Index Admission Emergency Laparoscopic Cholecystectomy and Common Bile Duct Exploration: Results From a Specialist Center in the United Kingdom.

BACKGROUND: The incidence of common bile duct (CBD) stones is between 10% to 18% in people undergoing cholecystectomy for gallstones. Laparoscopic exploration of the CBD is now becoming routine practice in the elective setting, however its safety and efficacy in emergencies is poorly understood. METHODS: We analyzed our results for index emergency admission laparoscopic cholecystectomy within a specialist center in the United Kingdom. Data from all emergency cholecystectomies in our unit, between 2011 to 2016 were collected and analyzed retrospectively. RESULTS: In total, 494 patients underwent emergency laparoscopic cholecystectomy; 53 (10.7%) patients underwent common bile duct exploration (CBDE), with 1 conversion and 1 bile leak. Indications for CBDE were based on preoperative imaging (41 cases, 81%) or intra-operative cholangiogram (44 cases, 83%) findings. CONCLUSIONS: Index admission laparoscopic cholecystectomy and concomitant CBDE is safe and should be the gold standard treatment for patients presenting with acute biliary complications, reducing readmissions and the need for a 2-stage procedure.

Impact of straight to test pathways on time to diagnosis in oesophageal and gastric cancer.

BACKGROUND: Cancer survival in the UK has doubled in the last 40 years; however, 1-year and 5-year survival rates are still lower than other countries. One cause may be a delay between referral into secondary care and subsequent investigation. We set out to evaluate the impact of a straight to test pathway (STTP) on time to diagnosis for upper gastrointestinal (UGI) cancer. METHODS: Six hospital Trusts across the East Midlands Clinical Network introduced a STTP enabling general practitioners to refer patients with suspected UGI cancer (oesophageal/gastric) for immediate investigation, without the need to see a hospital specialist first. Data were collected for all patients referred between 2013 and 2015 with suspected UGI cancer and stratified by STTP or traditional referral pathway. Overall time from referral to diagnosis was compared. Data from two Trusts who did not implement STTP acted as control. RESULTS: 340 patients followed the STTP pathway and 495 followed the traditional route. STTP saved a mean of 7 days from referral to treatment (with a 95% CI of 3 to 11 days, p<0.008) and a mean of 16 days from referral to diagnosis, when compared with a traditional referral pathway. The number of diagnostic tests performed using STTP or traditional referral pathways were similar. CONCLUSION: A STTP is associated with an overall reduction of 1 week from referral to treatment for UGI cancer. The approach is feasible and did not require more resource. Larger studies are required to assess whether this time saving translates into improved cancer outcomes.

Effects of short-term energy restriction on liver lipid content and inflammatory status in severely obese adults: Results of a randomized controlled trial using 2 dietary approaches.

Short-term very-low-energy diets (VLEDs) are used in clinical practice prior to bariatric surgery, but regimens vary and outcomes of a short intervention are unclear. We examined the effect of 2 VLEDs, a food-based diet (FD) and a meal-replacement plan (MRP; LighterLife UK Limited, Harlow, UK), over the course of 2 weeks in a randomized controlled trial. We collected clinical and anthropometric data, fasting blood samples, and dietary evaluation questionnaires. Surgeons took liver biopsies and made a visual assessment of the liver. We enrolled 60 participants of whom 54 completed the study (FD, n = 26; MRP, n = 28). Baseline demographic features, reported energy intake, dietary evaluation and liver histology were similar in the 2 groups. Both diets induced significant weight loss. Perceived difficulty of surgery correlated significantly with the degree of steatosis on histology. There were reductions in the circulating inflammatory mediators C-reactive protein, fetuin-A and interleukin-6 between baseline (pre-diet) and post-diet. The diets achieved similar weight loss and reduction in inflammatory biomarkers. There were no significant differences in perceived operative difficulty or between patients' evaluation of diet satisfaction, ease of use or hunger frequency. Non-alcoholic fatty liver disease histology assessments post-diet were also not significantly different between diets. The results of this study show the effectiveness of short-term VLEDs and energy restriction, irrespective of macronutrient composition, although the small sample size precluded detection of subtle differences between interventions.

