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Background: Research implicates inflammation in the vicious cycle between depression and obesity, yet few longitudinal studies exist. The rapid weight loss induced by bariatric surgery is known to improve depressive symptoms dramatically, but preoperative depression diagnosis may also increase the risk for poor weight loss. Therefore, we investigated longitudinal associations between depression and inflammatory markers and their effect on weight loss and clinical outcomes in bariatric patients. Methods: This longitudinal observational study of 85 patients with obesity undergoing bariatric surgery included 41 cases with depression and 44 controls. Before and 6 months after surgery, we assessed depression by clinical interview and measured serum high-sensitivity C-reactive protein (hsCRP) and inflammatory cytokines, including interleukin (IL)-6 and IL-10. Results: Before surgery, depression diagnosis was associated with significantly higher serum hsCRP, IL-6, and IL-6/10 ratio levels after controlling for confounders. Six months after surgery, patients with pre-existing depression still had significantly higher inflammation despite demonstrating similar weight loss to controls. Hierarchical regression showed higher baseline hsCRP levels predicted poorer weight loss (β = −0.28, p = 0.01) but had no effect on depression severity at follow-up (β = −0.02, p = 0.9). Instead, more severe baseline depressive symptoms and childhood emotional abuse predicted greater depression severity after surgery (β = 0.81, p < 0.001; and β = 0.31, p = 0.001, respectively). Conclusions: Depression was significantly associated with higher inflammation beyond the effect of obesity and other confounders. Higher inflammation at baseline predicted poorer weight loss 6 months after surgery, regardless of depression diagnosis. Increased inflammation, rather than depression, may drive poor weight loss outcomes among bariatric patients. [ABSTRACT FROM AUTHOR]

The aim of this meta-analysis was to assess whether treatment with ursodeoxycholic acid (UDCA) in patients who have undergone bariatric surgery reduces gallstone formation. A systematic literature search was performed using electronic databases (MEDLINE, Embase, CENTRAL, Web of Science, PROSPERO, Google Scholar and the WHO International Clinical Trials Registry platform). RCTs without restrictions on study language, year, status of publication and patient's age were used. Pooled risk ratios were calculated using a random-effects model. Subgroup analyses for drug dose, duration and procedure types were performed. Sensitivity analyses and a summary of findings table were generated to assess the robustness and the level of evidence provided, respectively. Fourteen trials were included (3619 patients, 2292 in UDCA vs 1327 in control group). Procedures included SG, RYGB, OAGB, AGB and Gastroplasty. UDCA dose ranged from 300 to 1200 mg per day. Gallstone formation occurred in 19.3% (8.3% in UDCA vs 38.1% in the control group). UDCA significantly reduced the risk of gallstone formation (14 trials, 3619 patients; RR 0.27, 95% CI 0.18–0.41; P < 0.001). UDCA significantly reduced the risk of symptomatic gallstone disease (6 trials, 2458 patients; RR 0.30, 95% CI 0.21–0.43; P < 0.001). No subgroup difference was found for different doses, duration and type of procedure performed. Oral UDCA treatment significantly reduces the risks of developing gallstones in postoperative bariatric patients from 38 to 8%. The use of 500 to 600 mg UDCA for 6 months is effective and should be implemented in all patients post-bariatric surgery. [ABSTRACT FROM AUTHOR]

Objective: Postprandial hyperinsulinemic hypoglycemia with neuroglycopenia is an increasingly recognized complication of Roux‐en‐Y gastric bypass and gastric sleeve surgery that may detrimentally affect patient quality of life. One likely causal factor is glucagon‐like peptide‐1 (GLP‐1), which has an exaggerated rise following ingestion of carbohydrates after bariatric surgery. This paper sought to assess the role of GLP‐1 receptor agonists (GLP‐1RAs) in managing postprandial hypoglycemia following bariatric surgery. Methods: MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov, and Scopus were systematically and critically appraised for all peer‐reviewed publications that suitably fulfilled the inclusion criteria established a priori. This systematic review was developed according to the Preferred Reporting Items for Systematic Review and Meta‐Analyses Protocols (PRISMA‐P). It followed methods outlined in the Cochrane Handbook for Systematic Reviews of Interventions and is registered with PROSPERO (International Prospective Register of Systematic Reviews; identifier CRD420212716429). Results and Conclusions: Postprandial hyperinsulinemic hypoglycemia remains a notoriously difficult to manage metabolic complication of bariatric surgery. This first, to the authors' knowledge, systematic review presents evidence suggesting that use of GLP‐1RAs does not lead to an increase of hypoglycemic episodes, and, although this approach may appear counterintuitive, the findings suggest that GLP‐1RAs could reduce the number of postprandial hypoglycemic episodes and improve glycemic variability. [ABSTRACT FROM AUTHOR]

Eosinophilic phenotypes in polycythemia vera (PV) and essential thrombocythemia (ET) are rare and poorly characterized. Co-occurring JAK2 mutations in cis, specifically L611S or N622Y mutations, appear to result in a more aggressive clinical phenotype. PV/ET with eosinophilic phenotypes may require full next-generation sequencing to capture co-occurring mutations as opposed to more prevalent single-gene assays. These eosinophilic phenotypes are highly thrombotic and systemic symptoms appear responsive to early use of the janus kinase inhibitor ruxolitinib. [ABSTRACT FROM AUTHOR]

This document is a reply to a letter from Dr. Chen and his colleagues regarding a recently published article on the role of Ursodeoxycholic Acid (UDCA) in preventing gallstones in bariatric patients. The authors express gratitude for the interest and positive comments on their article. They mention that the incidence of cholesterol gallstones after bariatric surgery is high and that the burden of gallstone disease on healthcare is likely to increase with the rising rates of obesity and bariatric surgeries. The authors conducted a sensitivity analysis to assess the reliability of their pooled estimates and found that UDCA is beneficial in reducing the risk of gallstone disease in post-operative bariatric patients. They suggest that future research should focus on determining the optimal dose and duration of UDCA in these patients. [Extracted from the article]

