Magnetic sphincter augmentation in the management of gastro-esophageal reflux disease: A systematic review and meta-analysis.

BACKGROUND: Magnetic sphincter augmentation (MSA) through placement of the LINX device is an alternative to fundoplication in the management of gastro-esophageal reflux disease (GERD). This systematic review and meta-analysis aimed to assess efficacy, quality of life and safety in patients that underwent MSA, with a comparison to fundoplication. METHODS: A literature search of MEDLINE, Embase, Emcare, Scopus, Web of Science and Cochrane library databases was performed for studies that reported data on outcomes of MSA, with or without a comparison group undergoing fundoplication, for GERD from January 2000 to January 2023. Meta-analysis was performed using random-effect models and between-study heterogeneity was assessed. RESULTS: Thirty-nine studies with 8,075 patients were included: 6,983 patients underwent MSA and 1,092 patients had laparoscopic fundoplication procedure. Ten of these studies (seven retrospective and three prospective) directly compared MSA with fundoplication. A higher proportion of individuals successfully discontinued proton-pump inhibitors (P<0.001; WMD 0.83; 95% CI 0.72-0.93; I2=96.8%) and had higher patient satisfaction (P<0.001; WMD 0.85; 95% CI 0.78-0.93; I2=85.2%) following MSA when compared to fundoplication. Functional outcomes were better after MSA than after fundoplication including ability to belch (P<0.001; WMD 0.96; 95% CI 0.93-0.98; I2=67.8) and emesis (P<0.001; WMD 0.92; 95% CI 0.89-0.95; I2=42.8%), and bloating (P=0.003; WMD 0.20; 95% CI 0.07-0.33; I2=97.0%). MSA had higher rates of dysphagia (P=0.001; WMD 0.41; 95% CI 0.17-0.65; I2=97.3%) when compared to fundoplication. The overall erosion and removal rate following MSA was 0.24% and 3.9% respectively, with no difference in surgical re-intervention rates between MSA and fundoplication (P=0.446; WMD 0.001; 95% CI -0.001-0.002; I2 =78.5%). CONCLUSIONS: MSA is a safe and effective procedure at reducing symptom burden of GERD and can potentially improve patient satisfaction and functional outcomes. However, randomized controlled trials directly comparing MSA with fundoplication are necessary to determine where MSA precisely fits in the management pathway of GERD.

Single stage management of suspected gallbladder cancer guided by intraoperative frozen section analysis: A retrospective cohort study.

BACKGROUND: The management of radiologically suspected gallbladder cancers (GBC) that lack definitive radiological features usually involves performing a first-stage routine laparoscopic cholecystectomy, followed by an open second-stage liver resection (segments IVB and V) and hilar lymphadenectomy (extended cholecystectomy) if subsequent formal histology confirms a malignancy. Performing a cholecystectomy with an intraoperative frozen section to guide the need for conversion to an extended cholecystectomy as a single-stage procedure has multiple benefits compared to a two-stage approach. However, the safety and efficacy of this approach have not yet been evaluated in a tertiary setting. METHODS: A retrospective cohort study was performed using a database of all consecutive patients with suspected GBC who had been referred to our tertiary unit. Following routine cholecystectomy, depending on the operative findings, the gallbladder specimen was removed and sent for frozen-section analysis. If malignancy was confirmed, the depth of tumour invasion was evaluated, followed by simultaneous extended cholecystectomy, when appropriate. The sensitivity and specificity of frozen section analysis for the diagnosis of GBC were measured using formal histopathology as a reference standard. RESULTS: A total of 37 consecutive cholecystectomies were performed. In nine cases, GBC was confirmed by intraoperative frozen section analysis, three of which had standard cholecystectomy only as their frozen section showed adenocarcinoma to be T1a or below (n=2) or were undetermined (n=1). In the remaining six cases, malignant invasion beyond the muscularis propria (T1b or above) was confirmed; thus, a synchronous extended cholecystectomy was performed. The sensitivity (95% CI 66.4%-100%) and specificity (95% CI 87.7%-100%) for identifying GBC using frozen section analysis were both 100%. The net cost of the single-stage pathway in comparison to the two-stage pathway resulted in overall savings of £3894. CONCLUSION: Intraoperative frozen section analysis is a reliable tool for guiding the use of a safe, single-stage approach for the management of GBC in radiologically equivocal cases. In addition to its lower costs compared to a conventional two-stage procedure, intraoperative analysis also affords the benefit of a single hospital admission and single administration of general anaesthesia, thus greatly enhancing the patient's experience and relieving the burden on waiting lists.

