Current recommendations for procedure selection in class I and II obesity developed by an expert modified Delphi consensus.

Metabolic and bariatric surgery (MBS) is widely considered the most effective option for treating obesity, a chronic, relapsing, and progressive disease. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued new guidelines on the indications for MBS, which have superseded the previous 1991 National Institutes of Health guidelines. The aim of this study is to establish the first set of consensus guidelines for selecting procedures in Class I and II obesity, using an Expert Modified Delphi Method. In this study, 78 experienced bariatric surgeons from 32 countries participated in a two-round Modified Delphi consensus voting process. The threshold for consensus was set at an agreement or disagreement of ≥ 70.0% among the experts. The experts reached a consensus on 54 statements. The committee of experts reached a consensus that MBS is a cost-effective treatment option for Class II obesity and for patients with Class I obesity who have not achieved significant weight loss through non-surgical methods. MBS was also considered suitable for patients with Type 2 diabetes mellitus (T2DM) and a body mass index (BMI) of 30 kg/m2 or higher. The committee identified intra-gastric balloon (IGB) as a treatment option for patients with class I obesity and endoscopic sleeve gastroplasty (ESG) as an option for patients with class I and II obesity, as well as for patients with T2DM and a BMI of ≥ 30 kg/m2. Sleeve gastrectomy (1) and Roux-en-Y gastric bypass (RYGB) were also recognized as viable treatment options for these patient groups. The committee also agreed that one anastomosis gastric bypass (OAGB) is a suitable option for patients with Class II obesity and T2DM, regardless of the presence or severity of obesity-related medical problems. The recommendations for selecting procedures in Class I and II obesity, developed through an Expert Modified Delphi Consensus, suggest that the use of standard primary bariatric endoscopic (IGB, ESG) and surgical procedures (SG, RYGB, OAGB) are acceptable in these patient groups, as consensus was reached regarding these procedures. However, randomized controlled trials are still needed in Class I and II Obesity to identify the best treatment approach for these patients in the future.

The existing scenario of haemophilia care in Canada and China - A review

ABSTRACT Hemophilia is an X-linked recessive genetic disorder which affects approximately 400,000 people globally. Differing healthcare reimbursement systems, budgetary constraints and geographical and cultural factors make it difficult for any country to fully deliver ideal care. Although developed countries have sufficient treatment products available, they are burdened by the higher expectation of outcomes, coupled with insufficient supportive care to monitor adherence and outcomes and to implement regular follow-up. In contrast, developing regions may not have ready access to factor replacement, but have developed excellent physiotherapy and rehabilitation programs. Although there are multiple studies that have attempted to assess country-specific variations in hemophilia care, very few compare hemophilia care between economically unequal countries and the challenges in achieving optimal hemophilia care. This literature review tries to bridge this gap and throws light on the country-specific differences in epidemiology, standard of hemophilia care and challenges faced in Canada and China. Data sources resulted in 20 studies (11 from Canada and 9 from China), which were reviewed. In a developed country, the main advantages are: the early treatment of bleeding episodes and the presence of a specialized interdisciplinary and comprehensive treatment concept. This is not the case in most developing countries, where the government does not have the resources to buy the necessary quantities of coagulation factors in the face of more urgent health priorities and hardly a few patients can afford to pay for their own treatment, even the on-demand home therapy.

The existing scenario of haemophilia care in Canada and China - A review.

Hemophilia is an X-linked recessive genetic disorder which affects approximately 400,000 people globally. Differing healthcare reimbursement systems, budgetary constraints and geographical and cultural factors make it difficult for any country to fully deliver ideal care. Although developed countries have sufficient treatment products available, they are burdened by the higher expectation of outcomes, coupled with insufficient supportive care to monitor adherence and outcomes and to implement regular follow-up. In contrast, developing regions may not have ready access to factor replacement, but have developed excellent physiotherapy and rehabilitation programs. Although there are multiple studies that have attempted to assess country-specific variations in hemophilia care, very few compare hemophilia care between economically unequal countries and the challenges in achieving optimal hemophilia care. This literature review tries to bridge this gap and throws light on the country-specific differences in epidemiology, standard of hemophilia care and challenges faced in Canada and China. Data sources resulted in 20 studies (11 from Canada and 9 from China), which were reviewed. In a developed country, the main advantages are: the early treatment of bleeding episodes and the presence of a specialized interdisciplinary and comprehensive treatment concept. This is not the case in most developing countries, where the government does not have the resources to buy the necessary quantities of coagulation factors in the face of more urgent health priorities and hardly a few patients can afford to pay for their own treatment, even the on-demand home therapy.

Is red meat intake a risk factor for breast cancer among premenopausal women?

Breast cancer is the second leading cause of cancer deaths in women today and is the most common cancer among women. Although a number of risk factors such as genetics, family history, parity, age at first birth, and age at menarche and menopause have been established, most are difficult to modify. Diet, however, is a potentially modifiable approach for prevention and a variety of dietary patterns have been examined with respect to their role in breast cancer. One such dietary factor is red meat consumption. Red meat intake has been hypothesized to increase breast cancer risk but while both case-control and ecologic studies have supported a positive association, prospective cohort studies have been inconsistent. One explanation for this inconsistency may be related to menopausal status. We performed a meta-analysis on the association between breast cancer risk and red meat consumption in premenopausal women. A total of ten studies were identified. The summary relative risk was 1.24 (95% CI 1.08-1.42). Case-control studies (N = 7) had a risk of 1.57 (95% CI 1.23-1.99), while cohort studies (N = 3) had a summary relative risk of 1.11 (95% CI 0.94-1.31).

