Long-term Outcomes of Laparoscopic Sleeve Gastrectomy as a Revisional Procedure Following Adjustable Gastric Banding: Variations in Outcomes Based on Indication.

BACKGROUND: Significant controversy exists regarding the indications and outcomes after laparoscopic adjustable gastric banding (LAGB) conversions to laparoscopic sleeve gastrectomy (LSG). AIM: To comprehensively determine the long-term outcomes of sleeve gastrectomy as a revisional procedure after LAGB across a range of measures and determine predictors of outcomes. METHODS: Six hundred revision LSG (RLSG) and 1200 controls (primary LSG (PLSG)) were included. Patient demographics, complications, follow-up, and patient-completed questionnaires were collected. RESULTS: RLSG vs controls; females 87% vs 78.8%, age 45 ± 19.4 vs 40.6 ± 10.6 years, p = 0.561; baseline weight 119.7 ± 26.2 vs 120.6 ± 26.5 kg p = 0.961). Follow-up was 87% vs 89.3%. Weight loss in RLSG at 5 years, 22.9% vs 29.6% TBWL, p = 0.001, 10 years: 19.5% vs 27% TBWL, p = 0.001. RLSG had more complications (4.8 vs 2.0% RR 2.4, p = 0.001), re-admissions (4.3 vs 2.4% RR 1.8, p = 0.012), staple line leaks (2.5 vs 0.9%, p = 0.003). Eroded bands and baseline weight were independent predictors of complications after RLSG. Long-term re-operation rate was 7.3% for RLSG compared to 3.2% in controls. Severe oesophageal dysmotility predicted poor weight loss. RLSG reported lower quality of life scores (SF-12 physical component scores 75.9 vs 88%, p = 0.001), satisfaction (69 vs 93%, p = 0.001) and more frequent regurgitation (58% vs 42%, p = 0.034). CONCLUSION: RLSG provides long-term weight loss, although peri-operative complications are significantly elevated compared to PLSG. Longer-term re-operation rates are elevated compared to PLSG. Four variables predicted worse outcomes: eroded band, multiple prior bands, severe oesophageal dysmotility and elevated baseline weight.

Long-Term Outcomes of Revisional Malabsorptive Bariatric Surgery: Do the Benefits Outweigh the Risk?

PURPOSE: To evaluate the long-term outcomes of revisional malabsorptive bariatric surgery. MATERIALS AND METHODS: Malabsorptive bariatric procedures are increasingly performed in the revisional setting. We collated and analysed prospectively recorded data for all patients who underwent a revisional Biliopancreatic diversion + / - duodenal switch (BPD + / - DS) over a 17-year period. RESULTS: We identified 102 patients who underwent a revisional BPD + / - DS. Median follow-up was 7 years (range 1-17). There were 21 (20.6%) patients permanently lost to follow-up at a median of 5 years postoperatively. Mean total weight loss since the revisional procedure of 22.7% (SD 13.4), 20.1% (SD 10.5) and 17.6% (SD 5.5) was recorded at 5, 10 and 15 years respectively. At the time of revisional surgery, 23 (22.5%) patients had diabetes and 16 (15.7%) had hypercholesterolaemia with remission of these occurring in 20 (87%) and 7 (44%) patients respectively. Nutritional deficiencies occurred in 82 (80.4%) patients, with 10 (9.8%) patients having severe deficiencies requiring periods of parenteral nutrition. Seven (6.9%) patients required limb lengthening or reversal procedures. There were 16 (15.7%) patients who experienced a complication within 30 days, including 3 (2.9%) anastomotic leaks. Surgery was required in 42 (41.2%) patients for late complications. CONCLUSION: Revisional malabsorptive bariatric surgery induces significant long-term weight loss and comorbidity resolution. High rates of temporary and permanent attrition from follow-up are of major concern, given the high prevalence of nutritional deficiencies. These data question the long-term safety of malabsorptive bariatric procedures due to the inability to ensure compliance with nutritional supplementation and long-term follow-up requirements. KEY POINTS: • Revisional bariatric surgery workload is increasing • Revisional malabsorptive surgery is efficacious for weight loss and comorbidity resolution • Revisional malabsorptive surgery is associated with high rates of nutritional deficiencies • Attrition from follow-up in this specific cohort of patients is of particular concern due to the risk of undiagnosed and untreated nutritional deficiencies.

