A systematic review on laparoscopic subtotal cholecystectomy for difficult gallbladders: a lifesaving bailout or an incomplete operation?

INTRODUCTION: Laparoscopic subtotal cholecystectomy (LSTC) is a bailout procedure that is undertaken when it is not safe to proceed with a laparoscopic total cholecystectomy owing to dense adhesions in Calot's triangle. The main aim of this review was to investigate the early (≤30 days) and late (>30 days) morbidity and mortality of LSTC. METHODS: A literature search of the PubMed® (MEDLINE®), Google Scholar™ and Embase® databases was conducted to identify all studies on LSTC published between 1985 and December 2020. A systematic review was then performed. RESULTS: Overall, 45 studies involving 2,166 subtotal cholecystectomy patients (51% female) were identified for inclusion in the review. The mean patient age was 55 years (standard deviation: 15 years). Just over half (53%) of the patients had an elective procedure. The conversion rate was 6.2% (n=135). The most common indication was acute cholecystitis (49%). Different techniques were used, with the majority having a closed cystic duct/gallbladder stump (71%). The most common closure technique was intracorporeal suturing (53%), followed by endoloop closure (15%). Four patients (0.18%) died within thirty days of surgery. Morbidity within 30 days included bile duct injury (0.23%), bile leak (18%) and intra-abdominal collection (4%). Reoperation was reported in 23 patients (1.2%), most commonly for unresolving intra-abdominal collections and failed endoscopic retrograde cholangiopancreatography to control bile leak. Long-term follow-up was reported in 30 studies, the median follow-up duration being 22 months. Late morbidity included incisional hernias (6%), symptomatic gallstones (4%) and common bile duct stones (2%), with 2% of cases requiring completion of cholecystectomy. CONCLUSIONS: LSTC is an acceptable alternative in patients with a "difficult" Calot's triangle.

An international survey of 1014 hernia surgeons: outcome of GLACIER (global practice of inguinal hernia repair) study.

INTRODUCTION: The practice of inguinal hernia repair varies internationally. The global practice of inguinal hernia repair study (GLACIER) aimed to capture these variations in open, laparoscopic, and robotic inguinal hernia repair. METHODS: A questionnaire-based survey was created on a web-based platform, and the link was shared on various social media platforms, personal e-mail network of authors, and e-mails to members of the endorsed organisations, which include British Hernia Society (BHS), The Upper Gastrointestinal Surgical Society (TUGSS), and Abdominal Core Health Quality Collaborative (ACHQC). RESULTS: A total of 1014 surgeons from 81 countries completed the survey. Open and laparoscopic approaches were preferred by 43% and 47% of participants, respectively. Transabdominal pre-peritoneal repair (TAPP) was the favoured minimally invasive approach. Bilateral and recurrent hernia following previous open repair were the most common indications for a minimally invasive procedure. Ninety-eight percent of the surgeons preferred repair with a mesh, and synthetic monofilament lightweight mesh with large pores was the most common choice. Lichtenstein repair was the most favoured open mesh repair technique (90%), while Shouldice repair was the favoured non-mesh repair technique. The risk of chronic groin pain was quoted as 5% after open repair and 1% after minimally invasive repair. Only 10% of surgeons preferred to perform an open repair using local anaesthesia. CONCLUSION: This survey identified similarities and variations in practice internationally and some discrepancies in inguinal hernia repair compared to best practice guidelines, such as low rates of repair using local anaesthesia and the use of lightweight mesh for minimally invasive repair. It also identifies several key areas for future research, such as incidence, risk factors, and management of chronic groin pain after hernia surgery and the clinical and cost-effectiveness of robotic hernia surgery.

Practice and short-term outcomes in ventral hernia repair: a prospective multicenter data audit of Indian Association of Gastrointestinal Endo Surgeons Research Collaborative.

