Life-threatening Petersen's hernia following open Beger's procedure.

Petersen's hernia (an internal hernia between the transverse mesocolon and Roux limb following Roux-en-Y reconstruction) is well described following laparoscopic gastric bypass surgery. We describe a Petersen-type hernia in a patient who had undergone complex open upper gastrointestinal surgery for chronic pancreatitis.

Obstructive sleep apnea can be safely managed in a level 2 critical care setting after laparoscopic bariatric surgery.

BACKGROUND: In the United Kingdom, demand for intensive care beds (level 3 critical care) often outstrips supply, leading to frequent and frustrating cancellation of complex elective surgery. It has been suggested that patients with obstructive sleep apnea who undergo bariatric surgery should be admitted to a level 3 facility for routine postoperative management. We have questioned the validity of this dogma in the era of laparoscopic bariatric surgery by using a simple easily applicable algorithm. OBJECTIVES: The aim of this study was to investigate the clinical outcome of patients with obstructive sleep apnea (OSA) without admission to the intensive care unit after laparoscopic bariatric surgery. METHODS: For the first 24 hours after surgery, all patients were admitted to a level 2 (high-dependency) area on a general surgical ward with experience of bariatric surgery. They received supplemental oxygen, continuous pulse oximetry, and judicious analgesic administration using a combination of small boluses of i.v. morphine together with i.v. paracetamol. Perioperative continuous positive airway pressure support was not routinely given, unless patients with OSA had oxygen saturation below their recorded preoperative level on 2 consecutive readings. RESULTS: A total of 1623 patients underwent laparoscopic bariatric surgery over a 12-year period. Of those, 192 had OSA with a median operative body mass index of 52 kg/m(2) (range 34-78 kg/m(2)). The incidence of respiratory complications and the median length of stay (3 nights) were identical in patients with OSA and those without OSA. Four patients self-administered perioperative continuous positive airway pressure, but none required transfer to intensive care or mechanical ventilation. There were no in-hospital deaths. CONCLUSION: Laparoscopic bariatric surgery in patients with OSA is well tolerated and does not require the routine use of level 3 critical care facilities.

Laparoscopic sleeve gastrectomy for high-risk patients: weight loss and comorbidity improvement--short-term results.

BACKGROUND: The obesity surgery mortality risk score (OS-MRS) is a five-point scoring system stratifying the risk of post-operative mortality. Patients with a body mass index (BMI) > 60 may also carry an increased risk of peri-operative complications. Laparoscopic sleeve gastrectomy (LSG) as an initial procedure could reduce weight and associated comorbidity allowing a safer, definitive second procedure. We investigated weight loss and risk reduction in patients having LSG as part of a planned two-stage definitive bariatric procedure. METHODS: Patients with a high OS-MRS (4-5), males with BMI > 60 or females with BMI > 65, who underwent LSG were identified from a prospective database. Data were analysed by means of the Mann-Whitney U and Chi-squared test. RESULTS: Sixty-eight patients underwent LSG. LSG reduced median BMI at 12 months (68 versus 54, P < 0.001) and the OS-MRS (3 versus 2, P = 0.005). An increase in patients considered low risk (OS-MRS, 0-1) was seen following LSG (35% versus 14%, P = 0.006). The proportion of patients with BMI < 50 increased from 0% to 30% (P < 0.001). Improvement or resolution of diabetes and hypertension was seen in 23% and 25% of cases, respectively. CONCLUSIONS: LSG achieves good weight loss, reduces the OS-MRS and improves obesity-related comorbidity in high-risk surgical patients.

Extended thromboprophylaxis reduces incidence of postoperative venous thromboembolism in laparoscopic bariatric surgery.

BACKGROUND: Venous thromboembolism (VTE) after laparoscopic bariatric surgery is a significant cause of morbidity and mortality. The objective of the present study was to study the incidence of symptomatic VTE in extended thromboprophylaxis regimens using dalteparin at an independent hospital in England, United Kingdom. METHODS: A prospective database of all patients undergoing bariatric surgery was retrospectively analyzed. All patients underwent VTE prophylaxis regimen using perioperative and extended postoperative low-molecular-weight heparin (dalteparin 2500 IU preoperatively, followed by 5000 IU daily postoperatively). The treatment period was 1 week for laparoscopic gastric banding or 3 weeks for all other procedures. Inferior vena cava filters were used in selected patients with thrombophilia, a history of pulmonary embolism, or >1 episode of deep vein thrombosis. The endpoint was the incidence of symptomatic VTE. RESULTS: A total of 735 patients underwent laparoscopic bariatric surgery, all of whom received dalteparin. The postoperative VTE incidence was 0%. The 30-day and 90-day all-cause mortality rate was 0%. A total of 3 adverse bleeding events occurred. CONCLUSION: An extended VTE prophylaxis regimen using low-molecular-weight heparin is simple and effective and was associated with a low incidence of bleeding complications.

