The fate of laparoscopic adjustable gastric band removal

Background: Long-term complications and lack of weight loss have caused a surge in laparoscopic adjustable gastric band (LAGB) removal. This study reviews the trend of LAGB removal and examines outcomes of patients undergoing subsequent revision bariatric surgery at a single tertiary care centre in Canada. Methods: All LAGB removals performed between January 2008 and December 2016 were reviewed. A subset of patients who underwent revision surgery was then analyzed for patient demographics, weight, body mass index and postoperative complications. Results: During the study period, 211 patients underwent LAGB removal (87.7% female). Most bands were inserted out of province. Reasons for band removal included dysphagia, band slip and weight recidivism. Fifty-nine patients (28%) underwent revision surgery at a mean of 12.8 ± 9.3 (range 0­55) months after LAGB removal. Mean age was 47 ± 9.7 (range 26­63) years, and mean pre-LAGB weight was 131.0 ± 30.0 kg. Following LAGB, the mean weight decreased to 120.5 ± 26.4 kg, but most regained weight after removal to a mean prerevision weight of 125.1 ± 27.0 kg. The lowest mean weight was achieved 12 months after revision surgery (98.7 ± 30.2 kg). The mean percent total weight loss was not significantly different after revision laparoscopic Roux-en-Y gastric bypass compared with revision laparoscopic sleeve gastrectomy (22.8 ± 9.6% v.17.5 ± 6.5%, p = 0.179). The overall revision surgery 30-day complication rate was 18.6% and increased to 23.7% long-term. No deaths occurred. Conclusion: The number of LAGB removals is increasing. Revision bariatric surgery leads to improved weight loss; however, revision surgery is associated with complications.

Contexte: Les complications à long terme et l'absence de perte de poids sont à l'origine de l'augmentation du nombre de retraits d'anneaux gastriques ajustables (AGA) installés par voie laparoscopique. Cette étude se penche sur la tendance aux retraits des AGA et sur les résultats chez les patients qui subissent une chirurgie bari atrique de révision par la suite dans un centre de soins tertiaire au Canada. Méthodes: Tous les retraits d'AGA effectués entre janvier 2008 et décembre 2016 ont été passés en revue. Un sous-groupe de patients ayant subi une chirurgie de révision a ensuite été analysé aux plans des caractéristiques démographiques, de la masse corporelle et des complications postopératoires. Résultats: Pendant la période de l'étude, 211 patients se sont fait retirer leur AGA (87,7 % de femmes). La plupart des anneaux avaient été insérés à l'extérieur de la province. Parmi les raisons invoquées pour les retraits, mentionnons dysphagie, glissement de l'anneau et reprise de poids. Cinquante-neuf patients (28 %) ont subi une chirurgie de révision en moyenne 12,8 ± 9,3 (éventail 0­55) mois après le retrait de l'AGA. L'âge moyen était de 47 ± 9,7 (éventail 26­63) ans et le poids moyen avant l'AGA était de 131,0 ± 30,0 kg. Après l'AGA, le poids moyen a diminué à 120,5 ± 26,4 kg, mais la plupart ont repris du poids après le retrait pour atteindre un poids moyen pré-révision de 125,1 ± 27,0 kg. Le plus bas poids moyen a été atteint 12 mois après la chirurgie de révision (98,7 ± 30,2 kg). La perte de poids totale moyenne en pourcentage n'était pas significativement différente après la dérivation de Roux-en-Y laparoscopique de révision, comparativement à la gastrectomie laparoscopique en manchon de révision (22,8 ± 9,6 % c. 17,5 ± 6,5 %, p = 0,179). Le taux global de complications des révisions chirurgicales à 30 jours a été de 18,6 % et est passé à 23,7 % à plus long terme. Aucun décès n'est survenu. Conclusion: Le nombre de retraits d'AGA est en hausse. La révision de la chirurgie bariatrique a amélioré la perte de poids, mais elle s'accompagne de complications.

Annual colonoscopy volume and maintenance of competency for surgeons.

