Intraoperative endomanometric laparoscopic Nissen fundoplication improves postoperative outcomes in large sliding hiatus hernias with severe gastroesophageal reflux disease: a retrospective cohort study.

BACKGROUND: Laparoscopic Nissen fundoplication (LNF) is the gold standard surgical intervention for gastroesophageal reflux disease (GERD). LNF can be followed by recurrent symptoms or complications affecting patient satisfaction. The aim of this study is to assess the value of the intraoperative endomanometric evaluation of esophagogastric competence and pressure combined with LNF in patients with large sliding hiatus hernia (>5 cm) with severe GERD (DeMeester score >100). MATERIALS AND METHODS: This is a retrospective, multicenter cohort study. Baseline characteristics, postoperative dysphagia and gas bloat syndrome, recurrent symptoms, and satisfaction were collected from a prospectively maintained database. Outcomes analyzed included recurrent reflux symptoms, postoperative side effects, and satisfaction with surgery. RESULTS: Three hundred sixty patients were stratified into endomanometric LNF (180 patients, LNF+) and LNF alone (180 patients, LNF). Recurrent heartburn (3.9 vs. 8.3%) and recurrent regurgitation (2.2 vs. 5%) showed a lower incidence in the LNF+ group ( P =0.012). Postoperative score III recurrent heartburn and score III regurgitations occurred in 0 vs. 3.3% and 0 vs. 2.8% cases in the LNF+ and LNF groups, respectively ( P =0.005). Postoperative persistent dysphagia and gas bloat syndrome occurred in 1.75 vs. 5.6% and 0 vs. 3.9% of patients ( P =0.001). Score III postoperative persistent dysphagia was 0 vs. 2.8% in the two groups ( P =0.007). There was no redo surgery for dysphagia after LNF+. Patient satisfaction at the end of the study was 93.3 vs. 86.7% in both cohorts, respectively ( P =0.05). CONCLUSIONS: Intraoperative high-resolution manometry and endoscopic were feasible in all patients, and the outcomes were favorable from an effectiveness and safety standpoint.

A prospective multicentre study evaluating the outcomes of the abdominal wall dehiscence repair using posterior component separation with transversus abdominis muscle release reinforced by a retro-muscular mesh: filling a step.

BACKGROUND: This study aimed to evaluate the results of posterior component separation (CS) and transversus abdominis muscle release (TAR) with retro-muscular mesh reinforcement in patients with primary abdominal wall dehiscence (AWD). The secondary aims were to detect the incidence of postoperative surgical site occurrence and risk factors of incisional hernia (IH) development following AWD repair with posterior CS with TAR reinforced by retromuscular mesh. METHODS: Between June 2014 and April 2018, 202 patients with grade IA primary AWD (Björck's first classification) following midline laparotomies were treated using posterior CS with TAR release reinforced by a retro-muscular mesh in a prospective multicenter cohort study. RESULTS: The mean age was 42 ± 10 years, with female predominance (59.9%). The mean time from index surgery (midline laparotomy) to primary AWD was 7 ± 3 days. The mean vertical length of primary AWD was 16 ± 2 cm. The median time from primary AWD occurrence to posterior CS + TAR surgery was 3 ± 1 days. The mean operative time of posterior CS + TAR was 95 ± 12 min. No recurrent AWD occurred. Surgical site infections (SSI), seroma, hematoma, IH, and infected mesh occurred in 7.9%, 12.4%, 2%, 8.9%, and 3%, respectively. Mortality was reported in 2.5%. Old age, male gender, smoking, albumin level < 3.5 gm%, time from AWD to posterior CS + TAR surgery, SSI, ileus, and infected mesh were significantly higher in IH. IH rate was 0.5% and 8.9% at two and three years, respectively. In multivariate logistic regression analyses, the predictors of IH were time from AWD till posterior CS + TAR surgical intervention, ileus, SSI, and infected mesh. CONCLUSION: Posterior CS with TAR reinforced by retro-muscular mesh insertion resulted in no AWD recurrence, low IH rates, and low mortality of 2.5%. Trial registration Clinical trial: NCT05278117.

Hepatobiliary manifestations following two-stages elective laparoscopic restorative proctocolectomy for patients with ulcerative colitis: A prospective observational study.

