Mediastinal herniation of the biliary tract leading to bile duct: obstruction following oesophagectomy.

Surgical management of oesophageal and gastro-oesophageal junction malignancies is one of the most challenging situations confronting the surgeon. Attaining a complete circumferential resection margin of lower-third oesophageal and gastro-oesophageal junction locally advanced carcinomas requires en-bloc resection of the hiatus and all the peri-oesophageal tissue and pleura. This results in an increased risk of herniation of the abdominal organs through the enlarged hiatus, which carries significant risk of morbidity and mortality. The incidence of this complication is higher than has been reported. Surgical management of symptomatic hernias is the standard treatment while criteria for managing asymptomatic hernias are less clear. We report a rare case of a late mediastinal herniation of the pancreas and bile duct, leading to obstructive jaundice following oesophagectomy which was treated successfully in our unit.

Endoluminal Vacuum Therapy (E-Vac): A Treatment Option in Oesophagogastric Surgery.

BACKGROUND: Leaks from the upper gastrointestinal tract often pose a management challenge, particularly when surgical treatment has failed or is impossible. Vacuum therapy has revolutionised the treatment of wounds, and its role in enabling and accelerating healing is now explored in oesophagogastric surgery. METHODS: A piece of open cell foam is sutured around the distal end of a nasogastric tube using a silk suture. Under general anaesthetic, the foam covered tip is placed endoscopically through the perforation and into any extra-luminal cavity. Continuous negative pressure (125 mmHg) is then applied. Re-evaluation with change of the negative pressure system is performed every 48-72 h depending on the clinical condition. Patients are fed enterally and treated with broad-spectrum antibiotics and anti-fungal medication until healing, assessed endoscopically and/or radiologically, is complete. RESULTS: Since April 2011, twenty one patients have been treated. The cause of the leak was postoperative/iatrogenic complications (14 patients) and ischaemic/spontaneous perforation (seven patients). Twenty patients (95%) completed treatment successfully with healing of the defect and/or resolution of the cavity and were subsequently discharged from our care. One patient died from sepsis related to an oesophageal leak after withdrawing consent for further intervention following a single endoluminal vacuum (E-Vac) treatment. In addition, two patients who were successfully treated with E-Vac for their leak subsequently died within 90 days of E-Vac treatment from complications that were not associated with the E-Vac procedure. In two patients, E-Vac treatment was complicated by bleeding. The median number of E-Vac changes was 7 (range 3-12), and the median length of hospital stay was 35 days (range 23-152). CONCLUSIONS: E-Vac therapy is a safe and effective treatment for upper gastrointestinal leaks and should be considered alongside more established therapies. Further research is now needed to understand the mechanism of action and to improve the ease with which E-Vac therapy can be delivered.

Spontaneous diaphragmatic rupture following robotic prostatectomy.

Robotic surgery is an established therapy for localised prostate cancer and is replacing conventional laparoscopic prostatectomy in developed countries. Port-site hernia is a recognised, albeit small, risk following laparoscopic or robotic surgery. We report a case of spontaneous rupture of the right hemidiaphragm following robotic prostatectomy.

Trimodality therapy and definitive chemoradiotherapy for esophageal cancer: a single-center experience and review of the literature.

In the UK, the standard of care for esophageal cancer has generally combined surgery with neoadjuvant chemotherapy, with definitive chemoradiotherapy (dCRT) being reserved for certain subgroups. Chemoradiotherapy followed by surgery (trimodality therapy) has not been widely adopted. The outcomes of patients undergoing dCRT or trimodality therapy at our cancer center between 2004 and 2012 were restrospectively analyzed. Trimodality therapy was offered to selected patients of good performance status (World Health Organisation performance status 0/1), with squamous cell carcinoma or bulky adenocarcinoma. dCRT was offered to patients of good PS but with comorbidities, upper third tumors or at patient's request. Patients received four cycles of chemotherapy with a platinum agent (mostly cisplatin) and a fluoropyrimidine (mostly 5-fluorouracil) over a total of 11 weeks. Cycles 3 and 4 were given concurrently with radiotherapy: 50 Gy in 25 fractions for dCRT and 45 Gy in 25 fractions in the trimodality group. Surgery occurred 8-10 weeks following the completion of chemoradiotherapy. The cut-off length for maximum gross tumor volume length was 10 cm. One hundred two patients were included (47 received dCRT, and 55 received trimodality treatment). The majority of tumors were stage III (80.4%), and two-thirds were located in the distal esophagus (64.7%). Median follow-up was 44 months. The 2-year overall survival (OS) was 57.3% (median OS 39.7 months) for the dCRT group and 77.8% (median not reached) for the trimodality group. The 5-year OS rates were 38% and 58%, respectively. Postoperative mortality rate was low at 1.8%, and the pathological complete response rate was 23.6%. In conclusion, trimodality treatment for patients with esophageal and junctional gastroesophageal tumors offers high rates of 2-year survival, and the potential for long-term cure. dCRT is an established alternative for patients that are not fit or suitable for surgery.

