Long-term Outcomes of Laparoscopic Sleeve Gastrectomy as a Revisional Procedure Following Adjustable Gastric Banding: Variations in Outcomes Based on Indication.

BACKGROUND: Significant controversy exists regarding the indications and outcomes after laparoscopic adjustable gastric banding (LAGB) conversions to laparoscopic sleeve gastrectomy (LSG). AIM: To comprehensively determine the long-term outcomes of sleeve gastrectomy as a revisional procedure after LAGB across a range of measures and determine predictors of outcomes. METHODS: Six hundred revision LSG (RLSG) and 1200 controls (primary LSG (PLSG)) were included. Patient demographics, complications, follow-up, and patient-completed questionnaires were collected. RESULTS: RLSG vs controls; females 87% vs 78.8%, age 45 ± 19.4 vs 40.6 ± 10.6 years, p = 0.561; baseline weight 119.7 ± 26.2 vs 120.6 ± 26.5 kg p = 0.961). Follow-up was 87% vs 89.3%. Weight loss in RLSG at 5 years, 22.9% vs 29.6% TBWL, p = 0.001, 10 years: 19.5% vs 27% TBWL, p = 0.001. RLSG had more complications (4.8 vs 2.0% RR 2.4, p = 0.001), re-admissions (4.3 vs 2.4% RR 1.8, p = 0.012), staple line leaks (2.5 vs 0.9%, p = 0.003). Eroded bands and baseline weight were independent predictors of complications after RLSG. Long-term re-operation rate was 7.3% for RLSG compared to 3.2% in controls. Severe oesophageal dysmotility predicted poor weight loss. RLSG reported lower quality of life scores (SF-12 physical component scores 75.9 vs 88%, p = 0.001), satisfaction (69 vs 93%, p = 0.001) and more frequent regurgitation (58% vs 42%, p = 0.034). CONCLUSION: RLSG provides long-term weight loss, although peri-operative complications are significantly elevated compared to PLSG. Longer-term re-operation rates are elevated compared to PLSG. Four variables predicted worse outcomes: eroded band, multiple prior bands, severe oesophageal dysmotility and elevated baseline weight.

Traumatic obturator foramen hernia. A rare aetiology of a rare condition: A case report.

Obturator hernias (OH) are rare, accounting for less than 0.05% of all hernias. The aetiology is usually attributed to chronically raised intra-abdominal pressure or cachexia with poor muscle mass. This case report describes a traumatic obturator hernia, an exceptionally rare aetiology of an already rare surgical condition. There are no previous reports of a traumatic obturator hernia in the current literature. This case reports upon the presentation, operative findings and management of a 48 year old male with abdominal and pelvic trauma following a motor bike collision. Laparotomy findings included a right sided traumatic incarcerated obturator foramen hernia with the comminuted pubic rami fracture trapping and piercing ileum within the hernia. In retrospect, the hernia was visible on CT scan. The hernia was repaired using biological mesh which was covered with adjacent peritoneum. As with much of trauma surgery, the management of this case required reliance on general principles and real time problem solving to address an issue not previously experienced by the operator, and not previously reported on in the current literature.

Non-diagnostic sonography may reduce negative appendicectomy rate in women when combined with abbreviated Alvarado score.

BACKGROUND: The diagnosis of acute appendicitis (AA) remains a clinical one, with selective use of adjunct imaging. Patients with equivocal clinical presentation often undergo a diagnostic laparoscopy. To help reduce negative appendicectomy rates in women, we aimed to develop a simple scoring system based on the Alvarado score (AS) and ultrasound scan (US), as a diagnostic aid for AA in females. METHODS: All patients who underwent appendicectomy for AA at The Alfred Hospital Melbourne between 1 July 2012 and 30 June 2017 were included for this case-control study. Logistic regression was used to identify pre-operative parameters predictive of AA. Histopathological identification of AA was interpreted as the gold standard. Statistical analysis was performed using IBM SPSS Statistics V26. RESULTS: A total of 1194 patients were included, with 26% negative appendicectomy rate in women. Of the 8 parameters in the AS, logistic regression identified migratory pain, leukocytosis and leukocyte left shift as most significant predictors for AA. These three parameters were used in a 3-point test which carried a sensitivity of 92.1% and specificity of 28.7%. In women, a negative or non-diagnostic US improved the negative predictive value of the 3-point test from 57% to 82%. CONCLUSION: The 3-point abbreviated AS in combination with US may be clinically useful in women to exclude appendicitis without diagnostic laparoscopy. Further large-scale prospective studies are required to validate the utility across different subgroups.

Caseload distribution of general surgeons in regional Australia: is there a role for a rural surgery sub-specialization?

BACKGROUND: Rural and regional Australia presents a unique challenge in the delivery of surgical services by virtue of its geographical vastness and low population density. While up to 33% of Australians live in rural or regional areas, only 14.8% of surgeons work in a rural or regional area. Data regarding the caseload distribution of general surgeons working in a regional setting in Australia remain scarce. In order to better examine the training needs of rural general surgeons, this study aims to examine the caseload distribution of general surgeons working in regional Australia. METHODS: A retrospective review of surgical procedures carried out by general surgeons at Albury Base Hospital between September 2006 and December 2014 was carried out. Surgical procedures were grouped according to the classifications of the Royal Australasian College of Surgeons Morbidity and Audit Logbook Tool. RESULTS: During the study period, 21 652 procedures were carried out by general surgeons. A total of 58.7% (12711) of these procedures consisted of general surgical procedures and 35.9% (7763) were endoscopic procedures. A total of 5.4% of procedures carried out by general surgeons fell outside the scope of traditional general surgery, including cardiothoracic, orthopaedic, ear, nose and throat, neurosurgical, vascular and urological procedures. All general surgeons performed operations in surgical specialities outside of general surgery. CONCLUSION: This study adds weight to the value of a broad skill set in provision of surgical services in a rural setting.