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.

Optimal common limb length in Roux-en-Y gastric bypass surgery: is it important for an ideal outcome? - a systematic review.

BACKGROUND: In Roux-en-Y gastric bypass (RYGB) surgery the common limb length (CLL) is thought to significantly impact on nutritional and metabolic outcomes. However, there has been little focus on establishing routine standardized CLL measurements and its subsequent effect on weight loss and nutritional status. This review aimed to determine the effect of variations of CLL in RYGB surgery on post-operative outcomes, particularly nutritional status, while considering the need for routine CLL measurements in addition to measuring biliopancreatic limb and alimentary limb lengths. METHODS: A systematic review was performed in accordance with the PRISMA guidelines. All English language articles addressing CLL and impact on weight loss, nutritional and metabolic outcomes were retrieved and reviewed. RESULTS: Thirteen relevant studies were identified with CLLs varying from 76 to >600 cm. No significant difference in total body weight loss or excess weight loss was observed. Significant metabolic improvements occurred with shorter CLLs. Nutritional deficiencies were more severe when the CLL was <400 cm. CONCLUSION: The data from this systematic review suggests that reasonable weight loss and positive impacts on metabolic outcomes can be achieved with CLLs of >400 cm.

Gastric Ischaemia After SADI with Right Gastric Artery Ligation.

There are several bariatric procedures used for the effective management of obesity that employ restrictive or malabsorptive components to achieve effective weight loss and reduction in metabolic disease. The single anastomosis duodeno-ileal (SADI) bypass was first introduced as a simplification of the biliopancreatic diversion with a duodenal switch [1], often accompanied by sleeve gastrectomy (SADI-S) or as an alternative gastric sleeve revision procedure to Roux-en-Y gastric bypass [2]. SADI was developed to address the technical complexity associated with other bypass reconstructions by involving only one anastomosis while preserving pyloric function, minimising dumping symptoms. This procedure has been proven to be safe and effective for sustained weight loss and resolution of metabolic disease, particularly in patients with a high carbohydrate diet [3, 4]. Currently, the SADI/SADI-S procedure is still considered a relatively novel technique with no absolute consensus over the exact surgical technique, and serious postoperative complications can still occur. A key discussion point is the utility of right gastric artery ligation depending on surgeon preference. This paper aims to describe the presentation and management of the first reported case of gastric ischaemia following sleeve to SADI revision with right gastric artery ligation.

Systematic Review of Thrombolysis Therapy in the Management of Non-Cirrhosis-Related Portal Vein Thrombosis.

PURPOSE: To review available evidence to assess the efficacy and safety of thrombolysis therapy for non-cirrhosis-related portal vein thrombosis (PVT) that has not improved with anti-coagulation. METHODS: A literature search of databases MEDLINE, EMBASE, PUBMED, Cochrane and World Wide Web identified studies after 2000 utilizing portal vein thrombolysis in non-cirrhotic patients, with a minimum of 5 patients. Nine studies met criteria with 134 patients. The primary outcome evaluated was radiological re-canalization of the portal vein and symptomatic improvement post treatment. Secondary data points obtained included morbidity, mortality, thrombolysis approach and technique. RESULTS: The re-canalization rate following thrombolysis was 84% (0.67-1.02 CI 95%) and the symptomatic improvement rate 86% (0.70-1.01 CI 95%). The major complication rate was 7% (0.01-0.14 CI 95%) and the overall complication rate 25% (0.08-0.41 CI 95%). The direct and systemic thrombolysis approach showed no significant re-canalization rates with an odds ratio of 0.78 (0.24-2.55 CI 95%, P = 0.68). Thrombectomy in conjunction with thrombolysis demonstrated no improved patency or symptom relief with an odds ratio of 1 (0.17-6.03 CI 95%, P = 1.00). CONCLUSION: Thrombolysis is an effective and safe therapy for portal vein thrombosis in non-cirrhotic patients where systemic anti-coagulation has failed. The heterogenicity of study thrombolysis protocols limits the evaluation of secondary outcomes, and future data should be standardized to determine the role of the thrombolysis access route and thrombectomy.

Review of the Endoscopic, Surgical and Radiological Techniques of Treating Choledocholithiasis in Bariatric Roux-en-Y Gastric Bypass Patients and Proposed Management Algorithm.

Choledocholithiasis in post-surgical bariatric Roux-en-Y gastric bypass patients presents a significant challenge secondary to altered anatomy. We aim to review the existing management options including either endoscopic, surgical, percutaneous or hybrid means. Current literature suggests reasonably successful cannulation rates for single- or double-balloon ERCP ranging from 50 to 70% and 63-83%, respectively. The hybrid technique of laparoscopic transgastric ERCP has gained popularity with success rates ranging from 90 to 100%. Conventional laparoscopic techniques like transcystic duct and transcholedochal bile duct exploration are still useful options (i.e. high success rates of 81-100% and 83-96%, respectively). The role of percutaneous transhepatic choledochography remains limited although it can help with rapid bile duct decompression. If feasible, treatment pathways should progress from least to more invasive options as required.

