Chemoradiotherapy Followed by Active Surveillance Versus Standard Esophagectomy for Esophageal Cancer: A Systematic Review and Individual Patient Data Meta-analysis.

OBJECTIVE: To compare overall survival of patients with a cCR undergoing active surveillance versus standard esophagectomy. SUMMARY OF BACKGROUND DATA: One-third of patients with esophageal cancer have a pathologically complete response in the resection specimen after neoadjuvant chemoradiotherapy. Active surveillance may be of benefit in patients with cCR, determined with diagnostics during response evaluations after chemoradiotherapy. METHODS: A systematic review and meta-analysis was performed comparing overall survival between patients with cCR after chemoradiotherapy undergoing active surveillance versus standard esophagectomy. Authors were contacted to supply individual patient data. Overall and progression-free survival were compared using random effects meta-analysis of randomized or propensity score matched data. Locoregional recurrence rate was assessed. The study-protocol was registered (PROSPERO: CRD42020167070). RESULTS: Seven studies were identified comprising 788 patients, of which after randomization or propensity score matching yielded 196 active surveillance and 257 standard esophagectomy patients. All authors provided individual patient data. The risk of all-cause mortality for active surveillance was 1.08 [95% confidence interval (CI): 0.62-1.87, P = 0.75] after intention-to-treat analysis and 0.93 (95% CI: 0.56-1.54, P = 0.75) after per-protocol analysis. The risk of progression or all-cause mortality for active surveillance was 1.14 (95% CI: 0.83-1.58, P = 0.36). Five-year locoregional recurrence rate during active surveillance was 40% (95% CI: 26%-59%). 95% of active surveillance patients undergoing postponed esophagectomy for locoregional recurrence had radical resection. CONCLUSIONS: Overall survival was comparable in patients with cCR after chemoradiotherapy undergoing active surveillance or standard esophagectomy. Diagnostic follow-up is mandatory in active surveillance and postponed esophagectomy should be offered to operable patients in case of locoregional recurrence.

Safe oesophageal stent deployment using a checklist system instead of fluoroscopy.

BACKGROUND: Stenting is the management of choice for many benign and malignant oesophageal conditions and in the interest of safety stent insertion has traditionally been performed under fluoroscopic guidance. But this incurs additional expense, time, radiation risk and for the foreseeable future, an increased risk of Covid infection to patients and healthcare personnel. We describe a protocol that obviates the need for fluoroscopic guidance, relying instead on a systematic checklist to ensure safe positioning of the guidewire and the accurate positioning of the stent. The aim of this retrospective study was to review our experience of stent insertion employing a checklist system and compare our outcomes with outcomes using fluoroscopy in the literature. METHODS: We performed a retrospective review of a prospectively collected dataset of all patients undergoing oesophageal stent insertion between December 2007 and October 2019. The primary end points were patient safety parameters and complications of stent insertion. RESULTS: Total of 163 stents were deployed of which 93 (57%) were in males and the median age was 67.9 years (25-92 years). Partially covered self-expanding metallic stents (SEMS) were used in 80% of procedures (130/163). One hundred nineteen stents (73%) were for malignant strictures and 127 (78%) were deployed for strictures in the lower third of the oesophagus. There was no stent misplacement, injury, perforation or death associated with the procedure. Vomiting was the main post-operative complication (14%). Severe odynophagia necessitated stent removal in 3 patients. Stent migration occurred in 17 (10%) procedures with a mean time to stent migration of 6.4 weeks (range 1-20 weeks). CONCLUSIONS: Oesophageal stent placement without fluoroscopy is safe provided that a strict checklist is adhered to. The outcomes are comparable to the results of fluoroscopic stent placement in the literature, with considerable saving in time, cost, personnel, and risks of radiation and Covid exposure.

The impossible gallbladder: aspiration as an alternative to conversion.

