Background
Laparoscopic inguinal hernia repair has a long learning curve. It can be a technically challenging procedure and initially presents an unfamiliar view of inguinal anatomy. The aim of this ...review was to evaluate published literature relating to the learning curve of laparoscopic inguinal hernia repair and identify the number of cases required for proficiency. The secondary aim was to compare outcomes between surgeons before and after this learning curve threshold had been attained.
Methods
A systematic literature search was conducted in databases of PubMed, Medline, Embase, Web of Science, and Cochrane Library, to identify studies that evaluated the learning curve of laparoscopic inguinal hernia repair. A meta-regression analysis was undertaken to identify the number of cases to achieve surgical proficiency, and a meta-analysis was performed to compare outcomes between cases that were undertaken during a surgeon’s
learning phase
and
experienced phase
of the curve.
Results
Twenty-two studies were included in this review, with 19 studies included in the meta-regression analysis, and 11 studies included in the meta-analysis. Mixed-effects Poisson regression demonstrated that there was a non-linear trend in the number of cases required to achieve surgical proficiency, with a 2.7% year-on-year decrease. The predicted number of cases to achieve surgical proficiency in 2020 was 32.5 (
p
< 0.01). The meta-analysis determined that surgeons in their
learning phase
may experience a higher rate of conversions to open (OR 4.43, 95% CI 1.65, 11.88), postoperative complications (OR 1.61, 95% CI 1.07, 2.42), and recurrences (OR 1.32, 95% CI 0.40, 4.30).
Conclusion
Laparoscopic inguinal hernia repair has a well-defined learning curve. While learning surgeons demonstrated reasonable outcomes, supervision during this period may be appropriate given the increased risk of conversion to open surgery. These data may benefit learning surgeons in the skill development of minimally invasive inguinal hernia repairs.
Graphical abstract
Very low-calorie diets (VLCDs) are used preoperatively in bariatric-metabolic surgery; however, this can lead to physiological ketosis. Euglycemic ketoacidosis is an increasingly recognized ...complication in diabetic patients on sodium-glucose-cotransporter-2 inhibitors (SGLT2i) undergoing surgery and requires assessment of ketones for diagnosis and monitoring. VLCD induced ketosis may confound monitoring in this group. We aimed to evaluate the influence of VLCD, compared to standard fasting, on perioperative ketone levels and acid-base balance.
Twenty-seven patients were prospectively recruited to the intervention group and 26 to the control group from two tertiary referral centres in Melbourne, Australia. Intervention group patients were severely obese (body mass index) (BMI) (≥35), undergoing bariatric-metabolic surgery, and prescribed 2 wk of VLCD preoperatively. Control group patients underwent general surgical procedures and prescribed standard procedural fasting only. Patients were excluded if diabetic or prescribed SGLT2i. Ketone and acid-base measurements were taken at regular intervals. Univariate and multivariate regression was utilised with significance defined as P < 0.005. ClinicalTrials.gov ID: NCT05442918.
Patients on VLCD, compared to standard fasting, had an increased median preoperative (0.60 versus 0.21 mmol/L), immediate postoperative (0.99 versus 0.34 mmol/L) and day 1 postoperative (0.69 versus 0.21 mmol/L) ketone level (P < 0.001). Preoperative acid-base balance was normal in both groups, however VLCD patients were found to have a metabolic acidosis immediately postoperatively (pH 7.29 versus pH 7.35) (P = 0.019). Acid-base balance had normalized in VLCD patients on postoperative day 1.
Preoperative VLCD resulted in increased pre- and postoperative ketone levels with immediate postoperative values consistent with metabolic ketoacidosis. This should be considered particularly when monitoring diabetic patients prescribed SGLT2i.
Laparoscopic bariatric surgery relies on technically challenging intracorporeal suturing for critical parts of the operation. Barbed sutures have been developed to provide an alternative to suturing ...for certain manoeuvres within a procedure. Barbed sutures theoretically negate the need for knot tying and allow for continuous application of tension; however the barbs can unintentionally adhere to surrounding tissues. We describe a case series of three patients who developed V-Loc™ (barbed) suture related small bowel obstruction (SBO) to promote awareness of this unusual but preventable complication.
