Role of Ursodeoxycholic Acid in the Prevention of Gallstones Formation in Bariatric Patients-a Systematic Review and Meta-Analysis of Randomised Trials.

The aim of this meta-analysis was to assess whether treatment with ursodeoxycholic acid (UDCA) in patients who have undergone bariatric surgery reduces gallstone formation. A systematic literature search was performed using electronic databases (MEDLINE, Embase, CENTRAL, Web of Science, PROSPERO, Google Scholar and the WHO International Clinical Trials Registry platform). RCTs without restrictions on study language, year, status of publication and patient's age were used. Pooled risk ratios were calculated using a random-effects model. Subgroup analyses for drug dose, duration and procedure types were performed. Sensitivity analyses and a summary of findings table were generated to assess the robustness and the level of evidence provided, respectively. Fourteen trials were included (3619 patients, 2292 in UDCA vs 1327 in control group). Procedures included SG, RYGB, OAGB, AGB and Gastroplasty. UDCA dose ranged from 300 to 1200 mg per day. Gallstone formation occurred in 19.3% (8.3% in UDCA vs 38.1% in the control group). UDCA significantly reduced the risk of gallstone formation (14 trials, 3619 patients; RR 0.27, 95% CI 0.18-0.41; P < 0.001). UDCA significantly reduced the risk of symptomatic gallstone disease (6 trials, 2458 patients; RR 0.30, 95% CI 0.21-0.43; P < 0.001). No subgroup difference was found for different doses, duration and type of procedure performed. Oral UDCA treatment significantly reduces the risks of developing gallstones in postoperative bariatric patients from 38 to 8%. The use of 500 to 600 mg UDCA for 6 months is effective and should be implemented in all patients post-bariatric surgery.

Successful endoscopic management of Bouveret syndrome.

We present a frail 83-year-old female with Bouveret syndrome managed using an endoscopic approach. Our patient attended the emergency department with abdominal pain, vomiting and signs of sepsis. She had a recent admission with acute cholecystitis that which had been managed conservatively. Axial imaging revealed aerobilia with a 14 mm common bile duct and a 3.5 cm calculus impacted in the duodenum, in association with a cholecysto-duodenal fistula. After resuscitation, an oesphagoduodenoscopy was performed under general anaesthesia. The large stone was seen impacted in the first part of duodenum. Mechanical lithotripsy and the Kudo snare were employed to fragment the stone and remove large fragments. Bouveret syndrome is rarely managed with success through endoscopy. The syndrome typically occurs in frail, elderly co-morbid patients who would benefit from endoscopic management over open surgery. Despite low success rates historically, endoscopic management is a reasonable and viable option in cases of Bouveret syndrome.

Effect of the learning curve on survival after laparoscopic liver resection for colorectal metastases.

BACKGROUND: Laparoscopic liver resection (LLR) is a highly demanding procedure with great variability. Previously published randomized trials have proven oncological safety of laparoscopic liver resection (LLR) as compared to open surgery. However, these were started after the learning curve (LC) was established. This leaves the question of whether the LC of LLR in the early laparoscopic era has affected the survival of patients with colorectal liver metastasis (CRLM). METHODS: All consecutive LLRs performed by a single surgeon between 2000 and 2019 were retrospectively analysed. A risk-adjusted cumulative sum (RA-CUSUM) chart for conversion rate and the log regression analysis of the blood loss identified two phases in the LC. This was then applied to patients with CRLM, and the two subgroups were compared for recurrence-free (RFS) and overall survival (OS). The analysis was repeated with propensity score-matched (PSM) groups. RESULTS: A total of 286 patients were included in the LC analysis, which identified two distinct phases, the early (EP; 68 patients) and the late (LP; 218 patients) phases. The LC was applied to 192 patients with colorectal liver metastasis (EPc, 45 patients; LPc, 147 patients). For patients with CRLM, R0 resection was achieved in 93 per cent: 100 per cent in the EPc group and 90 per cent in the LPc group (P = 0.026). Median OS and RFS were 60 and 16 months, respectively. The 5-year OS and RFS were 51 per cent and 32.7 per cent, respectively. OS (hazard ratio (h.r.) 0.78, 95 per cent confidence interval (c.i.) 0.51 to 1.2; P = 0.286) and RFS (h.r. 0.94, 95 per cent c.i. 0.64 to 1.37; P = 0.760) were not compromised by the learning curve. The results were replicated after PSM. CONCLUSION: In our experience, the development of a laparoscopic liver resection programme can be achieved without adverse effects on the long-term survival of patients with CRLM.

