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Obesity enhances the risk of type-2 diabetes, cardiovascular disease and inflammatory conditions and often leads to metal dyshomeostasis, which contributes to the negative health aspects associated with the disease. In severe cases, bariatric surgery can be recommended to achieve sustained weight loss and improvement in health. Here, magnesium, zinc, copper and selenium concentrations were examined in 24 obese patients (7 males; 17 females) before and 9 months after undergoing Roux-en-Y gastric bypass surgery. All patients lost weight over this period, with the mean BMI reducing from 51.2±7.1 kg/m 2 to 37.2±5.5 kg/m 2 . Moreover, whole-blood glycated haemoglobin (HbA1c), as a marker of average glycaemia, was also measured and a correlative analysis of this parameter with metal concentrations performed. Significant alterations in the plasma concentrations of magnesium, zinc (both increased by 13.2% and 25.2% respectively) and copper (decreased by 7.9%) were observed over this period (plasma selenium concentration was unchanged), with BMI values correlating with plasma magnesium (p = 0.004) and zinc (p = 0.022) concentrations. At 9 months post-surgery, an increase in mean zinc/copper ratio was observed (0.86±0.29 compared to 0.63±0.14 pre-surgery). Comparison of whole-blood HbA1c concentrations pre- and post-surgery revealed a reduction from 6.50±1.28% pre-surgery to 5.51±0.49% post-surgery. Differences in plasma HbA1c and magnesium at either pre- and post-surgery correlated significantly, as did HbA1c and magnesium levels when pre- and post-surgery values were analysed together. Collectively, this work reveals that bariatric surgery, in conjunction with lifestyle/dietary changes, lead to improvements in the nutritional status of magnesium, zinc and copper. Furthermore, the observed improvements in magnesium and zinc were associated with weight loss and in the case of magnesium, to better glycaemic control., (© 2022. The Author(s).)

Background: Laparoscopic roux-en-Y gastric bypass (LRYGB) has gained increasing popularity as the primary procedure of choice for the management of patients with morbid obesity. Despite the advances, a few patients will still develop complications and predicting these early complications in morbidly obese patients can prove to be difficult. Radiological investigations have limited diagnostic value and have associated side effects and cost. We propose that C-reactive protein (CRP) is a useful predictor for early postoperative complications. This study aims to determine the ability of CRP taken on postoperative day 1 (POD 1) and 2 to predict occurrence of complications within 30 days of surgery., Methods: This retrospective observational study selected 183 consecutive patients from the York bariatric database between 01 December 2010 and 23 March 2015., Exclusions: Patients undergoing dual procedures, conversion to open, and if no postoperative CRP measurement was performed., Results: In total, 138 patients satisfied the inclusion criteria during the study period (median age 44 years [20-68], BMI 50.6 kg/m2 [38.3-62.5]). Fifteen (10.8 %) patients had minor complications (CD of 2) and 8 (5.6 %) had major complications (CD 3 or above). A CRP of greater than 127 mg/L on POD 2 was found to predict complications with 93 % sensitivity and 64 % specificity with diagnostic accuracy 0.82 (95 % confidence interval 0.731-0.908)., Conclusions: In our patients, CRP on POD 2 has been shown to be a good predictor of both minor and major complications and can therefore be used to guide clinicians in making decision as to which patients may need further investigation or who can be safely discharged.

