Medical and surgical management of obesity and diabetes: what's new?

We conducted a narrative review of the medical and surgical management of people with obesity and diabetes. Results of this review showed that a 5-10% loss in body weight can be achieved with a change in lifestyle, diet and behaviour and with approved pharmacological therapies in people with obesity and diabetes. New targeted therapies are now available for patients with previously untreatable genetic causes of obesity. Compared to medical treatment, metabolic and bariatric surgery is associated with significantly higher rates of remission from type 2 diabetes and lower rates of incident macrovascular and microvascular complications and mortality. The National Institute for Health and Care Excellence and the American Diabetes Association endorse metabolic and bariatric surgery in obese adults with type 2 diabetes and there may also be a role for this in obese individuals with type 1 diabetes. The paediatric committee of the American Society for Metabolic and Bariatric Surgery have recommended metabolic and bariatric surgery in obese adolescents with type 2 diabetes. Earlier and more aggressive treatment with metabolic and bariatric surgery in obese or overweight people with diabetes can improve morbidity and mortality.

Multicentre observational cohort study of implementation and outcomes of laparoscopic distal pancreatectomy.

BACKGROUND: Laparoscopic distal pancreatectomy (LDP) is increasingly being performed as an alternative to open surgery. Whether the implementation and corresponding learning curve of LDP have an impact on patient outcome is unknown. The aim was to investigate the temporal trends in practice across UK centres. METHODS: This was a retrospective multicentre observational cohort study of LDP in 11 tertiary referral centres in the UK between 2006 and 2016. The learning curve was analysed by pooling data for the first 15 consecutive patients who had LDP and examining trends in surgical outcomes in subsequent patients. RESULTS: In total, 570 patients underwent LDP, whereas 888 underwent open resection. For LDP the median duration of operation was 240 min, with 200 ml blood loss. The conversion rate was 12·1 per cent. Neuroendocrine tumours (26·7 per cent) and mucinous cystic neoplasms (19·7 per cent) were commonest indications. The proportion of LDPs increased from 24·4 per cent in 2006-2009 (P1) to 46·0 per cent in 2014-2016 (P3) (P < 0·001). LDP was increasingly performed for patients aged 70 years or more (16 per cent in P1 versus 34·4 per cent in P3; P = 0·002), pancreatic ductal adenocarcinoma (6 versus 19·1 per cent; P = 0·005) and advanced malignant tumours (27 versus 52 per cent; P = 0·016). With increasing experience, there was a trend for a decrease in blood transfusion rate (14·1 per cent for procedures 1-15 to 3·5 per cent for procedures 46-75; P = 0·008), ICU admissions (32·7 to 19·2 per cent; P = 0·021) and median duration of hospital stay (7 (i.q.r. 5-9) to 6 (4-7) days; P = 0·002). After 30 procedures, a decrease was noted in rates of both overall morbidity (57·7 versus 42·2 per cent for procedures 16-30 versus 46-75 respectively; P = 0·009) and severe morbidity (18·8 versus 9·7 per cent; P = 0·031). CONCLUSION: LDP has increased as a treatment option for lesions of the distal pancreas as indications for the procedure have expanded. Perioperative outcomes improved with the number of procedures performed.

