Index admission vs elective laparoscopic common bile duct exploration: a district general hospital experience over 6 years.

BACKGROUND: Laparoscopic common bile duct exploration (LCBDE) is relatively a new approach for clearing choledocholithiasis. The aim of this study is to assess the safety of this approach to clearing common bile duct (CBD) stones on an index admission including emergency setting. METHODS: Retrospective data collection and analysis were carried out for 207 consecutive cases of LCBDE performed in Royal Cornwall Hospital over 6 years (2015-2020). Patients were divided into two groups (Index admission vs elective) then both groups compared. RESULTS: A total of 207 cases of LCBDE were performed in our unit during the time period. One hundred twenty-two operations were performed on the index admission and 85 on a subsequent elective list. Mean operative time was 146 ± 64 min in the index admission group and 145 ± 65 min in the elective group (p = 0.913). Length of stay post-operatively was 3.3 ± 6.3 days in the index admission cases and 3.5 ± 4.6 days after elective cases. Successful clearance was achieved at the end of the operation in 116 patients in the index admission group, clearance failed in one case and negative exploration in 5 patients. In the elective group 83 patients had a successful clearance at the end of the operation, and 2 patients has had a negative exploration. Twelve patients (index admission group) and 8 patients of the elective cases required post-operative Endoscopic Retrograde Cholangiopancreatography (ERCP) to manage retained stones, recurrent stones and bile leak (p = 0.921). Three patients required re-operation for post-operative complications in each group. CONCLUSION: Common bile duct exploration in index admission is safe with high success rate if performed by well-trained surgeons with advanced laparoscopic skills.

Effect of Preoperative Weight Loss and Baseline Comorbidity on Short-Term Complications and Reoperations After Laparoscopic Roux-en-Y Gastric Bypass in 2,067 Patients.

PURPOSE: Decreasing popularity of Roux-en-Y gastric bypass (RYGB) in bariatric-metabolic surgery may be due to higher perceived peri-operative complications. There are few studies on whether preoperative weight loss can reduce complications or reoperations following RYGB. We investigated this using a standardised operative technique. MATERIALS AND METHODS: Retrospective single-centre study of RYGB from 2004 to 2019 using a prospective database. Preoperative behavioural management included intentional weight loss. Maximum preoperative weight, weight on the day of operation, and Obesity-Surgery Mortality Risk Score (OS-MRS) class were recorded. Short-term outcomes (post-operative stay, 30-day complication and reoperation rates) were analysed. RESULTS: In 2,067 RYGB patients (1,901 primary and 166 revisional), median preoperative total body weight loss (TWL) was 6.2% (IQR: 2.5-10.7%). The median age was 46 (interquartile range (IQR) 38-54) and 80.4% were female (n=1,661). For primary surgery, the median body mass index (BMI) was 47.6 kg/m2 (IQR: 43.1-53.3). Excluding the 100-procedure learning curve, the complication rate for primary cases was 4.4% and reoperation rate of 2.8% and one peri-operative mortality (0.06%). OS-MRS ≥2 (class B or C) predicted higher risk of complications (6.1%) compared to those with a score <2 (class A) (3.8%, p=0.021), but not reoperations. Five percent preoperative TWL did not decrease complications compared to <5% TWL. Patients with ≥10% TWL had greater baseline risk and had an increased risk of complications (6.6% vs 3.7%, p=0.017) and reoperations (4.5% vs 2.7%, p<0.001). CONCLUSIONS: RYGB performed using a standardised technique has low overall risk. The influence of preoperative weight loss on outcomes was inconsistent.

How Effective Is the Multidisciplinary Team Approach in Bariatric Surgery?

