The transit of oral premedication beyond the stomach in patients undergoing laparoscopic sleeve gastrectomy: a retrospective observational multicentre study.

BACKGROUND: Antiemetic and analgesic oral premedications are frequently prescribed preoperatively to enhance recovery after laparoscopic sleeve gastrectomy. However, it is unknown whether these medications transit beyond the stomach or if they remain in the sleeve resection specimen, thereby negating their pharmacological effects. METHODS: A retrospective cohort study was performed on patients undergoing laparoscopic sleeve gastrectomy and receiving oral premedication (slow-release tapentadol and netupitant/palonosetron) as part of enhanced recovery after bariatric surgery program. Patients were stratified into the Transit group (premedication absent in the resection specimen) and Failure-to-Transit group (premedication present in the resection specimen). Age, sex, body mass index, and presence of diabetes were compared amongst the groups. The premedication lead time (time between premedications' administration and gastric specimen resection), and the premedication presence or absence in the specimen was evaluated. RESULTS: One hundred consecutive patients were included in the analysis. Ninety-nine patients (99%) were morbidly obese, and 17 patients (17%) had Type 2 diabetes mellitus. One hundred patients (100%) received tapentadol and 89 patients (89%) received netupitant/palonosetron. One or more tablets were discovered in the resected specimens of 38 patients (38%). No statistically significant differences were observed between the groups regarding age, sex, diabetes, or body mass index. The median (Q1‒Q3) premedication lead time was 80 min (57.8‒140.0) in the Failure-to-Transit group and 119.5 min (85.0‒171.3) in the Transit group; P = 0.006. The lead time required to expect complete absorption in 80% of patients was 232 min (95%CI:180‒310). CONCLUSIONS: Preoperative oral analgesia and antiemetics did not transit beyond the stomach in 38% of patients undergoing laparoscopic sleeve gastrectomy. When given orally in combination, tapentadol and netupitant/palonosetron should be administered at least 4 h before surgery to ensure transition beyond the stomach. Future enhanced recovery after bariatric surgery guidelines may benefit from the standardization of premedication lead times to facilitate increased absorption. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry; number ACTRN12623000187640; retrospective registered on 22/02/2023.

Australian experience with robot-assisted Roux-en-Y gastric bypass with comparison to a conventional laparoscopic series.

BACKGROUND: Robotic surgery is a novel approach to abdominal surgery. In Australia, the uptake of robotic assistance for bariatric surgery has been relatively slow compared to many other countries. The aim of this study is to report the first high volume experience of robotic-assisted Roux-en-Y gastric bypass surgery in Australia (RRYGB) and compare outcomes with a similar laparoscopic group (LRYGB). METHODS: Retrospective analysis of 100 RRYGB versus 100 LRYGB was carried out over a period of seven years performed by two surgeons. These groups were matched by revisional status. Outcomes recorded included operative times, conversion rate, hospital stay, short-term (30 days) complication rates, and long-term complication rates. Baseline comorbidities of patients were also recorded. RESULTS: Baseline characteristics of the two groups were similar except for comorbidity rates (higher in LRYGB group). The mean age was 43 (RRYGB) and 44(LRYGB) years, respectively. The mean pre-op BMI was 44.3 in the RRYGB group and 44.7 in the LRYGB group. Mean operating time in the RRYGB group was 208 min compared to 175 min in the LRYGB group. The number of patients with major complications was 1 in the robotic group versus 5 in the laparoscopic group (P: 0.2166). Minor complications were higher in the robotic group (17 vs. 5, P: 0.0054). Median length of stay of patients with RRYGB was 4 days compared to 5 days for the LRYGB group. CONCLUSION: RRYGB has been successfully implemented in Australia with low complication rates compared to conventional laparoscopic RYGB. Operating times are longer compared to LRYGB which is consistent with most published literature. To justify increased costs generally associated with robotic surgery, better quality studies are needed to accurately assess potential cost savings with length of stay and safety benefits to patients and institutions.

Dental and Orofacial Injuries.

