Small bowel obstruction secondary to barbed sutures in bariatric surgery: a cautionary tale.

BACKGROUND: Laparoscopic bariatric surgery relies on technically challenging intracorporeal suturing for critical parts of the operation. Barbed sutures have been developed to provide an alternative to suturing for certain manoeuvres within a procedure. Barbed sutures theoretically negate the need for knot tying and allow for continuous application of tension; however the barbs can unintentionally adhere to surrounding tissues. We describe a case series of three patients who developed V-Loc™ (barbed) suture related small bowel obstruction (SBO) to promote awareness of this unusual but preventable complication. METHODS: Medical records of patients diagnosed with V-Loc™ related SBO between 2018 and 2021 at a tertiary centre were reviewed. Data regarding presentation, diagnosis, management and outcomes were obtained. RESULTS: Three patients were identified where V-Loc™ sutures were aetiologically related to early post-surgical small bowel obstruction secondary to small bowel adherence to barbed suture tail or adhesions between barbed suture tail and unintended viscera. In these cases, non-absorbable V-Loc™ sutures were used to close the small bowel mesenteric defect at Roux-en-Y gastric bypass surgery. All patients required adhesiolysis at re-look laparoscopy prior to resolution. All patients were discharged home well after relook laparoscopy. CONCLUSION: Overly long or exposed V-Loc™ suture tails can result in SBO following laparoscopic bariatric surgery. Cutting the suture tail as close as practical to the final throw of the suture and/or covering exposed suture ends may prevent this complication.

Effect of laparoscopic sleeve gastrectomy versus laparoscopic Roux-en-Y gastric bypass on body composition.

BACKGROUND: There is limited data with respect to body composition changes for laparoscopic sleeve gastrectomy (SG) and laparoscopic Roux-en-Y gastric bypass (RYGB). The objective of this study was to analyse changes in body composition between these two procedures during the first year after bariatric surgery. METHODS: A prospective study was performed in patients undergoing bariatric surgery at two tertiary hospitals between 2017 and 2023. Body composition was assessed with dual-energy x-ray absorptiometry immediately before surgery, and at 1-, 6-, 12-, 18- and 24-months post-operatively, with a subgroup analysis performed for patients who undertook a scan at 18- and 24-months. Total weight loss (TWL), body mass index (BMI), fat mass (FM), lean body mass (LBM) and bone mineral content (BMC) parameters were compared between SG and RYGB. RESULTS: Forty-five patients were included in this series (SG n = 30, RYGB n = 15). There was a significant reduction in mean %TWL of 26.94 ± 8.86% and mean BMI of 11.12 ± 3.70 kg/m2 over 12-months. LBM accounted for 17.8% of TWL over 12-months, SG and RYGB did not differ in terms of loss of FM or LBM. For both procedures, the loss of LBM appeared to plateau at 6-months post-operatively. The only statistically significant finding between the two procedures was that RYGB resulted in an additional 0.06 kg loss compared with SG. CONCLUSION: SG and RYGB have been shown to have comparable weight loss and body composition changes in the short-to-medium term following surgery. LBM reduction was most significant in the early post-operative period across the entire cohort.

C-reactive protein is a predictor of severe infective complications following gastrectomy-a retrospective analysis.

Background: Post-operative complications are the main contributing factor to increased length of stay, increased cost of care and short-term mortality experienced by patients following gastrectomy. The purpose of this study was to determine the diagnostic accuracy of C-reactive protein (CRP) in predicting complications following gastrectomy. This may assist clinicians to make better informed clinical decisions in the post-operative period. Methods: A retrospective analysis of a prospectively maintained database was performed. Sixty patients who underwent gastrectomy for gastric cancer were included. Demographic information, operative data and post-operative details such as complications, unplanned intensive care unit (ICU) admission and readmission to hospital were analysed. Complications were further analysed based on whether they were either infective or non-infective in nature. Receiver operator characteristic (ROC) analysis was performed to examine the association between CRP and post-operative morbidity. Optimum cut-offs were determined using the Youden's index. Results: From the second post-operative day (POD), CRP levels were able to predict subsequent severe infective (SI) complications following gastrectomy [area under the curve (AUC): 0.789, 95% CI : 0.636-0.941]. An optimum cut-off of 180 mg/L resulted in a sensitivity of 87.50%. The negative predictive value (NPV) at this point was 96.30%. Conclusions: CRP is a strong negative predicter of SI complications following gastrectomy. This suggests early CRP values may be useful in prompting early investigation or facilitating safer, earlier discharge from hospital. Health services may benefit by determining similar cut-offs based on their own unique patient populations.

