Context: The importance of upper gastrointestinal (UGI) contrast study following sleeve gastrectomy (SG) is equivocal. It can, however, yield anatomical and functional details, the significance of which mostly remains unknown. Settings and Design: This prospective, single-center study included SG patients between January 2018 and January 2019. Materials and Methods: UGI contrast study was done on post-operative day 1. The findings of the study namely gastroesophageal junction (GEJ) holdup time, presence of fundus, gastroduodenal emptying (GDE) time, and sleeve shape were compared with weight loss, improvement of glycosylated hemoglobin (HbA1c) and gastroesophageal reflux disease (GERD) symptoms at 3, 6, and 12 months follow-up. Results: There were 138 patients with 100% follow-up. Radiological sleeve patterns observed were: tubular (62.3%), superior (16.0%), and inferior (21.7%) pouches. GEJ holdup time had no effect on percentage total weight loss (%TWL) (P = 0.09) or HbA1c improvement (P = 0.077). The absence of fundus led to greater %TWL at 6 months (P = 0.048). GDE time <15 s led to higher %TWL (P = 0.028) and lower HbA1c (P = 0.010) at 12 months. Antrum size <2 cm was associated with higher %TWL (P = 0.022) and lower HbA1c level (P = 0.047) at 12 months. Vomiting and regurgitation were common with tubular sleeves. Conclusion: UGI contrast study can predict weight loss, HbA1c improvement, and GERD symptoms. The absence of fundus, small antrum, and rapid GDE are associated with better weight loss. HbA1c improvement is better with small antrum and rapid GDE. Tubular sleeve predisposes to vomiting and regurgitation.

Introduction: Carpal Tunnel syndrome (CTS) is a common medical condition that occurs when the median nerve is compressed at the carpal tunnel. Many people, particularly females, in the general population are affected with CTS. This study aims to determine the level of awareness of CTS among dental professionals in India and Malaysia.

S53 Figure 1Rates of mortality against cumulative number of antibiotics received per patient during inpatient spell.[Figure omitted. See PDF]ConclusionIn both COVID-19 waves, antibiotic administration correlated to increased inpatient morbidity and mortality. Given a near-linear relationship of mortality and cumulative antibiotic numbers, antimicrobial stewardship is essential, and tapering an appropriate therapy for likely responsible pathogens will yield lower mortality compared to overlapping coverage and inappropriate escalation. We strongly discourage the use of empirical antibiotics without supporting biochemical evidence of bacterial co-infection for possible future COVID-19 waves.ReferenceRussell C, et al. Lancet Microbe. 2021 Jun 2. https://doi.org/10.1016/S2666-5247(21)00090-2

Background Procalcitonin (PCT) is an established biomarker of acute bacterial infection, and elevated levels of PCT may correlate with increased severity in patients with COVID-19 infection.1 Here, we assess if initial PCT levels are a viable prognostic marker to predict significant morbidity and mortality outcomes for hospitalised patients admitted due to COVID-19 infection. Method We performed retrospective analysis of initial blood results taken from 1189 patients with RT-PCR positive COVID-19 infection presenting to our District General Hospital between 1st November 2020 and 28th February 2021. Mortality encompassed both inpatient and within 28 days post-discharge. Significant morbidity was defined as admission to the Intensive Care Unit (ICU) for organ support. PCT was measured using Brahm's chemiluminescent micro particle assay (CMIA). Elevated PCT was defined at two levels: PCT ≥0.5µg/L and PCT ≥0.2µg/L, to account for variance amongst literature.2 Regression analysis was performed to determine independent significance, accounting for comorbidity and demographics. Results We found elevated PCT levels conferred a significant two-fold increase in mortality and ICU admission. Initial PCT ≥0.5µg/L was associated with a significantly increased risk of mortality than those with PCT <0.5µg/L (46.5% vs 24.2%; OR 2.847, p=0.0001). Significantly higher mortality risk was also observed when using lower cut-off values, i.e, PCT ≥0.2µg/L vs PCT <0.2µg/L (OR 2.042, p=0.00001). A significantly higher rate of ICU admission for initial PCT ≥0.5µg/L (OR 2.041, p=0.007) or PCT ≥0.2µg/L (OR 1.918, p=0.0008) was also observed within our cohort. Conclusions Here, we report the largest single-centre study to date in analysing a UK-based population for procalcitonin in COVID-19. We observed a significant correlation between elevated initial levels of PCT and incidence of ICU admission and mortality within our cohort, thereby demonstrating promise for PCT as an effective prognostic marker. Using a higher cut-off for PCT ≥0.5µg/L increased mortality by almost 50%, but had no effect on morbidity. We suggest that a lower universal cut-off point for PCT should be used for detecting secondary bacterial infections and procalcitonin-guided antimicrobial therapy. References Hu R, et al. International Journal of Antimicrobial Agents 2020;56(2):106051. Vazzana N, et al. Acta Clin Belg. 2020 Sep 23:1–5.