ANTECEDENTES: Cada día se utiliza más la pancreatectomía distal laparoscópica (laparoscopic distal pancreatectomy, LDP) como una alternativa a la cirugía abierta. Se desconoce si la implementación y la correspondiente curva de aprendizaje de la LDP tienen impacto en los resultados. El objetivo fue investigar las tendencias relacionadas con su implementación en los centros del Reino Unido a los largo del tiempo. MÉTODOS: Se realizó el estudio observacional retrospectivo y multicéntrico de una cohorte de LDP en once centros de referencia terciarios del Reino Unido entre 2006-2016. Se analizó la curva de aprendizaje agrupando los 15 primeros pacientes consecutivos de LDP y se compararon los resultados quirúrgicos con los obtenidos en los pacientes subsiguientes. RESULTADOS: En total, se incluyeron 570 pacientes con LDP y 888 con resección abierta. Para el LDP, la mediana de tiempo operatorio fue de 240 minutos con 200 ml de pérdida de sangre. La tasa de conversión fue del 12,2%. Las indicaciones más frecuentes fueron los tumores neuroendocrinos (26,7%) y las neoplasias quísticas mucinosas (19,7%). La proporción de LDP aumentó del 24% al 46% (de 2006-2009 a 2014-2016; P < 0,001). La LDP se realizó cada vez con mayor frecuencia en pacientes de ≥ 70 años (15,8% versus 34,4%, P = 0,002), en pacientes con adenocarcinoma ductal pancreático (6,5% versus 19,1%, P = 0,005) y en pacientes con tumores malignos avanzados (27,3% versus 51,85%, P = 0,016). Con el aumento de la experiencia, disminuyeron las tendencias de la tasa de transfusión sanguínea (14,1% al 3,5%, P = 0,008), los ingresos en la UCI (32,7% a 19,2%, P = 0.021) y la mediana de la duración de la estancia hospitalaria (7 (rango intercuartílico 5-9) a 6 (rango intercuartilico 4-7) días, P = 0,002). Tras 30 procedimientos, disminuyeron tanto la morbilidad global (57,7% versus 42,2%, P = 0,009) como las tasas de morbilidad grave (21,5% versus 14,6%, P = 0,022). CONCLUSIÓN: La pancreatectomía distal laparoscópica se ha incrementado como una opción de tratamiento para las lesiones del páncreas distal a medida que se han ido ampliando las indicaciones del procedimiento. Los resultados perioperatorios mejoran con el número de procedimientos realizados.

Digital histology quantification of intra-hepatic fat in patients undergoing liver resection.

BACKGROUND: High intra-hepatic fat (IHF) content is associated with insulin resistance, visceral adiposity, and increased morbidity and mortality following liver resection. However, in clinical practice, IHF is assessed indirectly by pre-operative imaging [for example, chemical-shift magnetic resonance (CS-MR)]. We used the opportunity in patients undergoing liver resection to quantify IHF by digital histology (D-IHF) and relate this to CT-derived anthropometrics, insulin-related serum biomarkers, and IHF estimated by CS-MR. METHODS: A reproducible method for quantification of D-IHF using 7 histology slides (inter- and intra-rater concordance: 0.97 and 0.98) was developed. In 35 patients undergoing resection for colorectal cancer metastases, we measured: CT-derived subcutaneous and visceral adipose tissue volumes, Homeostasis Model Assessment of Insulin Resistance (HOMA-IR), fasting serum adiponectin, leptin and fetuin-A. We estimated relative IHF using CS-MR and developed prediction models for IHF using a factor-clustered approach. RESULTS: The multivariate linear regression models showed that D-IHF was best predicted by HOMA-IR (Beta coefficient(per doubling): 2.410, 95% CI: 1.093, 5.313) and adiponectin (ß(per doubling): 0.197, 95% CI: 0.058, 0.667), but not by anthropometrics. MR-derived IHF correlated with D-IHF (rho: 0.626; p = 0.0001), but levels of agreement deviated in upper range values (CS-MR over-estimated IHF: regression versus zero, p = 0.009); this could be adjusted for by a correction factor (CF: 0.7816). CONCLUSIONS: Our findings show IHF is associated with measures of insulin resistance, but not measures of visceral adiposity. CS-MR over-estimated IHF in the upper range. Larger studies are indicated to test whether a correction of imaging-derived IHF estimates is valid.

Metabolic outcomes 2 years following gastric bypass surgery in people with type 2 diabetes: an observational cohort study.

