Pancreatic exocrine insufficiency post-gastrectomy, oesophagectomy and pancreatico-duodenectomy

Patients after the major upper gastrointestinal operations of gastrectomy, oesophagectomy and pancreatico-duodenectomy can have post-operative problems with malnutrition and weight loss. One contributing cause is postulated to be pancreatic exocrine insufficiency (PEl). There are several different tests which can be used to investigate pancreatic exocrine function, but each test has a practical disadvantage. One relatively new test of pancreatic exocrine function is the 6-hour Carbon 13 mixed triglyceride breath test (13C-MTG-BT), which is more convenient and acceptable to patients than some other tests. This research project aimed to use the 13C-MTG-BT to investigate pancreatic exocrine function in controls and post-operative patients in order to measure the incidence of PEl in patients after major upper gastrointestinal operations, and also to assess various clinical characteristics and correlate these with the 13C-MTG-BT results. Section 1 is the preface. Section 2 summarises the literature on pancreatic exocrine function tests, pancreatic exocrine function testing after gastrectomy, oesophagectomy and panrreatico-duodenectomy, and previous use of the 13C-MTG-BT. Section 3 describes the use of the 13C-MTG-BT in testing controls and post-operative patients. During the research and analysis of the 13C-MTG-BT results, it became apparent that there were two variables in test protocol which should be analysed further. Section 4 describes analysis of two variables in test protocol, which are reliability in sampling the initial breath only once, and variation in sampling the first and mid parts of the breath for each breath sample. Overall, the experimental program found a 15% incidence of PEl in the collective post-operative group of patients when assessed using the 13C-MTG-BT, although the difference between surgical cases and controls was not statistically significant. A larger study into post-operative pancreatic exocrine function is indicated. Analysis of the technique of breath sampling in the 13C-MTG-BT suggests that one baseline measurement can be highly variable and the mean of several measurements may be more accurate, and also that the part of the breath sampled is not particularly important but should be consistent. The test protocol needs further assessment to determine a more robust protocol before further investigations with the 13C-MTG-BT are performed

Pancreatic exocrine insufficiency post-gastrectomy, oesophagectomy and pancreatico-duodenectomy

Patients after the major upper gastrointestinal operations of gastrectomy, oesophagectomy and pancreatico-duodenectomy can have post-operative problems with malnutrition and weight loss. One contributing cause is postulated to be pancreatic exocrine insufficiency (PEl). There are several different tests which can be used to investigate pancreatic exocrine function, but each test has a practical disadvantage. One relatively new test of pancreatic exocrine function is the 6-hour Carbon 13 mixed triglyceride breath test (13C-MTG-BT), which is more convenient and acceptable to patients than some other tests. This research project aimed to use the 13C-MTG-BT to investigate pancreatic exocrine function in controls and post-operative patients in order to measure the incidence of PEl in patients after major upper gastrointestinal operations, and also to assess various clinical characteristics and correlate these with the 13C-MTG-BT results. Section 1 is the preface. Section 2 summarises the literature on pancreatic exocrine function tests, pancreatic exocrine function testing after gastrectomy, oesophagectomy and panrreatico-duodenectomy, and previous use of the 13C-MTG-BT. Section 3 describes the use of the 13C-MTG-BT in testing controls and post-operative patients. During the research and analysis of the 13C-MTG-BT results, it became apparent that there were two variables in test protocol which should be analysed further. Section 4 describes analysis of two variables in test protocol, which are reliability in sampling the initial breath only once, and variation in sampling the first and mid parts of the breath for each breath sample. Overall, the experimental program found a 15% incidence of PEl in the collective post-operative group of patients when assessed using the 13C-MTG-BT, although the difference between surgical cases and controls was not statistically significant. A larger study into post-operative pancreatic exocrine function is indicated. Analysis of the technique of breath sampling in the 13C-MTG-BT suggests that one baseline measurement can be highly variable and the mean of several measurements may be more accurate, and also that the part of the breath sampled is not particularly important but should be consistent. The test protocol needs further assessment to determine a more robust protocol before further investigations with the 13C-MTG-BT are performed