Body Composition Differences Between Excess Weight Loss ≥ 50% and < 50% at 12 Months Following Bariatric Surgery.

BACKGROUND: The relationship between weight loss and body composition is undefined after bariatric surgery. The objective of this study was to compare body composition changes in patients with excess weight loss ≥ 50% (EWL ≥ 50) and < 50% at 12 months post-operatively (EWL < 50). METHODS: A prospective cohort study was completed on patients undergoing bariatric surgery at two tertiary hospitals between 2017 and 2021. Body composition was measured with dual-energy X-ray absorptiometry immediately before surgery, and at 1, 6, and 12 months post-operatively. Body mass index (BMI), fat mass (FM), lean body mass (LBM), and skeletal muscle index (SMI) trajectories were analysed between patients with EWL ≥ 50% and EWL < 50%. RESULTS: Thirty-seven patients were included in this series (EWL ≥ 50% n = 25, EWL < 50% n = 12), comprising of both primary and revisional bariatric surgery cases, undergoing a sleeve gastrectomy (62.2%), Roux-en-Y gastric bypass (32.4%), or one anastomosis gastric bypass (5.4%). The EWL ≥ 50% group demonstrated a more optimal mean FM-to-LBM loss ratio than the EWL < 50% group. EWL ≥ 50% patients lost 2.0 kg more FM than EWL < 50% patients for each 1 kg of LBM lost. EWL ≥ 50% was also associated with an increase in mean SMI% over 12 months (5.5 vs. 2.4%; p < 0.0009). Across the whole cohort, the first month after surgery accounted for 67.4% of the total LBM reduction that occurred during the 12-month post-operative period. CONCLUSION: This data suggests EWL ≥ 50% is associated with a more optimal body composition outcome than EWL < 50%. LBM reduction occurs predominantly in the early post-operative period.

Effect of Roux-en-Y gastric bypass on Barrett's esophagus: a systematic review.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) has been recommended as the bariatric procedure of choice for morbidly obese patients with Barrett's esophagus (BE). OBJECTIVES: To systematically review the effect of RYGB on BE. SETTING: University hospital, Melbourne, Australia. METHODS: A systematic review was performed. Studies were included of patients who had BE who underwent RYGB and had minimum 1 follow-up gastroscopy postoperatively. English language full-text articles were included, with case reports excluded. Endoscopic assessment methods of BE were compared to the American College of Gastroenterology (ACG) clinical guideline recommendations. A novel methodological quality assessment tool to assess risk of bias was developed. For each study, potential confounders for the effect of RYGB on BE were analyzed. RESULTS: Of 28 articles, 5 publications met inclusion criteria. Quality assessment did not demonstrate any high-quality publications. Of 63 patients, no cases showed progression of BE. Overall, regression rates of BE assessed at the postoperative endoscopy varied from 36%-62%. There was a lack of consensus between authors on definition of regression and short- versus long-segment BE. Eighty percent of patients with dysplasia had regression of dysplasia. Both studies that provided all required endoscopic information had poor compliance with ACG recommendations. Potential confounding factors for the effect of RYGB on BE included preoperative risk factors, selection bias based on length of BE, type of RYGB (resectional or nonresectional), concomitant hiatus hernia repair, postoperative use of proton pump inhibitor, and amount of weight loss. CONCLUSION: RYGB has been shown to be associated with regression of BE and dysplasia in some patients, with no cases of progression after short-term postoperative endoscopic assessment. A clearer definition of regression of BE and following ACG recommendations is necessary to allow standardized reporting and comparison of future results. Long-term, larger, multicenter high-quality studies, including assessment of all potential contributing factors for BE regression, are required.