BACKGROUND: Gastric bypass surgery induces early remission or significant improvement in type 2 diabetes (T2D). AIM: To assess effectiveness of stopping glucose-lowering treatment at the time of surgery. DESIGN: Observational cohort analysis. METHODS: We identified 101 patients (62 women) with T2D who had undergone gastric bypass surgery at a mean (SD, standard deviation) age of 51.4 (9.0) years. We recorded weight, body mass index (BMI), glycosylated haemoglobin (HbA1c), blood pressure (BP), total and high-density lipoprotein (HDL) cholesterol preoperatively and at a median 4, 12 and 24 months postoperatively, and changes to glucose-lowering therapy. RESULTS: Mean (SD) baseline BMI was 50.3 (6.3) kg/m(2), HbA1c 65.3 (18.5) mmol/mol, systolic BP 146.0 (18.0) mmHg, diastolic BP 87.0 (10.8) mmHg and total cholesterol-to-HDL cholesterol ratio 4.0 (1.2). Mean (95% confidence interval) reduction in BMI was 16.4 (14.1-18.7) kg/m(2), HbA1c 23.6 (17.6-29.6) mmol/mol, systolic BP 12.9 (5.9-19.8) mmHg, diastolic BP 6.1 (1.8-10.5) mmHg and total cholesterol-to-HDL cholesterol ratio 1.1 (0.6-1.5) at 24 months (P < 0.001 for all measures). Although 91% of patients were receiving glucose-lowering therapies preoperatively, complete (HbA1c < 42 mmol/mol) and partial (HbA1c 42-48 mmol/mol) remissions of T2D were seen in 62.1% and 5.2% at 2 years postoperatively. CONCLUSIONS: Cessation of glucose-lowering therapies in people with T2D at the time of gastric bypass surgery was clinically effective. The majority of patients remained in complete or partial remission of diabetes up to 2 years postoperatively.

A comparison of diagnostic imaging modalities for colorectal liver metastases.

AIMS: The aims of this study were to compare the diagnostic performance of CT scan, MR liver, PET-CT and intra-operative ultrasound (IOUS) for the detection of liver metastases against the histopathological findings, and to compare PET-CT with CT for the detection of distant disease in metastatic colorectal cancer patients eligible for surgical treatment. METHODS: A prospective study was performed that measured concordance between the number and stage of metastatic lesions identified with various preoperative imaging modalities and histology of patients undergoing surgical treatment for CRLM. RESULTS: Compared with histopathology, concordance for the number of metastatic liver lesions was moderate for CT scan (K = 0.477, 95% CI: 0.28-0.66), moderate for MR scan (K = 0.574, 95% CI: 0.39-0.75), good for FDG PET-CT (K = 0.703, 95% CI: 0.52-0.87) and very good for IOUS (K = 0.904, 95% CI: 0.81-0.99). Additional CRLM were identified intraoperatively in six patients (9.1%) with IOUS and in 7.5% of the cases surgical strategy was changed according to the new intraoperative findings. The diagnosis of intra abdominal lymph node metastatic disease was made with PET-CT only in nine patients (13.6%) DISCUSSION: Our study supports the recent recommendations of the Oncosurg Multidisciplinary International Consensus regarding the importance of high quality CT and MR in the staging of CRLM but provides further evidence for the added value of PET-CT, especially in detecting extrahepatic intra-abdominal metastatic disease that may be amenable to potentially curative resection. Despite these advances in preoperative staging, there still remains a role for IOUS in detecting additional metastases at the time of surgery.

Bariatric surgery in women of childbearing age.

