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Magyar CTJ, Borbély Y, Wiest R, Stirnimann G, Candinas D, Lenglinger J, Nett PC, Kröll D. Gastroesophageal Junction and Pylorus Distensibility Before and After Sleeve Gastrectomy-pilot Study with EndoFlip TM. Obes Surg 2023; 33:2255-2260. [PMID: 37118639 PMCID: PMC10289900 DOI: 10.1007/s11695-023-06606-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 04/30/2023]
Abstract
Sleeve gastrectomy (SG) is the most frequently performed bariatric surgical intervention worldwide. Gastroesophageal reflux disease (GERD) is frequently observed after SG and is a relevant clinical problem. This prospective study investigated the gastroesophageal junction (GEJ) and pyloric sphincter by impedance planimetry (EndoFlipTM) and their association with GERD at a tertiary university hospital center. Between January and December 2018, patients undergoing routine laparoscopic SG had pre-, intra-, and postoperative assessments of the GEJ and pyloric sphincter by EndoFlipTM. The distensibility index (DI) was measured at different volumes and correlated with GERD (in accordance with the Lyon consensus guidelines). Nine patients were included (median age 48 years, preoperative BMI 45.1 kg/m2, 55.6% female). GERD (de novo or stable) was observed in 44.4% of patients one year postoperatively. At a 40-ml filling volume, DI increased significantly pre- vs. post-SG of the GEJ (1.4 mm2/mmHg [IQR 1.1-2.6] vs. 2.9 mm2/mmHg [2.6-5.3], p VALUE=0.046) and of the pylorus (6.0 mm2/mmHg [4.1-10.7] vs. 13.1 mm2/mmHg [7.6-19.2], p VALUE=0.046). Patients with postoperative de novo or stable GERD had a significantly increased preoperative DI at 40 ml of the GEJ (2.6 mm2/mmHg [1.9-3.5] vs. 0.5 mm2/mmHg [0.5-1.1], p VALUE=0.031). There was no significant difference in DI at 40 mL filling in the preoperative pylorus and postoperative GEJ or pylorus. In this prospective study, the DI of the GEJ and the pylorus significantly increased after SG. Postoperative GERD was associated with a significantly higher preoperative DI of the GEJ but not of the pylorus.
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Affiliation(s)
- Christian Tibor Josef Magyar
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Yves Borbély
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Reiner Wiest
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Guido Stirnimann
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Daniel Candinas
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Johannes Lenglinger
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Philipp C. Nett
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Dino Kröll
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
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Kröll D, Nett PC, Rommers N, Borbély Y, Deichsel F, Nocito A, Zehetner J, Kessler U, Fringeli Y, Alberio L, Candinas D, Stirnimann G. Efficacy and Safety of Rivaroxaban for Postoperative Thromboprophylaxis in Patients After Bariatric Surgery: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2315241. [PMID: 37227726 DOI: 10.1001/jamanetworkopen.2023.15241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Abstract
Importance Venous thromboembolism (VTE) is a leading cause of morbidity and mortality after bariatric surgery. Clinical end point studies on thromboprophylaxis with direct oral anticoagulants in patients undergoing bariatric surgery are lacking. Objective To assess the efficacy and safety of a prophylactic dose of 10 mg/d of rivaroxaban for both 7 and 28 days after bariatric surgery. Design, Setting, and Participants This assessor-blinded, phase 2, multicenter randomized clinical trial was conducted from July 1, 2018, through June 30, 2021, with participants from 3 academic and nonacademic hospitals in Switzerland. Intervention Patients were randomized 1 day after bariatric surgery to 10 mg of oral rivaroxaban for either 7 days (short prophylaxis) or 28 days (long prophylaxis). Main Outcomes and Measures The primary efficacy outcome was the composite of deep vein thrombosis (symptomatic or asymptomatic) and pulmonary embolism within 28 days after bariatric surgery. Main safety outcomes included major bleeding, clinically relevant nonmajor bleeding, and mortality. Results Of 300 patients, 272 (mean [SD] age, 40.0 [12.1] years; 216 women [80.3%]; mean body mass index, 42.2) were randomized; 134 received a 7-day and 135 a 28-day VTE prophylaxis course with rivaroxaban. Only 1 thromboembolic event (0.4%) occurred (asymptomatic thrombosis in a patient undergoing sleeve gastrectomy with extended prophylaxis). Major or clinically relevant nonmajor bleeding events were observed in 5 patients (1.9%): 2 in the short prophylaxis group and 3 in the long prophylaxis group. Clinically nonsignificant bleeding events were observed in 10 patients (3.7%): 3 in the short prophylaxis arm and 7 in the long prophylaxis arm. Conclusions and Relevance In this randomized clinical trial, once-daily VTE prophylaxis with 10 mg of rivaroxaban was effective and safe in the early postoperative phase after bariatric surgery in both the short and long prophylaxis groups. Trial Registration ClinicalTrials.gov Identifier: NCT03522259.
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Affiliation(s)
- Dino Kröll
- Department of Visceral Surgery and Medicine, Bern University Hospital (Inselspital) and University of Bern, Bern, Switzerland
| | - Philipp C Nett
- Department of Visceral Surgery and Medicine, Bern University Hospital (Inselspital) and University of Bern, Bern, Switzerland
| | - Nikki Rommers
- Department of Clinical Research, Clinical Trial Unit, University of Basel, Switzerland
| | - Yves Borbély
- Department of Visceral Surgery and Medicine, Bern University Hospital (Inselspital) and University of Bern, Bern, Switzerland
| | - Fabian Deichsel
- Department of Surgery, Cantonal Hospital of Baden, Baden, Switzerland
| | - Antonio Nocito
- Department of Surgery, Cantonal Hospital of Baden, Baden, Switzerland
| | - Jörg Zehetner
- Department of Visceral Surgery, Hirslanden Clinic Beau-Site, Bern, Switzerland
| | - Ulf Kessler
- Department of Visceral Surgery, Hirslanden Clinic Beau-Site, Bern, Switzerland
| | - Yannick Fringeli
- Department of Visceral Surgery, Hirslanden Clinic Beau-Site, Bern, Switzerland
| | - Lorenzo Alberio
- Division of Haematology and Central Haematology Laboratory, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - Daniel Candinas
- Department of Visceral Surgery and Medicine, Bern University Hospital (Inselspital) and University of Bern, Bern, Switzerland
| | - Guido Stirnimann
- Department of Visceral Surgery and Medicine, Bern University Hospital (Inselspital) and University of Bern, Bern, Switzerland
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Lavanchy JL, Gonzalez C, Kassem H, Nett PC, Mutter D, Padoy N. Proposal and multicentric validation of a laparoscopic Roux-en-Y gastric bypass surgery ontology. Surg Endosc 2023; 37:2070-2077. [PMID: 36289088 PMCID: PMC10017621 DOI: 10.1007/s00464-022-09745-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 10/14/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Phase and step annotation in surgical videos is a prerequisite for surgical scene understanding and for downstream tasks like intraoperative feedback or assistance. However, most ontologies are applied on small monocentric datasets and lack external validation. To overcome these limitations an ontology for phases and steps of laparoscopic Roux-en-Y gastric bypass (LRYGB) is proposed and validated on a multicentric dataset in terms of inter- and intra-rater reliability (inter-/intra-RR). METHODS The proposed LRYGB ontology consists of 12 phase and 46 step definitions that are hierarchically structured. Two board certified surgeons (raters) with > 10 years of clinical experience applied the proposed ontology on two datasets: (1) StraBypass40 consists of 40 LRYGB videos from Nouvel Hôpital Civil, Strasbourg, France and (2) BernBypass70 consists of 70 LRYGB videos from Inselspital, Bern University Hospital, Bern, Switzerland. To assess inter-RR the two raters' annotations of ten randomly chosen videos from StraBypass40 and BernBypass70 each, were compared. To assess intra-RR ten randomly chosen videos were annotated twice by the same rater and annotations were compared. Inter-RR was calculated using Cohen's kappa. Additionally, for inter- and intra-RR accuracy, precision, recall, F1-score, and application dependent metrics were applied. RESULTS The mean ± SD video duration was 108 ± 33 min and 75 ± 21 min in StraBypass40 and BernBypass70, respectively. The proposed ontology shows an inter-RR of 96.8 ± 2.7% for phases and 85.4 ± 6.0% for steps on StraBypass40 and 94.9 ± 5.8% for phases and 76.1 ± 13.9% for steps on BernBypass70. The overall Cohen's kappa of inter-RR was 95.9 ± 4.3% for phases and 80.8 ± 10.0% for steps. Intra-RR showed an accuracy of 98.4 ± 1.1% for phases and 88.1 ± 8.1% for steps. CONCLUSION The proposed ontology shows an excellent inter- and intra-RR and should therefore be implemented routinely in phase and step annotation of LRYGB.
