Effect of Metabolic and Bariatric Surgery on the Clinical Course of Multiple Sclerosis in Patients with Severe Obesity: a Systematic Review.

Multiple sclerosis (MS) is an autoimmune inflammatory condition affecting the central nervous system (CNS). A systematic review following the PRISMA guidelines was performed to explore the effect of metabolic and bariatric surgery (MBS) on the clinical course and outcomes in patients with multiple sclerosis. Eleven articles examining 394 patients were included in the final analysis. The mean MS duration at the time of surgery was 7.6 ± 4.6 years, and the mean postoperative follow-up was 35.5 ± 5.3 months. MBS leads to the same weight loss with the same complication rate as in patients without MS. Most of patients experienced improvement in clinical course of MS after MBS, compared to non-surgical group. However, there is a risk for MS exacerbation in a number of patients after MBS; they should not be disadvantaged from having MBS, since surgery leads to the same weight loss outcomes with the same complication rate as in patients without MS.

The First Modified Delphi Consensus-Building Exercise on Surgical Ward Rounds in the United Kingdom National Health Service.

BACKGROUND: The ward round is an integral part of everyday surgical practice. It is a complex clinical activity that requires both sound clinical management and communication skills. This study reports the results of a consensus-building exercise on the common aspects of the general surgical ward rounds. METHODS: The consensus-building committee involving a range of stakeholders from 16 United Kingdom (UK) National Health Service trusts took part in this consensus exercise. The members discussed and suggested a series of statements concerning surgical ward round. An agreement of ≥ 70% among members was regarded as a consensus. RESULTS: Thirty-two members voted on 60 statements. There was a consensus on fifty-nine statements after the first round of voting, and one statement was modified before it reached consensus in the second round. The statements covered nine sections: a preparation phase, team allocation, multidisciplinary approach to the ward round, structure of the round, teaching considerations, confidentiality and privacy, documentation, post-round arrangements, and weekend round. There was a consensus on spending time to prepare for the round, a consultant-led round, involvement of the nursing staff, an MDT round at the beginning and end of the week, a minimum of 5 min allocated to each patient, utilisation of a round checklist, afternoon virtual round, and a clear handover and plan for the weekend. CONCLUSION: The consensus committee achieved agreement on several aspects concerning the surgical ward rounds in the UK NHS. This should help improve the care of surgical patients in the UK.

Estimation of the organ of origin of peri-ampullary malignancy by preoperative CT scan.

BACKGROUND: Tumors occurring within the pancreatic head commonly arise from the pancreas, duodenal ampulla, distal bile duct, or duodenum. However, they are difficult to distinguish on standard preoperative imaging. PURPOSE: To assess the ability of specialist reporting of preoperative computed tomography (CT) scans to determine the organ of origin of pancreatic cancer (PC). MATERIAL AND METHODS: Blinded re-reporting of preoperative imaging from five hospitals was undertaken of a consecutive cohort of 411 patients undergoing surgery for PC between January 2006 and May 2014. Radiological identification of tumor site was determined by the presence of the main tumor bulk within the pancreatic head parenchyma and estimation of the pathological organ of origin of the PC was based on all the reported features. RESULTS: Each pathological tumor type was noted to have distinct radiological features. Localization of a visible tumor within the pancreatic parenchyma was seen most commonly in PC (92%) than other tumor types (P < 0.0001). Local invasion into the duodenum was a characteristic feature seen in 79% of patients with ampullary tumors and isolated dilation of the bile duct without dilation of the pancreatic duct was seen most commonly in patients with ampullary or bile duct cancer. In the assessment of tumor origin, good agreement (kappa = 0.6, 0.51-0.68) was noted between the consensus radiology opinion and the final histology result. Overall accuracy was greatest for ampullary cancer (88.1%) and lowest for PC (83.2%). CONCLUSION: Radiological assessment of preoperative imaging provides a high degree of accuracy in predicting the organ of origin of peri-ampullary cancer.

Endoscopic Evaluation of De Novo Esophagitis and Barrett's Esophagus, 5 Years After Sleeve Gastrectomy.

