Meta-analysis of Long-term De Novo Acid Reflux-Related Outcomes Following Sleeve Gastrectomy: Evidence Against the Need for Routine Postoperative Endoscopic Surveillance.

OBJECTIVES: To evaluate the incidence of long-term de novo acid reflux-related complications following sleeve gastrectomy (SG) to determine whether routine postoperative surveillance endoscopy is necessary. METHODS: A systematic search of Medline, Embase, CINAHL, CENTRAL, the Web of Science, and bibliographic reference lists was conducted. A proportion meta-analysis model was constructed to quantify the risk of the de novo gastro-oesophageal reflux disease (GORD), oesophagitis, and Barrett's oesophagus (BE) at least 4 years after SG. Random-effects modelling was applied to calculate pooled outcome data. RESULTS: Thirty-two observational studies were included reporting a total of 7904 patients who underwent primary SG and were followed up for at least 4 years. The median follow-up period was 60 months (48-132). Preoperative acid-reflux symptoms existed in 19.1% ± 15.1% of the patients. The risk of development of de novo GORD, oesophagitis, and BE after SG was 24.8% (95% CI 18.6-31.0%), 27.9% (95% CI 17.7-38.1%), and 6.7% (95% CI 3.7-9.7%), respectively. The between-study heterogeneity was significant in all outcome syntheses. It was suspected that several of the included studies have not reported BE and oesophagitis because such events might not have happened in their cohorts. CONCLUSIONS: Long-term risk of de novo GORD after SG seems to be comparable with those of the general population which questions the merit of surveillance endoscopy after SG in asymptomatic patients. De novo BE and oesophagitis after SG have not been reported by most of the available studies which may lead to overestimation of the rates of both outcomes in any evidence synthesis. We recommend endoscopic surveillance for symptomatic patients only.

Impelling Factors for Contracting COVID-19 Among Surgical Professionals During the Pandemic: A Multinational Cohort Study.

Background: Medical workers, including surgical professionals working in coronavirus disease 2019 (COVID-19) treating hospitals, were under enormous stress during the pandemic. This global study investigated factors endowing COVID-19 amongst surgical professionals and students. Methods: This global cross-sectional survey was made live on February 18, 2021 and closed for analysis on March 13, 2021. It was freely shared on social and scientific media platforms and was sent via email groups and circulated through a personal network of authors. Chi-square test for independence, and binary logistic regression analysis were carried out on determining predictors of surgical professionals contracting COVID-19. Results: This survey captured the response of 520 surgical professionals from 66 countries. Of the professionals, 92.5% (481/520) reported practising in hospitals managing COVID-19 patients. More than one-fourth (25.6%) of the respondents (133/520) reported suffering from COVID-19 which was more frequent in surgical professionals practising in public sector healthcare institutions (P = 0.001). Thirty-seven percent of those who reported never contracting COVID-19 (139/376) reported being still asked to practice self-isolation and wear a shield without the diagnosis (P = 0.001). Of those who did not contract COVID-19, 75.7% (283/376) were vaccinated (P < 0.001). Surgical professionals undergoing practice in the private sector (odds ratio (OR): 0.33; 95% confidence interval (CI): 0.14 - 0.77; P = 0.011) and receiving two doses of vaccine (OR: 0.55; 95% CI: 0.32 - 0.95; P = 0.031) were identified to enjoy decreased odds of contracting COVID-19. Only 6.9% of those who reported not contracting COVID-19 (26/376) were calculated to have the highest "overall composite level of harm" score (P < 0.001). Conclusions: High prevalence of respondents got COVID-19, which was more frequent in participants working in public sector hospitals. Those who reported contracting COVID-19 were calculated to have the highest level of harm score. Self-isolation or shield, getting two doses of vaccines decreases the odds of contracting COVID-19.

The global level of harm among surgical professionals during the COVID-19 pandemic: A multinational cross-sectional cohort study.

