Chetan Parmar

Monitoring of Liver Function Tests after Roux-en-Y Gastric Bypass: An Examination of Evidence Base

There is no consensus on the monitoring of liver function tests after Roux-en-Y gastric bypass (RYGB). Since the main objective of such monitoring would be to diagnose early those who will eventually develop liver failure after RYGB, we performed a systematic review on this topic. An extensive search of literature revealed only 10 such cases in 6 published articles. It would hence appear that liver failure is a rare problem after RYGB. Routine lifelong monitoring of liver function tests is therefore unnecessary for otherwise asymptomatic individuals. Such monitoring should hence be reserved for high-risk groups, such as patients with liver cirrhosis, those undergoing extended limb/distal RYGB, patients with new illnesses, those abusing alcohol, those on hepatotoxic drugs and those presenting with a surgical complication.

Impact of biliopancreatic limb length on severe protein–calorie malnutrition requiring revisional surgery after one anastomosis (mini) gastric bypass

Background: One anastomosis (mini) gastric bypass (OAGB) is believed to be more malabsorptive than Roux-en-Y gastric bypass. A number of patients undergoing this procedure suffer from severe protein–calorie malnutrition requiring revisional surgery. The purpose of this study was to find the magnitude of severe protein–calorie malnutrition requiring revisional surgery after OAGB and any potential relationship with biliopancreatic limb (BPL) length. Methods: A questionnaire-based survey was carried out on the surgeons performing OAGB. Data were further corroborated with the published scientific literature. Results: A total of 118 surgeons from thirty countries reported experience with 47,364 OAGB procedures. Overall, 0.37% (138/36,952) of patients needed revisional surgery for malnutrition. The highest percentage of 0.51% (120/23,277) was recorded with formulae using >200 cm of BPL for some patients, and lowest rate of 0% was seen with 150 cm BPL. These data were corroborated by published scientific literature, which has a record of 50 (0.56%) patients needing surgical revision for severe malnutrition after OAGB. Conclusions: A very small number of OAGB patients need surgical correction for severe protein–calorie malnutrition. Highest rates of 0.6% were seen in the hands of surgeons using BPL length of >250 cm for some of their patients, and the lowest rate of 0% was seen with BPL of 150 cm. Future studies are needed to examine the efficacy of a standardised BPL length of 150 cm with OAGB.

Routine Liver Biopsy During Bariatric Surgery: an Analysis of Evidence Base

Non-alcoholic fatty liver disease and non-alcoholic steato-hepatitis are common in patients undergoing bariatric surgery. Non-alcoholic steato-hepatitis can progress to cirrhosis of the liver and hepatocellular carcinoma. Non-invasive methods of diagnosing non-alcoholic steato-hepatitis are not as accurate as liver biopsy, and bariatric surgery presents a unique opportunity to carry out a simultaneous liver biopsy. Routine liver biopsy can help early and accurate diagnosis of obesity-associated liver conditions. This has led some surgeons to argue for routine liver biopsy at the time of bariatric surgery. However, most bariatric surgeons remain unconvinced and liver biopsy is currently not routine practice with bariatric surgery. This review examines published scientific literature to ascertain the usefulness of routine liver biopsy at the time of bariatric surgery.

Preoperative Interventions for Patients Being Considered for Bariatric Surgery: Separating the Fact from Fiction.

Preoperative interventions aimed at patients referred for bariatric surgery continue to divide funders, commissioners, and practitioners alike. A number of preoperative interventions and variables have been used to influence patient selection. Many of these are believed to lead to better postoperative outcomes by helping target a limited resource (bariatric surgery) at those most likely to benefit. Inevitably, this leads to competition amongst patients and some being denied benefits of surgery. There is a risk that these strategies for resource allocation may actually deprive the most vulnerable and those most in need. This review examines evidence and justification behind popular preoperative interventions for patients being considered for bariatric surgery patients in the light of published English language scientific literature.

Gastric Remnant Dilatation: a Rare Technical Complication Following Laparoscopic One Anastomosis (Mini) Gastric Bypass

