Roger Ackroyd

Obesity rates in the UK are high with over one-quarter of adults being classified as obese.1 Obesity is associated with a number of medical comorbidities, including type 2 diabetes mellitus, hypertension, obstructive sleep apnoea, and osteoarthritis. Consequently, obesity is linked with increased cardiovascular morbidity and mortality, cancer, functional impairment, and premature death, placing a financial burden on the NHS. Bariatric surgery has been demonstrated to be the most effective method for substantial and sustained weight loss, with a significant reduction in obesity-related comorbidities and long-term mortality.2 As a result, bariatric surgery rates are increasing in the UK for patients who have failed to respond to non-surgical therapies. GPs will therefore see an increasing number of patients with severe obesity who wish to be referred for surgery. GPs play a pivotal role in the management of obesity with early referral of motivated individuals who have failed to achieve substantial weight loss. Further, given the high level of psychosocial disorders in this patient group it is important to make an early assessment and provide support if appropriate. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) reported that only 29% of patients received psychological input, which mostly occurred following referral.3 Indications for bariatric surgery have been clearly defined by National Institute for Health and Care Excellence (NICE).4 However, in light of new evidence NICE has recently issued draft guidance on the management of obesity.5 As bariatric surgery has been demonstrated to improve glycaemic control and even remission of type 2 diabetes, NICE recommends that obese patients (body mass index [BMI] 30–34.9) with recent-onset type 2 diabetes (within the past 10 years) may benefit from surgery. Furthermore, patients of Asian origin with recent-onset type 2 diabetes may benefit from bariatric surgery at a lower …

Motor neurone disease (MND) is a devastating illness which leads to muscle weakness and death, usually within 2-3 years of symptom onset. Respiratory insufficiency is a common cause of morbidity, particularly in later stages of MND and respiratory complications are the leading cause of mortality in MND patients. Non Invasive Ventilation (NIV) is the current standard therapy to manage respiratory insufficiency. Some MND patients however do not tolerate NIV due to a number of issues including mask interface problems and claustrophobia. In those that do tolerate NIV, eventually respiratory muscle weakness will progress to a point at which intermittent/overnight NIV is ineffective. The NeuRx RA/4 Diaphragm Pacing System was originally developed for patients with respiratory insufficiency and diaphragm paralysis secondary to stable high spinal cord injuries. The DiPALS study will assess the effect of diaphragm pacing (DP) when used to treat patients with MND and respiratory insufficiency.

Background:  The aim of the study was to compare the effect of laparoscopic anterior and posterior fundoplication on gastro‐oesophageal reflux disease by means of a prospective randomized controlled trial.Methods:  One hundred and three patients were randomised to undergo either anterior (53) or posterior (50) fundoplication. Initial enrolment and subsequent clinical appointments were undertaken 1, 3, 6 and 12 months after the procedure using a standardized questionnaire. Ambulatory pH monitoring and manometry were undertaken both preoperatively and at approximately 3 months post‐procedure.Results:  The mean operating time was similar in both groups (48 versus 52 min). Two operations in each group were converted to open surgery. Post‐operative dysphagia in the first month was higher in the posterior fundoplication group compared with the anterior group (at 1 month, P= 0.002; and at 3 months, P= 0.014). The number of individuals suffering from post‐operative heartburn was greater in the anterior fundoplication group (at 1 month, P= 0.008; at 3 months, P < 0.001; and at 6 months, P= 0.002). Eight individuals required reoperation in the anterior group and two individuals in the posterior group (P= 0.057).Conclusion:  Anterior and posterior fundoplication each have their advantages and disadvantages. There is an increased risk of early post‐operative dysphagia after posterior fundoplication. Anterior fundoplication carries a greater risk of persistent or recurrent reflux. Overall, a posterior fundoplication produces a better management option for controlling gastro‐oesophageal reflux disease when compared with an anterior fundoplication technique which utilizes unilateral fixation of the gastric fundus.

Many trials have used intraesophageal manometry (IEM) to measure the adequacy of fundoplication. This pilot study aimed to assess the value of IEM in predicting postoperative dysphagia. A series of 40 patients underwent IEM studies before operative correction of gastroesophageal reflux disease and repeat studies 3 months after the procedure. During the operation, IEM studies were undertaken before pneumoperitoneum was established, after pneumoperitoneum, after pneumoperitoneum with fundoplication, and after fundoplication without pneumoperitoneum. All the patients were followed up 1, 6, and 12 months after the procedure for assessment to detect persistent reflux and postfundoplication dysphagia. Three patients demonstrated persistent dysphagia at the 12-month follow-up point. No statistically significant differences in preoperative manometry findings were observed in the dysphagic and nondysphagic groups, with the dysphagic group showing higher pressures. However, at the operation, statistically significant differences in the lower esophageal sphincter pressures were observed after anesthesia and no pneumoperitoneum (30.3 vs. 13.4 cm H₂O; p = 0.002), after anesthesia with pneumoperitoneum (40.3 vs. 18.3 cm H₂O; p < 0.001), and after fundoplication with pneumoperitoneum (47.3 vs. 23.4 cm H₂O; p = 0.001). No statistically significant differences were demonstrated in postoperative manometry at the 3-month follow-up point. Intraoperative manometry may be a useful tool compared with postoperative manometry in identifying patients who may experience postfundoplication dysphagia.

To compare the effect of laparoscopic Nissen and Lind fundoplication on gastro-oesophageal reflux disease by means of a prospective randomized controlled trial. One hundred and twenty-one patients were randomized to undergo either Nissen (61) or Lind (60) fundoplication. Initial enrollment and subsequent clinical appointments were undertaken 1, 3, 6 and 12 months after the procedure using a standardized questionnaire. Ambulatory pH monitoring and manometry were undertaken both preoperatively and at approximately 3 months post-procedure. The mean operating time was similar in both groups (44.8 versus 45 min). One operation in the Lind group was converted to open surgery. Postoperative dysphagia symptoms at 3 and 6 months were higher in the Nissen fundoplication group than in the Lind group (3 months p=0.003; 6 months p=0.020). The time taken to return to work was statistically longer in the Nissen group: at 1 month, 9 of 40 versus 2 of 45 patients had not returned to full activities (p=0.013). Three individuals required re-operation in the Nissen group and 4 individuals in the Lind group because of dysphagia caused by mechanical obstruction. Both procedures demonstrated good Visick scores at 12 months; the Nissen group having 33 (97%) patients with a Visick score of 1 or 2, and the Lind group having 38 (100%) patients with a Visick score of 1 or 2. Both operations provide good quantitative and qualitative control of gastro-oesophageal reflux. Operation time and postoperative comparators were similar in both groups. There were no statistically significant differences between the groups at 1 year.