Mesenteric Defect Closure and the Rate of Internal Hernia in Laparoscopic Roux-en-Y Gastric Bypass: A Systematic Review and Meta-analysis.

Internal hernias are a worrying complication from laparoscopic Roux-en-Y gastric bypass (LRGB), with potential small bowel necrosis and obstruction. An electronic database search of Medline, Embase, and Pubmed was performed. All studies investigating the internal hernia rates in patients whose mesenteric defects were closed vs. not closed during LRGB were analysed. Odds ratios were calculated to assess the difference in internal hernia rate. A total of 14 studies totalling 20,553 patients undergoing LRGB were included. Internal hernia rate (220/12,445 (2%) closure vs. 509/8108 (6%) non-closure) and re-operation for small bowel obstruction (86/5437 (2%) closed vs. 300/3132 (10%) non-closure) were reduced when defects were closed. There was no difference observed when sutures were used to close the defects compared to clips/staples.

Preoperative Oesophagogastroduodenoscopy and the Effect on Bariatric Surgery: a Systematic Review and Meta-Analysis.

Preoperative oesophagogastroduodenoscopy (OGD) in bariatric surgery remains a controversial topic, with a large variety in practice globally. An electronic database search of Medline, Embase and PubMed was performed in an aim to categorise the findings of preoperative endoscopies in bariatric patients. A total of 47 studies were included in this meta-analysis resulting in 23,368 patients being assessed. Of patients assessed, 40.8% were found to have no novel findings, 39.7% had novel findings which did not affect surgical planning, 19.8% had findings that affected their surgery and 0.3% were ruled to not be suitable for bariatric surgery. Preoperative OGD is altering surgical planning in one-fifth of patients; however, further comparative studies are required to determine if each patient should undergo this procedure especially if asymptomatic.

Single-Centre Retrospective Study on the Effects of Bariatric Surgery on Nocturia.

PURPOSE: The incidence of nocturia is increased in obesity, which causes significant negative impact on quality of life. Bariatric surgery is a reliable method in which to achieve major weight loss and this study aims to determine the effect of bariatric surgery on nocturia and other lower urinary tract symptoms (LUTS) in men and women. MATERIALS AND METHODS: Retrospective study of patients undergoing bariatric surgery had pre- and post-operative questionnaires using the validated International Prostate Symptoms Score (IPSS) to assess nocturia between 2018 and 2021. The primary outcome was effect of bariatric surgery on nocturia RESULTS: A total of 99 patients were included with median age of 52.9 (44.9-60.2) and 83.8% being female. The median weight was 129.9kg (110-151.9) and median BMI was 45.5 (41.4-53.4). Improvements were demonstrated in all criteria assessed in IPSS and nocturia significantly improved with a decrease in 1.14 points (p < 0.05). Linear regression analysis showed that, in the post operative period assessed, there were no significant effect on variables measured such as obstructive sleep apnoea, type 2 diabetes on the effect of IPSS post-bariatric surgery within the follow-up period of 4-6 months. CONCLUSION: Bariatric surgery can have significant improvements on nocturia symptoms in men and women with obesity. This is another means in how bariatric surgery can reduce morbidity and improve quality of life.

Resident phenotypically modulated vascular smooth muscle cells in healthy human arteries.

Vascular interstitial cells (VICs) are non-contractile cells with filopodia previously described in healthy blood vessels of rodents and their function remains unknown. The objective of this study was to identify VICs in human arteries and to ascertain their role. VICs were identified in the wall of human gastro-omental arteries using transmission electron microscopy. Isolated VICs showed ability to form new and elongate existing filopodia and actively change body shape. Most importantly sprouting VICs were also observed in cell dispersal. RT-PCR performed on separately collected contractile vascular smooth muscle cells (VSMCs) and VICs showed that both cell types expressed the gene for smooth muscle myosin heavy chain (SM-MHC). Immunofluorescent labelling showed that both VSMCs and VICs had similar fluorescence for SM-MHC and αSM-actin, VICs, however, had significantly lower fluorescence for smoothelin, myosin light chain kinase, h-calponin and SM22α. It was also found that VICs do not have cytoskeleton as rigid as in contractile VSMCs. VICs express number of VSMC-specific proteins and display features of phenotypically modulated VSMCs with increased migratory abilities. VICs, therefore represent resident phenotypically modulated VSMCs that are present in human arteries under normal physiological conditions.

