Does Bariatric Surgery Improve Faecal Incontinence? A Systematic Review and Meta-analysis.

INTRODUCTION: Obesity increases the risk of pelvic floor disorders in individuals with obesity, including faecal incontinence. Faecal incontinence (FI) is a condition with important clinical and psychosocial consequences. Though it is associated with obesity, the effect of bariatric surgery on the prevalence and severity of FI is not well reported. OBJECTIVE: To assess the effect of bariatric surgery on the prevalence and severity of FI in adult patients with obesity. METHODS: This systematic review was conducted in accordance with the PRISMA statement. Two independent reviewers performed a literature search in MEDLINE, PubMed, Cochrane and Embase from 1 January 1980 to 12 January 2019. We included published English-language randomized control trials and observational studies assessing pre- and post-bariatric surgery prevalence or severity of FI. Random-effects models with DerSimonian and Laird's variance estimator were used for meta-analysis. RESULTS: Thirteen studies were included, eight assessing prevalence (678 patients) and 11 assessing severity of FI (992 patients). There was no significant difference in prevalence post-operatively overall, though it trended towards a reduction [pooled OR=0.55; =0.075]. There was a significant reduction of FI prevalence in women post-bariatric surgery [95% CI 0.22 to 0.94, p=0.034]. There was a statistically significant reduction in FI prevalence following Roux-en-Y gastric bypass and one anastomosis gastric bypass [0.46, 95% CI 0.26 to 0.81; p=0.007]. There was no significant reduction of incontinence episodes post-operatively [pooled mean difference =-0.17, 95% CI -0.90 to 0.56; p=0.65]. Quality of life (QOL) was not significantly improved post-bariatric surgery [mean differences for the following facets of QOL: behaviour -0.35, 95% CI -0.94 to 0.24; depression 0.04, 95% CI -0.12 to 0.2; lifestyle -0.33, 95% CI -0.98 to 0.33; p values of 0.25, 0.61 and 0.33, respectively]. DISCUSSION: There was a significant reduction in FI prevalence in women and those who underwent Roux-en-Y or one anastomosis gastric bypass. Our results for FI prevalence overall, FI severity and impact on quality of life were not statistically significant. Larger studies are needed in this under-researched area to determine the true effect of bariatric surgery on FI.

How to repair a small umbilical hernia laparoscopically.

We describe a step by step technique for repair of a small umbilical hernia laparoscopically that aims to provide an excellent technical and cosmetic result without a significant increase in operative time or cost. Patients report good quality of life post-operatively and appear satisfied with the cosmetic result.

A Randomised Trial of Text Message Support for Reducing Weight Regain Following Sleeve Gastrectomy.

INTRODUCTION: Sleeve gastrectomy (SG) is a common bariatric procedure with high rates of weight regain (WR). Clinicians and patients have identified a lack of follow-up support and maladaptive lifestyle behaviours as potential causes for WR. While text message support has been shown to be effective for weight loss in non-surgical patients, it has not been investigated for reducing WR in bariatric patients. PURPOSE: To determine the effectiveness of text message support in reducing weight regain following sleeve gastrectomy. METHODS: A text message intervention was designed. The effectiveness of the intervention was investigated by a randomised trial powered to detect a 15% difference in the primary outcome of percent excess weight loss (84 participants required). Secondary outcomes were the Bariatric Analysis and Reporting System (BAROS) score and patient satisfaction. Outcomes were assessed at 6 and 12 months. RESULTS: Ninety-five participants were randomised to either standard care or text message support (daily text message for 1 year). While there was no significant difference in the primary outcome at 6 or 12 months, patients who received the intervention tended to have less WR and a significantly better BAROS score at 12 months. Participants who received text message support found it beneficial, would have liked the messages to continue, and felt WR was reduced by having the text message support. CONCLUSION: Text message support following SG is feasible, may reduce weight regain, improves the BAROS score and is valued by patients. TRIAL REGISTRATION: NCT02341001.

Derivation and validation of the APPEND score: an acute appendicitis clinical prediction rule.

