Yitka Graham

Revisional Roux-en-Y Gastric Bypass and Sleeve Gastrectomy: a Systematic Review of Comparative Outcomes with Respective Primary Procedures

Though primary bariatric surgery is now firmly established as the first-line treatment for morbid obesity, this is not the case with revisional bariatric surgery. Despite proven benefits and patient demand, revisional bariatric surgery continues to attract controversy. Even though it is widely believed to be riskier and less effective than primary bariatric surgery, there is currently no systematic review in literature addressing this point. This review aims to establish outcomes after revisional bariatric surgery in comparison with those after primary bariatric surgery. Since Roux-en-Y gastric bypass or sleeve gastrectomy is currently the commonest anatomy achieved after revisional bariatric surgery, this review focuses on the outcome of revisional Roux-en-Y gastric bypass and revisional sleeve gastrectomy in comparison with respective primary procedures.

Contraceptive needs of women following bariatric surgery

With one in four adults classified as obese in the UK,1 bariatric surgery is becoming an increasingly common weight loss intervention. The number of procedures has increased from fewer than 1000 procedures performed in 2000 to almost 10 000 in 2010.1 Compared to diet, exercise and pharmacotherapy, bariatric surgery offers sustained, long-term weight loss2 and improvement in obesity-related conditions. Following surgery, published data suggest that patients can expect up to a 72% chance of remission of type 2 diabetes,3 46% resolution of hypertension4 and 75% improvement in sleep apnoea.5 Weight loss through bariatric surgery has also been shown to improve menstrual cycle disorders and theoretically to improve fertility.6 ,7 The National Institute for Health and Care Excellence (NICE) guideline on management of adult obesity recommends bariatric surgery when other weight loss interventions have failed.8 National Health Service criteria for surgery are determined by a body mass index (BMI) (in kg/m2), greater than 40, or 35 with significant disease that could be improved with weight loss, such as type 2 diabetes or hypertension. For severely obese patients with a BMI >50, bariatric surgery may be considered as a first-line option.8 The UK National Bariatric Surgery Registry (NBRS) shows that 80% of bariatric procedures were performed in women, with the majority being in the reproductive age group.1 Compared to women with a normal BMI, obese women may be up to three times more likely to experience infertility.7 Generally, women who undergo bariatric surgical procedures experience improved fertility and maternal outcomes compared to obese cohorts.6 ,7 There is a paucity of literature investigating the effects of the different bariatric procedures on contraceptive efficacy, and whether specific methods should be recommended. Current recommendations advise against pregnancy following bariatric surgery for …

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.

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.

Marginal ulcers after one anastomosis (mini) gastric bypass: a survey of surgeons

Many surgeons believe that one anastomosis (mini) gastric bypass (OAGB/MGB) is associated with a high marginal ulcer (MU) rate and that this is associated with complications in a significant number of patients. The purpose of this survey was to find out the participant‐reported incidence of MU after OAGB/MGB and its complications. We also aimed to understand practices in this cohort concerning prophylaxis, diagnosis, treatment and management of complications. Bariatric surgeons who perform OAGB/MGB procedures were invited to participate in a confidential, online survey using SurveyMonkey®. A total of 86 surgeons performing OAGB/MGB procedures participated in the survey. The total number of OAGB/MGB procedures reported was 27 672, revealing 622 MU, giving an MU rate of 2.24 %. Most participants (69/84, 82.4%) routinely use proton pump inhibitor (PPI) prophylaxis, but there was variation in drugs, dosages and duration. The majority (49/85, 57.6%) of participants ‘always’ use endoscopy for diagnosis, and 48.1% (39/81) ‘always’ perform an endoscopy to ensure healing. Most (49/55) perforated ulcers were treated with laparoscopic repair +/− omentoplasty +/− drainage. Most (55/59, 93.0%) of the bleeding ulcers were managed with PPI +/− blood transfusions +/− endoscopic intervention (23/59, 39.0%). Non‐healing ulcers were treated by conversion to Roux‐en‐Y gastric bypass (RYGB) in 46.5% of patients (n = 20/43). The participants did not report any MU‐related mortality but described a number of risk factors for it. This survey is the first detailed attempt to understand the incidence of MU following OAGB/MGB; its complications; and practices concerning prophylaxis, diagnosis, treatment and management of complications.

A systematic review of the application of Wilson and Cleary health-related quality of life model in chronic diseases

BackgroundA conceptual model approach to clarify the elements of health-related quality of life (HRQL), their determinants and causal pathways is needed to aid researchers, health practitioners and policy makers in their bid to improve HRQL outcomes in patients. The aim of this systematic review was to appraise empirical evidence on the performance of the Wilson and Cleary Model of HRQL.MethodsWe conducted a search of MEDLINE, Science Direct, PsyARTICLES and CINAHL databases to identify articles that used Wilson and Cleary model to examine HRQL in chronic diseases. A narrative synthesis was employed in the review of the articles.ResultsEvidence supports linkages between adjacent concepts and between non-adjacent concepts of the Wilson and Cleary model indicating that in practice there is a need to examine relationships among constructs - or to consider interventions in terms of - both with and without mediators. Symptoms status has the highest magnitude of relative impact on health-related quality of life.ConclusionThe Wilson and Cleary model demonstrated good features suitable for evaluating health-related quality of life in chronic diseases.