Public Bariatric Surgery: A National Framework

Obesity is a chronic progressive disease that leads to physical, psychological, and metabolic health problems. The prevalence of obesity is increasing across the globe and in 2017-18 Australia ranked fifth among OECD countries with over one third (31%) of Australian adults living with obesity (1 p. 1). Despite this increasing prevalence, access to the full suite of effective treatments is limited in Australia, including access to bariatric-metabolic surgery Bariatric-metabolic surgery (also referred to as bariatric surgery) is a well-established, safe and effective form of obesity treatment with demonstrable meaningful and sustained weight loss over the medium to long term. Bariatric surgery has also been shown to be highly effective in reversing or improving obesity-related risks and complications in patients, especially for type 2 diabetes (2). Research evidence is consistent in supporting the cost-effectiveness of surgery in the treatment of obesity and its complication (3). Although bariatric-metabolic surgery (bariatric surgery) is one of the most effective methods for treatment of obesity, there remain barriers to access especially in the public hospital setting and access remain inadequate. Over 90% of all bariatric surgery is currently performed in the private system as access to the public hospital system remains poor, even for those with the greatest need (4 p. 5). In 2015-16 only 950 of approximately 24,000 bariatric surgeries performed in Australia occurred in public hospitals (5). A recent (2017) study suggested only 15 public hospitals from a potential 700 institutions nation-wide formally offered a bariatric-metabolic surgical programme (6). In 2019 the National Bariatric Registry recorded 22 public hospitals with bariatric cases but only 10 of these with significant (>75 per year) case load (7). This inequity of access to care is concerning. With appropriate considerations, making bariatric surgery available within the public hospital setting can provide life-changing health and wellbeing benefits to those who need it most. Further, there is increasing recognition of bariatric surgery as an early treatment option in the care of diabetes (and other chronic diseases) in both international and emerging Australian-developed guidelines (8). This is becoming the new “standard of care” for such diseases. Australian public hospitals have the opportunity to meet this standard of care through increased provision of bariatric surgery. The 2017 Public Bariatric Surgery ANZMOSS1 Summit identified that a National Framework was required to provide clear guidelines to health policy makers, clinical governance boards and health practitioners to enable: facilitation of successful implementation of bariatric surgery more widely in Australia’s public hospital system; standardisation of key care elements such as patient eligibility and prioritisation; a reduction in variations in preoperative and postoperative care pathways; development of a sustainable model of care integrated with multimodal treatment of obesity. This National Framework is the result of expert consensus from the ANZMOSS and Collective Public Bariatric Surgery Taskforce (the Taskforce), involving and endorsed by key stakeholder organisations in the treatment of obesity and bariatric surgery (see Taskforce members and participating organisations in Appendix A). The National Framework has been designed to deliver: efficient patient centred care; sustainable use of resources to cater to the disease burden of obesity in the community; deliver surgical care to the most appropriate patient populations. This Framework is complementary to the first National Framework for Clinical Obesity Services in Australia (9), developed by NACOS – a collaborative group of concerned health care professionals, which offers practical guidance on best design, delivery, and access to clinical obesity (or ‘weight management’) services in our health system. It is intended that as these frameworks go forward, surgical pathways of care as outlined in this framework and nationwide obesity services pathways and standards, as developed in the NACOS Framework, will be integrated further. Currently, this National Framework does not include considerations for children and adolescents who may need bariatric services. Additional considerations and guidelines will be developed for paediatric and adolescent bariatric surgery at a later stage

30-Day Morbidity and Mortality of Bariatric Surgery During the COVID-19 Pandemic: a Multinational Cohort Study of 7704 Patients from 42 Countries.

BACKGROUND There are data on the safety of cancer surgery and the efficacy of preventive strategies on the prevention of postoperative symptomatic COVID-19 in these patients. But there is little such data for any elective surgery. The main objectives of this study were to examine the safety of bariatric surgery (BS) during the coronavirus disease 2019 (COVID-19) pandemic and to determine the efficacy of perioperative COVID-19 protective strategies on postoperative symptomatic COVID-19 rates. METHODS We conducted an international cohort study to determine all-cause and COVID-19-specific 30-day morbidity and mortality of BS performed between 01/05/2020 and 31/10/2020. RESULTS Four hundred ninety-nine surgeons from 185 centres in 42 countries provided data on 7704 patients. Elective primary BS (n = 7084) was associated with a 30-day morbidity of 6.76% (n = 479) and a 30-day mortality of 0.14% (n = 10). Emergency BS, revisional BS, insulin-treated type 2 diabetes, and untreated obstructive sleep apnoea were associated with increased complications on multivariable analysis. Forty-three patients developed symptomatic COVID-19 postoperatively, with a higher risk in non-whites. Preoperative self-isolation, preoperative testing for SARS-CoV-2, and surgery in institutions not concurrently treating COVID-19 patients did not reduce the incidence of postoperative COVID-19. Postoperative symptomatic COVID-19 was more likely if the surgery was performed during a COVID-19 peak in that country. CONCLUSIONS BS can be performed safely during the COVID-19 pandemic with appropriate perioperative protocols. There was no relationship between preoperative testing for COVID-19 and self-isolation with symptomatic postoperative COVID-19. The risk of postoperative COVID-19 risk was greater in non-whites or if BS was performed during a local peak

