Intra-operative Tranexamic Acid Administration Significantly Decreases Incidence of Postoperative Bleeding Without Increasing Venous Thromboembolism Risk After Laparoscopic Sleeve Gastrectomy: a Retrospective Cohort Study of Over 400 Patients.

BACKGROUND: There is evidence that tranexamic acid (TXA) reduces surgical bleeding and is widely used in trauma, obstetrics and other specialties. This practice is less well-established in laparoscopic sleeve gastrectomy (LSG) due to concerns surrounding venous thromboembolism (VTE); equally postoperative bleeding is a serious complication often requiring re-operation. METHODS: This retrospective cohort study compared 30-day outcomes following primary LSG in patients receiving intra-operative TXA (March 2020-July 2022) to those who did not (March 2011-March 2020). The primary outcome was postoperative bleeding (Hb < 9 g/dL) requiring transfusion or re-operation. Secondary outcomes were incidence of VTE, serious postoperative complications (Clavien-Dindo > grade 3) and death. Patients underwent standardised-protocol LSG without staple line re-enforcement under a single surgeon within the independent sector (private practice). TXA 1 g intravenous was administered immediately after a methylene blue leak test, prior to extubation. RESULTS: TXA group had 226 patients and non-TXA group had 192 patients. Mean age was 40.5 ± 10.3 and 39.1 ± 9.8 years, respectively. In the TXA group, no postoperative bleeds [versus 3 (1.6%) in non-TXA group, p = 0.0279] occurred. One staple line leak (0.4%) occurred in the TXA group compared to zero in the non-TXA group (p = ns). There was no VTE or death. CONCLUSIONS: This is the largest cohort study of intra-operative TXA in primary LSG to date, which demonstrates significant decrease in postoperative bleeding without increasing VTE risk. The authors recommend administration of TXA immediately following leak test, or removal of bougie to maximise efficacy. Data of TXA in LSG is awaited from the randomised controlled PATAS trial.

Near-Infrared Fluorescence Cholangiography can be a Useful Adjunct during Emergency Cholecystectomies.

Background. Emergency cholecystectomy is the gold standard treatment for acute cholecystitis according to National Institute for Health and Care Excellence recommendations. The procedure is feasible but carries a higher risk of iatrogenic injury to the bile duct, which should be considered preventable. Intraoperative fluorescence cholangiography following injection of indocyanine green (ICG) has been reported to aid identification of the extrahepatic bile duct. Data on its feasibility in the context of emergency cholecystectomies are missing. Materials and Methods. Fluorescent ICG was used intraoperatively to enhance the biliary anatomy during 33 consecutive emergency laparoscopic cholecystectomies at our institution. Primary outcomes of surgery were considered the length of hospital stay, conversion to open and complications rate, including bile duct injury. Secondary outcome was operating time. A historical population of emergency cholecystectomies was used as control. Results. There were no common bile duct injuries, no adverse effects from ICG, no conversion to open surgery and no deaths. 90% of patients went home within 48 hours after the operation in the absence of complications. ICG demonstrated intraoperative biliary anatomy allowing greater confidence to the surgeon performing emergency cholecystectomies. Six patients were operated beyond 72 hours from admission, without experiencing any complication Clavien-Dindo ≥3. ICG population had the same post-operative hospitalisation and complications rate of the control group, with a shorter operating time. Conclusion. Intraoperative augmented visualisation of biliary anatomy with ICG cholangiography can be a useful technology tool, with the potential to extend the 72 hours window of safety for emergency cholecystectomies.

Hospital Presentations of Acute Diverticulitis During COVID-19 Pandemic may be More Likely to Require Surgery due to Increased Severity: A Single-Centre Experience.

