Changes in glycaemic control, blood pressure and lipids 5 years following laparoscopic adjustable gastric banding combined with medical care in patients with type 2 diabetes: a longitudinal analysis.

The long-term outcomes of weight loss maintenance induced by laparoscopic adjustable gastric band (LAGB) followed by multidisciplinary medical care in patients with type 2 diabetes mellitus (T2DM) (beyond 3 years) are scarcely reported. Study aims were to determine the longer term metabolic outcomes following LAGB combined with medical care in patients with T2DM. This is a longitudinal analysis of 200 adults with T2DM who had LAGB between 2003 and 2008 and were followed up till 2013 at a single bariatric unit in a tertiary UK centre. A total of 200 patients (age 47 ± 9.7 years; body mass index [BMI] 52.8 ± 9.2 kg m-2 ; glycosylated haemoglobin (HbA1c) 7.9 ± 1.9% [62.8 mmol mol-1 ]; women, n = 123 [61.5%]; insulin treatment, n = 71 [35.5%]) were included. The mean follow-up was 62.0 ± 13.0 months (range 18-84 months). There were significant reductions in body weight (-24.4 ± 12.3% [38 ± 22.7 kg]), HbA1c (-1.4 ± 2.0%), systolic blood pressure [BP] (-11.7 ± 23.5 mmHg), total cholesterol and triglyceride levels. The proportion of patients requiring insulin reduced from 36.2% to 12.3%. The overall band complication rate was 21% (21 patients). LAGB when combined with multidisciplinary medical care significantly improved metabolic outcomes in patients with T2DM independent of diabetes duration, and baseline BMI over 5 years. Diabetes duration and baseline BMI did not predict changes in glycaemic control, BP or lipids following LAGB.

An "all 5 mm ports" technique for laparoscopic day-case anti-reflux surgery: A consecutive case series of 205 patients.

INTRODUCTION: Laparoscopic anti-reflux surgery is conventionally performed using two 10/12 mm ports. While laparoscopic procedures reduce post-operative pain, the use of larger ports invariably increases discomfort and affects cosmesis. We describe a new all 5 mm ports technique for laparoscopic anti-reflux surgery and present a review of our initial experience with this approach. METHODS: All patients undergoing laparoscopic fundoplication over a 35 month period from February 2013 under the care of a single surgeon were included. A Lind laparoscopic fundoplication was performed using an all 5 mm port technique. Data was recorded prospectively on patient demographics, operating surgeon, surgical time, date of discharge, readmissions, complications, need for re-intervention, and reasons for admission. RESULTS: Two hundred and five consecutive patients underwent laparoscopic fundoplication over the study period. The all 5 mm port technique was used in all cases, with conversion to a 12 mm port only once (0.49%). Median operating time was 52 min 185 (90.2%) patients were discharged as day cases. Increasing ASA grade and the presence of a hiatus hernia were associated with the need for overnight stay with admission required in 33% of patients with ASA 3, compared to 4% with ASA 1 (p = 0.001), and 29% of those with a hiatus hernia vs. 5% without (p < 0.001). No port-related complications occurred, and no patients developed recurrence of reflux symptoms. A single patient required mesh repair of a large hiatus hernia. CONCLUSION: The all 5 mm ports approach to laparoscopic anti-reflux surgery is a safe, efficient, and cost-effective technique which facilitates same day discharge and minimises port related complications. National commissioning guidelines in the UK should target quality improvements in anti-reflux surgery based around day-case management. This would improve the service for these patients and culminate in cost savings for the NHS.

Day surgery for achalasia cardia: Time for consensus?

INTRODUCTION: Laparoscopic Heller's myotomy (LHM) is the most effective therapy for achalasia of the oesophagus. Most case series of LHM report a length of hospital stay (LOS) >1 day. We present 14 years of experience of LHM to examine the safety and feasibility of LHM as a day case procedure. METHODS: We retrospectively examined patients undergoing elective LHM for achalasia at our institution between 2000 and 2014. Demographics, episode statistics, prior investigations and interventions were collated. Outcomes, including LOS, complications and re-interventions, were compared for the periods before and after a consensus decision at our institution in 2008 to perform LHM as a day case procedure. RESULTS: Sixty patients with a mean age of 41 ± 13 years were included, of whom 58% were male. The median LOS for all patients was 1 day (interquartile range [IQR] 0-2.25). Overall, LHM was performed as a day case in 27 (45%) cases, at 2/26 (7.7%) in the first period versus 25/34 (73.5%) in the second (p<0.01). There were no significant differences in age, gender or previous interventions between day surgery and non-day surgery groups. One patient required subsequent unplanned surgery, while six (10%) needed endoscopic treatment of recurrent symptoms within 12 months. CONCLUSIONS: LHM can be performed safely as a day case procedure. Complication rates are low, with only a small proportion of patients requiring endoscopic treatment for symptom recurrence within 1 year.

