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.

Preoperative endoscopy may reduce the need for revisional surgery for gastro-oesophageal reflux disease following laparoscopic sleeve gastrectomy.

Laparoscopic sleeve gastrectomy is a safe and effective bariatric operation, but postoperative reflux symptoms can sometimes necessitate revisional surgery. Roux-en-Y gastric bypass is the preferred operation in morbidly obese patients with gastro-oesophageal reflux disease. In 2011, we introduced preoperative endoscopy to assess for hiatus hernia or evidence of oesophagitis in conjunction with an assessment of gastro-oesophageal reflux symptoms for all patients undergoing bariatric surgery with a view to avoid sleeve gastrectomy for these patients. A prospectively maintained database was used to identify patients who underwent sleeve gastrectomy before and after we changed the unit policy. The need for revisional surgery in patients with troublesome gastro-oesophageal reflux disease was examined. Prior to 2011, 130 patients underwent sleeve gastrectomy, and 11 (8.5%) of them required conversion to Roux-en-Y gastric bypass for symptomatic reflux disease. Following the policy change, 284 patients underwent sleeve gastrectomy, and to date, only five (1.8%) have required revisional surgery (p = 0.001). Baseline demographics were comparable between the groups, and average follow-up period was 47 and 33 months, respectively, for each group. Preoperative endoscopy and a detailed clinical history regarding gastro-oesophageal reflux symptoms may improve patient selection for sleeve gastrectomy. Avoiding sleeve gastrectomy in patients with reflux disease and/or hiatus hernia may reduce the incidence of revisional surgery.

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.

Routine magnetic resonance cholangiopancreatography and intra-operative cholangiogram in the evaluation of common bile duct stones.

INTRODUCTION: Magnetic resonance cholangiopancreatography (MRCP) is a safe and sensitive investigation for the imaging of common bile duct pathology. When used to exclude common bile duct (CBD) stones, MRCP may obviate the need for intra-operative cholangiogram (IOC). In this prospective study, we looked at the single centre results of patients who underwent cholecystectomy with IOC following pre-operative MRCP. PATIENTS AND METHODS: Over a period of 18 months, 69 patients (24 male and 45 female; mean age 59 years [range, 19-86 years]) were investigated by MRCP prior to cholecystectomy. All patients underwent IOC. Inclusion criteria for MRCP consisted of derangement of liver function tests and/or history of jaundice in cases of ultrasound-proven cholelithiasis. RESULTS: Sixteen patients had suspected stones or filling defects on MRCP; all but two of these were confirmed to be stones on IOC. In only one patient was a stone visualised on IOC and not seen on MRCP. CONCLUSION: MRCP may be the only pre-operative investigation needed for exclusion of CBD stones, obviating the necessity for IOC.

Does donor cardiopulmonary resuscitation time affect outcome in uncontrolled non-heart-beating donor renal transplants?

Uncontrolled non-heart-beating donors offer the opportunity to significantly expand the potential pool of kidney donors but are associated with a variable duration of cardiopulmonary resuscitation (CPR), where cardiac output is only 30% to 40% of normal. We were concerned that prolonged CPR would adversely affect the function of transplanted kidneys. In our series of 46 uncontrolled donors the mean duration of CPR was 60 minutes, which also represents a realistic cutoff point for CPR duration. Taking a cutoff point of 60 minutes, we found no differences in kidney discard rates following viability assessment, primary nonfunction rate, or duration of delayed graft function. We therefore conclude that if formal viability assessment is performed, kidneys may be retrieved from uncontrolled non-heart-beating donors irrespective of duration of CPR.

A simple cardiovascular risk score can predict poor outcome in NHBD renal transplantation.

A simple cardiovascular risk score used in our center to plan cardiovascular workup for renal transplantation can predict outcome in non-heart-beating donor (NHBD) renal transplantation. Patients in the higher risk group, with a score of >12 out of a maximum of 36 are likely to have a longer duration of delayed graft function, poorer glomerular filtration rate at 6 months, and inferior graft and patient survival, together with an relative rate of graft loss within 60 days of >4 (P = .053). Although a high cardiovascular risk score should not be regarded as a contraindication to NHBD transplantation, the score can be used to facilitate recipient selection.

Outcome of gall bladder polypoidal lesions detected by transabdominal ultrasound scanning: a nine year experience.

