 (IL-6) and interleukin-8 (IL-8), was determined on the day of diagnosis (or day of matching for controls), 4 and 2 d before diagnosis, and 2 d after diagnosis. The development of VAP was not associated with an increase in circulating levels of IL-6 or IL-8. Among patients in which VAP was associated with a clinical presentation of severe sepsis or septic shock (n = 10), IL-6 and IL-8 levels increased and were higher than in the corresponding controls. Moreover, 60% of cases with severe sepsis or septic shock died as compared with 20% of their matched controls (p = 0.06). Mortality rates were similar in patients with uncomplicated VAP and their matched controls (25% and 34%, respectively). High circulating levels of IL-6 and IL-8 were associated with higher mortality rates. The clinical picture of VAP can be subdivided into different types, ranging from uncomplicated to an infection associated with severe sepsis or septic shock, elevated circulating levels of IL-6 and IL-8, and an increased mortality rate.
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Affiliation(s)
- M J Bonten
- Department of Internal Medicine, University Hospital Maastricht, The Netherlands
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Vissers MC, Greve JW, Gouma DJ, van der Linden CJ, Hasman A. Introduction of a computerised protocol in clinical practice: is there anything to gain? Eur J Surg 1997; 163:245-54. [PMID: 9161821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To assess the potential benefit of a protocol for the diagnostic work-up and management of patients with obstructive jaundice, by comparing its recommendations with the policies actually followed in patients and to compare local expertise with diagnostic and therapeutic procedures with that described in published reports. DESIGN A retrospective analysis of patients' records. SETTING University hospital, The Netherlands. SUBJECTS 49 consecutive patients who presented to the departments of internal medicine and surgery between June 1990 and June 1992 with serum alkaline phosphatase activities > 125 mumol/L, and serum bilirubin concentrations > 17 mumol/L. MAIN OUTCOME MEASURES The proportions of diagnostic and therapeutic decisions that deviated from the recommendations, and the success rates of diagnostic and therapeutic procedures. RESULTS In patients with bile duct stones the treatment strategies did not deviate from those recommended in the protocol. In patients with cancer 38 (30%) of the 128 diagnostic decisions and 4 (11%) of the 37 therapeutic decisions deviated from the protocol. Success rates of all diagnostic investigations were comparable with those reported, and success rates of endoscopic biliary drainage tended to be lower than those reported. CONCLUSIONS The introduction of a protocol for the diagnostic work-up of patients with obstructive jaundice may reduce unnecessary investigations and diagnostic omissions by half. Because local expertise of some of the procedures seems to be significantly less than reported elsewhere it may be necessary to modify the protocol to better fit local circumstances.
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Affiliation(s)
- M C Vissers
- Department of Medical Informatics, University of Limburg, The Netherlands
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Abstract
BACKGROUND The VBG was originally performed with a Marlex band and characterized by a satisfactory weight loss and low morbidity. The effect of the material used for the banding procedure (Marlex vs Dacron) in vertical banded gastroplasty (VBG) is evaluated. METHODS In 49 consecutive obese patients treated with a VBG, a Marlex band was used in 17 patients and a Dacron band in 32 patients. Data were analyzed retrospectively with regard to the type of band, weight loss and complications. RESULTS A significant difference was found in the percentage excess weight 5 years postoperatively in favor of the Dacron group (59.2% vs 39.2%; p < 0.05) because of more band-related complications in the Marlex group. The difference in percentage excess weight disappeared 8 years postoperatively (43.3% vs 46.8%), due to the renewed weight loss of the Marlex group following reoperation. CONCLUSION The Dacron band is superior to the Marlex band in VBG because sustained weight loss is satisfactory and morbidity is low.
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Affiliation(s)
- W G van Gemert
- Department of Surgery, University Hospital Maastricht, The Netherlands
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Froon AM, Greve JW, Buurman WA, van der Linden CJ, Langemeijer HJ, Ulrich C, Bourgeois M. Treatment with the platelet-activating factor antagonist TCV-309 in patients with severe systemic inflammatory response syndrome: a prospective, multi-center, double-blind, randomized phase II trial. Shock 1996; 5:313-9. [PMID: 9156785 DOI: 10.1097/00024382-199605000-00001] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
In a prospective randomized, double-blind, placebo-controlled clinical study, the safety and efficacy of the platelet-activating factor antagonist TCV-309 in the treatment of systemic inflammatory response syndrome was studied. In total 29 patients were treated with 1.0 mg/kg TCV-309 twice daily during 7 days or with placebo. Study parameters were as follows: adverse events, 28 and 56 day all cause mortality, multi-organ failure scores, and the inflammatory mediators tumor necrosis factor, interleukin 6, interleukin 8, and soluble E-selectin. There was no difference in number and severity of adverse events between TCV-309- and placebo-treated patients. Day 28 and day 56 mortality was similar in both groups (day 56: 7/12 TCV-309 vs. 9/16 placebo, NS). Pulmonary and hematological failure scores improved significantly in TCV-309-treated patients (p < .05). There was no difference in inflammatory mediator levels between TCV-309- and placebo-treated patients. Treatment with TCV-309 appears to be safe in patients with systemic inflammatory response syndrome and does improve organ failure significantly.
