Bariatric-metabolic surgery for NHS patients with type 2 diabetes in the United Kingdom National Bariatric Surgery Registry.

AIM: Bariatric-metabolic surgery is approved by the National Institute of Health and Care Excellence (NICE) for people with severe obesity and type 2 diabetes (T2DM) (including class 1 obesity after 2014). This study analysed baseline characteristics, disease severity and operations undertaken in people with obesity and T2DM undergoing bariatric-metabolic surgery in the UK National Health Service (NHS) compared to those without T2DM. METHODS: Baseline characteristics, trends over time and operations undertaken were analysed for people undergoing primary bariatric-metabolic surgery in the NHS using the National Bariatric Surgical Registry (NBSR) for 11 years from 2009 to 2019. Clinical practice before and after the publication of the NICE guidance (2014) was examined. Multivariate logistic regression was used to determine associations with T2DM status and the procedure undertaken. RESULTS: 14,948/51,715 (28.9%) participants had T2DM, with 10,626 (71.1%) on oral hypoglycaemics, 4322 (28.9%) on insulin/other injectables, and with T2DM diagnosed 10+ years before surgery in 3876 (25.9%). Participants with T2DM, compared to those without T2DM, were associated with older age (p < 0.001), male sex (p < 0.001), poorer functional status (p < 0.001), dyslipidaemia (OR: 3.58 (CI: 3.39-3.79); p < 0.001), hypertension (OR: 2.32 (2.19-2.45); p < 0.001) and liver disease (OR: 1.73 (1.58-1.90); p < 0.001), but no difference in body mass index was noted. Fewer people receiving bariatric-metabolic surgery after 2015 had T2DM (p < 0.001), although a very small percentage increase of those with class I obesity and T2DM was noted. Gastric bypass was the commonest operation overall. T2DM status was associated with selection for gastric bypass compared to sleeve gastrectomy (p < 0.001). CONCLUSION: NHS bariatric-metabolic surgery is used for people with T2DM much later in the disease process when it is less effective. National guidance on bariatric-metabolic surgery and data from multiple RCTs have had little impact on clinical practice.

Pelvic pain is a common prolapse symptom and improvement after ventral mesh rectopexy is more frequent than deterioration or de novo pain.

AIM: The aim of this work was to assess the relationship between pelvic pain and rectal prolapse both before prolapse surgery and in the long term after ventral mesh rectopexy (VMR). METHOD: Patients undergoing VMR between 2004 and 2017 were contacted. Outcomes including the severity of pelvic pain were recorded using a numeric rating scale. RESULTS: Four hundred and seventy eight of the 749 patients (64%) were successfully contacted. Of these, 39% reported pre-existing pelvic pain prior to VMR (group A) and 61% were pain free (group B). The median follow-up time was 8.0 years (interquartile range 5.0-10.0 years). Symptoms of obstructed defaecation were significantly more common (p = 0.002) in group A (91/187, 49%) than in group B (101/291, 35%). In contrast, faecal incontinence was more common (p = 0.007) in group B (75/291, 26%) than in group A (29/187, 15%). In group A, 76% showed improvement in pelvic pain after VMR: 61% were pain free and 39% had partial improvement in their pre-existing pelvic pain. Patients with persistent pelvic pain were younger (p = 0.01) and more likely to have revisional surgery after VMR (p = 0.0003), but there was no relation to the indication for surgery (p = 0.59). In group B, 15% reported de novo pelvic pain after VMR, and this was more common in women under 50 years old (p = 0.001), when obstructed defaecation was the indication (p = 0.03), in mesh erosion (p = <0.05) and when associated with revisional surgery (p = 0.005). CONCLUSION: Pelvic pain is common (39%) in patients undergoing prolapse surgery, and VMR improves this pain in most patients (76%). However, a significant number of patients fail to improve (12%), experience worsening of pain (12%) or develop de novo pelvic pain (15%).

Patients' Perception of Long-term Outcome After Laparoscopic Ventral Mesh Rectopexy; Single Tertiary Center Experience.