Background Coronavirus infection (COVID-19) typically presents with mild symptoms;however, 15% of patients develop significant illness with up to 5% overall mortality Hence, there is an urgent and unmet need for identifying definitive pharmacological interventions Repurposing of Azithromycin presents encouraging early findings given its antiinflammatory properties and proven antiviral efficacy during the Ebola and Zika virus outbreaks To date, studies are limited to using Azithromycin and Hydroxychloroquine in conjunction Here, we present our findings on the isolated use of Azithromycin in the management of COVID-19 Methods We performed retrospective analysis of patients admitted between 1st March and 20th June 2020 to one of the most pressurised Greater London District General Hospitals during the early stages of the pandemic Pearson's Chisquared test was utilised to compare mortality outcomes between two patient groups;those receiving Azithromycin (500 mg once daily, prescribed for five days) and those of a non-Azithromycin control group, comprising those with contraindication or allergy Independent T-test analysed length of stay Results Overall, 628 patients were analysed (mean age 71 6;41 9% female);448 (71 3%) were COVID-19 PCR swab positive, and an additional 70 (11 1%) had negative PCR but positive radiology 394 (62 7%) received Azithromycin, whilst 234 (37 3%) constituted the non-Azithromycin control group We observed notably improved mortality rates in Azithromycin patients (41 1%;162/394) compared to control patients (50 4%;118/234;p=0 14) Interestingly, length of stay was similar between Azithromycin administration (11 92±10 85) and control groups (10 82±12 30) Conclusion To our knowledge, this is the first large-scale analysis of Azithromycin as a stand-alone pharmacological treatment of COVID-19 The combination of Hydroxychloroquine and Azithromcyin has been widely discussed, however mortality data is adversely skewed by significant antagonistic cardiac side-effects which hinders interpretation of their individual therapeutic efficacy Our preliminary results suggest, whilst just shy of statistical significance, a short course of Azithromycin in COVID-19 patients may reduce mortality, without negatively impacting length of stay This highlights the need for prospective validation of this data with randomised control trials;preceding this, we advocate the use of Azithromycin in clinically selected patient populations until other licensed therapies become available

Background Recent multicentre registries have shown cancer patients infected with SARS-CoV-2 have significantly higher mortality compared to patients without cancer1. Cancer-specific features associated with worse outcomes include advanced tumour stage, disease progression and lung cancer.1 Systemic anti-cancer treatments (SACT – chemotherapy, immunotherapy, targeted and hormone therapy) have been postulated to increase mortality from COVID-19 in cancer patients. Here, we aim to determine if cancer patients on SACT have a higher risk of mortality than those not on active treatment. Methods We retrospectively analysed cancer patients admitted to a Greater London District General Hospital between 1st November 2020 and 28th February 2021 with RT-PCR positive COVID-19. SACT was considered present if administered within 3 months of admission. Mortality encompassed hospitalised patients and those up to 28 days post-discharge. Association of cancer-specific demographics and mortality was assessed using logistic regression analyses adjusting for age, sex and comorbidities. Results Mortality rate was significantly higher in 122 cancer patients with COVID-19 than 1220 patients without cancer (OR 1.653, p=0.014), especially in patients with lung cancer (OR 4.664, p=0.002). 55 patients diagnosed with cancer within one year had a significantly higher mortality (OR 2.32, p=0.004). Stage 4, but not earlier stages of, cancer at diagnosis had much higher mortality (OR 2.82, p<0.001). Progression of cancer was highly predictive of mortality (OR 4.60, p=0.00002). SACT had no significant effect on mortality from COVID-19 disease when compared with cancer patients who had no active treatment. However, cancer patients that did not have SACT within 3 months were more likely to die (OR 1.80, p=0.025). Conclusion Among patients with cancer and COVID-19, mortality was high and associated with cancer-specific features. There was no evidence cancer patients on systemic anti-cancer treatments possessed higher mortality from COVID-19 disease, which correlates with findings from COVID-19 and cancer registries1. Patients that did not receive SACT within 3 months before COVID-19 and therefore more likely to have palliative treatment did demonstrate high mortality. Larger studies are needed to confirm the risk of mortality and timing of SACT before COVID-19 disease. Reference Lee AJ, et al. British Journal of Cancer 2021;124:1777–1784.