INTRODUCTION: There is considerable variation in the practice of ventral hernia repair (VHR). Consequently, both short- and long-term outcomes are different. We report the first multicenter data from India on the variations in procedures and short-term outcomes after ventral hernia repair. METHODS: A prospective study was planned under the aegis of the Indian Association of Gastrointestinal Endo Surgeons (IAGES). Participating surgeons prospectively recorded the data of patients who underwent VHR from January 21, 2021, to April 20, 2021. Patients were followed for 3-6 months. RESULTS: Data from 648 patients were analyzed for demographics, hernia characteristics, technical variations, and outcomes. 375 (57.8%) were primary hernias (PH) and 273 (42.15%) were incisional hernias (IH), of which 63 (9.7%) were recurrent hernias. In the PH group, there were 171 minimal access (MAS) and 170 open repair. In descending order of frequency, there were 111 (32.6%) open onlay, 83 (24.3%) intraperitoneal onlay meshplasty (IPOM) Plus, 36 (10.6%) IPOM, 35 (10.3%) suture repair, 22 (6.5%) endoscopic Rives Stoppa (eRS), 11 (3.2%) open RS, 11 (3.2%) TAPP, 7 (2%) hybrid, 6 (1.8%) open preperitoneal, 19 (5.6%) others. There were 3.73% seroma, 3.2% SSI, 0% 90-day readmission, 0% recurrence, and 0.3% mortality. In the IH group, 164 patients underwent open repair and 104 MAS repair. In descending order of frequency, there were 90 (33.6%) open onlay, 47 (17.5%) IPOM Plus, 38 (14.1%) open sublay, 28 (10.4%) IPOM, 12 (4.5%) Transversus Abdominis Release (TAR), 11 (4.1%) suture repair, 9 (3.4%) open preperitoneal, 7 (2.6%) hybrid, 6 (2.2%) TAPP, 5 (1.9%) eRS, 4 (1.5%) TARM, 3 (1.1%) endoscopic TAR (eTAR), and 8 (3%) others. There were 13.92% seroma, 4.4% hematoma, 9.5% SSI, 1.1% mesh explantation, 0.4% wound sinus, 2.2% 90-day readmission, 0% recurrence, and 1.1% mortality. CONCLUSION: Onlay meshplasty is the commonest procedure in India both in PH and IH. IPOM/IPOM plus is the second commonest procedure. TAR is the preferred component separation technique. Complication rates were comparable to published literature. TRIAL REGISTRATION: The study was registered with Clinical Trial Registry of India. CTRI number-CTRI/2021/01/030435.

Primary Banded Sleeve Gastrectomy: a Systematic Review.

We aim to investigate any advantages of primary banded sleeve gastrectomy (BSG) over laparoscopic sleeve gastrectomy (LSG). A literature search was performed according to the PRISMA guidelines. There were 236 patients with the mean age of 45.4 years, BMI of 47.9 kg/m2, operating time of 96.8 min, and LOS of 5.25 days. The median follow-up (F/U) was 1 year with mean F/U of 78% patients. Mean %EWL was 77.4% at 12 months, the complication rate of 11.8%, reoperation rate of 5.5%, and the mortality rate of 0.85%. There are small numbers of published cases with primary BSG in literature. This review is unable to examine the benefits versus risks of BSG in the long term. We need randomized studies with long-term F/U to adequately evaluate this procedure.

Occupational Outcomes of Obesity Surgery-Do the Employed Return to Work, and Do the Unemployed Find Work?

