Revisional One-Anastomosis Gastric Bypass After Restrictive Index Surgery-a Metaanalysis and Comparison with Revisional Roux-en-Y Gastric Bypass.

BACKGROUND: One-anastomosis gastric bypass (OAGB) was established as a recognized bariatric procedure in the 2018 International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) position statement. This study evaluates the outcomes of revisional OAGB (rOAGB) after a restrictive index procedure, and to compare it to revisional RYGB (rRYGB). METHODS: A literature search was performed according to the PRISMA guidelines on papers published from inception till February 2020. Original studies involving patients who underwent rOAGB after a primary failed restrictive procedure were included. The primary outcome measured was postrOAGB weight loss. Secondary outcome measures include comorbidity resolution, operative duration, length of stay, morbidity, and mortality. RESULTS: A total of 21 studies with 1377 patients were included. Five studies compared rOAGB versus rRYGB. Majority of the patients (76%) were female, with mean age of 43.5 years old. Mean body mass index (BMI) before revisional surgery was 41.6 kg/m2. The most common biliopancreatic limb length was 200 cm. Percentage of excess weight loss after rOAGB increases to a maximum of 76.0% at 48 months postsurgery. rOAGB resulted in a pooled prevalence of diabetes, hypertension, hyperlipidemia, and obstructive sleep apnea resolution of 74.9%, 48.4%, 63.2%, and 75.7% respectively. When compared to rRYGB, rOAGB demonstrated greater weight loss, comparable metabolic syndrome resolution, but with a shorter operating time. Morbidity and mortality rates were low across all studies. CONCLUSIONS: rOAGB has potential as an alternative revisional surgery, with weight loss profiles and rates of metabolic syndrome resolution that are comparable to rRYGB.

Telemedicine takes centre stage during COVID-19 pandemic.

The COVID-19 pandemic continues to spread rapidly and overwhelm health systems around the world. To cope with this unprecedented usage of healthcare resources, increasingly novel solutions are being brought into the fray. Telemedicine has been thrust into the spotlight in the fight against COVID-19 and is being employed in many different ways to better tackle the challenges. Telemedicine will likely have a more permanent place in traditional healthcare delivery long after COVID-19 is over as users and providers recognise its utility.

Eight-fold path to attain laparoscopic totally extraperitoneal (TEP) hernia repair Nirvana - a standardized technique to reduce the learning curve of surgical residents.

INTRODUCTION: Laparoscopic totally extraperitoneal (TEP) hernia repair remains technically challenging due to the steep learning curve and unfamiliar territory. This paper describes an eight-step standardized technique of laparoscopic TEP hernia repair that is easily reproducible, thus reducing the learning curve. MATERIALS AND SURGICAL TECHNIQUE: The eight steps are as follows: (a) creation of the pneumo pre-peritoneal space; (b) identify the pubis symphysis; (c) identify the inferior epigastric vessels; (d) lateral to medial dissection of the hernia sac; (e) identification of cord structures and triangle of doom/pain; (f) herniotomy; (g) parietalization of the hernia sac; (h) placement and fixation of the mesh. DISCUSSION: The learning curve of laparoscopic TEP can be decreased by proctoring, standardization of the procedure and having a formal set of operative steps that residents can follow and easily repeat.

Journey for patients following ileostomy creation is not straightforward.

BACKGROUND: An ileostomy is usually created to avert systemic sepsis in a patient with a tenuous anastomosis. However, what is often not reported are the numerous issues facing these patients subsequently, ranging from readmissions, non-reversal of the stoma, and complications from the closure. This study was performed to identify these issues among patients following creation of an ileostomy. METHODS: We conducted a retrospective analysis of consecutive patients who had an ileostomy created from January 2011 to December 2016 at two institutions. Statistical analysis was performed to identify risk factors associated with readmissions and ileostomy non-reversal. RESULTS: In total, 193 patients had an ileostomy created during the study period. Twenty-six (13.5%) patients developed stoma-related complications requiring readmission. The most common cause of readmission (9.3%) was due to dehydration and acute kidney injury secondary to high stoma output. One hundred thirty (67.4%) patients had their ileostomy reversed. On multivariate analysis, only stomas created during an ultra-low anterior resection were associated with reversal (OR 2.88 [95% CI, 1.24-6.68]; p = 0.014). Among the patients who underwent ileostomy reversal, seven (3.6%) patients developed complications from their ileostomy reversal. Four patients (2.1%) suffered from an anastomotic leak which required repeat surgical intervention with one mortality from the ensuing sepsis. CONCLUSION: Almost half of the patients who had an Ileostomy had an undesirable outcome, including readmissions, non-reversal, and post-operative complications following closure. Patients need to be properly counselled about the risks involved prior to the index operation.

