Evaluating the evidence for a liver shrinkage diet for obese patients prior to laparoscopic cholecystectomy: A systematic review and meta-analysis.

BACKGROUND: The role of a very low-calorie diet (VLCD) before cholecystectomy in obese patients is unclear. This study evaluated whether VLCD could be used as a risk mitigation strategy for this high-risk patient cohort. PATIENTS AND METHODS: A systematic review and meta-analysis was performed (PROSPERO ID CRD42022374610). The primary outcome was to determine the impact of pre-operative VLCD on the operative findings and ease of dissection during laparoscopic cholecystectomy (LC). RESULTS: Two studies were included with a total of 84 patients. VLCD was associated with a significantly easier Calot's dissection (MD: -0.58 (95% confidence interval [CI] [ -1.03, -0.13], P = 0.01) and was associated with a significantly higher rate of pre-operative weight loss (MD; 2.92 (95% CI [2.23, 3.62], P = 0.00001). CONCLUSIONS: The published evidence regarding VLCD before cholecystectomy in obese patients is limited. After acknowledging the limitations of the data, VLCD is associated with a significantly higher rate of weight loss preoperatively and directly impacts the ease of intraoperative dissection of Calot's triangle. Routine use of VLCD should be considered for all obese patients undergoing elective LC.

Predicting Early Disease Recurrence of Pancreatic Cancer following Surgery: Determining the Role of NUDT15 as a Prognostic Biomarker.

Surgical resection remains the only curative treatment strategy for Pancreatic Ductal Adenocarcinoma (PDAC). A proportion of patients succumb to early disease recurrence post-operatively despite receiving adjuvant chemotherapy. The ability to identify these high-risk individuals at their initial diagnosis, prior to surgery, could potentially alter their treatment algorithm. This unique patient cohort may benefit from neo-adjuvant chemotherapy, even in the context of resectable disease, as this may secure systemic control over their disease burden. It may also improve patient selection for surgery. Using the Cancer Genome Atlas dataset, we first confirmed the poor overall survival associated with early disease recurrence (p < 0.0001). The transcriptomic profiles of these tumours were analysed, and we identified key aberrant signalling pathways involved in early disease relapse; downregulation across several immune signalling pathways was noted. Differentially expressed genes that could serve as biomarkers were identified (BPI, C6orf58, CD177, MCM7 and NUDT15). Receiver operating characteristic curves were constructed in order to identify biomarkers with a high diagnostic ability to identify patients who developed early disease recurrence. NUDT15 expression had the highest discriminatory capability as a biomarker (AUC 80.8%). Its expression was confirmed and validated in an independent cohort of patients with resected PDAC (n = 13). Patients who developed an early recurrence had a statistically higher tumour expression of NUDT15 when compared to patients who did not recur early (p < 0.01). Our results suggest that NUDT15 can be used as a prognostic biomarker that can stratify patients according to their risk of developing early disease recurrence.

Mind the Gap-Disconnected Duct Syndrome: A Review of Current Diagnostic and Management Strategies.

ABSTRACT: Disconnected duct syndrome (DDS) is an adverse sequela of acute necrotizing pancreatitis in which there is disruption of the pancreatic duct leading to a failure to deliver pancreatic secretions into the duodenum. Its presentation may range from a persistent external pancreatic fistula to a treatment-resistant pancreatic pseudocyst. The diagnosis is often delayed in the acute setting if there is concurrent necrosis as management is often directed to the associated peripancreatic fluid collection. A combination of imaging modalities may be required to evaluate ductal anatomy. No definitive consensus has been achieved regarding the optimal treatment strategy for DDS, and there is a lack of published level I evidence on the topic. Treatment should be tailored to each individual patient, depending on the anatomy of ductal disruption, the presence of sepsis, the degree of physiological derangement, and the patients' performance status. Patients with DDS represent a specific cohort of patients with complex pancreatic disease that requires the input from a diverse multidisciplinary team to ensure that a good clinical outcome can be achieved.

Determining the optimal time interval for cholecystectomy in moderate to severe gallstone pancreatitis: A systematic review of published evidence.

BACKGROUND: /Objectives: A paradigm shift has been observed in the management of mild gallstone pancreatitis; current guidelines advocate definitive cholecystectomy on the index admission. Despite the abundance of published guidelines, uncertainty remains with regard to the timing of cholecystectomy in moderate and severe acute pancreatitis (MAP/SAP), and no definitive consensus has been declared. This systematic review aimed to evaluate the published guidelines and subsequent evidence quoted in order to determine the optimal timing for cholecystectomy in this high-risk patient cohort. METHOD: A systematic review of published literature was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) guidelines, and included a search of three online electronic databases. RESULTS: Eleven guidelines were included. Only 4 (36%) of guidelines specified an actual time frame for surgical intervention. Delaying surgery for a minimum of 6 weeks was advocated by all 4 guidelines. All recommendations were based upon weak or very low-quality evidence. Higher mortality rates were observed when patients underwent early cholecystectomy for SAP (1.3-44%) when compared to patients who underwent delayed surgery (0-11%). CONCLUSION: Marked variation was observed amongst the published guidelines on the definitive management of MAP and SAP and disparity remains on the timing of cholecystectomy. A minority of the guidelines proposed a specific time period for when cholecystectomy should be performed, and whilst based on low quality evidence, delaying surgery (for 6 weeks) is associated with a reduction in morbidity and mortality rates and should be advocated in MAP/SAP until level 1 evidence becomes available.

Mesenteric ischaemia secondary to portomesenteric venous thrombosis, 2 weeks post laparoscopic sleeve gastrectomy in a cirrhotic patient.

Portal vein thrombosis (PVT) following sleeve gastrectomy is rare. There are limited documented cases within the literature. The presentation of PVT varies on a spectrum from mild non-specific abdominal symptoms to life endangering clinical emergencies. This is the case of a 58-year-old woman who presented to the surgical assessment unit with acute onset abdominal pain 2 weeks post laparoscopic sleeve gastrectomy for morbid obesity. The initial diagnosis was that of a gastric sleeve leak. The patient deteriorated clinically and underwent a CT scan of her abdomen. This revealed the presence of an acute thrombus filling the portal vein with extension into the superior mesenteric vein branches. There were radiological changes suggestive of acute small bowel ischaemia. The patient underwent a laparotomy in theatre and 50 cm of the necrotic small bowel was resected. Postoperative care was carried out in the intensive care unit for 15 days.