Long-Term Outcomes of Revisional Malabsorptive Bariatric Surgery: Do the Benefits Outweigh the Risk?

PURPOSE: To evaluate the long-term outcomes of revisional malabsorptive bariatric surgery. MATERIALS AND METHODS: Malabsorptive bariatric procedures are increasingly performed in the revisional setting. We collated and analysed prospectively recorded data for all patients who underwent a revisional Biliopancreatic diversion + / - duodenal switch (BPD + / - DS) over a 17-year period. RESULTS: We identified 102 patients who underwent a revisional BPD + / - DS. Median follow-up was 7 years (range 1-17). There were 21 (20.6%) patients permanently lost to follow-up at a median of 5 years postoperatively. Mean total weight loss since the revisional procedure of 22.7% (SD 13.4), 20.1% (SD 10.5) and 17.6% (SD 5.5) was recorded at 5, 10 and 15 years respectively. At the time of revisional surgery, 23 (22.5%) patients had diabetes and 16 (15.7%) had hypercholesterolaemia with remission of these occurring in 20 (87%) and 7 (44%) patients respectively. Nutritional deficiencies occurred in 82 (80.4%) patients, with 10 (9.8%) patients having severe deficiencies requiring periods of parenteral nutrition. Seven (6.9%) patients required limb lengthening or reversal procedures. There were 16 (15.7%) patients who experienced a complication within 30 days, including 3 (2.9%) anastomotic leaks. Surgery was required in 42 (41.2%) patients for late complications. CONCLUSION: Revisional malabsorptive bariatric surgery induces significant long-term weight loss and comorbidity resolution. High rates of temporary and permanent attrition from follow-up are of major concern, given the high prevalence of nutritional deficiencies. These data question the long-term safety of malabsorptive bariatric procedures due to the inability to ensure compliance with nutritional supplementation and long-term follow-up requirements. KEY POINTS: • Revisional bariatric surgery workload is increasing • Revisional malabsorptive surgery is efficacious for weight loss and comorbidity resolution • Revisional malabsorptive surgery is associated with high rates of nutritional deficiencies • Attrition from follow-up in this specific cohort of patients is of particular concern due to the risk of undiagnosed and untreated nutritional deficiencies.

Considerations and management of a patient with three metachronous cancers in association with Lynch syndrome and ileal Crohn's disease: A case report.

INTRODUCTION: Lynch syndrome and Crohn's disease are two entirely separate conditions but each have major gastrointestinal characteristics and carry a substantial increase in the risk of intestinal malignancy. Their co-existence in the patient who is the subject of this report dictated the need for an individualised treatment plan to deal with both conditions adequately. PRESENTATION OF CASE: We report a case of a 51 year old female with a past medical history that includes Lynch syndrome and small bowel Crohn's disease. Over a period of fifteen months, she developed three separate primary metachronous tumors in her endometrium, colon and duodenum. DISCUSSION: A patient with a combination of Lynch syndrome and ileal Crohn's disease presents significant therapeutic implications that are not usually present when these conditions are treated in isolation. CONCLUSION: The surgical treatment of patients with Lynch syndrome requires a sound knowledge of the possible neoplastic conditions that can arise in the syndrome. Early detection is paramount, either by implementation of evidence based surveillance programs or at least by a heightened clinical awareness of the features of this disease. Ideally this will result in both reduced surgical morbidity and improved oncologic outcome. Furthermore, the medical treatment of Crohn's disease in a patient with tumors arising from Lynch syndrome must be undertaken with at least a consideration of the possibility that the use of immunosuppressive medication might increase the risk of cancer recurrence.

Outreach surgical consulting services in North East Victoria.

OBJECTIVE: There is a paucity of data regarding the provision of consultative outreach specialist surgical services to rural areas. This paper aims to describe a model of outreach consultative practice to deliver specialist surgical services to rural communities. DESIGN: Analysis of prospectively collected data for consultations in a three month period for two surgeons based in Wangaratta. SETTING: Two surgeons in regional Victoria based in Wangaratta, North East Victoria, conducting outreach consultations to Beechworth, Benalla, Bright and Mansfield. PARTICIPANTS: All patients seen in consultations over a 3-month period. MAIN OUTCOME MEASURES: Patient workload, casemix of presenting complaint, consultation outcome including plan for surgical procedure. RESULTS: Outreach surgical consulting was associated with a higher proportion of new consultations, and there was trend towards being more likely to result in a surgical procedure than consultations in the base rural centre. CONCLUSIONS: Outreach surgical consulting provides surgeons with a larger referral base and provides communities with better access to local specialists. Outreach practice should be encouraged for surgeons in regional centres.