Medical records of patients diagnosed with V-Loc™ related SBO between 2018 and 2021 at a tertiary centre were reviewed. Data regarding presentation, diagnosis, management and outcomes were obtained.
Three patients were identified where V-Loc™ sutures were aetiologically related to early post-surgical small bowel obstruction secondary to small bowel adherence to barbed suture tail or adhesions between barbed suture tail and unintended viscera. In these cases, non-absorbable V-Loc™ sutures were used to close the small bowel mesenteric defect at Roux-en-Y gastric bypass surgery. All patients required adhesiolysis at re-look laparoscopy prior to resolution. All patients were discharged home well after relook laparoscopy.
Overly long or exposed V-Loc™ suture tails can result in SBO following laparoscopic bariatric surgery. Cutting the suture tail as close as practical to the final throw of the suture and/or covering exposed suture ends may prevent this complication.
Obesity is a strong risk factor for Barrett's esophagus (BE), the only proven precursor lesion to esophageal adenocarcinoma (EAC). Bariatric surgery is currently the only reliable treatment that ...achieves long‐term sustained weight loss; however, it can markedly affect the development of de novo BE, and the progression or regression of existing BE. Bariatric procedures may also have implications on future surgical management of any consequent EAC. In this review, we examine the current evidence and published guidelines for BE in bariatric surgery. Current screening practices before bariatric surgery vary substantially, with conflicting recommendations from bariatric societies. If diagnosed, the presence of BE may alter the type of bariatric procedure. A selective screening approach prevents unnecessary endoscopy; however, there is poor symptom correlation with disease. Studies suggest that sleeve gastrectomy predisposes patients to gastroesophageal reflux and de novo BE. Conversely, Roux‐en‐Y gastric bypass is associated with decreased reflux and potential improvement or resolution of BE. There are currently no guidelines addressing the surveillance for BE following bariatric surgery. BE is an important consideration in the management of bariatric surgical patients. Evidence‐based recommendations are required to guide procedure selection and postoperative surveillance.
Background
Oesophageal cancer is the seventh most prevalent malignancy globally, and the sixth most common cause of cancer‐related death. Oesophageal cancer is also one of the most costly cancers to ...treat. The aim of this study was to assess the financial impact of post‐operative morbidity and hospital readmissions following oesophagectomy for oesophageal cancer.
Methods
A retrospective analysis was performed on a prospectively maintained database of patients with oesophageal cancer who underwent an oesophagectomy at a single centre between July 2014 and June 2019 (N = 56). Readmission costs were also assessed in this cohort for 12 months post‐operatively.
Results
The total median cost for oesophagectomy in this cohort was AU$57 250. Major complications occurred in 40% of patients, with a median total admission cost of AU$74 606, significantly higher than patients with either minor or no complications (median admission cost of AU$52 713, P < 0.001). Patients whose operation was complicated by an anastomotic leak had a higher median admission cost than those without a leak (AU$104 328 and AU$54 972 respectively, P < 0.001). Cost centres representing the greatest proportion of costs were theatre resources and surgical ward care (medical and nursing). A total of 110 readmissions in 25 patients were recorded in the 12 months post‐operatively, the majority for gastroscopy and dilatation of anastomotic stricture.
Conclusion
Post‐oesophagectomy morbidity greatly increases cost of care. In addition to the clinical benefits, interventions to minimize post‐operative complications are likely to result in substantial cost savings.
This study assessed the cost of complications after surgical management of oesophageal cancer. It found that major complications were associated with a significant increase in costs, as were readmissions after the initial operation.
Background
Fatty liver in obese patients increases the technical difficulty of bariatric surgery. Pre-operative weight loss with a very-low-calorie diet (VLCD) is commonly used to facilitate surgery. ...Few studies have quantified the systemic effect of rapid pre-operative weight loss on body composition. The objective of this study is to evaluate body composition changes in bariatric surgery patients undergoing a VLCD.