The Impact of Bariatric Surgery on Nocturia Symptoms: a Systematic Review and Meta-Analysis.

There is a significant association between obesity and nocturia, which can cause a significant negative impact on quality of life. This meta-analysis aims to determine the effects of bariatric surgery on nocturia in both men and women. Studies searched via MEDLINE and Embase databases. The primary outcome was difference in nocturia scores before and after bariatric surgery. A total of 522 patients were included in the analysis of this paper. Statistically significant decreases in nocturia scores were observed post-bariatric surgery. Bariatric surgery also resulted in statistically significant reduction of BMI. Bariatric surgery can have significant improvements on nocturia symptoms in men and women with obesity. This would thereby reduce morbidity and improve quality of life following bariatric surgery.

Comparing predicted and observed morbidity and mortality between emergency laparotomies conducted during the day and overnight at a district general hospital.

BACKGROUND: It is generally expected that emergency laparotomies performed at night confer a higher risk and thus outcomes are worse. This study hopes to determine whether there is a difference in risk of cases presenting at night, and overall outcome. METHODS: Data were retrospectively obtained using local notes archival software to obtain predicted and observed mortality, ASA (American Society of Anesthesiologists) grade and length of stay of emergency laparotomies conducted between August 2019 and March 2020. Day cases were defined as knife to skin time (KTS) between 08:00 and 19:59, whilst night cases were defined as KTS between 20:00 and 07:59. RESULTS: In all, 81 emergency laparotomies were performed during day-time hours over the 8­month period; 32 were performed overnight. Median ASA grade was 3 for both. Median length of stay was similar: 11 day, 12 overnight. Median P-POSSUM (Portsmouth Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity) morbidity score of day cases was 52% compared to 53.2% at night. Median mortality score of day cases was 5.6%, whilst at night was 2.7% (p = 0.27). Observed mortality after day cases was 13.5%, and overnight was 9.3%. Observed morbidity was 46.9% after day cases and 50% overnight. CONCLUSION: There was no statistically significant difference between predicted or observed morbidity and mortality between emergency laparotomies conducted during the day and those conducted overnight.

NHS litigation in bariatric surgery over a ten year period.

Negligence claims in the UK NHS has increased over the last 30 years. The aim of this present study was determine the number of claims and the cost of litigation in Bariatric Surgery and compare it to similar other specialties. Data was received from NHS Litigation Authority (NHSLA) in response to Freedom of Information data request. There was a total of 7 claims, of which 4 were successful. The total pay out sum was £210,000 in 10 years. This is a very low amount compared to other surgical specialties. This low level of litigation probably indicates that the current bariatric surgical services in the NHS are delivering safe care with good patient satisfaction. This needs to be carefully considered prior to changing the payment tariffs for bariatric surgery.

The role of colonoscopy and CT colonography in patients presenting with symptoms of constipation.

OBJECTIVE: There is controversy whether constipation as a primary presenting complaint is an indication for diagnostic colonoscopy. CT colonography (CTC) is a less invasive and more acceptable alternative. We compared the completion and sensitivity of colonoscopy with CTC in patients who presented with the primary symptom of constipation. METHODS: A retrospective study was conducted which examined the first 100 colonoscopies and 100 CTCs carried out for the primary symptom of constipation from June 2012 to December 2013. The primary outcome measure was failure rate of the investigations. Secondary outcomes included reasons for failure and comparison of cost effectiveness between the two modalities. RESULTS: A total of 200 patients were included in this study. Of these, the first consecutive 100 colonoscopies and 100 CTCs were included. One colonic cancer was detected in each of the CTC and the colonoscopy arm, respectively. 37 (37%) attempted colonoscopies were incomplete examinations. The most common reasons were discomfort (51.4%) and poor bowel preparation (27%). There was no failure of CTC. For 100 patients, CTC as a primary investigation was a more cost-effective investigation (p ≤ 0.01) costing £55,016 as compared with colonoscopy costing £73,666. CONCLUSION: There is an unacceptably high failure rate of colonoscopy in patients who presented with the primary symptom of constipation. Hence, we propose that CTC may be an acceptable first-line investigation with a further colonoscopy/flexible sigmoidoscopy if lesions are detected. Advances in knowledge: First study to examine the use of CTC in patients with constipation.

