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.

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.

Prehabilitation Before Major Abdominal Surgery: A Systematic Review and Meta-analysis.

INTRODUCTION: Prehabilitation prior to major surgery has increased in popularity over recent years and aims to improve pre-operative conditioning of patients to improve post-operative outcomes. The beneficial effect of such protocols is not well established with conflicting results reported. This review aimed to assess the effect of prehabilitation on post-operative outcome after major abdominal surgery. METHODS: EMBASE, Medline, PubMed and the Cochrane database were searched in August 2018 for trials comparing outcomes of patients undergoing prehabilitation involving prescribed respiratory and exercise interventions prior to abdominal surgery. Study characteristics, overall and pulmonary morbidity, length of stay (LOS), maximum inspiratory pressure and change in six-minute walking test (6MWT) distance were obtained. The primary outcome was post-operative overall morbidity within 30 days. Dichotomous data were analysed by fixed or random effects odds ratio. Continuous data were analysed with weighted mean difference. RESULTS: Fifteen RCTs were included in the analysis with 457 prehabilitation patients and 450 control group patients. A significant reduction in overall (OR 0.63 95% CI 0.46-0.87 I2 34%, p = 0.005) and pulmonary morbidity (OR 0.4 95% CI 0.23-0.68, I2 = 0%, p = 0.0007) was observed in the prehabilitation group. No significant difference in LOS (WMD -2.39 95% CI -4.86 to 0.08 I2 = 0%, p = 0.06) or change in 6MWT distance (WMD 9.06 95% CI -35.68, 53.81 I2 = 88%, p = 0.69) was observed. CONCLUSIONS: Prehabilitation can reduce overall and pulmonary morbidity following surgery and could be utilised routinely. The precise protocol of prehabilitation has not been completely established. Further work is required to tailor optimal prehabilitation protocols for specific operative procedures.

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.

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 audit of the 10-year outcomes from low dose-rate brachytherapy for early stage prostate cancer.

AIM: New Zealand men diagnosed with early stage prostate cancer need to know what outcomes to expect from management options. METHODS: Between 2001 and 2016, 951 men were treated with low dose-rate brachytherapy (permanent iodine-125 seed implantation) by the Wellington Prostate Brachytherapy Group based at Southern Cross Hospital, Wellington. At follow up after treatment, men had their PSA measured and were scored for urinary, bowel and sexual side effects. RESULTS: Median follow-up of men was 7.9 years (range 2.0-16.3 years). Ten-year PSA control was 95% for the 551 men with low-risk prostate cancer and 82% for the 400 men with intermediate-risk prostate cancer. Adverse effects were generally minor and short-term only. Temporary urinary obstruction developed soon after the implant in 2.6% men, and the 10-year cumulative risk of urethral stricture was 2.6%. Erectile dysfunction developed in 29% men, two-thirds of whom had a good response to a PDE5 inhibitor. Most men returned to a normal routine within four days of the implant. CONCLUSION: LDR brachytherapy is a highly effective low-impact treatment option for New Zealand men with early stage prostate cancer.

Systematic Review and Meta-Analysis of Epidural Analgesia Versus Different Analgesic Regimes Following Oesophagogastric Resection.

INTRODUCTION: Effective analgesia following open oesophagogastric (OG) resection is considered a key determinant of recovery. This review aimed to compare epidural to alternative analgesic techniques in patients undergoing major open resection for OG cancer. METHODS: A systematic review and meta-analysis was conducted of randomized controlled trials comparing epidural with alternative analgesic methods in open OG surgery. Primary outcome was the overall post-operative morbidity rate. Secondary outcomes included pulmonary complication rates, length of stay (LOS) and pain scores at 24 h. RESULTS: Six trials which comprised of 249 patients were identified (3 following gastrectomy and 3 following oesophagectomy). Following gastrectomy, secondary outcomes including pulmonary complications and dynamic pain scores at 24 h were improved in the epidural groups. No difference was observed in overall morbidity rates or LOS. Following oesophagectomy, overall morbidity rates were not reported at all. LOS was not shortened, and rest pain was not significantly different in the epidural group, but dynamic pain scores were reported to be improved. CONCLUSION: Few trials of analgesic regimen have been performed following open OG resection. In those trials that have been performed, epidural analgesia has not been shown to reduce overall morbidity. Epidural is associated with reduced pulmonary complications after gastrectomy, but no benefit has been shown after oesophagectomy. Whilst widespread investigation of minimally invasive OG techniques currently takes place, it is clear that the most effective patient pathway following open OG surgery, particularly oesophagectomy, is still not proven. Further trials are required.

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.

Surgical and endoscopic management of high grade dysplasia and early oesophageal adenocarcinoma.

