Significance of thickening of the upper gastrointestinal tract on cross sectional imaging: Endoscopic correlation.

AIM: To report the endoscopic findings for a cohort of patients referred for discussion at a specialist oesophago-gastric multi-disciplinary team (MDT) meeting, on the basis of CT mural thickening. PATIENTS AND METHODS: The records of patients discussed at a regional oesophago-gastric MDT during the time 1st April 2014 to 5th February 2016 were reviewed in order to identify patients who were endoscopy naïve at the time of CT and scans re-reviewed to measure maximum wall thickness. RESULTS: 456 patients were referred for discussion, 126 met the inclusion criteria. Endoscopy confirmed malignancy in 50/126 patients (40%); by site, oesophagus (21/67, 31%), stomach (25/50, 50%), duodenum (4/9, 44%). Malignancy was confirmed for 10/48 (21%) patients with isolated wall thickening, for 11/33 (33%) when regional lymphadenopathy was identified, and for 28/44 (64%) when possible metastatic disease was identified. The commonest source of diagnostic uncertainty was thickening around the gastro-oesophageal junction in the presence of a hiatal hernia. Wall thickening >20 mm was strongly associated with malignancy compared to thickening =<20 mm (p < 0.0001). Using this threshold would have resulted in a sensitivity of 32/50 (64%), a specificity of 55/76 (72%), a positive predictive value of 32/53 (60%) and a negative predictive value of 55/73 (75%) in this cohort. CONCLUSIONS: The cancer pick-up rate of 40% and the medicolegal consequences of a missed cancer suggest that endoscopy should be performed in all patients with CT identified mural thickening. In the presence of isolated mural thickening and a normal endoscopy, no formal MDT discussion is required.

A mesenteric defect causing internal herniation and ischaemia of both the ascending and sigmoid colons, treated with a bowel preserving surgery.

Internal hernias due to mesenteric defects are a rare cause of bowel obstruction, but once present their complications are associated with a high morbidity and mortality. We present the case of a 24-year-old patient who presented to the emergency department with a 6-hour history of abdominal pain. Initial surgical review, taking into consideration the patient's clinical, biochemical and radiological findings, led to the patient being taken for immediate surgical exploration. Operative findings included a very mobile caecum and proximal ascending colon which had herniated through a defect in the small bowel mesentery, the sigmoid colon had subsequently become incarcerated by the caecum and small bowel too. Both the ascending and sigmoid colon had become ischaemic. Due to the early decision for surgical intervention, we were able to consider a number of surgical strategies, and the surgery led to a positive outcome for our patient.

The Effect of Supplementary Omegaven® on the Clinical Outcome of Patients With Advanced Esophagogastric Adenocarcinoma Receiving Palliative Epirubicin, Oxaliplatin, and Capecitabine Chemotherapy: A Phase II clinical trial.

BACKGROUND/AIM: Previous studies have shown anti-proliferative and anti-apoptotic effects of omega-3 fatty acids (Omegaven®) in vitro and in vivo. Whether this effect can be exploited in patients with advanced esophago-gastric adenocarcinoma is unknown. The present study intended to determine the tumour radiological response and toxicity profile of intravenous omega-3 fish oil infusion when combined with standard palliative chemotherapy, and present the effects of this treatment on plasma cytokine biomarkers. MATERIALS AND METHODS: Participants with advanced esophago-gastric adenocarcinoma were enrolled in a phase II single-arm clinical trial of palliative chemotherapy (epirubicin, oxaliplatin, and capecitabine; EOX) coupled with weekly infusion of Omegaven®. Outcomes were compared to those observed in 37 historical control patients who had received EOX alone. Toxicity was graded using the CTCAE v4.03 and radiological response was assessed using RECIST v1.1. Plasma cytokine levels of IL-1, IL-2, IL-6, TNF-α, and VEGF were evaluated by ELISA. RESULTS: Twenty participants were included in the analysis. Radiological responses were as follows: partial response (EOX plus omega-3 group 73% vs. EOX alone 39%, p=0.03), stable disease (EOX plus omega-3 21% vs. EOX alone 39%, p=0.24), and progressive disease (EOX plus omega-3 7% vs. EOX alone 18%, p=0.34). Grade 3 or 4 toxicity was less common (thromboembolism & gastrointestinal) in those who received EOX plus omega-3. This translated into fewer hospital admissions. There were significant reductions in the concentrations of IL-2 (p=0.009), TNF-α (p<0.0001) and VEGF (p=0.002) following each treatment. CONCLUSION: The treatment with supplementary omega-3 fatty acids reduced chemotherapy-related toxicity and resulted in better radiological responses. The combination treatment resulted in a shift towards a favourable anti-inflammatory cytokine profile. These findings should be evaluated in a randomised clinical trial.