Metastasising pleomorphic adenoma: Systematic review.

BACKGROUND: Pleomorphic adenoma (PA) is the commonest benign neoplasm of salivary glands.(1) PA can undergo malignant transformation to ex-pleomorphic adenoma (2,3) but rarely, can metastasise without malignant transformation.(4,5) Metastasising pleomorphic adenoma (MPA) is a rare malignant tumour which, histologically, is indistinguishable from PA yet produces secondary tumours in distant sites.(6,7,8) OBJECTIVE: Our aim is to review the literature for all reported cases of MPA and create a virtual series. The age and location of primary tumour with the location and time to metastasise will be reviewed. The prognosis and treatment options will be explored. METHOD: We conducted a PUBMED search with a combination of keywords: metastasizing/metastasising AND pleomorphic adenoma OR mixed tumour. An author's own case has also been included. RESULTS: Between 1942 and 2014 there were 80 case reports included in the review, plus the authors own case. Mean age at diagnosis of MPA was 49.5 years (range 11-83). Male-to-female ratio was 34:46. The mean time between PA and MPA was 14.9 years (range 0-51), with three cases reporting simultaneous presentation. 72.8% (n = 59) of cases reported PA local recurrence prior to MPA. The three most common sites for MPA were: bone 36.6% (n = 28), lung 33.8% (n = 26) and neck lymph nodes 20.1% (n = 17). Survival was poorly reported, but 41 (80.4%) were alive at 1-year. CONCLUSION: Benign MPA is rare. Metastasis occurs years after the initial PA and is associated with multiple local recurrences. Histologically, MPA retain their benign nature yet demonstrate malignant behaviour.

Variations in oral vitamin and mineral supplementation following bariatric gastric bypass surgery: a national survey.

BACKGROUND: Bariatric surgery (including gastric bypass) is associated with long-term deficiencies in vitamins and minerals, which may have deleterious effects on physiology. The American Association of Clinical Endocrinologists' (AACE) guidelines regarding post-operative vitamin supplementation have recently been endorsed by the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO). Supplements have cost implications. Non-branded multivitamins may have similar compositions to branded multivitamins, but at a lower cost. This study assesses multivitamin supplementation following bariatric gastric bypass in England against AACE guidelines. It also examines the composition and cost of branded and non-branded multivitamins. METHODS: Micronutrient amounts in common multivitamin preparations were obtained from product literature. Costs were collected from a standard retailer. To determine vitamin prescribing patterns, the 37 NHS hospitals performing bariatric gastric bypasses in England were contacted. Practice was assessed against AACE guidelines. RESULTS: All non-branded multivitamins met AACE guidelines for composition. Most had similar compositions to branded multivitamins, and all were cheaper. There was no standard practice regarding post-operative supplementation among the 35 responding hospitals. Only 7/35 (20%) hospitals followed the guidance for two-tablet doses of multivitamins. Immediately post-operatively, 25/35 (71%) hospitals administered calcium carbonate and vitamin D (none recommended calcium citrate, as recommended by AACE to improve absorption), and only 9/35 (26%) hospitals recommended iron to all patients. CONCLUSION: Most non-branded multivitamins are lower cost alternatives to branded multivitamins, with similar compositions. The AACE recommendation for two-tablet doses of multivitamins is not being met by most English centres. Calcium and iron supplementation is also inadequate.