Development and Evaluation of a Quality Assessment Tool for Laparoscopic Sleeve Gastrectomy Videos: A Review and Comparison of Academic and Online Video Resources.

BACKGROUND: Video recording of surgical procedures is increasing in popularity. They are presented in various platforms, many of which are not peer-reviewed. Laparoscopic sleeve gastrectomy (LSG) videos are widely available; however, there is limited evidence supporting the use of reporting guidelines when uploading LSG videos to create a valuable educational video. We aimed to determine the variations and establish the quality of published LSG videos, in both peer-reviewed literature and on YouTube, using a newly designed checklist to improve the quality and enhance the transparency of video reporting. METHODS: A quality assessment tool was designed by using existing research and society guidelines, such as the Bariatric Metabolic Surgery Standardization (BMSS). A systematic review using PRISMA guidelines was performed on MEDLINE and EMBASE databases to identify video case reports (academic videos) and a similar search was performed on the commercial YouTube platform (commercial videos) simultaneously. All videos displaying LSG were reviewed and scored using the quality assessment tool. Academic and commercial videos were subsequently compared and an evidence-based checklist was created. RESULTS: A total of 93 LSG recordings including 26 academic and 67 commercial videos were reviewed. Mean score of the checklist was 5/11 and 4/11 for videos published in articles and YouTube, respectively. Academic videos had higher rates of describing instruments used, such as orogastric tube (P < 0.001) and stapler information (P = 0.04). Fifty-four percent of academic videos described short-term patient outcomes, while not reported in commercial videos (P < 0.001). Sleeve resection status was not universally reported. CONCLUSIONS: Videos published in the academic literature are describing steps in greater detail with more emphasis on specific technical elements and patient outcomes and thus have a higher educational value. A new quality assessment tool has been proposed for video reporting guidelines to improve the reliability and value of published video research.

Bone health following paediatric and adolescent bariatric surgery: a systematic review and meta-analysis.