BACKGROUND: Bariatric surgery offers excellent weight loss results and improvement in obesity-associated comorbidities. Many patients undergoing surgery are of working age, and so an understanding of any relationship between occupational outcomes and surgery is essential. The aim of this study was to ascertain the occupational outcomes of patients undergoing bariatric surgery at a high-volume centre. METHODS: A retrospective search was performed of a prospectively maintained consecutive electronic database. We collected data on patient demographics and employment status before and after bariatric surgery. All patients with a documented employment status within 30 months of surgery were included. Patients were divided into three groups: within 6 months post-operatively, 7-18 months post-operatively, and 19-30 months post-operatively. RESULTS: A total of 1011 patients were included. Median age was 47 years (range 18-78). Pre-operatively, 59.5% (444/746) were employed compared to 69.9% (707/1011) post-operatively (p < 0.05). The number of unemployed fell from 36.6% (273/746) pre-operatively to 21% (212/1011) post-operatively. The improvement in employment status was seen at all durations of follow-up. For those in employment pre-operatively, approximately 90% were still in employment at each subsequent follow-up. For those patients who were unemployed pre-operatively, approximately 40% were in employment at each subsequent follow-up. A significant improvement in the percentage employed was seen in all working age groups (p < 0.05). CONCLUSION: This is the largest study worldwide looking at employment outcomes following bariatric surgery. It demonstrates a significant increase in number of employed patients following bariatric surgery. Interestingly, it also showed that some patients employed pre-operatively become unemployed afterwards.

Haematological indices and haematinic levels after mini gastric bypass: a matched comparison with Roux-en-Y gastric bypass.

Many surgeons believe mini gastric bypass (MGB) is more likely to cause micronutrient malabsorption compared to Roux-en-Y gastric bypass (RYGB). Till date, there is no published study evaluating haematological indices and haematinic levels in patients undergoing MGB and comparing these with a matched cohort of RYGB. Two hundred patients who underwent MGB between October 2012 and October 2015 were matched to 200 patients who underwent RYGB for age, sex, body mass index and time of surgery. We then compared haemoglobin, mean corpuscular volume, iron, ferritin, vitamin B12 and folic acid levels preoperatively and at 6 monthly intervals after surgery until 2 years. The percentage total weight loss was significantly higher in the MGB group compared to the RYGB group at all time points. At 2 years, MGB and RYGB both led to an increase in anaemia rates but the difference was only significant for MGB group. Compared to RYGB, MGB patients were more likely to be anaemic at 2 years, although the difference was not significant statistically (16.6% vs. 12.7%; P value = 0.55). There was a trend for lower iron and folate levels in MGB group compared to RYGB group but the difference was statistically significant at some of the time periods only (significantly lower folate at 6 and 12 months and lower iron at 6 months in the MGB group). MGB leads to a significant increase in anaemia rates in a supplemented cohort. There is a trend towards lower iron and folate levels and higher anaemia rates in MGB group in comparison with RYGB. Larger studies with longer follow-up should evaluate results of MGB with a shorter biliopancreatic limb.

Patient experiences of adjusting to life in the first 2 years after bariatric surgery: a qualitative study.

There is currently little research into the experiences of those who have undergone bariatric surgery, or how surgery affects their lives and social interactions. Adopting a constructivist grounded theory methodological approach with a constant comparative analytical framework, semi-structured interviews were carried out with 18 participants (11 female, 7 male) who had undergone permanent bariatric surgical procedures 5-24 months prior to interview. Findings revealed that participants regarded social encounters after bariatric surgery as underpinned by risk. Their attitudes towards social situations guided their social interaction with others. Three profiles of attitudes towards risk were constructed: Risk Accepters, Risk Contenders and Risk Challengers. Profiles were based on participant-reported narratives of their experiences in the first two years after surgery. The social complexities which occurred as a consequence of bariatric surgery required adjustments to patients' lives. Participants reported that social aspects of bariatric surgery did not appear to be widely understood by those who have not undergone bariatric surgery. The three risk attitude profiles that emerged from our data offer an understanding of how patients adjust to life after surgery and can be used reflexively by healthcare professionals to support both patients pre- and post-operatively.

Marginal ulcers after one anastomosis (mini) gastric bypass: a survey of surgeons.

