Impact of retrograde transillumination while securing the airway in obese patients undergoing bariatric surgery

Video laryngoscopy (VL) is a well-established technique used in anaesthetising obese patients who present with higher risks of airway-related difficulties and desaturations due to shorter safe apnoea periods. However, VL has certain limitations and may fail. We present the Infrared Red Intubation System (IRRIS), a new technique facilitating glottis identification in severely obese patients undergoing anaesthesia for bariatric surgery. This single-centre, prospective trial assessed the efficacy of the IRRIS for VL tracheal intubation in 20 severely obese adult patients undergoing elective bariatric surgery under general anaesthesia. We assessed the ability of the IRRIS to differentiate the transilluminated glottis from the oesophagus and laryngeal folds and evaluated the ease of intubation. The average weight in the investigated patient cohort was 145 ± 29 kg, the suprasternal tissue thickness was 12 ± 4 mm. The median IQR [range] larynx recognition time was 10 [2–50] s, which was similar to that of lean patients. The degree of obesity correlated with the duration to achieve optimal laryngoscopic view and complete the intubation procedure. We achieved successful VL insertion on the first attempt in 13 of 20 cases (65%), and on the second attempt in 7 cases (35%), emphasising the increased probability of successful intubation on the first attempt. Tracheal intubation with the IRRIS lasted 50 [IQR 20–100] s. The lowest SpO2 during intubation was 98 [IQR 83–100] %. Addition of IRRIS to VL insertion facilitated the intubation of difficult airways in severely obese patients. IRRIS improves the visualization of the intubation pathway by selectively highlighting the airway entrance and shortens the time to successfully conclude the intubation procedure

Use of a penicillin allergy clinical decision rule to enable direct oral penicillin provocation: an international multicentre randomised control trial in an adult population (PALACE): study protocol

Introduction Penicillin allergies are highly prevalent in the healthcare setting and associated with the prescription of second-line inferior antibiotics. More than 85% of all penicillin allergy labels can be removed by skin testing and 96%–99% of low-risk penicillin allergy labels can be removed by direct oral challenge. An internally and externally validated clinical assessment tool for penicillin allergy, PEN-FAST, can identify a low-risk penicillin allergy without the need for skin testing; a score of less than 3 has a negative predictive value of 96.3% (95% CI, 94.1 to 97.8) for the presence of a penicillin allergy. It is hypothesised that PEN-FAST is a safe and effective tool for assessing penicillin allergy in an outpatient clinic setting. Methods and analysis This is an international, multicentre randomised control trial using the PEN-FAST tool to risk-stratify penicillin allergy labels in adult outpatients. The study’s primary objective is to evaluate the non-inferiority of using PEN-FAST score-guided management with direct oral challenge compared with standard care (defined as prick and intradermal skin testing followed by oral penicillin challenge). Participants will be randomised 1:1 to the intervention arm (direct oral penicillin challenge) or standard of care arm (skin testing followed by oral penicillin challenge, if skin testing is negative). The sample size of 380 randomised patients (190 per treatment arm) is required to demonstrate non-inferiority. Ethics and dissemination The study will be performed according to the guidelines of the Helsinki Declaration and is approved by the Austin Health Human Research Ethics Committee (HREC/62425/Austin-2020) in Melbourne Australia, Vanderbilt University Institutional Review Board (IRB #202174) in Tennessee, USA, Duke University Institutional Review Board (IRB #Pro00108461) in North Carolina, USA and McGill University Health Centre Research Ethics Board in Canada (PALACE/2022-7605). The results of this study will be published and presented in various scientific forums

Early Improvement in Glycemic Metabolism after Laparoscopic Sleeve Gastrectomy in Obese Patients -A Prospective Study