Background: Childhood obesity is a pressing health crisis of epidemic proportions. Bariatric surgery (BS) is an effective weight loss solution however its role in the paediatric population is contentious owing to the paucity of weight specific and generalised health outcomes. This systematic review and meta-analysis aimed to assess the impact of paediatric BS on bone health. Methods: This prospectively registered systematic review (PROSPERO ID: CRD42023432035) was performed in accordance with PRISMA guidelines. We searched MEDLINE (1946-1928 September 2023), EMBASE (1947-1928 September 2023) via the Ovid platform, and the Cochrane Review Library to identify scientific publications reporting bone outcome measures in patients under the age of 18 years who underwent BS. Meta-analysis was undertaken on post-operative weight and bone parameters in paediatric patients following BS. Outcomes were reported as weighted or standardized mean difference with 95 percent confidence intervals. Subgroup analysis by intervention, quality scoring and risk of bias were assessed. Findings: Twelve studies with 681 patients across 5 countries (mean age 17 ± 0.57 years) were included. The quality of included studies was rated as high and there was substantial between-study heterogeneity for most factors included in the meta-analysis (I2 from 0% to 99.1%). Patients underwent Roux-en-Y gastric bypass (RYGB, n = 216), sleeve gastrectomy (SG, n = 257), gastric band (n = 184) or intragastric balloon placement (n = 24). BS was associated with significant weight reduction, body mass index (BMI) -12.7 kg/m2 (95% CI -14.5 to -10.9, p < 0.001), with RYGB being most effective, BMI -16.58 kg/m2 (95% CI -19.6 to -13.6, p < 0.001). Patients who underwent SG or RYGB had significantly lower lumbar bone mineral density, -0.96 g/cm2 (95% CI -0.1 to -0.03, p < 0.001), Z score, -1.132 (95% CI -1.8 to -0.45, p < 0.001) and subtotal body bone mineral density, -0.7 g/cm2 (95% CI -1.2 to -0.2, p < 0.001) following surgery. This was accompanied with higher markers of bone resorption, C-terminal telopeptide of type 1 collagen 0.22 ng/ml (95% CI 0.12-0.32, p < 0.001) and osteocalcin, 10.83 ng/ml (95% CI 6.01-15.67, p < 0.001). There was a significant reduction in calcium levels following BS, -3.78 mg/dl (95% CI -6.1 to -1.5, p < 0.001) but no difference in 25-hydroxyvitamin D, phosphate, bone alkaline phosphatase, procollagen type 1 N propeptide or parathyroid hormone. Interpretation: BS effectively reduces weight in paediatric patients, but RYGB and SG may have adverse effects on bone health in the medium term. It is crucial to monitor and support bone health through appropriate nutritional supplementation and judicious follow-up. Long-term data is needed to fully understand the clinical implications of these findings on bone outcomes. Funding: Medical Research Council (MRC), United Kingdom.

Outcomes of One-Anastomosis Gastric Bypass Conversion to Roux-en-Y Gastric Bypass for Severe Obesity: A Systematic Review and Meta-analysis.

One-anastomosis gastric bypass (OAGB) is an effective procedure to treat severe obesity. However, conversion to Roux-en-Y gastric bypass (RYGB) is increasing. We therefore conducted a systematic review to determine the safety and efficacy associated with OAGB-RYGB conversion. A systematic search was conducted by three independent reviewers using Medline, Embase, and the Cochrane library following PRISMA guidelines. Six studies including 134 patients were selected who were undergoing OAGB-RYGB conversion. The most common indications were reflux (47.8%), malnutrition (31.3%), and inadequate weight loss (8.2%). Study outcomes demonstrated 100% resolution of bile reflux. Overall, there was medium-term weight gain of 0.61 BMI. OAGB to RYGB conversion leads to resolution of reflux symptoms. However, it is associated with weight regain, albeit this may be acceptable to patients to treat biliary reflux.

Artificial Intelligence in Surgery: The Future is Now.

Background Clinical Artificial intelligence (AI) has reached a critical inflection point. Advances in algorithmic science and increased understanding of operational considerations in AI deployment are opening the door to widespread clinical pathway transformation. For surgery in particular, the application of machine learning algorithms in fields such as computer vision and operative robotics are poised to radically change how we screen, diagnose, risk-stratify, treat and follow-up patients, in both pre- and post-operative stages, and within operating theatres. Summary In this paper, we summarise the current landscape of existing and emerging integrations within complex surgical care pathways. We investigate effective methods for practical use of AI throughout the patient pathway, from early screening and accurate diagnosis to intraoperative robotics, post-operative monitoring and follow-up. Horizon scanning of AI technologies in surgery is used to identify novel innovations that can enhance surgical practice today, with potential for paradigm shifts across core domains of surgical practice in the future. Any AI-driven future must be built on responsible and ethical usage, reinforced by effective oversight of data governance, and of risks to patient safety in deployment. Implementation is additionally bound to considerations of usability and pathway feasibility, and the need for robust healthcare technology assessment and evidence generation. While these factors are traditionally seen as barriers to translating AI into practice, we discuss how holistic implementation practices can create a solid foundation for scaling AI across pathways. Key Messages The next decade will see rapid translation of experimental development into real-world impact. AI will require evolution of work practices, but will also enhance patient safety, enhance surgical quality outcomes, and provide significant value for surgeons and health systems. Surgical practice has always sat on a bedrock of technological innovation. For those that follow this tradition, the future of AI in surgery starts now.