A 4-tier Protocolized Radiological Classification System for Leaks Following Sleeve Gastrectomy.

OBJECTIVES: To develop and validate a classification of sleeve gastrectomy leaks able to reliably predict outcomes, from protocolized computed tomography (CT) findings and readily available variables. SUMMARY OF BACKGROUND DATA: Leaks post sleeve gastrectomy remain morbid and resource-consuming. Incidence, treatments, and outcomes are variable, representing heterogeneity of the problem. A predictive tool available at presentation would aid management and predict outcomes. METHODS: From a prospective database (2009-2018) we reviewed patients with staple line leaks. A Delphi process was undertaken on candidate variables (80-20). Correlations were performed to stratify 4 groupings based on outcomes (salvage resection, length of stay, and complications) and predictor variables. Training and validation cohorts were established by block randomization. RESULTS: A 4-tiered classification was developed based on CT appearance and duration postsurgery. Interobserver agreement was high (κ = 0.85, P < 0.001). There were 59 patients, (training: 30, validation: 29). Age 42.5 ± 10.8 versus 38.9 ± 10.0 years (P = 0.187); female 65.5% versus 80.0% (P = 0.211), weight 127.4 ± 31.3 versus 141.0 ± 47.9 kg, (P = 0.203). In the training group, there was a trend toward longer hospital stays as grading increased (I = 10.5 d; II = 24 d; III = 66.5 d; IV = 72 d; P = 0.005). Risk of salvage resection increased (risk ratio grade 4 = 9; P = 0.043) as did complication severity (P = 0.027).Findings were reproduced in the validation group: risk of salvage resection (P = 0.007), hospital stay (P = 0.001), complications (P = 0.016). CONCLUSION: We have developed and validated a classification system, based on protocolized CT imaging that predicts a step-wise increased risk of salvage resection, complication severity, and increased hospital stay. The system should aid patient management and facilitate comparisons of outcomes and efficacy of interventions.

Initial radiologic appearance rather than management strategy predicts the outcomes of sleeve gastrectomy leaks.

BACKGROUND: Initial radiologic appearance rather than management strategy predicts the outcomes of sleeve gastrectomy leaks. OBJECTIVE: Multiple modalities have been advocated for the treatment of sleeve gastrectomy leak, and there remains no consensus on the best treatment paradigm. For more than 10 years, we have variably attempted luminal occlusive therapies and repeated endoscopic debridement as treatment options. By evaluating the outcomes from these approaches, we aimed to determine whether the first management strategy is superior to the second in terms of outcomes. METHODS: Patients were analyzed by group (luminal occlusive therapy versus repeated endoscopic debridement). Leaks were then stratified by radiologic appearance on computed tomography, defined as phlegmon, collection, contrast medium leak, or fistula. The primary outcome was length of stay (LOS). Secondary outcomes were comprehensive complication index and the need for resection. RESULTS: There were 54 patients, with 22 in the luminal occlusion group and 32 in the repeated debridement group. There was no difference in LOS (59.8 ± 41.6 versus 46.5 ± 51.2 days, P = .179) and no difference in the requirement for resection (4 versus 3 resections, p = .425). Subset analysis suggested that patients who underwent operative versus conservative management (P = .006) had a longer LOS. Excluding management strategy, radiologic appearance on admission significantly predicted LOS (P = .0053). Patients presenting with fistula (84 ± 25.4 days) and contrast medium leak (64.1 ± 40 days) had a significantly longer LOS than those diagnosed with phlegmon (13.5 ± 5.5 days). Radiologic appearance was predictive of complication severity (P < .0001) and salvage resection (P = .008). CONCLUSION: There was no significant difference in outcomes between patients treated with intraluminal occlusion or repeated debridement. Initial radiologic appearance was predictive of LOS and complication severity. This highlights the need for routine use of a validated classification system in studies reporting outcomes and treatment of sleeve leaks.

