Bariatric surgery for spontaneous ovulation in women living with polycystic ovary syndrome: the BAMBINI multicentre, open-label, randomised controlled trial.

BACKGROUND: Polycystic ovary syndrome (PCOS) is the most common cause of anovulatory infertility. Obesity exacerbates the reproductive complications of PCOS; however, the management of obesity in women with PCOS remains a large unmet clinical need. Observational studies have indicated that bariatric surgery could improve the rates of ovulatory cycles and prospects of fertility; however, the efficacy of surgery on ovulation rates has not yet been compared with behavioural modifications and medical therapy in a randomised trial. The aim of this study was to compare the safety and efficacy of bariatric surgery versus medical care on ovulation rates in women with PCOS, obesity, and oligomenorrhoea or amenorrhoea. METHODS: In this multicentre, open-label, randomised controlled trial, 80 women older than 18 years, with a diagnosis of PCOS based on the 2018 international evidence-based guidelines for assessing and managing PCOS, and a BMI of 35 kg/m2 or higher, were recruited from two specialist obesity management centres and via social media. Participants were randomly assigned at a 1:1 ratio to either vertical sleeve gastrectomy or behavioural interventions and medical therapy using a computer-generated random sequence (PLAN procedure in SAS) by an independent researcher not involved with any other aspect of the clinical trial. The median age of the entire cohort was 31 years and 79% of participants were White. The primary outcome was the number of biochemically confirmed ovulatory events over 52 weeks, and was assessed using weekly serum progesterone measurements. The primary endpoint included the intention-to-treat population and safety analyses were per-protocol population. This study is registered with the ISRCTN registry (ISRCTN16668711). FINDINGS: Participants were recruited from Feb 20, 2020 to Feb 1, 2021. 40 participants were assigned to each group and there were seven dropouts in the medical group and ten dropouts in the surgical group. The median number of ovulations was 6 (IQR 3·5-10·0) in the surgical group and 2 (0·0-4·0) in the medical group. Women in the surgical group had 2.5 times more spontaneous ovulations compared with the medical group (incidence rate ratio 2·5 [95% CI 1·5-4·2], p<0·0007). There were more complications in the surgical group than the medical group, although without long-term sequelae. There were 24 (66·7%) adverse events in the surgical group and 12 (30·0%) in the medical group. There were no treatment-related deaths. INTERPRETATION: Bariatric surgery was more effective than medical care for the induction of spontaneous ovulation in women with PCOS, obesity, and oligomenorrhoea or amenorrhoea. Bariatric surgery could, therefore, enhance the prospects of spontaneous fertility in this group of women. FUNDING: The Jon Moulton Charity Trust.

Bouveret's syndrome: An old diagnosis. A modern multimodality approach (endoscopic and robotic surgical) of gastric outlet obstruction: Report of two cases.

INTRODUCTION AND IMPORTANCE: Bouveret's syndrome is an uncommon condition characterized by the impaction of a gallstone in the pylorus or duodenum via a cholecysto-enteric fistula causing gastric outlet obstruction. We report two unusual cases of Bouveret's syndrome causing gastric outlet obstruction in two elderly patients. CASE PRESENTATION: Two elderly female patients presented to the surgical assessment unit with features of gastric outlet obstruction. In both cases, an urgent computed tomography (CT) of the abdomen showed pneumobilia, gastric distension, and gallstones impaction at the duodenal bulb. In Patient 1, endoscopic removal of the impacted gallstones was done successfully. She was discharged three days following an uneventful recovery. In Patient 2, an endoscopic removal of a single large gallstone was attempted, which was unsuccessful. She underwent robotic gastrotomy with extraction of the large gallstone with primary repair. She was discharged on 8th postoperative day. CLINICAL DISCUSSION: Treatment options for Bouveret's syndrome include endoscopic management and surgery. The selection of treatment options depends upon factors like the degree of obstruction, the impaction site, number, type or size of gallstones, patient co-morbidities and clinical parameters at presentation, as well as expertise available, both endoscopic and surgical. CONCLUSIONS: Bouveret's syndrome is one of the rare complications of gallstone. Endoscopic management can be effective at removing the impacted gallstones, which is particularly helpful for those elderly patients who have multiple medical co-morbidities, as in our first patient. Surgical management like minimal invasive surgery (robotic) can be beneficial in failed endoscopic attempt of removal of stone like in the second patient.

