Background
Since 2014, the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) has produced an annual report of all bariatric surgery submitted to the Global Registry. ...We describe baseline demographics of international practice from the 4th report.
Methods
The IFSO Global Registry amalgamated data from 51 different countries, 14 of which provided data from their national registries. Data were available from 394,431 individual records, of which 190,177 were primary operations performed since 2014.
Results
Data were submitted on 72,645 Roux en Y gastric bypass operations (38.2%), 87,467 sleeve gastrectomy operations (46.0%), 14,516 one anastomosis gastric bypass procedures (7.6%) and 9534 gastric banding operations (5.0%) as the primary operation since 2014. The median patient body mass index (BMI) pre-surgery was 41.7 kg m
2
(inter-quartile range: 38.3–46.1 kg m
2
). Following gastric bypass, 84.1% of patients were discharged within 2 days of surgery; and 84.5% of sleeve gastrectomy patients were discharged within 3 days. Assessing operations performed between 2012 and 2016, at one year after surgery, the mean recorded percentage weight loss was 28.9% and 66.1% of those taking medication for type 2 diabetes were recorded as not using them. The proportion of patients no longer receiving treatment for diabetes was highly dependent on weight loss achieved. There was marked variation in access and practice.
Conclusions
A global description of patients undergoing bariatric surgery is emerging. Future iterations of the registry have the potential to describe the operated patients comprehensively.
Purpose
Gallstones are common in bariatric patients due to obesity and rapid weight loss. Bile duct stones after Roux-en-Y gastric bypass (RYGB) pose a technical challenge. We present our experience ...in management of bile duct stones following RYGB using laparoscopic-assisted endoscopic retrograde cholangiopancreatography (LA-ERCP).
Materials and Methods
Retrospective review of RYGB patients who had endoscopic intervention for bile duct stones between 2010 and 2019. We assessed demographic and clinical outcomes.
Results
There were 12 patients: 9 females, median age 64 years (range 34–73), median ASA score 3 (range 2–3), and median body mass index (BMI) 30 kg/m
2
(range 24.4–46). Median time of presentation since RYGB was 5 years (range 6–96 months). Clinical presentations were biliary pain with deranged liver function tests (
n
= 8, 67%) and cholangitis (
n
= 4, 33%). Ten patients (83%) had cholecystectomy prior to presentation. LA-ERCP was performed in all 12 patients. It was successful in 10 patients (83%) of which 7 were performed as a primary intervention for bile duct stones and 3 were for residual stones following previous bile duct exploration. Two out of 12 LA-ERCPs (17%) were converted to open duct clearance. Median overall hospital stay was 2.5 days (range 1–10). One patient developed post-ERCP pancreatitis; one had chronic pain. There was no major complication or mortality.
Conclusion
LA-ERCP is feasible for bile duct stones after RYGB and can clear the duct primarily or following previous surgical exploration. It also provides an opportunity to perform cholecystectomy and diagnostic laparoscopy
.
Background
Comparative international practice of patients undergoing bariatric-metabolic surgery for type 2 diabetes mellitus (T2DM) is unknown. We aimed to ascertain baseline age, sex, body mass ...index (BMI) and types of operations performed for patients with T2DM submitted to the IFSO Global Registry.
Materials and Methods
Cross-sectional analysis of patients having primary surgery in 2015–2018 for countries with ≥90% T2DM data completion and ≥ 1000 submitted records.
Results
Fifteen countries including 11 national registries met the inclusion criteria. The rate of T2DM was 24.2% (99,537 of 411,581 patients, country range 12.0–55.1%) and 77.1% of all patients were women. In every country, patients with T2DM were older than those without T2DM (overall mean age 49.2 SD 11.4 years vs 41.8 11.9 years, all
p
< 0.001). Men were more likely to have T2DM than women, odds ratio (OR) 1.68 (95% CI 1.65–1.71),
p
< 0.001. Men showed higher rates of T2DM for BMI <35 kg/m
2
compared to BMI ≥35.0 kg/m
2
, OR 2.76 (2.52–3.03),
p
< 0.001. This was not seen in women, OR 0.78 (0.73–0.83),
p
< 0.001. Sleeve gastrectomy was the commonest operation overall, but less frequent for patients with T2DM, patients with T2DM 54.9% vs without T2DM 65.8%, OR 0.63 (0.63–0.64),
p
< 0.001. Twelve out of 15 countries had higher proportions of gastric bypass compared to non-bypass operations for T2DM, OR 1.70 (1.67–1.72),
p
< 0.001.
