Effect of BMI on safety of bariatric surgery during the COVID-19 pandemic, procedure choice, and safety protocols - An analysis from the GENEVA Study

It has been suggested that patients with a Body Mass Index (BMI) of > 60 kg/m2 should be offered expedited Bariatric Surgery (BS) during the Coronavirus Disease-2019 (COVID-19) pandemic. The main objective of this study was to assess the safety of this approach

Gastric Fistula in the Chest After Sleeve Gastrectomy: a Systematic Review of Diagnostic and Treatment Options.

This study aimed to establish the optimal diagnostic and treatment algorithm for the management of gastric fistula in the chest (GFIC) after sleeve gastrectomy (SG) through a systematic review of published cases. A multi-database search was performed, which produced 1182 results, of which 26 studies were included in this systematic review. The initial presentation included subphrenic collections, leaks, or (recurrent) pneumonia with associated symptoms such as persistent cough, fever, and/or dyspnea. Computed tomography (CT) scan in combination with either upper gastrointestinal (UGI) series or an esophagogastroduodenoscopy (EGD) was used to adequately diagnose the fistulas. Initial treatment was either with clips and/or clips and stents that were placed endoscopically. When unsuccessful in the majority of the cases, the surgical treatment consisted of total gastrectomy and Roux-en-Y esophagojejunostomy in a laparoscopic or open fashion

Operative management of acute abdomen after bariatric surgery in the emergency setting: the OBA guidelines

Background: Patients presenting with acute abdominal pain that occurs after months or years following bariatric surgery may present for assessment and management in the local emergency units. Due to the large variety of surgical bariatric techniques, emergency surgeons have to be aware of the main functional outcomes and long-term surgical complications following the most performed bariatric surgical procedures. The purpose of these evidence-based guidelines is to present a consensus position from members of the WSES in collaboration with IFSO bariatric experienced surgeons, on the management of acute abdomen after bariatric surgery focusing on long-term complications in patients who have undergone laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass. Method: A working group of experienced general, acute care, and bariatric surgeons was created to carry out a systematic review of the literature following the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) and to answer the PICO questions formulated after the Operative management in bariatric acute abdomen survey. The literature search was limited to late/long-term complications following laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass. Conclusions: The acute abdomen after bariatric surgery is a common cause of admission in emergency departments. Knowledge of the most common late/long-term complications (> 4 weeks after surgical procedure) following sleeve gastrectomy and Roux-en-Y gastric bypass and their anatomy leads to a focused management in the emergency setting with good outcomes and decreased morbidity and mortality rates. A close collaboration between emergency surgeons, radiologists, endoscopists, and anesthesiologists is mandatory in the management of this group of patients in the emergency setting

Pyruvate Dehydrogenase Kinase (PDK): An attractive target for anticancer therapy

Cancer cells are highly dependent on glycolysis. which provides protection against the hypoxic tumour microenvironment. Colorectal cancer cells have been reported to undergo increased glycolysis, the so-called 'Warburg's effect'. Previous research in our laboratory revealed increased expression of hypoxic and glycolytic markers to be associated with aggressive colorectal cancer phenotype. Pyruvate dehydrogenase kinase (PDK) is a crucial mitochondrial enzyme, which plays an important role linking glycolysis to oxidative phosphorylation. Inhibiting PDK with its pharmacological inhibitor, Dichloroacetate, or with RNA interference has been reported to have anti-cancer effects in other solid cancers such as head and neck squamous cell cancer. Since colorectal cancer cells are also known to be reliant on glycolysis, my aim was to determine if switching metabolism from glycolysis towards mitochondrial respiration, by inhibiting PDK, would reduce growth preferentially in colorectal cancer cells over normal cetis, and to examine the underlying mechanisms. Representative colorectal cancer (HT29, SW4BO and LaVa) and non-cancerous cell lines (HB2 and 293) were treated with Dichloroacetate (DCA), an inhibitor of PDK. 20mM DCA did not reduce growth of non-cancerous cells but caused significant decrease in cancer cell proliferation, which was associated with apoptosis and G2 phase cell cycle arrest. DCA reduced lactate levels in growth media and induced dephosphorylation of E10 sub-unit of pyruvate dehydrogenase complex in all cell lines, but the intrinsic mitochondrial membrane potential was reduced in only cancer cells. PDK exists in four isoenzymes (PDK 1-4). Next, I aimed to examine expression levels of the individual PDK isoenzymes in the panel of cell lines used, downregulate the individual PDK isoenzymes using short interierence RNA (siRNA), and • - 6 - investigate whether a subset of the PDK isoenzymes represents the actual target of DCA. Expression levels of individual PDK isoenzymes varied amongst the cell lines in a manner that did not suggest which was the main target of DCA. Down regulation 01 individual PDK isoenzymes failed to induce apoptosis in the cancer cells and, interestingly there was a compensatory rise in the mRNA levels of the other PDK isoenzymes. Treatment with siRNAs directed against various combinations of PDK isoenzymes did not induce apoptosis in cancer cells. Treatment of cells with DCA led to an up regulation of PDK isoenzymes, particularly PDK4. These results indicate that it is difficult to isolate a subset of PDK isoenzymes as potential therapeutic targets since a combination of functional redundancy and compensatory up-regulation among the isoenzymes means that sufficient overall PDK activity is maintained. Cancer cells are most sensitive to radiation in the G2-M phase of the cell cycle. Since DCA induced G2 arrest in the colorectal cancer cells, my hypothesis was that it sensitises these cells to radiation. HT29, SW480, LoVo, and 293 cells were treated with 10 and 20mM DCA, and irradiated. DCA did not induce any change in the sensitivity of 293 or HT29 cells to radiation. In contrast, SW480 and LoVo cells were significantly sensitised to radiation after pre-treatment with 10mM, but not 20mM DCA. There were minimal effects of 10 and 20mM DCA on the cell cycle profiles of all the cell lines studied. The cell lines derived from the poorly differentiated or metastatic cancers were sensitised to radiation following pretreatment with DCA, and cell lines derived from well-differentiated colorectal cancer or non-cancerous epithelial cells were resistant to any such sensitisation. However I am unable to provide any evidence to explain this radiosensitisation effect. This warrants further experiments to confirm the underlying molecular basis of these effects of DCA .EThOS - Electronic Theses Online ServiceGBUnited Kingdo

