Prospective evaluation of platelet function and fibrinolysis in 20 dogs with trauma.

OBJECTIVES: To determine platelet function and assess fibrinolysis in dogs following trauma using multiple electrical impedance aggregometry and a modified thromboelastographic (TEG) technique. To determine if the severity of trauma, as assessed by the Animal Trauma Triage (ATT) score and clinicopathological markers of shock, is associated with a greater degree of platelet dysfunction and fibrinolysis. SETTING: University teaching hospital. ANIMALS: Twenty client-owned dogs with trauma (occurring <24 h prior to admission and blood sampling) and ATT score of >4 were prospectively recruited. A control group of 10 healthy dogs was included. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Platelet function was measured using multiple electrode platelet aggregometry (MEPA) utilizing arachidonic acid, ADP, and collagen agonists. Fibrinolysis was assessed in citrated whole blood with the addition of tissue plasminogen activator (tPA; 50 U/mL) using kaolin-activated TEG. Conventional statistical analysis was performed to compare coagulation parameters between the groups and assess linear correlations. Median (interquartile range) ATT score was 5 (5-7), and 65% (n = 13) of dogs suffered polytrauma. Mean (± SD) time from trauma to blood sampling was 9 hours (± 6). Median (interquartile range) shock index and plasma lactate concentration were 1.1 (0.7-2.0, n = 16) and 2.9 mmol/L (0.9-16.0, n = 18), respectively. Four dogs did not survive to discharge (20%). There were no differences between the trauma and control group coagulation variables. A moderate negative correlation between ATT score and area under the curve for ADP was found (P = 0.043, r2  = -0.496). CONCLUSIONS: Preliminary evaluation of platelet function measured by MEPA, and fibrinolysis measured by tPA-modified TEG, is not significantly different in this population of dogs with traumatic injury compared to healthy dogs.

Robotic Vagus-Sparing Total Gastrectomy for CDH1 Gene Mutation Treatment.

Hereditary diffuse gastric cancer (HDGC) caused by the CDH1 gene mutation is an inherited cancer syndrome that increases the risk of diffuse gastric cancer and is nearly impossible to detect by screening gastroscopy. The recommended preventative treatment is a total gastrectomy. Robotic surgery facilitates the use of minimally invasive surgical (MIS) techniques for anastomoses and posterior vagus preservation to potentially reduce adverse functional outcomes. An asymptomatic 24 year old male with the CDH1 gene mutation proven by genetic testing and a family history of a brother having a total gastrectomy for HDGC was treated with this technique. This video case report demonstrates the techniques and pitfalls of robotic surgery in terms of the patient positioning and port placement, posterior vagus-preserving dissection, sutured esophagojejunostomy, jejunal pouch formation, and Roux-en-Y reconstruction with a staple-stapled jejunojejunostomy. While these techniques are demonstrated in the case of prophylactic gastrectomy, many of them can be applied to other benign and bariatric foregut and general surgery types.Robotic surgery can facilitate the foregut MIS technique, as described in this case of a vagus-sparing total gastrectomy.

A Systematic Review of Microwave Ablation for Colorectal Pulmonary Metastases.

BACKGROUND/AIM: Pulmonary metastases are the second most common site of metastasis in colorectal cancer after the liver, and microwave ablation (MWA) for its treatment has grown in popularity in patients who are not suitable for pulmonary metastatectomy. However, its long-term efficacy remains unknown. MATERIALS AND METHODS: A systematic review was conducted in July 2022 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, using PubMed, EMBASE, Scopus, and Cochrane databases. Studies adopting MWA for colorectal cancer pulmonary metastases were included. RESULTS: A total of 488 lesions were ablated in 230 patients across eight studies. The median duration of ablation was 10 minutes. The mean length of stay in hospital was 2.3 days. Complications included pneumothorax in 128 (52%) patients; pneumonia, which occurred in 4 (1.7%) patients, and pulmonary haemorrhage in 23 (10.0%) patients. Complete remission was achieved in 85 (37.0%) patients, local control was achieved in 103 (44.8%) patients, and residual or progressive disease remained in 85 (37.0%). Survival post ablation at 1 year was 89.2% and at 3 years was 40.3%. Post-ablation disease-free survival was 43.2% at 3 years. CONCLUSION: MWA is an alternative treatment for pulmonary metastases of colorectal cancer. It has competitive theoretical properties and local recurrence rate compared to radiofrequency ablation.