Background Laparoscopic liver resection (LLR) is a highly demanding procedure with great variability. Previously published randomized trials have proven oncological safety of laparoscopic liver resection (LLR) as compared to open surgery. However, these were started after the learning curve (LC) was established. This leaves the question of whether the LC of LLR in the early laparoscopic era has affected the survival of patients with colorectal liver metastasis (CRLM). Methods All consecutive LLRs performed by a single surgeon between 2000 and 2019 were retrospectively analysed. A risk-adjusted cumulative sum (RA-CUSUM) chart for conversion rate and the log regression analysis of the blood loss identified two phases in the LC. This was then applied to patients with CRLM, and the two subgroups were compared for recurrence-free (RFS) and overall survival (OS). The analysis was repeated with propensity score-matched (PSM) groups Results A total of 286 patients were included in the LC analysis, which identified two distinct phases, the early (EP; 68 patients) and the late (LP; 218 patients) phases. The LC was applied to 192 patients with colorectal liver metastasis (EPc, 45 patients; LPc, 147 patients). For patients with CRLM, R0 resection was achieved in 93 per cent: 100 per cent in the EPc group and 90 per cent in the LPc group (P  = 0.026). Median OS and RFS were 60 and 16 months, respectively. The 5-year OS and RFS were 51 per cent and 32.7 per cent, respectively. OS (hazard ratio (h.r.) 0.78, 95 per cent confidence interval (c.i.) 0.51 to 1.2; P  = 0.286) and RFS (h.r. 0.94, 95 per cent c.i. 0.64 to 1.37; P  = 0.760) were not compromised by the learning curve. The results were replicated after PSM. Conclusion In our experience, the development of a laparoscopic liver resection programme can be achieved without adverse effects on the long-term survival of patients with CRLM. [ABSTRACT FROM AUTHOR]

We report a rare silent migration of a fishbone into the liver and review the relevant literature. A 56-year-old man presented with a 2-day history of dull epigastric pain and raised inflammatory markers. Computerized tomography scan revealed a 4-cm abscess in the left lobe of the liver, with a linear radio-dense foreign body within the collection. At laparoscopy the hepatogastric fistula was disconnected. The fishbone was retrieved from the liver. Gastrostomy was closed with an omental patch. The patient had an uneventful recovery. Fifty-two cases of liver abscess secondary to enterohepatic fishbone migration were reported with over two-thirds presenting with a left-lobe abscess. There was marked variability in the management of liver abscess in the setting of fishbone migration-summarized in table. We believe that laparoscopic drainage of the abscess and extraction of the foreign body offer control of the source of sepsis and diminishes recurrence, whilst having a low-risk profile. [ABSTRACT FROM AUTHOR]

We present a frail 83-year-old female with Bouveret syndrome managed using an endoscopic approach. Our patient attended the emergency department with abdominal pain, vomiting and signs of sepsis. She had a recent admission with acute cholecystitis that which had been managed conservatively. Axial imaging revealed aerobilia with a 14 mm common bile duct and a 3.5 cm calculus impacted in the duodenum, in association with a cholecysto-duodenal fistula. After resuscitation, an oesphagoduodenoscopy was performed under general anaesthesia. The large stone was seen impacted in the first part of duodenum. Mechanical lithotripsy and the Kudo snare were employed to fragment the stone and remove large fragments. Bouveret syndrome is rarely managed with success through endoscopy. The syndrome typically occurs in frail, elderly co-morbid patients who would benefit from endoscopic management over open surgery. Despite low success rates historically, endoscopic management is a reasonable and viable option in cases of Bouveret syndrome. [ABSTRACT FROM AUTHOR]

Summary: Chimaeric antigen receptor T‐cell (CAR T) therapy has evolved at an exponential pace and seeks to revolutionize the CAR T space with next‐generation CARs and expanding indications in plasma cell dyscrasias. Recent developments in Bispecific T‐cell engager therapy (BiTEs) may level the playing field with CAR T therapy, offering key advantages with off‐the‐shelf or on‐demand treatment and a manageable toxicity profile to encompass a wider pool of eligible patients in the outpatient setting. The coexistence of both modalities will remain important in overall management and accelerate the next iteration of both cellular and BiTEs. This article summarises the current progress, potential future of both therapies for haematologic malignancies, and their economic implications on the healthcare system. [ABSTRACT FROM AUTHOR]

Objective: Roux-en-Y gastric bypass (RYGB) characteristically enhances postprandial levels of glucagon-like peptide 1 (GLP-1), a mechanism that contributes to its profound glucose-lowering effects. This enhancement is thought to be triggered by bypass of food to the distal small intestine with higher densities of neuroendocrine L-cells. We hypothesized that if this is the predominant mechanism behind the enhanced secretion of GLP-1, a longer intestinal bypass would potentiate the postprandial peak in GLP-1, translating into higher insulin secretion and, thus, additional improvements in glucose tolerance. To investigate this, we conducted a mechanistic study comparing two variants of RYGB that differ in the length of intestinal bypass.Research Design and Methods: A total of 53 patients with type 2 diabetes (T2D) and obesity were randomized to either standard limb RYGB (50-cm biliopancreatic limb) or long limb RYGB (150-cm biliopancreatic limb). They underwent measurements of GLP-1 and insulin secretion following a mixed meal and insulin sensitivity using euglycemic hyperinsulinemic clamps at baseline and 2 weeks and at 20% weight loss after surgery.Results: Both groups exhibited enhancement in postprandial GLP-1 secretion and improvements in glycemia compared with baseline. There were no significant differences in postprandial peak concentrations of GLP-1, time to peak, insulin secretion, and insulin sensitivity.Conclusions: The findings of this study demonstrate that lengthening of the intestinal bypass in RYGB does not affect GLP-1 secretion. Thus, the characteristic enhancement of GLP-1 response after RYGB might not depend on delivery of nutrients to more distal intestinal segments. [ABSTRACT FROM AUTHOR]

Background and purpose: MR contrast-enhanced techniques are undergoing increased scrutiny since the FDA applied a warning for gadolinium-based MR contrast agents due to gadolinium deposition within multiple organ systems. While CE-MRA provides excellent image quality, is it required in a screening carotid study? This study compares 2D TOF and 3D TOF MRA vs. CE-MRA in defining carotid stenosis in a large clinical patient population, and with multiple readers with varying experience. Materials and methods: 200 consecutive patients had their carotid bifurcations evaluated with 2D TOF, 3D TOF and CE-MRA sequences by 6 board-certified neuroradiologists. Stenosis and quality of examinations were defined for each study. Inter-rater reliability was assessed using two-way random effects intraclass correlation coefficients. Intra-reader reliability was computed via weighted Cohen's κ. Weighted Cohen's κ were also computed to assess agreement in stenosis ratings between enhanced images and unenhanced images. Results: Agreement between unenhanced and enhanced ratings was substantial with a pooled weighted κ of 0.733 (0.628–0.811). For 5 of the 6 readers, the combination of unenhanced 2D TOF and 3D TOF showed better agreement with contrast-enhanced than either 2D TOF or 3D TOF alone. Intra-reader reliability was substantial. Conclusions: The combination of 2D TOF and 3D TOF MRA showed substantial agreement with CE-MRA regarding degree of carotid stenosis in this large outpatient population across multiple readers of varying experience. Given the scrutiny that GBCA are undergoing due to concerns regarding CNS and soft tissue deposition, it seems prudent to reserve CE-MRA for cases which are not satisfactorily answered by the nonenhanced study or other noninvasive examinations. [ABSTRACT FROM AUTHOR]

