Noel Edward Donlon

Introduction: Venous thromboembolism (VTE) remains a leading cause of preventable morbidity and mortality following metabolic bariatric surgery (MBS). Low-molecular-weight heparin (LMWH) is widely used for thromboprophylaxis; however, the optimal prophylactic enoxaparin dose in patients with obesity remains uncertain. Anti-factor Xa (anti-Xa) activity is commonly used as a surrogate marker of pharmacological efficacy. Methods: A systematic review and meta-analysis was conducted in accordance with PRISMA guidelines and registered with PROSPERO. PubMed, EMBASE, the Cochrane Library, and ClinicalTrials.gov were searched from inception to 31 March 2026. Studies evaluating prophylactic enoxaparin dosing in patients with obesity undergoing MBS, with reported anti-Xa levels, were included. Random-effects meta-analyses compared lower (30–40 mg) versus higher (60 mg) enoxaparin regimens with respect to attainment of prophylactic anti-Xa levels with secondary outcomes including mean anti-Xa activity, VTE and bleeding event rates. Results: Ten studies comprising 1,069 enrolled patients, of whom 1,016 contributed to the primary meta-analysis, met the inclusion criteria. There was no significant difference in the proportion of patients achieving prophylactic anti-Xa levels between higher and lower dose regimens (risk ratio 1.05, 95% CI 0.91–1.20; I² = 58.2%, p = 0.0104). Higher doses were associated with significantly increased mean anti-Xa levels (mean difference 0.13 IU/mL, 95% CI 0.05–0.21; p = 0.001). Conclusion: Higher prophylactic enoxaparin doses increase anti-Xa levels but do not improve attainment of prophylactic targets compared with standard dosing following MBS. In a post-hoc, exploratory, hypothesis-generating subgroup analysis, BMI-adjusted dosing strategies demonstrated comparable pharmacodynamic efficacy to fixed higher doses; this finding is not pre-specified and should not be used to support definitive conclusions. High-quality multicentre randomised trials are required to define optimal thromboprophylaxis strategies in this high-risk population.

Background: Transversus abdominis plane (TAP) block is commonly used as an element of multimodal analgesia following abdominal surgery; however, its efficacy in Roux-en-Y gastric bypass (RYGB) remains uncertain. Aim: To perform a systematic review and meta-analysis of randomised clinical trials (RCTs) to evaluate the effectiveness of TAP block following RYGB. Methods: A comprehensive search was performed as per PRISMA guidelines. RCTs comparing TAP block with control in adult patients undergoing RYGB were included. Primary outcomes were postoperative pain scores (visual analogues scores (VAS)/numeric rating scale (NRS)) in recovery and at 6, 12, and 24-hours. Data analytics were performed using RevMan v.5.3. Results: Five RCTs comprising 481 patients were included. TAP block did not significantly reduce pain scores in recovery, at 6-hours, or at 12-hours postoperatively. A significant reduction in pain was observed at 24-hours (mean difference (MD) -0.57, 95% CI -0.96- -0.17, p = 0.005, I ² = 92%). Patients receiving TAP block were significantly less likely to require breakthrough opioid analgesia (odds ratio (OR) 0.09, 95% confidence interval (CI) 0.02–0.32, p = 0.0003, I ² = 51%). TAP block was also associated with earlier ambulation (MD -1.65, 95% CI -2.32- -0.98, p < 0.00001, I ² = 0%). No significant differences were observed in PONV or LOS. Conclusion: While TAP block provided limited benefit in early postoperative pain control in patients undergoing RYGB, it was associated with reduced ‘breakthrough’ opioid requirements, earlier mobilisation, and a significant analgesic effect at 24 h. These findings support the use of TAP blocks as an opioid-sparing adjunct within enhanced recovery after bariatric surgery pathways.