A rare case of benign pneumatosis intestinalis in Sjogren's syndrome.

Pneumatosis intestinalis (PI)-the presence of intramural bowel gas-is an uncommon radiological finding, the severity of which depends on the underlying pathological process, ranging from benign disease to life-threatening ischaemia and intra-abdominal sepsis. PI has been described in systemic sclerosis and mixed connective tissue disease; however, few cases have been reported in Sjogren's syndrome (SjS). The exact pathogenesis of PI in systemic connective tissue disorders is not fully understood and likely multifactorial. We have described a unique case of PI without evidence of peritonitis in a stable patient with long-standing SjS managed non-operatively. An awareness of such benign PI, particularly amongst patients with systemic connective tissue disease, is crucial for diagnostic accuracy and safe patient care, particularly in preventing unnecessary surgical intervention.

Medium Term Outcomes of Revision Laparoscopic Sleeve Gastrectomy after Gastric Banding: A Propensity Score Matched Study.

PURPOSE: Revision bariatric surgery may be undertaken after weight loss failure and/or complications following primary bariatric surgery. This study aims to compare the efficacy and safety of revision laparoscopic sleeve gastrectomy (RLSG) after gastric banding (GB) to those of primary laparoscopic sleeve gastrectomy (PLSG). MATERIALS AND METHODS: A retrospective, propensity-score matched study was conducted to compare between PLSG (control) patients and RLSG after GB (treatment) patients. Patients were matched using 2:1 nearest neighbor propensity score matching without replacement. Patients were compared on weight loss outcomes and postoperative complications for up to five years. RESULTS: 144 PLSG patients were compared against 72 RLSG patients. At 36 months, PLSG patients had significantly higher mean %TWL than RLSG patients (27.4 ± 8.6 [9.3-48.9]% vs. 17.9 ± 10.2 [1.7-36.3]%, p < 0.01). At 60 months, both groups had similar mean %TWL (16.6 ± 8.1 [4.6-31.3]% vs. 16.2 ± 6.0 [8.8-22.4)]%, p > 0.05). Early functional complication rates were slightly higher with PLSG (13.9% vs. 9.7%), but late functional complication rates were comparatively higher with RLSG (50.0% vs. 37.5%). The differences were not statistically significant (p > 0.05). Both early (0.7% vs 4.2%) and late (3.5% vs 8.3%) surgical complication rates were lower in PLSG patients compared to RLSG patients but did not reach statistical significance (p > 0.05). CONCLUSION: RLSG after GB has poorer weight loss outcomes than PLSG in the short-term. Although RLSG may carry higher risks of functional complications, the safety of RLSG and PLSG are overall comparable.

An investigation into an outbreak of pancytopenia in cats in the United Kingdom.

BACKGROUND: In spring 2021 increasing numbers of cats presenting with severe pancytopenia were noted in United Kingdom (UK). OBJECTIVE: To describe process and outcome of the investigation performed into the outbreak of pancytopenia in cats. ANIMALS: Five hundred and eighty client owned cats that presented with severe bi- or pancytopenia of unknown cause. METHODS: Real-time data collection was performed by an online registration forum available to all veterinary surgeons in UK. Data collected included demographics, clinicopathological findings, diagnostic testing, dietary and drug history, outcome and COVID household status. Mycotoxicological feed analysis was performed on feed samples of 3 diets frequently mentioned in the database and 3 control diets. RESULTS: Five hundred and eighty cats presented to 378 veterinary practices were included for analysis. Case fatality rate was 63.3%. Dietary history was available for 544 (93.8%) cats, of which 500 (86%) were fed 1 of 3 diets (which were recalled midinvestigation). 54 (9.3%) cats were not fed a recalled product, with diet information unknown in 26 (4.5%) cats. Analysis of feed samples revealed concentrations of hematotoxic trichothecene T-2/HT-2 mycotoxins greater than recommended by the European Commission in 5/7 recalled diet samples but in none of control diet samples. The trichothecene mycotoxin diacetoxyscirpenol (DAS) was detectable in all recalled diet samples but not in any of control samples. CONCLUSION AND CLINICAL IMPORTANCE: Contaminated-feed induced trichothecene mycotoxicosis should be considered as a differential diagnosis for pancytopenia in cats.