Bariatric surgery improves access to renal transplantation and is safe in renal failure as well as after transplantation: A systematic review and meta-analysis.

INTRODUCTION: Effective workup and listing of end-stage renal disease (ESRD) patients for renal transplantation, often with multiple co-morbidities, poses a challenge for transplant teams. Obesity is a common co-morbidity associated with adverse outcomes in ESRD and kidney transplant (KT) recipients. Bariatric and metabolic surgery (BMS) has long been established as a safe and effective treatment for morbid obesity. In this study, the authors aimed to evaluate the strength of evidence for both the efficacy and safety of bariatric surgery in patients with ESRD or kidney transplantation. METHODS: A literature search was performed using key terms including "transplantation", "kidney", "renal", "obesity", and "bariatric". Databases searched include MEDLINE, EMBASE and Web of Science from inception to date (April 2021). Methodological quality was assessed using the Newcastle-Ottawa tool. Selected articles were then categorised into patients awaiting waiting list acceptance, patients awaiting transplantation, patients undergoing simultaneous BMS + KT and patients undergoing BMS following a previous renal transplant. Summary effects are presented with a level of statistical significance and 95% Confidence Intervals. RESULTS: A total of 28 articles were selected following the literature search. Fourteen studies on patients awaiting listing (n = 1903), nine on patients on the KT waiting list (n = 196), a single study on simultaneous BMS and KT and ten studies on patients undergoing BMS following KT (n = 198). Mean change in BMI for patients awaiting listing was -11.3 kg/m2 (95%CI: -15.3 to -7.3, p < 0.001), mean change in BMI for patients listed for KT was -11.2 kg/m 2(95%CI: -12.9 to -9.5, p 0.001) and mean change for patients with prior KT was -11.0 kg/m2 (95%CI: -7.09 to -14.9, p < 0.001). The combined mortality rate for patients who had undergone both BMS and KT was 4% (n = 15). DISCUSSION: This review demonstrates BMS is both safe and efficacious in patients with ESRD prior to KT and in those post KT. It would enable difficult-to-list obese recipients the possibility to undergo transplantation and should be considered as part of the work up process.

Vitamin D Levels as an Important Predictor for Type 2 Diabetes Mellitus and Weight Regain Post-Sleeve Gastrectomy.

Weight Loss Surgery (WLS), including sleeve-gastrectomy (SG), results in significant weight loss and improved metabolic health in severe obesity (BMI ≥ 35 kg/m2). Previous studies suggest post-operative health benefits are impacted by nutrient deficiencies, such as Vitamin D (25(OH)D) deficiency, while it is currently unknown whether nutrient levels may actually predict post-surgery outcomes. As such, this study investigated whether 25(OH)D levels could predict metabolic improvements in patients who underwent SG. Patients with severe obesity (n = 309; 75% female) undergoing SG participated in this ethics-approved, non-randomized retrospective cohort study. Anthropometry, clinical data, 25(OH)D levels and serum markers were collected at baseline, 6-, 12- and 18-months post-surgery. SG surgery resulted in significant improvements in metabolic health at 6- and 12-months post-surgery compared with baseline, as expected. Patients with higher baseline 25(OH)D had significantly lower HbA1c levels post-surgery (p < 0.01) and better post-surgical T2DM outcomes, including reduced weight regain (p < 0.05). Further analysis revealed that baseline 25(OH)D could predict HbA1c levels, weight regain and T2DM remission one-year post-surgery, accounting for 7.5% of HbA1c divergence (p < 0.01). These data highlight that higher circulating 25(OH)D levels are associated with significant metabolic health improvements post-surgery, notably, that such baseline levels are able to predict those who attain T2DM remission. This highlights the importance of 25(OH)D as a predictive biomarker of post-surgery benefits.

