Given the increasing prevalence of diabetes and obesity worldwide, the deleterious effects of non-alcoholic fatty liver disease (NAFLD) are becoming a growing challenge for public health. NAFLD is ...the most common chronic liver disease in the Western world. NAFLD is closely associated with metabolic disorders, including central obesity, dyslipidaemia, hypertension, hyperglycaemia and persistent abnormalities of liver function tests.In general NAFLD is a common denominer for a broad spectrum of damage to the liver, which can be due to hepatocyte injury, inflammatory processes and fibrosis. This is normally seen on liver biopsy and can range from milder forms (steatosis) to the more severe forms (non-alcoholic steatohepatitis (NASH), advanced fibrosis, cirrhosis and liver failure). In these patients, advanced fibrosis is the major predictor of morbidity and liver-related mortality, and an accurate diagnosis of NASH and NAFLD is mandatory. Histologic evaluation with liver biopsy remains the gold standard to diagnose NAFLD. Diagnosis of NAFLD is defined as presence of hepatic steatosis, ballooning and lobular inflammation with or without fibrosis. Weight loss, dietary modification, and the treatment of underlying metabolic syndrome remain the mainstays of therapy once the diagnosis is established. Dietary recommendations and lifestyle interventions, weight loss, and the treatment of underlying metabolic syndrome remain the mainstays of therapy once the diagnosis is established with promising results but are difficult to maintain. Pioglitazone and vitamin E are recommended by guidelines in selected patients. This review gives an overview of NAFLD and its treatment options.
Purpose
Failure of weight loss is the most common indication for revisional surgery following sleeve gastrectomy (SG) as reported by Guan et al. (Obes Surg.
2019
; 29:1965–1975). Recent evidence ...suggests that the revision rates for SG can be up to 10% when patients are followed up for more than 3 years and as high as 22% after 10 years as reported by Guan et al. (Obes Surg.
2019
; 29:1965–1975). Options for revisional surgery following a SG include Roux-en-Y gastric bypass (RYGB), one anastomosis gastric bypass (OAGB), and re-sleeve as the commonest procedures. There is good evidence supporting revisional surgery following failure of weight loss post-primary surgery as reported by Guan et al. (Obes Surg.
2019
; 29:1965–1975); Cheung et al. (Obes Surg.
2014
; 24:1757–1763); Shimizu et al. (Obes Surg.
2013
; 23:1766–1773); and Mora Oliver et al. (Cirugia Espanola.
2019
; 97:568–574). However, at the same time, retrospective studies suggest higher complication rates following revisional surgery with a major complication rate up to 10% as reported by Yilmaz et al. (Obes Surg.
2017
; 27:2855–2860); Fulton et al. (Can J Surg J Can Chir.
2017
; 60:205–211); and Abdelgawad et al. (Obes Surg.
2016
; 26:2144–2149). Additionally, the durability of weight loss and morbidity reduction in re-operated patients is still debated and overall high-quality evidence in the field is lacking as discussed by Abdelgawad et al. (Obes Surg.
2016
; 26:2144–2149). Aim of this educational video is to demonstrate a revisional bariatric procedure which was technically difficult due to extensive intra-abdominal adhesions and explain the available surgical options and the decision-making process adopted by the surgeons.
Materials and Methods
The video describes a laparoscopic conversion of a SG to OAGB in a 37-year-old female patient due to weight regain. Her primary bariatric procedure was planned to be a RYGB but due to extensive intra-abdominal adhesions discovered at the time of primary surgery, a SG was performed. Pre-primary procedure weight was 134kg with a BMI of 52.3kg/m
2
. After SG, the patient lost a maximum of 50kg (71.4% excess BMI loss) within the first 18 months before she started regaining weight. Her BMI was 45.4kg/m
2
when she was referred for revisional surgery. During the procedure, dense small bowel adhesions were encountered and required meticulous dissection in order to free adequate small bowel to allow a safe, effective, and tension-free anastomosis. One hundred fifty centimeters of small bowel was the maximum length that could be safely dissected starting from the ligament of Treitz. An OAGB was preferred to RYGB as it is routine practice in our unit to bypass 200cm of small bowel for revisional RYGB procedures (50-cm biliopancreatic limb and 150-cm alimentary limb), whilst all OAGB’s (primary and revisional) have an afferent limb of 150cm. A re-sleeve was also considered as a viable alternative.
Results
Extensive adhesiolysis followed by OAGB were performed successfully with an uneventful post-operative course. The patient was discharged on the second post-operative day. Excess BMI loss was 58% at 1-year follow-up.
Conclusion
Revisional surgery can be a challenging especially in the context of extensive surgical history. OAGB can be used as an alternative to RYGB.
