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.

Evaluation of treatment delays in hepatopancreatico-biliary surgery during the first COVID-19 wave

INTRODUCTION

The COVID-19 pandemic has caused oncological services worldwide to face unprecedented challenges resulting in treatment disruption for surgical patients. Hepatopancreatico-biliary (HPB) cancers are characterised by rapid disease progression. This study aims to assess delays in receiving surgery for this patient cohort during the first COVID-19 wave.

METHODS

Patients undergoing surgery between April and July 2020 (COVID-19 period) were compared with a control group from the preceding year. Delay in receiving surgery was defined as more than 50 days between referral and surgery date. Statistical analysis was carried out to evaluate predictors of delay and short-term outcomes.

RESULTS

During the COVID-19 and pre-COVID-19 periods, 94 and 115 patients underwent surgery, respectively. No patients contracted COVID-19 postoperatively. Some 118 patients waited more than 50 days for surgery versus 91 who received surgery within 50 days from referral. Independent predictors for surgical delay were undergoing surgery in the COVID-19 era (odds ratio (OR) 2.2, 95% confidence interval (CI) 1.2-4.1; p=0.015), referral pathway (OR 35.1, 95% CI 4.2-296; p=0.001) and presenting pathology (OR 8.3, 95% CI 1.2-56.1; p=0.03). Short-term outcomes were comparable between groups.

CONCLUSIONS

Patient referral pathway and presenting pathology may contribute to delays in undergoing HPB cancer surgery during COVID-19 outbreaks. It is hoped that a better understanding of these factors will aid in designing shifts in healthcare policy during future pandemic outbreaks.

PANC Study (Pancreatitis: A National Cohort Study): national cohort study examining the first 30 days from presentation of acute pancreatitis in the UK

BACKGROUND

Acute pancreatitis is a common, yet complex, emergency surgical presentation. Multiple guidelines exist and management can vary significantly. The aim of this first UK, multicentre, prospective cohort study was to assess the variation in management of acute pancreatitis to guide resource planning and optimize treatment.

METHODS

All patients aged greater than or equal to 18 years presenting with acute pancreatitis, as per the Atlanta criteria, from March to April 2021 were eligible for inclusion and followed up for 30 days. Anonymized data were uploaded to a secure electronic database in line with local governance approvals.

RESULTS

A total of 113 hospitals contributed data on 2580 patients, with an equal sex distribution and a mean age of 57 years. The aetiology was gallstones in 50.6 per cent, with idiopathic the next most common (22.4 per cent). In addition to the 7.6 per cent with a diagnosis of chronic pancreatitis, 20.1 per cent of patients had a previous episode of acute pancreatitis. One in 20 patients were classed as having severe pancreatitis, as per the Atlanta criteria. The overall mortality rate was 2.3 per cent at 30 days, but rose to one in three in the severe group. Predictors of death included male sex, increased age, and frailty; previous acute pancreatitis and gallstones as aetiologies were protective. Smoking status and body mass index did not affect death.

CONCLUSION

Most patients presenting with acute pancreatitis have a mild, self-limiting disease. Rates of patients with idiopathic pancreatitis are high. Recurrent attacks of pancreatitis are common, but are likely to have reduced risk of death on subsequent admissions.

The efficacy of GLP-1RAs for the management of postprandial hypoglycemia following bariatric surgery: a systematic review

OBJECTIVE

Postprandial hyperinsulinemic hypoglycemia with neuroglycopenia is an increasingly recognized complication of Roux-en-Y gastric bypass and gastric sleeve surgery that may detrimentally affect patient quality of life. One likely causal factor is glucagon-like peptide-1 (GLP-1), which has an exaggerated rise following ingestion of carbohydrates after bariatric surgery. This paper sought to assess the role of GLP-1 receptor agonists (GLP-1RAs) in managing postprandial hypoglycemia following bariatric surgery.

METHODS

MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov, and Scopus were systematically and critically appraised for all peer-reviewed publications that suitably fulfilled the inclusion criteria established a priori. This systematic review was developed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses Protocols (PRISMA-P). It followed methods outlined in the Cochrane Handbook for Systematic Reviews of Interventions and is registered with PROSPERO (International Prospective Register of Systematic Reviews; identifier CRD420212716429).

RESULTS AND CONCLUSIONS

Postprandial hyperinsulinemic hypoglycemia remains a notoriously difficult to manage metabolic complication of bariatric surgery. This first, to the authors' knowledge, systematic review presents evidence suggesting that use of GLP-1RAs does not lead to an increase of hypoglycemic episodes, and, although this approach may appear counterintuitive, the findings suggest that GLP-1RAs could reduce the number of postprandial hypoglycemic episodes and improve glycemic variability.

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.

OUP accepted manuscript

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.

Weight loss with bariatric surgery or behaviour modification and the impact on female obesity-related urine incontinence: A comprehensive systematic review and meta-analysis