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Affiliation(s)
- Joël L Lavanchy
- IHU Strasbourg, 1 Place de l'Hôpital, 67000, Strasbourg, France.
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Cristians Gonzalez
- IHU Strasbourg, 1 Place de l'Hôpital, 67000, Strasbourg, France
- University Hospital of Strasbourg, Strasbourg, France
| | - Hasan Kassem
- ICube, CNRS, University of Strasbourg, Strasbourg, France
| | - Philipp C Nett
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Didier Mutter
- IHU Strasbourg, 1 Place de l'Hôpital, 67000, Strasbourg, France
- University Hospital of Strasbourg, Strasbourg, France
| | - Nicolas Padoy
- IHU Strasbourg, 1 Place de l'Hôpital, 67000, Strasbourg, France
- ICube, CNRS, University of Strasbourg, Strasbourg, France
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Lunger F, Aeschbacher P, Nett PC, Peros G. The impact of bariatric and metabolic surgery on cancer development. Front Surg 2022; 9:918272. [PMID: 35910464 PMCID: PMC9334768 DOI: 10.3389/fsurg.2022.918272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/30/2022] [Indexed: 12/21/2022] Open
Abstract
Obesity (BMI ≥ 30 kg/m2) with related comorbidities such as type 2 diabetes mellitus, cardiovascular disease, sleep apnea syndrome, and fatty liver disease is one of the most common preventable risk factors for cancer development worldwide. They are responsible for at least 40% of all newly diagnosed cancers, including colon, ovarian, uterine, breast, pancreatic, and esophageal cancer. Although various efforts are being made to reduce the incidence of obesity, its prevalence continues to spread in the Western world. Weight loss therapies such as lifestyle change, diets, drug therapies (GLP-1-receptor agonists) as well as bariatric and metabolic surgery are associated with an overall risk reduction of cancer. Therefore, these strategies should always be essential in therapeutical concepts in obese patients. This review discusses pre- and post-interventional aspects of bariatric and metabolic surgery and its potential benefit on cancer development in obese patients.
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Affiliation(s)
- Fabian Lunger
- Department for Visceral Surgery and Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Visceral and Thoracic Surgery, Cantonal Hospital of Winterthur, Winterthur, Switzerland
| | - Pauline Aeschbacher
- Department for Visceral Surgery and Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Philipp C. Nett
- Department for Visceral Surgery and Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
- Correspondance: Philipp C. Nett
| | - Georgios Peros
- Department of Visceral and Thoracic Surgery, Cantonal Hospital of Winterthur, Winterthur, Switzerland
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Magyar CTJ, Prevost GA, Nett PC. Vasoconstrictor nasal spray causing life-threatening complications after bariatric surgery: A case report. Int J Surg Case Rep 2021; 89:106574. [PMID: 34864257 PMCID: PMC8645905 DOI: 10.1016/j.ijscr.2021.106574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/31/2021] [Accepted: 10/31/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction and importance Bariatric surgery is an evolving surgical field with increasing cases per year, as obesity is prevalent, especially in developed countries. Complication diagnosis and management can be challenging. Marginal ulcers and anastomosis perforation are rare, but their incidence is likely underestimated. Case presentation To the best of our knowledge, we present the first case with a two and a half years history of recurrent ischemia, marginal ulcers, and recurrent perforation after laparoscopic omega loop gastric bypass, most likely due to an abuse of an over-the-counter (OTC) sympathomimetic nasal spray. The complications (Clavien-Dindo classification IIIb) caused the necessity of recurrent hospitalizations and diagnostic interventions and an open conversion into Roux-Y gastric bypass in a damage control manner. Clinical discussion and conclusion Conclusively, we advocate evaluating drug abuse, including OTC medications that patients might not report on a daily-based medical history, as an etiology for marginal ulcers and anastomosis perforation, especially in late and recurrent cases. Abuse of OTC sympathomimetic nasal spray can cause recurrent gastrojejunal anastomosis ischemia. Re-Do surgery cannot prevent recurrence of ischemia in these cases. In recurrence of ischemia, detailed medical history, including OTC drugs, is crucial.
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Affiliation(s)
- Christian T J Magyar
- Department for Visceral Surgery and Medicine, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland
| | - Gian A Prevost
- Department for Visceral Surgery and Medicine, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland
| | - Philipp C Nett
- Department for Visceral Surgery and Medicine, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland.
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Müller M, Nett PC, Borbély YM, Buri C, Stirnimann G, Laederach K, Kröll D. Mental Illness Has a Negative Impact on Weight Loss in Bariatric Patients: a 4-Year Follow-up. J Gastrointest Surg 2019; 23:232-238. [PMID: 30091038 DOI: 10.1007/s11605-018-3903-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 07/24/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Mental health disorders are highly prevalent among bariatric surgery patients. Bariatric surgery induces weight loss with continuous health improvements. However, long-term follow-up data on weight loss and quality of life data of patients who have a mental illness after bariatric surgery are scarce, and it is not clear whether mental illness is associated with more pronounced weight regain. The aim was to investigate the impact of preoperative mental illness on the course of long-term weight changes after bariatric surgery. METHODS Patients with sleeve gastrectomy (SG) or Roux-en-Y gastric bypass surgery (RYGB) between 2005 and 2013 with a follow-up of at least 3 years were included. The study population was divided into two groups: patients with mental illness (MI) and patients without (No-MI). Weight loss outcomes over time were compared using mixed models up to 4 years after surgery. RESULTS In total, 254 patients (RYGB 61.0%, SG 39%) were included. The distribution of baseline characteristics was similar between the MI (n = 108) and No-MI groups (n = 146). The most prevalent mental illness was depressive disorder (63.9%). In the MI group, the percent of total weight loss (%TWL) was significantly smaller over the study period. After 36 months, the predicted mean group-difference of %TWL was 4.6% (95% CI 1.9, 7.2; p = 0.001), and the predicted odds ratio for weight regain was 4.9 (95% CI 1.6, 15.1) for patients in the MI group. CONCLUSION Preoperative mental illness leads to lower long-term weight loss and an increased risk of weight regain after bariatric surgery.