BACKGROUND: The introduction of endoscopic techniques has led to debate about optimal management of early oesophageal adenocarcinoma. The aim was to evaluate patient selection and outcomes for endoscopic or surgical treatment at a tertiary referral centre. METHODS: A prospectively collected database of consecutive patients staged with high-grade dysplasia (HGD) or T1 oesophageal adenocarcinoma treated with curative intent between 2005 and 2013 was undertaken. All patients were discussed at the multidisciplinary team meeting. Surgical treatment was by thoracoscopic assisted or standard/laparoscopic assisted Ivor Lewis oesophagectomy. Endoscopic treatment was a structured programme of endoscopic mucosal resection (EMR) and/or radiofrequency ablation (RFA). Outcomes included treatment variables, recurrence and complications. RESULTS: 83 patients treated; 50 with endoscopic therapy (EMR only-4, EMR then RFA-22, RFA only-24) and 38 by surgery (33 straight to surgery and 5 following EMR). Median age (67) and mean follow-up (21 months) were similar. HGD was more common in the endoscopic group (32/50, 64%, vs.3/33, 9%, p = 0.0001). Significant complications were more common following surgery (13/38, 34%, vs. 1/50, 2%, p = 0.0001). There were two in-hospital deaths following oesophagectomy (1 open, 1 thoracoscopic). Endoscopic treatment beyond 12 months for persisting HGD/intramucosal disease was required in 2 patients. Recurrence of HGD/invasive cancer was diagnosed in 2/36 (5.6%, T1a recurrence) of endoscopic and 1/38 (2.6%, T2N0 - subsequent hepatic metastases) surgical patients. CONCLUSION: A management algorithm including both endoscopic treatment and oesophagectomy provides optimal outcome for these patients. Due to additional morbidity of surgery, endoscopic treatment is appropriate first-line treatment.

Patterns of failure after iodine-125 seed implantation for prostate cancer.

PURPOSE: To determine the site of relapse when biochemical failure (BF) occurs after iodine-125 seed implantation for prostate cancer. MATERIALS AND METHODS: From 2001-2009, 500 men underwent implantation in Wellington, New Zealand. Men who sustained BF were placed on relapse guidelines that delayed restaging and intervention until the prostate-specific antigen (PSA) was ⩾20 ng/mL. RESULTS: Most implants (86%) had a prostate D90 of ⩾90%, and multivariate analysis showed that this parameter was not a variable that affected the risk of BF. Of 21 BFs that occurred, the site of failure was discovered to be local in one case and distant in nine cases. Restaging failed to identify the site of relapse in two cases. In nine cases the trigger for restaging had not been reached. CONCLUSIONS: If post-implant dosimetry is generally within the optimal range, distant rather than local failure appears to be the main cause of BF. Hormone treatment is therefore the most commonly indicated secondary treatment intervention (STI). Delaying the start of STI prevents the unnecessary treatment of men who undergo PSA 'bounce' and have PSA dynamics initially mimicking those of BF.

Feasibility study of sentinel lymph node biopsy in esophageal cancer with conservative lymphadenectomy.

INTRODUCTION: Lymphoscintigraphy and sentinel node mapping is established in breast cancer and melanoma but not in esophageal cancer, even though many centers have shown that occult tumor deposits in lymph nodes influence prognosis. We report our initial experience with lymphoscintigraphy and sentinel lymph node biopsy in patients undergoing resection for esophageal cancer. METHODS: Sixteen of 17 consecutive patients underwent resection for invasive esophageal cancer along with sentinel lymph node retrieval (resection rate, 94%). Peritumoral injection of (99m)Tc antimony colloid was performed by upper endoscopy prior to the operation. A two-surgeon synchronous approach via right thoracotomy and laparotomy was performed with conservative lymphadenectomy. Sentinel lymph nodes were identified using a gamma probe both in vivo and ex vivo. Sentinel lymph nodes were sent off separately for serial sections and immunohistochemistry. RESULTS: Median patient age was 60.4 years (range, 45-75 years). Fifteen were male, and thirteen had adenocarcinoma. At least one sentinel lymph node (median, 2) was identified in 14 of 16 patients (success rate, 88%). Sentinel nodes were present in more than one nodal station in five patients (31%). In all 14 patients, the sentinel lymph node accurately predicted findings in non-sentinel nodes (accuracy, 100%). Three patients with positive sentinel lymph nodes had metastases identified in non-sentinel nodes (sensitivity, 100%). CONCLUSIONS: Sentinel lymph node biopsy is feasible in esophageal resection with conservative lymphadenectomy, and initial results suggest it is accurate in predicting overall nodal status. Further study is needed to assess impact on patient management and prognosis.

The role of lymphadenectomy in esophageal cancer.