INTRODUCTION: To determine whether the annual case volume of general surgeons (greater or less than 200 colonoscopies) is associated with quality outcomes. METHODS: This retrospective cohort study involved all adults who underwent colonoscopy by a surgeon in the city of St. John's, NL, during the first 6 months of 2012. Subjects were identified through records from the health authority, and data were recorded on a standardized data sheet. Univariate analysis followed by stepwise multivariable logistic regression was performed to determine whether there was an association between quality outcomes (colonoscopy completion rate, adenoma detection rate) and predictors of these outcomes including annual colonoscopy volume, patient age, gender, indication for colonoscopy, and ASA score. A Chi-squared test was used to determine whether other outcomes were associated with annual colonoscopy volume. RESULTS: Data were collected on 1060 patients. Mean age was 59.5 (sd 12.2) years with 550 females. A total of 13 surgeons were studied, of which 7 performed less than 200 annual colonoscopies over the previous 2 years (low-volume group) and 6 performed more than 200 annual colonoscopies over the previous 2 years (high-volume group). While there was a significant difference in the colonoscopy completion rate favoring the high-volume group (82.2 vs. 91.1 %, p < 0.001), no difference was noted in the adenoma detection rate between groups (16.7 vs. 17.7 %, p = 0.762). The regression model revealed that colonoscopy completion was also associated with an indication of screening or surveillance and an ASA score of 1 or 2. The adenoma detection rate was associated with older age and male gender. There was no statistically significant association between annual colonoscopy volume and other safety outcome measures. CONCLUSION: Performing over 200 colonoscopies annually is associated with higher colonoscopy completion rates, but does not appear to be associated with other quality measures.

Laparoscopic sleeve gastrectomy at a new bariatric surgery centre in Canada: 30-day complication rates using the Clavien-Dindo classification.

BACKGROUND: Newfoundland and Labrador (NL) has the highest rate of obesity in Canada, prompting the establishment of a bariatric surgery program at the Health Sciences Centre in NL. This retrospective study examined 30-day complication rates in more than 200 consecutive patients who underwent laparoscopic sleeve gastrectomy (LSG) between May 2011 and February 2014. METHODS: We performed a chart review and collected data on 30-day postoperative complications. Complications were graded and reported using the Clavien-Dindo classification. Grades I and II were defined as minor and grades III and higher were defined as major complications. RESULTS: We reviewed the charts of the first 209 patients to undergo LSG. The mean body mass index was 49.2, 81% were women and the average age was 43 years. Comorbidities included hypertension (55.0%), obstructive sleep apnea (46.4%), dyslipidemia (42.1%), diabetes (37.3%), osteoarthritis (36.4%) and cardiovascular disease with previous cardiac stents (5.3%). Furthermore, 38.3% of patients reported psychiatric diagnoses, such as depression and anxiety. The overall 30-day complication rate was 15.3%. The complication rate for minor complications was 13.4% and for major complications was 1.9% (2 leaks, 1 stricture and 1 fistula). CONCLUSION: Our results support the feasibility of safely performing LSG surgery at bariatric centres completing fewer than 125 procedures annually.

CONTEXTE: Comme la province de Terre-Neuve-et-Labrador (T.-N.-L.) a le taux d'obésité le plus élevé au Canada, un programme de chirurgie bariatrique a été mis en place au Centre des sciences de la santé de T.-N.-L. La présente étude rétrospective a étudié les taux de complications dans les 30 premiers jours chez plus de 200 patients consécutifs ayant subi une gastrectomie longitudinale laparoscopique (GLL) entre mai 2011 et février 2014. MÉTHODES: Après avoir effectué une analyse des dossiers et recueilli des données sur les complications postopératoires survenues dans les 30 jours, nous avons évalué et consigné les complications à l'aide de la classification de Clavien­Dindo. Les grades I et II étaient des complications mineures et les grades III et plus, des complications majeures. RÉSULTANTS: Nous avons analysé les dossiers des 209 premiers patients à avoir subi une GLL. L'indice de masse corporelle moyen était de 49,2, 81 % des patients étaient des femmes et l'âge moyen était de 43 ans. Les comorbidités comprenaient l'hypertension (55,0 %), l'apnée obstructive du sommeil (46,4 %), la dyslipidémie (42,1 %), le diabète (37,3 %), l'arthrose (36,4 %) et les maladies cardiovasculaires avec des antécédents d'endoprothèses cardiaques (5,3 %). De plus, 38,3 % des patients ont mentionné un diagnostic psychiatrique, comme la dépression ou l'anxiété. Le taux global de complications dans les 30 jours était de 15,3 %. Le taux de complications mineures était de 13,4 % et celui de complications majeures, de 1,9 % (2 fuites, 1 striction et 1 fistule). CONCLUSION: Nos résultats viennent confirmer qu'il est possible d'effectuer des GLL de façon sécuritaire dans les centres bariatriques qui pratiquent moins de 125 interventions par année.

The Evolution of EUS-Guided Transluminal Drainage for the Treatment of Pancreatic Fluid Collections: A Comparison of Clinical and Cost Outcomes with Double-Pigtail Plastic Stents, Conventional Metal Stents and Lumen-Apposing Metal Stents.

