Pregnancy after bariatric surgery and adverse perinatal outcomes: A systematic review and meta-analysis.

BACKGROUND: Women who undergo bariatric surgery prior to pregnancy are less likely to experience comorbidities associated with obesity such as gestational diabetes and hypertension. However, bariatric surgery, particularly malabsorptive procedures, can make patients susceptible to deficiencies in nutrients that are essential for healthy fetal development. The objective of this systematic review and meta-analysis is to investigate the association between pregnancy after bariatric surgery and adverse perinatal outcomes. METHODS AND FINDINGS: Searches were conducted in Medline, Embase, PsycINFO, CINAHL, Scopus, and Google Scholar from inception to June 2019, supplemented by hand-searching reference lists, citations, and journals. Observational studies comparing perinatal outcomes post-bariatric surgery to pregnancies without prior bariatric surgery were included. Outcomes of interest were perinatal mortality, congenital anomalies, preterm birth, postterm birth, small and large for gestational age (SGA/LGA), and neonatal intensive care unit (NICU) admission. Pooled effect sizes were calculated using random-effects meta-analysis. Where data were available, results were subgrouped by type of bariatric surgery. We included 33 studies with 14,880 pregnancies post-bariatric surgery and 3,979,978 controls. Odds ratios (ORs) were increased after bariatric surgery (all types combined) for perinatal mortality (1.38, 95% confidence interval [CI] 1.03-1.85, p = 0.031), congenital anomalies (1.29, 95% CI 1.04-1.59, p = 0.019), preterm birth (1.57, 95% CI 1.38-1.79, p < 0.001), and NICU admission (1.41, 95% CI 1.25-1.59, p < 0.001). Postterm birth decreased after bariatric surgery (OR 0.46, 95% CI 0.35-0.60, p < 0.001). ORs for SGA increased (2.72, 95% CI 2.32-3.20, p < 0.001) and LGA decreased (0.24, 95% CI 0.14-0.41, p < 0.001) after gastric bypass but not after gastric banding. Babies born after bariatric surgery (all types combined) weighed over 200 g less than those born to mothers without prior bariatric surgery (weighted mean difference -242.42 g, 95% CI -307.43 to -177.40 g, p < 0.001). There was low heterogeneity for all outcomes (I2 < 40%) except LGA. Limitations of our study are that as a meta-analysis of existing studies, the results are limited by the quality of the included studies and available data, unmeasured confounders, and the small number of studies for some outcomes. CONCLUSIONS: In our systematic review of observational studies, we found that bariatric surgery, especially gastric bypass, prior to pregnancy was associated with increased risk of some adverse perinatal outcomes. This suggests that women who have undergone bariatric surgery may benefit from specific preconception and pregnancy nutritional support and increased monitoring of fetal growth and development. Future studies should explore whether restrictive surgery results in better perinatal outcomes, compared to malabsorptive surgery, without compromising maternal outcomes. If so, these may be the preferred surgery for women of reproductive age. TRIAL REGISTRATION: PROSPERO CRD42017051537.

Insulating Josephson Junction Chains as Pinned Luttinger Liquids.

Quantum physics in one spatial dimension is remarkably rich, yet even with strong interactions and disorder, surprisingly tractable. This is due to the fact that the low-energy physics of nearly all one-dimensional systems can be cast in terms of the Luttinger liquid, a key concept that parallels that of the Fermi liquid in higher dimensions. Although there have been many theoretical proposals to use linear chains and ladders of Josephson junctions to create novel quantum phases and devices, only modest progress has been made experimentally. One major roadblock has been understanding the role of disorder in such systems. We present experimental results that establish the insulating state of linear chains of submicron Josephson junctions as Luttinger liquids pinned by random offset charges, providing a one-dimensional implementation of the Bose glass, strongly validating the quantum many-body theory of one-dimensional disordered systems. The ubiquity of such an electronic glass in Josephson-junction chains has important implications for their proposed use as a fundamental current standard, which is based on synchronization of coherent tunneling of flux quanta (quantum phase slips).

Preconception and Pregnancy Nutrition Support for Women with a History of Bariatric Surgery: A Mixed-Methods Survey of Healthcare Professionals in the UK.

