A systematic review on laparoscopic subtotal cholecystectomy for difficult gallbladders: a lifesaving bailout or an incomplete operation?

INTRODUCTION

Laparoscopic subtotal cholecystectomy (LSTC) is a bailout procedure that is undertaken when it is not safe to proceed with a laparoscopic total cholecystectomy owing to dense adhesions in Calot's triangle. The main aim of this review was to investigate the early (≤30 days) and late (>30 days) morbidity and mortality of LSTC.

METHODS

A literature search of the PubMed® (MEDLINE®), Google Scholar™ and Embase® databases was conducted to identify all studies on LSTC published between 1985 and December 2020. A systematic review was then performed.

RESULTS

Overall, 45 studies involving 2,166 subtotal cholecystectomy patients (51% female) were identified for inclusion in the review. The mean patient age was 55 years (standard deviation: 15 years). Just over half (53%) of the patients had an elective procedure. The conversion rate was 6.2% (n=135). The most common indication was acute cholecystitis (49%). Different techniques were used, with the majority having a closed cystic duct/gallbladder stump (71%). The most common closure technique was intracorporeal suturing (53%), followed by endoloop closure (15%). Four patients (0.18%) died within thirty days of surgery. Morbidity within 30 days included bile duct injury (0.23%), bile leak (18%) and intra-abdominal collection (4%). Reoperation was reported in 23 patients (1.2%), most commonly for unresolving intra-abdominal collections and failed endoscopic retrograde cholangiopancreatography to control bile leak. Long-term follow-up was reported in 30 studies, the median follow-up duration being 22 months. Late morbidity included incisional hernias (6%), symptomatic gallstones (4%) and common bile duct stones (2%), with 2% of cases requiring completion of cholecystectomy.

CONCLUSIONS

LSTC is an acceptable alternative in patients with a "difficult" Calot's triangle.

An international survey of 1014 hernia surgeons: outcome of GLACIER (global practice of inguinal hernia repair) study

INTRODUCTION

The practice of inguinal hernia repair varies internationally. The global practice of inguinal hernia repair study (GLACIER) aimed to capture these variations in open, laparoscopic, and robotic inguinal hernia repair.

METHODS

A questionnaire-based survey was created on a web-based platform, and the link was shared on various social media platforms, personal e-mail network of authors, and e-mails to members of the endorsed organisations, which include British Hernia Society (BHS), The Upper Gastrointestinal Surgical Society (TUGSS), and Abdominal Core Health Quality Collaborative (ACHQC).

RESULTS

A total of 1014 surgeons from 81 countries completed the survey. Open and laparoscopic approaches were preferred by 43% and 47% of participants, respectively. Transabdominal pre-peritoneal repair (TAPP) was the favoured minimally invasive approach. Bilateral and recurrent hernia following previous open repair were the most common indications for a minimally invasive procedure. Ninety-eight percent of the surgeons preferred repair with a mesh, and synthetic monofilament lightweight mesh with large pores was the most common choice. Lichtenstein repair was the most favoured open mesh repair technique (90%), while Shouldice repair was the favoured non-mesh repair technique. The risk of chronic groin pain was quoted as 5% after open repair and 1% after minimally invasive repair. Only 10% of surgeons preferred to perform an open repair using local anaesthesia.

CONCLUSION

This survey identified similarities and variations in practice internationally and some discrepancies in inguinal hernia repair compared to best practice guidelines, such as low rates of repair using local anaesthesia and the use of lightweight mesh for minimally invasive repair. It also identifies several key areas for future research, such as incidence, risk factors, and management of chronic groin pain after hernia surgery and the clinical and cost-effectiveness of robotic hernia surgery.