Dear Editor, One anastomosis (Mini) gastric bypass (OAGB/MGB) is gaining popularity in the world. Rutledge performed world’s first OAGB/MGB in 1997 and published in 2001. Since then, OAGB is increasingly being advocated as an effective bariatric operation with acceptable weight loss, comorbidity resolution, and complication rates in the short and medium term [1, 2]. It is acknowledged that OAGB takes less time to perform, has a shorter learning curve and is associated with fewer complications [2]. However from its early days, this operation has attracted controversy [3]. Gastric remnant dilatation is a rare complication following OAGB with only one report in the published literature of acute gastric remnant dilatation [4]. Through this letter, we would like to draw your attention to this somewhat rare complication. We wish to make surgeons aware of this problem, suggest ways to prevent it and discuss available management options. A 49-year-old woman with a weight of 110 kg and a body mass index (BMI) of 36.8 kg/m underwent an uneventful OAGB in March 2015 and was discharged 2 days later. Her past medical history included asthma and an overactive bladder. The procedure was carried out following standardized steps reported previously by us [5]. She was readmitted 5 days postoperatively with epigastric pain, nausea and vomiting. She had opened her bowels on the day of admission. General examination was unremarkable apart from tachycardia of 102. Blood results revealed elevated white cell count (WCC) of 15.53 × 10/L (4–11 × 10) and C reactive protein (CRP) 343 × 10/L (<5 × 10/L). An urgent contrast-enhanced computed tomography (CT) of the abdomen and pelvis showed a distended stomach (Fig. 1). Diagnostic laparoscopy revealed a dilated bypassed stomach due to narrowing at proximal antrum. A mini-laparotomy was carried out with a sideto-side stapled anastomosis of the body and distal antrum. The patient had an uneventful recovery and is doing well on follow-up. Acute gastric dilatation is a surgical emergency that can potentially lead to staple line dehiscence or rupture of the bypassed stomach with disastrous consequences. Distention of excluded stomach produces symptoms of nausea and vomiting and can threaten disruption of a recently placed surgical suture line. Prompt diagnosis and management, as in our case, can however result in complete resolution. A literature review by Han et al. [6] noted that acute gastric remnant dilatation occurs in 0–0.8% of cases following Roux-en-Y gastric bypass (RYGB). This complication has been routinely managed with radiological percutaneous drainage of the remnant stomach using gastrostomy tube [6–8]. If the patient presents late with a ruptured remnant stomach or necrosis of stomach wall then a gastrectomymay be needed. There is only one case report of this complication after OAGB in scientific literature to the best of our knowledge [4]. In this case report, patient underwent percutaneous image-guided decompression of the bypassed stomach. It is believed that the gastric pouch length is an important determinant of gastro-oesophageal reflux symptoms after OAGB with a shorter gastric pouch predisposing to more biliary reflux due to proximity of the anastomosis with the oesophagus. This is despite the fact that no published evidence yet exists to prove an increased biliary gastro-oesophageal reflux after this procedure. It is possible that in our pursuit of achieving the longest possible gastric pouch, we went too close to the greater curvature of the stomach during performance of the primary * Chetan D. Parmar cparmar@nhs.net

Need for Standardization of Perioperative Practices in MGB/OAGB

Dear Editor, We read the article by Taha et al. about their experience of 1520 patients with great interest [1]. They have rightly mentioned that there has been an increase in the number of MGB/ OAGB performed in the world [1]. Their conclusion that MGB/OAGB is safe, effective and has acceptable complications, mortality rates, and better weight loss (WL) outcomes, matches with our experience [2]. We suggest that in future studies, the authors should report their perioperative practices along with their weight loss and comorbidity outcomes. This would help standardize the steps for the MGB/OAGB and allow consensus building [3]. In their Bpreoperative evaluation,^ they havementioned the use of preoperative lowmolecular weight heparin (LMWH) in selective high-risk patients only. Their operative time is the lowest in the series published till date. This combined with early ambulation of their patients help reducing the incidence of thromboembolism-related complications. Their mortality of 0.1% is comparable to larger series. However, it would be helpful to know whether the two deaths due to pulmonary embolism (PE), other five patients with PE, and one patient with deep vein thrombosis treated medically were the patients who received preoperative LMWH or not [4]. They quote that further, 13 patients presented with respiratory distress; all of them were treated medically. Were they suspected of PE?Was CT pulmonary angiogram (CTPA) done and had treatment dose LMWH started empirically? Did these patients receive preoperative LMWH? Six (1.7%) patients presented with bleeding as their early complication (17—trocar site, 9—GI bleeding). Again, were these the cohort who did or did not receive LMWH? They report that their anemia rate of 3.1% (47 patients) was higher compared to other sleeve gastrectomy (SG) and RYGB series. They used variable limb length (LL) in their study (150–300 cm). It would be a learning experience for bariatric surgeons to know the LL in these anemia patients [5]. This would help the debate of ideal LL for MGB/OAGB patients. There is a suggestion that 150 cm should be the ideal limb length in MGB/OAGB [5, 6]. Eighteen patients had weight gain in their study. It would be educational to make the readers aware of the LL. If these are the patients with shorter limb length, then that would counter the debate of 150 cm as standard LL for all patients with variable bodymass index. Similarly, it would be good to know the limb length of their three patients who had EWL of > 100% and what revisional surgery was offered. The LL in patients with anemia, weight regain, and EWL > 100% highlight the need for prospective robust studies to know the impact of limb length on different outcomes [5].

