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Roux-en-Y gastric bypass and sleeve gastrectomy are two of the most common bariatric procedures performed in 2011. Although the complication rates associated with these procedures are low, the consequences of these complications are significant and can be associated with high morbidity and mortality. Timely diagnosis and proper management of these complications are extremely important. The most commonly used radiologic studies in bariatric surgery are the upper GI contrast study and the CT scan, which are used to rule out leak, obstruction, perforation, anastomotic stricture, or pouch dilatation. As with all imaging studies, a negative result should not override strong clinical suspicion of a complication. [ABSTRACT FROM AUTHOR]

Background: The peer review process is the gold standard by which academic manuscripts are vetted for publication. However, some investigators have raised concerns regarding its unopposed supremacy, including lack of expediency, susceptibility to editorial bias and statistical limitation due to the small number of reviewers used. Post-publication review-in which the article is assessed by the general readership of the journal instead of a small group of appointed reviewers-could potentially supplement or replace the peer-review process. In this study, we created a computer model to compare the traditional peer-review process to that of post-publication reader review. Methods: We created a mathematical model of the manuscript review process. A hypothetical manuscript was randomly assigned a 'true value' representing its intrinsic quality. We modeled a group of three expert peer reviewers and compared it to modeled groups of 10, 20, 50, or 100 reader-reviewers. Reader-reviewers were assumed to be less skillful at reviewing and were thus modeled to be only ¼ as accurate as expert reviewers. Percentage of correct assessments was calculated for each group. Results: 400,000 hypothetical manuscripts were modeled. The accuracy of the reader-reviewer group was inferior to the expert reviewer group in the 10-reviewer trial (93.24% correct vs. 97.67%, p < 0.0001) and the 20-reviewer trial (95.50% correct, p < 0.0001). However, the reader-reviewer group surpassed the expert reviewer group in accuracy when 50 or 100 reader-reviewers were used (97.92 and 99.20% respectively, p < 0.0001). Conclusions: In a mathematical model of the peer review process, the accuracy of public reader-reviewers can surpass that of a small group of expert reviewers if the group of public reviewers is of sufficient size. Further study will be required to determine whether the mathematical assumptions of this model are valid in actual use. [ABSTRACT FROM AUTHOR]

Background: This study aimed to compare the rates for resolution and improvement of common comorbidities between laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding. The comorbid conditions included were type 2 diabetes mellitus (DM), hypertension (HTN), hyperlipidemias (LPD), degenerative joint disease (DJD), gastroesophageal reflux disease (GERD), obstructive sleep apnea (OSA), and asthma. Methods: A retrospective chart review of the patients who underwent LSG or laparoscopic adjustable gastric banding at our institution from July 2004 to July 2007 was performed. The resolution of comorbidities was determined via patient-completed questionnaires and objective data. Results: Of the 123 patients (29 men and 94 women) reviewed, 49 had undergone LSG, and 74 had undergone laparoscopic adjustable gastric banding. The mean preoperative body mass index (BMI) was 52 kg/m for the LSG patients and 44 kg/m for the laparoscopic adjustable gastric banding patients. The overall percentages of excess weight loss (%EWL) were respectively 50.6 and 40.3% ( P = 0.03) during mean follow-up periods of 15 and 17 months. There was a greater resolution or improvement of DM after LSG (100% vs 46%), HTN (78% vs 48%), and LPD (87% vs. 50%) than after laparoscopic adjustable gastric banding. Other comorbidities resolved or improved at a similar rate. Conclusions: Although both LSG and laparoscopic adjustable gastric banding resulted in postoperative improvement or resolution of comorbidities associated with obesity, LSG statistically showed a significantly higher rate of resolution or improvement of DM, HTN, and LPD. There was no significant difference between the groups for DJD, GERD, OSA, or asthma. [ABSTRACT FROM AUTHOR]

Gastrojejunal anastomotic stricture is the most commonly occurring short-term complication after Roux-en-Y gastric bypass. Endoscopic balloon dilation is the first-line treatment for stricture. However, an optimal dilation protocol has not been identified. This study aimed to document routine management of stricture after laparoscopic gastric bypass and its impact on postoperative weight loss. Charts of patients who underwent gastric bypass from 2000 to 2006 were reviewed using a standardized abstraction form. Patients with stricture were matched with control subjects based on age ±5 years, gender, and preoperative body mass index (BMI ± 5). Patients with at least 6 months of follow-up assessment were included in the study. Of the 113 patients included in the study, 20% were male, 26% black, 19% Hispanic, and 51% white. Their mean age was 42 ± 10 years (range, 22–66 years). The mean preoperative BMI was 47.0 ± 5.4 kg/m2 for the case group and 46.6 ± 5.5 kg/m2 for the control group ( p = 0.3). After adjustment for patient characteristics, using a larger balloon was associated with reduced odds of stricture recurrence (odds ratio [OR], 0.32; 95% confidence interval [CI], 0.12–0.85; p = 0.02). All the patients were without signs or symptoms of stricture at the last follow-up visit (20 ± 17 months). Weight loss was similar between the two groups. The percentage of estimated weight loss (%EWL) at 12 months postoperatively was 66% for the study participants and 67% for the control subjects ( p = 0.5). Baseline alcohol use and higher preoperative BMI were associated with a higher BMI 6 months postoperatively ( p = 0.004 and p < 0.001, respectively). Initial dilation with a larger balloon is safe and may prevent stricture recurrence. Further study of modifiable risk factors for reduced weight loss after surgery, such as alcohol use, may improve patient outcomes. [ABSTRACT FROM AUTHOR]