OBJECTIVE: To assess patients' long-term outcome and satisfaction after laparoscopic ventral mesh rectopexy (LVMR). SUMMARY OF BACKGROUND DATA: Data on the long-term outcome and satisfaction of patients undergoing LVMR are limited. METHODS: Patients who underwent LVMR between 2004 and 2017 were identified from a prospectively maintained database. We attempted to contact all patients by telephone for an interview using a standardized questionnaire to record pre-LVMR symptoms, long-term outcome, and overall satisfaction. RESULTS: Total number of patients who underwent LVMR was 848 and 99(12%) were deceased at follow-up. In the end, 544 (64%) patients were contacted successfully and 478 (56%) were able to complete the questionnaire. Median time elapsed since surgery was 7 years and mean age was 62 years. Patients' reported preoperative symptoms were obstructed defecation syndrome in 40%, fecal incontinence in 22%, combination of obstructed defecation syndrome and fecal incontinence in 21% and other conditions in 17%. Bowel symptoms were reported as improved by 69% of patients and worse by 12%. Pelvic pain was reported to be improved in 47% of the patients after LVMR but new onset of pelvic pain appeared in 15%. Sexual function was reported to be better and worse with equal frequency. Overall, 63% of the patients were satisfied with the outcome and 76% would recommend this procedure to others with similar symptoms. CONCLUSION: LVMR offers acceptable long-term outcomes and satisfaction. There is a mixed impact on pelvic pain and sexual function which requires careful consideration in counseling patients for this procedure.

Does Smoking Cessation Reduce Surgical Recurrence After Primary Ileocolic Resection for Crohn's Disease?

BACKGROUND: Tobacco smoking is a known risk factor for recurrence of Crohn's disease after surgical resection. OBJECTIVE: This study assessed the effect of smoking cessation on long-term surgical recurrence after primary ileocolic resection for Crohn's disease. DESIGN: A retrospective review of a prospectively maintained database was conducted. SETTINGS: Patient demographic data and medical and surgical details were combined from 2 specialist centers. After ethical approval, patients were contacted in case of missing data regarding smoking habit. PATIENTS: All patients undergoing ileocolic resection between 2000 and 2012 for histologically confirmed Crohn's disease were included. Those with previous intestinal resection, strictureplasty for Crohn's disease, leak after ileocolic resection, or who were never reversed were excluded. MAIN OUTCOME MEASURES: The primary end point was surgical recurrence measured by Kaplan-Meier survival analysis and secondary medical therapy at time of follow-up. RESULTS: Over a 12-year period, 290 patients underwent ileocolic resection. Full smoking data were available for 242 (83%) of 290 patients. There were 169 nonsmokers (70%; group 1), 42 active smokers at the time of ileocolic resection who continued smoking up to last follow-up (17%; group 2), and 31 (13%) who quit smoking after ileocolic resection (group 3). The median time of smoking exposure after ileocolic resection for group 3 was 3 years (interquartile range, 0-6 y), and median follow-up time for the whole group was 112 months (9 mo; interquartile range, 84-148 mo). Kaplan-Meier survival analysis showed a significantly higher surgical recurrence rate for group 2 compared with group 3 (16/42 (38%) vs 3/31 (10%); p = 0.02; risk ratio = 3.9 (95% CI, 1-12)). In addition, significantly more patients in group 2 without surgical recurrence received immunomodulatory maintenance therapy compared with group 3 (12/26 (46%) vs 4/28 (14%); p = 0.01; risk ratio = 3.2 (95% CI, 1-9)). LIMITATIONS: The study was limited by its retrospective design and small number of patients. CONCLUSIONS: Smoking cessation after primary ileocolic resection for Crohn's disease may significantly reduce long-term risk of surgical recurrence and is associated with less use of maintenance therapy. See Video Abstract at http://links.lww.com/DCR/B86. ¿DEJAR DE FUMAR REDUCE LA RECURRENCIA QUIRÚRGICA DESPUÉS DE LA RESECCIÓN ILEOCÓLICA PRIMARIA PARA LA ENFERMEDAD DE CROHN?: Fumar tabaco es un factor de riesgo conocido para la recurrencia de la enfermedad de Crohn después de la resección quirúrgica.Evaluar el efecto de dejar de fumar en la recurrencia quirúrgica a largo plazo después de la resección ileocólica primaria para la enfermedad de Crohn.Revisión retrospectiva de una base de datos mantenida prospectivamente.Se combinaron datos demográficos del paciente, así como detalles médicos y quirúrgicos de dos centros especializados. Después de la aprobación ética, se contactó a los pacientes en caso de falta de datos sobre el hábito de fumar.Todos los pacientes sometidos a resección ileocólica entre 2000 y 2012 por enfermedad de Crohn confirmada histológicamente. Se excluyeron aquellos con resección intestinal previa, estenosis por enfermedad de Crohn, fuga después de resección ileocólica o que nunca se revirtieron.La principal variable fue la recurrencia quirúrgica medida por análisis de supervivencia de Kaplan-Meier, terapia médica secundaria en el momento del seguimiento.Durante un período de 12 años, 290 pacientes fueron sometidos a resección ileocólica. Se dispuso de datos completos sobre el tabaquismo para 242/290 (83%). Hubo 169 no fumadores (70%) (grupo 1), 42 (17%) fumadores activos en el momento de la resección ileocólica que continuaron fumando hasta el último seguimiento (grupo 2) y 31 (13%) que dejaron de fumar después de resección ileocólica (grupo 3). La mediana del tiempo de exposición al tabaquismo después de la resección ileocólica para el grupo 3 fue de 3 años (IQR 0-6) y la mediana del tiempo de seguimiento para todo el grupo fue de 112 meses (9 años) (IQR 84-148). El análisis de supervivencia de Kaplan-Meier mostró una tasa de recurrencia quirúrgica significativamente mayor para el grupo 2 en comparación con el grupo 3 (16/42 (38%) frente a 3/31 (10%), p = 0.02; razón de riesgo 3.9 (IC 95% 1-12)). Además, un número significativamente mayor de pacientes del grupo 2 sin recurrencia quirúrgica recibieron terapia de mantenimiento inmunomoduladora en comparación con el grupo 3 (12/26 (46%) frente a 4/28 (14%), p = 0.01; razón de riesgo 3.2 (IC 95% 1-9)).Diseño retrospectivo y pequeño número de pacientes.Dejar de fumar después de la resección ileocólica primaria para la enfermedad de Crohn puede reducir significativamente el riesgo a largo plazo de recurrencia quirúrgica y se asocia con un menor uso del tratamiento de mantenimiento. Consulte Video Resumen en http://links.lww.com/DCR/B86. (Traducción-Dr. Gonzalo Federico Hagerman).