Women with obesity are at risk of pelvic floor dysfunction with a 3-fold increased incidence of urge urinary incontinence (UUI) and double the risk of stress urinary incontinence (SUI). The National Institute for Health and Care Excellence (NICE) and European Association of Urology (EAU) recommend that women with a body mass index ≥30 kg/m² should consider weight loss prior to consideration for incontinence surgery. This systematic review and meta-analysis will assess this recommendation to aid in the counselling of women with obesity-related urinary incontinence (UI). Medical Literature Analysis and Retrieval System online (MEDLINE), EMBASE, Cochrane, ClinicalTrials.gov, and SCOPUS were systematically and critically appraised for all peer reviewed manuscripts that suitably fulfilled the inclusion criteria established a priori and presented original, empirical data relevant to weight loss intervention in the management of urinary incontinence. Thirty-three studies and their outcomes were meta-analysed. Weight loss interventions were associated in a decreased prevalence in UI (OR 0.222, 95% CI [0.147, 0.336]), SUI (OR 0.354, 95% CI [0.256, 0.489]), UUI (OR 0.437, 95% CI [0.295, 0.649]) and improved quality of life (PFDI-20, SMD -0.774 (95% CI [-1.236, -0.312]). This systematic review and meta-analysis provide evidence that weight loss interventions are effective in reducing the prevalence of obesity-related UI symptoms in women. Bariatric surgery in particular shows greater sustained weight loss and improvements in UI prevalence. Further large scale, randomized control trials assessing the effect of bariatric surgery on women with obesity-related UI are needed to confirm this study's findings.

Male Obesity Associated Gonadal Dysfunction and the Role of Bariatric Surgery

Obesity is an ever growing pandemic and a prevalent problem among men of reproductive age that can both cause and exacerbate male-factor infertility by means of endocrine abnormalities, associated comorbidities, and direct effects on the precision and throughput of spermatogenesis. Robust epidemiologic, clinical, genetic, epigenetic, and preclinical data support these findings. Clinical studies on the impact of medically induced weight loss on serum testosterone concentrations and spermatogenesis is promising but may show differential and unsustainable results. In contrast, literature has demonstrated that weight loss after bariatric surgery is correlated with an increase in serum testosterone concentrations that is superior than that obtained with only lifestyle modifications, supporting a further metabolic benefit from surgery that may be specific to the male reproductive system. The data on sperm and semen parameters is controversial to date. Emerging evidence in the burgeoning field of genetics and epigenetics has demonstrated that paternal obesity can affect offspring metabolic and reproductive phenotypes by means of epigenetic reprogramming of spermatogonial stem cells. Understanding the impact of this reprogramming is critical to a comprehensive view of the impact of obesity on subsequent generations. Furthermore, conveying the potential impact of these lifestyle changes on future progeny can serve as a powerful tool for obese men to modify their behavior. Healthcare professionals treating male infertility and obesity need to adapt their practice to assimilate these new findings to better counsel men about the importance of paternal preconception health and the impact of novel non-medical therapeutic interventions. Herein, we summarize the pathophysiology of obesity on the male reproductive system and emerging evidence regarding the potential role of bariatric surgery as treatment of male obesity-associated gonadal dysfunction.

Preoperative liver shrinking diet for bariatric surgery may impact wound healing: a randomized controlled trial

BACKGROUND

In bariatric surgery, preoperative very low-calorie diets (VLCD) may better meet the technical demands of surgery by shrinking the liver. However, diets may affect tissue healing and influence bowel anastomosis in an as-yet-undefined manner.

OBJECTIVE

This randomized controlled trial aimed to examine the effect on collagen deposition in wounds in patients on a 4-week VLCD before laparoscopic gastric bypass.

SETTING

University hospital.

METHODS

The trial was undertaken in patients undergoing laparoscopic Roux-en-Y gastric bypass, with a control group (n = 10) on normal diet and an intervention group (n = 10) on VLCD (800 kcal) for 4 weeks. The primary outcome measured was expression of collagen I and III in skin wounds, with biopsies taken before and after the diet and 7 days postoperatively as a surrogate of anastomotic healing. Secondary outcome measures included liver volume and fibrosis score, body composition, operating time, blood loss, hospital stay, and complications.

RESULTS

Patients in both groups were similar in age, sex, body mass index (53.4 versus 52.8 kg/m²), co-morbidities, liver volume, and body composition. Expression of mature collagen type I was significantly decreased in diet patients compared with controls after 4 weeks of diet and 7 days after surgery. This was significant decrease in liver volume (23% versus 2%, P = .03) but no difference in operating times (129 versus 139 min, P = .16), blood loss, length of stay, or incidence of complications.

CONCLUSIONS

Preoperative diets shrink liver volume and decrease expression of mature collagen in wounds after surgery. Whether the latter has a detrimental effect on clinical outcomes requires further evaluation.

Measurement of hepatic insulin sensitivity early after the bypass of the proximal small bowel in humans

OBJECTIVE

Unlike gastric banding or sleeve gastrectomy procedures, intestinal bypass procedures, Roux-en-Y gastric bypass in particular, lead to rapid improvements in glycaemia early after surgery. The bypass of the proximal small bowel may have weight loss and even caloric restriction-independent glucose-lowering properties on hepatic insulin sensitivity. In this first human mechanistic study, we examined this hypothesis by investigating the early effects of the duodeno-jejunal bypass liner (DJBL; GI Dynamics, USA) on the hepatic insulin sensitivity by using the gold standard euglycaemic hyperinsulinaemic clamp methodology.

METHOD

Seven patients with obesity underwent measurement of hepatic insulin sensitivity at baseline, 1 week after a low-calorie liquid diet and after a further 1 week following insertion of the DJBL whilst on the same diet.

RESULTS

Duodeno-jejunal bypass liner did not improve the insulin sensitivity of hepatic glucose production beyond the improvements achieved with caloric restriction.

CONCLUSIONS

Caloric restriction may be the predominant driver of early increases in hepatic insulin sensitivity after the endoscopic bypass of the proximal small bowel. The same mechanism may be at play after Roux-en-Y gastric bypass and explain, at least in part, the rapid improvements in glycaemia.