Weight regain after Roux-en-Y gastric bypass may be caused by pouch enlargement or dilatation of the gastrojejunostomy (stoma). In order to avoid the substantial morbidity of revisional bariatric surgery, investigators have recently demonstrated the feasibility of reducing stoma diameter using transoral endoscopic suturing techniques. Our aim was to demonstrate the feasibility of performing both pouch and stomal reduction using transoral endoscopically placed tissue anchors in an ex vivo and acute animate model. Part I: We created an ex vivo model of a dilated gastric pouch and stoma using four explanted porcine stomachs. The stomach was divided to create an upper pouch of approx. 100 ml volume, which was reconnected to the lower portion of the stomach (gastric remnant) via an anastomosis of 18 to 20 mm diameter. Endoscopically placed anchors were then used to create plications of the stoma and reduce its diameter. In two stomachs, anchor plications were also used to decrease pouch volume. Pouch volumes and stoma diameters were measured pre- and post-procedure. Part II: A similar experimental model was created in vivo using three pigs. Anchors were placed in the stoma and pouch. The animals were immediately sacrificed and similar measurements were obtained. In the ex vivo model, stoma diameter was successfully reduced in all four stomachs by a mean of 8 mm (41%). This represented a mean decrease in cross-sectional area of 65%. Pouch volume was reduced by a mean of 28 ml (30%) in two stomachs. Stomal plications were successfully placed in two of the live animals, with a mean stoma diameter reduction of 11.5 mm (53%). Feasibility of pouch reduction using plicating anchors was confirmed. This is the first study to demonstrate the feasibility of using endoscopically placed tissue anchors to reduce both stoma diameter and pouch volume. This technique may ultimately be clinically useful in treating weight regain after gastric bypass surgery. [ABSTRACT FROM AUTHOR]

Abstract: Background: Similar to gastric bypass patients, a regimen of ursodeoxycholic acid in the immediate postoperative period might obviate the need for routine cholecystectomy. Routine cholecystectomy has been recommended for patients who undergo biliopancreatic diversion (BPD), because of the high prevalence of gallstones in the obese patient and presumed development of gallstones postoperatively. We have considered elective cholecystectomy only if gallbladder disease were present. The aim of this study was to assess the need for cholecystectomy in the postoperative period in such patients. Methods: In this retrospective study, the data from 219 patients who had undergone BPD with duodenal switch (BPD/DS), from January 1999 to January 2003, were analyzed. We performed a 150-cm alimentary limb and 100-cm common channel BPD/DS. The patients received 600 mg ursodeoxycholic acid orally daily for 6 months. The following data were recorded: demographics, medical history, medication, weight loss, diagnostic evaluation, and operative and pathologic data. Results: Of the 219 patients who underwent surgery, 59 were men (26.9%) and 160 women were (73.1%) (mean age 41.7 years, mean body mass index 55.7 kg/m2). The mean follow-up was 30 months (range 12–48). Of the 219 patients, 57 (19.6%) underwent cholecystectomy: 28 (12.7%) preoperatively, 10 (4.5%) simultaneously, and 19 (8.7%) postoperatively. Simultaneous cholecystectomy was performed when the patient had a history of colic episodes with gallbladder disease (disclosed by preoperative ultrasonography). The postoperative cholecystectomy pathology reports showed cholecystitis in only 7 patients. Conclusion: The results of our study have shown that the incidence of postoperative cholecystectomy in BPD/DS patients is low, and cholecystitis is rare. Routine cholecystectomy in BPD/DS patients is no longer recommended. [Copyright &y& Elsevier]

Background: Several large series of laparoscopic donor nephrectomy (LDN) have been published, largely focusing on immediate results and short-term complications. The aim of this study was to examine the results of LDN and collect medium-term and long-term donor followup.Methods: We examined the results of two surgeons who performed 500 consecutive LDNs from 1996 to 2005. Prospective databases were reviewed for both donors and recipients to record demographics, medical history, intraoperative events, and complications. Patients were followed between 1 month and 9 years after surgery to assess for delayed complications, especially hypertension, renal insufficiency, incisional hernia, bowel obstruction, and chronic pain.Results: Left kidneys were procured in 86.2% of cases. Mean operative time was 3.5 h, and warm ischemia time averaged 3.4 min. Hand-assistance was used in 13.8%, and conversion rate was 1.8%. Intraoperative complication rate was 5.8% and was predominantly bleeding (93.1%). Most (86.2%) of the operative complications occurred during the initial 150 cases of a surgeon, compared with 10.3% in the subsequent 150 cases (p = 0.003). Operative time decreased by 87 min after the initial 150 cases (p < 0.001). Immediate graft survival was 97.5%. Delayed graft function occurred in 3.0% of recipients, and acute tubular necrosis occurred in 7.0%. Thirty-day donor complication rate was 9.8%. Mean donor creatinine was 1.24 on the first postoperative day, 1.27 at 2 weeks, and 1.24 at 1 year. At a mean followup of 32.8 months, long-term donor complications consisted of 11 cases of hypertension, 9 cases of prolonged pain or paresthesia, 2 incisional hernias, 1 small bowel obstruction requiring laparoscopic lysis of adhesions, and 1 hydrocele requiring repair.Conclusions: LDN can be performed with acceptable immediate morbidity and excellent graft function. Operative time and complications decreased significantly after a surgeon performed 150 cases. Long-term complications were uncommon but included a likely underestimated incidence of hypertension. [ABSTRACT FROM AUTHOR]

