Paul Super

More than meets the eye: subtle but important CT findings in Bouveret's syndrome.

OBJECTIVE Gallstones are a rare cause of duodenal or gastric outlet obstruction and therefore are not commonly suspected. Riglers radiographic triad of pneumobilia, bowel obstruction, and an ectopic gallstone is seen in few of these patients. The symptoms are insidious and nonspecific, and the diagnosis is usually made radiologically. Although CT scans are far more sensitive, 25% of cases are still missed, often because the size of the offending gallstone is underestimated. CONCLUSION Better assessment of stone size, and therefore higher accuracy of diagnosis, could be achieved if attention is paid to more subtle but nonetheless important signs. These include compressed air in dependent areas of the duodenal lumen, an area of soft-tissue rather than fluid density surrounding the calcified rim of the stone, and a faint radiolucency in or beyond this soft-tissue area that could represent laminations of fat or air in the stone.

Role of laparoscopic adjustable gastric banding in the treatment of obesity and related disorders

Bariatric Surgery is increasing in popularity as an approach to the treatment of obesity, with a consequent benefit on co-morbid conditions. Laparoscopic gastric banding, as discussed herein, in a relatively safe, simple procedure in comparison with Roux-en-Y gastric bypass. The former technique offers comparable weight loss, but with some compromise on resolution of metabolic co-morbidities. The advantage, mainly relating to patient safety, makes laparoscopic gastric banding an effective option for any obese individual in whom weight loss surgery is indicated.

Day surgery for achalasia cardia: Time for consensus?

INTRODUCTION Laparoscopic Hellers myotomy (LHM) is the most effective therapy for achalasia of the oesophagus. Most case series of LHM report a length of hospital stay (LOS) >1 day. We present 14 years of experience of LHM to examine the safety and feasibility of LHM as a day case procedure. METHODS We retrospectively examined patients undergoing elective LHM for achalasia at our institution between 2000 and 2014. Demographics, episode statistics, prior investigations and interventions were collated. Outcomes, including LOS, complications and re-interventions, were compared for the periods before and after a consensus decision at our institution in 2008 to perform LHM as a day case procedure. RESULTS Sixty patients with a mean age of 41 ± 13 years were included, of whom 58% were male. The median LOS for all patients was 1 day (interquartile range [IQR] 0-2.25). Overall, LHM was performed as a day case in 27 (45%) cases, at 2/26 (7.7%) in the first period versus 25/34 (73.5%) in the second (p<0.01). There were no significant differences in age, gender or previous interventions between day surgery and non-day surgery groups. One patient required subsequent unplanned surgery, while six (10%) needed endoscopic treatment of recurrent symptoms within 12 months. CONCLUSIONS LHM can be performed safely as a day case procedure. Complication rates are low, with only a small proportion of patients requiring endoscopic treatment for symptom recurrence within 1 year.

Adjustable Gastric Banding

Gastric banding is one of the so-called restrictive procedures in bariatric surgery. The aim is to limit the size of the stomach to a small pouch, which is created by tightening the gastric band (Figs. 2.1 and 2.2).

Changes in glycaemic control, blood pressure and lipids 5 years following laparoscopic adjustable gastric banding combined with medical care in patients with type 2 diabetes: a longitudinal analysis: Gastric banding in type 2 diabetes P. Mistry et al

The long‐term outcomes of weight loss maintenance induced by laparoscopic adjustable gastric band (LAGB) followed by multidisciplinary medical care in patients with type 2 diabetes mellitus (T2DM) (beyond 3 years) are scarcely reported. Study aims were to determine the longer term metabolic outcomes following LAGB combined with medical care in patients with T2DM. This is a longitudinal analysis of 200 adults with T2DM who had LAGB between 2003 and 2008 and were followed up till 2013 at a single bariatric unit in a tertiary UK centre. A total of 200 patients (age 47 ± 9.7 years; body mass index [BMI] 52.8 ± 9.2 kg m−2; glycosylated haemoglobin (HbA1c) 7.9 ± 1.9% [62.8 mmol mol−1]; women, n = 123 [61.5%]; insulin treatment, n = 71 [35.5%]) were included. The mean follow‐up was 62.0 ± 13.0 months (range 18–84 months). There were significant reductions in body weight (−24.4 ± 12.3% [38 ± 22.7 kg]), HbA1c (−1.4 ± 2.0%), systolic blood pressure [BP] (−11.7 ± 23.5 mmHg), total cholesterol and triglyceride levels. The proportion of patients requiring insulin reduced from 36.2% to 12.3%. The overall band complication rate was 21% (21 patients). LAGB when combined with multidisciplinary medical care significantly improved metabolic outcomes in patients with T2DM independent of diabetes duration, and baseline BMI over 5 years. Diabetes duration and baseline BMI did not predict changes in glycaemic control, BP or lipids following LAGB.

Preoperative Very Low-Calorie Diet Reduces Technical Difficulty During Laparoscopic Cholecystectomy in Obese Patients.

This study investigates the effectiveness of preoperative very low-calorie diet (VLCD) in laparoscopic cholecystectomy. A prospective observational study of consecutive patients undergoing laparoscopic cholecystectomy was undertaken. At the preoperative visit, all patients were advised to adhere to VLCD for 2 weeks before surgery (<800 kcal/d). Patients were judged to have complied with the VLCD if weight loss >2 kg. Technical difficulty was assessed using questionnaires. A total of 38 patients met the inclusion criteria. Difficulty of visualization and dissection of Calot’s triangle in obese patients was twice that of nonobese patients (P=0.01). In 62% of procedures involving obese VLCD noncompliant patients, the surgeon experienced ≥1 area of technical difficulty, compared with 0% of procedures on obese, compliant patients (P=0.018). Difficulty of dissection of the gallbladder bed was 3 times higher in obese, noncompliant patients, compared with obese, compliant patients (P=0.07). Adherence to a 2-week preoperative VLCD may reduce technical difficulty of laparoscopic cholecystectomy in obese patients.