The effects of bariatric surgery on cardiac function: a systematic review and meta-analysis.

INTRODUCTION: Obesity is associated with alterations in cardiac structure and haemodynamics leading to cardiovascular mortality and morbidity. Culminating evidence suggests improvement of cardiac structure and function following bariatric surgery. OBJECTIVE: To evaluate the effect of bariatric surgery on cardiac structure and function in patients before and after bariatric surgery. METHODS: Systematic review and meta-analysis of studies reporting pre- and postoperative cardiac structure and function parameters on cardiac imaging in patients undergoing bariatric surgery. RESULTS: Eighty studies of 3332 patients were included. Bariatric surgery is associated with a statistically significant improvement in cardiac geometry and function including a decrease of 12.2% (95% CI 0.096-0.149; p < 0.001) in left ventricular (LV) mass index, an increase of 0.155 (95% CI 0.106-0.205; p < 0.001) in E/A ratio, a decrease of 2.012 mm (95% CI 1.356-2.699; p < 0.001) in left atrial diameter, a decrease of 1.16 mm (95% CI 0.62-1.69; p < 0.001) in LV diastolic dimension, and an increase of 1.636% (95% CI 0.706-2.566; p < 0.001) in LV ejection fraction after surgery. CONCLUSION: Bariatric surgery led to reverse remodelling and improvement in cardiac geometry and function driven by metabolic and haemodynamic factors.

Medium-Term Weight Loss and Remission of Comorbidities Following Endoscopic Sleeve Gastroplasty: a Systematic Review and Meta-analysis.

This systematic review and meta-analysis aimed to determine the short- and medium-term weight loss outcomes and comorbidity resolution following endoscopic sleeve gastroplasty. Our search identified 35 relevant studies containing data from 7525 patients. Overall, pooled short-term (12 months) total weight loss (TWL) was 16.2% (95% CI 13.1-19.4%) in 23 studies (n = 5659). Pooled medium-term TWL was 15.4% (95% CI 13.7-17.2%) in 10 studies (n = 4040). Diabetes resolution was 55.4% (95% CI 46-64%), hypertension resolution was 62.8% (95% CI 43-82%), dyslipidaemia resolution was 56.3% (95% CI 49-63%), and obstructive sleep apnoea resolution was 51.7% (95% CI 16.2-87.3%) in four studies (n = 480). This pooled analysis demonstrates that ESG can induce durable weight loss and resolution of obesity-associated comorbidities in patients with moderate obesity.

Vagal Nerve Therapy in the Management of Obesity: A Systematic Review and Meta-Analysis.

INTRODUCTION: The vagus nerve has an important role in satiety, metabolism, and autonomic control in upper gastrointestinal function. However, the role and effects of vagal nerve therapy on weight loss remain controversial. This systematic review and meta-analysis assessed the effects of vagal nerve therapy on weight loss, body mass index (BMI), and obesity-related conditions. METHODS: MEDLINE, EMBASE, and CINAHL databases were searched for studies up to April 2022 that reported on percentage excess weight loss (%EWL) or BMI at 12 months or remission of obesity-related conditions following vagal nerve therapy from January 2000 to April 2022. Weighted mean difference (WMD) was calculated, meta-analysis was performed using random-effects models, and between-study heterogeneity was assessed. RESULTS: Fifteen studies, of which nine were randomised controlled trials, of 1,447 patients were included. Vagal nerve therapy led to some improvement in %EWL (WMD 17.19%; 95% confidence interval [CI]: 10.94-23.44; p < 0.001) and BMI (WMD -2.24 kg/m2; 95% CI: -4.07 to -0.42; p = 0.016). There was a general improvement found in HbA1c following vagal nerve therapy when compared to no treatment given. No major complications were reported. CONCLUSIONS: Vagal nerve therapy can safely result in a mild-to-moderate improvement in weight loss. However, further clinical trials are required to confirm these results and investigate the possibility of the long-term benefit of vagal nerve therapy as a dual therapy combined with standard surgical bariatric interventions.