A prospective cross-sectional study of laparoscopic subtotal Lind fundoplication for gastro-oesophageal reflux disease--a durable and effective anti-reflux procedure.

INTRODUCTION: Laparoscopic partial fundoplication for gastro-oesophageal reflux disease (GORD) is reported to have fewer side effects when compared to Nissen fundoplication, but doubts remain over its long term durability in controlling reflux. The aim of this study was to assess outcome of symptoms for all patients presenting with GORD undergoing routine laparoscopic subtotal Lind fundoplication. MATERIALS & METHODS: All patients undergoing laparoscopic fundoplication between August, 1999 and November, 2007 performed by a single surgeon were included in the study. The anti-reflux procedure studied was laparoscopic Lind (300°) fundoplication with crural repair in all cases. Patients completed pre and post-operative questionnaires containing validated scoring systems for heartburn, gas bloat, dysphagia and overall patient satisfaction. RESULTS: Over the 100-month period, 320 consecutive patients underwent laparoscopic subtotal Lind fundoplication. Of these, 256 (80%) replied to the questionnaire at a mean of 31 months (range 3-96 months) following surgery. 91.4% of respondents had an improvement in heartburn symptom score with a significant reduction in score from 7.74 preoperatively to 1.25 postoperatively (p<0.001). There was also a significant reduction of mean modified Visick score for reflux control (heartburn and regurgitation) from 3.49 preoperatively to 1.48 after surgery (p<0.001). In total, 22 patients developed recurrent reflux symptoms with half of these reporting their recurrence within two years following surgery. Because of this all were tested with post-operative pH testing, yet only one had a 24-h pH time outside the normal range. Overall patient satisfaction was high with a visual analogue score of 9 and 88% of the patients claimed they would have the operation again. CONCLUSION: Laparoscopic Lind fundoplication demonstrates excellent reflux control when performed routinely for all patients presenting with GORD. This technique is both durable and efficacious in controlling reflux symptoms.

Prospective study of routine day-case laparoscopic modified Lind partial fundoplication.

BACKGROUND: The aim of the present study was to prospectively assess the feasibility, safety, and acceptability of performing day-case laparoscopic modified Lind fundoplication for gastroesophageal reflux disease on a routine basis and to determine possible implications for health care costs to the hospital. METHODS: All patients undergoing laparoscopic fundoplication between November 2005 and November 2007 under the care of one surgeon were included in the study. Inclusion criteria were American Society of Anesthesiologists (ASA) grade I and II with adequate home support. The surgical procedure was laparoscopic modified Lind fundoplication in all the cases. Patients were reviewed in the clinic at 6 weeks and were subsequently assessed through a structured postal questionnaire at a median of 1 year. RESULTS: Over the 25-month period, a total of 130 laparoscopic modified Lind fundoplications were performed, of which 103 (79.2%) met the inclusion criteria for day-case surgery. The patients were 16 to 75 years of age. Ninety (87.4%) were discharged on the same day as planned, and 11 patients were admitted overnight because of nausea. At clinic follow-up at a median of 6 weeks all patients expressed satisfaction and were reflux free. There was a significant reduction of mean modified Visick score and visual analog scale for reflux at a median of 1 year after surgery. CONCLUSIONS: Routine day-case laparoscopic modified Lind fundoplication for gastroesophageal reflux disease is safe and well tolerated, with high levels of patient satisfaction and reduced costs to the hospital. Patients with ASA grade >2 and redo antireflux surgery should not be considered for day-case surgery. Hospital readmission was required in less than 3% of patients after discharge home, but those readmissions were not related to early discharge on the same day of surgery.

The driving force in trocar insertion: a comparison between disposable and reusable trocars.

