A Video-Based Review of Important Technical Concepts in the Nissen-Sleeve Gastrectomy.

PURPOSE: The development of gastroesophageal reflux disease (GERD) is a commonly encountered scenario after sleeve gastrectomy. A recently reported technical amendment to incorporate a Nissen fundoplication is discussed in this multimedia article focussing on optimising outcomes and reducing complications. MATERIALS AND METHODS: An intraoperative video has been edited to demonstrate the Nissen-Sleeve Gastrectomy and important technical considerations in its technical performance. RESULTS: Gastrolysis is performed proximally from 6 cm proximal to the pylorus. Routine full mediastinal mobilisation of the oesophagus (5 cm) is completed. Cruroplasty is routinely performed. A short Nissen fundoplication is completed calibrated on a 37 French bougie and then sleeve gastrectomy is performed. Our team's experience suggests that careful manipulation of the fundus and using reproducible measurements of the fundus are key to completing the fundoplication whilst minimising complications. A control test with mobilisation of the bougie through the wrap is recommended at the end of the procedure. CONCLUSION: The Nissen-Sleeve Gastrectomy, as presented in this video, is safe and has good short-term efficacy outcomes. Longer term and randomised studies are ongoing.

Network Meta-Analysis of Metabolic Surgery Procedures for the Treatment of Obesity and Diabetes.

BACKGROUND: Metabolic surgery is part of a well-established treatment intensification strategy for obesity and its related comorbidities including type 2 diabetes (T2DM). Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG) and one-anastomosis gastric bypass (OAGB) are the most commonly performed metabolic surgeries worldwide, but comparative efficacy is uncertain. This study employed network meta-analysis to compare weight loss, T2DM remission and perioperative complications in adults between RYGB, SG and OAGB. METHODS: MEDLINE, EMBASE, trial registries were searched for randomised trials comparing RYGB, SG and OAGB. Study outcomes were excess weight loss (at 1, 2 and 3-5 years), trial-defined T2DM remission at any time point and perioperative complications. RESULTS: Twenty randomised controlled trials were included involving 1803 patients investigating the three metabolic surgical interventions. RYGB was the index for comparison. The excess weight loss (EWL) demonstrated minor differences at 1 and 2 years, but no differences between interventions at 3-5 years. T2DM remission was more likely to occur with either RYGB or OAGB when compared to SG. Perioperative complications were higher with RYGB when compared to either SG or OAGB. Two-way analysis of EWL and T2DM remission against the risk of perioperative complications demonstrated OAGB was the most positive on this assessment at all time points. CONCLUSION: OAGB offers comparable metabolic control through weight loss and T2DM remission to RYGB and SG whilst minimising perioperative complications. Registration number: CRD42020199779 (https:// www.crd.york.ac.uk/PROSPERO ).

Obstructive sleep apnea remission following bariatric surgery: a national registry cohort study.

BACKGROUND: Obstructive sleep apnea (OSA) is strongly associated with metabolic syndrome. Bariatric surgery is an effective available treatment for OSA; however, limited research predicts which patients undergoing bariatric surgery will undergo OSA resolution. OBJECTIVES: To determine perioperative predictors for OSA resolution following bariatric surgery using a national database. SETTING: United Kingdom national bariatric surgery database. METHODS: The UK National Bariatric Surgery Registry (NBSR) was interrogated to identify all patients with OSA that underwent primary bariatric surgery between January 2009 and June 2017. Those with at least 1 follow-up recording postoperative OSA status were selected for further analysis. Demographic, pre- and postoperative outcomes were collected and analyzed. Poisson multivariate regression was conducted to identify predictors of OSA remission. RESULTS: A total of 4015 bariatric cases were eligible for inclusion: 2482 (61.8%) patients underwent laparoscopic Roux-en-Y gastric bypass (LRYGB), 1196 (29.8%) sleeve gastrectomy (LSG), and 337 (8.4%) adjustable gastric banding (LAGB). Overall, the mean excess weight loss (EWL) % for the whole group was 61.2 (SD ± 27.2). OSA resolution was recorded in 2377 (59.2%) patients. Following Poisson regression, LRYGB (risk ratio [RR], 1.49 confidence interval [CI] 1.25-1.78) and LSG (RR, 1.46 [CI 1.22-1.75] were associated with approximately 50% increased likelihood of OSA remission compared with LAGB. Greater weight loss following intervention was associated with greater likelihood of OSA remission, while both greater age and greater preoperative body mass index (BMI) were associated with reduced likelihood of OSA remission (P < .001). CONCLUSION: This study demonstrated that metabolic surgery results in OSA remission in the majority of patients with obesity. Younger age, lower BMI preprocedure, greater %EWL and the use of LSG or LRYGB positively predicted OSA remission.

