Effectiveness of sleeve gastrectomy plus fundoplication versus sleeve gastrectomy alone for treatment of patients with severe obesity: a systematic review and meta-analysis

BACKGROUND

Laparoscopic sleeve gastrectomy (SG) is a widely performed bariatric surgery, but it is associated with an increased risk of gastroesophageal reflux (GERD) in the long term. The addition of fundoplication to laparoscopic SG may improve lower oesophageal sphincter function and reduce postoperative GERD.

OBJECTIVES

This systematic review and meta-analysis aims to compare the efficacy and safety of SG plus fundoplication (SG + F) versus SG alone for the treatment of patients with severe obesity (≥35 kg/m2).

SETTING

Meta-analysis.

METHODS

Three electronic databases were searched from inception until January 2023. Studies were included if they compared outcomes of SG + F versus SG in patients with severe obesity (≥35 kg/m2). The primary outcome was remission of GERD postoperatively. Secondary outcomes were the percentage of excess weight loss, percentage of total weight loss, postoperative complication rate, operative time, and length of stay.

RESULTS

A total of 5 studies with 539 subjects (212 SG + F and 327 SG alone) were included. The mean preoperative body mass index was 42.6 kg/m2. SG + F achieved higher remission of GERD compared with laparoscopic SG (odds ratio [OR] = 13.13; 95% CI, 3.54-48.73; I2 = 0%). However, the percentage of total weight loss was lower in the SG + F group (mean difference [MD] = -2.75, 95% CI, -4.28 to -1.23; I2 = 0%), whereas there was no difference in the percentage of excess weight loss (MD = -0.64; 95% CI, -20.62-19.34; I2 = 83%). There were higher postoperative complications in SG + F (OR = 2.56; 95% CI, 1.12-5.87; I2 = 0%) as well. There was no difference in operative time or length of stay between the 2 groups.

CONCLUSION

SG + F achieved better GERD remission but is associated with lesser weight loss and increased postoperative complications compared with SG alone. Further studies are required to ascertain the overall clinical benefit of SG + F for patients with severe obesity.

Rationale and Trial Protocol for a Double-Blinded Randomized Controlled Trial to assess the Impact of a Concomitant Crural Repair during Laparoscopic Sleeve Gastrectomy in Patients with a Lax Gastroesophageal Junction without Frank Hiatal Hernia (REPAIR trial protocol)

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) is associated with postoperative gastroesophageal reflux disease (GERD) and erosive esophagitis (EE). The role of crural repair during LSG is still controversial. The preoperative laxity of the gastroesophageal junction (GEJ), graded by the Hill's classification, is more predictive for postoperative GERD and EE after LSG than the presence of a hiatal hernia seen on endoscopy. Thus, the authors hypothesize that a concomitant crural repair in a specific subgroup of patients with a lax GEJ (Hill's III) may reduce the incidence of postoperative GERD and EE.

METHODS

A double-blinded, randomized controlled trial of patients with Hill's III GEJ undergoing LSG will be randomized to a concomitant crural repair (experimental) versus LSG alone (control). Primary outcome measures will be presence of EE at 1-year. Secondary outcome measures will include proton pump inhibitor use, postoperative complications, operative time, blood loss, quality of life, GERD and gastrointestinal symptoms.

CONCLUSION

Conflicting crural repair results may be explained by differences in preoperative GEJ laxity. Patients with a frank hiatal hernia and patulous GEJ (Hill's IV) have a very high, while patients with an apposed GEJ (Hill's I, Hill's II) have a low incidence of postoperative GERD and EE respectively. Thus, the authors hypothesize that patients with a lax GEJ without frank hiatal hernia (Hill's III), might benefit from a crural repair. This study results can potentially highlight the clinical importance of preoperative endoscopic evaluation of the GEJ in all patients planned for LSG, to determine which subgroup patients may benefit from a crural repair. (Clinicaltrials.gov: NCT05330910, Registered 15-April-2022).

Nutrition Care after Hospital Discharge in Singapore: Evidence-Based Best-Practice Recommendations

The nutritional status of hospitalised patients is often at risk or compromised and predisposed to further deterioration after discharge, leading to poor clinical outcomes, high healthcare costs, and poor quality of life. This paper aims to provide evidence-based best-practice recommendations to address this, supported by a national survey of healthcare professionals in Singapore and reviewed by a multidisciplinary expert panel under the Sarcopenia Interest Group of Society of Parenteral and Enteral Nutrition Singapore (SingSPEN). We advocate screening all patients with a validated tool which includes a disease activity/burden component, an easily accessible dietitian referral pathway for patients at risk of malnutrition, and an individualised nutrition care plan formulated and delivered using a multidisciplinary team approach for patients at risk or with malnutrition. A comprehensive team would include not only dietitians but also physicians, nurses, physiotherapists, speech therapists, and medical social workers working together towards a common goal. Information on why nutrition is important for good health and how it can be achieved should also be provided to all patients and their caregivers before and after hospital discharge. With the above recommendations, we seek to improve upon the current nutrition care processes at discharge for healthcare institutions in Singapore.