Influence of ventilatory parameters on the concentration of exhaled volatile organic compounds in mechanically ventilated patients.

Analysis of volatile organic compounds (VOC) within exhaled breath is subject to numerous sources of methodological and physiological variability. Whilst breathing pattern is expected to influence the concentrations of selected exhaled VOCs, it remains challenging to investigate respiratory rate and depth accurately in awake subjects. Online breath sampling was performed in 20 mechanically ventilated patients using proton transfer reaction time-of-flight mass spectrometry (PTR-ToF-MS). The effect of variation in respiratory rate (RR) and tidal volume (TV) on the VOC release profiles was examined. A panel of nineteen VOCs were selected, including isoprene, acetone, propofol, volatile aldehydes, acids and phenols. Variation in RR had the greatest influence on exhaled isoprene levels, with maximum and average concentrations being inversely correlated with RR. Variations in RR had a statistically significant impact on acetone, C3-C7 linear aldehydes and acetic acid. In comparison, phenols (including propofol), C8-C10 aldehydes and C3-C6 carboxylic acids were not influenced by RR. Isoprene was the only compound to be influenced by variation in TV. These findings, obtained under controlled conditions, provide useful guidelines for the optimisation of breath sampling protocols to be applied on awake patients.

Medicolegal Cases in Bariatric Surgery in the United Kingdom.

PURPOSE OF REVIEW: To evaluate the current state of bariatric medicolegal activity and explore the reasons of litigation in bariatric surgery. The underlying legal principles in bariatric medicolegal cases and most frequent pitfalls will also be discussed. RECENT FINDINGS: There is a growing number of litigations in bariatric surgery, particularly relating to complications and long waiting lists for bariatric surgery within the public-funded health systems. The main issues are related to consent, lack of follow-up, delayed identification of complications and lack of appropriate emergency management of complications, involving bariatric surgeons, clinicians, general practitioners and multidisciplinary team members. Appropriate multidisciplinary involvement pre- and postoperatively and robust follow-up protocols can help to mitigate the risks. Bariatric surgery requires a unique paradigm with a multidisciplinary approach both pre- and postoperatively to improve the long-term functional outcomes of patients. There is a rising incidence of medicolegal claims following bariatric surgery. The underlying reasons for this are multifactorial including an increase in the volume of surgery, high patient expectations, the incidence of long-term postoperative complications and the requirement of long-term follow-up.

Gastrojejunostomy Closure Technique and Risk of Leak: an Evaluation in Ex Vivo Porcine Models.

INTRODUCTION: Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed bariatric operations worldwide. Leaks following RYGB are rare, but the consequences can be devastating. Although most leaks occur at the gastrojejunostomy (GJ) anastomosis, there is a lack of data on modifiable technical factors that can reduce the risk of leaks. Therefore, we evaluated whether the leak pressure of a GJ linear stapled anastomosis is dependent on the closure technique. METHODS: Two expert surgeons constructed gastric pouches and GJ anastomoses on ex vivo porcine models in a laparoscopic simulator using 30-mm and 45-mm endoscopic staplers. The GJ anastomosis was closed using either a single layer suture, double layer suture or stapler. The endpoints were leak pressure to air insufflation, measured by two independent observers, site of leak and internal circumference of the GJ anastomosis. RESULTS: In total, 30 GJ anastomoses were constructed (30 mm, n = 15; 45 mm, n = 15). The GJ anastomosis was closed using single layer (n = 9), double layer (n = 9) and stapled techniques (n = 12). Inter-observer agreement was high. Stapled and double layer closures were more resilient than a single layer closure, with 75% (9/12) stapled closures remaining intact at < 70 mmHg. GJ stoma circumference was lower using a 30-mm stapler (64.8 mm vs 80.2 mm; p < 0.05) but independent of closure technique. The most common leak site was the corner of the closure (67%). CONCLUSION: In summary, the GJ anastomosis closure technique may be a modifiable factor to prevent anastomotic leak.

