Global variations in preoperative practices concerning patients seeking primary bariatric and metabolic surgery (PACT Study): A survey of 634 bariatric healthcare professionals.

BACKGROUND: Bariatric and Metabolic Surgery (BMS) is a popular weight loss intervention worldwide, yet few scientific studies have examined variations in preoperative practices globally. This study aimed to capture global variations in preoperative practices concerning patients planned for BMS. METHODS: A 41-item questionnaire-based survey was designed and the survey link was freely distributed on social and scientific media platforms, email groups and circulated through personal connections of authors. The survey included eight parts: basic information; criteria for BMS; preoperative nutritional screening; preoperative weight loss; preoperative diets for liver size reduction; preoperative glycemic control; other laboratory investigations and preparations; decision making, education, and consents. Descriptive statistics were used to analyse data and graphs were used for representation where applicable. RESULTS: Six hundred thirty-four bariatric healthcare professionals from 76 countries/regions completed the survey. Of these, n = 310 (48.9%) were from public hospitals, n = 466 (73.5%) were surgeons, and the rest were multidisciplinary professionals. More than half of respondents reported using local society/association guidelines in their practice (n = 310, 61.6%). The great majority of respondents routinely recommend nutritional screening preoperatively (n = 385, 77.5%), mandatory preoperative diets for liver size reduction (n = 220, 53.1%), routine screening for T2DM (n = 371, 90.7%), and mandate a glycemic control target before BMS in patients with T2DM (n = 203, 55.6%). However, less than half (n = 183, 43.9%) recommend mandatory preoperative weight loss to all patients. Most respondents (n = 296, 77.1%) recommend psychological intervention before surgery for patients diagnosed with psychological conditions. Variations were also identified in laboratory investigations and optimisation; and in the aspects of decision making, education and consent. CONCLUSIONS: This survey identified significant global variations in preoperative practices concerning patients seeking primary BMS. Our findings could facilitate future research for the determination of best practice in these areas of variations, and consensus-building to guide clinical practice while we wait for that evidence to emerge.

Surgical management of obesity: what you need to know.

Obesity is a worldwide epidemic and official figures demonstrate a rising prevalence, both in the UK and globally. Increasingly, there is a recognised place for surgical intervention in carefully selected patients, but there is limited understanding of the pathway and process among non-specialist clinicians. This article summarises the available guidelines and literature on the surgical management of obesity for hospital physicians, surgeons and GPs. The focus is on appropriate referral criteria, key bariatric procedures, postoperative management and, most importantly, the complications of surgery and how to recognise them.

The Effect of Participation in Tier 3 Services on the Uptake of Bariatric Surgery.

BACKGROUND: Despite the recognised advantages of bariatric and metabolic surgery, only a small proportion of patients receive this intervention. In the UK, weight management systems are divided into four tiers. Tier 3 is a clinician-lead weight loss service while tier 4 considers surgery. While there is little evidence that tier 3 has any long-term benefits for weight loss, this study aims to determine whether tier 3 improves the uptake of surgery. METHOD: A retrospective cohort study of all referrals to our unit between 2013 and 2016 was categorised according to source-tier 3, directly from the general practitioner (GP) or from another speciality. The likelihood of surgery was calculated using a regression model after considering patient demographics, comorbidities and distance from our hospital. RESULTS: Of the 399 patients, 69.2% were referred directly from the GP, 21.3% from tier 3, and 9.5% from another speciality of which 69.4%, 56.2%, and 36.8% progressed to surgery (p = 0.01). On regression analysis, patients from another speciality or GP were more likely to decide against surgery (OR 2.44 CI 1.13-6.80 p = 0.03 and OR 1.65 CI 1.10-3.12 p = 0.04 respectively) and more likely to be deemed not suitable for surgery by the MDT (OR 6.42 CI 1.25-33.1 p = 0.02 and OR 3.47 CI 1.11-12.9 p = 0.03) compared with tier 3 referrals. CONCLUSION: As patients from tier 3 were more likely to undergo bariatric and metabolic surgery, this intervention remains a relevant step in the pathway. Such patients are likely to be better informed about the benefits of surgery and risks of severe obesity.

Is Bariatric Surgery Better than Nonsurgical Weight Loss for Improving Asthma Control? A Systematic Review.