Dilatation of the pancreatic duct and common bile duct, known as double duct sign (DDS), suggests sinister pathology at the periampullary region. Non-jaundiced patients with incidental DDS and otherwise normal cross-sectional imaging present a diagnostic dilemma to the multidisciplinary team (MDT). The primary aim of this review was to assess the diagnostic yield of endoscopic ultrasound (EUS) in detecting causal pathology in this patient population. A systematic literature search (Medline, EMBASE, Google Scholar, Cochrane database and PROSPERO) was performed to identify original studies that reported EUS findings in patients with incidental DDS. Primary outcome was detection of a periampullary tumour. Secondary outcome was detection of benign causal pathology. Meta-analysis was used to calculate an absolute measure (pooled proportion) of pathology detection. Four studies (177 patients) were included. EUS detection rate for a periampullary tumour was 5% (95% CI, 0–10%) including both adenocarcinomas and adenomas. EUS detection rate for benign causal pathology was 22% (95% CI, 10–34%), the most common being chronic pancreatitis Non-jaundiced patients with incidental DDS on cross-sectional imaging have a 5% risk of a periampullary tumour that can be detected by EUS. [ABSTRACT FROM AUTHOR]

Obesity is an ever growing pandemic and a prevalent problem among men of reproductive age that can both cause and exacerbate male-factor infertility by means of endocrine abnormalities, associated comorbidities, and direct effects on the precision and throughput of spermatogenesis. Robust epidemiologic, clinical, genetic, epigenetic, and preclinical data support these findings. Clinical studies on the impact of medically induced weight loss on serum testosterone concentrations and spermatogenesis is promising but may show differential and unsustainable results. In contrast, literature has demonstrated that weight loss after bariatric surgery is correlated with an increase in serum testosterone concentrations that is superior than that obtained with only lifestyle modifications, supporting a further metabolic benefit from surgery that may be specific to the male reproductive system. The data on sperm and semen parameters is controversial to date. Emerging evidence in the burgeoning field of genetics and epigenetics has demonstrated that paternal obesity can affect offspring metabolic and reproductive phenotypes by means of epigenetic reprogramming of spermatogonial stem cells. Understanding the impact of this reprogramming is critical to a comprehensive view of the impact of obesity on subsequent generations. Furthermore, conveying the potential impact of these lifestyle changes on future progeny can serve as a powerful tool for obese men to modify their behavior. Healthcare professionals treating male infertility and obesity need to adapt their practice to assimilate these new findings to better counsel men about the importance of paternal preconception health and the impact of novel non-medical therapeutic interventions. Herein, we summarize the pathophysiology of obesity on the male reproductive system and emerging evidence regarding the potential role of bariatric surgery as treatment of male obesity-associated gonadal dysfunction. [ABSTRACT FROM AUTHOR]

Introduction: Ten percent of cirrhotic patients are known to have a high risk of postoperative complications. Ninety percent of bariatric patients suffer from non-alcoholic fatty liver disease (NAFLD), and 50% of them may develop non-alcoholic steatohepatitis (NASH) which can progress to cirrhosis. The aim of this study was to assess whether the presence of cirrhosis at the time of bariatric surgery is associated with an increased rate and severity of short- and long-term cirrhotic complications. Methods: A cohort of 110 bariatric patients, between May 2003 and February 2018, who had undergone liver biopsy at the time of bariatric surgery were reassessed for histological outcome and divided into two groups based on the presence (C, n = 26) or absence (NC, n = 84) of cirrhosis. The NC group consisted of NASH (n = 49), NAFLD (n = 24) and non-NAFLD (n = 11) liver histology. Medical notes were retrospectively assessed for patient characteristics, development of 30-day postoperative complications, severity of complications (Clavien-Dindo (CD) classification) and length of stay. The C group was further assessed for long-term cirrhosis-related outcomes. Results: The C group was older (52 years vs 43 years) and had lower BMI (46 kg/m2 vs 52 kg/m2) and weight (126 kg vs 145 kg) compared to the NC group (p < 0.05). The C group had significantly higher overall complication rate (10/26 vs 14/84, p < 0.05) and severity of complications (CD class ≥ III, 12% vs 7%, p < 0.05) when compared to the NC group. The length of stay was similar between the two groups (5 days vs 4 days). The C group had significant improvement in model end-stage liver disease scores (7 vs 6, p < 0.01) with median follow-up of 4.5 years (range 2–11 years). There were no long-term cirrhosis-related complications or mortality in our studied cohort (0/26). Conclusion: Bariatric surgery in cirrhotic patients has a higher risk of immediate postoperative complications. Long-term cirrhosis-related complications or mortality was not increased in this small cohort. Preoperative identification of liver cirrhosis may be useful for risk stratification, optimisation and informed consent. Bariatric surgery in well-compensated cirrhotic patients may be used as an aid to improve long-term outcome. [ABSTRACT FROM AUTHOR]

Summary: The day 14 bone marrow aspirate and biopsy (D14BM) is regularly used to predict achievement of complete remission (CR) with induction chemotherapy in acute myeloid leukemia (AML), however its utility has been questioned. Clearance of peripheral blood blasts (PBB) may serve as an early measure of chemosensitivity. PBB rate of clearance (PBB‐RC) was calculated for treatment‐naive AML patients (n = 164) undergoing induction with an anthracycline and cytarabine (7+3) and with detectable PBB at diagnosis. PBB‐RC was defined as the percentage of the absolute PBB count on the day of diagnosis that was cleared with each day of therapy, on average, until D14 or day of PBB clearance. Each 5% increase in PBB‐RC approximately doubled the likelihood of D14BM clearance (OR = 1·81; 95% CI: 1·24–2·64, P < 0·005). PBB‐RC was also associated with improved CR rates (OR per 5% = 1·97; 95% CI: 1·27–3·01, P < 0·005) and overall survival (OS) [hazard ratio (HR) per 5% = 0·67; 95% CI: 0·52–0·87]. African American patients had poorer OS adjusted for PBB‐RC (HR = 2·18; 95% CI: 1·13–4·23), while race was not associated with D14BM or CR rate. PBB‐RC during induction chemotherapy is predictive of D14BM clearance, CR, and OS, and can therefore serve as a prognostic marker for clinical outcomes in AML. [ABSTRACT FROM AUTHOR]