Rezumat Ameliorarea rapidã a metabolismului glucidic dupã gastrectomia longitudinalã laparoscopicã la pacienåii cu obezitate -studiu prospectiv Introducere: Conform Organizaåiei Mondiale a Sãnãtãåii, existau în 2014 peste 600 de milioane de adulåi cu obezitate (mai mult decât dublu faåã de anul 1980) care prezintã un risc crescut de dezvoltare a sindromului metabolic, deci inclusiv pentru diabetul zaharat de tip 2. Datoritã controlului slab glicemic în urma tratamentului conservator al DZ tip 2, chirurgia metabolicã a fost capabilã sã câaetige un rol important în managementul pacientului cu DZ tip 2 aei obezitate, cu remisii sau îmbunãtãåiri semnificative raportate în literatura de specialitate. Obiectiv: studierea efectelor gastrectomiei longitudinale laparoscopice (LSG) asupra metabolismului glucidic la pacienåii cu obezitate, cu sau fãrã DZ tip 2. Metodã: 60 de pacienåi consecutivi, operaåi în spitalul Ponderas pentru obezitate prin gastrectomie longitudinalã laparoscopicã, au fost incluaei într-un studiu prospectiv, în perioada FebruarieMartie 2013. IMC-ul (indicele de masã corporalã), circumferinåã abdominalã aei parametrii glicemici au fost studiaåi pre-operator, la 10 zile aei 6 luni postoperator. Rezultate: controlul glicemic a fost semnificant îmbunãtãåit începând cu ziua 10 postoperatorie. Imbunãtãåiri semnificative statistic au fost notate la 6 luni postoperator în valorile IMCului (p<0.0001), circumferinåa abdominalã (p<0.0001), glicemie (p<0.0001), insulinemie (p<0.0001), peptid C (p<0.0001) aei HOMA. Concluzii: o îmbunãtãåire rapidã a metabolismului glucidic, atât la pacienåii cu obezitate aei DZ tip 2 cât aei la cei fãrã DZ tip 2, se regãseaete înaintea scãderii ponderale semnificative (10 zile postoperator). La 6 luni postoperator, când se asociazã aei o scãdere ponderalã semnificativã, atât pacienåii diabetici cât aei cei nediabetici prezintã o îmbunãtãåire suplimentarã a metabolismului glicemic, care poate susåine ideea ca gastrectomia longitudinalã laparoscopicã este o metodã eficientã pentru tratamentul pacienåilor cu obezitate aei sindrom metabolic. Aceste modificãri benefice pot explica atât remisia DZ tip 2 dar aei prevenåia acestuia la pacienåii cu obezitate supuaei tratamentului chirurgical metabolic. Cuvinte cheie: obezitate, metabolism glucidic, gastrectomie longitudinalã laparoscopicã, remisia aei prevenåia diabetului zaharat tip 2 Abstract Background: according to W.H.O. in 2014 more than 600 million adults were obese, (more than doubled since 1980), and face a major risk for the onset of metabolic syndrome, including T2DM. Due to the poor control of glycemic imbalance for the conservative treatment of T2DM, the metabolic surgery was able to gain an important role in modern management of T2DM, with significant reported improvements or remissions for these patients. Objective: to study the effects of laparoscopic sleeve gastrec- BMI, waist circumference and glycemic parameters were studied at the moment of entering the study, 10 days after surgery and at 6 months follow up. Results: the glycemic control was significantly improved starting with postoperative day 10. Statistically significant improvements were noticed after six months postoperatively in BMI values (p<0,0001), waist circumference (p<0,0001), glycemic levels (p<0,0001), insulin (p<0,0001), C-peptide (p<0,0001) and HOMA. Conclusions: a rapid induced improvement of glucose metabolism in both diabetic and non-diabetic patients occurs before a significant weight loss (POD 10). At 6 months, when associated with an important weight loss, both diabetic and non-diabetic patients present a furthermore improvement in glycemic metabolism, that enables us to consider that sleeve gastrectomy is an efficient method for a sustained improvement in the metabolic status of patients with obesity. These beneficial changes that can explain the remission of T2DM can also explain the prevention of T2DM after metabolic surgery