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Affiliation(s)
- Martin Müller
- Department of Emergency Medicine, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Philipp C Nett
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Yves Michael Borbély
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Caroline Buri
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Guido Stirnimann
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Kurt Laederach
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Dino Kröll
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital and University of Bern, 3010, Bern, Switzerland.
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Nett PC. [Internal hernias after bariatric and metabolic surgery]. Ther Umsch 2019; 76:591-595. [PMID: 32238114 DOI: 10.1024/0040-5930/a001138] [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: 11/19/2022]
Abstract
Internal hernias after bariatric and metabolic surgery Abstract. Internal hernias are among the most common long-term complications of morbid obesity following gastric bypass procedures. The diagnosis of an internal hernia after a gastric bypass is often uncertain due to unspecific clinical symptoms and is difficult despite various diagnostic procedures. This fact requires special attention in the postbariatric follow-up after gastric bypass surgery and the knowledge of the possibility of the development of internal hernias. In addition, the recurrence rate after surgical treatment is not insignificant.
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Affiliation(s)
- Philipp C Nett
- Universitätsklinik für Viszerale Chirurgie und Medizin, Inselspital Bern
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Kröll D, Nett PC, Borbély YM, Schädelin S, Bertaggia Calderara D, Alberio L, Stirnimann G. The effect of bariatric surgery on the direct oral anticoagulant rivaroxaban: the extension study. Surg Obes Relat Dis 2018; 14:1890-1896. [DOI: 10.1016/j.soard.2018.08.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/20/2018] [Accepted: 08/27/2018] [Indexed: 01/06/2023]
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Borbély Y, Kröll D, Nett PC, Moreno P, Tutuian R, Lenglinger J. Radiologic, endoscopic, and functional patterns in patients with symptomatic gastroesophageal reflux disease after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2018; 14:764-768. [PMID: 29631982 DOI: 10.1016/j.soard.2018.02.028] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 01/20/2018] [Accepted: 02/26/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) is considered the gold standard in treatment of morbid obesity and gastroesophageal reflux disease (GERD). Resolution of GERD symptoms is reported to be approximately 85% to 90%. OBJECTIVE To evaluate patients with persistent GERD symptoms after RYGB and to identify contributing factors. SETTING University hospital, cross-sectional study. METHODS Data of patients evaluated for persistent GERD with a history of RYGB between January 2012 and December 2015 were reviewed. GERD was assessed with questionnaires, endoscopy, 24-hour pH-impendance manometry, and barium swallow. RESULTS Of 47 patients, 44 (93.6%) presented with typical GERD, 18 (38.3%) with obstruction, 8 (17%) with pulmonary symptoms, and 21 (44.7%) with pain. The interval between RYGB and evaluation was a median of 3.8 years (range .8-12.6); median patient age was 36.5 years (19.1-67.2). Median body mass index was 30.3 kg/m2 (20.3-47.2). Pouch gastric fistulas were seen in 2 (5.1%), enlarged pouches in 5 (10.6%), and hiatal hernias in 25 patients (53.2%). Twelve (23.4%) had esophagitis>Los Angeles (LA) grade B. Manometry was performed in 45 (95.7%) and off-proton pump inhibitor 24-hour pH-impedance-metry in 44 patients (94.6%). Seventeen patients (37.8%) had esophageal hypomotility or aperistalsis; hypotensive lower esophageal sphincter was seen in 26 patients (57.8%). Increased esophageal acid exposure (>4% pH<4) was found in 27 (61.4%), an increased number of reflux episodes (>53) in 30 patients (68.2%). Symptoms were deemed as functional in 6 (12.8%). CONCLUSION The evaluation for persistent GERD after RYGB revealed a high percentage of hiatal hernias, hypotensive lower esophageal sphincter, and severe esophageal motility disorders. These findings might have an influence on hiatal hernia closure concomitant with RYGB and the role of pH manometry in the preoperative bariatric assessment.
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Affiliation(s)
- Yves Borbély
- Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland.
| | - Dino Kröll
- Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Philipp C Nett
- Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Peter Moreno
- Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Radu Tutuian
- Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Johannes Lenglinger
- Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
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Nett PC. Answer to: Micronutrient Supplementation after Biliopancreatic Diversion with Duodenal Switch in the Long Term: Using Refill Bypass Is the Solution. Obes Surg 2018; 26:1939. [PMID: 27229735 DOI: 10.1007/s11695-016-2241-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Philipp C Nett
- Department of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, University Bern, Bern, 3010, Switzerland. .,Leiter universitäres Adipositaszentrum Bern und Leiter bariatrische und metabolische Chirurgie, Universitäre Klinik für viszerale Chirurgie und Medizin Inselspital, Freiburgstrasse, 3010, Bern, Switzerland.
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Borbély YM, Osterwalder A, Kröll D, Nett PC, Inglin RA. Diarrhea after bariatric procedures: Diagnosis and therapy. World J Gastroenterol 2017; 23:4689-4700. [PMID: 28765690 PMCID: PMC5514634 DOI: 10.3748/wjg.v23.i26.4689] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 03/30/2017] [Accepted: 06/19/2017] [Indexed: 02/07/2023] Open
Abstract
Diarrhea after bariatric procedures, mainly those with malabsorptive elements including Roux-Y Gastric Bypass and Biliopancreatic Diversion, is common and an essential determinant of quality of life and micro- and macronutrient deficiencies. Bariatric surgery is the only sustainably successful method to address morbid obesity and its comorbidities, particularly gaining more and more importance in the specific treatment of diabetic patients. Approximately half a million procedures are annually performed around the world, with numbers expected to rise drastically in the near future. A multitude of factors exert their influence on bowel habits; preoperative comorbidities and procedure-related aspects are intertwined with postoperative nutritional habits. Diagnosis may be challenging owing to the characteristics of post-bariatric surgery anatomy with hindered accessibility of excluded segments of the small bowel and restriction at the gastric level. Conventional testing measures, if available, generally yield low accuracy and are usually not validated in this specific population. Limited trials of empiric treatment are a practical alternative and oftentimes an indispensable part of the diagnostic process. This review provides an overview of causes for chronic post-bariatric surgery diarrhea and details the particularities of its diagnosis and treatment in this specific patient population. Topics of current interest such as the impact of gut microbiota and the influence of bile acids on morbid obesity and especially their role in diarrhea are highlighted in order to provide a better understanding of the specific problems and chances of future treatment in post-bariatric surgery patients.