Hiatal reconstruction is safe and effective for control of reflux after laparoscopic sleeve gastrectomy.

BACKGROUND: Gastroesophageal reflux is a known complication following laparoscopic sleeve gastrectomy (LSG) as anatomical changes predispose to reduced lower esophageal sphincter pressure and development of hiatus hernia. The mainstay of surgical management has been Roux-en-Y gastric bypass (RYGB) which is not without risk. Hiatus hernia repair (HHR) with surgical reattachment of the oesophagus to the crura, recreating the phreno-esophageal ligament is a simple procedure specifically targeting a number of anatomical changes responsible for reflux in this population. METHODS: We conducted a single centre retrospective analysis of adult patients with post-sleeve reflux refractory to medical treatment, managed with either HHR, RYGB or One-anastomosis Duodenal switch (OADS). PPI use and symptoms of reflux were assessed at early and mid-term time points via validated questionnaires. RESULTS: 99 patients were included, of these the surgical procedure was HHR alone in 58, RYGB in 29 and OADS in 12. At early follow-up control of reflux symptoms was achieved in 72.4% after HHR, 82.1% after RYGB and 100% after OADS with no significant difference between groups (p = 0.09). At mid-term followup (median 10 months IQR 7-21) there was no significant difference in the presence of symptomatic reflux as determined by post-op Visick score nor a difference in PPI use. The GerdQ score was significantly lower after OADS as compared to HHR and RYGB (4.6 ± 2.3 vs 7.7 ± 2.2 vs 8.7 ± 3.5, p = 0.006). CONCLUSION: HHR with reconstruction of the phreno-esophageal ligament is a safe and effective procedure for patients with reflux after LSG, that avoids more complex operations such as RYGB and OADS and their associated long-term sequelae.

2022 Update of the Consensus on the Rational Use of Antithrombotics and Thrombolytics in Veterinary Critical Care (CURATIVE) Domain 6: Defining rational use of thrombolytics.

OBJECTIVES: To systematically review available evidence and establish guidelines related to the use of thrombolytics for the management of small animals with suspected or confirmed thrombosis. DESIGN: PICO (Population, Intervention, Control, and Outcome) questions were formulated, and worksheets completed as part of a standardized and systematic literature evaluation. The population of interest included dogs and cats (considered separately) and arterial and venous thrombosis. The interventions assessed were the use of thrombolytics, compared to no thrombolytics, with or without anticoagulants or antiplatelet agents. Specific protocols for recombinant tissue plasminogen activator were also evaluated. Outcomes assessed included efficacy and safety. Relevant articles were categorized according to level of evidence, quality, and as to whether they supported, were neutral to, or opposed the PICO questions. Conclusions from the PICO worksheets were used to draft guidelines, which were subsequently refined via Delphi surveys undertaken by the Consensus on the Rational Use of Antithrombotics and Thrombolytics in Veterinary Critical Care (CURATIVE) working group. RESULTS: Fourteen PICO questions were developed, generating 14 guidelines. The majority of the literature addressing the PICO questions in dogs is experimental studies (level of evidence 3), thus providing insufficient evidence to determine if thrombolysis improves patient-centered outcomes. In cats, literature was more limited and often neutral to the PICO questions, precluding strong evidence-based recommendations for thrombolytic use. Rather, for both species, suggestions are made regarding considerations for when thrombolytic drugs may be considered, the combination of thrombolytics with anticoagulant or antiplatelet drugs, and the choice of thrombolytic agent. CONCLUSIONS: Substantial additional research is needed to address the role of thrombolytics for the treatment of arterial and venous thrombosis in dogs and cats. Clinical trials with patient-centered outcomes will be most valuable for addressing knowledge gaps in the field.

