The Safety of Incisional Hernia Surgical Repair in Patients ≥70 Years.

Introduction Incisional hernias (IHs) are common complications of abdominal surgery. Frailty and advancing age could be related to poor outcomes after surgical interventions, especially after operating on challenging surgical fields with adhesions and dense scars. This study assesses the safety of IH surgical repair in patients aged 70 years and above. Methods A retrospective analysis of all patients who had IH surgical repair on an emergency and elective basis at a district hospital in the UK. The cohort was categorised into group I (<70 years) and group II (≥70 years). A comparative analysis was conducted between these groups based on demographic data, comorbidities, hernia characteristics, operative data, and patient outcomes. Results This study encompassed 262 patients, with a mean age of 61.8 SD± 14.2 years, of whom 152 (58%) were females. Of these, group I comprised 173, and group II included 89 patients. Notably, group I exhibited a higher prevalence of morbid obesity, with 46 (28.8%) cases, as opposed to 12 (15.2%) in group II; p=0.021. Conversely, group II demonstrated a greater incidence of individuals with at least one comorbidity and chronic obstructive pulmonary disease (COPD) than group I, p=0.004 and 0.003, respectively. Fifty-five (32%) and 49 (29.3%) of group I had multiple defects and recurrent hernias compared to 24 (28.2%) and 16 (18.8%) in group II, p=0.541 and 0.071, respectively. The mean hospital stays were 5.5 ± 8.3 and 8.33 ± 18.7 days, and the mean durations of surgery were 131.6 ± 105.2 and 106.73 ± 74.22 minutes in groups I and II, p=0.057 and 0.181, respectively. No significant differences were observed in overall or wound-related complications, p=0.587 and 0.125. The rates of mortality within 30 days were three (1.7%) in group I and three (3.4%) in group II, with 90-day mortality rates at four (2.3%) and three (3.4%), respectively, indicating no significant difference. Similarly, no significant differences emerged between the groups regarding hernia recurrence rates (with a mean follow-up of 56 months) or 90-day readmission rates. Conclusions Surgical repair of IH is safe and effective in patients ≥70 years with comparable outcomes to younger patients.

Outcomes of Surgical Repair of Incisional Hernia in Patients With Severe and Morbid Obesity: A Comparative Study.

Introduction Incisional hernia (IH) is a common complication after open and minimal access abdominal surgery. The current practice guidelines recommend weight reduction to achieve a body mass index (BMI) < 35 kg/m2 before surgical repair of ventral hernias. However, this could be challenging to achieve, especially in emergency presentations. This study aims to assess the safety of surgical repair of IH in patients with BMI ≥35 kg/m2. Methods A retrospective comparative study has been conducted to include all patients who had surgical repair of IH on an elective and emergency basis in a UK District General Hospital. The patients were divided into two groups. Group I BMI < 35 kg/m2 and Group II with BMI ≥35 kg/m2. A comparison was made between the two groups according to demographics, comorbidities, hernia characteristics, operative data, and outcomes. Results The study included 239 patients, 181 in Group I and 58 in Group II. Morbid obesity was associated with male patients, and they were younger than Group I, p= 0.001 and 0.013, respectively. 13.8% of Group I had DM compared to 29.3% in Group II, p= 0.007. There were no significant differences in hernia characteristics or mode of surgery between the two groups. However, Group II had more overall and wound-related complications, p= <0.001 each. There were no significant differences in 30-day and 90-day mortality, recurrence rate, or 90-day readmissions. Conclusions Surgical repair of IH in patients with severe and morbid obesity is associated with more overall and wound-related complications.

Differentiating patients with psoriasis from psoriatic arthritis using collagen biomarkers.