Systematic Review and Meta-Analysis of the Impact of Bariatric Surgery on Lower Urinary Tract Symptoms in Males.

BACKGROUND: Obesity is a chronic disease with multisystem morbidity. There are multiple studies reporting the effect of bariatric surgery on cardiovascular and metabolic disease, but few examine its impact on lower urinary tract symptoms. This article aims to perform a systematic review with meta-analysis, to determine the effects of bariatric surgery on lower urinary tract symptoms in male patients. METHODS: Medline, Embase, conference proceedings, and reference lists were searched for studies reporting the quantitative measurement of lower urinary tract symptoms score pre- and postweight loss surgery. The primary outcome was International Prostate Symptom Score (IPSS) before and after bariatric surgery. Secondary outcomes were changed in body mass index (BMI) and total body weight (TBW). Weighted mean differences (MD) were calculated for continuous outcomes. RESULTS: Seven studies were included in the analysis of 334 patients undergoing bariatric surgery. Mean study follow-up was between 3 and 36 months. IPSS score ranged from 3-12.7 preoperatively and 1.9-6.9 postoperatively. There was a statistically significant improvement in the IPSS score following bariatric surgery (MD 2.82, 95% CI 0.96 to 4.69, p=0.003). Bariatric surgery also resulted in statistically significant reduction of BMI and TBW. CONCLUSION: Bariatric surgery produces a significant improvement on lower urinary tract symptoms in men with obesity. This may be due to improvement of insulin sensitivity, testosterone levels or lipid profile associated with weight loss.

Systematic Review of Innovation Reporting in Endoscopic Sleeve Gastroplasty.

BACKGROUND: Endoscopic sleeve gastroplasty (ESG) is a novel endoscopic procedure used to treat obesity-related comorbidities. Whilst its use is increasing in clinical practice, there is comparatively little understanding about how it has been evaluated. This study aimed to systematically summarize and appraise the reporting of ESG in the context of guidelines for evaluating innovative surgical devices and procedures. METHODS: Systematic searches were used to identify all published studies reporting ESG insertion. Data collected included patient selection, governance arrangements, proceduralist expertise, technique description and outcome reporting. RESULTS: Searches identified 2289 abstracts; 37 full-text papers were included (one prospective comparative cohort study, 16 retrospective cohort studies, 17 prospective cohort studies and three case reports). No randomized trials were identified. Eighteen studies were conducted prospectively. The number of patients in the included studies ranged from 1 to 1000. The lower BMI limit ranged from 27 to 35 kg/m2. Research approvals were reported in 26 studies. Two studies reported on the learning curve. All studies reported some aspect of technical implementation, but many variations were noted. Suturing device used and suture pattern were the most commonly reported aspects (32 studies). Follow-up ranged from 1 to 24 months, but was 12 months or less in 28 studies. Forty-eight different outcomes were reported across all studies. CONCLUSION: The literature on ESG has demonstrated some progression in reporting and analysis and the next stage of assessment should be a randomized controlled trial to demonstrate efficacy.

A multicenter prospective audit to investigate the current management of patients undergoing anti-reflux surgery in the UK: Audit & Review of Anti-Reflux Operations & Workup.

BACKGROUND: There are a variety of surgical and endoscopic interventions available to treat gastroesophageal reflux disease. There is, however, no consensus on which approach is best.The aim of this national audit is to describe the current variation in the UK clinical practice in relation to anti-reflux surgery (ARS) and to report adherence to available clinical guidelines. METHODS: This national audit will be conducted at centers across the UK using the secure online web platform ALEA. The study will comprise two parts: a registration questionnaire and a prospective multicenter audit of ARS. All participating centers will be required to complete the registration questionnaire comprising details regarding pre-, peri-, and post-operative care pathways and whether or not these are standardized within each center. Following this, a 12-month multicenter prospective audit will be undertaken to capture data including patient demographics, predominant symptoms, preoperative investigations, surgery indication, intraoperative details, and postoperative outcomes within the first 90 days.Local teams will retain access to their own data to facilitate local quality improvement. The full dataset will be reported at national and international scientific congresses and will contribute to peer-reviewed publications and national quality improvement initiatives. CONCLUSIONS: This study will identify and explore variation in the processes and outcomes following ARS within the UK using a collaborative cohort methodology. The results generated by this audit will facilitate local and national quality improvement initiatives and generate new possibilities for future research in anti-reflux interventions.