2022 ISFM Consensus Guidelines on Management of the Inappetent Hospitalised Cat.

PRACTICAL RELEVANCE: Inappetence may have many origins and, as a presenting sign or observation in the hospitalised patient, is common in feline practice. Nutritional assessment of every patient is encouraged, to identify the need for, and appropriate type of, intervention indicated. The impact of malnutrition may be significant on the feline patient, perpetuating illness, delaying recovery, slowing wound healing and negatively impacting gut health and immunity. Delayed intervention may result in the cat's deterioration; hence prompt control of contributing factors such as the underlying illness, pain, nausea, ileus and stress is vital to optimise voluntary food intake. Management is multimodal, comprising reduction of stress, medications and assisted nutrition in the form of tube feeding or parenteral nutrition. Use of antiemetic, analgesic, prokinetic and appetite stimulant medications may restore appetite, but placement of feeding tubes should not be delayed. Feeding tubes are generally well tolerated and allow provision of food, water and medication with minimal stress, although clinicians must be aware of complications such as stoma site infections and refeeding syndrome. CLINICAL CHALLENGES: Cats are vulnerable to malnutrition owing to their unique metabolism and specific nutritional requirements. Moreover, their nature as a species means they are susceptible to stress in the hospital environment, which may result in reduced food intake; previous negative experiences may compound the problem. In particular, an inappropriate clinic environment and/or handling may cause or exacerbate inappetence in hospitalised patients, with negative impacts on recovery. Postponing interventions such as feeding tube placement to await improvement, owing to clinician or caregiver apprehension, may hinder recovery and worsen nutritional deficits. EVIDENCE BASE: The 2022 ISFM Consensus Guidelines on Management of the Inappetent Hospitalised Cat have been created by a panel of experts brought together by the International Society of Feline Medicine (ISFM). Information is based on the available literature, expert opinion and the panel members' experience.

2022 Update of the Consensus on the Rational Use of Antithrombotics and Thrombolytics in Veterinary Critical Care (CURATIVE) Domain 1- Defining populations at risk.

OBJECTIVES: To expand the number of conditions and interventions explored for their associations with thrombosis in the veterinary literature and to provide the basis for prescribing recommendations. DESIGN: A population exposure comparison outcome format was used to represent patient, exposure, comparison, and outcome. Population Exposure Comparison Outcome questions were distributed to worksheet authors who performed comprehensive searches, summarized the evidence, and created guideline recommendations that were reviewed by domain chairs. The revised guidelines then underwent the Delphi survey process to reach consensus on the final guidelines. Diseases evaluated in this iteration included heartworm disease (dogs and cats), immune-mediated hemolytic anemia (cats), protein-losing nephropathy (cats), protein-losing enteropathy (dogs and cats), sepsis (cats), hyperadrenocorticism (cats), liver disease (dogs), congenital portosystemic shunts (dogs and cats) and the following interventions: IV catheters (dogs and cats), arterial catheters (dogs and cats), vascular access ports (dogs and cats), extracorporeal circuits (dogs and cats) and transvenous pacemakers (dogs and cats). RESULTS: Of the diseases evaluated in this iteration, a high risk for thrombosis was defined as heartworm disease or protein-losing enteropathy. Low risk for thrombosis was defined as dogs with liver disease, cats with immune-mediated hemolytic anemia, protein-losing nephropathy, sepsis, or hyperadrenocorticism. CONCLUSIONS: Associations with thrombosis are outlined for various conditions and interventions and provide the basis for management recommendations. Numerous knowledge gaps were identified that represent opportunities for future studies.

Fertility, pregnancy and post partum management after bariatric surgery: a narrative review.