INTRODUCTION:Data on laparoscopic treatment of operable gastric cancer from India is sparse. This study aims to document outcomes of laparoscopic D2 gastrectomy in an Indian population.MATERIALS AND METHODS:Data of patients who underwent laparoscopic D2 gastrectomy for operable advanced gastric cancer between February 2012 and January 2017 were collected from electronic hospital records supplemented by telephonic interviews and analyzed. Survival was evaluated using Kaplan-Meier survival analysis curves.RESULTS:In total 121 patients were included. Conversion to open gastrectomy was 5.7%. One hundred and fourteen patients (73 laparoscopic subtotal gastrectomy and 41 laparoscopic total gastrectomy) were included for analysis. D2 lymphadenectomy was done in all cases; mean number of dissected lymph nodes was 23.12 ± 9.14 (12-45). Major complications (Clavien-Dindo Grade III and IV) was seen in 6.1% of cases with reoperation rate of 3.5% (4/114). Stage 3 disease was seen in 60.6% cases and stage 2 disease in 32.5%. Follow-up data were available for 76.3% of patients with mean follow-up of 29.5 months. Overall survival across all stages was 38.7 months. Five-year disease-free survival and overall survival were 36.7% and 55.9% respectively, across all stages.CONCLUSION:Laparoscopic D2 gastrectomy is safe, feasible with similar postoperative complications and comparable survival outcomes across all stages when compared to available literature on open gastrectomy cases.

Background Bacterial infection has previously been observed in only 8% of COVID-19 patients,1 yet antibiotics are administered to 85% of inpatients. Typically, Gram negative organisms and Staphylococcus aureus are isolated as responsible pathogens.2 Here, we investigate the rates of bacterial infection during the second UK COVID-19 wave, its sources, the responsible organisms, and its impact on morbidity and mortality. Methods 1342 RT-PCR positive COVID-19 patients admitted to a Greater London District General Hospital between 1st November 2020 and 28th February 2021 were retrospectively analysed (44.6% female; mean age 68.8; mortality 26.9%). Mortality encompassed hospitalised patients and those up to 28 days post-discharge. Morbidity was assessed by length-of-stay and need for intensive care. Positive cultures due to contaminants were excluded. Independent correlation was assessed with multilinear regression analysis adjusting for demographics and comorbidities. Results 226 patients (16.8%) with COVID-19 had ≥1 bacterial infection. These patients possessed significantly higher independent mortality (35.0% vs. 25.3%, p<0.009), more frequently required intensive care support (19.5% vs 10.6%, p<0.00004), and required longer inpatient spells (19.6 days vs 9.46 days, p<0.0001). Greater number of positive culture types cumulatively increased mean length-of-stay (OR 9.08, p<0.00001); ≥2 culture type positivity (n=44) related to 31.5 days; ≥3 culture type positivity (n=12) 46.0 days. There was significantly higher mortality rate in patients receiving ≥1 antibiotic (30.2%) compared to no antibiotics (6.4%, p<0.00001). Conclusion Bacterial infection is observed far more frequently in COVID-19 patients than previously reported and adversely affects morbidity and mortality. Multiple sites of bacterial infection prolongs inpatient stay and increases mortality. Thorough culture collection should be encouraged in COVID-19 patients with biochemical evidence of bacterial infection to identify responsible pathogens and respective antimicrobial sensitivity. Given the higher mortality rates, empirical use of antibiotics in COVID-19 patients without supporting evidence of bacterial infection is strongly discouraged. References Lansbury, et al. J Infect. 2020 Aug;81(2):266–2. Russell C, et al. Lancet Microbe. 2021 Jun 2. https://doi.org/10.1016/S2666-5247(21)00090-2