BACKGROUND: Laparoscopic cholecystectomy is the standard of care for symptomatic gallstone disease but when laparoscopic removal proves impossible the standard advice is to convert to open surgery. This jettisons the advantages of laparoscopy for a procedure which surgeons no longer perform routinely, so it may no longer be the safest practice. We hypothesised that gallbladder aspiration would be a safer alternative when laparoscopic removal is impossible. METHODS: A retrospective analysis was performed of all laparoscopic cholecystectomies attempted under one surgeon's care over 19 years, and the outcomes of gallbladder aspiration were compared with the standard conversion-to-open procedure within the same institution. RESULTS: Of 757 laparoscopic cholecystectomies attempted, 714 (94.3%) were successful, while 40 (5.3%) were impossible laparoscopically and underwent gallbladder aspiration. Interval cholecystectomy was later performed in 34/40 (85%). Only 3/757 (0.4%) were converted to open. No aspiration-related complications occurred and excessive bile leakage from the gallbladder was not observed. During this time 1209 laparoscopic cholecystectomies were attempted by other surgeons in the institution of which 55 (4.55%) were converted to open and 22 (40%) had procedure-associated complications. There was a significant difference in the mean (± SEM) post-operative hospital stay between laparoscopic gallbladder aspiration [3.12 (± 0.558) days] and institutional conversion-to-open cholecystectomy [9.38 (± 1.04) days] (p < 0.001), with attendant cost savings. CONCLUSION: Laparoscopic gallbladder aspiration is a safe alternative to conversion when inflammation makes cholecystectomy impossible laparoscopically, especially in the sickest patients and for surgeons with limited open surgery experience. This approach minimises morbidity and permits laparoscopic cholecystectomy in the majority after a suitable interval or referral of predicted difficult cases to specialist hepatobiliary centres.

Distribution of lymph node metastases in esophageal carcinoma [TIGER study]: study protocol of a multinational observational study.

BACKGROUND: An important parameter for survival in patients with esophageal carcinoma is lymph node status. The distribution of lymph node metastases depends on tumor characteristics such as tumor location, histology, invasion depth, and on neoadjuvant treatment. The exact distribution is unknown. Neoadjuvant treatment and surgical strategy depends on the distribution pattern of nodal metastases but consensus on the extent of lymphadenectomy has not been reached. The aim of this study is to determine the distribution of lymph node metastases in patients with resectable esophageal or gastro-esophageal junction carcinoma in whom a transthoracic esophagectomy with a 2- or 3-field lymphadenectomy is performed. This can be the foundation for a uniform worldwide staging system and establishment of the optimal surgical strategy for esophageal cancer patients. METHODS: The TIGER study is an international observational cohort study with 50 participating centers. Patients with a resectable esophageal or gastro-esophageal junction carcinoma in whom a transthoracic esophagectomy with a 2- or 3-field lymphadenectomy is performed in participating centers will be included. All lymph node stations will be excised and separately individually analyzed by pathological examination. The aim is to include 5000 patients. The primary endpoint is the distribution of lymph node metastases in esophageal and esophago-gastric junction carcinoma specimens following transthoracic esophagectomy with at least 2-field lymphadenectomy in relation to tumor histology, tumor location, invasion depth, number of lymph nodes and lymph node metastases, pre-operative diagnostics, neo-adjuvant therapy and (disease free) survival. DISCUSSION: The TIGER study will provide a roadmap of the location of lymph node metastases in relation to tumor histology, tumor location, invasion depth, number of lymph nodes and lymph node metastases, pre-operative diagnostics, neo-adjuvant therapy and survival. Patient-tailored treatment can be developed based on these results, such as the optimal radiation field and extent of lymphadenectomy based on the primary tumor characteristics. TRIAL REGISTRATION: NCT03222895 , date of registration: July 19th, 2017.

Extending the reach of stapled anastomosis with a prepared OrVil™ device in laparoscopic oesophageal and gastric cancer surgery.