Safety of Bariatric Surgery in ≥ 65-Year-Old Patients During the COVID-19 Pandemic

Background Age >= 65 years is regarded as a relative contraindication for bariatric surgery. Advanced age is also a recognised risk factor for adverse outcomes with Coronavirus Disease-2019 (COVID-19) which continues to wreak havoc on global populations. This study aimed to assess the safety of bariatric surgery (BS) in this particular age group during the COVID-19 pandemic in comparison with the younger cohort.Methods We conducted a prospective international study of patients who underwent BS between 1/05/2020 and 31/10/2020. Patients were divided into two groups - patients >= 65-years-old (Group I) and patients < 65-years-old (Group II). The two groups were compared for 30-day morbidity and mortality.Results There were 149 patients in Group 1 and 6923 patients in Group II. The mean age, preoperative weight, and BMI were 67.6 +/- 2.5 years, 119.5 +/- 24.5 kg, and 43 +/- 7 in Group I and 39.8 +/- 11.3 years, 117.7 +/- 20.4 kg, and 43.7 +/- 7 in Group II, respectively. Approximately, 95% of patients in Group 1 had at least one co-morbidity compared to 68% of patients in Group 2 (p = < 0.001). The 30-day morbidity was significantly higher in Group I ( 11.4%) compared to Group II (6.6%) (p = 0.022). However, the 30-day mortality and COVID-19 infection rates were not significantly different between the two groups.Conclusions Bariatric surgery during the COVID-19 pandemic is associated with a higher complication rate in those >= 65 years of age compared to those < 65 years old. However, the mortality and postoperative COVID-19 infection rates are not significantly different between the two groups

30-Day morbidity and mortality of bariatric metabolic surgery in adolescence during the COVID-19 pandemic – The GENEVA study

Background: Metabolic and bariatric surgery (MBS) is an effective treatment for adolescents with severe obesity. Objectives: This study examined the safety of MBS in adolescents during the coronavirus disease 2019 (COVID-19) pandemic. Methods: This was a global, multicentre and observational cohort study of MBS performed between May 01, 2020, and October 10,2020, in 68 centres from 24 countries. Data collection included in-hospital and 30-day COVID-19 and surgery-specific morbidity/mortality. Results: One hundred and seventy adolescent patients (mean age: 17.75 ± 1.30 years), mostly females (n = 122, 71.8%), underwent MBS during the study period. The mean pre-operative weight and body mass index were 122.16 ± 15.92 kg and 43.7 ± 7.11 kg/m2, respectively. Although majority of patients had pre-operative testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (n = 146; 85.9%), only 42.4% (n = 72) of the patients were asked to self-isolate pre-operatively. Two patients developed symptomatic SARS-CoV-2 infection post-operatively (1.2%). The overall complication rate was 5.3% (n = 9). There was no mortality in this cohort. Conclusions: MBS in adolescents with obesity is safe during the COVID-19 pandemic when performed within the context of local precautionary procedures (such as pre-operative testing). The 30-day morbidity rates were similar to those reported pre-pandemic. These data will help facilitate the safe re-introduction of MBS services for this group of patients

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/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. 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 (BMI < 50 kg/m2), Group II (BMI 50-60 kg/m2), and Group III (BMI > 60 kg/m2). 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 & PLUSMN; 24.4 Kgs and 43.03 & PLUSMN; 6.9 Kg/m2, 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 = < 0.001). A significantly higher proportion of patients in group III received Sleeve Gastrectomy or One Anastomosis Gastric Bypass compared to other groups. Patients with a BMI of > 70 kg/m2 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/m2. There was, however, no significant difference in complications rates in different BMI groups, probably due to differences in procedure selection