BACKGROUND: Health care workers, including surgical professionals, experienced psychological burnout and physical harm during the coronavirus 2019 pandemic. This global survey investigated the coronavirus 2019 pandemic impact on psychological and physical health. METHODS: We conducted a global cross-sectional survey between February 18, 2021 and March 13, 2021. The primary outcome was to assess the psychological burnout, fulfillment, and self-reported physical level of harm. A validated Stanford Professional Fulfilment Index score with a self-reported physical level of harm was employed. We used a practical overall composite level of harm score to calculate the level of harm gradient 1-4, combining psychological burnout with self-reported physical level of harm score. RESULTS: A total of 545 participants from 66 countries participated. The final analysis included 520 (95.4%) surgical professionals barring medical students. Most of the participants (81.3%) were professionally unfulfilled. The psychological burnout was evident in 57.7% and was significantly common in those <50 years (P = .002) and those working in the public sector (P = .005). Approximately 41.7% of respondents showed changes in the physical health with self-remedy and no impact on work, whereas 14.9% reported changes to their physical health with <2 weeks off work, and 10.1% reported changes in physical health requiring >2 weeks off work. Severe harm (level of harm 4) was detected in 10.6%, whereas moderate harm (level of harm 3) affected 40.2% of the participants. Low and no harm (level of harm 2 and level of harm 1) represented 27.5% and 21.7%, respectively. CONCLUSION: Our study showed that high levels of psychological burnout, professional unfulfillment, work exhaustion, and severe level of harm was more frequent in younger professionals working in the public sector. The findings correlated with a high level of harm in surgical professionals impacting surgical services.

Emergency appendicectomy during COVID-19 pandemic - A single UK centre experience.

Background - In December 2019 following an outbreak of Novel coronavirus infection (COVID-19) in Wuhan, China, it spread rapidly overwhelming the healthcare systems globally. With little knowledge of COVID-19 virus, very few published reports on surgical outcomes; hospitals stopped elective surgery, whilst emergency surgery was offered only after exhausting all conservative treatment modalities. This study presents our experience of outcomes of emergency appendectomies performed during the pandemic. Methods - Prospectively we collected data on 132 patients in peak pandemic period from 1st March to 5th June 2020 and data compared with 206 patients operated in similar period in 2019. Patient demographics, presenting symptoms, pre-operative events, investigations, surgical management, postoperative outcomes and complications were analysed. Results - Demographics and ASA grades of both cohorts were comparable. In study cohort 84.4% and 96.7% in control cohort had laparoscopic appendicectomy. Whilst the study cohort had 13.6% primary open operations, control cohort had 5.3%. Mean length of stay and early post-operative complications (<30 days) were similar in both cohorts apart from surgical site infections (p = 0.02) and one mortality in study cohort. Conclusion - In these overwhelming pandemic times, although conservative treatment of acute appendicitis is an option, a proportion of patients will need surgery. Our study shows that with careful planning and strict theatre protocols, emergency appendicectomy can be safely offered with minimal risk of spreading COVID-19 infection. These observations warrant further prospective randomised studies. Keywords - appendicectomy, COVID-19, Coronavirus, emergency surgery, laparoscopy.

Bariatric surgery for patients with type 2 diabetes mellitus requiring insulin: Clinical outcome and cost-effectiveness analyses.

BACKGROUND: Although bariatric surgery is well established as an effective treatment for patients with obesity and type 2 diabetes mellitus (T2DM), there exists reluctance to increase its availability for patients with severe T2DM. The aims of this study were to examine the impact of bariatric surgery on T2DM resolution in patients with obesity and T2DM requiring insulin (T2DM-Ins) using data from a national database and to develop a health economic model to evaluate the cost-effectiveness of surgery in this cohort when compared to best medical treatment (BMT). METHODS AND FINDINGS: Clinical data from the National Bariatric Surgical Registry (NBSR), a comprehensive database of bariatric surgery in the United Kingdom, were extracted to analyse outcomes of patients with obesity and T2DM-Ins who underwent primary bariatric surgery between 2009 and 2017. Outcomes for this group were combined with data sourced from a comprehensive literature review in order to develop a state-transition microsimulation model to evaluate cost-effectiveness of bariatric surgery versus BMT for patients over a 5-year time horizon. The main outcome measure for the clinical study was insulin cessation at 1-year post-surgery: relative risks (RR) summarising predictive factors were determined, unadjusted, and after adjusting for variables including age, initial body mass index (BMI), duration of T2DM, and weight loss. Main outcome measures for the economic evaluation were total costs, total quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER) at willingness-to-pay threshold of GBP£20,000. A total of 2,484 patients were eligible for inclusion, of which 1,847 had 1-year follow-up data (mean age of 51 years, mean initial BMI 47.2 kg/m2, and 64% female). 67% of patients no longer required insulin at 1-year postoperatively: these rates persisted for 4 years. Roux-en-Y gastric bypass (RYGB) was associated with a higher rate of insulin cessation (71.7%) than sleeve gastrectomy (SG; 64.5%; RR 0.92, confidence interval (CI) 0.86-0.99) and adjustable gastric band (AGB; 33.6%; RR 0.45, CI 0.34-0.60; p < 0.001). When adjusted for percentage total weight loss and demographic variables, insulin cessation following surgery was comparable for RYGB and SG (RR 0.97, CI 0.90-1.04), with AGB having the lowest cessation rates (RR 0.55, CI 0.40-0.74; p < 0.001). Over 5 years, bariatric surgery was cost saving compared to BMT (total cost GBP£22,057 versus GBP£26,286 respectively, incremental difference GBP£4,229). This was due to lower treatment costs as well as reduced diabetes-related complications costs and increased health benefits. Limitations of this study include loss to follow-up of patients within the NBSR dataset and that the time horizon for the economic analysis is limited to 5 years. In addition, the study reflects current medical and surgical treatment regimens for this cohort of patients, which may change. CONCLUSIONS: In this study, we observed that in patients with obesity and T2DM-Ins, bariatric surgery was associated with high rates of postoperative cessation of insulin therapy, which is, in turn, a major driver of overall reductions in direct healthcare cost. Our findings suggest that a strategy utilising bariatric surgery for patients with obesity and T2DM-Ins is cost saving to the national healthcare provider (National Health Service (NHS)) over a 5-year time horizon.