BACKGROUND: Multidisciplinary team (MDT) meetings are widely recommended in the management of bariatric surgery patients; however, there is limited evidence for their effectiveness. The aims of this study were to evaluate the decision-making process of a single-day bariatric MDT clinic and secondly to evaluate whether these MDT decisions were implemented. METHODS: This was a retrospective observational study analysing MDT treatment decisions from February 2012 to June 2013 using an MDT proforma. The decision-making process of the MDT meeting was investigated by assessing the alterations in management plan between the surgeon and the rest of the MDT. Adherence to MDT decisions was also assessed. RESULTS: Decisions regarding 200 consecutive patients were analyzed. There was MDT agreement for 55%, and patients were listed for surgery on the day of the MDT. There was MDT disagreement regarding 45%, with conflicting opinions expressed by surgeons in 33/200 (17%), anaesthetists in 60/200 (30%) and dieticians in 65/200 (33%). The MDT plan was instigated in 78% and the most common reason for failure was patients failing to attend for further assessment. By the end of the study, 85% of patients underwent bariatric surgery, 11.5% declined further input, 2.5% chose further weight loss and 1% were removed from waiting list. CONCLUSION: Use of a single-day MDT clinic format resulted in a change in plan for a significant number of patients. This can be interpreted as improved quality of care for these patients, and we conclude the MDT approach is valuable.

Single-stage conversions from failed gastric band to sleeve gastrectomy versus Roux-en-Y gastric bypass: results from the United Kingdom National Bariatric Surgical Registry.

BACKGROUND: For patients in whom laparoscopic adjustable gastric band has failed, conversion to Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy are both options for further surgical treatment. There are limited data comparing these 2 procedures. The National Bariatric Surgery Registry is a comprehensive United Kingdom-wide database of bariatric procedures, in which preoperative demographic characteristics and clinical outcomes are prospectively recorded. OBJECTIVES: To compare perioperative complication rate and short-term outcomes of patients undergoing single-stage conversion of gastric band to Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy. SETTING: United Kingdom national bariatric surgery database. METHODS: From the National Bariatric Surgical Registry data set, we identified 141 patients undergoing single-stage conversion from gastric band to either gastric bypass (113) or sleeve gastrectomy (28) between 2009 and 2014, and analyzed their clinical outcomes. RESULTS: With respect to perioperative outcomes gastric bypass was associated with a higher incidence of readmission or reintervention postoperatively (16 versus 0; P = .04). There was no difference in percentage excess weight loss between sleeve gastrectomy and gastric bypass at final follow-up at 1 year (52.1% versus 57.1% respectively; P = .4). CONCLUSIONS: Conversion from band to sleeve or bypass give comparable good early excess weight loss; however, conversion to sleeve is associated with a better perioperative safety profile.

Obesity surgery makes patients healthier and more functional: real world results from the United Kingdom National Bariatric Surgery Registry.

BACKGROUND: The National Bariatric Surgery Registry (NBSR) is the largest bespoke database in the field in the United Kingdom. OBJECTIVES: Our aim was to analyze the NBSR to determine whether the effects of obesity surgery on associated co-morbidities observed in small randomized controlled clinical trials could be replicated in a "real life" setting within U.K. healthcare. SETTING: United Kingdom. METHODS: All NBSR entries for operations between 2000 and 2015 with associated demographic and co-morbidity data were analyzed retrospectively. RESULTS: A total of 50,782 entries were analyzed. The patients were predominantly female (78%) and white European with a mean age of 45 ± 11 years and a mean body mass index of 48 ± 8 kg/m2. Over 5 years of follow-up, statistically significant reductions in the prevalence of type 2 diabetes, hypertension, dyslipidemia, sleep apnea, asthma, functional impairment, arthritis, and gastroesophageal reflux disease were observed. The "remission" of these co-morbidities was evident 1 year postoperatively and reached a plateau 2 to 5 years after surgery. Obesity surgery was particularly effective on functional impairment and diabetes, almost doubling the proportion of patients able to climb 3 flights of stairs and halving the proportion of patients with diabetes related hyperglycemia compared with preoperatively. Surgery was safe with a morbidity of 3.1% and in-hospital mortality of .07% and a reduced median inpatient stay of 2 days, despite an increasingly sick patient population. CONCLUSIONS: Obesity surgery in the U.K. results not only in weight loss, but also in substantial improvements in obesity-related co-morbidities. Appropriate support and funding will help improve the quality of the NBSR data set even further, thus enabling its use to inform healthcare policy.