Regional Variation in Unmet Need for Metabolic Surgery in England: a Retrospective, Multicohort Analysis.

Metabolic surgery provision is severely limited despite extensive supportive trial evidence. This study estimated the eligible population and the unmet need for metabolic surgery within English regions. Health Survey for England, National Diabetes Audit and population estimates were used to estimate the metabolic surgery eligible population by English region. Hospital Episode Statistics data was examined for metabolic surgery procedure volume by region (2013-2019). Regression analysis examined factors associated with metabolic surgery eligibility. 7.3% of the English population is potentially eligible for metabolic surgery; equivalent to 3.21 million people. Only 0.20% of the eligible English population receive metabolic surgery per year (regional variation 0.08-0.41%). The metabolic surgery eligible population was more likely to be female, older, have fewer educational qualifications and live in more deprived areas.

A Meta-analysis of the Impact of Bariatric Surgery on Back Pain.

BACKGROUND: The functional aspects of obesity are increasingly recognised as a significant clinical and public health concern. Whilst there is substantial evidence for the beneficial impact of bariatric surgery on metabolic and cardiovascular disease, there is less understanding of the quantitative effect of bariatric surgery on back pain. The aim of this meta-analysis was to assess the impact of bariatric surgery on back pain in reported studies. METHODS: Medline, Embase, conference proceedings and reference lists were searched for studies assessing quantitative back pain scores both before and after bariatric surgery. The primary outcome was visual analogue score for back pain pre- and post-bariatric surgery. Secondary outcomes were change in BMI, SF-36 quality of life scores and Oswestry Disability Index (ODI) scores. Weighted mean differences (MD) were calculated for continuous outcomes. RESULTS: Seven studies were included in the analysis of 246 patients undergoing bariatric surgery. Mean study follow-up was between 3 and 24 months. There was a statistically significant reduction in visual analogue score for back pain following bariatric surgery (MD - 3.01; 95% CI - 4.19 to - 1.89; p < 0.001). Bariatric surgery also resulted in statistically significant improvements in BMI, SF-36 score and ODI score. CONCLUSIONS: Bariatric surgery produces significant and quantifiable reductions in back pain. This may be commuted through reductions in axial load or improved quality of life, but further studies will improve understanding and aid preoperative counselling.

Acceptable outcomes after fundoplication-different views are held by patients, GPs, and surgeons.

Antireflux surgery aims to improve quality of life. However, whether patients and clinicians agree on what this means, and what is an acceptable outcome following fundoplication, is unknown. This study used clinical scenarios pertinent to laparoscopic fundoplication for gastroesophageal reflux to define acceptable outcomes from the perspective of patients, surgeons, and general practitioners (GPs). Patients who had previously undergone a laparoscopic fundoplication, general practitioners, and esophagogastric surgeons were invited to rank 11 clinical scenarios of outcomes following laparoscopic fundoplication for acceptability. Clinicopathological and practice variables were collated for patients and clinicians, respectively. GPs and esophagogastric surgeons additionally were asked to estimate postfundoplication outcome probabilities. Descriptive and multivariate statistical analyses were undertaken to examine for associations with acceptability. Reponses were received from 331 patients (36.4% response rate), 93 GPs (13.4% response), and 60 surgeons (36.4% response). Bloating and inability to belch was less acceptable and dysphagia requiring intervention more acceptable to patients compared to clinicians. On regression analysis, female patients found bloating to be less acceptable (OR: 0.51 [95%CI: 0.29-0.91]; P = 0.022), but dysphagia more acceptable (OR: 1.93 [95%CI: 1.17-3.21]; P = 0.011). Postfundoplication estimation of reflux resolution was higher and that of bloating was lower for GPs compared to esophagogastric surgeons. Patients and clinicians have different appreciations of an acceptable outcome following antireflux surgery. Female patients are more concerned about wind-related side effects than male patients. The opposite holds true for dysphagia. Surgeons and GPs differ in their estimation of event probability for patient recovery following antireflux surgery, and this might explain their differing considerations of acceptable outcomes.

Intraoperative Sentinel Node Mapping in the Colon: Potential and Pitfalls.

Sentinel lymph node mapping (SLNM) may play a significant role in future delivery of colon cancer surgery because of an increase in early-stage, node-negative disease due to national bowel cancer screening programmes. Traditionally, colon lymphatic drainage has not been thought relevant as the operative approach cannot be tailored. Recent advances in local and endoscopic risk-reducing interventions for colonic malignancy have caused a rethink in approach. SLNM was initially attempted with blue dye techniques with limited success. Technological improvement has allowed surgeons to use near-infrared (NIR) light and NIR active tracers such as indocyanine green. This review provides an overview of the current status of intraoperative lymph node mapping in the colon, identifies challenges to the delivery of the techniques, and discusses potential solutions that may help SLNM play a role in improving the delivery of surgical care for patients with colon cancer.