OBJECTIVE: To address the role of lymphadenectomy in the treatment of esophageal cancer. BACKGROUND: The role of lymphadenectomy in esophageal cancer surgery is controversial, and there is a lack of uniformity as to what the term means. METHODS: The published data was reviewed to evaluate the evidence base for, and the terminology associated with, lymphadenectomy for esophageal cancer. RESULTS: Recommendations are given for a standardization of terminology for radical and nonradical lymphadenectomy procedures. Although there is no doubt that the presence of lymph node metastases worsens prognosis for a patient, there is a lack of high-level evidence to support lymphadenectomy. Logically, the best procedure, from a staging and perhaps theoretical oncologic point of view, is a 3-field lymphadenectomy but it is not clear which patients, if any, are most likely to benefit. CONCLUSIONS: Well-designed randomized controlled trials are required to test, in a scientific manner, which of these procedures we should be offering our patients.

Laparoscopic fundoplication in patients with a hypertensive lower esophageal sphincter.

BACKGROUND: A small proportion of patients evaluated with manometry prior to a fundoplication have a high-pressure lower esophageal sphincter (LES). This paper examines the outcome of laparoscopic fundoplication for these patients. MATERIAL AND METHODS: Between October 1991 and December 2006, 1,886 patients underwent primary laparoscopic fundoplication. Those with a high-pressure LES on preoperative manometry (LESP > or = 30 mm Hg at end expiration) were identified from a prospective database. Long-term outcomes were determined using analogue symptom scores (0-10) for heartburn, dysphagia, and patient satisfaction and compared to those of a matched control group. RESULTS: Thirty patients (1.6%), nine men and 21 women, median age 51 years, had a hypertensive LES (mean, 36 mmHg; range, 30-55). Median follow-up after fundoplication was 99 (12-182) months. These patients had similar mean symptom scores to 30 matched controls for heartburn (2.3 vs. 2.2, P = 0.541), dysphagia (2.7 vs. 3.1, P = 0.539), and satisfaction (7.4 vs. 7.6, P = 0.546). Five patients required revision for dysphagia compared to no control patients (P = 0.005). These patients had a higher preoperative dysphagia score (6.6 vs. 3.1, P = 0.036). CONCLUSION: Laparoscopic fundoplication can be performed with good long-term results for patients with reflux and a hypertensive LES. However, those with preoperative dysphagia have a higher failure rate.

Improving the accuracy of TNM staging in esophageal cancer: a pathological review of resected specimens.

BACKGROUND: Controversy exists over the Sixth Edition of the International Union Against Cancer (UICC) TNM staging system for esophageal cancer. Inclusion of additional information such as the number of metastatic lymph nodes and extracapsular lymph node invasion may improve the current staging system and lead to optimization of patient treatment. METHODS: All patients in Adelaide who underwent resection for esophageal cancer between 1997 and 2007 were identified from a prospective database. Two independent observers then reexamined all pathology slides from the original resection. Univariate and multivariate analysis was performed to identify significant prognostic factors. The goodness of fit and accuracy of additional prognostic factors were assessed, and the staging system was modified according to this information. RESULTS: There were 240 patients (mean age, 62 years) who met the inclusion criteria. The 5-year overall survival rate was 36% (median, 24 months). Only histological grade and a refined pN stage were found to be independent prognostic factors that could then be used to improve current TNM staging. Subdivision of pN stage into three groups (0, 1-2, and >2 positive nodes) showed significant differences in 5-year survival between all three groups: 53% vs 27% vs 6%, respectively (P < .01). The optimal staging model was the same for patients who received neoadjuvant therapy and surgery (n = 116), and those who underwent surgery alone (n = 124). CONCLUSION: A staging model that incorporates a refined pN stage and histological grade appears to be more accurate than the current UICC-TNM staging system. This staging model is still applicable in patients who receive neoadjuvant therapy.

African droughts and dust transport to the Caribbean: climate change implications.

Great quantities of African dust are carried over large areas of the Atlantic and to the Caribbean during much of the year. Measurements made from 1965 to 1998 in Barbados trade winds show large interannual changes that are highly anticorrelated with rainfall in the Soudano-Sahel, a region that has suffered varying degrees of drought since 1970. Regression estimates based on long-term rainfall data suggest that dust concentrations were sharply lower during much of the 20th century before 1970, when rainfall was more normal. Because of the great sensitivity of dust emissions to climate, future changes in climate could result in large changes in emissions from African and other arid regions that, in turn, could lead to impacts on climate over large areas.

Speeding up the diagnosis of oesophago-gastric cancer.

National referral guidelines have been developed for patients with suspected oesphago-gastric cancer with the aim of reducing the delay from presentation to referral and, therefore, reducing overall delay in diagnosis. This study evaluates the impact of these guidelines and shows that they have resulted in a significant decrease in the time from referral to endoscopy for patients. Nurses can further contribute to this by increasing patient awareness of symptoms. A course is being developed to provide the necessary knowledge.