Effect of obesity on perioperative outcomes following gastrointestinal surgery: meta-analysis.

BACKGROUND: Obesity can pose perioperative challenges related to obesity-associated co-morbidities and technical factors. However, the true impact of obesity on postoperative outcomes is not well established and reports are conflicting. The aim was to perform a systematic review and meta-analysis to explore the effect of obesity on perioperative outcomes for general surgery procedures in distinct obesity subtypes. METHODS: A systematic review was performed for studies reporting postoperative outcomes in relation to BMI in upper gastrointestinal, hepatobiliary and colorectal based on an electronic search using the Cochrane Library, Science Direct, PubMed and Embase up to January 2022. The primary outcome was the incidence of 30-day postoperative mortality among patients with obesity undergoing general surgical procedures in comparison to patients with normal range BMI. RESULTS: Sixty-two studies, including 1 886 326 patients, were eligible for inclusion. Overall, patients with obesity (including class I/II/II) had lower 30-day mortality rates in comparison to patients with a normal BMI (odds ratio (OR) 0.75, 95 per cent c.i. 0.66 to 0.86, P < 0.0001, I2 = 71 per cent); this was also observed specifically in emergency general surgery (OR 0.83, 95 per cent c.i. 0.79 to 0.87, P < 0.0000001, I2 = 7 per cent). Compared with normal BMI, obesity was positively associated with an increased risk of 30-day postoperative morbidity (OR 1.11, 95 per cent c.i. 1.04 to 1.19, P = 0.002, I2 = 85 per cent). However, there was no significant difference in postoperative morbidity rates between the cohorts of patients with a normal BMI and class I/II obesity (OR 0.98, 95 per cent c.i. 0.92 to 1.04, P = 0.542, I2 = 92 per cent). Overall, the cohort with obesity had a higher rate of postoperative wound infections compared with the non-obese group (OR 1.40, 95 per cent c.i. 1.24 to 1.59, P < 0.0001, I2 = 82 per cent). CONCLUSION: These data suggest a possible 'obesity paradox' and challenge the assumption that patients with obesity have higher postoperative mortality compared with patients with normal range BMI. Increased BMI alone is not associated with increased perioperative mortality in general surgery, highlighting the importance of more accurate body composition assessment, such as computed tomography anthropometrics, to support perioperative risk stratification and decision-making. REGISTRATION NUMBER: CRD42022337442 (PROSPERO https://www.crd.york.ac.uk/prospero/).

Global Incidence and Risk Factors Associated With Postoperative Urinary Retention Following Elective Inguinal Hernia Repair: The Retention of Urine After Inguinal Hernia Elective Repair (RETAINER I) Study.

Importance: Postoperative urinary retention (POUR) is a well-recognized complication of inguinal hernia repair (IHR). A variable incidence of POUR has previously been reported in this context, and contradictory evidence surrounds potential risk factors. Objective: To ascertain the incidence of, explore risk factors for, and determine the health service outcomes of POUR following elective IHR. Design, Setting, and Participants: The Retention of Urine After Inguinal Hernia Elective Repair (RETAINER I) study, an international, prospective cohort study, recruited participants between March 1 and October 31, 2021. This study was conducted across 209 centers in 32 countries in a consecutive sample of adult patients undergoing elective IHR. Exposure: Open or minimally invasive IHR by any surgical technique, under local, neuraxial regional, or general anesthesia. Main Outcomes and Measures: The primary outcome was the incidence of POUR following elective IHR. Secondary outcomes were perioperative risk factors, management, clinical consequences, and health service outcomes of POUR. A preoperative International Prostate Symptom Score was measured in male patients. Results: In total, 4151 patients (3882 male and 269 female; median [IQR] age, 56 [43-68] years) were studied. Inguinal hernia repair was commenced via an open surgical approach in 82.2% of patients (n = 3414) and minimally invasive surgery in 17.8% (n = 737). The primary form of anesthesia was general in 40.9% of patients (n = 1696), neuraxial regional in 45.8% (n = 1902), and local in 10.7% (n = 446). Postoperative urinary retention occurred in 5.8% of male patients (n = 224), 2.97% of female patients (n = 8), and 9.5% (119 of 1252) of male patients aged 65 years or older. Risk factors for POUR after adjusted analyses included increasing age, anticholinergic medication, history of urinary retention, constipation, out-of-hours surgery, involvement of urinary bladder within the hernia, temporary intraoperative urethral catheterization, and increasing operative duration. Postoperative urinary retention was the primary reason for 27.8% of unplanned day-case surgery admissions (n = 74) and 51.8% of 30-day readmissions (n = 72). Conclusions: The findings of this cohort study suggest that 1 in 17 male patients, 1 in 11 male patients aged 65 years or older, and 1 in 34 female patients may develop POUR following IHR. These findings could inform preoperative patient counseling. In addition, awareness of modifiable risk factors may help to identify patients at increased risk of POUR who may benefit from perioperative risk mitigation strategies.