Aim: To help the surgeon in decision making when treating a patient with recurrent gallstone ileus (RGSI)., Methods: A systematic review related to RGSI was performed using the databases CINAHL, EMBASE, MEDLINE via PubMed from May 1912 to April 2015. All languages were included and the grey literature was also searched. The abstracts were explored for relevance to the topic and full texts obtained as appropriate. A manual search was carried out by scrutinising the reference lists of all the full text articles and further articles were identified and obtained. Total of 903 articles were identified, 656 were excluded after abstract review, 247 full text articles were reviewed and 91 articles selected for final analysis. There were 113 cases of RGSI., Results: There were 113 cases of RGSI reported in 91 articles. The majority of the recurrences, 62.6%, occurred within 6 wk of the index event. The male to female ratio was 1:7. The mean age was 69.6 years (SD 11.2) with a range of 38-95 years. The small bowel was the commonest site of impaction (92.2%). Treatment data was available for 104 patients. The two main operations performed were: (1) Enterolithotomy without repair of biliary fistula in 70.1% of all patients with a procedural mortality rate of 16.4% (12/73) and (2) a single stage surgery approach involving enterolithotomy with cholecystectomy and repair of the biliary enteric fistula in 16.3% with a procedural mortality of 11.7% (2/17). A subset analysis over last 25 years showed mortality from eneterolithotomy was 4.8% while single stage mortality was 22.2%. Enterolithotomy alone was the commonest operation performed for RGSI with four patients (5.4%) having a further recurrence of gallstone ileus., Conclusion: Enterolithotomy alone or followed by a delayed two-stage treatment approach is the preferred choice offering low mortality and reduced risk of recurrence.

Background: Type 2 diabetes mellitus (T2DM) is a well-recognised complication of obesity. One of the microvascular complications of T2DM is diabetic retinopathy (DR). Bariatric surgery has been shown to effectively treat obesity and can induce remission of T2DM. It is not known what effect this improvement may have on pre-existing DR. We aimed to investigate this., Method: A dual-centre, observer-blinded, case-control study investigated the progression of DR in patients who received Roux-en-Y gastric bypass (treatment group (TG)), compared with controls who received medical therapy (control group (CG)) for their T2DM. Retinal images were taken pre-operatively and approximately 2 years post-operatively for the TG and over a 2-year interval for the CG. Data were collected for confounding variables, including glycaemic control (HbA(1c)) and BMI., Results: Forty-five patients were recruited (TG = 21, CG = 24). Groups were significantly heterogeneous. DR showed significant progression for those in the CG (p = 0.03) but not in TG (p = 0.135), no significant difference was found when adjusting for confounding variables (p = 0.480). There was a significant trend in favour of surgery in improvement of glycaemic control (p = 0.017)., Conclusion: The trends within these pilot data may represent a real difference in the progression of DR in patients who have received surgery, compared with medical treatment alone. Due to heterogeneity of group characteristics, further work needs to be done to validate these results. Should there be a true difference, there will be potential cost savings for the National Health Service (NHS) along with a reduced burden of disease for patients.

Obesity has become an increasingly important health problem over the past 30 years. Presently around a quarter of the UK adult population are obese and this figure is set to increase further in the coming decades. The health consequences of obesity on multiple body systems have been well established as has the financial cost of the condition to both the individuals affected as well as to society as a whole. Bariatric surgery has been shown to be the only long term effective solution in terms of sustained weight loss and comorbidity resolution. The commonest bariatric procedure in the UK is the Roux-en-y gastric bypass which consistently results in the loss of 70%-80% of excess bodyweight. Results however are variable and in order to optimise resource allocation and avoid exposing patients unlikely to benefit from surgery to its inherent risks, much research has been done to try to identify those patients most likely to obtain a good result. The only factor which has been subjected to meta-analysis is that of preoperative weight loss which shows a positive association with postoperative weight loss following bypass surgery. Although the remaining data are not based on level 1 evidence those other preoperatively identifiable factors which are associated with an improved outcome include Caucasian or Hispanic ethnicity, higher educational status, non-shift-work working patterns, female gender and divorced or single marital status. Similarly increased levels of preoperative physical activity and an absence of binge eating behaviour are consistent with a favourable result whereas increased age, smoking and other socioeconomic factors have not been shown to have a significant impact. Conversely diabetes mellitus seems to have a slight negative correlation with postoperative weight loss; however, a history of sexual abuse or psychiatric illness has not been shown to have a lasting influence.

It is well established that hypertension and obesity appear to be associated. The exact mechanism by which they are linked is unclear and remains a topic of a great deal of research. Current NICE guidelines recommend that patients with a BMI in excess of 35 kg/m(2) should be considered for bariatric surgery if they have a concomitant obesity-associated condition, of which hypertension is one. The commonest bariatric procedure in the UK is the Roux-en-Y gastric bypass, which has been shown to result in long-standing remission of hypertension in up to 93% of patients. This paper summarizes the existing literature on the main theories as to how obesity leads to hypertension as well as the literature concerning the effects of gastric bypass surgery on hypertension.