Orienting an Organic Semiconductor into DNA 3D Arrays by Covalent Bonds.

A quasi-one-dimensional organic semiconductor, hepta(p-phenylene vinylene) (HPV), was incorporated into a DNA tensegrity triangle motif using a covalent strategy. 3D arrays were self-assembled from an HPV-DNA pseudo-rhombohedron edge by rational design and characterized by X-ray diffraction. Templated by the DNA motif, HPV molecules exist as single-molecule fluorescence emitters at the concentration of 8 mM within the crystal lattice. The anisotropic fluorescence emission from HPV-DNA crystals indicates HPV molecules are well aligned in the macroscopic 3D DNA lattices. Sophisticated nanodevices and functional materials constructed from DNA can be developed from this strategy by addressing functional components with molecular accuracy.

Unusual case of hyperemesis in a pregnant patient with prior antireflux surgery.

A 33-year-old, 8 weeks pregnant, presented with severe upper abdominal pain with vomiting on a background of a previous laparoscopic Nissen fundoplication for reflux disease. An urgent MRI had shown herniation of the fundoplication wrap through the diaphragmatic hiatus. The cause of her symptoms was attributed to hyperemesis gravidarum. The plan was to manage this patient conservatively until the conclusion of her pregnancy. This plan was revised when she presented for the second time and developed worsening pain and haematemesis. An emergency gastroscopy showed ischaemic changes in most of the stomach requiring the patient to undergo an emergency laparotomy. In pregnant patients, presenting with abdominal pain, vomiting as well as haematemesis, having had previous antireflux surgery, incarceration of the stomach must be considered as a differential. Prompt assessment and early senior decision-making is extremely important in avoiding a potentially catastrophic outcome for such patients.

Effect of COVID-19 pandemic on global Bariatric surgery PRActiceS - The COBRAS study.

INTRODUCTION: There is a paucity of data in scientific literature on the impact of Coronavirus Disease 2019 (COVID-19) pandemic on bariatric surgery. The aim of this study was to evaluate the impact of COVID-19 pandemic on Bariatric Surgery globally. METHODS: We conducted a global online survey of bariatric surgeons between 16/04/20 - 15/05/20. The survey was endorsed by five national bariatric surgery societies and circulated amongst their memberships. Authors also shared the link through their personal networks, email groups, and social media. RESULTS: 703 respondents from 77 countries completed the survey. Respondents reported a drop in elective bariatric activity from a median (IQR) of 130 (60-250) procedures in 2019 to a median of 0 (0-2) between16/03/2020 and 15/04/2020 during the pandemic. The corresponding figures for emergency activity were 5 (2-10) and 0 (0-1) respectively. 441 (63%) respondents did not perform any bariatric procedures during this time period. Surgeons reported outcomes of 61 elective bariatric surgical procedures during the pandemic with 13 (21%) needing ventilation and 2 (3.3%) deaths. Of the 13 emergency bariatric procedures reported, 5 (38%) needed ventilation and 4 (31%) died. 90 (13%) surgeons reported having had to perform a bariatric surgical or endoscopic procedure without adequate Personal Protective Equipment. CONCLUSIONS: COVID-19 pandemic led to a remarkable decline in global elective and emergency bariatric surgery activity at its beginning. Both elective and emergency procedures performed at this stage of the pandemic had considerable morbidity and mortality.

The first modified Delphi consensus statement on sleeve gastrectomy.