OBJECTIVES: Around 30% of patients diagnosed with cutaneous psoriasis (PsC) will go on to develop psoriatic arthritis (PsA) which includes inflammation of the joints. Collagens are core proteins in all tissues, which are involved in the inflammatory process in both PsC and PsA. The aim of this study is to investigate collagen biomarkers and their potential use in separating the three patient groupings: PsC, PsA and healthy donors. METHODS: Healthy donors (n=41), patients with PsC (n=30) and patients with PsA (n=30) were recruited. Clinical disease parameters were recorded. Collagen remodelling was measured using ELISA immunoassays which detect the serological anabolic biomarkers quantifying formation of type I, III and IV collagen (PRO-C1, PRO-C3 and PRO-C4 respectively), and the catabolic biomarkers measuring degradation of type I, II, III, IV and X collagen (C1M, C2M, C3M, C4M and C10C respectively). RESULTS: Patients with PsC and PsA presented lower levels of PRO-C1 and C3M compared to healthy controls (p<0.05-p<0.0001), C1M was higher in PsA compared to healthy controls (p<0.0001) and C2M was all elevated in PsC and PsA compared to healthy controls (p=0.0002 and p=0.0004 respectively), reflecting alterations in the tissues. In addition, C1M was able to separate between PsC and PsA patients with an AUROC=0.664, indicating that this biomarker may be a biomarker of joint involvement. CONCLUSIONS: This work provides evidence that serum collagen biomarkers are dysregulated in PsC and PsA, as compared to healthy controls. C1M was able to differentiate patients with PsC from PsA and could be a potential biomarker of inflammatory systemic musculoskeletal involvement.

Incisional Hernia: A Surgical Complication or Medical Disease?

Incisional hernia (IH) is a frequent complication following abdominal surgery. The development of IH could be more sophisticated than a simple anatomical failure of the abdominal wall. Reported IH incidence varies among studies. This review presented an overview of definitions, molecular basis, risk factors, incidence, clinical presentation, surgical techniques, postoperative care, cost, risk prediction tools, and proposed preventative measures. A literature search of PubMed was conducted to include high-quality studies on IH. The incidence of IH depends on the primary surgical pathology, incision site and extent, associated medical comorbidities, and risk factors. The review highlighted inherent and modifiable risk factors. The disorganisation of the extracellular matrix, defective fibroblast functions, and ratio variations of different collagen types are implicated in molecular mechanisms. Elective repair of IH alleviates symptoms, prevents complications, and improves the quality of life (QOL). Recent studies introduced risk prediction tools to implement preventative measures, including suture line reinforcement or prophylactic mesh application in high-risk groups. Elective repair improves QOL and prevents sinister outcomes associated with emergency IH repair. The watchful wait strategy should be reviewed, and options should be discussed thoroughly during patients' counselling. Risk stratification tools for predicting IH would help adopt prophylactic measures.

The influence of preoperative CT imaging on surgical delay in patients with acutely symptomatic abdominal wall hernias.

PURPOSE: Abdominal wall hernias are common in the UK and many present in an emergent fashion. The widespread introduction of computed tomography (CT) imaging has transformed surgical practice but out of hours access can be limited by hospital resources and introduce delays. We investigated the influence of preoperative CT imaging in acutely symptomatic hernia and the association with surgical delay and risks of bowel ischemia. METHODS: A retrospective analysis of patients undergoing emergency hernia surgery between 2013 and 2021 in a busy UK district general hospital. We evaluated the role of preoperative CT and its influence on timing of surgery, postoperative complications, critical care admission and hospital length of stay. RESULTS: Five hundred and five patients were studied. Of these, 191 had a preoperative CT scan. Sites of hernia included inguinal in 164 patients (33%); umbilical in 164 (33%); femoral in 69 (14%); incisional in 69 (14%); epigastric in 30 (6%) and Spigelian hernia 9 (2%). Preoperative CT imaging was associated with surgical delay (22.0 h vs 13.0 h, p < 0.001) and an increased need for bowel resection (12% vs 6%, p = 0.027). Delay in surgery was not associated with increased postoperative complications (5% vs 4%, p = 0.474) but was associated with increased critical care admission (11.0% vs 4.8%, p = 0.014). CONCLUSIONS: Preoperative CT scan for emergent hernias can delay often inevitable surgery and is associated with an increasing need for more complex, resectional surgery .