Background: Venous thromboembolism (VTE) is a recognized complication of sickle cell disease (SCD), yet the optimal pharmacologic anticoagulant is unknown. Methods: A retrospective single-institution cohort study of patients with SCD complicated by first VTE from January 2009 through July 2017 was performed using ICD 9/10 codes. Data collected included the anticoagulant used, VTE recurrence, and incidence of bleeding. Results: 109 patients with VTE were identified. SCD genotypes included HbSS in 92 (84%), HbSC in 13 (12%), and HbS-β+ thalassemia in 4 (4%). After the initial VTE event, 32 patients received a vitamin K antagonist (VKA), 34 for low-molecular-weight heparin (LMWH), and 43 for direct oral anticoagulants (DOACs). 16 patients (15%) experienced a clinically significant bleeding event, including 9 on VKA, 5 on LMWH, and 2 on DOACs. At a median follow-up of 11.8 (range, 3.4–60) months, 33 patients had a recurrent VTE, including 10 on VKA, 10 on LMWH, and 13 on DOACs (p = 0.833). Bleeding incidence was least with the DOACs, which were associated with fewer bleeding events (OR 0.22), and greatest with VKA (OR 1.55) (p < 0.05). Conclusion: There was no difference between VTE recurrence and choice of anticoagulation in SCD patients with VTE. Bleeding events were lower for DOACs compared to VKA or LMWH. [ABSTRACT FROM AUTHOR]

Background: Obesity surgery mortality risk scoring system (OS-MRS) classifies patients into high, intermediate and low risk, based on age, body mass index, sex and other comorbidities such as hypertension and history of pulmonary embolism. High-risk patients not only have a higher mortality but are more likely to develop post-operative complications necessitating intervention or prolonged hospital stay following bariatric surgery. Endoscopically placed duodenal-jejunal bypass sleeve (Endobarrier) has been designed to achieve weight loss and improve glycaemic control in morbidly obese patients with clinically proven effectiveness.The aim of this study was to assess if pre-operative insertion of endobarrier in high-risk patients can decrease morbidity and length of stay after bariatric surgery.Materials and Methods: Between 2012 and 2014, a cohort of 11 high-risk patients had an Endobarrier inserted (E&BS group) for 1 year prior to definitive bariatric surgery. These patients were compared against a similar group undergoing primary bariatric surgery (PBS group) during same duration. The two groups were matched for age, gender, body mass index, comorbidities, surgical procedure and OS-MRS using propensity score matching. Outcome measures included operative time, morbidity, length of stay, intensive therapy unit (ITU) stay, readmission rate, percentage excess weight loss (%EWL) and percentage total weight loss (%TWL).Results: Patient characteristics and OS-MRS were similar in both groups (match tolerance 0.1). There was no significant difference in total length of stay, readmission rate, %EWL and %TWL. Operative time, ITU stay, post-operative complications and severity of complications were significantly less in the E&BS group (p < 0.05) with significant likelihood of planned ITU admissions in the PBS group (p < 0.05).Conclusion: Endobarrier could be considered as a pre bariatric surgical intervention in high-risk patients. It may result in improved post-operative outcomes in high-risk bariatric patients. [ABSTRACT FROM AUTHOR]

Pantopaque (iophendylate) is an oily contrast medium historically used during spine imaging. Due to its persistence in the subarachnoid space and the potential to lead to severe arachnoiditis, it is no longer used today. We present a 40-year-old male with new-onset headaches, imbalance, and vertigo. Brain magnetic resonance imaging revealed a 2-mm T1 -hyperintense intracanalicular lesion. Numerous hyperdense foci were scattered throughout the subarachnoid space on computed tomography. Further history revealed the patient received Pantopaque 30 years prior, after sustaining spinal trauma. Remnant Pantopaque contrast is an important differential when evaluating a patient with a suspected intracranial tumor in order to avoid unwarranted surgical intervention. Laryngoscope, 127:1916-1919, 2017. [ABSTRACT FROM AUTHOR]

Objective The objective of this study was to determine the prevalence of facial nerve vascular contact on magnetic resonance imaging (MRI) in patients without hemifacial spasm (HFS). Study Design Our radiology database was queried to identify consecutive adult patients without a history of HFS, intracranial tumor, brain radiation therapy, intracranial surgery, traumatic brain injury, or trigeminal nerve vascular compression. One hundred high-resolution MRIs of the posterior fossa were independently reviewed by two neuroradiologists for facial nerve vascular contact (200 sides). Main Outcome Measures The prevalence of vascular nerve contact in the non-HFS patient, the location of contact along the facial nerve, the culprit vessel, and severity of compression was recorded. Results The presence of vascular contact in the non-HFS patient may be as high as 53%. It is typically mild to moderate in severity, most commonly involves the cisternal portion, and usually caused by the anterior inferior cerebellar artery. Conclusion Vascular contact of the facial nerve is frequently identified in asymptomatic individuals but tends to be more peripheral and mild compared with previous descriptions of neurovascular contact in HFS patients. These results should be considered in assessing the candidacy of HFS patients for microvascular decompression. [ABSTRACT FROM AUTHOR]

Objective: Improved appetite control, possibly mediated by exaggerated gut peptide responses to eating, may contribute to weight loss after Roux-en-Y gastric bypass (RYGB). This study compared brain responses to food ingestion between post-RYGB (RYGB), normal weight (NW), and obese (Ob) unoperated subjects and explored the role of gut peptide responses in RYGB.Research Design and Methods: Neuroimaging with [(18)F]-fluorodeoxyglucose (FDG) positron emission tomography was performed in 12 NW, 21 Ob, and 9 RYGB (18 ± 13 months postsurgery) subjects after an overnight fast, once FED (400 kcal mixed meal), and once FASTED, in random order. RYGB subjects repeated the studies with somatostatin infusion and basal insulin replacement. Fullness, sickness, and postscan ad libitum meal consumption were measured. Regional brain FDG uptake was compared using statistical parametric mapping.Results: RYGB subjects had higher overall fullness and food-induced sickness and lower ad libitum consumption. Brain responses to eating differed in the hypothalamus and pituitary (exaggerated activation in RYGB), left medial orbital cortex (OC) (activation in RYGB, deactivation in NW), right dorsolateral frontal cortex (deactivation in RYGB and NW, absent in Ob), and regions mapping to the default mode network (exaggerated deactivation in RYGB). Somatostatin in RYGB reduced postprandial gut peptide responses, sickness, and medial OC activation.Conclusions: RYGB induces weight loss by augmenting normal brain responses to eating in energy balance regions, restoring lost inhibitory control, and altering hedonic responses. Altered postprandial gut peptide responses primarily mediate changes in food-induced sickness and OC responses, likely to associate with food avoidance. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 62-year-old male with history of right-sided headaches. Topics mentioned include the Bone marrow biopsy performed to him, the diagnosis of inflammatory myofibroblastic tumor (IMT), and the treatment for IMT. Also mentioned are the effectiveness of methylprednisolone drug and the rituximab therapy suggested to the patient.

