Research & Publications

Summary

Endoscopic sleeve gastroplasty reshapes the stomach into a narrow tube using stitches placed through the mouth with an endoscope — no incisions, and no part of the stomach removed. It is offered to people who do not qualify for weight-loss surgery, or who would rather avoid it. This study followed 61 adults treated at a public hospital in Kuwait, the first such report from the country. Their average starting weight was 84 kg, with a BMI of 32.5. Weight came off steadily across the year: 10.6% of body weight by three months, 13.4% by six, and 16.1% by twelve months among the 49 people still being followed. More than half had lost over 15% of their weight at a year, and ten reached a BMI in the normal range. Side effects were mild — lasting nausea, constipation, and one stomach ulcer treated without surgery — and no patient needed an operation to correct a problem. Eleven patients were also taking semaglutide or tirzepatide and did not lose noticeably more than the rest. The authors note that the group was small, followed for only a year, and that cost and a shortage of trained specialists limit access in Kuwait.

Summary

Weight-loss injections are often compared with weight-loss surgery, but the two are rarely tested side by side. This laboratory study did exactly that — in rats, not people. Researchers in Kuwait fed rats a high-fat, high-sugar diet until they became obese, then divided them into groups: sleeve gastrectomy surgery, daily semaglutide, daily tirzepatide at one of three doses, and an untreated comparison group. Six weeks later, the surgery group had lost 15.5% of their body weight and the semaglutide group 10.7%. Tirzepatide's effect depended on the dose: the lowest dose produced only 5.0% weight loss, while the middle and highest doses produced 14.9% and 17.7%, matching or exceeding surgery. All the treatments improved how well the animals handled a sugar load, shrank their fat stores, and reduced the fat build-up in the liver that causes fatty liver disease. The highest tirzepatide dose gave the strongest results overall, including a drop in the deeper abdominal fat linked to insulin resistance. The authors stress that this was a short animal experiment, that the doses used cannot be translated directly to people, and that studies in humans are needed before any conclusions are drawn about patients.

Summary

People fitted with a gastric balloon lose very different amounts of weight. In this group the results ranged from a 23% loss of body weight to a 7% gain. Diet and activity explain much of that spread, but genes may play a part too. Researchers at Kuwait University examined one common variation in the BDNF gene, which helps regulate appetite and the sense of fullness. They collected saliva samples from 106 adults treated with a gastric balloon at a Kuwait City clinic, then compared the genetic results with weight loss at three months in the 71 people who came back for follow-up. Those carrying two copies of the A version of the gene lost an average of 11.6% of their body weight; those with one copy lost 8.7%, and those with two copies of the G version lost 5.1%. The same pattern appeared across three different ways of measuring weight loss. The authors suggest the G version may be linked to weaker fullness signals. This is early work: only six people carried two G copies, a third of participants did not return, and diet was not recorded. It is not yet a test that can predict who will succeed.

Summary

Gastric balloons are a temporary, non-surgical option for people who want to lose weight but don't qualify for bariatric surgery, or don't want it. A soft balloon sits in the stomach so the person feels full sooner. This study from a private clinic in Kuwait compared two fluid-filled types in 358 adults. The Elipse is swallowed as a capsule, needs no endoscopy or sedation, and empties by itself after about four months. The Orbera365 is placed and removed by endoscopy under anaesthetic and stays in for a year. At the four-month mark the two performed almost identically, with around 10% of body weight lost. By the end of each treatment the Orbera365 group had lost more — 14.7% at twelve months, against 10.0% for the Elipse — but the researchers put this down to the longer time in place rather than the balloon itself. The trade-off was tolerance: 9.7% of Orbera365 patients needed the balloon taken out early, compared with 3.4% of Elipse patients, usually because they could not cope with it. Four patients across both groups developed pancreatitis. The study looked back at existing records, and weight regain after removal was not tracked.

Summary

Fatty liver disease — a build-up of fat in the liver unrelated to alcohol — now affects an estimated 38% of adults and 13% of children worldwide, making it the most common liver disease in history. Research has advanced considerably, but the effort has been scattered. This project set out to agree on what should be studied next. Nine chairs drafted an initial list of research priorities, which 40 core authors debated at a three-day meeting in the UK. A worldwide panel of experts then reviewed and voted on the list in two rounds: 344 people took part in the first and 288 in the second, drawn from more than 90 countries. The result is 28 agreed priorities across six areas — the harm the disease causes, how care is organised, treatment, education, patients' own perspectives, and policy. Five priorities were backed unanimously and the rest by more than 90% of the panel. The highest-ranked included long-term studies following patients over time, better non-invasive tests to replace liver biopsy, and identifying what doctors outside liver medicine need to know. The panel was mostly academic and based in wealthy countries, and the survey ran in English.