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Affiliation(s)
- A M Froon
- Academic Hospital Maastricht, The Netherlands
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Froon AH, Greve JW, Van der Linden CJ, Buurman WA. Increased concentrations of cytokines and adhesion molecules in patients after repair of abdominal aortic aneurysm. Eur J Surg 1996; 162:287-96. [PMID: 8739415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To evaluate the association between inflammatory mediators and clinical outcome in patients after repair of abdominal aortic aneurysms. DESIGN Prospective study. SETTING University hospital, The Netherlands. PATIENTS 30 Consecutive patients who had undergone elective or acute repair of abdominal aortic aneurysms. MAIN OUTCOME MEASURES Plasma concentrations of the cytokines tumour necrosis factor (TNF), interleukin-6 (IL-6) and interleukin-8 (IL-8) as well as soluble TNF receptors and the soluble (s) adhesion molecules E-selectin and intercellular adhesion molecule 1 (ICAM-1) were measured and correlated with the degree of systemic hypotension (shock: hypotension more than 15 minutes) and clinical outcome. RESULTS Peak plasma concentrations of TNF and IL-6 were significantly higher in shocked patients (p < 0.005 and p < 0.0005, respectively) and those who died (both p < 0.01), whereas concentrations of IL-8 increased only when shock complicated rupture of the aneurysm (p < 0.01). Increases in the concentrations of TNF receptors reflected impaired renal function. In contrast to sE-selectin concentrations, peak sICAM-1 concentrations were significantly higher in shocked patients (p < 0.01) and those that died (p < 0.01). CONCLUSIONS These results strongly suggest that increased concentrations of sICAM-1 and IL-6 reflect the inflammatory response induced by ischaemia after repair of an abdominal aortic aneurysm, and indicate that the postoperative course is likely to be complicated.
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Affiliation(s)
- A H Froon
- Department of Surgery, University Hospital Maastricht, The Netherlands
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Bemelmans MH, Greve JW, Gouma DJ, Buurman WA. Increased concentrations of tumour necrosis factor (TNF) and soluble TNF receptors in biliary obstruction in mice; soluble TNF receptors as prognostic factors for mortality. Gut 1996; 38:447-53. [PMID: 8675101 PMCID: PMC1383077 DOI: 10.1136/gut.38.3.447] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Systemic tumour necrosis factor (TNF) is present in jaundiced mice. Two soluble TNF receptors, sTNFr-P55 and sTNFr-P75 are reported to play a part in the natural defence against TNF. This study investigated the properties of circulating TNF and sTNFr in jaundiced mice. The data show that TNF in these mice is biologically inactive and that an increase of both sTNFr is seen (p < 0.001). Surgical trauma in jaundiced mice is known to be accompanied by a high mortality (36%) and increased TNF concentrations. This study shows that both systemic TNF and sTNFr concentrations are increased after surgical trauma in jaundiced mice and that sTNFr concentrations rather than TNF concentrations were found to be correlated with mortality. In line with this finding this study showed that lactulose pretreatment before a surgical trauma in these mice significantly reduces postoperative concentrations of sTNFr-P75 (p < 0.005) and mortality (0%; p < 0.05) without reducing TNF concentrations, while anti-TNF antibodies were ineffective. In conclusion, these data suggest that TNF in biliary obstruction is rapidly inactivated by increased concentrations of sTNFr. Furthermore, sTNFr concentrations rather than TNF concentrations show a good correlation with mortality after surgery in obstructive jaundice. The positive effect of lactulose on mortality could be caused by a decreased inflammatory status.