The influence of intraoperative rectal washout on local recurrence of colorectal cancer following curative resection: a systematic review and meta-analysis.

PURPOSE: To determine the effectiveness of rectal washout in preventing local recurrence of distal colorectal cancer following curative resection. METHODS: A systematic review and meta-analysis was performed after a literature search was conducted on MEDLINE, EMBASE, the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), ClinicalTrials.gov, and the ISRCTN registry. The study was reported using PRISMA guidelines. The primary endpoint was incidence of local recurrence of cancer after distal colonic and rectal cancer surgery. RESULTS: After screening, 8 studies with a total sample size of 6739 patients were identified. At 5-year follow-up, local recurrence in the washout group (WO) was 6.08% compared to 9.48% in the no-washout group (NWO) group (OR 0.63, 95% CI = 0.51-0.78, Chi2 = 6.76, df = 7, p = 0.45). The relative risk reduction was 36.9%. To exclude a 36.9% relative risk reduction from 9.48 to 6.08% with a 5% significance level and 80% power a randomized control trial would require a total sample size of 1946 participants distributed equally between the two treatment arms. CONCLUSION: It is safe to recommend the use of rectal washout for left sided and rectal tumour resections. It is a simple and safe step during colorectal surgery that appears to improve long-term oncological outcomes and was not reported to be associated with any complications.

Sarcopenia estimation using psoas major enhances P-POSSUM mortality prediction in older patients undergoing emergency laparotomy: cross-sectional study.

INTRODUCTION: Emergency laparotomy is a considerable component of a colorectal surgeon's workload and conveys substantial morbidity and mortality, particularly in older patients. Frailty is associated with poorer surgical outcomes. Frailty and sarcopenia assessment using Computed Tomography (CT) calculation of psoas major area predicts outcomes in elective and emergency surgery. Current risk predictors do not incorporate frailty metrics. We investigated whether sarcopenia measurement enhanced mortality prediction in over-65 s who underwent emergency laparotomy and emergency colorectal resection. METHODS: An analysis of data collected prospectively during the National Emergency Laparotomy Audit (NELA) was conducted. Psoas major (PM) cross-sectional area was measured at the L3 level and a ratio of PM to L3 vertebral body area (PML3) was calculated. Outcome measures included inpatient, 30-day and 90-day mortality. Statistical analysis was conducted using Mann-Whitney, Chi-squared and receiver operating characteristics (ROC). Logistic regression was conducted using P-POSSUM variables with and without the addition of PML3. RESULTS: Nine-hundred and forty-four over-65 s underwent emergency laparotomy from three United Kingdom hospitals were included. Median age was 76 years (IQR 70-82 years). Inpatient mortality was 21.9%, 30-day mortality was 16.3% and 90-day mortality was 20.7%. PML3 less than 0.39 for males and 0.31 for females indicated significantly worse outcomes (inpatient mortality 68% vs 5.6%, 30-day mortality 50.6% vs 4.0%,90-day mortality 64% vs 5.2%, p < 0.0001). PML3 was independently associated with mortality in multivariate analysis (p < 0.0001). Addition of PML3 to P-POSSUM variables improved area under the curve (AUC) on ROC analysis for inpatient mortality (P-POSSUM:0.78 vs P-POSSUM + PML3:0.917), 30-day mortality(P-POSSUM:0.802 vs P-POSSUM + PML3: 0.91) and 90-day mortality (P-POSSUM:0.79 vs P-POSSUM + PML3: 0.91). CONCLUSION: PML3 is an accurate predictor of mortality in over-65 s undergoing emergency laparotomy. Addition of PML3 to POSSUM appears to improve mortality risk prediction.

Biomarkers predictive of treatment response in psoriasis and psoriatic arthritis: a systematic review.