Robotic Abdominal Surgery and COVID-19: A Systematic Review of Published Literature and Peer-Reviewed Guidelines during the SARS-CoV-2 Pandemic.

Background: Significant concern emerged at the beginning of the SARS-CoV-2 pandemic regarding the safety and practicality of robotic-assisted surgery (RAS). We aimed to review reported surgical practice and peer-reviewed published review recommendations and guidelines relating to RAS during the pandemic. Methods: A systematic review was performed in keeping with PRISMA guidelines. This study was registered on Open Science Framework. Databases were searched using the following search terms: 'robotic surgery', 'robotics', 'COVID-19', and 'SARS-CoV-2'. Firstly, articles describing any outcome from or reference to robotic surgery during the COVID-19/SARS-CoV-2 pandemic were considered for inclusion. Guidelines or review articles that outlined recommendations were included if published in a peer-reviewed journal and incorporating direct reference to RAS practice during the pandemic. The ROBINS-I (Risk of Bias in Non-Randomised Studies of Intervention) tool was used to assess the quality of surgical practice articles and guidelines and recommendation publications were assessed using the AGREE-II reporting tool. Publication trends, median time from submission to acceptance were reported along with clinical outcomes and practice recommendations. Results: Twenty-nine articles were included: 15 reporting RAS practice and 14 comprising peer-reviewed guidelines or review recommendations related to RAS during the pandemic, with multiple specialities (i.e., urology, colorectal, digestive surgery, and general minimally invasive surgery) covered. Included articles were published April 2020-December 2021, and the median interval from first submission to acceptance was 92 days. All surgical practice studies scored 'low' or 'moderate' risk of bias on the ROBINS-I assessment. All guidelines and recommendations scored 'moderately well' on the AGREE-II assessment; however, all underperformed in the domain of public and patient involvement. Overall, there were no increases in perioperative complication rates or mortalities in patients who underwent RAS compared to that expected in non-COVID practice. RAS was deemed safe, with recommendations for mitigation of risk of viral transmission. Conclusions: Continuation of RAS was feasible and safe during the SARS-CoV-2 pandemic where resources permitted. Post-pandemic reflections upon published robotic data and publication patterns allows us to better prepare for future events and to enhance urgent guideline design processes.

Quality and reliability evaluation of current Internet information regarding mesh use in inguinal hernia surgery using HONcode and the DISCERN instrument.