Patient's views of the consent process for groin hernia repair: Use of consent template improves compliance with best practice (Original research).

BACKGROUND: Informed consent obtained for day case surgery has been historically incomplete. An assessment of consenting practice for groin hernia was performed relative to existing gold standards and patient's perception of the consent process was evaluated with a questionnaire. The aim of the study was to identify areas of improvement to comply with best practice. METHODS: A retrospective audit of adult patients undergoing groin hernia repair (June-November 2016) at a tertiary care centre was performed. The same cohort of patients was surveyed with a self-administered questionnaire to identify their view on consenting practice. RESULTS: 113 patients were identified who underwent groin hernia repair during the study period. Pre-printed consent templates-stickers (as opposed to hand-written) were used in 53(47%) cases. In 75(66%) cases, there was complete documentation of the risks and benefits of surgery. 81(72%) patients received information about the full benefits of surgery. 27(23%) patients received partial information and 7(6%) patients had no mention of benefit recorded. Postoperative recovery was fully explained to 85(75%) patients. Use of pre-printed templates ensured 100% documentation compared to handwritten consent forms (risks 37%, benefits 47%, and recovery 53%). Preference for the timing of consent was in clinic (64%), day of surgery (25%). 34(56%) felt the choice for the technique and 22(36%) felt the choice for anaesthesia. Satisfaction was non-significantly better in those consented in clinic (87% versus 76% p = 0.74). 49(80%) felt happy with the overall consent process. 57(93%) felt that they received support and advice. 60(98%) responders felt confidence in the National Health Service and 59(97%) would recommend treatment to family and friends. CONCLUSIONS: The use of pre-printed consent and discharge summary templates improve compliance with best practice. Whilst patient preference favours consent in the outpatient clinic, satisfaction levels were high wherever consent was obtained. Patients should have more choice.

Variation in laparoscopic anti-reflux surgery across England: a 5-year review.

BACKGROUND: Laparoscopic anti-reflux surgery (LARS) remains central to the management of gastro-oesophageal reflux disease but the scale and variation in provision in England is unknown. The aims of this study were firstly to examine the processes and outcomes of anti-reflux surgery in England and compare them to national guidelines and secondly to explore potential variations in practice nationally and establish peer benchmarks. METHODS: All adult patients who underwent LARSin England during the Financial years FY 2011/2012-FY 2016/2017 were identified in the Surgeon's Workload Outcomes and Research Database (SWORD), which is based on the Hospital Episode Statistics (HES) data warehouse. Outcomes included activity volume, day-case rate, short-stay rate, 2- and 30-day readmission rates and 30-day re-operation rates. Funnel plots were used to identify national variation in practice. RESULTS: In total, 12,086 patients underwent LARS in England during the study period. The operation rate decreased slightly over the study period from 5.2 to 4.6 per 100,000 people. Most outcomes were in line with national guidelines including the conversion rate (0.76%), 30-day re-operation rate (1.43%) and 2- and 30-day readmission rates (1.65 and 8.54%, respectively). The day-case rate was low but increased from 7.4 to 15.1% during the 5-year period. Significant variation was found, particularly in terms of hospital volume, and day-case, short-stay and conversion rates. CONCLUSION: Although overall outcomes are comparable to studies from other countries, there is significant variation in anti-reflux surgery activity and outcomes in England. We recommend that units use these data to drive local quality improvement efforts.

Effects of Omegaven®, EPA, DHA and oxaliplatin on oesophageal adenocarcinoma cell lines growth, cytokine and cell signal biomarkers expression.

