Does hiatal repair affect gastroesophageal reflux symptoms in patients undergoing laparoscopic sleeve gastrectomy?

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has gained popularity as a treatment of choice for morbid obesity and associated comorbidities. There has been a concern about new onset or worsening of gastroesophageal reflux (GERD) following LSG. OBJECTIVE: The objective of the study was to evaluate the effect of surgically treating hiatal weakness on GERD symptoms in patients undergoing LSG. SETTING: Single tertiary referral institution, Sydney, Australia. METHODS: A prospective observational cohort study was conducted with consecutive patients undergoing LSG. Hiatal findings, patient demographics, medications and reflux score were recorded prospectively. Patients were followed up post-operatively for a minimum of 12 months and assessed using GERD-HRQL score to quantify reflux symptoms. RESULTS: Data from 100 patients with a minimum of 1-year follow-up were analysed. Mean follow-up was 18.9 months. Overall, GERD-HRQL improved from mean 4.5 ± 5.8 pre-operatively to 0.76 ± 1.5 after 18.9 months (p = 0.0001). For those with pre-operative reflux, GERD-HRQL improved from mean (SD) 8.43 ± 6.26 pre-operatively to 0.94 ± 1.55 (p = 0.0001). All the nine patients with troublesome daily reflux significantly improved. For those without pre-operative reflux, GERD-HRQL improved from 0.88 ± 1.37 to 0.47 ± 1.25 (p-ns) post-operatively. On multivariate analysis, higher pre-operative reflux and dysphagia/bloat scores, younger age and lower percentage excess weight loss after 18.9 months were associated with GERD-HRQL improvement. CONCLUSION: In the medium term, GERD-HRQL improves following sleeve gastrectomy with meticulous hiatal assessment and repair of hiatal laxity and herniation.

'Step-port' laparoscopic cystgastrostomy for the management of organized solid predominant post-acute fluid collections after severe acute pancreatitis.

BACKGROUND: Post-acute pancreatic collections (PAPCs) may require intervention when persistent, large or symptomatic. An open cystgastrostomy is an effective treatment option particularly for larger, solid predominant collections. A laparoscopic cystgastrostomy (LCG) as initially described, could be technically challenging. This report describes the evolution of the operative technique and the results from LCG in a tertiary referral centre. METHODS: Retrospective analysis of the unit's prospectively populated database was conducted. All patients who underwent a surgical cystgastrostomy (SCG) were identified. Patient demographics, outcome and complications were collected and analysed. RESULTS: Forty-four patients underwent SCG: 8 open and 36 laparoscopic. Of the 36 LCG, 6 required open conversion, although with evolution of the technique all of the last 17 cases were completed laparoscopically. The median interquartile range (IQR) length of stay in patients completed laparoscopically was 6 (2-10) compared with 15.5 days (8-19) in those patients who were converted (P = 0.0351). The only peri-operative complication after a LCG was a self-limiting upper gastrointestinal bleed. With a median (IQR) follow-up of 891 days (527-1495) one patient required re-intervention for a residual collection with no recurrent collections identified. CONCLUSION: LCG is a safe and effective procedure in patients with large, solid predominant PAPCs. With increased experience and technical expertise conversion rates can be lowered and outcome optimized.

B-type natriuretic peptide predicts postoperative cardiac events and mortality after elective open abdominal aortic aneurysm repair.

OBJECTIVE: The aim of this study was to determine if a single preoperative B-type natriuretic peptide (BNP) level correlated with perioperative cardiac events, cardiac death, and all-cause mortality in elective open abdominal aortic aneurysm (AAA) repair in the short term, intermediate term, and long term. METHODS: A prospective, 2-year multicenter observational cohort study in the three vascular units in Glasgow was performed. All patients who were admitted for elective open AAA repair were recruited. Preoperative BNP levels were performed and batch analyzed at the end of the study. Postoperative screening for cardiac events (nonfatal myocardial infarction and cardiac death) was performed at 2, 5, and 30 days. Follow-up for all-cause mortality was sustained to a minimum of 3 years, where possible. RESULTS: A total of 106 of 111 patients were recruited. Median BNP concentrations were higher in the 16 patients (15%) with immediate postoperative cardiac events (P = .001) and the five with cardiac death (P = .043). Area under the receiver-operating characteristic (AUC) curve analysis indicated BNP concentrations of 99.5 pg/mL best predicted cardiac events (AUC, 0.927), and 448 pg/mL predicted cardiac death (AUC, 0.963). BNP also predicted all-cause mortality in the short-term (P = .028), intermediate-term (P < .001), and long-term (P < .001) postoperative periods. CONCLUSIONS: Preoperative serum BNP concentration predicted postoperative cardiac events, cardiac death, and all-cause mortality in patients undergoing elective open AAA repair on short-term, intermediate-term, and long-term follow-up on an individual basis with greater accuracy than currently available risk prediction tools.