Several large series of laparoscopic donor nephrectomy (LDN) have been published, largely focusing on immediate results and short-term complications. The aim of this study was to examine the results of LDN and collect medium-term and long-term donor followup. We examined the results of two surgeons who performed 500 consecutive LDNs from 1996 to 2005. Prospective databases were reviewed for both donors and recipients to record demographics, medical history, intraoperative events, and complications. Patients were followed between 1 month and 9 years after surgery to assess for delayed complications, especially hypertension, renal insufficiency, incisional hernia, bowel obstruction, and chronic pain. Left kidneys were procured in 86.2% of cases. Mean operative time was 3.5 h, and warm ischemia time averaged 3.4 min. Hand-assistance was used in 13.8%, and conversion rate was 1.8%. Intraoperative complication rate was 5.8% and was predominantly bleeding (93.1%). Most (86.2%) of the operative complications occurred during the initial 150 cases of a surgeon, compared with 10.3% in the subsequent 150 cases ( p = 0.003). Operative time decreased by 87 min after the initial 150 cases ( p < 0.001). Immediate graft survival was 97.5%. Delayed graft function occurred in 3.0% of recipients, and acute tubular necrosis occurred in 7.0%. Thirty-day donor complication rate was 9.8%. Mean donor creatinine was 1.24 on the first postoperative day, 1.27 at 2 weeks, and 1.24 at 1 year. At a mean followup of 32.8 months, long-term donor complications consisted of 11 cases of hypertension, 9 cases of prolonged pain or paresthesia, 2 incisional hernias, 1 small bowel obstruction requiring laparoscopic lysis of adhesions, and 1 hydrocele requiring repair. LDN can be performed with acceptable immediate morbidity and excellent graft function. Operative time and complications decreased significantly after a surgeon performed 150 cases. Long-term complications were uncommon but included a likely underestimated incidence of hypertension. [ABSTRACT FROM AUTHOR]

Abstract: Background: Previous reports have questioned the safety of bariatric surgery in older patients. The aim of this study was to quantify the perioperative morbidity and mortality of older patients undergoing laparoscopic bariatric procedures at our institution. Methods: A retrospective chart review of all laparoscopic bariatric procedures performed from February 1999 to September 2005 was performed to identify patients at Mount Sinai Medical Center who were older than 60 years at surgery. Results: We identified 55 patients (36 women and 19 men). The mean age was 61.5 years (range 60–70), and the mean body mass index was 46.2 kg/m2 (range 38.1–61.0). Of the 55 patients, 33 (60%) had undergone laparoscopic Roux-en-Y gastric bypass, 9 (16%) laparoscopic gastric banding, 7 (13%) laparoscopic biliopancreatic diversion with duodenal switch, 3 (5.5%) laparoscopic revisional surgery, and 3 (5.5%) laparoscopic sleeve gastrectomy. The mean operative time was 2.3 hours (range 1.1–5.5). No patients required conversion to open surgery, and no perioperative mortality occurred within 30 days. The morbidity rate was 7.3% (n = 4). One patient developed an anastomotic bleed that was treated conservatively, and another patient developed an empyema that was successfully drained with a chest tube. That patient also developed a urinary tract infection, and another patient had a wound infection. The mean length of stay was 2.8 days (range 1–14). Conclusions: In a carefully selected patient population in a medical center with appropriate experience, laparoscopic bariatric surgery can be performed safely with low morbidity and mortality in the elderly population. [Copyright &y& Elsevier]

Deficiencies in vitamins and other nutrients are common following the Roux-en-Y gastric bypass (RYGBP), biliopancreatic diversion (BPD) and biliopancreatic diversion with duodenal switch (BPDDS), and may become clinically significant if not recognized and treated with supplementation. This paper presents a review of the current literature and evidence of the most commonly deficient vitamins and minerals following weight loss surgery, including protein, iron, vitamin B12, folate, calcium, the fat-soluble vitamins (A, D, E, K), and other micronutrients. The deficiencies appear to be more substantial following malabsorptive procedures such as BPD, but occur with restrictive procedures as well. The review suggests that further studies are needed to evaluate the clinical significance of the nutritional deficiencies, and to determine guidelines for supplementation. [ABSTRACT FROM AUTHOR]

