Laparoscopic hand-sewn cardioplasty: an alternative procedure for end-stage achalasia.

BACKGROUND: Primary achalasia is a rare oesophageal motor disorder characterized by the absence of swallow-induced relaxation of the lower oesophageal sphincter and diminished or absent oesophageal body peristalsis. Around 5% of these patients will develop end-stage achalasia, where oesophagectomy may be advocated. We present the laparoscopic hand-sewn cardioplasty as an alternative 'oesophagus-preserving' procedure in patients with end-stage achalasia. METHODS: We present a retrospective review of four patients who underwent laparoscopic hand-sewn cardioplasty. Data collected included pre-operative demographic information and investigations; and post-operative outcomes. Patients were scored pre- and post-operatively using Reflux Symptom Index, Eating Assessment Tool-10 and Voice Handicap Index-10 questionnaires. RESULTS: Four patients underwent laparoscopic hand-sewn cardioplasty during the study period. In one patient, it was performed as a rescue procedure during attempted myotomy following multiple perforations of friable mucosa. In the other three patients, laparoscopic hand-sewn cardioplasty was performed for end-stage achalasia. None of the patients had post-operative complications and all patients were discharged on the second post-operative day. All patients experienced improvement in swallowing symptoms (EAT-10; p = 0.03) but developed post-operative gastroesophageal reflux. CONCLUSION: To our knowledge, this is the first published case series of laparoscopic hand-sewn cardioplasty for end-stage achalasia. It appears to be a safe and effective procedure for the treatment of end-stage achalasia, offering an alternative minimally invasive procedure to oesophagectomy. Laparoscopic hand-sewn cardioplasty can also be used as a 'rescue' procedure during myotomy in patients who have poor-quality mucosa which perforates intra-operatively or is at high risk of perforation/leaking post-operatively.

Mitigating surgical emergency practice during COVID-19 pandemic?

PURPOSE: To define the change in Emergency Surgical Unit (ESU) workload during the COVID-19 pandemic. METHODS: Patient data for a three-week period was prospectively collected for ESU patients during lockdown period and compared to the ESU workload for the same time period prior to lockdown. RESULTS: Surgical emergencies admissions reduced by 2.5 times during our study period (p value = 0.001). In this changed paradigm, the overall number of surgical emergencies were reduced. A high mortality (n = 4, 5.7%) was noted during lockdown period as compared to pre-lockdown period (n = 1, 0.58%, p value = 0.025). Almost half of surgical admissions were tested for COVID-19 based on their symptoms and more than third (n=14, 38.9%) of them were positive. Gastrointestinal symptoms were common in COVID-19 positive group (85.7%) and only a third (36%) of COVID-19 positive patients needed surgical attention. Chest x-ray findings were comparable to PCR testing in terms of sensitivity and specificity but CT chest was more sensitive. CONCLUSIONS: It remains unclear how COVID-19 reduced surgical emergencies. A significant proportion of COVID-19 presented with gastrointestinal symptoms. In a new outbreak all General Surgical patients should be tested with CRP and WCC used as a triage adjunct. KEY WORDS: Coronavirus, COVID-19, Emergency Surgery Pandemic, General Surgery.

Financial implications of a model heart failure disease management program for providers, hospital, healthcare systems, and payer perspectives.

Although heart failure disease management (HFDM) programs improve patient outcomes, the implementation of these programs has been limited because of financial barriers. We undertook the present study to understand the economic incentives and disincentives for adoption of disease management strategies from the perspectives of a physician (group), a hospital, an integrated health system, and a third-party payer. Using the combined results of a group of randomized controlled trials and a set of financial assumptions from a single academic medical center, a financial model was developed to compute the expected costs before and after the implementation of a HFDM program by 3 provider types (physicians, hospitals, and health systems), as well as the costs incurred from a payer perspective. The base-case model showed that implementation of HFDM results in a net financial loss to all potential providers of HFDM. Implementation of HFDM as described in our base-case analysis would create a net loss of US dollars 179,549 in the first year for a physician practice, US dollars 464,132 for an integrated health system, and US dollars 652,643 in the first year for a hospital. Third-party payers would be able to save US dollars 713,661 annually for the care of 350 patients with heart failure in a HFDM program. In conclusion, although HFDM programs may provide patients with improved clinical outcomes and decreased hospitalizations that save third-party payers money, limited financial incentives are currently in place for healthcare providers and hospitals to initiate these programs.