INTRODUCTION: The introduction of minimally invasive surgery and the use of laparoscopic techniques have significantly improved patient outcomes and have offered a new range of options for the restoration of intestinal continuity. Various reconstruction techniques have been described and various devices employed but none has been established as superior. This study evaluates our experience with, and modifications of, the orally inserted anvil (OrVil™). METHODS: We conducted a prospective observational study on 72 consecutive patients who underwent OrVil™-assisted oesophago-gastric or oesophago-jejunal anastomosis between September 2010 and September 2013. We collected data including patient demographics, disease site, type of procedure, location of the anastomosis, involvement of resection margins and peri-operative complications. RESULTS: Seventy-two patients were included in the study. Patient ages ranged from 45 to 92 years (median ± SD = 69 ± 10 years). Total gastrectomy with Roux-en-Y anastomosis was the most-commonly performed procedure (n = 41; 57 %). R 0 resection was achieved in 67 patients (93 %). There were no Orvil™-related clinical leaks during the study period, and just two patients (2.8 %) demonstrated radiological evidence of leak, both of whom were managed conservatively. There were three in-hospital mortalities during the study period; these were unrelated to the anastomotic technique. CONCLUSION: Despite a steep learning curve, the OrVil™ device is safe and reliable. It also permits the creation of higher trans-hiatal anastomoses without resorting to thoracotomy in high-risk patients with cardia tumours. Certain shortcomings of the device, that had implications for patient safety, were identified and addressed by intra-operative modification during the study period. We commend the use of a prepared OrVil™ device, as a game changer, for upper gastrointestinal reconstruction.

Validating the 5Fs mnemonic for cholelithiasis: time to include family history.

BACKGROUND: The time-honoured mnemonic of '5Fs' is a reminder to students that patients with upper abdominal pain and who conform to a profile of 'fair, fat, female, fertile and forty' are likely to have cholelithiasis. We feel, however, that a most important 'F'-that for 'family history'-is overlooked and should be introduced to enhance the value of a useful aide memoire. METHODS: To assess the usefulness of each of the existing factors of a popular mnemonic, 398 patients admitted with upper abdominal pain between March 2009 and April 2010 were studied. The clinical features expressed in the cholelithiasis mnemonic in patients with sonographic evidence of cholelithiasis were compared with those of patients without. FINDINGS: In the cholelithiasis group, significantly more patients were women (150/198 (75.8%) vs 111/200 (55.5%), p<0.001), fair (144/198 (62.9%) vs 54/200 (32.1%), (p<0.001)), fertile (135/198 (68.2%) vs 50/200 (25%) (p<0.001)) and had a body mass index >30 (56/198 (28.3%) vs 19/200 (9.5%) (p<0.001)) compared with controls; but age over 40 years did not predict cholelithiasis (82/198 (41.4%) vs 79/200 (39.5%) (p=0.697)). In the cholelithiasis group, 78/198 (39.4%) had a family history in at least one first-degree relative, compared with 27/200 (13.5%) of controls, (p<0.001). Where the phenotypic elements of the history existed in combination, that patient was found to be at an increased risk of cholelithiasis. INTERPRETATION: Our study found that the validated 'students' 5Fs' mnemonic retains a role in clinical diagnosis of patients suspected of cholelithiasis but the factor 'familial' should be substituted for 'forty' in recognition of the role of inheritance and the changing demographics of gallstone incidence.

The Esophagogastric Anastomosis: The Importance of Anchoring Sutures in Reducing Anastomotic Leak Rates.

Background: The incidence of anastomotic leakage in gastrointestinal surgery is highest after esophagogastric anastomosis, with leakage rates of 10% to 38% still being reported, but little consensus as to cause or corrective. The role of anastomotic tension from a series of physiological forces acting on the anastomosis from the moment of recovery from anesthesia may be underestimated. It was hypothesized that anchoring the conduit in the mediastinum would provide the greatest protection during the vulnerable healing phase. Patients and Methods: A prospectively maintained database was interrogated for anastomotic leakage following the introduction of an anastomotic technique employing anchoring sutures where the gastric conduit was secured to the mediastinal pleura with 3 obliquely inserted load-bearing sutures. A contrast study was performed between days 5 and 7 and all intrahospital mortalities underwent autopsy. Clinical, radiological, and autopsy leaks were recorded. Results: Of 146 intrathoracic esophagogastric anastomoses in 144 patients, 81 (55%) of which were stapled, there was 1 clinical leak and 1 patient with an aortoenteric fistula, considered at autopsy to be possibly due to an anastomotic leak, to give an anastomotic leak rate of 2 in 146 (1.37%). Conclusion: The low anastomotic leak rate in this series is potentially due to the protective effect of anchoring sutures, the chief difference from an otherwise standard anastomotic technique. These sutures protect the anastomosis from a series of distracting forces during the most vulnerable phase of healing. It is intuitive that the absence of tension would also reduce any risk posed by a minor impairment of blood supply or any imperfection of the technique.