INTRODUCTION: Sleeve gastrectomy (SG) is the commonest bariatric procedure worldwide. Yet there is significant variation in practice concerning its various aspects. This paper report results from the first modified Delphi consensus-building exercise on SG. METHODS: We established a committee of 54 globally recognized opinion makers in this field. The committee agreed to vote on several statements concerning SG. An agreement or disagreement amongst ≥ 70.0% experts was construed as a consensus. RESULTS: The committee achieved a consensus of agreement (n = 71) or disagreement (n = 7) for 78 out of 97 proposed statements after two rounds of voting. The committee agreed with 96.3% consensus that the characterization of SG as a purely restrictive procedure was inaccurate and there was 88.7% consensus that SG was not a suitable standalone, primary, surgical weight loss option for patients with Barrett's esophagus (BE) without dysplasia. There was an overwhelming consensus of 92.5% that the sleeve should be fashioned over an orogastric tube of 36-40 Fr and a 90.7% consensus that surgeons should stay at least 1 cm away from the angle of His. Remarkably, the committee agreed with 81.1% consensus that SG patients should undergo a screening endoscopy every 5 years after surgery to screen for BE. CONCLUSION: A multinational team of experts achieved consensus on several aspects of SG. The findings of this exercise should help improve the outcomes of SG, the commonest bariatric procedure worldwide, and guide future research on this topic.

Time-Varying Functional Connectivity Decreases as a Function of Acute Nicotine Abstinence.

BACKGROUND: The nicotine withdrawal syndrome (NWS) includes affective and cognitive disruptions whose incidence and severity vary across time during acute abstinence. However, most network-level neuroimaging uses static measures of resting-state functional connectivity and assumes time-invariance and is thus unable to capture dynamic brain-behavior relationships. Recent advances in resting-state functional connectivity signal processing allow characterization of time-varying functional connectivity (TVFC), which characterizes network communication between networks that reconfigure over the course of data collection. Therefore, TVFC may more fully describe network dysfunction related to the NWS. METHODS: To isolate alterations in the frequency and diversity of communication across network boundaries during acute nicotine abstinence, we scanned 25 cigarette smokers in the nicotine-sated and abstinent states and applied a previously validated method to characterize TVFC at a network and a nodal level within the brain. RESULTS: During abstinence, we found brain-wide decreases in the frequency of interactions between network nodes in different modular communities (i.e., temporal flexibility). In addition, within a subset of the networks examined, the variability of these interactions across community boundaries (i.e., spatiotemporal diversity) also decreased. Finally, within 2 of these networks, the decrease in spatiotemporal diversity was significantly related to NWS clinical symptoms. CONCLUSIONS: Using multiple measures of TVFC in a within-subjects design, we characterized a novel set of changes in network communication and linked these changes to specific behavioral symptoms of the NWS. These reductions in TVFC provide a meso-scale network description of the relative inflexibility of specific large-scale brain networks during acute abstinence.

Impact of COVID-19 on Obesity Management Services in the United Kingdom (The COMS-UK study).

Coronavirus Disease-2019 (COVID-19) has had a severe impact on all aspects of global healthcare delivery. This study aimed to investigate the nationwide impact of the pandemic on obesity management services in the UK in a questionnaire-based survey conducted of professionals involved in the delivery. A total of 168 clinicians took the survey; the majority of which maintained their usual clinical roles and were not redeployed except physicians and nurse specialists. Nearly all (97.8%) elective bariatric surgery was cancelled, 67.3% of units cancelled all multidisciplinary meeting activity, and the majority reduced clinics (69.6%). Most respondents anticipated that the services would recommence within 1-3 months. This study found that the COVID-19 pandemic has had a severe impact on the services involved in the management of patients suffering from severe, complex obesity in the UK.

Bariatric surgery for patients with type 2 diabetes mellitus requiring insulin: Clinical outcome and cost-effectiveness analyses.