Predictors of Inadequate Weight Loss After Laparoscopic Gastric Bypass for Morbid Obesity.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is an effective treatment for morbid obesity resulting in approx. 70% excess weight loss (EWL) at 1-2 years. The aim of this study was to identify factors predictive of inadequate EWL following primary LRYGB. METHODS: Data on consecutive patients who underwent primary LRYGB between September 2009 and March 2013 were collected prospectively. The effects of age, gender, baseline body mass index (BMI), preoperative EWL, length of time between initial consultation and surgery (TtS), presence of diabetes mellitus (DM), arthritis, obstructive sleep apnea (OSA) and postoperative length of hospital stay (LOS) on EWL at 12 months were studied. General linear regression models were used to evaluate group differences in EWL and to assess independent associations between baseline variables and EWL at 12 months. Stepwise regression analyses were used to estimate individual contributions of independent variables to the variance in EWL at 12 months. In this study, inadequate EWL was defined as <50% EWL at 12 months. RESULTS: LRYGB was performed in 227 patients with a mean ± SD age and BMI of 48.6 ± 11 years and 53.6 ± 7.1 kg/m2, respectively. Female to male ratio was 3:1. EWL at 12 months had an inverse correlation with age (p = 0.01), baseline BMI (p < 0.001), TtS (p = 0.001), OSA (p = 0.039) and DM (p = 0.039). Conversely, there was a significant positive association between preoperative EWL and that at 12 months (p = 0.009). There was no effect of gender, arthritis or LOS on EWL at 12 months. Multiple regression analysis demonstrated inadequate EWL at 12 months to be predicted by older age (>60 years), patients with diabetes, higher baseline BMI (>60), those who gained weight preoperatively and in patients who waited longer than 18 months for surgery (p = 0.027). CONCLUSIONS: Preoperative factors that predict inadequate EWL at 12 months following primary LRYGB include higher initial BMI, older age, presence of DM and preoperative weight gain. Identification of these factors preoperatively should aid in providing intensive support to these at-risk patient groups.

Mid-Term Remission of Type 2 Diabetes Mellitus After Laparoscopic Roux En-Y Gastric Bypass.

BACKGROUND: Laparoscopic Roux en-Y gastric bypass (LRYGB) is an established therapeutic modality for type 2 diabetes mellitus (T2DM). However, there is paucity of data on the outcomes of LRYGB on T2DM beyond 2 years. This study aimed to examine the medium-term effects of LRYGB on T2DM and determine the predictors of T2DM resolution. METHODS: Prospective data were collected for all consecutive LRYGB performed from September 2009 to November 2010. The American Diabetes Association guidelines were used to define complete (CR) or partial (PR) remission of diabetes. Diabetes status was considered improved when there was >50 % reduction in the dose of medications or when glycaemic control was achieved after stopping insulin. The effects of baseline characteristics, diabetes data and weight loss data at 4 years on T2DM remission were studied. RESULTS: Forty-six patients with T2DM underwent LRYGB with mean ± SD age and body mass index (BMI) of 48.6 ± 9.6 years and 50.4 ± 6.5 kg/m2, respectively. Median (IQR, interquartile range) duration of T2DM preoperatively was 60 (36-126) months. Median (IQR) follow-up was 52 (50-57) months. T2DM remission was achieved in 64 % of patients (44 % CR, 20 % PR), and a further 28 % of patients had improvement in their diabetes status. Multivariate analyses demonstrated significant excess weight loss (EWL) [P = 0.008] and lower BMI [P = 0.04] at 4 years to be the only independent predictors of T2DM medium-term outcomes. CONCLUSION: The medium-term effects of LRYGB on T2DM remission/improvement were maintained in 92 % of patients. EWL and lower BMI at 4 years were independent predictors of T2DM remission.

Are we meeting the British Society of Gastroenterology guidelines for cholecystectomy post-gallstone pancreatitis?

BACKGROUND: The aim of this study was to audit the current management of patients suffering with gallstone pancreatitis (GSP) at a university teaching hospital for compliance with the British Society of Gastroenterology (BSG) guidelines regarding cholecystectomy post-GSP. METHODS: Data were collected on all patients identified via the hospital coding department that presented with GSP between January 2011 and November 2013. Patients with alcoholic pancreatitis were excluded. The primary outcome was the length of time in days from diagnosis of GSP to cholecystectomy. Secondary outcomes included readmission with gallstone-related disease prior to definitive management and admitting speciality. RESULTS: One hundred and fifty-eight patients were identified with a presentation of GSP during the study period. Thirty-nine patients were treated conservatively. One hundred and six patients underwent laparoscopic cholecystectomy a median (interquartile range) interval of 33.5 days (64 days) post-admission. Patients with a severe attack as classified by the Glasgow severity score (n = 16) waited a median of 79.5 days (71.5) for cholecystectomy. Only 32% (n = 34) of patients with mild disease underwent cholecystectomy during the index admission or within 2 weeks. When grouped by admitting speciality, patients admitted initially under hepatobiliary surgery waited significantly fewer days for definitive treatment compared with other specialities (P < 0.0001). Twenty-one patients (19.8%) re-presented with gallstone-related pathology prior to undergoing cholecystectomy. CONCLUSIONS: Only 32.1% were treated as per BSG guidelines. About 19.8% (n = 21) of the patients suffered further morbidity as a result of a delayed operation and there is a clear difference between admitting speciality and the median time to operation.

Pre-operative dietary restriction for patients undergoing bariatric surgery in the UK: observational study of current practice and dietary effects.