The prevalence of obesity in the United States is increasing to epidemic proportions. At present, more than 60% of Americans are overweight. While a variety of medications are available for the treatment of obesity, none results in the long-term loss of more than 10% of body weight. The current standard for the treatment of severe obesity, defined as a body mass index of greater than 35-40 kg/m², is surgical. Several surgical procedures are currently available, including gastric bypass, biliopancreatic diversion with duodenal switch, and the adjustable gastric band. These operations may be performed using laparoscopic surgical techniques to minimize perioperative morbidity and postoperative recovery time. To optimize the outcome of this type of procedure, bariatric surgery should be performed on carefully selected patients, in centers specially equipped to care for the obese, within a broadly based, multidisciplinary setting providing lifelong postoperative care. [ABSTRACT FROM AUTHOR]

Biliopancreatic diversion with duodenal switch (BPD-DS) is a well-known emerging open procedure that appears to be as effective as other bariatric operations and has been shown to provide excellent long-term weight loss. Therefore we looked at the safety and efficacy of the laparoscopic BPD-DS procedure compared to open BPD-DS in superobese patients (body mass index >60). A retrospective study of 54 superobese patients (body mass index >60) was carried out from July 1999 to June 2001: laparoscopic BPD-DS in 26 patients and open BPD-DS in 28 patients. Median preoperative body weight was 189.8 kg (range 155.1 to 271.2 kg) in the laparoscopic BPD-DS group and 196.5 kg (range 160.3 to 298.9 kg) in the open BPD-DS group. Median body mass index was 66.9 kg/m2 in the laparoscopic group and 68.9 kg/m2 in the open group. The two groups were compared by means of the unpaired t test, which yielded the following results: Major morbidity occurred in six patients (23%) in the laparoscopic BPD-DS group and in five patients (17%) in the open BPD-DS group (P = 0.63). There were two deaths in the laparoscopic BPD-DS group (7.6% mortality) and one death (3.5% mortality) in the open BPD-DS group (P = 0.51). Preoperative comorbidity was improved in eight patients in the laparoscopic BPD-DS group and two patients in the open BPD-DS group (P < 0.02). Laparoscopic BPD-DS is a technically feasible procedure that results in effective weight loss similar to the open procedure. However, both open and laparoscopic BPD-DS procedures are associated with appreciable morbidity and mortality in the superobese population. Additional studies are needed to determine the best surgical treatment for superobesity. (J Gastrointest Surg 2003;7:552–557.) [Copyright &y& Elsevier]

Background: 10 to 25% of patients undergoing bariatric surgery will require a revision, either for unsatisfactory weight loss or for complications. Reoperation is associated with a higher morbidity and has traditionally been done in open fashion.The purpose of this study was to determine the safety and efficacy of reoperative surgery using a laparoscopic approach. Methods: A retrospective review of medical records over a 22-month period was conducted. 27 consecutive obesity surgery patients, who had undergone a laparoscopic revision, were identified. 26 of the 27 patients were women. The average age was 40.3 years (range 20 to 58 years) and average original preoperative body mass index (BMI) was 51.6 kg/m2 (range 42 to 66.5).The 27 primary bariatric operations consisted of vertical banded gastroplasty (12), gastric band placement (9) and gastric bypass (6). 17 of them were open procedures. After the primary surgery, the lowest average BMI was 37.6 kg/m2 (range 21 to 52), which increased to 42.7 kg/m2 (range 29 to 56) before reoperation. 24 of the 27 reoperations were indicated for insufficient weight loss. On average, revision was undertaken 52 months after the primary procedure (range 12 to 240 months). Results: 24 of the 27 laparoscopic reoperations were conversions to a gastric bypass. A second reoperation was indicated for insufficient weight loss on four occasions. In one case, conversion to open surgery was required. The average operative time was 232 ± 18.5 minutes (range 120 to 480) and length of hospital stay was 3.7 days (range 1 to 9). 22% percent of patients (6) experienced complications, including pneumothorax, gastric remnant dilation, gastrojejunostomy stenosis, port-site hernia and protein malnutrition. There was no mortality in the study.The average BMI was 35.9 kg/m2 (range 27 to 45.5) 8 months after surgery (range 1 to 22 months). Compared with a preoperative BMI of 42.7 kg/m2, the weight loss was statistically significant (p<0.001). Conclusion: Our results compare favorably with those reported for open reoperative bariatric surgery. A laparoscopic approach may be considered a feasible and safe alternative to an open operation. [ABSTRACT FROM AUTHOR]

The article in Clinical & Translational Discovery identifies a rare population of metallothionein-expressing macrophages present in all vital human organs. Using single-cell RNA sequencing data, the study characterizes these macrophages in the liver, kidney, and lung, highlighting their gene expression patterns and potential functional roles. Immunohistochemistry techniques confirm the presence of these macrophages in human liver tissue, suggesting a role in neoangiogenesis. The research sets the stage for further studies on the functional role of these macrophages in tissue homeostasis and remodeling. [Extracted from the article]