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Kröll D, Stirnimann G, Vogt A, Lai DLL, Borbély YM, Altmeier J, Schädelin S, Candinas D, Alberio L, Nett PC. Pharmacokinetics and pharmacodynamics of single doses of rivaroxaban in obese patients prior to and after bariatric surgery. Br J Clin Pharmacol 2017; 83:1466-1475. [PMID: 28121368 DOI: 10.1111/bcp.13243] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 01/17/2017] [Accepted: 01/23/2017] [Indexed: 01/05/2023] Open
Abstract
AIMS Venous thromboembolism is an important cause of postoperative morbidity and mortality in bariatric surgery. Studies of direct oral anticoagulants (DOACs) are not available in this surgical field. The objective of this phase 1 clinical trial was to investigate pharmacokinetic and pharmacodynamic (PK/PD) parameters of rivaroxaban in bariatric patients. METHODS In this single-centre study, obese patients received single oral doses of rivaroxaban (10 mg) 1 day prior to and 3 days after bariatric surgery. PK and PD parameters were assessed at baseline and during 24 h after drug ingestion. RESULTS Six Roux-en-Y gastric bypass patients and six sleeve gastrectomy patients completed the study. Mean rivaroxaban area under plasma concentration-time curve, peak plasma concentration, time to peak plasma concentration and terminal half-life were 971.9 μg·h l-1 (coefficient of variation: 10.6), 135.3 μg l-1 (26.7), 1.5 h and 13.1 h (34.1) prior to and 1165.8 (21.9), 170.0 (15.9), 1.5 and 8.9 (44.6) postsurgery for SG patients and 933.7 μg·h l-1 (22.3), 136.5 μg l-1 (10.7), 1.5 h und 13.8 h (46.6) prior to and 1029.4 (7.4), 110.8 (31.8), 2.5 and 15 (60.0) postsurgery for Roux-en-Y gastric bypass patients, respectively. Prothrombin fragments (F1 + 2) decreased during the first 12 hours and increased thereafter in the pre- and the postbariatric setting. Thrombin-antithrombin complexes dropped within 1-3 h in the prebariatric setting and remained low after surgery until they increased at 24 h postdose. Rivaroxaban was well tolerated and no relevant safety issues were observed. CONCLUSIONS Bariatric surgery does not appear to alter PK of rivaroxaban in a clinically relevant way. Effective prophylactic postbariatric anticoagulation is supported by changes in PD.
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Affiliation(s)
- Dino Kröll
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Guido Stirnimann
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Andreas Vogt
- Department of Anaesthesiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Desirée Lin Lee Lai
- Department of Anaesthesiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Yves Michael Borbély
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Julia Altmeier
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Sabine Schädelin
- Department of Clinical Research, Clinical Trial Unit, Spitalstrasse 12, 4031, Basel, Switzerland
| | - Daniel Candinas
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Lorenzo Alberio
- Division of Haematology and Central Haematology Laboratory, Centre Hospitalier Universitaire Vaudois, University of Lausanne, CH 1011, Lausanne, Switzerland
| | - Philipp C Nett
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
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Borbély Y, Juilland O, Altmeier J, Kröll D, Nett PC. Perioperative outcome of laparoscopic sleeve gastrectomy for high-risk patients. Surg Obes Relat Dis 2016; 13:155-160. [PMID: 28029598 DOI: 10.1016/j.soard.2016.08.492] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 08/14/2016] [Accepted: 08/19/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND Morbidly obese patients with excessive concomitant disease carry a significantly increased perioperative risk. Although they may benefit most from a bariatric intervention, they are often denied surgery. Laparoscopic sleeve gastrectomy (LSG), as it is less complication-prone than other bariatric procedures, suits the needs of those patients. OBJECTIVE To review the short-term outcome of LSG for high-risk patients SETTING: University hospital, Switzerland. METHODS A total of 110 patients with high perioperative risk undergoing LSG between January 2008 and December 2014 were prospectively recorded. Patients were defined as "high-risk" if they met 2 of the following criteria: American Society of Anesthesiologists physical status score (ASA)>III, Obesity Surgery Mortality Risk Score (OS-MRS)≥4, Revised Cardiac Risk Index (RCRI) class IV, Obstructive Sleep Apnea-Severity Index (OSA-SI)≥5, renal insufficiency chronic kidney disease ≥3, liver cirrhosis, or history of life-threatening perioperative events. RESULTS Of the patients, 59 (54%) were male. Median age was 49 years (range: 18-69), and median BMI was 51.7 kg/m2 (38.7-89.2). Median operating time was 65 minutes (27-260). Eighty-six patients (78%) were classified as ASA IV, 65 (59%) as RCRI class IV, 51 (46%) as OS-MRS≥4 and 63 (57%) as OSA-SI≥5. Eighty-nine (81%) had type 2 diabetes, 70 (64%) were under antiplatelet and or anticoagulant therapy. Four patients (4%) were converted to open. Length of stay was 5 days (1-70). Major complications occurred in 12 patients (11%), including 1 mortality (1%). CONCLUSION "High-risk"-patients identified using a combination of established obesity- and co-morbidity-related risk scores profit from LSG as part of a uniform treatment pathway. Given the severity of co-morbidities, LSG can be performed safely. (Surg Obes Relat Dis 2016;X:XXX-XXX.) © 2016 American Society for Metabolic and Bariatric Surgery. All rights reserved.
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Affiliation(s)
- Yves Borbély
- Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, and University of Bern, Berne, Switzerland.
| | - Olivier Juilland
- Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, and University of Bern, Berne, Switzerland
| | - Julia Altmeier
- Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, and University of Bern, Berne, Switzerland
| | - Dino Kröll
- Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, and University of Bern, Berne, Switzerland
| | - Philipp C Nett
- Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, and University of Bern, Berne, Switzerland
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14
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Nett PC, Kröll D, Borbély Y. Re-sleeve gastrectomy as revisional bariatric procedure after biliopancreatic diversion with duodenal switch. Surg Endosc 2016; 30:3511-5. [DOI: 10.1007/s00464-015-4640-9] [Citation(s) in RCA: 6] [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] [Received: 06/27/2015] [Accepted: 10/22/2015] [Indexed: 12/25/2022]
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15
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Borbély Y, Plebani A, Kröll D, Ghisla S, Nett PC. Exocrine Pancreatic Insufficiency after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2015; 12:790-794. [PMID: 26965152 DOI: 10.1016/j.soard.2015.10.084] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 10/13/2015] [Accepted: 10/21/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Gastric resection, short bowel syndrome, and diabetes mellitus are risk factors for development of exocrine pancreatic insufficiency (EPI). Reasons are multifactorial and not completely elucidated. OBJECTIVES To determine the prevalence of EPI after distal (dRYGB) and proximal Roux-en-Y gastric bypass (pRYGB) and to assess the influence of respective limb lengths. SETTING University hospital, Switzerland. METHODS The study comprised 188 consecutive patients who underwent primary dRYGB (common channel<120 cm, biliopancreatic limb 80-100 cm) or pRYGB (alimentary limb = 155 cm, biliopancreatic limb 40-75 cm) and who were followed-up for at least 2 years. Patients with a history of gastrointestinal or hepatobiliary resection (except for cholecystectomy), postoperative pregnancy, and any revision of RYGB (gastric pouch, limb lengths) were excluded. EPI was defined by clinical symptoms in combination with fecal pancreatic elastase-1<200 μg/g stool or fecal pancreatic elastase-1>200 and<500 μg/g stool and positive dechallenge-rechallenge test with pancreatic enzyme replacement therapy. RESULTS Mean follow-up was 52.2 months (range 24-120). Seventy-nine patients (42%) underwent dRYGB, and 109 (58%) underwent pRYGB. Of those, 59 (31%) patients were diagnosed with EPI after a mean 12.5±16.3 months. There was a significant difference between dRYGB and pRYGB groups in initial body mass index (dRYGB 47.1±8.1 kg/m(2) versus pRYGB 42.7±6.1 kg/m(2); P<.01), patients in Obesity Surgery Mortality Risk Score group C (13% versus 3%; P = .02), and prevalence of EPI (48% versus 19%; P<.01). Neither overall small bowel length nor absolute or relative limb lengths were influencing factors on EPI after dRYGB. CONCLUSION Prevalence of EPI after dRYGB (48%) and pRYGB (19%) is of clinical importance. There was no significant difference in absolute or relative limb lengths between EPI and non-EPI groups after dRYGB.