Summary

Sleeve gastrectomy is an effective operation, but some patients regain weight afterwards or never lose as much as they hoped. This study asked whether liraglutide, a daily injectable medicine approved for weight management, can help. Records from 57 patients at a private clinic in Kuwait were reviewed. All had previously had a sleeve gastrectomy, falling from an average of 121.5 kg to 77.8 kg, but had since climbed back to 96.1 kg. Most were women and the average age was about 37. After roughly three months on liraglutide, the average weight was 90.2 kg — a loss of 5.9 kg, or about 6% of body weight. Slightly more than half the patients lost at least 5%. Those who could tolerate a higher dose lost more: around 8%, compared with just over 4% on lower doses. Patients in their thirties responded best. Only about four in ten reached the full recommended dose of 3 mg a day, and the records rarely explained why doses were reduced. The study looked back at existing records, had no comparison group and followed patients only briefly. It was funded by Novo Nordisk, the company that makes liraglutide.

Summary

Sleeve gastrectomy — an operation that removes a large part of the stomach — helps people lose weight and often improves blood sugar control quickly, well before much weight has come off. Why this happens is not fully understood. This laboratory study used rats to examine the gut hormones involved. The rats were fed either standard food or a "cafeteria" diet of highly palatable foods and sugary drinks, which left them roughly 35% heavier. Some of the heavier rats then had a sleeve gastrectomy, some had a dummy operation, and some had no surgery. A month after the operation, the sleeve gastrectomy rats weighed considerably less than the other heavy rats and about the same as the lean ones. Their livers held far less fat, although still more than the lean rats' livers. After a test meal, they released more of three hormones: GLP-1 and GIP, which help control blood sugar, and — unexpectedly — glucagon, which normally raises it. The authors caution that the laboratory test used may also detect closely related molecules rather than glucagon itself, so this finding needs confirmation. Food intake after surgery was not recorded, which limits what can be concluded about the weight loss.

Summary

Sleeve gastrectomy is one of the most effective treatments for obesity, but some people gradually regain weight in the years that follow. The usual solution has been a second, more complex operation, which carries higher risks. This study from a private clinic in Kuwait asked whether weight-loss injections could be an alternative. The researchers reviewed 115 adults who had regained at least 10% of the lowest weight they reached after their sleeve. Seventy were treated with semaglutide and 45 with tirzepatide, alongside a high-protein diet and a daily walking goal. After six months, the semaglutide group had lost an average of 10.3% of their body weight and the tirzepatide group 15.5% — roughly half of the weight they had regained. Almost all tirzepatide patients (97%) lost at least 5% of their weight, compared with 80% of those on semaglutide. Side effects such as nausea, fatigue and constipation were mild, and nobody stopped treatment because of them. The authors caution that follow-up was short, the groups were small, there was no comparison group, and weight tends to return once the medication is stopped. These medications are also expensive, which can limit who is able to stay on them.

Summary

Weight-loss surgery does more than shrink the stomach — it changes the body's chemistry. This study followed what happens to a group of proteins involved in burning energy and controlling inflammation. Forty adults in Kuwait took part: 20 with severe obesity who underwent weight-loss surgery, most of them a sleeve gastrectomy, and 20 people of normal weight for comparison. Blood was taken before surgery and again at six and twelve months. Average weight fell from 111.7 kg before surgery to 86.4 kg at six months and 79.2 kg at one year, with body mass index dropping from 39.7 to 27.9. Every patient who had a related condition — diabetes, high blood pressure, sleep apnoea, fatty liver or polycystic ovary syndrome — reported improvement or complete resolution. C-reactive protein, a marker of inflammation, fell steadily throughout. Inside the immune cells, the proteins behaved in distinct ways. METRNL and irisin rose at six months and eased back by one year, while UCP2 — thought to shield cells from stress — kept climbing. UCP1 and UCP3 returned to normal levels. The pattern suggests surgery works partly by changing how cells handle energy and inflammation.