Necrotising soft tissue infection in western Sydney: An 8-year experience.

BACKGROUND: This study aimed to assess the risk factors, management, imaging validity, Laboratory Risk Indicator for Necrotising infection (LRINEC) score and outcomes of necrotising soft tissue infection (NSTI) at a western Sydney tertiary hospital. METHODS: A retrospective study was conducted of all patients with NSTI from 2012 to 2019 at our institution. Patient characteristics, imaging, microbiology and site, LRINEC score, surgical management and outcomes/disposition were collected. RESULTS: Thirty-six patients met the inclusion criteria with mean age of 52 years and body mass index of 38.1; 55.6% were male, 48% of Polynesian descent and 55.6% were diabetic. The most frequent sites of NSTI were perineal (30.6%), lower limb (30.6%), perianal (19.3%) and trunk (11.1%). A total of 64% of patients underwent computed tomography radiological imaging with diagnostic accuracy of 50%. The mean LRINEC score was 7 (1-20). A total of 52.8% were transferred from another facility or non-surgical teams which delayed surgical review by 11.4 h (P < 0.03) and operating time by 12.4 h (P < 0.04) compared with direct emergency department referrals to the on-call surgical team. There was no statistical difference in outcomes in both groups. The overall average time to surgical debridement was 16.2 h (standard deviation 19.6, range 3.4-105.1). The mean hospital length of stay was 20.9 days; 44.4% of patients were transferred for rehabilitation or plastic reconstruction with a single mortality from multi-organ failure. CONCLUSION: The optimal management of NSTI requires a high index of suspicion and LRINEC score is a useful adjunct in aiding a clinician's decision. Early surgical debridement within 24 h of diagnosis and a multidisciplinary approach is associated with a lower mortality rate.

Role of bariatric surgery in a COVID-19 era: a review of economic costs.

Obesity has rapidly become a significant public health issue. As the prevalence of obesity continues to rise, so does its economic burden as a result of both direct and indirect costs. Likewise, since 2019, the coronavirus disease of 2019 (COVID-19) has become a global pandemic with rising infection rates carrying significant economic costs associated with treatment of the disease and the reduction in economic activity due to government regulations. The COVID-19 pandemic has had a detrimental impact on obesity, not only creating an increasingly obesogenic environment but also reducing access to bariatric care and treatment of obesity-related diseases. In this article, we form a compelling argument for the resumption of bariatric services as soon as it is safe to do so because bariatric surgery brings significant additional medical and economic benefits. Medically, obesity is a risk factor for increased severity of COVID-19 infections, and therefore, treatment of obesity should be a priority in the current pandemic. Additionally, bariatric surgery has been shown to be a cost-saving procedure in the long term and thus has significant economic benefit in reducing the costs of obesity in the future as we recover from the economic collapse following the global pandemic.

Systematic Review and Meta-Analysis of Endoscopic Sleeve Gastroplasty with Comparison to Laparoscopic Sleeve Gastrectomy.

PURPOSE: Endoscopic sleeve gastroplasty (ESG) has grown in popularity as a potential minimally invasive bariatric procedure with acceptable short- and medium-term outcomes. This review aims to assess the safety and weight loss outcomes of ESG and compare it with laparoscopic sleeve gastrectomy (LSG). MATERIAL AND METHODS: A comprehensive search of MEDLINE, EMBASE, Cochrane and World Wide Web was conducted. RESULTS: Five studies were reviewed, three ESG cohort studies and two case-matched cohort studies comparing ESG with LSG. Total unique ESG and LSG patients were 1451 and 203, respectively. All papers demonstrated a modest short-term total body weight loss (TBWL%) at 6 months ranging from 13.7 to 15.2% for ESG. Comparably, the two LSG papers demonstrated a superior TBWL% of 23.5 and 23.6% at 6 months, with one paper reporting a 12-month TBWL% of 29.3%. Two ESG papers reported medium-term results at 18 and 24 months of 14.8% and 18.6%, respectively. Excluding Clavien-Dindo 1 complications, ESG had a complication rate between 2.0 and 2.7%, while comparatively, LSG had a complication rate between 9.2 and 16.9% (current literature reported as 8.7%). In both procedures, there were no grade IV or V complications. CONCLUSION: ESG when compared with LSG has lower short-term weight loss outcomes with fewer complications. Weight loss results for ESG appear to plateau after the 1-year mark. The future and uptake of ESG as a minimally invasive bariatric procedure will be determined by its long-term data on potential weight loss sustainability.

Reversal of endoscopic sleeve gastroplasty and conversion to sleeve gastrectomy - Two case reports.