The potential impact of local excision for T1 colonic cancer in elderly and comorbid populations: a decision analysis.

BACKGROUND: Population-based bowel cancer screening has resulted in increasing numbers of patients with T1 colonic cancer. The need for colectomy in this group is questioned due to the low risk of lymphatic spread and increased treatment morbidity, particularly for elderly, comorbid patients. This study examined the quality-of-life benefits and risks of endoscopic resection compared with results after colectomy, for low-risk and high-risk T1 colonic cancer. METHODS: Decision analysis using a Markov simulation model was performed; patients were managed with either endoscopic resection (advanced therapeutic endoscopy) or colectomy. Lesions were considered high risk according to accepted national guidelines. Probabilities and utilities (perception of quality of life) were derived from published data. Hypothetical cohorts of 65- and 80-year-old, fit and unfit patients with low-risk or high-risk T1 colonic cancer were studied. The primary outcome was quality-adjusted life expectancy (QALE) in life-years (QALYs). RESULTS: In low-risk T1 colonic neoplasia, endoscopic resection increases QALE by 0.09 QALYS for fit 65-year-olds and by 0.67 for unfit 80-year-olds. For high-risk T1 cancers, the QALE benefit for surgical resection is 0.24 QALYs for fit 65-year-olds and the endoscopic QALE benefit is 0.47 for unfit 80-year-olds. The model findings only favored surgery with high local recurrence rates and when quality of life under surveillance was perceived poorly. CONCLUSIONS: Under broad assumptions, endoscopic resection is a reasonable treatment option for both low-risk and high-risk T1 colonic cancer, particularly in elderly, comorbid patients. Exploration of methods to facilitate endoscopic resection of T1 colonic neoplasia appears warranted.

Skeletal Muscle Changes After Elective Colorectal Cancer Resection: A Longitudinal Study.

BACKGROUND: Muscle depletion is a poor prognostic indicator in colorectal cancer (CRC) patients, but there were no data assessing comparative temporal body composition changes following elective CRC surgery. We examined patient skeletal muscle index trajectories over time after surgery and determined factors that may contribute to those alterations. METHODS: Patients diagnosed with CRC undergoing elective surgical resection between 2006 and 2013 were included in this study. Image analysis of serial computed tomography (CT) scans was used to calculate lumbar skeletal muscle index (LSMI). A multilevel mixed-effect linear regression model was applied using STATA (version 12.0) using the xtmixed command to fit growth curve models (GCM) for LSMI and time. RESULTS: In 856 patients, a total of 2136 CT images were analyzed; 856 (38.2 %) were preoperative. A quadratic GCM with random intercept and random slope for patients' LSMI was identified that demonstrated laparoscopy produces a positive change on the LSMI curve [estimate = 0.17 cm(2)/m(2), standard error (SE) 0.06 cm(2)/m(2); p = 0.03], whereas Union for International Cancer Control (UICC) stage III + IV disease contributed to a negative curve change (estimate = -0.19 cm(2)/m(2), SE 0.09 cm(2)/m(2); p = 0.03). Older age (p < 0.01), female gender (p < 0.01), higher American Society of Anesthesiologists (ASA) score (p < 0.01), and altered systemic inflammatory response [SIR] (p = 0.03) were factors significantly associated with lower values of LSMI over time. CONCLUSION: In patients undergoing CRC surgery, laparoscopy and the absence of a significantly elevated SIR favored preservation and restoration of skeletal muscle, postoperatively. These emerging data may permit the development of new treatment protocols whereby monitoring and modification of body composition has therapeutic potential.

International expert consensus on endpoints for full-thickness laparoendoscopic colonic excision.