Efficiency and risks of laparoscopic conversion of omega anastomosis gastric bypass to Roux-en-Y gastric bypass.

BACKGROUND: There is a paucity on literature data related to conversion of Omega anastomosis gastric bypass (OAGB) to Roux-en-Y gastric bypass (RYGB). METHODS: This is a retrospective study. Records of all patients who underwent this conversion were analyzed. Additionally, patients were contacted to answer a questionnaire on their current clinical condition. RESULTS: Twenty-eight patients underwent laparoscopic conversion between September 2007 and June 2016. Indications were peritonitis in 7 patients (leaks after OAGB in 5, perforated marginal ulcer (MU) and blow-out remnant with concomitant leak in one patient each), anastomotic bleeding in one, bile reflux in 6, recalcitrant MU in 4, afferent loop syndrome in 6, postprandial vomiting in 2 (related to anastomotic stenosis and perianastomotic diverticulum, one each), and malnutrition and hypoglycemia both in 1. Thirty-day mortality was zero, complication rate (Clavien-Dindo grade III or more) 5% ((N = 1/20), abscess) when conversion was elective and 50.0% ((N = 4/8), all persisting leaks) when conversion was urgent. All 4 leaks persisting after conversion were successfully treated by endoscopic stenting, despite stent migration in 2 patients. Follow-up was available in 92.9%, for a mean time of 64.5 ± 30.1 months. Successful symptom relief (Likert score 4 or more) was noted for bile reflux and postprandial vomiting. Additionally, malnutrition was corrected. CONCLUSIONS: When indicated, conversion of OAGB to RYGB is a safe treatment strategy. In case conversion is performed for leak after OAGB, persisting subclinical leaks are frequent but can be efficiently addressed by endoscopic stenting.

Long-term (>10 Yrs) Outcome of the Laparoscopic Biliopancreatic Diversion With Duodenal Switch.

