Perioperative strategies for patients undergoing subtotal cholecystectomy: a single-center retrospective review of 102 procedures

BACKGROUND

Calculous gall bladder disease is often handled by laparoscopic cholecystectomy. In cases where a safe dissection of the hepatocystic triangle cannot be carried out, a subtotal cholecystectomy (STC) may be performed. The perioperative management of patients undergoing STC is characterized by limited evidence. This large single-center series explores some of the perioperative aspects and outcomes after STC.

MATERIALS AND METHODS

The study population includes all patients who underwent STC at Oslo University Hospital (Ullevål and Aker Hospitals) from 01.01.2014 to 30.09.2020. A STC was defined as a cholecystectomy where there was a failure to control the cystic duct during surgery. Study variables included demographic data, comorbidities, previous biliopancreatic disease, indication for surgery, perioperative information, subsequent interventions and outcome data.

RESULTS

During the study period, 2376 cholecystectomies were performed, and 102 (4.3%) were categorized as STC. Of all patients with STC, 48 (47.1%) had an intra- or postoperative ERCP during the index hospital admission. The indication for ERCP was bile leak in 37 (42.6%) of the cases. The bile leak resolution rate was 60.0 % in intraoperative ERCP vs 95.7% in postoperative ERCP. Among the STC patients, there were no injuries to the central bile ducts. Later, one patient has undergone a remnant cholecystectomy, following fenestrating STC.

CONCLUSION

STC was a safe bailout strategy for dissection in the hepatocystic triangle in difficult cholecystectomies. Intraoperative ERCP increased procedure time and was associated with a lower rate of leak resolution, as compared to postoperative ERCP.

Intraoperative distensibility measurement in POEM for achalasia: impact on patient outcome and associations with other outcome variables at 1-year follow-up

BACKGROUND AND AIMS

The functional luminal imaging probe (FLIP) can provide measurements of lower esophageal sphincter (LES) distensibility. Studies report that use of intraoperative FLIP examination during peroral endoscopic myotomy (POEM) for achalasia is associated with treatment success, but evidence is limited and inconsistent. The main aim of the present study was to assess associations between intraoperative FLIP values and 1-year outcomes. Additionally, associations between 1-year FLIP measurements and other 1-year outcome variables were studied.

METHODS

We performed a single-center prospective study of consecutive achalasia patients treated with POEM with a standardized 1-year follow-up. The inclusion period was from June 2017 to January 2020. We compared 1-year outcomes (FLIP measurement values, Eckardt score (ES), reflux esophagitis, timed barium esophagogram (TBE), and lower esophageal sphincter resting pressure (LES-rp)) in patients with and without intraoperative FLIP examination. We also assessed associations between intraoperative FLIP values, 1-year FLIP values, and other 1-year outcomes. Results are given as median (IQR), and non-parametrical statistical analyses were applied.

RESULTS

Sixty-two patients (27 females) with median age 45 years (35-54) were included. Baseline characteristics were similar in patients with (n = 32) and without (n = 30) intraoperative FLIP examination. In patients with intraoperative FLIP, ES was 2 (1-3) and LES distensibility index (DI) 3.7 (2.6-5.4) after 1 year, compared with ES 2 (1-3) and DI 4.0 (3.1-6.8)) in patients without intraoperative FLIP (ns). Intraoperative DI was not correlated with 1-year ES or DI. One-year DI correlated significantly with 1-year ES (rs - 0.42), TBE (rs - 0.34), and LES-rp (rs - 0.29).

CONCLUSIONS

Use of intraoperative FLIP measurements in POEM for achalasia is not associated with improved 1-year outcome, and the clinical value of intraoperative FLIP in POEM for achalasia is questioned. Follow-up FLIP measurements are moderately associated with symptomatic outcome, and may serve as an additional diagnostic modality in post-treatment evaluation.

Single anastomosis gastric bypass for morbid obesity

BACKGROUND

Mini-gastric bypass is a new surgical method for the treatment of morbid obesity. The method was introduced at Oslo University Hospital in 2016.

MATERIAL AND METHOD

We performed a retrospective analysis of prospective data collected over a two-year period following mini-gastric bypass between 1 March 2016 and 1 April 2021.