There is clear evidence to support the use of pre-operative concurrent chemo-radiotherapy (CRT) in locally advanced rectal cancer. In the UK, most patients are selected for treatment if the resection margin is predicted to be involved. The selection criteria used includes primary tumours that threaten the resection margins on high-resolution pelvic MRI and low tumours requiring abdominoperineal excision. There is no consensus, however, to guide the treatment of patients who present with advanced rectal disease and synchronous, potentially resectable, metastatic disease. This case illustrates the potential risk of omitting radiation following a good response to neoadjuvant systemic chemotherapy.

This paper presents the findings of a nationwide investigation into the mental well-being and job satisfaction of minority ethnic teachers in the UK. Data were collected via a questionnaire containing both open and closed questions. The sample, totalling 208 participants was derived from the National Union of Teachers (NUT) database of minority ethnic teachers and an advertisement in the NUT's Teacher magazine. Univariate analysis of the results revealed that this group of teachers, as compared with other groups were experiencing poorer mental health and lower job satisfaction. Multivariate analysis revealed four reliable factors regarding the 'sources of stress' these minority ethnic teachers perceived they were experiencing. They are the 'hierarchy and culture of the school', workload', 'cultural barriers', and the 'lack of status and promotion'. Some minority ethnic teachers reported that ethnic discrimination on a daily basis or at least several times per week was a contributory factor in their experience of stress. Many of the teachers believed they worked within an institutionally racist environment. Multiple regression analysis discovered that 'total stress', 'total self-esteem', 'working conditions job satisfaction' and 'total discrimination' were the major predictors of mental ill-health in the minority ethnic teachers. Job dissatisfaction was predicted by 'total discrimination', 'workload', 'total general health', 'resolution strategy', and the 'lack of status and promotion'.

Background & Aim: Feeding jejunostomy is recommended to facilitate early enteral nutrition after major upper gastrointestinal surgery. We aimed to determine the benefits and risks associated with routine practice of feeding needle catheter jejunostomy (NCJ) in high-risk upper gastrointestinal surgery., Method: This is a prospective consecutive cohort study of 84 patients underwent feeding NCJ over a 3 years period in an Upper Gastrointestinal Surgical Unit., Results: Feeding NCJ was placed after two-stage oesophago-gastrectomy in 24 patients (28.6%), after gastrectomy in 29 patients (34.5%), after liver resections in 7 patients (8.3%), pancreatic resection in 6 patients (7.1%), bile duct reconstruction in 8 patients (9.5%) and other operations in 10 patients (12%). The mean (SE) estimated nutritional requirement per 24 h was 1791 (31)kcal. Eighty-two patients (98%) started enteral feed on day 1 after surgery. Fifty-seven patients (68%) achieved the target nutritional requirements in 3 days. Four patients were discharged home on jejunal feed whilst only two patients required parenteral nutrition support. The rest tolerated full oral diet. There was no procedure related mortality. The morbidity related to feeding tube and feeding were 12.9% and 20%, respectively., Conclusions: Routine practice of feeding NCJ is safe. Their benefits outweigh the risks in a specialist centre., (Copyright 2003 Elsevier Ltd.)