AIM: To determine the outcome of polypoidal lesions within the gall bladder (PLG) diagnosed by trans-abdominal scanning. METHODS: A nine-year (1993-2002) retrospective case-note review of all patients who underwent ultrasound scanning after referral to a single Upper GI Surgeon at a District General Hospital was conducted. Patients who were diagnosed with a PLG were included in our study. A database was constructed and patient details, investigations including ultrasound scan (USS) findings, treatment and histology and final diagnosis were recorded. RESULTS: Twenty-three (out of 651) patients were diagnosed pre-operatively by USS to have a polyp-like gall bladder lesion (PLG). Post cholecystectomy histological examination revealed 12 gallstones, 7 cholesterol polyps, 3 adenocarcinomas within polyps and 1 normal gall bladder. The specificity of USS in the diagnosis of PLG was 92.3%. All the true polyps were malignant. Overall USS had 66.66% sensitivity and 100% specificity in the pre-operative suspicion of malignancy. Using size greater than 10 mm as measured on USS as a cut-off, we find 100% sensitivity and 86.95% specificity with a positive predictive value of 50% in the diagnosis of malignancy in PLG. CONCLUSION: A large number of PLG are in fact calculi within diseased gall bladder. In cases of gall bladder polyps more then 10 mm in size on USS further imaging (cross-sectional and/or EUS) is indicated prior to surgery. This will help in the optimal management of patients and avoid histological surprises.

Factors predicting duration of delayed graft function in non-heart-beating donor kidney transplantation.

Non-heart-beating donors (NHBDs) are an important potential source of donor organs, but kidneys from such donors are prone to delayed graft function (DGF) and primary nonfunction, which are multifactorial in origin but believed to be mainly due to warm ischemic injury. This retrospective study examined a series of 88 transplants from Maastricht category II and III NHBDs to examine the role of factors to predict the duration of DGF. The main factors affecting duration of DGF were total warm ischemic time, cold ischemic time, product of perfusate GST concentration and donor age, quality of postoperative graft perfusion, incidence of acute rejection, recipient cardiovascular risk score, maximum pressure on machine perfusion, and weight gain during machine perfusion. Primary nonfunction was not accurately predicted from these factors for kidneys that had passed the viability assessment.

A simple cardiovascular risk score can predict poor outcome in non-heart-beating donor renal transplantation.

A simple cardiovascular risk score used in our centre to plan cardiovascular work-up for renal transplantation can predict outcome in non-heart-beating donor (NHBD) renal transplantation. Patients in the higher-risk group, with a score of >12 of a maximum of 36 are likely to have a longer duration of delayed graft function, poorer glomerular filtration rate at 6 months, and inferior graft and patient survival, together with a relative rate of graft loss within 60 days of 4.514 (P = .019) and within 1 year of 3.511 (P = .036). Although a high cardiovascular risk score should not be regarded as a contraindication to NHBD transplantation, the score can be used to facilitate recipient selection.

Weight increase during machine perfusion may be an indicator of organ and in particular, vascular damage.

OBJECTIVES: Hypothermic machine perfusion preservation has been shown to improve the outcome of renal grafts from non-heartbeating donors. We have noticed that organs gain a variable amount of weight during perfusion. METHODS: All grafts, whether used or discarded, were assessed with respect to their weight gain. Primary outcome measures were the results of viability testing. Secondary outcomes were early transplant variables including incidence and duration of delayed graft function and histological examination of protocol graft biopsies. RESULTS: Weight increase data was available on 97 grafts. There were no significant differences in weight gain between kidneys used and discarded (17% vs 20%). 14 patients received grafts which gained over 30% of their initial retrieval weight. There were no significant differences in secondary outcome measures between this group of recipients and patients who had received less "waterlogged" kidneys. Histological changes including endothelial inflammation and oedema were observed. CONCLUSIONS: Kidney grafts which have gained over 30% of weight on hypothermic machine perfusion preservation can be transplanted successfully. Complex interactions between the period of warm ischaemia, in situ flushing, perfusion pressures and perfusate probably lead to the phenomenon of excessive graft weight gain.

Machine perfusion for kidneys: how to do it at minimal cost.

Due to a shortage of organs for transplantation, many centres use marginal grafts to increase their donor pool. As kidneys from non-heart-beating donors (NHBD) have sustained initial ischaemic damage, their viability is difficult to predict. Hypothermic pulsatile perfusion has not only been used to improve the condition of such grafts, but also allows viability assessment. Suitable systems are becoming more readily available, but they are expensive. We have used existing dialysis equipment with modified sterilised inserts to create a pulsatile hypothermic perfusion system. With this system, 41 NHBD kidneys were perfused for up to 8 h; their intravascular renal resistance (IRVR), flow characteristics as well as glutathione S transferase (GST) measurements were performed to assess viability. This hypothermic pulsatile perfusion system is now an integral component of our NHBD programme.