BACKGROUND: There is limited evidence assessing the effects of omega-3 polyunsaturated fatty acids (PUFAs) on oesophageal adenocarcinoma, both in vitro and in vivo. We evaluated the effects of the omega-3 PUFA and oxaliplatin on OE33 and OE19 cells. METHOD: The two oesophageal cells were treated with Omegaven® (fish oil emulsion), EPA, DHA and oxaliplatin and incubated for up to 144 h. RESULTS: The following inhibitory effects were observed on OE33 cells: EPA reduced cell growth by 39% (p = 0.001), DHA by 59% (p < 0.000) and Oxaliplatin by 77% (p < 0.000). For OE19 cells, the EPA reduced growth by 1% (p = 0.992), DHA by 26% (p = 0.019) and oxaliplatin by 76% (p < 0.000). For both cells, Omegaven® resulted in reduced cell growth at intermediate concentrations (20-40 µM) and increased cell growth at low (10 µM) and high (50 µM) concentrations. DHA, Omegaven® and oxaliplatin were associated with significant downregulation of VEGF and p53 protein, and upregulation of p21 protein. DHA, Omegaven® and Oxaliplatin also led to significant downregulation of the total ERK1/2 and Akt proteins. CONCLUSION: DHA, Omegaven® and oxaliplatin were associated with downregulation of p53 and VEGF in both cells. Of the PUFAs studied, DHA alone or in combination (Omegaven®) had greater in vitro anti-cancer effects than EPA alone.

Feeding Jejunostomy-Associated Small Bowel Necrosis After Elective Esophago-Gastric Resection.

BACKGROUND: Feeding jejunostomy has increasingly become a standard adjunctive procedure during major esophago-gastric resections. They provide nutritional support during the post-operative period as required. However, significant early complications have been reported, most notably small bowel necrosis. Literature reports have been restricted to case reports or series. This study aims to determine the frequency of this complication in a cohort of patients undergoing esophago-gastric resection, and identify any difference in the risk of this complication between patients undergoing esophagectomy and gastrectomy. METHODS: Consecutive patients who had esophago-gastric resections for malignancy and who had a feeding jejunostomy placed were identified from a prospectively maintained database at Leicester Royal Infirmary during the years 2009-2015. Case notes were reviewed to extract information relating to demographics, presenting features and clinical outcome. RESULTS: The study included 360 patients, 285 of which had esophagectomy and 75 had gastrectomy. There were no small bowel complications among esophagectomy patients (0%), while six patients who had total gastrectomy developed small bowel ischemia or necrosis (8%), p = 0.05, in spite of an identical feeding regimen. Every patient that developed the complication underwent surgery with five out six having resection of the infarcted segment and double-barrel stoma formation. A 6-8-week period of parenteral nutrition was required before stoma reversal. One patient had leucocytosis on the day of diagnosis. The other five patients showed no derangements in biochemical or clinical parameters in the preceding 48 h. Five of the six patients survived. CONCLUSIONS: Small bowel necrosis and perforation is a life-threatening complication of feeding jejunostomy. In our cohort, it happened exclusively in total gastrectomy patients. Antecedent signs were lacking. The condition requires prompt attention with earlier use of CT scanning and a return to the operating room. The presence of pneumatosis intestinalis on CT scan should prompt surgical intervention that improves survival.

A systematic review of the nutritional consequences of esophagectomy.

BACKGROUND & AIMS: As improved outcomes after esophagectomy have been observed over the last two decades, the focus on care has shifted to survivorship and quality of life. The aim of this review was to determine changes in nutrition after esophagectomy and to assess the evidence for extended nutrition support. METHODS: A search strategy was developed to identify primary research reporting change in nutritional status a minimum of one month after esophagectomy. RESULTS: Changes in nutritional parameters reported by 18 studies indicated a weight loss of 5-12% at six months postoperatively. More than half of patients lost >10% of body weight at 12 months. One study reported a persistent weight loss of 14% from baseline three years after surgery. Three studies reporting on longer term follow up noted that 27%-95% of patients failed to regain their baseline weight. Changes in dietary intake (three studies) indicated inadequate energy and protein intake up to three years after surgery. Global quality of life scores reported in one study correlated with better weight preservation. There were a high frequency of gastrointestinal symptoms reported in six studies, most notably in the first year after surgery, but persisting up to 19 years. Extended enteral nutrition on a selective basis has been reported in several studies. CONCLUSIONS: Nutritional status is compromised in the months/years following oesophagectomy and may never return to baseline levels. The causes/consequences of weight loss/impaired nutritional intake require further investigation. The role of extended nutritional support in this population remains unclear.