Recently we have shown that laparoscopic Toupet fundoplication is associated with a high degree of late failure when employed as a primary treatment for gastroesophageal reflux disease (GERD). This study defines preoperative risk factors that predispose patients to failure. Data from 48 patients with objective follow-up performed as part of a prospective long-term outcomes project (24-hour pH monitoring, manometry, and esophagogastroduodenoscopy [EGD] at 6 months, 3 years, and 6 years) was analyzed. Preoperative studies of patients with documented postoperative failure (n = 22), defined as an abnormal 24-hour pH study (DeMeester score >14.9), were compared to preoperative studies of patients with normal 24-hour pH studies (n = 26). Outcomes were assessed at a mean of 22 months (range 18 to 37 months) postoperatively. Of the 22 patients in the failure group, 16 (77%) were symptomatic and the majority (64%) had resumed proton pump inhibitor therapy. Preoperative indices of severe reflux were significantly more prevalent in the failure group including a very low or absent lower esophageal sphincter (LES) pressure on manometry, biopsy-proved Barrett’s metaplasia, presence of a stricture, grade III or greater esophagitis, and a DeMeester score greater than 50 with ambulatory 24-hour pH testing. Comparison of pre- and postoperative manometric analysis of the LES revealed adequate augmentation of the LES in both groups and there were no wrap disruptions documented by postoperative EGD or manometry, indicating that reflux was most likely occurring through an intact wrap in the failure group. Esophageal dysmotility was present before surgery in four of the nonrefluxing patients and in three of the failures. Intact wraps were noted to have herniated in eight patients, all of whom had postoperative reflux. Laparoscopic Toupet fundoplication is associated with a high rate of failure both clinically and by objective testing. Surgery is more likely to fail in patients with severe GERD than in patients with uncomplicated or mild disease. A preoperative DeMeester score greater than 50 was 86% sensitive for predicting failure in our patient population. Laparoscopic Toupet fundoplication should not be used as a standard antireflux procedure particularly in patients with severe or complicated reflux disease. [ABSTRACT FROM AUTHOR]

Hollow fibre membrane contactor (HFMC) technology has been developed for CO2 absorption primarily using synthetic gas, which neglects the critical impact that trace contaminants might have on separation efficiency and robustness in industrial gases. This study, therefore, commissioned a demonstration-scale HFMC for CO2 separation at a full-scale anaerobic digester facility to evaluate membrane integrity over six months of operation on real biogas. The CO2 capture efficiency identified using real biogas was benchmarked at comparable conditions on synthetic gas of an equivalent partial pressure, and an equivalent performance identified. Two HFMC were subsequently compared, one with and one without a pre-treatment stage that targeted particulates, volatile organic compounds (VOCs) and humidity. Similar CO2 separation efficiency was again demonstrated, indicating limited impact within the timescale evaluated. However, gas phase pre-treatment is advised in order to ensure robustness in the long term. Over longer-term operation, a decline in CO2 separation efficiency was observed. Membrane autopsy identified shell-side deposition, where the structural morphology and confirmation of amide I and II groups, indicated biofouling. Separation efficiency was reinstated via chemical cleaning, which demonstrated that proactive maintenance could minimise process risk. [ABSTRACT FROM AUTHOR]

Research and innovation in biomedicine and health care increasingly depend on electronic data. The emergence of data-driven technologies and associated digital transformations has focused attention on the value of such data. Despite the broad consensus of the value of health data, there is less consensus on the basis for that value; thus, the nature and extent of health data value remain unclear. Much of the existing literature presupposes that the value of data is to be understood primarily in financial terms, and assumes that a single financial value can be assigned. We here argue that the value of a dataset is instead relational; that is, the value depends on who wants to use it and for what purposes. Moreover, data are valued for both nonfinancial and financial reasons. Thus, it may be more accurate to discuss the values (plural) of a dataset rather than the singular value. This plurality of values opens up an important set of questions about how health data should be valued for the purposes of public policy. We argue that public value models provide a useful approach in this regard. According to public value theory, public value is created, or captured, to the extent that public sector institutions further their democratically established goals, and their impact on improving the lives of citizens. This article outlines how adopting such an approach might be operationalized within existing health care systems such as the English National Health Service, with particular focus on actionable conclusions. [ABSTRACT FROM AUTHOR]

Background: The National Health Service (NHS) has pledged to reach carbon net-zero by 2040. In alignment with this goal, a London hospital's anaesthesia department is actively reducing desflurane use and transitioning towards total intravenous anaesthesia (TIVA) as a sustainable alternative, contributing to environmentally responsible practices within the healthcare sector. Methods: We conducted a rapid qualitative appraisal through online interviews with 17 anaesthetic practitioners to explore their perspectives regarding this climate change mitigation strategy. Data analysis was undertaken through the use of rapid appraisal sheets and a framework analysis method. Results: Participants highlighted the disadvantages of TIVA, including the increased effort, heightened monitoring requirements, operational challenges, and a lack of clinical confidence associated with its use. Despite these reservations, participants acknowledged TIVA's potential to reduce postoperative nausea. There were perceptions that senior staff members might resist this change due to habits and scepticism over its impact on climate change. To facilitate greater TIVA adoption, participants recommended enhanced training, the implementation of a dashboard to raise awareness of greenhouse gas (GHG) emissions, and the presence of strong climate change leadership within the department. Participants believed that a shift to TIVA should be followed by specific measures such as addressing waste management which is crucial for GHG reduction, emphasising the perceived link between waste and emissions. Conclusions: The evaluation examines stakeholder attitudes, perceptions, and behaviours, focusing on transitioning from desflurane to TIVA. The study highlights the importance of staff engagement, organisational support, and underscores the crucial role that healthcare practitioners and leadership play in fostering sustainability within the healthcare sector. [ABSTRACT FROM AUTHOR]