Liver abscess secondary to fishbone ingestion: case report and review of the literature.

We report a rare silent migration of a fishbone into the liver and review the relevant literature. A 56-year-old man presented with a 2-day history of dull epigastric pain and raised inflammatory markers. Computerized tomography scan revealed a 4-cm abscess in the left lobe of the liver, with a linear radio-dense foreign body within the collection. At laparoscopy the hepatogastric fistula was disconnected. The fishbone was retrieved from the liver. Gastrostomy was closed with an omental patch. The patient had an uneventful recovery. Fifty-two cases of liver abscess secondary to enterohepatic fishbone migration were reported with over two-thirds presenting with a left-lobe abscess. There was marked variability in the management of liver abscess in the setting of fishbone migration-summarized in table. We believe that laparoscopic drainage of the abscess and extraction of the foreign body offer control of the source of sepsis and diminishes recurrence, whilst having a low-risk profile.

Helicobacter pylori Does not Affect Postoperative Outcomes After Sleeve Gastrectomy.

BACKGROUND: The effect of Helicobacter pylori (HP) colonization of the stomach of patients undergoing laparoscopic sleeve gastrectomy (LSG) is unclear. OBJECTIVE: The objective of this study is to evaluate the effect of HP colonization on postoperative outcomes of LSG. SETTING: The setting of this study is in University Hospital. METHODS: This study was a retrospective cohort study of prospectively maintained database of all patients who underwent LSG at Jordan University Hospital from 2008 to 2015. RESULTS: Five hundred patients were included (362 females and 138 males). The mean preoperative weight was 124.5 ± 23.8 kg. The mean preoperative body mass index (BMI) was 45.5 ± 6.9 kg/m2. Two hundred sixteen (43.2%) patients were found to be HP positive. The differences between the HP positive and negative groups in respect of sex, baseline weight, and BMI were not statistically significant. However, patients who were HP positive were significantly older. All patients were followed for at least 3 months. We had an overall complication rate of 2.6%. Differences in the complication rate between the two groups were not statistically significant. Follow-up was 61% at 1 year. The mean percent total weight loss (%TWL) was 32.9 ± 7.9, and the mean percent excess weight loss (%EWL) was 76.9 ± 21.1. The decrease in BMI was 15.2 ± 5.2. The difference between the two groups was not statistically significant. CONCLUSION: There is no clear association between HP infection at the time of surgery and postoperative complications, especially leaks.

The impact of family members on weight loss after sleeve gastrectomy.

BACKGROUND: Weight loss after laparoscopic sleeve gastrectomy (LSG) is multifactorial. Postoperative compliance with appropriate dietary guidance may be affected by psychosocial factors and may influence the success of surgery. OBJECTIVE: To evaluate the effect of LSG in siblings compared to case-matched controls. SETTING: University hospital. METHODS: Siblings who had undergone LSG were compared with controls case-matched by age, sex, and body mass index. The percentage excess weight loss (%EWL) was calculated at 3, 6, and 12 months postoperatively. RESULTS: We had 32 siblings, of which 4 were lost to follow-up. Thus, 28 (87.5%) siblings completed 1 year of follow-up and were included in the study. In the family group, the %EWL was 72.7±15.0% at 1 year while in the control group the mean %EWL was 62.1±21.4%. Patients in the family group had significantly greater weight loss. Within the family group, the outcomes of family order had no statistically significant difference in weight loss between the first family member who had undergone LSG and subsequent family members. In addition, family members who had resided together in the same home had no advantage over those who resided separately. CONCLUSION: Genetic and environmental factors may have great influence on outcomes after bariatric surgery.

Early Weight Loss as a Predictor of 2-Year Weight Loss and Resolution of Comorbidities After Sleeve Gastrectomy.