Weight loss specific to indication, remission of diabetes, and short-term complications after sleeve gastrectomy conversion to Roux-en-Y gastric bypass: a systematic review and meta-analysis.

Laparoscopic sleeve gastrectomy (SG) is the most frequently performed bariatric procedure worldwide. Long-term complications such as insufficient weight loss (IWL) and gastroesophageal reflux disease (GERD) may necessitate SG conversion to Roux-en-Y gastric bypass (RYGB). The aim of this review was to determine the indication-specific weight loss and diabetes remission after SG conversion to RYGB (STOBY). Our objective was to extract all available published data on indication for conversion, weight loss, remission of diabetes, and short-term complications after STOBY. A systematic literature search was conducted to identify studies reporting outcomes following STOBY. A random effects model was used for meta-analysis. The search identified 44 relevant studies. Overall short-term (12-mo) excess weight loss (EWL) was 54.6% (95% confidence interval [CI], 46%-63%) in 23 studies (n = 712) and total weight loss (TWL) was 19.9% (95% CI, 14%-25%) in 21 studies (n = 740). For IWL, short-term (12-mo) pooled weight loss outcomes were 53.9% EWL (95% CI, 48%-59%) in 14 studies (n = 295) and 22.7% TWL (95% CI, 17%-28%) in 12 studies (n = 219), and medium-term (2-5 yr) outcomes were 45.8% EWL (95% CI, 38%-53%) in 7 studies (n = 154) and 20.6% TWL (95% CI, 15%-26%) in 9 studies (n = 206). Overall diabetes remission was 53% (95% CI, 33%-72%), and the perioperative complication rate was 8.2% (95% CI, 7.6%-8.7%). Revisional SG conversion to RYGB for IWL can achieve good weight loss outcomes and diabetes remission.

Pancreaticoduodenectomy with right hemicolectomy for advanced malignancy: a single UK hepatopancreaticobiliary centre experience.

AIM: Locally advanced intestinal neoplasms including colon cancer may require radical en bloc pancreaticoduodenectomy and right hemicolectomy (PD-RC) to achieve curative, margin-negative resection, but the safety and benefit of this uncommon procedure has not been established. The Association of Coloproctology of Great Britain and Ireland IMPACT initiative has also highlighted a lack of awareness about current services available within the UK for patients with advanced colorectal cancer and concerns about low-volume centres managing complex cases. Thus, we aimed to review the feasibility, safety and long-term outcomes of this procedure at a single high-volume hepatopancreaticobiliary surgery unit in the UK. METHOD: A retrospective cohort study was performed using a database of all consecutive patients with intestinal cancer who had been referred to our regional advanced multidisciplinary team and undergone PD-RC in a 7-year period (2013-2020). Clinico-pathological and outcome data were reviewed. RESULTS: Ten patients (mean age 54 ± 13, 8/10 men) were identified. Final histology revealed the primary tumour sites were colon (n = 7) and duodenum (n = 3). R0 resection was achieved in all cases. The major complication rate (Clavien-Dindo ≥ 3) was 10% (1/10) with no deaths within 90 days of surgery. The Kaplan-Meier estimated 5-year overall survival was 83.3% (95% CI 58.3%-100%). Univariate survival analysis identified perineural invasion and extra-colonic origin as predictors of poor survival (log-rank P < 0.05). CONCLUSION: En bloc PD-RC for locally advanced intestinal cancer can be performed safely with a high proportion of margin-negative resections and resultant long-term survival in carefully selected patients.