BACKGROUND: Insertion of the first trocar during the "closed" technique of creating a pneumoperitoneum remains one of the most hazardous maneuvres in laparoscopic surgery, with complications such as major vascular and bowel injuries. The ease with which trocars are inserted through the abdominal wall may have some bearing on these complications. METHODS: A range of both disposable and reusable trocars, which were identical in point cross section and size, were compared in an abdominal wall model reconstructed with animal hide, using a hand-held pressure transducer. Multiple insertions were performed, and the results were expressed in pounds per square inch (PSI). RESULTS: The disposable trocar tested required the least effort to insert (mean pressure, 2.76 PSI), followed by the new reusable (mean pressure, 3.42 PSI), with the used reusable trocar requiring the greatest force for insertion (mean pressure, 4.80 PSI). CONCLUSIONS: The effect of previous use on ease of insertion demonstrates an obvious disadvantage of reusable instruments. The excessive force required to insert some trocars may place the patient at greater risk of trocar injury.

A comparison of avian hematozoan epizootiology in two California coastal scrub communities.

Passerine birds within two California (USA) coastal scrub ecosystems, an island and a mainland site, were examined for hematozoa from 1984 to 1990. Island birds had a significantly lower hematozoan prevalence than mainland birds. This prevalence difference can be related to a lack of appropriate hematozoan vectors on the island. Haemoproteus spp. and Leucocytozoon spp. were the most commonly encountered hematozoa; four new species of Leucocytozoon spp. and one new Haemoproteus sp. were found in five host families. No transmission of hematozoan parasites was detected at the island site during the study. At the mainland coastal scrub site, Leucocytozoon spp. was transmitted each year while Plasmodium spp. and Haemoproteus spp. transmission varied between years. There was evidence that some species of birds acquired infections outside of their breeding season. Results of this study lend further support to the prediction of decreased disease on remote island ecosystems.

Cause and prevention of electrosurgical injuries in laparoscopy.

BACKGROUND: Electrosurgical injuries occur during laparoscopic operations and are potentially serious. The overall incidence of recognized injuries is between one and two patients per 1,000 operations. The majority go unrecognized at the time of the electrical insult and commonly present three to seven days afterward with fever and pain in the abdomen. Since these injuries appear late the pathophysiology remains speculative. STUDY DESIGN: This article reviewed the physics of electrosurgery and provides the surgeon with an insight to the mechanisms responsible in each type of injury. In addition, a comprehensive search of the world literature has reviewed all articles on the topic. RESULTS: The main causes of electrosurgical injuries are: inadvertent touching or grasping of tissue during current application, direct coupling between a portion of intestine and a metal probe that is touching the activated probe, insulation breaks in the electrodes, direct sparking to the intestine from the diathermy probe, and current passage to the intestine from recently coagulated, electrically isolated tissue. The majority of injuries, not surprisingly, are caused by monopolar diathermy. Bipolar diathermy is safer and should be used in preference to monopolar diathermy, especially in anatomically crowded areas. CONCLUSIONS: An awareness of the hazards of diathermy together with an understanding of the mechanisms of injury should enable the surgeon to dissect tissue and to achieve hemostasis, while at the same time decreasing the risk of serious complications to the patient.

Laparoscopic sigmoid colectomy: total laparoscopic approach.

Laparoscopic surgery seems set to make a significant impact on the practice of colorectal surgery. However, to date, the majority of surgeons have used a technique of laparoscopic assistance whereby initial laparoscopic mobilization of the bowel is followed by extracorporeal mesenteric and bowel division and subsequent restoration of bowel continuity. This report describes a technique of totally laparoscopic left-sided colonic resection, transanal specimen delivery, and intracorporeal colorectal anastomosis. The technique employed is described in detail and the indications and controversies surrounding such an approach are discussed.

Relation between distance heterophoria and tonic vergence.

The distance heterophoria was measured using both the von Graefe and Maddox rod clinic procedures under standard reduced illumination conditions and in total darkness. Tonic vergence was measured in total darkness. The phoria measures were more divergent than tonic vergence, with the von Graefe being the more divergent of the two measures. The difference between the phoria and tonic vergence position is believed to be due to accommodative divergence derived from the decrease of accommodation, relative to the tonic level, required to focus the distance phoria target. Equations were derived to predict tonic vergence from the phoria value.

Stability of tonic vergence.

Tonic vergence was monitored at 30 min intervals over a 10 hr period of a single day and at intervals of approximately 14 days over a period of 19 weeks. Measurements were also made during a continuous 112 min period in total darkness. Tonic vergence showed neither significant systematic variation nor large random fluctuations during the course of either a day or weeks, demonstrating stability under naturally occurring viewing conditions. During the period in total darkness, however, tonic vergence exhibited a significant decreasing trend, ie, eye position became less convergent with time. Stability was therefore poorer in the absence of visual stimuli.