Early laparoscopic cholecystectomy in a district general hospital: is it safe and feasible?

BACKGROUND: Early laparoscopic cholecystectomy (ELC) is becoming the accepted treatment for the management of acute gallstone disease in specialist centres. It has also been achieved safely in the district general hospital (DGH) setting. We audited the management of acute gallstone disease in our DGH and set about to see if we could implement ELC safely and effectively. PATIENTS AND METHODS: A retrospective audit of 2 years of practice was performed using our hospital-computerised systems. Following this, departmental education regarding the benefits of early cholecystectomy was widely disseminated. Management guidelines were altered to promote and consider ELC for all suitable patients. A prospective audit of practice was then performed for 6 months. RESULTS: The first cycle revealed that only 10.42% of emergency patients admitted with gallstone-related disease had ELC. In the second cycle, 63 patients were admitted with acute gallstone disease. Three died from acute pancreatitis. Twenty-one (58%) of the 36, who were deemed suitable, had ELC. Fifteen (42%) had planned delayed laparoscopic cholecystectomy (DLC), with six (40%) being readmitted whilst waiting for their elective surgery (all undergoing ELC during their readmission). Conversion rates were similar between all groups. One of the patients having DLC had a bile leak, which settled following Endoscopic Retrograde Cholangiopancreatography and stent. CONCLUSION: We were able to increase ELC rates following the implementation of necessary changes. There did not appear to be any difference in conversion or morbidity rates between ELC and DLC. We conclude ELC is safe and feasible in the DGH setting.

Rapid significant weight loss and regional lipid deposition: Implications for insulin sensitivity.

AIM: To compare regional lipid deposition and insulin sensitivity after differing weight loss strategies: very low calorie diet (VLCD) and laparoscopic adjustable gastric banding (LAGB). METHOD: Thirty-nine obese women underwent anthropometry, proton magnetic resonance (MR) spectroscopy for assessment of liver fat (LFAT) and MR imaging for visceral (VAT) and subcutaneous abdominal fat volume (SAT) determination. Fasting blood was taken for insulin, glucose and free fatty acid (FFA) analysis. Measurements were repeated after 6-weeks Optifast VLCD (n = 14) or 3 months after LAGB (n = 25). RESULTS: Similar, significant (p < 0.001) weight loss occurred after VLCD (8%) and LAGB (9%). Both interventions induced significant (p < 0.001) and similar reductions in body mass index (BMI) and waist circumference, and in SAT and VAT (VLCD p < 0.05, LAGB p < 0.001). LFAT fell only after VLCD (p < 0.05). Plasma FFA only fell after LAGB (p < 0.05). Homeostasis model assessment (HOMA-R) improved only following VLCD (p < 0.05). No relations were detected between the changes in LFAT, VAT and SAT. The change in LFAT related to the change in HOMA-R in both interventions combined (r = 0.410, p = 0.013) and in the VLCD group (r = 0.660, p = 0.020). There was no change in relative dietary fat intake after LAGB (p = 0.11). CONCLUSION: Caloric and fat restriction for 6 weeks (VLCD) reduces weight, SAT, VAT, LFAT and HOMA-R. Less severe caloric restriction for 12 weeks (LAGB) causes significant loss of weight, VAT and SAT but no detectable change in LFAT and HOMA-R. Following weight loss, a change in LFAT is related more to changes in insulin sensitivity or dietary fat than to abdominal adiposity loss.

Change in liver size and fat content after treatment with Optifast very low calorie diet.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) requires surgical access to the gastroesophageal junction, which may be compromised by the enlarged, fatty liver that is frequently encountered in the obese. Liver size appears reduced and surgical access improved following preoperative weight loss with Optifast Very Low Calorie Diet (VLCD). The aim of this study was to assess the effects of 6 weeks Optifast VLCD on liver volume and fat content. METHODS: 18 morbidly obese subjects underwent magnetic resonance imaging and spectroscopy to measure liver size and fat content before and after intensive treatment with Optifast VLCD for 6 weeks. RESULTS: All subjects completing 6 weeks Optifast VLCD lost weight. Body weight and BMI (median [interquartile range]) reduced from 119.7 [111.9-131.3] kg and 44 [40-51] kg/m(2) respectively, to 110.6 [98.0124.5] kg and 40 [36-47] kg/m(2), P<0.001. Median excess weight loss (EWL) was 15.1 [9.6-21.1]%. Baseline liver volume and fat content were related (r=0.633, P=0.005). After 6 weeks Optifast VLCD, there was a 14.7% reduction in mean liver volume (P<0.001) and a 43% reduction in mean liver fat (P=0.016). The change in liver volume was predicted by the change in the liver fat (r = 0.610, P=0.012). CONCLUSION: This study has demonstrated that a 6 week diet with Optifast VLCD results in significant related reductions in liver size and liver fat content. This suggests that the reduction in liver volume is due to loss of fat. The reduction in liver fat and volume likely accounts for the perceived improved operability in patients undergoing LAGB.

The early effects of weight loss surgery on regional adiposity.

BACKGROUND: Weight loss beyond 6 months following laparoscopic adjustable gastric banding (LAGB) is associated with a preferential mobilization of visceral adipose tissue and an improvement in insulin sensitivity in insulin resistant subjects. Because the rate of weight loss is greatest in the first 3 months after LAGB, we investigated the impact of LAGB on changes in regional lipid deposition and insulin sensitivity over this period. METHODS: 10 female obese non-diabetic subjects underwent magnetic resonance (MR) imaging and spectroscopy before and 12 weeks after LAGB (using the Swedish band), for the quantification of abdominal subcutaneous and visceral adipose tissue areas and intrahepatic lipid. Fasting blood free fatty acids were analyzed. Insulin sensitivity was monitored by fasting insulin and homeostasis model assessment (HOMA). RESULTS: Median weight loss 12 weeks after gastric banding was 9.5 kg [interquartile range (IQR): -16.5 to -6]. There were significant reductions in median abdominal subcutaneous (-20% [IQR: -24 to -13]) and visceral (-15% [IQR: -49 to -8]) adipose tissue depots as well as plasma free fatty acids (-34% [IQR: -79 to -8]). The amount of weight lost was directly proportional to the initial BMI (r=0.778; P=0.008). Visceral fat loss was proportional to initial visceral adiposity (r=0.80, P=0.01). There was no significant improvement in insulin sensitivity. CONCLUSION: Significant fat loss occurs 3 months after LAGB. The absence of a concurrent improvement in insulin sensitivity may reflect the relatively small reduction in visceral adipose tissue at this stage. Improvement in insulin sensitivity beyond 3 months after LAGB may be due to the continued loss of visceral adipose tissue.