Preconception bariatric surgery improves obesity-related maternal pregnancy complications but may reduce the absorption of nutrients required for healthy fetal growth and development. Women who receive preconception nutritional support after bariatric surgery are less likely to have adverse pregnancy outcomes. This study aimed to investigate the provision of preconception and pregnancy-specific nutritional support for women having bariatric surgery in the UK. A mixed-methods survey was distributed to healthcare professionals working in obesity or maternity services between December 2018 and October 2019. We collected both quantitative and qualitative data which were analysed using a mixed-methods approach. We received 135 responses from online (n = 99) and postal (n = 36) questionnaires. Only 45% of participants reported being 'very familiar' with the preconception/pregnancy nutritional needs of this population. Barriers to providing nutritional support included: a lack of resources and time; poor communication both across services and with women; not having contact with women preconception; and a lack of information and guidance. Respondents felt that dietitians have the expertise in nutrition necessary to provide support; however, GPs and midwives have the most frequent patient access post-surgery, both before and during pregnancy. Optimal preconception and pregnancy-related nutritional support requires multidisciplinary care pre- and post-surgery, and healthcare professionals require training and guidance to inform practice.

Protocol for diaphragm pacing in patients with respiratory muscle weakness due to motor neurone disease (DiPALS): a randomised controlled trial.

BACKGROUND: Motor neurone disease (MND) is a devastating illness which leads to muscle weakness and death, usually within 2-3 years of symptom onset. Respiratory insufficiency is a common cause of morbidity, particularly in later stages of MND and respiratory complications are the leading cause of mortality in MND patients. Non Invasive Ventilation (NIV) is the current standard therapy to manage respiratory insufficiency. Some MND patients however do not tolerate NIV due to a number of issues including mask interface problems and claustrophobia. In those that do tolerate NIV, eventually respiratory muscle weakness will progress to a point at which intermittent/overnight NIV is ineffective. The NeuRx RA/4 Diaphragm Pacing System was originally developed for patients with respiratory insufficiency and diaphragm paralysis secondary to stable high spinal cord injuries. The DiPALS study will assess the effect of diaphragm pacing (DP) when used to treat patients with MND and respiratory insufficiency. METHOD/DESIGN: 108 patients will be recruited to the study at 5 sites in the UK. Patients will be randomised to either receive NIV (current standard care) or receive DP in addition to NIV. Study participants will be required to complete outcome measures at 5 follow up time points (2, 3, 6, 9 and 12 months) plus an additional surgery and 1 week post operative visit for those in the DP group. 12 patients (and their carers) from the DP group will also be asked to complete 2 qualitative interviews. DISCUSSION: The primary objective of this trial will be to evaluate the effect of Diaphragm Pacing (DP) on survival over the study duration in patients with MND with respiratory muscle weakness. The project is funded by the National Institute for Health Research, Health Technology Assessment (HTA) Programme (project number 09/55/33) and the Motor Neurone Disease Association and the Henry Smith Charity. TRIAL REGISTRATION: Current controlled trials ISRCTN53817913. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HTA programme, NIHR, NHS or the Department of Health.

Effectiveness and Safety of Laparoscopic Sleeve Gastrectomy for Weight Loss in Mild Obesity: Prospective Cohort Study with 3-Year Follow-up.

PURPOSE: Patients with mild obesity especially in absence of associated medical problems (OAMP) are commonly managed by non-surgical approaches. Laparoscopic sleeve gastrectomy (LSG) has proved itself to be effective and it is now the most performed weight loss procedure. We aimed to study the effectiveness and safety of LSG for weight loss in mild obesity. METHODS: A prospective cohort study. Group A; BMI (30-34.9 kg/m2), and group B; BMI ≥ 40 or BMI ≥ 35 with OAMP. Demographic data, perioperative complications, % excess weight loss (EWL), % total weight loss (TWL), nutritional profile, and evolution of OAMP were recorded and statistically analyzed. RESULTS: A total of 250 patients, with 80 patients (32%) in group A, and 170 (68%) in group B. The majority were female. The mean preoperative weight, BMI, and excess weight were 90.1 ± 9.52, 32.7 ± 1.4, and 21.5 ± 4.9 in group A, and 129.88 ± 26.12, 47.8 ± 8.2, and 62.3 ± 23.6 kg in group B respectively. The low BMI group had significantly lower OAMP, with higher pre-LSG non-surgical procedures rate. Overall post-operative morbidity rate was significantly higher in group B. %TWL was significantly lower in low BMI group. Nutritional profile was within the normal range in both groups at 3-year follow-up. CONCLUSION: Laparoscopic sleeve gastrectomy is a safe and effective weight loss solution for mild obesity with better outcome than for higher BMI. Further studies are warranted to reconsider NIH's statement for medicolegal aspects, and for matching the current changes in bariatric surgery practice, safety evidence, and patients' demand.

