American Gastroenterological Association technical review on the management of Barrett's esophagus.

Importance Sleeve gastrectomy is increasingly used in the treatment of morbid obesity, but its long-term outcome vs the standard Roux-en-Y gastric bypass procedure is unknown. Objective To determine whether there are differences between sleeve gastrectomy and Roux-en-Y gastric bypass in terms of weight loss, changes in comorbidities, increase in quality of life, and adverse events. Design, Setting, and Participants The Swiss Multicenter Bypass or Sleeve Study (SM-BOSS), a 2-group randomized trial, was conducted from January 2007 until November 2011 (last follow-up in March 2017). Of 3971 morbidly obese patients evaluated for bariatric surgery at 4 Swiss bariatric centers, 217 patients were enrolled and randomly assigned to sleeve gastrectomy or Roux-en-Y gastric bypass with a 5-year follow-up period. Interventions Patients were randomly assigned to undergo laparoscopic sleeve gastrectomy (n = 107) or laparoscopic Roux-en-Y gastric bypass (n = 110). Main Outcomes and Measures The primary end point was weight loss, expressed as percentage excess body mass index (BMI) loss. Exploratory end points were changes in comorbidities and adverse events. Results Among the 217 patients (mean age, 45.5 years; 72% women; mean BMI, 43.9) 205 (94.5%) completed the trial. Excess BMI loss was not significantly different at 5 years: for sleeve gastrectomy, 61.1%, vs Roux-en-Y gastric bypass, 68.3% (absolute difference, −7.18%; 95% CI, −14.30% to −0.06%;P = .22 after adjustment for multiple comparisons). Gastric reflux remission was observed more frequently after Roux-en-Y gastric bypass (60.4%) than after sleeve gastrectomy (25.0%). Gastric reflux worsened (more symptoms or increase in therapy) more often after sleeve gastrectomy (31.8%) than after Roux-en-Y gastric bypass (6.3%). The number of patients with reoperations or interventions was 16/101 (15.8%) after sleeve gastrectomy and 23/104 (22.1%) after Roux-en-Y gastric bypass. Conclusions and Relevance Among patients with morbid obesity, there was no significant difference in excess BMI loss between laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass at 5 years of follow-up after surgery. Trial Registration clinicaltrials.gov Identifier:NCT00356213

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Effect of Laparoscopic Sleeve Gastrectomy vs Laparoscopic Roux-en-Y Gastric Bypass on Weight Loss in Patients With Morbid Obesity: The SM-BOSS Randomized Clinical Trial

Objective:To investigate which perioperative treatment, ie, laparoscopic or open surgery combined with fast track (FT) or standard care, is the optimal approach for patients undergoing segmental resection for colon cancer.Summary Background Data:Important developments in elective colorectal surgery

Laparoscopy in Combination with Fast Track Multimodal Management is the Best Perioperative Strategy in Patients Undergoing Colonic Surgery A Randomized Clinical Trial (LAFA-study)

Background The preoperative period (prehabilitation) may represent a more appropriate time than the postoperative period to implement an intervention. The impact of prehabilitation on recovery of function al exercise capacity was thus studied in patients undergoing colorectal resection for cancer. Methods A parallel-arm single-blind superiority randomized controlled trial was conducted. Seventy-seven patients were randomized to receive either prehabilitation (n = 38) or rehabilitation (n = 39). Both groups received a home-based intervention of moderate aerobic and resistance exercises, nutritional counseling with protein supplementation, and relaxation exercises initiated either 4 weeks before surgery (prehabilitation) or immediately after surgery (rehabilitation), and continued for 8 weeks after surgery. Patients were managed with an enhanced recovery pathway. Primary outcome was functional exercise capacity measured using the validated 6-min walk test. Results Median duration of prehabilitation was 24.5 days. While awaiting surgery, functional walking capacity increased (≥ 20 m) in a higher proportion of the prehabilitation group compared with the rehabilitation group (53 vs. 15%, adjusted P = 0.006). Complication rates and duration of hospital stay were similar. The difference between baseline and 8-week 6-min walking test was significantly higher in the prehabilitation compared with the rehabilitation group (+23.7 m [SD, 54.8] vs. -21.8 m [SD, 80.7]; mean difference 45.4 m [95% CI, 13.9 to 77.0]). A higher proportion of the prehabilitation group were also recovered to or above baseline exercise capacity at 8 weeks compared with the rehabilitation group (84 vs. 62%, adjusted P = 0.049). Conclusion Meaningful changes in postoperative functional exercise capacity can be achieved with a prehabilitation program.

Prehabilitation versus rehabilitation: a randomized control trial in patients undergoing colorectal resection for cancer.

How irritable bowel syndrome (IBS) and itstreatment affect quality of life (QOL) is important. Todevelop a quality-of-life measure specific to irritablebowel syndrome, items were generated using a conceptual model and qualitative interviews with personsdiagnosed using the Rome criteria. Symptom frequency andbothersomeness indices were created. Psychometricevaluation methods involved an initial cross-sectional survey followed by a repeat survey. Theresulting 34-item measure demonstrated high internalconsistency (Cronbach's alpha = 0.95) and highreproducibility (ICC = 0.86) with average time of sevendays (SD = 1). For discriminant validity: number of symptoms(P < 0.05), self-reported severity of symptoms (P< 0.001), and the functional bowel disorder severityindex (P < 0.001) significantly predicted IBS-QOLscores. Convergent validity and analyses confirmedpredictions that scores are more closely related topsychological well-being (0.45) than to function (0.36).We conclude this measure meets established psychometric criteria for reliability and validity; testingof its responsiveness is warranted.