BACKGROUND: Although bariatric surgery in women of childbearing age reduces the risks of pregnancy complications associated with maternal obesity, little is known of the effect of gestation on weight loss outcomes. AIM: To study weight loss and pregnancy outcomes after bariatric surgery in women of childbearing age. DESIGN AND METHODS: We performed a retrospective, observational cohort analysis of women aged 18-45 years in a university teaching hospital. The results shown represent mean ± standard deviation where appropriate. RESULTS: A total of 232 women aged 34.0 ± 5.9 years with pre-operative weight 137.7 ± 21.3 kg and body mass index (BMI) 50.6 ± 7.2 kg/m(2) underwent bariatric surgery that included 197 (84.9%) gastric bypass, 19 (8.2%) gastric banding, 8 (3.4%) sleeve gastrectomy and 8 other procedures. Twenty-one women had 28 pregnancies following bariatric surgery, of which 24 (85.7%) resulted in live births, 3 (10.7%) terminations of pregnancy and 1 (3.6%) spontaneous miscarriage. The pregnancy group was younger compared with the non-pregnancy group (28.0 ± 5.4 vs. 34.6 ± 5.6 years; P < 0.001) but well matched for pre-operative weight (136.5 ± 18.5 vs. 137.8 ± 21.6 kg), BMI (49.2 ± 7.4 vs. 50.7 ± 7.2 kg/m(2)) and bariatric procedure. The interval between bariatric surgery and first pregnancy was a median 11 months. The pregnancy group lost 70.4% of excess weight compared with 70.0% in the non-pregnancy group at median 30 months of follow-up. CONCLUSION: Pregnancy after bariatric surgery is safe and does not adversely affect weight loss outcomes.

Laparoscopic partial splenectomy for littoral cell angioma.

Littoral cell angioma (LCA) is a rare benign splenic vascular neoplasm. We report a case of a 58-year-old man with a 5.5-cm lesion in the upper pole of the spleen. A laparoscopic partial splenectomy was performed. He was discharged on the second postoperative day. Pathology revealed LCA. Laparoscopic partial splenectomy can be performed safely in selected cases and is an appropriate option in patients with benign conditions as it enables preservation of the immunologic function of the spleen. Long-term follow up in patients with LCA is important given its high association with other malignancies.

Evaluation of surgical outcome scores according to ISGPS definitions in patients undergoing pancreatic resection.

AIMS: To evaluate the role of the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM), the Portsmouth variant (p-POSSUM) and the Glasgow Prognostic Score (GPS) in predicting outcome after pancreatic surgery with reference to the International Study Group of Pancreatic Surgery (ISGPS) definitions of post-pancreatectomy complications. METHODS: All consecutive patients undergoing major pancreatic resection over a 32- month period were included. POSSUM, p-POSSUM and GPS score were calculated for each patient and correlated against the observed mortality and morbidity using the ISGPS definitions. RESULTS: The observed:expected ratios for POSSUM mortality, POSSUM morbidity and p-POSSUM mortality were 0.24 (p < 0.0001), 0.86 (p < 0.0001) and 0.79 (p = 0.09), respectively. POSSUM had a 'poor fit' with respect to predicting morbidity (χ(2) = 16.4, 8 d.f., p = 0.04). Multifactorial regression analysis revealed the GPS as an independent predictor of post-operative outcome (GPS 1, p = 0.03, OR 2.99, 95% CI 1.4-7.9, and GPS 2, p = 0.02, OR 4.3, 95% CI 1.8-15.5). CONCLUSION: POSSUM has a limited role as an outcome score in pancreatic resection. The GPS may be a novel alternative to POSSUM as a pre-operative predictor of outcome.

Infiltration of wounds and extraperitoneal space with local anesthetic in patients undergoing laparoscopic totally extraperitoneal repair of unilateral inguinal hernias: a randomized double-blind placebo-controlled trial.