A Systematic Review and Meta-analysis of the Effect of Gastric Bypass Surgery on Plasma Lipid Levels

BACKGROUND

Obesity-related dyslipidaemia comprises hypercholesterolaemia, hypertriglyceridaemia, low HDL-cholesterol and normal to raised LDL-cholesterol levels. 40% of morbidly obese surgical patients have dyslipidaemia. Roux-en-Y gastric bypass (RYGB) surgery has many beneficial metabolic effects, but the full impact on plasma lipids has not been clearly defined.

METHODS

A systematic review of electronic databases (Ovid; Medline; PubMed; Embase) between 1960 and March 2012 was performed using search terms including the following: obesity surgery, bariatric surgery, gastric bypass, cholesterol, lipids, triglycerides and non-esterified fatty acids. A total of 2442 manuscripts were screened. Papers with paired plasma lipid levels around RYGB surgery were included. Exclusions included the following: editorials, dual publications, n < 10, resulting in 75 papers of relevance. A meta-analysis was performed of the effect of RYGB surgery upon plasma lipids at different time points up to 4 years following surgery, using a random effects model.

RESULTS

Paired data were available for 7815 subjects around RYGB surgery for morbid obesity with a baseline BMI 48 kg/m(2) (n = 2331). There was a reduction in plasma total cholesterol and LDL-C from 1 month up to 4 years post-RYGB (p < 0.00001, p < 0.00001). Following RYGB, HDL-C increased from 1 year onwards (p < 0.00001), and triglyceride levels were reduced postoperatively from 3 months up to 4 years (p < 0.00001). NEFA levels were increased at 1 month postoperatively (p = 0.003), but from 3 months onwards did not differ from preoperative levels (p = 0.07).

CONCLUSIONS

RYGB surgery reverses the dyslipidaemia of obesity. These findings support the use of RYGB in the management of high cardiovascular risk lipid profiles in morbid obesity.

Differences in Regional Brain Responses to Food Ingestion After Roux-en-Y Gastric Bypass and the Role of Gut Peptides: A Neuroimaging Study

OBJECTIVE

Improved appetite control, possibly mediated by exaggerated gut peptide responses to eating, may contribute to weight loss after Roux-en-Y gastric bypass (RYGB). This study compared brain responses to food ingestion between post-RYGB (RYGB), normal weight (NW), and obese (Ob) unoperated subjects and explored the role of gut peptide responses in RYGB.

RESEARCH DESIGN AND METHODS

Neuroimaging with [(18)F]-fluorodeoxyglucose (FDG) positron emission tomography was performed in 12 NW, 21 Ob, and 9 RYGB (18 ± 13 months postsurgery) subjects after an overnight fast, once FED (400 kcal mixed meal), and once FASTED, in random order. RYGB subjects repeated the studies with somatostatin infusion and basal insulin replacement. Fullness, sickness, and postscan ad libitum meal consumption were measured. Regional brain FDG uptake was compared using statistical parametric mapping.

RESULTS

RYGB subjects had higher overall fullness and food-induced sickness and lower ad libitum consumption. Brain responses to eating differed in the hypothalamus and pituitary (exaggerated activation in RYGB), left medial orbital cortex (OC) (activation in RYGB, deactivation in NW), right dorsolateral frontal cortex (deactivation in RYGB and NW, absent in Ob), and regions mapping to the default mode network (exaggerated deactivation in RYGB). Somatostatin in RYGB reduced postprandial gut peptide responses, sickness, and medial OC activation.

CONCLUSIONS

RYGB induces weight loss by augmenting normal brain responses to eating in energy balance regions, restoring lost inhibitory control, and altering hedonic responses. Altered postprandial gut peptide responses primarily mediate changes in food-induced sickness and OC responses, likely to associate with food avoidance.

Benign histology after pancreaticoduodenectomy for suspected malignancy. Lessons to be learned--a single centre experience

The aim of the study was to perform a comprehensive analysis of patients with a benign final histology after pancreaticoduodenectomies (PD) for suspected pancreatic and periampullary cancer.

MATERIAL AND METHODS

We searched the pathology database at the King's College Hospital for negative PD specimens submitted between January 2004-December 2010. Clinical, diagnostic, surgical,histopathological and outcome data were collected retrospectively. Pathology specimens and imaging results have been re-evaluated. A literature review was performed to identify factors affecting the incidence across centres.

RESULTS

469 PD were performed for presumed cancer. The incidence of benign disease encountered in this group was 7.25% (34/469). Autoimmune pancreatitis (AIP) was a finding in 26.47% (9/34) of cases. 17.65% of PD were complicated by a pancreatic leak and the overall mortality rate was 8.82%(3/34). Radiologists revised over 75% of pre-operative diagnoses. The incidence of benign disease was correlated with the overall centre experience and utilisation of CT imaging, but not ERCP or EUS.

CONCLUSIONS

It is impossible with current diagnostics to entirely avoid cases of benign disease inpatients undergoing PD for suspected cancer. The mortality rate is higher in this group, but it is possible to avoid unnecessary procedures in experienced centres. AIP represents an important diagnostic entity, which should be actively pursued pre-operatively.

Spleen-preserving distal pancreatectomy with and without splenic vessel ligation: a systematic review

BACKGROUND

Splenic preservation during a distal pancreatectomy (SPDP) may be performed with splenic vessel ligation, known as Warshaw's Technique (WT) or splenic vessel preservation (SVP). The consensus on which approach is best is divided. A systematic review of evidence in the literature was undertaken with the aim of analysing the merits and disadvantages of both WT and SVP.

