Purpose Gastric staple line leakage (GL) is a serious complication of laparoscopic sleeve gastrectomy (LSG), with a specific mortality ranging from 0.2 to 3.7%. The current treatment of choice is stent insertion. However, it is unclear whether the type of stent which is inserted affects treatment outcome. Therefore, we aimed not only to determine the effectiveness of stent treatment for GL but also to specifically clarify whether treatment outcome was dependent on the type of stent (small- (SS) or megastent (MS)) which was used. Patients and Methods A single-centre retrospective study of 23 consecutive patients was conducted to compare the outcomes of SS (n = 12) and MS (n = 11) for the treatment of GL following LSG. The primary outcome measure was the success rate of stenting, defined as complete healing of the GL without changing the treatment strategy. Treatment change or death were both coded as failure. Results The success rate of MS was 91% (10/11) compared to only 50% (6/12) for SS (p = 0.006). An average of 2.3 ± 0.5 and 6.8 ± 3.7 endoscopies were required to achieve healing in the MS and SS groups respectively (p < 0.001). The average time to resumption of oral nutrition was shorter in the MS group (1.4 ± 1.1 days vs. 23.1 ± 33.1 days, p = 0.003). Conclusions Stent therapy is only effective and safe for the treatment of GL after LSG if a MS is used. Treatment with a MS may not only increase treatment success rates but may also facilitate earlier resumption of oral nutrition and shorten the duration of hospitalization. Graphical Abstract

Zusammenfassung An 55 Schweinen wurde der Bromsulphaleintest nach der klassischen Methode ausgeführt. Nach Verabreichung von 5 mg Bromsulphalein/kg KGW wurde nach einer Testdauer von 15 Minuten die Retention in % errechnet. Unterschiede zwischen den Testergebnissen bei der Verwendung von Plasma oder Serum bzw. bei direkter oder indirekter Messung der Proben konnten nicht festgestellt werden. Aus Gründen der Einfachheit der Laboratoriumsarbeit ist deshalb die direkte Messung von Plasmaproben vorzuziehen. Durch die statistische Betrachtung der Normalwerte lassen sich die Einflüsse des Plasmavolumens, Herzminutenvolumens und Lebergewichts auf das Testergebnis bei den einzelnen Altersgruppen weitgehend ausschalten. Für Schweine bis 100 kg KGW sind Bromsulphaleinretentionen von ˜3–4% noch normal, während für Schweine von 100 bis 200 kg Retentionswerte von ˜ 4–5% noch als normal angesehen werden können. Mit Hilfe des Bromsulphaleintestes lassen sich ebenso wie beim Menschen auch beim Schwein Störungen der Exkretionsfunktion der Leber sicher diagnostizieren. Summary Bromsulphthalein as a clinical liver function test in the pig This test was carried out in the classical way on 55 pigs. After giving 5 mg. of bromsulphthalein per kg. bodyweight, its retention was determined as a percentage 15 minutes later. No differences were found between using plasma or serum or between direct and indirect measurement. On grounds of simplicity in the laboratory a direct test measurement on plasma samples is therefore preferable. Statistical consideration of normal values enables the influence of plasma volume, heart minute volume and liver‐weight to be taken into proper account in different age groups. For pigs of 100 kg. bodyweight, bromsulphthalein retention values of ˜ 3–4% are within the normal range and for pigs weighing 100–200 kg., values of ˜ 4–5% can also be regarded as normal. This test can be used as a reliable method of determining the excretory function of the liver in the pig, as in man. Résumé Le test de la bromosulfophtaléine pour une détermination de la fonction hépatique chez le porc On pratique le test de la bromosulfophtaléine selon la méthode classique sur 55 porcs. On administre 5 mg de bromosulfophtaléine/kg de poids du corps, puis on calcule la rétention en pourcents, après avoir laissé agir le test pendant 15 minutes. On n'a pas observé de différences dans les résultats du test en employant le plasma ou le sérum, ni en procédant à des mesures directes ou indirectes des échantillons. Pour des raisons de simplification du travail de laboratoire, il est donc préférable d'employer la mesure directe sur échantillons de plasma. Par une appréciation statistique des valeurs normales, on peut éliminer pour une grande part les influences du volume plasmatique, du volume‐minute cardiaque et du poids du foie sur le résultat du test dans les différentes catégories d'âge. Chez les porcs pesant jusqu'à 100 kg, des valeurs de rétention de bromosulfophtaléine d'env. 3–4% sont encore normales, alors que chez les porcs de 100 à 20...

Background Insufflation pressures of or in excess of 25 mm Hg CO 2 are routinely used during posterior retroperitoneoscopic adrenalectomy (PRA) in most centres. A critical analysis of the surgical literature provides limited evidence to support this strategy. Objective To determine whether high pressure (≥ 25 mm Hg) compared with lower pressure (< 25 mm Hg) retroperitoneoscopy reduces operating time and complications. Methods A multi-centre retrospective cohort study was performed using data collected over a period of almost one decade (1st November 2008 until 1st February 2018) from surgical centres in Germany. A total of 1032 patients with benign adrenal tumours were identified. We compared patients undergoing PRA with insufflation pressures of < 25 mm Hg (G20 group) versus ≥ 25 mm Hg (G25 group). A propensity score matching analysis was performed using BMI, tumour size and surgeon's experience as independent variables. The main outcomes were (1) the incidence of perioperative complications and (2) the length of operating time. Results The baseline patient characteristics were similar in both groups, with the exception of tumour size, BMI and surgeon's experience in PRA. After propensity score matching, perioperative outcomes, especially perioperative complications (3.7% vs. 5.5% in G20 and G25, respectively; p = 0.335) and operation duration (47 min vs. 45 min in G20 and G25, respectively; p = 0.673), did not significantly differ between the groups. Conclusion Neither patient safety nor operative success was compromised when PRA was performed with insufflation pressures below 25 mm Hg. Prospective studies are required to determine whether an optimal insufflation pressure exists that maximizes patient safety and minimizes the risks of post-surgical complications. Nevertheless, our results call for a careful re-evaluation of the routine use of high insufflation pressures during PRA. In the absence of prospective data, commencing PRA with lower insufflation pressures, with the option of increasing insufflation pressures to counter intraoperative bleeding or exposition difficulties, may represent a reasonable strategy. Keywords Adrenalectomy • Retroperitoneal space • Minimally invasive surgical procedures • Surgery Abbreviations PRA Posterior retroperitoneoscopic adrenalectomy mm Hg Used for mm Hg CO 2 IQR InterQuartile range SD Standard deviation ASA American Society of Anaesthesiologists PaCO2 Partial pressure of carbon dioxide in the arterial blood Minimally invasive surgery is considered to be the gold standard for the surgical removal of benign functioning and non-functioning adrenal tumours [1-3]. Since its first description [4], minimally invasive adrenal surgery has