EAES Recommendations for Recovery Plan in Minimally Invasive Surgery Amid COVID-19 Pandemic

Background: COVID-19 pandemic presented an unexpected challenge for the surgical community in general and Minimally Invasive Surgery (MIS) specialists in particular. This document aims to summarize recent evidence and experts’ opinion and formulate recommendations to guide the surgical community on how to best organize the recovery plan for surgical activity across diferent sub-specialities after the COVID-19 pandemic. Methods: Recommendations were developed through a Delphi process for establishment of expert consensus. Domain topics were formulated and subsequently subdivided into questions pertinent to diferent surgical specialities following the COVID-19 crisis. Sixty-fve experts from 24 countries, representing the entire EAES board, were invited. Fifty clinicians and six engineers accepted the invitation and drafted statements based on specifc key questions. Anonymous voting on the statements was performed until consensus was achieved, defned by at least 70% agreement. Results: A total of 92 consensus statements were formulated with regard to safe resumption of surgery across eight domains, addressing general surgery, upper GI, lower GI, bariatrics, endocrine, HPB, abdominal wall and technology/research. The statements addressed elective and emergency services across all subspecialties with specifc attention to the role of MIS during the recovery plan. Eighty-four of the statements were approved during the frst round of Delphi voting (91.3%) and another 8 during the following round after substantial modifcation, resulting in a 100% consensus. Conclusion: The recommendations formulated by the EAES board establish a framework for resumption of surgery following COVID-19 pandemic with particular focus on the role of MIS across surgical specialities. The statements have the potential for wide application in the clinical setting, education activities and research work across diferent healthcare systems

Study protocol: Australasian Registry of Severe Cutaneous Adverse Reactions (AUS-SCAR)

Introduction Severe cutaneous adverse reactions (SCAR) are a group of T cell-mediated hypersensitivities associated with significant morbidity, mortality and hospital costs. Clinical phenotypes include Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS) and acute generalised exanthematous pustulosis (AGEP). In this Australasian, multicentre, prospective registry, we plan to examine the clinical presentation, drug causality, genomic predictors, potential diagnostic approaches, treatments and long-term outcomes of SCAR in Australia and New Zealand. Methods and analysis Adult and adolescent patients with SCAR including SJS, TEN, DRESS, AGEP and another T cell-mediated hypersensitivity, generalised bullous fixed drug eruption, will be prospectively recruited. A waiver of consent has been granted for some sites to retrospectively include cases which result in early mortality. DNA will be collected for all prospective cases. Blood, blister fluid and skin biopsy sampling is optional and subject to patient consent and site capacity. To develop culprit drug identification and prevention, genomic testing will be performed to confirm human leukocyte antigen (HLA) type and ex vivo testing will be performed via interferon-γ release enzyme linked immunospot assay using collected peripheral blood mononuclear cells. The long-term outcomes of SCAR will be investigated with a 12-month quality of life survey and examination of prescribing and mortality data. Ethics and dissemination This study was reviewed and approved by the Austin Health Human Research Ethics Committee (HREC/50791/Austin-19). Results will be published in peer-reviewed journals and presented at relevant conferences

Clinical practice guidelines of the European Association for Endoscopic Surgery (EAES) on bariatric surgery: update 2020 endorsed by IFSO-EC, EASO and ESPCOP

Background: Surgery for obesity and metabolic diseases has been evolved in the light of new scientific evidence, long-term outcomes and accumulated experience. EAES has sponsored an update of previous guidelines on bariatric surgery. Methods: A multidisciplinary group of bariatric surgeons, obesity physicians, nutritional experts, psychologists, anesthetists and a patient representative comprised the guideline development panel. Development and reporting conformed to GRADE guidelines and AGREE II standards. Results: Systematic review of databases, record selection, data extraction and synthesis, evidence appraisal and evidence-to-decision frameworks were developed for 42 key questions in the domains Indication; Preoperative work-up; Perioperative management; Non-bypass, bypass and one-anastomosis procedures; Revisional surgery; Postoperative care; and Investigational procedures. A total of 36 recommendations and position statements were formed through a modified Delphi procedure. Conclusion: This document summarizes the latest evidence on bariatric surgery through state-of-the art guideline development, aiming to facilitate evidence-based clinical decisions

