Evaluation of 30-day morbidity and mortality of laparoscopic cholecystectomy: a multicenter prospective observational Indian Association of Gastrointestinal Endoscopic Surgeons (IAGES) Study.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the standard of care for benign gallstone disease. There are no robust Indian data on the 30-day morbidity and mortality of this procedure. A prospective multicentre observational study was conducted by the Indian Association of Gastro-Intestinal Endo Surgeons (IAGES) to assess the 30-day morbidity and mortality of LC in India. MATERIALS AND METHODS: Participating surgeons were invited to submit data on all consecutive LCs for benign diseases performed between 09/12/2020 and 08/03/2021 in adults. Primary outcome measures were 30-day morbidity and mortality. Univariate and multivariate analyses were performed to identify variables significantly associated with primary outcomes. RESULTS: A total of 293 surgeons from 125 centres submitted data on 6666 patients. Of these, 71.7% (n = 4780) were elective. A total LC was carried out in 95% (n = 6331). Laparoscopic subtotal cholecystectomy was performed in 1.9% (n = 126) and the procedure were converted to open in 1.4% of patients. Bile duct injury was seen in 0.3% (n = 20). Overall, 30-day morbidity and mortality were 11.1% (n = 743) and 0.2% (n = 14), respectively. Nature of practice, ischemic heart disease, emergency surgery, postoperative intensive care, and postoperative hospital stay were independently associated with 30-day mortality. Age, weight, body mass index, duration of symptoms, nature of the practice, history of Coronavirus Disease-2019, previous major abdominal surgery, acute cholecystitis, use of electrosurgical or ultrasonic or bipolar energy for cystic artery control; use of polymer clips for cystic duct control; conversion to open surgery, subtotal cholecystectomy, simultaneous common bile duct exploration, mucocele, gangrenous gall bladder, dense adhesions, intraoperative cholangiogram, and use of drain were independently associated with 30-day morbidity. CONCLUSION: LC has 30-day morbidity of 11.1%, 30-day mortality of 0.2%, conversion to open rate of 1.4%, and bile duct injury rate of 0.3% in India.

Utility of Tokyo guidelines and intraoperative safety steps in improving the outcome of laparoscopic cholecystectomy in complex acute calculus cholecystitis: a prospective study.

BACKGROUND: Laparoscopic cholecystectomy (LC) in complicated acute calculus cholecystitis (ACC) poses multiple challenges. This prospective, observational study assessed the utility and safety of a set protocol and intraoperative steps in LC for complex ACC. METHODS: All cases of ACC from 2008 to 2018 were graded as per Tokyo guidelines; moderate and severe ACC were termed as 'complex ACC (CACC).' Patients were subjected to upfront LC or percutaneous drainage (PCD) followed by LC. Seven intraoperative safety steps were used to achieve critical view of safety (CVS). Use of safety steps, duration of surgery, and length of hospital stay were compared between moderate and severe ACC; complications were classified using Clavien-Dindo classification. RESULTS: We analyzed 145 patients with moderate (74.5%) and severe (25.5%) ACC. There were significantly more male (p = 0.0059) and older (p = 0.0006) patients with severe ACC. Upfront LC was performed in 81.4%; PCD required in 6.9%. Timing of LC from symptom onset was < 1 week (53.1%), 2-5 weeks (28.3%), and ≥ 6 weeks (18.6%). CVS was achieved in 97.2%, subtotal cholecystectomy performed in 2.8%, conversion rate was 1.4%, major postoperative complications (Clavien-Dindo Grade IIIa and IIIb) were seen in 4.1%, no bile duct injury, and mortality was 0.7%. The outcomes were similar irrespective of timing of intervention. CONCLUSION: The study concludes that preoperative assessment by Tokyo guidelines, algorithmic plan of treatment and use of intraoperative safety steps results in favorable outcome of LC in ACC.

Banded Sleeve Gastrectomy and One Anastomosis Gastric Bypass/Mini-gastric Bypass for Treatment of Obesity: a Retrospective Cohort Comparative Study with 6 years follow-up.

