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BackgroundRoux-en-Y gastric bypass (RYGB) has emerged as the most effective treatment in reversing insulin resistance in patients with type 2 diabetes mellitus (T2DM). A number of models and statistical tools have been proposed to predict patients likely to experience diabetes remission post-RYGB. The purpose of our study was to evaluate the preoperative accuracy of DiaRem score in predicting T2DM remission at 1 year of follow-up in a retrospective analysis of diabetic morbidly obese patients who underwent RYGB.MethodsOne hundred and forty-three patients underwent RYGB between January 2018 and December 2018. We conducted a retrospective analysis in 55 patients (38.46%) with T2DM with 1 year of follow-up. DiaRem score was calculated, and patients were stratified in five groups.ResultAt a 1-year follow-up, we found a higher proportion of patients with T2DM remission in the lower score group compared to a lower proportion of patients with remission in the higher score group. We derived a DiaRem cut-off score of 6.5 that had high sensitivity and specificity to predict T2DM remission preoperatively. We found a significant decrease in BMI and HbA1C values post-operatively at 1 year following RYGB.ConclusionDiaRem score is an easy to determine score based on basic clinical parameters that could identify patients with T2DM who would achieve maximal benefit in terms of remission after bariatric surgery. The development of a suitable scoring tool would be clinically useful as it would enable clinicians to better triage patients for RYGB.

BackgroundRevisional bariatric surgery (RBS) constitutes a possible solution for patients who experience an inadequate response following bariatric surgery or significant weight regain following an initial satisfactory response. This paper reports results from the first modified Delphi consensus-building exercise on RBS.MethodsWe created a committee of 22 recognised opinion-makers with a special interest in RBS. The committee invited 70 RBS experts from 27 countries to vote on 39 statements concerning RBS. An agreement amongst ≥ 70.0% experts was regarded as a consensus.ResultsSeventy experts from twenty-seven countries took part. There was a consensus that the decision for RBS should be individualised (100.0%) and multi-disciplinary (92.8%). Experts recommended a preoperative nutritional (95.7%) and psychological evaluation (85.7%), endoscopy (97.1%), and a contrast series (94.3%). Experts agreed that Roux-Y gastric bypass (RYGB) (94.3%), One anastomosis gastric bypass (OAGB) (82.8%), and single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) (71.4%) were acceptable RBS options after gastric banding (84.3%). OAGB (84.3%), bilio-pancreatic diversion/duodenal switch (BPD/DS) (81.4%), and SADI-S (88.5%) were agreed as consensus RBS options after sleeve gastrectomy. lengthening of bilio-pancreatic limb was the only consensus RBS option after RYGB (94.3%) and OAGB (72.8%).ConclusionExperts achieved consensus on a number of aspects of RBS. Though expert opinion can only be regarded as low-quality evidence, the findings of this exercise should help improve the outcomes of RBS while we develop robust evidence to inform future practice.

Background: Robotic cholecystectomy appears to be a natural evolution of the well-established gold standard procedure for gallstones, namely laparoscopic cholecystectomy. Akin to the early days of laparoscopy, robotic surgery is associated with a learning curve. We present our experiences in adapting to robotic surgery after the first 100 robotic cholecystectomies at a minimal access surgery tertiary care hospital. Material and Methods: The first consecutive 100 robotic cholecystectomies performed by a single surgeon on the Versius robotic surgical system (CMR Surgical, UK) were included in the study. Patients unwilling to give consent and complex pathologies such as gangrene, perforation and cholecystoenteric fistulas were excluded from the study. Operative time, robotic setup time, incidence and indication for conversion to manual (laparoscopic) procedure were recorded while subjective assessment of interruptions due to machine alarms and errors was made. All data were compared between the first 50 and last 50 procedures. Results: Our data revealed a gradual reduction in operative time from 28.53 min for the first 50 procedures to 22.06 min for the last 50 procedures. An improvement in draping and setup times was also noted, reducing from 7.74 to 5.14 min and 7.96 to 5.32 min, respectively. There were no conversions during the last 50 procedures, though the first 50 procedures resulted in 3 conversions to a laparoscopic procedure. In addition, we also noted a subjective reduction in the incidence of machine errors and alarms as we became more versed with the robotic system. Conclusion: Our single-centre experience indicates that newer modular robotic systems present a rapid and natural progression for experienced surgeons looking to venture into robotic surgery. The well-established advantages of robotic surgery in the form of enhanced ergonomics, three-dimensional vision and improved dexterity are validated as indispensable aids in a surgeon's armamentarium. Our initial experience reveals that robotic surgery for more common surgical procedures such as cholecystectomies will be rapidly accepted, safe and effective. There is a need to innovate and expand the range of instrumentation and energy devices available.