Techniques for mesoappendix transection and appendix resection: insights from the ESTES SnapAppy study.

INTRODUCTION: Surgically managed appendicitis exhibits great heterogeneity in techniques for mesoappendix transection and appendix amputation from its base. It is unclear whether a particular surgical technique provides outcome benefit or reduces complications. MATERIAL AND METHODS: We undertook a pre-specified subgroup analysis of all patients who underwent laparoscopic appendectomy at index admission during SnapAppy (ClinicalTrials.gov Registration: NCT04365491). We collected routine, anonymized observational data regarding surgical technique, patient demographics and indices of disease severity, without change to clinical care pathway or usual surgeon preference. Outcome measures of interest were the incidence of complications, unplanned reoperation, readmission, admission to the ICU, death, hospital length of stay, and procedure duration. We used Poisson regression models with robust standard errors to calculate incident rate ratios (IRRs) and 95% confidence intervals (CIs). RESULTS: Three-thousand seven hundred sixty-eight consecutive adult patients, included from 71 centers in 14 countries, were followed up from date of admission for 90 days. The mesoappendix was divided hemostatically using electrocautery in 1564(69.4%) and an energy device in 688(30.5%). The appendix was amputated by division of its base between looped ligatures in 1379(37.0%), with a stapler in 1421(38.1%) and between clips in 929(24.9%). The technique for securely dividing the appendix at its base in acutely inflamed (AAST Grade 1) appendicitis was equally divided between division between looped ligatures, clips and stapled transection. However, the technique used differed in complicated appendicitis (AAST Grade 2 +) compared with uncomplicated (Grade 1), with a shift toward transection of the appendix base by stapler (58% vs. 38%; p < 0.001). While no statistical difference in outcomes could be detected between different techniques for division of appendix base, decreased risk of any [adjusted IRR (95% CI): 0.58 (0.41-0.82), p = 0.002] and severe [adjusted IRR (95% CI): 0.33 (0.11-0.96), p = 0.045] complications could be detected when using energy devices. CONCLUSIONS: Safe mesoappendix transection and appendix resection are accomplished using heterogeneous techniques. Technique selection for both mesoappendix transection and appendix resection correlates with AAST grade. Higher grade led to more ultrasonic tissue transection and stapled appendix resection. Higher AAST appendicitis grade also correlated with infection-related complication occurrence. Despite the overall well-tolerated heterogeneity of approaches to acute appendicitis, increasing disease acuity or complexity appears to encourage homogeneity of intraoperative surgical technique toward advanced adjuncts.

Surgical management of acute appendicitis during the European COVID-19 second wave: safe and effective.