Summary

Bones and muscles do more than hold the body up — they also release hormones that influence metabolism. This study asked whether two such hormones, irisin and meteorin-like protein (METRNL), which come mainly from muscle and fat tissue, are linked to markers of bone health in people with obesity and type 2 diabetes. Blood samples from 228 adults in Kuwait were analysed: 104 with type 2 diabetes and 124 without. Four bone-related proteins were measured — osteoactivin, osteoprotegerin (OPG), osteonectin (SPARC) and syndecan. All four were higher in people with diabetes than in those without. Osteoactivin and OPG were also higher in people with obesity, whether or not they had diabetes. Among participants without diabetes, higher irisin levels went together with higher osteoactivin and OPG, and higher METRNL went together with higher osteoactivin. The results point to a two-way exchange of signals between muscle, fat and bone that appears disturbed in obesity and diabetes, and may help explain why these conditions are linked to weaker bones and loss of muscle. Because all participants were tested at a single point in time, the study cannot show cause and effect, and further research is needed.

Summary

Setting up a liver transplant program is difficult for any country with a small population, because it requires not just skilled surgeons but a whole team of specialists — and enough cases to keep their skills sharp. This article tells the story of how Kuwait launched its own liver transplant program. Kuwait has a long history in transplantation, performing the Gulf region's first living-donor kidney transplant back in 1979. But until recently, patients needing a new liver had to travel abroad, usually to the United States or United Kingdom, at enormous cost to the government and often with long waits — some patients died before ever reaching a transplant list. The need was growing, driven largely by fatty liver disease linked to obesity, which is common in Kuwait. After years of planning, Kuwaiti doctors partnered with King's College Hospital in London, whose specialist team flew in to work alongside local surgeons. The first successful liver transplant in Kuwait took place in January 2018, and ten more followed. Ten of the eleven patients remained alive with working transplants. The authors describe this partnership model as a practical way for smaller countries to build such programs safely, while noting that expanding organ donation remains a challenge.

Summary

Most people who catch COVID-19 recover with only mild illness, but a smaller number become seriously ill. During the pandemic, doctors needed a quick way to spot — right at the moment of diagnosis — which patients were likely to get worse, so hospital beds and resources could be directed to those who needed them most. This study from Kuwait set out to build exactly such a tool. Researchers analyzed data from 643 COVID-19 patients at Jaber Al-Ahmad Al-Sabah Hospital, where everyone who tested positive was admitted, including those with no symptoms. Using a machine-learning method, they identified six simple factors measurable from a blood test and the patient's age that together predicted who would develop severe disease: age, and levels of CRP, procalcitonin, lymphocytes, monocytes, and albumin. From these, they created a simple point-based tool called the Kuwait Progression Indicator (KPI) score, which sorts patients into low, uncertain, or high risk. The score proved accurate not only in Kuwait but also when tested against separate patient data from Wuhan, China. The researchers made the calculator freely available online so clinicians anywhere could use it to prioritize care during the pandemic.

Summary

Doctors in Kuwait studied a newer weight-loss device called the Orbera365 — a soft balloon placed in the stomach through an endoscope (a thin camera tube) and left in place for up to 12 months, roughly twice as long as older balloons. Ninety-seven adults had the balloon fitted between September 2019 and August 2020. Most were women, and the average age was 31. Before the procedure patients weighed 93.8 kg on average. By around eight months the average had fallen to 80.6 kg, and at the final check-up about 13 months later it was 82.4 kg — a loss of roughly 16% of total body weight, or about 55% of excess weight. Side effects were common: around half had abdominal pain and about two-thirds had nausea and vomiting in the days after insertion. Fourteen patients could not tolerate the balloon and had it removed early. Less common problems included balloon leakage or deflation, and two cases of pancreatitis (inflammation of the pancreas). Overall, roughly one in four patients had some complication. The authors conclude that the Orbera365 is effective for weight loss, but larger studies are needed to confirm how safe it is. This was the first published research on the Orbera 365.

Summary

Non-alcoholic fatty liver disease (NAFLD) — a build-up of fat in the liver that is not caused by alcohol — affects roughly a quarter of adults worldwide, yet it barely appears in national health plans. This paper reports an international effort to change that. Led by the EASL International Liver Foundation, a core group of 33 experts guided a panel of 218 specialists from around the world through three rounds of anonymous surveys between December 2020 and March 2021, using a method called Delphi that is designed to build agreement step by step. The panel included doctors, researchers, patient advocates and public health experts. The outcome was 37 agreed statements and 26 recommendations, supported almost unanimously. Among them: invest in better data, particularly on children; help family doctors and diabetes specialists recognise advanced liver scarring; create clear referral pathways; offer structured programmes to support weight loss; involve patient groups and confront the stigma attached to liver disease and obesity; write NAFLD into national plans for chronic diseases; and dedicate a World Health Day to liver health. Because the whole process was conducted in English, the make-up of the panel may not fully represent every region.