METHODS

A systematic search of medical literature from 1985-2011 was undertaken to identify all comparative studies and case series on SPDP. Non-English papers, series with < 5 patients, technical reports and reviews were excluded. The remaining articles were reviewed considering the study design, surgical technique, outcomes and complications.

RESULTS

In 23 relevant studies, 356 patients underwent WT and 572 underwent SVP. In WT patients, the mean operating time (160 versus 215 min, P < 0.001), mean estimated blood loss (301 versus 390 ml, P < 0.001) and length of stay (8 versus 11 days, P < 0.001) was significantly less than the SVP patients, respectively. Considering complications, splenic infarction and splenectomy occurred more frequently in WT patients (P < 0.05).

DISCUSSION

WT is technically easier to perform than SVP but has a higher incidence of subsequent splenectomies. Surgeons should be able to perform both procedures and tailor the technique according to the patient.

The impact of varying post-operative dressing size on recovery from laparoscopic cholecystectomy

This study aimed to explore the impact of the size of a post-operative dressing and the subsequent visibility of the wound on recovery from laparoscopic cholecystectomy (LC). A randomised controlled trial was conducted. Fourty-one patients (8 men and 33 women, mean age = 44 years) scheduled for LC were included. Participants were randomly assigned to receive either small gauze dressings (n = 19) or large gauze dressings (n = 22) which were directly applied on post-operative incisions. Patients' mood, psychological well-being, illness cognitions, and pain and recovery were assessed at three time points: baseline, immediately after the procedure and then two weeks later. The findings suggest that the management of post-surgical incisions influences patients' interpretation of their illness which in turn has an impact upon the process of recovery from LC. This implies that visual information available to patients after the procedure through the cognitive and emotional mechanisms involved in their processing can alter the process of convalescence from LC.

Single incision laparoscopic adjustable gastric banding: 111 cases

BACKGROUND

As single incision surgery increases in popularity, the feasibility of offering this approach in bariatric surgery is further progression of this surgical technique. With the technical challenges that both operating on the morbidly obese patient and single incision surgery present, we describe our initial experience undertaking 111 single-incision gastric band insertions.

METHODS

From June 2009 to October 2010, 111 obese patients underwent single-incision laparoscopic adjustable gastric banding through a single transverse incision using a multichannel single port and a pars flaccida technique. Prospective data collection was undertaken, including visual analog scores.

RESULTS

In this initial series, the median operative time was 65 minutes (range 34-165). There was 1 conversion to a 5-port laparoscopic technique (.9%), and an additional port was placed in 7 patients (6%). Male patients were more likely to require an additional port (P < .05). The single-incision size ranged from 26 to 45 mm (median 35). At 23 hours postoperatively, the median pain score was 2.5 on a 0-10 visual analog score. On multivariate analysis, pain was found to increase with operation time (P < .001). The median length of stay was 24 hours (range 5.5-48). There was no mortality and minimal morbidity, with 1 wound infection necessitating band removal.

CONCLUSIONS

Single-incision laparoscopic adjustable gastric banding can be performed safely with minimal morbidity and mortality in the morbidly obese patient, and our technique has a high rate of success. The benefits compared with the traditional laparoscopic approach and long-term outcomes are yet to be established. However, if the intra-abdominal operative time is >60 minutes, one should consider the placement of an additional port, especially in male patients.

Video. Single-incision laparoscopic left lateral segmentectomy of colorectal liver metastasis

Laparoscopic surgery via a single port is an evolving technique being applied to an increasing variety of operations [1]. Multiple series over the past 3 years have shown single-incision laparoscopic cholecystectomy to be feasible and safe [2]. The ergonomic difficulties of single-port laparoscopy include a loss of instrument triangulation and operation with camera and instruments in parallel. Many different modifications of techniques and equipment have been used to compensate. Single-port techniques have been applied by a few authors to laparoscopic nephrectomy [3], splenectomy [4], and obesity surgery [5, 6]. Laparoscopic liver resection is well established and shown to be safe in multiple series [7]. The laparoscopic approach is accepted as the gold standard for resection of segments 2 and 3 [8]. To the authors' knowledge, no reports of laparoscopic liver resection via a single port have been published. They report the use of their technique for single-incision laparoscopic left lateral segmentectomy in a patient with a solitary segment 2 colorectal liver metastasis. The authors maintained strict oncologic principles and adhered to their standard laparoscopic technique as far as possible. They used a TriPort (Advanced Surgical Concepts, Wicklow, Ireland) placed via a 12-mm incision at the umbilicus. Following diagnostic laparoscopy and intraoperative liver ultrasound, hepatic attachments were divided using electrocautery. Parenchymal transection and vascular control were achieved using an ultrasonic dissector and laparoscopic staplers. Standard straight laparoscopic instruments were used. A number of technical challenges were apparent. Movement of instruments was jerky at times, either because instruments were clashing with one another other or deflecting the camera. The multiport device can be stiff, requiring copious lubrication throughout surgery. Crossing hands facilitates internal triangulation of the operating instruments to allow retraction or to apply tension, for example, during the division of hepatic attachments. Control of minor hemorrhage is possible with judicious and patient application of pressure using small pieces of surgical gauze. An articulating laparoscopic stapler is useful to achieve the ideal angle of staple deployment during transection of vascular pedicles. The specimen was extracted by extending the umbilical incision. No complications occurred. The patient was able to resume an oral diet and full mobility free of opioid analgesia on the first postoperative day. The resection margin was clear. This video demonstrates that the authors' technique is feasible and oncologically safe for selected patients requiring liver resection.

