Intensive pre-operative information course (IPIC) and pre-operative weight loss results in long-term sustained weight loss following bariatric surgery: 11 years results from a tertiary referral centre.

INTRODUCTION: Outcomes of long-term (5-10-year) weight loss have not been investigated thoroughly and the role of pre-operative weight loss on long-term weight loss, among other factors, are unknown. Our regional bariatric service introduced a 12 week intensive pre-operative information course (IPIC) to optimise pre-operative weight loss and provide education prior to bariatric surgery. The present study determines the effect of pre-operative weight loss and an intense pre-operative information course (IPIC), on long-term weight outcomes and sustained weight loss post-bariatric surgery. METHODS: Data were collected prospectively from a bariatric center (2008-2022). Excess weight loss (EWL) ≥ 50% and ≥ 70% were considered outcome measures. Survival analysis and logistic regression identified variables associated with overall and sustained EWL ≥ 50% and ≥ 70%. RESULTS: Three hundred thirty-nine patients (median age, 49 years; median follow-up, 7 years [0.5-11 years]; median EWL%, 49.6%.) were evaluated, including 158 gastric sleeve and 161 gastric bypass. During follow-up 273 patients (80.5%) and 196 patients (53.1%) achieved EWL ≥ 50% and ≥ 70%, respectively. In multivariate survival analyses, pre-operative weight loss through IPIC, both < 10.5% and > 10.5% EWL, were positively associated with EWL ≥ 50% (HR 2.23, p < 0.001) and EWL ≥ 70% (HR 3.24, p < 0.001), respectively. After a median of 6.5 years after achieving EWL50% or EWL70%, 56.8% (154/271) had sustained EWL50% and 50.6% (85/168) sustained EWL70%. Higher pre-operative weight loss through IPIC increased the likelihood of sustained EWL ≥ 50% (OR, 2.36; p = 0.013) and EWL ≥ 70% (OR, 2.03; p = 0.011) at the end of follow-up. CONCLUSIONS: IPIC and higher pre-operative weight loss improve weight loss post-bariatric surgery and reduce the likelihood of weight regain during long-term follow-up.

Definitions for Loss of Domain: An International Delphi Consensus of Expert Surgeons.

BACKGROUND: No standardized written or volumetric definition exists for 'loss of domain' (LOD). This limits the utility of LOD as a morphological descriptor and as a predictor of peri- and postoperative outcomes. Consequently, our aim was to establish definitions for LOD via consensus of expert abdominal wall surgeons. METHODS: A Delphi study involving 20 internationally recognized abdominal wall reconstruction (AWR) surgeons was performed. Four written and two volumetric definitions of LOD were identified via systematic review. Panelists completed a questionnaire that suggested these definitions as standardized definitions of LOD. Consensus on a preferred term was pre-defined as achieved when selected by ≥80% of panelists. Terms scoring <20% were removed. RESULTS: Voting commenced August 2018 and was completed in January 2019. Written definition: During Round 1, two definitions were removed and seven new definitions were suggested, leaving nine definitions for consideration. For Round 2, panelists were asked to select all appealing definitions. Thereafter, common concepts were identified during analysis, from which the facilitators advanced a new written definition. This received 100% agreement in Round 3. Volumetric definition: Initially, panelists were evenly split, but consensus for the Sabbagh method was achieved. Panelists could not reach consensus regarding a threshold LOD value that would preclude surgery. CONCLUSIONS: Consensus for written and volumetric definitions of LOD was achieved from 20 internationally recognized AWR surgeons. Adoption of these definitions will help standardize the use of LOD for both clinical and academic activities.

Peritoneal Flap Hernioplasty for Reconstruction of Large Ventral Hernias: Long-Term Outcome in 251 Patients.