Background: Access to minimally invasive surgery (MIS) is limited in Sub‐Saharan African countries. In 2019, the Mount Sinai Department of Surgery in New York collaborated with local Ugandans to construct the Kyabirwa Surgical Center (KSC), an independent, replicable, self‐sustaining ambulatory surgical center in Uganda. We developed a focused MIS training program using a combination of in‐person training and supervised telementoring. We present the results of our initial MIS telementoring experience. Methods: We worked jointly with Ugandan staff to construct the KSC in the rural province of Jinja. A solar‐powered backup battery system ensured continuous power availability. Underground fiber optic cables were installed to provide stable high‐speed Internet. The local Ugandan general surgeon (JOD) underwent a mini‐fellowship in MIS and then trained extensively using the Fundamentals of Laparoscopic Surgery program. After a weeklong in‐person session to train the Ugandan OR team, JOD performed laparoscopic cases with telementoring, which was conducted remotely by surgeons in New York via audiovisual feeds from the KSC OR. Results: From October 2021 to February 2024, JOD performed 61 telementored laparoscopic operations at KSC including 37 appendectomies and 24 cholecystectomies. Feedback was provided regarding patient positioning, port placement, surgical technique, instrument use, and critical steps of the operation. There were no intra‐operative complications. Postoperatively, field medical workers visited patients at home to collect follow‐up information. Two superficial wound infections (3.3%) were reported in the short‐term follow‐up. Conclusion: Telementoring can be safely implemented to assist surgeons in previously underserved areas to provide advanced laparoscopic surgical care to the local patient population. [ABSTRACT FROM AUTHOR]

Failure to attend scheduled hospital appointments disrupts clinical management and consumes resource estimated at £1 billion annually in the United Kingdom National Health Service alone. Accurate stratification of absence risk can maximize the yield of preventative interventions. The wide multiplicity of potential causes, and the poor performance of systems based on simple, linear, low-dimensional models, suggests complex predictive models of attendance are needed. Here, we quantify the effect of using complex, non-linear, high-dimensional models enabled by machine learning. Models systematically varying in complexity based on logistic regression, support vector machines, random forests, AdaBoost, or gradient boosting machines were trained and evaluated on an unselected set of 22,318 consecutive scheduled magnetic resonance imaging appointments at two UCL hospitals. High-dimensional Gradient Boosting Machine-based models achieved the best performance reported in the literature, exhibiting an area under the receiver operating characteristic curve of 0.852 and average precision of 0.511. Optimal predictive performance required 81 variables. Simulations showed net potential benefit across a wide range of attendance characteristics, peaking at £3.15 per appointment at current prevalence and call efficiency. Optimal attendance prediction requires more complex models than have hitherto been applied in the field, reflecting the complex interplay of patient, environmental, and operational causal factors. Far from an exotic luxury, high-dimensional models based on machine learning are likely essential to optimal scheduling amongst other operational aspects of hospital care. High predictive performance is achievable with data from a single institution, obviating the need for aggregating large-scale sensitive data across governance boundaries. [ABSTRACT FROM AUTHOR]

Purpose: To compare the intra- and postoperative outcomes of single-port robotic donor nephrectomies (SP RDNs) and laparoscopic donor nephrectomies (LDNs). Materials and Methods: We retrospectively reviewed our institutional database for patients who received LDN or SP RDN between September 2020 and December 2022. Donor baseline characteristics, intraoperative outcomes, postoperative outcomes, and recipient renal function were extracted and compared between LDN and SP RDN. SP RDN learning curve analysis based on operative time and graft extraction time was performed using cumulative sum analysis. Results: One hundred forty-four patients underwent LDN and 32 patients underwent SP RDN. LDN and SP RDN had similar operative times (LDN: 190.3 ± 28.0 minutes, SP RDN: 194.5 ± 35.1 minutes, p = 0.3253). SP RDN patients had significantly greater extraction times (LDN: 83.2 ± 40.3 seconds, SP RDN: 204.1 ± 52.2 seconds, p < 0.0001) and warm ischemia times (LDN: 145.1 ± 61.7 seconds, SP RDN: 275.4 ± 65.6 seconds, p < 0.0001). There were no differences in patient subjective pain scores, inpatient opioid usage, or Clavien–Dindo II+ complications. Short- and medium-term postoperative donor and recipient renal function were also similar between the groups. SP RDN graft extraction time and total operative time learning curves were achieved at case 27 and 13, respectively. Conclusion: SP RDN is a safe and feasible alternative to LDN that minimizes postoperative abdominal incisional scars and has a short learning curve. Future randomized prospective clinical trials are needed to confirm the findings of this study and to identify other potential benefits and drawbacks of SP RDNs. [ABSTRACT FROM AUTHOR]