Surgical and medical therapy for pancreatic carcinoma.

Progress on the treatment of pancreatic ductal adenocarcinoma has involved advances in medical and surgical care with important contributions from disciplines such as radiology and intensive care. In the last decade large randomized controlled trials have been undertaken that demonstrate the improved patient outcomes. There is an increased risk of pancreatic cancer in chronic pancreatitis, hereditary pancreatitis and a variety of familial cancer syndromes. The optimum outcome from pancreatic cancer needs management by multidisciplinary teams in regional specialist units. Endoscopic stenting, good pain relief and pancreatic enzyme supplementation are the basis of care in advanced pancreatic cancer. Chemotherapy prolongs survival in advanced pancreatic cancer with little to be gained using drugs other than 5FU. Resection, if possible, prolongs life and provides the best quality of life. Adjuvant chemoradiotherapy is of no benefit but chemotherapy may improve survival. Alongside the evolution in clinical management has been the elucidation of the molecular events that underlie pancreatic cancer and this knowledge has guided the introduction of targeted treatments for pancreatic cancer.

Update on pancreatic cancer.

Pancreatic cancer is one of the commonest causes of cancer death worldwide. Patients with pancreatic cancer benefit from resectional surgery (improved quality of life) and adjuvant treatment (enhanced survival). This review covers advances in the understanding of the development of pancreatic cancer, state-of-the-art clinical management and, finally, novel treatment and screening techniques.

The role of adjuvant therapy for pancreatic cancer.

Patients with pancreatic cancer have a very poor outlook. There have been major advances in the standard surgical treatment of this disease, resulting in decreased post-operative mortality and morbidity. The use of chemotherapy and radiotherapy has been developed to increase long-term patient survival following potentially curative resection. The standard chemotherapeutic agent is 5-fluorouracil (5-FU), although newer cytotoxic agents are in clinical trials for advanced cancer. Initial studies of adjuvant therapy have been based on small numbers of patients, but recently two large European randomised controlled trials of adjuvant therapy (EORTC and ESPAC-1) have been completed. These suggest that adjuvant chemotherapy has a significant survival advantage over resection alone but chemoradiotherapy does not. Promising new agents are being developed and tested mainly in clinical trials of advanced pancreatic cancer. The results of large-scale randomised controlled trials to assess adjuvant therapies for pancreatic cancer demonstrate the great surgical and oncological progress that has been made over the past decade.

New Techniques and Agents in the Adjuvant Therapy of Pancreatic Cancer.

Pancreatic ductal adenocarcinoma represents a major oncological challenge. Despite improvements in surgical techniques, long-term survival after resection is poor, with few patients surviving after 5 years. Until recently, there have been no large randomized trials of adjuvant therapy in pancreatic ductal adenocarcinoma. However, major trials such as the European Study Group for Pancreatic Cancer (ESPAC-1) and ESPAC-3 trials have set new standards for patient recruitment and development in this field. Adjuvant therapy has the potential to improve both patient survival and quality of life after curative resection. Currently, the best treatment is with 5-fluorouracil with folinic acid, but in the light of ongoing clinical trials, this may be supplanted by gemcitabine as the treatment of choice. Chemoradiotherapy does not appear to be beneficial in the adjuvant setting, but trials of a wide variety of other techniques and agents in the treatment of advanced disease are being undertaken and some of these will almost certainly be extended into the adjuvant setting in time. Great progress has been made in the adjuvant treatment of pancreatic cancer in the past 10 years and similar advances are likely over the next decade.

New techniques and agents in the adjuvant therapy of pancreatic cancer.

Pancreatic ductal adenocarcinoma represents a major oncological challenge. Despite improvements in surgical techniques, long-term survival after resection is poor, with few patients surviving after 5 years. Until recently, there have been no large randomized trials of adjuvant therapy in pancreatic ductal adenocarcinoma. However, major trials such as the European Study Group for Pancreatic Cancer (ESPAC-1) and ESPAC-3 trials have set new standards for patient recruitment and development in this field. Adjuvant therapy has the potential to improve both patient survival and quality of life after curative resection. Currently, the best treatment is with 5-fluorouracil with folinic acid, but in the light of ongoing clinical trials, this may be supplanted by gemcitabine as the treatment of choice. Chemoradiotherapy does not appear to be beneficial in the adjuvant setting, but trials of a wide variety of other techniques and agents in the treatment of advanced disease are being undertaken and some of these will almost certainly be extended into the adjuvant setting in time. Great progress has been made in the adjuvant treatment of pancreatic cancer in the past 10 years and similar advances are likely over the next decade.