Major limb amputation and mortality in patients with neuro-ischaemic lower extremity wounds managed in a tertiary hospital: Focus on the differences among patients with diabetes, peripheral arterial disease and both

A majority of lower extremities neuro‐ischaemic wounds (NIU) are related to: (a) only diabetes (DM); (b) only peripheral artery disease (PAD); (c) co‐existing diabetes and peripheral artery disease (DM‐PAD). This study aims to characterise the major clinical outcomes of forementioned three groups of lower extremity wound patients in Singapore. Patients hospitalised for lower extremity NIU between January 2014 and October 2017 in a tertiary hospital in Singapore were analysed. Patients' major limb amputation and mortality were assessed using Cox regression models. Cumulative survival and amputation‐free survival among the three classified groups were calculated using Kaplan‐Meier analysis. Compared with patients with only DM, those in the PAD group and the DM‐PAD group had higher risk of major limb amputation (adjusted hazard ratio: 2.47, 95% CI: 1.65‐3.70; adjusted hazard ratio: 2.01, 95% CI: 1.53‐2.65 respectively) and mortality (adjusted hazard ratio: 2.36, 95% CI: 1.57‐3.55; adjusted hazard ratio: 2.46, 95% CI: 1.86‐3.26 respectively). The 3‐year survival and amputation‐free survival were lowest in the DM‐PAD group (52.1% and 41.5% respectively), followed by the PAD group (53.3% and 44.6% respectively) and the DM group (74.2% and 68.5% respectively). Lower extremity NIU patients with PAD or DM‐PAD were found to have poorer clinical prognosis than those with DM only.

Admission discipline and timing of admission may influence outcomes for gastrointestinal bleeding patients

BACKGROUND

Bleeding of the gastrointestinal tract (BGIT) is a common gastrointestinal emergency. There is no consensus whether this condition should be admitted to medical or surgical discipline. Timing of presentation may also impact patient outcomes due to differences in healthcare resource availability. This study thus aims to investigate the impact of admitting discipline and timing of admission on patient outcomes in BGIT.

METHODS

A 2-year tertiary institution database was retrospectively reviewed. Outcome measures included 30-day mortality, 30-day readmissions and rebleeding requiring repeat endoscopic, angiographic or surgical interventions. Secondary outcome measures included time to endoscopy, percutaneous angiographic interventions and surgery. The effect of admission discipline (medical versus surgical) and time of admission (office-hours versus after office-hours) were analysed using a propensity-score-adjusted estimate.

RESULTS

A total of 1384 patients were included for analysis, medical (n = 853), surgical (n = 530); during office-hours (n = 785) and after office-hours (n = 595). After propensity-score-adjusted analysis, no significant differences in mortality or readmissions were noted between medical or surgical admissions. Patients admitted under surgery were less likely to sustain rebleeding (P = 0.004) for lower BGIT and had an earlier time to endoscopy for upper BGIT (P = 0.04). Patients admitted after office-hours had similar outcomes with those admitted during office hours apart from a delay in time to endoscopy (P = 0.02).

CONCLUSION

For BGIT patients, admission to a surgical discipline compared to a medical discipline appeared to have at least equivalent patient outcomes. Patients presenting with BGIT after office-hours were more likely to experience a delay to endoscopy, although it did not affect patient mortality.

Safety, pharmacokinetics and tissue penetration of PIPAC paclitaxel in a swine model

INTRODUCTION

Peritoneal carcinomatosis is difficult to treat. Pressurized Intra-Peritoneal Aerosolised Chemotherapy (PIPAC) is a novel method of delivering chemotherapy to the peritoneal cavity, aiming for homogenous and deeper drug distribution. To date, limited chemotherapeutics have been used with promising results. Here, we evaluate the pharmacokinetics, peritoneal tissue drug concentration, penetration, and short-term safety of PIPAC using solvent-based paclitaxel in swine to guide clinical trials.

MATERIALS AND METHODS

PIPAC solvent-based paclitaxel was administered at 60, 30, and 15mg/m² for 3 cohorts. Each PIPAC procedure was followed by intravenous (IV) administration of the same dose of solvent-based paclitaxel on Day 7, serving as control for pharmacokinetic comparison in the same pig. Safety and toxicity were evaluated by clinical assessment, blood counts and biochemistry. Blood samples were taken for pharmacokinetic analysis. Peritoneal biopsies were taken to measure tissue paclitaxel concentrations and distribution.

