Intensive pre-operative information course (IPIC) and pre-operative weight loss results in long-term sustained weight loss following bariatric surgery: 11 years results from a tertiary referral centre.

INTRODUCTION: Outcomes of long-term (5-10-year) weight loss have not been investigated thoroughly and the role of pre-operative weight loss on long-term weight loss, among other factors, are unknown. Our regional bariatric service introduced a 12 week intensive pre-operative information course (IPIC) to optimise pre-operative weight loss and provide education prior to bariatric surgery. The present study determines the effect of pre-operative weight loss and an intense pre-operative information course (IPIC), on long-term weight outcomes and sustained weight loss post-bariatric surgery. METHODS: Data were collected prospectively from a bariatric center (2008-2022). Excess weight loss (EWL) ≥ 50% and ≥ 70% were considered outcome measures. Survival analysis and logistic regression identified variables associated with overall and sustained EWL ≥ 50% and ≥ 70%. RESULTS: Three hundred thirty-nine patients (median age, 49 years; median follow-up, 7 years [0.5-11 years]; median EWL%, 49.6%.) were evaluated, including 158 gastric sleeve and 161 gastric bypass. During follow-up 273 patients (80.5%) and 196 patients (53.1%) achieved EWL ≥ 50% and ≥ 70%, respectively. In multivariate survival analyses, pre-operative weight loss through IPIC, both < 10.5% and > 10.5% EWL, were positively associated with EWL ≥ 50% (HR 2.23, p < 0.001) and EWL ≥ 70% (HR 3.24, p < 0.001), respectively. After a median of 6.5 years after achieving EWL50% or EWL70%, 56.8% (154/271) had sustained EWL50% and 50.6% (85/168) sustained EWL70%. Higher pre-operative weight loss through IPIC increased the likelihood of sustained EWL ≥ 50% (OR, 2.36; p = 0.013) and EWL ≥ 70% (OR, 2.03; p = 0.011) at the end of follow-up. CONCLUSIONS: IPIC and higher pre-operative weight loss improve weight loss post-bariatric surgery and reduce the likelihood of weight regain during long-term follow-up.

Laparoscopic Lumen-guided cholecystectomy in face of the difficult gallbladder.

BACKGROUND: Where the critical view of safety cannot be established during cholecystectomy, certain salvage techniques are indicated to reduce the likelihood of bile duct injury. The present study describes a salvage technique termed the "laparoscopic lumen-guided cholecystectomy" (LLC) and reports its peri-operative outcomes. METHOD: A summary of the technique is as follows: (1) Hartmann's pouch is incised and stones are evacuated; (2) the cystic anatomy is inspected from the inside of the gallbladder; (3) the lumen is used to guide retrograde dissection towards the cystic pedicle; (4) cystic duct control is achieved if deemed safe. LLC cases performed between June 2020 and January 2022 in a single health board were included. The operative details and peri-operative outcomes of the technique are reported and compared to cases of similar difficulty where the LLC was not attempted. RESULTS: LLC was performed in 4.6% (27/587) of cases. In all 27 cases, LLC was performed for a "frozen" cholecystohepatic triangle. Hartmann's pouch was completely excised in all cases (27/27) and cystic duct control was achieved in 85.2% of cases (23/27). No cases of bile leak or ductal injury were reported. Rates of bile leak, post-operative complications and ERCP were lower following LLC compared to the group where LLC was not attempted (p < 0.01). CONCLUSION: LLC is a safe salvage technique and should be considered in cases where the critical view of safety cannot be established. The technique achieves cystic duct control in the majority of cases and favourable outcomes in the face of a difficult cholecystectomy.

A Systematic Review of Patient and Public Involvement (PPI) in Bariatric Research Trials: The Need for More Work.