Obesity is associated with increased severity of asthma. Bariatric surgery can be effective in weight loss and improvement in asthma. Two reviewers conducted a systematic review using search terms: 'weight loss', 'bariatric surgery', and 'asthma'. Adult studies including all bariatric procedures and nonsurgical weight loss regimes were included. Thirty-nine studies, including twenty-six bariatric studies and thirteen nonsurgical studies, were found. No study directly compared bariatric surgery to nonsurgical techniques. Bariatric surgery offered greater weight loss (22-36%) than nonsurgical programmes (4.1-14.2%) and more consistently improved medication use, airway hyperresponsiveness, hospitalisation rate or ED attendance and lung function, while change in inflammatory markers were variable. Bariatric surgery appears to be superior in treating asthma; however, further study on surgery for both mild and severe asthma is required.

SARS-CoV-2 infection in acute pancreatitis increases disease severity and 30-day mortality: COVID PAN collaborative study.

OBJECTIVE: There is emerging evidence that the pancreas may be a target organ of SARS-CoV-2 infection. This aim of this study was to investigate the outcome of patients with acute pancreatitis (AP) and coexistent SARS-CoV-2 infection. DESIGN: A prospective international multicentre cohort study including consecutive patients admitted with AP during the current pandemic was undertaken. Primary outcome measure was severity of AP. Secondary outcome measures were aetiology of AP, intensive care unit (ICU) admission, length of hospital stay, local complications, acute respiratory distress syndrome (ARDS), persistent organ failure and 30-day mortality. Multilevel logistic regression was used to compare the two groups. RESULTS: 1777 patients with AP were included during the study period from 1 March to 23 July 2020. 149 patients (8.3%) had concomitant SARS-CoV-2 infection. Overall, SARS-CoV-2-positive patients were older male patients and more likely to develop severe AP and ARDS (p<0.001). Unadjusted analysis showed that SARS-CoV-2-positive patients with AP were more likely to require ICU admission (OR 5.21, p<0.001), local complications (OR 2.91, p<0.001), persistent organ failure (OR 7.32, p<0.001), prolonged hospital stay (OR 1.89, p<0.001) and a higher 30-day mortality (OR 6.56, p<0.001). Adjusted analysis showed length of stay (OR 1.32, p<0.001), persistent organ failure (OR 2.77, p<0.003) and 30-day mortality (OR 2.41, p<0.04) were significantly higher in SARS-CoV-2 co-infection. CONCLUSION: Patients with AP and coexistent SARS-CoV-2 infection are at increased risk of severe AP, worse clinical outcomes, prolonged length of hospital stay and high 30-day mortality.

Practices Concerning Revisional Bariatric Surgery: a Survey of 460 Surgeons.

BACKGROUND: There is currently little evidence available on various aspects of Revisional Bariatric Surgery (RBS) and no published consensus amongst experts. The purpose of this study was to understand variation in practices concerning RBS. METHODS: Bariatric surgeons from around the world who perform RBS were invited to participate in a questionnaire-based survey on SurveyMonkey®. RESULTS: A total of 460 respondents from 62 countries took the survey. For revision after gastric banding, Roux-en-Y gastric bypass (RYGB) (75.5%, n = 345) emerged as the commonest choice followed by sleeve gastrectomy (SG) (56.9%, n = 260) and one anastomosis gastric bypass (OAGB) (37.2%, n = 170). For revision after SG, RYGB (77.7%, n = 355) was the commonest option followed by OAGB (42.45%, n = 194) and re-sleeve (22.32%, n = 102). For revision after RYGB, surgical pouch reduction (49.1%, n = 223), prolongation of bilio-pancreatic limb (30.0%, n = 136), and surgical stoma size reduction (26.43%, n = 120) were the most preferred options. Approximately 90.0% of respondents (n = 406/454) routinely perform an upper gastrointestinal endoscopy before an RBS, and 85.6% (n = 388/453) routinely perform a contrast study. Ninety percent (n = 403/445) reported that the demand for RBS was usually patient-driven, and there was wide variation in criteria used to define successful response, non-responders, and significant weight regain. CONCLUSIONS: This survey is the first attempt to understand various aspects of RBS. The findings will help in identifying areas for research and allow consensus building amongst experts.