OBJECTIVE: The aim of the study was to report 10+ year outcome of laparoscopic biliopancreatic diversion with duodenal switch (LDS), with special focus on quality of life. BACKGROUND:: Reports on long-term morbidity and quality of life after LDS are rare. METHODS: Records of all patients who underwent LDS 10+ years ago were analyzed. Patients were contacted to answer a questionnaire based on Bariatric Analysis and Reporting Outcome System. Blood work was reported when performed within the past year. RESULTS: Of the 153 patients who underwent LDS, follow-up was available for 113 patients (78.5%). Mean follow-up was 130.2 ±â€Š4.6 months. Percentage total weight loss was 40.7 ±â€Š10.8%. Weight loss was greatest in the super obese category (BMI > 50 kg/m). Remission rate for type 2 diabetes was 87.5% (21/24) and for arterial hypertension 80.9% (38/47). Dyslipidemia remission rates were 93.3% (28/30) for total cholesterol, 89.7% (26/29) for triglycerides, and 95.0% (19/20) for low-density lipoprotein cholesterol. However, 42.5% of the patients needed reoperation, including 10.6% for correction of protein malnutrition, the latter exclusively in non-super obese individuals. Most common deficiencies concerned vitamin A and D, iron, and zinc. De novo gastroesophageal reflux disease was reported in 43.8%. The Bariatric Analysis and Reporting Outcome System score was good at 4.9 ±â€Š2.2, and 82.3% of participants would choose the procedure again. CONCLUSIONS: LDS is a very effective metabolic procedure, at the cost of occasional protein and other nutritional deficiencies. Outcome in the long term is best in super obese patients. Overall quality of life is good. The high reoperation rate and incidence of gastroesophageal reflux disease are concerning.

Clinical characteristics of patients undergoing primary bariatric surgery in the United Kingdom based on the National Bariatric Surgery Registry.

Baseline demographic characteristics and operations undertaken for patients having bariatric surgery in the United Kingdom are largely unknown. This study aimed to describe the profile of patients having primary bariatric surgery in the National Health Service (NHS) or by self-pay, and associated operations performed for both pathways. The National Bariatric Surgery Registry dataset for 5 years between January 2015 and December 2019 was used. 34 580 patients underwent primary bariatric surgery, of which 75.9% were NHS patients. Mean patient age and initial body mass index were significantly higher for NHS compared to self-pay patients (mean age 45.8 ± 11.3 [SD] vs. 43.0 ± 12.0 years and initial body mass index 48.0 ± 7.9 vs. 42.9 ± 7.3 kg/m2 , p < .001). NHS patients were more likely to have obesity-related complications compared to self-pay patients: prevalence of Type 2 diabetes mellitus 27.7% versus 8.3%, hypertension 37.1% versus 20.1%, obstructive sleep apnoea 27.4% versus 8.9%, severely impaired functional status 19.3% versus 13.9%, musculoskeletal pain 32.5% versus 20.1% and being on medication for depression 31.0% versus 25.9%, respectively (all p < .001). Gastric bypass was the most commonly performed primary NHS bariatric operation 57.2%, but sleeve gastrectomy predominated in self-pay patients 48.7% (both p < .001). In contrast to self-pay patients, NHS patients are receiving bariatric surgery only once they are older and at a much more advanced stage of obesity-related disease complications.

Intrathoracic sleeve gastrectomy migration with gastric volvulus treated with laparoscopic repair and conversion to gastric bypass.

A 43 years old female with laparoscopic sleeve gastrectomy (SG) and an 'anterior' hiatal hernia repair 11 years ago, presented with 3 years history dysphagia and heartburn. Upper gastrointestinal barium showed an almost complete intrathoracic migration of the SG with a partial organoaxial volvulus. Upper endoscopy revealed a 10 cm hiatal hernia with grade B esophagitis. Laparoscopic revision surgery with reduction of the gastric sleeve, standard posterior hiatal hernia repair, resection of the narrowed remnant of the SG and conversion to a gastric bypass was performed. No postoperative complications occurred. The patient is asymptomatic at 2 years of follow-up. We present the technical standards for the management and discuss the suspected pathophysiology of this rare but challenging condition.