Laparoscopic adjustable gastric banding and laparoscopic sleeve gastrectomy are popular bariatric procedures. Certain complications may necessitate revision. Adverse outcomes are reported after revisional bariatric surgery. We compared patients undergoing revisional versus primary laparoscopic Roux-en-Y gastric bypass (LRYGB). This was retrospective comparative 1:1 case-matched analysis of revisional LRYGB Group A versus primary LRYGB (pLRYGB/Group B). Matching was based on body mass index (BMI) and comorbidities. BMI decrease at 6 and 12 months post-surgery, comorbidity resolution, operative time, morbidity and length of hospital stay (LOS) were compared. Total decrease in BMI, i.e., change from before initial bariatric procedure to 12 months after revision for Group A was also compared. Median BMI (inter-quartile range) for Group A decreased to 44.74 (7.09) and 41.49 (6.26) at 6 and 12 months, respectively, for Group B corresponding figures were 38.74 (6.9) and 33.79 (6.64) (P = 0.001 and P = 0.0001, respectively). Total decrease in BMI (Group A) was 9.8, whereas BMI decrease at 12 months for Group B was 15.2 (P = 0.23). Hypertension resolved in 63% (Group A), 70% (Group B) (P = 0.6). Diabetes resolution was 80% (Group A), 63% (Group B) (P = 0.8). Operative time for Groups A, B was 151 ± 17, 137 ± 11 min, respectively (P = 0.004). There was no difference in morbidity and LOS. Comorbidity resolution after revisional and pLRYGB are similar. Less weight loss is achieved after revision than after pLRYGB, but total weight loss is comparable. Revisional surgery is safe when performed by experienced surgeons in high-volume centres.

Associations of BMI with body composition and health outcomes may differ between Asian and European populations. Asian populations have also been shown to have an elevated risk of type 2 diabetes, hypertension, and hyperlipidemia at a relatively low level of BMI. New surgical indication for Asian patients should be discussed by the expert of this field. Forty-four bariatric experts in Asia-Pacific and other regions were chosen to have a voting privilege for IFSO-APC Consensus at the 2nd IFSO-APC Congress. A computerized audience-response voting system was used to analyze the agreement with the sentence of the consensus. Of all delegates, 95% agreed with the necessity of the establishment of IFSO-APC consensus statements, and 98% agreed with the necessity of a new indication for Asian patients. IFSO-APC Consensus statements 2011 Bariatric surgery should be considered for the treatment of obesity for acceptable Asian candidates with BMI ≥ 35 with or without co-morbidities Bariatric/GI metabolic surgery should be considered for the treatment of T2DM or metabolic syndrome for patients who are inadequately controlled by lifestyle alternations and medical treatment for acceptable Asian candidates with BMI ≥ 30 The surgical approach may be considered as a non-primary alternative to treat inadequately controlled T2DM, or metabolic syndrome, for suitable Asian candidates with BMI ≥ 27.5. Other eight sentences are agreed with by majority of the voting delegates to form IFSO-APC consensus statements. This will help to make safe and wholesome the progress of bariatric and metabolic surgery in Asia.

The effect of bariatric surgery on renal functions of patients with chronic kidney disease (CKD) is not well characterized. This prospective study included 13 adult patients having chronic kidney disease who underwent bariatric surgery. The primary objective was to examine the change in glomerular filtration rate (GFR) at 6 months post-bariatric surgery. Median GFR (measured by creatinine clearance) did not change significantly (55 ml/min vs 59 ml/min, p = 0.345) although there was a significant decrease in the protein excretion rate (1700 mg/day vs 900 mg/day, p = 0.001) at 6 months. An improvement in the KDIGO CKD risk category was seen in 30.7% patients. In CKD patients undergoing bariatric surgery, renal function improves over the first 6 months with a decrease in proteinuria and a stable GFR.

With increasing complexity of ventral incisional hernias being operated on, the treatment strategy has also evolved to obtain optimal results. Hybrid ventral hernia repair is a promising technique in management of complex/difficult ventral incisional hernias. The aim of this article is to review the literature and analyse the results of hybrid technique in management of ventral incisional hernia and determine its clinical status and ascertain its role. We reviewed the literature on hybrid technique for incisional ventral hernia repair on PubMed, Medline and Google Scholar database published between 2002 and 2019 and out of 218 articles screened, 10 studies were included in the review. Selection of articles was in accordance with the PRISMA guideline. Variables analysed were seroma, wound infection, chronic pain and recurrence. Qualitative analysis of the variables was carried out. In this systematic review, the incidence of complications associated within this procedure were seroma formation (5.47%), wound infections (6.53%) and chronic pain (4.49%). Recurrence was seen in 3.29% of patients. Hybrid ventral hernia repair represents a natural evolution in advancement of hernia repair. The judicious use of hybrid repair in selected patients combines the safety of open surgery with several advantages of the laparoscopic approach with favourable surgical outcomes in terms of recurrence, seroma and incidence of chronic pain. However, larger multi-centric prospective studies with long term follow up is required to standardise the technique and to establish it as a procedure of choice for this complex disease entity.