•Of the women who gave birth in Australia in 2018, 47% had overweight or obesity, with obesity being associated with both maternal and fetal complications. •Bariatric surgery improves fertility and some pregnancy-related outcomes. •Following bariatric surgery, pregnancy should be delayed by at least 12-18 months due to adverse pregnancy outcomes associated with rapid weight loss. •Contraception should be prescribed after bariatric surgery, although the effectiveness of the oral contraceptive pill may be reduced due to malabsorption and contraceptive devices such as intrauterine devices should be considered as first line therapy. •After bariatric surgery, women should undergo close monitoring for nutritional insufficiencies before, during and after pregnancy. Expert opinion recommends these women undergo dietary assessment and supplementation to prevent micronutrient deficiencies. •Bariatric surgeons, bariatric medical practitioners, bariatric dieticians, the patient's usual general practitioner, obstetricians, and maternity specialists should be involved to assist in the multidisciplinary management of these complex patients.

Randomized double-blinded clinical trial on acute transfusion reactions in dogs receiving leukoreduced versus nonleukoreduced packed red blood cells.

BACKGROUND: Leukoreduction of blood products is commonly performed in human medicine, but its effect on outcome or incidence of transfusion reactions (TRs) in dogs is unknown. OBJECTIVES: To prospectively evaluate the incidence of acute TRs in, and the outcome of, dogs receiving either leukoreduced (LR) or nonleukoreduced (N-LR) packed red blood cells (PRBC). ANIMALS: Dogs (n = 194) administered PRBC between August 2017 and June 2020. METHODS: Prospective randomized double-blinded clinical trial. Dogs were randomized to receive either LR or N-LR PRBC and clinicians, nurses and investigators were blinded to the group allocations. The incidence of TRs, change in PCV, hospitalization duration, and survival to discharge were recorded. RESULTS: Out of the 194 dogs, 96 received LR and 98 received N-LR PRBCs. The mean 12-hour change in PCV value was +9.22% (SD 5.27%) for dogs that received N-LR and +10.69% (SD 6.44%) for dogs that received LR PRBC (effect size 0.26, 95% confidence interval [CI] -0.02 to 0.55), which was not significantly different (P = .08). TRs were documented in 16/194 (8.24%) dogs, with 1/194 (0.51%) being a mild allergic reaction, while 15/194 (7.73%) had suspected febrile nonhemolytic TRs (FNHTRs). FNHTR incidence was not significantly different between the LR (6/96, 6.25%, 95% CI 2.8-13.56) and N-LR (9/98, 9.18%, 95% CI 4.92-17.11) groups (P = .81). Of the 156 dogs that survived to discharge, 80/156 received N-LR PRBC and 76/156 received LR PRBC which was not significantly different (P = .66). CONCLUSIONS AND CLINICAL IMPORTANCE: A clinical advantage of using LR over N-LR PRBC in terms of TRs and increase in PCV after transfusion was not detected.

Accuracy of High-Resolution Manometry in Hiatal Hernia Diagnosis in Primary and Revision Bariatric Surgery.

PURPOSE: There is a complex association between obesity, hiatal hernia (HH), and reflux. There is a deficiency of literature on the accuracy of preoperative high-resolution manometry (HRM) in detecting HH before both primary and revision bariatric surgery. MATERIALS AND METHODS: A retrospective analysis of a prospective database of all HRM performed before bariatric surgery from 2014 to 2019. An electronic medical records review was conducted. Sensitivity, specificity, and global diagnostic test accuracy were calculated. RESULTS: Sixty-seven patients with HRM (mean age of 44.0 ± 11.3 years, body mass index 40.8 ± 6.9 kg/m2) were eligible. Intraoperative diagnosis of HH was made in 37 patients (55.2% prevalence). The HRM sensitivity was 48.7% (95% confidence interval (CI) 31.9-65.6%), specificity 90.0% (95% CI 73.5-97.9%), and accuracy was 67.2% (95% CI 54.6-78.2%). Comparing primary (28) and revision (39) surgery, the sensitivity (37.5% vs 57.1%), specificity (75.0% vs 100%), and diagnostic accuracy (54.3% vs 76.3%) were comparable, with overlapping 95% CI. Endoscopy performed in 30 patients had a sensitivity of 25.5% (95% CI 6.8-49.9%), specificity of 100% (95% CI 75.3-100%), and accuracy of 57.8% (95% CI 38.5-75.5%) and was comparable to HRM. CONCLUSION: High-resolution manometry for the detection of HH before bariatric surgery has a high specificity and maintains a high accuracy in both primary and revision bariatric surgery.