Pregnancy after Bariatric Surgery: A Nested Case-Control Study of Risk Factors for Small for Gestational Age Babies in AURORA.

Bariatric surgery prior to pregnancy is a significant risk factor for small for gestational age (SGA) babies. This case-control study investigated differences between mothers delivering an SGA baby following bariatric surgery, compared to those delivering an appropriate for gestational age (AGA) baby. Out of 129 babies born to mothers in the AURORA cohort study, 25 were SGA (<10th percentile) and 97 were AGA (10th-90th percentile). Higher gestational weight gain (GWG) was significantly associated with decreased odds of SGA (aOR per kg 0.92, 95% CI 0.85-0.99). According to the Institute of Medicine GWG guidelines, 44% of SGA mothers had 'inadequate' GWG compared to 17% of AGA mothers. Nearly half of the mothers had 'excessive' GWG yet still gave birth to an SGA or AGA baby. Mothers of SGA babies lost more weight following bariatric surgery (45.6 ± 14.4 kg vs. 39.0 ± 17.9 kg). Women who reported receiving nutritional advice following bariatric surgery were significantly less likely to have an SGA baby (aOR 0.15, 95% CI 0.0.4-0.55). Women with a history of bariatric surgery should be provided with specialized support before and during pregnancy to encourage adequate nutritional intake and weight gain to support healthy fetal growth.

After you Roux, what do you do? A systematic review of most successful advanced assisted ERCP techniques in patients with various altered upper gastrointestinal surgical anatomical reconstructions with particular focus on RYGB (last 10 years).

Access to the Common Bile Duct in patients with surgically altered UGI anatomy such as RYGB is exceptionally challenging. Previously, these patients could only be treated by open surgery; however, multiple new advanced assisted ERCP techniques such as EDGE, LA-ERCP, and DEA-ERCP have now been developed and indeed successfully used to treat these patients. Despite growing experience, these techniques have yet to become part of our mainstream practice and many clinicians remain unfamiliar or even unaware of them; as a result, they are unfortunately often overlooked. We conducted this systematic review to try and shed more light on them and understand which of these techniques resulted in the best patient outcomes. We conducted a systematic review of PubMed database publications between December 2008 and December 2018. Keyword variants of "EDGE, Enteroscopy-assisted & laparoscopy-assisted ERCP" and "altered surgical anatomy" were combined to identify relevant papers for inclusion. We identified 34 studies, comprising a total of 1848 advanced assisted ERCPs in patients with altered UGI anatomy from 12 different countries. These papers were critically appraised, summarised, and presented in table format. EDGE and LA-ERCP were associated with both the highest overall combined CBD cannulation rates (99.3% for both vs 74.6% for DEA-ERCP) and ERCP interventional success (98.3% for EDGE vs 97.4% for LA-ERCP and 67.6% for DEA-ERCP). Advanced ERCP is associated with excellent success rates and a higher safety profile than surgery; however, patient selection and identification of the exact surgical anatomy are key.

Randomized controlled trial of laparoscopic Nissen versus Lind fundoplication for gastro-oesophageal reflux disease.

OBJECTIVE: To compare the effect of laparoscopic Nissen and Lind fundoplication on gastro-oesophageal reflux disease by means of a prospective randomized controlled trial. MATERIAL AND METHODS: One hundred and twenty-one patients were randomized to undergo either Nissen (61) or Lind (60) fundoplication. Initial enrollment and subsequent clinical appointments were undertaken 1, 3, 6 and 12 months after the procedure using a standardized questionnaire. Ambulatory pH monitoring and manometry were undertaken both preoperatively and at approximately 3 months post-procedure. RESULTS: The mean operating time was similar in both groups (44.8 versus 45 min). One operation in the Lind group was converted to open surgery. Postoperative dysphagia symptoms at 3 and 6 months were higher in the Nissen fundoplication group than in the Lind group (3 months p=0.003; 6 months p=0.020). The time taken to return to work was statistically longer in the Nissen group: at 1 month, 9 of 40 versus 2 of 45 patients had not returned to full activities (p=0.013). Three individuals required re-operation in the Nissen group and 4 individuals in the Lind group because of dysphagia caused by mechanical obstruction. Both procedures demonstrated good Visick scores at 12 months; the Nissen group having 33 (97%) patients with a Visick score of 1 or 2, and the Lind group having 38 (100%) patients with a Visick score of 1 or 2. CONCLUSIONS: Both operations provide good quantitative and qualitative control of gastro-oesophageal reflux. Operation time and postoperative comparators were similar in both groups. There were no statistically significant differences between the groups at 1 year.