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Affiliation(s)
- M H Bemelmans
- Department of Surgery, University of Limburg, Maastricht, Netherlands
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Abstract
The toxicity of lipopolysaccharide (LPS) is modified by several proteins, such as bactericidal/permeability-increasing protein (BPI) and LPS-binding protein (LBP). BPI and LBP plasma levels were measured in patients with gram-negative (n = 36) or gram-positive (n = 28) bacteremia. Levels of BPI and LBP, which are proteins that neutralize and enhance LPS effects, respectively, were increased before bacteremia was first detected. The BPI/neutrophil ratio, reflecting neutrophil activation, was significantly associated with the presence of sepsis syndrome and death in bacteremic patients: 1.06 (0.11-6.49) versus 0.57 (0.06-3.82) in patients with and without sepsis syndrome (P < .01), respectively, and 0.64 (0.06-3.82) versus 1.02 (0.12-6.49) in survivors and nonsurvivors (P < .05), respectively (ratio in nanograms of BPI per 10(6) neutrophils). High LBP peak levels were significantly associated with the presence of sepsis syndrome (P < .01). No differences in BPI and LBP levels were observed in patients with gram-negative versus gram-positive bacteremia. BPI/neutrophil ratio, as a parameter of neutrophil activation, may be useful in monitoring infectious disease.
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Affiliation(s)
- A H Froon
- Department of Surgery, University Hospital Maastricht, University of Limburg, Netherlands
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Härtel J, Pöhl A, Greve JW. [Fractures of the facial skull in the growth period and concomitant injuries]. Unfallchirurg 1994; 97:991-3. [PMID: 7973755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
From 1968 to 1990, 135 children up to the age of 14 years were treated as in-patients for fractures of the facial skull. Most had been sustained in traffic accident. Other associated lesions were seen in 80 patients. In 21 of these we observed general surgical traumas or fractures of the base of the skull, and in 23 patients cerebral traumas were detected. Treatment was instituted an average of 1.7 days after the trauma in the case of patients with no associated injuries and of 5.6 days in the case of those with other injuries. Definitive treatment had been applied within 6 days after the accident in 80% of patients with other injuries and/or with fractures of the skull base.
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Affiliation(s)
- J Härtel
- Klinik und Poliklinik für Mund-Kiefer-Gesichtschirurgie und Plastische Operationen, Universität Rostock
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Froon AH, Bemelmans MH, Greve JW, van der Linden CJ, Buurman WA. Increased plasma concentrations of soluble tumor necrosis factor receptors in sepsis syndrome: correlation with plasma creatinine values. Crit Care Med 1994; 22:803-9. [PMID: 8181289 DOI: 10.1097/00003246-199405000-00015] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES Tumor necrosis factor (TNF) is an important mediator in the complex pathophysiology of sepsis syndrome. Although a positive correlation with mortality rate has been demonstrated, TNF has not been found consistently in sepsis. Since prolonged increases in soluble TNF receptor concentrations were demonstrated after endotoxin and TNF administration, we investigated whether the measurement of TNF receptor concentrations could provide a better indicator of disease than plasma TNF and interleukin (IL)-6 concentrations. DESIGN Prospective analysis. SETTING General intensive care unit (ICU) of a university hospital. PATIENTS Twenty-six patients with sepsis syndrome and proven bacteremia. MEASUREMENTS AND MAIN RESULTS Plasma peak concentrations of the soluble 55-kilodalton molecular weight TNF receptor were significantly higher (p < .005) in nonsurvivors compared with survivors of sepsis syndrome, whereas the difference in peak concentrations of the soluble 75-kilodalton TNF receptor did not reach significance (p = .06). In contrast to TNF peak concentrations (p = .14), significantly higher (p < .05) IL-6 peak concentrations were measured in nonsurvivors. Besides the positive correlation between the soluble 55-kilodalton TNF receptor and the soluble 75-kilodalton TNF receptor (r2 = .68; p < .0001), peak concentrations of both soluble 55-kilodalton TNF receptor and 75-kilodalton TNF receptor correlated significantly with plasma creatinine values, an indicator of renal function (r2 = .60; p < .0001 and r2 = .44; p < .001, respectively). Plasma creatinine concentrations were significantly higher in nonsurvivors (p < .001). CONCLUSIONS In the population studied, plasma-soluble TNF receptor concentrations correlated with outcome as well as with plasma creatinine concentrations. The data presented suggest that increased plasma-soluble TNF receptor concentrations in patients with sepsis syndrome are merely the result of renal failure complicating sepsis, and are similarly correlated with mortality rate.
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Affiliation(s)
- A H Froon
- Department of Surgery, University Hospital Maastricht, University of Limburg, The Netherlands
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Abstract
Forty-one (impending) fractures were reviewed in 39 patients with metastatic bone disease. Thirty-one lesions were located in the femur, and the remaining ten lesions were located in the humerus. In 22 cases there were multiple lesions in the affected bone. All patients were treated with intramedullary nailing, 21 times because of a pathologic fracture and 20 times because of an impending pathologic fracture. There was no mortality related to the surgical procedures. In nine patients the postoperative course was complicated (four technical and five systemic complications). Pain relief was achieved in 29 patients. Ambulatory status was improved in 27 patients. A pathologic refracture in the same bone occurred in five cases, all located in the femoral neck. Intramedullary nailing is useful in the treatment of metastatic bone disease. This technique facilitates stabilization of the whole bone, which in our view, with respect to the presented data, is mandatory.