BACKGROUND: Hepatobiliary manifestations occur in ulcerative colitis (UC) patients. The effect of laparoscopic restorative proctocolectomy (LRP) with ileal pouch anal anastomosis (IPAA) on hepatobiliary manifestations is debated. AIM: To evaluate hepatobiliary changes after two-stages elective laparoscopic restorative proctocolectomy for patients with UC. METHODS: Between June 2013 and June 2018, 167 patients with hepatobiliary symptoms underwent two-stage elective LRP for UC in a prospective observational study. Patients with UC and having at least one hepatobiliary manifestation who underwent LRP with IPAA were included in the study. The patients were followed up for four years to assess the outcomes of hepatobiliary manifestations. RESULTS: The patients' mean age was 36 ± 8 years, and males predominated (67.1%). The most common hepatobiliary diagnostic method was liver biopsy (85.6%), followed by Magnetic resonance cholangiopancreatography (63.5%), Antineutrophil cytoplasmic antibodies (62.5%), abdominal ultrasonography (35.9%), and Endoscopic retrograde cholangiopancreatography (6%). The most common hepatobiliary symptom was Primary sclerosing cholangitis (PSC) (62.3%), followed by fatty liver (16.8%) and gallbladder stone (10.2%). 66.4% of patients showed a stable course after surgery. Progressive or regressive courses occurred in 16.8% of each. Mortality was 6%, and recurrence or progression of symptoms required surgery for 15%. Most PSC patients (87.5%) had a stable course, and only 12.5% became worse. Two-thirds (64.3%) of fatty liver patients showed a regressive course, while one-third (35.7%) showed a stable course. Survival rates were 98.8%, 97%, 95.8%, and 94% at 12 mo, 24 mo, 36 mo, and at the end of the follow-up. CONCLUSION: In patients with UC who had LRP, there is a positive impact on hepatobiliary disease. It caused an improvement in PSC and fatty liver disease. The most prevalent unchanged course was PSC, while the most common improvement was fatty liver disease.

Recurrent appendicitis following successful drainage of appendicular abscess in adult without interval appendectomy during COVID-19. Prospective cohort study.

BACKGROUND: COVID-19 infection is a global pandemic that affected routine health services and made patients fear to consult for medical health problems, even acute abdominal pain. Subsequently, the incidence of complicated appendicitis increased during the Covid-19 pandemic. This study aimed to evaluate recurrent appendicitis after successful drainage of appendicular abscess during COVID-19. MATERIAL AND METHODS: A prospective cohort study conducted in the surgical emergency units of our Universities' Hospitals between March 15, 2020 to August 15, 2020 including patients who were admitted with the diagnosis of an appendicular abscess and who underwent open or radiological drainage. Main outcomes included incidence, severity, and risk factors of recurrent appendicitis in patients without interval appendectomy. RESULTS: A total of 316 patients were included for analysis. The mean age of the patients was 37 years (SD ± 13). About two-thirds of patients were males (60.1%). More than one-third (39.6%) had co-morbidities; type 2 diabetes mellitus (T2DM) (22.5%) and hypertension (17.1%) were the most frequent. Approximately one quarter (25.6%) had confirmed COVID 19 infection. About one-third of the patients (30.4%) had recurrent appendicitis. More than half of them (56.3%) showed recurrence after three months, and 43.8% of patients showed recurrence in the first three months. The most frequent grade was grade I (63.5%). Most patients (77.1%) underwent open surgery. Age, T2DM, hypertension, COVID-19 infection and abscess size >3 cm were significantly risking predictors for recurrent appendicitis. CONCLUSIONS: Interval appendectomy is suggested to prevent 56.3% of recurrent appendicitis that occurs after 3 months. We recommend performing interval appendectomy in older age, people with diabetes, COVID-19 infected, and abscesses more than 3 cm in diameter. RESEARCH QUESTION: Is interval appendectomy preventing a high incidence of recurrent appendicitis after successful drainage of appendicular abscess during COVID-19 pandemic?

Effect of one anastomosis gastric bypass on liver function tests: A comparison between 150 cm and 200 cm biliopancreatic limbs.