Audit of the provision of nutritional support to mechanically ventilated dogs and cats.

OBJECTIVES: To evaluate the use of enteral and parenteral nutrition in a population of mechanically ventilated cats and dogs, identify factors associated with implementation of nutrition, and assess the frequency of nutritional support within 72 hours of absent caloric intake. DESIGN: Retrospective, single-center audit from June 2013 to June 2016. SETTING: ICU of a veterinary university teaching hospital. ANIMALS: Fifty-eight animals (50 dogs, 8 cats) that underwent mechanical ventilation for ≥6 hours with complete medical records. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data collected included nutritional provision, time to initiation of nutrition, period of absent caloric intake, percentage of caloric intake obtained, and possible factors contributing to the delay or failure to implement nutrition. Thirty-one percent of patients (dogs 16/50, 32%; cats 2/8, 25%) received nutritional support during mechanical ventilation with all but 2 dogs receiving parenteral nutrition. Of those patients that did not receive nutrition (dogs 34/50, 68%; cats 6/8, 75%), documented contraindications or notations within the medical record for its omission were present in 16 of 34 dogs (47%) and 4 of 6 cats (66.7%). Thirteen animals (11 dogs, 2 cats) had >72 hours of absent caloric intake with only a small number of these receiving nutrition (dogs 4/11, 36.4%; cats 0/2, 0%). CONCLUSIONS: Only 18 of 58 (31%) mechanically ventilated dogs and cats at our institution received nutritional support, and the majority of these were fed parenterally (16/18, 88.9%). For animals that did not receive nutrition, there was no clear reason for its absence in many cases. Animals with absent caloric intake >72 hours had poor implementation of nutritional support in contrast to current guidelines. A repeat audit after implementing changes to institutional protocols for nutritional provision is warranted to assess the impact on morbidity and mortality.

Barrett's Oesophagus and Bariatric/Metabolic Surgery-IFSO 2020 Position Statement.

The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) has been playing an integral role in educating both the metabolic surgical and the medical community at large about the importance of surgical and/or endoscopic interventions in treating adiposity-based chronic diseases. The occurrence of chronic conditions following bariatric/metabolic surgery (BMS), such as gastro-oesophageal reflux disease (GERD) and columnar (intestinal) epithelial metaplasia of the distal oesophagus (also known as Barrett's oesophagus (BE)), has long been discussed in the metabolic surgical and medical community. Equally, the risk of neoplastic progression of Barrett's oesophagus to oesophageal adenocarcinoma (EAC) and the resulting requirement for surgery are the source of some concern for many involved in the care of these patients, as the surgical alteration of the gastrointestinal tract may lead to impaired reconstructive options. As such, there is a requirement for guidance of the community.The IFSO commissioned a task force to elucidate three aspects of the presenting problem: First, to determine what the estimated incidence of Barrett's oesophagus is in patients presenting for BMS; second, to determine the frequency at which Barrett's oesophagus may develop following BMS (with a particular focus on the laparoscopic sleeve gastrectomy (LSG)); and third, to determine if regression of Barrett's oesophagus may occur following BMS given the close relationship of obesity and the development of BE/EAC. Based on these findings, a position statement regarding the management of this pathology in the context of BMS was developed. The following position statement is issued by the IFSO Barrett's Oesophagus task force andapproved by the IFSO Scientific Committee and Executive Board. This statement is based on current clinical knowledge, expert opinion and published peer-reviewed scientific evidence. It will be reviewed regularly.

Retrospective evaluation of refeeding syndrome in cats: 11 cases (2013-2019).