Prospective randomized trial of argon plasma coagulation ablation versus endoscopic surveillance of Barrett's esophagus in patients treated with antisecretory medication.

Argon plasma coagulation (APC) has been used to ablate Barrett's esophagus, however, its role in the management of non-dysplastic Barrett's esophagus is uncertain. The purpose of this study is to determine the efficacy of endoscopic argon plasma coagulation (APC) for ablation of Barrett's esophagus in a prospective randomized controlled trial in two university teaching hospitals. Fifty-seven patients using proton pump inhibitor (PPI) medication and with Barrett's esophagus were randomized to undergo either ablation using endoscopic argon plasma coagulation (APC) or ongoing surveillance. Fifty-one patients underwent endoscopy at 12 months. Endoscopic argon plasma coagulation (APC) versus surveillance endoscopy was studied. Endoscopy and histopathological appearances of Barrett's esophagus at 12 months follow-up was also studied. Initially, at least 95% ablation of the metaplastic mucosa was achieved in 25 of the 26 treated patients. At 12 months, 14 of 23 APC patients had at least 95% regression, and nine of 23 had complete regression of Barrett's esophagus. No surveillance patient had more than 95% regression. The length of Barrett's esophagus shortened significantly after APC (mean 3.0 vs. 0.5 cm). Significant regression of Barrett's esophagus follows ablation with APC, although complete regression was achieved in less than half. The role of APC ablation of non-dysplastic Barrett's esophagus remains uncertain.

Proton pump inhibitor influence on reflux in Barrett's oesophagus.

OBJECTIVES: It is important to identify factors responsible for the development of Barrett's oesophagus (BO). The effect of proton pump inhibitors (PPIs) on oesophageal clearance of both acid and alkaline reflux in these patients is uncertain and studies comparing BO patients and healthy controls (HCs) have not been performed earlier. METHODS: Two groups of patients were studied: 18 HCs and 12 BO patients. Oesophageal motility, acid reflux and duodenogastro-oesophageal reflux (DGOR) were measured using a three-pressure transducer catheter with an antimony pH tip, connected to a sodium ion selective electrode. All patients were studied both on and off PPIs. RESULTS: Without PPI therapy, BO patients had significantly more upright and supine acid reflux and upright DGOR compared with HCs. During acid reflux, HC demonstrated more peristalsis than BO [HC, % peristalsis=64 (9), BO=53 (8), P<0.01], but this was not seen during DGOR. [HC, % peristalsis=68 (14), BO=56 (11)]. In Barrett's patients, DGOR was significantly reduced with PPIs [off PPI, % upright DGOR=61 (17), on PPIs=19 (15), P<0.01], and no oesophageal motility differences were seen compared with results without PPIs. CONCLUSION: HCs demonstrate better oesophageal motility compared with BO patients to prevent acid and alkaline reflux. When acid reflux occurred, HCs had better coordinated motility to remove it. This increased coordination did not occur during DGOR, suggesting different stimulation mechanisms. PPI reduced DGOR in BO patients, without any change in oesophageal motility.

Cholesterol crystal embolism leading to perforation of the gallbladder.

BACKGROUND: Cholesterol crystal embolism (CCE) from atherosclerotic arterial disease leading to perforation of the gallbladder is rare. We describe our experience of managing a patient with perforation of gallbladder caused by CCE. METHODS: A 64-year-old man was admitted to this hospital because of acute abdominal pain with clinical features suggestive of peritonitis. He was known to suffer from atherosclerotic peripheral arterial disease and had undergone aortobifemoral bypass 17 years ago. A CT scan showed a collection of peri-hepatic fluid. The gallbladder was normal in appearance but contained multiple calculi. At laparotomy, free bile was observed in the peritoneal cavity, leaking from a pin-hole size peroration of the fundus of the gallbladder. Hence cholecystectomy was performed. RESULTS: The patient made an uneventful recovery. Histological study of the gallbladder showed chronic cholecystitis and obliteration of the lumen of the mural arteries with cholesterol crystals within, indicating CCE. CONCLUSIONS: Although perforation of the gallbladder following CCE of its mural arteries is rare, the diagnosis should be considered in patients with abdominal pain and known atherosclerotic arterial disease. Management should include an early recognition of this condition, prompt institution of treatment, prevention of further insults by discontinuing or avoiding predisposing factors, and modification of cardiovascular risk factors.