AIMS: The ability to predict response to treatment remains a key unmet need in psoriatic disease. We conducted a systematic review of studies relating to biomarkers associated with response to treatment in either psoriasis vulgaris (PsV) or psoriatic arthritis (PsA). METHODS: A search was conducted in PubMed, Embase and the Cochrane library from their inception to 2 September 2020, and conference proceedings from four major rheumatology conferences. Original research articles studying pre-treatment biomarker levels associated with subsequent response to pharmacologic treatment in either PsV or PsA were included. RESULTS: A total of 765 articles were retrieved and after review, 44 articles (22 relating to PsV and 22 to PsA) met the systematic review's eligibility criteria. One study examined the response to methotrexate, one the response to tofacitinib and all the other studies to biologic disease-modifying antirheumatic drugs (DMARDs). Whilst several studies examined the HLA-C*06 allele in PsV, the results were conflicting. Interleukin (IL)-12 serum levels and polymorphisms in the IL-12B gene show promise as biomarkers of treatment response in PsV. Most, but not all, studies found that higher baseline levels of C-reactive protein (CRP) were associated with a better clinical response to treatment in patients with PsA. CONCLUSION: Several studies have identified biomarkers associated with subsequent response to treatment in psoriatic disease. However, due to the different types of biomarkers, treatments and outcome measures used, firm conclusions cannot be drawn. Further validation is needed before any of these biomarkers translate to clinical practice.

The Role of the Computed Tomography (CT) Thorax in the Diagnosis of COVID-19 for Patients Presenting with Acute Surgical Emergencies. A Single Institute Experience.

The current Coronavirus disease 2019 (COVID-19) pandemic has had a huge impact on emergency surgical services in the UK. The Royal College of Surgeons (RCS) published guidelines about COVID-19 pandemic in March, 2020 to aid decision making for the surgeons. These guidelines recommended that all patients requiring urgent surgery should have reverse transcriptase polymerase chain reaction (RT-PCR) and/or computed tomography (CT) thorax pre-operatively. However, it is currently unclear whether the use of CT thorax is a sensitive and specific diagnostic test. The objective of this study was to find out whether CT thorax is a reliable and accurate test in the diagnosis of COVID-19 compared to RT-PCR. This is particularly important in surgical patients where there is no time to wait for RT-PCR results. A prospective cohort study of patients presented with acute surgical emergencies at a University Teaching Hospital was conducted. Data was collected from March 23, to May 15, 2020, during the peak of the crisis in the UK. All adult patients presented with operable general surgical emergencies were considered eligible. Another group of patients, admitted with acute medical emergencies but with suspected COVID-19 infection, was used for comparison. Data was manually collected, and sensitivity, specificity and predictive value were calculated using the MedCalc statistical software version 19.2.6. Standard reporting for COVID-19 infection for CT chest based on guidelines from British Society of Thoracic Imaging (BSTI) and Radiological Society of North America (RSNA) was used. Patients who had their CT thorax reported as typical or classic of COVID 19 (high probability) were treated as infected cases with extra precautions in the wards and surgical theatres as suggested by health and safety executive (HSE). These patients had serial RT-PCR during their admissions or in the post-operative phase, if the first swab was negative. For the study, 259 patients were considered eligible for inclusion from both groups. Patients admitted for acute surgical emergencies were treated according to RCS guidelines and subjected to RT-PCR test and/or CT scan of the thorax. There were 207 patients with high clinical suspicion of COVID-19. Of those 207 patients, 77 patients had CT thorax with radiographic features consistent with COVID-19 pneumonia. However, only 40 patients had a positive RT-PCR result. CT thorax was normal in 130 patients, out of which 29 patients were found to have COVID-19 diagnosis after swab test. Sensitivity of CT scan to diagnose COVID-19 infection was found to be 58% (95% CI; 45.48% to 69.76%) whilst specificity was 73% (95% CI; 64.99% to 80.37%) with a negative predictive value of 77.69% (95% CI; 72.17% to 82.39%). CT scan was found to be a reliable tool in the diagnosis of COVID-19. With a negative predictive value of up to 82.4%, CT thorax can play an important role to help surgeons in their decision making for asymptomatic suspected cases of COVID-19. However, over-reliance on CT scan which also has a high false positive rate for diagnosis of COVID-19 infections can lead to overtreatment, overuse of resources and delays in decision-making process. Hence, results should be interpreted with caution and correlated with clinical presentation and swab test results.