Fluorescence‐based bowel anastomosis perfusion evaluation: results from the IHU‐IRCAD‐EAES EURO‐FIGS registry

Background: Anastomotic leakage (AL) is one of the dreaded complications following surgery in the digestive tract. Near-infrared fluorescence (NIRF) imaging is a means to intraoperatively visualize anastomotic perfusion, facilitating fluorescence image-guided surgery (FIGS) with the purpose to reduce the incidence of AL. The aim of this study was to analyze the current practices and results of NIRF imaging of the anastomosis in digestive tract surgery through the EURO-FIGS registry. Methods: Analysis of data prospectively collected by the registry members provided patient and procedural data along with the ICG dose, timing, and consequences of NIRF imaging. Among the included upper-GI, colorectal, and bariatric surgeries, subgroup analysis was performed to identify risk factors associated with complications. Results: A total of 1240 patients were included in the study. The included patients, 74.8% of whom were operated on for cancer, originated from 8 European countries and 30 hospitals. A total of 54 surgeons performed the procedures. In 83.8% of cases, a pre-anastomotic ICG dose was administered, and in 60.1% of cases, a post-anastomotic ICG dose was administered. A significant difference (p < 0.001) was found in the ICG dose given in the four pathology groups registered (range: 0.013–0.89 mg/kg) and a significant (p < 0.001) negative correlation was found between the ICG dose and BMI. In 27.3% of the procedures, the choice of the anastomotic level was guided by means of NIRF imaging which means that in these cases NIRF imaging changed the level of anastomosis which was first decided based on visual findings in conventional white light imaging. In 98.7% of the procedures, the use of ICG partly or strongly provided a sense of confidence about the anastomosis. A total of 133 complications occurred, without any statistical significance in the incidence of complications in the anastomoses, whether they were ICG-guided or not. Conclusion: The EURO-FIGS registry provides an insight into the current clinical practice across Europe with respect to NIRF imaging of anastomotic perfusion during digestive tract surgery

EAES Recommendations for Recovery Plan in Minimally Invasive Surgery Amid COVID-19 Pandemic

Background COVID-19 pandemic presented an unexpected challenge for the surgical community in general and Minimally Invasive Surgery (MIS) specialists in particular. This document aims to summarize recent evidence and experts’ opinion and formulate recommendations to guide the surgical community on how to best organize the recovery plan for surgical activity across different sub-specialities after the COVID-19 pandemic. Methods Recommendations were developed through a Delphi process for establishment of expert consensus. Domain topics were formulated and subsequently subdivided into questions pertinent to different surgical specialities following the COVID-19 crisis. Sixty-five experts from 24 countries, representing the entire EAES board, were invited. Fifty clinicians and six engineers accepted the invitation and drafted statements based on specific key questions. Anonymous voting on the statements was performed until consensus was achieved, defined by at least 70% agreement. Results A total of 92 consensus statements were formulated with regard to safe resumption of surgery across eight domains, addressing general surgery, upper GI, lower GI, bariatrics, endocrine, HPB, abdominal wall and technology/research. The statements addressed elective and emergency services across all subspecialties with specific attention to the role of MIS during the recovery plan. Eighty-four of the statements were approved during the first round of Delphi voting (91.3%) and another 8 during the following round after substantial modification, resulting in a 100% consensus. Conclusion The recommendations formulated by the EAES board establish a framework for resumption of surgery following COVID-19 pandemic with particular focus on the role of MIS across surgical specialities. The statements have the potential for wide application in the clinical setting, education activities and research work across different healthcare systems