Background: The contribution of glyceryl trinitrate (GTN) to prevention of peripheral vein thrombophlebitis (PVT) during peripheral intravenous nutrition delivered by fine-bore midline intravenous catheter is unclear. The aim of this study was to establish its role., Methods: Two consecutive randomized clinical trials were conducted. In trial 1 patients were randomized to receive standard peripheral intravenous nutrition containing heparin and hydrocortisone with or without the placement of a topical GTN patch (triple therapy or dual therapy). In trial 2 patients were randomized to receive standard peripheral intravenous nutrition with either dual therapy or topical GTN alone (monotherapy)., Results: Dual therapy was as effective as triple therapy in preventing PVT (incidence 10 of 37 versus 11 of 39 patients respectively). Dual therapy reduced the incidence and increased the time to onset of PVT compared with monotherapy (14 of 41 versus 22 of 35 patients respectively, P = 0.012; median 17.3 (95 per cent confidence interval (c.i.) 13.4 to 21.1) versus 8.9 (95 per cent c.i. 6.7 to 11.0) days, P = 0.007)., Conclusion: Use of a topical GTN patch confers no benefit when peripheral intravenous nutrition is delivered via a fine-bore midline intravenous catheter., (Copyright 2003 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Background: Laparotomy remains the commonest intervention in patients with abdominal complications of laparoscopic surgery. Our own policy is to employ relaparoscopy to avoid diagnostic delay and unnecessary laparotomy. The results of using this policy in patients with suspected intra-abdominal complications following laparoscopic cholecystectomy are reviewed., Methods: Data were collected from laparoscopic cholecystectomies carried out by five consultant surgeons in one center. Details of relaparoscopy for complications were analyzed., Results: Thirteen patients underwent relaparoscopy within 7 days of laparoscopic cholecystectomy for intra-abdominal bleeding (2 patients) or abdominal pain (11 patients). The causes of pain were subhepatic haematoma (1), acute pancreatitis (1), small bowel injury (1), and minor bile leakage (6). In 2 patients no cause was identified. Twelve patients were managed laparoscopically and 1 patient required laparotomy. Median stay after relaparoscopy was 7 days (range 2 to 19)., Conclusions: Exploratory laparotomy can be avoided by prompt relaparoscopy in the majority of patients with abdominal complications of laparoscopic cholecystectomy.

Peritonitis is the most frequent cause for emergency hospital admission in continuous ambulatory peritoneal dialysis (CAPD) patients. Patients may present with 'surgical' peritonitis from other intra-abdominal pathology, but are treated initially as CAPD-related peritonitis. We present nine such cases, each failing to respond to standard conservative treatment, and ultimately coming to laparotomy. Of the nine patients, six survived, five transferring to long-term haemodialysis and one patient returning to CAPD. Failure to respond to standard measures should alert the physician to the possibility of an intra-abdominal emergency. The presence of enteric organisms, particularly E. coli, is an additional suspicious feature. The diagnosis may be difficult and we recommend early surgical referral and appropriate surgical measures (laparotomy rather than simple catheter removal) in order to decrease morbidity and mortality.

Background: Does the use of the histamine H2 receptor antagonist ranitidine improve the outcome of patients with gastric cancer?, Patients: A total of 222 patients with gastric cancer who had received radical or palliative resection or who were deemed inoperable at presentation., Setting: Hospitals within Yorkshire, the participating clinicians being members of the Yorkshire GI Tumour Group., Methods: A multicentre prospective randomised double blind trial comparing ranitidine 150 mg twice daily with placebo twice daily was undertaken. The principal outcome measures were survival and survival excluding those who died within 30 days of operation., Results: The median survival (95% confidence intervals) was 331 (232 to 393) days for patients in the ranitidine group compared with 187 (143 to 269) for those in the placebo group. The difference in survival was not statistically significant (p = 0.225). When patients who died within 30 days of operation were excluded (21 in the placebo group, 15 in the ranitidine group), the difference in survival remained not significant (p = 0.358). No subgroup could be identified who significantly benefited from treatment, but for patients with stage VIa cancer the median survival was 134 days with placebo compared with 313 days with ranitidine (p = 0.073)., Conclusion: This study does not show significant benefit from the use of ranitidine for gastric cancer but further larger studies may be indicated.

Background: The treatment of low fistula in ano is well accepted but controversy surrounds the management of high trans-sphincteric fistulas and more complex fistulas. This study assesses the clinical results of advancement flap techniques in association with core fistulectomy for complex fistula in ano., Methods: A retrospective analysis of the use of advancement flap techniques together with core fistulectomy in 25 patients (26 fistulas) was performed. Clinical outcome was assessed in terms of fistula healing, continence, failure and technical problems., Results: Successful healing of 20 of the 26 complex fistulas was achieved using this technique with no disturbance of continence and minimal (technical) complications., Conclusion: Flap advancement and core fistulectomy is a safe, effective procedure for complex rectal fistulas with good functional results and minimal or no disturbance of continence, and should be considered for the treatment of complex perianal fistulas.