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Affiliation(s)
- Yves Borbély
- Department of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland.
| | - Andrin Plebani
- Department of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Dino Kröll
- Department of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Simone Ghisla
- Department of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Philipp C Nett
- Department of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
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16
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Nett PC. [Bariatric and metabolic surgery]. Ther Umsch 2013; 70:119-22. [PMID: 23385191 DOI: 10.1024/0040-5930/a000376] [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: 11/19/2022]
Abstract
The prevalence of obesity and its comorbidities is constantly rising and is one of the most threatening global health and economic problems worldwide. Whereas bariatric surgery is well accepted in the treatment of morbid obesity, surgical treatment for ist comorbidities (metabolic surgery) such as type 2 diabetes mellitus, dyslipidemia and other diseases are still under discussion. A more profound knowledge of its physiologic mechanisms is crucial for the future implementation of the bariatric and metabolic surgery to treat obesity-related comorbidities.
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Affiliation(s)
- Philipp C Nett
- Bariatrische und metabolische Chirurgie, Universitäre Klinik für viszerale Chirurgie und Medizin, Inselspital, Bern, Switzerland.
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17
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Abstract
With the increase of patients after bariatric and metabolic surgery the long-term follow-up of this population will become a challenge. Bariatric patients require regular and life-long follow-up in order to affect the long-term achievements of this therapy in a positive way. For that reason bariatric patients should be followed in the first phase by a multidisciplinary team of the bariatric centre. Taking into account some fundamental considerations general practinioner should be involved in the care of these patients when a stable situation occured.
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Affiliation(s)
- Yves Borbély
- Universitätsklinik für viszerale Chirurgie und Medizin, Bariatrische und Metabolische Chirurgie, Inselspital, Bern, Switzerland
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19
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Kugelmeier P, Nett PC, Züllig R, Lehmann R, Weber M, Moritz W. Expression and hypoxic regulation of the endothelin system in endocrine cells of human and rat pancreatic islets. JOP 2008; 9:133-149. [PMID: 18326921] [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: 05/26/2023]
Abstract
CONTEXT The success of pancreatic islet transplantation depends largely on the capacity of the islet graft to survive the initial phase immediately after transplantation until revascularization is completed. Endothelin-1 (ET-1) is a strong vasoconstrictor which has been involved in solid organ graft failure but is also known to be a potent mitogenic/anti-apoptotic factor which could also potentially enhance the survival of the transplanted islets. OBJECTIVE Characterization of the endothelin system with regard to a potential endothelin agonist/antagonist treatment. DESIGN Regulated expression of the endothelin system in human and rat pancreatic islets and beta-cell lines was assessed by means of immunohistochemistry, competition binding studies, western blot, RT-PCR, real-time PCR and transplant studies. RESULTS ET-1, ETA- and ETB-receptor immunoreactivity was identified in the endocrine cells of human and rat pancreatic islets. The corresponding mRNA was detectable in rat beta-cell lines and isolated rat and human pancreatic islets. Competition binding studies on rat islets revealed binding sites for both receptor types. ET-1 stimulated the phosphorylation of mitogen-activated protein kinase, which was prevented by ETA- and ETB-receptor antagonists. After exposure to hypoxia equal to post-transplant environment oxygen tension, mRNA levels of ET-1 and ETB-receptor of human islets were robustly induced whereas ETA-receptor mRNA did not show significant changes. Immunostaining signals for ET-1 and ETA-receptor of transplanted rat islets were markedly decreased when compared to native pancreatic sections. CONCLUSIONS In pancreatic islets, ET-1 and its receptors are differentially expressed by hypoxia and after transplantation. Our results provide the biological basis for the study of the potential use of endothelin agonists/antagonists to improve islet transplantation outcome.
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Affiliation(s)
- Patrick Kugelmeier
- Clinic for Visceral and Transplant Surgery, Department of Surgery, Zurich University Hospital. Zurich, Switzerland
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20
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Traupe T, Nett PC, Frank B, Tornillo L, Hofmann-Lehmann R, Terracciano LM, Barton M. Impaired vascular function in normoglycemic mice prone to autoimmune diabetes: Role of nitric oxide. Eur J Pharmacol 2007; 557:161-7. [PMID: 17182032 DOI: 10.1016/j.ejphar.2006.11.021] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2006] [Revised: 11/06/2006] [Accepted: 11/08/2006] [Indexed: 12/31/2022]
Abstract
Type 1 diabetes is an immuno-inflammatory condition which increases the risk of cardiovascular disease, particularly in young adults. This study investigated whether vascular function is altered in mice prone to autoimmune diabetes and whether the nitric oxide (NO)-cyclic GMP axis is involved. Aortic rings suspended in organ chambers and precontracted with phenylephrine were exposed to cumulative concentrations of acetylcholine. To investigate the role of NO, some experiments were performed in the presence of either 1400W (N-(3-aminomethyl)benzyl-acetamidine hydrochloride), a selective inhibitor of the iNOS-isoform, L-NAME (N(G)-nitro-L-arginine methyl ester hydrochloride), an inhibitor of all three NOS-isoforms, or ODQ (1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one), a selective inhibitor of guanylate cyclase. Moreover, contractility to phenylephrine, big endothelin-1, and endothelin-1 was assessed and histological analysis and iNOS immunohistochemistry were performed. Endothelium-dependent relaxation was reduced in prediabetic NOD mice (78+/-4 vs. 88+/-2%, respectively, P<0.05 vs. control) despite normal plasma glucose levels (n.s. vs. control). Preincubation with 1400W further attenuated responses in prediabetic (P<0.05 vs. untreated) but not in diabetic or in control mice. In contrast, basal NO bioactivity remained unaffected until the onset of diabetes in NOD mice. Contractile responses to big endothelin-1 and endothelin-1 were reduced in prediabetic animals (P<0.05 vs. control), whereas in diabetic mice only responses to big endothelin-1 were decreased (P<0.05 vs. control). These data demonstrate that endothelium-dependent and -independent vascular function in NOD mice is abnormal already in prediabetes in the absence of structural injury. Early proinflammatory activation due to iNOS in diabetes-prone NOD mice appears to be one of the mechanisms contributing to impaired vasoreactivity.