A randomised controlled trial of six weeks of home enteral nutrition versus standard care after oesophagectomy or total gastrectomy for cancer: report on a pilot and feasibility study.

BACKGROUND: Poor nutrition in the first months after oesophago-gastric resection is a contributing factor to the reduced quality of life seen in these patients. The aim of this pilot and feasibility study was to ascertain the feasibility of conducting a multi-centre randomised controlled trial to evaluate routine home enteral nutrition in these patients. METHODS: Patients undergoing oesophagectomy or total gastrectomy were randomised to either six weeks of home feeding through a jejunostomy (intervention), or treatment as usual (control). Intervention comprised overnight feeding, providing 50 % of energy and protein requirements, in addition to usual oral intake. Primary outcome measures were recruitment and retention rates at six weeks and six months. Nutritional intake, nutritional parameters, quality of life and healthcare costs were also collected. Interviews were conducted with a sample of participants, to ascertain patient and carer experiences. RESULTS: Fifty-four of 112 (48 %) eligible patients participated in the study over the 20 months. Study retention at six weeks was 41/54 patients (76 %) and at six months was 36/54 (67 %). At six weeks, participants in the control group had lost on average 3.9 kg more than participants in the intervention group (95 % confidence interval [CI] 1.6 to 6.2). These differences remained evident at three months (mean difference 2.5 kg, 95 % CI -0.5 to 5.6) and at six months (mean difference 2.5 kg, 95 % CI -1.2 to 6.1). The mean values observed in the intervention group for mid arm circumference, mid arm muscle circumference, triceps skin fold thickness and right hand grip strength were greater than for the control group at all post hospital discharge time points. The economic evaluation suggested that it was feasible to collect resource use and EQ-5D data for a full cost-effectiveness analysis. Thematic analysis of 15 interviews identified three main themes related to the intervention and the trial: 1) a positive experience, 2) the reasons for taking part, and 3) uncertainty of the study process. CONCLUSIONS: This study demonstrated that home enteral feeding by jejunostomy was feasible, safe and acceptable to patients and their carers. Whether home enteral feeding as 'usual practice' is a cost-effective therapy would require confirmation in an appropriately powered, multi-centre study. TRIAL REGISTRATION: UK Clinical Research Network ID 12447 (main trial, first registered 30 May 2012); UK Clinical Research Network ID 13361 (qualitative substudy, first registered 30 May 2012); ClinicalTrials.gov NCT01870817 (first registered 28 May 2013).

Gastropericardial fistula after Roux-en-Y bypass for reflux disease.

A 49-year-old man was admitted to his local hospital with a 3-day history of left-sided chest pain which started after a coughing paroxysm. His surgical history included laparoscopic Toupet fundoplication 30 months earlier and revisional reflux surgery (Roux-en-Y gastric bypass) 11 months earlier. On admission, he was found to be tachycardic at 110 bpm, hypotensive (90/65 mm Hg). He had ST depression in ECG leads V2-5 with a normal troponin I level. Chest radiography indicated a pneumopericardium which prompted referral to the oesophagogastric surgery unit. Endoscopy and CT with oral contrast confirmed a gastropericardial fistula. This was managed by total gastrectomy through a left thoracoabdominal approach. The patient was discharged home 2 months later. We report the fourth case of gastropericardial fistula in the literature as a long-term complication of Roux-en-Y gastric bypass with a favourable outcome and mini literature review.

Six weeks of home enteral nutrition versus standard care after esophagectomy or total gastrectomy for cancer: study protocol for a randomized controlled trial.