Understanding Objections to One Anastomosis (Mini) Gastric Bypass: A Survey of 417 Surgeons Not Performing this Procedure.

BACKGROUND: Despite published experience with thousands of patients, the uptake of One Anastomosis/Mini Gastric Bypass (OAGB/MGB) has been less than enthusiastic and many surgeons still harbour objections to this procedure. The purpose of this study was to understand these objections scientifically. METHODS: Bariatric surgeons from around the world were invited to participate in a questionnaire-based survey on SurveyMonkey®. Surgeons already performing this procedure were excluded. RESULTS: Four hundred seventeen bariatric surgeons (from 42 countries) not currently performing OAGB/MGB took the survey. There were 211/414 (50.97%) and 188/414 (45.41%) respondents who expressed concerns that it will lead to an increased risk of gastric and oesophageal cancers respectively. A total of 62/416 (14.9%) and 201/413 (n = 48.6%) surgeons respectively felt that OAGB/MGB was associated with a higher early (30-day) and late complication rate compared to the RYGB. Moreover, 7.8% (n = 32/411) and 16.26% (n = 67/412) of the respondents were concerned that OAGB/MGB carried a higher early (30-day) and late mortality, respectively, in comparison with the RYGB. There were 79/410 (19.27%) and 88/413 (21.3%) respondents who were concerned that OAGB/MGB was not an effective procedure for weight loss and co-morbidity resolution, respectively. A total of 258/411 (62.77%) respondents reported that OAGB/MGB was not approved by their national society as a mainstream bariatric procedure; 51.0% of these surgeons would start performing this procedure if it was. CONCLUSIONS: Surgeons not performing OAGB/MGB cite a number of concerns for not performing this operation. This survey is the first scientific attempt to understand these objections scientifically.

Criteria for Inclusion of Newer Bariatric and Metabolic Procedures into the Mainstream: a Survey of 396 Bariatric Surgeons.

BACKGROUND: There is currently no consensus on the criteria for inclusion of new bariatric procedures into routine clinical practice. This study canvasses bariatric surgeons in an attempt to define these criteria. METHODS: Bariatric Surgeons from around the world were invited to participate in a questionnaire-based survey on SurveyMonkey ®. RESULTS: 396 bariatric surgeons, 337 International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) members, took the survey. Five clinical studies conducted under the strict monitoring of an Institutional Review Board would satisfy most surgeons (67.7 %, n = 266). When asked regarding the number of patients in these studies, a cumulative number of 500 patients would satisfy 64.5 % (n = 255) of the surgeons. Most respondents regarded endorsement by their national society and IFSO as 'very important' or 'extremely important'. An overwhelming 74.4 % (n = 294) felt that every new procedure should undergo a randomized comparison against one of the established alternatives like Roux-en-Y Gastric Bypass or Sleeve Gastrectomy. CONCLUSION: Evaluation of a new bariatric procedure in at least 5 adequately supervised clinical studies (four of which must be randomized comparisons with one of the existing alternatives) reporting at least 5 years results on a minimum of 500 patients would satisfy majority of bariatric surgeons for the inclusion of a new bariatric procedure into clinical practice. The findings of this survey are simply aimed at starting a discussion on this topic and cannot be used to influence the ground reality until an international consensus can be reached amongst experts.

Bariatric Surgery, Polycystic Ovary Syndrome, and Infertility.

Background. Polycystic ovary syndrome (PCOS) is the commonest cause of female infertility. Visceral obesity and insulin resistance are key pathophysiological mechanisms behind PCOS. Women suffering from this syndrome and infertility often seek bariatric surgery hoping that they would be able to conceive postoperatively. Objective. At present, there is no consensus on the role of bariatric surgery in the management of PCOS-associated infertility within the medical community, making it difficult to give specific advice to these women, so a review of the literature was necessary. Results. A detailed review of the literature was performed. Only 6 manuscripts were relevant and contained quantitative data. They demonstrated that bariatric surgery results in postoperative conception rates varying from 33% to 100%. Surgery is also associated with amelioration of menstrual irregularities, hormonal abnormalities, and hirsutism that are associated with PCOS. These studies were retrospective and only had a small number of participants with infertility. Conclusions. Bariatric surgery has been shown to conclusively improve life expectancy, quality of life, and comorbidities like type 2 diabetes and obstructive sleep apnea. However, further research is required to identify whether weight loss surgery results in significant improvement in fertility of women with PCOS and to investigate which operation has the best results.