BACKGROUND: Repair of large ventral hernias is challenging when primary fascial closure cannot be achieved. The peritoneal flap hernioplasty, a modification of the Rives-Stoppa retromuscular mesh repair, addresses this problem by using the hernial sac to bridge the fascial gap and isolate the mesh from both the intraperitoneal contents and the subcutaneous space. It is applicable to both midline and transverse hernias. We report the results from our institution using this repair based on a retrospective review of 251 cases. METHODS: Patients undergoing peritoneal flap hernioplasty repair from January 1, 2010-December 31, 2014 were identified from the Lothian Surgical Audit system, a prospectively maintained computer database of all surgical procedures in the Edinburgh region of southeast Scotland. Patient demographics, clinical presentation, location of the hernia and surgical treatment were obtained from the hospital case-notes. Follow-up consisted of a clinical consultation 3 months postoperatively and a retrospective review of patient files completed December 2018. Patients presenting signs of complications were assessed during a clinical review. RESULTS: Two hundred and fifty-one patients underwent incisional hernia repair, 68.1% in the midline and 31.9% arising through transverse incisions. Forty-three of these (17%) were recurrences referred from other centers. Mean BMI was 32.1 kg/m2 (range 20-59.4 kg/m2). Mean defect width was 9.2 ± 4.2 cm (range 2.5-24.2 cm). Mean mesh size was 752 cm2 (range 150-1760 cm2). Some form of abdominoplasty was performed in 59% of cases. Mean postoperative stay was 6.3 days (range 1-33 days). Mean follow-up time was 75 months (range 44-104 months). Fifty-three patients (21.1%) developed postoperative complications. Three (1.2%) developed superficial skin necrosis and 27 (10.8%) a superficial wound infection, but none developed deep mesh infection. Twelve (4.8%) developed symptomatic seroma and 11 (4.4%) a hematoma requiring surgical intervention. Seven (2.8%) patients developed recurrence within the follow-up period. CONCLUSION: Peritoneal flap hernioplasty is an excellent and versatile method for reconstruction of large ventral hernias arising in both midline and transverse incisions. The technique is safe and associated with few complications and a very low recurrence rate.

A prospective study of gastro-oesophageal reflux disease symptoms and quality of life 1-year post-laparoscopic sleeve gastrectomy.

INTRODUCTION: There are concerns that laparoscopic sleeve gastrectomy (LSG) can cause severe gastro-oesophageal reflux disease (GORD). The aim of this study was to assess GORD symptoms and quality of life following LSG. METHODS: A prospective study of patients undergoing LSG (2014-2016) was performed with follow-up by DeMeester Reflux/Regurgitation Score, Bariatric Quality of Life Index (BQLI) and Bariatric Analysis and Reporting Outcome System (BAROS) Score pre-operatively, 6 months and 1-year post-operatively. RESULTS: Twenty-two patients were studied. Mean modified DeMeester Reflux/Regurgitation Score improved from 2.25 (±0.67) pre-operatively to 0.81 (±0.25) at 12 months (P = 0.04). At 12 months, two patients had symptomatic reflux, but overall satisfaction score was unaffected. Mean BQLI Score underwent a non-significant improvement at 12 months. BAROS Score showed all patients to have excellent (n = 19) or very good (n = 3) results (12 months). CONCLUSION: GORD symptoms improve for most patients' 1-year post-operatively. A small proportion of patients will develop troublesome GORD, but overall satisfaction remains high.

Acute physiological effects of glucocorticoids on fuel metabolism in humans are permissive but not direct.

BACKGROUND AND AIMS: The effects of glucocorticoids on fuel metabolism are complex. Acute glucocorticoid excess promotes lipolysis but chronic glucocorticoid excess causes visceral fat accumulation. We hypothesized that interactions between cortisol and insulin and adrenaline account for these conflicting results. We tested the effect of cortisol on lipolysis and glucose production with and without insulin and adrenaline in humans both in vivo and in vitro. MATERIALS AND METHODS: A total of 20 healthy men were randomized to low and high insulin groups (both n = 10). Subjects attended on 3 occasions and received low (c. 150 nM), medium (c. 400 nM) or high (c. 1400 nM) cortisol infusion in a randomized crossover design. Deuterated glucose and glycerol were infused intravenously along with a pancreatic clamp (somatostatin with replacement of glucagon, insulin and growth hormone) and adrenaline. Subcutaneous adipose tissue was obtained for analysis. In parallel, the effect of cortisol on lipolysis was tested in paired primary cultures of human subcutaneous and visceral adipocytes. RESULTS: In vivo, high cortisol increased lipolysis only in the presence of high insulin and/or adrenaline but did not alter glucose kinetics. High cortisol increased adipose mRNA levels of ATGL, HSL and CGI-58 and suppressed G0S2. In vitro, high cortisol increased lipolysis in the presence of insulin in subcutaneous, but not visceral, adipocytes. CONCLUSIONS: The acute lipolytic effects of cortisol require supraphysiological concentrations, are dependent on insulin and adrenaline and are observed only in subcutaneous adipose tissue. The resistance of visceral adipose tissue to cortisol's lipolytic effects may contribute to the central fat accumulation observed with chronic glucocorticoid excess.