Many surgeons believe that one anastomosis (mini) gastric bypass (OAGB/MGB) is associated with a high marginal ulcer (MU) rate and that this is associated with complications in a significant number of patients. The purpose of this survey was to find out the participant-reported incidence of MU after OAGB/MGB and its complications. We also aimed to understand practices in this cohort concerning prophylaxis, diagnosis, treatment and management of complications. Bariatric surgeons who perform OAGB/MGB procedures were invited to participate in a confidential, online survey using SurveyMonkey®. A total of 86 surgeons performing OAGB/MGB procedures participated in the survey. The total number of OAGB/MGB procedures reported was 27 672, revealing 622 MU, giving an MU rate of 2.24 %. Most participants (69/84, 82.4%) routinely use proton pump inhibitor (PPI) prophylaxis, but there was variation in drugs, dosages and duration. The majority (49/85, 57.6%) of participants 'always' use endoscopy for diagnosis, and 48.1% (39/81) 'always' perform an endoscopy to ensure healing. Most (49/55) perforated ulcers were treated with laparoscopic repair +/- omentoplasty +/- drainage. Most (55/59, 93.0%) of the bleeding ulcers were managed with PPI +/- blood transfusions +/- endoscopic intervention (23/59, 39.0%). Non-healing ulcers were treated by conversion to Roux-en-Y gastric bypass (RYGB) in 46.5% of patients (n = 20/43). The participants did not report any MU-related mortality but described a number of risk factors for it. This survey is the first detailed attempt to understand the incidence of MU following OAGB/MGB; its complications; and practices concerning prophylaxis, diagnosis, treatment and management of complications.

Mini Gastric Bypass: first report of 125 consecutive cases from United Kingdom.

Mini Gastric Bypass is a promising bariatric procedure with multiple apparent benefits. Ours is the first unit within the National Health Service of the United Kingdom to be routinely performing this procedure. This retrospective cohort study reports our experience with first 125 procedures. Data were retrospectively analysed from a prospective database. Information was further supplemented by interviewing team members, contacting patients' general practitioners and telephonic follow-up. The mean follow-up was 11.4 months. There were 86 (68.8%) females and the mean age was 45 (range 20-70) years. Mean weight and body mass index was 135.8 (range 85-244) kilograms and 48.1 (range 34.5-73.8) kg m(-2) , respectively. The mean operating time was 92.4 (range 45-150) minutes and the mean post-operative hospital stay was 2.2 (range 2-17) days. There was no leak, one 30-day reoperation and no mortality in this study. Three patients required late reoperations and four patients developed marginal ulcers. At 6 months follow-up (n = 114), 27.5 (range 11.4-47.4) % total body weight loss and 60.1 (range 23.2-117.5) % excess body weight loss was seen. The figures at 12 months follow-up (n = 65) were 36.8 (range 23.7-55.4) % and 79.5 (range 44.9-138.3) %, respectively. This study demonstrates early safety and efficacy of Mini Gastric Bypass in a carefully selected British obese population in a high-volume centre.

Laparoscopic adjustable gastric band survival in a high-volume bariatric unit.

BACKGROUND: Although laparoscopic adjustable gastric bands (LAGBs) have been shown to be efficacious, their long-term usefulness has been questioned. This study examined the fate of LAGBs in a unit with over a decade of experience in their use. Patient factors related to the need for, and timing of, band removal were investigated. METHODS: A prospectively maintained database was used to identify all patients with a LAGB. Patient demographics, need for band removal and band survival were examined. Logistic regression modelling was done and Kaplan-Meier curves were calculated for band survival. RESULTS: Between 2000 and 2012, 674 bands were placed in 665 patients. Of these, 143 (21.2 per cent) were removed. There was no difference in rates of removal by sex (P = 0.910). The highest rates of removal were in patients aged less than 40 years (26.7 per cent), and those with a BMI greater than 60 kg/m2 (28.6 per cent). Earlier band removal was seen in younger patients (P = 0.002). Rates of removal increased linearly by earlier year of placement. Of bands placed 4 or more years previously, 35.0 per cent required removal. Eighty-three patients (58.0 per cent) who had a LAGB removed went on to have a further bariatric procedure (band to bypass, 66; band to sleeve, 17). CONCLUSION: Even in experienced hands LAGB does not appear to be a definitive solution. In a large number of patients there appears to be a finite 'band life', with the majority of patients requiring conversion to a further bariatric procedure.