Long-Term Matched Comparison of Adjustable Gastric Banding Versus Sleeve Gastrectomy: Weight Loss, Quality of Life, Hospital Resource Use and Patient-Reported Outcome Measures.

BACKGROUND: Comparisons of bariatric procedures across a range of outcomes are required to better inform selection of procedures and optimally allocate health care resources. AIMS: To determine differences in outcomes between laparoscopic adjustable gastric banding (LAGB) and laparoscopic sleeve gastrectomy (LSG) across nine outcome domains. METHODS: Matched primary LSG or LAGB across age, weight and surgery date were recruited. Data were collected from a prospective database and patient-completed questionnaires. RESULTS: Patients (n = 520) were well-matched (LAGB vs. LSG; age 41.8 ± 11.2 vs. 42.7 ± 11.7 years, p = 0.37; male 32.4% vs. 30.2%, p = 0.57; baseline weight 131.2 ± 30.5 vs. 131.0 ± 31.1 kg, p = 0.94). Follow-up rate was 95% at a mean of 4.8 years. LAGB attended more follow-up visits (21 vs. 13, p < 0.05). Mean total body weight loss was 27.7 ± 11.7% vs. 19.4 ± 11.1% (LSG vs. LAGB, p < 0.001). LAGB had more complications (23.8% vs. 10.8%, p < 0.001), re-operations (89 vs. 13, p < 0.001) and readmissions (87 vs. 32, p < 0.001). However, early post-operative complications were higher post-LSG (2.6 vs. 9.2%, p = 0.007). Length of stay (LOS) was higher post-LSG compared with LAGB (5.2 ± 10.9 vs. 1.5 ± 2.2 days, p < 0.001). LSG patients reported better quality of life (SF-36 physical component score 54.7 ± 7.9 vs. 47.7 ± 10.8, p = 0.002) and satisfaction (9.2 ± 1.9 vs. 8.4 ± 1.6, p = 0.001) and less frequent regurgitation (1.2 ± 1.2 vs. 0.7 ± - 1.1, p = 0.032) and dysphagia (2.0 ± 1.3 vs. 1.3 ± 1.6, p = 0.007). CONCLUSION: This study showed high long-term follow-up rates in a large cohort of well-matched patients. Weight loss was greater with LSG. LAGB reported more re-operations and less satisfaction with the outcome. LOS was driven by patients with complications. This study has reinforced the need for comprehensive measurement of outcomes in bariatric surgery.

Indications and efficacy of endoscopic vacuum-assisted closure therapy for upper gastrointestinal perforations.

BACKGROUND: Endoscopic vacuum-assisted closure (EndoVAC) therapy is a recent innovation described for use in upper gastrointestinal perforations and leaks, with reported success of 80-90%. It provides sepsis control and collapses the cavity preventing stasis, encouraging healing of the defect. Whilst promising, initial reports of this new technique have not established clear indications, feasibility and optimal technique. METHODS: We analysed all patients who underwent EndoVAC therapy between 2014 and 2016. The technique involved a standard gastroscope, nasogastric tube and vacuum-assisted closure dressing kit, with endoscopic placement of the polyurethane sponge. Data were collected on indication, technique, sepsis control, outcomes and drainage volumes. RESULTS: Ten patients were treated. Average age was 56.7 ± 12.3 years. There were three mortalities. EndoVAC placement was feasible in nine patients and successful healing was observed in six patients. Failure was more likely in the cases of large (>8 cm), chronic or complex cavities. A three-phase response was seen in successful cases, with initial reduction in external drainage (average: 143-17 mL/day within 1 week), followed by a progressive reduction in inflammatory markers (2 weeks) and finally a healing phase with reduction in cavity size (3 weeks). CONCLUSION: EndoVAC therapy is a potentially useful adjunct to conventional treatments of a subset of upper gastrointestinal leaks and perforations when there is a contained cavity <8 cm. It appears less effective in an uncontained perforation or chronically established tract. It has clear advantages of being easily applied with readily available equipment and disposables.