Dual-console robotic systems represent a paradigm shift in surgical education, allowing real-time shared control and instructor intervention. Although increasingly adopted, their impact across specialties, educational effectiveness, and implementation barriers are not fully established. To perform a systematic review to provide a comprehensive overview of dual – console training in robotic surgery by synthesizing available evidence regarding training outcomes, implementation strategies, educational effectiveness, and the broader impact of dual – console systems on surgical education and surgical performance. A systematic search was performed as per PRISMA guidelines. Descriptive statistics were recorded and analysed using SPSS v26.0. Overall, 12 studies including 1,267 participants were included. These included residents from gynecology, urology, colorectal surgery, general surgery, and hepatopancreatobiliary surgery. Dual consoles consistently increased trainee operative exposure, autonomy scores, and skill acquisition, with improvements in suturing times and procedural step completion. Safety outcomes were preserved or improved, however operative efficiency varied with some studies demonstrating reduced operative times, while others reported neutral or slightly prolonged procedures due to greater trainee participation. Trainee and instructor satisfaction was uniformly high, citing improved communication, confidence, and educational quality. Implementation barriers included cost, curriculum integration, and faculty development needs. Dual-console systems significantly enhance robotic surgical training by improving technical skill acquisition, trainee engagement, and perceived educational quality, while maintaining patient safety. Operative efficiency outcomes are variable and context-dependent. Despite clear educational advantages, widespread adoption is limited by financial and curricular barriers. Future efforts should focus upon the integration of dual-console training into surgical training curricula.

Background: The anticipated surgical and postoperative outcomes following robotic-assisted single anastomosis duodeno-ileal bypass with sleeve gastrectomy (R-SADI-S) are not well described in the surgical literature. Aims: To perform a systematic review to evaluate clinical and surgical outcomes in patients who have undergone R-SADI-S. Methods: A systematic review was performed in accordance with the PRISMA guidelines. Basic descriptive statistics were performed using SPSS v26.0. Results: Overall, 4 studies including data from 160 patients were included. The mean age at the time of surgery was 38.1 years and 55.6% of patients were female (89/160). The mean reported preoperative weight was 122.2 kg and mean body mass index was 45.1 kg/m ² . The mean time taken for R-SADI-S was 181 min and 7.5% of patients experienced postoperative complications (12/160), however, just 1.4% of patients required either reintervention and readmission (2/144) respectively. At 24-months follow-up, patients who had undergone-R-SADI-S experienced an average weight loss of 60.7 kg, a BMI change of -18.0 kg/m ² , a total body weight loss of 44.6% and excess weight loss of 113.7%. Conclusion: R-SADI-S is a seemingly safe procedure which provides excellent weight loss results when performed for patients living with severe obesity. Given R-SADI-S is a novel technique, these results require further ratification once the learning curve is navigated in prospective analyses to ensure the optimisation of patient outcomes.

SUMMARY: Pneumonia is common following transthoracic esophagectomy (TTE). The diagnosis in the early postoperative period is partly subjective’ and may vary among clinicians, with sensitivity reduced by post-operative inflammatory changes and altered thoracic anatomy. Despite its clinical importance, inter-observer agreement in diagnosing post-esophagectomy pneumonia has not been systematically evaluated. This retrospective study evaluated inter-observer variability among four senior specialists (surgeon, radiologist, intensivist, and pulmonologist) in diagnosing pneumonia from chest radiographs of 200 consecutive TTE patients. Using a web-based platform, blinded reviewers independently assessed anonymized chest radiographs from post-operative days 3 and 7 using a three-class scale (yes/no/maybe). When ‘maybe’ was selected, standardized clinical data (vital signs at 23:00 hours) were automatically provided. Cohen’s kappa coefficient quantified pairwise agreement, while Fleiss’ kappa assessed overall concordance. Of the 200 patients, pneumonia was documented in 54 (27%) per American Thoracic Society (ATS) criteria. Initial radiographic assessment showed fair inter-observer agreement (κ = 0.207–0.230) compared to the radiologist reference. Diagnostic uncertainty (‘maybe’ responses) occurred in 307/1600 assessments (19.2%), varying significantly by specialty: surgeon, 41.5%; radiologist, 22.0%; intensivist, 13.0%; pulmonologist, 14.0% (P < 0.001). After clinical correlation, agreement improved modestly: surgeon κ = 0.334, intensivist κ = 0.398, pulmonologist κ = 0.356 (all P < 0.001), but remained in the ‘fair’ range. Overall multi-rater agreement (Fleiss’ κ) improved from 0.270 to 0.421 (+56% improvement, P < 0.001), transitioning from fair to moderate agreement. When clinical data points were made available for equivocal cases, 124 responders (40.4%) changed their initial assessment from ‘maybe’ to ‘yes’, indicating a preference for therapy, while 89 (29.0%) changed their unsure response to ‘no’. Considerable inter-observer variability in pneumonia diagnosis after TTE exists, with ‘fair’ interrater agreement in documenting radiologic pneumonia, and ‘poor’ consistency in determining antibiotic use according to the ATS criteria. Current pneumonia diagnostic criteria are fundamentally limited by poor radiographic inter-observer agreement, indicating the timely need for standardization of definition terminology and supports the development of integrated diagnostic protocols.