INTRODUCTION: Mesh-related complications following pelvic prolapse surgery has potentiated societal fear and led to increased investigation into mesh use in inguinal hernia repair (IHR) surgery online. However concern exists regarding the quality of Internet health informatics. The DISCERN Instrument and HONcode  tool can be used to assess the quality and reliability of online health information. The aim of this study is to investigate the reliability and quality of online information pertaining to mesh use in IHR surgery using the DISCERN instrument and HONcode tool. METHODS: An Internet search using the keywords: 'mesh', 'inguinal hernia' and 'surgery' was carried out via Google, Yahoo, Bing, Facebook and Twitter. The HONcode and DISCERN scores were generated for each of the first ten search engine result pages (SERPs). RESULTS: Google provided the most reliable [Median HONcode score 77% (IQR 25.5%)] and highest quality information [Median DISCERN score; 61.5 (IQR 18.25)]. Social media yielded both the most unreliable and lowest quality information. Facebook was the most unreliable [Median HONcode score 21% (IQR 14.25%)], while Twitter imparted the lowest quality information [Median DISCERN score of 18.5 (IQR 25.25)]. DISCUSSION: A 2018 Cochrane review concluded the use of mesh in IHR to be safe and associated with superior outcomes. However, numerous SERPs present results contradicting this, based solely upon Level 5 evidence. Commercialisation of the Internet has resulted in search engine optimisation, which can permit lesser quality sites to obtain higher SERP ranking. Alarmingly  if only a limited search is carried out by patients [4], lower quality, sensationalist evidence may be the only information they are exposed to. As such this may negatively influence the patient decision-making process detrimentally. However utilisation of social media by healthcare professionals may offer a solution to bridge the gap between the public and high quality medical information. CONCLUSIONS: Online information regarding mesh repair of inguinal herniae is of variable quality and reliability. Enhanced quality assurance of online health information is necessary. However, increased presence by hernia societies on social media may help to disseminate high quality information to patients, thus enabling pre-hospital education to set the scene prior to formal hospital consultation.

Late biliary endoclip migration after laparoscopic cholecystectomy: Case report and literature review.

INTRODUCTION: Although formerly considered a rarity, biliary endoclip-related complications are being diagnosed with increasing frequencies. Among these, migration of endoclip into the common bile duct (CBD) is a rare encounter that usually presents in the first two years after surgery. PRESENTATION OF CASE: This case demonstrates a late biliary endoclip migration after laparoscopic cholecystectomy. DISCUSSION: An 82-year-old male patient, with a history of laparoscopic cholecystectomy 22 years ago, presented with two-day history of severe upper abdominal pain. Routine hemogram and serum chemistry were remarkable for slightly raised alanine aminotransferase and C-reactive protein. A computed tomographic (CT) scan demonstrated a new metallic density within the CBD when compared to a previous CT scan 14 months earlier. An endoscopic retrograde cholangiography confirmed a metal endoclip within the mid-CBD contained within a choledochal stone. Balloon extraction of the endoclip and stone was successfully performed. The patient was discharged 2 days later, and remained symptom free for 1 year. CONCLUSION: To our knowledge, a latency of 22 years between cholecystectomy and clip migration has never been reported before. In cases of post-cholecystectomy abdominal pain the awareness of the surgeon should always be drawn to a clinical suspicion of endoclip migration into the CBD that can be easily remedied. Endoscopic biliary sphincterotomy with endoclip/stone removal is the therapeutic procedure of choice which usually circumvents the need for surgical extraction.

Cortical thinning and caudate abnormalities in first episode psychosis and their association with clinical outcome.

First episode psychosis (FEP) has been associated with structural brain changes, largely identified by volumetric analyses. Advances in neuroimaging processing have made it possible to measure geometric properties that may identify subtle structural changes not appreciated by a measure of volume alone. In this study we adopt complementary methods of assessing the structural integrity of grey matter in FEP patients and assess whether these relate to patient clinical and functional outcome at 3 year follow-up. 1.5 Tesla T1-weighted Magnetic Resonance (MR) images were acquired for 46 patients experiencing their first episode of psychosis and 46 healthy controls. Cerebral cortical thickness and local gyrification index (LGI) were investigated using FreeSurfer software. Volume and shape of the hippocampus, caudate and lateral ventricles were assessed using manual tracing and spherical harmonics applied for shape description. A cluster of cortical thinning was identified in FEP compared to controls; this was located in the right superior temporal gyrus, sulcus, extended into the middle temporal gyrus (lateral temporal cortex - LTC). Bilateral caudate volumes were significantly lower in FEP relative to controls and the right caudate also displayed regions of shape deflation in the FEP group. No significant structural abnormalities were identified in cortical LGI or hippocampal or lateral ventricle volume/shape. Neither LTC nor caudate abnormalities were related to change in symptom severity or global functioning 3 years later. LTC and caudate abnormalities are present at the first episode of psychosis but do not appear to directly affect clinical or functional outcome.