BACKGROUND: Although bariatric surgery is well established as an effective treatment for patients with obesity and type 2 diabetes mellitus (T2DM), there exists reluctance to increase its availability for patients with severe T2DM. The aims of this study were to examine the impact of bariatric surgery on T2DM resolution in patients with obesity and T2DM requiring insulin (T2DM-Ins) using data from a national database and to develop a health economic model to evaluate the cost-effectiveness of surgery in this cohort when compared to best medical treatment (BMT). METHODS AND FINDINGS: Clinical data from the National Bariatric Surgical Registry (NBSR), a comprehensive database of bariatric surgery in the United Kingdom, were extracted to analyse outcomes of patients with obesity and T2DM-Ins who underwent primary bariatric surgery between 2009 and 2017. Outcomes for this group were combined with data sourced from a comprehensive literature review in order to develop a state-transition microsimulation model to evaluate cost-effectiveness of bariatric surgery versus BMT for patients over a 5-year time horizon. The main outcome measure for the clinical study was insulin cessation at 1-year post-surgery: relative risks (RR) summarising predictive factors were determined, unadjusted, and after adjusting for variables including age, initial body mass index (BMI), duration of T2DM, and weight loss. Main outcome measures for the economic evaluation were total costs, total quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER) at willingness-to-pay threshold of GBP£20,000. A total of 2,484 patients were eligible for inclusion, of which 1,847 had 1-year follow-up data (mean age of 51 years, mean initial BMI 47.2 kg/m2, and 64% female). 67% of patients no longer required insulin at 1-year postoperatively: these rates persisted for 4 years. Roux-en-Y gastric bypass (RYGB) was associated with a higher rate of insulin cessation (71.7%) than sleeve gastrectomy (SG; 64.5%; RR 0.92, confidence interval (CI) 0.86-0.99) and adjustable gastric band (AGB; 33.6%; RR 0.45, CI 0.34-0.60; p < 0.001). When adjusted for percentage total weight loss and demographic variables, insulin cessation following surgery was comparable for RYGB and SG (RR 0.97, CI 0.90-1.04), with AGB having the lowest cessation rates (RR 0.55, CI 0.40-0.74; p < 0.001). Over 5 years, bariatric surgery was cost saving compared to BMT (total cost GBP£22,057 versus GBP£26,286 respectively, incremental difference GBP£4,229). This was due to lower treatment costs as well as reduced diabetes-related complications costs and increased health benefits. Limitations of this study include loss to follow-up of patients within the NBSR dataset and that the time horizon for the economic analysis is limited to 5 years. In addition, the study reflects current medical and surgical treatment regimens for this cohort of patients, which may change. CONCLUSIONS: In this study, we observed that in patients with obesity and T2DM-Ins, bariatric surgery was associated with high rates of postoperative cessation of insulin therapy, which is, in turn, a major driver of overall reductions in direct healthcare cost. Our findings suggest that a strategy utilising bariatric surgery for patients with obesity and T2DM-Ins is cost saving to the national healthcare provider (National Health Service (NHS)) over a 5-year time horizon.

Modification of fecal microbiota as a mediator of effective weight loss and metabolic benefits following bariatric surgery.

INTRODUCTION: Bariatric surgery (primarily Laparoscopic Sleeve Gastrectomy [LSG] and Roux-en-Y Gastric Bypass [RYGB]) is an efficacious and durable therapeutic option for weight loss in obesity. The mechanisms that mediate weight loss following bariatric surgery remain incompletely understood. AREAS COVERED: Pubmed search of published data on fecal microbiota, metabolic health, LSG, and RYGB. The fecal microbiome plays a key role in the establishment and maintenance of metabolic wellbeing, and may also contribute (through fecal dysbiosis) to metabolic dysfunction. LSG and RYGB both result in characteristic, procedure-specific changes to the fecal microbiota that may mediate at least some of the resultant weight-loss and metabolically beneficial effects, when applied to the management of obesity. EXPERT OPINION: The human fecal microbiome, containing around 100 trillion microbes, evolved over millions of years and interacts symbiotically with its human host. Rodent-based studies have provided insights into the complexities of the gut-microbiome-brain axis. This includes the important role of the gut microbiome in the mediation of normal immunological development, inflammatory pathways, metabolic functioning, hypothalamic appetite regulation, and the absorption of essential nutrients as by-products of bacterial metabolism. Fecal transformation is likely to provide an important therapeutic target for future prevention and management of obesity and metabolic dysfunction.