OBJECTIVES: The aim of this study was to describe the clinicopathological findings, management and outcome of cats with refeeding syndrome (RS) following prolonged starvation. METHODS: Records from four referral hospitals were searched between May 2013 and November 2019 and retrospectively evaluated. Inclusion criteria were the presence of a risk factor for RS, such as severe weight loss or emaciation following a period of presumed starvation, hypophosphataemia or a delta phosphorous exceeding 30% reduction following refeeding, being treated on the basis of a clinical diagnosis of RS and one or more derangement of hypokalaemia, hypoglycaemia or hyperglycaemia. RESULTS: Eleven cats were identified, which had been missing for a median of 6 weeks (range 3-104 weeks). Mean ± SD percentage weight loss was 46% ± 7% (n = 8). Eight of 11 cats developed hypophosphataemia with a mean delta phosphorous of -47% ± 9%. All cats were documented to be hypokalaemic. During hospitalisation, 10/11 cats developed hyperglycaemia and 7/11 cats developed hypoglycaemia. Cardiovascular, gastrointestinal and neurological signs were common. Eight of 11 cats displayed new or progressive neurological deficits after refeeding, including mentation changes and cerebellar dysfunction. All cats became anaemic and seven cats required a blood transfusion. Eight cats survived to discharge after a mean of 14 ± 4 days of hospitalisation. Six cats developed acute kidney injury (AKI; International Renal Interest Society stage 1). The presence of AKI (P = 0.024) was associated with non-survival and maximum bilirubin concentration was significantly higher in non-survivors (P = 0.018). CONCLUSIONS AND RELEVANCE: Cats with RS in this cohort had been missing, presumed starved, for more than 3 weeks. In addition to hypophosphataemia and hypokalaemia, altered glucose homeostasis and organ damage involving the liver and kidneys were common. Cats with RS appear to have a good prognosis, but prolonged intensive care is required.

High-resolution impedance manometry and 24-hour multichannel intraluminal impedance with pH testing before and after sleeve gastrectomy: de novo reflux in a prospective series.

BACKGROUND: Laparoscopic sleeve gastrectomy (SG) is increasingly popular but concern regarding its effect on gastroesophageal reflux disease remain. The current literature is conflicting, and there have been little objective data. OBJECTIVES: To objectively and more accurately assess the impact of SG on esophago-gastric physiology. SETTING: Centre of Excellence in Metabolic and Bariatric Surgery, Private Hospital, Australia. METHODS: Prospective cohort study of 31 patients undergoing SG with high-resolution impedance manometry (HRM), 24-hour multichannel intraluminal impedance combined with pH testing (MII-pH), and Gastroesophageal Reflux Disease Symptom Assessment Scale (GSAS) questionnaire 1 month before and 6 months after SG. RESULTS: There were 31 patients that underwent SG, 20 with synchronous hiatal repair and fixation, and 6 that were excluded. HRM demonstrated significantly increased intragastric pressures (15.5-29.6 mm Hg) and failed swallows (3.1-7.5%) but no other change in esophageal motility. MII-pH did not demonstrate significant changes in acid exposure time (8.5%-7.5%) or number of reflux episodes, although the numbers of long reflux episodes (2.3-4.7) and weak acid reflux episodes were significantly increased (15.4-55.2). DeMeester and GSAS scores were not significantly changed. There was no significant difference in patients with preexisting reflux. However, for patients without preexisting reflux, acid exposure time increased significantly (1.3%-6.7%), as did DeMeester scores (5.8-24.5) and the numbers of long reflux episodes (.1-4.4) and weakly acidic episodes (22.1-89.2). CONCLUSION: SG was associated with increased intragastric pressures, without changes in esophageal motility or acid exposure. For patients without preexisting reflux, there were increases in acid exposure time, long reflux episodes, weakly acidic reflux episodes, and DeMeester score.

Outcomes with Intra-gastric Balloon Therapy in BMI < 35 Non-morbid Obesity: 10-Year Follow-Up Study of an RCT.