CONTEXT: Some studies have shown that one anastomosis gastric bypass (OAGB) results in the derangement of liver function tests (LFTs). We wanted to study this in our patients. AIMS: The aims are to study the effect of OAGB on LFTs and to compare the effect of a biliopancreatic limb (BPL) of 150 cm (OAGB-150) to a BPL of 200 cm (OAGB-200). SETTINGS AND DESIGN: The study was a retrospective cohort study conducted at a university hospital. MATERIALS AND METHODS: Information was obtained from our prospectively maintained database and hospital's computerised records. STATISTICAL ANALYSIS: A P < 0.05 was regarded statistically significant; however, given the number of variables examined, findings should be regarded as exploratory. RESULTS: A total of 405 patients underwent an OAGB-200 (n = 234) or OAGB-150 (n = 171) in our unit between October 2012 and July 2018. There were significant improvements in gamma-glutamyl transpeptidase (GGT) levels at 1 and 2 years after OAGB-200 and significant worsening in the levels of alkaline phosphatase (ALP) and albumin at 1 and 2 years. There was a significant improvement in GGT levels at 1 and 2 years after OAGB-150 and in alanine transaminase levels at 1 year. There was a significant worsening in ALP and albumin levels at both follow-up points in this group. OAGB-150 group had a significantly lower bilirubin level at 1 year and significantly fewer abnormal ALP values at 2 years in comparison with OAGB-200 patients. CONCLUSIONS: This exploratory study demonstrates the overall safety of OAGB with regard to its effect on LFTs, with no remarkable difference between OAGB-150 and OAGB-200.

Is Specialisation Needed in Laparoscopic Cholecystectomy? A Retrospective Cohort Study of 5122 Patients.

Background: Gallstone disease is a common problem and laparoscopic cholecystectomy (LC) is a common elective procedure. This operation was performed by a general surgeon, colorectal surgeons, breast and vascular surgeons according to the largest UK's audit (CholeS study). Objectives: To compare the outcomes of laparoscopic cholecystectomy performed by a specialist upper gastrointestinal (UGI) surgeon to that of CholeS and large international studies. Our hypothesis is: UGI specialist is producing better outcomes for LC patients. Methods: All patient who underwent LC between 1999 and 2019 at one hospital by an UGI consultant and 2014-2019 at another hospital by another UGI consultant surgeon were included. The inclusion criteria were LC performed by UGI surgeon. Lost to follow up, procedures done by trainees and gallbladder cancer patients were excluded. The outcome measures of bile leak, bile duct injuries, bleeding, infectious complications, bowel injuries, vascular injuries and pseudoaneurysms, neuralgia, port site hernia, mesenteric haematoma, 30-day mortality and conversion to open were reported. Statistical tests were used to assess the significant differences, the confidence interval was 95% and the p-value was taken as 0.05. Results: Two UGI specialists performed 5122 LC, 4396 (86%) were female and 715 (14%) male. The age was 13-93 year (median of 48 years). 3681 (72 %) was done as a day surgery case. 1431(28%) as an inpatient and 287 (5.6%) emergency LC. There was no death in the 30 days periods of surgery, 8 (0.15%) biliary leak from the duct of Luschka, 4 (0.19%) common bile duct (CBD) injuries, 9(0.02%) conversions and 17(0.33%) procedures were abandoned. There were significant differences in the above complications between our study and the CholeS report. Conclusions: Laparoscopic cholecystectomy is associated with acceptable outcomes, low risk of bile duct injury and no mortality when performed by a specialist upper GI surgeon.

Obesity and mortality of COVID-19. Meta-analysis.

BACKGROUND: Obesity is a global disease with at least 2.8 million people dying each year as a result of being overweight or obese according to the world health organization figures. This paper aims to explore the links between obesity and mortality in COVID-19. METHODS: Electronic search was made for the papers studying obesity as a risk factor for mortality following COVID-19 infection. Three authors independently selected the papers and agreed for final inclusion. The outcomes were the age, gender, body mass index, severe comorbidities, respiratory support and the critical illness related mortality in COVID-19. 572 publications were identified and 42 studies were selected including one unpublished study data. Only 14 studies were selected for quantitative analysis. RESULTS: All the primary points but the gender are significantly associated with COVID-19 mortality. The age >70, [odd ratio (OR): 0.17, CI; 95%, P-value: <0.00001], gender [OR: 0.89; CI: 95%, P-value: 0.32], BMI > 25 kg/m2 [OR: 3.68, CI: 95%, P-value: <0.003], severe comorbidities [OR: 1.84, CI:95%, P-value: <0.00001], advanced respiratory support [OR: 6.98, CI: 95%, P-value: <0.00001], and critical illness [OR: 2.03, CI: 95%, P-value: <0.00001]. CONCLUSIONS: Patients with obesity are at high risk of mortality from COVID-19 infection.