Laparoscopic repair of giant hiatus hernia: prosthesis is not required for successful outcome.

BACKGROUND: Giant hiatus hernia (GHH) are difficult to manage effectively. This study reports a laparoscopic, prosthesis-free technique to repair of GHH. METHODS: Retrospective analysis of a prospectively populated database of a single surgeon's experience of GHH (>30 % intrathoracic stomach) repair using a novel, uniform technique was performed. Routine postoperative endoscopy, quality of life (QOL), and Visick scoring was conducted. RESULTS: Surgery was conducted in 100 patients (70F, 30 M). Mean (standard deviation [SD]) age was 69.1 (±11.4), median (interquartile range) ASA was 2 (range, 2-3), and mean (SD) body mass index (BMI) was 29.1 (±4.5). Mean follow-up was 574.1 (±240.5) days. One (1 %) patient was converted to an open procedure due to technical issues. Median stay was 2.5 days (range, 2-4). One postoperative death occurred secondary to respiratory sepsis. Eight (8 %) patients had perioperative complications: 4 major (PE, non-ST elevation MI, postoperative bleed managed conservatively, infected mediastinal fluid collection); and 4 minor (pneumothorax, asymptomatic troponin leak, subacute small bowel obstruction, and urinary retention). Ninety-nine (99 %) patients had objective screening for recurrence at 3-6 months. Two (2 %) patients have had symptomatic recurrence of their hiatus hernia; both involved a recurrent fundal herniation. Another seven (7 %) had small (<2 cm), asymptomatic recurrences diagnosed only on routine follow-up. Seven (7 %) patients have required reintervention for dysphagia with endoscopic dilatation conducted to good effect in all cases. Two (2 %) patients have required revisional surgery: one for a symptomatic recurrence at 3 months and a second for recurrent mediastinal collection. The Visick score fell from a mean (SD) of 3 (±1.1) to 1.7 (±0.8) postoperatively (p < 0.0001). The mean (SD) QOL preoperatively was 87.8 (±24) versus 109.1 (±22.3) postoperatively (p < 0.0001). CONCLUSIONS: GHH can be managed safely and effectively laparoscopically, without the use of a prosthesis.

Is there still a role for preoperative 12-lead electrocardiography?

BACKGROUND: Twelve-lead electrocardiography is a standard preoperative investigation for patients undergoing major surgery. There is uncertainty and debate over the usefulness of this test for stratifying postoperative cardiac risk. The aim of this study was to investigate the correlation between an abnormal electrocardiogram (ECG) and the postoperative cardiac event rate. METHODS: A prospective single-center observational cohort study in patients undergoing major noncardiac surgery was performed. ECGs were analyzed at the end of the study by a cardiologist and a clinician blinded to the clinical outcomes. The primary endpoints were a major adverse cardiac event (MACE), defined as nonfatal myocardial infarction or cardiac death, and perioperative mortality. RESULTS: A total of 345 patients were included, who had undergone aortic surgery 25.8%, lower limb bypass 29.0%, amputation 25.2%, or laparotomy 20.0%. An abnormal ECG was present in 141 (40.9%) patients. MACE occurred in 46 (13.3%) cases. Patients with an abnormal ECG had a significantly higher incidence of MACE (21.6 vs. 8.3%, P < 0.001). Multivariate analysis showed that left ventricular strain and a prolonged QTc interval (>440 ms) were independent predictors of postoperative adverse events. Among patients with no prior history of ischemic heart disease, those with an abnormal ECG had a higher MACE rate (20.3%) than those patients with a normal ECG (8.6%) (P = 0.01). CONCLUSION: Preoperative electrocardiography is a useful screening test for predicting perioperative cardiac events. Patients with an abnormal ECG but without a prior history of heart disease are a high-risk group potentially amenable to intervention and risk reduction.

Predicting the occurrence of major adverse cardiac events within 30 days of a vascular surgery: an empirical comparison of the minimum p value method and ROC curve approach using individual patient data meta-analysis.

We aimed to compare the minimum p value method and the area under the receiver operating characteristics (ROC) curve approach to categorize continuous biomarkers for the prediction of postoperative 30-day major adverse cardiac events in noncardiac vascular surgery patients. Individual-patient data from six cohorts reporting B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NTproBNP) were obtained. These biomarkers were dichotomized using the minimum p value method and compared with previously reported ROC curve-derived thresholds using logistic regression analysis. A final prediction model was developed, internally validated, and assessed for its sensitivity to clustering effects. Finally, a preoperative risk score system was proposed. Thresholds identified by the minimum p value method and ROC curve approach were 115.57 pg/ml (p < 0.001) and 116 pg/ml for BNP, and 241.7 pg/ml (p = 0.001) and 277.5 pg/ml for NTproBNP, respectively. The minimum p value thresholds were slightly stronger predictors based on our logistic regression analysis. The final model included a composite predictor of the minimum p value method's BNP and NTproBNP thresholds [odds ratio (OR) = 8.5, p < 0.001], surgery type (OR = 2.5, p = 0.002), and diabetes (OR = 2.1, p = 0.015). Preoperative risks using the scoring system ranged from 2 to 49 %. The minimum p value method and ROC curve approach identify similar optimal thresholds. We propose to replace the revised cardiac risk index with our risk score system for individual-specific preoperative risk stratification after noncardiac nonvascular surgery.