A prospective cross-sectional study of laparoscopic subtotal Lind fundoplication for gastro-oesophageal reflux disease--a durable and effective anti-reflux procedure

INTRODUCTION Laparoscopic partial fundoplication for gastro-oesophageal reflux disease (GORD) is reported to have fewer side effects when compared to Nissen fundoplication, but doubts remain over its long term durability in controlling reflux. The aim of this study was to assess outcome of symptoms for all patients presenting with GORD undergoing routine laparoscopic subtotal Lind fundoplication. MATERIALS & METHODS All patients undergoing laparoscopic fundoplication between August, 1999 and November, 2007 performed by a single surgeon were included in the study. The anti-reflux procedure studied was laparoscopic Lind (300°) fundoplication with crural repair in all cases. Patients completed pre and post-operative questionnaires containing validated scoring systems for heartburn, gas bloat, dysphagia and overall patient satisfaction. RESULTS Over the 100-month period, 320 consecutive patients underwent laparoscopic subtotal Lind fundoplication. Of these, 256 (80%) replied to the questionnaire at a mean of 31 months (range 3-96 months) following surgery. 91.4% of respondents had an improvement in heartburn symptom score with a significant reduction in score from 7.74 preoperatively to 1.25 postoperatively (p<0.001). There was also a significant reduction of mean modified Visick score for reflux control (heartburn and regurgitation) from 3.49 preoperatively to 1.48 after surgery (p<0.001). In total, 22 patients developed recurrent reflux symptoms with half of these reporting their recurrence within two years following surgery. Because of this all were tested with post-operative pH testing, yet only one had a 24-h pH time outside the normal range. Overall patient satisfaction was high with a visual analogue score of 9 and 88% of the patients claimed they would have the operation again. CONCLUSION Laparoscopic Lind fundoplication demonstrates excellent reflux control when performed routinely for all patients presenting with GORD. This technique is both durable and efficacious in controlling reflux symptoms.

Impact of Bariatric Surgical Intervention on Peripheral Blood Neutrophil (PBN) Function in Obesity

AimThe aim of this study was to investigate the impact of weight loss following gastric band surgery on multiple measures of peripheral blood neutrophil (PBN) function.Material and MethodsTwenty-three obese patients undergoing gastric band surgery were recruited to a longitudinal intervention study, alongside non-obese, healthy gender- and age-matched controls. Eighteen pairs of patients and controls completed all stages of the study. PBNs were isolated by density centrifugation and a comprehensive analysis of PBN function was undertaken at various stages of the patients’ bariatric surgical care pathway.ResultsObese patients exhibited exaggerated PBN activity in response to various stimuli, characterised by higher reactive oxygen species (ROS) generation (n = 18, p < 0.001) and release of pro-inflammatory cytokines (n = 10, p < 0.05) and lower PBN extracellular trap (NET) formation (n = 18, p < 0.01). PBN chemotactic accuracy was also impaired prior to surgery (n = 18, p < 0.01). Weight loss was associated with normalised NET production and lower ROS production and cytokine release relative to healthy controls. However, chemotactic accuracy remained impaired in patients.ConclusionsWeight loss following gastric band surgery was associated with a decrease in the pro-inflammatory activities of peripheral blood neutrophils (PBNs). A hyper-inflammatory PBN phenotype, involving excess ROS and cytokine release, reduced NET formation and chemotaxis, may lead to a reduced ability to eliminate infection, alongside inflammation-mediated tissue damage in obese individuals.

Building a model for day case hiatal surgery - Lessons learnt over a 10 year period in a high volume unit: A case series

BACKGROUND Laparoscopic anti-reflux surgery has become the standard treatment for symptomatic gastro-oesophageal reflux disease refractory to medical therapy. Successful anti-reflux surgery involves safe, minimally invasive surgery, resulting in symptom resolution with minimal side effects. This study aims to assess the feasibility and safety of day case anti-reflux surgery focussing on peri- and post-operative outcomes as a measure of success. METHODS Data was collected from the hospital database from 2003 to 2012. Data collection included demographics, surgeon, mode of admission, length of stay and complications. Electronic records were independently scrutinised for all patients with a length of stay of more than two nights. RESULTS 723 patients underwent laparoscopic fundoplication ± small hiatus hernia repair (<5 cm) with a day case rate of 67.1%. The 30 day readmission rate in these patients was 2.9% (21/723 patients). Nine patients had a failure of their initial laparoscopic fundoplication (defined as recurrence of symptoms). Three patients required a re-operation within 12 months of their initial procedure (re-operation rate = 0.41% (3/723 patients)). CONCLUSION Laparoscopic hiatal surgery can be performed safely as a day case in high volume specialist centres with good outcomes. Raising the national standard for day case fundoplication promotes good practice and should be the model for future commissioning.

Corrigendum to “An “all 5 mm ports” technique for laparoscopic day-case anti-reflux surgery: A consecutive case series of 205 patients” [Int. J. Surg. 35 (2016) 214–217]

Corrigendum to “An “all 5 mm ports” technique for laparoscopic day-case anti-reflux surgery: A consecutive case series of 205 patients” [Int. J. Surg. 35 (2016) 214e217] L.M. Almond a, , V. Charalampakis , P. Mistry , M. Naqvi , J. Hodson , G. Lafaurie , J. Matthews , R. Singhal , P. Super a a Department of Upper Gastrointestinal Surgery, Heart of England NHS Foundation Trust, United Kingdom b Department of Medical Statistics, University of Birmingham, United Kingdom