N-acetylcysteine improves the viability of human hepatocytes isolated from severely steatotic donor liver tissue

Hepatocyte transplantation is dependent on the availability of good quality human hepatocytes isolated from donor liver tissue. Hepatocytes obtained from livers rejected for transplantation on the grounds of steatosis are often of low viability and not suitable for clinical use. The aim of this study was to evaluate the effects of the antioxidant N-acetylcysteine (NAC) on the function of hepatocytes isolated from steatotic donor livers. Human hepatocytes were isolated from 10 severely steatotic (>60%) donor livers rejected for transplantation. The left lateral segment of the donor liver was dissected into two equal size pieces and randomized to NAC or control. NAC (5 mM) was added to the first perfusion buffer of the standard collagenase digestion technique. Cells from tissues perfused with NAC had a significantly higher mean viability (81.1 ± 1.7% vs. 66.0 ± 4.7%; p = 0.003) and cell attachment (1.08 ± 0.26 vs. 0.67 ± 0.18 OD units; p = 0.012). Addition of NAC during isolation of human hepatocytes from steatotic donor liver tissue significantly improved the outcome of cell isolation. Further studies are needed to investigate the mechanism(s) of this effect. Incorporation of NAC in the hepatocyte isolation protocol could increase the availability of hepatocytes for transplantation.

Novel deployment of a covered duodenal stent in open surgery to facilitate closure of a malignant duodenal perforation

Background

Its a dilemma to attempt a palliative procedure to debulk the tumour and/or prevent future obstructive complications in a locally advanced intra abdominal malignancy.

Case presentation

A 38 year old Vietnamese man presented with a carcinoma of the colon which had invaded the gallbladder and duodenum with a sealed perforation of the second part of the duodenum. Following surgical exploration, it was evident that primary closure of the perforated duodenum was not possible due to the presence of unresectable residual tumour.

Conclusion

We describe a novel technique using a covered duodenal stent deployed at open surgery to aid closure of a malignant duodenal perforation.

Strategy to reduce the risk of positive pancreatic resection margin at pancreatico-duodenectomy

BACKGROUND

The accuracy of histological assessment of frozen section (FS) of the pancreatic resection margin (PRM) at pancreatico-duodenectomy can be improved by concurrent FS examination of a sample of the suspected pancreatic lesion.

METHODS

A prospective trial was conducted using archived material. FS of all the PRM and suspected pancreatic lesion of 12 patients randomly selected from a historical group who underwent pancreatico-duodenectomy for suspected malignancy were examined by five histopathologists. They were asked to examine the PRM alone and alongside the suspected lesion. The diagnosis of the PRM was 'benign', 'malignant' or 'defer to paraffin section'. All the histopathologists were blinded to the paraffin section diagnosis.

RESULTS

The main outcome measures were sensitivity, specificity and the incidence of deferring to paraffin section. In this respect examination of the PRM alone had a sensitivity of 70% and a specificity of 87.5%. Concurrent FS examination of PRM with the pancreatic lesion increased the sensitivity to 90% and the specificity to 92.5%. The incidence of deferring to paraffin section was reduced from 17 to 7% (P = 0.03).

CONCLUSION

This policy is recommended because it improves the diagnostic accuracy of FS evaluation of the PRM resulting in a reduction of residual pancreatic cancer at the pancreatic transection line.

Biliopancreatic diversion in rats is associated with intestinal hypertrophy and with increased GLP-1, GLP-2 and PYY levels

BACKGROUND

Factors leading to weight loss and weight stabilization after bariatric surgery are not fully understood. The aims of this study were to develop an animal model for biliopancreatic diversion (BPD) and to determine changes in gut hormones, malabsorption and small bowel histology postoperatively.

METHODS

2 groups of Wistar rats underwent sham and BPD surgery. Daily postoperative weights and food intake were measured. 24-hour fecal collections were performed at Day 6 and 21. Bomb calorimetry was performed to determine the fecal calorific values. At day 23, levels of peptide YY (PYY), glucagon-like peptide 1 (GLP-1) and glucagon-like peptide 2 (GLP-2) were determined and small bowel biopsies were taken.

RESULTS

Animals in the BPD group had significant reduction in weight (P<0.001) and in food intake (P<0.001) compared to the sham group. Serum levels of PYY, GLP-1 and GLP-2 in the BPD group were significantly higher (P<0.005). Animals in the BPD group had significantly higher fecal energy content at Day 6 (P<0.001) but not at Day 21 when compared to the sham group. Small bowel histology confirmed the presence of significantly increased mitosis (P=0.03) and labelled cells (P=0.002) in the BPD animals when compared to sham.

CONCLUSIONS

In our animal model, the higher levels of PYY, GLP-1 and GLP-2 after BPD may be due to gut adaptation and hypertrophy and could be important in inducing and maintaining weight loss after bariatric surgery.

Bilateral sciatic nerve palsy following a bariatic operation

Iatrogenic nerve injuries have been rarely reported following laparoscopic abdominal surgeries. These can be serious complications with the potential for long-term disability. We present a rare case of bilateral sciatic nerve palsy following laparoscopic sleeve gastrectomy on a super-super-obese male with BMI 78.04 kg/m2. The procedure was completed laparoscopically in 7 hours duration, and in spite of adequate precautions, he developed bilateral sciatic nerve palsy. Nerve conduction studies showed denervation of L5/S1 confirming the diagnosis. The patient showed gradual recovery with physiotherapy, and at 18 months follow-up he was mobilizing without any walking aids, with BMI 47.34 kg/m2. Compressive nerve injuries following prolonged laparoscopic operations should be included in the list of procedural complications, especially in morbidly obese patients where the risk is significantly higher.