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Affiliation(s)
- R R van der Hulst
- Department of Surgery, University Hospital Maastricht, The Netherlands
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47
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van den Wildenberg FA, Greve JW. Intramedullary stabilization of a bowing fracture of the forearm with Ender's nails: case report. J Trauma 1993; 35:808-9. [PMID: 8230351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
A case history of a young man with a bowing fracture of the forearm is presented. The fracture was reduced and stabilized using shortened Ender's nails. Both soft tissues and fractures healed uneventfully and complete restoration of function resulted.
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48
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Bemelmans MH, Gouma DJ, Greve JW, Buurman WA. Effect of antitumour necrosis factor treatment on circulating tumour necrosis factor levels and mortality after surgery in jaundiced mice. Br J Surg 1993; 80:1055-8. [PMID: 8402066 DOI: 10.1002/bjs.1800800845] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Tumour necrosis factor (TNF) may play an important role in the increased incidence of complications after surgery in patients with obstructive jaundice. This study evaluated the effect of three different anti-TNF treatments, a monoclonal anti-TNF antibody (TN3), pentoxifylline and lactulose, on outcome after severe surgical trauma in mice with experimental biliary obstruction. Circulating serum TNF levels and mortality rate were monitored. Severe surgical trauma, such as renal ischaemia, in jaundiced mice resulted in increased levels of circulating TNF (3.5 ng/ml) and a high mortality rate (54 per cent). The three different anti-TNF treatments caused a significant reduction in postoperative levels of circulating TNF (TN3, P < 0.001; pentoxifylline, P < 0.01; lactulose, P < 0.05). Treatment with TN3 and pentoxifylline did not lead to a significantly reduced mortality rate (36 and 44 per cent respectively). Only lactulose treatment produced a significantly reduced mortality rate (7 per cent, P < 0.01). TNF is therefore not the only mediator responsible for death after surgery in jaundiced mice. Other mechanisms affected by lactulose are also involved.
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Affiliation(s)
- M H Bemelmans
- Department of Surgery, University of Limburg, Maastricht, The Netherlands
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Abstract
The putative role of the cytokines interleukin-6 and tumor necrosis factor in the pathophysiology of the complications and mortality after surgery in jaundiced patients was studied in a murine model. Cytokine serum levels were determined in mice with experimental biliary obstruction. As an indicator of the activation status of macrophages, cytokine release by mononuclear phagocytes obtained from such mice was assessed. Following surgery, interleukin-6 levels increased to 2 to 3 ng/ml after 3 to 4 hr, but declined rapidly afterward to levels of 60 pg/ml after 10 days. After 12 days, substantial interleukin-6 levels were observed in jaundiced mice (100 pg/ml), whereas levels in sham mice further decreased (p less than 0.001). The cytokine tumor necrosis factor was frequently present in the serum of jaundiced mice. After 22 days, when killed, all jaundiced mice showed significant tumor necrosis factor levels (p less than 0.001). This was in contrast to sham mice in which tumor necrosis factor was never detected. The presence of an activated state of macrophages in jaundiced mice was concluded from the observed high spontaneous cytokine release and significantly higher release after stimulation (p less than 0.05). The presence of circulating cytokines was discussed in the context of the postoperative complications observed in jaundiced patients.
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Affiliation(s)
- M H Bemelmans
- Department of Surgery, University of Limburg, Maastricht, The Netherlands
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50
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Abstract
Surgical treatment of patients with obstructive jaundice is associated with a high postoperative morbidity and mortality. A correlation was suggested between endotoxins and the observed complications. The mechanism by which endotoxins affect the negative outcome in operated jaundiced patients was, however, not clear, nor was the mechanism of clinically used preventive treatments. Several experiments were therefore performed in rats with biliary obstruction, to investigate whether and how endotoxins are active. The role of endotoxins was studied in a model in which endotoxins were absent. In germfree rats (free of bacteria and thus of endotoxin) the effect of biliary obstruction was studied and compared with biliary obstruction in conventional rats. To substantiate further the role of endotoxin, anti-endotoxin treatments (oral lactulose or internal drainage) were tested in rats with obstructive jaundice undergoing a severe surgical trauma. It is shown that endotoxins are responsible for complications (suppression of cellular immunity, kidney function, mortality) and that these complications can be prevented with an anti-endotoxin treatment. These results may have implications for preoperative treatment of jaundiced patients.
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Affiliation(s)
- J W Greve
- Dept. of Surgery, University of Limburg, Maastricht, The Netherlands
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