Summary

Early in the COVID-19 pandemic, Kuwait took an unusual approach: it screened incoming travelers and anyone who had been in contact with infected people, then hospitalized everyone who tested positive — even those with no symptoms — at a single hospital. This gave researchers a rare chance to study the full range of the disease, not just severe cases. This study looked at the first 1,096 patients diagnosed with COVID-19 in Kuwait. Their average age was 41, and most (81%) were men. Notably, nearly half had no symptoms when admitted, and about 60% showed no signs of infection at all. Most had a mild course: only 3.6% needed intensive care, and 1.7% died. The researchers identified factors linked to more severe illness. Needing intensive care was associated with being over 50, smoking, and higher levels of certain inflammation markers in the blood. Death was linked to smoking, asthma, and one particular blood marker (procalcitonin). Because so many patients had mild or no symptoms, the study offered a more complete picture of COVID-19 than earlier reports that focused only on seriously ill patients. It also raised questions about whether fever alone is a reliable way to screen for the virus.

Summary

Obesity is a growing health problem worldwide, and when diet and lifestyle changes aren't enough, weight-loss (bariatric) surgery can help. This study from Kuwait looked at a procedure called one-anastomosis gastric bypass (OAGB), which reshapes the stomach and reroutes part of the digestive tract to reduce how much a person eats and absorbs. OAGB is relatively new to the Gulf region, so the researchers wanted to test how safe and effective it is when used as a patient's first weight-loss operation. They followed 40 patients (mostly women) for an average of about two and a half years. The results were strong: patients weighed 116 kg on average before surgery and dropped to around 75 kg — a loss of roughly a third of their body weight that held steady over time. The surgery also greatly helped with obesity-related conditions: patients with high blood pressure, diabetes, asthma, acid reflux, sleep apnea, or irregular menstrual cycles all saw their conditions either resolve completely or improve. Complications were rare — there were no ulcers, leaks, or narrowing, and just one patient experienced bile reflux, which was managed with medication. The authors concluded that OAGB is a safe and effective first-line option, this being the first such report from a Gulf country.

Summary

Weight-loss (bariatric) surgery is very common in Kuwait, one of the countries with the highest obesity rates in the world. The most popular procedure is the "sleeve gastrectomy," which removes part of the stomach. It works well at first, but some patients regain weight over the years. When this happens, doctors need a second operation to help. This study from Kuwait looked at one such option called "one anastomosis gastric bypass" (OAGB) — a procedure that reroutes the digestive tract. Researchers followed 56 patients (mostly women) who had this surgery after their sleeve operation failed. On average, patients weighed 112 kg before the bypass and dropped to about 85 kg afterward. Their weight loss improved steadily over the first year. The surgery also helped with related health problems: some patients with high blood pressure and diabetes were able to reduce or stop their medications. Serious complications were rare — two patients developed stomach ulcers, one of which was serious, but there were no deaths, leaks, or acid reflux problems. The researchers concluded that OAGB is a safe and effective option for patients who regain weight after a sleeve operation, though longer-term studies are still needed.

Summary

While most people with COVID-19 experience only mild illness, some become severely ill and need intensive care. Doctors have wondered which health conditions make a serious outcome more likely. This study from Kuwait examined whether obesity and diabetes raise the risk. Researchers reviewed the records of 1,158 patients hospitalized with COVID-19 at a single hospital and looked at who ended up needing intensive care (ICU). The findings were clear: patients who were overweight or obese were more likely to be admitted to the ICU, and the risk grew with higher weight — those with severe (morbid) obesity were around five times more likely to need intensive care than people of normal weight. Diabetes also stood out as a strong risk factor, making ICU admission several times more likely. Interestingly, when the researchers accounted for other factors, high blood pressure did not add to the risk and even appeared protective in their analysis, though this finding needs further study. The authors concluded that people with COVID-19 who also have obesity or diabetes should be treated as a high-risk group and monitored closely. Because these conditions are common in the Middle East, the findings are especially relevant to the region.