Can the rat be used as a valid model of human esophageal adenocarcinoma?

Animal models of Barrett's metaplasia and esophageal adenocarcinoma are important to further characterize the disease and test potential therapies. This paper reviews the development of the surgical model of esophageal adenocarcinoma in the rat and considers whether this model provides a biologically accurate representation of Barrett's esophagus and esophageal adenocarcinoma in humans.

Security swipe cards and scanners are a potential reservoir for hospital-acquired infection.

INTRODUCTION: Hospital-acquired infections complicate 10% of hospital admissions resulting in increased morbidity, mortality and cost to hospitals. Most hospitals issue doctors with plastic swipe cards that function as electronic keys to access clinical areas. The card is handled many times a day, often before direct patient contact. The aim of this study was to determine if swipe cards harbour potentially harmful bacteria. SUBJECTS AND METHODS: On a single day, doctors working in the surgical directorate completed a questionnaire to determine their pattern of swipe card use. Cards were inoculated onto agar plates and incubated for 48 h under standard laboratory conditions, following which the number of colony forming units (CFUs) cultured from each card was determined. Representative colonies were sampled and sub-cultured for staphlococcal, enterococcal, coliform and pseudomonad species. Isolated bacterial pathogens were tested for antimicrobial sensitivity. Swipe-card scanners were swabbed for microbiological culture on the same day. RESULTS: All cards were colonised with environmental bacteria (mean, 73 CFU). Of cards, 21% were contaminated with pathogenic bacteria including Staphylococcus aureus (5.1%), Pseudomonas putida (2.6%), and coliform species (12.8%). The pattern of card use did not significantly affect the amount of bacterial contamination, but infrequent use of the card and keeping the card in a pocket or wallet was associated with higher levels of contamination. Environmental bacteria were cultured from 88% of card scanners, the highest counts coming from scanners in main theatres and the day-surgery unit. CONCLUSIONS: Doctors' swipe cards are contaminated with, and may therefore be a reservoir for, pathogenic bacteria implicated in hospital-acquired infection.

Prospective randomized trial of laparoscopic gastrojejunostomy versus duodenal stenting for malignant gastric outflow obstruction.

BACKGROUND: We prospectively compared laparoscopic gastrojejunostomy with duodenal stenting as a means of palliating malignant gastric outflow obstruction. METHODS: A total of 27 patients with malignant gastric outflow obstruction were randomized to either laparoscopic gastrojejunostomy (LGJ) or duodenal stenting (DS) over a 3-year period. RESULTS: Thirteen patients underwent successful LGJ and 10 had successful DS. Eight patients had complications after LGJ, but none had complications after DS. Patients who underwent LGJ had a significant increase in visual analog pain score at day 1 (p = 0.05), and also had a longer hospital stay compared to those who underwent DS (11.4 vs. 5.2 days, p = 0.02). After DS, patients experienced an improvement in physical health at 1 month as measured using the Short Form-36 (SF-36) questionnaire (p < 0.01). There was no change following LGJ. CONCLUSION: Duodenal stenting is a safe means of palliating malignant gastric outflow obstruction. It offers significant advantages for patients compared with minimal-access surgery.

Endoscopy waiting times and impact of the two week wait scheme on diagnosis and outcome of upper gastrointestinal cancer.