BACKGROUND: Bariatric surgery is effective at achieving weight loss in the severely obese, with the majority of procedures performed laparoscopically. A short-term pre-operative energy restrictive diet is widely adopted to enable surgery by reducing liver size and improving liver flexibility. However, the dietary approach is not standardised. This observational study reports on pre-operative restrictive diets in use across bariatric services in the UK. METHODS: Between September and November 2012, information was collected from bariatric services on current or past pre-operative diets, and any research providing evidence for the use or modification of their diets. RESULTS: Around one third of bariatric services (28) in the UK responded, with a total of 49 diets in current use. Types of diet include low energy, low carbohydrate and liquid, with 59 % offering low energy/low carbohydrate food-based, 21 % milk/yoghurt, 18 % meal replacement (liquid) and 2 % clear liquid. Diet duration varies between 7 and 42 days. Limited anecdotal evidence was provided by services evaluating the pre-operative diet, and its alternative approaches, with dietary choice primarily clinician-led. CONCLUSIONS: This study has highlighted variability and lack of consensus in the form of pre-bariatric surgery diet used across different centres. Further research comparing outcomes for alternative diets would support best practice in the future.

An unusual cause of dysuria.

Laparoscopic adjustable gastric band (LAGB) insertion has become an increasingly common treatment for severe obesity worldwide. As a consequence, LAGB complications are reported in increasing numbers and usually present to acute surgical units. This report describes the development of lower abdominal pain and dysuria in a patient who had undergone LAGB surgery 20 months previously. Repeated symptomatic treatment for a possible urinary tract infection in the community setting had been unsuccessful. The cause was found to be a fracture in the tubing connecting the LAGB device with its subcutaneous adjusting port, which was causing persistent bladder irritation. It is recommended that when LAGB patients present with acute lower abdominal pain, consideration should be made as to whether a tubing disconnection has occurred. Such a complication may be visualised by abdominal radiography. Advice can be sought on this and other complications of bariatric surgery by contacting the regional bariatric surgical centre where definitive management would be undertaken.

A pre-operative elevated neutrophil: lymphocyte ratio does not predict survival from oesophageal cancer resection.

BACKGROUND: Elevated pre-operative neutrophil: lymphocyte ratio (NLR) has been identified as a predictor of survival in patients with hepatocellular and colorectal cancer. The aim of this study was to examine the prognostic value of an elevated preoperative NLR following resection for oesophageal cancer. METHODS: Patients who underwent resection for oesophageal carcinoma from June 1997 to September 2007 were identified from a local cancer database. Data on demographics, conventional prognostic markers, laboratory analyses including blood count results, and histopathology were collected and analysed. RESULTS: A total of 294 patients were identified with a median age at diagnosis of 65.2 (IQR 59-72) years. The median pre-operative time of blood sample collection was three days (IQR 1-8). The median neutrophil count was 64.2 x 10-9/litre, median lymphocyte count 23.9 x 10-9/litre, whilst the NLR was 2.69 (IQR 1.95-4.02). NLR did not prove to be a significant predictor of number of involved lymph nodes (Cox regression, p = 0.754), disease recurrence (p = 0.288) or death (Cox regression, p = 0.374). Furthermore, survival time was not significantly different between patients with high (>or= 3.5) or low (< 3.5) NLR (p = 0.49). CONCLUSION: Preoperative NLR does not appear to offer useful predictive ability for outcome, disease-free and overall survival following oesophageal cancer resection.

Delayed presentation of small bowel injury during suprapubic catheterisation.

We present a case of small intestine injury resulting from suprapubic catheter insertion. This case is of particular interest for three reasons. Firstly, the presentation of the injury was delayed by three months, until the time of the first catheter exchange. Secondly, the injury was managed conservatively, without surgical exploration. Finally, the injury occurred using a newer, Seldinger-type suprapubic catheter insertion kit.

Is harmonic scalpel an effective tool for oesophagectomy?

INTRODUCTION: Use of electrocautery in oesophagectomy is standard; however, the introduction of the harmonic scalpel (HS) and its use has changed the methodology of oesophagectomy in recent years. We have assessed the efficiency of HS in oesophageal cancer surgery. The parameters studied were blood loss, transfusion rates, and postoperative complications. METHODS: Our cohort included 142 patients who underwent elective oesophagectomy from January 1999 to December 2004. The control group was the patients undergoing electrocautery oesophagectomy (n=98) between 1999 and 2002. Furthermore, 44 patients who were operated with the HS were included in the study group. RESULTS: The numbers of units transfused were significantly less in HS group (median 0) in comparison with controls (median 2), p=0.003. Median blood loss in HS and the controls was 500 and 700 ml respectively (p=0.123). Mortality in HS group was 2.27%compared to 3.06% in controls (p=0.14). The complication (principally respiratory) rate was only 13.6% of patients in HS group compared to 17.3% in the controls. CONCLUSION: Our study shows that HS reduces transfusion rates and postoperative complications, highlighting it as a safe and effective alternative to traditional electrocautery.