Best evidence topic: Should ventral hernia repair be performed at the same time as bariatric surgery?

A best evidence topic has been constructed using a described protocol. The three-part question addressed was: In morbidly obese patients undergoing bariatric surgery, when a ventral hernia is picked up in clinic or intraoperatively is concurrent repair of the hernia better than delayed repair after weight loss with regards to complication rates? Using the reported search, 179 papers were found. 5 studies were deemed to be suitable to answer the question. All 5 studies assessed were non randomised studies either retrospective or prospective and the overall quality of these studies was poor. The outcomes assessed were incidence of complications associated with hernia repair (recurrence, infection) and deferral of repair (small bowel obstruction). The patient's symptoms and anatomy is important in determining the timing of repair. The evidence does not provide a consensus for the optimal timing of ventral hernia repair for patients undergoing bariatric surgery, with some of the selected studies contradicting each other. However, the studies do affirm the risk of small bowel obstruction if hernias are left alone. The reported rate of surgical site infection is low when mesh repair is performed at the same time as weight loss surgery. Until large volume, high quality randomized control trials can be performed, a case by case approach is best, where the patients' symptoms, anatomy, type of bariatric surgery and their personal preferences are considered, and an open discussion on the risks and benefits of each approach is undertaken.

Metastases of lobular breast carcinoma in the terminal ileum and ileocaecal valve.

Gastrointestinal (GI) metastases from primary breast carcinoma are rare but more common in invasive lobular carcinoma than invasive ductal carcinoma. The symptoms may be non-specific and the presentation can occur many years after the initial primary breast carcinoma. Radiological and endoscopic findings can be difficult to distinguish from inflammatory bowel disease and primary carcinoma of the GI tract. Histological and immunohistopathology assessment will usually confirm the diagnosis of metastatic breast carcinoma. We report the first case of lobular breast carcinoma metastasizing to the terminal ileum and ileocaecal valve 19 years following treatment for breast cancer in an 82-year-old woman. Staging investigations revealed synchronous metastases in bones and the pleura. A high index of suspicion and awareness of the potential long interval in the presentation of metastatic breast cancer help in making an accurate diagnosis and rapid clinical management.

The F.R.I.D.A.Y.S. checklist - Preparing our patients for a safe weekend.

There is a higher incidence of mortality and adverse events among inpatients in UK hospitals at the weekend compared to weekdays. The high volume of routine tasks handed over by the weekday doctors on Fridays may be a contributing factor. An audit was carried out on four acute wards on a Friday evening at University Hospital Lewisham (UHL). It demonstrated that most patients had at least one outstanding task that would need completing by the on-call team over the weekend. To address this problem a concise and memorable checklist was created to ensure that routine jobs are completed by the weekday team prior to the weekend. The checklist uses the acronym "F.R.I.D.A.Y.S." to prompt doctors to hand over weekend bloods, ensure drug charts are reviewed, document a plan for IV fluids, complete discharge summaries, monitor antibiotic levels, dose warfarin, and clearly document the ceiling of care. The F.R.I.D.A.Y.S. checklist was printed onto history paper and integrated into the patient notes on a Friday ward round. The efficacy of the checklist was evaluated by reviewing the number of outstanding jobs on the wards after 17:00 on a Friday in the categories listed. F-Phlebotomy R-Rewrite drug chart I-IV fluids D-Discharge summaries A-Antibiotic levels Y-Yellow book (warfarin) S-Resuscitation Status The number of outstanding jobs on a ward (A) that used F.R.I.D.A.Y.S. was 3 out of a total 132 jobs (2.3%) compared with 47 out of a total of 103 (45.6%) on a ward that did not use the checklist (B). When the F.R.I.D.A.Y.S. checklist is implemented there is an increase in the number of routine jobs that are carried out by the weekday team, and therefore a reduction in workload for the weekend on call team. Patient safety is improved as management decisions are made by a team that is familiar with the patient, and on call teams are able to prioritise emergencies. The cost saving of using the F.R.I.D.A.Y.S. checklist if implemented throughout UHL is estimated at £317,136 per annum.