INTRODUCTION: The COVID-19 (SARS-CoV-2) pandemic drove acute care surgeons to pivot from long established practice patterns. Early safety concerns regarding increased postoperative complication risk in those with active COVID infection promoted antibiotic-driven non-operative therapy for select conditions ahead of an evidence-base. Our study assesses whether active or recent SARS-CoV-2 positivity increases hospital length of stay (LOS) or postoperative complications following appendectomy. METHODS: Data were derived from the prospective multi-institutional observational SnapAppy cohort study. This preplanned data analysis assessed consecutive patients aged ≥ 15 years who underwent appendectomy for appendicitis (November 2020-May 2021). Patients were categorized based on SARS-CoV-2 seropositivity: no infection, active infection, and prior infection. Appendectomy method, LOS, and complications were abstracted. The association between SARS-CoV-2 seropositivity and complications was determined using Poisson regression, while the association with LOS was calculated using a quantile regression model. RESULTS: Appendectomy for acute appendicitis was performed in 4047 patients during the second and third European COVID waves. The majority were SARS-CoV-2 uninfected (3861, 95.4%), while 70 (1.7%) were acutely SARS-CoV-2 positive, and 116 (2.8%) reported prior SARS-CoV-2 infection. After confounder adjustment, there was no statistically significant association between SARS-CoV-2 seropositivity and LOS, any complication, or severe complications. CONCLUSION: During sequential SARS-CoV-2 infection waves, neither active nor prior SARS-CoV-2 infection was associated with prolonged hospital LOS or postoperative complication. Despite early concerns regarding postoperative safety and outcome during active SARS-CoV-2 infection, no such association was noted for those with appendicitis who underwent operative management.

Surgeon-Performed Point-of-Care Ultrasound in the Diagnosis of Acute Sigmoid Diverticulitis: A Pragmatic Prospective Multicenter Cohort Study.

Background and purpose Early diagnosis and risk stratification of sigmoid diverticulitis rely heavily on timely imaging. Computerized tomography (CT), the gold standard diagnostic test, may be delayed due to resource constraints or patient comorbidity. Point-of-care ultrasound (POCUS) has an established role in trauma evaluation, and could potentially diagnose and stage acute diverticulitis, thus shortening the time to definitive treatment.  Aims This study aimed to benchmark the accuracy of surgeon-performed POCUS against CT in diagnosing and staging acute diverticulitis. A secondary aim was to evaluate the duration between the POCUS and the confirmatory CT scan report. Patients and methods A pragmatic prospective multicenter cohort study (ClinicalTrials.gov Identifier: NCT02682368) was conducted. Surgeons performed point-of-care ultrasound as first-line imaging for suspected acute diverticulitis. POCUS diagnosis and radiologic Hinchey classification were compared to CT as the reference standard. Results Of 45 patients with suspected acute diverticulitis, POCUS classified 37 (82.2%) as uncomplicated diverticulitis, four (8.8%) as complicated diverticulitis, and four (8.8%) as other diagnoses. The POCUS-estimated modified radiologic Hinchey classification was largely concordant with CT staging with an accuracy of 88.8% (95% CI, 75.95-96.2%), a sensitivity of 100% (95% CI, 90.2- 100%) and a specificity of 44.4% (95% CI, 13.7-78.8%). The positive predictive value (PPV) was 87.8% and the negative predictive value (NPV) was 100%. There was moderate agreement between CT and POCUS, with a Cohen's kappa coefficient of 0.56. The mean delay between CT and POCUS was 9.14 hours (range 0.33 to 43.5). Conclusion We examined the role of POCUS in the management of acute diverticulitis and our findings suggest that it is a promising imaging modality with the potential to reduce radiation exposure and treatment delays. Adding a POCUS training module to the surgical curriculum could enhance diagnosis and expedite the management of acute diverticulitis.

Oesophageal cancer metastases: An observational study of a more aggressive approach.