BackgroundVitamin D plays a vital part in modulating the immune system, with Vitamin D deficiency leading to increased susceptibility to infection.1 There is some evidence to suggest Vitamin D may play a protective role in the prevention of COVID-19 infection in hospitalised patients,2 but the topic remains controversial. Our study aims to investigate if low Vitamin D levels correlate with increased risk of COVID-19 infection, thereby representing a modifiable risk factor for COVID-19 infection.MethodA retrospective observational study was conducted on 3198 health care workers of a Greater London District General Hospital, who had undergone testing for 25-OH Vitamin D levels and COVID-19 antibody in June 2020. In accordance with NICE guidelines, Vitamin D deficiency was defined as less than 25 nmol/L, insufficiency as 25–50 nmol/L, and those with levels over 50 nmol/L were used as control comparisons. Evidence of previous SARS-CoV-2 infection was assessed by detection of SARS-CoV-2 IgG antibodies. Regression analysis was performed to determine independent significance, accounting for age and gender.Results3191 participants were included in this study, with age ranging from 19–78 years (mean 42.9) of which 78.2% were female. Both age and gender were not independently associated with positive SARS-CoV-2 IgG antibodies. 1997 (62.6%) participants had Vitamin D levels within the normal range, 899 (28.2%) participants had insufficient levels and 302 (9.4%) had Vitamin D deficiency. Both Vitamin D deficiency (OR 1.61, p=0.002) and insufficiency (OR 1.33, p=0.006) independently correlated with significantly increased incidence of positive COVID-19 antibodies than personnel with normal Vitamin D levels.ConclusionsWe report the largest single-centre study investigating the impact of low Vitamin D levels within healthcare workers to date. Significant correlation between low levels of Vitamin D and previous COVID-19 infection was identified. Oral Vitamin D supplementation to maintain levels >50 nmol/L may play a protective role against COVID-19. Larger studies are needed to investigate the role of Vitamin D supplementation in healthcare workers for further COVID-19 waves.ReferencesAranow C, et al. Journal of Investigative Medicine 2011;59:881–886.Nogues X, et al. J Clin Endocrinol Metab. 2021 Jun 7:dgab405.

Laparoscopic Roux-en-Y gastric bypass (RYGB) is the oldest and most widely performed bariatric surgery worldwide. There is, however, a scarcity of mid- to long-term data of RYGB, especially from the Indian subcontinent. The study was a single-center, retrospective analysis from patients who underwent RYGB between January 2009 and November 2014 from a tertiary care center in India. Percent of total weight loss (%TWL) was taken as the primary outcome of the study. Secondary outcomes included type 2 diabetes mellitus (T2DM) remission, comorbidity resolution, revisional surgeries, and complications related to RYGB at 1 year, at 3 years, and during the long term, following surgery. Postoperative visits took place at 1 and 3 years, while the long-term outcome was at median 8.3 years (range 5.4–11.2 years), with a follow-up of 92.4% (488/528), 80.5% (424/527) and 69.5% (363/522), respectively. Out of 528 patients studied, 56% were females. The mean body mass index (BMI) was 40.6 ± 6.9 kg/m2. The %TWL in the long-term follow-up was 21.8 ± 11.3%. T2DM remission rates at 1 year, at 3 years, and during the long term were 84.5%, 70.0%, and 60.0%, respectively. Preoperative HBA1c (p = 0.002) and insulin usage (p = 0.016) had a significant predictive effect on T2DM remission. Gastroesophageal reflux disease (GERD) improved significantly (p < 0.001). Early (< 30 days) and late (> 30 days) complications were observed in 2.3% and 4.3% of the patients, respectively. Weight loss during mid to long-term follow-up was maintained in the majority of the patients after RYGB. However, a small proportion had significant weight regain in the long term. T2DM, GERD, and other comorbidities were well improved after RYGB.