Visual Liver Score to Stratify Non-Alcoholic Steatohepatitis Risk and Determine Selective Intraoperative Liver Biopsy in Obesity.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) and its progressive form, non-alcoholic steatohepatitis (NASH), are endemic in obesity. We aimed to evaluate the diagnostic accuracy and reproducibility of a simple intraoperative visual liver score to stratify the risk of NASH and NAFLD in obesity and determine the need for liver biopsy. METHODS: This is a prospective cohort study of obese adults undergoing bariatric surgery. The surgical team used a visual liver score to evaluate liver colour, size and surface. This was compared to histology from an intraoperative liver biopsy. RESULTS: There were 152 participants, age 44.6 ± 12 years, BMI 45 ± 8.3 kg/m2. Prevalence of NAFLD was 70.4%, with 12.1% NASH and 26.4% borderline NASH. Single-visual components were less accurate than total composite score. Steatosis was most accurately identified (significant steatosis: AUROC 0.746, p < 0.05; severe steatosis: AUROC 0.855, p < 0.05). NASH was identified with moderate accuracy (AUROC 0.746, p = 0.001), with sensitivity 75% for a score ≥ 2. Stratification into low (≤ 1) and high-risk (≥ 4) scores accurately identified patients who should or should not have an intraoperative biopsy. Most patients with a normal-appearing liver did not have disease (94.4%). The structured visual assessment was quick and interobserver agreement was reasonable (κ = 0.53, p < 0.05). CONCLUSIONS: A simple, structured tool based on liver appearance can be a useful and reliable tool for NAFLD risk stratification and identification of patients who would most and least benefit from a biopsy. A normal liver appearance reliably excludes significant liver disease, avoiding the need for liver biopsy in patients otherwise at high clinical risk of NASH.

Radical gastric cancer surgery results in widespread upregulation of pro-tumourigenic intraperitoneal cytokines.

BACKGROUND: Radical surgical resection is the mainstay of curative treatment for oesophagogastric malignancy. However, survival and recurrence rates remain poor. Theoretical data suggests that the inflammatory response to surgery can promote tumour recurrence. The local and systemic inflammatory response to radical oesophagogastric cancer surgery has not been fully characterized. We aimed to measure this response, particularly factors associated with tumour implantation. METHODS: Consecutive patients undergoing radical junctional or gastric cancer resection over 12 months were recruited. Repeated serum and adipose tissue were collected intra-operatively. Adipose tissue was collected adjacent and remote to the tumour, and cytokine messenger RNA (mRNA) expression was measured. Post-operatively, daily serum was collected for 7 days, and analysed for inflammatory cell profile and cytokine concentration. RESULTS: There were nine patients recruited (67.1 ± 2.1 years). mRNA expression of interleukin-6 (IL-6), CC-chemokine ligand-2 and IL-1ß increased in adipose tissue intra-operatively (P < 0.05), equally both adjacent and remote from the tumour site. Serum IL-6 concentration increased from 23.3 pg/mL to 161.8 pg/mL intra-operatively (P < 0.05) before falling steadily to 35.7 pg/mL post-operatively (P < 0.05). Serum tumour necrosis factor-α was elevated throughout, and IL-1ß levels were unaffected. Leukocyte and neutrophil populations increased, while T-cell and dendritic cell populations decreased intra-operatively (P < 0.05). CONCLUSION: Radical surgery dramatically upregulates the expression of pro-tumourigenic cytokines in the peritoneum. There is also a marked systemic immune and inflammatory response to surgery, including downregulation of T-cell and dendritic cell populations. This offers two potential pathways that may facilitate tumour progression - local inflammation promoting peritoneal adherence and implantation, and secondary suppression of immunosurveillance due to circulating inflammatory response.

Assessing quality of care in oesophago-gastric cancer surgery in Australia.