Summary

Type 2 diabetes and obesity are growing health problems worldwide, especially in the Arab region. This study from Kuwait looked at two hormones — Meteorin-like hormone (METRNL) and irisin — that are released by muscle and fat tissue and are thought to help the body burn energy and manage blood sugar. Researchers studied 228 Arab adults, some with type 2 diabetes and some without, and measured the levels of these two hormones in their blood. They found that people with type 2 diabetes had higher levels of both METRNL and irisin than people without diabetes. Levels were also higher in people who were obese compared to those who were not. Interestingly, the two hormones rose together — when one was high, the other tended to be high as well, a link that was especially clear in men. Both hormones were also connected to other markers of diabetes and obesity, such as body weight and cholesterol. The reason these "helpful" hormones are higher in diabetes is still unclear; it may be the body's attempt to fight the disease. More research is needed to understand their exact role.

Summary

A duodenal ulcer that bursts through the wall of the gut is a surgical emergency. It can be repaired in two ways: through one large abdominal cut (open surgery), or through several small cuts using a camera and fine instruments (keyhole, or laparoscopic, surgery). Keyhole repair is becoming more common, but many hospitals still do not use it as their first choice in emergencies, partly out of concern that it takes longer and may be riskier for very sick patients. Surgeons in Kuwait reviewed the records of 100 patients treated for a perforated duodenal ulcer at Mubarak and Amiri hospitals between 2009 and 2013. Keyhole surgery was started in 76 patients and completed without switching to open surgery in 64. Patients treated by keyhole surgery went home sooner (about 2.6 days versus 3.1). They also had fewer kidney injuries and less severe lung complications, and fewer needed intensive care. Overall, their chance of a smooth, complication-free recovery was about four times higher than after open surgery. The authors conclude that keyhole repair is safe and can be used routinely — including in patients with other health problems.

Summary

During the early months of the COVID-19 pandemic, researchers wanted to find out how much the public really understood about the virus — and social media offered a fast way to ask. This study posted a short survey on Instagram, Twitter, and WhatsApp, and 5,677 adults completed it within a single week. Most respondents lived in the Arabian Gulf, mainly Bahrain, Kuwait, and Saudi Arabia. The results were encouraging: most people correctly recognized the main symptoms of COVID-19, such as fever, shortness of breath, and cough, and most were taking sensible precautions like frequent handwashing and avoiding crowds. Social media was by far the most common source of information (used by 84%), followed by the World Health Organization (50%). The study also found some interesting patterns. Younger people, men, and those working or studying in healthcare felt more likely to catch the virus — and were also more willing to get vaccinated. Overall, the researchers concluded that this group was fairly well-informed, but noted gaps in knowledge about vaccination that public health campaigns should address. They also highlighted that social media can be a powerful tool for both studying and educating the public during a health crisis.

Summary

A gastric balloon is a soft device placed in the stomach to help people feel full sooner and eat less. Older balloons must be put in and taken out using a camera tube (endoscopy) under sedation. The Elipse balloon is different: the patient swallows it inside a capsule, and after about four months it empties itself and passes out naturally through the bowel — no endoscopy needed at either end. Doctors in Kuwait followed 112 patients who received this balloon between 2016 and 2017. Six could not tolerate it and had it removed. The rest were followed for about a year and a half after the balloon left the body. On average, patients started at 92 kg. They lost roughly 11% of their body weight by three and six months. Some weight came back afterwards, but about 8% of the starting weight was still gone at final follow-up. People who began with a lower weight kept the loss better than those who were heavier. Nausea, vomiting and stomach pain were common in the first days. One patient developed a bowel blockage from a faulty valve, treated by keyhole surgery. The authors conclude the balloon is safe and effective, particularly for people who are less severely overweight.

Summary

This review tells the story of how Kuwait Medical School was created. Until the 1960s, the Gulf region had no medical school of its own, and the region's existing schools in Cairo, Beirut and Baghdad had all been founded under colonial rule. Kuwait's would be the first in the Gulf, and the first in the Middle East established by its own people. The authors traced the story through original planning documents, two World Health Organization reports, and interviews with the founders — including the founding dean, Professor Abdulmohsin Al-Abdulrazzaq. Much of the official archive was lost during the Iraqi invasion, making these oral accounts essential. A 1965 WHO visit concluded Kuwait was not yet ready: too few local doctors, no teaching hospital, too few applicants. A second WHO review in 1968 found the country transformed and recommended going ahead. Officials debated whether to build a school or simply send students abroad, and later argued for years over buildings and budgets. The school chose a traditional teaching method over newer experimental ones, recruited staff from Britain, North America, Sweden and Malta, and opened in November 1976 with thirty students.