Systematic review and retrospective validation of prediction models for weight loss after bariatric surgery.

BACKGROUND: Patients often have less than realistic expectations of the weight loss they are likely to achieve after bariatric surgery. It would be useful to have a well-validated prediction tool that could give patients a realistic estimate of their expected weight loss. OBJECTIVES: To perform a systematic review of the literature to identify existing prediction models and attempt to validate these models. SETTING: University hospital, United Kingdom. METHODS: A systematic review was performed. All English language studies were included if they used data to create a prediction model for postoperative weight loss after bariatric surgery. These models were then tested on patients undergoing bariatric surgery between January 1, 2013 and December 31, 2014 within our unit. RESULTS: An initial literature search produced 446 results, of which only 4 were included in the final review. Our study population included 317 patients. Mean preoperative body mass index was 46.1 ± 7.1. For 257 (81.1%) patients, 12-month follow-up was available, and mean body mass index and percentage excess weight loss at 12 months was 33.0 ± 6.7 and 66.1% ± 23.7%, respectively. All 4 of the prediction models significantly overestimated the amount of weight loss achieved by patients. The best performing prediction model in our series produced a correlation coefficient (R2) of .61 and an area under the curve of .71 on receiver operating curve analysis. CONCLUSIONS: All prediction models overestimated weight loss after bariatric surgery in our cohort. There is a need to develop better procedures and patient-specific models for better patient counselling.

Systematic Review and Meta-Analysis of Occupational Outcomes after Bariatric Surgery.

INTRODUCTION: Obesity has been linked with reduced productivity in the workplace and is associated with higher levels of unemployment and absenteeism. Studies have shown improvement in functioning and enhanced activity levels in patients after bariatric surgery. OBJECTIVES: We perform a systematic review and meta-analysis of the literature to assess the impact of bariatric surgery on occupational outcomes. METHODS: Medline, Embase, The Cochrane Library and NHS Evidence were searched for English language studies assessing factors related to employment both preoperatively and postoperatively. RESULTS: The initial search produced 189 results. Ten studies met our inclusion criteria and were included in the review. Meta-analysis did not suggest a significant improvement in overall employment rates after surgery (RR 1.058, p = 0.155). However, pooled analysis of studies analysing unemployed patients separately demonstrates that 26.4 % (95 % CI 21.6-31.5 %) of unemployed patients are able to return to work after bariatric surgery. Pooled analysis on two studies suggests that those undergoing surgery are 3.24 (p = 0.01) times more likely to return to work than non-surgical controls. Three studies demonstrated significant reductions in the mean number of annual sick days. CONCLUSIONS: There is limited evidence in the literature regarding occupational outcomes following bariatric surgery, and further studies are required before firm conclusions can be drawn. However, the existing evidence does suggest that bariatric surgery has a generally positive impact on occupational outcomes. This suggests that surgery may have wider economic, social and psychological benefits above and beyond its immediate health benefits.

Environmental Noise as an Operative Stressor During Simulated Laparoscopic Surgery.

