A 53-Year-Old Man Presenting with Pancreatic Exocrine Insufficiency 7 Years After Gastric Bypass Bariatric Surgery.

BACKGROUND Pancreatic exocrine insufficiency (PEI) is a clinical condition characterized by reduced or inappropriate pancreatic enzymes and secretions. It can have a variable clinical presentation and can affect patient quality of life. PEI can be associated with pancreatic and nonpancreatic disorders. Pancreatic insufficiency is a recognized complication of bariatric surgery, but there is limited awareness. This report is of a 53-year-old man who presented with PEI 7 years after his initial bariatric surgery. Revision surgery resulted in the resolution of chronic diarrhea and progressive weight loss. CASE REPORT A 53-year-old man who had gastric bypass surgery had developed pancreatic insufficiency 7 years after the surgery. This diagnosis was a challenge to make and therefore treat. A multi-modal approach and revision surgery helped resolve his symptoms. CONCLUSIONS Pancreatic insufficiency is a challenging complication to treat after bariatric surgery. Its management includes a multi-disciplinary approach, and such cases should be managed in dedicated bariatric units. This report has highlighted the importance of excluding PEI as a complication of bariatric surgery and its management.

Weight loss with bariatric surgery or behaviour modification and the impact on female obesity-related urine incontinence: A comprehensive systematic review and meta-analysis.

Women with obesity are at risk of pelvic floor dysfunction with a 3-fold increased incidence of urge urinary incontinence (UUI) and double the risk of stress urinary incontinence (SUI). The National Institute for Health and Care Excellence (NICE) and European Association of Urology (EAU) recommend that women with a body mass index ≥30 kg/m2 should consider weight loss prior to consideration for incontinence surgery. This systematic review and meta-analysis will assess this recommendation to aid in the counselling of women with obesity-related urinary incontinence (UI). Medical Literature Analysis and Retrieval System online (MEDLINE), EMBASE, Cochrane, ClinicalTrials.gov, and SCOPUS were systematically and critically appraised for all peer reviewed manuscripts that suitably fulfilled the inclusion criteria established a priori and presented original, empirical data relevant to weight loss intervention in the management of urinary incontinence. Thirty-three studies and their outcomes were meta-analysed. Weight loss interventions were associated in a decreased prevalence in UI (OR 0.222, 95% CI [0.147, 0.336]), SUI (OR 0.354, 95% CI [0.256, 0.489]), UUI (OR 0.437, 95% CI [0.295, 0.649]) and improved quality of life (PFDI-20, SMD -0.774 (95% CI [-1.236, -0.312]). This systematic review and meta-analysis provide evidence that weight loss interventions are effective in reducing the prevalence of obesity-related UI symptoms in women. Bariatric surgery in particular shows greater sustained weight loss and improvements in UI prevalence. Further large scale, randomized control trials assessing the effect of bariatric surgery on women with obesity-related UI are needed to confirm this study's findings.

Is Specialisation Needed in Laparoscopic Cholecystectomy? A Retrospective Cohort Study of 5122 Patients.

Background: Gallstone disease is a common problem and laparoscopic cholecystectomy (LC) is a common elective procedure. This operation was performed by a general surgeon, colorectal surgeons, breast and vascular surgeons according to the largest UK's audit (CholeS study). Objectives: To compare the outcomes of laparoscopic cholecystectomy performed by a specialist upper gastrointestinal (UGI) surgeon to that of CholeS and large international studies. Our hypothesis is: UGI specialist is producing better outcomes for LC patients. Methods: All patient who underwent LC between 1999 and 2019 at one hospital by an UGI consultant and 2014-2019 at another hospital by another UGI consultant surgeon were included. The inclusion criteria were LC performed by UGI surgeon. Lost to follow up, procedures done by trainees and gallbladder cancer patients were excluded. The outcome measures of bile leak, bile duct injuries, bleeding, infectious complications, bowel injuries, vascular injuries and pseudoaneurysms, neuralgia, port site hernia, mesenteric haematoma, 30-day mortality and conversion to open were reported. Statistical tests were used to assess the significant differences, the confidence interval was 95% and the p-value was taken as 0.05. Results: Two UGI specialists performed 5122 LC, 4396 (86%) were female and 715 (14%) male. The age was 13-93 year (median of 48 years). 3681 (72 %) was done as a day surgery case. 1431(28%) as an inpatient and 287 (5.6%) emergency LC. There was no death in the 30 days periods of surgery, 8 (0.15%) biliary leak from the duct of Luschka, 4 (0.19%) common bile duct (CBD) injuries, 9(0.02%) conversions and 17(0.33%) procedures were abandoned. There were significant differences in the above complications between our study and the CholeS report. Conclusions: Laparoscopic cholecystectomy is associated with acceptable outcomes, low risk of bile duct injury and no mortality when performed by a specialist upper GI surgeon.

Extent of infectious SARS-CoV-2 aerosolisation as a result of oesophagogastroduodenoscopy or colonoscopy.