Levels of purine, kynurenine and lipid peroxidation products in patients with inflammatory bowel disease.

The factors affecting gut activity in inflammatory bowel disease are unclear, but purines and kynurenines may be involved in the regulation of neuronal activity and therefore gut motility and secretion. We have measured the serum levels of these compounds in patients and in sex- and age-matched controls. Purines and kynurenines were analysed using HPLC. The levels of tryptophan and its metabolites 3-hydroxykynurenine, 3-hydroxyanthranilic acid and xanthurenic acid were unchanged in all patients. However, the levels of kynurenine and kynurenic acid were significantly elevated in patients with inflammatory bowel disease when compared to control subjects. There were no significant differences between patients and controls for any of the purines analysed or for neopterin. In the inflammatory bowel disease patients serum lipid peroxidation products were significantly elevated when compared to control subjects, suggesting the presence of increased oxidative stress consistent with inflammatory activity. The elevated level of kynurenic acid may represent either a compensatory response to elevated activation of enteric neurones, or a primary abnormality, which induces a compensatory increase in gut activity, but may indicate a role for kynurenine modulation of glutamate receptors in the symptoms of inflammatory bowel disease.

Gastric perforation by a foreign body presenting as a pancreatic pseudotumour.

INTRODUCTION: Foreign body ingestion rarely causes complications, though it can pose a significant diagnostic challenge. Perforation, particularly of more muscular viscera, can present insidiously with a wide range of differential diagnoses. PRESENTATION OF CASE: Here we present a case of 75 year-old woman presenting with chest and epigastric pain. Initial imaging suggested a pancreatic lesion. Despite appropriate treatment she deteriorated clinically, and following urgent laparotomy a duck bone fragment was found to have perforated the lesser curvature of the stomach and embedded within the liver causing subhepatic abscess formation and associated inflammation. DISCUSSION: There are a number of examples of insidious presentations of gastrointestinal perforation. However, we have found only one other case of a perforation presenting as a pancreatic pseudotumour, and ours is the first to have been successfully managed by removal of the foreign body and drainage of the abscess alone. CONCLUSION: A high level of suspicion is required to make the correct diagnosis in cases such as these where the symptoms are not clear-cut. Thorough review and discussion of imaging prior to surgical treatment is essential to prevent unnecessary intervention.

A rare cause of faecal peritonitis: jejunal perforation in a patient undergoing treatment for pulmonary tuberculosis.

Abdominal tuberculosis (TB) is a rare but well-documented cause of faecal peritonitis, occasionally occurring in cases where the diagnosis has been delayed, thus resulting in progressive disease. Frequently occurring in the ileo-caecal region, it requires commencement of anti-tubercular regimen and can necessitate surgical intervention. We present a rare case of faecal peritonitis in a young immuno-competent patient with a perforated jejunal stricture, despite triple therapy for known pulmonary TB.

Left atrial volume: comparison of 2D and 3D transthoracic echocardiography with ECG-gated CT angiography.

RATIONALE AND OBJECTIVES: Left atrial volume (LAV) measurement by conventional two-dimensional (2D) transthoracic echocardiography (TTE) may be limited by the geometric model, by suboptimal definition of left atrial endocardium, or by chamber foreshortening. Three-dimensional (3D) TTE is posited to eliminate chamber foreshortening, and LAV measurement by 3D TTE should be more reflective of true LAV. The aim of this study was to compare conventional 2D TTE and newer 3D TTE for measurements of LAV to multidetector computed tomographic (MDCT) measurements using automated chamber reconstruction (ACR). MATERIALS AND METHODS: Twenty-two subjects consented to undergo 2D TTE and 3D TTE immediately prior to or following coronary computed tomographic angiography. LAV was calculated from 2D TTE using the area-length method (ALM) and from 3D TTE with the ALM as well as with a 3D model. Electrocardiographically gated coronary computed tomographic angiography was performed in helical mode. LAV was measured using the ALM as well as ACR. RESULTS: LAV was significantly smaller by 2D TTE (80 ± 21 mL) and 3D-TTE (90 ± 24 mL with the ALM, 61 ± 16 mL with the 3D model) compared to MDCT ACR (120 ± 30 mL) (P < .01). Correlation between MDCT ALM and MDCT ACR was excellent (mean Δ = -1.4 ± 14 mL, r = 0.91). Correlation with MDCT ACR was no better for 3D TTE (r = 0.80) than for 2D TTE (r = 0.80). CONCLUSIONS: LAV is underestimated by both 2D TTE and 3D TTE relative to coronary computed tomographic angiography. Excellent agreement between the ALM and ACR with MDCT imaging suggests that the geometric model plays a negligible role in the underestimation of LAV. Underestimation of LAV by echocardiography is likely related to suboptimal definition of left atrial contour.