INTRODUCTION: With the advent of more minimally invasive procedures like endoscopic sleeve gastroplasty (ESG) for weight loss and metabolic disorders, we are seeing more cases of patients presenting with sub-optimal results for consideration of alternative weight loss surgery. The report aims to describe our experience in converting ESG to laparoscopic sleeve gastrectomy and highlight our suggested technique, challenges and pitfalls. PRESENTATION OF CASES: We described two bariatrics cases detailing our findings on initial endoscopy along with methods used to reverse ESG hardware, followed by issues encountered during sleeve gastrectomy 1 month later. Case 1 being of a 33 year old female (BMI - 50.7) with previous laparoscopic band removal and 2 ESG attempts, while case 2 is a 31 year old female (BMI 44.6) with previously failed gastric balloon and ESG. DISCUSSION: ESG reversal was performed without difficulty via endoscopy with visible sutures cut and hardware removed with snares. In both cases, the stomach was easily endoscopically distensible. During sleeve gastrectomy, extra-gastric adhesions along with more gastro-gastric sutures were encountered in case 1. In case 2, ESG hardware was noted on the external surface of stomach with misfiring of 3rd stapler reload during sleeve gastrectomy likely related to unidentified retained hardware. No post-operative complications occurred in either of the cases with adequate weight loss on one month follow up. CONCLUSION: In our experience, ESG conversion to sleeve gastrectomy is feasible and for the most part, uncomplicated. In our case series, we described a two staged approach to conversion although a single staged conversion is theoretically feasible.

Fate of Abstracts Presented at the Transplantation Society of Australia and New Zealand Annual Scientific Meetings.

BACKGROUND: The numbers and characteristics of the abstracts presented at the Annual Scientific Meetings (ASM) of the Transplantation Society of Australia and New Zealand (TSANZ) that are converted to peer-reviewed publications have not been analyzed previously. METHODS: All abstracts presented at the TSANZ ASM from 2013 to 2017 were reviewed. A literature search was performed using a search algorithm to identify the full-text publications of the presented abstracts. Correlation between abstract characteristics and publication rate was then examined using Cox proportional hazards regression and Kaplan-Meier curves to distinguish the predictors for publication. Over the 5-year period, 576 abstracts were presented, with a total of 164 (28.6%) presentations converted to publications. The majority of publications occurred within the first 3 years, with the mean time to publication being 16.6 (standard deviation = 14.6) months. The median impact factor for published research was 4.74 (interquartile range = 3.06-5.58). Multivariate analysis identified clinical science papers, systematic reviews and surveys (likelihood ratio = 1.42, 5.02, and 2.01; P = .040, .000, and .010, respectively) as the most important predictors for publication. CONCLUSIONS: The rate of abstracts presented at the TSANZ ASM over 5 years that were converted to publication in a peer-reviewed journal was 28.6%. Clinical papers, systematic reviews, and surveys were more likely to be published. An ongoing strict abstract selection process will contribute to improving conversion of abstracts into full-text peer-reviewed articles.

Systematic review and meta-analysis of laparoscopic versus open distal gastrectomy.

BACKGROUND: Laparoscopic distal gastrectomy has been increasingly utilized in the treatment of gastric adenocarcinoma. This study aims to compare the morbidity/mortality and postoperative outcomes of laparoscopic-assisted versus open distal gastrectomy since 2000. METHODS: A comprehensive search of MEDLINE and EMBASE was conducted including studies published between 2000 and present. RESULTS: Seventeen studies with a total of 7,109 distal gastrectomies (3,496 lap vs 3,613 open) were included. Across all studies, postoperative morbidity rates for laparoscopic gastrectomy were lower than that of open [median (range) 10 (0-36) % vs 17 (0-43) %]. Meta-analysis of postoperative morbidity rates in prospective studies only yielded pooled odds ratio of 0.52 (95 % CI 0.33-0.81) (P = 0.004). In-hospital mortality rates were comparable between the two (range: laparoscopic 0-3.3 vs open 0-6.7 %). The long-term oncological outcomes of resection were difficult to analyze given variable reporting but appeared similar between the two. Meta-analysis of prospective studies showed that laparoscopic-assisted distal gastrectomy was associated with significantly shorter hospital length of stay [standard mean difference (SMD) = -0.78 (95 % CI = -1.0 to -0.56)], comparable intraoperative bleeding [SMD = 0.64 (95 % CI = -1.3-0.0430) P = 0.066] and longer operative time compared to open gastrectomy [1.9 (95 % CI 0.05-3.8) P = 0.045, with P < 0.001]. CONCLUSION: This study supports the use of laparoscopic-assisted distal gastrectomy for treatment of gastric adenocarcinoma with evidence of comparable, if not better, short-term postoperative parameters when compared to open distal gastrectomy. The long-term oncological outcomes appear similar but may require more evaluation.