Patient and public involvement (PPI) has gained increased attention in research circles. The consistency of PPI reporting has been addressed by the development of validated checklists such as GRIPP and GRIPP2. The primary aim of this study was to identify the incidence of PPI reporting in bariatric research. MEDLINE/PubMed, EMBASE, and CINAHL/Cochrane databases were searched for publications between 1st January 2018 to 31st December 2021 for "bariatric surgery" OR "weight loss surgery" OR "obesity surgery" AND "randomized controlled trials." Ninety studies fulfilled exclusion criteria; two studies reported direct PPI involvement, one indirectly used PPI and one reported not using PPI methods. No other study made direct or indirect mention of PPI. Concluding, that GRIPP2 and PPI reporting in bariatric surgery trials is lacking.

How safe bariatric surgery is-An update on perioperative mortality for clinicians and patients.

Bariatric, metabolic or weight loss surgery produces sustained weight loss and imporovement in obesity related diseases. Bariatric surgery has existed for decades but there is limited reliable data on the risk of perioperative mortality following the procedures. This commentary focuses on a recent meta-analysis which has produced contemporaneous mortality data, and the findings are significant. Utilising data from 3.6 million patients the study has shown an overall pooled perioperative mortality of 0.08%, a significantly reduced risk compared to previous, smaller studies. This finding increases our knowledge of surgical risk for these procedures and should now equip health care groups to challenge barriers to uptake of bariatric surgery. Barriers currently include a worldwide lack of focus on treating obesity, lack of funding and resource from commissioners, and a general public and professional view that bariatric surgery may be high risk. In reality, this figure equates to mortality risk for procedures generally considered 'safe' such as laparoscopic cholecystectomy and knee arthroplasty. Bariatric surgery is a safe option for achieving sustained weight-loss and the treatment of obesity related diseases, and refusing access to surgery on the grounds of perioperative safety should now be an outdated premise.

Long-term outcomes following surgical repair of giant paraoesophageal hiatus hernia.

INTRODUCTION: There are limited data regarding long-term outcomes after surgical repair of giant paraoesophageal hiatus hernia (GPHH). The aim of this study was to assess symptomatic recurrence and patient-reported outcomes following GPHH repair. METHODS: 178 patients undergoing elective (127) and emergency (51) GPHH repair between 1994 and 2015 were identified from the prospectively collected Lothian Surgical Audit database. Electronic patient records were used to determine rate of clinical recurrence. A postal questionnaire was used to assess modified DeMeester, 'Gastrointestinal Symptom Rating Scale' symptom scores, breathing and exercise tolerance, and patient satisfaction. RESULTS: Median follow-up was 35 months (range 12-238). 15 (8.4%) patients developed a clinical recurrence and 13 (7.3%) underwent a further operation. The clinical recurrence rates were similar in patients followed-up less than 5 years and beyond 5 years [10/128 (7.8%) vs 5/50 (10%)]. Mortality rate was 1.6% for elective compared with 16.7% for emergency procedures (P < 0.001). Completed questionnaires were received from 95 (78.5%) of 121 eligible patients. Mean symptom scores were low (Modified DeMeester 2.6). 83.7% of patients reported a good or excellent outcome, and 97.8% believed they had made the correct decision to undergo surgery. CONCLUSIONS: Surgical repair of GPHH is associated with high levels of patient satisfaction and good overall symptom outcome. There is a clinical recurrence rate of 8.4%, which does not significantly increase with long-term follow-up.

A prospective study of gastro-oesophageal reflux disease symptoms and quality of life 1-year post-laparoscopic sleeve gastrectomy.

INTRODUCTION: There are concerns that laparoscopic sleeve gastrectomy (LSG) can cause severe gastro-oesophageal reflux disease (GORD). The aim of this study was to assess GORD symptoms and quality of life following LSG. METHODS: A prospective study of patients undergoing LSG (2014-2016) was performed with follow-up by DeMeester Reflux/Regurgitation Score, Bariatric Quality of Life Index (BQLI) and Bariatric Analysis and Reporting Outcome System (BAROS) Score pre-operatively, 6 months and 1-year post-operatively. RESULTS: Twenty-two patients were studied. Mean modified DeMeester Reflux/Regurgitation Score improved from 2.25 (±0.67) pre-operatively to 0.81 (±0.25) at 12 months (P = 0.04). At 12 months, two patients had symptomatic reflux, but overall satisfaction score was unaffected. Mean BQLI Score underwent a non-significant improvement at 12 months. BAROS Score showed all patients to have excellent (n = 19) or very good (n = 3) results (12 months). CONCLUSION: GORD symptoms improve for most patients' 1-year post-operatively. A small proportion of patients will develop troublesome GORD, but overall satisfaction remains high.