Success and duration of dynamic bracing for pectus carinatum: A four-year prospective study.

BACKGROUND: This study sought to establish factors that can prognosticate outcomes of bracing for pectus carinatum (PC). METHODS: Prospective data were collected on all patients enrolled in a dynamic bracing protocol from July 2011 to July 2015. Pressure of correction (POC) was measured at initiation of treatment, and pressure of treatment (POT) was measured pre- and post-adjustment at every follow-up visit. Univariate and Cox regression analysis tested the following possible determinants of success and bracing duration: age, sex, symmetry, POC, and POT drop during the first two follow-up visits. RESULTS: Of 114 patients, 64 (56%) succeeded, 33 (29%) were still in active bracing, and 17 (15%) failed or were lost to follow-up. In successful patients, active and maintenance bracing was 5.66±3.81 and 8.80±3.94months, respectively. Asymmetry and older age were significantly associated with failure. Multivariable Cox proportional hazard analysis of time-to-maintenance showed that asymmetry (p=0.01) and smaller first drop in POT (p=0.02) were associated with longer time to reach maintenance. CONCLUSIONS: Pressure of correction does not predict failure of bracing, but older age, asymmetry, and smaller first drop in pressure of treatment are associated with failure and longer bracing duration. LEVEL OF EVIDENCE: Prospective Study/Level of Evidence IV.

Laparoscopic repair of coexisting prevascular and obturator hernias.

A prevascular femoral hernia is a rare type of femoral hernia in which the neck lies anterior to the femoral vessels. Obturator hernias are unusual herniations through the obturator foramen. There are no reports in the literature of coexisting prevascular and obturator hernias. Although obturator hernias have been treated successfully by laparoscopic techniques, there are no published reports of prevascular hernias treated in this way. We report the first case in the literature of a patient with a prevascular femoral hernia treated successfully by laparoscopic preperitoneal mesh repair in a rare case associated with ipsilateral obturator and classic femoral hernias. Prevascular femoral hernias are rare, potentially difficult to treat and are ideally suited to investigation and repair by laparoscopic means.

Abnormal colonic motility: a possible association with urge fecal incontinence.

PURPOSE: Fecal incontinence is a distressing condition affecting up to 7% of the population. Severe urgency is a symptom associated with hypersensitivity of the rectum, a common finding in both fecal incontinence and irritable bowel syndrome. The purpose of this study was to investigate whether patients with fecal incontinence, urgency, and rectal hypersensitivity have abnormal hindgut motility, suggestive of a more generalized motility problem. METHODS: Eleven females with urgency-associated incontinence and without anal sphincter injury were compared with 5 controls. After full clinical, ultrasonographic, and physiological assessment, patients underwent prolonged colonic manometry studies. Motility patterns were recorded and, in particular, the response to a standard gastrocolic reflex was noted. RESULTS: Rectal sensation values in patients were as follows: first sensation, 22 (range, 5-58) mls; desire to defecate, 31 (range, 13-166) mls; and maximum tolerated volume, 64 (range, 21-254) mls. Compared with controls, patients had significantly higher numbers of 1) low amplitude waves (>5 mmHg) in both the sigmoid colon (101 vs 46.5; P = .028) and the descending colon (101.5 vs 41; P = .036) in the hour before the meal stimulus, and 2) high amplitude waves (>50 mmHg) in the sigmoid colon (2 vs 0; P = .006) in the fasting state. CONCLUSION: Patients with fecal incontinence associated with severe urgency may have rectal hypersensitivity and a more global colonic motility problem similar to irritable bowel syndrome.

Assessment of dietary intake and trace element status in patients with ileal pouch-anal anastomosis.