Laparoscopic sleeve gastrectomy: review of 500 cases in single surgeon Australian practice.

INTRODUCTION: Reported results and techniques of laparoscopic sleeve gastrectomy (LSG) are variable. Our objective was to assess results of weight loss, complications and reflux in a large consecutive series of LSG, describing technical detail which contributed to outcomes. METHODS: Retrospective review of prospectively collected data of 500 consecutive patients undergoing LSG. Patient demographics, weight loss, complications and functional outcomes were analysed and operative technique described. RESULTS: Five hundred patients underwent LSG over 3 years (37 revisional). Mean (range) preoperative body mass index was 45 kg/m(2) (35-76 kg/m(2) ). Mean follow-up and length of hospital stay were 14 months (1-34) and 3.8 days (3-12), respectively. All-cause 30-day readmission rate 1.2%. Mean excess weight loss (interquartile range, available patient data) was 43% (22-65%, 423 patients), 58% (45-70%, 352 patients), 76% (52-84%, 258 patients), 71% (51-87%, 102 patients) and 73% (55-86%, 13 patients) at 3, 6, 12, 24, 36 months, respectively. There was no mortality. Intraoperative complications occurred in two (0.4%) - splenic bleeding; bougie related oesophageal injury. Early surgical complications in four (1.2%) patients (one staple line leak and three post-operative bleeds). Other early complications occurred in three (0.6%) patients (one pseudomembranous colitis; one central line sepsis; one portal venous thrombosis) and late in four (0.8%) patients (three port-site incisional hernias; mid-sleeve stricture requiring endoscopic dilatation). Gastro-oesophageal reflux symptoms decreased from 45 to 6%. CONCLUSION: With attention to detail, LSG can lead to good excess weight loss with minimal complications. Tenants to success include repair of hiatal laxity, generous width at angula incisura and complete resection of posterior fundus.

The predictive ability of pre-operative B-type natriuretic peptide in vascular patients for major adverse cardiac events: an individual patient data meta-analysis.

OBJECTIVES: The aims of this study were to perform an individual patient data meta-analysis of studies using B-type natriuretic peptides (BNPs) to predict the primary composite endpoint of cardiac death and nonfatal myocardial infarction (MI) within 30 days of vascular surgery and to determine: 1) the cut points for a natriuretic peptide (NP) diagnostic, optimal, and screening test; and 2) if pre-operative NPs improve the predictive accuracy of the revised cardiac risk index (RCRI). BACKGROUND: NPs are independent predictors of cardiovascular events in noncardiac and vascular surgery. Their addition to clinical risk indexes may improve pre-operative risk stratification. METHODS: Studies reporting the association of pre-operative NP concentrations and the primary study endpoint, post-operative major adverse cardiovascular events (defined as cardiovascular death and nonfatal MI) in vascular surgery, were identified by electronic database search. Secondary study endpoints included all-cause mortality, cardiac death, and nonfatal MI. RESULTS: Six data sets were obtained, 5 for BNP (n = 632) and 1 for N-terminal pro-BNP (n = 218). An NP level higher than the optimal cut point was an independent predictor for the primary composite endpoint (odds ratio: 7.9; 95% confidence interval: 4.7 to 13.3). BNP cut points were 30 pg/ml for screening (95% sensitivity, 44% specificity), 116 pg/ml for optimal (highest accuracy point; 66% sensitivity, 82% specificity), and 372 pg/ml for diagnostic (32% sensitivity, 95% specificity). Subsequent to revised cardiac risk index stratification, reclassification using the optimal cut point significantly improved risk prediction in all groups (net reclassification improvement 58%, p < 0.000001), particularly in the intermediate-risk group (net reclassification improvement 84%, p < 0.001). CONCLUSIONS: Pre-operative NP levels can be used to independently predict cardiovascular events in the first 30 days after vascular surgery and to significantly improve the predictive performance of the revised cardiac risk index.

Mitral valve replacement for mitral stenosis secondary to Hunter's syndrome.

Hunter's syndrome is a rare, X-linked recessive, mucopolysaccharidosis. Survival into adulthood is uncommon. Mitral valve disease, predominantly regurgitation, has been reported in these patients. We have found no reports of mitral valve replacement for mitral stenosis secondary to Hunter's syndrome in the English literature. We report that mitral valve replacement for this pathology is a viable treatment option in an adult patient; however, specific precautions must be considered.