Cost-effectiveness and budget impact of obesity surgery in patients with type-2 diabetes in three European countries.

BACKGROUND: We aimed to establish a payer-perspective cost-effectiveness and budget impact (BI) model of adjustable gastric banding (AGB) and gastric bypass (GBP) vs conventional treatment (CT) in patients with BMI > or =35 kg/m(2) and type-2 diabetes T2DM, in Germany, UK and France. METHODS: Clinical evidence was obtained from literature and patient-reported EQ-5D scores given BMI and T2DM status from HODaR. Resource utilization data in AGB, GBP and CT were obtained from quoted publications so as to reflect practice in 2005. CT in each country was based on descriptions in HTA reports or based on co-authors' experience of current practice. Unit costs were obtained from published sources when available, or from co-authors' institutions. A deterministic algorithm with cost and utility discounting, enabled selection of inputs independently throughout the time scope for each of the 3 treatments, and included mean BMI, amounts of resources and unit costs. RESULTS: The base case time-scope was 5 years, and the annual discount rate for utilities and costs was 3.5%. Compared to CT, GBP yielded +80.8 kg/m(2).years, +2.6 T2DM-free-years and +1.34 QALYs. AGB yielded +57.8 kg/m(2).years, +2.5 T2DM-free-years and +1.03 QALYs. In Germany and France, both GBP and AGB yielded a cost decrease, and were thus dominant in terms of ICER compared to CT. In the UK, GBP and AGB yielded a cost increase, but were cost-effective. CONCLUSION: In patients with T2DM and BMI > or =35 kg/m(2), AGB and GBP are effective at 5-year follow-up in cost-saving in Germany and France, and are cost-effective in the UK with a moderate BI vs CT.

DiPALS: Diaphragm Pacing in patients with Amyotrophic Lateral Sclerosis - a randomised controlled trial.

BACKGROUND: Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease resulting in death, usually from respiratory failure, within 2-3 years of symptom onset. Non-invasive ventilation (NIV) is a treatment that when given to patients in respiratory failure leads to improved survival and quality of life. Diaphragm pacing (DP), using the NeuRx/4(®) diaphragm pacing system (DPS)™ (Synapse Biomedical, Oberlin, OH, USA), is a new technique that may offer additional or alternative benefits to patients with ALS who are in respiratory failure. OBJECTIVE: The Diaphragm Pacing in patients with Amyotrophic Lateral Sclerosis (DiPALS) trial evaluated the effect of DP on survival over the study duration in patients with ALS with respiratory failure. DESIGN: The DiPALS trial was a multicentre, parallel-group, open-label, randomised controlled trial incorporating health economic analyses and a qualitative longitudinal substudy. PARTICIPANTS: Eligible participants had a diagnosis of ALS (ALS laboratory-supported probable, clinically probable or clinically definite according to the World Federation of Neurology revised El Escorial criteria), had been stabilised on riluzole for 30 days, were aged ≥ 18 years and were in respiratory failure. We planned to recruit 108 patients from seven UK-based specialist ALS or respiratory centres. Allocation was performed using 1 : 1 non-deterministic minimisation. INTERVENTIONS: Participants were randomised to either standard care (NIV alone) or standard care (NIV) plus DP using the NeuRX/4 DPS. MAIN OUTCOME MEASURES: The primary outcome was overall survival, defined as the time from randomisation to death from any cause. Secondary outcomes were patient quality of life [assessed by European Quality of Life-5 Dimensions, three levels (EQ-5D-3L), Short Form questionnaire-36 items and Sleep Apnoea Quality of Life Index questionnaire]; carer quality of life (EQ-5D-3L and Caregiver Burden Inventory); cost-utility analysis and health-care resource use; tolerability and adverse events. Acceptability and attitudes to DP were assessed in a qualitative substudy. RESULTS: In total, 74 participants were randomised into the trial and analysed, 37 participants to NIV plus pacing and 37 to standard care, before the Data Monitoring and Ethics Committee advised initial suspension of recruitment (December 2013) and subsequent discontinuation of pacing (on safety grounds) in all patients (June 2014). Follow-up assessments continued until the planned end of the study in December 2014. The median survival (interquartile range) was 22.5 months (lower quartile 11.8 months; upper quartile not reached) in the NIV arm and 11.0 months (6.7 to 17.0 months) in the NIV plus pacing arm, with an adjusted hazard ratio of 2.27 (95% confidence interval 1.22 to 4.25; p = 0.01). CONCLUSIONS: Diaphragmatic pacing should not be used as a routine treatment for patients with ALS in respiratory failure. FUTURE WORK: It may be that certain population subgroups benefit from DP. We are unable to explain the mechanism behind the excess mortality in the pacing arm, something the small trial size cannot help address. Future research should investigate the mechanism by which harm or benefit occurs further. TRIAL REGISTRATION: Current Controlled Trials ISRCTN53817913. FUNDING: This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 45. See the HTA programme website for further project information. Additional funding was provided by the Motor Neurone Disease Association of England, Wales and Northern Ireland.