BACKGROUND: COVID-19 has caused an unprecedented pandemic and medical emergency that has changed routine care pathways. This article discusses the extent of aerosolisation of severe acute respiratory syndrome coronavirus 2, the virus that causes COVID-19, as a result of oesophagogastroduodenoscopy and colonoscopy. METHODS: PubMed and Google Scholar were searched for relevant publications, using the terms COVID-19 aerosolisation, COVID-19 infection, COVID-19 transmission, COVID-19 pandemic, COVID-19 and endoscopy, Endoscopy for COVID-19 patients. RESULTS: A total of 3745 articles were identified, 26 of which were selected to answer the question of the extent of SARS-CoV-2 aerosolisation during upper and lower gastrointestinal endoscopy. All studies suggested high infectivity from contact and droplet spread. No clinical study has yet reported the viral load in the aerosol and therefore the infective dose has not been accurately determined. However, aerosol-generating procedures are potentially risky and full personal protective equipment should be used. CONCLUSIONS: As it is a highly infectious disease, clinicians treating patients with COVID-19 require effective personal protective equipment. The main routes of infection are direct contact and droplets in the air and on surfaces. Aerosolisation carries a substantial risk of infection, so any aerosol-producing procedure, such as endoscopy, should be performed wearing personal protective equipment and with extra caution to protect the endoscopist, staff and patients from cross-infection via the respiratory system.

The value of laparoscopy in the management of chronic groin pain.

BACKGROUND: Chronic groin pain problem represents a diagnostic and management challenge. This study is reporting all patients who underwent laparoscopic exploration of the groin and pelvis for undiagnosed chronic groin pain. MATERIALS AND METHODS: A retrospective cohort study. Evaluators were not involved in the operations. Laparoscopic exploration and mesh insertion using Trans-Abdominal Pre-Preitoneal (TAPP) approach was performed for all patients. Follow up in the; clinic at 2 weeks and 6 months was arranged. This was a consecutive series of patients who were presented with chronic groin pain and no pre-operative radiological, orthopedic, gynecological or urologic abnormalities. Patients who were diagnosed with clinical hernia or other positive finding were excluded. RESULTS: Data were collected and analyzed for 92 patients. The operation had successfully managed the groin pain in 81 patients (88.04%), and the pain was improved in another 3 patients (3.26%). Six patients (6.52%) had no change in their symptoms, and worse pain was reported in two patient (2.17%). CONCLUSION: Laparoscopic groin exploration is an effective method to diagnose the chronic groin pain that under diagnosed by clinical, ultrasound and MRI tests. Laparoscopic management had resulted in resolution of the pain in the majority of the patients. The procedure is effective in athletes' patients who did not have clinical, radiological and laparoscopic evidence of groin hernia.

Laparoscopic adjustable gastric band: how to reduce the early morbidity.

BACKGROUND: Laparoscopic adjustable gastric band insertion is a safe weight reduction procedure, but serious complications can develop. The aim of this study was to evaluate our technique in preventing early band complications. METHODS: Patients were given the choice of procedure according to body mass index, the presence of diabetes, and preference. Weight loss data were not considered, as our aim was to evaluate the morbidity of band surgery using a specific technique. A pars flaccida approach and plication technique were used for all patients. Postoperative follow-up was provided at 1 month, 2 months, and every 3 months for the first year and then yearly for a further 2 years. Thereafter, general practitioners referred patients if late complications arose. RESULTS: From January 2007 to August 2011, 1149 patients (245 men [21.32%], 904 women [78.67%]) underwent laparoscopic adjustable gastric band insertion under the care of a single bariatric surgeon. Patients were hospitalized for 1 night only unless they developed early complications. The primary and secondary outcomes were major and minor band complications, respectively. Patients' age range was 18 to 64 years (mean, 44 years). Body mass index ranged from 33 to 62 kg/m2 (mean, 42 kg/m2). There were 2 band erosions (0.17%), 6 cases of band prolapse (0.52%), 4 port problems (0.34%), 1 band leak (0.08%), 3 tight bands (0.26%), 2 port infections (0.17%), and no deaths. Five procedures (0.43%) were abandoned and excluded from this study, and 1 (0.17%) was converted to minilaparotomy to control abdominal wall bleeding. The duration of follow-up ranged from 16 to 60 months. CONCLUSIONS: A combined pars flaccida and plication technique is associated with a low early complication rate.

Bariatric emergencies: current evidence and strategies of management.

BACKGROUND: The demand for bariatric surgery is increasing and the postoperative complications are seen more frequently. The aim of this paper is to review the current outcomes of bariatric surgery emergencies and to formulate a pathway of safe management. METHODS: The PubMed and Google search for English literatures relevant to emergencies of bariatric surgery was made, 6358 articles were found and 90 papers were selected based on relevance, power of the study, recent papers and laparoscopic workload. The pooled data was collected from these articles that were addressing the complications and emergency treatment of bariatric patients. 830,998 patients were included in this review. RESULTS: Bariatric emergencies were increasingly seen in the Accident and Emergency departments, the serious outcomes were reported following complex operations like gastric bypass but also after gastric band and the causes were technical errors, suboptimal evaluation, failure of effective communication with bariatric teams who performed the initial operation, patients factors, and delay in the presentation. The mortality ranged from 0.14%-2.2% and increased for revisional surgery to 6.5% (p = 0.002). Inspite of this, mortality following bariatric surgery is still less than that of control group of obese patients (p = value 0.01). CONCLUSIONS: Most mortality and catastrophic outcomes following bariatric surgery are preventable. The awareness of bariatric emergencies and its effective management are the gold standards for best outcomes. An algorithm is suggested and needs further evaluation.