BACKGROUND: Outcomes of oesophago-gastric cancer are poor and highly variable between centres. It is important that complex multimodal treatments are applied optimally. Low case volumes at Australian centres mean that the analysis of crude outcomes is an inadequate assessment of overall quality of care. Detailed analysis across a range of quality domains offers the opportunity to measure performance. METHODS: We compared data from the UK National Oesophago-gastric Cancer Audit 2010 with the prospective Alfred Hospital oesophago-gastric cancer database. RESULTS: There were 314 Alfred and 17 279 UK patients identified. The volume of patients assessed by the Alfred was equal to the second highest quartile in the UK trust (4-5 new cases per month). Case ascertainment was better, capturing 84% of all oesophago-gastric cancer within the Alfred prospective audit (P < 0.001). The use of staging CT and PET scans was more common among Alfred patients (99% versus 89%, P < 0.01 and 83.8% versus 17%, P < 0.01, respectively). More patients embarked on a curative pathway (P < 0.01), with greater use of neo-adjuvant therapies. Acceptable lymph node yields were less in oesophagectomies (88.2% versus 96.2%, P < 0.01) and similar in gastrectomies (77.4% versus 74.6%, P = 0.61). Higher overall complications were observed in Alfred patients (P < 0.01), predominantly due to respiratory complications. Perioperative mortality after resection and 1-year survival was similar. CONCLUSIONS: Comparing a range of quality domains as a means of identifying areas of deficiency is feasible. This allows for contemporaneous improvements in service quality and may be more appropriate in the Australian setting than focusing on volume.

The Physiology and Pathophysiology of Gastroesophageal Reflux in Patients with Laparoscopic Adjustable Gastric Band.

INTRODUCTION: The effect of the laparoscopic adjustable gastric band (LAGB) on esophageal acid exposure and reflux is poorly understood. Optimal technique and normative values for acid exposure have not been established in this group. METHODS: High-resolution manometry (HRM) and 24-h ambulatory esophageal pH monitoring were performed in three groups: asymptomatic LAGB, symptomatic LAGB, and pre-operative reflux patients. This technique utilized intraluminal pressure signatures during HRM to guide accurate pH sensor placement. RESULTS: The LAGB groups were well matched: age 48 vs 51 years (p = 0.249), weight loss 27.3 vs 26.7 kg (p = 0.911). The symptomatic group had a larger gastric pouch (5.2 vs 3.3 cm, p = 0.012), with higher esophageal acid exposure (10.8 vs 0.9%, p < 0.001). Two acidification patterns were observed: irritant and volume acidification, associated with substantial supine acidification. Symptomatic LAGB had altered esophageal motility, with poorer lower esophageal sphincter basal tone (8.0 vs 17.7 mmHg, p = 0.022) and impaired contractility of the lower esophageal segment (90 vs 40%, p = 0.009). Compared to pre-operative reflux patients, symptomatic LAGB patients demonstrated higher total and supine esophageal acid exposure (10.8 vs 7.0%, p = 0.010; 14.9 vs 5.1%, p < 0.001), less symptoms (2 vs 6, p = 0.001) and lower symptom index (0.7 vs 0.9, p = 0.010). CONCLUSIONS: Ambulatory pH monitoring is an effective technique if the pH sensor is positioned appropriately using HRM. The correctly positioned LAGB appears associated with low esophageal acidification. In contrast, patients with symptoms or pouch dilatation can have markedly elevated esophageal acidification, particularly when supine. This is a different pattern compared to pre-operative patients and importantly can be disproportionate to symptoms.

Diagnosis and Management of Oesophageal Cancer in Bariatric Surgical Patients.

BACKGROUND: Oesophageal cancer following bariatric surgery adds significant complexity to an already challenging disease. There is limited data on the diagnosis, presentation and management in these complex cases. METHODS: A retrospective cohort study on prospectively collected data over 10 years was conducted. The oesophago-gastric cancer database was searched for patients with prior bariatric surgery. Data were retrieved on bariatric and cancer management. RESULTS: We identified nine patients with oesophageal or gastro-oesophageal junction adenocarcinoma after bariatric surgery. Mean age was 58.3 ± 6.9 years, and duration from bariatric surgery was 13.2 ± 9.4 years. Weight loss at diagnosis was 30.6 ± 23.3 kg (excess weight loss 58.1 % ± 29.6). Modes of presentation were Barrett's surveillance (n = 3), reflux symptoms (n = 4) and incidental (n = 2). Management was surgical resection (n = 4), endoscopic mucosal resection (n = 2) and palliative (n = 3). Surgical resections were challenging due to adhesions, obesity, luminal dilatation and scarring on the stomach. There were two substantial leaks following gastroplasty. CONCLUSIONS: Oesophageal cancer following bariatric surgery is a challenging problem, and surgical resection carries high risk. A high index of suspicion is required and symptoms investigated precipitously. Technical challenges of operating on obese patients and the specific effects of previous bariatric procedures need to be understood, particularly the limitations on reconstructive options.

