Safety and feasibility of revisional bariatric surgery following Laparoscopic Adjustable Gastric Band - Outcomes from a large UK private practice.

BACKGROUND: Revisional bariatric surgery is unavoidable in a proportion of patients. Despite its need, the development of this speciality has been hampered by its complexity and preferred delivery in institutional set ups. Although primary bariatric surgery can be delivered in the private sector; safety and feasibility of revisional bariatric surgery remains unexplored in this setting. MATERIALS AND METHODS: Patients undergoing revisional bariatric surgery following previous Laparoscopic Adjustable Gastric Band (LAGB) between 2008 and 2019 at a single private bariatric unit with a minimum follow up of at least 6 months were included. The primary aim was safety outcomes and 30-day morbidity. RESULTS: 178 patients with BMI of 45.6 ± 8.2 kg/m2 underwent revisional bariatric surgery. One stage conversion was performed for 86.5% of the cases. At 9.5 ± 5.3 months follow up, BMI and percentage excess BMI loss were 31.8 ± 6.2 kg/m2 and 62.6 ± 40% respectively. There was no mortality, and the major complication rate was 2.8%. There was no statistically significant difference in the incidence of complications based on one-stage vs. two-stage conversion (p = 0.52). There were no differences in weight loss outcomes post-revisional surgery according to the indication for revision (p = 0.446) or weight loss following primary surgery (p = 0.12). CONCLUSION: Revisional bariatric surgery can be delivered safely in the private sector with good outcomes. One-stage conversions are feasible and do not detrimentally affect the morbidity of the procedure or the weight loss outcomes. More importantly, success following revisional surgery is independent of the indication for revision and weight loss outcomes following primary surgery.

Volkman's Contracture, Persistent Limb Ischaemia, and Amputation: A Complication of Brachial Artery Catheterisation for Haemodynamic Monitoring Using PiCCO.

We report a case of a 64-year-old woman who was admitted to intensive care unit with multiorgan failure secondary to Plasmodium falciparum malaria. Haemodynamic monitoring using the transpulmonary thermodilution with pulse contour analysis system (PiCCO) was achieved via the left brachial artery. Two days later, a flexion deformity of the left hand was noted, and examination revealed left lower arm ischaemia. Removal of the catheter resulted in an immediate improvement of the contracture. However, distal pulses were still absent, and the arm remained ischaemic resulting in a below elbow amputation. This is the first documented case of a persistent limb ischaemia following the insertion of an arterial catheter for haemodynamic monitoring with PiCCO. We therefore highlight the need for regular assessment of limb perfusion after arterial catheterisation for haemodynamic monitoring with PiCCO. In addition, the brachial artery should be avoided, and femoral artery catheterisation is recommended.

A randomised controlled trial comparing Mediwrap heat retention and forced air warming for maintaining normothermia in thoracic surgery.

Hypothermia is one of the common complications in the perioperative period. Currently, normothermia is maintained with forced air warming (FAW) or passive heat retention methods. We compared the efficacy of the Mediwrap blanket with FAW in maintaining normothermia during intra-operative period in thoracic surgery in a prospective randomised controlled trial on 30 patients. Core temperature was measured at 30-min intervals in the perioperative period and the time taken to attain baseline in the postoperative periods in the two groups was compared. There was no difference in core temperatures between the groups during pre- and intra-operative period, with mean+/-S.D. final core temperatures of 36.2+/-0.6 degrees C with Mediwrap and 36+/-0.9 degrees C with the FAW blanket. However, the postoperative core temperatures were significantly higher in the Mediwrap group. The time required to reach baseline temperature was lower in the Mediwrap group with a mean+/-S.D. of 66+/-66 min as compared to 161+/-108 min in the FAW group. The Mediwrap blanket is as effective as the FAW blanket in maintaining core body temperature during thoracotomy when applied thirty minutes before the surgery.

Is tracheal stenosis caused by percutaneous tracheostomy different from that by surgical tracheostomy?

STUDY OBJECTIVE: To compare the surgical findings of tracheal stenosis caused by percutaneous tracheostomy (PCT) and surgical tracheostomy (SGT). DESIGN AND SETTING: A combined prospective (from 2001 to 2003) and retrospective (from 1993 to 2001) observational study of the patients undergoing tracheal resection and reconstruction for treatment of tracheal stenosis following PCT or SGT in a national referral center for thoracic surgery in the United Kingdom. PATIENTS AND MEASUREMENTS: We studied 29 patients presenting with symptomatic tracheal stenosis requiring tracheal reconstruction. We recorded the demographic data, duration of mechanical ventilation, onset of tracheal stenosis after decannulation, and type of tracheostomy (PCT or SGT) from referral notes. Tracheal reconstruction was preceded by rigid bronchoscopy, through which the distance of the superior level of stenosis to the vocal cords, and the length and the diameter of stenosis were measured. The type of surgical technique for tracheal resection was also recorded. We then compared the stenosis caused by PCT (n = 15) and SGT (n = 14) using an unpaired t test, Mann-Whitney U test, or Fisher exact test as appropriate for statistical analysis. RESULTS: The mean distance from the superior level of stenosis in the PCT group was significantly closer to the vocal cords compared with the mean distance in the SGT group: 1.6 cm (95% confidence interval [CI], 1.1 to 2.1) vs 3.4 cm (95% CI, 2.3 to 4.5), respectively (p = 0.04). The mean onset of stenosis was significantly earlier in the PCT group compared to the SGT group: 5.0 weeks (95% CI, 5.0 to 6.0) vs 28.5 weeks (95% CI, 12 to 84), respectively (p = 0.009). Seven of 15 patients in the PCT group required partial cricoid resection and a mucosal flap, compared with 1 of 14 patients in the SGT group, although the difference did not reach statistic significance (p = 0.23). CONCLUSION: Stenosis caused by PCT occurred earlier and was subglottic in nature compared to that by SGT. Surgical correction of stenosis was more difficult in the PCT group due to its presentation in the subglottic area.