The NHS has introduced the two week wait scheme to detect upper gastrointestinal cancers at an early stage and improve survival rates The aim of this study was to assess the impact of this scheme and changes in endoscopy waiting times on tumour stage and resection rates over a four year period. Data were analysed prospectively for all patients diagnosed with oesophagogastric cancer between September 1998 and September 2002 and from those referred under the two week wait scheme since its introduction in 2000. Of those tumours diagnosed by this scheme (15%) only 5% were early disease (stage 1 or 2). Patients with early cancer, mainly diagnosed by routine gastroscopy, do not present with symptoms meeting the two week wait criteria. An increase in the resection rates for early disease will most probably be seen with a reduction in routine endoscopy waiting times.

Changes in functional gastrointestinal symptoms as a result of antireflux surgery.

BACKGROUND: This study identifies how functional symptoms are altered after antireflux surgery and whether there are any predictors of such change. METHODS: A total of 206 patients underwent successful laparoscopic Nissen fundoplication. A questionnaire was sent at a median of 4.3 years (range = 0.3-8.4) after fundoplication. Patients were asked to provide scores for reflux and functional symptoms that were experienced prior to surgery and at the time of the questionnaire. RESULTS: Eighty-one percent of patients responded. Scores for heartburn, regurgitation, and difficulty swallowing were felt to have significantly improved (p < 0.01). Flatulence was the only functional symptom to have significantly worsened (p < 0.01). A regression analysis incorporating prospectively collected data identified variables that were predictive of changes in functional symptoms following surgery. CONCLUSIONS: Flatulence was the only functional symptom to have worsened overall after surgery. Predictors of changes in functional symptoms may help clinicians when informing patients about gastrointestinal side effects following antireflux surgery.

Laparoscopic resection of gastric gastrointestinal stromal tumors.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) are neoplasms with low malignant potential. They occur most commonly in the stomach, where they are amenable to laparoscopic resection. METHODS: A case note review of all patients undergoing laparoscopic resection of a presumed gastric GIST at the Norfolk and Norwich University Hospital, United Kingdom, was conducted. RESULTS: Since September 1995, 30 patients have undergone this procedure. The patients had a mean age of 64.2 years (range, 31-87 years) and a mean weight of 74.1 kg (range, 44-104 kg). A presumptive diagnosis of GIST was made in all the cases based on the endoscopic and radiologic appearance of the lesion. Laparoscopic resection was completed successfully in 23 patients with a mean operating time of 73.8 min (range, 26-160 min). Seven procedures were converted to open surgery: three because the tumor was deemed too large for laparoscopic resection, two because the tumor could not be identified, one because of dense peritoneal adhesions, and one because of bleeding. The mean estimated blood loss was 196 ml (range, 0-1,000 ml), and the mean hospital stay was 5 days (ranges, 1-11 days). Pathologic analysis of the resected specimens showed 22 GISTs, 3 inflammatory fibroids, 2 submucosal lipomas, 1 submucosal varix, and 1 nest of heterotopic pancreatic tissue. D: uring a median follow-up period of 18 months (range, 2-101 months) there have been two cases of recurrence. In both cases, the tumor was catagorized as high risk for aggressive behavior after primary resection. CONCLUSION: Stapled laparoscopic resection is a safe and effective treatment option for nonmetastatic primary gastric GIST.

Randomized clinical trial of laparoscopic Nissen fundoplication compared with proton-pump inhibitors for treatment of chronic gastro-oesophageal reflux.

BACKGROUND: Both laparoscopic Nissen fundoplication (LNF) and proton-pump inhibitor (PPI) therapy are established in the treatment of gastro-oesophageal reflux disease (GORD). The aim of this study was to compare these two treatments in a randomized clinical trial. METHODS: Between July 1997 and August 2001, 340 patients with a history of GORD for at least 6 months were investigated by endoscopy, 24-h pH monitoring and manometry. Of these, 217 were randomized, 109 to LNF and 108 to PPI therapy. The two groups were well matched for age, sex, weight and severity of reflux. Twenty-four-hour pH monitoring and manometry were performed 3 months after treatment, and quality of life was assessed in both groups using the Psychological General Well-being Index and the Gastrointestinal Symptom Rating Scale at 3 and 12 months after treatment. RESULTS: At 3 months there was an improvement in lower oesophageal sphincter pressure from 6.3 to 17.2 mmHg in the LNF group but no change in the PPI group (8.1 and 7.9 mmHg before and after treatment respectively) (P < 0.001). The mean DeMeester acid exposure score improved from 42.7 to 8.6 (P < 0.001) in the LNF group and from 36.9 to 17.7 in the PPI group (P < 0.001). The mean gastrointestinal symptom and general well-being scores improved from 31.7 and 95.4 respectively before treatment to 37.0 and 106.2 at 12 months after LNF, compared with changes from 34.3 and 98.5 to 35.0 and 100.4 respectively in the PPI group. The differences in both of these scores were significant between the two groups at 12 months (P = 0.003). CONCLUSION: LNF leads to significantly less acid exposure of the lower oesophagus at 3 months and significantly greater improvements in both gastrointestinal and general well-being after 12 months compared with PPI treatment.