Gastric band connection tube results in small bowel obstruction: an acute emergency.

The laparoscopic adjustable gastric band (LAGB) is a widely performed procedure for the morbid obesity epidemic. Despite its low mortality compared with other mainstream bariatric surgeries, it is not without its complications. The authors report a late and rare complication of a small bowel obstruction in a 52-year-old woman from an LAGB placed for 2 years. She was diagnosed clinically and radiologically with a small bowel obstruction. However, in the setting of an LAGB, this became a closed-loop obstruction. She proceeded to an emergency laparoscopy, which revealed that the port connection tube had formed dense adhesions to the jejunum causing an obstructive band. This is only the fifth reported case in Australia; as bariatric surgery continues to rise, these patients may present unannounced to any emergency department and as such should be treated as a closed-loop obstruction with immediate resuscitative and surgical management instituted.

Patient and Parent Perspectives of Adolescent Laparoscopic Adjustable Gastric Banding (LAGB).

BACKGROUND: Adolescent obesity is a significant global health challenge and severely obese adolescents commonly experience serious medical and psychosocial challenges. Consequently, severe adolescent obesity is increasingly being treated surgically. The limited available research examining the effectiveness of adolescent bariatric surgery focuses primarily on bio-medical outcomes. There is a need for a more comprehensive understanding of the behavioural, emotional and social factors which affect adolescents' and parents' experience of weight loss surgery. METHODS: Patient and parents' perspectives of adolescent LAGB were examined using a qualitative research methodology. Individual, semi-structured interviews were conducted with eight adolescent patients and five parents. Thematic analysis was used to identify key themes in the qualitative data. RESULTS: Patients and parents generally considered adolescent laparoscopic adjustable gastric banding (LAGB) to be a life-changing experience, resulting in physical and mental health benefits. Factors considered to facilitate weight loss following surgery included parental support and adherence to treatment guidelines. Many adolescents reported experiencing surgical weight loss stigma and challenging interpersonal outcomes after weight loss for which they felt unprepared. CONCLUSIONS: Patients and parents perceived LAGB positively. There are opportunities to improve both the experience and outcomes of adolescent LAGB through parental education and enhancements to surgical aftercare programmes.

A Pre-Hospital Patient Education Program Improves Outcomes of Bariatric Surgery.

BACKGROUND: We designed an assessment and education program which was delivered to patients prior to first outpatient appointment for bariatric surgery. We hypothesised that this program would streamline care and would lead to improved weight loss following bariatric surgery. METHODS: The program incorporates a structured general practitioners (GP) review, a patient information evening and an on-line learning package. It was introduced in September 2012. Patient flow through the program was recorded. Outcomes of the new program were compared with contemporaneously treated patients who did not undertake the pre-hospital program. RESULTS: All 636 patients on the waiting list for first appointment at the Alfred Health bariatric surgery clinic were invited to participate. There were 400 patients ultimately removed from the waiting list for first appointment. Of the remaining 236 patients, 229 consented to participate in the new program. The mean BMI was 47.8 ± 9.2. The fail to attend first appointment rate dropped from 12 to 2.1 %. At 12 months post-bariatric surgery, patients who undertook the new program (n = 82) had a mean excess weight loss (EWL) of 41.1 ± 20.3 % where as those treated on the standard pathway (n = 61) had a mean EWL 32 ± 18.0 % (p = 0.012). CONCLUSIONS: The introduction of a pre-hospital education program has led to an improvement in attendance rates and early weight loss post-bariatric surgery.

