The Effect of Participation in Tier 3 Services on the Uptake of Bariatric Surgery.

BACKGROUND: Despite the recognised advantages of bariatric and metabolic surgery, only a small proportion of patients receive this intervention. In the UK, weight management systems are divided into four tiers. Tier 3 is a clinician-lead weight loss service while tier 4 considers surgery. While there is little evidence that tier 3 has any long-term benefits for weight loss, this study aims to determine whether tier 3 improves the uptake of surgery. METHOD: A retrospective cohort study of all referrals to our unit between 2013 and 2016 was categorised according to source-tier 3, directly from the general practitioner (GP) or from another speciality. The likelihood of surgery was calculated using a regression model after considering patient demographics, comorbidities and distance from our hospital. RESULTS: Of the 399 patients, 69.2% were referred directly from the GP, 21.3% from tier 3, and 9.5% from another speciality of which 69.4%, 56.2%, and 36.8% progressed to surgery (p = 0.01). On regression analysis, patients from another speciality or GP were more likely to decide against surgery (OR 2.44 CI 1.13-6.80 p = 0.03 and OR 1.65 CI 1.10-3.12 p = 0.04 respectively) and more likely to be deemed not suitable for surgery by the MDT (OR 6.42 CI 1.25-33.1 p = 0.02 and OR 3.47 CI 1.11-12.9 p = 0.03) compared with tier 3 referrals. CONCLUSION: As patients from tier 3 were more likely to undergo bariatric and metabolic surgery, this intervention remains a relevant step in the pathway. Such patients are likely to be better informed about the benefits of surgery and risks of severe obesity.

A case of a chronic salmonella infection following Roux-en-Y gastric bypass surgery, treated successfully by a laparoscopic cholecystectomy.

We report a case of chronic infection caused by Salmonella and cured by a laparoscopic cholecystectomy after Roux-en-Y gastric bypass (RYGB) surgery for obesity. This patient presented with a 2-year history of chronic abdominal pain, loose stools and excessive weight loss. Her stool and urine cultures were positive for Salmonella Despite multiple courses of antibiotics, she remained positive.After undergoing a laparoscopic cholecystectomy, the patient became asymptomatic and stools remained negative. In chronic carriers for Salmonella, the gall bladder is the common reservoir for the bacteria and removing it is usually curative.The possibility that the source of the may be in the biliary limb of her bariatric procedure and not in the gall bladder remained a concern.In patients who have had a RYGB, cholecystectomy is an effective treatment.All patients presenting with abdominal symptoms following RYGB should have stool and urine cultures taken as part of their work up.

Port site endometrioma: a rare cause of abdominal wall pain following laparoscopic surgery.

Endometriomas are a rare cause of abdominal wall pain. We report a case of a port site endometrioma presenting with an umbilical swelling. The patient underwent a laparoscopy for pelvic endometriosis 6 months previously and presented with a swelling around her umbilical port site scar associated with cyclical pain during menses. Ultrasound scan reported a well-defined lesion in the umbilicus and MRI scanning excluded other pathology. As she was symptomatic, she underwent an exploration of the scar and excision of the endometrioma with resolution of her symptoms. Precautions should be taken to reduce the risk of endometrial seeding during laparoscopic surgery. All tissues should be removed in an appropriate retrieval bag and the pneumoperitoneum should be deflated completely before removing ports to reduce the chimney effect of tissue being forced through the port site. The diagnosis should be considered in all women of reproductive age presenting with a painful port site scar.

A case of endometriosis presenting as an inguinal hernia.

Endometriosis is a common clinical presentation for gynaecologists. Occasionally it can present to general surgeons as a swelling in the groin or abdominal wall. This condition should be included in the differential diagnosis in female patients. A 32-year-old woman with a 2-year history of a painful persistent lump in her right groin was referred to the general surgeons by her general practitioner. She was referred with a diagnosis of a suspected inguinal hernia. MRI excluded a hernia and exploration of the groin and subsequent histology confirmed the lesion to be an endometrial deposit.

Paraganglioma mimicking adrenal incidentaloma.

Paragangliomas can be confused with adrenal incidentalomas because of their proximity to the adrenal glands. A 71-year-old man presented with left-sided abdominal pain. A computed tomography scan showed a large cystic mass with a solid component arising from the left adrenal gland (Figure 1).

Ileo-ileal intussusception from Crohn's ileitis.

Crohn's disease can cause abdominal pain and diarrhoea. A 33-year-old man presented with a 3-month history of recurrent abdominal pain and occasional diarrhoea.

Endovascular management of grade V blunt renal trauma with associated splenic injury.

BACKGROUND: A 15-year-old boy presented to hospital with tenderness in his left loin and hypochondrium, and frank hematuria; he was hemodynamically stable. The patient was overweight and had fallen onto his left flank from his bicycle 2 h previously. INVESTIGATIONS: Physical examination, routine blood tests, contrast-enhanced CT of the abdomen and pelvis, renal MRI and percutaneous transfemoral angiography. DIAGNOSIS: Grade V blunt renal trauma, grade IV splenic injury and left renal vein thrombosis. MANAGEMENT: The patient received conservative management with supportive measures followed by percutaneous transfemoral angiography and embolization of the injured left kidney. He recovered well and was able to resume normal activities.

Isolated duodenal rupture due to go-karting accidents--braking news.

INTRODUCTION: Isolated duodenal injury due to blunt abdominal trauma is extremely rare. We present a series of three such injuries due to go-karting accidents, which presented to our hospital over 5 months. CASE REPORTS: Between October 2007 and February 2008, three cases of D3/D4 duodenal rupture presented to our hospital after go-karting accidents. Trauma occurred as a result of the steering wheel impacting on the abdomen. All patients presented similarly with symptoms of epigastric and right upper quadrant pain. In all cases, computed tomography scanning was highly suggestive of duodenal injury and, in particular, demonstrated presence of retroperitoneal air centred around the duodenum. Treatment required laparotomy and operative repair in all cases. CONCLUSIONS: Duodenal injury presents insidiously due to its retroperitoneal position. A low threshold for investigating patients presenting with epigastric and right upper quadrant pain should be adopted along with active clinical vigilance to exclude serious and life-threatening trauma after go-karting accidents.