Health economic analysis of curative-intent gastrectomy for gastric carcinoma and the costs related to post-operative complications.

BACKGROUND: The management of post-gastrectomy complications requires considerable resources and is likely associated with a substantial economic burden. The objectives of this study were to perform a cost analysis of admissions following gastrectomy for gastric carcinoma and then to quantify the financial impact of post-operative complications. METHODS: A retrospective analysis was conducted in patients that underwent a gastrectomy from 2008 to 2019. Demographic data, operative information, post-operative complications and facility costs were compared. RESULTS: A total of 74 patients underwent a curative-intent gastrectomy during the study period. The 36 (48.6%) patients that had no complications had a median total admission cost of AU$29 228. A total of 21 (28.4%) patients had a minor complication and 17 (23.0%) patients had a major complication, with a median total admission cost of AU$36 592 and AU$71 808, respectively. The difference across all three groups was statistically significant. In patients who had major complications compared to those without complications, there was a significant increase in the cost of intensive care services, theatre resources and nursing care. Across the whole cohort, the principal cost centres accounting for the largest proportion of total cost were theatre equipment and resources (33.9%), nursing care on the ward (23.0%) and staffing time of the surgical team (16.7%). CONCLUSION: The surgical management of gastric cancer carries a substantial cost burden. The presence and severity of post-operative complications is strongly associated with increasing cost. Minimizing complications, in addition to obvious clinical benefits, enables a large reduction in costs of care.

Pre-operative low muscle mass is associated with major complications and lower recurrence-free survival after gastric cancer surgery.

BACKGROUND: Low muscle mass (LMM) has been associated with post-operative morbidity. This study aimed to examine the relationship between pre-operative LMM and major post-operative complications and survival in patients undergoing curative resection for gastric cancer. METHODS: A single-centre retrospective cohort study was conducted on consecutive patients who underwent surgical resection for gastric adenocarcinoma between 2008 and 2018. Patient demographics, radiological parameters, pathological data and complications were recorded. Skeletal muscle index was calculated using OsiriX software by manually measuring the cross-sectional skeletal muscle area at the third lumbar vertebra and correcting to the patient's height. Univariate and multivariate analyses were used to identify the risk factors associated with the outcomes. RESULTS: A total of 62 patients (36 males, mean age 68.3 ± 1.5 years) met the inclusion criteria. Twenty-six (41.9%) patients had LMM pre-operatively. Demographic data in the non-LMM and LMM groups were equally matched except for body mass index (27.6 ± 0.8 kg/m2 versus 24.3 ± 1.1 kg/m2 ; P = 0.012) and serum albumin (36.7 ± 0.7 g/L versus 33.8 ± 1.0 g/L; P = 0.017), which were higher in the non-LMM. LMM was associated with higher incidence of total (35.5% versus 64.5%; P = 0.006), minor (40% versus 60%; P = 0.030), major (9.1% versus 90.9%; P = 0.004) post-operative complications and decreased recurrence-free survival (hazard ratio 2.29; 95% confidence interval 1.10-4.77; P = 0.027). CONCLUSION: LMM is a significant independent risk factor for major post-operative complications and recurrence-free survival after gastrectomy. Pre-operative identification of LMM could be a useful tool for prognostication and may identify a group suitable for prehabilitation.

Body Composition Changes Following a Very-Low-Calorie Pre-Operative Diet in Patients Undergoing Bariatric Surgery.