RESULTS

Altogether, 241/1611 (15 %) patients who underwent surgery at the Centre for Morbid Obesity in the five-year period received a mini-gastric bypass. A total of 147/241 (61 %) met the inclusion criteria and 125/147 (85 %) were included in the study. Average age was 47.4 years (standard deviation 10.7), and 81/125 (64.8 %) were women. Average weight was 134 (25) kg before and 90 (20) kg after surgery. Total average weight loss two years after surgery was 33.1 % (9.1). Before surgery and two years post-surgery, 20.0 % and 27.2 % had gastroesophageal reflux, 38.3 % and 8.8 % had type II diabetes and 84.8 % and 44.0 % had dyslipidaemia, respectively. Altogether, 12 % developed anaemia, 6.3 % iron deficiency and 23.1 % vitamin D deficiency. Early complications (< 30 days) were recorded in 6/125 (4.8 %) patients and late complications (> 30 days) in 7/125 (5.6 %) patients. The results were comparable to all the quality indicators in the Scandinavian Obesity Surgery Registry Norway.

INTERPRETATION

Mini-gastric bypass can be performed with few complications and with a beneficial effect on secondary comorbidity up to two years after surgery.

Bariatric surgery at Oslo University Hospital 2004–14

BACKGROUND

Bariatric surgery has been performed at Oslo University Hospital since 2004. We wished to describe patient characteristics, use of surgical methods and perioperative complications in the period 2004-14.

MATERIAL AND METHOD

We performed a retrospective analysis of prospective data collected for the period 2004-14. Complications include events during hospitalisation and up to 6-8 weeks postoperatively.

RESULTS

Altogether 2 127 patients underwent surgery for morbid obesity, whereof 1 468 were women. Average age and body mass index were 42 years (range 17-73) and 46.2 kg/m2 (range 26-92). A total of 512 had a body mass index ≥ 50 kg/m2. Obesity-related sequelae were registered in 1 196 patients before surgery. Gastric bypass was performed in 1 966 patients, gastric sleeve resection in 122 (17 of these later underwent duodenal switch) and duodenal switch in 56 patients. All patients were operated laparoscopically, and four procedures were converted to laparotomy. Median hospitalisation time was two days (range 1-78). Complications were registered in 209 patients, 75 of whom had severe complications (grade ≥ IIIb on the Clavien-Dindo classification system). Patients with a body mass index ≥ 50 kg/m2 had a higher incidence of complications (12.5 % vs 8.9 %). Altogether 67 patients underwent further surgery. Six patients died, two of whom more than 30 days after the operation. The incidence of complications was reduced during the period.

INTERPRETATION

Bariatric surgery may be performed laparoscopically with a low incidence of complications and short hospitalisation times. A large proportion of the patients who underwent surgery had obesity-related sequalae.

Incarcerated paraesophageal hernia complicated by pancreatic damage and unusual comorbidity: Two retrospective case series

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We present two cases of paraesophageal hernia that both needed total gastrectomy due to gangrene.

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Both patients had clinical relevant comorbidities, respectively trisomy 21 and hereditary spastic paresis.

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Due to compression from the dilated stomach one of the patients developed ischemia of the pancreas with leakage of peptidases which in turn caused anastomotic dehisence and intraabdominal abscess.

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The pancreatic damage and anastomotic leakage was treated conservatively with repeated stenting and percutaeous drainage.

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Immediate diagnosis and treatment for incarcerated paraesophageal hernias are vital to reduce morbidity and mortality.

Introduction: About 1% of paraesophageal hernias (PEH) require emergency surgery due to obstruction or gangrene. We present two complicated cases of incarcerated PEH.

Presentation of cases: A patient aged 18 with trisomy 21 was admitted after four days of vomiting and epigastric pain. CT scan revealed a large PEH. The stomach was massively dilated with compression of adjacent viscera and the celiac trunk. The stomach was repositioned laparoscopically and deflated by endoscopy in an attempt to avoid resection. During second look laparoscopy a gastrectomy was necessary. The patient was reoperated for intestinal obstruction, and treated for dehiscence of the esophagojejunostomy and a pancreatic fistula. A patient aged 65 with hereditary spastic paresis had two days history of emesis and epigastric pain. Upon arrival he was hemodynamically unstable and a CT scan revealed perforation of the herniated stomach. A subtotal gastrectomy without reconstruction was performed with vacuum closure of the abdomen. Later a gastrectomy was completed with a Roux-en-Y reconstruction. Except from reoperation for wound dehiscence after 14 days, the recovery was uneventful.