Oral and facial injuries are very common in sport, and can be very expensive to treat. Many of these injuries are preventable with proper pre-competition assessment and suitable well-designed protection. Prompt sideline identification and management of orofacial injuries and appropriate follow-up are crucial to successful outcomes. There have been significant recent advances in both trauma management and mouth guard design and fabrication techniques. Athletes have a unique set of challenges-including collisions, finances, travel and training, dehydration, sport beverages, and high carbohydrate diets-that may compromise their oral health.

Outcome of three common bariatric procedures in the public sector.

BACKGROUND: In Australia, over 90% of bariatric surgery is performed in the private sector by paying patients with health insurance. The demand for government funded services is overwhelming and data are needed on the efficiency, safety and effectiveness of the current range of bariatric procedures in a public hospital setting. The aim of this study was to document medium term outcomes of gastric banding (laparoscopic adjustable gastric banding (LAGB)), gastric bypass (Roux-en-Y gastric bypass (RYGB)) and sleeve gastrectomy (SG) in a publicly funded programme. METHODS: Primary cases with minimum 18 months' follow up were included. Hospital usage, complications, weight loss and co-morbidity outcomes were compared. RESULTS: A total of 229 patients (125 LAGB, 42 RYGB, 62 SG) were included. Mean weight (body mass index) for LAGB, RYGB and SG was 130.6 (46.3), 137.2 (50.5) and 162.7 (55.2) kg (kg/m2 ), respectively (P < 0.001). Operative time and hospital stay were longest for RYGB and intensive care stay was longest for SG. Major complications occurred at 0.0%, 11.9% and 12.9% (P < 0.001) and major reoperations occurred over 5 years 11.2%, 21.4% and 6.5% (P = 0.064). Mean (standard deviation) excess weight loss was 29.9% (33.1), 75.7% (31.8) and 52.7% (19.7) with mean follow up of 3.6 years and 79.0% complete data. CONCLUSIONS: In our public bariatric programme, LAGB patients perform relatively poorly. An increased focus on SG may be appropriate as weight loss is more reliable, major reoperation rates are low and follow up less important. Our experience should be useful for those considering how best to structure and fund a public bariatric programme.

Intermittent gastric prolapse after adjustable gastric banding is a potential cause of band intolerance: clinical and diagnostic findings from eight patients.

BACKGROUND: Gastric banding surgery can fail if the patient develops frequent vomiting, intolerance of common food types or reflux. These patients can be divided into those with a well-defined anatomical problem such as slippage and those without. Intermittent gastric prolapse (IGP) is a possible explanation for some patients who do not achieve adequate early satiety without excessive food intolerance but have normal imaging. METHODS: A series of eight patients was identified over a 2-year period with findings consistent with IGP. Cases were identified in the process of normal clinical practice and details reviewed retrospectively. Specific diagnostic methods included measures to increase pouch pressure above the band by either stress barium or endoscopy with pressure challenge. RESULTS: The median time until diagnosis of IGP was 48.0 months (16-124), and weight loss over that time was 26.4 kg, or 69.6 % excess weight loss (EWL) (5.8-101.8). This fell to 43.7 % EWL after IGP was diagnosed and managed. The mean fill volume when the patients experienced IGP was 6.8 ml (4.5-9.0). Most patients were diagnosed by radiological investigation. Four patients underwent revisional surgery with the remainder treated conservatively. CONCLUSIONS: Intermittent gastric prolapse may explain excessive food and fluid intolerance in gastric band patients who have normal initial imaging. These patients typically experience gross food intolerance with a relatively small increment in fluid volume with relief when the increment is removed. The diagnosis is best made with either modified stress barium or endoscopy with pressure challenge. Management entails establishment of a safe fill volume, modification of weight loss expectations and earlier discussion of revisional surgery.

The use of Permacol™ mesh in contaminated complex abdominal wall defects.