A Commentary review on Endoscopic sleeve gastroplasty: Indications, outcomes, and future implications

Metabolic and Bariatric surgeries (MBS) have been shown to be the most effective strategy to induce and maintain significant weight loss for people living with severe obesity. However, ongoing concerns regarding operative risks, irreversibility and excess costs limit their broader clinical use. Endoscopic bariatric therapies are pragmatic alternatives for patients who are not suitable for MBS or who are concerned regarding its long-term safety. Endoscopic sleeve gastroplasty (ESG) has emerged as a novel technique of endoscopic bariatric therapies which have garnered significant interests and evidence based in the past few years. Its safety, efficacy, and cost-effectiveness have been shown in various studies while comparison with sleeve gastrectomy has been widely made. This review brings together current evidence pertaining to the technicality of the procedure itself, current indications, safety and efficacy, cost-effectiveness as well as its future role and development

Identification of Common Themes from Never Events Data Published by NHS England.

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

Effect of BMI on safety of bariatric surgery during the COVID-19 pandemic, procedure choice, and safety protocols - An analysis from the GENEVA Study.

BACKGROUND It has been suggested that patients with a Body Mass Index (BMI) of > 60 kg/m should be offered expedited Bariatric Surgery (BS) during the Coronavirus Disease-2019 (COVID-19) pandemic. The main objective of this study was to assess the safety of this approach. METHODS We conducted a global study of patients who underwent BS between 1/05/2020 and 31/10/2020. Patients were divided into three groups according to their preoperative BMI - Group I (BMI60 kg/m). The effect of preoperative BMI on 30-day morbidity and mortality, procedure choice, COVID-19 specific safety protocols, and comorbidities was assessed. RESULTS This study included 7084 patients (5197;73.4 % females). The mean preoperative weight and BMI were 119.49 ± 24.4 Kgs and 43.03 ± 6.9 Kg/m respectively. Group I included 6024 (85 %) patients, whereas Groups II and III included 905 (13 %) and 155 (2 %) patients, respectively. The 30-day mortality rate was higher in Group III (p = 0.001). The complication rate and COVID-19 infection were not different. Comorbidities were significantly more likely in Group III (p =  70 kg/m had a 30-day mortality of 7.7 % (2/26). None of these patients underwent a Roux-en-Y Gastric Bypass. CONCLUSION The 30-day mortality rate was significantly higher in patients with BMI > 60 kg/m. There was, however, no significant difference in complications rates in different BMI groups, probably due to differences in procedure selection

Chyloperitoneum and Chylothorax Following Bariatric Surgery: a Systematic Review.

Chyloperitoneum and chylothorax (ChP/ChT) are rare complications after bariatric surgery. This systematic review aims to evaluate the incidence, cause, treatment, and outcome of ChP and ChT after bariatric surgery. This review investigates published English language scientific literature systematically in an attempt to answer these questions. Our literature search revealed 66 studies, of which 23 were included. There were a total of 40 patients (38, ChP; 2, ChT). Eighteen of 40 (43.9%) patients were treated laparoscopically, and one patient (2.44%) underwent thoracoscopy and ligation of the thoracic duct. Both ChP and ChT are rare complications after bariatric surgery

Splenic abcess following sleeve gastrectomy: a systematic review of clinical presentation and management methods

Background: Splenic abscess is a rare complication following Sleeve Gastrectomy. Methods: We performed a systematic review to clarify its clinical significance, presentation, and management. PubMed, Embase, MEDLINE, Google Scholar, and The Cochrane Library were searched up to the 19th of July 2020. Results: A total of 18 patients were included, of which 11 were female, and 7 were male. The mean age was 34.1 ± 12.3 years, and the mean body mass index was 45.8 ± 7.6 kg/m2. Type 2 diabetes mellitus was reported in 11.1% of patients, and hypertension in 22.2%. Fever was the most common presenting symptom seen in 17 (94.4%) patients, followed by abdominal pain in 10 (55.6%). The mean duration from surgery to presentation was 98.6 ± 132.7 days (range 10 -547 days). Computed Tomography was used for investigations in 17/18 (94.4%) patients. Seven patients had reported leak, three reported bleeding, and 2 reported pleural effusion. 13 patients had unilocular abscess. All patients were treated with antibiotics. 4 patients needed Total Parenteral Nutrition, and three were given Proton Pump Inhibitor. In total, 11 patients needed percutaneous drainage as a part of treatment and 11 patients needed total splenectomy, and 1 needed partial splenectomy. Conclusion: Splenic abscess following sleeve gastrectomy is a rare identity. The etiology of formation of splenic abscess needs further studies. A computed tomography of the abdomen with contrast is the preferred diagnostic tool. There is no gold standard treatment for splenic abscess