Extent of infectious SARS-CoV-2 aerosolisation as a result of oesophagogastroduodenoscopy or colonoscopy.

BACKGROUND: COVID-19 has caused an unprecedented pandemic and medical emergency that has changed routine care pathways. This article discusses the extent of aerosolisation of severe acute respiratory syndrome coronavirus 2, the virus that causes COVID-19, as a result of oesophagogastroduodenoscopy and colonoscopy. METHODS: PubMed and Google Scholar were searched for relevant publications, using the terms COVID-19 aerosolisation, COVID-19 infection, COVID-19 transmission, COVID-19 pandemic, COVID-19 and endoscopy, Endoscopy for COVID-19 patients. RESULTS: A total of 3745 articles were identified, 26 of which were selected to answer the question of the extent of SARS-CoV-2 aerosolisation during upper and lower gastrointestinal endoscopy. All studies suggested high infectivity from contact and droplet spread. No clinical study has yet reported the viral load in the aerosol and therefore the infective dose has not been accurately determined. However, aerosol-generating procedures are potentially risky and full personal protective equipment should be used. CONCLUSIONS: As it is a highly infectious disease, clinicians treating patients with COVID-19 require effective personal protective equipment. The main routes of infection are direct contact and droplets in the air and on surfaces. Aerosolisation carries a substantial risk of infection, so any aerosol-producing procedure, such as endoscopy, should be performed wearing personal protective equipment and with extra caution to protect the endoscopist, staff and patients from cross-infection via the respiratory system.

What Every Bariatric Surgeon Should Know: How to Relieve Obstruction at the Jejuno-jejunostomy After Roux-en-Y Gastric Bypass.

INTRODUCTION: Roux-en-Y gastric bypass (RYGB) remains one of the key bariatric procedures worldwide. In addition to bleeding and anastomotic leak, there are rarely occurring complications such as obstruction at the jejuno-jejunostomy in the early postoperative phase. PATIENT AND METHODS: A 51-year-old lady (weight 122 kg; BMI 46 kg/m2; with type 2 diabetes mellitus and hypertension) underwent RYGB in our tertiary referral centre 3 days prior to admission. She originally recovered well from the uneventful operation, but began vomiting on day 3. At this point, she complained of no other symptoms. An urgent CT scan identified a gastric remnant dilatation, and an obstructed jejuno-jejunostomy. An urgent laparoscopic exploration was performed, which identified obstruction at this level. RESULTS: Within our video-presentation, detailed technical steps are described. First, gastric remnant decompression was performed by inserting a tube gastrostomy. Secondly, the obstruction was identified. Consequently, a new jejuno-jejunostomy was created, proximal to the original anastomosis, using a linear stapler, and direct suture closure of the enterotomy defects. After thorough washout, drains were placed in the pelvis and alongside the jejuno-jejunostomy. The patient was discharged home after a 2-week hospital stay which included 5 days of invasive ventilation on the ITU. CONCLUSION: A high-level of suspicion is required to suspect, diagnose and treat post-RYGB complications. A bariatric on-call rota with appropriately trained personnel is essential.

Obstructive Sleep Apnoea Screening Preoperatively with the Epworth Questionnaire: Is It Worth It ?

BACKGROUND: The prevalence of obstructive sleep apnoea (OSA) in the bariatric population has been reported to be as high as 60-83%. The Epworth Sleepiness Scale (ESS) is a validated, self-administrated eight-item questionnaire that measures subjective daytime sleepiness and thus helps to identify high-risk for OSA. OBJECTIVES: To find the prevalence of OSA in patients undergoing bariatric surgery who do not routinely undergo polysomnography (PSG) and are screened by the ESS. METHODS: All consecutive 425 patients who underwent bariatric surgery in our tercier referral centre from January 2012 to June 2017 were included in this prospective study. Patient demographics and ESS score were recorded prior to the bariatric surgery and patients were divided into low-risk (ESS < 11), high-risk (≥ 11) and "known-OSA" groups. RESULTS: The community-based OSA prevalence was 14% (59 patients). ESS-positive predictive value was 60%. There was no significant difference in BMI and excess body-weight, but patients with OSA were older and had a lower female ratio (75% vs 42%). The unplanned ICU admission rate was comparable amongst the low- and high-ESS group (2.2% and 2.1%, respectively); similarly, the respiratory and chest complication rate were similar. The median hospital stay for patients diagnosed with OSA was a half day longer; the high-score patients stayed significantly longer than the low-score patients (p = 0.017). CONCLUSION: In our study, the OSA prevalence was low (20%). We think that the ESS does not have significant predicting value before bariatric surgery and overall the OSA is "overhyped" in the bariatric pathway.