The repair of complex abdominal wall defects in contaminated fields often presents a dilemma for general surgeons. Synthetic mesh, although strong, may lead to chronic infection or even visceral erosion. Leaving the abdomen open presents challenges for ward management and delays definitive care, as well as allowing the musculature to retract over time. Numerous biological mesh alternatives have arisen over the previous decade, which may make primary closure in this setting a practical alternative, although durability may prove the downside. Here we present our local experience with PermacolTM mesh (Porcine Acellular Dermal Matrix - PADM; Covidien, Mansfield, MA) in four challenging cases and discuss the role this relatively new mesh may have for these and other applications.

Laparoscopic reduction of an internal hernia of transverse colon through the foramen of Winslow.

Large bowel obstruction by incarceration in the lesser sac through the foramen of Winslow is exceedingly rare and often associated with nonviable bowel at the time of operation according to older reports. In modern times, widespread availability of computed tomography (CT) for investigation of the acute abdomen may decrease the necessity of bowel resection in these cases. Here, we present a case of laparoscopic reduction of viable transverse colon from the lesser sac in a young woman. With the diagnosis suggested by CT, we were able to approach the case with two five millimeter working ports and 1 optical port, reducing the hernia by means of traction on the distal limb of transverse colon. The patient recovered well and was discharged on day 4 postoperative after bowel movement was achieved. Internal hernia represents one of the few cases in which laparoscopy may be the preferred approach to large bowel obstruction.

Porcine small intestine submucosa matrix (Surgisis) for esophageal perforation.

We present a case of traumatic cervical esophageal perforation complicated by delayed diagnosis and foreign body presence successfully repaired with acellular matrix biomaterial made from porcine submucosa (Surgisis mesh [Wilson-Cook, Winston-Salem, NC]). With metal plating eroding into the esophagus from a spinal fixation procedure, the mesh was applied to the defect just under the cricopharyngeus. The patient re-commenced oral intake after 7 days, and an endoscopy at 4 weeks revealed a well-incorporated mesh in an intact esophagus with normal caliber. In this case, Surgisis mesh (Wilson-Cook) proved effective in providing temporary esophageal integrity to allow healing in an infected field where diversion was impossible.

Subfascial port placement in gastric banding surgery.

BACKGROUND: In some bariatric patients with predominantly intra-abdominal fat a shallow fat layer separates the gastric band access port from the skin. We hypothesise that subfascial port placement in these patients reduces skin erosions and port infections and improves cosmesis as weight loss occurs. AIM: This study aims to compare port complications, cosmetic outcome and ease of band adjustment with access ports in front of or behind the rectus muscle. METHOD: We retrospectively compared complications and cosmetic outcomes of patients with subfascial ports to a control group matched for gender, BMI and age. Each subject completed a questionnaire utilising a 1 to 10 scale for nine parameters related to comfort and cosmesis and two parameters related to discomfort during adjustments. RESULTS: Sixty-eight patients with subfascial ports were identified and the overall response rate was 84%. The groups were well matched for gender (m:f ratio 1.8:1 vs. 1.7:1, p = 1.000), age (51.0 vs. 49.6 years, p = 0.528) and BMI (39.8 vs. 40.3 kg/m², p = 0.585). There was no difference in port infection rates (0/68 vs. 1/68, p = 1.000) but the subfascial group had more hernias (3/68 vs. 0/68, p = 0.244). Subfascial patients experienced more pain during adjustments (score 4.3 vs. 2.6, p = 0.047) but a combined analysis of cosmesis showed a slight positive trend (1.58 vs. 1.76, p = 0.379). CONCLUSION: Both port locations are well tolerated. Subfascial placement is associated with more pain during adjustments but there is no difference in port infection or skin erosion rates.

Laparoscopic gastric banding in over 60s.