Measuring sarcopenia on pre-operative CT in older adults undergoing emergency laparotomy: a comparison of three different calculations.

INTRODUCTION: Sarcopenia is associated with outcomes in older-adults undergoing emergency surgery. Psoas major measurement is a surrogate marker of sarcopenia with multiple calculations existing normalising to body size and no consensus as to which is optimal. We compared three different psoas-major calculations to predict outcomes in older adults undergoing emergency laparotomy. METHODS: Consecutive over 65s were identified from the National Emergency Laparotomy Audit(NELA) database at a single centre between 2014 and 2018. Psoas major was measured at the L3 level and normalised to height (psoas muscle index, PMI), L3 vertebral body (psoas muscle:L3 ratio, PML3) or body surface area (psoas:body surface area, PBSA) and each correlated to outcomes. Outcome measures included inpatient, 30-day and 90-day mortality. A comparison of the three calculations was performed using the Mann-Whitney U, chi-squared, receiver operating characteristic curves (ROC) and binary logistic regression. RESULTS: Two hundred and sixty-four older adults underwent emergency laparotomy (median age, 75 years ((IQR, 70-81 years), 50% female)). Inpatient mortality was 19.6%, 30-day mortality was 15.1% and 90-day mortality was 18.5%. A total of 31.1% of males and 30% of females were sarcopenic (30.6% overall). A multivariate analysis confirmed each method of psoas major calculation (p < 0.0001) to be associated with mortality, as was ASA-grade (p < 0.0001). Area under the curve (AUC) was greatest for PML3 in predicting mortality (inpatient: PML3, 0.76; PMI, 0.71; PBSA, 0.70; 30-day: PML3, 0.74; PMI, 0.68; PBSA, 0.68; and 90-day: PML3, 0.78; PMI, 0.71; PBSA, 0.70). ASA-grade, P-POSSUM and PML3 were independently associated with mortality on multivariate analysis. ROC analysis of predictions from logistic regression models demonstrated PML3 to be more closely aligned to mortality than ASA or P-POSSUM (inpatient: AUC:PML3, 0.807; ASA, 0.783; P-POSSUM, 0.762; 30-day:AUC: PML3, 0.799; ASA, 0.784; P-POSSUM, 0.787; and 90-day: AUC:PML3, 0.805; ASA, 0.781; P-POSSUM, 0.756). CONCLUSIONS: Sarcopenia was present in 30.6% of older adults undergoing emergency surgery and is associated with a significantly increased mortality. PML3 is superior to PMI or PBSA and should be considered the method of calculation of choice. Additionally, PML3 compares favourably to ASA and P-POSSUM.

Pre-operative psoas major measurement compared to P-POSSUM as a prognostic indicator in over-80s undergoing emergency laparotomy.