Revisional laparoscopic Roux-en-Y gastric bypass following failed laparoscopic adjustable gastric banding.

BACKGROUND: Obesity is a worldwide epidemic and surgery is the only proven long-term treatment. The two most commonly performed bariatric procedures are laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB). There are advocates of both procedures but LAGB is associated with potentially high failure rates and may require conversion to an alternative procedure. METHODS: This study reports our unit results for failed LAGB converted to LRYGB and compares them to primary LRYGB patients. All patients undergoing revisional LRYGB from July 2006 to December 2011 were included in the study. Comparisons were made to patients undergoing primary LRYGB over the same time period for post-operative weight loss, complications and length of stay. RESULTS: Of the patients, 722 were analysed of which 55 underwent revisional surgery. There was no statistical difference in percentage of excess weight loss at 6 months, 1 year or 2 years following surgery between the primary and revisional surgery cohorts (54.5, 63.7, 65.2 vs 51.6, 59.5, 59.4, p = NS). There was no difference in morbidity, mortality or length of stay between the two groups. Revisional LRYGB was carried out as a single surgery in 43 (78 %) patients. CONCLUSIONS: Revisional LRYGB surgery can be carried out safely and efficiently in experienced bariatric units. Good short- and medium-term weight loss can be achieved with no increase in morbidity, mortality or length of hospital stay. This study adds weight to the argument that LRYGB is the revisional procedure of choice following failed LAGB.

The relationship of distance from the surgical centre on attendance and weight loss after laparoscopic gastric bypass surgery in the United Kingdom.

Obesity remains a significant worldwide health problem and is currently increasing. Surgery remains the only proven long-term intervention and has been shown to be cost-effective. Evidence suggests that regular follow-up following laparoscopic adjustable gastric banding is related to improved outcome, such evidence is lacking for laparoscopic gastric bypass surgery (laparoscopic Roux-en-Y gastric bypass [LRYGB]). This study examines the effect of distance on attendance at post-operative clinics and subsequent weight loss following surgery. A prospectively maintained database was interrogated to analyze patients undergoing LRYGB before August 2010. Patient demographics, percentage excess weight loss (%EWL), compliance with out-patient clinic attendances and the distance the patients lived from the hospital were examined. Perfect clinic attendees were compared with non-attendees and the distances patients lived from the hospital evaluated. There was a significantly greater %EWL at 1 year post-op observed in the perfect attendees group (65.5 vs. 59.5, P = 0.01). Increased %EWL was also evident at 2 years post-op but did not reach statistical significance (66.9 vs. 59.5, P = 0.06). There was a negative correlation observed between post-operative weight loss and distance from the bariatric centre (R = -0.21, P = 0.04). Close follow-up following LRYGB is essential to optimize outcomes. Increased frequency of out-patient clinic visits was associated with improved post-operative weight loss. Increasing distance between the patient's home and the bariatric centre was associated with worse post-operative weight loss.

Laparoscopic adjustable gastric banding: a 10-year single-centre experience of 575 cases with weight loss following surgery.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) is one of the commonest bariatric procedures in the UK. This study reports our experience with this procedure over the last 10 years. METHODS: A prospectively maintained database of all the patients undergoing LAGB at our centre between March 2000 and August 2010 was analysed. RESULTS: Five hundred seventy-five patients underwent LAGB at our centre. There was no mortality in this series. Early (30-day) morbidity rate was 2.2 %. Late complications (20 %) comprised: 78 repositioning of the inflation port in 65 patients, repositioning of band in 24 patients (4 %), removal of band in 20 patients (3.4 %), conversion to bypass in 41 patients (7 %), diagnostic laparoscopy in 1 patient and subtotal gastrectomy in 1 patient. Median follow-up was 29 months. The median of percentage of weight loss (%WL) and excess body weight loss (EBWL) was 18.3 and 40 %, respectively, at ≥ 5 years post-LAGB. Patients with body mass index (BMI) over 50 kg/m(2) were compared to those with BMI ≤ 50 kg/m(2). No significant difference was noted in the weight loss between both of these groups. No significant difference was noted with regards to weight loss between patients <60 and >60 years of age. CONCLUSIONS: In this cohort of patients, %WL and EBWL were 18.3 and 40 % ≥ 5 years after LAGB, respectively, and early and late complication rates were 2.2 and 20 %, respectively. Majority of late complications were in the first 100 patients. Multifactorial causes included the surgical learning curve and patient selection process.