BACKGROUND: The potential analgesic benefit of infiltration of the wounds and extraperitoneal space with local anesthetic in patients undergoing laparoscopic totally extraperitoneal (TEP) repair of inguinal hernias remains unclear. METHODS: Consenting adults scheduled to undergo laparoscopic TEP repair of unilateral inguinal hernias were recruited to this randomized double-blind placebo-controlled clinical trial of 0.25% bupivacaine (Group I) versus saline (Group II) infiltration of abdominal wounds and the extraperitoneal space. Pain scores were assessed at 4 and 24 hours postoperatively using the short-form McGill pain questionnaire (SF-MPQ), the Present Pain Index (PPI) score and the visual analogue scale (VAS). The intravenous and oral analgesic requirements were recorded. Each patient completed questionnaire to assess their satisfaction with the postoperative analgesia. RESULTS: 40 patients were randomized (Group I, n = 20; Group II, n = 20). The two groups were comparable for age, gender, body mass index, and operating time. Minor complications occurred in one patient in each group. There were no significant differences in the postoperative SF-MPQ scores, PPI and VAS at 4 hours (p = 0.413, p = 0.631, p = 0.615 respectively) and 24 hours (p = 0.116, p = 0.310, p = 0.100 respectively) post-operatively. The parenteral and oral analgesics consumed post-surgery were comparable (p = 0.605, p = 0.235). No difference was ob-served in the patient satisfaction scores. CONCLUSIONS: Infiltration of abdominal wounds and extraperitoneal space with bupivacaine in patients undergoing laparoscopic TEP repair of unilateral inguinal hernias does not appear to offer analgesic benefits.Key words: Laparoscopic; extraperitoneal; inguinal hernia; repair; pain; bupivacaine; analgesia; satisfaction; day case; randomized.

Laparoscopic liver resection: preliminary results from a UK centre.

BACKGROUND AND AIMS: Advancements in surgical technique and technology have facilitated safe laparoscopic liver resection in selected patients. The aim of this study is to evaluate the feasibility and outcome of laparoscopic liver resection. METHODS: Patients with lesions situated in the anterior and left lateral segments were selected for laparoscopic resection. Data were collected prospectively. RESULTS: Between 2003 and 2007, 24 patients (12 males) with a median (range) age of 65 (30-83) years underwent 24 laparoscopic hepatic resections for presumed colorectal metastases (n=20) and other indications (n=4). The resections included left hepatic lobectomy (n=14), other resections of two or three segments with or without metastasectomy (n=5), left hemihepatectomy (n=2) and unisegmentectomy (n=3). All procedures were completed laparoscopically. Median operating time was 155 min. Estimated median (range) blood loss was 100 (25-1100) ml and one patient received two units blood transfusion. The operative morbidity rate was 4%, and there were no operative deaths. The median (range) postoperative hospital stay was 3 (1-14) days. At median (range) follow-up of 13.5 (5-36) months, 4 patients (21%) had disease recurrence and 17 patients (89%) remained alive. CONCLUSIONS: In selected patients with lesions in the anterior and left lateral segments, laparoscopic liver resection is feasible, achieves adequate cancer resection and is associated with smooth and rapid recovery. Long-term follow-up data are required for oncological results.

Laparoscopic and endoscopic approaches for drainage of pancreatic pseudocysts: a systematic review of published series.

BACKGROUND: The laparoscopic and endoscopic approaches to internal drainage of pancreatic pseudocysts (PPs) are the current minimally invasive management options. This article reviews the evidence available on their effectiveness. METHODS: A computerized search was made of the MEDLINE, PubMed, and EMBASE databases for English language publications from 1974 to 2005. RESULTS: A total of 118 and 569 patients featured, respectively, in 19 and 25 reports underwent 118 and 583 laparoscopic and endoscopic drainage procedures, respectively. Pancreatic pseudocysts were considerably larger in the laparoscopic series (mean, 13 vs. 7 cm; p < 0.0001). The success rates for achieving resolution of the PPs in the laparoscopic and endoscopic series were 98.3% and 80.8% respectively, with morbidity rates of 4.2% and 12% and mortality rates of 0% and 0.4%, respectively. During follow-up period (mean, 13 vs 24 months; p < 0.0001), PPs recurred for 2.5% of the patients in the laparoscopic series and 14.4% of the patients in the endoscopic series, and the reintervention rates were 0.9% and 11.8%, respectively. CONCLUSIONS: The laparoscopic and endoscopic approaches to internal drainage of PPs are safe. Although laparoscopic drainage appears to carry a higher success rate and lower rates of morbidity and recurrence, the heterogeneity of the published reports and the varied follow-up periods limit direct comparisons. Data from longer follow-up periods and randomized comparative trials are needed.