Background: Staple line bleeding (SLB) is a common intraoperative complication following resection in laparoscopic sleeve gastrectomy (SG). Opinion is divided on the best measure to deal with SLB which includes expensive reinforcement strategies, suturing the staple line or diathermy. Tranexemic acid is a relatively inexpensive drug known to reduce bleeding in trauma and surgery. The aim of this study was to evaluate whether intraoperative tranexemic acid reduces staple line bleeding. Methods: In this prospective matched comparative study of SG, one cohort of patients was administered tranexemic acid (1 g) after induction and compared to a control group. The primary outcome compared the number of staple line bleeding points requiring intervention intra-operatively. Secondary outcomes included estimated blood loss and operating time. The anaesthetic and thromboprophylaxis protocols were uniform. Operative technique and stapling equipment were identical in all patients. Results: Twenty-five patients were allocated to both the control and treatment arms. Patient characteristics in both groups were similar in age (median 34 vs 43 years), body mass index (median 54.7 vs 52 kg/m), gender distribution (female:male = 20:5) and co-morbidities. The treatment group receiving tranexemic acid, required significantly less number of haemostatic stitches for staple line bleeding (19 vs 46, p < 0.05), incurred less intraoperative blood loss ( p < 0.01) and had quicker operating times (median 66 vs 80 min, p < 0.05). There was no difference in morbidity or mortality in both groups. Conclusion: Intraoperative prophylactic tranexemic acid use is a simple and economical option for effectively reducing staple line bleeds leading to significant decrease in operating times. [ABSTRACT FROM AUTHOR]

Background: Bile acids (BA) modulate lipid and glucose metabolism in a feedback loop through production of fibroblast growth factor (FGF) 19 in the terminal ileum. Changes in BA after bariatric surgery may lead to improvements in the metabolic syndrome, including fatty liver disease. This study investigated the relationship between BA and metabolic and inflammatory profiles after laparoscopic sleeve gastrectomy (LSG). Methods: Patients undergoing LSG had fasting blood samples taken pre-operatively and 6 months post-surgery. Liver injury was measured using cytokeratin (CK) 18 fragments. BA were measured using liquid chromatography tandem-mass spectrometry. FGF-19 was measured using enzyme-linked immunosorbent assay. Results: The study included 18 patients (12 females), with mean age 46.3 years (SEM ± 2.9) and BMI 60.1 kg/m (±2.6). After 6 months, patients lost 39.8 kg (±3.1; p < 0.001). Fourteen patients (78 %) had steatosis. FGF-19 increased from median 128.1 (IQR 89.4-210.1) to 177.1 (121.8-288.9, p = 0.045) at 6 months. Although total BA did not change, primary glycine- and taurine-conjugated BA, cholic acid decreased, and secondary BA, glycine-conjugated urodeoxycholic acid increased over the study period. These changes are associated with reduction in insulin resistance, pro-inflammatory cytokines and CK-18 levels. Conclusions: The profile of individual BA is altered after LSG. These changes occur in the presence of reductions in inflammatory cytokines and markers of liver injury. This study supports evidence from recent animal models that LSG may have an effect on fatty liver through changes in BA metabolism. [ABSTRACT FROM AUTHOR]

Background: The combination of pneumoperitoneum and intraoperative retraction of the left lobe of the liver leads to hepatocellular injury during laparoscopic gastric surgery. Fatty livers are more susceptible to ischaemic insults. This trial investigated whether the antioxidant N-acetylcysteine (NAC) reduced liver injury during laparoscopic sleeve gastrectomy (LSG). Methods: Patients undergoing LSG were randomised (single blinded) to receive intraoperative NAC infusion or standard anaesthetic treatment. Blood samples were taken before and after surgery (days 0 to 4). Primary endpoints included serum aminotransferases. Secondary measures were C-reactive protein, weight cell count (WCC), cytokines (interleukin 6 and 10) and cytokeratin-18 as markers of apoptosis. Intraoperative liver biopsy samples were assessed using a locally developed injury score. Results: Twenty patients (14 females, mean age 44.5 (SEM ± 2.9) years, mean BMI 60.8 (SEM ± 2.4) kg/m) were recruited (NAC n = 10, control n = 10). The trial was stopped early after a planned interim analysis. Baseline liver function was similar. The peak rise in liver enzymes was on day 1, but levels were not significantly different between the groups. Rates of complications and length of stay were not significantly different. Secondary outcome measures, including white cell count (WCC), cytokines and cytokeratin (CK)-18 fragments, were not different between groups. Liver injury scores did not differ significantly. Conclusions: NAC did not reduce intraoperative liver injury in this small number of patients. The heterogenous nature of the study population, with differences in co-morbidities, body mass index and intraabdominal anatomy, leads to a varied post-operative inflammatory response. Significant hepatocyte injury occurs through both necrosis and apoptosis. [ABSTRACT FROM AUTHOR]

Background: Obesity-related dyslipidaemia comprises hypercholesterolaemia, hypertriglyceridaemia, low HDL-cholesterol and normal to raised LDL-cholesterol levels. 40 % of morbidly obese surgical patients have dyslipidaemia. Roux-en-Y gastric bypass (RYGB) surgery has many beneficial metabolic effects, but the full impact on plasma lipids has not been clearly defined. Methods: A systematic review of electronic databases (Ovid; Medline; PubMed; Embase) between 1960 and March 2012 was performed using search terms including the following: obesity surgery, bariatric surgery, gastric bypass, cholesterol, lipids, triglycerides and non-esterified fatty acids. A total of 2442 manuscripts were screened. Papers with paired plasma lipid levels around RYGB surgery were included. Exclusions included the following: editorials, dual publications, n < 10, resulting in 75 papers of relevance. A meta-analysis was performed of the effect of RYGB surgery upon plasma lipids at different time points up to 4 years following surgery, using a random effects model. Results: Paired data were available for 7815 subjects around RYGB surgery for morbid obesity with a baseline BMI 48 kg/m ( n = 2331). There was a reduction in plasma total cholesterol and LDL-C from 1 month up to 4 years post-RYGB ( p < 0.00001, p < 0.00001). Following RYGB, HDL-C increased from 1 year onwards ( p < 0.00001), and triglyceride levels were reduced postoperatively from 3 months up to 4 years ( p < 0.00001). NEFA levels were increased at 1 month postoperatively ( p = 0.003), but from 3 months onwards did not differ from preoperative levels ( p = 0.07). Conclusions: RYGB surgery reverses the dyslipidaemia of obesity. These findings support the use of RYGB in the management of high cardiovascular risk lipid profiles in morbid obesity. [ABSTRACT FROM AUTHOR]