Methods
Body composition assessments were performed between August 2017 and January 2019 using dual-energy X-ray absorptiometry immediately before and after a 2-week VLCD at St Vincent’s Hospital Melbourne. Data collected prospectively pre- and post-VLCD included total body weight, excess body weight, body mass index (BMI), lean body mass (LBM), fat mass (FM) and bone mineral content (BMC). The pre- and post-operative results were compared.
Results
Forty-four patients completed both the 2-week VLCD and body composition assessments. Following a 2-week VLCD, patients lost a mean of 4.5 kg (range − 0.3 to 9.5) in a total body weight and 8.8% (range − 0.9 to 17.1) of excess body weight, with a mean reduction in body mass index of 1.6 kg/m
2
(range − 0.2 to 3.1). Loss of LBM was 2.8 kg and was significantly greater than loss of FM, 1.7 kg (
p
< 0.05). BMC changes were insignificant.
Conclusion
A VLCD is an effective tool for pre-operative weight reduction. In this cohort, a large amount of the total weight loss was attributed to a loss of lean body mass. The impact of significant lean body mass loss and its relationship to short- and long-term health outcomes warrants further assessment.
Background
Telemedicine provides healthcare to patients at a distance from their treating clinician. There is a lack of high‐quality evidence to support the safety and acceptability of telemedicine ...for postoperative outpatient follow‐up. This randomized controlled trial—conducted before the COVID‐19 pandemic—aimed to assess patient satisfaction and safety (as determined by readmission, reoperation and complication rates) by telephone compared to face‐to‐face follow‐up after uncomplicated general surgical procedures.
Methods
Patients following laparoscopic appendicectomy or cholecystectomy and laparoscopic or open umbilical or inguinal hernia repairs were randomized to a telephone or face‐to‐face outpatient clinic. Patient demographics, perioperative details and postoperative outcomes were compared. Patient satisfaction was assessed via a standardized Likert‐style scale.
Results
One hundred and twenty‐three patients were randomized over 12 months. Mean consultation times were significantly shorter for telemedicine than face‐to‐face clinics (telemedicine 10.52 ± 7.2 min, face‐to‐face 15.95 ± 9.96 min, P = 0.0021). There was no difference between groups in the attendance rates, nor the incidence or detection of postoperative complications. Of the 58 patients randomized to the telemedicine arm, 40% reported high, and 60% reported very high satisfaction with the method of clinic follow‐up.
Conclusion
Telemedicine postoperative follow‐up is safe and acceptable to patients and could be considered in patients undergoing uncomplicated benign general surgery.
Telemedicine postoperative follow‐up is safe and acceptable to patients and could be considered in patients undergoing uncomplicated benign general surgery.
Gastrointestinal nutrient sensing via taste receptors may contribute to weight loss, metabolic improvements, and a reduced preference for sweet and fatty foods following bariatric surgery. This ...review aimed to investigate the effect of bariatric surgery on the expression of oral and post-oral gastrointestinal taste receptors and associations between taste receptor alterations and clinical outcomes of bariatric surgery. A systematic review was conducted to capture data from both human and animal studies on changes in the expression of taste receptors in oral or post-oral gastrointestinal tissue following any type of bariatric surgery. Databases searched included Medline, Embase, Emcare, APA PsychInfo, Cochrane Library, and CINAHL. Two human and 21 animal studies were included. Bariatric surgery alters the quantity of many sweet, umami, and fatty acid taste receptors in the gastrointestinal tract. Changes to the expression of sweet and amino acid receptors occur most often in intestinal segments surgically repositioned more proximally, such as the alimentary limb after gastric bypass. Conversely, changes to fatty acid receptors were observed more frequently in the colon than in the small intestine. Significant heterogeneity in the methodology of included studies limited conclusions regarding the direction of change in taste receptor expression induced by bariatric surgeries. Few studies have investigated associations between taste receptor expression and clinical outcomes of bariatric surgery. As such, future studies should look to investigate the relationship between bariatric surgery-induced changes to gut taste receptor expression and function and the impact of surgery on taste preferences, food palatability, and eating behaviour.
Registration code in PROSPERO:
CRD42022313992
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