Certified Fellowship in Abdominal Wall Surgery-A Collaboration Between the UEMS and the European Hernia Society.

Background: Abdominal wall surgery (AWS) is characterised by the increasing caseload and the complexity of the surgical procedures. The introduction of a tailored approach to AWS utilising laparoendoscopic, robotic and/or open techniques requires the surgeon to master several surgical techniques. All of which have an associated learning curve, and the necessary knowledge/experience to know which operation is the right one for the individual patient. However, the reality in general surgery training shows that training in just a limited number of procedures is not enough. By the end of general surgery training, many chief residents do not feel they are yet ready to carry out surgery independently. Therefore, hernia surgery experts and societies have called for the introduction of a Fellowship in Abdominal Wall Surgery. Methods: The UEMS (Union Européenne des Médecins Spécialistes, European Union of Medical Specialists) in collaboration with the European Hernia Society (EHS) introduced a fellowship by examination in 2019. As a prerequisite, candidates must complete further training of at least 2 years with a special focus on abdominal wall surgery after having completed their training in general surgery. To be eligible for the examination, candidates must provide evidence of having performed 300 hernia procedures. In addition, candidates must have accrued sufficient "knowledge points" by attending abdominal wall surgery congresses, courses and clinical visitations, and engaged in scientific activities. On meeting the requirements, a candidate may be admitted to the written and oral examination. Results: To date, three examinations have been held on the occasion of the Annual Congress of the European Hernia Society in Copenhagen (2021), Manchester (2022) and Barcelona (2023). Having met the requirements, 48 surgeons passed the written and oral examination and were awarded the Fellow European Board of Surgery-Abdominal Wall Surgery certificate. During this time period, a further 25 surgeons applied to sit the examination but did not fulfil all the criteria to be eligible for the examination. Fifty experienced abdominal wall surgeons applied to become an Honorary Fellow European Board of Surgery-Abdominal Wall Surgery. Fourty eight were successful in their application. Conclusion: The Fellowship of the European Board of Surgery - Abdominal Wall Surgery by examination has been successfully introduced at European level by the joint work of the UEMS and the EHS. The examination is also open to surgeons who work outside the European area, if they can fulfil the eligibility criteria.

The Women Making Their Mark in Modern Scottish Medical History.

Introduction: Women in medicine and surgery are a recent phenomenon. The aim of this study was to review the modern history of pioneering women in medicine and surgery in Scotland. Methods: A variety of sources were searched including Google, PubMed, and the Royal College of Surgeons of Edinburgh publications to source the material for this paper. Results: Despite over five centuries of Scottish universities offering medical degrees, women have only had the right to study medicine for 150 years. However, the lives of women pioneers who either circumnavigated or surmounted this inequality, namely, "James Barry" and Sophia Jex-Blake, are briefly told. Conclusion: Doctors today owe a debt to those who pushed the boundaries, challenged the unfair rules and tackled institutional gender inequality in medicine. Reading about their lives and work is uplifting.

Update of the international HerniaSurge guidelines for groin hernia management.