Single-incision surgery in the morbidly obese patient has not been widely adopted, but remains a popular choice amongst patients. In the bariatric patient, it presents its own surgical challenges with hepatomegaly and increased abdominal adiposity. Here, we present our experience of 275 single-incision laparoscopic gastric bands.Between June 2009 and April 2013, 275 obese patients underwent single-incision laparoscopic adjustable gastric banding through a single incision using a multichannel single port and via a pars flaccida approach. Prospective data collection was undertaken including operating time, additional ports and additional procedures undertaken.In this series, median operative time was 60 (range 34-170) min. An additional port was placed in 15 patients (5 %), including two conversions to four-port technique (0.7 %). Of these patients ( n = 15), the majority were male ( p < 0.0001). Reasons for additional port placement included bleeding and anatomical abnormalities. Additional port placement occurred more often within the first 50 cases (5/50, 10 % vs 10/225, 4 %). An umbilical incision resulted in more wound-related complications than a transverse incision in the upper abdomen ( p < 0.001). There were no 30-day mortality and minimal morbidity with two wound infections resulting in band removal.Single-incision laparoscopic adjustable gastric banding can be performed safely with minimal morbidity in the morbidly obese patient, and our technique has a high rate of success for all BMIs. Following 275 single-incision band insertions additional port placements were more commonly required in male patients, BMI >45 and earlier in the learning curve. [ABSTRACT FROM AUTHOR]

Background: Bariatric surgical procedures are classified by their presumed mechanisms of action: restrictive, malabsorptive or a combination of both. However, this dogma is questionable and remains unproven. We investigated post-operative changes in nutrient absorption and transit time following bariatric surgery. Methods: Participants were recruited into four groups: obese controls (body mass index (BMI) >30 kg/m, n = 7), adjustable gastric banding ( n = 6), Roux-en-Y gastric bypass (RYGB, n = 7) and biliopancreatic diversion with duodenal switch (DS, n = 5). Participants underwent sulphasalazine/sulphapyridine tests (oro-caecal transit time); fasting plasma citrulline (functional enterocyte mass); 3 days faecal collection for faecal elastase 1 (FE-1); calprotectin (FCp); faecal fatty acids (pancreatic exocrine function, gut inflammation and fat excretion, respectively); and 5 h d-xylose, l-rhamnose and lactulose test (intestinal absorption and permeability). Results: Age and gender were not different but BMI differed between groups ( p = 0.001). No difference in oro-caecal transit time ( p = 0.935) or functional enterocyte mass ( p = 0.819) was detected. FCp was elevated post-RYGB vs obese ( p = 0.016) and FE-1 was reduced post-RYGB vs obese ( p = 0.002). Faecal fat concentrations were increased post-DS vs obese ( p = 0.038) and RYGB ( p = 0.024) and were also higher post-RYGB vs obese ( p = 0.033). Urinary excretion of d-xylose and l-rhamnose was not different between the groups; however, lactulose/rhamnose ratio was elevated post-DS vs other groups (all p < 0.02), suggesting increased intestinal permeability. Conclusions: Following RYGB, there are surprisingly few abnormalities or indications of severe malabsorption of fats or sugars. Small bowel adaptation after bariatric surgery may be key to understanding the mechanisms responsible for the beneficial metabolic effects of these operations. [ABSTRACT FROM AUTHOR]

Background: Rhabdomyolysis (RML) is a rare complication of bariatric surgery. A systematic review was performed to identify risk factors and patient outcomes in morbidly obese patients undergoing bariatric surgery who develop RML. Methods: A comprehensive search was performed between January 1990 and March 2012 using relevant MeSH terms. Studies were chosen based on predefined inclusion criteria. RML was defined as a creatine kinase of more than 1,000 IU/L. The parameters assessed included patient characteristics of the RML population, type of bariatric surgery performed, operating time, complications, presentation and diagnosis of RML. Results: Twenty-two studies were analysed which included 11 case reports, two case series, six prospective and three retrospective comparative studies. Overall 145 patients with RML were reported following bariatric surgery. Acute renal failure was found in 20 patients (14 %) and was significantly more likely to occur in patients with postoperative muscle pain ( p < 0.05). The mortality rate after renal failure was 25 % ( n = 5). In the comparative studies, 87 RML patients were compared with 325 non-RML patients. The RML patients were more likely to be male, had a greater mean body mass index (BMI) (52 vs 48 kg/m, p < 0.01) and underwent a longer operation (255 vs 207 min, p < 0.01) compared to non-RML patients. Conclusions: Risk factors of developing RML following bariatric surgery include male gender, elevated BMI and prolonged operating time. Patients with a biochemical diagnosis of RML and postoperative myalgia after bariatric surgery are at increased risk of developing acute renal failure and mortality. These patients must be identified and treated promptly. [ABSTRACT FROM AUTHOR]

Background: Single incision laparoscopic bariatric surgery has developed over the last few years, with single incision laparoscopic adjustable gastric banding (SILS-AGB) being performed most commonly. However, there are no randomised controlled trials and few matched studies comparing SILS-AGB to conventional laparoscopic multi-port multiport adjustable gastric banding (LAGB). Our aim was to study any differences in outcome and analgesic requirements between two matched groups of gastric band patients (SILS-AGB and LAGB). Methods: Between June 2009 and September 2010, 111 patients underwent SILS-AGB and 99 patients underwent LAGB performed by a single surgeon (AGP). Patients were matched for age, sex, weight, BMI and co-morbidities. Forty six SILS-AGB and LAGB patients were included for analysis. Their outcomes were compared for operating times, conversions, analgesia requirements, morbidity and mortality. Results: Patients characteristics between the SILS-AGB and LAGB groups were similar with no differences in their median age (44 vs 47 years), sex (m:f; 7:39 vs 4:42), body mass index (43.1 vs 44.4 kg/m) or co morbidities respectively. In the SILS-AGB group the median operating time (70 min) was not significantly longer than in LAGB group (61.5 min, p = 0.07). However, SILS-AGB patients used less opiates ( p < 0.01) than the LAGB patients. There was no difference in morbidity, mortality or readmission rates. Conclusion: SILS-AGB is a safe and feasible option and is comparable with LAGB. Post operative demand for analgesia was significantly less in the SILS-AGB group. Further comparisons of post operative pain and long term outcomes are required; however preliminary results are promising. [ABSTRACT FROM AUTHOR]

Background and Purpose: Laparoscopic radical prostatectomy (LRP) is an established treatment for patients with prostate cancer in selected centers with appropriate expertise. We studied our single-center experience of developing a LRP service and subsequent training of two additional surgeons by the initial surgeon. We assessed the learning curve of the three surgeons with regard to perioperative outcomes and oncologic results. Patients and Methods: Three hundred consecutive patients underwent a LRP between January 2005 and April 2011. Patients were divided into three equal groups (1-100 group 1], 101-200 [group 2], and 201-300 [group 3]). Age, American Society of Anesthesiologists score, preoperative comorbidities, and indications for LRP were comparable for all three patient groups. Perioperative and oncologic outcomes were compared across all three groups to assess the impact of the learning curve for LRP. All surgical complications were classified using the Clavien-Dindo system (CDS). Results: The mean age was 61.9 years (range 46-74 y). There was a significant reduction in the mean operative time ( P<0.05), mean blood loss ( P<0.05), mean duration of hospital stay ( P<0.05), and duration of catherization ( P<0.05) between the three groups as the series progressed. The two most important factors predictive of positive surgical margins at LRP were the initial prostate-specific antigen level and tumor stage at diagnosis. The overall positive margin rate was 27.7%. For pT2 tumors, the positive margin rate was 21%, while patients with pT3 tumors had a positive margin of 44%. For pT2 tumors, positive margin rates decreased with increasing experience (group 1, 27% vs group 2, 17% vs group 3, 19%). The incidence of major complications-ie, grade CDS score ≤III-was 4.6% (14/300). Conclusion: LRP is a safe procedure with low morbidity. As surgeons progress through the learning curve, perioperative parameters and oncologic outcomes improve. Using a carefully mentored approach, LRP can be safely introduced as a new procedure without compromising patient outcomes. [ABSTRACT FROM AUTHOR]