Results of a national multicenter audit assessment of gynecologic history in surgical patients.

OBJECTIVE: To determine the adequacy of assessing gynecologic history for females of reproductive age (FRA) admitted to a general surgery department. METHODS: The present prospective multicenter audit included FRA who were admitted for elective or emergency procedures to general surgery departments in Scotland between May 11 and May 25, 2015. Data were compared between patients who were admitted for elective and emergency treatment. RESULTS: There were 530 FRA included from 18 centers, including 169 (31.9%) and 361 (68.1%) elective and emergency admissions, respectively. The date of last menstrual period was document for 203 (38.3%) patients, use of contraception for 149 (28.1%), sexual activity for 83 (15.7%), pregnancy status for 274 (51.7%), and the possibility of pregnancy for 237 (44.7%). A higher incidence of documented date of last menstrual period (P=0.002) and pregnancy status (P<0.001) were identified among emergency admissions, and the possibility of pregnancy was documented more commonly among elective admissions (P<0.001). CONCLUSIONS: Key factors required for gynecologic assessment were often not documented for FRA admitted to general surgery both as elective and emergency admissions. Surgical teams and medical undergraduates require educating regarding the importance of obtaining gynecologic history for all FRA.

National multicentre audit of pregnancy status in general surgery admissions in Scotland.

BACKGROUND: Documentation of pregnancy status (PS) is an integral component of the assessment of women of reproductive age when admitted to hospital. Our aim was to determine how accurately PS was documented in a multicentre audit of female admissions to general surgery. METHODS: A prospective multicentre audit of elective and emergency admissions was performed in 18 Scottish centres between 08:00 on 11 May 2015 and 07:59 on 25 May 2015. The lower age limit was the minimum age for admission to the adult surgical ward and the upper age limit was 55 years. RESULTS: There were 2743 admissions, with 612 (22.3%) women of reproductive age. After 82 exclusions, the final total was 530: 169 (31.9%) elective and 361 (68.1%) emergency. Documentation of PS was achieved in 274 (51.7%) cases: 52 (30.8%) elective and 222 (61.5%) emergency. In 318 (88.1%) of the emergency admissions, the patient had abdominal pain. Of these, 211 (65.1%) had a documented PS. The possibility of pregnancy was established in 237 (44.7%) cases. DISCUSSION: Establishing the possibility of pregnancy before surgery is poor, particularly in the elective setting. Objective documentation of PS in the emergency setting in those with abdominal pain is also poor. Our study highlights an important safety issue in the management of female patients. We advocate electronic storage of pregnancy test results and new guidelines to cover both elective and emergency surgery. PS should form part of the pre-theatre safety brief and checklist.

Long-term outcomes following laparoscopic anterior and Nissen fundoplication.

BACKGROUND: Limited evidence exists to which operation gives best long-term outcomes for gastro-oesophageal reflux disease. This study aimed to assess long-term symptomatic outcome and satisfaction following laparoscopic anterior (LA) or Nissen fundoplication in a specialist upper gastrointestinal unit. METHODS: Patients who underwent primary LA or Nissen (LN) fundoplication between May 1994 and June 2010 were identified from a prospectively collected database. DeMeester, modified DeMeester, 'Gastrointestinal Symptom Rating Scale' scores and patient satisfaction were assessed by questionnaire. RESULTS: A total of 387 patients underwent surgery and 246 patients (65%) completed questionnaires, with 181 LA patients and 65 LN patients. Median follow-up was 83 months for LA and 179 months for LN (P < 0.001). A total of 218/245 (89%) reported major improvement in symptoms and 27 (11%) reported poor outcomes. There was no differences between LA and LN for symptom scores at short (<5 years) or long-term follow-up (>5 years). Women reported significantly higher DeMeester scores and lower satisfaction (P = 0.012). One hundred and eighteen (48%) patients were taking proton pump inhibitors (PPI) at follow-up despite high satisfaction rates. CONCLUSION: LA and LN have similar long-term results with patients reporting high satisfaction levels. Women reported more symptoms and less satisfaction than men. Despite high satisfaction rates a high percentage of patients take PPIs.