A prospective evaluation of CT features predictive of intra-abdominal hypertension and abdominal compartment syndrome in critically ill surgical patients.

AIM: The aim of this study was to validate the computed tomography (CT) features of intra-abdominal hypertension (IAH) by relating them to the clinical measurement of intra-abdominal pressure (IAP) in critically ill surgical patients. MATERIALS AND METHODS: The intra-vesical pressure was measured to reflect IAP in 24 critically ill patients. CT examinations obtained within 24h of IAP measurement were reviewed and scored independently by two consultant radiologists. Each CT examination was scored for the seven proposed features of IAH. Images obtained during the presence of IAH were compared with those obtained in the absence of IAH. RESULTS: Forty-eight abdominal CT examinations were evaluated, of which 18 (38%) were obtained in the presence of IAH, whereas eight (17%) were obtained in the presence of abdominal compartment syndrome (ACS). At CT, the round belly sign (RBS) and bowel wall thickening with enhancement (BWTE) were significantly more frequently detected during the presence of IAH than when the IAP was less than 12 mmHg (78 versus 20% of examinations, p<0.001 and 39 versus 3% of examinations, p=0.003, respectively), but only BWTE was significantly associated with the presence of ACS (40 versus 11% of examinations, p=0.047). CONCLUSION: The presence of RBS and BWTE on CT images of critically ill surgical patients should alert clinicians to the possibility of presence of IAH and ACS, and prompt measurement of the IAP and consideration of suitable interventions.

Fixity of ports to the abdominal wall during laparoscopic surgery: a randomized comparison of cutting versus blunt trocars.

BACKGROUND: Dislodgement of ports from the abdominal wall is a common problem during laparoscopic surgery. The aim of this study was to evaluate port stability using either cutting or blunt-tipped trocars. METHODS: Patients undergoing laparoscopic surgery were randomized to have the secondary ports inserted using either cutting or blunt-tipped trocars. The fixity of ports to the abdominal wall was evaluated at the start and completion of surgery by measuring the total traction force required to displace the ports. Similarly, the friction forces required to displace instruments within the ports were measured. RESULTS: Thirty patients were randomized into two groups (15 patients in each group), and a total of 114 ports (cutting, n = 51; blunt, n = 63) were evaluated. The groups were comparable in age, gender, body mass index, and operating time. The total traction forces needed to displace the 5-mm and 10-mm ports were significantly lower when cutting trocars were used at both the beginning (2.6 vs. 11.8 N, p < 0.001, and 6.3 vs. 15.5 N, p = 0.014, respectively) and completion of surgery (1.3 vs. 6.7 N, p < 0.001, and 1.1 vs. 12.0 N, p = 0.001, respectively). The declines in the total traction forces from the start to the completion of surgery were significant for the 5-mm and 10-mm cutting-trocar ports (p = 0.031 and p = 0.043, respectively) but not for the blunt-trocar ports (p = 0.088 and p = 0.152, respectively). While no significant differences between the instruments' friction forces and the traction forces of the cutting-trocar ports were observed, the former were significantly lower than the traction force needed to displace the blunt-trocar ports. This explains the significantly greater frequency of spontaneous port dislodgements when cutting ports were employed (25.5% vs. 1.6%, p < 0.001). Port-site bleeding was encountered only in patients (n = 2, 13%) where cutting trocars were used. CONCLUSIONS: Port fixity to the abdominal wall during laparoscopic surgery declines with time. The insertion of ports using a blunt-tipped trocar is associated with significantly greater stability and fixity of the port to the abdominal wall. The use of blunt-tipped trocars is recommended for routine practice in laparoscopic surgery.