Conclusion
Patients with T2DM had different characteristics to those without T2DM. Older men were more likely to have T2DM, with higher rates of BMI <35 kg/m
2
and increased likelihood of food rerouting operations.
Purpose
Decreasing popularity of Roux-en-Y gastric bypass (RYGB) in bariatric-metabolic surgery may be due to higher perceived peri-operative complications. There are few studies on whether ...preoperative weight loss can reduce complications or reoperations following RYGB. We investigated this using a standardised operative technique.
Materials and Methods
Retrospective single-centre study of RYGB from 2004 to 2019 using a prospective database. Preoperative behavioural management included intentional weight loss. Maximum preoperative weight, weight on the day of operation, and Obesity-Surgery Mortality Risk Score (OS-MRS) class were recorded. Short-term outcomes (post-operative stay, 30-day complication and reoperation rates) were analysed.
Results
In 2,067 RYGB patients (1,901 primary and 166 revisional), median preoperative total body weight loss (TWL) was 6.2% (IQR: 2.5–10.7%). The median age was 46 (interquartile range (IQR) 38–54) and 80.4% were female (
n
=1,661). For primary surgery, the median body mass index (BMI) was 47.6 kg/m
2
(IQR: 43.1–53.3). Excluding the 100-procedure learning curve, the complication rate for primary cases was 4.4% and reoperation rate of 2.8% and one peri-operative mortality (0.06%). OS-MRS ≥2 (class B or C) predicted higher risk of complications (6.1%) compared to those with a score <2 (class A) (3.8%,
p
=0.021), but not reoperations. Five percent preoperative TWL did not decrease complications compared to <5% TWL. Patients with ≥10% TWL had greater baseline risk and had an increased risk of complications (6.6% vs 3.7%,
p
=0.017) and reoperations (4.5% vs 2.7%,
p
<0.001).
Conclusions
RYGB performed using a standardised technique has low overall risk. The influence of preoperative weight loss on outcomes was inconsistent.
Graphical abstract
Background
Acute appendicitis is one of the most common emergency general surgical conditions worldwide. Uncomplicated/simple appendicitis can be treated with appendectomy or antibiotics. Some ...studies have suggested possible benefits with antibiotics with reduced complications, length of hospital stay, and the number of days off work. However, surgery may improve success of treatment as antibiotic treatment is associated with recurrence and future need for surgery.
Objectives
To assess the effects of antibiotic treatment for uncomplicated/simple acute appendicitis compared with appendectomy for resolution of symptoms and complications.
Search methods
We searched CENTRAL, MEDLINE, Embase, and two trial registers (World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov) on 19 July 2022. We also searched for unpublished studies in conference proceedings together with reference checking and citation search. There were no restrictions on date, publication status, or language of publication.
Selection criteria
We included parallel‐group randomised controlled trials (RCTs) only. We included studies where most participants were adults with uncomplicated/simple appendicitis. Interventions included antibiotics (by any route) compared with appendectomy (open or laparoscopic).
Data collection and analysis
We used standard methodology expected by Cochrane. We used GRADE to assess the certainty of evidence for each outcome. Primary outcomes included mortality and success of treatment, and secondary outcomes included number of participants requiring appendectomy in the antibiotic group, complications, pain, length of hospital stay, sick leave, malignancy in the antibiotic group, negative appendectomy rate, and quality of life. Success of treatment definitions were heterogeneous although mainly based on resolution of symptoms rather than incorporation of long‐term recurrence or need for surgery in the antibiotic group.