Technical limitations of lymph node mapping in pancreatic cancer

AIM

The high incidence of lymphatic and peri-neural invasion in pancreatic cancer results in poor loco-regional control. Radical pancreatico-duodenectomy may achieve better loco-regional control, but is accompanied by increasing morbidity. Our hypothesis was that if intra-operative mapping of pathological lymph nodes (LN) is technically feasible in pancreatic cancer, it would allow for selective radical resection.

METHODS

In an ethically approved and statistically powered feasibility study of 72 (stopped after 20% enrollment) patients with suspected pancreatic cancer undergoing resection, we injected methylene blue dye peri- and intra-tumorally and studied its progress to identify putative 'sentinel lymph node(s)'. The Kausch-Whipple procedure (or total pancreatectomy, if required) was carried out in addition to radical LN dissection, which was evaluated histopathologically according to the Japanese criteria.

RESULTS

Over 18 months, 14/16 patients prospectively recruited underwent lymph node mapping and a mean of 20 (range 11-37) LNs per patient were harvested. Methylene blue dye injection identified blue LN(s) in 4/14 patients, none of which were positive for malignant deposits, whilst 10/14 patients had LN metastases. The commonest stations for LN metastasis were 17A or B (9/10), 8A (2/10) and 6 (3/10). The median survival for the 13 patients with cancer was 22.3 months (IQR: 10.4-30 months).

CONCLUSION

Sentinel lymph node mapping is not technically feasible in pancreatic cancer.

Divergent effects of angiotensin-converting enzyme inhibition on blood pressure and endothelial function in obese humans

Endothelial dysfunction is a pivotal early event in the development of atherosclerosis and a characteristic feature of obesity. This study was designed to investigate the effect of angiotensin-converting enzyme (ACE) inhibition on endothelial function in people who were obese but otherwise healthy. We performed a double-blind, randomised, placebo-controlled study examining the effect of the ACE inhibitor perindopril (4 mg per day) on flow-mediated vasodilatation (FMD) of the brachial artery, arterial blood pressure, glucose homeostasis and inflammatory cytokines. Eighteen obese subjects (all body mass index > 30 kg/m2) were randomised to receive perindopril or placebo for four weeks. Perindopril led to a fall in systolic blood pressure from 131 (standard error of mean [SEM] 3) to 117(5) mmHg and diastolic blood pressure from 74(4) mmHg to 68(4) mmHg, both p<0.001. Despite this fall in blood pressure, ACE inhibition had no effect on FMD, 8.2 (1.2)% versus 8.3 (1.5)%, p=0.9. ACE inhibition had no effect on insulin, lipids or circulating cytokines. In healthy obese humans, despite a significant reduction in blood pressure, ACE inhibition had no effect on FMD.

Progressive rise in gut hormone levels after Roux-en-Y gastric bypass suggests gut adaptation and explains altered satiety

BACKGROUND

Bariatric surgery is the most effective treatment for achieving long-term weight loss in morbidly obese patients. This study investigated prospective changes in gut hormones and metabolic indices after Roux-en-Y gastric bypass (RYGB).

METHODS

Six patients were seen before, and at 1, 3 and 6 months after operation. Blood was collected after a 12-h fast and at regular intervals after a mixed 420-kcal meal. Hormonal responses were determined, and comparisons between basal levels and areas under the curve were made. Visual analogue scores were used to assess satiety, hunger and nausea.

RESULTS

Mean body mass index decreased from 48.3 kg/m(2) before surgery to 36.4 kg/m(2) 6 months after RYGB. This was accompanied by a decrease in fasting leptin (P < 0.001) and insulin (P = 0.021) levels. At 1, 3 and 6 months after operation, progressively increasing peptide YY (P < 0.001), enteroglucagon (P = 0.045) and glucagon-like peptide 1 (P = 0.042) responses were observed. There was no change in fasting ghrelin levels (P = 0.144). Postprandial satiety was significantly increased by 1 month after surgery and this was maintained until the end of the study (P < 0.001).

CONCLUSION

RYGB resulted in substantial weight loss with enhanced postprandial satiety, a sustained weight plateau, and proportionate reduction in fasting insulin and leptin levels. Lack of the expected increase in appetite and food intake as components of a counter-regulatory response may be explained by gut adaptation and the consequent graded rise in the levels of gut hormones that promote satiety.

Gut hormone profiles following bariatric surgery favor an anorectic state, facilitate weight loss, and improve metabolic parameters

OBJECTIVE

To study the effect of bariatric surgery on the entero-hypothalamic endocrine axis of humans and rodents.

BACKGROUND

Bariatric surgery is the most effective obesity treatment as it achieves substantial and sustained weight loss. Glycemic control and enhanced satiation improve before substantial weight loss occurs. Gut peptides, acting both peripherally and centrally, contribute to glycemic control and regulate food intake.

METHODS

We examined meal-stimulated responses of insulin, ghrelin, peptide YY (PYY), glucagon-like-peptide-1 (GLP-1), and pancreatic polypeptide (PP) in humans and rodents following different bariatric surgical techniques.

RESULTS

Compared with lean and obese controls, patients following Roux-en-Y gastric bypass (RYGB) had increased postprandial plasma PYY and GLP-1 favoring enhanced satiety. Furthermore, RYGB patients had early and exaggerated insulin responses, potentially mediating improved glycemic control. None of these effects were observed in patients losing equivalent weight through gastric banding. Leptin, ghrelin, and PP were similar in both the surgical groups. Using a rodent model of jejuno-intestinal bypass (JIB), we showed elevated PYY and GLP-1 in JIB rats compared with sham-operated rats. Moreover, exogenous PYY reduced food intake and blockade of endogenous PYY increased food intake. Thus, higher plasma PYY following JIB may contribute to reduced food intake and contribute to weight loss.