Introduction: Persistent musculoskeletal (MSK) pain is associated with physical inactivity in older people. While walking is an acceptable form of physical activity, the effectiveness of walking interventions in this population has yet to be established. Objectives: To assess the acceptability and feasibility of conducting a randomised controlled trial (RCT) to test the effectiveness of a healthcare assistant‐led walking intervention for older people with persistent MSK pain (iPOPP) in primary care. Methods: A mixed method, three arm pilot RCT was conducted in four general practices and recruited patients aged ≥65 years with persistent MSK pain. Participants were randomised in a 1:1:1 ratio to: (i) usual care, (ii) usual care plus a pedometer intervention, or (iii) usual care plus the iPOPP walking intervention. Descriptive statistics were used in an exploratory analysis of the quantitative data. Qualitative data were analysed using thematic analysis. A triangulation protocol was used to integrate the analyses from the mixed methods. Results: All pre‐specified success criteria were achieved in terms of feasibility (recruitment, follow‐up and iPOPP intervention adherence) and acceptability. Triangulation of the data identified the need, in the future, to make the iPOPP training (for intervention deliverers) more patient‐centred to better support already active patients and the use of individualised goal setting and improve accelerometry data collection processes to increase the amount of valid data. Conclusions: This pilot trial suggests that the iPOPP intervention and a future full‐scale RCT are both acceptable and feasible. The use of a triangulation protocol enabled more robust conclusions about acceptability and feasibility to be drawn. [ABSTRACT FROM AUTHOR]

Introduction: Patients suffering from advanced heart failure may undergo left ventricular assist device (LVAD) placement as a bridge to cardiac transplantation. However, those with a BMI above 35 kg/m2 are generally not considered eligible for transplant due to their elevated cardiac risk. We review our experience with bariatric surgery in this high-risk population to assess its safety and efficacy in reducing BMI to permit cardiac transplantation. Methods: We retrospectively reviewed all patients on durable LVAD support who underwent sleeve gastrectomy (SG) at Mount Sinai Hospital between August 2018 and December 2022. Electronic medical records were reviewed to analyze patient demographics, surgical details, and outcomes regarding weight loss and heart transplantation. Results: We identified twelve LVAD patients who underwent SG. Three were performed laparoscopically and 9 via robotic approach. Four patients (33.3%) underwent an orthotopic heart transplant (OHTx). Half of these patients were female. For patients who underwent OHTx, mean age at LVAD placement was 41.0 (R30.6–52.2), at SG was 43.9 (R32.7–55.0) and at OHTx was 45.3 years (R33.3–56.8). Mean BMI increased from 38.8 at LVAD placement to 42.5 prior to SG. Mean time from SG to OHTx was 17.9 months (R6-7-27.5) during which BMI decreased to mean 32.8 at the time of OHTx. At most recent follow-up, mean BMI was 31.9. All patients were anticoagulated prior to surgery; one required return to the operating room on post-operative day 1 after SG for bleeding and one was re-admitted on post-operative day 7 for hematochezia treated conservatively. Conclusion: SG is a safe and effective operation in patients with severe obesity and heart failure requiring an LVAD. 66.7% of our cohort achieved target BMI < 35 and 33.3% underwent heart transplantation. Longer term follow-up is needed to clarify full bridge-to-transplant rate and long-term survival outcomes. [ABSTRACT FROM AUTHOR]

Summary: Several studies in clinical and non‐clinical populations indicate differences between rationally and empirically derived subscales for the Eating Disorder Examination Questionnaire (EDE‐Q), including samples of patients seeking bariatric surgery. This study aimed to use exploratory structural equation modelling (ESEM) to estimate the factor structure of the EDE‐Q and assess for the additive value of alternative measurement of eating disorder symptoms. Adolescents and adults completed the EDE‐Q and a psychiatric evaluation prior to bariatric surgery. Data from 330 participants were analysed using the original four‐factor and modified three‐factor structure of the EDE‐Q using both confirmatory factor analysis (CFA) and exploratory structural equation modelling (ESEM). Age, ethnicity, and body mass index were examined as covariates in the best fitting model, and model subscales used to generate a predictive model of clinician screened DSM‐5 eating disorder diagnoses for criterion validity. A CFA of the four‐factor EDE‐Q provided poor model fit for a pre‐surgical bariatric population, but the three‐factor EDE‐Q and an ESEM of the four‐factor EDE‐Q provided excellent model fit. The Eating Concern subscale of the four‐factor ESEM model significantly predicted eating disorder diagnosis and was positively correlated with age. Our results suggest the ESEM derived factors of the EDE‐Q offered some improvements to the original empirically derived factor structure, as subscale scores based on the original items and cross‐loading items yielded an adequate prediction of clinician diagnoses. [ABSTRACT FROM AUTHOR]

Objective: To evaluate effects of bariatric surgery on pelvic floor mediated quality of life in morbidly obese women. Study Design: Prospective cohort study of 44 women undergoing bariatric surgery. Results: Thirty-six women gave data at baseline and at mean follow-up of 3.15 years following bariatric surgery. Although urinary impact questionnaire scores improved (−34.92, P = .0020), colorectal-anal impact questionnaire and pelvic organ prolapse impact questionnaire scores did not improve despite significant weight loss. Baseline female sexual function index scores were low (17.70 ± 8.38) and did not improve with weight loss (16.91 ± 9.75, P = .5832). Pelvic organ prolapse/urinary incontinence sexual questionnaire scores did improve (35.78 ± 6.06 preoperatively vs 38.22 ± 6.03 postoperatively, P = .0193). Conclusion: Bariatric surgery is associated with significant improvement in the impact of urinary incontinence on quality of life. Sexual function was poor, and improved only on the pelvic organ prolapse/urinary incontinence sexual questionnaire that evaluated urinary incontinence. [ABSTRACT FROM AUTHOR]