Stapled laparoscopic cystgastrostomy: a series with 15 cases.

BACKGROUND: The goal of this study was to assess the clinical outcome of patients undergoing laparoscopic stapled cystgastrostomy for pancreatic pseudocysts in contact with the posterior wall of the stomach. METHODS: We performed a case note review of all patients who have undergone stapled laparoscopic cystgastrostomy in Norwich, UK. The cystgastrostomy was fashioned through an anterior gastrotomy using a vascular ETS stapling device in all cases. RESULTS: Fifteen patients have undergone stapled laparoscopic cystgastrostomy. The procedure was completed successfully in 12 patients. Three procedures were converted to open surgery for technical reasons. There were no complications due to bleeding from the cystgastrostomy. Early complications included systemic sepsis (one), bleeding gastric ulcer (one) and pseudocyst recurrence due to partial closure of the cystgastrostomy (two). No late recurrences or other complications have been found at a median follow-up of 37 months. CONCLUSION: Stapled laparoscopic cystgastrostomy is a safe and effective procedure for draining pancreatic pseudocysts in contact with the posterior wall of the stomach. The use of a hemostatic stapling device to fashion the cystgastrostomy may reduce the risk of catastrophic hemorrhage from the pseudocyst wall.

Attendance at a pain clinic with severe chronic pain after open and laparoscopic inguinal hernia repairs.

BACKGROUND: The aim was to compare the frequency of severe chronic pain that required attendance at a pain clinic after open and laparoscopic inguinal hernia repairs. METHODS: This was a retrospective analysis of 7999 patients who underwent inguinal hernia repair between January 1994 and December 2001. The definition of severe chronic pain was pain related to inguinal hernia surgery that was bad enough for the patient to seek further medical help and be referred to the specialist pain clinic after exclusion of surgically correctable pathology such as hernia recurrence. RESULTS: During the study there were 7153 open repairs and 846 laparoscopic repairs. Sixty-nine patients (1.0 per cent) were referred to the pain clinic a median of 16.9 (range 5.1-69.4) months after open hernia repair. Three patients (0.4 per cent) were referred a median of 16.5 (range 7.3-21.5) months after laparoscopic hernia repair (P = 0.045). CONCLUSION: Laparoscopic inguinal hernia repair was associated with a significantly lower frequency of attendance at the pain clinic with severe chronic pain.

Vitamin E deficiency and metabolic deficits in neuronal ceroid lipofuscinosis described by bioinformatics.

The mnd mouse, a model of neuronal ceroid lipofusinosis (NCL), has a profound vitamin E deficiency in sera and brain, associated with cerebral deterioration characteristic of NCL. In this study, the vitamin E deficiency is corrected using dietary supplementation. However, the histopathological features associated with NCL remained. With use of a bioinformatics approach based on high-resolution solid and solution state 1H-NMR spectroscopy and principal component analysis (PCA), the deficits associated with NCL are defined in terms of a metabolic phenotype. Although vitamin E supplementation reversed some of the metabolic abnormalities, in particular the concentration of phenylalanine in extracts of cerebral tissue, PCA demonstrated that metabolic deficits associated with NCL were greater than any effects produced from vitamin E supplementation. These deficits included increased glutamate and N-acetyl-L-aspartate and decreased creatine and glutamine concentrations in aqueous extracts of the cortex, as well as profound accumulation of lipid in intact cerebral tissue. This is discussed in terms of faulty production of mitochondrial-associated membranes, thought to be central to the deficits in mnd mice.