Routine group and save unnecessary for gastric band surgery: a retrospective case review audit of 1018 bariatric patients.

UNLABELLED: What is already known about this subject • The demand for bariatric surgery is increasing. • NHS Trusts are expected to instigate cost-efficiency measures. • Previous articles have discussed the need for routine preoperative cross-match. What this study adds • No gastric band patient suffered a significant drop in haemoglobin or needed a blood transfusion. • Group and save samples could be safely stored in the laboratory and only sent for analysis if clinically indicated. • Even greater cost savings could be achieved if prudent use of perioperative blood testing and blood transfusion was implemented. SUMMARY: Current guidance at our Trust is that all bariatric surgical patients should have preoperative group and save (G&S) and full blood count (FBC) tests, as well as a FBC check 1 d post-operatively. Our aim was to investigate blood transfusion requirements of these patients and whether we could reduce the number of investigations requested. 1018 consecutive elective laparoscopic gastric band and laparoscopic Roux-en-Y gastric bypass patients who were operated on in our bariatric unit from March 2000 until January 2011 were identified. Patients' haemoglobin levels, G&S status and blood transfusion requirements were analyzed using our online pathology system. 607 patients had a laparoscopic gastric band, with 411 undergoing a laparoscopic Roux-en-Y gastric bypass. None of our gastric band patients required a transfusion; however, nine patients (2.2%) undergoing a gastric bypass needed a transfusion. Two patients required transfusion within 24 h of surgery while six of the remaining seven patients received blood 3-4 d post-operatively. Costs incurred on FBC and G&S tests during this time were estimated to exceed £15 700. G&S and post-operative FBC tests could be abandoned for laparoscopic gastric band patients with significant financial and person-time savings. However, given that 2.2% of laparoscopic Roux-en-Y gastric bypass patients needed a blood transfusion, we believe that post-operative FBC tests are still warranted in this patient group, with a G&S sample stored in pathology. Much greater financial savings could be achieved if prudent use of preoperative investigations, including storing G&S samples in the laboratory, was adopted for all elective operations.

Iatrogenic femoropopliteal graft entrapment leading to thrombus formation.

Femoropopliteal bypass graft entrapment by the gastrocnemius muscle and tendons is an unusual cause of graft stenosis or thrombosis. Before graft occlusion occurs, reduced flow may be seen either with the knee in extension or hyperextension or by passive dorsiflexion of the ankle. We report a case of a femoropopliteal bypass graft entrapment causing a thrombus in the distal graft. Duplex imaging, angiography, MRI and graft surveillance programs are useful diagnostic tools. Treatment options include dividing the occluding muscles and tendons and rerouting the graft.

Successful live related renal transplant in a case of tuberous sclerosis.

Tuberous sclerosis (TS) is an autosomal dominant multisystemic disease involving primarily the skin, the brain and the kidneys. Inspite of the kidney being involved in 40-80% of patients with this disease, the incidence of end stage renal disease is only about 1%. There are only 34 reported cases of successful renal transplantation in tuberous sclerosis patients with end stage renal disease. We report a case of successful renal transplantation in a patient of tuberous sclerosis with bilateral polycystic kidneys presenting with renal failure who also underwent bilateral native nephrectomies on follow up.