PURPOSE: Panproctocolectomy and ileal pouch-anal anastomosis is the operation of choice for patients with ulcerative colitis and familial polyposis. The long-term nutritional consequences after pouch surgery are unknown. We have assessed the nutritional status of the essential trace elements-zinc, copper, manganese, and selenium-in patients several years (median, 10 (range, 2-15) years) after surgery. METHODS: Fifty-five patients with uncomplicated ileal pouch-anal anastomosis and 46 healthy control subjects were studied. A dietary assessment of trace element intake was undertaken by using a semiquantitative food frequency questionnaire. The patients' trace elements status for zinc, copper, manganese, and selenium was assessed by measuring their concentrations in blood. RESULTS: The dietary intake of individual trace elements was similar in both groups (all P values > 0.4). There was no significant difference in the concentrations of plasma copper, zinc, and selenium between patients and healthy control subjects (all P values > 0.07). The concentration of whole blood manganese was significantly higher (P = 0.004) in patients (median, 178.5 nmol/l; range, 59-478 nmol/l) compared with healthy control subjects (median, 140 nmol/l; range, 53-267 nmol/l). Four (7 percent) patients had manganese concentrations more than three standard deviations of the mean of control group (>255 nmol/l). CONCLUSIONS: This study shows that patients who have had uncomplicated pouch surgery have a normal dietary intake of trace elements and do not develop deficiencies in copper, zinc, manganese, and selenium. However, these patients may be at increased risk of manganese toxicity.

Paid work increases and state benefit claims decrease after bariatric surgery.

BACKGROUND: Bariatric surgery is a clinically effective treatment for obesity and has been shown to be cost-effective. The impact of bariatric surgery on the subsequent ability to work and the uptake of state-funded benefits is not well documented. METHODS: A consecutive series of 79 patients who had undergone laparoscopic Roux-en-Y gastric bypass (LRYGBP) or laparoscopic adjustable gastric banding (LAGB) were surveyed to assess changes in their ability to work and the number and type of state benefits claimed after surgery. RESULTS: 59 patients (75%) responded, median age 45, median follow-up 14 months. There was a 32% increase in the number of respondents in paid work after surgery (P<0.05). The mean weekly hours worked increased from 30.1 to 35.8 hours (P<0.01). Respondents also reported a decrease in obesity-related physical and emotional constraints on their ability to do work (P<0.01). Fewer patients claimed state benefits postoperatively (P<0.01). CONCLUSION: More patients perform paid work after LRYGBP and LAGB than beforehand, and the number of weekly hours they work increases. After surgery, patients claim fewer state benefits.

Large volume hepatic freezing: association with significant release of the cytokines interleukin-6 and tumor necrosis factor a in a rat model.

Although cryotherapy of liver tumors is generally considered a safe procedure, a syndrome of coagulopathy and fatal multiorgan failure has been observed in some patients and is called the cryoshock phenomenon. Our aim was to establish an animal model of this phenomenon and examine the effects of the basic parameters of freezing or cryotherapy on it. A group of 75 female Sprague-Dawley rats were allocated randomly to five groups: (1) sham laparotomy (n = 15); (2) small (25% liver volume) single freeze (n = 15); (3) small (25% liver volume) double freeze (n = 15); (4) large (50% liver volume) single freeze (n = 15); (5) large (50% liver volume) double freeze (n = 15). Blood samples were collected at different postoperative times, and organs were harvested for histopathology. There was a significant release of tumor necrosis factor-a (TNFa) and interleukin 6 (IL-6) following hepatic freezing, which was greatest in group 5. Postoperative serum cytokine levels were significantly associated with hepatocellular injury, as measured by postoperative serum aspartate transaminase (AST) concentrations. Severe hemoglobinuria and renal injury, as demonstrated by the serum creatinine level and the glomerular neutrophil count, were observed and were greatest in group 5. Hepatic cryosurgery is associated with release of IL-6 and TNFa and renal injury in a rat model. It is likely that the cryoshock phenomenon is another form of the systemic inflammatory response syndrome. Based on the results of this study, it is possibly mediated by cytokines released from the frozen liver tissue. We therefore caution against cryotherapy of large tumor volumes.