Discussion: Trisomy 21 and hereditary spastic paresis may increase the risk of developing PEH. Challenges in regard to symptom evaluation may delay diagnosis. The pressure of the dilated stomach can give rise to ischemic and mechanical damage from compression of major blood vessels and organs. Urgent diagnosis and gastric deflation is required.

Conclusions: In patients with known PEH or with comorbidity that may increase the risk of PEH, this diagnosis should be considered early on.

Relationships of serum 25-hydroxyvitamin D, ionized calcium and parathyroid hormone after obesity surgery

OBJECTIVE

The high prevalence of secondary hyperparathyroidism (SHPT) after obesity surgery is a concern for long-term bone health. Limited knowledge exists about optimal vitamin D and suppression of parathyroid hormone (PTH) after these procedures. The aim of this study was to investigate the prevalence of SHPT and its relation to vitamin D status.

DESIGN

A cross-sectional study at Oslo University Hospital, Norway.

PATIENTS

A total of 502 consecutive patients, age 22-64 years, attending 2-year follow-up after Roux-en-Y gastric bypass.

MEASUREMENTS

A serum intact PTH >7.0 pmol/L in the absence of elevated serum ionized calcium (iCa) was considered as SHPT. Vitamin D status was defined by serum concentrations of 25-hydroxyvitamin D (S-25(OH)D).

RESULTS

Altogether, 171 patients (34%) had SHPT. The prevalence of SHPT varied across the range of S-25(OH)D (P < 0.001), being highest (71%) with S-25(OH)D < 25 nmol/L. Compared with S-25(OH)D < 50 nmol/L, the prevalence of SHPT was lower with S-25(OH)D ≥ 50 nmol/L (29.0%; RR = 0.64 (95%-CI:0.50-0.81)) and S-25(OH)D ≥ 75 nmol/L (27.7%; RR = 0.61 (95%-CI:0.44-0.84)). S-25(OH)D ≥ 100 nmol/L was associated with the lowest PTH and the lowest prevalence of SHPT (16.0%; RR = 0.35 (95%-CI:0.14-0.88) compared with S-25(OH)D < 50 nmol/L) and the most normal calcium distribution. These associations were most pronounced with iCa in the lower range. A synergistic association was found for S-25(OH)D and iCa on SHPT.

CONCLUSIONS

Vitamin D deficient patients had the highest prevalence of SHPT 2 years after gastric bypass. PTH and the prevalence of SHPT were notably lower with S-25(OH)D ≥ 100 nmol/L, compared with lower target levels.

Application of the International Diabetes Federation and American Diabetes Association criteria in the assessment of metabolic control after bariatric surgery

The International Diabetes Federation (IDF) and the American Diabetes Association (ADA) have introduced specific criteria to define the 'optimization' of the metabolic state and glycaemic 'remission' of type 2 diabetes mellitus (T2DM) after bariatric surgery, respectively. Our objective was to assess the percentage of patients achieving these criteria. Data were collected for body mass index, glycaemic markers, lipids, blood pressure, hypoglycaemia and medication usage from 396 morbidly obese T2DM patients who underwent bariatric surgery in two centres and followed up for 2 years. At year 1, 14% of patients achieved the IDF criteria and 38% the ADA criteria, whereas at 2 years 8 and 9% satisfied these criteria, respectively. A relatively low proportion of patients achieved optimization of the metabolic state and T2DM remission. These patients may potentially benefit from the combination of bariatric surgery and adjuvant medical therapy to achieve optimal metabolic outcomes.

Moral challenges with surgical treatment of type 2 diabetes

AIM

To review the most important moral challenges following from the widespread use of bariatric surgery for type 2 diabetes for patients with BMI <35kg/m(2), although high quality evidence for its short and long term effectiveness and safety is limited.

METHODS

Extensive literature search to identify and analyze morally relevant issues. A question based method in ethics was applied to facilitate assessment and decision making.