BACKGROUND: The novel coronavirus disease 2019 (COVID-19) pandemic has resulted in fewer emergency presentations of many acute medical and surgical conditions. The purpose of this study was to assess the severity of disease at presentation and quantify the change in number of presentations during this period. METHODS: This retrospective study includes all patients diagnosed with acute diverticulitis on abdominopelvic computerised tomography (CT) between March 1, 2020 and June 30, 2020, compared to the same period in 2019. Follow up scans on the index admission were excluded. Hinchey grade was assessed for all CT scans. Inflammatory markers were analysed, along with outcome measures including length of stay and mortality. RESULTS: Acute diverticulitis was diagnosed in 52 CT scans in the acute pandemic period - a decrease of 51.4%. Average age at presentation was unchanged (63.3 ± 14.3 vs. 62.8 ± 13.8, P = .848). The number of Hinchey II, III and IV presentations were significantly higher in the acute pandemic period (28.8% vs. 11.2%, P = .005) and significantly more emergency operations were carried out (7.69% vs. .93%, P = .04). Mortality was not significantly increased, nor were serum levels of C-reactive protein, white cell count and lactate. DISCUSSION: During the COVID-19 pandemic, fewer patients presented and were diagnosed with acute diverticulitis. A significantly greater proportion presented at a more advanced stage and required emergency surgery, suggesting late presentation. Our findings support the need for maintaining acute surgical services and the provision of early radiological and surgical input in patients presenting with signs and symptoms of acute diverticulitis in future pandemics.

Is Bariatric Surgery Better than Nonsurgical Weight Loss for Improving Asthma Control? A Systematic Review.

Obesity is associated with increased severity of asthma. Bariatric surgery can be effective in weight loss and improvement in asthma. Two reviewers conducted a systematic review using search terms: 'weight loss', 'bariatric surgery', and 'asthma'. Adult studies including all bariatric procedures and nonsurgical weight loss regimes were included. Thirty-nine studies, including twenty-six bariatric studies and thirteen nonsurgical studies, were found. No study directly compared bariatric surgery to nonsurgical techniques. Bariatric surgery offered greater weight loss (22-36%) than nonsurgical programmes (4.1-14.2%) and more consistently improved medication use, airway hyperresponsiveness, hospitalisation rate or ED attendance and lung function, while change in inflammatory markers were variable. Bariatric surgery appears to be superior in treating asthma; however, further study on surgery for both mild and severe asthma is required.

Vermiform appendix within incisional hernia.

The vermiform appendix (whether inflamed or not) within a hernia is very rare occurrence. We present the unprecedented case of a normal appendix found within a Pfannenstiel incisional hernia. A diagnostic laparoscopy was performed as appendicitis was suspected. However, the tip of a normal appendix was visualised within a previous Pfannenstiel incision. Laparoscopic appendicectomy was carried successfully and the patient was discharged. The patient later returned for a successful elective laparoscopic incisional hernia repair.

Comparison of acrylic and titanium cranioplasty.

INTRODUCTION: There are many indications for cranioplasty with an increasing incidence partly attributable to an increase in decompressive craniectomy following trauma and stroke. The aim of this study was to compare the survival of acrylic and titanium cranioplasties used in our department. MATERIALS AND METHODS: Retrospective cohort study of 126 patients who underwent cranioplasty between 1997 and 2007. A comparison was made between those with acrylic (n = 61) and titanium (n = 65) cranioplasties. There was no significant difference in age and length of time between craniectomy and cranioplasty between the two groups. The indications for titanium cranioplasty tended to be classified as 'high risk' indications including trauma and stroke. A higher rate of pre-existing infection was noted in the acrylic group. Mean follow-up was 97.2 and 34 months for acrylic and titanium cranioplasties respectively. RESULTS: Mean survival (95% confidence intervals) was 135 months (134-153) and 92 months (82-102) for acrylic and cranioplasty respectively. Out of 13 failures, only two were associated with pre-existing infection. Overall cumulative survival was better for acrylic cranioplasty although this difference did not reach statistical significance. DISCUSSION: Although survival of acrylic cranioplasty appears to be better than titanium plates, there is no statistical significance. Acrylic has the advantage of being able to be applied at the time of surgery without any planning and does not cause artefact on future imaging. Titanium cranioplasty is strong, light-weight and inert and can be fashioned in the pre-operative setting.