Gastric band port site fixation: which method is best?

Laparoscopic adjustable gastric banding is a popular and successful bariatric surgical technique. Although short-term complications are few in number, long-term complications are more common. One such complication is flippage of the gastric band port. This study compares three popular methods of port fixation and demonstrates that fixation with nonabsorbable mesh helps to prevent port flippage when compared to other techniques, reducing the need for repositioning operations.

Does the addition of a prokinetic to proton pump inhibitor therapy help reduce duodenogastro-oesophageal reflux in patients with Barrett's oesophagus?

OBJECTIVE: The metaplastic change of Barrett's oesophagus is linked to both acid and duodenal reflux together with impaired motility. Proton pump inhibitors (PPI) reduce acid reflux, but no treatment is available that reduces duodenogastro-oesophageal reflux (DGOR). The aim of this study was to investigate whether adding a prokinetic to PPI treatment could improve oesophageal motility and subsequently reduce reflux. METHODS: Two groups of patients with Barrett's oesophagus on PPI therapy (prokinetic, n = 12; placebo, n = 11) were investigated. At visit 1, ambulatory oesophageal manometry was performed, and peristaltic and simultaneous wave percentage and characteristics were measured. DGOR and pH measurements were also performed. After treatment with either the prokinetic cisapride or placebo, all investigations were repeated (visit 2). Analysis of covariance and Spearman's correlation coefficients of changes from visit 1 to visit 2 were used to compare data. RESULTS: There was no significant difference between the two groups with respect to DGOR, DGOR characteristics, or the percentage of peristalsis and simultaneous waves and their characteristics. There was no correlation between DGOR and motility changes. Although no significant differences existed between acid reflux in the two groups, five patients with high supine acid reflux showed a significant reduction after treatment with cisapride. CONCLUSIONS: Addition of cisapride to PPI treatment does not appear to improve oesophageal motility or reduce DGOR in patients with Barrett's oesophagus.

Barrett's oesophagus and photodynamic therapy (PDT).

Barrett's oesophagus is a precursor of oesophageal adenocarcinoma. This cancer has the fastest growing incidence of any solid tumour in the Western world. Surveillance of Barrett's oesophagus is routinely undertaken to detect early malignant transformation. However, ablative endoscopic treatments are available and these can obliterate the abnormal epithelium, allowing neo-squamous re-growth. Photodynamic therapy (PDT) using haematoporphyrin derivative (HpD)/porfimer sodium (Photofrin(®)), m-tetrahydroxyphenyl chlorin (mTHPC) and 5-aminolaevulinic acid (ALA) utilise such a technique. In this non-thermal method of ablation, the photosensitisers, together with light and oxygen, produce local tissue destruction. The use of PDT ablation of Barrett's oesophagus is reviewed.

Bariatric surgery in severely obese adolescents: a single-centre experience.