RESULTS

Several important moral issues were identified: assessing and informing about safety, patient outcomes, and stakeholder interests; acquiring valid informed consent; defining and selecting outcome measures; stigmatization and discrimination of the patient group, as well as providing just distribution of health care. The main sources of these challenges are lack of high quality evidence, disagreement on clinical indications and endpoints, and the disciplining of human behavior by surgical interventions.

CONCLUSION

A lack of high quality evidence on the effect of bariatric surgery for the treatment of T2DM in patients with BMI<35/kg/m(2) poses a wide variety of moral challenges, which are important for decisions on the individual patient level, on the management level, and on the health policy making level. Strong preferences among surgeons and patients may hamper high quality research.

Effect of the definition of type II diabetes remission in the evaluation of bariatric surgery for metabolic disorders

BACKGROUND

The American Diabetes Association recently defined remission of type II diabetes as a return to normal measures of glucose metabolism (haemoglobin (Hb) A1c below 6 per cent, fasting glucose less than 5·6 mmol/l) at least 1 year after bariatric surgery without hypoglycaemic medication. A previously used common definition was: being off diabetes medication with normal fasting blood glucose level or HbA1c below 6 per cent. This study evaluated the proportion of patients achieving complete remission of type II diabetes following bariatric surgery according to these definitions.

METHODS

This was a retrospective review of data collected prospectively in three bariatric centres on patients undergoing gastric bypass, sleeve gastrectomy and gastric banding.

RESULTS

Some 1006 patients underwent surgery, of whom 209 had type II diabetes. Median follow-up was 23 (range 12-75) months. HbA1c was reduced after operation in all three surgical groups (P < 0·001). A total of 72 (34·4 per cent) of 209 patients had complete remission of diabetes, according to the new definition; the remission rates were 40·6 per cent (65 of 160) after gastric bypass, 26 per cent (5 of 19) after sleeve gastrectomy and 7 per cent (2 of 30) after gastric banding (P < 0·001 between groups). The remission rate for gastric bypass was significantly lower with the new definition than with the previously used definition (40·6 versus 57·5 per cent; P = 0·003).

CONCLUSION

Expectations of patients and clinicians may have to be adjusted as regards remission of type II diabetes after bariatric surgery. Focusing on improved glycaemic control rather than remission may better reflect the benefit of this type of surgery and facilitate improved glycaemic control after surgery.

Randomized clinical trial of laparoscopic gastric bypass versus laparoscopic duodenal switch for superobesity

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic biliopancreatic diversion with duodenal switch (LDS) are surgical options for superobesity. A randomized trial was conducted to evaluate perioperative (30-day) safety and 1-year results.

METHODS

Sixty patients with a body mass index (BMI) of 50-60 kg/m(2) were randomized to LRYGB or LDS. BMI, percentage of excess BMI lost, complications and readmissions were compared between groups.

RESULTS

Patient characteristics were similar in the two groups. Mean operating time was 91 min for LRYGB and 206 min for LDS (P < 0.001). One LDS was converted to open surgery. Early complications occurred in four patients undergoing LRYGB and seven having LDS (P = 0.327), with no deaths. Median stay was 2 days after LRYGB and 4 days after LDS (P < 0.001). Four and nine patients respectively had late complications (P = 0.121). Mean BMI at 1 year decreased from 54.8 to 38.5 kg/m(2) after LRYGB and from 55.2 to 32.5 kg/m(2) after LDS; percentage of excess BMI lost was greater after LDS (74.8 versus 54.4 per cent; P < 0.001).

CONCLUSION

LRYGB and LDS can be performed with comparable perioperative safety in superobese patients. LDS provides greater weight loss in the first year.

[Use of influenza vaccine in Norway]

Following the 1993/94 influenza season a questionnaire study was carried out to evaluate the use of influenza vaccine among at-risk groups. 275,000 doses of influenza vaccine were provided free of charge by the National Institute of Public Health to about 500 municipal health care units. 104 of 150 randomly selected units responded to our questionnaire. A majority correctly estimated the vaccine efficacy to be 70-80%, and 90% of the persons who were vaccinated belonged to the defined target groups. Two of three respondents were in favour of the government's support. Influenza among the target groups was mainly regarded as an individual problem, but considered to be a community issue for the general public. The strain on public health budgets for treatment of the old and infirm during influenza epidemics is obviously not fully appreciated.