BACKGROUND: Full-thickness laparoendoscopic excision has been reported for complex endoscopically unresectable colonic polyps. However, the endpoints used in these studies vary significantly and therefore making definitive conclusions regarding the novel procedure would be improved if a common data set were adopted. This study sought to define most appropriate endpoints that should be measured and reported for research on full-thickness laparoendoscopic excision of colonic polyps. METHODS: A Web-based Delphi Questionnaire was developed using a systematic literature review of reported endpoints. Outcomes were grouped into general, complication, technical and histopathology endpoints. International specialists in laparoscopic surgery, endoscopy and transanal endoscopic microsurgery were invited to participate. The questionnaire required prioritization of outcomes on a 5-point Likert scale. Respondents were then sent a second questionnaire containing feedback on scores from round 1 and asked to re-prioritize outcomes based on the feedback received to identify a final core outcome set. RESULTS: A total of 33 (75% response rate) participants from 11 countries completed the round 1 Delphi of 28 proposed endpoints, and all completed the second round. Eight endpoints were rated the most important to stakeholders within the four domains--reoperation (general); anastomotic leak, mortality (complications); secure closure of the excision site, macroscopic completeness of excision (technical); presence of cancer, clearance of resected margins and en bloc specimen production (histopathology). CONCLUSIONS: This study has developed a provisional consensus on a minimum number of feasible and clinically meaningful outcome measures to use in studies of full-thickness laparoendoscopic excision of colonic polyps. Widespread adoption will allow better reporting of the technique and more efficient development in clinical practice.

Factors Implicated for Delay of Adjuvant Chemotherapy in Colorectal Cancer: A Meta-analysis of Observational Studies.

BACKGROUND: The survival benefit of administering adjuvant chemotherapy (AC) in colorectal cancer is well established, as is the impact of its timing. Although various factors have been associated with treatment delay, their implications remain controversial. We determined clinicopathological factors associated with delay in transition to AC via systematic review and meta-analysis. METHODS: Studies assessing factors for delay in initiating AC were identified from MEDLINE, EMBASE, and Cochrane Databases. Studies were included only if relevant clinicopathological factors were adequately described and appropriate comparative groups were balanced. For each study, the odds ratio (OR) and 95 % confidence interval (CI) were estimated, regarding response to early versus delayed AC initiation. RESULTS: We identified 15 eligible studies involving 67,537 patients. Twelve studies were multicentre studies and three were single-center cohort studies. Meta-analysis demonstrated age >75 years [4 studies, OR = 1.44 (95 % CI 1.32-1.58)], marital status-single [3 studies, OR = 1.32 (95 % CI 1.20-1.44)], low socioeconomic status (SES) [7 studies, OR = 1.67 (95 % CI 1.32-2.12)], worse comorbidity status [5 studies, OR = 1.47 (95 % CI 1.14-1.90)], low tumour grade [7 studies, OR = 1.06 (95 % CI 1.02-1.11)], prolonged length of stay [3 studies, OR 2.37 (95 % CI 2.10-2.68)], and readmission [3 studies, OR = 3.23 (95 % CI 1.66-6.26)] were significant predictors of delayed initiation of AC. Laparoscopy compared to an open surgical approach was a significant predictor of earlier AC initiation [5 studies, OR = 0.70 (95 % CI 0.51-0.97)]. CONCLUSIONS: Laparoscopy is associated with earlier initiation of AC, encouraging its increased adoption. Social isolation and low SES merit consideration of approaches that counter the lack of social support and deprivation to improve cancer outcomes.

Tuberculosis in renal transplant recipients: the evidence for prophylaxis.

BACKGROUND: Tuberculosis (TB) remains a leading cause of death in endemic countries and is 20 to 70 times more common in renal transplant recipients, where it contributes to both increased morbidity and mortality. This review will focus on the epidemiology of TB in renal transplant recipients and critically appraise the published literature on isoniazid prophylaxis in renal transplantation. METHODS: A literature search for randomized and nonrandomized studies investigating the use of isoniazid prophylaxis in renal transplant recipients was conducted using Ovid MEDLINE, the Cochrane Library, the Transplant Library, and EMBASE. Relative risks (RRs) with 95% confidence intervals (CIs) are reported. Meta-analysis of the randomized controlled trials (RCTs) was performed with a fixed-effects model. RESULTS: Eleven relevant studies were identified; six nonrandomized and five RCTs. The nonrandomized studies indicate a reduced risk of TB with isoniazid prophylaxis. The RCTs demonstrated conflicting results, with two studies finding a reduction in TB with prophylaxis and two studies finding no difference. Meta-analysis of the 709 patients from the four RCTs demonstrated a reduced risk of TB with isoniazid prophylaxis (RR, 0.31; 95% CI, 0.19-0.51). No significant difference was found in the incidence of hepatitis (RR, 1.22; 95% CI, 0.91-1.65). CONCLUSION: Both randomized and nonrandomized studies support the value of isoniazid as TB prophylaxis in renal transplant recipients at risk of active infection. Clinicians should consider prophylaxis in renal transplant recipients in endemic areas or in recipients in nonendemic countries who are at risk. However, the evidence for the benefit of isoniazid prophylaxis in renal transplantation is not robust and there is still a need for a large multicenter trial of isoniazid prophylaxis in kidney transplantation in an endemic area.