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Affiliation(s)
- Tobias Traupe
- Department of Medicine, Internal Medicine I, Medical Policlinic, University Hospital Zurich, Switzerland
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21
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Ortmann J, Nett PC, Celeiro J, Hofmann-Lehmann R, Tornillo L, Terracciano LM, Barton M. Downregulation of renal endothelin-converting enzyme 2 expression in early autoimmune diabetes. Exp Biol Med (Maywood) 2006; 231:1030-3. [PMID: 16741043] [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: 05/09/2023] Open
Abstract
To determine whether renal expression of endothelin-converting enzymes (ECEs) and endothelin (ET) is affected in the early stages of autoimmune diabetes mellitus and whether ET(A) receptors are involved, prediabetic nonobese diabetic (NOD) and control mice were treated with the ET(A) receptor antagonist BSF461314 (a follow-up compound of darusentan) or with placebo. Blood samples were analyzed for glucose levels, and renal gene expression of ECE-1, ECE-2, and prepro-ET-1 was determined using real-time polymerase chain reaction. Renal morphology was assessed using standard histologic techniques. ECE-1, ECE-2, and prepro-ET-1 mRNA was detected in the kidneys of NOD and control mice. Despite normal renal histology, expression of ECE-1 and prepro-ET-1 was reduced in NOD mice by approximately 50% compared with controls (P < 0.01); ECE-2 was markedly decreased by almost 90% compared with controls (P < 0.001). Treatment with BSF461314 for 6 weeks delayed the onset of diabetes (P < 0.05) and increased expression of all three genes (P < 0.05) in NOD mice only. Hyperglycemia at an early stage of autoimmune diabetes is associated with transcriptional downregulation of ECE-1, ECE-2, and prepro-ET-1 in the kidney. Blockade of ET(A) receptors inhibits diabetes-associated gene regulation and delays the onset of diabetes, suggesting its therapeutic potential for the treatment of autoimmune forms of diabetes.
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Affiliation(s)
- Jana Ortmann
- Medical Policlinic, Department of Internal Medicine, University Hospital Zürich, Switzerland
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22
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Nett PC, Ortmann J, Celeiro J, Haas E, Hofmann-Lehmann R, Tornillo L, Terraciano LM, Barton M. Transcriptional regulation of vascular bone morphogenetic protein by endothelin receptors in early autoimmune diabetes mellitus. Life Sci 2005; 78:2213-8. [PMID: 16300798 DOI: 10.1016/j.lfs.2005.09.026] [Citation(s) in RCA: 18] [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] [Received: 05/17/2005] [Accepted: 09/08/2005] [Indexed: 10/25/2022]
Abstract
Endothelin (ET) and bone morphogenic proteins (BMP) have been implicated in the development of micro- and macrovascular complications of type 2 diabetes mellitus due to atherosclerosis. This study investigated vascular BMP-expression during early development of experimental autoimmune diabetes mellitus and whether ET(A) receptors are involved in its regulation, using the selective ET(A) receptor antagonist BSF461314. Specificity of BSF461314 was confirmed through ET-mediated p44/42 mitogen-activated protein kinase (ERK1/2) phosphorylation experiments. For animal studies, non-obese diabetic (NOD) and control mice at 16 weeks of age were treated with BSF461314 for 6 weeks. Plasma glucose levels were measured before and after treatment and vascular gene expression of BMP-2, BMP-7, and BMP-type II receptor was determined in the aorta by quantitative real-time polymerase chain reaction analysis. At the beginning of the study in all animals, plasma glucose levels were within the normal range. After 6 weeks gene expression of vascular BMP-2, BMP-7 and BMP-type II receptor was almost doubled in NOD mice compared with non-diabetic controls (p < 0.05). Concomitant treatment with BSF461314 significantly reduced expression of all BMPs and lowered plasma glucose levels in NOD mice close to controls (all p < 0.05 versus untreated). In conclusion, vascular BMP-2, BMP-7, and BMP-type II receptor expression is upregulated in early stages of autoimmune diabetes mellitus. The data further indicate that ET(A) receptors inhibit diabetes-associated activation of vascular BMPs and regulate plasma glucose levels suggesting that ET(A) receptors might provide a new therapeutic target to interfere with the early development of atherosclerosis in patients with type 1 diabetes mellitus.
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MESH Headings
- Animals
- Bone Morphogenetic Proteins/genetics
- Cells, Cultured
- Diabetes Mellitus, Experimental/metabolism
- Diabetes Mellitus, Type 1/metabolism
- Endothelin A Receptor Antagonists
- Female
- Humans
- Mice
- Mice, Inbred Strains
- Mitogen-Activated Protein Kinase 1/metabolism
- Mitogen-Activated Protein Kinase 3/metabolism
- Muscle, Smooth, Vascular/enzymology
- Muscle, Smooth, Vascular/metabolism
- Muscle, Smooth, Vascular/pathology
- Phosphorylation
- Receptor, Endothelin A/metabolism
- Transcription, Genetic
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Affiliation(s)
- Philipp C Nett
- Medical Policlinic, University Hospital of Zürich, Switzerland
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23
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Ortmann J, Nett PC, Celeiro J, Traupe T, Tornillo L, Hofmann-Lehmann R, Haas E, Frank B, Terraciano LM, Barton M. Endothelin inhibition delays onset of hyperglycemia and associated vascular injury in type I diabetes: evidence for endothelin release by pancreatic islet beta-cells. Biochem Biophys Res Commun 2005; 334:689-95. [PMID: 16009335 DOI: 10.1016/j.bbrc.2005.06.140] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [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: 06/13/2005] [Accepted: 06/20/2005] [Indexed: 02/02/2023]
Abstract
This study investigated the role of endothelin-1 for hyperglycemia, vascular, and pancreatic injury in early type I diabetes in non-obese-diabetic (NOD) mice. Endothelium dependent relaxation to acetylcholine and vascular gene expression of endothelin converting enzyme (ECE) isoforms 1 and 2 were studied as indicators of vascular injury. Endothelial NO bioactivity in the aorta was reduced in diabetic NOD mice while vascular expression of ECE-1 and ECE-2 mRNA was increased compared with controls (all p<0.05). Vascular histology was normal in all animals. Unexpectedly, treatment of prediabetic NOD mice for 6 weeks with the orally active ET(A) receptor antagonist BSF461314 prevented onset of diabetes without affecting insulitis severity. ET(A) receptor blockade also restored abnormal endothelial NO bioactivity and reduced ECE-1 and ECE-2 gene expression in NOD mice to levels comparable with healthy controls (p<0.05). Moreover, secretion of endothelin-1 in a time-dependent fashion was observed by pancreatic islet beta-cells cultured in vitro. These data suggest a critical role for ET(A) receptor signaling in the development of autoimmune forms of diabetes and the early vascular injury associated with it.
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Affiliation(s)
- Jana Ortmann
- Medical Policlinic, University Hospital Zürich, Switzerland
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24
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Nett PC, Heisey DM, Shames BD, Fernandez LA, Pirsch JD, Sollinger HW. Influence of kidney function to the impact of acute rejection on long-term kidney transplant survival. Transpl Int 2005; 18:385-9. [PMID: 15773955 DOI: 10.1111/j.1432-2277.2004.00035.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [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: 11/30/2022]
Abstract
In kidney transplantation, timing of an initial acute rejection (AR) is correlated with a variable risk of graft loss. However, it is unknown whether the increased risk for graft loss because of AR is conditioned by impaired graft function. A total of 730 cadaveric kidney transplant recipients were retrospectively evaluated from 1994 to 2001. When AR occurred, the risk ratio (RR) for graft loss was strongly time-dependent and increased, the later the rejection episode occurred. Compared with the reference group (no rejection) having an AR within 0-30, 31-365, or >365 days post-transplant conferred a 3.1-, 9.1- and 49.3-fold risk for subsequent graft loss (P < 0.001). By including serum creatinine as an indicator for graft function at the time of rejection RR decreased to 2.4-, 7.1- and 21.8-fold, but remained still significant (P = 0.023). In conclusion, the higher risk of graft loss after late AR is not fully explained by impaired graft function measured by serum creatinine.