Acute oesophageal necrosis syndrome.

An 89-year-old woman with a known hiatus hernia presented to the accident and emergency department with acute onset epigastric pain. CT of the thorax and abdomen revealed a large hiatus hernia with mesentero-axial volvulus but no evidence of strangulation. A large aneurysmal aortic arch and descending aorta were visible with associated mural thrombus. As the pain was worsening, following discussion with the patient, the decision to operate was taken. The hiatus hernia was successfully reduced and the stomach looked healthy. The oesophagus, however, appeared black almost throughout its entire length consistent with acute oesophageal necrosis syndrome, a rare and lethal disease. Left lateral thoracotomy followed by cervicotomy was performed to retrieve a healthy oesophageal segment, which was anastomosed to the cardiac end of the stomach. Despite treatment in the intensive care unit, the patient's condition progressively deteriorated and she died of multiorgan failure 12 days later.

Effectiveness of a clinical-decision-support system in improving compliance with cardiac-care quality measures and supporting resident training.

Many of the quality measures for patients with heart failure (HF) or acute myocardial infarction (AMI) require the completion of comprehensive discharge instructions, including instructions about medications to be taken after discharge. To improve compliance in a tertiary care teaching hospital with these evidence-based quality measures, a clinical-decision-support system (CDSS) that uses an electronic checklist was developed. The CDSS prompts clinicians at every training level to consistently create comprehensive discharge instructions addressing quality measures. The authors compared compliance during the 15-month preintervention and postintervention periods. Compliance with discharge measures for AMI (i.e., aspirin, beta-blocker, angiotensin-converting enzyme inhibitor [ACEI], or angiotensin receptor blocker [ARB] use) and for HF (i.e., discharge instructions, left ventricular systolic function [LVSF] evaluation, and ACEI/ARB use) was assessed. The delivery of discharge instructions showed significant improvement from the preintervention period to the postintervention period (37.2% to 93.0%; P < .001). Compliance with prescription of ACEI or ARB also improved significantly for HF (80.7% to 96.4%; P < .001) and AMI (88.1% to 100%; P = .014) patients. Compliance with the remaining measures was higher before intervention, and, thus, the modest improvement in the postintervention period was not statistically significant (AMI patients: aspirin, 97.5% to 98.8%; P = .43; and beta-blocker, 97.9% to 98.7%; P = .78; HF patients: LVSF, 99.3% to 99.1%; P = .78). Implementation of a CDSS with computerized electronic prompts improved compliance with selected cardiac-care quality measures. The design of quality-improvement decision-support tools should incorporate educational missions in their message and design.

The effects of carbon dioxide in champagne on psychometric performance and blood-alcohol concentration.

AIMS: To assess the effects of carbon dioxide (CO(2)) in champagne on psychomotor performance and blood-alcohol concentration (BAC). METHODS: Twelve subjects consumed ethanol (0.6 g/kg body weight) served as champagne or champagne with the CO(2) removed, in a crossover study. RESULTS: Champagne produced significantly greater BACs and significantly increased reaction times in a divided attention task, than degassed champagne. CONCLUSIONS: The CO(2) in champagne may accelerate absorption of alcohol, leading to more rapid or severe intoxication.

Resection of soft tissue sarcomas with intra-operative magnetic resonance guidance.

PURPOSE: To report on a preliminary series of magnetic resonance (MR)-guided sarcoma resections. MATERIALS AND METHODS: Three patients with the skin sarcoma dermatofibrosarcoma protuberans underwent MR-guided resection. RESULTS: The extent of the tumor at MR imaging was greater in each case than suggested by clinical examination. Adequate resection margins were planned using short Tau inversion recovery (STIR) sequences and intra-operative imaging was used to confirm complete tumor excision. Histological examination confirmed clear surgical margins of at least 1 cm in each case. CONCLUSION: We believe this technique may reduce the incidence of specimen margins positive for tumor following resection, and consequently reduce the need for further excisional surgery.