Obesity increases the risk of progression of chronic kidney disease (CKD) towards kidney failure and may preclude access to kidney transplantation. Weight loss surgery remains relatively novel in obese patients with CKD, with several studies reporting results using Roux-en-Y bypass and adjustable gastric banding. However, in obese patients with CKD, kidney failure after bypass surgery and gastric band erosion after kidney transplantation have been reported. We present the first report of laparoscopic sleeve gastrectomy (LSG) performed for the treatment of obesity in patients with CKD. Weight loss, blood pressure and lipids, estimated kidney function, surgical complications and adverse events were studied. Nine obese patients with CKD (five of whom were undergoing haemodialysis treatment) underwent LSG, with median body mass index decrease of 8.4 kg/m and excess weight loss of 43.0% after 6 months. Four of the five patients on haemodialysis were added to the kidney transplantation waiting list as a result of weight loss achieved with LSG. Adverse events occurred in three patients: myocardial infarction (one patient), acute kidney injury secondary to dehydration (one patient) and compromised dialysis access (one patient). There was one complication-a gastric leak, detected 7 months after LSG, requiring further surgical intervention and nasojejunal feeding, and no mortality. Our preliminary evidence suggests that LSG is an effective treatment for obesity in patients with CKD. However, there may be additional risk associated with the procedure in patients with CKD, requiring further study. [ABSTRACT FROM AUTHOR]

Background: An increasing number of techniques are emerging in the literature describing single-incision laparoscopic cholecystectomy (SILC). The advent of a new surgical approach is a reminder of the increase in bile duct injuries in the past when laparoscopic cholecystectomy was first introduced. With this in mind, the authors describe a safe and reproducible approach to SILC. Methods: Between August 2008 and August 2009, 20 patients with symptomatic gallbladder disease underwent SILC using a totally transumbilical fundus-first approach with an intraoperative cholangiogram. Data including pain scores were collected prospectively. Results: In this initial series, the median operative time was 103 min (range, 55-177 min), including the time for two patients undergoing additional procedures at the time of surgery. Intraoperative cholangiograms were completed for 18 of 19 patients. Additional ports were required in four patients for safe completion of the procedure. The mean pain score 12 h postoperatively was 2.5 on a visual analogue scale with a range of 0-10. There was no morbidity or mortality. Conclusion: According to the findings, SILC with an intraoperative cholangiogram can be performed safely using a fundus-first approach. However, for SILC to become the operation of choice for the treatment of gallbladder disease, evidence is required to demonstrate its advantage over laparoscopic cholecystectomy. [ABSTRACT FROM AUTHOR]

The laparoscopic technique is becoming the approach of choice as surgical expertise in advanced laparoscopy has developed. Laparoscopy is also being increasingly utilized in the management of gastrointestinal emergencies. In this article, we report a series of 3 patients with ruptured liver tumors who underwent laparoscopic liver resection. The issues surrounding safety, feasibility, and appropriateness of laparoscopic surgical management in these cases are discussed. With appropriate patient selection and preoperative stabilization, laparoscopic resection has a place in the management algorithm of ruptured liver tumors. [ABSTRACT FROM AUTHOR]

Endothelial dysfunction is a pivotal early event in the development of atherosclerosis and a characteristic feature of obesity. This study was designed to investigate the effect of angiotensin-converting enzyme (ACE) inhibition on endothelial function in people who were obese but otherwise healthy. We performed a double-blind, randomised, placebo-controlled study examining the effect of the ACE inhibitor perindopril (4 mg per day) on flow-mediated vasodilatation (FMD) of the brachial artery, arterial blood pressure, glucose homeostasis and inflammatory cytokines. Eighteen obese subjects (all body mass index > 30 kg/m2) were randomised to receive perindopril or placebo for four weeks. Perindopril led to a fall in systolic blood pressure from 131 (standard error of mean [SEM] 3) to 117(5) mmHg and diastolic blood pressure from 74(4) mmHg to 68(4) mmHg, both p<0.001. Despite this fall in blood pressure, ACE inhibition had no effect on FMD, 8.2 (1.2)% versus 8.3 (1.5)%, p=0.9. ACE inhibition had no effect on insulin, lipids or circulating cytokines. In healthy obese humans, despite a significant reduction in blood pressure, ACE inhibition had no effect on FMD. [ABSTRACT FROM PUBLISHER]

Background: Obesity is a major risk factor for the development of endothelial dysfunction. We explored the effect of different degrees of body mass on endothelial function, lipids, systemic inflammation and glucose homeostasis and the effect of surgically-induced weight loss on endothelial function in severely obese humans. Methods: A cross-sectional study of healthy subjects across a wide range of body fatness was performed to characterize the effect of obesity on flow-mediated dilatation (FMD), systemic inflammation, blood pressure and insulin sensitivity. A longitudinal study was performed to assess the effect of bariatric surgery induced weight loss on these parameters. 73 healthy subjects across a wide range of body mass were recruited; of these, 8 underwent bariatric surgery (median BMI 52.2 kg/m2, interquartile range 50.355.9). Endothelial dependent vasodilatation was measured using the brachial artery vasodilatory response to forearm hyperemia assessed using highresolution ultrasonography. Results: Obese subjects were characterised by a complex collection of abnormalities, with hypertension, impaired glucose homeostasis, systemic inflammation and reduced FMD. BMI ≤25 kg/m2 (median FMD 9.7%, interquartile range 6.8-12.2), BMI >30 kg/m2 (median FMD 6.7% 4.8-7.5), P=0.01 comparing FMD in lean and obese subjects. A mean reduction in weight of 23.4 (4.6) kg produced an improvement in FMD from 5.3% (3.87.0) to 10.2% (7.6-13.3), P=0.01. Conclusions: Even moderate obesity leads to endothelial dysfunction. In severely obese subjects, FMD is normalized by weight loss. This improvement in FMD is associated with a decline in inflammatory markers, blood pressure and insulin. The improvement in FMD occurred despite patients remaining significantly obese. These results suggest that an integrated approach to improving endothelial function in obese humans may be necessary. [ABSTRACT FROM AUTHOR]