Acute pancreatitis: an under-recognized risk of percutaneous transhepatic distal biliary intervention.

OBJECTIVE: Percutaneous transhepatic biliary intervention (PTBI) plays an important role in the management of biliary obstruction, and this may be complicated by acute pancreatitis. The aim of this study was to assess the incidence of acute pancreatitis following PTBI. PATIENTS AND METHODS: Patients who underwent PTBI between January 1992 and December 2003 in a tertiary referral centre were identified from the hospital database. Patients who did not have their amylase measured post-procedure were excluded, as acute pancreatitis might have been missed. Acute pancreatitis was defined as hyperamylasaemia of three times or more above normal in association with abdominal pain. RESULTS: Over a 12-year period, 331 patients underwent 613 procedures. Serum amylase was measured after 134 procedures (21.9%) and was elevated in 26 of those (19.4%). There was no difference in the frequency of hyperamylasaemia between proximal and distal PTBI (14/73 [19.2%] vs 12/61 [19.7%] procedures, p=NS). However, acute pancreatitis developed after 4 of 61 (6.6%) distal PTBI (stent, n=3; internal-external catheter insertion, n=1) but not after proximal PTBI (cholangiography or external drainage) (p=0.041). The attacks were mild in three of the four patients. No pancreatitis-related deaths occurred. CONCLUSION: The risk of acute pancreatitis after distal PTBI is under-recognized and should be considered as a consent issue in patients scheduled for distal PTBI and when post-procedure abdominal pain ensues.

Therapeutic, prophylactic, and preresection applications of laparoscopic gastric and biliary bypass for patients with periampullary malignancy.

BACKGROUND: Laparoscopic bypass surgery for the palliation of gastric and biliary obstruction is associated with a rapid recovery. This study aimed to extend its application to other aspects in the management of patients with periampullary cancer. METHODS: Between 2001 and 2004, 21 patients (median age, 68 years) underwent laparoscopic gastric (n = 8), biliary (n = 5), and combined gastric and biliary (n = 8) bypass. In addition to its therapeutic role (n = 12), indications included a concomitant prophylactic gastric (n = 3) and biliary (n = 2) bypass as well as pre- 1 Whipple's relief of deep jaundice at the time of staging laparoscopy (n = 3). Construction of the biliary bypass to the gallbladder (n = 11) or bile duct (n = 2) was based on preoperative imaging. RESULTS: All procedures were completed laparoscopically. The median operating times for gastric, biliary, and combined bypass were 75, 60, and 130 min, respectively. The addition of a prophylactic bypass did not significantly prolong the operating time, as compared with a single therapeutic bypass. One patient died postoperatively of aspiration pneumonia. The postoperative hospital stay (median, 4 days) was not significantly influenced by the type of bypass. No recurrence of or new obstructive symptoms developed during the follow-up period after a therapeutic or prophylactic bypass. CONCLUSIONS: Applications of laparoscopic gastric and biliary bypass can safely be expanded to include a prophylactic role and preresection relief of obstructive jaundice. Prophylactic bypass surgery does not prolong operating time or hospital stay significantly and prevents future onset of obstructive symptoms.

Laparoscopic exclusion gastroenterostomy for palliation of gastric outlet obstruction secondary to recurrent cholangiocarcinoma.