BACKGROUND: Although many clinical prediction rules (CPRs) for appendicitis exist, none have been developed for a New Zealand population presenting with right iliac fossa (RIF) pain. The aim of this study was to derive and validate an appendicitis CPR for our population. METHOD: This is a retrospective review of all patients from December 2010 to February 2012 of at least 15 years of age presenting to the general surgery service with RIF pain. Patient data were divided into derivation and validation groups. Univariate and multiple regression analyses identified significant predictors of appendicitis which were used to construct a CPR. A retrospective validation study was then performed and the CPR was refined accordingly. Finally, the accuracy of the CPR was tested. RESULTS: The final components of the new CPR, the APPEND score, were Anorexia, migratory Pain, local Peritonism, Elevated C-reactive protein, Neutrophilia and male gender (Dude). This CPR has an area under the receiver operating characteristic curve of 0.84. The CPR can stratify patients into low, intermediate and high-risk groups which may standardize patient care and reduce the negative appendicectomy rate. CONCLUSION: A new CPR for predicting appendicitis, in patients presenting with RIF pain, has been derived and validated for use in our population. A prospective study to further evaluate its performance is required.

Intravenous lignocaine in colorectal surgery: a systematic review.

BACKGROUND: Colorectal surgery leads to morbidity during recovery including pain and fatigue. Intravenous (IV) lignocaine (IVL) has both analgesic and anti-inflammatory effects that may improve post-operative pain and recovery. The aim of this review is to compare the effectiveness of IVL to other perioperative analgesia regimens for reducing pain and opioid consumption following colorectal surgery. METHODS: Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement, a literature search was conducted to identify randomized clinical trials that compared IVL with IV placebo or epidural anaesthesia in open or laparoscopic colorectal surgery. The primary outcomes were opioid requirements and pain scores assessed by visual analogue score. Data were entered into pre-designed electronic spreadsheets. RESULTS: The literature search identified 2707 studies. A total of nine randomized clinical trials met the inclusion criteria. Five studies investigated IVL compared with IV placebo and four studies investigated IVL compared with epidural anaesthesia. Two out of the five studies comparing IVL and placebo showed statistically significant reductions in opioid consumption with IVL. There was a variable degree of improvement in pain scores when IVL was compared with epidural. Two studies showed a significant difference, with lower opioid consumption and pain scores in the epidural group. Laparoscopic and open procedures could not be compared between the IVL and placebo group. CONCLUSION: IVL has shown limited benefit towards reducing early pain and morphine consumption when compared with placebo in colorectal surgery. However, IVL did not show any significant reduction in pain or opioid consumption when compared with epidural. Further research investigating IVL combined with intraperitoneal local anaesthetic is warranted.

Definition determines weight regain outcomes after sleeve gastrectomy.

BACKGROUND: Sleeve gastrectomy (SG) is one of the most commonly undertaken bariatric procedures. Weight regain after bariatric surgery, when significant, may be associated with recurrence of diabetes and deterioration in quality of life. Furthermore, it may be more common after SG than bypass procedures. Yet the understanding of the significance of weight regain is hampered by poor reporting and no consensus statements or guidelines. OBJECTIVES: To illustrate how the lack of a standard definition significantly alters reported SG outcomes and to contribute to the discussion of how weight regain should be defined. SETTING: Counties Manukau Health, a public teaching hospital that performs over 150 bariatric procedures per year. METHODS: A retrospective cohort of SG patients followed up at 5 years was used to illustrate how the presence of multiple definitions in the literature significantly affects outcome reporting for weight regain. Post hoc analyses were used to explore the relationship between weight change and clinical outcomes. RESULTS: Applying 6 definitions of weight regain to a retrospective cohort of SG patients resulted in 6 different rates ranging from 9%-91%. Post hoc analyses revealed significant associations between weight change and the Bariatric Analysis Reporting Outcome System (BAROS) score as well as patient opinion. CONCLUSION: The nonuniform reporting of weight regain appears to significantly affect SG outcome reporting. Development of consensus statements and guidelines would ameliorate this problem. Ideally, research groups with access to large robust databases would aid in the development of any proposed weight regain definitions. In the interim, bariatric literature would benefit by all published series clearly reporting how weight regain is defined in the study population.

Clinical Prediction Rules for Appendicitis in Adults: Which Is Best?