Summary

How risky is weight-loss surgery for patients on steroids or immune-suppressing drugs? Many people take steroids or immune-suppressing medication long-term for conditions such as asthma, rheumatoid arthritis or inflammatory bowel disease, or after a transplant. These drugs are known to slow healing and raise infection risk after major surgery, but little had been published on what they mean for weight-loss surgery specifically. We analysed a North American surgical database covering 114,169 patients who had weight-loss surgery between 2005 and 2013. Around 1% were taking these medications. Their risk was higher, though the absolute numbers stayed low. Deaths within 30 days occurred in 0.55% of them versus 0.11% of other patients, and serious complications in 5% versus 2.5% — differences that persisted after we accounted for the fact that these patients were older and sicker to begin with. They were also readmitted more often and stayed in hospital longer. Reassuringly, among these patients gastric bypass was no riskier than sleeve gastrectomy, so the more effective operation need not be ruled out. Because these operations are elective, there may be room to pause the medication beforehand where the underlying illness allows — though the right timing is not yet established.

Summary

Who is most likely to need their gallbladder removed after weight-loss surgery? Both obesity and rapid weight loss encourage gallstones to form, which puts patients having weight-loss surgery in an awkward position: the operation treats one risk factor by creating another. Surgeons disagree about what to do — remove the gallbladder preventively during the original operation, or wait and see who develops trouble. We reviewed 3,765 patients who had weight-loss surgery at the Cleveland Clinic between 2005 and 2012. Around 4% later developed gallbladder or bile-duct problems, most commonly gallbladder inflammation, appearing on average about two years after surgery. All needed their gallbladder removed, nearly always by keyhole surgery, and none died. Age was the one factor that held up under closer analysis: patients over 50 were at higher risk. How much weight patients lost did not predict trouble. We think this is most useful for counselling patients beforehand — particularly older patients having gastric bypass, where the rearranged anatomy makes later access to the bile ducts difficult. This was a single-centre records review.

Summary

Testing a pancreatic cancer score at a different hospital We had previously developed the McGill-Brisbane Symptom Score, which predicts survival in pancreatic cancer using only four things a patient reports at their first visit: weight loss, abdominal pain, jaundice and smoking history. But a score developed at one hospital can flatter itself; it has to work elsewhere to be trusted. So we tested it on 633 patients treated between 2001 and 2010 at the Marshfield Clinic in rural Wisconsin — a different country, a different health system, patients we had no hand in selecting. The score held up. Among patients whose tumours could be operated on, those with a low score lived a median of 817 days, roughly twice as long as those with a high score. Among patients whose tumours could not be removed, the difference was smaller and emerged only later on. After accounting for age, sex and chemotherapy, a high score still predicted worse survival in both groups. Notably, the score did not track with CA 19-9, the standard blood marker — it appears to capture something different. Symptoms are self-reported, which introduces imprecision, and this was a specialist centre, so patients may have been sicker than average.

Summary

Repairing an abnormal connection that reopens the stomach after gastric bypass Gastric bypass works by dividing the stomach into a small pouch and a larger remnant, so food bypasses most of the stomach. Occasionally an unwanted channel forms between the two — a gastrogastric fistula — which lets food take the old route again. Patients typically come back with abdominal pain, heartburn, vomiting, or weight regain, and often an ulcer at the join. We reviewed 36 patients we operated on for this problem at the Cleveland Clinic between 2005 and 2013, on average about six years after their original bypass. Diagnosis was easier when we combined two tests: camera examination of the stomach and a contrast X-ray. Endoscopy found several fistulas the X-ray missed. We used one of two repairs, chosen according to symptoms and anatomy. Rebuilding the pouch and its connection suited patients with weight regain or an enlarged pouch; removing the stomach remnant suited those with pain alone. These were long, difficult operations on scarred tissue. No patient died, but six had early complications — all in the rebuilding group. Patients who had regained weight lost a substantial amount afterwards. With 36 patients reviewed retrospectively, we cannot say which repair is better overall.