The feasibility of introducing advanced minimally invasive surgery into surgical practice.

BACKGROUND: This study investigates the feasibility of performing advanced minimally invasive surgery (MIS) in a nonspecialized practice environment. METHODS: We conducted a cross-sectional survey of all community general surgeons currently practising in Ontario. RESULTS: Few community surgeons perform a high volume (> 10 procedures per yr) of advanced MIS. Most (70%) believe it is important to acquire additional skills in advanced MIS. The most appropriate methods for learning advanced MIS are believed to be expert mentoring (79.7%), courses (77.2%) and a colleague mentor (63.9%). A total of 57.6% of respondents have attended a course in MIS while in practice, and most have access to a reasonable variety of instrumentation. Respondents believe that 57.6% of assistants, 54.8% of nurses and 43.4% of anaesthetists are relatively inexperienced with advanced MIS. Barriers to establishing advanced MIS include limited operating room access (50%), resources or equipment (45.2%) and limited expert mentoring (43.6%). Surgeons with less than 10 years of practice found lack of trained nursing staff (7.9% v. 4.2%, p = 0.01) and experienced assistants (12% v. 6.2%, p = 0.008) to be more important barriers than did those with over 10 years of practice, respectively. CONCLUSION: Most general surgeons working in Ontario are self-taught with respect to MIS skills, and few perform a high volume of advanced MIS. Only one-half of all respondents have access to skilled MIS operating room nurses, surgical assistants or anesthesiology. Despite this, general surgeons perceive the greatest barriers to introducing advanced MIS procedures to be limited access to operating rooms, resources or equipment and limited mentoring. This study has shown that the role of the surgical team in advanced MIS may be underestimated by many general surgeons. These data have important implications in training general surgeons and in incorporating additional advanced MIS procedures into the armamentarium of general surgeons.

Splenic malignancy: a minimally invasive approach.

UNLABELLED: Since the advent of laparoscopy and its general acceptance for treating benign diseases, indications for malignant disease have been investigated. Recently, greater evidence shows that laparoscopy for malignant disease is oncologically safe. DESIGN: We review a minimally invasive approach to splenic malignancy and the common malignant diseases involving the spleen. We outline our preferred technique for splenectomy in detail. Additionally, the recent literature is reviewed regarding outcome after laparoscopic splenectomy for benign and malignant disease. The data from three studies, containing a total of 327 were analyzed. Complication rates, mortality, and length of stay were compared. RESULTS: There was no statistically significant difference identified between those undergoing laparoscopic splenectomy for benign versus malignant disease in terms of length of stay, complication rate or mortality. There were significant differences between the two groups in terms of operative time and spleen weight. DISCUSSION: In open splenectomy series for patients with malignant diseases of the spleen, complication and mortality are much higher when compared to those patients undergoing open splenectomy for benign disease. The discussed series show no difference in endpoints when laparoscopy is used. Laparoscopic splenectomy for malignant disease confers significant benefit and rapid recovery for an otherwise at risk population.

Device-related reoperations after laparoscopic adjustable gastric banding.

Laparoscopic adjustable gastric banding (LAGB) is considered a relatively safe weight loss procedure with low morbidity. When complications occur, obstruction, erosion, and port malfunction require reoperation. We retrospectively reviewed our experience with 270 consecutive patients who underwent LAGB. Device-related reoperations were performed in 26 (10%) patients. Reoperations were related to the band in 13, to port/tubing in 11, and related to both in 2 patients. Of the 15 band-related problems, it was removed in 5 (2%): slippage (3), intra-abdominal abscess (1), and during emergent operation for bleeding duodenal ulcer (1). Revision or immediate replacement was performed in 10 (4%): slippage (5), obstruction (4), and leak from the reservoir (1). Port/tubing problems were the reason for reoperations in 13 (5%): infection (5), crack at tubing-port connection (6), and port rotation (2). Port removal for infection was followed later by port replacement (average 9 months). Overall, slippage occurred in 8 (3%), obstruction in 4 (1.5%), leak from reservoir in 7 (3%), and infection in 5 (2%) patients. Fifteen device-related problems occurred during our first 100 cases and 12 subsequently (P = 0.057). Permanent LapBand loss was only 5 per cent, leading to overall rate of 95 per cent of LapBand preservation as a restrictive device.

Esophageal leiomyomatosis.

BACKGROUND: Esophageal leiomyomatosis is rare with an incidence that is essentially unknown with only a few reported cases. Characteristically there is proliferation of smooth muscle cells in the esophageal wall causing localized circumferential thickening. Esophageal leiomyomas are usually very slow growing and often asymptomatic. Symptomatic tumors are usually greater than five centimeters in diameter. The accepted treatment for esophageal leiomyomatosis has been surgical removal, which frequently requires esophagectomy with reconstruction. CASE REPORT: We report a case of a 29-year-old woman with esophageal leiomyomatosis whose presentation was not typical and magnetic resonance imaging proved diagnostic. This patient was effectively with enucleation of the tumor. CONCLUSIONS: Recommended treatment for this condition has been total esophagectomy with reconstruction, but we report a case treated with enucleation of the tumor.