Accuracy of FAST scan in blunt abdominal trauma in a major London trauma centre.

INTRODUCTION: Blunt abdominal trauma (BAT) is a leading cause of morbidity and mortality. Rapid diagnosis and treatment with the Advanced Trauma Life Support guidelines are vital, leading to the development of Focused Assessment with Sonography in Trauma (FAST). METHODS: A retrospective study carried out from January 2007-2008 on all patients who presented with BAT and underwent FAST scan. All patients subsequently had a CT scan within 2 h of admission or a laparotomy within two days. The presence of intra-peritoneal free fluid was interpreted as positive. RESULTS: 100 patients with BAT presented; 71 had complete data. The accuracy of FAST in BAT was 59.2%; in these 31 (43.7%) were confirmed by CT and 11 (15%) by laparotomy. There were 29 (40.8%) inaccurate FAST scans, all confirmed by CT. FAST had a specificity of 94.7% (95% CI: 0.75-0.99) and sensitivity of 46.2% (95% CI: 0.33-0.60). Positive Predictive Value of 0.96 (0.81-0.99) and Negative Predictive Value of 0.39 (0.26-0.54). Fisher's exact test shows positive FAST is significantly associated with Intra-abdominal pathology (p=0.001). Cohen's chance corrected agreement was 0.3. 21 out of 28 who underwent laparotomies had positive FAST results indicating accuracy of 75% (95% CI: 57%-87%). CONCLUSION: Patients with false negative scans, requiring therapeutic laparotomy is concerning. In unstable patients FAST may help in triaging and identifying those requiring laparotomy. Negative FAST scans do not exclude abdominal injury. Further randomised control trials are recommended if the role of FAST is to be better understood.

Objective assessment of the core laparoscopic skills course.

Objective. The demand for laparoscopic surgery has led to the core laparoscopic skills course (CLSC) becoming mandatory for trainees in UK. Virtual reality simulation (VR) has a great potential as a training and assessment tool of laparoscopic skills. The aim of this study was to determine the role of the CLSC in developing laparoscopic skills using the VR. Design. Prospective study. Doctors were given teaching to explain how to perform PEG transfer and clipping skills using the VR. They carried out these skills before and after the course. During the course they were trained using the Box Trainer (BT). Certain parameters assessed. Setting. Between 2008 and 2010, doctors attending the CLSC at St Georges Hospital. Participants. All doctors with minimal laparoscopic experience attending the CLSC. Results. Forty eight doctors were included. The time taken for the PEG skill improved by 52%, total left hand and right hand length by 41% and 48%. The total time in the clipping skill improved by 57%. Improvement in clips applied in the marked area was 38% and 45% in maximum vessel stretch. Conclusions. This study demonstrated that CLSC improved some aspects of the laparoscopic surgical skills. It addresses Practice-based Learning and patient care.

Consenting practice for laparoscopic cholecystectomy - are we doing enough to warn patients about their operation?

INTRODUCTION: Provision of informed consent prior to surgery is fundamental in allowing patients to make balanced choices about their care. This study compares consenting practice amongst different grade of surgeons for Laparoscopic Cholecystectomy (LC) with specific reference to the documentation of the complications of surgery. Timing and delivery of source of information is also evaluated. METHODS: Retrospective review of medical notes of all patients undergoing LC at London district general hospital between September 2006 to April 2009. RESULTS: Records were successfully retrieved for 163 patients. The five most commonly mentioned complications were bleeding (99%), infection (95%), conversion to open (93%), bile duct injury (82%) and visceral injury (65%). There were 27 documented complications in 23 patients and in 9 of these patients (39%) the specific complication was not discussed during the written consent process. Consultant surgeons tended to focus on important operation-specific risks such as bile duct injury whereas junior surgeons tend to focus on a broad range of general complications. CONCLUSION: Consenting practice for LC remains variable and is resulting in failure to warn patients of significant complications. This can lead to potential medico-legal implications. Having a structured consent form detailing all significant and common risk is one way of improving the consent process.