PURPOSE: Sleeve gastrectomy (SG) is the most common bariatric procedure worldwide. It has been reported that there is a strong association between SG and the development of gastroesophageal reflux disease (GERD) and Barrett's esophagus (BE). This study was conducted to evaluate esophagogastroduodenoscopy (EGD) findings in patients with a history of SG with more than 5-year follow-up. METHODS: This is a retrospective cohort study of prospectively maintained database. Inclusion criteria included patients who underwent SG between April 2015 and March 2016, aged 18 and above, BMI ≥ 40 kg/m2. Patients with 5 years of follow-up were invited to take part in the study and underwent EGD and biopsy. RESULTS: One hundred twenty-six patients were recruited with a mean age of 44.6 ± 11.1 years. After a 5-year follow-up, there were 31 (29.5%) patients with reflux esophagitis. The grades of GERD were A, B, and C in 16 (15.2), 12 (11.4), and 3 (2.9%) patients, respectively. Incidence of BE was 5.7% after 5 years from SG. There was a 16.6% lost to follow-up at 5 years after SG. CONCLUSION: The diagnosis and severity of GERD and the search for BE justify endoscopic surveillance in all long-term post-sleeve patients, regardless of reflux symptoms.

Structural Diversity, LC-MS-MS Analysis and Potential Biological Activities of Brevibacillus laterosporus Extract.

Lake Mariout is Egypt's degraded coastal marine habitat that encompasses a variety of wastes. The biodiversity and hard environmental conditions allow the co-existence of organisms with high resistance and rich metabolism, making them potential candidates for screening and isolating novel microbial strains. A bacterial isolate (BF202) cultured from the marine sediments of Alexandria's Mariout Lake (Egypt) was tested for its antimicrobial and anticancer potential. The phylogenetic analysis of the isolated strain's 16S rDNA and gyrB revealed that BF202 belongs to Brevibacillus laterosporus (B. laterosporus). Antibiosis of B. laterosporus was confirmed against microbial pathogens including Escherichia coli, Klebsiella pneumoniae, Salmonella typhi, and Staphylococcus aureus. The highest antibacterial activity was detected on glucose peptone medium after 18 h of incubation at 35 °C, and at pH of 7.0 in the presence of mannose and ammonium carbonate as carbon and nitrogen sources, respectively. The cytotoxicity of the methanolic extract against breast cancer (MCF-7) and normal Vero cell lines, using the MTT test, revealed IC50 values of 7.93 and 23.79 µg/mL, respectively. To identify apoptotic and necrotic cells, a flow cytometric analysis using annexin V-FITC/PI dual-labeling was utilized and recorded a higher number of necrotic cells compared to apoptotic ones. Similarly, the cell cycle S-phase arrest was reported. The LC-MS-MS investigation of B. laterosporus extract and the molecular networking database analysis demonstrated five strategic diketopiperazine compounds with antimicrobial and anticancer activities. Taken together, this research shows that the crude extract of B. laterosporus might be an effective agent against drug-resistant bacteria and malignant disorders due to its richness in diketopiperazines.

Post-Bariatric Splenic Complications; Diagnosis and Treatment. A Systematic Review.

This systematic review intends to evaluate incidence and symptoms of post-bariatric splenic complications as well as best available modalities establishing the diagnosis and management protocols. A systematic literature search was performed in electronic database until March 2022. A total of 41 articles were included on the subject of splenic complications following bariatric/metabolic surgery (BMS). Splenic abscess was the most common splenic complications (44.2%) after BMS and leak was the most common reported etiology of the splenic abscess. Fever and abdominal pain were the most common presenting symptom in all splenic complications and CT scan was the most common diagnostic modality. Splenic complications after BMS are relatively rare but may lead to dangerous consequences. Prompt diagnosis and treatment can prevent potentially life-threatening outcomes.

The first international Delphi consensus statement on Laparoscopic Gastrointestinal surgery.