Introduction: Transversus abdominis plane (TAP) block is now a well-established technique in post-operative analgesia for lower abdominal surgeries. We evaluated the effect of ultrasound-guided TAP block on recovery parameters in patients undergoing endoscopic repair of abdominal wall hernia. Methods: Thirty adults were randomised to receive either ropivacaine with dexmedetomidine (TR) or saline (TP) in TAP block, before emergence from anaesthesia. The patients were assessed for pain relief, sedation, time to ambulate (TA), discharge readiness (DR), postoperative opioid requirement and any adverse events. Results: The median visual analogue scale pain score of the study group (TR) and the control group (TP) showed a significant difference at all time points. TA was 5.3 ± 0.5 (TR) versus 7.4 ± 0.8 (TP), P< 0.001 and DR was 7.5 ± 0.9 (TR) versus 8.9 ± 0.6 (TP), P< 0.001 in hours. No adverse events were observed in any group. Conclusion: This study demonstrates that TAP block is a feasible option for pain relief following endoscopic repair of abdominal wall hernias. It produces markedly improved pain scores and promotes early ambulation leading to greater patient satisfaction and earlier discharge.

Incomplete gallbladder removal following open and laparoscopic techniques leads to residual gallbladder stones. The commonest presentation is abdominal pain, dyspepsia and jaundice. We reviewed the literature to report diagnostic modalities, management options and outcomes in patients with residual gallbladder stones after cholecystectomy. Medline, Google and Cochrane library between 1993 and 2013 were reviewed using search terms residual gallstones, post-cholecystectomy syndrome, retained gallbladder stones, gallbladder remnant, cystic duct remnant and subtotal cholecystectomy. Bibliographical references from selected articles were also analyzed. The parameters that were assessed include demographics, time of detection, clinical presentation, mode of diagnosis, nature of intervention, site of stone, surgical findings, procedure performed, complete stone clearance, sequelae and follow-up. Out of 83 articles that were retrieved between 1993 and 2013, 22 met the inclusion criteria. In most series, primary diagnosis was established by ultrasound/computed tomography scan. Localization of calculi and delineation of biliary tract was performed using magnetic resonance imaging/magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography. In few series, diagnosis was established by endoscopic ultrasound, intraoperative cholangiogram and percutaneous transhepatic cholangiography. Laparoscopic surgery, endoscopic techniques and open surgery were the most common treatment modalities. The most common sites of residual gallstones were gallbladder remnant, cystic duct remnant and common bile duct. Residual gallbladder stones following incomplete gallbladder removal is an important sequelae after cholecystectomy. Completion cholecystectomy (open or laparoscopic) is the most common treatment modality reported in the literature for the management of residual gallbladder stones.

Background Suprapubic hernias are considered difficult to repair laparoscopically due to deficient posterior rectus sheath and proximity to important neurovascular structures and the urinary bladder. Methods We retrospectively reviewed 72 patients (18 males, 54 females) who, between 1998 and 2008, had undergone laparoscopic repair for suprapubic hernial defects located less than 5 cm from the pubic arch. Five patients (6.9%) had recurrent hernias. A peritoneal flap was dissected distally to facilitate a mesh overlap of at least 5 cm from the hernial defect. The lower margin of the mesh was fixed under direct vision to Cooper’s ligaments bilaterally. The raised peritoneal flap was reattached to the anterior abdominal wall thereby partially extraperitonealizing the mesh. Results Mean diameter of the hernial defect was 5.2 cm (range = 3.1–7.3 cm) as measured intraperitoneally. Mean size of the mesh used was 328.8 cm 2 (range = 225–506 cm 2 ). Mean operating time was 116 min (range = 64–170 min). Overall complication rate was 27.8%. There were no conversions. No recurrences were observed at a mean follow-up of 4.8 years (range = 1.2–6.9 years) and a follow-up rate of 84.7% Conclusion A mesh overlap of at least 5 cm and fixation of the lower margin of the mesh under direct vision to Cooper’s ligaments appears to confer increased strength and durability and contribute to low hernia recurrence rates in patients with suprapubic hernias.