The Devine exclusion gastroenterostomy is recommended as a palliative procedure for unresectable gastric carcinoma, and avoids the problem of delayed gastric emptying. It is conventionally performed by a laparotomy. We report the successful laparoscopic application of this technique in a patient with gastric outlet obstruction secondary to recurrence of a previously resected hilar cholangiocarcinoma. A 38-year-old gentleman who had undergone a left hepatectomy with caudate lobectomy, excision of extrahepatic biliary tree, D2 regional lymphadenectomy and Roux-en-Y right hepaticojejunostomy presented 6 months later with symptoms of gastric outlet obstruction. Computed tomography revealed a tumor mass in the region of the gastric antrum. Attempted endoscopic treatment with a metal stent was unsuccessful. He underwent a laparoscopic exclusion gastroenterostomy. The operative time was 200 minutes. Postoperative recovery was uncomplicated. There was no delay in gastric emptying and no recurrence of gastric outlet obstruction until the time of death 41 days later. Laparoscopic exclusion gastrojejunostomy is a feasible option for the palliation of gastric outlet obstruction caused by recurrent cholangiocarcinoma.

Laparoscopic hand-assisted pancreaticoduodenectomy: initial UK experience.

BACKGROUND: By and large, the limited world experience with laparoscopic pancreaticoduodenectomy (PD) has been unfavorable, but the laparoscopic hand-assisted approach to PD has recently shown promising results. We report the first successful UK experience with laparoscopic hand-assisted PD (LHAPD). METHODS: A 62-year-old man who presented with painless obstructive jaundice was found at endoscopy, to have an ampullary tumor. Preoperative biopsy specimens confirmed the diagnosis of an adenocarcinoma, and CT showed no evidence of either vascular involvement or metastatic disease. A staging laparoscopy showed no intraabdominal metastases, and an LHAPD was performed using a Gelport. RESULTS: The intraoperative course was uneventful. Two units of blood were transfused intraoperatively, but no postoperative blood transfusion was required. The operative time was 11 h (plus a 30-min break). The patients postoperative recovery was uneventful except for superficial pressure sores over the buttocks and elbows. The patient resumed oral fluid and dietary intake on the 1st and 3rd postoperative days, respectively, and was discharged from hospital on the 9th postoperative day. Histology demonstrated an ampullary adenocarcinoma with clear resection margins and involvement of two of the 13 lymph nodes examined. At 2-month follow-up, the patient remains well and is receiving adjuvant chemotherapy. CONCLUSIONS: LHAPD achieves good oncological clearance and can be performed safely in selected patients. The early promising results with this approach will undoubtedly encourage wider adoption of this procedure and are likely to widen the selection criteria.

A survey of the timing and approach to the surgical management of cholelithiasis in patients with acute biliary pancreatitis and acute cholecystitis in the UK.

BACKGROUND: Recent management guidelines and randomised clinical trials have provided evidence-based guidance to the management of acute biliary pancreatitis and acute cholecystitis. METHODS: A questionnaire was sent to the 1086 members of the Association of Surgeons of Great Britain and Ireland. There were 583 responders (54%). RESULTS: A policy of cholecystectomy during the index admission or within 4 weeks in fit patients recovering from mild acute biliary pancreatitis was adopted by 58% of surgeons, and was significantly associated with an upper gastrointestinal and hepato-pancreato-biliary subspecialty interest and a volume of more than 50 cholecystectomies per annum (OR, 0.43; 95% CI, 0.26-0.72; P = 0.001: and OR, 0.46; 95% CI, 0.29-0.74; P = 0.001, respectively). A policy of urgent cholecystectomy for acute cholecystitis was adopted by 20% of surgeons, and was significantly associated with an upper gastrointestinal/hepato-pancreato-biliary subspecialty interest and the 'routine' adoption of laparoscopic approach to cholecystectomy (OR, 0.34; 95% CI, 0.19-0.60; P < 0.001: and OR, 0.51; 95% CI, 0.3-0.86; P = 0.01, respectively). CONCLUSIONS: The management of cholelithiasis in patients with acute biliary pancreatitis in the UK remains suboptimal. Moreover, only a minority of surgeons offer patients presenting with acute cholecystitis the benefits of early laparoscopic cholecystectomy. The management of acute biliary disease may be improved if these cases were concentrated in the hands of surgeons with upper gastrointestinal/hepato-pancreato-biliary interest and those who perform laparoscopic cholecystectomy regularly.