Outcomes of high-volume bariatric surgery in the public system.

BACKGROUND: Bariatric surgery has not been widely used in the Australian public health system. As obesity is strongly associated with socio-economic status, excluding its use from the public system will deny many of the most in-need access to a potentially very effective treatment. Alternatively, with rigorous follow-up and behavioural change requirements, highly successful outcomes in the private system may not translate to the public system. METHODS: The Alfred Hospital rapidly expanded bariatric surgery from 2007. A 6-year prospective follow-up study was conducted with annual review of weight, co-morbidities, retention in follow-up, serum HbA1c, quality of life and patient satisfaction. RESULTS: There were 1453 patients. Procedures were predominantly laparoscopic-adjustable gastric bands (n = 861). Patient details were age 49 ± 11 years, body mass index 50.7 ± 11.2 kg/m(2) and weight 139.0 ± 30.2 kg. There was no mortality, and mean length of stay was 1.1 ± 1.2 days. Follow-up was 98% (1 year) and 85% (6 years). Weight loss was 22 ± 13.1 kg (32.8 ± 18% excess weight loss) at 1 and 30.1 ± 16.8 kg (60 ± 28%) at 6 years. The mean number of co-morbidities was 4.2 ± 1.1 with significant improvements observed. Patient satisfaction was 7.7 ± 2.3 out of 10. Mental and physical summary scores (SF-36) improved from 41.02 ± 13.17 to 45.50 ± 13.27 (P < 0.001) and 33.97 ± 10.53 to 44.79 ± 11.19 (P < 0.001). CONCLUSIONS: Patients were older, heavier and suffered more co-morbid disease than previously reported cohorts. For the first time, excellent outcomes across a range of key quality domains in a large patient cohort have been reported in the public system. High-volume bariatric surgery in the public system is viable.

Ex vivo dissection increases lymph node yield in oesophagogastric cancer.

BACKGROUND: Retrieval and analysis of an adequate number of lymph nodes is critical for accurate staging of oesophageal and gastric cancer. Higher total node counts reported by pathologists are associated with improved survival. A prospective study was undertaken to understand the factors contributing to variability in lymph node counts after oesophagogastric cancer resections and to determine whether a novel strategy of ex vivo dissection of resected specimens into nodal stations improves node counts reported by pathologists. METHODS: The study involved 88 patients with potentially curable oesophagogastric cancer undergoing radical resection. Lymph node counts were obtained from pathology reports and analysed in relation to multiple variables including the introduction of ex vivo dissection of nodal stations in theatre. RESULTS: Higher lymph node counts were obtained with ex vivo dissection of nodal stations (median 19 versus 8, P < 0.01). Node counts also varied significantly with the reporting pathologist (median range 4 to 48, P = 0.02) which was independent of the level of experience of the pathologist (P = 0.67). Node counts were not affected by patient age (P = 0.26), gender (P = 0.50), operative approach (P = 0.50) or neoadjuvant therapy (P = 0.83). CONCLUSIONS: Specimen handling is a significant factor in determining lymph node yield following radical oesophageal and gastric cancer resections. Ex vivo dissection of resected specimens into nodal stations improves node counts without alterations to surgical techniques. Ex vivo dissection should be considered routine.

Outcomes of revision laparoscopic gastric banding: a retrospective study.

BACKGROUND: Obesity is a health problem approaching pandemic proportions. Laparoscopic adjustable gastric banding (LAGB) is the bariatric procedure of choice in Australia for effective surgical treatment of severe obesity. Complications of LAGB lead to a high proportion of patients requiring revision surgery. However, literature regarding outcomes and failure rates of revision bariatric surgery is scarce, such that the choice of procedure at reoperation remains controversial. This paper aims to present outcomes of revision laparoscopic gastric banding. METHODS: One hundred eighty-three consecutive revision LAGB procedures were performed in 163 patients between March 1998 and July 2009. Patients were followed up for a median period of 36 months. Weight change in terms of body mass index (BMI) and percentage excess weight loss (%EWL), morbidity and patient tolerance were examined. RESULTS: The average reduction in BMI from the primary LAGB procedure was 8.45 kg/m(2) , equivalent to a %EWL of 50.55. BMI of patients who underwent revision LAGB appears to remain stable, with mean change of +0.25 kg/m(2) (%EWL 45.76, P = 0.5) at 3 years and -1.59 (%EWL 51.52, P = 0.12) at 5 years. The overall complication rate of revision LAGB was 13.7%, most commonly recurrent gastric pouch dilatation. CONCLUSIONS: Revision LAGB is reasonably well tolerated by most patients. Preliminary outcome data indicate that revision gastric banding does not result in further weight loss in patients who have lost weight from primary banding, but does maintain the weight loss achieved.