Introduction: Rapid emergence from anaesthesia and postoperative recovery of cognitive function is one of the most important requirements of a day care surgery. Propofol is a near-ideal intravenous anaesthetic agent for day care surgeries due to its pharmacological properties. Similarly, amongst inhalational anaesthetic agents, sevoflurane is the preferred agent due to low blood-gas solubility. Aim: To evaluate sevoflurane and propofol for general and psychomotor recovery profile in day care anaesthesia techniques. Materials and Methods: This randomised clinical trial was conducted at GGS Medical College and Hospital, Faridkot, Punjab after getting approval by Institutional Ethical Committee. A total of 70 American society of Anaesthesiologists’ (ASA) Grade I and II patients aged 18-60 years, scheduled to undergo elective day care surgery under general anaesthesia were enrolled. In group A (n=35) anaesthesia was induced with propofol 2 mg/kg intravenously and maintained with variable-rate propofol infusion. In group B (n=35) anaesthesia was induced with sevoflurane 8% and maintained with sevoflurane. In both the groups general {mean time to remove Laryngeal Mask Airway (LMA), emergence, time to responds to commands, mean orientation time} and psychomotor recovery profile was evaluated using unpaired student’s t-test and Chi-square test. Results: Mean Time to remove LMA in Group B was earlier being 5.30±1.23 minutes vs 8.65±2.40 minutes in group A (p<0.001). Mean emergence time in Group B was 5.83±1.23 minutes and in Group A was 8.87±2.42 minutes (p<0.001). Time to respond to commands in Group B was 6.81±1.39 minutes and in Group A was 10.01±2.52 minutes (p<0.001). Mean Orientation time in Group B was 7.15±1.53 minutes and in Group A was 10.76±2.61 minutes (p<0.001). Psychomotor recovery was also faster with sevoflurane as compared to propofol. Conclusion: Both sevoflurane and propofol are useful agents for day care surgery. Sevoflurane provides a rapid return of psychomotor and cognitive ability as compared to propofol.

The enhanced recovery after surgery (ERAS) pathway is an evidence-based perioperative pathway that results in less pain, earlier recovery, and lower complication rates. Studies to prove their efficacy over standard recovery pathways in the Indian population are scarce. Our study intends to compare the outcomes of these pathways in the Indian community focusing on hospital stay, postoperative pain, and time for rescue analgesia. This is a single-blinded RCT involving 112 patients who underwent laparoscopic sleeve gastrectomy (LSG). The groups were divided into ERAS and standard pathway arms by closed envelope technique. The primary outcome was the length of hospital stay, while the secondary outcomes included pain score; postoperative nausea, and vomiting (PONV); time for rescue analgesia; and ambulation. Of 112 patients included, 56 were allocated in the ERAS group, and the remaining 56 were included in the standard pathway group. We found no significant differences in the baseline characteristics between the two groups. Mean hospital stay was significantly lower in the ERAS group compared to the standard group (p = 0.003). In comparison to the standard group, ERAS patients were ambulated early, and the difference was highly significant (p < 0.001). Pain scores between the two groups showed a significant difference during the 4th hour and 8th hour. We also found a significant variation between the time for first rescue analgesia and the two groups (p < 0.001). Patients who followed ERAS protocol were found to have shortened hospital stay, decreased pain, early ambulation, and reduced need for rescue analgesia. ClinicalTrials.gov Identifier: NCT03191318

INTRODUCTION:Obesity has a derogatory effect on female reproductive health. Obesity contributes to difficulty in natural conception, increased risk of pregnancy-associated complications, miscarriages, congenital anomalies, and also the long-term negative impact on both mother and the child. OBJECTIVES:Our study aimed to analyze and assess the reproductive health-associated outcomes of females who underwent bariatric surgery. METHODS:We performed a retrospective analysis from a prospectively collected database from June 2013 to June2016. Out of 71 females studied, 45 patients (63.5%) had completed 3 years of follow-up. The data were collected from inpatient and outpatient records. Patients were studied under three groups (A, patients with polycystic ovarian disease (PCOD) symptoms; B, patients with primary infertility; and C, patients who conceived after bariatric surgery that were included in groups A and B). RESULTS:Out of 45 patients studied, 40 patients underwent laparoscopic sleeve gastrectomy (LSG), four patients underwent laparoscopic Roux-en-Y gastric bypass (RYGB), and one patient underwent laparoscopic adjustable gastric banding (LAGB). The mean BMI of the patients was 43.64 ± 6.8 kg/m2. PCOD symptoms improved symptomatically (p = 0.001) after surgery in the group. Seven (43.75%) primary infertility patients conceived after surgery. Three (42.9%) patients conceived naturally while 4 (57.1%) conceived with ART in group B. Out of total population of 45 in group C, percentages of patients who delivered baby with short gestational age (SGA), low birth weight (LBW), normal vaginal deliveries (NVD), and maternal anemia were 63.15%,47.3%,73.4%, and26.3%, respectively. CONCLUSION:Obesity is closely associated with primary infertility and PCOD. Menstrual abnormalities associated with PCOD significantly improve after bariatric surgery with significant improvement in fertility along with maternal outcomes.