BACKGROUND: Groin hernia repair is one of the most common operations performed globally, with more than 20 million procedures per year. The last guidelines on groin hernia management were published in 2018 by the HerniaSurge Group. The aim of this project was to assess new evidence and update the guidelines. The guideline is intended for general and abdominal wall surgeons treating adult patients with groin hernias. METHOD: A working group of 30 international groin hernia experts and all involved stakeholders was formed and examined all new literature on groin hernia management, available until April 2022. Articles were screened for eligibility and assessed according to GRADE methodologies. New evidence was included, and chapters were rewritten. Statements and recommendations were updated or newly formulated as necessary. RESULTS: Ten chapters of the original HerniaSurge inguinal hernia guidelines were updated. In total, 39 new statements and 32 recommendations were formulated (16 strong recommendations). A modified Delphi method was used to reach consensus on all statements and recommendations among the groin hernia experts and at the European Hernia Society meeting in Manchester on October 21, 2022. CONCLUSION: The HerniaSurge Collaboration has updated the international guidelines for groin hernia management. The updated guidelines provide an overview of the best available evidence on groin hernia management and include evidence-based statements and recommendations for daily practice. Future guideline development will change according to emerging guideline methodology.

The Impact of the COVID-19 Pandemic on Hernia Surgery: The South-East Scotland Experience.

Aim The coronavirus disease 2019 (COVID-19) pandemic resulted in a lockdown in South East Scotland on 23 March 2020. This had an impact on the volume of benign elective surgery able to be undertaken. The degree to which this reduced hernia surgery was unknown. The aim of this study was to review the hernia surgery workload in the Lothian region of Scotland and assess the impact of COVID-19 on hernia surgery. Methods The Lothian Surgical Audit database was used to identify all elective and emergency hernia operations over a six-month period from 23 March 2020 and for the same time period in 2019. Data were collected on age, gender, anatomical location of the hernia, hernia repair technique, and whether elective or emergency operation. Statistical analysis was performed using the chi-squared test in R-Studio, with a p-value of <0.05 accepted as statistically significant. Results The total number of hernia repairs reduced considerably between 2019 and 2020 (570 vs 149). The majority of this can be explained by a decrease in elective operating (488 vs 87), with the percentage of elective repairs reducing significantly from 85.6% to 58.4% (p<0.001). The inguinal hernia subgroup had a 24% rise in emergency operations from 21 to 26 operations, despite a reduction from 270 to 84 total inguinal repairs. There were just two elective hernia repairs carried out in the first three months of the 2020 study period (5.6% of all operations for April-June) compared to 265 (87.7%) for the same period in 2019 (p<0.001). No statistically significant differences were observed in the rates of laparoscopic versus open operating techniques across the two study periods on any analysis. The age and gender of the patients were similar over the two time periods. Conclusion The COVID-19 pandemic led to a marked reduction in the number of elective hernia repairs (especially incisional hernia surgery), with the effect most pronounced over the first three months of lockdown. Despite an overall reduction in total emergency operative figures, possibly due to more widespread use of non-operative strategies, there was still an increase in emergency inguinal hernia repairs during the lockdown. Further studies are needed to evaluate if the delays to elective operating will result in a long-term increase in the rates of emergency presentation.

Description of the Current Da Vinci® Training Pathway for Robotic Abdominal Wall Surgery by the European Hernia Society.

Background: Robot assisted laparoscopic abdominal wall surgery (RAWS) has seen a rapid adoption in recent years. The safe introduction of the robot platform in the treatment of abdominal wall hernias is important to safeguard the patient from harm during the learning curve. The scope of this paper is to describe the current European training curriculum in RAWS. Methods and Analysis: The pathway to competence in RAWS will depend on the robot platform, experience in other abdominal procedures (novice to expert) and experience in the abdominal wall repair techniques. An overview of the learning curve effect in the initial case series of several early adopters in RAWS was reviewed. In European centres, current training for surgeons wanting to adopt RAWS is managed by the specific technology-based training organized by the company providing the robot. It consists of four phases where phases I and II are preclinical, while phases III and IV focus on the introduction of the robotic platform into surgical practice. Conclusion: On behalf of the Robotic Surgery Task Force of the European Hernia Society (EHS) we believe that the EHS should play an important role in the clinical phases III and IV training. Courses organized in collaboration with the robot provider on relevant surgical anatomy of the abdominal wall and procedural steps in complex abdominal wall reconstruction like transversus abdominis release are essential. Whereas the robot provider should be responsible for the preclinical phases I and II to gain familiarity in the specific robot platform.

Leveraging Twitter and its Unique #HashTag Capability: A Novel Social Media Resource From the European Hernia Society.