Introducing Anecdote Circles as an alternative Method to Focus Groups in the Pedagogic Impact Evaluation of a new Digital Nurse Navigator System

The construction and labeling of a relatively disparate set of university information technology systems as the “Nurse Navigator System” were routed in the principles of broader design research where methodologies of teaching, learning, and assessment were used to drive educational innovation within and between clinical and academic teaching. In terms of pragmatic design and appearance, this was straightforward; however, the theoretical basis of the design was more complex and rooted in core pedagogic design principles. Responding to the outcome of the initial evaluation of the system was therefore critical in the iterative developmental design of the Nurse Navigator System. Evaluation necessitated the collation of data which could tangibly and qualitatively examine whether expectations of such a conglomerate set of information technology criteria were realistic in practice. This pilot period of adjustment was recognized as a time to allow for configuring, fine-tuning, and assessment of purposefulness to the student cohort using it and in keeping with the need to co-construct learning and resource needs of students in practice. Evaluating the effectiveness of the preliminary pedagogic design of the Nurse Navigator System necessitated reliable indicators of engagement and learning. This research methods case study provides an overview of the qualitative evaluation of the impact of the new Nurse Navigator System using anecdote circles as an alternative to Focus Groups.

RESKO: Repositioning drugs by using side effects and knowledge from ontologies

Abstract The objective of drug repositioning is to apply existing drugs to different diseases or medical conditions than the original target, and thus alleviate to a certain extent the time and cost expended in drug development. Our system RESKO, RE positioning drugs using S ide Effects and K nowledge from O ntologies, identifies drugs with similar side-effects which are potential candidates for use elsewhere, the supposition is that similar side-effects may be caused by drugs targeting similar proteins and pathways. RESKO, integrates drug chemical data, protein interaction and ontological knowledge. The novel aspects of our system include a high level of biological knowledge through the use of pathway and biological ontology integration. This provides a explanation facility lacking in most of the existing methods and improves the repositioning process. We evaluate the shared side effects from the eight conventional Alzheimer drugs, from which sixty-seven candidate drugs based on a side-effect commonality were identified. The top 25 drugs on the list were further investigated in depth for their suitability to be repositioned, the literature revealed that many of the candidate drugs appear to have been trialed for Alzheimer’s disease. Thus verifying the accuracy of our system, we also compare our technique with several competing systems found in the literature.

Contraceptive practices and menstrual patterns in women aged 18–50 years awaiting bariatric surgery

The Faculty of Sexual & Reproductive Healthcare (FSRH) Clinical Effectiveness Unit is developing a guideline looking at contraceptive options for women with weight issues. We hope that this guideline will include information for those facing bariatric surgery as almost 80% of women requesting this procedure are in their reproductive years.1 These women are also advised to avoid pregnancy for up to 24 months following surgery, making effective, reversible contraception an ideal choice.2 With this in mind, we therefore asked women aged between 18 and 50 years on a bariatric surgery waiting list to complete a voluntary, anonymous online survey about their sexual and reproductive health. Ethical approval was granted by the National Health Service, University of Sunderland and City Hospitals Sunderland NHS Foundation Trust Research Ethics Committees. There were 42 responders with the majority (38%, n=16) aged between 35 and 44 years old, 92% (n=38) were heterosexual and 71% (n=30) had children. All participants …

The Effects of Obesity on Reproductive Health

Obesity exerts an adverse effect on both male and female reproductive health. In both sexes obesity can lead to a dysregulation of the hypothalamic–pituitary–gonadal axis with a detrimental effect on the hormonal control of gametogenesis. In the obese male, abnormal spermatogenesis could potentially lead to abnormalities in semen parameters and sperm function. Obesity-related effects on sperm genetic integrity may contribute to a potential transgenerational epigenetic inheritance with consequent impact on the development of offspring. Female obesity is associated with reduced frequency of ovulation and also with detrimental effects on oocyte quality, endometrial development, and implantation. The net result of these changes is that there is an increased time to conception if either partner is obese. Unfortunately, there is also increasing evidence that obesity is associated with a negative impact on the success rates of assisted reproductive treatments and also an increased risk of early pregnancy failure. Weight loss through lifestyle modification, or medical or surgical treatment may improve the chance of successful spontaneous or assisted conception. Further studies are required to increase the understanding of how obesity affects human fertility and the adverse effect of obesity on assisted conception.