Background: Gastric gastrointestinal stromal tumours (GISTs) are rare neoplasms that require excision for cure. Although the feasibility of laparoscopic resection of smaller gastric GIST has been established, the feasibility and long-term efficacy of these techniques are unclear in larger lesions. This study is done to assess the feasibility of the laparoscopic resection of gastric GISTs and their long-term outcomes. Methods: Patients who underwent laparoscopic resection of gastric GISTs were identified in a prospectively collected database. Outcome measures included patient demographics, operative findings, morbidity and histopathologic characteristics of the tumour. Patient and tumour characteristics were analysed to identify risk factors for tumour recurrence. Results: There were 42 patients with a mean age of 56.7 years and had a mean tumour size was 4.5 ± 2.7 cm. Laparoscopic wedge resection was the most common procedure done. There were no major perioperative complications or mortalities. All lesions had negative resection margins. At a mean follow-up of 48 months, 36/39 (92.3%) patients were disease free and 3/39 (7.6%) had progressive disease. Univariate analysis showed that there was a statistically significant association of disease progression with tumour size, high mitotic index, tumour ulceration and tumour necrosis. The presence of >10 mitotic figures/50 high-power field was an independent predictor of disease progression. Conclusion: Our study establishes laparoscopic resection is feasible and safe in treating gastric GISTs for tumours >5 cm size. The long-term disease-free survival in our study shows acceptable oncological results in comparison to historical open resections.

Purpose Bariatric procedures reduce the capacity of the gut and alter the gastrointestinal transit time predisposing to micro-nutritional deficiencies. This study analyzed and compared the micro-nutritional parameters following laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB) in the Indian population. Materials and Methods This is a retrospective study of patients who underwent LSG or RYGB for morbid obesity at a tertiary care center between January 2015 and December 2016. The micronutrient parameters, namely, serum ferritin, vitamin B12, ionized calcium, vitamin D3, and parathormone (PTH) in the preoperative settings and subsequently at 1, 2, and 3 years were analyzed. Results A total of 390 patients were studied, of which 258 (66.15%) underwent LSG while 132 (33.85%) underwent RYGB. Baseline micronutrient parameters were comparable in the two groups. Anemia (58.1% vs. 59.1%), deficiencies of ferritin (31.7% vs. 34.3%), vitamin B12 (18.8% vs. 36.4%), ionized calcium (65.1% vs. 72.7%), vitamin D3 (95.3% vs. 90.9%), and secondary hyperparathyroidism (45.5% vs. 58.1%) were seen following LSG and RYGB at the end of 3 years, respectively. There was no significant difference found between LSG and RYGB in terms of micronutrient deficiencies studied, including rising in PTH at 1, 2, and 3 years. Vitamin D3 levels were significantly lower at 2 and 3 years following RYGB ( p = 0.035 and p = 0.032, respectively). Conclusion LSG and RYGB have comparable micronutrient deficiencies in the short- and mid-term except for vitamin D3, which is higher following RYGB. Long-term studies are needed to define optimum micronutrient supplement dosages for the Indian population.

Posterior gastric vessel is commonly encountered (4–99%) during surgery of the stomach, spleen, and pancreas. Due to high variations in its origin, and course, it has not been unanimously described in literature. Its significance in bariatric surgery is largely neglected. We reviewed videos of 100 bariatric surgery cases done in our institute. This vessel was noted in 88 cases. We could identify the vessel in 54/63 LSG cases and all cases required division to free the fundus. It was identified in 34/37 RYGB cases. Thirty-one cases required lateralization while 3 cases required division due to more medial origin of the vessel. Its division or lateralization facilitates adequate mobilization of fundus to achieve the ideal configuration of sleeve in LSG and pouch in LRYGB.