BACKGROUND: Banded sleeve gastrectomy (BSG), a modification of the laparoscopic sleeve gastrectomy (SG), and one anastomotic gastric bypass/mini-gastric bypass (OAGB/MGB), a modification to the Roux-en-Y gastric bypass (RYGB), have been reported to enhance weight loss and minimize significant weight regain when compared with the SG and RYGB respectively. However, there has not been any report or study comparing these two operations. OBJECTIVE: We did a retrospective cohort study comparing these two operations and present a review and analysis with follow-up for 6 years. METHOD: A review of all the operations performed at MBRSC in 2011 from a prospectively maintained database was done. Patients who had either a BSG or OAGB/MGB were identified. Data on the patients' profile, co-morbid conditions, perioperative complications, late complications, weight loss, resolution of comorbidities, and changes in quality of life (QLF) were collected reviewed and analyzed. RESULT: Sixty-eight patients were identified who had a primary BSG and 55 who had an OAGB/MGB in 2011. The follow-up rate, the age, BMI, and gender composition were similar in both groups. There were more patients with type 2 diabetes (T2D) in the BSG group than in the OAGB/MGB group (44.1% vs. 27.2%). The incidences of hypertension (HTN) and obstructive sleep apnea (OSA) were higher in the OAGB/MGB group (62% vs. 36% and 96.3% vs. 2.9% respectively). The weight loss was faster in the OAGB/MGB group in the first year, but by the sixth year, the weight loss was slightly higher in the BSG group (84% vs. 79%). Resolution rate of T2D and HTN was higher after the OAGB/MGB group, 86.6% vs. 75.7% and 85.3% vs. 64.0% respectively. There was a 20% incidence of nutrient deficiencies in OAGB/MGB group and none in the BSG group. CONCLUSION: Both operations produced excellent weight loss and maintenance in the short to intermediate term. There was better resolution of T2D and HTN after OAGB/MGB at the expense of a higher incidence of nutrient deficiency and some protein caloric malnutrition. There is need for prospective and larger series studies to confirm these findings.

Assessment of functional ability of nonambulatory patients with obesity: after and before bariatric surgery.

INTRODUCTION: Functional ability is often impaired as a direct consequence of severe obesity. Bariatric surgery is the most effective treatment for severe obesity. OBJECTIVE: To examine the effect of weight loss after bariatric surgery on patients with impaired functional ambulatory abilities due to obesity. SETTINGS: A high-volume university-affiliated bariatric surgery center in India. METHOD: We conducted a prospective study in a cohort of nonambulatory patients with functional disabilities (bedridden, wheelchair-bound, or walker-dependent) who underwent bariatric surgery. Data on sex, body mass index, co-morbid conditions, the severity of pain, and types of limitations in functional abilities were collected at baseline and at 1 year after bariatric surgery and analyzed. RESULTS: Forty-five patients were enrolled in this study with 100% follow-up at 1 year. The mean age and body mass index of the patients were 54.7 ± 8.5 years and 54.2 ± 8.6 kg/m2, respectively. Thirty-four (75.5%) were female, 27 (60%) were walker-dependent, 14 (31.1%) were wheelchair-bound, and 4 (8.9%) were bedridden. At baseline 88.8% and 75.5% patients had severe knee and back pain, respectively. The percentage of total weight loss was 22% and 31% at 6 and 12 months, respectively. At 1 year, 37 (82.2%) patients were ambulating independently, only 1 (2.2%) patient was still bedridden, and 7 (15.5%) patients were walker-dependent. Mild, moderate, and severe classification on all functional ability scales were significantly improved. CONCLUSION: Weight loss after bariatric surgery results in significant amelioration of knee and/or back pain with an improvement in functional abilities and quality of life.

Revision operation to one-anastomosis gastric bypass for failed sleeve gastrectomy.

BACKGROUND: There are few publications on revising sleeve gastrectomy (SG) to one-anastomosis gastric bypass (OAGB). OBJECTIVE: This study was undertaken to determine outcomes in terms of weight loss and resolution of co-morbidities in patients who had SG revised to OAGB. SETTINGS: A high-volume university-affiliated bariatric surgery center in India. METHOD: Information was collected from patients identified in a prospectively maintained database of patients who had a revision from SG to OAGB. An analysis of outcomes in terms of weight loss and maintenance with up to 3-years follow-up is reported. RESULTS: Thirty-two patients were revised from SG to OAGB. Of the 32 revised patients, 9 (28%) had type 2 diabetes, 15 (47%) had hypertension, and 2 (6%) had sleep apnea at the time of the initial SG. At the time of revision only 2 of 32 (6.25%) had type 2 diabetes, 3 (9.4%) had hypertension, and none had sleep apnea. The average initial weight in this study before SG was 118 kg and body mass index was 44.04 kg/m2. The average weight at the nadir and at revision was 92.1 and 103.5 kg, respectively. Average weight was 93.5, 94.3, and 100.6 kg (P < .002) at 1-, 2-, and 3-year follow-up, respectively. There was reoccurrence of type 2 diabetes in 1 patient at 3 years after revision due to weight regain. There were no complications in this study. CONCLUSION: In this study, revision of SG to OAGB because of inadequate weight loss or significant weight regain was safe and effective at 2-year follow-up; however, there was a tendency toward weight regain at 3 years. Multicenter studies with larger series of patients and longer-term follow-up after SG revision to OAGB are needed.

Laparoscopic-assisted mini percutaneous nephrolithotomy for treatment of large calculi in pelvic ectopic kidney.

We report two cases of male patients with pelvic ectopic kidney with large stones cleared with laparoscopic-assisted minimally invasive percutaneous nephrolithotomy (Mini-PERC) and holmium laser. These are the first cases of Mini-PERC done for pelvic ectopic kidney reported thus far.