Quality of Life in Persons with Irritable Bowel Syndrome (Development and Validation of a New Measure)

At present, an instrument for measuring the quality of life, specifically for patients with gastrointestinal disease, is not available. A new instrument for gastrointestinal disorders that is system-specific has been developed in three phases. In the first phase, questions were collated and then tested on 70 patients with gastrointestinal diseases and those that worked well were retained. In the second phase, the questions were modified and tested on 204 patients and the results verified by international experts. The instrument was also validated against other generic measures of quality of life. During the third phase, the instrument was validated with 168 normal individuals. Reproducibility was tested on 25 patients with stable gastrointestinal disease and responsiveness was tested on 194 patients undergoing laparoscopic cholecystectomy. The result is a bilingual (German and English) questionnaire containing 36 questions each with five response categories. The responses to questions are summed to give a numerical score. It is concluded that the Gastrointestinal Quality of Life Index (GIQLI) is ready to be used in clinical practice and research.

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Gastrointestinal Quality of Life Index: Development, validation and application of a new instrument

Measuring health-related quality of life (QoL) after surgery is essential for decision making by patients, surgeons, and payers. The aim of this consensus conference was twofold. First, it was to determine for which diseases endoscopic surgery results in better postoperative QoL than open surgery. Second, it was to recommend QoL instruments for clinical research. An expert panel selected 12 conditions in which QoL and endoscopic surgery are important. For each condition, studies comparing endoscopic and open surgery in terms of QoL were identified. The expert panel reached consensus on the relative benefits of endoscopic surgery and recommended generic and disease-specific QoL instruments for use in clinical research. Randomized trials indicate that QoL improves earlier after endoscopic than open surgery for gastroesophageal reflux disease (GERD), cholecystolithiasis, colorectal cancer, inguinal hernia, obesity (gastric bypass), and uterine disorders that require hysterectomy. For spleen, prostate, malignant kidney, benign colorectal, and benign non-GERD esophageal diseases, evidence from nonrandomized trials supports the use of laparoscopic surgery. However, many studies failed to collect long-term results, used nonvalidated questionnaires, or measured QoL components only incompletely. The following QoL instruments can be recommended: for benign esophageal and gallbladder disease, the GIQLI or the QOLRAD together with SF-36 or the PGWB; for obesity surgery, the IWQOL-Lite with the SF-36; for colorectal cancer, the FACT-C or the EORTC QLQ-C30/CR38; for inguinal and renal surgery, the VAS for pain with the SF-36 (or the EORTC QLQ-C30 in case of malignancy); and after hysterectomy, the SF-36 together with an evaluation of urinary and sexual function. Laparoscopic surgery provides better postoperative QoL in many clinical situations. Researchers would improve the quality of future studies by using validated QoL instruments such as those recommended here.

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Evaluation of quality of life after laparoscopic surgery: evidence-based guidelines of the European Association for Endoscopic Surgery.

Since the measurement of quality of life is a relevant endpoint of patient assessment, an international team of methodologists and surgeons have developed a new system-specific index In different phases, items were collected, tested, rejected or retained and finally verified by international experts The instrument was also validated against other generic measures, it was compared to 150 normals, tested for reproducibility with 50 stable patients and for responsiveness with 159 patients undergoing laparoscopic cholecystectomy The product is a bilingual (German and English) questionnaire containing 36 items Although further testing is in order, we conclude that the Gastrointestinal Quality-of-Life Index is ready to be used in clinical practice and research

The Gastrointestinal Quality of Life Index. A clinical index for measuring patient status in gastroenterologic surgery

In October 1999, an international and interdisciplinary consensus conference was held about the assessment and application of quality of life (QoL) measures after multiple trauma. Four working groups represented the following patients: children with traumatic brain injury (TBI); adults with TBI, adults with multiple injuries (but without TBI), and adults with spinal cord injury. According to predefined questions, the groups tried to identify the relevant problems of the patients, at different time points after the traumatic event. A review of the existing instruments for quality of life assessment and the evidence of their application in trauma patients in the scientific literature was performed by each group. Based on the results of these literature reviews it was concluded that there are not enough data to establish "evidence-based" guidelines for QoL assessments in these patients. Nevertheless, the groups comprised of experts clinicians and methodologists, agreed on the Glasgow Outcome Scale and the SF-36 as generic tools for QoL assessment across all trauma patients. It was further recommended to use these generic tools in combination with condition-specific instruments to better reflect the specific problems of the patients. Finally, the whole group suggested that it was not appropriate to view this conference as a "final report" about QoL assessment in trauma patients, but rather it should be seen as a starting point for increased efforts to initiate clinical research projects using QoL as an outcome, to develop better instruments, and to include QoL assessments into daily routines.

Quality of life after multiple trauma--summary and recommendations of the consensus conference.

Outcome after surgical treatment has been based predominantly on objective criteria (biomedical model) and has largely ignored, until recently, the expectations, personal feelings, satisfaction, and quality of life of patients (outcomes model). The importance of this derives from considerations that the viewpoints and priorities of patients may not be the same as those of their surgeons. Furthermore, there is often little correlation between symptom severity and disease severity. Measures of quality of life and patient satisfaction are, thus, important in valid assessment of the results of surgical treatment. Global assessment based on both the biomedical and outcomes models constitutes the ideal. Questionnaires designed to measure both quality life (generic and specific) and patient satisfaction with treatment require careful development and validation by appropriate studies.

S. Wood-Dauphinee

Papers

Gastrointestinal Quality of Life Index: Development, validation and application of a new instrument

Evaluation of quality of life after laparoscopic surgery: evidence-based guidelines of the European Association for Endoscopic Surgery.

The Gastrointestinal Quality of Life Index. A clinical index for measuring patient status in gastroenterologic surgery

Quality of life after multiple trauma--summary and recommendations of the consensus conference.

Patient-reported outcomes. How important are they?