Impact of bariatric surgery on serum uric acid levels and the incidence of gout-A meta-analysis.

Gout is characterized by high serum uric acid (SUA) levels and arthritis. It is associated with obesity and metabolic syndrome. Bariatric surgery has been associated with decreased SUA levels and overall gout incidence. This meta-analysis aims to summarize the current evidence on bariatric surgery, gout and SUA levels. A literature review was performed on papers published from 2000 up till December 2018. Original studies investigating the impact of bariatric surgery on SUA levels or gout incidence were evaluated. Twenty studies with a total of 5,233 patients were analysed. Majority (n=14) had a follow-up duration of at least 12 months. The mean preoperative body mass index (BMI) was 45.2kg m-2 . The mean preoperative SUA level was 6.5mg dL-1 . Subgroup analysis demonstrated a mean decrease in SUA levels (-0.73mg dL-1 ) from the third postoperative month onwards, which was sustained until the third postoperative year (-1.91mg dL-1 ). There was a rise in SUA levels in the first post-operative month. Meta-regression analyses demonstrated a proportionate linear relationship between the change in BMI and SUA levels. Post-bariatric surgery weight loss is associated with reduced SUA levels and decreased incidence of gout attacks. However, this is only evident from the third post-operative month onwards.

A rare case of bipartite combined tumour of the oesophagus.

BACKGROUND: Bipartite combined oesophageal tumours are an exceedingly rare entity and much less is known about the natural history of these tumours following curative surgery. The authors present a case of a bipartite combined oesophageal tumour comprising of sarcomatoid carcinoma and small cell carcinoma with early postoperative recurrence. CASE PRESENTATION: A 63-year-old Chinese male with a smoking history presents with hemoptysis on a background of dysphagia and odynophagia for 1 month. An endoscopic evaluation found an exophytic oesophageal tumour with contact bleeding for which biopsy of this lesion returned as a malignant high-grade tumour where immunohistochemistry staining was unable to establish the lineage of the tumour. Differential diagnoses include sarcomatoid carcinoma and malignant undifferentiated sarcoma. With the provisional diagnosis of a high-grade oesopheageal sarcoma, the patient underwent minimally invasive McKeown's oesophagectomy. Final histological assessment was pT1bN0 with two histological types of malignancy within a single tumour-70% poorly differentiated spindle cell squamous carcinoma and small cell carcinoma. He was planned for adjuvant chemotherapy in view of the small cell carcinoma component after the resolution of the postoperative infective collections. A computed tomographic scan performed 4 months postoperatively demonstrated metastasis to the lung, pleura, thoracic nodes and liver. Biopsy of the largest lung nodule confirmed small cell neuroendocrine carcinoma with features similar to the small cell carcinoma component in the prior oesophagectomy specimen. He was thereafter initiated on palliative chemotherapy aimed at three weekly carboplatin and etoposide aimed at a total of 4 cycles with peglasta support. Etoposide was stopped during the first cycle due to asymptomatic bradycardia. The regime was then converted to carboplatin with irinotecan for 5 cycles. Repeat computed tomographic scan performed 3 weeks after the completion of chemotherapy showed a complete response of lung and liver metastasis and no evidence of local recurrence or distant metastasis. CONCLUSION: The management of bipartite combined oesophageal tumours should be guided by its more aggressive component. Bipartite combined oesophageal tumours with a small cell carcinoma component are believed to demonstrate aggressive tumour biology likened to that of primary oesophageal small cell carcinoma. Preoperative confirmation of a combined tumour may be challenging, and biopsy results may only yield one of the two components. The more aggressive component is usually a small cell carcinoma, for which the mainstay of therapy is platinum-based chemotherapy rather than surgery.

Outcomes After Metabolic Surgery in Asians-a Meta-analysis.