Single Anastomosis Gastro-Ileal Bypass (SAGI)

Mini-Gastric Bypass—One Anastomosis Gastric Bypass (MGB-OAGB) is now prominent in the bariatric surgical world. Single Anastomosis Gastro Ileal (SAGI) bypass is a modification of the technique of the MGB whereby a fixed length of common channel is constructed, by performing the gastro-intestinal anastomosis 300 cm proximal to the ileocecal junction. This operation was performed on seven consecutive patients with mean BMI 42.1 kg/m2. There were no intraoperative complications. There was no mortality at 6 months follow-up. The authors concluded that SAGI may be a safer option compared to standard MGB in terms of malnutrition. However, long-term results are awaited.

Treatment of Marginal Ulcer

Marginal ulcer (MU) infrequently follows MGB or OAGB. MU has been associated with smoking, NSAIDs, steroids, spicy foods, and very heavy alcohol intake, which should be avoided. H. pylori infection may be a cause and should be treated. MU is confirmed by gastroscopy. The incidence after RYGB has been higher.

Reply to “Bleeding in Sleeve Gastrectomy—A Simple and Cost-Effective Solution”

Dear Editor, We read this paper [1] by Chakravartty S and teamwith a great interest. Staple line bleeding in sleeve gastrectomy (SG) is a well-recognized problem. Besides intraoperative bleeding causing delay and frustration, it can also cause postoperative problems like hematomas, abscess, delayed leak, and add to morbidity. Chakravartty et al. have rightly addressed this problem and highlighted a simple solution of administering tranexamic acid (TXA). They concluded that this effectively reduced bleeding and significantly reduced operating time. In their study, they have used a uniform thromboprophylaxis of 40 mg enoxaparin by both groups. They have used the Echelon FlexTM Endopath® Stapler (Ethicon Endo Surgery Inc., Cincinnati, OH) with cartridges of a decreasing staple height (4.1, 3.8, and 3.5 mm) in both groups. The operating surgeon was however different in the two groups. It would be helpful to know if both groups followed the same compression period prior to firing the stapler as recommended by the manufacturers. Was there a difference in the time between stapler application and firing? They have mentioned raising the systolic blood pressure above 130 mm of Hg. Sroka G et al. [2] concluded in their randomized trial that the routine elevation of systolic blood pressure to 140 mm of Hg and suturing of the staple line in SG minimized hemorrhagic complications, without much prolongation of the procedure. Mahawar et al. [3] had also highlighted that raising the blood pressure intraoperatively and addressing the bleeding points reduce the reoperation rate for hemorrhage.We agree that this is a good practice which we routinely follow. The use of antifibrinolytics can reduce blood loss in cardiac surgery, trauma, liver surgery, and solid organ transplantation and non-surgical diseases. However, tranexemic acid use has its own risks. The CRASH 2 trial [4] quotes a 1.7% incidence of vaso-occlusive events in the tranexamic acid group and 0.3% deaths due to vascular occlusion. This risk is compounded to up to 3% risk of thromboembolism in bariatric patients undergoing surgery. Laparoscopic procedure in itself increases this risk. The risk of fulminant pulmonary embolism in patients undergoing bariatric surgery is around 0.3% [5]. The authors mention that all patients received preoperative enoxaparin. This works by binding to antithrombin to irreversibly inactivate clotting factor Xa. Then, to administer TXA which blocks the fibrinolytic pathway, in simple terms, appear to counteract the effect. (Fig. 1) There is currently no consensus as to the optimal thromboprophylaxis regimen for patients undergoing bariatric surgery. [6] Given the paucity of trials addressing the risks of staple line bleeding alongside the optimal thromboembolic prophylaxis, we wonder if in the future it would be possible to do a trial by the authors with half dose of perioperative LMWH in one group and full dose in the other. Tailoring the dose of LMWH according to the patient weight would be another thought. Instead of administering tranexamic acid, is it worth omitting the LMWH before surgery and giving it few hours postoperatively? These are practical questions that can only be answered by following robust trails. * Chetan Parmar cparmar@nhs.net

Intestinal spirochaetosis mimicking acute appendicitis with review of the literature

Human intestinal spirochaetosis is a well-established micro-organism existing in the colon. It is less commonly seen in the appendix, and rarely presents as acute appendicitis. We present a case of a man presenting with symptoms consistent with acute appendicitis. The literature on spirochaetosis presenting as acute appendicitis is also reviewed.