BACKGROUND: Fatty liver in obese patients increases the technical difficulty of bariatric surgery. Pre-operative weight loss with a very-low-calorie diet (VLCD) is commonly used to facilitate surgery. Few studies have quantified the systemic effect of rapid pre-operative weight loss on body composition. The objective of this study is to evaluate body composition changes in bariatric surgery patients undergoing a VLCD. METHODS: Body composition assessments were performed between August 2017 and January 2019 using dual-energy X-ray absorptiometry immediately before and after a 2-week VLCD at St Vincent's Hospital Melbourne. Data collected prospectively pre- and post-VLCD included total body weight, excess body weight, body mass index (BMI), lean body mass (LBM), fat mass (FM) and bone mineral content (BMC). The pre- and post-operative results were compared. RESULTS: Forty-four patients completed both the 2-week VLCD and body composition assessments. Following a 2-week VLCD, patients lost a mean of 4.5 kg (range - 0.3 to 9.5) in a total body weight and 8.8% (range - 0.9 to 17.1) of excess body weight, with a mean reduction in body mass index of 1.6 kg/m2 (range - 0.2 to 3.1). Loss of LBM was 2.8 kg and was significantly greater than loss of FM, 1.7 kg (p < 0.05). BMC changes were insignificant. CONCLUSION: A VLCD is an effective tool for pre-operative weight reduction. In this cohort, a large amount of the total weight loss was attributed to a loss of lean body mass. The impact of significant lean body mass loss and its relationship to short- and long-term health outcomes warrants further assessment.

Variations in practice of thromboprophylaxis across general surgical subspecialties: a multicentre (PROTECTinG) study of elective major surgeries.

BACKGROUND: Despite guidelines recommending perioperative thromboprophylaxis for patients undergoing general surgery, we have observed significant variations in its practice. This may compromise patient safety. Here, we quantify the heterogeneity of perioperative thromboprophylaxis across all major general surgical operations, and place them in relation to their risk of bleeding and venous thromboembolism. METHODS: Retrospective review of all elective major general surgeries performed between 1 January 2018 and 30 June 2019 across seven Victorian hospitals was conducted. RESULTS: A total of 5912 patients who underwent 6628 procedures were reviewed. Significant heterogeneity was found in the use of chemoprophylaxis, timing of its initiation, type of anticoagulant administered and application of extended chemoprophylaxis. These variations were observed within the same procedure, and between different surgeries and subspecialties. Contrastingly, there was minimal heterogeneity with the use of mechanical thromboprophylaxis. Oesophago-gastric, liver and colorectal cancer resections had the highest thromboembolic risk. Breast, oesophago-gastric, liver, pancreas and colon cancer resections had the highest bleeding risk. CONCLUSION: Perioperative chemoprophylaxis across general surgery is highly variable. This study has highlighted key areas of variance. Our findings also enable surgeons to compare their practices, and provide baseline data to inform future efforts towards optimizing thromboprophylaxis for general surgical patients.

Pre-operative and intra-operative chemical thromboprophylaxis increases bleeding risk following elective cholecystectomy: a multicentre (PROTECTinG) study.

BACKGROUND: Cholecystectomy is commonly performed in general surgery. Despite guidelines recommending chemical thromboprophylaxis in the perioperative period, the most appropriate time for its initiation is unknown. Here, we investigated whether timing of chemoprophylaxis affected venous thromboembolism (VTE) and bleeding rates post-cholecystectomy. METHODS: Retrospective review of all elective cholecystectomies performed between 1 January 2018 and 30 June 2019, across seven Victorian hospitals. Clinical VTE was defined as imaging-proven symptomatic disease within 30 days of surgery. Major bleeding was defined as the need for blood transfusion, surgical intervention or >20 g/L fall in haemoglobin from baseline. RESULTS: A total of 1744 cases were reviewed. Chemoprophylaxis was given early (pre- or intra-operatively), post-operatively or not given in 847 (48.6%), 573 (32.9%) and 324 (18.6%) patients, respectively. This varied significantly between surgeons, fellows, trainees and institutions. Clinical VTE occurred in 5 (0.3%) patients and was not associated with chemoprophylaxis timing. Bleeding occurred in 42 (2.4%) patients. Of this, half were major events, requiring surgical control in 5 (11.9%) patients and blood transfusion in 9 (21.4%) patients. Bleeding also extended length of stay (mean (SD), 3.1 (4.0) versus 1.4 (2.2) days, P < 0.001). One bleeding-related mortality was recorded. Importantly, when compared with post-operative (risk ratio 1.46, 95% confidence interval 1.21-1.62) and no (RR 1.23, 95% CI 1.03-1.35) chemoprophylaxis, early usage significantly increased bleeding risk and independently predicted its occurrence. CONCLUSIONS: Perioperative chemoprophylaxis is variable among patients undergoing elective cholecystectomy. The rate of clinical VTE post-cholecystectomy is low. Early chemoprophylaxis increases bleeding risk without an appreciable additional protection from VTE.