Laparoscopic Adjustable Gastric Banding-Should a Second Chance Be Given?

BACKGROUND: Obesity is a chronic relapsing-remitting disease and a global pandemic, being associated with multiple comorbidities. Laparoscopic adjustable gastric banding (LAGB) is one of the safest surgical procedures used for the treatment of obesity, and even though its popularity has been decreasing over time, it still remains an option for a certain group of patients, producing considerable weight loss and improvement in obesity-associated comorbidities. METHODS: The aim of this study was to evaluate the impact of weight loss following LAGB on obesity-associated comorbidities, and to identify factors that could predict better response to surgery, and patient sub-groups exhibiting greatest benefit. A total of 99 severely obese patients (81.2% women, mean age 44.19 ± 10.94 years, mean body mass index (BMI) 51.84 ± 8.77 kg/m2) underwent LAGB in a single institution. Results obtained 1, 2, and 5 years postoperatively were compared with the pre-operative values using SPPS software version 20. RESULTS: A significant drop in BMI was recorded throughout the follow-up period, as well as in A1c and triglycerides, with greatest improvement seen 2 years after surgery (51.8 ± 8.7 kg/m2 vs 42.3 ± 9.2 kg/m2, p < 0.05, 55.5 ± 19.1 mmol/mol vs 45.8 ± 13.7 mmol/mol, p < 0.05, and 2.2 ± 1.7 mmol/l vs 1.5 ± 0.6 mmol/l). Better outcomes were seen in younger patients, with lower duration of diabetes before surgery, and lower pre-operative systolic blood pressure. CONCLUSIONS: Younger age, lower degree of obesity, and lower severity of comorbidities at the time of surgery can be important predictors of successful weight loss, making this group of patients the ideal candidates for LAGB.

An Examination of Who Is Eligible and Who Is Receiving Bariatric Surgery in England: Secondary Analysis of the Health Survey for England Dataset.

BACKGROUND: Over 2 million people in England were estimated to be eligible for bariatric surgery in 2006. In 2014, clinical guidelines were updated, widening potential eligibility, meanwhile, obesity prevalence rose. However, numbers receiving surgery decreased, and concerns exist of inequalities in access between population groups. This study is aimed at estimating the number of adults eligible for surgery in England and to compare demographics with those that receive surgery. METHODS: BMI and comorbidity status were used to determine eligibility for bariatric surgery within participants of the 2014 Health Survey for England dataset (6938 adults), based on the National Institute of Health and Care Excellence guidelines. Results were scaled up using national population estimates. The demographics of eligible participants were compared against 2014/2015 hospital episode statistics for sex and age group using a chi-squared analysis. RESULTS: Of the total population of England, 7.78% (95% CI 7.1-8.6%), or 3,623,505 people, could have been eligible for bariatric surgery in 2014; nearly a million more than if previous guidelines applied. Eligibility peaked at ages 45-54, with most in the 35-64 age group (58.9%). 58.4% of those eligible were women. Patients receiving surgery were far more likely to be female than male (76.1%) and the distribution skewed towards younger ages when compared with those eligible. CONCLUSION: Bariatric surgery may benefit many people in England; significant investment is required so that service provision is adequate for demand. Differences between demographics of those eligible and receiving surgery may be explainable; however, the potential health inequality should be investigated.

Improved Thyroid Hypoechogenicity Following Bariatric-Induced Weight Loss in Euthyroid Adults With Severe Obesity-a Pilot Study.