BACKGROUND: Obesity and type 2 diabetes mellitus (T2DM) are now increasingly epidemic in Asia. As obesity and T2DM have different disease patterns in Asians compared to Westerners, outcomes after metabolic surgery may differ. The aim of this meta-analysis was to gather the current available evidence on the outcomes after metabolic surgery in Asians. METHODS: A literature search was conducted in September 2017. Four outcome measures were examined: (1) % excess weight loss (EWL), (2) post-intervention body mass index (BMI), (3) T2DM resolution or improvement, and (4) hypertension resolution. RESULTS: Thirteen publications with a total of 1052 patients were analyzed, of which nine were randomized controlled trials, and four were case-matched studies. All the studies had a minimum follow-up duration of at least 1 year. % EWL was significantly higher in those who have undergone Roux-en-Y gastric bypass (RYGB) (SMD 0.53, 95% CI 0.12 to 0.94) versus sleeve gastrectomy (SG). T2DM resolution/improvement was favorable in those who have undergone RYGB (pooled OR 1.39, 95% CI 0.53 to 3.67) versus SG, although not statistically significant. Hypertension resolution was not significantly different between patients who have undergone SG versus RYGB (pooled OR 0.96, 95% CI 0.44 to 2.11). CONCLUSION: RYGB results in better weight loss compared to SG in Asians, but the rate of T2DM resolution/improvement and improvement of hypertension appears to be similar. In Asian patients without symptoms of gastro-esophageal reflux disease in whom metabolic surgery is performed mainly for T2DM and metabolic syndrome, SG may be the surgery of choice.

Incidence of venous thromboembolism and its pharmacological prophylaxis in Asian general surgery patients: a systematic review.

BACKGROUND: Venous thromboembolism (VTE) is a condition that has always been perceived to be rare in Asia. The aim of this systematic review was to gather the current available evidence on the incidence of VTE in this population. A secondary aim was to assess the efficacy of pharmacological prophylaxis, and hence determine its role, in the Asian population. METHODS: A comprehensive literature search was performed using MEDLINE, Embase, and the Cochrane Database of Systematic Reviews in June 2014. Articles found using search terms related to venous thromboembolism (VTE), Asian countries and general surgery procedures and pathologies were screened using the following inclusion criteria: (1) either the population studied was primarily Asian or the study was conducted in an Asian country, (2) the subjects studied underwent a major gastrointestinal or other general surgery procedure, (3) the primary outcome was the incidence of deep vein thrombosis (DVT) or pulmonary embolus (PE), and (4) secondary outcomes assessed included mortality and complications due to the VTE or prophylaxis against VTE. RESULTS: Fourteen publications with a total of 11,218 patients were analyzed. Nine of the fourteen were observational studies, with half being prospective in nature. There were five interventional studies of which two were randomized controlled trials. Among the observational studies, the median (range) incidence of above-knee DVT was 0.08 % (0-2.9 %), while the median (range) incidence of PE was 0.18 % (0-0.58 %). The rates of DVT in the control groups were reported to be between 0 and 7.4 %, while the incidence of PE in the control groups ranged from 0 to 1.9 %. Analysis of the comparative studies revealed that the incidence of bleeding-related complications varied from 0 to 18.1 % in the low-molecular-weight heparin (LMWH) group compared to 0-7.5 % in the control group. The difference in minor bleeding complications between the LMWH group and the control group was found to be statistically significant. CONCLUSION: Data from this systematic review suggest that the risk of VTE in Asian general surgery patients is low, even in the context of risk factors typically regarded as high risk.

Hemorrhoidectomy - making sense of the surgical options.

While debate continues as to which is the best surgical method for the treatment of hemorrhoids, none of the currently available surgical methods approach the ideal surgical option, which is one that is effective while being safe and painless. In reality, the less painful the procedure, the more likely it is to be associated with recurrence post-op. Where hemorrhoids surgery is concerned, there isn't a "one size fits all" option. Most of the randomized controlled trials performed to date include hemorrhoids of various grades and with a focus on only comparing surgical methods while failing to stratify the outcomes according to the grade of hemorrhoid. We believe that surgery needs to be tailored not only to the grade of the hemorrhoids, but also to the size, circumferential nature of the disease, and prevailing symptomatology.