Retrospective cohort study of 925 OAGB procedures. The UK MGB/OAGB collaborative group.

BACKGROUND: Mini-One Anastomosis Gastric Bypass is a new operation that provides comparable outcomes to the common bariatric procedures. Revisional surgery is still needed after a number of MGB-OAGB procedures. The aim of this study is to report the causes and management of these revisions. METHODS: From 2010 to 2018, 925 MGB-OAGB operations were performed at 7 bariatric units across the United Kingdom and included in this retrospective cohort study. The data was retrospectively collected and analysed. The primary end point was the identification of the causes and management of revisions. Follow up ranged from 6 months to 3 years. RESULTS: Twenty-two patients [2.3%] required revisional surgery after MGB-OAGB. Five patients [0.5%] developed severe diarrhoea managed by shortening the bilio-pancreatic limb to 150 cm. Four patients [0.4%] developed afferent loop syndrome and bile reflux was reported in another 3 [0.3%] cases; all were managed by either conversion to Roux en Y Gastric Bypass or a Braun anastomosis. Postoperative bleeding was controlled laparoscopically in 3 patients [0.3%]. Liver decompensation that was reported in 2 patients [0.2%] was treated by shortening the BPL in one patient and a reversal to normal anatomy in another. The liver failure resolved in both patients. Other indications for revision included two gastro-jejunal stenosis [0.2%], one perforated ulcer [0.1%], one patient [0.1%] with excessive weight loss and one case [0.1%] of protein malnutrition. None of the 22 patients undergoing revisional surgery after MGB-OAGB died. Lost to follow up rate was 0.2%. CONCLUSION: Complications requiring revisional surgery after MGB-OAGB are uncommon [2.3%] and the majority can be managed by bilio-pancreatic limb shortening, the addition of a Braun side-to-side anastomosis or conversion to RYGB. Bilio-pancreatic limb length of 200 cm or more resulted in serious complications of liver failure, protein malnutrition, excessive weight loss and diarrhoea.

Short- and Mid-term Outcomes of 527 One Anastomosis Gastric Bypass/Mini-Gastric Bypass (OAGB/MGB) Operations: Retrospective Study.

BACKGROUND: One anastomosis gastric bypass/mini-gastric bypass (OAGB/MGB) is considered an alternative option in metabolic and bariatric surgery. The aim of this study was to evaluate the safety, efficacy and postoperative challenges of OAGB/MGB as a new procedure. METHODS: We performed 519 primary MGBs and 8 additional second-stage MGBs during 2014-2018. The data were collected from patients' notes as well as the surgeons' prospective data sheets. Two senior surgeons performed the operations. The ultimate primary measures were assessment of the safety and management of the complications. The secondary outcomes were excess weight loss and resolution of the comorbidities. RESULTS: The type 2 diabetes mellitus (T2DM) remission rate was 83% and 70% over 1 and 3 years, respectively (HBA1C < 6.5%). Weight loss was 28-152 kg (SD 23.11). Excess weight loss ranged from 41 to 125%. Hypertension resolution was 61%, 58% and 58% in the first, second and third years, respectively. Ninety-nine per cent of sleep apnoea patients improved symptomatically and went off the continuous positive airway pressure (CPAP) machine. Two (0.37%) patients developed diarrhoea, cured by shortening the afferent biliopancreatic limb (BPL). Eight (1.5%) stomal ulcers were reported. Two patients (0.37%) developed deranged liver function, revised by shortening the BPL in one patient and a reversal in the second patient. The mean follow-up was 2.5 years. Mortality was zero. CONCLUSIONS: This is the largest UK OAGB/MGB study to date showing safety and acceptable results for metabolic syndrome and obesity problems. OAGB/MGB revisional options are rectifying the morbidity and no mortality.

A rare complication of acute appendicitis: Superior mesenteric vein thrombosis.