The effect of metabolic surgery on type 1 diabetes: meta-analysis.

OBJECTIVE: Metabolic and bariatric surgery has a definite role in the management of obese patients with type 2 diabetes mellitus (T2DM). There is also evidence of such surgery improving the health of type 1 diabetic (T1DM) patients. The aim of this paper is to explore the effect of metabolic and bariatric surgery on T1DM. MATERIALS AND METHODS: A comprehensive search of PubMed and Google Scholar was performed to identify relevant papers reporting metabolic and bariatric surgery effects on T1DM. A statistical analysis is applied after data synthesis. A forest plot and Pearson correlation are then calculated. RESULTS: Of the 567 papers that were identified, 558 articles did not fulfill the inclusion criteria and were therefore excluded. Nine studies involving 78 patients were selected for this metaanalysis. There was improvement in HBA1c (p value = 0.40), insulin dose (p value = 0.0001) and BMI (p value = 0.00001) after surgery. However, improvement in the HBA1c did not reach statistical significance. There was a weak correlation between postoperative insulin dose and BMI change after surgery (r = -0.177). There was a negligible correlation between HBA1c and BMI change after operations (r = -0.01). CONCLUSION: Current metabolic/bariatric surgery is improving T1DM in obese and morbidly obese patients. This is not exclusively related to excess weight loss (EWL) as previously thought. Therefore, there is a role for other factors, which are potential players to reproduce the same effect in nonobese T1DM patients.

The effect of metabolic surgery on type 1 diabetes: meta-analysis

ABSTRACT Objective Metabolic and bariatric surgery has a definite role in the management of obese patients with type 2 diabetes mellitus (T2DM). There is also evidence of such surgery improving the health of type 1 diabetic (T1DM) patients. The aim of this paper is to explore the effect of metabolic and bariatric surgery on T1DM. Materials and methods A comprehensive search of PubMed and Google Scholar was performed to identify relevant papers reporting metabolic and bariatric surgery effects on T1DM. A statistical analysis is applied after data synthesis. A forest plot and Pearson correlation are then calculated. Results Of the 567 papers that were identified, 558 articles did not fulfill the inclusion criteria and were therefore excluded. Nine studies involving 78 patients were selected for this metaanalysis. There was improvement in HBA1c (p value = 0.40), insulin dose (p value = 0.0001) and BMI (p value = 0.00001) after surgery. However, improvement in the HBA1c did not reach statistical significance. There was a weak correlation between postoperative insulin dose and BMI change after surgery (r = -0.177). There was a negligible correlation between HBA1c and BMI change after operations (r = -0.01). Conclusion Current metabolic/bariatric surgery is improving T1DM in obese and morbidly obese patients. This is not exclusively related to excess weight loss (EWL) as previously thought. Therefore, there is a role for other factors, which are potential players to reproduce the same effect in nonobese T1DM patients.

The value of laparoscopy in the management of chronic groin pain.

BACKGROUND: Chronic groin pain problem represents a diagnostic and management challenge. This study is reporting all patients who underwent laparoscopic exploration of the groin and pelvis for undiagnosed chronic groin pain. MATERIALS AND METHODS: A retrospective cohort study. Evaluators were not involved in the operations. Laparoscopic exploration and mesh insertion using Trans-Abdominal Pre-Preitoneal (TAPP) approach was performed for all patients. Follow up in the; clinic at 2 weeks and 6 months was arranged. This was a consecutive series of patients who were presented with chronic groin pain and no pre-operative radiological, orthopedic, gynecological or urologic abnormalities. Patients who were diagnosed with clinical hernia or other positive finding were excluded. RESULTS: Data were collected and analyzed for 92 patients. The operation had successfully managed the groin pain in 81 patients (88.04%), and the pain was improved in another 3 patients (3.26%). Six patients (6.52%) had no change in their symptoms, and worse pain was reported in two patient (2.17%). CONCLUSION: Laparoscopic groin exploration is an effective method to diagnose the chronic groin pain that under diagnosed by clinical, ultrasound and MRI tests. Laparoscopic management had resulted in resolution of the pain in the majority of the patients. The procedure is effective in athletes' patients who did not have clinical, radiological and laparoscopic evidence of groin hernia.