RESULTS

12 Yorkshire x Landrace pigs underwent trial procedures. With PIPAC, there was linear pharmacokinetics and lower systemic exposure to paclitaxel compared to IV administration. MALDI-MSI demonstrated concentration of paclitaxel at the peritoneal surface, with estimated 2 mm penetration. PIPAC paclitaxel had favorable toxicity profile. The most significant adverse event was neutropenia which was dose dependent, with absolute neutrophil count <1.0 × 10³/μL seen at the highest dose. One pig developed grade 2 hypersensitivity reaction during IV infusion and one death occurred during the PIPAC procedure, likely from anaphylaxis; these are known potential adverse events mandating standard precautions and monitoring.

CONCLUSION

PIPAC paclitaxel at 15mg/m² may be considered for a Phase I study.

Cutaneous port-site recurrence secondary to tumour seeding following implantation of an intraperitoneal chemotherapy access port for gastric cancer

Intraperitoneal chemotherapy has shown promising results for the treatment of peritoneal carcinomatosis in gastric cancer. However, the implantation of an intraperitoneal chemotherapy port may be associated with catheter-related complications. The authors describe a case of cutaneous port-site recurrence secondary to tumour seeding from an intraperitoneal chemotherapy access port.

Safety and tolerability of oxaliplatin based pressurized intraperitoneal aerosol chemotherapy (PIPAC) for patients with peritoneal carcinomatosis: A phase I dose-finding study in Asian patients

360

Background: PIPAC is a novel, laparoscopic intraperitoneal chemotherapy delivery technique which aims to improve on hyperthermic intraperitoneal chemotherapy (HIPEC), ameliorating drug distribution and tissue penetration. Thus far, PIPAC has been conducted with oxaliplatin chemotherapy in Europe, at an arbitrary dose of 92mg/m2; 150mg/m2 was found to be intolerable. We conducted a dose-escalation phase 1 study to establish the safety, tolerability and recommended phase 2 dose (RP2D) for PIPAC in Asian patients. Methods: This phase 1 study of oxaliplatin administered via PIPAC was designed as a traditional 3+3 dose escalation study for patients with predominant peritoneal metastasis from a gastrointestinal primary tumor, after failure of standard therapies. Dose levels were planned at 45, 60, 90 and 120mg/m2. Repeat doses of PIPAC were permitted, 6 weeks apart. Dose limiting toxicities (DLT) were defined as any clinically relevant grade 3 adverse events occurring within 28 days after PIPAC. Results: This study included 16 patients (25 PIPAC procedures; 8 gastric, 4 colorectal and 1 gallbladder, pancreas and appendix cancer each). Median age was 62 years, with a median peritoneal carcinomatosis index (PCI) score of 17 (range 1 - 39). Two patients developed pancreatitis (grade 2 and 3) on day 6 and day 9 after PIPAC administration at the dose cohort of 45mg/m2, necessitating cohort expansion to 6 patients. One patient was noted to have asymptomatic grade 3 hyperamylasemia (90mg/m2 cohort). There were no other DLTs and all 3 patients in the highest dose cohort (120mg/m2) tolerated PIPAC well. Nine patients who underwent a 2nd PIPAC procedure had a decrease in PCI score from 18.4 to 15.5; one patient at 120mg/m2 had an improvement in PCI from 30 to 12. Conclusions: The RP2D of PIPAC with oxaliplatin is 120mg/m2. Single agent PIPAC is well tolerated, and future studies with PIPAC must consider a bi-directional approach with the incorporation of systemic therapy, with either chemotherapy or immunotherapy to improve efficacy. Clinical trial information: NCT03172416.

Right adrenal gland pseudocyst masquerading as a large symptomatic hepatic cyst: Single incision laparoscopic (SILS) resection and a review of current literature

Adrenal pseudocysts are rare entities, which are usually asymptomatic. Large symptomatic adrenal pseudocysts may cause compressive symptoms. The etiology of these cysts is unknown, although the cyst wall is all lined by fibrous tissue, without any epithelial or endothelial lining. We report a case of a 26-year-old lady who presented with a symptomatic right adrenal pseudocyst measuring 7.6 cm in size. Magnetic resonance imaging confirmed the presence of a right retroperitoneal cystic lesion which was hyperintense on T2 sequencing. An attempted single incision transumbilical laparoscopic surgery (SILS) was performed to excise the right adrenal pseudocyst. However, due to the retro-hepatic nature of the lesion and as the medial wall of the cyst was adherent to the inferior vena cava, an additional 5 mm port was inserted to facilitate retraction of the liver. The post-operative period was uneventful. She was successfully discharged from the hospital as a day surgery patient. The final pathology showed an adrenal pseudocyst.