BACKGROUND: The prognosis for oesophageal carcinoma is poor, but once distant metastases emerge the prognosis is considered hopeless. There is no consistent protocol for the early identification and aggressive management of metastases. AIM: To examine the outcome of a policy of active postoperative surveillance with aggressive treatment of confirmed metastases. METHODS: A prospectively maintained database of 205 patients diagnosed with oesophageal carcinoma between 1998 and 2019 and treated with curative intent was interrogated for patients with metastases, either at diagnosis or on follow-up surveillance and treated for cure. This cohort was compared with incomplete clinical responders to neoadjuvant chemoradiotherapy (nCRT) who subsequently underwent surgery on their primary tumour. Overall survival was estimated using the Kaplan-Meier method, and the log-rank test was used to compare survival differences between groups. RESULTS: Of 205 patients, 11 (5.4%) had metastases treated for cure (82% male; median age 60 years; 9 adenocarcinoma and 2 squamous cell carcinomas). All had undergone neoadjuvant chemotherapy or chemoradiotherapy, followed by surgery in all but 1 case. Of the 11 patients, 4 had metastatic disease at diagnosis, of whom 3 were successfully downstaged with nCRT before definitive surgery; 2 of these 4 also developed oligometastatic recurrence and were treated with curative intent. Following definitive treatment, 7 had treatment for metachronous oligometastatic disease; 5 of whom underwent metastasectomy (adrenal × 2; lung × 2; liver × 1). The median overall survival was 10.9 years [95% confidence interval (CI): 0.7-21.0 years], which was statistically significantly longer than incomplete clinical responders undergoing surgery on the primary tumour without metastatic intervention [n = 62; median overall survival = 1.9 (95%CI: 1.1-2.7; P = 0.012]. The cumulative proportion surviving 1, 3, and 5 years was 100%, 91%, and 61%, respectively compared to 71%, 36%, and 25% for incomplete clinical responders undergoing surgery on the primary tumour who did not undergo treatment for metastatic disease. CONCLUSION: Metastatic oesophageal cancer represents a unique challenge, but aggressive treatment can be rewarded with impressive survival data. In view of recent advances in targeted therapies, intensive follow-up may yield a greater number of patients with curative potential and thus improved long-term survival.

Transgastric Drainage for Esophageal Injuries: A Dynamic Strategy for a Heterogenous Patient Cohort.

BACKGROUND: Esophageal injury is a rare but potentially lethal surgical emergency. It is associated with significant morbidity and mortality because of mediastinal contamination and difficulty of access. Surgery in such septic patients exacts a heavy physiological price, mandating consideration of more conservative measures. We review our experience with transgastric drainage for esophageal perforation and high-risk anastomotic dehiscence. PATIENTS AND METHODS: A select cohort of patients presenting with esophageal perforation, or complex anastomotic leaks, over 10 years were considered for transgastric drainage (TGD). A modified 36F chest drainage tube was inserted by percutaneous endoscopic gastrostomy technique, either endoscopically or at open surgery, and a negative pressure (-10 cmH2O) was applied until the leak had sealed. Endpoints include, length of stay, restoration of gastrointestinal tract continuity and mortality. RESULTS: Of 14 patients treated, 10 had perforations and 4 had complex anastomotic leaks. Ten patients had drainage alone, while 4 required concomitant operative intervention. The median duration of drain insertion for those treated with TGD alone was 19.5 days. Complete restoration of gastrointestinal tract continuity was achieved in all patients. There was no procedure-related morbidity or mortality. CONCLUSION: These results show that TGD is a safe and effective management strategy. We advocate its use alone or as an adjunct to operative treatment for esophageal perforation or anastomotic leaks. This is the first report of completely endoscopic TGD for esophageal perforation.

Quality of life in patients with upper GI malignancies managed by a strategy of chemoradiotherapy alone versus surgery.

BACKGROUND AND OBJECTIVES: Neoadjuvant chemoradiotherapy (nCRT) induces a pathological complete response (pCR) in 25-85% of oesophago-gastric cancer. As surgery entails morbidity and mortality risks and quality of life (QL) impairment, its avoidance in patients without residual disease is desirable. This study aimed to compare quality of life of patients with a cCR who chose surveillance with those who chose surgery. METHODS: Four groups of patients were studied. Group 1(n = 31) were controls; Group 2 (n = 26) had chemoradiotherapy only; Group 3 (n = 31) had oesophagectomy after nCRT; Group 4 (n = 26) had gastrectomy alone. A 33-point novel questionnaire was administered at two 3 month time points. Participants were also interviewed with a validated questionnaire. RESULTS: Mean(±sd) quality of life scores in cCR patients offered surveillance (28.9 ±â€¯4.5) were superior to patients undergoing oesophagectomy (32.3 ±â€¯58. p=0.042) or gastrectomy (33.19 ±â€¯5.9, p=0.004). This result was replicated in the validated questionnaire (p=0.017). There was a trend towards increased reflux-related respiratory symptoms in the oesophagectomy group (7.3 ±â€¯2.2 vs 6.5 ±â€¯1.9; p=0.396) and towards early dumping (8.2 ±â€¯1.4 vs 7.1 ±â€¯1.; p=0.239) and vagotomy-related symptoms (1.82 ±â€¯0.9 vs 1.4 ±â€¯0.6; p=0.438) in the gastrectomy group. CONCLUSIONS: Avoidance of surgery in cCR patients is rewarded with a superior quality of life to those undergoing surgery.