Vitello-intestinal duct injury after transabdominal preperitoneal inguinal hernia repair.

A 71-year-old patient underwent a transabdominal preperitoneal right inguinal hernia repair and presented to the emergency department 48 hours postoperatively with nonspecific abdominal and chest pain and was diagnosed an abdominal abscess at the umbilicus by computed tomography. Laparotomy showed a vitello-intestinal duct injury caused by the umbilical trocar at his previous laparoscopic surgery. We will discuss this rare complication and how to avoid it in future practice.

Small cell carcinoma of the lung presented as acute pancreatitis. Case report and review of the literature.

CONTEXT: Small cell carcinoma of the lung is an aggressive cancer with gloomy prognosis. Links to acute pancreatitis is extremely rare. CASE REPORT: We are reporting a 53-year-old patient who was admitted because of acute pancreatitis. She had no history of gallstones, alcohol abuse, medications or any other predisposition for acute pancreatitis. Further investigations of blood, CT of chest abdomen and neck and ultrasound scan of abdomen, bone marrow and neck lymph node biopsies confirmed advanced small cell carcinoma of the lung with hypercalcemia, which was the only definite cause of acute pancreatitis. The patient made good recovery from pancreatitis after controlling the hypercalcemia. She was referred to respiratory team for further management of lung cancer. CONCLUSION: Acute pancreatitis due to hypercalcemia of advanced small cell carcinoma of the lung is an extremely rare condition. Acute pancreatitis due to hypercalcemia should be thoroughly investigated to exclude serious pathology as in our case.

Technical tips following more than 2000 transabdominal preperitoneal (TAPP) repair of the groin hernia.

BACKGROUND: Laparoscopic approach is increasingly adopted as a preferred method to treat inguinal hernia. Transabdominal preperitoneal and total extraperitoneal repairs are the 2 techniques currently used. METHODS: Between September 1999 and July 2009, more than 2000 patients underwent transabdominal preperitoneal repair of groin hernia at our minimal access unit. A standard technique is used in the majority of patients. Modifications are applied when necessary depending on the complexity of the case. All patients are considered for laparoscopic repair unless they have large irreducible inguino-scrotal hernia or are considered high risk for pneumoperitoneum because of their cardiorespiratory problems. Day surgery, 23-hour service, and inpatient admission are adopted depending on the age, body mass index, comorbidities, and social support. Outpatient postoperative follow-up is normally arranged for 1 visit. RESULTS: A total of 2196 patients underwent transabdominal preperitoneal groin hernia repair. Morbidity included 63 (2.86%) seromas. Hematoma is reported in 6 (0.27%), 2 (0.09%) patients needed blood transfusion whereas 1 patient needed reexploration. Pain and parasthesia at 6 months are reported in 6 (0.27%) and 2 (0.09%) patients, respectively. Port-site hernia is confirmed in 5 (0.22%) patients, whereas in 2 (0.09%) mesh infections are reported. Both were treated successfully using intravenous antibiotics. Four (0.1%) hydroceles are confirmed and 1 (0.04%) bowel obstruction through a defect in the peritoneal flap. Recurrence of hernia is confirmed in 4 (0.18%) patients. CONCLUSIONS: A standardized technique of laparoscopic hernia repair is associated with minimum morbidity. Modification of the technique is necessary in some patients depending on the complexity of the case.

A modified approach to laparoscopic antireflux surgery may decrease postoperative dysphagia and gas bloat syndrome.

BACKGROUND: Laparoscopic antireflux surgery has passed the test of time to prove its efficacy and advantage over the traditional approach. Several modifications of the original Nissen fundoplication have been introduced and practiced by surgeons with variable outcomes. METHODS: This modified technique of laparoscopic fundoplication, which we use, is basically a spiral wrap. It is constructed by using several specifically located Ethibond stitches to keep the gastroesophageal junction and a length of the esophagus inside the abdomen without esophageal stitching. Postoperative outcome including patient satisfaction was assessed clinically during follow-up visits. Patients with recurrent symptoms and complications were assessed by appropriate tests. All patients were seen at 6 weeks, 6 months, 12 months, and annually after the operation. RESULTS: Fifty-seven patients underwent laparoscopic antireflux surgery using the spiral wrap technique. Four patients reported occasional heartburn and only 1 patient developed regurgitation after 1 year from the operation. Nine patients developed early dysphagia and 2 patients had gas bloat syndrome at 6 weeks postoperative assessment. No dysphagia or gas bloat syndrome was confirmed after a year and no revisional surgery was reported. CONCLUSIONS: Modification of the classic fundoplication to spiral wrap is associated with acceptable morbidity and low incidence of postoperative dysphagia and gas bloat syndrome.