Religious Fasting of Muslim Patients After Metabolic and Bariatric Surgery: a Modified Delphi Consensus.

BACKGROUND: Fasting during Ramadan is one of the five pillars of the Muslim faith. Despite the positive effects of fasting on health, there are no guidelines or clear recommendations regarding fasting after metabolic/bariatric surgery (MBS). The current study reports the result of a modified Delphi consensus among expert metabolic/bariatric surgeons with experience in managing patients who fast after MBS. METHODS: A committee of 61 well-known metabolic and bariatric surgeons from 24 countries was created to participate in the Delphi consensus. The committee voted on 45 statements regarding recommendations and controversies around fasting after MBS. An agreement/disagreement ≥ of 70.0% was regarded as consensus. RESULTS: The experts reached a consensus on 40 out of 45 statements after two rounds of voting. One hundred percent of the experts believed that fasting needs special nutritional support in patients who underwent MBS. The decision regarding fasting must be coordinated among the surgeon, the nutritionist and the patient. At any time after MBS, 96.7% advised stopping fasting in the presence of persistent symptoms of intolerance. Seventy percent of the experts recommended delaying fasting after MBS for 6 to 12 months after combined and malabsorptive procedures according to the patient's situation and surgeon's experience, and 90.1% felt that proton pump inhibitors should be continued in patients who start fasting less than 6 months after MBS. There was consensus that fasting may help in weight loss, improvement/remission of non-alcoholic fatty liver disease, dyslipidemia, hypertension and type 2 diabetes mellitus among 88.5%, 90.2%, 88.5%, 85.2% and 85.2% of experts, respectively. CONCLUSION: Experts voted and reached a consensus on 40 statements covering various aspects of fasting after MBS.

Cleaning the laparoscopic camera port by a microbiology culture swab.

INTRODUCTION: The 5-mm camera is currently widely utilized in Laparoscopic surgery. A disturbing problem for the laparoscopic surgeon is when this Port is becoming smudged by fat or blood, affecting the cleanliness of the 5-mm camera lens after insertion. Due to its narrow, long tube, cleaning this port is tricky. In this paper, we advocate a simple, cheap, and effective method for preventing the staining of the port, using a sterile culture swab stick. METHODS: Once the first port is inserted, it will be cleaned with a sterile culture swab with a repeated in-and-out movement inside the port to clean it circumferentially until there is no further smudging of the swab. The camera is then introduced into the abdominal cavity. Each time either fat or blood stain the port, the culture swab stick is then utilized to wipe it. RESULTS: In our experience, the use of the culture swab stick beforehand to clean the 5-mm camera port prior to insertion renders the use of any other cleaning method unnecessary. CONCLUSION: Using the microbiology sterile culture swab stick to clean the 5-mm camera port is a simple, cheap method to clean the port from any debris.

Primary closure of choledochotomy after emergency laparoscopic common bile duct exploration.

INTRODUCTION: The debate into whether or not to drain the common bile duct after laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis continues. Reports are in favour of primary closure of choledochotomy in elective setting. The aim of this study is to evaluate our experience in the primary closure of choledochotomy in emergency setting by analysing indications, operative time, hospital stay, complications, and outcome. METHODS: All patients undergoing LCBDE were prospectively entered into a database incorporating demographic and clinical data including mode of admission, indication for surgery, operation details and clinical outcome. All operations were performed by the same consultant (A. Baker). RESULTS: All 81 patients had primary closure after LCBDE between October 2003 and April 2007. The male to female ratio was 1:3. Median age was 68 years (range 19-90 years). Nineteen (23%) patients had obstructive jaundice, 4 (5%) had cholangitis, 7 (8.6%) had acute pancreatitis, 9 (11.1%) had failed ERCP, and 42 (51.8%) had biliary colic or cholecystitis with positive intraoperative cholangiogram (IOC). Those patients were divided into two groups: elective LCBDE (ElLCBDE) (n=33, 41%) and emergency LCBDE (EmLCBDE) (n=48, 59%). There was no significant difference in the median operative time, median hospital stay and complication rate. Total laparoscopic clearance rate in this series was 95%. CONCLUSIONS: To our knowledge, this is the first publication in the literature in which primary closure after laparoscopic common bile duct exploration in emergency setting was used. With no significant difference in operative time, hospital stay and complications, in experienced hands primary closure of CBD in emergency settings is safe and feasible.

Severe proctitis, perforation, and fatal rectal bleeding secondary to cytomegalovirus in an immunocompetent patient: report of a case.

Cytomegalovirus (CMV) infection is associated with significant morbidity and mortality in immunocompromised patients. In immunocompetent individuals, the infection is usually subclinical but it can sometimes be life threatening. We describe a case of fatal CMV proctitis in a 71-year-old man following an Ivor-Lewis esophagectomy. After surgery he developed renal failure, methicillin-resistant Staphylococcus aureus pneumonia, and acute respiratory distress syndrome. He recovered but developed melena and massive fresh rectal bleeding. Sigmoidoscopy revealed severe proctitis and a biopsy was consistent with ischemia. Despite undergoing a proctectomy he continued to bleed and died despite every effort. The final histological examination of the rectum revealed a CMV infection.