PURPOSE: Intra-gastric balloon (IGB) therapy is the most established endoscopic treatment of obesity, but there is a paucity of literature on long-term efficacy. This study aims to evaluate the short- and long-term weight loss efficacy of IGB. MATERIALS AND METHODS: Double-blinded RCT with 6-month IGB vs with sham endoscopy, in body mass index (BMI) 27-35 patients. Anthropometric, fasting glucose, and lipid profile measurement as early outcomes (up to 2 years) and 10-year follow-up. Primary outcomes were total body weight loss (kg) and BMI. Secondary outcomes were new-onset diabetes mellitus, other new comorbidities, and willingness for further intervention. RESULTS: Initial RCT recruited 99 patients (50 IGB vs 49 sibutramine group). Forty-nine patients (26 IGB vs 23 control group) participated in a 10-year review (follow-up rate of 51.6%). Total body weight loss at 6 (9.75 vs 7.48 kg, p = 0.03), 12 (6.52 vs 4.42 kg, p = 0.05), 18 (5.42 vs 3.57, p = 0.32), and 24 months (4.07 vs 2.93 kg, p = 0.56) favored the IGB group. Total weight loss (TWL) at 10 years (0.03 vs - 2.32 kg, p = 0.05) and %TWL (- 0.16 ± 12.8% vs - 2.84 ± 5.6%, p = 0.39) were not significantly different between groups. Follow-up BMI (30.97 ± 1.6 vs 30.38 ± 1.8 kg/m2, p = 1.00) was similar. At 10 years, new-onset diabetes mellitus, sleep apnoea, metabolic syndrome, and arthralgia were not significant (p > 0.05). Twenty-three (81%) IGB group vs 13 (56%) control expressed a willingness for further intervention (p < 0.01). CONCLUSION: IGB delivers weight loss to 2 years and is superior to control. However, new comorbidity development is not significantly different at 10 years. Patient that received IGB therapy were subsequently more willing for further bariatric metabolic intervention.

Accuracy of hiatal hernia diagnosis in bariatric patients: Preoperative endoscopy versus intraoperative reference.

BACKGROUND AND AIM: Obesity is becoming increasingly prevalent in Asia. Bariatric surgery in the region is growing in popularity to reflect increasing demand. Hiatal hernia (HH) is common among the obese population. There is a lack of evidence comparing preoperative endoscopy against intraoperative findings as a standard of reference for HH diagnosis. METHODS: This was a retrospective analysis of a bariatric procedure database from a single tertiary teaching hospital and high-volume endoscopy center. Electronic medical records were reviewed. Endoscopy results were compared to intraoperative findings, and subgroup analysis of >2 cm hernias was performed. Sensitivity, specificity, predictive values, likelihood ratios, and global diagnostic test accuracy were calculated. RESULTS: A total of 434 patients were eligible for this study, of which HH was detected in 37 patients (prevalence rate 8.55%). Mean age was 41.51 ± 11.07 years, and body mass index was 39.37 ± 5.67 kg/m2. Endoscopy sensitivity was 75.68% (95% confidence interval, 58.80-88.23%) and specificity 91.44% (88.24-94.00%). Positive likelihood ratio was 8.53 (6.11-12.79) and negative likelihood ratio 0.27 (0.15-0.47). Positive predictive value was 45.16% (36.27-54.38%) and negative predictive value 97.58% (95.80-98.62%). Accuracy of endoscopy for preoperative HH diagnosis was 90.09% (86.89-92.74%). CONCLUSION: Endoscopy can have a high diagnostic accuracy of preoperative HH diagnosis in obese Asian patients using intraoperative diagnosis as the reference standard.

Nutritional Support of the Critically Ill Small Animal Patient.

Over the past couple of decades, a component of veterinary critical care was simply to ensure that nutritional support formed some part of the treatment plan. Great emphasis was made on early placement of feeding tubes in critically ill veterinary patients to facilitate enteral feeding. Progress has been made on techniques for nutritional provision, establishing feasibility of nutritional interventions in various patient populations and establishing that nutritional support does have an important role in veterinary critical care. Some refinement of appropriate caloric targets in critically ill animals has decreased complications relating to overfeeding, but further work is required to establish optimal feeding regimes.