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Affiliation(s)
- Philipp C Nett
- Division of Organ Transplantation, University of Wisconsin Hospital and Clinics, Madison, USA
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25
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Abstract
Different strain combinations of rat are available to study immunological and transplant-related problems in kidney transplant models. Although numerous modifications of surgical techniques for ureteric reconstruction have been evaluated in order to reduce complications and to extend long-term survival, ureteric complications still occur frequently, especially when there is a disproportion in the diameter of donor and host ureters. Instead of using the current nonsplinted ureteroureterostomy, a versatile and rapid technical modification was developed to perform reconstruct the ureters of disproportionate diameter. The overall incidence of ureteric complications was 80% (8/10) using the former method, whereas this rate was significantly reduced to 15% (3/20) using the new method (P < .001). Our modification shows the feasibility of a nonsplinted ureteroureterostomy for the technical, highly demanding rat model of kidney transplantation with an acceptable rate of ureteric complications considering disproportionate differences in diameter between the host and the donor ureter.
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Affiliation(s)
- A P Pietsch
- Division of General Vascular, Thoracic and Transplantation Surgery, Rostock University, Rostock, Germany
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26
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Nett PC, Heisey DM, Fernandez LA, Sollinger HW, Pirsch JD. Association of Cytomegalovirus Disease and Acute Rejection with Graft Loss in Kidney Transplantation. Transplantation 2004; 78:1036-41. [PMID: 15480171 DOI: 10.1097/01.tp.0000137105.92464.f3] [Citation(s) in RCA: 62] [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: 11/25/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) and acute rejection (AR) alone have been associated with an increased risk of graft loss in kidney transplantation. However, little is known about their association with graft loss when both affect the transplant recipient. METHODS By using the dynamic time-varying covariate approach to the Cox-proportional hazards model, we retrospectively analyzed the strength of association of AR and CMV disease on graft loss in a single-center kidney and simultaneous pancreas-kidney transplant population. RESULTS Between January 1990 and December 2000, 2,740 kidney and simultaneous pancreas-kidney transplants were performed at the authors' center. The overall 5-year incidence of biopsy-proven AR and CMV disease was 45.8% (n=1,254) and 15.3% (n=420), respectively. The risk ratio (RR) for graft loss was increased by the presence of AR (RR=3.7; P<0.0001), CMV disease (RR=1.9; P=0.0007), AR following CMV disease (RR=6.6; P<0.0001), and CMV disease following AR (RR=3.3; P<0.0001). In patients with AR and CMV disease the average time until AR occurred was longer (441 days) when AR followed CMV disease in comparison with when AR preceded CMV disease (47 days). After adjusting for time-dependent risk of AR for kidney graft loss, the order of AR and CMV disease had no association with graft loss (RR=1.2; P=0.5055). CONCLUSIONS These results demonstrate the strength of AR and CMV disease as prognosticators of impeding kidney graft loss in transplant recipients. Although AR usually precedes CMV disease, the order of AR and CMV disease has no impact on kidney graft loss in kidney and simultaneous pancreas-kidney transplant recipients.
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Affiliation(s)
- Philipp C Nett
- Division of Organ Transplantation, University of Wisconsin Hospital and Clinics, Madison, WI 53792, USA
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27
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Abstract
Different strain combinations of rats are available to study immunological and transplant-related problems in the models of kidney transplantation. Although numerous modifications of surgical techniques for ureteric reconstruction are evaluated in order to reduce complications and to extend long-term survival, ureteric complications still occur frequently, especially when the difference in diameter of both donor and host ureters is disproportionate. Instead of using the current nonsplinted ureteroureterostomy (method A), a versatile and rapid technical modification (method B) was developed to perform reconstruction of ureters with disproportionate diameters. The overall incidence of ureteric complications was 80% (8/10) using method A, whereas this rate was significantly reduced to 15% (3/20) using method B (P < 0.001). Our modification proves the feasibility of nonsplinted ureteroureterostomy in a technical, highly demanding rat model of kidney transplantation with an acceptable rate of ureteric complication, considering the disproportionate difference in diameter between the host and donor ureters.
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Affiliation(s)
- Alexander Pietsch
- Division of Organ Transplantation, University of Wisconsin Hospital and Clinics, Madison, WI 53792-3236, USA
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28
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Abstract
Insulin-dependent diabetes mellitus (IDDM) is an autoimmune disease resulting in destruction of the pancreatic beta-cells in the islets of Langerhans. Commonly employed treatment of IDDM requires periodic insulin therapy, which is not ideal because of its inability to prevent chronic complications such as nephropathy, neuropathy and retinopathy. Although pancreas or islet transplantation are effective treatments that can reverse metabolic abnormalities and prevent or minimize many of the chronic complications of IDDM, their usefulness is limited as a result of shortage of donor pancreas organs. Gene therapy as a novel field of medicine holds tremendous therapeutic potential for a variety of human diseases including IDDM. This review focuses on the liver-based gene therapy for generation of surrogate pancreatic beta-cells for insulin replacement because of the innate ability of hepatocytes to sense and metabolically respond to changes in glucose levels and their high capacity to synthesize and secrete proteins. Recent advances in the use of gene therapy to prevent or regenerate beta-cells from autoimmune destruction are also discussed.
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Affiliation(s)
- Philipp C Nett
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, WI, USA
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Nett PC, Pfammatter T, Turina M, Lachat ML. Repair of bilateral common iliac artery aneurysm by potentially reversible, unilateral internal iliac artery embolisation followed by endovascular Y-stenting. VASA 2003; 32:103-7. [PMID: 12945105 DOI: 10.1024/0301-1526.32.2.103] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Bilateral common iliac artery (CIA) aneurysms are rare, but more frequently symptomatic than abdominal aortic aneurysms (AAA). In elderly patients with coexisting medical problems, transluminal and/or endovascular procedures are preferred to avoid the risk of morbidity and mortality associated with further general anesthesia and surgery. However, bilateral internal iliac artery (IIA) occlusion during endovascular repair might be associated with significant morbidity, including gluteal claudicatio, and ischemia of the sigmoid colon and perineum. In the presented case report we describe the successful repair of bilateral CIA aneurysms by a total transluminal and endovascular approach. The potentially reversible embolisation of the less diseased IIA with detachable latex balloons preceded the implantation of a bilateral endovascular Y-stent. Both CIA aneurysms were successfully excluded from circulation. No complications were noted and the patient could be discharged four days after surgery. Probationary detachable balloon embolisation of the IIA followed by implantation of an endovascular bifurcated stentgraft is a safe technique. It allows clinical monitoring of acute ischemic complications before bilateral IIA occlusion by the stentgraft. In comparison to coil embolisation these balloons may be easier to remove if for instance, an external-internal iliac artery bypass is needed. Percutaneous balloon puncture might be another option to reverse acute ischemia.