Feasibility of abdomino-pelvic T1-weighted real-time thermal mapping of laser ablation.

PURPOSE: To prove the hypothesis that T1-weighted (T1W) thermal mapping is reliable and achievable in magnetic resonance (MR)-guided laser tumor ablation. MATERIALS AND METHODS: Near real-time gray and color-scale T1W thermal maps in 111 MR-guided laser thermal ablations (LTA) of liver, kidney, and uterine tumors were studied. After laser fiber placement, near real-time gray and color-scale thermal maps were produced. Previous work showed T1 signal is inversely proportional to temperature below 55 degrees C (the point of irreversible necrosis). RESULTS: Thermal mapping was successful in 84% of uterine, 74% of hepatic, and 20% of renal ablations. For hepatic and uterine tumors, size and conspicuity of thermal lesions were significantly greater on subtracted colorized images rather than gray-scale raw image mapping (P = 0.001, paired Student's t-test). Patient movement (N = 24), fiber charring N = 2), magnetic field distortion, and reconstruction errors (N = 2) caused mapping failure. For both renal and hepatic tumors, comparison of near real-time T1W colorized thermal map and follow up gadolinium-enhanced MR imaging revealed moderate correlation (Pearson correlation coefficient of 0.55 and 0.5, respectively). CONCLUSION: In hepatic, renal, and uterine thermal maps, the color scale produced significantly greater sized lesions with significantly greater conspicuity than the gray scale. T1W thermal mapping was reliable and successfully achieved in 73.7% of procedures, and predicted the ablated area of the tumor moderately well.

Purine, kynurenine, neopterin and lipid peroxidation levels in inflammatory bowel disease.

The kynurenine metabolites of tryptophan may be involved in the regulation of neuronal activity and thus gut motility and secretion. We have now performed a pilot study to measure serum concentrations of purines and kynurenines in patients with mild inflammatory bowel disease, as well as in sex- and age-matched control subjects. For some analyses, the patients were subdivided into subgroups of those with Crohn's disease and those with ulcerative colitis. The analyses indicated an increased activity in one branch of the kynurenine pathway. While there was no demonstrable difference in neopterin levels in either of the patient groups compared with controls, indicating that the disorders were in an inactive quiescent phase, both groups showed significantly higher levels of lipid peroxidation products. This suggests the presence of increased oxidative stress even during relative disease inactivity. The increased level of kynurenic acid may represent either a compensatory response to elevated activation of enteric neurones or a primary abnormality which induces a compensatory increase in gut activity. In either case, the data may indicate a role for kynurenine modulation of glutamate receptors in the symptoms of inflammatory bowel disease.

Efficacy of fibrin sealant in the management of complex anal fistula: a prospective trial.

PURPOSE: A prospective trial was conducted to establish long-term healing of complex idiopathic anorectal fistula, without extension, after fibrin glue treatment, with clinical assessment and magnetic resonance imaging to determine tract healing. METHODS: Twenty-two patients undergoing glue instillation after fistula curettage and irrigation were followed up for a median of 14 months. Clinical assessment, short tau inversion recovery sequence magnetic resonance imaging, and combined short tau inversion recovery and dynamic contrast-enhanced magnetic resonance imaging were performed at a median of three months postoperatively, and their ability to predict outcome in the presence of early skin healing was determined. RESULTS: Of 22 patients, 19 (86.5 percent) had transsphincteric fistulas, 1 (4.5 percent) had a suprasphincteric fistula, 1 (4.5 percent) had an extrasphincteric fistula, and 1 (4.5 percent) had a rectovaginal fistula. None had clinical or radiologic evidence of secondary extension. Despite skin healing in 17 (77 percent) of 22 patients at a median of 14 days after treatment, only 3 (14 percent) remained healed at 16 months. Magnetic resonance imaging with short tau inversion recovery sequences in combination with dynamic contrast-enhanced magnetic resonance imaging predicted outcome in all 10 assessments (100 percent), compared with short tau inversion recovery sequence alone in 16 (94 percent) of 17 assessments or clinical examination in 12 (71 percent) of 17 (P = 0.02). CONCLUSIONS: The success rate of fibrin glue application for complex anorectal fistulas without extension is 14 percent. Magnetic resonance imaging predicts outcome at an earlier stage than clinical examination.