Background: Digital and Social Media (#SoMe) platforms have revolutionized the way information is shared, classified and accessed among medical professionals worldwide. The aim of this study was to review the hashtags used on Twitter by @EuroHerniaS to provide a practical roadmap for easier social media utilization for hernia surgery stakeholders. Methods: The hashtags used in tweets and retweets of the @EuroHerniaS Twitter feed were collated since its foundation in November 2016. Results: The first hashtag used was #HerniaSurgery. Since foundation to July 2021, the @EuroHerniaS Twitter feed has used 90 separate hashtags. The number of new hashtags per year was increasing leading to the development of an online library. The increasing diversity of hernia related hashtags allows for the more detailed posting and searching of hernia related information on the #SoMe platform Twitter. Conclusion: The more detailed use of hashtags on Twitter is to be encouraged. Hernia surgeons can make use of them both when posting and reviewing posts to aid the categorization of posts.

Patient Views Around Their Hernia Surgery: A Worldwide Online Survey Promoted Through Social Media.

Introduction: Hernias are one of the most common surgical diagnoses, and general surgical operations are performed. The involvement of patients in the decision making can be limited. The aim of this study was to explore the perspectives of patients around their hernia and its management, to aid future planning of hernia services to maximise patient experience, and good outcomes for the patient. Methods: A SurveyMonkey questionnaire was developed by patient advocates with some advice from surgeons. It was promoted on Twitter and Facebook, such as all found "hernia help" groups on these platforms over a 6-week period during the summer of 2020. Demographics, the reasons for seeking a hernia repair, decision making around the choice of surgeon, hospital, mesh type, pre-habilitation, complications, and participation in a hernia registry were collected. Results: In total, 397 questionnaires were completed in the study period. The majority of cases were from English speaking countries. There was a strong request for hernia specialists to perform the surgery, to have detailed knowledge about all aspects of hernia disease and its management, such as no operation and non-mesh options. Chronic pain was the most feared complication. The desire for knowledge about the effect of the hernia and surgery on the sexual function in all age groups was a notable finding. Pre-habilitation and a hernia registry participation were well-supported. Conclusions: Hernia repair is a quality of life surgery. Whether awaiting surgery or having had surgery with a good or bad outcome, patients want information about their condition and treatment, such as the effect on aspects of life, such as sex, and they wish greater involvement in their management decisions. Patients want their surgery by surgeons who can also manage complications of such surgery or recommend further treatment. A large group of "hernia surgery injured" patients feel abandoned by their general surgeon when complications ensue.

Surgical Strategy for Contralateral Groin Management in Patients Scheduled for Unilateral Inguinal Hernia Repair: An International Web-Based Surveymonkey® Questionnaire: Strategy for Contralateral Groin Management during Inguinal Hernia Repair.

BACKGROUND: A contralateral occult inguinal hernia is frequently observed in patients planned for a unilateral laparoscopic inguinal hernia repair. Surgical strategy for contralateral groin management in patients scheduled for an endo-laparoscopic unilateral inguinal hernia repair is controversial and based on questionable evidence. This study aimed to gather international opinion concerning the surgical strategy for the contralateral asymptomatic side when no hernia or lipoma is clinically evident at the preoperative examination or anamnesis. METHODS: An international Internet-based questionnaire was sent to all the members of the European Hernia Society, the Americas Hernia Society, and the Asia Pacific Hernia Society. The clinical scenario for responders was a patient with a unilateral symptomatic inguinal hernia planned for endo-laparoscopic repair with no preoperative symptoms/lump on the contralateral side. RESULTS: A total of 640 surgeons replied (response rate = 26%), of whom 506 were included for analysis. Most surgeons had performed > 300 repairs. The preferred surgical technique was evenly distributed between laparoscopic total extraperitoneal repair and laparoscopic transabdominal preperitoneal repair. In total, 54% preferred to implant a prophylactic mesh on the contralateral side when an occult hernia was found, 47% when a lipoma was found, and 6% when no occult hernia/lipoma was identified. CONCLUSIONS: Mesh implementation was preferred by half of the endo-laparoscopic hernia surgeons for a contralateral occult hernia and/or lipoma. Although not supported by strong evidence, mesh implantation on the asymptomatic contralateral side might be cost-effective and perhaps beneficial in the long term but could be offset by increased risk of chronic pain and sexual dysfunction.