Purpose
Evidence suggests that ethnicity and socioeconomic status of patients with chronic diseases influence their healthcare outcomes. The aim of this study was to assess the impact of these ...factors on the surgical outcome of patients with inflammatory bowel disease (IBD) over a 15-year period.
Methods
A retrospective observational study investigated IBD patients operated on at an NHS Trust between 2000–2015, with follow-up data until 2020. Logistic regression models were used to determine the relationship between ethnic minority background and Index of Multiple Deprivation (IMD) on outcomes including requirement for intra-abdominal surgery, permanent stoma, re-do surgery and surgical complications, accounting for age, gender, smoking history and biologic treatment.
Results
There were 1,620 patients (56.7% ulcerative colitis (UC) and 43.3% Crohn’s disease (CD)). Median age was 32 years, and 49.6% were female. Patients with an ethnic minority background accounted for 20.6%. Within 5 years of first presentation, 369 patients required intra-abdominal surgery, 95 permanent stomas and 107 re-do surgery. For CD patients, younger age at diagnosis, female patients, those with an ethnic minority background, higher IMD quintile, smoking history and biologic treatment were more likely to have intra-abdominal surgery. Ethnic minority background and higher IMD score were further associated with surgical complications for CD but not UC patients.
Conclusion
Ethnic minority status and socioeconomic deprivation were associated with worse surgical outcomes within our cohort of IBD patients. These findings may stimulate discourse regarding the strategic planning of equitable healthcare services.
Background
Never events (NEs) are serious clinical incidents that cause potentially avoidable harm and impose a significant financial burden on healthcare systems. The purpose of this study was to ...identify common never events.
Methods
We analysed the NHS England NE data from 2012 to 2020 to identify common never events category and themes.
Results
We identified 51 common NE themes in 4 main categories out of a total of 3247 NE reported during this period. Wrong-site surgery was the most common category (
n
= 1307;40.25%) followed by retained foreign objects (
n
= 901;27.75%); wrong implant or prosthesis (
n
= 425;13.09%); and non-surgical/infrequent ones (
n
= 614; 18.9%). Wrong-side (laterality) and wrong tooth removal were the most common wrong-site NE accounting for 300 (22.95%) and 263 (20.12%) incidents, respectively. There were 197 (15%) wrong-site blocks, 125 (9.56%) wrong procedures, and 96 (7.3%) wrong skin lesions excised. Vaginal swabs were the most commonly retained items (276;30.63%) followed by surgical swabs (164;18.20%) and guidewires (152;16.87%). There were 67 (7.44%) incidents of retained parts of instruments and 48 (5.33%) retained instruments. Wrong intraocular lenses (165; 38.82%) were the most common wrong implants followed by wrong hip prostheses (
n
= 94; 22.11%) and wrong knees (
n
= 91; 21.41%). Non-surgical events accounted for 18.9% (
n
= 614) of the total incidents. Misplaced naso-or oro-gastric tubes (
n
= 178;29%) and wrong-route administration of medications were the most common events in this category (
n
= 111;18%), followed by unintentional connection of a patient requiring oxygen to an air flow-meter (
n
= 93; 15%).
Conclusion
This paper identifies common NE categories and themes. Awareness of these might help reduce their incidence.
Introduction
Laparoscopic adjustable gastric band (LAGB)-related complications have been reported in significant numbers of patients often leading to band removal. Increasingly revisional bariatric ...surgery (RBS) is offered, most commonly either band to Roux-en-Y gastric bypass (B-RYGB) or band to sleeve gastrectomy (B-SG).
Objectives
We conducted a systematic review and meta-analysis of studies to evaluate the efficacy of RBS following failed LAGB.
Methods
Medline, Embase, The Cochrane Library and NHS Evidence were searched for English language studies assessing patients who had undergone LAGB and who subsequently underwent either B-RYGB or B-SG.
Results
Thirty-six studies met the inclusion criteria. There were 2617 patients. B-RYGB was performed in 60.5% (
n
= 1583). There was one death within 30 days (0.0004%). The overall pooled morbidity rate was 13.2%. There was no difference between the B-RYGB and B-SG groups in morbidity, leak rate or return to theatre. Percentage excess weight loss (%EWL) following the revisional procedure for all patients combined at 6, 12 and 24 months was 44.5, 55.7 and 59.7%, respectively. There was no statistical difference in %EWL between B-RYGB and B-SG at any time point. The rates of remission of diabetes, hypertension and obstructive sleep apnoea were 46.5, 35.9 and 80.8%, respectively.
Conclusions
Randomised controlled trials (RCTs) do not exist on this issue but the available observational evidence does suggest that RBS is associated with generally good outcomes similar to those experienced after primary surgery. Further, high-quality research, particularly RCTs, is required to assess long-term weight loss, comorbidity and quality of life outcomes.
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