Main results
We included 13 studies in the review covering 1675 participants randomised to antibiotics and 1683 participants randomised to appendectomy. One study was unpublished. All were conducted in secondary care and two studies received pharmaceutical funding. All studies used broad‐spectrum antibiotic regimens expected to cover gastrointestinal bacteria. Most studies used predominantly laparoscopic surgery, but some included mainly open procedures. Six studies included adults and children. Almost all studies aimed to exclude participants with complicated appendicitis prior to randomisation, although one study included 12% with perforation. The diagnostic technique was clinical assessment and imaging in most studies. Only one study limited inclusion by sex (male only). Follow‐up ranged from hospital admission only to seven years. Certainty of evidence was mainly affected by risk of bias (due to lack of blinding and loss to follow‐up) and imprecision.
Primary outcomes
It is uncertain whether there was any difference in mortality due to the very low‐certainty evidence (Peto odds ratio (OR) 0.51, 95% confidence interval (CI) 0.05 to 4.95; 1 study, 492 participants). There may be 76 more people per 1000 having unsuccessful treatment in the antibiotic group compared with surgery, which did not reach our predefined level for clinical significance (risk ratio (RR) 0.91, 95% CI 0.87 to 0.96; I2 = 69%; 7 studies, 2471 participants; low‐certainty evidence).
Secondary outcomes
At one year, 30.7% (95% CI 24.0 to 37.8; I2 = 80%; 9 studies, 1396 participants) of participants in the antibiotic group required appendectomy or, alternatively, more than two‐thirds of antibiotic‐treated participants avoided surgery in the first year, but the evidence is very uncertain. Regarding complications, it is uncertain whether there is any difference in episodes of Clostridium difficile diarrhoea due to very low‐certainty evidence (Peto OR 0.97, 95% CI 0.24 to 3.89; 1 study, 1332 participants). There may be a clinically significant reduction in wound infections with antibiotics (RR 0.25, 95% CI 0.09 to 0.68; I2 = 16%; 9 studies, 2606 participants; low‐certainty evidence). It is uncertain whether antibiotics affect the incidence of intra‐abdominal abscess or collection (RR 1.58, 95% CI 0.61 to 4.07; I2 = 19%; 6 studies, 1831 participants), or reoperation (Peto OR 0.13, 95% CI 0.01 to 2.16; 1 study, 492 participants) due to very low‐certainty evidence, mainly due to rare events causing imprecision and risk of bias. It is uncertain if antibiotics prolonged length of hospital stay by half a day due to the very low‐certainty evidence (MD 0.54, 95% CI 0.06 to 1.01; I2 = 97%; 11 studies, 3192 participants). The incidence of malignancy was 0.3% (95% CI 0 to 1.5; 5 studies, 403 participants) in the antibiotic group although follow‐up was variable. Antibiotics probably increased the number of negative appendectomies at surgery (RR 3.16, 95% CI 1.54 to 6.49; I2 = 17%; 5 studies, 707 participants; moderate‐certainty evidence).
Authors' conclusions
Antibiotics may be associated with higher rates of unsuccessful treatment for 76 per 1000 people, although differences may not be clinically significant. It is uncertain if antibiotics increase length of hospital stay by half a day. Antibiotics may reduce wound infections. A third of the participants initially treated with antibiotics required subsequent appendectomy or two‐thirds avoided surgery within one year, but the evidence is very uncertain. There were too few data from the included studies to comment on major complications.