BACKGROUND: Each year approximately 3000 patients in the United Kingdom undergo surgery for esophagogastric cancer. Jejunostomy feeding tubes, placed at the time of surgery for early postoperative nutrition, have been shown to have a positive impact on clinical outcomes in the short term. Whether feeding out of hospital is of benefit is unknown. Local experience has identified that between 15 and 20% of patients required 'rescue' jejunostomy feeding for nutritional problems and weight loss while at home. This weight loss and poor nutrition may contribute to the detrimental effect on the overall quality of life (QoL) reported in these patients. METHODS/DESIGN: This randomized pilot and feasibility study will provide preliminary information on the routine use of jejunostomy feeding after hospital discharge in terms of clinical benefits and QoL. Sixty participants undergoing esophagectomy or total gastrectomy will be randomized to receive either a planned program of six weeks of home jejunostomy feeding after discharge from hospital (intervention) or treatment-as-usual (control). The intention of this study is to inform a multi-centre randomized controlled trial. The primary outcome measures will be recruitment and retention rates at six weeks and six months. Secondary outcome measures will include disease specific and general QoL measures, nutritional parameters, total and oral nutritional intake, hospital readmission rates, and estimates of healthcare costs. Up to 20 participants will also be enrolled in a qualitative sub-study that will explore participants' and carers' experiences of home tube feeding.The results will be disseminated by presentation at surgical, gastroenterological and dietetic meetings and publication in appropriate peer review journals. A patient-friendly lay summary will be made available on the University of Leicester and the University Hospitals of Leicester NHS Trust websites. The study has full ethical and institutional approval and started recruitment in July 2012. TRIAL REGISTRATION: UKClinical Research Network ID #12447 (Main study); UKCRN ID#13361 (Qualitative sub study); ClinicalTrials.gov #NCT01870817 (First registered 28 May 2013).

Prognostic value of baseline FDG uptake on PET-CT in esophageal carcinoma.

AIM: To evaluate the influence of baseline maximum standardized uptake value (SUVmax) on survival in a cohort of patients, undergoing positron emission tomography-computed tomography (PET-CT) scan for esophageal carcinoma. METHODS: The pre-treatment SUVmax numeric reading was determined in patients with confirmed esophageal or junctional cancer having PET-CT scan during the time period 1(st) January 2007 until 31(st) July 2012. A minimum follow up of 12 mo was required. Patients were subdivided into quartiles according to SUVmax value and the influence of SUVmax on survival was assessed using univariate and multivariate analysis. The following pre-treatment factors were investigated: patient characteristics, tumor characteristics and planned treatment. RESULTS: The study population was 271 patients (191 male) with esophageal or junctional carcinoma. The median age was 65 years (range 40-85) and histologic subtype was adenocarcinoma in 197 patients and squamous carcinoma in 74 patients. The treatment intent was radical in 182 and palliative in 89 patients. SUVmax was linked to histologic subtype (P = 0.008), tumor site (P = 0.01) and Union for International Cancer Control (UICC) stage (P < 0.001). On univariate analysis, prognosis was significantly associated with SUVmax (P = 0.001), T-stage (P < 0.001) and UICC stage (P < 0.001). On multivariate analysis, only T-stage and UICC stage remained significant. CONCLUSION: Pretreatment SUVmax was not a useful marker in isolation for determining prognosis of patients with esophageal carcinoma.

How do early emotional experiences in the operating theatre influence medical student learning in this environment?

BACKGROUND: The emotions experienced by medical students on first exposure to the operating theatre are unknown. It is also unclear what influence these emotions have on the learning process. PURPOSES: To understand the emotions experienced by students when in the operating theatre for the first time and the impact of these emotions on learning. METHODS: Nine 3rd-year medical students participated in semistructured interviews to explore these themes. A qualitative approach was used; interviews were transcribed and coded thematically. RESULTS: All participants reported initial negative emotions (apprehension, anxiety, fear, shame, overwhelmed), with excitement being reported by 3. Six participants considered that their anxiety was so overwhelming that it was detrimental to their learning. Participants described a period of familiarization to the environment, after which learning was facilitated. Early learning experiences centered around adjustment to the physical environment of the operating theatre. Factors driving initial negative feelings were loss of familiarity, organizational issues, concerns about violating protocol, and a fear of syncope. Participants considered that it took a median of 1 week (range = 1 day-3 weeks) or 5 visits to the operating theatre (range = 1-10) before feeling comfortable in the new setting. Emotions experienced on subsequent visits to the operating theatre were predominantly positive (enjoyment, happiness, confident, involved, pride). Two participants reported negative feelings related to social exclusion. Being included in the team was a powerful determinant of enjoyment. CONCLUSIONS: These findings indicate that for learning in the operating theatre to be effective, addressing the negative emotions of the students might be beneficial. This could be achieved by a formal orientation program for both learners and tutors in advance of attendance in the operating theatre. For learning to be optimized, students must feel a sense of inclusion in the theatre community of practice.