CONCLUSIONS

Following RYGB and JIB, a pleiotropic endocrine response may contribute to the improved glycemic control, appetite reduction, and long-term changes in body weight.

Endothelial function and weight loss in obese humans

BACKGROUND

Obesity is a major risk factor for the development of endothelial dysfunction. We explored the effect of different degrees of body mass on endothelial function, lipids, systemic inflammation and glucose homeostasis and the effect of surgically-induced weight loss on endothelial function in severely obese humans.

METHODS

A cross-sectional study of healthy subjects across a wide range of body fatness was performed to characterize the effect of obesity on flow-mediated dilatation (FMD), systemic inflammation, blood pressure and insulin sensitivity. A longitudinal study was performed to assess the effect of bariatric surgery induced weight loss on these parameters. 73 healthy subjects across a wide range of body mass were recruited; of these, 8 underwent bariatric surgery (median BMI 52.2 kg/m2, interquartile range 50.355.9). Endothelial dependent vasodilatation was measured using the brachial artery vasodilatory response to forearm hyperemia assessed using highresolution ultrasonography.

RESULTS

Obese subjects were characterised by a complex collection of abnormalities, with hypertension, impaired glucose homeostasis, systemic inflammation and reduced FMD. BMI < or =25 kg/m2 (median FMD 9.7%, interquartile range 6.8-12.2), BMI >30 kg/m2 (median FMD 6.7% 4.8-7.5), P=0.01 comparing FMD in lean and obese subjects. A mean reduction in weight of 23.4 (4.6) kg produced an improvement in FMD from 5.3% (3.87.0) to 10.2% (7.6-13.3), P=0.01.

CONCLUSIONS

Even moderate obesity leads to endothelial dysfunction. In severely obese subjects, FMD is normalized by weight loss. This improvement in FMD is associated with a decline in inflammatory markers, blood pressure and insulin. The improvement in FMD occurred despite patients remaining significantly obese. These results suggest that an integrated approach to improving endothelial function in obese humans may be necessary.

Post-traumatic posterior heel soft tissue defect reconstruction

We present a simple algorithm for management of post-traumatic posterior heel defect. We covered these with various flaps depending upon the defect size, its exact location, associated injuries, extent of zone of trauma, and complexity of the defect. The aim was to select the most suitable method for soft tissue coverage for posterior heel reconstruction.

Risk-adjustment in hepatobiliarypancreatic surgery

AIM: The present study evaluates the performance of the POSSUM, the American Society of Anesthetists (ASA), APACHE and Childs classification in predicting mortality and morbidity in hepatopancreaticobiliary (HPB) surgery. We describe especially the limitations and advantages of risk in stratifying the patients.

METHODS: We investigated 177 randomly chosen patients undergoing elective complex HPB surgery in a single institution with a total of 71 pre-operative and intra-operative risk factors. Primary endpoint was in-hospital mortality and morbidity. Ordered logistic regression analysis was used to identify individual predictors of operative morbidity and mortality.

RESULTS: The operative mortality in the series was 3.95%. This compared well with the p-POSSUM and APACHE predicted mortality of 4.31% and 4.29% respectively. Post-operative complications amounted to 45% with 24 (13.6%) patients having a major adverse event. On multivariate analysis the pre-operative POSSUM physiological score (OR = 1.18, P = 0.009) was superior in predicting complications compared to the ASA (P = 0.108), APACHE (P = 0.117) or Childs classification (P = 0.136). In addition, serum sodium, creatinine, international normalized ratio (INR), pulse rate, and intra-operative blood loss were independent risk factors. A combination of the POSSUM variables and INR offered the optimal combination of risk factors for risk prognostication in HPB surgery.

CONCLUSION: Morbidity for elective HPB surgery can be accurately predicted and applied in everyday surgical practice as an adjunct in the process of informed consent and for effective allocation of resources for intensive and high-dependency care facilities.

Expression of Ras GTPase isoforms in normal and diseased pancreas

BACKGROUND

Ki-Ras is well studied in its oncogenic form in relation to pancreatic pathologies. However, the individual contribution of each of the wild-type Ras isoforms (Ha-, Ki-, and N-) in pancreatic cells in health and disease is unknown.

METHODS

Archival formalin-fixed, paraffin-embedded specimens of normal (n = 6) and malignant pancreas (n = 35) were used for immuno-histochemical detection of Ras isoforms using a modified polymer system. In addition, immunogold labelling for Ras isoforms was done for subcellular localisation under electron microscopy.

RESULTS

Pancreatic ductal cells expressed Ha-Ras in the cytoplasm, with Ki-Ras in the apical region and N-Ras (50% of cases) in a supranuclear distribution. Pancreatic acinar cells express all three isoforms with some nuclear expression of Ki-Ras and supranuclear expression of N-Ras. Islets show Ki- and Ha-Ras mainly with differential expression of Ha-Ras (beta cells showing less Ha-Ras and more Ki-Ras than alpha cells). Electron microscopy shows that Ha-Ras is mainly localised in the endoplasmic reticulum and Golgi apparatus of the acinar cells with some plasma membrane localisation of Ki-Ras in the ductal cells. There was no change in any of the Ras isoform expression in the ductal or acinar cells in various malignancies studied (Mann-Whitney U test, p > 0.1).