ObjectiveThere is emerging evidence that the pancreas may be a target organ of SARS-CoV-2 infection. This aim of this study was to investigate the outcome of patients with acute pancreatitis (AP) and ...coexistent SARS-CoV-2 infection.DesignA prospective international multicentre cohort study including consecutive patients admitted with AP during the current pandemic was undertaken. Primary outcome measure was severity of AP. Secondary outcome measures were aetiology of AP, intensive care unit (ICU) admission, length of hospital stay, local complications, acute respiratory distress syndrome (ARDS), persistent organ failure and 30-day mortality. Multilevel logistic regression was used to compare the two groups.Results1777 patients with AP were included during the study period from 1 March to 23 July 2020. 149 patients (8.3%) had concomitant SARS-CoV-2 infection. Overall, SARS-CoV-2-positive patients were older male patients and more likely to develop severe AP and ARDS (p<0.001). Unadjusted analysis showed that SARS-CoV-2-positive patients with AP were more likely to require ICU admission (OR 5.21, p<0.001), local complications (OR 2.91, p<0.001), persistent organ failure (OR 7.32, p<0.001), prolonged hospital stay (OR 1.89, p<0.001) and a higher 30-day mortality (OR 6.56, p<0.001). Adjusted analysis showed length of stay (OR 1.32, p<0.001), persistent organ failure (OR 2.77, p<0.003) and 30-day mortality (OR 2.41, p<0.04) were significantly higher in SARS-CoV-2 co-infection.ConclusionPatients with AP and coexistent SARS-CoV-2 infection are at increased risk of severe AP, worse clinical outcomes, prolonged length of hospital stay and high 30-day mortality.
Objective:
To define “best possible” outcomes for secondary bariatric surgery (BS).
Background:
Management of poor response and of long-term complications after BS is complex and under-investigated. ...Indications and types of reoperations vary widely and postoperative complication rates are higher compared to primary BS.
Methods:
Out of 44,884 BS performed in 18 high-volume centers from 4 continents between 06/2013-05/2019, 5,349 (12%) secondary BS cases were identified. Twenty-one outcome benchmarks were established in low-risk patients, defined as the 75th percentile of the median outcome values of centers. Benchmark cases had no previous laparotomy, diabetes, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, thromboembolic events, BMI> 50 kg/m
2
or age> 65 years.
Results:
The benchmark cohort included 3143 cases, mainly females (85%), aged 43.8 ± 10 years, 8.4 ± 5.3 years after primary BS, with a BMI 35.2 ± 7 kg/m
2
. Main indications were insufficient weight loss (43%) and gastro-esophageal reflux disease/dysphagia (25%). 90-days postoperatively, 14.6% of benchmark patients presented ≥1 complication, mortality was 0.06% (n = 2). Significantly higher morbidity was observed in non-benchmark cases (OR 1.37) and after conversional/reversal or revisional procedures with gastrointestinal suture/stapling (OR 1.84). Benchmark cutoffs for conversional BS were ≤4.5% re-intervention, ≤8.3% re-operation 90-days postoperatively. At 2-years (IQR 1–3) 15.6% of benchmark patients required a reoperation.
Conclusion:
Secondary BS is safe, although postoperative morbidity exceeds the established benchmarks for primary BS. The excess morbidity is due to an increased risk of gastrointestinal leakage and higher need for intensive care. The considerable rate of tertiary BS warrants expertise and future research to optimize the management of non-success after BS.
Abstract
Gastro-esophageal reflux disease (GERD) is a common, significant health burden. United Kingdom guidance states that surgery should be considered for patients with a diagnosis of GERD not ...suitable for long-term acid suppression. There is no consensus on many aspects of patient pathways and optimal surgical technique, and an absence of information on how patients are currently selected for surgery. Further detail on the delivery of anti-reflux surgery (ARS) is required. A United Kingdom-wide survey was designed to gather surgeon opinion regarding pre-, peri- and post-operative practice of ARS. Responses were received from 155 surgeons at 57 institutions. Most agreed that endoscopy (99%), 24-hour pH monitoring (83%) and esophageal manometry (83%) were essential investigations prior to surgery. Of 57 units, 30 (53%) had access to a multidisciplinary team to discuss cases; case-loads were higher in those units (median 50 vs. 30, P < 0.024). The most popular form of fundoplication was a Nissen posterior 360° (75% of surgeons), followed by a posterior 270° Toupet (48%). Only seven surgeons stated they had no upper limit of body mass index prior to surgery. A total of 46% of respondents maintain a database of their practice and less than a fifth routinely record quality of life scores before (19%) or after (14%) surgery. While there are areas of consensus, a lack of evidence to support workup, intervention and outcome evaluation is reflected in the variability of practice. ARS patients are not receiving the same level of evidence-based care as other patient groups.
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