An approach to the assessment and management of the laparoscopic adjustable gastric band patient in the emergency department.

OBJECTIVE: As the number of obese people in Australia continues to increase, laparoscopic adjustable gastric banding (LAGB) surgery will become increasingly common. It is important for practitioners involved in the care of such patients to be able to accurately diagnose, and initially manage, pathology relating to the LAGB. METHODS: A retrospective review of 56 presentations in 41 patients with LAGB, who presented to the ED of a major tertiary hospital, was performed. Note was made of presenting symptoms, investigations undertaken, subsequent diagnosis, and initial and definitive management. RESULTS AND DISCUSSION: The commonest presenting symptoms included abdominal pain, nausea, vomiting and dysphagia. The ultimate diagnosis was food bolus obstruction (18 presentations; 32.1%), port infection (11 presentations; 19.6%), band prolapse (9 presentations; 16.1%), band erosion (2 presentations; 3.6%) and subacute bowel obstruction (1 presentation; 1.8%). Food bolus obstruction was best diagnosed clinically. Plain abdominal X-ray was useful to identify prolapse. Infection was best diagnosed with the combination of clinical picture and wound swab. CT scan was helpful when suspecting a deep source of infection. From these data, two algorithms were developed, which can be used as a clinical aide to help practitioners in diagnosing and treating such complications appropriately. CONCLUSION: It is important that health-care professionals are aware of the common presentations of problems following LAGB and have a basic paradigm for initial care. The present study identifies the presenting picture of various complications that can arise postoperatively, and describes an approach to the assessment and management of the LAGB patient in the ED.

Transoral incisionless fundoplication 2.0 procedure using EsophyX™ for gastroesophageal reflux disease.

BACKGROUND: Transoral incisionless fundoplication (TIF) using the EsophyX™ system has been introduced as a possible alternative for the treatment of gastroesophageal reflux disease (GERD). The efficacy of this procedure in our centers was evaluated. METHODS: Patients were selected for treatment if they had typical GERD symptoms, failed management with proton pump inhibitors (PPIs), a positive esophageal pH test with symptom correlation, and no hiatus hernia larger than 2 cm. RESULTS: Nineteen patients (11 men, 8 women) underwent the TIF procedure between April 2008 and July 2009. Mean age was 48.2 years and body mass index was 24.6. The major complication rate was 3/19, including esophageal perforation, hemorrhage requiring transfusion, and permanent numbness of tongue. At mean 10.8 months follow-up, 5/19 had completely discontinued PPIs, and 3/19 had decreased their PPI dose. However, 10/19 had been converted to laparoscopic fundoplication for recurrent reflux symptoms and an endoscopically confirmed failed valve. Nine of 17 were dissatisfied with the outcome, and eight were satisfied. Thirteen of 19 (68%) were considered to have been unsuccessful. CONCLUSION: At short-term follow-up, the TIF procedure is associated with an excessive early symptomatic failure rate, and a high surgical re-intervention rate. This procedure should not be performed outside of a clinical trial.

Small bowel obstruction creates a closed loop in patients with a laparoscopic adjustable gastric band.

We report on two cases of small bowel obstruction in the setting of a previous laparoscopic adjustable gastric band insertion. In both cases, a closed loop obstruction was created by the band and delayed diagnosis resulted in significant morbidity. Early recognition with deflation of the adjustable gastric band and nasogastric tube insertion is paramount to managing these patients.