BACKGROUND: The aggressive pursuit of weight loss in the elderly remains a controversial objective. In this series of 113 patients over 60 years of age who underwent laparoscopic gastric banding surgery, we report on complications, co-morbidity change, quality-of-life improvement and changes in medication use over a median follow-up period of 25.5 months. METHODS: A prospectively kept database was reviewed from January 1999 to September 2008 identifying patients over 60 who underwent gastric banding surgery. Baseline and follow-up SF-36® survey scores were compared longitudinally. Co-morbidity change and medication use were assessed by questionnaire and electronic record review. RESULTS: Major complications were experienced by 7.1% over the follow-up period with a re-operation rate of 15.0%. Excess BMI loss was 44.1% after 5 years and combined mean SF-36® quality-of-life scores (out of 100) improved 22.1 points, achieving parity with age-matched norms for the general population. Diabetes improved in 74.2% with hypertension, hyperlipidaemia and depression improving in 57.1, 51.1 and 35.9% of cases. A significant drop in medication use was not seen, and cancer was responsible for three deaths over the follow-up period. No surgical mortality was incurred. CONCLUSION: Laparoscopic gastric banding can markedly improve quality of life for morbidly obese over 60s. Health gains are significant, but medication use is not substantially altered. Gastric banding is an ideal weight loss operation for this age group due to its safety and efficacy, and the primary goal should be quality-of-life improvement.

Factors associated with postoperative pulmonary morbidity after esophagectomy for cancer.

BACKGROUND: Most studies analyzing risk factors for pulmonary morbidity date from the early 1990s. Changes in technology and treatment such as minimally invasive esophagectomy (MIE) and neoadjuvant treatment mandate analysis of more contemporary cohorts. METHODS: Predictive factors for overall and specific pulmonary morbidity in 858 patients undergoing esophagectomy between 1998 and 2008 in five Australian university hospitals were analyzed by logistic regression models. RESULTS: A total of 394 patients underwent open esophagectomy, and 464 patients underwent MIE. A total of 259 patients received neoadjuvant chemoradiotherapy, 139 preoperative chemotherapy alone, and 2 preoperative radiotherapy alone. In-hospital mortality was 3.5%. Smoking and the number of comorbidities were risk factors for overall pulmonary morbidity (odds ratio [OR] 1.47, P = 0.016; OR 1.35, P = 0.001) and pneumonia (OR 2.29, P = 0.002; 1.56, P = 0.005). The risk of respiratory failure was higher in patients with more comorbidities (OR 1.4, P = 0.035). Respiratory comorbidities (OR 3.81, P = 0.017) were strongly predictive of postoperative acute respiratory distress syndrome (ARDS). ARDS (4.51, P = 0.032) or respiratory failure (OR 8.7, P < 0.001), but not anastomotic leak (OR 2.22, P = 0.074), were independent risk factors for death. MIE (OR 0.11, P < 0.001) and thoracic epidural analgesia (OR 0.12, P = 0.003) decreased the risk of respiratory failure. Neoadjuvant treatment was not associated with an increased risk of pulmonary complications. CONCLUSIONS: Preoperative comorbidity and smoking were risk factors for respiratory complications, whereas neoadjuvant treatment was not. MIE and the use of thoracic epidural analgesia decreased the risk of respiratory failure. Respiratory failure and ARDS were the only independent factors associated with an increased risk of in-hospital death, whereas anastomotic leakage was not.

Adenoid cystic carcinoma of the trachea: a long-term problem.

Adenoid cystic carcinoma of the trachea, although rare, is the second most common primary tumour of the trachea. It is a slow-growing tumour found in younger patients than the more common squamous cell carcinoma and is relatively resistant to treatment, but metastasizes late in the course of disease and even in unresectable cases can be palliated successfully for many years. We present a retrospective 20-year series of this condition from a single institute encompassing 13 patients of whom 6 were resected and 7 treated by palliative methods. A review of hospital records was carried out over the period 1984-2003. Details collected included symptoms before diagnosis, length of time from onset of the first symptom to diagnosis, resection details, survival statistics and accessory procedures tried before and after consideration of resection. The overall 5-year survival was 38.5%, but the mean survival in resected patients was 66 months as against 36 months for unresectable patients. Although most patients presented with dyspnoea, this was initially often attributed to other factors. The mean time of diagnosis from the onset of symptoms was 16 months. Although complete resection remains the management of choice if feasible, modern techniques of maintaining the airway in unresectable patients can give useful palliation for years.