Aspiration and allograft injury secondary to gastroesophageal reflux occur in the immediate post-lung transplantation period (prospective clinical trial).

OBJECTIVES: To provide novel pilot data to quantify reflux, aspiration, and allograft injury immediately post-lung transplantation. BACKGROUND: Asymptomatic reflux/aspiration, associated with allograft dysfunction, occurs in lung transplant recipients. Early fundoplication has been advocated. Indications for surgery include elevated biomarkers of aspiration (bile salts) in bronchoalveolar lavage fluid (BALF). Measurements have been mostly documented after the immediate posttransplant period. We report the first prospective study of reflux/aspiration immediately posttransplantation to date. METHODS: Lung transplant recipients were recruited over 12 months. At 1 month posttransplantation, patients completed a Reflux Symptom Index questionnaire and underwent objective assessment for reflux (manometry and pH/impedance). Testing was performed on maintenance proton pump inhibitor. BALF was assessed for pepsin, bile salts, interleukin-8 and neutrophils. RESULTS: Eighteen lung transplant recipients, median age of 46 years (range: 22-59 years), were recruited. Eight of 18 patients had abnormal esophageal peristalsis. Five of 17 patients were positive on Reflux Symptom Index questionnaire. Twelve of 17 patients had reflux. Three patients exclusively had weakly acid reflux. Median acid exposure was 4.8% (range: 1%-79.9%) and median esophageal volume exposure was 1.6% (range: 0.7-5.5). There was a median of 72 reflux events (range: 27-147) per 24 hours. A correlation existed between Reflux Symptom Index score and proximal reflux (r = 0.533, P = 0.006). Pepsin was detected in 11 of 15 BALF samples signifying aspiration (median: 18 ng/mL; range: 0-43). Bile salts were undetectable, using spectrophotometry and rarely detectable using dual mass spectrometry (2/15) (levels 0.2 and 1.2 µmol/L). Lavage interleukin-8 and neutrophil levels were elevated. A correlation existed between proximal reflux events and neutrophilia (r = 0.52, P = 0.03). CONCLUSIONS: Lung transplant recipients should be routinely assessed for reflux/aspiration within the first month posttransplant. Reflux/aspiration can be present early postoperatively. Pepsin was detected suggesting aspiration. Bile salts were rarely detected. Proximal reflux events correlated with neutrophilia, linked to allograft dysfunction and mortality. These results support the need for early assessment of reflux/aspiration, which may inform fundoplication.

Are the enzymatic methods currently being used to measure bronchoalveolar lavage bile salt levels fit for purpose?