BACKGROUND: Clinical prediction rules (CPRs) provide an objective method of assessment in the diagnosis of acute appendicitis. There are a number of available CPRs for the diagnosis of appendicitis, but it is unknown which performs best. AIM: The aim of this study was to identify what CPRs are available and how they perform when diagnosing appendicitis in adults. METHOD: A systematic review was performed in accordance with the PRISMA guidelines. Studies that derived or validated a CPR were included. Their performance was assessed on sensitivity, specificity and area under curve (AUC) values. RESULTS: Thirty-four articles were included in this review. Of these 12 derived a CPR and 22 validated these CPRs. A narrative analysis was performed as meta-analysis was precluded due to study heterogeneity and quality of included studies. The results from validation studies showed that the overall best performer in terms of sensitivity (92%), specificity (63%) and AUC values (0.84-0.97) was the AIR score but only a limited number of studies investigated at this score. Although the Alvarado and Modified Alvarado scores were the most commonly validated, results from these studies were variable. The Alvarado score outperformed the modified Alvarado score in terms of sensitivity, specificity and AUC values. CONCLUSION: There are 12 CPRs available for diagnosis of appendicitis in adults. The AIR score appeared to be the best performer and most pragmatic CPR.

Weight Regain Following Sleeve Gastrectomy-a Systematic Review.

Sleeve gastrectomy (SG) is a commonly performed bariatric procedure. Weight regain following SG is a significant issue. Yet the defining, reporting and understanding of this phenomenon remains largely neglected. Systematic review was performed to locate articles reporting the definition, rate and/or cause of weight regain in patients at least 2 years post-SG. A range of definitions employed to describe weight regain were identified in the literature. Rates of regain ranged from 5.7 % at 2 years to 75.6 % at 6 years. Proposed causes of weight regain included initial sleeve size, sleeve dilation, increased ghrelin levels, inadequate follow-up support and maladaptive lifestyle behaviours. Bariatric literature would benefit from standardising definitions used to report weight regain and its rate in clinical series. Larger prospective studies are required to further understand mechanisms of weight regain following SG.

Patient Perspectives About Follow-Up Care and Weight Regain Following Sleeve Gastrectomy.

BACKGROUND: Weight regain following sleeve gastrectomy is an increasingly recognised and important problem. Similar to other centres, we have noticed an association between the onset of weight regain and discharge from the bariatric service. We aimed to elucidate this further from the patient perspective. METHODS: Patients at least 2 years from sleeve gastrectomy, who had experienced weight regain, were invited to participate in a focus group discussion. Participants were asked to complete a demographic survey and discussions were audio-recorded. Transcripts underwent content analysis using an inductive approach. RESULTS: Thirty-eight participants participated in one of seven focus group discussions. The majority of participants were female, European and satisfied with the surgery and follow-up care. Participants described positive and negative aspects of the surgery, their follow-up care and causes of weight regain. Important emergent themes included the desire for more support, that is delivered within the overarching principles of providing individualised, specialised care by providers that maintain good rapport and assist in maintaining motivation. Furthermore, this follow-up support may be delivered in non-traditional ways rather than conventional face-to-face consultations. CONCLUSION: Explorative focus group discussions in a group of patients who had regained weight following sleeve gastrectomy revealed a desire for more support after discharge from the bariatric service.

What Does the Excised Stomach from Sleeve Gastrectomy Tell us?

INTRODUCTION: Staple-line leak and haemorrhage are the most serious complications following sleeve gastrectomy. The operation is often performed without prior endoscopy. Given that gastric inflammatory conditions are common, could they predispose patients to suffering a serious complication following sleeve gastrectomy? METHODS: Consecutive patients undergoing laparoscopic sleeve gastrectomy from March 2007 to May 2014 were included in the study. All final histologic reports were coded and investigated against whether or not the patient had a post-operative leak and/or haemorrhage. Associations were explored using Fisher's exact test. RESULTS: Over this period, 976 laparoscopic sleeve gastrectomies were performed with a pre-operative gastroscopy rate of 2.2%. Over half of the specimens demonstrated a histopathologic abnormality. Helicobacter pylori infection occurred in 8.6%, and the most common histopathologic abnormality was chronic gastritis in 38.9%. There was no association between H. pylori infection or inflammation and staple-line leak and/or haemorrhage. CONCLUSION: We conclude that inflammatory gastric conditions are unlikely to predispose patients to staple-line leaks or haemorrhages following sleeve gastrectomy and that selective pre-operative gastroscopy may be an appropriate standard of care.