OBJECTIVE: This study aimed to determine what effect environmental noise has upon the psychological and physiological stress response of medical students during simulated laparoscopic surgery. MATERIALS AND METHODS: An anonymous cohort of medical students were randomized into 2 arms and performed a laparoscopic task on a simulator. The "control" group performed the task in silence, whereas the "noise" group were exposed to an 80 dB verbal recording. Operator stress response was measured using a validated acute stress questionnaire and continuous heart rate (HR). RESULTS: A total of 70 medical students participated. The "state" component of the State Trait Anxiety Inventory questionnaire increased significantly following the task in both groups with globally higher scores recorded in the noise group. Peak-resting HR values were significantly higher in the noise group. Mean-resting HR was significantly higher in the noise group. CONCLUSIONS: Environmental noise in a simulated theater environment generates a measurable increase in operator stress response during laparoscopy.

Evaluation of the role of laparoscopic ultrasonography in the staging of oesophagogastric cancers.

INTRODUCTION: The role of laparoscopic ultrasound (LUS) during staging laparoscopy for pancreatic cancers is established but remains debatable in evaluating oesophagogastric cancers. METHODS: A retrospective consecutive case series consisting of patients undergoing staging laparoscopy in two centres (centre A and B) was carried out over a 5-year period (2000-2005). Patients in centre B underwent LUS following laparoscopic assessment using a 7.5-MHz probe. Staging laparoscopy in both centres was performed using a standardised three-port protocol using a 30 degrees laparoscope. All suspicious lesions were sent for histological assessment for confirmation of malignancy. RESULTS: There were 201 patients in centre A (83 gastric, 138 lower oesophageal/junctional cancers) and 119 patients in centre B (51 and 68, respectively). There were no differences between the two centres for patient demographics and tumour site. There was no difference between the two centres for the detection of metastatic disease using laparoscopic assessment alone (A 13% versus B 20%, p = 0.12). However, there was a significant difference (13% versus 28%, p = 0.001) with the additional use of LUS in centre B. The findings in the additional 8% (n = 9) were para-aortic lymphadenopathy (n = 5), liver metastasis (n = 3) and local extension (n = 1). Five had gastric and four lower oesophageal/junctional cancers. The negative predictive value was 6.4% for centre A and 4.5% for centre B. CONCLUSION: The addition of LUS increased the detection rate of metastasis by 8% but there was little impact on the false-negative rate. LUS is useful in detecting metastatic lymphadenopathy beyond the limits of curative resection and liver metastasis.

Comparison between open and laparoscopic repair of perforated peptic ulcer disease.

BACKGROUND: The place of laparoscopic repair of perforated peptic ulcer followed by peritoneal toilet has been established, although it is not routinely practiced. This prospective study compared laparoscopic and open repair of perforated peptic ulcer disease. We evaluated whether the early results from laparoscopic repair resulted in improved patient outcome compared with conventional open repair. METHODS: All patients who underwent repair of perforated peptic ulcer disease during a 12-month period in our unit were included in the study. The primary end points that were evaluated were total operative time, nasogastric tube utilisation, intravenous fluid requirement, total time of urinary catheter and abdominal drainage usage, time taken to return to normal diet, intravenous/intramuscular opiate use, time to full mobilization, and total in-patient hospital stay. RESULTS: Thirty-three patients underwent surgical repair of perforated peptic ulcer disease (19 laparoscopic repairs and 14 open repairs; mean age, 54.2 (range, 32-82) years). There was no increase in total operative time in patients who had undergone laparoscopic repair (mean: 61 minutes laparoscopic versus 57 minutes open). There was significantly less requirement for intravenous/intramuscular opiate analgesia in patients who had undergone laparoscopic repair (mean time to oral analgesia: 1.2 days laparoscopic versus 3.8 days open). In addition there was a significant decrease in the time that the nasogastric tube (mean: 2.1 days laparoscopic versus 3.1 days open), urinary catheter (mean: 2.3 days laparoscopic versus 3.7 days open) and abdominal drain (mean: 2.2 days laparoscopic versus 3.8 days open) were required during the postoperative period. Patients who had undergone laparoscopic repair required less intravenous fluids (mean: 1.4 days laparoscopic versus 3.1 days open) and returned to normal diet (mean: 2.3 days laparoscopic versus 4.8 days open) and full mobilization significantly earlier than those who had undergone open repair (mean: 2.3 days laparoscopic versus 3.3 days open). In addition, patients who had undergone laparoscopic repair required a shorter in-patient hospital stay (mean: 3.1 days laparoscopic versus 4.3 days open). CONCLUSIONS: Laparoscopic repair is a viable and safe surgical option for patients with perforated peptic ulcer disease and should be considered for all patients, providing that the necessary expertise is available.