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Affiliation(s)
- P C Nett
- Clinic of Cardiovascular Surgery, University Hospital Zürich, Switzerland
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Moritz W, Meier F, Stroka DM, Giuliani M, Kugelmeier P, Nett PC, Lehmann R, Candinas D, Gassmann M, Weber M. Apoptosis in hypoxic human pancreatic islets correlates with HIF-1alpha expression. FASEB J 2002; 16:745-7. [PMID: 11923216 DOI: 10.1096/fj.01-0403fje] [Citation(s) in RCA: 148] [Impact Index Per Article: 6.7] [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: 12/20/2022]
Abstract
To become insulin independent, patients with type 1 diabetes mellitus require transplantation of at least two donor pancreata because of massive beta-cell loss in the early post-transplantation period. Many studies describing the introduction of new immunosuppressive protocols have shown that this loss is due to not only immunological events but also nonimmunological factors. To test to what extent hypoxia may contribute to early graft loss, we analyzed the occurrence of apoptotic events and the expression of hypoxia-inducible factor 1 (HIF-1), a heterodimeric transcription factor consisting of an oxygen-dependent alpha subunit and a constitutive beta subunit. Histological analysis of human and rat islets revealed nuclear pyknosis as early as 6 h after hypoxic exposure (1% O2). Moreover, immunoreactivity to activated caspase-3 was observed in the core region of isolated human islets. Of note, both of these markers of apoptosis topographically overlap with HIF-1alpha immunoreactivity. HIF-1alpha mRNA was detected in islets from human and rat as well as in several murine beta-cell lines. When exposed to hypoxia, mouse insulinoma cells (MIN6) had an increased HIF-1alpha protein level, whereas its mRNA level did not alter. In conclusion, our data provide convincing evidence that reduced oxygenation is an important cause of beta-cell loss and suggest that HIF-1alpha protein level is an indicator for hypoxic regions undergoing apoptotic cell death. These observations suggest that gene expression under the control of HIF-1 represents a potential therapeutic tool for improving engraftment of transplanted islets.
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Affiliation(s)
- Wolfgang Moritz
- Clinic for Visceral and Transplant Surgery, University Hospital Zürich, CH-8091 Zürich, Switzerland
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Nett PC, Zund G, Prêtre R, Niederhouser U, Vogt PR, Turina M. A 20-year follow-up of internal carotid artery endarterectomy with bifurcation advancement. Thorac Cardiovasc Surg 2000; 48:279-84. [PMID: 11100760 DOI: 10.1055/s-2000-7880] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [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: 10/17/2022]
Abstract
BACKGROUND Carotid artery disease is a frequent cause of transient ischemic attack and of cerebral infarction. For two last decades, we have been performing endarterectomy of the internal carotid artery with bifurcation advancement. METHODS From January 1977 until December 1997, all records of patients who underwent internal carotid artery endarterectomy with bifurcation advancement were reviewed. Data were collected from patients charts and by a questionnaire. 160 patients (80.6% men, 19.4% women, average lifetime 65.1 year) underwent a total of 181 endarterectomies with bifurcation advancement. RESULTS The 30-day mortality was 1.9% and the postoperative stroke plus death rate 3.1%. The incidence of reoperations was 0.6% with an average follow up of 64 months. In one patient (0.6%), a significant restenosis of the repaired carotid artery was observed. The 1, 5 and 10 years neurological death free survival (including early mortality) was 99.3%, 97.2% and 92.5% and the overall survival (including early mortality) was 96.3%, 78.9% and 59.3% (Kaplan-Meier). CONCLUSIONS The technique of the internal carotid artery endarterectomy by bifurcation advancement is a safe and reliable method for improvement of cerebral blood supply. Or foreign material or autologous vein can thus be avoided. This method offers excellent long term patency and has a notable lack of late restenosis.
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Affiliation(s)
- P C Nett
- Clinic of Cardiovascular Surgery, University Hospital, Zurich, Switzerland.
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Abstract
OBJECTIVE Evaluate the accuracy of this bedside method to determine hemoglobin (Hb) concentration in general surgery over a wide range of Hb values and to determine potential sources of error. METHODS Accuracy of Hb measurement using HemoCue (AB Leo Diagnostics, Helsinborg, Sweden) was assessed in 140 surgical blood samples using 7 HemoCue devices in comparison with a CO-Oximeter (IL 482, Instrumentation Laboratory, Lexington, MA). To analyze potential sources of error, packed red cells and fresh frozen plasma were reconstituted to randomized Hb levels of 2-18 g/dL. RESULTS In the surgical blood samples, the Hb concentration determined by the CO-Oximeter (HbCOOX) ranged from 5.1 to 16.7 g/dL and the Hb concentration measured by HemoCue (HbHC) from 4.7 to 16.0 g/dL. Bias (HbCOOX - HbHC) between HbCOOX and HbHC was 0.6+/-0.6 g/dL (mean +/- SD) or 5.4+/-5.0% (p < 0.001). Also in the reconstituted blood, the bias between HbCOOX and HbHC was significant (0.2+/-0.3 g/dL or 2.1+/-3.2%; p < 0.001). The microcuvette explained 68% of the variability between HbCOOX and HbHC. HemoCue thus underestimates the Hb concentration by 2-5% and exhibits a 8-10 times higher variability with only 86.4% of HbHC being within +/- 10% of HbCOOX. CONCLUSION. Although the mean bias between HbCOOX and HbHC was relatively low, Hb measurement by HemoCue exhibited a significant variability. Loading multiple microcuvettes and averaging the results may increase the accuracy of Hb measurement by HemoCue.
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Affiliation(s)
- C E Rippmann
- Institute of Anesthesiology, University Hospital, Zurich, Switzerland
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Alon E, Kocian R, Nett PC, Koechli OR, Baettig U, Grimaudo V. Tropisetron for the prevention of postoperative nausea and vomiting in women undergoing gynecologic surgery. Anesth Analg 1996; 82:338-41. [PMID: 8561338 DOI: 10.1097/00000539-199602000-00022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [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: 01/31/2023]
Abstract
The aim of this study was to evaluate the efficacy of tropisetron, a selective 5-hydroxytryptamine type 3 (5-HT3) receptor antagonist, versus placebo in the prevention of postoperative nausea and vomiting in patients undergoing general anesthesia for gynecologic surgery. Ten minutes before induction of general anesthesia, 80 patients received in a double-blind manner a single intravenous (IV) injection of either 5 mg tropisetron or a matching placebo. Anesthesia was induced with thiopental and maintained with nitrous oxide and enflurane in oxygen. In the first 24 h postoperatively 7 of 40 patients (17.5%) given tropisetron and 16 of 40 patients (40%) receiving placebo vomited (P < 0.05). The incidence of nausea was 30% (12/40) in the tropisetron group and 52% (21/40) in the placebo group (P < 0.05). A total effective antiemetic response showed 26 patients (65%) in the tropisetron group and 16 patients (40%) in the placebo group (P < 0.05). We conclude that tropisetron given IV prior to gynecologic procedures in general anesthesia significantly reduces postoperative nausea and vomiting when compared to placebo without causing any adverse effect.
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Affiliation(s)
- E Alon
- Department of Anesthesiology, Zurich University Hospital, Switzerland
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