BACKGROUND: The objective of this study was to investigate whether early postoperative weight loss predicts weight loss 1 and 2 years after laparoscopic sleeve gastrectomy (LSG) and to determine its effect on the resolution of comorbidities. METHODS: This was a prospective study of patients who underwent LSG at Jordan University Hospital from February 2009 to January 2014. RESULTS: One hundred ninety patients (mean age 34.0 ± 10.8 years; mean preoperative body mass index 46.2 ± 7.7 kg/m(2)) were included in the study. Of these, 146 were followed for 1 year and 73 were followed for 2 years. Thirty patients (20.5 %) had hypertension, 23 (15.8 %) had diabetes, 78 (53.4 %) had hyperlipidemia, 30 (20.5 %) had obstructive sleep apnea, and 50 (34.2 %) had more than one comorbidity. The percentage of excess weight loss (%EWL) was 22.7 ± 8.1, 75.1 ± 22.8, and 72.6 ± 17.5 at 1, 12, and 24 months, respectively. Fifty-five patients (37.7 %) had a 1-year %EWL of ≥80 %, and 29 (39.7 %) had a 2-year %EWL of ≥80 %. Linear regression analysis showed a strong correlation between 1-month %EWL and %EWL at 1 year (r (2) = 0.23, p < 0.001) and 2 years (r (2) = 0.28, p < 0.001). Resolution of comorbidities was associated with higher %EWL achieved at 1 year, but early postoperative weight loss did not have a significant effect on comorbidity resolution. CONCLUSIONS: Early postoperative weight loss can be used to identify and target poor responders.

The Magnitude of Antral Resection in Laparoscopic Sleeve Gastrectomy and its Relationship to Excess Weight Loss.

BACKGROUND: The objective of this study was to evaluate the effect of antral resection on weight loss and complications after laparoscopic sleeve gastrectomy (LSG). METHODS: This was a retrospective study of the prospectively collected data of patients who underwent LSG at Jordan University Hospital from February 2011 to February 2012. Patients were divided into two groups based on antral resection: group A underwent a 6-cm antral resection, and group B underwent a 2-cm antral resection. The percentage of excess weight loss (%EWL) was calculated at 3, 6, 12, and 24 months postoperatively. RESULTS: One hundred and ten patients were included in the study, all of whom completed at least 24 months of follow-up (mean follow-up, 33 months). Their mean body mass index was 46.1 ± 7.9 kg/m(2). In group A, the mean %EWL was 38.1 ± 14.1, 54.9 ± 19.9, 65.6 ± 22.8, and 66.8 ± 28.4% at 3, 6, 12, and 24 months, respectively. However, in group B, the mean %EWL was 42.1 ± 13.4, 63.8 ± 19.8, 80.0 ± 22.1, and 81.5 ± 22.9% at 3, 6, 12, and 24 months, respectively. Patients in group B experienced statistically significant greater weight loss than patients in group A. Statistically significant greater weight regain was seen in group A. Group A had a higher incidence of reflux symptoms (six patients; 11%) than group B (four patients; 7.1%). CONCLUSIONS: Radical antral resection in association with LSG safely potentiates the restrictive effect achieved and may result in greater and better maintained weight loss.

Volume of resected stomach as a predictor of excess weight loss after sleeve gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is gaining popularity for the treatment of obesity. The objective of this study was to evaluate the volume of the resected stomach (VRS) as a predictor of the percentage of excess weight loss (%EWL) 1 year after LSG. METHODS: This was a single-surgeon study of prospectively collected data of patients who underwent LSG at Jordan University Hospital (February 2009 to February 2012). The VRS was measured using a standardized technique. The %EWL was calculated at 3, 6, and 12 months postoperatively. The correlation between the VRS and %EWL was statistically evaluated. RESULTS: Ninety patients underwent LSG during the study period. Of these, 73 patients (57 female) completed at least 1 year of follow-up and were analyzed; their body mass index was 45 ± 7.6 kg/m(2) (33-81). The VRS was 1,337.4 ± 435.2 ml (600-2,800). The %EWL was 33.6 ± 11.1 % at 3 months, 48.6 ± 15.5 % at 6 months, and 56.8 ± 18.9 % at 12 months. A significant correlation was observed between the VRS and %EWL at 1 year (p = 0.003). Patients with a VRS of >1,100 ml (n = 43) achieved significantly greater %EWL at 12 months than did those with a VRS of ≤ 1,100 (n = 30). Removal of >1,100 ml of gastric volume was associated with a sensitivity and specificity of 75.5 and 46.2 %, respectively, for achieving a %EWL of ≥ 50 %. CONCLUSION: The VRS can be used as an indicator of excess weight loss 1 year after LSG.