BACKGROUND: While most pancreatic fluid collections (PFCs) resolve spontaneously, endoscopic ultrasound-guided transluminal drainage (EUS-TD) may be necessary. EUS-TD has evolved from multiple double-pigtail plastic stents (DPPS) to fully covered self-expanding metal stents (FCSEMS) and lumen-apposing metal stents (LAMS). This study compares clinical attributes of DPPS, FCSEMS and LAMS. METHODS: This is a single-centre retrospective review of EUS-TD for PFCs. The primary outcome was clinical success. Secondary outcomes were technical success, procedure time, hospital length of stay (HLOS), number of endoscopies, need for necrosectomy, adverse events (AEs) and overall cost. RESULTS: Fifty-eight patients (37 male, average age 49 years) underwent a total of 60 EUS-TD procedures for PFCs (average size 11.2 cm with 29 pseudocysts and 29 walled-off necrosis). Ten patients (17%) underwent EUS-TD with DPPS and 48 patients (83%) with metal stents (32 FCSEMS, 16 LAMS). Overall technical and clinical success was 100% and 84%, respectively. Lumen-apposing metal stents had shorter procedure times (14.9 versus 63.6 DPPS, 39.1 min FCSEMS, P < 0.001), and no difference in AEs (3 of 16 versus 4 of 10 DPPS, 12 of 34 FCSEMS, ns). Double-pigtail plastic stents required more endoscopies (3.7 versus 2.3 LAMS, 2.3 FCSEMS, P = 0.013) and necrosectomies (4 of 10 [40%]) compared with 5 of 34 [15%] in the FCSEMS group and 3 of 16 [19%] in the LAMS group, respectively, P = 0.001) to achieve clinical resolution. The overall cost and HLOS was not significantly different between groups. CONCLUSION: The use of LAMS for PFCs is not associated with any significant increase in cost despite technical (shorter procedure time) and clinical advantages (shorter indwell time, reduced need for necrosectomy and no increase in AEs).

Long-term follow-up in patients with gastric antral vascular ectasia (GAVE) after treatment with endoscopic band ligation (EBL).

Background and study aims Gastric antral vascular ectasia (GAVE) is a capillary-type vascular malformation of the gastric antrum, usually diagnosed endoscopically in patients presenting with iron deficiency anemia or gastrointestinal bleeding. While there is established evidence for treatment with thermal modalities, such as argon plasma coagulation (APC) therapy, more recent studies have shown endoscopic band ligation (EBL) to be safe and effective in achieving remission. Our study aimed to evaluate long-term outcomes of patients with GAVE who underwent EBL at our institution. Patients and methods We retrospectively reviewed data from 33 patients with GAVE who underwent esophagogastroduodenoscopy and EBL between September 2012 and July 2017 within our institution, looking primarily at clinical response, recurrence, and blood transfusion requirements. Results Clinical response was achieved in 27 patients (81.8%). Among responders, recurrence-free survival decreased with time from 88 % at 1 year to 44 % at 2 years. Thirteen patients (48.1 %) had recurrence of GAVE at a mean time of 18.2 months (range 4.7 - 51.8). The only predictor of recurrence was greater number of pre-procedure blood transfusions. Conclusion This is the first study to evaluate long-term response and recurrence in patients with GAVE after treatment with EBL and predictors of clinical response after initial endoscopic therapy have been identified. While we were able to demonstrate excellent remission achievement rates in our GAVE patients who had undergone EBL, close clinical follow-up is clearly required as almost 50 % will have recurrence at around 18 months.

Acute acalculous cholecystitis of an intrahepatic gallbladder causing Mirizzi's syndrome.

We present the case of a young female with symptoms of biliary colic and a biochemical profile consistent with biliary obstruction. Imaging was suspicious for Mirizzi's syndrome. Intraoperatively, the patient was found to have a complete intrahepatic gallbladder causing common hepatic duct compression with final pathology confirming acute cholecystitis. We review the embryological development of the gallbladder as well as clinical presentation of Mirizzi's syndrome. Special consideration for clinical workup and surgical management is discussed.

Endoscopic diagnosis of a goblet cell carcinoid tumour of the appendix.

Primary malignancies of the appendix are rare. Of these, less than 5% are goblet cell carcinoid (GCC) tumours. The majority of GCC present with findings of acute appendicitis or advanced peritoneal spread. We describe a rare presentation of GCC as subtle mucosal abnormality of the appendiceal orifice seen on colonoscopy performed for iron-deficiency anaemia. Biopsies were interpreted as adenocarcinoma; however, final surgical pathology confirmed GCC of the appendix with caecal involvement. The patient recovered well from surgery, anaemia resolved and follow-up did not show metastatic disease.