Background: Ki-Ras is well studied in its oncogenic form in relation to pancreatic pathologies. However, the individual contribution of each of the wild-type Ras isoforms (Ha-, Ki-, and N-) in pancreatic cells in health and disease is unknown. Methods: Archival formalin-fixed, paraffin-embedded specimens of normal (n = 6) and malignant pancreas (n = 35) were used for immuno-histochemical detection of Ras isoforms using a modified polymer system. In addition, immunogold labelling for Ras isoforms was done for subcellular localisation under electron microscopy. Results: Pancreatic ductal cells expressed Ha-Ras in the cytoplasm, with Ki-Ras in the apical region and N-Ras (50% of cases) in a supranuclear distribution. Pancreatic acinar cells express all three isoforms with some nuclear expression of Ki-Ras and supranuclear expression of N-Ras. Islets show Ki- and Ha-Ras mainly with differential expression of Ha-Ras (β cells showing less Ha-Ras and more Ki-Ras than α cells). Electron microscopy shows that Ha-Ras is mainly localised in the endoplasmic reticulum and Golgi apparatus of the acinar cells with some plasma membrane localisation of Ki-Ras in the ductal cells. There was no change in any of the Ras isoform expression in the ductal or acinar cells in various malignancies studied (Mann-Whitney U test, p > 0.1). Conclusions: Ras isoforms have distinct and separate cellular and subcellular distribution that may persist even in the malignantly transformed state. Understanding this distinct functional distribution patterns in detail is an essential step if mutant Ki-Ras is to be targeted in the pancreas by genetic or molecular therapeutic tools. Copyright © 2005 S. Karger AG, Basel and IAP [ABSTRACT FROM AUTHOR]

Background: Obesity surgery has been shown to result not only in sustained weight loss, but also in improvements in psychological morbidity and quality of life. The present study aimed to explore the mechanisms behind the success of surgery and to examine how it might bring about such changes in patients' health status. Methods: Both quantitative and qualitative methods were used. A questionnaire was completed by patients who had undergone bariatric surgery in the past 4 years (n=22) and a matched-group of waiting list controls (n=39). In depth interviews were then carried out with 15 surgical patients. Results: The quantitative study showed that the surgical group weighed less, had more negative experiences of eating and yet reported improved subjective health status using a range of validated tools. The qualitative study provided some insights into this improved health status, with the surgical patients reporting improved energy and self-esteem. The patients also reported a fundamental shift in their relationship with food. In particular, they described changes in their eating behavior and stated that they had a new experience of fullness and a reduction in their hunger. Furthermore, they described how food now had a reduced role in their lives and that the operation had made them feel more in control of their food intake. Conclusion: Post-surgical improvements in health status may not only be a result of the non-specific consequences of surgery brought about by weight loss, but also a result of the specific impact of the surgical procedure itself. By enforcing a reduction in the amount of food that can be eaten, restrictive surgery seems to generate changes in the individuals' relationship to food and may help to re-establish a perception of control over eating behavior. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the accuracy of operative assessment of the condition of the appendix during laparoscopic and open appendicectomy, and to assess whether a normal-looking appendix should be excised routinely during a laparoscopic operation. Design: Prospective study. Setting: District general hospital, UK. Subjects: 387 patients who presented with signs and symptoms of appendicitis and underwent appendicectomy. Intervention: 63 patients (16%) were operated on laparoscopically, of whom 48 were female. Main outcome measures: Correlation of operative with histological findings. Results: The positive predictive value of operative assessment was increased during the laparoscopic procedure in both male (94.4% to 100%) and female (78% to 88%) patients. Of 21 female patients whose appendixes looked normal at laparoscopy, 5 had other conditions (appendixes normal on histological examination) and 4 were inflamed. Conclusion: In women of childbearing age a normal-looking appendix should be resected during laparoscopic appendicectomy unless another condition is obviously the cause of the signs and symptoms. [ABSTRACT FROM AUTHOR]

Background: The accuracy of histological assessment of frozen section (FS) of the pancreatic resection margin (PRM) at pancreatico-duodenectomy can be improved by concurrent FS examination of a sample of the suspected pancreatic lesion. Methods: A prospective trial was conducted using archived material. FS of all the PRM and suspected pancreatic lesion of 12 patients randomly selected from a historical group who underwent pancreatico-duodenectomy for suspected malignancy were examined by five histopathologists. They were asked to examine the PRM alone and alongside the suspected lesion. The diagnosis of the PRM was ‘benign’, ‘malignant’ or ‘defer to paraffin section’. All the histopathologists were blinded to the paraffin section diagnosis. Results: The main outcome measures were sensitivity, specificity and the incidence of deferring to paraffin section. In this respect examination of the PRM alone had a sensitivity of 70% and a specificity of 87.5%. Concurrent FS examination of PRM with the pancreatic lesion increased the sensitivity to 90% and the specificity to 92.5%. The incidence of deferring to paraffin section was reduced from 17 to 7% ( P = 0.03). Conclusion: This policy is recommended because it improves the diagnostic accuracy of FS evaluation of the PRM resulting in a reduction of residual pancreatic cancer at the pancreatic transection line. [ABSTRACT FROM AUTHOR]

Background: This study examines the effect of alcohol intake on surgical dexterity immediately after and the morning after alcohol intake and minimal sleep deprivation by simulating a typical night out on the town. Methods: Five surgeons (all men, aged 31–40 years) were trained on a laparoscopic surgical simulator (minimally invasive surgical trainer-virtual reality) to reach a desired standard of performance. Three experimental settings were used: (i) a control night with no alcohol and full night's sleep; (ii) a sham night out (sleep deprived) without alcohol; and (iii) a night out with alcohol ad libitum. The parameters recorded were the average time taken to carry out a task, error rate, average diathermy time and diathermy (damage) time to main object. Comparisons between baseline readings, those in the middle of the night and those of the following morning were made by applyingANOVA methods after logarithmic transformation of the data. Results: The candidates consumed, on average, 10.33 units (range, 6–15 units) of alcohol and had 0.86% (range, 0.71–1.1%) of breath alcohol levels and an average of 3.75 h (range, 3–5 h) of sleep after a typical night out. The morning-after breath alcohol levels were 0%. There was significant deterioration in performance, as measured by all indicators, immediately after alcohol consumption. The adverse effects on time taken to complete the task and total diathermy time were still apparent the morning after. The sham night out appeared to affect only ‘time parameters’. No significant changes in performance were seen in the control setting. Conclusion: Both alcohol consumption and sleep deprivation adversely affect the ability to carry out surgical procedures. Our simulation study suggests that the adverse effects of alcohol intake persist the following morning. [ABSTRACT FROM AUTHOR]