BACKGROUND: Microaspiration after gastroesophageal reflux has been implicated in the chronic loss of allograft function in lung transplant patients. Bronchoalveolar lavage fluid (BALF) assessment for pepsin and bile salts is a common method to document reflux and aspiration. Clinically used methods for bile salt analysis include tandem mass spectrometry and diagnostic enzymatic kits designed to measure bile salts in serum. In clinical research, the enzymatic kits have been commonly used for BALF assays in lung transplant recipients, with reports of detection limits of 0.2 µmol/liter, and the levels used to inform clinical decisions. This study assessed the sensitivity of detection by 2 enzymatic assay kits compared with tandem mass spectrometry. METHODS: These 2 kits were used to measure (1) the absorbance changes for 0 to 50 µmol/liter bile salts, (2) levels in gastric juice (10-10,010 µmol/liter), and (3) bile salt levels of 40 BALF samples that were also measured using tandem mass spectrometry (0.01-1.19 µmol/liter). Measurements of pH/impedance were done in 14 of 15 patients. RESULTS: Neither kit had detection limits as low as claimed in previous BALF studies. The kits could be made more sensitive with a longer incubation time, (5 µmol/liter). All patients had detectable lavage bile acids using mass spectroscopy, 71% had pathologic distal gastroesophageal reflux, and 43% had pathologic proximal reflux. CONCLUSIONS: The enzymatic kits are not sensitive enough for use in situations where bile salt levels are much below 5 µmol/liter, which is the case in BALF. In addition, reports in the literature of levels significantly below 5 µmol/liter need reassessing. Tandem mass spectrometry with a lower limit of detection of 0.01 µmol/liter should be the method of choice.

Fukushima nuclear incident: the challenges of risk communication.

On March 11, 2011, a magnitude 9.0 earthquake occurred off the Sanriku coast of Japan, which resulted in multiple tsunamis. The earthquake and tsunami damaged several nuclear power stations, with the Fukushima Dai-ichi Nuclear Power Plant being the worst affected, which led Japan to declare a State of Nuclear Emergency. As of November 9, 2011, the National Police Agency of Japan reported a death toll of 15 836 people, with 3664 people still reported missing, following the earthquake and tsunami. Australian radiation health advisers were deployed to Tokyo early in the nuclear emergency to assist the Australian Embassy in assessing the radiological threat, to provide risk advice to Embassy staff and Australian citizens in Japan, and to plan for any further deterioration in the nuclear situation. This article explores the challenges of risk assessment, risk communication, and contingency planning for expatriate staff in the worst nuclear incident since Chernobyl, outlines what measures were successful in addressing heightened perceived risks, and identifies areas where further research is required, particularly in a radiological context.

Leadership and use of standards by Australian disaster medical assistance teams: results of a national survey of team members.

INTRODUCTION: It is likely that calls for disaster medical assistance teams (DMATs) will continue in response to international disasters. OBJECTIVE: As part of a national survey, the present study was designed to evaluate leadership issues and use of standards in Australian DMATs. METHODS: Data was collected via an anonymous mailed survey distributed via State and Territory representatives on the Australian Health Protection Committee, who identified team members associated with Australian DMAT deployments from the 2004 Asian Tsunami disaster. RESULTS: The response rate for this survey was estimated to be approximately 50% (59/118). Most of the personnel had deployed to the Asian Tsunami affected areas. The DMAT members were quite experienced, with 53% (31/59) of personnel in the 45-55 years of age group. Seventy-five percent (44/59) of the respondents were male. Fifty-eight percent (34/59) of the survey participants had significant experience in international disasters, although few felt they had previous experience in disaster management (5%, 3/59). There was unanimous support for a clear command structure (100%, 59/59), with strong support for leadership training for DMAT commanders (85%, 50/59). However only 34% (20/59) felt that their roles were clearly defined pre-deployment, and 59% (35/59) felt that team members could be identified easily. Leadership was identified by two team members as one of the biggest personal hardships faced during their deployment. While no respondents disagreed with the need for meaningful, evidence-based standards to be developed, only 51% (30/59) stated that indicators of effectiveness were used for the deployment. CONCLUSIONS: In this study of Australian DMAT members, there was unanimous support for a clear command structure in future deployments, with clearly defined team roles and reporting structures. This should be supported by clear identification of team leaders to assist inter-agency coordination, and by leadership training for DMAT commanders. Members of Australian DMATs would also support the development and implementation of meaningful, evidence-based standards. More work is needed to identify or develop actual standards and the measures of effectiveness to be used, as well as the contents and nature of leadership training.

Education and training of Australian disaster medical assistance team members: results of a national survey.