Clinical outcomes of single-stage versus two-stage laparoscopic Roux-en-y gastric bypass in the management of obesity (BMI ≥ 50 kg/m2): a retrospective cohort study.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) in patients with obesity, BMI ≥ 50 kg/m2, can be a challenging operation. Weight loss with intra-gastric balloon (IGB) insertion prior to LRYGB may improve operative outcomes. METHODS: Between June 2000 and June 2020, patients with a BMI ≥ 50 kg/m2 underwent either IGB insertion followed by LRYGB (two-stage group), or LRYGB as the definitive bariatric procedure (single-stage group) in our institution. The two-stage procedure was adopted for high risk individuals. Primary outcome measures were percentage total weight loss (%TWL) at 24 months, length of stay and postoperative morbidity. Propensity score analysis was used to account for differences between groups. RESULTS: A total of 155 (mean age 42.9 years ± 10.60; mean BMI 54.6 kg/m2 ± 4.53) underwent either the two-stage (n = 30) or single-stage procedure (n = 125) depending on preoperative fitness. At 6 months following LRYGB, there was a significant difference in %TWL between the groups in a matched analysis (11.9% vs 23.7%, p < 0.001). At 24 months, there was no difference in %TWL (32.0% vs 34.7%, p = 0.13). Median hospital stay following LRYGB was 2.0 (1-4) days with the two-stage vs 2.0 (0-14) days for the single-stage approach (p = 0.75). There was also no significant difference in complication rates (p = 0.058) between the two groups. CONCLUSIONS: There was no difference in weight loss after one or two-stage procedures in the treatment of patients with a BMI ≥ 50 kg/m2 super obesity in a propensity score weighted analysis at 24 months. Length of stay and perioperative complications were similar for high risk patients; however, the two-stage approach was associated with delayed weight loss. Single-stage management is recommended for moderate risk patients, particularly with significant metabolic disorders, whilst two-stage approach is a safe and feasible pathway for high risk individuals.

Unusual cause of intraoperative haemorrhage: a lesson for patient counselling.

Hepatocellular carcinoma (HCC) is a well-known malignant neoplasm of the liver associated with spontaneous haemorrhage in 3%-15% of cases. This complication is life threatening and has a mortality rate of 33%-100%. Despite the frequency and severity of spontaneous haemorrhage, the importance of patient education about this complication has not been highlighted before. There is currently no information available on the NHS UK website, and no publications have addressed the effect of patient education. We present this case report describing a patient who developed classical symptoms of haemorrhage the day before her elective HCC resection, but was unaware of its importance, and thus did not seek medical attention. She was subsequently found to have a large volume haemoperitoneum, anaemia and a ruptured HCC intraoperatively. This case illustrates the significant importance of counselled regarding the symptoms and risk of spontaneous rupture of HCC to prompt early presentation to medical services.

Can surgical skills be taught using technological advances online? A comparative study of online and face-to-face surgical skills training.

INTRODUCTION: Online teaching has rapidly emerged as a viable alternative to traditional face-to-face education. How to teach surgical skills in the online environment, however, has not yet been fully established nor evaluated. METHODS: An international 1-day online surgical skills course consisting of lectures, pre-recorded virtual workshops, live demonstrations and along with surgical skills teaching in breakout rooms was organised. Based on existing learning theories, new methods were developed to deliver skills teaching online. Simultaneously, traditional in-person surgical skills teaching was also conducted and used as a benchmark. Skills development was assessed by trained demonstrators and self-reported competency scores were compared between the online and face-to-face event. RESULTS: 553 delegates from 20 different countries attended the online course. Of these, 64 were trained in breakout rooms with a 1:5 demonstrator-to-delegate ratio whilst the remaining 489 delegates participated in didactic skills development sessions. In a separate face-to-face course, 20 delegates were trained with traditional methods. Demonstrators rated the competency of delegates for suturing, tendon repair and vascular anastomosis. There was no significant difference in the competency ratings of delegates receiving online teaching or face-to-face teaching (p = 0.253, p = 0.084, p = 1.00, respectively). The development of the same skills to "articulation" were not different between formats (p = 0.841, p = 0.792, p = 1.00, respectively). Post course self-rated competency scores improved for all technical skills (p < 0.001). Small group sessions, both online and face-to-face, received higher satisfaction ratings compared to large group sessions in terms of clarity of instructions, answers to questions and demonstrator feedback. Overall feedback on teaching quality, however, was equivalent across both groups. DISCUSSION: Online teaching of surgical skills for early training years is an appropriate alternative to face-to-face teaching.