INTRODUCTION: Emergency laparotomy in patients over the age of 80 is associated with high morbidity and mortality. Accurate risk prediction in this patient population is desirable. Sarcopenia has been shown to be associated with outcome in multiple clinical settings and the psoas major muscle as measured on computed tomography (CT) imaging has been demonstrated as a marker of sarcopenia. We aim to assess the use of psoas major measurement on pre-operative CT as a prognostic indicator in over-80s undergoing emergency laparotomy and compare this measurement to P-POSSUM. METHODS: A retrospective interrogation of the prospectively collected National Emergency Laparotomy Database including all over-80s undergoing emergency laparotomy between January 2014 and September 2016 was conducted. Demographic, operative data and P-POSSUM data were collected and analysed. Computed tomography (CT) images were accessed and analysed, and cross-sectional areas of psoas major and the corresponding lumbar vertebral body at the level of the L3 inferior end plate were calculated. The ratio of psoas major-to-L3 cross-sectional area (PM:L3) was calculated for each patient. Mann-Whitney U test and receiver-operating characteristics (ROC) curves were used for statistical analysis. RESULTS: One hundred and three over-80s underwent emergency laparotomy. Male:female ratio was 60:43. Median age was 84 years (range 80-98 years). 30-day mortality was 19.4%.90-day mortality was 25.2%. Median PM:L3 ratio in patients who died as an inpatient was 0.3 and PM:L3 ratio in patients who survived to discharge was 0.52 (p < 0.0001). Median PM:L3 ratio in patient who died within 30 days post-op was 0.28 and 0.48 in those patients who survived to 30 days (p < 0.0001). Median PM:L3 ratio in patient who died within 90 days post-op was 0.28 and 0.51 in those patients who survived to 90 days (p < 0.0001). ROC analysis gave an area under the curve (AUC) of 0.85 for in-patient mortality, 0.86 for 30-day mortality, and 0.88 for 90-day mortality. ROC analysis for P-POSSUM in this data set demonstrated an AUC of 0.51 for in-patient mortality and 0.75 for 30- and 90-day mortality. CONCLUSION: CT imaging of the abdomen and pelvis is routinely used in over-80s prior to emergency laparotomy making PM:L3 calculation feasible for the majority of patients in this group. PM:L3 ratio is a useful prognostic indicator for prediction of mortality in patients over the age of 80. PM:L3 is superior to the P-POSSUM score in this series.

Proceedings of the 2018 GRAPPA Collaborative Research Network Meeting.

The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA)-Collaborative Research Network (CRN) intends to launch and secure funding for 3 pilot projects related to psoriatic disease, psoriatic arthritis (PsA), and cutaneous psoriasis (PsC). The first pilot project, a PsA Biomarkers for Joint Damage (BioDAM) pilot, will seek to determine the independent predictive ability of serum biomarkers for joint damage in PsA. The second pilot project will aim to identify predictors of the development of PsA among patients with PsC. The third pilot project will aim to identify biomarkers that predict treatment response in PsA and PsC. These pilot projects will prompt the development of clinical protocols to operate across participating centers, lead to the development of standard operating procedures for the collection and transport of biosamples across international borders, and begin to establish administrative and managerial structures for the CRN. The CRN hopes that the successful completion and research outputs of these 3 pilot projects will demonstrate the CRN's value to prospective collaborators and sponsors and thereby secure sustainable longterm funding.

Perioperative Practices Concerning One Anastomosis (Mini) Gastric Bypass: A Survey of 210 Surgeons.

BACKGROUND: There is currently little evidence available on the perioperative practices concerning one anastomosis/mini gastric bypass (OAGB/MGB) and no published consensus amongst experts. Even the published papers are not clear on these aspects. The purpose of this study was to understand various perioperative practices concerning OAGB/MGB. METHODS: Bariatric surgeons from around the world were invited to participate in a questionnaire-based survey. Only surgeons performing this procedure were included. RESULTS: Two hundred and ten surgeons from 39 countries with a cumulative experience of 68,442 procedures took the survey. Surgeons described a large number of absolute (n = 55) and relative contraindications (n = 59) to this procedure in their practice. Approximately 71.0% (n = 148/208), 70.0% (n = 147/208) and 65.0% (n = 137/209), respectively, routinely perform a preoperative endoscopy, screening for Helicobacter pylori and ultrasound scan of the abdomen. A minority (35.0%, n = 74/208) of the surgeons used a constant bilio-pancreatic limb (BPL) length for all the patients with remaining preferring to tailor the limb length to the patient and approximately half (49.0%, n = 101/206) routinely approximate diaphragmatic crura in patients with hiatus hernia. Some 48.5% (n = 101/208) and 40.0% (n = 53/205) surgeons, respectively, do not recommend routine iron and calcium supplementation. CONCLUSION: This survey is the first attempt to understand a range of perioperative practices with OAGB/MGB. The findings will help in identifying areas for future research and allow consensus building amongst experts with preparation of guidelines for future practice.

Life-threatening Petersen's hernia following open Beger's procedure.