Patient experiences of adjusting to life in the first 2 years after bariatric surgery: a qualitative study

There is currently little research into the experiences of those who have undergone bariatric surgery, or how surgery affects their lives and social interactions. Adopting a constructivist grounded theory methodological approach with a constant comparative analytical framework, semi-structured interviews were carried out with 18 participants (11 female, 7 male) who had undergone permanent bariatric surgical procedures 5-24 months prior to interview. Findings revealed that participants regarded social encounters after bariatric surgery as underpinned by risk. Their attitudes towards social situations guided their social interaction with others. Three profiles of attitudes towards risk were constructed: Risk Accepters, Risk Contenders and Risk Challengers. Profiles were based on participant-reported narratives of their experiences in the first two years after surgery. The social complexities which occurred as a consequence of bariatric surgery required adjustments to patients' lives. Participants reported that social aspects of bariatric surgery did not appear to be widely understood by those who have not undergone bariatric surgery. The three risk attitude profiles that emerged from our data offer an understanding of how patients adjust to life after surgery and can be used reflexively by healthcare professionals to support both patients pre- and post-operatively.

The relationship of distance from the surgical centre on attendance and weight loss after laparoscopic gastric bypass surgery in the United Kingdom

Obesity remains a significant worldwide health problem and is currently increasing. Surgery remains the only proven long-term intervention and has been shown to be cost-effective. Evidence suggests that regular follow-up following laparoscopic adjustable gastric banding is related to improved outcome, such evidence is lacking for laparoscopic gastric bypass surgery (laparoscopic Roux-en-Y gastric bypass [LRYGB]). This study examines the effect of distance on attendance at post-operative clinics and subsequent weight loss following surgery. A prospectively maintained database was interrogated to analyze patients undergoing LRYGB before August 2010. Patient demographics, percentage excess weight loss (%EWL), compliance with out-patient clinic attendances and the distance the patients lived from the hospital were examined. Perfect clinic attendees were compared with non-attendees and the distances patients lived from the hospital evaluated. There was a significantly greater %EWL at 1 year post-op observed in the perfect attendees group (65.5 vs. 59.5, P = 0.01). Increased %EWL was also evident at 2 years post-op but did not reach statistical significance (66.9 vs. 59.5, P = 0.06). There was a negative correlation observed between post-operative weight loss and distance from the bariatric centre (R = -0.21, P = 0.04). Close follow-up following LRYGB is essential to optimize outcomes. Increased frequency of out-patient clinic visits was associated with improved post-operative weight loss. Increasing distance between the patient's home and the bariatric centre was associated with worse post-operative weight loss.

Laparoscopic adjustable gastric band survival in a high-volume bariatric unit

Background

Although laparoscopic adjustable gastric bands (LAGBs) have been shown to be efficacious, their long-term usefulness has been questioned. This study examined the fate of LAGBs in a unit with over a decade of experience in their use. Patient factors related to the need for, and timing of, band removal were investigated.

Methods

A prospectively maintained database was used to identify all patients with a LAGB. Patient demographics, need for band removal and band survival were examined. Logistic regression modelling was done and Kaplan–Meier curves were calculated for band survival.

Results

Between 2000 and 2012, 674 bands were placed in 665 patients. Of these, 143 (21·2 per cent) were removed. There was no difference in rates of removal by sex (P = 0·910). The highest rates of removal were in patients aged less than 40 years (26·7 per cent), and those with a BMI greater than 60 kg/m2 (28·6 per cent). Earlier band removal was seen in younger patients (P = 0·002). Rates of removal increased linearly by earlier year of placement. Of bands placed 4 or more years previously, 35·0 per cent required removal. Eighty-three patients (58·0 per cent) who had a LAGB removed went on to have a further bariatric procedure (band to bypass, 66; band to sleeve, 17).

Conclusion

Even in experienced hands LAGB does not appear to be a definitive solution. In a large number of patients there appears to be a finite ‘band life’, with the majority of patients requiring conversion to a further bariatric procedure.

Presented in part to a meeting of the British Obesity and Metabolic Surgery Society, Glasgow, UK, January 2013, as an oral presentation for which it was awarded the council prize; published in abstract form as Br J Surg 2013; 100(Suppl 3): 2

Laparoscopic adjustable gastric banding: a 10-year single-centre experience of 575 cases with weight loss following surgery

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) is one of the commonest bariatric procedures in the UK. This study reports our experience with this procedure over the last 10 years.

METHODS

A prospectively maintained database of all the patients undergoing LAGB at our centre between March 2000 and August 2010 was analysed.