Major Gastric Haemorrhage After Intragastric Balloon Insertion: Case Report.

Intragastric balloons are a minimally invasive option for weight loss. They are generally well tolerated and rarely associated with serious adverse events. We report a case of major upper gastrointestinal haemorrhage after insertion of an Orbera® intragastric balloon.

The Anti-Factor Xa Range For Low Molecular Weight Heparin Thromboprophylaxis.

Low molecular weight heparins (LMWHs) are now the mainstay option in the prevention and treatment of venous thromboembolism. In some patients receiving therapeutic doses of LMWH, activity can be measured by quantifying the presence of Anti-factor Xa (AFXa) for dose adjustment. However, currently there are no guidelines for LMWH monitoring in patients on thromboprophylactic, doses, despite certain patient populations may be at risk of suboptimal dosing. This review found that while the AFXa ranges for therapeutic levels of LMWHs are relatively well defined in the literature, prophylactic ranges are much less clear, thus making it difficult to interpret current research data. From the studies published to date, we concluded that a reasonable AFXa target range for LMWH deep venous thromboses prophylaxis might be 0.2-0.5 IU/mL.

Gallbladder carcinoma as a long-term complication of cholecystojejunostomy.

INTRODUCTION: Development of gallbladder cancer following cholecystojejunostomy has not previously been described. METHODS: A case of a patient who developed gallbladder cancer 22 years following cholecystojejunostomy is presented, and a literature review of known complications of cholecysto-enteric anastomosis was performed. DISCUSSION: Cholangitis is the commonest reported complication, known to predispose the biliary epithelium to malignant change, but has not been described until now as being carcinogenic for the gallbladder. Gallbladder carcinoma may be a rare long-term complication of cholecystojejunostomy.

Capsule endoscopy: a surgical perspective.

BACKGROUND: Capsule endoscopy (CE) is gaining acceptance as an accurate method of imaging the small bowel. However, it is still being assessed for its use in successfully changing management and improving outcomes. We report the initial experience of CE in Tasmania. METHODS: Findings were collected retrospectively for the first 55 consecutive CE carried out in Tasmania from May 2003 to June 2005. One surgeon had carried out and reported on these tests. Findings included indication, previous tests, abnormalities detected, subsequent change in management and outcomes. RESULTS: The median age was 68 years (range 33-87). Fifty-two CE were carried out for obscure gastrointestinal bleeding (23 for overt and 29 for occult bleeding) and 3 for abdominal pain without bleeding. Fifty-six per cent of tests had an abnormal result. Seven laparotomies were carried out to treat the abnormal findings of three suspected small bowel angiodysplasias, two suspected small bowel tumours, one patient with slow small bowel transit and abdominal pain and one patient with suspected Crohn's disease. Two patients died of cardiac arrest within 1 week of surgery, three patients showed improvement of their symptoms of gastrointestinal bleeding, one patient had resection and definitive diagnosis of Crohn's disease and another had excision of a bleeding Meckel's diverticulum. CONCLUSION: CE is an effective investigation for diagnosis of small bowel diseases amenable to medical or surgical management. However, the most appropriate use of this test to achieve an improvement in outcome is yet to be determined.