Petersen's hernia (an internal hernia between the transverse mesocolon and Roux limb following Roux-en-Y reconstruction) is well described following laparoscopic gastric bypass surgery. We describe a Petersen-type hernia in a patient who had undergone complex open upper gastrointestinal surgery for chronic pancreatitis.

Lassoing of the small bowel mesentery and abdominal pain caused by band tubing after "band on bypass".

Weight regain after laparoscopic gastric bypass can be difficult to manage. A common finding is an enlarged gastrojejunal complex (dilated gastric pouch and/or jejunum, dilated gastrojejunal anastomosis). Revision of the gastrojejunal complex can be accomplished by surgical resection, endoscopic plication techniques, or more recently, placement of an adjustable band around the dilated gastric pouch ("band on bypass," BoB). We present an unusual complication of the BoB procedure, in which the band tubing looped around the small bowel causing severe abdominal pain.

Obstructive sleep apnea can be safely managed in a level 2 critical care setting after laparoscopic bariatric surgery.

BACKGROUND: In the United Kingdom, demand for intensive care beds (level 3 critical care) often outstrips supply, leading to frequent and frustrating cancellation of complex elective surgery. It has been suggested that patients with obstructive sleep apnea who undergo bariatric surgery should be admitted to a level 3 facility for routine postoperative management. We have questioned the validity of this dogma in the era of laparoscopic bariatric surgery by using a simple easily applicable algorithm. OBJECTIVES: The aim of this study was to investigate the clinical outcome of patients with obstructive sleep apnea (OSA) without admission to the intensive care unit after laparoscopic bariatric surgery. METHODS: For the first 24 hours after surgery, all patients were admitted to a level 2 (high-dependency) area on a general surgical ward with experience of bariatric surgery. They received supplemental oxygen, continuous pulse oximetry, and judicious analgesic administration using a combination of small boluses of i.v. morphine together with i.v. paracetamol. Perioperative continuous positive airway pressure support was not routinely given, unless patients with OSA had oxygen saturation below their recorded preoperative level on 2 consecutive readings. RESULTS: A total of 1623 patients underwent laparoscopic bariatric surgery over a 12-year period. Of those, 192 had OSA with a median operative body mass index of 52 kg/m(2) (range 34-78 kg/m(2)). The incidence of respiratory complications and the median length of stay (3 nights) were identical in patients with OSA and those without OSA. Four patients self-administered perioperative continuous positive airway pressure, but none required transfer to intensive care or mechanical ventilation. There were no in-hospital deaths. CONCLUSION: Laparoscopic bariatric surgery in patients with OSA is well tolerated and does not require the routine use of level 3 critical care facilities.

Laparoscopic sleeve gastrectomy for high-risk patients: weight loss and comorbidity improvement--short-term results.

BACKGROUND: The obesity surgery mortality risk score (OS-MRS) is a five-point scoring system stratifying the risk of post-operative mortality. Patients with a body mass index (BMI) > 60 may also carry an increased risk of peri-operative complications. Laparoscopic sleeve gastrectomy (LSG) as an initial procedure could reduce weight and associated comorbidity allowing a safer, definitive second procedure. We investigated weight loss and risk reduction in patients having LSG as part of a planned two-stage definitive bariatric procedure. METHODS: Patients with a high OS-MRS (4-5), males with BMI > 60 or females with BMI > 65, who underwent LSG were identified from a prospective database. Data were analysed by means of the Mann-Whitney U and Chi-squared test. RESULTS: Sixty-eight patients underwent LSG. LSG reduced median BMI at 12 months (68 versus 54, P < 0.001) and the OS-MRS (3 versus 2, P = 0.005). An increase in patients considered low risk (OS-MRS, 0-1) was seen following LSG (35% versus 14%, P = 0.006). The proportion of patients with BMI < 50 increased from 0% to 30% (P < 0.001). Improvement or resolution of diabetes and hypertension was seen in 23% and 25% of cases, respectively. CONCLUSIONS: LSG achieves good weight loss, reduces the OS-MRS and improves obesity-related comorbidity in high-risk surgical patients.