Red cell distribution width and neutrophil to lymphocyte ratio as predictors of outcomes in acute pancreatitis: A retrospective cohort study.

BACKGROUND: Acute pancreatitis is a commonly encountered emergency but accurately predicting that subset of patients who will become systemically unwell has proven difficult. Simple haematological prognostic markers, such as red cell distribution width (RDW) and neutrophil to lymphocyte ratio (NLR), could identify such patients. The aim of this study was to assess the usefulness of RDW and NLR measured on admission as predictors of mortality and intensive care (ICU) or high dependency unit (HDU) admission in patients with acute pancreatitis. MATERIALS AND METHODS: All patient who presented to our institution with acute pancreatitis between August 2013 and August 2016 were retrospectively identified using the prospectively maintained Hospital In-Patient Enquiry (HIPE) discharge audit. Data on survival, admission to HDU or ICU, length of stay and haematological parameters including RDW and NLR on presentation to the emergency department were collected. RESULTS: A total of 185 patients with acute pancreatitis were included of which 23 (12%) patients had a RDW above the upper limit of normal (ULN), which was associated with a significantly increased likelihood of admission to ICU or HDU (RR3.5; p = 0.01); 117 (63%) patients had a NLR above 5 on presentation, which also increased the risk of ICU or HDU admission (RR 8.1; p = 0.01). Patients who had both a RDW above the ULN and a raised NLR had an increased risk of inpatient mortality (RR 9.9; p = 0.04). CONCLUSION: RDW and NLR can identify patients at increased risk of severe acute pancreatitis on presentation to the Emergency Department.

Primary squamous cell carcinoma of the breast: value of positron emission tomography scanning in confirming the diagnosis.

Pure primary squamous cell carcinoma of the breast is rare. Controversy exists as to whether a pure form exists or whether described cases represent extreme squamous metaplasia within an adenocarcinoma. We present a case of pure primary squamous cell carcinoma of the breast confirmed histopathologically with the absence of a distant primary tumor excluded using positron emission tomography. Because of the paucity of guidelines in the literature for this rare tumor, it is difficult to draw firm conclusions regarding the optimal treatment modality or the overall prognosis.

Trans-Balloon Visualisation During Dilatation (TBVD) of Oesophageal Strictures: a Novel Innovation.

BACKGROUND: Hydrostatic balloon dilatation of upper gastrointestinal strictures is associated with a risk of perforation that varies with the underlying pathology and with the technique employed. We present a technique of trans-balloon visualisation of the stricture during dilatation (TBVD) that allows direct 'real-time' observation of the effect of dilatation on the stricture, facilitating early recognition of mucosal abruption, thereby reducing the perforation rate. PATIENTS AND METHODS: We retrospectively analysed 100 consecutive patients, undergoing balloon dilatation of oesophageal strictures between 1st of January 2011 and 1st of July 2014. RESULTS: One hundred patients underwent 186 dilatations, with 34 having multiple procedures (mean 1.86). All had oesophageal strictures (mean diameter 8.49 mm, range 5-11 mm) and most underwent dilatation up to a maximum of 17 mm (mean 14.7 mm). Fifty-six percent were male and the average age was 62.5 years (17-89 years). Only one patient (0.5% of all procedures) had a full-thickness perforation requiring intervention while just one further patient had a deep mucosal tear that did not require intervention. CONCLUSIONS: TBVD is a safe technique with a short learning curve and is one of the important factors that allow potentially difficult dilatations to be performed safely with an exceptionally low rate of adverse events of less than 1%.