Summary

How safe is weight-loss surgery? Weight-loss surgery is the most effective lasting treatment for severe obesity, yet many patients and doctors still hesitate over safety. The concern is not academic: in 2013 Kuwait became the only country in the world to ban these operations, a suspension lasting three months that followed public and political pressure over safety. We reviewed the published evidence to see what the numbers actually show. They show a procedure that has become considerably safer. Deaths within thirty days now run at roughly three in a thousand — comparable to having a gallbladder removed or a knee replaced, and far below operations such as heart bypass surgery. Complications affect roughly two to four in a hundred patients. Mortality has fallen substantially over the past two decades, largely because most operations are now done through keyhole rather than open surgery. Even patients considered very high risk — older, heavier, with heart and lung disease — can be operated on safely. Advanced age and severe illness are not by themselves reasons to refuse someone surgery. Safety depends on where and how the surgery is done: high-volume centres, careful preoperative assessment, and matching the right operation to the right patient.

Summary

Can a few simple questions predict survival in pancreatic cancer better than a blood test? Pancreatic cancer is usually advanced by the time it is found, and doctors have few reliable ways to tell who will live longer. We previously developed the McGill-Brisbane Symptom Score, which uses only what a patient reports at the first visit: weight loss, pain, jaundice and smoking history. The alternative is CA 19-9, a blood marker widely used in this cancer. But tumours in the head of the pancreas often block the bile duct, and that blockage alone raises CA 19-9 — so a high reading may reflect the obstruction rather than the cancer. Dividing CA 19-9 by bilirubin, a measure of blockage, is one proposed correction. We reviewed 133 patients treated at the McGill University Health Centre from 2005 onward, with both blood values available in 52. The blood marker alone predicted survival poorly. The symptom score performed far better: when it was low, nine out of ten patients lived beyond nine months. Correcting the marker for bilirubin helped, and combining it with the symptom score was the most informative approach of all. Bedside questions outperformed the laboratory here. This was a records review, so the findings need testing in larger groups.

Summary

**A procedure that grows the liver also seems to grow the tumours** When bowel cancer spreads to the liver, surgery offers the best chance of cure — but only if enough healthy liver will remain afterwards. To make surgery possible, we can block the blood supply to the diseased half of the liver, a procedure called portal vein embolization. The healthy half then grows to compensate, usually within about a month. We reviewed 109 patients who had this procedure at the McGill University Health Centre, comparing their scans with 11 similar patients who did not. The liver grew as intended. But the tumours grew too, and substantially: after the procedure they enlarged by about a third on the blocked side and by half on the growing side, whereas in patients without the procedure the tumours actually shrank by roughly a third. Eight patients developed new tumours in the half of the liver we were trying to preserve, and most of them could no longer be operated on. Patients taking the drug bevacizumab showed less tumour growth, but the difference could have been chance. The procedure remains a valuable tool, but we need ways to grow the liver without feeding the cancer. This was a look back at records, not a trial. ---

Summary

**Operating multiple to remove liver tumours others called inoperable** When bowel cancer spreads to both halves of the liver, surgery is often ruled out because removing all the tumours at once would leave too little liver to survive on. One way around this is to operate in stages: clear one side first, let the liver regrow over several months — sometimes helped by blocking the blood supply to the diseased side — then remove the rest in a second operation. We reviewed 85 patients we put on this pathway at the Royal Victoria Hospital in Montreal between 2003 and 2011. All had been considered inoperable at the outset. Just over half — 44 patients — completed both operations. They lived a median of 46 months from diagnosis, and 42% were alive at five years, an outcome that would have been out of reach with chemotherapy alone. The 30 patients whose cancer progressed before the second operation did considerably worse, with median survival of 22 months. Cancer that had already spread beyond the liver was the strongest sign the plan would fail. Complications were manageable and no patient died from surgery. We reviewed past records rather than running a trial, so selection effects cannot be excluded.

Summary

Working hours restrictions and surgical outcomes **Did shorter working hours for surgical trainees harm patients?** In 2003, US regulators capped the hours that doctors in surgical training could work. Many surgeons objected, arguing that shorter shifts mean more handovers between doctors and less continuity in a patient's care — and that patients might suffer as a result. We gathered every published study that compared surgical patients before and after the rules took effect, pooling ten studies covering more than 730,000 patients for deaths and over 64,000 for complications. The feared harm did not appear. Complication rates were essentially unchanged. Deaths were, if anything, slightly lower after the rules came in, though the difference was small enough that it could have been chance. We are careful about what this proves. Surgery has been getting steadily safer for decades for many reasons — better intensive care, earlier diagnosis, more planned rather than emergency operations. Shorter hours also came with closer supervision from senior surgeons. So our results show that restricting hours did not reverse the trend toward better outcomes, but we cannot separate out its individual effect. None of the studies we found were randomised trials, which limits how firmly we can draw conclusions.