Background: People with inflammatory rheumatological conditions such as rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, polymyalgia rheumatica and giant cell arteritis are at an increased risk of common comorbidities including cardiovascular disease, osteoporosis and mood problems, leading to increased morbidity and mortality. Identifying and treating these problems could lead to improved patient quality of life and outcomes. Despite these risks being well-established, patients currently are not systematically targeted for management interventions for these morbidities. This study aimed to assess the feasibility of conducting a randomised controlled trial (RCT) of a nurse-led integrated care review in primary care to identify and manage these morbidities. Methods: A pilot cluster RCT was delivered across four UK general practices. Patients with a diagnostic Read code for one of the inflammatory rheumatological conditions of interest were recruited by post. In intervention practices (n = 2), eligible patients were invited to attend the INCLUDE review. Outcome measures included health-related quality of life (EQ-5D-5L), patient activation, self-efficacy and treatment burden. A sample (n = 24) of INCLUDE review consultations were audio-recorded and assessed against a fidelity checklist. Results: 453/789 (57%) patients responded to the invitation, although 114/453 (25%) were excluded as they either did not fulfil eligibility criteria or failed to provide full written consent. In the intervention practices, uptake of the INCLUDE review was high at 72%. Retention at 3 and 6 months both reached pre-specified success criteria. Participants in intervention practices had more primary care contacts than controls (mean 29 vs 22) over the 12 months, with higher prescribing of all relevant medication classes in participants in intervention practices, particularly so for osteoporosis medication (baseline 29% vs 12 month 46%). The intervention was delivered with fidelity, although potential areas for improvement were identified. Conclusions: The findings of this pilot study suggest it is feasible to deliver an RCT of the nurse-led integrated care (INCLUDE) review in primary care. A significant morbidity burden was identified. Early results suggest the INCLUDE review was associated with changes in practice. Lessons have been learnt around Read codes for patient identification and refining the nurse training. Trial registration: ISRCTN, ISRCTN12765345 [ABSTRACT FROM AUTHOR]

Introduction: To enlarge the donor pool, kidney donors with obesity have been considered. We hypothesized that it is safe for patients with obesity to serve as living kidney donors.Methods: In this single-center retrospective analysis, we examined the effect of obesity (body mass index (BMI) of 30-35 kg/m2) on glomerular filtration rate (GFR) and creatinine in patients undergoing laparoscopic donor nephrectomy. Other outcomes included intraoperative, 30-, and 90-day complications. We examined the trajectory between patients with obesity versus patients without obesity over time using mixed effects models for the outcomes of creatinine in mg/dL and GFR in mL/min/1.73 m2. RESULTS: Among donors with obesity versus donors without obesity, there were no significant differences in demographics or comorbidities. Baseline creatinine in donors with obesity was significantly greater than that of donors without obesity (p = 0.02). Operative time was significantly longer in donors with obesity versus without obesity (p = 0.03). There was no significant difference in 30-day morbidity between donors with obesity versus without obesity (6.52 vs. 3.57%, respectively; p = 0.38). The rate of graft complications was 8.7% in donors with obesity versus 7.1% in donors without obesity (p = 1.0). 90-day complications were infrequent, and not significant different between the groups. At 6, 12, and 24-month postoperative follow-up, the mean creatinine level in patients with obesity was not significantly different from that of patients without obesity (1.23 vs. 1.31, 1.23 vs. 1.26, and 1.17 vs. 1.19 at 6, 12, and 24 months, respectively). Mean GFR was also not significantly different at 6, 12, and, 24 months.Conclusion: Postoperative creatinine and GFR changes were not significantly different in patients with obesity versus without obesity after laparoscopic donor nephrectomy. These findings suggest that carefully screened living kidney donors with obesity do not experience decreased postoperative renal function. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure in the United States. Postoperative migration of the stomach into the chest is a rare complication of this procedure. In this study, we present a compilation of acute and chronic intrathoracic sleeve migrations (ITSMs) after LSG and present possible underlying mechanisms of this complication, as described in the literature. Methods: We retrospectively reviewed the preoperative, intraoperative, and postoperative course of patients who had an ITSM after LSG between 2011 and 2019. Results: Two patients presented with this complication in the acute setting, whereas 3 patients developed ITSM as a chronic issue years after the primary procedure. All 5 were female patients, with a mean age and body mass index of 55.6 ± 9.5 (years) and 37.8 ± 2.9 kg/m2, respectively. None of the cases had a hiatal hernia repair during the initial operation. All cases were completed laparoscopically with reduction of the migrated sleeve into the abdomen and primary hiatal hernia repair. One case required a return to the operating room for an acute reherniation. Conclusion: In this article, we report a compilation of cases of ITSMs after LSG with distinct clinical features that highlight the diversity of possible reasons and risk factors for its development. [ABSTRACT FROM AUTHOR]