CONCLUSIONS

Ras isoforms have distinct and separate cellular and subcellular distribution that may persist even in the malignantly transformed state. Understanding this distinct functional distribution patterns in detail is an essential step if mutant Ki-Ras is to be targeted in the pancreas by genetic or molecular therapeutic tools.

Massive splenomegaly is associated with significant morbidity after laparoscopic splenectomy

OBJECTIVE

To evaluate the impact of spleen weight on operative and clinical outcome in a series of 108 consecutive laparoscopic splenectomies.

BACKGROUND

Laparoscopic splenectomy as an alternative to open splenectomy for splenomegaly is regarded as controversial.

METHODS

Patients underwent laparoscopic splenectomy for a range of hematological disorders between November 1992 and February 2000. Multiple linear and logistic regression analysis were used to assess the effect of massive splenomegaly (>1000 g) on perioperative mortality and morbidity, after adjusting for the joint effects of patient age, weight, pre- and postoperative full blood counts, operating time, estimated blood loss, conversion rate, reoperation rate, and duration of hospital stay.

RESULTS

Massive splenomegaly was recorded in 27 of 108 (25%) cases. In this group, splenic weight ranged from 1000 to 4750 g (median, 2500 g). Patients with splenic weight >1000 g had a significantly longer median operating time (170 vs. 102 minutes, P < 0.01), conversion rate (5/27 vs. 4/81, P < 0.05), postoperative morbidity (15/27 vs. 4/81, P < 0.01), and median postoperative stay (5 vs. 3 days, P < 0.01). Multivariate analysis found splenic weight to be the most powerful predictor of morbidity (P < 0.01). Patients with splenomegaly (>1000 g) were 14 times likely to have post operative complications. One patient died 3 days after surgery, following a pulmonary embolus (spleen weight 500 g, mortality 1/108, 0.9%).

CONCLUSIONS

Laparoscopic splenectomy is feasible in patients with giant spleens. However, it is associated with greater morbidity, and the advantages of minimal access surgery in this subgroup of patients are not so clear.

Meta-analysis suggests antibiotic prophylaxis is not warranted in low-risk patients undergoing laparoscopic cholecystectomy

A financially important conclusion

Prediction of inflammation of the appendix at open and laparoscopic appendicectomy: findings and consequences

OBJECTIVE

To evaluate the accuracy of operative assessment of the condition of the appendix during laparoscopic and open appendicectomy, and to assess whether a normal-looking appendix should be excised routinely during a laparoscopic operation.

DESIGN

Prospective study.

SETTING

District general hospital, UK.

SUBJECTS

387 patients who presented with signs and symptoms of appendicitis and underwent appendicectomy.

INTERVENTION

63 patients (16%) were operated on laparoscopically, of whom 48 were female.

MAIN OUTCOME MEASURES

Correlation of operative with histological findings.

RESULTS

The positive predictive value of operative assessment was increased during the laparoscopic procedure in both male (94.4% to 100%) and female (78% to 88%) patients. Of 21 female patients whose appendixes looked normal at laparoscopy, 5 had other conditions (appendixes normal on histological examination) and 4 were inflamed.

CONCLUSION

In women of childbearing age a normal-looking appendix should be resected during laparoscopic appendicectomy unless another condition is obviously the cause of the signs and symptoms.

Incidental ultrasound diagnosis of pseudomyxoma peritonei in an asymptomatic woman

An incidental finding of pseudomyxoma peritonei is reported in a woman with a 6-month history of postmenopausal bleeding. A transvaginal ultrasound scan revealed a poorly defined echogenic mass in the right iliac fossa above the right ovary and free fluid of mixed echogenicity in the pouch of Douglas. Laparoscopic appendicectomy and aspiration of mucinous fluid was performed without adjuvant chemotherapy. Regular postoperative follow-up scans, which are needed as the disease may have an indolent course, showed no signs of recurrence. The differential diagnosis and management of pseudomyxoma peritonei are discussed.

Effect of topical glyceryl trinitrate on anodermal blood flow in patients with chronic anal fissures

INTRODUCTION

Recent studies have highlighted the role of increased internal anal sphincter pressure and decreased anodermal blood flow in the pathogenesis of chronic anal fissures. The duration of the effect of topical 0.2% glyceryl trinitrate (GTN) ointment on anodermal blood flow in fissure and normal areas was investigated in patients with chronic anal fissures.

METHODS

Six patients with chronic anal fissures in the posterior midline participated in the study. Blood flow measurements were performed on the anoderm using laser Doppler flowmetry before and immediately after the topical application of 0.2% GTN ointment and subsequent readings were taken at 5, 15, 30, 45 and 60 min in all four quadrants.

RESULTS

The mean anodermal blood flow in the fissure region is significantly lower than the mean blood flow of the rest of the anoderm before 0.2% GTN ointment is applied (228.7 +/- 61.8 flux units vs 439.3 +/- 25.5 flux units, respectively; P < 0.05). Immediately after the application of local 0.2% GTN ointment there is a significant increase in anodermal blood flow over the anal fissure region (457.8 +/- 56.5 flux units; P < 0.05) compared to the rest of the anoderm (457.4 +/- 30.8 flux units). This increase is most marked at 5 min post-GTN ointment application in the fissure area (474.6 +/- 41.1 flux units) and the blood flow in the fissure region is consistently above the rest of the anoderm for most of the 60 min.

CONCLUSION

There is clearly reduced blood flow to the chronic anal fissure region compared to the rest of the anoderm. Topical application of glyceryl trinitrate ointment seems to significantly improve the blood flow to the fissured area in the first hour. This may therefore help in the healing of chronic anal fissures.