Bile acids associate with specific gut microbiota, low-level alcohol consumption and liver fibrosis in patients with non-alcoholic fatty liver disease.

BACKGROUND: Bile acids (BAs) are synthesized by the liver and modified by gut bacteria, and may play an intermediary role between the gut microbiome and liver in promoting fibrosis in non-alcoholic fatty liver disease (NAFLD). We investigated the associations between serum and faecal BAs, gut microbiome and fibrosis in patients with and without NAFLD and examined the impact of diet and alcohol consumption on these relationships. METHODS: Adult patients (n = 122) underwent liver biopsy and BAs characterization by high-performance liquid chromatography/mass spectrometry. Gut microbiome composition was analysed using next-generation 16S rRNA sequencing. Diet and alcohol intake were determined by 3-day food diary. RESULTS: Serum and faecal BA concentrations increased progressively among non-NAFLD controls (n = 55), NAFLD patients with no/mild fibrosis (F0-2, n = 58) and NAFLD with advanced fibrosis (F3/4, n = 9). Progressive increases in serum BAs were driven by primary conjugated BAs including glycocholic acid [GCA] and secondary conjugated BAs. In contrast, faecal BA increase was driven by secondary unconjugated BAs (predominately deoxycholic acid [DCA]). Serum GCA levels and faecal DCA levels correlated with the abundance of Bacteroidaceae and Lachnospiraceae, and stool secondary BAs with an unclassifiable family of the order Bacteroidales (Bacteroidales;other). These bacterial taxa were also associated with advanced fibrosis. Modest alcohol consumption was positively correlated with faecal DCA levels and relative abundance of Lachnospiracaea and Bacteroidales;other. CONCLUSIONS: Higher serum and faecal BA levels are associated with advanced fibrosis in NAFLD. Specific gut bacteria link alterations in BA profiles and advanced fibrosis, and may be influenced by low-level alcohol consumption.

Mesh versus non-mesh repair of groin hernias: a rapid review.

BACKGROUND: Mesh is frequently utilized intraoperatively for the repair of groin hernias. However, patients may request non-mesh hernia repairs owing to adverse events reported in other mesh procedures. To inform surgical safety, this study aimed to compare postoperative complications between mesh and non-mesh groin hernia repairs and identify other operative and patient-related risk factors associated with poor postoperative outcomes. METHODS: Ovid MEDLINE and grey literature were searched to 9 June 2021 for studies comparing mesh to non-mesh techniques for primary groin hernia repair. Outcomes of interest were postoperative complications, recurrence of hernia, pain and risk factors associated with poorer surgical outcomes. Methodological quality was appraised using the AMSTAR 2 tool. RESULTS: The systematic search returned 4268 results, which included seven systematic reviews and five registry analyses. Mesh repair techniques resulted in lower hernia recurrence rates, with no difference in chronic pain, seroma, haematoma or wound infection, compared to non-mesh techniques. Risk factors associated with increased risk of hernia recurrence were increased body mass index (BMI), positive smoking status and direct hernia. These were independent of surgical technique. Patients under 40 years of age were at increased risk of postoperative pain. CONCLUSIONS: Surgical repair of primary groin hernias using mesh achieves lower recurrence rates, with no difference in safety outcomes, compared with non-mesh repairs. Additional risk factors associated with increased recurrence include increased BMI, history of smoking and hernia subtype.

Diagnosis and management of gastric leaks after laparoscopic sleeve gastrectomy for morbid obesity.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is increasingly being recognised as a valid stand-alone procedure for the surgical management of morbid obesity. The leak rate from the gastric staple line ranges from 1.4% to 20%. From our experience of management of LSG leaks, we have been able to formulate an algorithm-based approach to the management of these patients. METHODS: All patients referred to our hospital within a 24-month period with a diagnosis of gastric staple line leak in the background of a previous LSG were included in the study. A retrospective case note review was undertaken for these patients and an algorithm formulated. RESULTS: There were fourteen patients in the study. There were four males and ten females. Patients were managed with a combination of laparotomy, laparoscopy, endoscopic covered stenting, percutaneous radiologically guided drainage,jejunal enteric feeding and total parenteral nutrition. In five patients, re-look laparoscopy or laparotomy with washout and drainage was performed. The remaining eight patients were managed conservatively. There were no deaths. CONCLUSIONS: Although it is often disappointing when LSG leaks do occur, with adherence to the basic tenets of the surgical management of enterocutaneous fistulae as well as early detection and a high index of suspicion, these complications can be successfully managed using an algorithm-based multi-disciplinary team approach.

Laparoscopic cholecystectomy in chronic ambulatory peritoneal dialysis.

Laparoscopic cholecystectomy is the established procedure for treatment of cholelithiasis. There is no consensus on its use in patients receiving chronic ambulatory peritoneal dialysis, and there is no clear recommendation in the literature of how to manage perioperative dialysis. With the increased practice of laparoscopic techniques, peritoneal dialysis can be resumed soon after the surgical procedure without interruption of hemodialysis. We present a successful case of laparoscopic cholecystectomy in a patient receiving chronic ambulatory peritoneal dialysis, and we recommend that laparoscopic cholecystectomy should be used in this patient population who are often at an increased risk for perioperative complications and would benefit from a less invasive surgical technique.

Air embolism in gastroscopy.

Endoscopy of the upper gastrointestinal tract (GIT) is a common medical examination. One of the rare but serious, albeit fatal complications of gastroscopy is venous air embolism. We performed a literature search with the keywords "air embolism", "gastroscopy", and "endoscopy". There were 14 cases of air embolism associated with gastroscopy. The median age was 66 years old (range 4 months-80 years old). The main presenting symptoms were neurological (n=9) and respiratory compromise (n=7). The main investigation used for diagnosis were CT (n=10) and ECHO (n=6). The main risk factor identified was mucosal breach (n=9). Hyperbaric oxygen therapy was used in four cases. The mortality rate is 57.1%. Air embolism is a very rare complication and is often overlooked. Rapid diagnosis is vital for successful treatment. It should be considered in any patient with sudden onset of severe cardiopulmonary and/or neurologic decompensation during gastroscopy.