Neoadjuvant chemotherapy for carcinoma of the oesophagus and oesophago-gastric junction: a six-year experience.

BACKGROUND: Oesophageal cancer is a major clinical problem with a generally poor prognosis. As a result there has been interest in combining surgery with neoadjuvant chemotherapy to try and improve outcomes, although the current evidence for benefit is inconsistent. We aimed to compare, in a non-randomised study, the post-operative complication rate and short and long-term survival of patients who underwent surgical resection for carcinoma of the oesophagus and types I and II carcinoma of the oesophago-gastric junction with or without neo-adjuvant chemotherapy. METHODS: Details of all resections for oesophageal/junctional (types I and II) adenocarcinoma or squamous cell carcinoma between April 2000 and July 2006 were collected prospectively. Data from patients with T3 and/or N1 disease who underwent either neoadjuvant chemotherapy (NAC) or not (non-NAC) were compared. Data were analysed using Kaplan-Meier plots, Mann-Whitney U-test, Cox Regression modelling, and Chi-squared test with Yates' correction where sample sizes <10. RESULTS: 167 patients were included (89 NAC and 78 non-NAC). The in-hospital post-operative mortality rate of the NAC group (n = 2 deaths; 2.2%) was significantly lower (p = 0.045) than the non-NAC group (n = 6 deaths; 7.7%). Most deaths were due to cardio-respiratory complications; however, there was no significant difference in rates of chest infections, anastomotic leaks, wound infections, re-operations, readmission to ITU or overall complications between the two groups. Although both the two-year survival rate (60.7%) and long-term survival of NAC patients (median survival = 793 days; 95% CI = 390-1196) was greater than non-NAC patients (two-year survival rate = 48.7%; median survival = 554 days; 95% CI = 246-862 respectively), these differences were not statistically significant. CONCLUSION: This non-randomised study demonstrated that NAC was associated with a significant reduction in post-operative inpatient mortality rate. Whether this can be explained by a decreased co-morbidity in NAC patients or a protective phenomenon associated with NAC remains unclear. This study also demonstrated a greater two-year survival rate and overall median survival time following NAC but this was not statistically significant.

Emergency general surgery 'Hot Clinics' reduce admission rates and duration of inpatient stay.

OBJECTIVE: To determine the impact of a 'Hot Clinic' (HC) on emergency general surgery patient flow-through. DESIGN: Prospective service evaluation study. SETTING: HC is a four-bedded area coordinated by a specialist nurse. The HC consultant sees emergency patients referred from the emergency department, general practitioners or those in preceding 24 h considered suitable for interim discharge while awaiting investigations and HC reassessment. PATIENTS: All patients with acute abdominal pain were evaluated in three 4 week groups: before (group 1), 1 month (group 2) and 6 months after the HC was introduced (group 3). Interhospital transfers, intrahospital ward referrals and trauma patients were excluded. INTERVENTION: Introduction of consultant-led surgical HC every weekday afternoon. MAIN OUTCOME MEASURES: Proportion of patients admitted under general surgeons, length of inpatient stay and the proportion of patients referred again within 3 months were investigated. RESULTS: 1409 patients were referred, of which 1061 met the inclusion criteria: 307 in group 1, 326 in group 2 and 428 in group 3. There was no difference in gender distribution (p=0.759). Inpatient admissions were significantly reduced (85.0% vs 78.2% vs 54.4%; p<0.001) and the inpatient duration of stay was significantly shorter after HC introduction (median (IQR) (95% CI) 63.8 (29.0-111.6) (51.8 to 72.8) hours vs 48.8 (21.7-101.2) (42.0 to 55.6) hours vs 47.7 (20.9-92.7) (42.8 to 56.9) hours; p=0.011). CONCLUSIONS: Emergency general surgery HCs are associated with significant reductions in admission rates and inpatient bed occupancy. This service redesign has the potential to dramatically relieve pressure on acute surgical services.