BACKGROUND: Laparoscopic surgery has almost replaced open surgery in many areas of Gastro-Intestinal (GI) surgery. There is currently no published expert consensus statement on the principles of laparoscopic GI surgery. This may have affected the training of new surgeons. This exercise aimed to achieve an expert consensus on important principles of laparoscopic GI surgery. METHODS: A committee of 38 international experts in laparoscopic GI surgery proposed and voted on 149 statements in two rounds following a strict modified Delphi protocol. RESULTS: A consensus was achieved on 133 statements after two rounds of voting. All experts agreed on tailoring the first port site to the patient, whereas 84.2% advised avoiding the umbilical area for pneumoperitoneum in patients who had a prior midline laparotomy. Moreover, 86.8% agreed on closing all 15 mm ports irrespective of the patient's body mass index. There was a 100% consensus on using cartridges of appropriate height for stapling, checking the doughnuts after using circular staplers, and keeping the vibrating blade of the ultrasonic energy device in view and away from vascular structures. An 84.2% advised avoiding drain insertion through a ≥10 mm port site as it increases the risk of port-site hernia. There was 94.7% consensus on adding laparoscopic retrieval bags to the operating count and ensuring any surgical specimen left inside for later removal is added to the operating count. CONCLUSION: Thirty-eight experts achieved a consensus on 133 statements concerning various aspects of laparoscopic GI Surgery. Increased awareness of these could facilitate training and improve patient outcomes.

Gastric Remnant Mucocele after Conversion of Vertical Band Gastroplasty to One Anastomosis Gastric Bypass: a Video Vignette.

Conversional bariatric surgery is a challenging procedure to patients as well as the surgeon. One anastomosis gastric bypass (OAGB) is a known safe conversional procedure after primary restrictive weight loss surgeries such as vertical banded gastroplasty (VBG). A very rare reported complication after these operations is the formation of mucocele of gastric remnant during pouch creation. This is a video report of diagnosis and management of gastric remnant mucocele after conversion of VBG to OAGB.

Penile Rings: No Innovation without Evaluation.

Penile strangulation is a rare clinical entity which if left untreated can cause serious urogenital problems. We present the case of 45-year-old male patient who presented with penile strangulation after applying a metallic ring. Strangulation of the external male genitalia is a serious problem that requires urgent intervention in order to avoid serious complications. If left untreated, it can result in gangrene and penile amputation. Management of penile strangulation is a real challenge for the treating surgeon and should be treated as an emergency in order to avoid vascular compromise. LEARNING POINTS: Penile strangulation by metallic rings is not routinely encountered in daily emergency practice and can be a challenge for the treating surgeon.Problem awareness is a crucial part of the management of such a rare entity.Every attempt should be made as early as possible to preserve penile arterial supply.

Variation in survival after surgery for peri-ampullary cancer in a regional cancer network.

BACKGROUND: Centralisation of specialist surgical services requires that patients are referred to a regional centre for surgery. This process may disadvantage patients who live far from the regional centre or are referred from other hospitals by making referral less likely and by delaying treatment, thereby allowing tumour progression. The aim of this study is to explore the outcome of surgery for peri-ampullary cancer (PC) with respect to referring hospital and travel distance for treatment within a network served by five hospitals. METHODS: Review of a unit database was undertaken of patients undergoing surgery for PC between January 2006 and May 2014. RESULTS: 394 patients were studied. Although both the median travel distance for patients from the five hospitals (10.8, 86, 78.8, 54.7 and 89.2 km) (p < 0.05), and the annual operation rate for PC (2.99, 3.29, 2.13, 3.32 and 3.07 per 100,000) (p = 0.044) were significantly different, no correlation was noted between patient travel distance and population operation rate at each hospital. No difference was noted between patients from each hospital in terms of resection completion rate or pathological stage of the resected tumours. The median survival after diagnosis for patients referred from different hospitals ranged from 1.2 to 1.7 years and regression analysis revealed that increased travel distance to the regional centre was associated with a small survival advantage. CONCLUSION: Although variation in the provision and outcome of surgery for PC between regional hospitals is noted, this is not adversely affected by geographical isolation from the regional centre. TRIAL REGISTRATION: This study is part of post-graduate research degree project. The study is registered with ClinicalTrials.gov (unique identifier NCT02296736 ) November 18, 2014.