Background: Much controversy exists as to the value of computed tomography (CT) in the preoperative staging of gastric cancer, because of its limited ability to identify correctly lymph node (LN) metastases, invasion of adjacent organs, or hepatic and peritoneal metastases. Spiral CT scanners have a number of potential advantages over conventional scanners, including the absence of respiratory misregistration, image reconstruction smaller than scan collimation permitting overlapping slices and optimisation of intravenous contrast enhancement., Aim: To compare the performance of spiral CT and operative assessment against formal (TNM) pathological staging., Patients and Methods: A study of 105 consecutive patients who underwent both spiral CT and operative staging was performed. All CT scans were reviewed by a radiologist who commented on tumour location and size, evidence of adjacent organ invasion, lymph node metastases to both N1 and N2 nodes, and evidence of hepatic and peritoneal metastases. All patients underwent careful operative assessment at the time of surgery, along the lines suggested by Rohde and colleagues., Results: Spiral CT remained poor at identifying LN metastases to both N1 and N2 lymph nodes, with sensitivity ranging from 24 to 43%; specificity, however, was 100%. Operative staging was superior, with sensitivities between 84 and 94%, but specificity was much lower (63-74%). Spiral CT correctly detected 13 of 17 cases of invasion of either the colon or the mesocolon (sensitivity 76%) compared with 16 of 17 cases at operative staging (sensitivity 94%). Spiral CT correctly identified three of six cases with invasion of the pancreas (sensitivity 50%) compared with six of six cases on operative staging (sensitivity 100%). Spiral CT correctly identified 12 of 17 cases of peritoneal metastases (sensitivity 71%) and four of seven cases of hepatic metastases (sensitivity 57%)., Conclusion: Whilst spiral CT remains poor at identifying lymph node metastases, it correctly identified most cases with invasion of either the colon or the mesocolon and half the cases of pancreatic invasion. It was of value in detecting peritoneal metastases and some cases with hepatic metastases. At present, at Leeds General Infirmary spiral CT is performed routinely on all patients with gastric cancer and a selective staging laparoscopy policy is adopted in those patients in whom the status of the peritoneal cavity and liver is in doubt.

During two consecutive study periods (24 months and 16 months), 997 patients (1322 legs) with varicose veins underwent surgical treatment in Huddersfield Royal Infirmary, using a variety of surgical techniques. The average length of stay was 1.5 days, and 95.5% of patients had a hospital stay of less than 2 days. Complications occurred in seven inpatients. A further 16 patients developed complications requiring readmission to hospital (10 minor and intermediate; 6 major). The complication rate appeared to be operator-dependent: an increased complication rate (particularly major complications) occurred after surgery by junior surgeons. Major complications included femoral vein injury (1 patient), postoperative deep venous thrombosis (4 patients), pulmonary embolism (1 patient) and groin lymphatic fistula requiring reoperation (1 patient). Between the first and second study period, a change in policy regarding the type of bandaging used and the use of postoperative antiembolic stockings occurred and appears to have reduced the incidence of thromboembolic complications from 0.7% to 0.2%. Varicose vein surgery is not without major complications though, fortunately, there was no mortality in this series. These complications can be minimised with good surgical technique and better supervision of surgical trainees. Modification of postoperative management can further enhance the safety of this procedure.