RESULTS

Five hundred seventy-five patients underwent LAGB at our centre. There was no mortality in this series. Early (30-day) morbidity rate was 2.2 %. Late complications (20 %) comprised: 78 repositioning of the inflation port in 65 patients, repositioning of band in 24 patients (4 %), removal of band in 20 patients (3.4 %), conversion to bypass in 41 patients (7 %), diagnostic laparoscopy in 1 patient and subtotal gastrectomy in 1 patient. Median follow-up was 29 months. The median of percentage of weight loss (%WL) and excess body weight loss (EBWL) was 18.3 and 40 %, respectively, at ≥ 5 years post-LAGB. Patients with body mass index (BMI) over 50 kg/m(2) were compared to those with BMI ≤ 50 kg/m(2). No significant difference was noted in the weight loss between both of these groups. No significant difference was noted with regards to weight loss between patients <60 and >60 years of age.

CONCLUSIONS

In this cohort of patients, %WL and EBWL were 18.3 and 40 % ≥ 5 years after LAGB, respectively, and early and late complication rates were 2.2 and 20 %, respectively. Majority of late complications were in the first 100 patients. Multifactorial causes included the surgical learning curve and patient selection process.

Routine group and save unnecessary for gastric band surgery: a retrospective case review audit of 1018 bariatric patients

What is already known about this subject •  The demand for bariatric surgery is increasing. •  NHS Trusts are expected to instigate cost-efficiency measures. •  Previous articles have discussed the need for routine preoperative cross-match. What this study adds •  No gastric band patient suffered a significant drop in haemoglobin or needed a blood transfusion. •  Group and save samples could be safely stored in the laboratory and only sent for analysis if clinically indicated. •  Even greater cost savings could be achieved if prudent use of perioperative blood testing and blood transfusion was implemented.

SUMMARY

Current guidance at our Trust is that all bariatric surgical patients should have preoperative group and save (G&S) and full blood count (FBC) tests, as well as a FBC check 1 d post-operatively. Our aim was to investigate blood transfusion requirements of these patients and whether we could reduce the number of investigations requested. 1018 consecutive elective laparoscopic gastric band and laparoscopic Roux-en-Y gastric bypass patients who were operated on in our bariatric unit from March 2000 until January 2011 were identified. Patients' haemoglobin levels, G&S status and blood transfusion requirements were analyzed using our online pathology system. 607 patients had a laparoscopic gastric band, with 411 undergoing a laparoscopic Roux-en-Y gastric bypass. None of our gastric band patients required a transfusion; however, nine patients (2.2%) undergoing a gastric bypass needed a transfusion. Two patients required transfusion within 24 h of surgery while six of the remaining seven patients received blood 3-4 d post-operatively. Costs incurred on FBC and G&S tests during this time were estimated to exceed £15 700. G&S and post-operative FBC tests could be abandoned for laparoscopic gastric band patients with significant financial and person-time savings. However, given that 2.2% of laparoscopic Roux-en-Y gastric bypass patients needed a blood transfusion, we believe that post-operative FBC tests are still warranted in this patient group, with a G&S sample stored in pathology. Much greater financial savings could be achieved if prudent use of preoperative investigations, including storing G&S samples in the laboratory, was adopted for all elective operations.

Iatrogenic femoropopliteal graft entrapment leading to thrombus formation

Femoropopliteal bypass graft entrapment by the gastrocnemius muscle and tendons is an unusual cause of graft stenosis or thrombosis. Before graft occlusion occurs, reduced flow may be seen either with the knee in extension or hyperextension or by passive dorsiflexion of the ankle. We report a case of a femoropopliteal bypass graft entrapment causing a thrombus in the distal graft. Duplex imaging, angiography, MRI and graft surveillance programs are useful diagnostic tools. Treatment options include dividing the occluding muscles and tendons and rerouting the graft.

Successful live related renal transplant in a case of tuberous sclerosis

Tuberous sclerosis (TS) is an autosomal dominant multisystemic disease involving primarily the skin, the brain and the kidneys. Inspite of the kidney being involved in 40-80% of patients with this disease, the incidence of end stage renal disease is only about 1%. There are only 34 reported cases of successful renal transplantation in tuberous sclerosis patients with end stage renal disease. We report a case of successful renal transplantation in a patient of tuberous sclerosis with bilateral polycystic kidneys presenting with renal failure who also underwent bilateral native nephrectomies on follow up.