Background The optimal hypoabsorptive surgical approach for management of severe obesity remains unclear. Aim To perform a network meta-analysis (NMA) of randomized clinical trials (RCTs) comparing Roux-en-y gastric bypass (RYGB), SADI-S (single anastomosis duodeno-ileal bypass with sleeve gastrectomy), one anastomosis gastric bypass (OAGB) and duodenal switch (DS). Methods A systematic review was performed as per PRISMA-NMA guidelines. Statistical analyses were performed using R and shiny. Results 12 RCTs (with 5 sequential analyses) were included, involving 986 patients [471 RYGB (47.8%), 341 OAGB (34.6%), 145 DS (14.7%), and 29 SADI-S (2.9%)]. Patient age, gender, BMI, and ASA grade were similar (all P > 0.050). Patient follow-up ranged from 1.0–15.4 years. Compared to RYGB, DS [mean difference (MD): -13.9, 95% confidence interval (CI): -18.7; -9.1) and SADI-S (MD: -12.4, 95% CI: 19.8; 5.0) significantly increased total body weight loss, while DS (MD: -10.5, 95% CI: -13.1; -7.9), OAGB (MD: -3.1, 95% CI: -5.1; -1.2) and SADI-S (MD: -8.1, 95% CI: -16.1; -0.1) significantly increased excess body weight loss. Relative to RYGB, DS (MD: -24.9, 95% CI: -28.3; -21.5) and OAGB (MD: -1.8, 95% CI: -3.4; -0.3) significantly increased weight loss, while DS (MD: -13.6, 95% CI: -16.0; -11.2) and SADI-S (MD: -16.0, 95% CI: -23.62; -8.38) significantly increased excess weight loss. Importantly, DS (MD: 2.1, 95% CI: 0.1; 4.0) significantly increased length of stay while OAGB was associated with long-term severe malabsorption rates. Conclusion DS, SADI-S and OAGB all serve in significantly inducing weight loss, albeit results in support of SADI-S are limited due to a small sample size. Nevertheless, based on the data presented in this study, there is no consensus as to the optimal hypoabsorptive bariatric surgical approach.

Background: Transversus abdominus plane (TAP) blocks have become increasingly popular, due to a perceived reduction in post-operative pain following laparoscopic surgery. Their value following sleeve gastrectomy remains unclear. Objectives: To perform a systematic review and meta-analysis of randomized clinical trials (RCTs) evaluating the efficacy of TAP block in patients undergoing laparoscopic sleeve gastrectomy. Setting: Integration of data from bariatric surgery units across the world. Methods: A systematic review was performed as per PRISMA guidelines. Meta-analysis was performed using Review Manager v5.4. Results: Eleven RCTs including 776 patients were included with 338 randomized to TAP block (50.0%). A non-significant equipoise was observed between groups for mean age, gender, body mass indices, and American Society of Anesthesiologists grades (all P > 0.050). At meta-analyses, patients receiving TAP block had significantly reduced post-operative visual analogue scores (VAS) at 0–60 min (mean difference (MD), − 1.23; 95% confidence interval (CI), − 1.87 to − 0.58; P < 0.001), 2 h (MD, − 1.78; 95% CI, − 3.28 to − 0.27; P < 0.001), 4 h (MD, − 1.00; 95% CI, − 1.24 to − 0.76; P < 0.001), 6 h (MD, − 1.58; 95% CI, − 2.46 to − 0.69; P < 0.001), 12 h (MD, − 1.13; 95% CI, − 1.80 to − 0.46; P = 0.001), and 24 h (MD, − 0.77; 95% CI − 1.42 to − 0.12; P < 0.001) respectively. At meta-analysis, a non-significant difference was observed for breakthrough analgesia consumption, time to rescue analgesia, post-operative nausea and vomiting, time to ambulation, length of stay, and post-operative complications. Patient satisfaction scores were significantly in favour of TAP block (MD, 0.88; 95% CI, 0.49–1.28; P < 0.001). Conclusion: TAP block significantly reduced post-operative pain and improved patient satisfaction following sleeve gastrectomy. TAP block should be considered for patients undergoing this procedure, should expertise allow.