This study examined the expression of receptors of the bombesin (BBS) family in human gastric-cancer cell lines. Of 5 cell lines screened, only one, St42, demonstrated specific binding sites for 125I-Tyr4-BBS, which have been further characterized. This binding was saturable, and temperature- and time-dependent. Scatchard analysis of displacement data performed at 37 degrees C revealed 2 binding sites: a high-affinity, low-capacity site (KD = 0.13 nM, Bmax = 1500 sites/cell) and a lower-affinity, higher-capacity site (KD = 11 nM, Bmax = 35,000 sites/cell); the latter was lost when internalization of peptide was prevented, suggesting that it may be an artefact. Displacement assays with gastrin-releasing peptide (GRP) and neuromedin B (NMB) revealed that the receptor was of the GRP-preferring sub-type (GRP IC50 = 0.35 nM; NMB IC50 = 112 nM). Co-valent cross-linking of 125I-Tyr4-BBS to the receptor demonstrated the presence of a single band corresponding to a molecular weight of 37 to 44 kDa on SDS-PAGE, similar to that of the cloned GRP receptor protein core. G-protein linkage of this receptor was demonstrated by selective inhibition of 125I-Tyr4-BBS binding by guanosine nucleotides. The binding of BBS to the receptor resulted in a rise in intracellular calcium. Three of four structurally distinct BBS antagonists bound to the receptor with high affinity, but [DPhe12, Leu14]-bombesin did not cause any displacement of 125I-Tyr4-BBS even at 10 mM. The functional significance of GRP receptors on human gastric-cancer cells is as yet unknown, but further studies may determine whether such receptors have importance in the therapy of gastric cancer.

This study characterises the somatostatin binding site in human gastrointestinal cancer and mucosa in terms of cationic specificity and relative affinity for three somatostatin analogues. Competitive displacement assays were performed on plasma membranes from human gastric and colonic tissues using radiolabelled somatostatin-14 as ligand. Comparison was made with the somatostatin binding site in rat cerebral cortex. In gastrointestinal tissue, magnesium decreased and sodium increased specific binding. By contrast, in rat cerebral cortex, the converse cationic effect was seen. These changes resulted from alterations in receptor density, with no change in receptor affinity. Displacement studies were then performed with somatostatin-14 and somatostatin analogues RC-160, somatuline, and octreotide. RC-160 and somatuline displaced radiolabel from binding sites in gastric and colonic cancer and mucosa with 10-fold lower affinity than the native peptide. Octreotide did not displace radioligand in gastric or colonic cancer at any concentration tested. By contrast, in rat cortex, although all three analogues displaced with a lower affinity than the native peptide, there was no difference between analogues. These data suggest a distinct somatostatin receptor subtype in gastrointestinal tissues.

Autologous blood transfusion in surgery for cancer has been avoided because of the metastatic potential of reinfused malignant cells. This study determined whether viable tumour cells remain in the red cell concentrate after separation and whether blood transfusion filters remove these tumour cells before reinfusion. Units of banked blood were inoculated with tumour cell lines: breast cancer SKBr3; colon cancer COLO 320; lymphoma Daudi; erythroleukaemia K562. After processing with the Cell Saver, aliquots of the red cell concentrate and waste saline wash were examined for tumour cells and cultured. Tumour cells from all four cell lines were identified in the red cell concentrate but not in the waste saline wash. All the cell lines except Daudi grew from the red cell concentrate. Experiments on two of the cell lines (SKBr3 and COLO 320) were performed in which the red cell concentrate was either unfiltered (control) or filtered with SQ40S blood transfusion filter or RC100 leucocyte depletion filter. Both cell lines were present in the control samples and after filtration with SQ40S filters, and cells from these samples grew normally in culture. No tumour cells were evident after filtration with the RC100 filters and no growth of either cell line was found after 1 week in culture. The Cell Saver in combination with RC100 filters may be suitable for use during the surgical treatment of malignant disease.

Lipofuscin granules (age pigments) emit yellow light under ultraviolet excitation in the fluorescence microscope. The reported blue emission maximum of extracts of lipofuscin-laden cells may result from instrumental bias. The major fluorescent components that accumulate with age in these lysosomal residual bodies of human retinal pigment epithelium are yellow-emitting fluorophores. Different age-related fluorophores, which do emit blue light, are derived from other intracellular sources. A reevaluation of the connection between blue-emitting lipid peroxidation products and the age-related lipofuscin granules of classical pathology is necessary.

Elevated titers of serum agglutinators (anti-FabIgG) are associated with significant and severe suppurative infection. Immunosuppression and long-term antibiotic therapy, however, may lead to negative tests.