A two-consultant approach is a safe and efficient strategy to adopt during the learning curve for laparoscopic Roux-en-Y gastric bypass: our results in the first 100 procedures.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) can be technically challenging. It is imperative that patient morbidity and mortality are minimized while teams are on the learning curve for this procedure. METHODS: This retrospective study evaluated the peri-operative risk of LRYGBP utilizing a two-consultant surgeon approach in a newly established bariatric service. 100 consecutive patients undergoing LRYGBP were included. Two consultants participated in each procedure. RESULTS: Median operative duration was 113 minutes (range 80-240) and fell with increasing experience [127 minutes (range 90-240) in cases 1-50 and 105 minutes (range 80-210) in cases 51-100; P=0.009]. Multivariate analysis found operation time correlated only with number of procedures performed (P<0.001). There were no conversions to laparotomy. Intra-operatively, 2 patients had hand-assisted completion of the jejuno-jejunostomy, and 2 underwent laparoscopic revision of the reconstruction. Postoperative complications were observed in 8 patients on the operative admission. Median stay was 4 days (range 3-7). 4 patients required readmission. There was no mortality. Percentage of excess BMI loss was 47%, 53% and 70% at 3, 6 and 12 months respectively. CONCLUSION: A learning curve for LRYGBP is evidenced in this series by reduction in operative time with increasing experience. Complication rates in line with large published series can be achieved by adopting a two-surgeon approach, which we propose as a safe method to adopt in the development of new bariatric services.

Multiple-choice examinations: adopting an evidence-based approach to exam technique.

Negatively marked multiple-choice questions (MCQs) are part of the assessment process in both the Primary and Final examinations for the fellowship of the Royal College of Anaesthetists. It is said that candidates who guess will lose marks in the MCQ paper. We studied candidates attending a pre-examination revision course and have shown that an evaluation of examination technique is an important part of an individual's preparation. All candidates benefited substantially from backing their educated guesses while only 3 out of 27 lost marks from backing their wild guesses. Failure to appreciate the relationship between knowledge and technique may significantly affect a candidate's performance in the examination.

An unusual presentation of meningitis as a consequence of inadvertent dural puncture.

Bacterial meningitis and aseptic meningitis have been reported as a consequence of spinal anaesthesia. The case we report is of an unusual presentation of meningitis, for which no cause was found, in a patient who received epidural anaesthesia, complicated by dural puncture.

Acute infective airway obstruction associated with subglottic stenosis.

Pre-existing subglottic stenosis in a 22-month-old child with laryngotracheobronchitis resulted in failure to intubate the trachea on the intensive therapy unit. Tracheostomy was necessary in the operating theatre to secure the airway. The implications for safe management are discussed.

A new dual function nerve stimulator.

The Duostim model TV02 is a new peripheral nerve stimulator designed both for nerve identification in the performance of regional anaesthesia and for monitoring neuromuscular blockade. The output pulses are unipolar and of adjustable constant current. The provision of single twitch (1 Hz and 1/15 Hz) train-of-four and tetanic stimuli, together with indication of the current delivered and the small size of the unit, facilitate its clinical use. Performance was assessed and found to be according to specification.

A modified expiratory valve for teaching.

The shrouding of anaesthetic expiratory valves prevents the anaesthetist from either seeing valve disc movement or hearing clearly the escape of gas during expiration. A modification to one type of valve (Medishield II) is described which replaces this lost information by providing a direct indication of valve opening.