De Garengeot's hernia: an unusual case on call.

De Garengeot's hernia is defined as a femoral hernia that contains the appendix. Owing to the extreme rarity of de Garengeot's hernia, it could represent a diagnostic challenge; however, it should remain in the differential diagnosis, particularly in this patient demographic. A female patient aged 96 years, who presented as an emergency with acute right iliac fossa pain, was found to have de Garengeot's hernia. The diagnosis was made intraoperatively, where she was treated with an appendicectomy and repair of the hernia defect. The incidence of de Garengeot's hernia is 0.5-5% and the incidence of appendicitis within a femoral hernia is extremely rare. Preoperative diagnosis is challenging to the treating surgeon, which requires a high index of suspicion and is usually made intraoperatively. There is no standard treatment; however, simple appendicectomy and hernia repair seems to be an accepted management.

Assessment of the effect of interval from presentation to surgery on outcome in patients with peri-ampullary malignancy.

BACKGROUND: Delay between diagnosis of peri-ampullary cancer (PC) and surgery may allow tumour progression and affect outcome. The aim of this study was to explore associations of interval to surgery (IS) with pathological outcomes and survival in patients with PC. METHOD: A database review of all patients undergoing surgery between 2006 and 2014 was undertaken. IS was measured from diagnosis by imaging. Potential association between IS and survival was measured using Cox regression analysis, and between IS and pathological outcome with multivariate logistic analysis. RESULTS: 388 patients underwent surgery. The median IS was 49 days (1-551 days), and was not associated with any of the evaluated outcomes in patients with pancreatic (149) or distal bile duct (46) cancer. For patients with ampullary cancer (71) longer IS was associated with improved survival, with median survival of 27.5 months for patients waiting ≤ median IS (35) and 38.3 months for patients waiting > median IS (36) for surgery (p = 0.041). A higher rate of margin positivity (31.4%) was also noted among patients who waited less than the median IS compared to those waiting longer than this interval (11.4%) (p = 0.032). CONCLUSION: For patients with ampullary cancer there is a paradoxical improvement in outcome among those with a longer IS, which may be explained by progression to inoperability of more aggressive lesions.

Primary appendicular adenocarcinoma presenting as haematuria.

Adenocarcinoma of the vermiform appendix is a rare malignant neoplasm of the gastrointestinal tract encountered rarely within general surgical practice. We present the case of a 49-year-old man who, while undergoing investigations for haematuria, was diagnosed with an appendicular adenocarcinoma following bladder biopsy. Consequently he underwent right hemicolectomy and partial cystectomy followed by adjuvant chemotherapy. By discussing this case we hope to raise awareness within the medical profession of this rare presentation so that it may be considered within clinicians' differential diagnoses.

Lingual thyroid: A case report.

INTRODUCTION: Lingual thyroid (LT) gland is a rare clinical entity which was found to occur due to the failure of the thyroid gland to descend to its normal cervical location during embryogenesis. The presence of an ectopic thyroid gland located at the base of the tongue may present with symptoms like dysphagia, dysphonia, upper airway obstruction or even hemorrhage at any time from infancy through adulthood. PRESENTATION OF CASE: We are presenting a case of 5-year-old girl who presented with lingual thyroid, treated with Suppression treatment followed by elective surgical resection. DISCUSSION: Incidence of ectopic lingual thyroid gland is reported as 1:100,000. It is more common in females. Most of presentations due to oropharyngeal obstruction, including dysphagia, dyspnea and dysphonia. Investigations include thyroid function tests, neck US, Technetium scanning and C.T. CONCLUSION: Lingual thyroid is a rare anomaly. Dysphagia and dysphonia are common presenting symptoms. Pathogenesis of this ectopic is unknown. Different types of surgical approaches have been described in the management.