INTRODUCTION: Very few cases of superior mesenteric vein thrombosis have been reported as a complication of appendicitis. In these handful of cases, the thrombosis was identified early with computerised tomography scan and patients have been managed conservatively with antibiotics and anticoagulation. PRESENTATION OF CASE: A 45-year-old gentleman presented to the emergency department with a 13-day history of right lower quadrant abdominal pain and rigors. CT scan of the abdomen revealed an appendicular mass and superior mesenteric vein thrombosis. The patient was initially managed by anticoagulation and antibiotics for two weeks and was discharged after satisfactory clinical improvement. He represented after discharge for increased severity of his abdominal pain and abnormal inflammatory markers. Emergency open appendicectomy for complicated appendicitis was performed and his postoperative course was unremarkable. He was discharged on the 7th postoperative day with anticoagulation. Outpatient review at two months was unremarkable. DISCUSSION: Acute appendicitis is a common surgical presentation where history and examination is key in clinching the diagnosis. Inflammatory markers and imaging modalities such as a CT scan can be helpful. Although surgical intervention is the mainstay of treatment, conservative management with antibiotics is an option if the diagnosis of appendicitis is equivocal. Recent evidence has revealed that elective appendicectomy is not necessary upon successful conservative management. Acute appendicitis can lead to local perforations and abscesses. Complications such as thrombosis in the superior mesenteric vein are rare and can be managed successfully with anticoagulants. CONCLUSION: Although this is a rare complication of appendicitis, the case was managed successfully with a conservative approach. This is inline with the general consensus which is to treat superior mesenteric vein thrombosis secondary to appendicitis conservatively unless the patient deteriorates.

Gastric plication can reduce slippage rate after laparoscopic gastric banding.

BACKGROUND: Laparoscopic insertion of a gastric band for weight reduction is increasingly performed in obese and morbidly obese patients. Complication rates after gastric band insertion are reduced by using certain techniques. PATIENTS AND METHODS: This was a prospective study of all patients who underwent laparoscopic adjustable gastric band (LAGB) insertion at our unit. This procedure is performed through the classical 4-port technique and the use of a liver retractor. The pars flaccida method is performed in all patients, and the gold finger, a malleable instrument, is used to guide the band through the retroesophageal window in patients with difficult anatomy. Band slippage is avoided by using 2 types of gastric plication, depending on the anatomical characteristics of the stomach. Outcomes and morbidity are recorded, and patients are followed up in outpatient clinics. RESULTS: Laparoscopic adjustable gastric band (LAGB) insertion was performed in 464 patients. A single consultant surgeon performed all procedures over a 2-year period. From August 2005 through August 2007, 380 (81.89%) women and 84 (18.10%) men were included in this study. The mean age was 41 years (range, 21 to 62). The mean body mass index was 43 (range, 35 to 62). Morbidity included dysphagia, epigastric pain, port displacement, port infection, erosion, and acute respiratory distress. Only one (0.21%) case of band slippage was reported. The mean follow-up was 26 months (range, 18 to 42). CONCLUSION: Laparoscopic gastric plication adds greater security and provides optimum gastric band placement. It is an effective method to reduce slippage after gastric band insertion.

Laparoscopic subtotal cholecystectomy: initial experience with laparoscopic management of difficult cholecystitis.

AIM: Laparoscopic cholecystectomy (LC) is now accepted as the 'gold standard' procedure for cholecystectomy. However, a significant proportion of patients with complicated cholecystitis are still converted to 'open' to complete the procedure. Laparoscopic subtotal cholecystectomy (LSC) is an option, which is still too infrequently used. METHODS: A single surgeon in our NHS trust has performed 1150 LCs since September 1999. The procedure was converted to LSC in 52 cases (4.52%) due to complicated cholecystitis. The data were collected and prospectively analysed for any morbidity or complications in the peri-operative period. RESULTS: At the initial presentation, 21 patients (40.38%) were diagnosed with recurrent biliary colic, 24 patients (46.15%) had acute cholecystitis, 6 patients (11.53%) had jaundice, and 1 patient (1.92%) had peritonitis due to gallbladder (GB) perforation. Twenty-six cases (50%) were performed as emergencies, i.e. within one week of symptoms, and 26 (50%) were planned for surgery within four weeks after symptoms started. The cystic duct or Hartmann's pouch stump was closed using endo-loop application in 34 (65.38%), intracorporeal suturing of stump of Hartmann's pouch in 13 (25%), and closure of cystic duct opening in the Hartmann's pouch by purse-string suturing in 5 cases (9.62%). CONCLUSION: LSC is a safe option in treating gallstone disease when inflammation or fibrosis precludes conventional dissection of Calot's triangle. LSC can clearly help reduce morbidity associated with open laparotomy.