BACKGROUND: Increasing numbers of severely obese young people undergo bariatric surgery in the USA with reports of substantial weight loss after 1 year. National Institute for Clinical Excellence 2006 suggests considering surgery for young people in 'exceptional circumstances'. We present six patients operated upon 2004-2012 at our centre in the UK. CASE SERIES: Six patients (4 male) aged 14-16 years (mean age 15.10) underwent surgery. Mean preoperative body mass index (BMI) was 62.7 kg/m(2) and BMI SDS +4.4. Comorbidities included hypertension, insulin resistance, obstructive sleep apnoea, limited mobility, benign intracranial hypertension and psychosocial issues. All six patients had prior involvement with local lifestyle weight management services and had pharmacological intervention. Four laparoscopic gastric bypass procedures, one laparoscopic gastric banding (patient had a gastric balloon prior to band) and one laparoscopic sleeve gastrectomy were performed. RESULTS: There were no major postoperative procedural complications (one patient had a port rotation). Mean percentage of weight loss, as a percentage of total body weight at 6 and 12 months, was 22 and 27%, respectively. Average absolute weight loss at current follow-up is 54 kg. Mean BMI at 12 months postprocedure was 46.5 kg/m(2)-a mean fall of 16.2 kg/m(2). Mean BMI SDS fell from +4.4 to +3.8 at 12 months and +3.1 at 2 years. Resolution of hypertension, improved school attendance and no progression to T2DM were the benefits noted. CONCLUSIONS: Recent systematic reviews and meta-analyses suggest that bariatric surgery results in sustained and clinically significant weight loss in paediatric populations. The surgical option should continue to be exercised with extreme caution only in severely obese adolescents and done so in appropriate case results in positive outcomes.

A study examining the complications associated with gastric banding.

BACKGROUND: Gastric banding is a well-recognized and common method of weight reduction surgery. Between November 2001 and September 2011, 1,100 laparoscopic adjustable gastric banding operations were performed in Sheffield. This study examines the long-term complication rate. METHODS: All available medical notes for patients undergoing gastric banding by one surgeon were reviewed. Data were available for 1,079 patients. RESULTS: A total of 932 females and 147 males underwent gastric banding. Mean weight was 120 kg, with body mass index of 43.3. Complications occurred in 347 patients (32.1 %). One hundred three (13.2 %) patients experienced band slippage; re-operation was required in half of these cases. Eighty-two patients had their band removed due to complications; there was slippage in 60, erosion in 17, and band intolerance in 5. One hundred thirty-six (12.6 %) patients experienced problems with their port or port tubing. Thirty-seven ports were flipped, noted during clinical or radiological fills (3.4 %), and 17 patients experienced port infection (1.5 %). Fifty ports required repositioning (4.6 %); 16 (1.4 %) were removed or replaced including five for cutaneous erosion. Eleven patients experienced tubing problems. Four patients required procedures to deal with intraoperative complications. Eighteen patients had a concurrent procedure. One postoperative death was due to biliary peritonitis in a patient who had undergone simultaneous cholecystectomy. CONCLUSION: Complication rates reflect those in the literature. Slippage rate may appear higher in our patients, but this is a reflection of the fact that most patients undergo radiological band fills; hence, many non-symptomatic slippages are detected. Only half of our slippages (6.6 % of all patients) were clinically apparent or needed any intervention.

Role of intragastric balloon in cardiac surgery: an adjunct to preoperative optimization for morbid obesity.

Obesity is associated with a high risk of developing intraoperative and postoperative complications in patients undergoing cardiac surgery. Morbid obesity is a relatively common cause for delay in surgery, whereas the patients are optimized to a near normal body mass index. We evaluate the role of intragastric balloon in this group of patients. We present the case of a 68-year-old man who had successful treatment of his obesity prior to undergoing a successful triple bypass using an intragastric balloon. We draw the conclusion that intragastric balloon is a simple, safe procedure for preoperative optimization in patients with morbid obesity prior to cardiac surgery.

Revision of vertical banded gastroplasty complicated by a large para-esophageal hernia.

Patients who have undergone bariatric surgery and present with upper abdominal symptoms pose a diagnostic and management challenge. This is a case report of a 53-year-old lady who presented a number of years after vertical banded gastroplasty with upper abdominal pain and weight gain. Radiological investigation demonstrated a large para-esophageal hernia including the stapled area of the stomach, but with a staple-line dehiscence. She successfully underwent repair of the hiatus hernia and conversion to a Roux-en-Y gastric bypass resulting in resolution of the abdominal pain and weight loss.