Is arterial base deficit still a useful prognostic marker in trauma? A systematic review

BACKGROUND

Arterial base deficit (BD) has been widely used in trauma patients since 1960. However, trauma management has also evolved significantly in the last 2 decades. The first objective of this study was to systematically review the literature on the relationship between arterial BD as a prognostic marker for trauma outcomes (mortality, significant injuries, and major complications) in the acute setting. The second objective was to evaluate arterial BD as a prognosis marker, specifically, in the elderly and in patients with positive blood alcohol levels.

METHODS

MEDLINE, EMBASE, Scopus, Web of Science, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews were searched from January 1, 1990, to August 6, 2015. Bibliographies of articles were also hand searched for relevant citations.

RESULTS

Thirty-four studies were included in this review. The studies consistently showed that a higher arterial BD was associated with increased mortality, significant injuries, and major complications. The threshold BD value of 6 mmol/L was also useful in discriminating for poorer outcomes. The presence of alcohol did not affect the ability of arterial BD to discriminate between major and minor injuries. Elderly patients had higher mortality in all arterial BD categories compared to the younger age group.

CONCLUSIONS

Despite the advances in trauma care in the last 2 decades, arterial BD remains a useful prognostic marker in trauma patients, even in elderly patients and in patients who had consumed alcohol. The threshold BD value of 6 mmol/L was useful to prognosticate poorer outcomes.

Stroke literacy in Singapore: data from a survey of public housing estate residents

INTRODUCTION

Knowledge of stroke symptoms is associated with seeking medical attention early, and knowledge of risk factors is an essential factor in stroke prevention. In this study, we evaluated the level of stroke literacy in Singapore.

MATERIALS AND METHODS

A cross-sectional study of Singapore citizens and permanent residents aged 21 years and above was conducted in a public housing estate. Participants were randomly sampled using multi-stage stratified sampling. Assessment of awareness of stroke symptoms and risk factors was performed using open-ended questions. In total, 687 respondents were recruited, with a response rate of 69.7%.

RESULTS

Overall, 52.4% of respondents identified the brain as the source of pathology, and 47.6% could cite at least 1 of the 3 FAST symptoms (facial droop, arm weakness and speech difficulty), while 40% could name 2 or more of 7 established risk factors for stroke (high blood pressure, high cholesterol, cigarette smoking, diabetes mellitus, older age, previous heart attacks and stroke). Respondents at higher risk of stroke (older individuals and those with stroke risk factors) did not have greater awareness of stroke symptoms and risk factors. The majority of respondents reported they would seek immediate medical care if they experienced stroke symptoms. Only 59.4% knew the emergency ambulance service telephone number.

CONCLUSION

In a sample of Singaporean adults residing in a public housing estate, we found evidence of poor stroke literacy, highlighting the need for comprehensive population-based education efforts. There is a role for opportunistic education among those at higher risk of stroke.

Predicting the likelihood of additional lymph node metastasis in sentinel lymph node positive breast cancer: validation of the Memorial Sloan-Kettering Cancer Centre (MSKCC) nomogram

AIM

To identify important clinicopathological parameters that are most helpful in predicting additional non-sentinel lymph node (SLN) metastasis among patients with a positive SLN biopsy in the Singapore breast cancer population.

METHODS

A total of 1409 patients who underwent SLN biopsy were reviewed over a 5 year period from July 2004 to October 2009. A Singapore General Hospital (SGH) nomogram was developed from predictors in the Memorial Sloan-Kettering Cancer Centre (MSKCC) nomogram using 266 patients with primary invasive breast cancer and a positive SLN biopsy who subsequently had an axillary lymph node dissection. The SGH nomogram was calibrated using bootstrapped data, while the MSKCC nomogram was calibrated using SGH data. The performance of these two nomograms was compared with the calculation of the area under the receiver-operator characteristics curve and adequacy indices.

RESULTS

The MSKCC nomogram achieved an area under the curve (AUC) of 0.716 (range 0.653-0.779) in our study population, while the SGH nomogram, which used only three pathological parameters, lymphovascular invasion, number of positive and negative SLN biopsies, achieved an AUC of 0.750 (range 0.691-0.808). The SGH nomogram with a higher adequacy index (0.969) provided better estimates compared with the MSKCC nomogram (0.689).

CONCLUSIONS

The use of the MSKCC nomogram was validated in our local patient population. The SGH nomogram showed promise to be equally, if not, more predictive as a model in our own population, while using only three pathological parameters.