Management of Laryngotracheal Stenosis in Obesity. Is This Another Co-morbidity that Can Be Improved with Weight Loss Following Bariatric Surgery?

PURPOSE: Bariatric surgery improves several obesity-related comorbidities. Laryngotracheal stenosis is a rare condition that is usually managed with repeated endoscopic airway interventions and reconstructive airway surgery. The outcome of these definitive operations is worse in individuals with obesity. There are no studies investigating the effect of weight loss following bariatric surgery in the management of laryngotracheal stenosis. MATERIALS AND METHODS: In an observational study, consecutive patients with a BMI over 35 kg/m2 and laryngotracheal stenosis were prospectively recruited to a bariatric and airway stenosis database in two tertiary care centres. Patients were treated with laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy and control subjects were managed conservatively. RESULTS: A total of eleven patients with an initial body mass index of 43 kg/m2 (37-45) were enrolled to this study. Six patients underwent bariatric surgery and five subjects were treated conservatively. After 12 months, the total weight loss of patients undergoing bariatric surgery was 19.4% (14-24%) whilst 2.3% (1-3%) in the control group. The annual number of endoscopic airway interventions following bariatric surgery reduced (p = 0.002). Higher weight loss in patients led to less frequent interventions compared to control subjects (p = 0.004). Patients undergoing laryngotracheal reconstruction following bariatric surgery needed less endoscopic intervention, an annual average of 1.9 interventions before vs 0.5 intervention after. Conservatively managed control subjects required more frequent endoscopic intervention, 1.8 before vs 3.4 after airway reconstruction. CONCLUSION: Bariatric surgery reduced the number of endoscopic airway interventions and enabled patients to undergo successful definitive airway reconstructive surgery.

Gastrojejunal Anastomotic Technique. Does It Matter? Weight Loss and Weight Regain 5 Years After Laparoscopic Roux-en-Y Gastric Bypass.

PURPOSE: The gastrojejunostomy during laparoscopic Roux-en-Y gastric bypass (LRYGB) can be constructed by hand sewn (HSA), linear (LSA) and circular (CSA) stapler technique. They are all considered safe; however, it is not known which the best technique is. Short-term follow-up suggest no difference in weight loss or weight regain between them. However, there is no information on these parameters in the long term. Theatre time and cost are other important factors defining the best way to form gastrojejunostomy. MATERIALS AND METHODS: In a prospective longitudinal cohort study consecutive patients following primary LRYGB were recruited to a bariatric database in a tertiary care centre. Anastomotic technique, diameter, the length of operations and associated costs, weight loss and weight regain were recorded. Patients were followed up for 5 years. RESULTS: A total of 385 patients with an initial body mass index of 47.1 kg/m2 (35-68) were enrolled to this study. This decreased to 33.3 kg/m2 (21-54 kg/m2) after 5 years. There was no difference in %TWL after 3 years, P = 0.296, or 5 years, P = 0.187, between the techniques. The number of patients with weight regain was not different after 3 years, P = 0.224, or 5 years, P = 0.795. All techniques had similar operative time. CSA has a higher material cost. Early anastomotic stricture was more common following HSA; however, the difference was not significant. CONCLUSION: Mid-term weight loss and weight regain are not related to anastomotic technique, and there is no difference in operative time associated to them. Circular stapler technique has a higher material cost due to the additional stapler.