A case of recurrent mesocolon myxoid liposarcoma and review of the literature.

Background. Liposarcoma is the second most common soft tissue sarcoma affecting predominantly the retroperitoneal space and extremities. Mesenteric liposarcoma is uncommon and occurs in the small bowel mesentery. In this paper we report the case of a recurrent mesocolon myxoid liposarcoma manifesting 6 years from the initial right hemicolectomy for the primary tumour. Case Report. A 41-year-old female presented with a 4-day history of signs and symptoms indicative of small bowel obstruction, subsequently confirmed on plain abdominal X-ray. In 2006 she underwent a right hemicolectomy for a myxoid liposarcoma of the mesentery. The patient was initially managed conservatively; however she showed no signs of improvement and was taken to theatre for an exploratory laparotomy and division of adhesional bands. During this procedure an incidental finding of a dark purple, smooth pelvic mass was identified with similar macroscopic appearance to that of splenic tissue. Histological examination revealed a recurrent mesocolon myxoid liposarcoma. Conclusion. Mesocolon myxoid liposarcoma is a rare soft tissue neoplastic pathology and carries a high risk of recurrence. Therefore, a symptomatic patient with a previous history of primary liposarcoma excision should be treated with a high index of suspicion and a longer period of followup should be considered.

An audit to determine if vitamin b12 supplementation is necessary after sleeve gastrectomy.

ABSTRACT: Sleeve gastrectomy has increased in popularity over the last five years and it is likely to supersede gastric banding. Nevertheless, it is unclear whether vitamin B12 supplementation is required after surgery. The aim of this short report is to identify any vitamin B12 deficiency and highlight the necessity of post laparoscopic sleeve gastrectomy vitamin B12 monitoring. PATIENTS AND METHODS: A review of 66 patients underwent LSG in our institution. 25 patients were excluded as they had no postoperative vitamin B12 screening. 41 patients were included as screened for vitamin B12 and other micronutrients including selenium, serum folate, ferritin, iron, zinc, copper, magnesium and vitamin D. RESULT: There were 5 male (12%) and 36 females (88%), 8/41 patients (20%) had Vitamin B12 deficiency, none of them developed macrocytic anaemia. 17/21 (81%) patient were vitamin D deficient and 9/21 (43%) exhibited low selenium. CONCLUSION: In this small group, a 20% prevalence of vitamin B12 was identified. As a consequence vitamin B12 monitoring and supplementation will be a standard of care in the early postoperative period after LSG at this institution.

Small bowel hamartoma: a huge diverticulum of small bowel.

A-20-year old male, with no significant medical history, presented with clinical features mimicking a perforated acute appendicitis. Because of features of peritonitis, a laparotomy was performed which showed a segment of small bowel with multiple large diverticula and mesenteric cysts. A segmental small bowel resection was performed. The patient made an uneventful recovery from surgery. Histology revealed features of a small bowel hamartoma.

One-year audit of complaints made against a University Hospital Surgical Department.

BACKGROUND: There is relatively little in the medical literature relating to complaints about the healthcare process. The aim of this study was to report the frequency and content of patient complaints against a University Hospital Surgical Department. In particular, the study aimed to relate the number of complaints to the number of health-care episodes and to determine the frequency of patient safety incidents and subsequent medico-legal action. METHODS: Retrospective interrogation of a prospectively maintained Complaints Department database at a University Hospital for the calendar year 2009. RESULTS: Complaints relating to 360 aspects of the health-care journey in 113 patients were made. This translated into one complaint per 400 health-care episodes. Concerns about clinical care were cited in 31%, delays in the health-care process in 30%, communication issues in 19%, the institutional environment in 8% and poor discharge planning in 6%. Overall, 16 complaints (4%) were raised as patient safety incidents. Eighty-three per cent of complaints were addressed by a telephone conversation or a single letter response, 13% by a face-to-face meeting. Two per cent resulted in subsequent medico-legal action. CONCLUSIONS: Although perceived in a negative way by health-care professionals, only 1 in 400 health-care episodes resulted in a complaint. Only a small number related to patient safety incidents or resulted in medico-legal instructions. Attention should focus on developing effective strategies to improve patient satisfaction with all aspects of the patient journey.