INTRODUCTION: Calls for disaster medical assistance teams (DMATs) are likely to continue in response to international disasters. OBJECTIVE: As part of a national survey, the present study was designed to evaluate the education and training of Australian DMATs. METHODS: Data were collected via an anonymous, mailed survey distributed via State and Territory representatives on the Australian Health Protection Committee, who identified team members associated with Australian DMAT deployments from the 2004 Southeast Asia tsunami disaster. RESULTS: The response rate for this survey was 50% (59/118). Most of the personnel had deployed to the tsunami-affected areas. The DMAT members were quite experienced, with 53% of personnel in the 45-55-year age group (31/59). Seventy-six percent of the respondents were male (44/58). While most respondents had not participated in any specific training or educationalprogram, any kind of relevant training was regarded as important in preparing personnel for deployment. The majority of respondents had experience in disasters, ranging from hypothetical exercises (58%, 34/59) to actual military (41%, 24/49) and non-governmental organization (32%, 19/59) deployments. Only 27% of respondents felt that existing training programs had adequately prepared them for deployment. Thirty-four percent of respondents (20/59) indicated that they had not received cultural awareness training prior to deployment, and 42% (25/59) received no communication equipment training. Most respondents felt that DMAT members needed to be able to handle practical aspects of deployments, such as training as a team (68%, 40/59), use of communications equipment (93%, 55/59), ability to erect tents/shelters (90%, 53/59), and use of water purification equipment (86%, 51/59). Most respondents (85%, 50/59) felt leadership training was essential for DMAT commanders. Most (88%, 52/59) agreed that teams need to be adequately trained prior to deployment, and that a specific DMAT training program should be developed (86%, 51/59). CONCLUSIONS: This study of Australian DMAT members suggests that more emphasis should be placed on the education and training. Prior planning is required to ensure the success of DMAT deployments and training should include practical aspects of deployment. Leadership training was seen as essential for DMAT commanders, as was team-based training. While any kind of relevant training was regarded as important for preparing personnel for deployment, Australian DMAT members, who generally are a highly experienced group of health professionals, have identified the need for specific DMAT training.

Hepatitis B outbreak following a mass-casualty incident, Australia.

On 16 April 2009, a boat carrying 47 Afghan asylum seekers and 2 Indonesian crew exploded in Australian waters, resulting in mass casualties. Of these casualties, 23 persons who suffered significant burns were transferred to Royal Perth Hospital, Perth, Western Australia. One patient was subsequently shown to be a hepatitis B virus (HBV) carrier at the time of the explosion. Over the following months, 3 other patients received a diagnosis of acute hepatitis B, and an additional 4 patients showed serological evidence of recent HBV infection, including 1 patient who was transferred to another Australian city. Molecular typing determined that the strains from the HBV carrier and the acute and recent case patients formed a closely related cluster, and the investigation suggested that transmission occurred at or around the time of the boat explosion. This is the first report of confirmed transmission of HBV following a disaster, and it reinforces the importance of postexposure prophylaxis for HBV in mass casualty situations.

Response to pandemic (H1N1) 2009 influenza in Australia - lessons from a State health department perspective.

This article reviews the lessons that can be learned by the health sector, in particular, and the public sector, more generally, from the governmental response to pandemic (H1N1) 2009 influenza A (pH1N1) in Australia during 2009. It covers the period from the emergence of the epidemic to the release of the vaccine, and describes a range of impacts on the Western Australian health system, the government sector and the community. There are three main themes considered from a State government agency perspective: how decisions were influenced by prior planning; how the decision making and communication processes were intimately linked; and the interdependent roles of States and the Commonwealth Government in national programs. We conclude that: (a) communications were generally effective, but need to be improved and better coordinated between the Australian Government, States and general practice; (b) decision making was appropriately flexible, but there needs to be better alignment with expert advice, and consideration of the need for a national disease control agency in Australia; and (c) national funding arrangements need to fit with the model of state-based service delivery and to support critical workforce needs for surge capacity, as well as stockpile and infrastructure requirements.