Summary

**What do Canadian surgical trainees think about an 80-hour work week?** The United States limited trainee doctors' working hours in 2003. Canada had no such national rule, and debate was underway about whether to introduce one. We wanted to know what the trainees themselves thought, so in 2009 we surveyed general surgery residents across the country. 158 replied. Their working lives were demanding: 79% reported 75–100 hours a week, and 15% worked more than 100. Opinion was split almost down the middle — 47% supported an 80-hour limit. The clearest divide was between junior and senior trainees. Seniors, who spend more time operating as they approach independent practice, worried most about losing surgical experience: 74% thought a cap would reduce their time in the operating room, compared with 43% of juniors. Juniors were twice as likely to see 24-hour shifts as a danger to their own health (60% versus 30%). Almost everyone agreed a cap would improve quality of life. But only 31% wanted 24-hour shifts abolished, mainly fearing lost training. Both groups strongly felt that lengthening residency to seven years would deter people from choosing surgery. Only 44% of those invited responded, so these views may not represent everyone. ---

Summary

Comparing two ways of connecting a transplanted kidney to the bladder When a kidney is transplanted, the surgeon must join the ureter — the tube that carries urine from the kidney — to the patient's bladder. Two common methods exist: the Lich-Gregoire technique, which uses several stitches, and the Taguchi technique, a faster single-stitch method. We at McGill University Health Centre in Montreal reviewed 372 adult kidney transplants performed between 2000 and 2009. Of these, 209 used the Taguchi method and 163 used Lich-Gregoire. Both techniques performed similarly overall. Urine leaks and narrowing of the ureter were uncommon and occurred at the same rate in both groups, and there was no difference in how many kidneys were lost or rejected. The main difference was bleeding into the urine that needed treatment: it affected 17% of Taguchi patients compared with 11% of Lich-Gregoire patients — a difference that fell just short of statistical certainty. Patients who developed a narrowed ureter tended to experience rejection sooner. The authors conclude that either technique is acceptable, though the findings modestly favour Lich-Gregoire. As a look back at past records rather than a randomised trial, the study cannot prove one method is better

Summary

During breast cancer surgery, doctors check a "sentinel" lymph node to see if cancer has spread. A quick test during surgery (frozen section) can find cancer, but it mainly catches larger cancer deposits, not tiny ones. When this quick test is negative, it usually means only tiny amounts of cancer may be present, if any. Patients with a negative test have a very low chance (about 10%) of cancer in other lymph nodes. This means many patients can safely avoid removing all the underarm lymph nodes, reducing complications.

Summary

**Which patients benefit most from radiation beads for neuroendocrine liver tumours?** Neuroendocrine tumours are slow-growing cancers that often spread to the liver. When surgery isn't an option, one treatment is radio-embolization: tiny glass beads carrying a radioactive isotope are threaded through an artery directly into the liver, where they lodge in the tumour's blood supply and irradiate it from within. The treatment is expensive and demanding, so we wanted to know which patients respond best. We reviewed 25 patients treated at the McGill University Health Centre between 2006 and 2009, measuring how much tumour tissue died after treatment. On average, roughly half the tumour tissue was destroyed, and about two-thirds of patients responded meaningfully. The strongest predictor was previous surgery: patients who had already had tumour removed or destroyed responded roughly twice as well as those who hadn't (67% versus 32% of tumour killed). Patients with smaller tumours, disease in only one half of the liver, or less of the liver affected also tended to do better, though those patterns weren't statistically firm. Our conclusion is that reducing the tumour bulk surgically first may help the beads work better. With only 25 patients, this needs confirming in a larger study before it changes practice. ---

Summary

In 2011, this systematic review was the largest and most current analysis of how the 2003 ACGME 80-hour duty hours restrictions affected U.S. surgical training. Drawing on 56 studies (16 of high quality) published between 2000 and 2008, we assessed impacts on resident education, resident well-being, and surgical faculty. Importantly, the restrictions did not reduce residents' operating-room experience or examination scores, and most studies reported neutral-to-positive educational outcomes. Residents' quality of life clearly improved, with none of the studies reporting negative effects on well-being. Surgical faculty, however, viewed the changes negatively, citing heavier workloads and concerns about resident training and continuity of patient care.