Background: Obesity may affect both biochemical thyroid function tests; and thyroid morphology, as assessed using ultrasound scans (US). The aim of the present pilot study was to explore whether weight loss achieved by bariatric surgery alters thyroid US morphology including gray-scale measurements; and/or function in euthyroid adults with severe obesity. Methods: Euthyroid adults (>18 years) with body mass index (BMI) ≥40 kg/m2 and negative thyroid peroxidase antibodies were assessed at baseline (pre-surgery) and after achieving at least 5% weight loss of their baseline body weight following bariatric surgery. Anthropometric assessments, biochemical/hormonal measurements (TSH, free-T4, free-T3, reverse-T3, and leptin) and thyroid US with gray-scale histogram analysis were performed at the baseline and post-surgery follow-up. Results: Ten Caucasian, euthyroid patients (women/men: 8/2; age: 48.6 ± 3.1 years; BMI: 51.4 ± 1.8 kg/m2) successfully completed this study with significantly decreased body weight (>5% weight loss), waist circumference and serum leptin levels post-surgery (mean post-surgery follow-up duration: 16.5 ± 2.5 months). In parallel to the observed bariatric-induced weight loss, thyroid US echogenicity increased by 25% (p = 0.03), without significant changes in thyroid volume. No significant changes in thyroid function tests were detected. No significant correlations were observed between the increase in thyroid echogenicity and the decreases in anthropometric parameters and circulating leptin. Conclusion: Our results indicate that in euthyroid adults with severe obesity, marked weight loss achieved by bariatric surgery is associated with a parallel significant increase in the thyroid US echogenicity, suggesting that morphological changes of the thyroid in obesity are reversible with weight loss. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03048708.

Effective Implementation of Peri-operative Local Guidelines for Metabolic Surgery in Patients with Diabetes Mellitus in a Tier 4 Setting Demonstrate Improved Work Efficiency and Resource Allocation.

BACKGROUND: Dynamic changes in glycaemia predominate peri-operatively in patients with type 2 diabetes mellitus (T2DM) undergoing metabolic surgery. There is a lack of consensus and clear guidance on effective glycaemic management of such patients. The aim of this study was to design, pilot, and implement a proforma to improve consistency of glycaemic management and clarity of communication with healthcare professionals following metabolic surgery in patients with T2DM, thereby reducing unnecessary diabetes specialist nurse (DSN) referrals. METHODS: A proforma was designed and piloted for 12 months to guide healthcare professionals on managing glycaemic therapies for T2DM patients undergoing metabolic surgery. Glycaemic control (HbA1c) and glycaemic therapies were reviewed 3 weeks pre-operatively and a proforma was completed accordingly. RESULTS: Of the patients with T2DM (n = 34) who underwent metabolic surgery prior to the new proforma being implemented, 71% (n = 24) had a DSN referral. Half of these referrals were deemed unnecessary by the DSNs. Of the patients with T2DM (n = 33) who underwent metabolic surgery following implementation of the proforma, 21% (n = 7) had a DSN referral. Only 10% of these were deemed unnecessary. Despite the reduced DSN input, no diabetes-related complications were reported. CONCLUSION: Implementation of our proforma effectively halved the proportion of patients with T2DM requiring a DSN referral. Additionally, there was a 40% absolute reduction in the proportion of unnecessary DSN referrals. The proforma improved clarity of communication and guidance for healthcare professionals in the glycaemic management of patients. This also facilitated improved work efficiency and resource allocation.

A delayed presentation of Boerhaave's syndrome with mediastinitis managed using the over-the-scope clip.

Boerhaave syndrome is a spontaneous perforation of the oesophagus secondary to forceful emesis. Surgery has been advocated in delayed presentations of Boerhaave's syndrome with mediastinitis. The over-the-scope clip (OTSC) by OVESCO(®) (Tubingen, Germany) has been used in the endoscopic management of gastrointestinal bleeds, fistulae and anastamotic leaks. We describe the successful endoscopic use of the OTSC in a delayed presentation of Boerhaave syndrome with mediastinitis. A 69-year-old gentleman underwent a computerised tomography scan, which demonstrated a lower oesophageal perforation and mediastinitis 7 days after admission, having presented with forceful emesis and chest discomfort. During endoscopy the defect was visualized and successfully closed using the OTSC. This resulted in a favourable outcome and is a technique not previously described in the literature to manage this condition.